Beruflich Dokumente
Kultur Dokumente
Field Manual
What are the defensive mechanisms which the body sets in motion to repair wound damage and protect the whole system from the consequent dangers? This is the vital question to which we should know the answer before undertaking any kind of treatment. Joseph Trueta, 1938 Surgeon of the Spanish Republican Army
Our increased understanding of inflammatory mediators released with injury and the resulting complex physiological changes, has led to new approaches of management based on preventing further injury. The past approach of simply maintaining stable vital signs can no longer be considered state-of-the-art management. John A. Weigelt, 1996 Professor of Surgery, Medical College of Wisconsin
War Surgery
Field Manual
Hans Husum, MD, PhD
Associate Professor of Surgery, Institute of Clinical Medicine, University of Tromsoe. Director, Tromsoe Mine Victim Resource Center, University Hospital North Norway
War Surgery, field manual is a joint publication by Third World Network, an independent non-profit international network of organizations and individuals involved in issues relating to development, Third World and North-South affairs; and Trauma Care Foundation, a Norwegian resource center for humanitarian medical relief and research. Copyright to the first edition: Hans Husum, 1994 Copyright to the second revised edition: Hans Husum and Third World Network, 2011 Non-commercial use and reproduction of any part of this publication is permitted and encouraged, on the condition that the source of reference is cited: Husum, H et al: War Surgery, field manual. Third World Network, Penang 2011. This book is also available in DVD format and as pdf-files for free download from the Internet under a Creative Common license. For information, address to: Third World Network 131 MacalisterRoad 10400 Penang, Malaysia Tel: + 604 2266 728 / 604 2266 159 Fax: + 604 2264 505 E-mail: twnet@po.jaring.my Trauma Care Foundation Po. Box 80 N-9038 University Hospital North Norway Tel: +47 77 62 62 27 E-mail: tmc@unn.no
Photos p. 45 and p. 134 (left) by Islamic Health Society Lebanon; photos p. 46, p. 49, p. 134, and p. 240 by Ministry of Health, Gaza; photos p. 72 and p. 259 by Johan Pillgram-Larsen; photos p. 147 by Hanna H. Hansen; photo p. 276 by Sina Trauma Center, Teheran. All other photos by Trauma Care Foundation. Note War Surgery, field manual encourages non-graduate health workers to engage in war casualty management, although the manual cannot replace practical instruction by qualified experts. Neither the publishers nor the authors of this volume are responsible for damage done by unqualified implementation of the described procedures.
Library of Congress Cataloging in Publication Data Hans Husum, Swee Chai Ang, Erik Fosse. War Surgery, field manual, second edition. Includes glossary and index. ISBN 978-983-2729-21-1 1. Traumatology. 2. Wounds and injuries. I. Husum, Hans. II. Ang, Swee Chai. III. Fosse, Erik Text illustrations: Hans Husum Design and cover: Hans Husum Typography and composition: KIO Grafisk as, N-9710 Indre Billefjord, Norway Printer and binder: The Phoenix Press Sdn Bhd, Penang, Malaysia
Contents
.............................................................. ..................................................
15 17
21
Contents
4 Trauma severity scoring and quality control ....................... 95 Without research practice is blind ............................................. 96 Severity scoring ................................................................... 97 Identify patients with unexpected outcomes ................................. 105 Trauma Registries ................................................................. 108 Data gathering forms ............................................................. 114 Brief guide to Trauma Registry analysis ....................................... 120
Contents
8 Life-saving surgery ........................................................... 233 Two kinds of surgery: Damage Control versus repair ...................... 234 Staged surgery: Head injuries ................................................... 239 Staged surgery: Vascular injuries ............................................... 247 Staged surgery: Chest injuries .................................................. 249 Staged surgery: Damage Control laparotomy ............................... 251 Temporary abdominal closure .................................................. 258 Staged surgery for the abdominal organs and the pelvis ................... 260 Staged surgery: Limb injuries ................................................... 272 Multi-injured burn cases ......................................................... 273 Feeding tube-gastrostomy ....................................................... 274 9 Triage sorting casualties ................................................. 277 The principles of triage .......................................................... 278 Triage in mass casualties ......................................................... 281 Triage action plan ................................................................. 283
Contents
Protect the joints .................................................................. 346 External fixation .................................................................. 346 Traction ............................................................................. 349 Orthosis when the fracture is semi-stable .................................... 352 Infected fractures and delayed healing ........................................ 354 14 Joint injuries .................................................................... 359 Evaluation of joint function ..................................................... 360 The soft tissue problem .......................................................... 361 Fractures through joints ......................................................... 362 Infected joints ...................................................................... 364 15 Tendon injuries ................................................................ 367 Primary management ............................................................ 368 Secondary reconstruction ....................................................... 368 16 Nerve injuries .................................................................. 373 Diagnosis and exploration ....................................................... 374 Secondary nerve repair .......................................................... 375 17 Amputations .................................................................... 379 Amputation or limb salvage? .................................................... 380 Land mine amputations .......................................................... 382 Techniques for the primary amputation (first stage) ....................... 383 Techniques for the definitive amputation (second stage) .................. 386 Get going again: Early temporary prosthesis fitting ........................ 388 Definitive prosthesis fitting ..................................................... 392 18 Wound closure ................................................................. 395 Monitor the wounds .............................................................. 396 Closure by spontaneous granulation ........................................... 397 Delayed primary suture (DPS) ................................................. 397 Skin grafts .......................................................................... 398 Skin flaps ............................................................................ 401 19 Injuries to children and old people .................................... 405 The injured child .................................................................. 406 Trauma care in old people ....................................................... 410 20 Emergency blood transfusion ............................................ 415 Indications for blood transfusion ............................................... 416 Emergency blood transfusion ................................................... 417 Autotransfusion ................................................................... 419 Complications of blood transfusion ............................................ 419 21 Hypothermia and hyperthermia ........................................ 423 Management of hypothermia ................................................... 424 Management of acute hyperthermia ........................................... 426
Contents
22 Diseases interfering with surgery ....................................... 429 Types of anemia ................................................................... 430 Malabsorption and vitamin deficiencies ....................................... 432 Schistosomiasis .................................................................... 434 Ascariasis ........................................................................... 434 Amebiasis ........................................................................... 435 Malaria .............................................................................. 436 Typhoid fever ...................................................................... 437 HIV and AIDS ...................................................................... 438
Contents
Preparations for surgery ......................................................... 499 Chest wall injury .................................................................. 500 Exploratory thoracotomy ........................................................ 501 Cardiac injury ...................................................................... 503 Complications of injury and surgery .......................................... 504 28 Abdominal injuries in general ........................................... 507 Wartime abdominal injuries .................................................... 508 Preparations for surgery ......................................................... 510 Abdominal wall injury ........................................................... 512 Exploratory laparotomy ......................................................... 513 Decompression drainage closure .......................................... 521 29 Injury to the intestine ....................................................... 525 Surgical anatomy .................................................................. 526 Debridement and enterostomy ................................................. 527 Injury to the small intestine ..................................................... 530 Injury to the rectum .............................................................. 536 Reconstruction after enterostomy ............................................. 537 30 Injury to the stomach and duodenum ................................ 539 Surgical anatomy .................................................................. 540 Stomach injury .................................................................... 541 Injury to the duodenum and upper jejunum ................................. 542 Complications of injury and surgery .......................................... 544 31 Injury to the liver and biliary tract .................................... 547 Surgical anatomy .................................................................. 548 Liver injury ......................................................................... 549 Complications of liver injury and surgery .................................... 551 Injury to the biliary tract ........................................................ 552 32 Injury to the spleen .......................................................... 555 Surgical anatomy .................................................................. 556 Removal of the spleen splenectomy ......................................... 557 Complications of injury and surgery .......................................... 558 33 Injury to the pancreas ....................................................... 561 Surgical anatomy .................................................................. 562 Pancreatic injury .................................................................. 563 Complications of injury and surgery .......................................... 564 34 Injury to the kidneys ........................................................ 567 Surgical anatomy .................................................................. 568 Injury to the kidney ............................................................... 570 Injury to the ureter ............................................................... 571 Complications of injury and surgery .......................................... 573 35 Injury to the urinary bladder and urethra .......................... 577 Surgical anatomy .................................................................. 578
Contents
Types of injury ..................................................................... 579 Injury to the bladder .............................................................. 580 Injury to the urethra .............................................................. 582 Complications of injury and surgery .......................................... 584 36 Injury to the male organs
..................................................
587
37 Injury to the female organs ............................................... 591 Surgical anatomy and physiology ............................................... 592 Preparations for surgery in the pregnant patient ............................ 595 Injury to the pregnant woman .................................................. 596 Injury to the non-pregnant woman ............................................ 599 Complications of injury and surgery .......................................... 601 38 Complications of abdominal surgery .................................. 603 Post-operative care ............................................................... 604 The management of common complications ................................ 607 39 Pelvic injury ..................................................................... 613 Surgical anatomy .................................................................. 614 Preparations for surgery ......................................................... 616 Surgical strategy ................................................................... 617 Hip joint injury .................................................................... 619 Exploration of the main arteries ............................................... 621 Pelvic fractures .................................................................... 622 Complications of injury and surgery .......................................... 623 40 Upper limb injury ............................................................ 627 Preparations for surgery ......................................................... 628 Shoulder and arm injury ......................................................... 631 Surgical anatomy ............................................................... 631 Exploration of shoulder injuries ............................................. 632 Shoulder fractures .............................................................. 634 Extensive shoulder injury ..................................................... 635 Exploration of arm injury .................................................... 635 Open arm fractures ............................................................ 636 Above-elbow amputations .................................................... 637 Elbow injury ....................................................................... 638 Surgical anatomy ............................................................... 638 Exploration of elbow injury .................................................. 639 Elbow fractures ................................................................. 640 Extensive elbow injury ........................................................ 642 Forearm and hand injury ........................................................ 642 Surgical anatomy ............................................................... 642 Exploration of the forearm and hand injury ............................... 646 Fractures of the forearm and hand .......................................... 648 Extensive hand injury ......................................................... 649 Amputations at the forearm and hand ...................................... 651 Complications of injury and surgery .......................................... 653
Contents
41 Lower limb injury ............................................................. 657 Preparations for surgery ......................................................... 658 Thigh injury ........................................................................ 661 Surgical anatomy: Case studies of thigh gunshot wounds ............... 661 Fasciotomy and exploration .................................................. 665 Thigh vascular injury: Repair, shunt, or ligature? ........................ 667 Fracture management ......................................................... 667 Crush injuries ................................................................... 670 Amputations at the thigh ...................................................... 670 Injury to distal thigh and knee .................................................. 671 Surgical anatomy ............................................................... 671 Preparations for surgery ...................................................... 674 Penetrating injuries ............................................................ 674 Exploration ...................................................................... 675 Extensive joint injury .......................................................... 676 Open joint fractures ........................................................... 676 Fractures of the plateau of tibia .............................................. 678 Amputations at the knee joint ............................................... 679 Lower leg injury ................................................................... 680 Surgical anatomy ............................................................... 680 Fascia compartments of the lower leg and the foot ...................... 683 Fracture management ......................................................... 686 Amputations at the lower leg and foot ..................................... 688 Complications of limb injury and surgery .................................... 690 42 Burns ............................................................................... 695 The physiology of burn injuries ................................................ 696 Examination and classification of burns ....................................... 697 Fluid therapy ....................................................................... 699 Nutrition ........................................................................... 700 Triage of wartime burns ......................................................... 701 Life support and life-saving surgery ........................................... 703 Wound care and burn surgery .................................................. 707 Some special burn wounds ...................................................... 710 Complications of burns .......................................................... 712
Contents
44 Microbiology and infections ............................................. 741 What is bacteria ................................................................... 742 What is infection .................................................................. 742 Guidelines for treatment ........................................................ 743 Septic shock ........................................................................ 745 Bacteria important in surgery .................................................. 746 Common infections and common antibiotics ................................ 749 Resistance to antibiotics ......................................................... 758 Disinfection and sterilization ................................................... 760 45 Nutrition after injury and surgery ..................................... 765 Why enteral feeding why home-made diets ............................... 766 Metabolic response to injury and surgery .................................... 767 Malnutrition complicates surgery .............................................. 770 Planning post-operative nutrition .............................................. 773 Monitor the nutrition ............................................................ 777 Enteral feeding .................................................................... 778 The feeding procedure ........................................................... 780 Common foodstuffs and their nutrient values ............................... 782 Food processing and the viscosity problem .................................. 783 Home-made diets for enteral feeding ......................................... 786 Common high-energy diets for oral feeding ................................. 790 Field standards of volume and weight ......................................... 791
Section 6: Anesthesia
46 Wartime anesthesia ........................................................... 795 Airway obstruction ............................................................... 796 Circulatory collapse .............................................................. 797 Sympathetic hyperactivity ....................................................... 798 Which anesthesia to use? ........................................................ 799 47 Ketamine anesthesia
.........................................................
803
48 Local anesthesia ................................................................ 809 Infiltration anesthesia ............................................................. 810 The nerve block principle ....................................................... 811 Intercostal nerve block anesthesia ............................................. 812 Pleural analgesia ................................................................... 813 Brachial plexus nerve block ..................................................... 813 Axillary nerve block .............................................................. 814 Nerve block of the hand ......................................................... 815 Femoral nerve block .............................................................. 816 Nerve block of the foot .......................................................... 817 Regional intravenous anesthesia ................................................ 818 49 Spinal anesthesia .............................................................. 821 The anesthetics .................................................................... 822 The procedure ..................................................................... 823
Contents
Appendices 1 Blood-grouping, cross-matching, and blood-banking ................... 829 2 Microscopic examination of bacteria. The gram stain procedure ..... 833 3 Data gathering forms .......................................................... 837 4 Websites and books for further studies .................................... 845 Acknowledgements Glossary Index
...............................................................
................................................................................
.................................................................................... ..............................................
Pocket folder
Do not let the size of this book intimidate you. Let it be your companion in the war zone. It has to be comprehensive, since it might be the only book you can afford. We also know many of you have only very basic medical education. We therefore spend time explaining things.
niques, to encourage each other, to constructively critique each other so that we are no longer alone. This is the culture of enabling survival the forum for survival. There is one more book to study. Surgeons often consider the job done when the patient is carried out of the operating theatre and definitely so when he is discharged from the hospital. Thirty years of surgery in the war zones in the South has taught us that they are wrong: a lot of survivors in poor communities suffer from chronic pain and a sense of worthlessness, so much that they cannot carry an artificial limb, and much less provide for their family. In fact, poverty is as much a trauma as the injury itself. So, the end-point where you should measure success or failure of treatment is not the operating theatre but the village and the urban slum, months and years after injury. Lizz Hobbs beautiful rehabilitation manual, Life After Injury, helps you find ways to cope in the long term, see reference list, see p. 849. There is a pocket folder at the back cover. It helps you keep the head cool in difficult situations, especially when treating child victims.
16
War Surgery, field manual is written for health workers and doctors in the front line, how-to-do-it-yourself, and teach others to do it. It is on life- and limb-saving procedures, and on organizing war medical services in the field.We also hope it is useful to the experienced surgeon faced with mass casualties under difficult conditions with few resources. There are other books on war surgery, mainly written for well-equipped armies and hospitals. This manual looks at surgery from a different angle from the standpoint of deprived Third World communities caught in wars they did not ask for. As surgeons working with Afghan peasants, the Palestinians in refugee camps, guerrillas in rural areas in South-east Asia people caught in wars they did not start and are unable to stop we should be truly depressed by the injustice of the situation: Poorly equipped local medical services in poverty-stricken areas and paramedics with little formal education are made to cope with injuries from the most advanced weapons of modern warfare. Logic would say that when a village or refugee camp is blanket bombed to saturation level, the people being injured there would stand no chance of survival. But the reverse is true.We learn from our fellow health workers a whole new way of looking at problems. We should not simply look at the wounded in the way surgical textbooks have taught us dividing the patient into systems. Because resources are so scarce, we have to look at the enormous healing capacity of the human body as our best ally and look at surgery as a total supportive strategy to assist that healing capacity. And we should look at the injured person as someone who is not a passive recipient of medical attention. The patient is actively trying to help himself, and so are his family and friends.The patient and his community therefore become part of the medical team, as operation assistants, blood donors, nurses and physiotherapists. They also teach us how to use local food resources for nutrition, and how to improvise and pirate equipment which would otherwise be beyond their reach. The wounded start dying at the time of injury, and can only survive if he receives life support and surgery immediately. In the war zones of the Third World, who are the surgeons? We ourselves have to come to terms with the traditional hangup that only qualified surgeons can do life-saving operations. One of us had an
17
Afghan peasant as a fellow surgeon, and the other a nurse as chief orthopedic resident surgeon. And it is our belief that if the copyright and patent on surgical knowledge are broken, then many more talented people will come forward. With an experience drawn from 15 years working in various war-fronts, and always under the constant teaching of the people we work with, we feel ready to synthesize what we learnt in the field, teaching materials from training courses we conducted, and our scientific medical background into this manual. Our book is written for and about the little man struggling under enormous odds, with very little to fall back upon. We can only admire his strength. His survival proves the effectiveness of his methods. This manual is dedicated to him. 1994 Hans Husum
18
Much has happened since the first edition of War Surgery, written a decade and a half ago. We quoted Joseph Trueta, the English surgeon who worked in the Spanish Civil War, in the front cover of that edition: What are the defensive mechanisms which the body sets in motion to repair wound damage and to protect the whole system from the consequent dangers? This is the vital question to which we should know the answer before undertaking any kind of treatment. Dr. Trueta is still with us; his warning to trauma care providers, made in 1938, has become even more relevant today. The close of the twentieth century and the dawn of the new millennium have seen massive advancement in weapon technology. Moreover there is much readiness to use these weapons with impunity. Modern warfare seems no longer about conquest and rule it is about deconstruction, fragmentation and destruction of entire communities and even countries. Freed from the need to restore stability after conquest, modern wars are simply about destruction just lay waste and leave. More importantly, they have the ability to carry it out, and within a short time frame. Targets are no longer limited to combatants but intentionally include large numbers of civilians. Neither is war confined to fire-power only; starvation and hunger, economic embargo have all been mobilised in the service of the powerful in their attempts to break down those their weapons failed to kill. Manipulation of public opinion and the media ensures that truth becomes a casualty of such wars. They seek to destroy life, but also hope, aspiration, and truth. So what do we do at the receiving end? We have to strengthen our defence force against these aggressions. Firstly, we have to keep abreast of the latest advancement in weapon technology and understand the special effects they create. For instance, to effectively treat the casualties we have to know how the newly developed DIME Dense Inert Metal Explosives work. Secondly, our knowledge of how the body works in response to injury has also advanced. Our understanding of physiology has improved, and concepts such as hypotensive resuscitation and damage control surgery develop as a result. Better understanding of microbiology such as bacterial biofilms has reinforced our practice of meticulous debridement as infec19
tion control rather than depend on antibiotics. Perforator soft tissue flaps make us heal open fractures in a better way. These are but a few examples. The first edition of War Surgery is doing well, and has found its way into clinics and hospitals all over the world. In this second edition we updated the chapters on prehospital care with guidelines from the handbook Save Lives, Save Limbs (see books recommended for further studies, see p. 846). Also the information on modern weaponry and the physiological responses to injury are brought up to date.We now know that surgery is perceived by the injured body as another traumatic event, that it may be devastating if carried out wrongly. A protocol for staged life-saving surgery is therefore included in the revised edition. The Foreword to the First Edition of War Surgery resounds with our respect and confidence in the abilities of health workers in Third World war zones. Since then, we have seen the publication of solid reports documenting improvement in survival rates in the Third World through the implementation of low-tech chain-ofsurvival trauma systems. Our confidence in our colleagues graduate and nongraduate in the South is therefore well founded. Facing the atrocities of the 4th Generation War we should not be intimidated, but go on to heal the wounds, rebuild the broken societies, and teach new generations better strategies for survival. 2011 Hans Husum, Swee Chai Ang, Erik Fosse
20
Hans Husum
is a general surgeon with thirty years of experience with popular movements in the war zones and mine fields of the Middle East, Iraq, Afghanistan, and South-east Asia. He is a founding member of Trauma Care Foundation, an institution developing teaching aids in trauma care for low-resource communities. Hans Husum heads Tromsoe Mine Victim Resource Center, an action-research center at the University Hospital of North Norway and has published extensively on trauma systems in war with colleagues in the South.
Erik Fosse
is a specialist in general and cardiothoracic surgery. He is professor of surgery at the University of Oslo and director of the Interventional Centre, which is a research and development department at Oslo University Hospital. Erik Fosse is the director of NORWAC, a humanitarian medical NGO working mainly in the Middle East and the Balkans. He worked as a surgeon with the Afghan resistance in 1986 and in Albania during the Kosovo war in 1999. Since 1979 he has worked during several wars in Lebanon and Palestine with Palestinian organizations, including the war in Gaza in January 2009. Erik Fosse is consultant in war surgery with the Norwegian Military Medical Services.
21
List of contributors
Abbas Stroemmen-Bakhtiar, PhD Graduate School of Business, University of Nordland, Norway Chapter 5 Yang Van Heng, MPH Director, Trauma Care Foundation Cambodia. Chapter 1 and 2 Mohamad I. Hijazi, MPH Director, Rassoul Alazam Hospital, Lebanon. Chapter 1 Bjoern Karlsson, Orthopedic Engineer Tromsoe Mine Victim Resource Center, University Hospital North Norway. Chapter 13 and 17 Johan Pillgram-Larsen MD Senior Consultant, Department of Cardio-Thoracic Surgery, Ullevaal University Hospital, Norway. Chief Consultant Surgeon, Norwegian Armed Forces Medical Services. Chapter 8 Ole-Kristian Storjord Losvik MD Director of Research, Tromsoe Mine Victim Resource Center, University Hospital North Norway. Chapter 4 and 6 Mudhafar Kareem Murad MD Director, Trauma Care Foundation Iraq. Chapter 1 and 2 Assaddullah Reha MD, PhD Director, Mobile Emergency Medical Center, Afghanistan. Chapter 1 and 3 Mohamad H. Sayeed MD Consultant, Department of Surgery, Rassoul Alazam Hospital, Lebanon. Islamic Health Society, Directorate of Civil Defense. Chapter 1 and 8 Nenad Tajsic MD, PhD Senior Consultant, Department of Orthopedic and Plastic Surgery, University Hospital North Norway. Chapter 13
22
Knut Wester MD, PhD Senior Consultant, Department of Neurosurgery, Haukeland University Hospital, Norway. Professor, Faculty of Medicine, University of Bergen. Chapter 8 Reiner Winkel MD Chief, Department of Hand and Reconstructive Surgery, BGU Trauma Center, Frankfurt am Main, Germany Chapter 13
Chapters 2 and 7 are based on the manual Save Lives, Save Limbs, Third World Network, Penang, 2000, by Hans Husum, professor Mads Gilbert, Department of Emergency Medicine, University Hospital North Norway, and professor Torben Wisborg, Department of Acute Care, Hammerfest Hospital, Norway. The authors of War Surgery are responsible for the revision of the original text.
23
24
25
Uncontrolled bleeding is a major killer in trauma. Bleeding is dangerous in two ways: the blood pressure becomes too low for tissue perfusion, and red blood cells carrying oxygen are lost. The result of both factors is oxygen starvation in the tissues. When tissues are starved of oxygen they produce acids. Acidosis causes impairment of the coagulation system and the bleeding increases. When patients have large open wounds and poor blood circulation, the body temperature falls. A reduction in blood temperature of 2-3 C also causes further coagulation failure. We call this vicious circle of uncontrolled bleeding, acidosis and hypothermia the Triad of Death. The aim of trauma life support and life-saving surgery is to break this circle: Stop bleeding to save the red blood cells and maintain adequate blood pressure, support the breathing to avoid acidosis, and keep the patient warm. Study the most common reasons for avoidable deaths, see p. 29. The Chain-of-Survival A network model where life support is provided at three levels, see p. 33. Historical lessons How to organize the medical network is too important to be left for non-medical personnel. There is a lot to learn from previous failures. And there are some success stories, see pp. 34-47. New models Since the late twentieth century and especially the war on Belgrade 1999 we are facing new weapons and new types of warfare. Consequently we have to find new ways of saving lives and limbs, see p. 48.
26
28 34
This is the chain of survival ....................................................... 33 Models and experiences from recent wars
....................................
27
See chapters on physiology of the effects of oxygen starvation, p. 162 and 174.
The patient starts dying at the time of injury: About 60% of the patients in war have minor or non-lethal injuries, the so-called walking wounded. The rest have started dying at the time of injury. Early death within the first few minutes and hours normally results from oxygen starvation (hypoxemia) or severe bleeding. Among the initial survivors there still exist injuries that will kill within hours or days. The fundamental condition for survival is getting enough oxygen to the tissues. Without oxygen there is no life. The oxygen starvation may be caused by airway blockage, ineffective breathing and/or blood loss. To reverse the process is not a matter of surgery alone. High quality pre-hospital trauma care is a key element in the chain of survival.
28
Trauma system mortality in Iraq: Where the surgical hospital is far and prehospital transit times are over four hours, around 40% of war victims will die on site or during the evacuation if nobody provides life support outside hospital. The graph illustrates the outcome of a chain-of-survival trauma system for land mine and war victims in Northern Iraq. This system comprises 5,000 trauma first responders, 100 trauma paramedics and one surgical center. The mean prehospital transit time from injury to hospital admission in the actual scenario is five hours. By the introduction of high-quality prehospital care, the pre-intervention trauma mortality level of 40% dropped to approximately 10% during the study period. Similarly our experience from war theatres in Afghanistan and South-east Asia confirms that 50-75% of war time trauma deaths are avoidable. In contrast, during the attack on Gaza from December 2008 to January 2009, most of the patients had a very short evacuation time to a competent trauma hospital, and rapid evacuation was more important in preventing mortality.
29
Common reasons for avoidable early deaths: experiences from the Iraqi trauma system* Airway blockage 25% of avoidable deaths Tongue blocks airway in unconscious patients. Aspiration of blood and vomit in unconscious patients. Mechanical block due to face/neck injuries. * The epidemiology of avoidable deaths differ between war scenes depending on weaponry and the quality of medical care. Breathing problems 25% of avoidable deaths Severe pain makes breathing inefficient. Abdominal organs block diaphragm. Hemo/pneumothorax. Circulatory problems 25% of avoidable deaths Blood loss in pelvic, abdominal and extremity injuries. Coagulation failure induced by hypothermia.
Often, simple things are crucial in life support. Most of the risk factors listed in the table can be controlled by any trained non-doctor who carries a small medical kit. But somebody has to do the right measures there and then; consequently there has to be a lot of somebodies trained and equipped in the catchment areas of the trauma system.
Damage control
Chemicals trigger
The drivers of trauma death: To cope with severe injuries, we should understand the critical factors driving the physiological processes of destruction and death. Tissue destruction caused by the injury immediately initiates a cascade of responses that act on the entire physiological system of the body. The endothelial cells lining blood vessels, the T-cells of the white blood cell system, and the mucosa of the small intestine seem to be headquarters in this post-injury chain reaction. A lot of signal substances chemical triggers released from damaged tissues mobilize the headquarters to initiate the post-injury stress response. This response is a comprehensive physiological reaction taking the immune system, coagulation and
30
the metabolism out of balance. The more severe the initial tissue damage, the stronger is the post-injury stress response and the higher the risk of physiological derangement. Note: Not only the wound but also other factors accelerate the post-injury stress response cellular hypoxia, persistent pain, inflammation and reperfusion syndrome are the most important triggers. Based on this understanding we should revise our concept of injury severity. Injury severity The probability of trauma death, Pd, is a function of the injury severity on one hand, and the bodys capacity to resist and heal on the other hand: injury severity Pd = physiological capacity
The actual severity in the individual trauma victims does not correlate with severity of the injury alone, but is determined also by the triggers of the post-injury chain reaction.The pathophysiological flow chart (p. 30) can therefore be expressed as a severity equation: Injury severity = (wound) (t shock) (pain) (reperfusion syndrome) (inflammation) Post-injury stress response in detail, see p. 165. The Pd is thus not a constant, but varies as a function of time and the efficacy of life support provided. In order to put off an uncontrolled explosion of the postinjury chain reaction, the period of circulatory shock (oxygen starvation at the cellular level), reperfusion syndrome and sepsis must be prevented at the very beginning: Insufficient breathing: The stress response increases the consumption of oxygen at the cellular level; to avoid further oxygen starvation improved oxygen delivery is thus mandatory. Is the breathing effective? Besides being an independent trigger of post-injury stress, persistent pain also prevents efficient breathing. Reperfusion syndrome is a devastating secondary injury which arises when an organ system remains exposed to low blood flow for a period of 90 minutes before being reperfused.The reperfusion injury with thrombus formation in small caliber blood vessels and damage to the endothelial cells does not affect the hypoperfused organ only, but is sent to the whole body with resulting physiological catastrophe. Inflammation and infection: The stress response is also amplified by inflammation mediated by the white blood cell system. War wounds are heavily contaminated from the time of injury and bacteria start to multiply immediately and rapidly. Bacterial by-products created by ongoing infection are signal substances for a further acceleration of the post-injury responses.
31
See more on the double-hit effect on p. 234. In malaria Falciparum parasite carriers damage control surgery reduces the risk of post-operative malaria relapse. See www.traumacare.no/malaria
Early damage control makes a difference: The physiological capacity of a trauma victim some hours after injury depends on life support previously provided. Without in-field life support, the surgeon, a few hours after the injury may encounter a physiological system out of balance, a patient on his way onto immunodepression and coagulation failure; extensive surgery is risky! But if proper damage control was provided early, that same patient with identical wound severity would be a patient in reasonable physiological balance, who six hours later would be able to withstand elaborate surgery. From the perspective of the bodys physiology, extensive surgery even well done is a traumatic event.
32
War zone
The chain of survival: We should organize the trauma system based on our understanding of the devastating physiological responses initiated by the primary injury.The answer to that challenge is a network model where life support is provided at three levels.
Trauma first responders We need an army of lay person villagers or soldiers to start basic life support within 5 minutes, assist the patient all the way to paramedic, and assist the paramedic. This is the first response protocol: Airways: Head tilt chin lift tongue extraction recovery position Breathing: Awake patients in half-sitting position Circulation: Stop external bleeding: artery compression + subfascial packing + long compressive dressing + hypothermia prevention CPR. Paramedics We need at least one trained paramedic in every area where injuries are expected. The paramedics train and work in team with first responders. Within 30 minutes after injury the paramedic team should supplement basic life support measures with advanced techniques: Airways: Endotracheal intubation or airway cut down (emergency crico-thyrotomy) Breathing: IV ketamine analgesia. Gastric decompression. Chest tube placement Circulation: Hypotensive warm IV fluid resuscitation. Limb compartment fasciotomy. Whether damage control laparotomy should be included in the protocol depends on paramedics skill and evacuation times Anti-infective: Antibiotics. Antimalarials In-field triage Medical documentation.
Mobile clinic in the combat area: Dr. Reha with paramedics at Jalalabad, 1990.
Forward clinic Damage control surgery is a well documented strategy for primary trauma surgery on severely injured patients. Surgery in patients who are in a state of full-blown post-injury stress is a risky matter. Even when performed properly, extensive operations in such patients are felt by the body as another trauma, and will therefore further boost devastating physiological stress reactions. The answer to this problem is staged intervention: Stage 1: control the triggers immediately on admission, no time for repair: Stop bleeding by rapid and temporary techniques. Shunt tears of vital arteries by temporary measures. Tie off leaks from intestines. Prevent limb compartment syndromes by fasciotomy and perform a temporary and rough reduction of fractures. The duration of the damage control intervention should not exceed 45 minutes. Stage 2: intensive resuscitation for 24-72 hours: Support breathing. Provide efficient analgesia. Correct blood loss and hypovolemia. Correct hypothermia. Provide nutrition and anti-infective therapy. Stage 3: surgical repair when patient is as stable as can be: The patient is now strong enough to sustain well planned and prepared surgical reconstruction of injured structures. The damage control strategy is indicated in patients severely injured, patients in poor physiological condition after protracted evacuations and in patients with poor capacity due to malnutrition and/or pre-injury illness (malaria, HIV, tuberculosis, hepatitis etc.). In other patients primary surgery should be done as one-stage intervention within six hours after injury. Surgical center Local hospitals and forward surgical clinics are able to manage 80% of all war injuries including most traumatic brain injuries provided the teams are trained properly and equipped with a minimum of technical resources. Patients in need of extensive neurosurgery, vascular repair and microsurgery should be transferred to specialized surgical centers (level-I centers). Level-I centers are not an integral part of our chain-of-survival trauma system, and such surgical management is outside the scope of this manual.
34
2nd generation war: First World War The speed of weapon increases (guns), but the war is still stationary (trenches). Aim: Take over and control territory. 3rd generation war: Second World War The speed and range of weapons increase further. Warfare is mobile (tanks, submarines). Aim: Take over and control territory. 4th generation war: NATO bombs Belgrade 1999, Gaza 2009 ... The speed and range of weapons are unlimited. The war is everywhere, deterritorialized. Aim: Shock and awe. Break morale, destroy culture and society. The actual design of the chain-of-survival depends on the type of war, the scene of combat, the extent of local popular support, types of weapons and injuries encountered and the skills and resources of your staff.The organization of the medical network is a main concern for the war surgeon and should not be left for administrators and non-medical staff to decide. Study the local setting carefully and design the model accordingly; some of the case studies below demonstrate that blind implementation of pre-set models from one war theatre to another causes unnecessary losses.
35
The Khmer Rouge movement in Cambodia 1970-1990: Mobile surgical teams in the jungle
Contrary to the Vietnamese, the Cambodian movement built a trauma system of small stationary jungle hospitals supported by forward mobile surgical teams. Each surgical team comprised one senior medical officer and two paramedics. At makeshift training centers at the jungle hospitals the Khmer Rouge medical officers were systematically trained in life-saving surgery by professional surgeons. When applied to the war zones, the surgical teams were thus able to perform damage control interventions on the scene in hammocks in the jungle or local villages such as splenectomy, liver suture, relief stoma in colon wounds, amputations and vascular repairs. As the US-Lon Nol forces and later the invading Vietnamese army controlled major cities and roads, evacuations to rear surgical hospitals took days in the Cambodia war theatre. In this setting, the flexible design of small stationary hospitals and forward mobile surgical teams was efficient. Lessons learned from previous SE Asian wars Trauma surgery does not depend on stationary hospitals; in most cases it can be well done in any village by a skilled medical officer. Where the prehospital evacuation is protracted and hard, well-trained forward mobile paramedic teams are crucial. Top-heavy trauma systems may seem nice on paper but can be dangerous when implemented in a rough and unpredictable war theatre. Even where popular support is massive, shortage of food and water for major hospitals may compromise the results of excellent surgery.
In 1993 Palestinian and patriotic Lebanese forces were kept under siege by Syrian and Israeli forces in the Lebanese city of Tripoli.The scenario was one of close-range fighting with sniping, mortars, short-range rockets and naval artillery, but no aer-
ial bombardment.The city had a population of 200,000.There was a general shortage of food, fuel and medical supplies, but the popular support to the resistance was massive.The combat areas were located on the outskirts of the city; evacuation time from injury to the hospital was short, normally less than 30 minutes. Post-operative evacuation of casualties to other hospitals in Lebanon was impossible due to tight siege. In this scenario it was possibe to become stuck in a Beirut trap unless satellite rehabilitation centers could unload the patients from the main surgical hospital. Palestinian Forward Hospital with rehab centers in Tripoli Ambulance with paramedics giving infusion during evacuation from fighting area to the forward hospital. Here definitive surgery was done on all casualties. When stable after the surgery (1-5 days) patients were distributed among satellite rehabilitation centers (RC) inside the city to relieve the load upon the main hospital. In the RCs they were attended to daily by medical teams from the hospital and readmitted to the hospital for check-ups and reconstructive surgery. The Tripoli hospital was located underground in a concrete building giving protection against artillery hits.The electric supply was sufficient and stable.The emergency department was always manned by the senior surgeon and the most experienced nurses. The operating theater was manned by three teams, each with one surgeon, one assistant doctor, two scrub nurses and one anesthesia technician. Each team could manage 10 operations/24 hours. The bed department was staffed by two doctors and five experienced nurses on 24 hours duty. The surgeons made the first post-operative dressing themselves. Each of the rehabilitation centers was manned by two doctors, four nurses and one physiotherapist. Results: 1,500 war casualties were admitted during 35 days. Out of these, 400 cases were hospitalized and given definitive primary surgery, the rest were managed as out-patients. Rates of in-hospital mortality and post-operative wound infections were low. None of the in-patients or staff on duty were injured during the war. Internal organization Tripoli Forward Hospital Emergency room (ER) with four beds, mobile X-ray apparatus and manual developer. All casualties were taken here for triage. Urgent damage control surgery was not done in the ER but transferred to the operating theatre (OT) to avoid congestion in the ER. At any time the most experienced surgeon was heading the ER.The OT had three parallel operating tables. The bed department contained 50 beds, all in one large room. A simple laboratory also comprised a blood bank with 30 units of blood, mainly donations from patients family members. Lessons learned from previous Middle East urban wars Keep standards of ethics high: No weapons allowed in medical facilities. Equal and optimal treatment for all regardless of ethnicity and political/religious affiliation. The risk of wound infection increases with long hospital stays: In major permanent wartime clinics one third of major wounds get infected with gramnegative strains within ten days after admission. The Tripoli model kept inhospital turn-over high due to early post-operative evacuation to satellite centers.
The surgical hospital: The theater should be close to the emergency room.
37
DD
DD
DD
CD
in his village one hour after the attack. Reconstructive surgery including rather extensive procedures such as vascular reconstructions, thoracotomy and hemicolectomy was done in village houses at night-time due to enemy air-surveillance. Before sunrise the patients were distributed to neighboring villages where they were monitored by the local paramedic and attended by the FC team every 3-5 days.
Mujahed Medical Center (MMC) at Jalalabad: Forward mobile teams (FT) provided in-field advanced life support before evacuation to the forward surgical clinic (FC) a mobile truck operation theater with capacity to treat three cases at a time. Across the border in Pakistan were second line clinics and hospitals run by the resistance forces and international relief organizations. Each MMC ambulance and paramedic team carried a kit for ATLS: Stethoscope, oral airways, suction unit and intubation set Face masks, self-inflating bag, chest tube unit and naso-gastric tubes Instruments for venous cut-down, NaCl infusion 10,000 ml, plasma expander 2,000 ml, large gauze packs and elastic bandages Ketamine, local anesthesia, diazepam, atropine and antibiotics Headlights.
39
The mobile surgical unit carried surgical instruments for major interventions including abdominal surgery, skull trephination, amputations and vascular surgery. Electricity was supplied by car batteries and a diesel generator. There were no lab or X-ray services.
Early response makes a difference: The rescue system was developed gradually during the 5-year battle: During period 1, 1989-1990, the mean delay from the time of injury to the first paramedic contact in-field was one hour, and mortality rate 26%.To reduce in-field response times and improve survival more mobile paramedic teams were established, and during period 2, 1991-1993 the delay infield was reduced to 30 minutes. In-field trauma care also became more aggressive and included chest tube placement on-site. As a consequence, the mortality rate in period 2 came down to 13.5%. Especially noted was a significant reduction in limb and chest injury mortality. All surgical interventions were done under ketamine anesthesia, with no adverse effects reported. A total of 5,500 war casualties were managed and evacuated by the MMC network; out of these 15% were classified as T1 injuries by triage and 3,800 required hospital surgery. Seven MMC staff members were injured on duty, three of them seriously.
staffed and equipped for any kind of trauma surgery. Level 2: In each region there are several field hospitals (FH) located at the main army bases. Despite being named light, the NATO field hospitals are heavy and far from mobile. Level 3: During military operations a forward station (FS) is set up where the injured should be collected for evacuation to level 2 facilities. At level 3 there are no surgeons; the FS medical team is headed by junior medical doctors without experience and training in damage control surgery. Level 4: Paramedics (PM) take part in the field operation alongside fellow soldiers, provide on-site life support, and transport the wounded by vehicles to the FS and then go back to their field unit. In addition each soldier is equipped with tourniquets and drugs to stop bleeding until they are reached by the paramedics. The FS is the hub of the prehospital network; it may work well as long as further evacuation to level 1 and 2 runs smoothly and rapidly. That transport totally depends on helicopters. But when the forward units including the FS are under attack, helicopters cannot pick up the injured from the FS, and the wounded are stuck at level 3 without qualified medical officers to support them. The system is efficient but needs superior fire-power. The set-up is rigid and does not adapt to settings where supremacy in fire power is lost. Lessons learned from Afghanistan The Ghazni network model is efficient in moderate casualty loads: 75 surgical operations were performed within two months, all patients given definitive treatment and secondary surgery at the FC. The mortality among cases admitted for surgery was less than 10%, the rate of post-operative infections was 10%. The main advantage of this decentralized model was its flexibility, giving safety for staff and patients. The main strength of the Jalalabad model was its flexibility, high capacity, and very early provision of in-field life ALS. However, working conditions were tough and security was poor for both patients and staff. The NATO set-up obviously suffers from the traditional hang-up that only qualified surgeons can do surgery. Even if we know that damage control is efficient only when provided early, the forward combat casualty care in Afghanistan faces trouble when it is most needed.
The democratic resistance in Burma 1992-1995: mobile teams with an army of village first responders
When rescue systems in the Burmese democratic resistance in the 1990s were established the lessons learned in Afghanistan were applied. When the Burmese generals staged a coup in 1990 and ousted democratically elected Ang San Suu Kyi from power, all ethnic groups in Burma set up armed resistance against the Rangoon regime. The Burmese army massacred villagers countrywide and warfare was of the guerilla type. As the regime controlled main roads, cities and all hospitals, casualties had either to be managed on-site in makeshift mobile clinics or to be tak41
en for days on foot and by river boats to surgical centers in Thailand. It was decided to adapt the model from rural Afghanistan and set up Jungle University sessions for resistance paramedics at the Thai border.The paramedic teams were trained and equipped to provide ALS and damage control surgery at makeshift clinics in jungle villages before taking on the long and rough evacuation of the wounded cross-border to Thailand. A modified and improved version of NATOs medical backpack-kit was designed and produced locally.The Burma Pack, total weight 25 kg, contained life support and surgical equipment for three major trauma cases. To improve the in-field care, the paramedics systematically trained thousands of villagers in basic life support techniques: positioning to control airways, bleeding control by subfascial gauze packing and hypothermia prevention. Due to logistic difficulties, it has not been possible to scientifically evaluate the results of the Burma model. However, case reports indicate that severe penetrating chest and abdominal injuries as well as successful resuscitation of post-injury tetanus have been successfully managed in the jungle. Till this day the decentralized rural trauma network is functional in parts of the country. Lessons learned from Burma The main strength of the Burmese model is its outreach and flexibility. Under the slogan Treat and Teach! knowledge in basic trauma care is spread throughout the villages. Such systematic education of lay persons has anchored the trauma system in the local community and helped it endure years of hardship. The drawback of the model is its poor capacity to handle mass casualties, and tough and risky working conditions for the medical teams. The Jungle University in Burma.
Victim of fragmentation mine managed by village first helpers. Northern Iraq, 2001.
42
Burns as triggers of post-injury stress, see p. 696. Trauma system outcome in North Iraq, see p. 29 and www.traumacare.no/publications Injury Severity Score (ISS), see p. 103.
Ten-year experience from the war in Iraq: The trauma system set-up in Iraq is a systematic prospective clinical study conducted in close cooperation with the local health authorities. Prehospital and hospital end-point data are systematically gathered on all injured consecutively managed by the system. The injury severity remained constant and high throughout the study period (median ISS at 9). Also the prehospital transport times remained high, mean 4.5 hours over the ten-year period. Still the system was able reduce trauma mortality from a pre-intervention level at 40% in 1996 to approximately 10% during the US war. However, during period 3 the rate of burn deaths increased as illustrated in the graph. This points at a major problem in modern warfare: Multi-injured patients with associated burns.
43
The mine fields of Cambodia 2002-2005: Local non-doctors can perform trauma surgery
In most countries in the South the health infrastructure is broken due to wars, structural poverty and political corruption.There is a massive and systematic brain-drain of trained doctors and health workers from low-income countries to the rich countries. Consequently most hospitals in the rural South are run by medical officers short of formal medical training, but rich in hands-on experience with wartime trauma and emergencies. This setting leaves us with two options for emergency relief: set up and run surgical centers by expert outsiders, or build the local capacity based on what is available of local health workers. In the mine fields of NorthWestern Cambodia a four-year program was conducted to see if local medical officers at rural hospitals could provide high-quality trauma surgery to land mine victims. The intervention was conducted as a controlled clinical trial at five district hospitals. The training program in Cambodia consisted of five courses in primary trauma surgery. Twenty local medical officers participated as trainees, all of them with years of practical experience with wartime and land mine injuries. Land mine injuries are traditionally perceived as traumatic limb amputations it is not so. The main challenge in land mine victims are high-energy fragmentation wounds to critical body areas. Besides targeting amputation techniques and open fracture management, the training program focused on head, chest, and abdominal damage control surgery. Animal models and human casualties were used as teaching cases. Results: All operations were done under ketamine anesthesia; there were no complications related to the anesthesia. The in-hospital mortality rate during the study period was low (1.5%), and the rate of post-operative wound infection fell from pre-intervention level at 21% to 6.5%. The result compares well to Western emergency relief surgical centers reporting infection rates at 15-22%. The injuries under study in rural Cambodia were severe with mean ISS at 10.5. Among cases successfully managed were major liver tears, compound depressed skull fractures and high-energy compound fractures of the lower leg. Lessons learned from the mine fields The quality of rural paramedics is a key factor for success. In North Iraq the paramedics are carefully selected among the health workers most trusted by the local population. The army of first helpers make response times short, and they link up with the local paramedic in mass casualties and difficult evacuations. It is possible to build proper trauma registries in war scenarios. At monthly meetings with the paramedics, the instructors identify and scrutinize cases with unexpected outcome also. The local paramedics provide rehearsal training for the villagers at regular intervals. Trauma registries and quality control, see p. 108 and www.traumacare.no/traumaregistry When properly trained, experienced local non-doctors do trauma surgery as well as expatriate experts.
44
Fallujah 2006, a father with his daughter. Warfare guided by Rumsfelds slogan: The Unspecified Enemy.
Blackwater, Aegis etc. Highly trained and equipped Western paramilitary forces operating beyond law and borders. Weapons of 4th generation warfare, see p. 128.
45
46
At Shifa the Emergency Room was staffed with a surgeon, residents, medical students and experienced nurses. There were 12 examination benches in the room. The hospital also had two rooms with two beds in each and a little more equipment so that more advanced life support could be provided. The system had no problem coping with 5-10 injured patients, but in a mass casualty situation the area was too small. The radiology department was in the basement and the operating theaters were on the third floor. In the mass casualty situation the time to x-ray was too long. All patients were registered on admission to the emergency department. On the first day of the attack, this system broke down, but later all patients were registered. A handwritten journal was filled out for all patients. This short handwritten note followed the patient through the system. The Shifa hospital was fairly advanced, but for the year preceding the attack, Israel blockaded Gaza and made the import of new equipment like monitors, ventilators and x-ray cassettes extremely difficult. Even spare parts were hard to come by and the hospital stores of these and disposables were almost empty by the time the attack began.
47
The Invisible Umbrella, a new concept of resistance: The drawing illustrates a network-clinic organized in a few villages or city bocks in the war zone. With two competent surgical teams and four post-operative teams this network can manage at least ten casualties/day. The surgical team: one surgeon, one anesthesia technician and two assistants. The p.o. team: one doctor or experienced nurse with village first helpers.
48
49
50
52 53 57 59
................................................................. ..............................................
First helper training ................................................................ 66 Village course for first helpers ................................................... 68 Training in surgical techniques
..................................................
70
51
Simple, but good enough. The author teaching at the Battle of Jalalabad, Afghanistan.
52
2. Simple teaching and plain words: A teacher of good professional knowledge and experience is always able to get the message across; there is no room for sophisticated academic terminology at the Village University.The pathophysiology of trauma is taught with focus on cellular hypoxia. The guideline throughout the training is to understand reasons for oxygen starvation and how it can be prevented by simple measures. 3. Problem shooting: Most war victims have multiple injuries, and there is not one war victim with injuries similar to another. Strict treatment protocols and flow charts do not work in a chaotic and dangerous field setting with minimum equipment. Therefore systematic and exact first survey clinical examination is emphasized: how to see/hear/feel clinical signs of oxygen starvation by examining airways, breathing and circulation. A circular approach is adapted: identify the main problem; solve the main problem; examine again, identify the next main problem, take action and so on. This method is applied again and again during the animal model training. 4. Learning by doing: Theory alone is useless unless it can help us change the world. Lectures constitute not more than 25% of the course and practice should always follow classroom sessions. Real-life case stories are a gold mine for learning: All trainees present their trauma care experience in daily plenary sessions. 5. Local take-over: After three Village University courses, the students should have the capacity to perform as local instructors and set up, adapt, run and monitor local training programs themselves.
Equipment for animal anesthesia Endotracheal tubes no. 6, 7, and 8. Stethoscope. Ribbon gauze. Self-inating bag for assisted breathing. Suction apparatus and catheters. Large artery forceps. Syringes 2 mL and 10 mL. Injection needles 1.5 mm x 50 mm. IV cannulas. 5L Ringer. Ketamine 50 mg/mL for IM, diluted to 10 mg/mL for IV use. Atropine 1 mg/mL. Diazepam 5 mg/mL.
Check the animal The students training in life support on an animal must also be responsible for the anesthesia on that animal. Make an anesthesia chart. Assess the weight of the animal, measure the HR, RR, and body temperature (mouth) and ll them in the chart. The animals stomach should be empty. Sheep and goats should have no food for 24 hours and no water the last 12 hours. Pigs and dogs: no food for the last 8 hours, but free access to water.
Recommended doses for anesthesia on pig, dog, sheep, and goat Ketamine starting dose: 20 mg/kg IM. Ketamine maintenance dose: 1-2 mg/kg IV. Atropine: 1 mg IM/IV. Diazepam: 10-20 mg IM or 5 mg IV. Note: There is no such thing as xed doses of ketamine. The correct dose is the dose necessary to take away all pain.
54
Use the Anesthesia Chart Record the HR and RR every 5 minutes on the chart. If the HR is above normal, the blood volume is too low or the animal has pain. If the animals tongue is dry, the blood volume is far too low ush in the IV infusions. This is the Anesthesia Chart for pig no. 6 at a Burmese Village University. It was shot in the belly at 8:53 a.m. Ten minutes after the injury the HR increased from 140 to 190/minute a heavy blood loss. The laparotomy was done in 35 minutes (X X). After 4 L of Ringer the blood loss was compensated. The total dose of ketamine was 900 mg.
End of training, enjoy the meat! Each animal must be killed painlessly at the end of the training.You can bleed the animal to death with a stab wound in the neck artery. Dead dogs can spread infections and parasites: bury them deeply and cover with stones. Other animals can be used for food. The ketamine left in the animal meat will not affect a person who eats it. Make sure the animal is bled well before the meat is processed. Fried smoked meat avored with curry-salt is a popular delicacy for villagers as well as for hardworking students.
55
Where there are no monitors: HR and RR are sensitive indicators of oxygen starvation.
Damage control laparotomy at the clinic Now the HR is 150/minute. The limb wound does not bleed. He is still losing blood, we must do an urgent laparotomy! Please give him 50 mg ketamine IV! Two minutes later the abdomen is split open. They nd the right upper quadrant lled with blood. One student immediately clamps the main blood vessels to the liver with his hand (see drawing p. 257).They nd a large tear in the right part of the liver, but no other major sources of bleeding. The group decides to wait for 10 minutes while nger clamping the liver vessels. They give warm IV infusions in both lines. Ten minutes later the HR has dropped to 110. They pack the liver tear carefully with gauze and place large gauze packs around the liver. Release nger clamping and press on the gauze packs while I explore the gut, the group leader says. There are no injuries to the gut. They close the abdominal cut with stay sutures of broad gauze band. Fortyve minutes have passed since the injury. The pig has got 3 L of Ringer, is breathing well, with HR stable at 100/minute. The students deserve the warm applause.
Paramedic training
pistol shot through the mouth exactly on the mid line making a briskly bleeding wound of the tongue. The student group is called and told: This is a 10-year-old boy who stepped on a Valmara mine 5 minutes ago. It is a cold winter with snow.The nearest village clinic is 10 minutes from here, the hospital is 6 hours off. Please start! Find and solve the main problem They can hear the goat snoring as the airway is partly blocked by blood. The group leader immediately decides to intubate the victim. Two other students are working to stop the bleeding from the thigh wounds. I cannot see the vocal chords, it is all blood here even with suction, the group leader shouts. Give me a scalpel! Have airway tube no 6 ready. Ill do airway cut-down. The airway cut-down is done 6 minutes after the injury, the tube is in place and xed, and the airway well cleared with suction. At this time the goat is breathing well, RR around 20/minute. Assess the effect of the life support. Find all injuries When the limb bleeding is stopped 15 minutes after the injury, the HR is 100/minute. The breathing rate seems to be increasing. The students examine the chest and the abdomen, but only from the front and miss the stab wound in the back. The victim is in good shape, no other injuries, the group leader says. They take the victim to the operating room. Once again they examine the victim, once again they miss the stab wound and forget to check the breathing rate. The victim is ready for evacuation to the hospital, they say. No, denitely not, says the teacher.
Paramedic training
Well trained paramedics outside hospital and in the hospital Emergency Room teams make the backbone of any trauma system. Success, however, does not depend solely on a good training program; personal capabilities also matter. Make a careful selection of trainees: They should be locals and know the actual scenario by personal life experience. They should have hands-on experience with wartime injuries. They should be persons of solid moral standing, trusted by fellow villagers or soldiers. They should be doers, problem-solvers. They should be literate and know basic algebra. Gender matters: there should be female and male trainees. Map the injuries, target the training Study carefully the pattern of injuries in the catchment area before you set up the Village University courses. Not only the selection of trainees but also the medical teaching should depend on types of weapons and locations of fighting. However, epidemiological wartime surveys are not an easy task. Many victims die on the way and escape public registration; most rural massacres go hidden from journalists, high-ranking officers, and hospital-based doctors. It is our experience that only primary informants can provide you with solid baseline information; conduct semistructured interviews among villagers, private army personnel and staff at local health centers. Remember that time is a critical factor in trauma care: gather systematic information on means and times of transport.
57
Basic things done early are the key to life support However, most physicians are unable to perform cardio-pulmonary resuscitation (CPR) properly; neither can they place an external jugular IV cannula. The trauma training should thus start with the essential basic procedures for airway, breathing, and circulatory support. Only when basics are in place and skills are proved by practical results should you take the trainees further up the ladder of knowledge. Village University, training course 3 Agenda: Advanced life support (II) Duration: 100-150 hours Working period at home Agenda: Treat mine victims, train village rst helpers and train new mine medics Duration: Life-long
Village University, training course 2 Agenda: Advanced life support (I) Duration: 100-150 hours
Working period at home Agenda: Treat mine victims and train village rst helpers Duration: 6-12 months
Village University, training course 1 Agenda: Simple life support Duration: 100-150 hours
Working period at home Agenda: Treat mine victims and train village rst helpers Duration: 6-12 months
Course 1: A good compressive dressing is crucial. Paramedic Choot is training villagers, Cambodia 1998.
Course 2: Bebak is placing a chest tube for the 10th time. The patient (a goat) is under ketamine anesthesia and has already another chest tube.
59
Teach the exact technique with pairs of students practicing on each other, then with group circle practice. Explain the function, cleaning and maintenance of suction apparatus.
60
Simple life support for breathing Half-sitting position Pain relief Stomach tube Mouth-to-mouth rescue breathing. Simple life support for the circulation Stop limb bleeding by lifting limb pressing on the artery packing the wound compressive dressing IV cannulation of limbs. IV and oral volume treatment Prevent cooling. Ways of warming CPR in infants and adults Damage caused by tourniquets. Medical documentation Fill in Injury Charts and Hospital Charts. Prevent infection Disinfection Antibiotics. Nutrition Make drinks and solutions for tube feeding based on local foodstuffs. Teach village rst helpers Teaching aims Teaching aids and methods.
Practice: How to position and carry chest-injured victims. The students place stomach tubes on each other. Rescue breathing: Use dummies or practice on fellow students, see p. 178. Classes: Ketamine pain relief, how to calculate doses, see p. 186 and pocket folder at back cover. Students train in pairs and groups on how to apply exactly artery pressure and compressive dressing. Also ask children to act as victims. Cover victims with blankets, use warm stones or bottles with hot water for warming. Train in IV cannulation on fellow students. Volume treatment: Learn from case stories how to assess volumes needed IV and by mouth.
Give case reports and let each student ll in the charts, see p. 115. Wash and disinfect equipment and instruments, use different methods, see p. 78. Calculate doses of antibiotics, see pocket folder at back cover. If the hospital is far away: Study local food processing and diets together with villagers. Set up a few high-energy standard solutions for feeding mine victims, see p. 790. Teach groups of women, men and schoolchildren in neighboring villages, see pp. 66-70.
Certication as Basic Mine Medics At the end of the course you will know the students well, having watched them carefully throughout the training.You may let students pass with a certicate even if they have some trouble with the theory but not if they do poorly in practice. Before you end the course Select a few of the best students as supervisors for the others. Make detailed arrangements on how to report treatment of victims and to get supplies of medical items. Also set up plans for training village rst helpers, see more on p. 66. Decide to meet monthly or bi-monthly to revise the work and refresh practical skills.
61
Advanced life support for the airways The anatomy of the larynx Endotracheal intubation Breathing bag-to-mask and bag-to-tube Airway cut-down.
Cannulation of the external jugular vein Fasciotomy Why and when? Fasciotomy on amputation stumps Fasciotomy on the lower leg and the forearm. Ketamine anesthesia On animals (for training purposes) On human mine victims for chest tube placement and fasciotomy.
62
Surgical technique How the instruments are used Disinfection Maintenance of instruments Sutures and knots. Life support for mass casualties
Agree on routines for disinfection, maintenance and storing, see p. 77 and p. 89. Practice on slaughtered animal: Cuts with scalpel and scissors. Skin sutures and suture xation of drains. Classes: Discuss case reports where several people were injured at the time. Role-play: Let the groups train in mass-casualty management with 2-4 students acting as mine victims.
Simple and advanced life support for animals injured under anesthesia Giving anesthesia. Fill in anesthesia charts Simple life support measures Airway cut-down in face-injured cases Examination and diagnosis of chest injuries including diagnostic needle puncture of the chest Chest tube placement, suction, and underwater seal Fasciotomy.
One group gives the anesthesia and the life support, the other students watch and assess. First, role-play in life support When the animals are under anesthesia, they are injured in various ways gunshot through both thighs, amputations, pistol shots through the mouth, stab wounds to the chest, pistol shots through the right chest etc. The injured animal is placed on the ground and the student group is called (Help, help!). Life support is done at the site with only one medical kit.When the life support at the site is completed (give a minimum of 20-40 minutes), the animal is carried on stretcher to the village clinic (operating hut). Here the condition is re-assessed and further life support given if necessary. The group gives a detailed plan on how they would evacuate this mine victim further to the hospital. Then, take a break for 5 minutes around the animal to discuss and assess the life support. Second, practice life support measures The animal is still alive and under anesthesia. The students train in pairs: Chest tube placement, xation, suction, and underwater seal. (Six tubes can be placed on each side of the chest.) Fasciotomy. Suture technique.
Certication as Advanced Mine Medics Advanced life support measures can damage even kill the patients if done incorrectly. Observe each student carefully during the course. Do not certify anybody for advanced life support unless he or she did well during the practice. Before you end the course Evaluate all elements in the chain of survival training of village rst helpers, warning systems, patient transport, medical supplies: How did it work out during the previous working period? How did the supervisors do? Again, make detailed plans for training more village rst helpers. Continue to meet monthly or bi-monthly for refresher training (especially of endotracheal intubation) and to discuss mine victim case reports.
63
64
Surgical instruments and techniques The mid-line laparotomy cut The routine for exploring the abdominal cavity Clamping blood vessels with artery forceps The technique of gauze packing to stop bleeding Temporary closure of the abdomen. Damage control laparotomy To conduct the anesthesia and ll in anesthesia chart To assess a victim with abdominal injury: Is it bleeding inside? And how much? Should damage control laparotomy be done in-eld? The mid-line cut Find the bleeding source Stop the bleeding by packing with gauze Tie off leaks from intestinal wounds Temporary closure of the abdomen within 45 minutes Life support during transport to hospital.
The teacher demonstrates the surgical techniques slowly and step-by-step on a live animal under anesthesia. This is also an excellent opportunity to give a lecture on loss of heat: Let the animal have cold IV uids only. Measure the rectal temperature of the animal during the demonstration. Let the students see how rapidly the rectal temperature drops when the abdomen is cut wide open. Conclusion: This is why damage control laparotomy should not last for more than 45 minutes! As in course no. 2, each animal is used for two types of practice: First, roleplay for one student group with the animal in place of a mine victim. Second, all students train on the animal in the technique of airway cutdown, chest tube placement and fasciotomy. Role-play, one group in action The animal is under anesthesia, but not intubated. Make a thigh gunshot or chest stab wound. Then shoot the animal through the upper part of the abdomen with a 9 mm pistol. Dont hit the kidneys or major blood vessels. Place the victim on the ground and call for the life support group. The students stop the bleeding from other injuries and place IV lines before the victim is carried to the district clinic (operating hut). At the clinic, nd out if damage control laparotomy has to be done: If the HR increases despite good anesthesia and a lot of warm IV uid, damage control laparotomy should be done immediately, see anesthesia chart p. 843. Measure the time taken, the laparotomy should not be more than 45 minutes. When the abdomen is closed, warm IV infusions should be ushed in until the HR comes down to normal. The group makes its plan for further treatment during the transport to the hospital. All students, learning by doing Train the students in the techniques of other life support measures while the animal is still alive and under anesthesia.
Certication according to skills Assess the skills of each student carefully. Of twenty students, maybe only ve should be certied for damage control laparotomy. Consult local health authorities and the surgical hospital. Before you end the course Sum up and assess the results of the previous working period. There are always things that can be improved. Continue to meet regularly to discuss case reports, study, and train. Dont forget: In life support, simple things are most important. So set up plans for training more village rst helpers, see p. 68. Arrange a decent closing ceremony with the villagers and local authorities. Let the Village University students be the honored guests at the ceremony they deserve it.
65
Osman Hama Salah, supervisor paramedic of Trauma Care Foundation Iraq. Trauma Care Foundation, see www.traumacare.no
the site when they heard the explosion and they sent one man to call me. I grabbed my medical kit and ran towards the site. I met the villagers carrying the father on a stretcher they had made.The father had his hand blown off. He also had injuries to the face and could not see. He was breathing well, he could talk, but was very confused. The boy was uninjured but could not speak. Till this day he still cannot speak. He is now 10 years old. The villagers who carried the father had all attended a 2-day rst aid course that I had taught in Sarkan village. They had done as I instructed them: Stopped the bleeding by packing the wound with clothes and placed a compressive dressing of elastic bandages. I used to give elastic bandages to the most clever farmers at rst aid courses. We covered the victim with more clothes, and I placed two IV lines, gave ketamine and penicillin. Luckily a car passed by when we eventually came down to the road. We asked the passengers to get out so that we could take the victim to the surgical hospital in Suleimaniah. They agreed to this and also took the boy who could not talk back to his village. Villagers have a strong spirit of cooperation in a crisis like this. The father is doing well now. He can still do some farming, and after several eye operations he can see again.
67
stops the bleeding by lifting the leg and pressing on the artery. He shows how to pack gauze into the wound and how to apply a compressive dressing. The mine victim vomits and the instructor demonstrates the recovery position with a head tilt-chin lift. Its the rainy season, so the victim becomes wet and cold.The instructor covers him with blankets and calls for bottles of warm water. Conclusion: These simple measures save lives. Lesson one: Oxygen starvation The candle ame dies without oxygen. Describe the airways and point out one reason for death blocked airways. Let all practice the recovery position. Show how the lungs work like a suction pump, taking oxygen into the blood, point out another reason for death poor breathing. Practice the half-sitting position. Compare the blood circulation to a watering system: a leak at one point causes slow ow and dry elds. Point out another main reason for death blood loss. Practice artery compression on the arm and at the groin. Lesson two: Airways and breathing practice First, the patient is breathing but the airways are blocked: How to examine the airways. Head tilt-chin lift. Recovery position, carry patients over the shoulder and facedown on the stretcher. Carry patients half-sitting. Second, the patient does not breathe: Mouth-to-mouth rescue breathing on dummies or simulate the method on each other. Lesson three: Stop the bleeding practice Lift the bleeding limb, press on the brachial artery or the femoral artery, imitate packing of deep fragment wounds or amputation wounds with cloth. Criss-cross compressive dressings from the toes to the groin and from the ngers to the armpit by using elastic bandages. Practice measures to keep the patient warm. Let the villagers come up with their own ideas. Dinner and informal discussions Discuss previous accidents in the area: If you knew then what you know now could you have saved lives in those cases? Would you feel more condent assisting at an accident now? Work out ways of calling out the rst helpers and the paramedic in case of accidents.
Take a lot of tea-breaks. Humor and high spirits help the learning.
Conclusion Make a local action plan: Use recent local accidents as examples. Agree on a system to alert the rst helpers and the paramedic. If the victim is lying inside a mineeld, who should get him out? And how? Should stretchers be prepared? And a car? Certication and elastic bandages: Certify the trainees as rst helpers. A certicate with the signature of the instructor can be useful if they have to take a victim through checkpoints. Give ve rolls of elastic bandages to each.
70
Injuries to the skull The teaching aims are: Trepanation: Burr holes to evacuate intracranial hematoma Reduction of fractures with depressed fragments Repair of dural tears Debridement of brain tissue Mobilization of fascia-skin flaps to cover soft tissue defects. The anatomy of dogs makes them a useful model for technical training on head trauma. Give anesthesia, shave the skull and inflict compound fracture to the temporal bone by blunt trauma. Debride the wound to skin and fascia. Control bleeding by infiltration of adrenaline (e.g. local anesthetic with adrenaline) or by electro-cautery. Access the fracture and identify depressed bone fragments. Drill burr holes, nibble off bone to expose the fracture, lift off depressed bone fragments and store in Ringer solution. Extend dural tears and examine the brain for crush injury. Bleeding is controlled by adrenaline infiltration, cautery or patches of crushed muscle. If available, demonstrate the use of hemostatic clips. Necrotic brain tissue is removed by careful suction. Suture dural tears, dissect the skin off the muscle and mobilize the skin flap to close the incision. Thoracotomy and suture of lung tears Around 5-10% of wartime chest injuries cannot be controlled by chest tube management and need thoracotomy. The technique can be demonstrated on any animal. Use the standard antero-lateral approach. Demonstrate crucial anatomical details such as the danger of accidental damage to the internal mammary artery. Cut the lung; then control bleeding and close the cut by double deep continuous interlocking sutures. Place chest tube by separate incision, guide the tube in place under visual control and close the thoracotomy carefully. Place the animal in different positions to demonstrate the importance of correct positioning in active drainage of chest bleeds. Extra-peritoneal packing of pelvic fractures Before performing a laparotomy, you may demonstrate how major fracture bleeds in the pelvic cavity can be controlled by gauze packing. Make a small midline incision proximal to the public bone, split the soft tissues outside the peritoneum by careful blunt dissection along the pelvic wings and place extra-peritoneal large gauze packs deep inside the pelvic wings on both sides. The skin incision is closed temporarily by sutures or towel clamps. Demonstrate compression of unstable pelvic ring fractures by large towels or bands of canvas. Abdominal injuries The teaching aims are: Intestinal resection and anastomosis Deliver and close enterostomies Correct abdominal drainage Suture liver tears Nephrectomy. Pigs and dogs are the best models for training in abdominal surgery. Access the abdominal cavity by long midline incisions. Demonstrate the intestinal blood sup71
Medical officers at Cambodian rural hospitals train surgery on animal models; here, a compound skull fracture with depressed bone fragments is debrided. Techniques to control bleeding, see p. 244. Indications for urgent thoracotomy, see p. 501.
ply: cut some vessels at the base of the mesentery, tie the vessels and carefully identify the ischemic gut segment; resect the segment and repair by end-to-end anastomosis. Demonstrate how omental flaps can be mobilized to secure intestinal suture lines. Learn the technique of distal ileostomy. Deliver loop colostomies as well as end-colostomies; also learn how to close enterostomies. Demonstrate placement of dependent drains in all quarters of the abdomen. Make deep cuts in the liver, control bleeding by Pringles finger clamping, control intra-hepatic bleeding by cautery if available and close the liver tear by deep interrupted sutures. Cut into the kidney to train bleeding control and nephrectomy. Demonstrate how the kidney can be taken out by a flank incision to gain control of the renal vessels. Also resect a 1-2 meter sample of the small intestine, store on alcohol or formalin, and let students practice one- and two-layer anastomosis repeatedly until the suture line is water tight.
Damage Control laparotomy: Bogota Bag for temporary closure after damage control laparotomy on pig model.
Intestinal injuries: Training end-to-end anastomosis of the small intestine. Is the suture line water tight? Vascular trauma The teaching aims are: Place temporary vascular shunts End-to-end anastomosis of limb vessels Venous patches Venous graft interposition Mobilization of muscle flaps for soft tissue defects. Temporary vascular shunt Temporary shunting should be trained on anesthetized animals, but suture techniques can also be trained on samples of artery and vein grafts harvested from the animal when the live demonstration is concluded. Most animals are feasible for surgical training as the anatomy of extremities corresponds to human anatomy. Demonstrate standard vascular incisions, vascular anatomy, bulldog clamps and silicon banding. Cut the iliac artery and demonstrate patching and end-to-end repair; demonstrate the embolectomy catheter and precautions when you use it. Let trainees harvest grafts of the saphenous vein. Then you may step up the training by making stab wounds into the femoral artery; let one assistant control
72
bleeding by manual pressure on the proximal artery until the injury is exposed and controlled. First place temporary shunts by various plastic tubes, then train on surgical repair.You may also inflict blunt injuries and crush segments of the brachial or femoral artery where venous graft interposition is needed for repair. Explain why vascular repairs must be covered by viable soft tissue.The trainees should learn to mobilize some of the standard pedicle muscle flaps such as the brachio-radial flap for vascular trauma at the elbow and arm, gastrocnemius flaps (medial and lateral) should be mobilized for the popliteal area. Take special care to identify proximal perforator arteries for correct placement of flaps pivot point. External fixators plus soft tissue flaps for compound fractures Use the femur of cows etc. to train the technique of two-plane external fixation. Inflict compound fractures at the forearm or lower leg on an animal model (dog or goat) by close range pistol shots or blunt trauma. Observe that the debridement is complete, especially of the deep muscles. The trainees should learn to use some of the most versatile muscle flaps such as the gastrocnemius, anterior tibial split (see photo), the proximally hinged forearm flaps as well as the sural perforator flap.
Two-plane external fixator on a cows femur. The fixator is made at a small jungle-town workshop in Cambodia. Local production of instruments, see p. 90.
73
74
3 Material input
Life support kits
....................................................................
76 79 87 89
In-field disinfection and sterilization ............................................ 77 Surgical sets for forward clinics Consumption estimates
................................................. ........................................................... .....................
75
3 Material input
76
Drugs Syringes (disposable) Injection cannulas Injection ketamine 50 mg/mL Injection pentazocine 30 mg/mL Injection atropine 1 mg/mL Injection diazepam 5 mg/mL Injection adrenaline 1 mg/mL Injection penicillin Injection ampicillin Infusion metronidazole 5 mg/mL
No. 20 20 2 10 5 5 5 20 3 1
Sizes 2 mL and 5 mL 0.8 mm x 38 mm vials of 10 or 20 mL vials of 1 mL vials of 1 mL vials of 2 mL vials of 1 mL vials of 1 mega IU vials of 2 mg bags of 300 mL
Others Blanket/clothes to keep the victim warm and dry. Injury Charts and pencil. Headlight, spare batteries, rope, scissors and knife. Supplements for advanced life support Laryngoscope Endotracheal tube without cuff Endotracheal tube with cuff Flexible stylet for the tubes Magills forceps for the tubes Chest tubes (home-made) Artery forceps (curved) Scalpel Surgical scissors (curved) Tissue forceps Towel clamps Sutures (non-resorbable) No. 1 3 3 2 2 4 6 1 1 2 12 10 Sizes blade for child and adult diameters 3 mm, 4 mm, and 5 mm diameters 6 mm, 7 mm, and 8 mm 2.6 mm and 3.6 mm one for child, one for adult diameters 6 mm and 10 mm 14 cm and 18 cm with 20 blades size no. 20 18 cm 18 cm, with teeth and without 12 cm size 1-0 and 2-0 on cutting needle
3 Material input
For the airways: There are always bacteria in the airways and esophagus. Tubes and equipment should be clean, but not disinfected. Clean procedures Injections, IV cannulation, and venous cut-down: Needles and IV cannulas must be sterile. Surgical instruments and suture materials must be disinfected. Cutting through the skin: For fasciotomy, chest tube placement and damage control laparotomy you need to disinfect hands, gauze and instruments. Wash in cold water before you disinfect! For the disinfectant to act be it heat or a chemical agent the instruments must be clean. Blood and body fluids clot at 43 C and in contact with chemicals. Both your hands and instruments should be washed in cold water without soap before you start disinfecting them.
78
Work cleanly in the field Disinfect instruments and gloves every 2 weeks. Store them in an airtight box that has also been disinfected. Disinfected gauze should be packed and stored in a disinfected plastic bag. Also disinfect a few towels or sheets of tight woven cotton (1 m x 1 m) and wrap them in airtight plastic. Before you start work on the victim, place these towels on the ground to prevent the instruments and sutures from becoming dirty. What about emergencies? You may say: I have no time to boil for 20 minutes in an emergency! This is true. If a patient has a blocked upper airway and you are unable to pass the endotracheal tube, you have to do an airway cut-down with any sharp knife at hand, no matter how dirty that knife is. If you do not do this, the patient will die before the water starts to boil. Do not worry about disinfection in emergencies. Always have disinfected equipment ready Either disinfect medical kit instruments every 2 weeks and store in an airtight box. Or have a bottle of isopropanol at hand.
79
3 Material input
Standard equipment for surgical units Light unit: 2 Burma Packs Infusions and drugs in stock Ringer or NaCl 0.9% Infusion sets IV cannulas diam 0.6 and 1.4 Complete unit: 4 Burma Packs Infusions and drugs in stock Ringer or NaCl 0.9% Infusion sets IV cannulas diam. 0.6, 1.0, 1.4, 1.7, and 2.0 Long IV catheter (subclavian) 3-way stopcock for infusion lines Blood transfusion bags (autotransfusion) Micropore filters (autotransfusion) Inj. Ketamine 50 mg/ml Inj. morphine 10 mg/ml or buprenorphine 0.3 mg/ml Inj. midazolam 1 mg/ml Inj. chlorpromazine 25 mg/ml Inj. diazepam 5 mg/ml Inj. atropine 1 mg/ml Inj. metoclopramide 5 mg/ml Inj. adrenaline 0.1 mg/ml Inj. ephedrine 50 mg/ml Inj. heparin 100 IU/ml and 5,000 IU/ml Inf. metronidazole 5 mg/ml Inj. penicillin 5 mega IU Inj. ampicillin 2 g Inj. Dicloxacillin 1g Inj. frusemide 10 mg/ml Inf. mannitol 150 mg/ml Inj. KCl 1 mmol/ml Inj. CaCl 1 mmol/ml Inj. lidocaine 5 mg/ml Inj. lidocaine 10 mg/ml with adrenaline Inj. bupivacaine 5 mg/ml Syringes 2 ml, 5 ml, 10 ml Cannulas 0.6 x 25 mm, 0.8 x 40 mm Spinal needles
Inj. diazepam 5 mg/ml Inj. atropine 1 mg/ml Inj. adrenaline 0.1 mg/ml Inf. metronidazole 5 mg/ml Inj. penicillin 5 mega IU Inj. ampicillin 2 g
Inj. lidocaine 10 mg/ml Inj. lidocaine 10 mg/ml with adrenaline Syringes 2 ml, 5 ml, 10 ml Cannulas 0.6 x 25 mm, 0.8 x 40 mm
80
Basic surgical set Light unit: 4 sets No. 2 1 1 2 1 1 4 4 2 2 12 2 2 6 1 Item Knife handle no. 4 Knife blades no. 22 Scissors, curved 18 cm Scissors, for bandages Needle holder 16 cm Dissecting forceps (surgical) 18 cm Dissecting forceps (anatomical) 18 cm Hemostatic forceps (curved) 12.5 cm Hemostatic forceps (curved) 18.5 cm Retractor (sharp) Bowl (stainless) 17 cm Towel forceps Pair of sterile gloves Surgeons mask, cap, and gown? Corrugated drain Tube drain Surgical drape (linen) 50 x 70 cm Surgical drape with slit Complete unit: 8 sets No. 1 2 1 1 1 1 1 1 1 1 1 4 4 4 2 2 2 12 4 2 6 1 Item Instrument tray 26 x 32 cm Knife handle no. 3 and 4 Knife blades no. 15, 20 and 22 Scissors, curved 14.5 cm Scissors, curved 18 cm Scissors, for bandages Needle holder 16 cm Needle holder 18 cm Dissecting forceps (surgical) 14 cm Dissecting forceps (surgical) 18 cm Dissecting forceps (anatomical) 14 cm Dissecting forceps (anatomical) 18 cm Hemostatic forceps (curved) 12.5 cm Hemostatic forceps (curved) 14 cm Hemostatic forceps (curved) 18.5 cm Retractor (sharp) Retractor (blunt) Bowl (stainless) 17 cm Towel forceps Pair of sterile gloves Surgeons mask, cap, and gown Corrugated drain Tube drain Surgical drape 50 x 70 cm Surgical drape with slit
81
3 Material input
Supplement for orthopedic surgery Light unit: 1 set No. 1 1 1 Item Bone nibbler (straight) Bone wire saw (Gigli), 3 mm Bone file Complete unit: 2 sets No. 1 1 1 1 1 1 1 2 1 1 6 6 6 6 1 1 Item Bone nibbler (straight) Bone nibbler (curved) Bone wire saw (Gigli), 3 mm Bone file Raspatorium Chisel (straight) Hammer Bone hook (sharp) Bone awl Hand drill Steinmann pin 2 mm Steinmann pin 4 mm Bone wire (Kirschner) 1 mm Bone wire (Kirschner) 1.5 mm Wire-cutting forceps External fracture fixation set
1 6 6 6 6 1 1
Hand drill Steinmann pin 2 mm Steinmann pin 4 mm Bone wire (Kirschner) 1 mm Bone wire (Kirschner) 1.5 mm Wire-cutting forceps External fracture fixation set
Supplement for chest and abdominal surgery Light unit: 1 set No. Item Complete unit: 2 sets No. 1 1 2 2 4 2 4 2 1 Item Knife handle no. 5 Needle holder 23 cm Abdominal retractor (50 mm broad) Abdominal retractor (S-shaped) Artery forceps (curved) 24 cm Intestinal clamp (curved, elastic) Intestinal tissue forceps (10 teeth) 15.5 cm Surgical drape 1.5 x 2 m Surgical drape 1.5 x 2 m with slit
2 1 2 2 1
Abdominal retractor (50 mm broad) Abdominal retractor (S-shaped) Intestinal clamp (curved, elastic) Surgical drape (linen) 1.5 x 2 m Surgical drape 1.5 x 2 m with slit
82
Supplement for vascular surgery Complete unit: 1 set No. 1 1 1 4 2 Item Vascular scissors (curved 60) 19 cm Artery forceps curved (Satinsky) 27 cm Artery forceps curved (Satinsky) 20 cm Artery forceps curved (bulldog) 6.5 cm Embolectomy catheters caliber 3, 4, 5 Magnifying glasses (2.5 x magnification) or reading glasses
Supplement for skull surgery Light unit: 1 set for trephination No. 1 1 2 Item Hand drill Perforator (Doyen) Burr (Doyen), small and large Complete unit: 1 set No. 1 1 2 1 1 2 1 1 1 1 Item Hand drill Perforator (Doyen) Burr (Doyen), small and large Bone nibbler (curved) Dura elevator Dura hook Wire saw (Gigli) Conductor for wire saw Brain spatula Forceps for hemostatic clips (Adson) Hemostatic clips
Supplement for skin grafting Light unit: 1 set No. 1 Item Dermatome, small (Silver) Razor blades (for Silver) Wooden plate (for grafts) Adhesive skin closure, 6 x 10 mm Complete unit: 1 set No. 1 1 1 1 Item Dermatome, small (Silver) Razor blades Dermatome (Humby) Blades (Humby) Wooden plate Adhesive skin closure
83
3 Material input
Other instruments No. Item Ophthalmoscope Otoscope Cornea scrape Oxygen cylinder or oxygen concentrator 2 Head lights (halogen) 2 Suture materials (size USP) Dexon/Vicryl/Catgut 1-0 (cutting needle) 2-0 (large round needle) 3-0 (cutting needle) 3-0 (round needle) 5-0 (cutting needle) Ethilon (Silk) 1-0 (cutting needle) 3-0 (cutting needle) 3-0 (round needle) 5-0 (cutting needle) Dexon/Vicryl/Catgut 1-0 (cutting needle) 2-0 (large round needle) 3-0 (cutting needle) 3-0 (round needle) Ethilon (Silk) 2 (cutting needle) 1-0 (cutting needle) 3-0 (cutting needle) 3-0 (round needle) 5-0 (cutting needle) Prolene 4-0 (round needle) 6-0 (round needle) 8-0 (round needle) Vessel tie Mersilene (silk) 3-0 Dexon 0 Dexon 3-0 Vessel tie Mersilene (silk) 3-0 Dexon 0 Dexon 3-0 No. Item Ophthalmoscope Otoscope Cornea scrape Electro-cautery unit Head lights (halogen) Operation lamp
84
Dressing materials No. 10 10 4 4 Item Gauze packs 10 x 20 cm, no. 5 Gauze packs 30 x 30 cm, no. 5 Surgical drape, 50 x 70 cm, no. 6 Surgical drape 1.5 x 2 m Gauze, rolls of 100 m Vaseline gauze Elastic bandage 5 cm, 10 cm, 15 cm Adhesive tape 25 mm, 50 mm Cotton, rolls Plaster of Paris, rolls 10 cm, 15 cm Plaster shears Plaster cast bending forceps Flexible splint frames Sterilization and disinfection Soap Savlon (conc.) Bowls (stainless) 17 cm Wash basin (stainless) 4 l Buckets 10 l Examination gloves (vinyl) Sterile gloves Surgeons mask Aprons (vinyl), disposable Drape (vinyl), rolls Waste bags (plastic) 60 x 60 cm Nail brush Water tank Water filter and chemicals for purification Isopropanol 45%, or Pressure boiler (10 l) + primus heater Grates (stainless) with holes Sterilizer drums Soap Hydrogen peroxide solution Bowls (stainless) 17 cm Wash basin (stainless) 4 l Buckets 10 l Examination gloves (vinyl) Sterile gloves Surgeons mask Aprons (vinyl), disposable Drape (vinyl), rolls Waste bags (plastic) 60 x 60 cm Nail brush Water tank Isopropanol 45%, or Pressure boiler (10 l) + primus heater or autoclave Grates (stainless) with holes Sterilizer drums No. 10 10 4 4 Item Gauze packs 10 x 20 cm, no. 5 Gauze packs 30 x 30 cm, no. 5 Surgical drape, 50 x 70 cm, no. 6 Surgical drape 1.5 x 2 m Gauze, rolls of 100 m Tubular gauze (no. 34 and 56) Applicator (tubular gauze) no. 1 Vaseline gauze Elastic bandage 5 cm, 10 cm, 15 cm Adhesive tape 25 mm, 50 mm Cotton, rolls Plaster of Paris, rolls 7.5 cm, 10 cm, 15 cm Plaster shears Plaster cast bending forceps Plaster cast spreader Plaster cast cutter (electric) Flexible splint frames
85
3 Material input
Laboratory Thermometers Hemoglobin meter Pulse oxymeter Test strip (urine) Rapid tests HIV Hepatitis B and hepatitis C Malaria? Microscope? Thermometers Hemoglobin meter Test strip (urine) Rapid tests HIV Hepatitis B and hepatitis C Malaria Microscope Blood-typing equipment Blood bags and refrigerator Measure (glass), 100 ml Measure (stainless), 1,000 ml Measure tape (100 cm) Weighing scale
Nutrition High-energy, high-protein nutrients Large bore naso-gastric tubes for feeding Technical items Marker pens Injury charts Anesthesia charts Kerosene lamp Batteries for lights and scopes Plain tables (surgery) Stretchers Axe, nails, spade Rope 6 mm Insecticide sprayer Mosquito nets? Mobile phones or VHF units Marker pens Injury charts Anesthesia charts Kerosene lamp Batteries for lights and scopes Electric generator 2-4 kW, cables Operating tables Instrument tables Stretchers Axe, nails, spade Rope 6 mm Insecticide sprayer Mosquito nets? Mobile phones or VHF units Mobile X-ray apparatus X-ray film and cassettes, 24 x 30 cm, 35 x 35 cm Developer, fix, processing tanks, red light bulb Lead markers (R and L) Lead apron High-energy, high-protein nutrients Large bore naso-gastric tubes for feeding
86
Consumption estimates
The actual consumption depends upon several factors and cannot be exactly assessed beforehand. On one hand it is our obligation to supply all surgical units with resources required to provide the minimum acceptable quality of treatment. On the other hand supply over-load and heavy stores adversely affect clinic mobility and security. Based upon statistics from a variety of war theaters we can approximate rates of the main surgical interventions and set up consumption estimates. Rates of surgical operations at a forward clinic Type of surgery Minor debridements Major debridements/fractures/burns Chest drainage Laparotomy Amputations Thoracotomy Vascular surgery Skull surgery % of all interventions 50 20 10 5-10 5-10 <5 <5 <5
87
3 Material input
Consumption estimates per 100 war casualties, prehospital care included Item Infusions Inf. Ringer or NaCl 0.9% Inf. metronidazole 5 mg/ml Infusion sets IV cannulas 0.6 mm IV cannulas 1.4 mm IV cannulas 1.7 mm IV cannulas 2.0 mm Drugs Inj. ketamine 50 mg/ml Inj. diazepam 5 mg/ml Inj. atropine 1 mg/ml Inj. metoclopramide 5 mg/ml Inj. penicillin 5 mega IU Inj. ampicillin 2 g Inj. lidocaine-adrenaline 10 mg/ml Inj. bupivacaine 5 mg/ml Syringe Syringe Dressing materials Gauze 100 m Elastic bandage Plaster of Paris 10 cm Plaster of Paris 15 cm Savlon (conc.) Drape (vinyl) disposable Examination gloves (disposable) Sterile gloves Apron (disposable) Surgeons mask (disposable) Catheters and drains Catheter, airway suction Urinary bladder catheter (Foley) Urine bag Chest tube Drain, corrugated Drain, tube Nutrition High-energy nutrients for 10 cases for 10 days Large-bore naso-gastric feeding tubes Unit 1,000 ml 100 ml No. of units 250 10 150 10 60 60 30 50 50 20 30 300 150 15 15 400 200 5 200 30 30 5 3 250 200 100 100 50 20 20 10 3 10
10 ml 2 ml 1 ml 2 ml vial vial 20 ml 20 ml 2 ml 5 ml roll roll roll roll 5l roll, 100 m pairs pairs
sheet 1m
10
88
Consumption estimates
Unit
Instrument maintenance
Most surgical instruments are made of stainless steel (18% chromium, 8% nickel, 2-4% molybdenum, 18-8-SMO) hardened to Rockwell C 35 or 60 degrees. Stainless steel instruments have a special surface polish protecting them against corrosion; if that polish is damaged corrosion starts. Some instruments are made of low-carbon steel (Rockwell C 55-65 degrees) with a nickel-chromium surface polish protecting them against corrosion. Still, they are prone to corrosion after some time. Notice that corrosion is infectious; damaged surface polish on one instrument may cause corrosion on other instruments during sterilization. Cleaning: Old blood and debris prevents effective sterilization. Clean immediately after use: First wash in cold water without soap to remove blood and proteins. Then brush thoroughly with warm water and soap, rinse with water and dry well. Leave scissors and forceps open during drying. Instruments used on infected cases are kept in a disinfectant solution for one hour before drying and re-sterilization (isopropanol is perfect). Maintenance: Surgical instruments in use should be oiled every second day (weapon oil or special fat-less instrument oil) and dust-free stored. In hot and moist areas, instruments not in use should be vacuum-packed in plastic to prevent corrosion. Check the instruments ahead of each sterilization: Control the surface polish and adjust screws. Blunt knives, chisels and scissors are sharpened with a fine well-oiled grind-stone. Never use grind-steel for surgical instruments. One common problem is surgeons using surgical scissors on gauze and sutures, and orthopedic chisels as screw drivers; better tell them how to behave! Sterilization: The instruments must be clean and dry before sterilization starts. Remove oil and fat with alcohol. Do not close scissors and clamps during sterilization; the steam must have access to all parts of all instruments.Wrap sharp instruments in paper, gauze or thin dry cloth to protect them from damage. Notice that
89
3 Material input
the drape wrapped around sets of instruments must be dry before sterilization starts as moisture will prevent the steam from penetrating the cloth. The disadvantage of boiling is that steam makes sharp instruments and needles blunt; either maintain by intermittent grinding or sterilize by chemicals. Disinfection and sterilization, see p. 79 and p. 758. Packing of surgical sets: Preferably one stainless steel crate with holes is used for each set of instruments. Use double sheets of drape (cloth or paper) to wrap the grate. Mark the set: Contents and date of sterilization. Rubber and plastic equipment Tubes, catheters, gloves etc. are washed in cold water immediately after use, then in warm water with soap, rinsed with water and properly dried. Rubber will adhere and become damaged if stored in a moist state. Gloves are tested by blowing them; holes are then closed by patches from the inside. Before storage and sterilization, gloves are powdered with talc. Rubber and plastic deteriorate after repeated sterilizations; do not use steam temperatures higher than 120 C.
Trauma Care Foundation Cambodia is producing high-quality external fixators at a small workshop inside the mine fields. Market price US$ 300.
If you dont have what you need, use what you have
Remember the first Ilizarov frames were made from bicycle wheels. In emergencies ordinary tools from the carpenter, tailor or mechanic may be used. Listed below are some improvisations that have proved workable. The list does not pretend to be complete; our intention is just to encourage surgeons not to complain when there are shortages.
90
Neck collars and splints for limb fractures can be made from any plastic bucket. Heat the plastic in the fire or an oven at 170 C. Airway cut-down (crico-laryngotomy) is done on site with any sharp knife at hand. Any plastic tube or your own finger secures passage of air. As this is an emergency life-saving intervention, sterility does not matter. Chest tubes are made out of plastic water tubes of appropriate diameter.The tube must be stiff enough not to collapse at the chest wall. The tube end is trimmed by scissors and some side holes are made. Instead of chest tube suction: After insertion the tube end is fixed underwater in a bottle of soap solution, analgesia is given and the patient instructed to blow childrens balloons or surgeons gloves. The positive respiratory pressure inflates the lungs and promotes chest drainage. Large-bore venous catheters for high volume infusions are made out of the standard sterile IV set tube (see p. 205). The tube fits the saphenous veins (ankle cut-down), the cephalic vein in male adults (elbow cut-down) and femoral veins in children (groin cut-down). Instead of IV infusion: If the patient cannot drink (unconsciousness, abdominal injury), rectal drip is a good alternative. Place a size 14 French bladder catheter 10 cm into the rectum, inflate the balloon and pull the catheter down until the balloon rests inside the anal ring. Fit the IV set into the catheter and give IV electrolyte infusion, oral rehydration solution, or home-made salt-sugar-water solution slowly, at a rate of 1 liter per hour. The fluid is rapidly absorbed and leaking by the anus is moderate. Carpenters tools in fracture management: Use an ordinary awl and drill to make a hole for tibia traction. The traction pin is a thick welding rod inserted by careful blows with a hammer. Corks are applied against the skin and ropes tied to sandbags for traction. For olecranon traction (arm fractures) and trochanter traction (pelvic acetabular fractures) carpenters eye screws may be used; they may create some local irritation of the tissues, but can still be used safely for 4-6 weeks. Amputations: A carpenters saw, a sharp chisel or a straight gouge works well to set off the bone. As an alternative small-caliber drill holes are made in the bone at close intervals at the level of amputation, and the bone fractured transversely by manual force.You can also set off the bone by making a track in the outer cortex around the entire circumference of the bone by light hammer blows upon a knife, and then break the bone at that level by manual force. Head injuries: Carpenters burr for concrete (8-12 mm) and drill may be used for trephination, but take care not to penetrate dura (better remove the inner table of the skull bone by nibbling with Kocher forceps). Dermatome: In careful hands a straight scalpel blade or a razor blade upon a needle holder, or a barbers knife can take skin grafts of any thickness.
91
3 Material input
Retractors: There may be shortage of instruments, but hardly on man power; most major incisions can be retracted by assistants hands. That said, nice skin hooks can be made from bent hypodermic needles or soft metal rods and standard retractors, sharp and blunt, can be made at low price by any local mechanical workshop. Home-made wound retractor made from 3 mm stiff metal rod. Self-retaining retractors: Stiff metal rods are formed into retractors, 3 mm rods for minor surgery, heavier rods for major wounds. Home-made laryngoscope: For children the blade should be 10-12 cm long. Wound drains: Any soft plastic tube or piece of rubber (bicycle tube), cloth/canvas or synthetic rope bought at the local market can be used as a drain. Instead of medical gauze: Packs with good suction capacity are made of linen or silk (not too tightly woven) wrapped around a core of fluffy cotton. Suture materials: Put fishing nylon thread 0.25 mm into a 23 G injection steel cannula, break and take off the needle hub, and fix the thread by squeezing the cannula with a needle holder. You may curve the needle by heating. Also threads of natural silk or linen/flax do well for sutures and ligatures.You may soak the threads in sterile water before use, or wax them for better flexibility. Cotton is not fit as suture material. Tailors needles can be used for sutures, round needles in soft tissues, cutting needles (triangular sharpened leather needles) for fascia and tendons.
92
93
94
96
Severity scoring ..................................................................... 97 Identify patients with unexpected outcomes .................................. 105 Trauma Registries
.................................................................. .............................................................. ........................................
95
icine or trauma surgery, neither is the matter on the agenda at Southern medical universities; this important medical knowledge escapes the institutions. Let us look at yet another example which actually belongs to the matter under study in this chapter, trauma severity scoring: Recent advances in trauma physiology research have taught us that time is a critical factor for survival. The longer our patients remain in a state of physiological imbalance in pain, under oxygen starvation, with aggressive bacteria multiplying inside dirty wound tracks the more severe the coagulation system derangement, the more severe the immune depression. The physiological capacity of a bleeding patient with systolic blood pressure at 70 mm Hg is therefore completely different if he remained in that hypotensive state for 30 minutes or if he stayed in hemorrhagic shock for three full hours. But despite our knowledge of the time factor impact, severity scoring systems developed on data bases of urban US patients injured less than one hour from the surgical centers are gladly used in studies of rural trauma populations with six hours prehospital transport times which is scientifically unsound. There is thus an urgent need for health workers in the South to come forward, sum up and publish their experiences and conduct trauma research relevant to the actual problems they are facing. In war we should also encourage trainees and colleagues to integrate clinical practice and targeted research to their daily duties. Especially when we break new ground, implementing new treatment protocols, or delegating life-saving skills to non-doctors, we should be obliged to scientifically monitor the outcome quality.
Severity scoring
In any trauma patient the outcome of treatment provided depends on two main variables: the severity of the actual injury, and the patients physiological capacity. The combination of the two variables constitutes the risk of dismal results, be it wound infection, organ failure or trauma death. To assess the risk of trouble and estimate success or failure of treatment we therefore need accurate descriptors of severity. Severity descriptors are used for three different purposes: 1. Triage: We have to sort injured patients relative to their severity.This is to identify the individuals with first priority for life support and surgery. For this we use physiological severity scores. 2. Monitor prehospital treatment effect: Life support goes on all the way from the scene of injury to the hospital emergency room. We need solid physiological indicators which can tell us if the individual patient improves or is deteriorating in our hands. Also for this we use physiological severity scores. 3. Control quality of the trauma system: A trauma system is not good simply because the surgeon says so. To check treatment quality over time, to compare efficacy of one surgical clinic against another, to identify types of injuries where we do not do well enough we need descriptors to characterize the injury severity in populations of patients. That is done by the Injury Severity Score, an anatomical descriptor characterizing the extent of tissue damage.
97
The physiological severity status in a given patient is not constant, but depends on the devastating impact of the primary injury and what you do to control the damage and provide life support. The RTS for any patient at any time can thus take on values from 0 (lifeless) to 12 (no physiological derangement). Warning: The intervals and rates for GCS, BP and RR in the RTS are calculated from large US trauma data bases of mainly healthy urban patients. But countries differ, age groups differ patient populations differ; the cut-off level for any diagnostic test should of course be defined on the actual patient population under study. A gold standard like the RTS is therefore neither sacred nor universal but may have to be revised for our actual aims. The Glasgow Coma Scale, GCS Clinical sign Eye opening Stimulus Spontaneous To voice To pain None Oriented Confused Inappropriate words Incomprehensible sound None Obey command Localize pain Withdrawal on pain Flexion on pain Extension on pain None Score 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1
Verbal function
Motor function
98
Severity scoring
Using GCS to monitor patients with brain injury, is another matter, see p. 241.
Warning: There are drawbacks with GCS accuracy. Scientific studies document that the GCS is a rather inaccurate measure; the GCS rating is based on subjective clinical assessments and there are considerable differences between paramedics and also between neurosurgeons when they set the GCS scores. Besides, the GCS is rather complex and hard to remember spontaneously in a tough setting. In fact it seems that the GCS diagnostic is too elaborate; studies on large US trauma data bases confirm that the GCS motor function element alone (rated from 5 to 1) measures severity as good as the complete GCS rating. Recommendation: Simplify the Glasgow Coma Scale For severity screening in trauma patients, you may substitute the entire GCS with plain ratings of consciousness level: Awake =4 Drowsy =3 Coma, reacts on sound = 2 Coma, reacts on pain only = 1 No reaction =0 Now we can replace the original RTS with a more straightforward physiological scoring system: Physiological Severity Score, PSS RR 10-30 > 30 6-9 1-5 no breathing 3 BP > 90 76-89 50-75 1-49 no carotid pulse 3 Consciousness awake confused responds to sound responds to pain only no response 4 coded value 4 3 2 1 0 10
Over-triage versus under-triage Optimal PSS of 12 indicates no physiological derangement; score of 0 indicates lifelessness. A patient with RR 35/minute, BP 80 mm Hg, awake and oriented, gets a score of 10 which indicates trouble: he has lost blood and is probably trying to compensate low levels of blood oxygenation by increased respiratory efforts. If the score of 10 was taken at the scene of injury, the actual patient should be given priority for life support and evacuation. Early signs of breathing problems or internal bleeding may be very discreet, especially in children; it is vital not to miss these patients. Therefore we should set triage criteria so that we are 95% sure to identify critical cases that is, undertriage rates should not exceed 5%.The consequence of such policy is to accept some over-triage; a few cases will be given urgent life support and evacuation despite
99
not being in a critical condition. On the other hand, if over-triage is too frequent, the trauma system will be over-loaded with referrals. Triage sensitivity is thus relative to system capacity; in mass casualties we should be strict, in peaceful periods we can accept more of an over-triage. It is our experience from several war theaters that a PSS of 10 is a reasonable cut-off for triage. Patients with in-field PSS < 11 should be ink pen-marked: T1 = First Priority Give ketamine before counting the RR The authors have examined the accuracy of the Physiological Severity Score (PSS) on sets of several thousand land mine victims and war injured. The score performs well with accuracy similar to the more elaborate Revised Trauma Score/GCS. Note: The regulatory nervous center for breathing registers the pH of blood and cerebrospinal fluid, and is thus very sensitive to alterations of oxygenation. That makes increased respiratory rate a solid and early indicator of oxygen starvation. But pain, anxiety and psychological stress also trigger the sympathetic nervous system and increase respiratory rate.To eliminate the stress effect and get a true baseline estimate of blood oxygenation, you should give efficient pain relief before counting the RR for triage.
Respiratory rate as triage tool: In a study of 700 land mine victims and war injured patients with long prehospital evacuations (5.5 hours) we compared the accuracy of the RR and the PSS rating for trauma death prediction. The analysis of accuracy is made with Receiver Operating Characteristics (ROC) methodology. The ROC curve is a useful measure of the sensitivity and the specificity of any test. The bigger the area under the ROC curve, the higher is the over-all performance of the test or indicator.Where the ROC curve comes closest to the upperleft corner is the optimal cut-off value for the indicator. We found that PSS (the
100
Severity scoring
simplified RTS) was a solid risk indicator; it predicted trauma death in the 700 mine victims with very high accuracy (area under ROC curve 0.93). Interestingly we found that the respiratory rate after in-field pain relief (RR2) as a single indicator predicted trauma death as well as the entire PSS calculator. In a desperate triage situation mass slaughter or under fire you may thus simply give one dose of IV ketamine analgesia, then count respiratory rate, and give priority to those casualties with RR > 30/minute.
101
12 9 6 3 0 BP 120 mm Hg 4 RR 20/minute 4 Awake 4 PSS 12 BP 80 mm Hg 3 RR 35/minute 3 Responds to sound 2 PSS 8 Early life support by villagers. PSS
12 = normal 0 = death PSS up, or down? Obviously patients with PSS < 0 are risk cases. If alive on hospital admission, they may need damage control surgery urgently. The PSS is thus a useful tool also for triage in hospital emergency rooms. For that it is crucial that the prehospital teams make exact written registrations of the three main risk variables. Children are different The normal values of respiratory rate and blood pressure are different in children and adults. Also children respond differently to blood loss; e.g. falling systolic blood pressure is a very late sign of hypovolemia in infants and indicates a desperately dangerous condition. Thus the standard PSS may be an inaccurate severity measure in child victims as it systematically underestimates trauma severity. In child victim less than 12 years old consider the use of the Pediatric Trauma Score (PTS). On the other hand, recent studies of our trauma registries in Iraq document that the PSS predicts trauma death with high accuracy also in children. Pediatric Trauma Score +2 body weight airway more than 20 kg normal +1 10-20 kg moderate obstruction of oral airway 50-90 mm Hg -1 less than 10 kg obstructed or intubated less than 50 mm Hg
more than 90 mm Hg
102
Severity scoring
+2 conscious level open wound fractures TOTAL Maybe the PTS is not needed? Recent studies of war wounded in Iraq show that the standard PSS predicts trauma mortality accurately also in child victims. See www.traumacare.no/ publications completely awake none none
Normal PTS values depend on age and varies from 9 (infants <10 kg) to 12 (children >20 kg). Any injured child with PTS at 7 or less is in immediate danger and has priority for life support and urgent evacuation. Also in children PTS = (PTS on hospital admission) (PTS at first encounter) is a measure of treatment effect, PTS <0 indicating a child with ongoing physiological derangement.
for any patient. If the actual patient has a penetrating chest injury, X-ray showing double rib fractures, and he also has a compound femur fracture, you can find his ISS score from the list of diagnosis in the AIS manual. From the AIS manual we can read: Fracture of 2-3 ribs with hemo/pneumothorax: 450220.3 Femur fracture open/displaced/comminuted: 851801.3 The six-digit number is a specific descriptor for each diagnosis. The severity classification for that specific diagnosis is indicated by the figure after the dot, the AIS code. In this case the AIS code is.3 for both diagnoses. ISS is by rule calculated as the sum of the squared AIS codes for the three most severe injuries. For our patient the ISS = (3x3, for chest injury) + (3x3, for femur fracture) = 18. By tradition we regard ISS values <9 as moderate; ISS 9-15 as serious; and ISS > 15 as major trauma victim. Worked example: Comparing performances between two hospitals Hospital A managed 135 patients in March 2006, the mean ISS being 9; Hospital B had 90 patients in March, mean ISS at 14. We do not have data on the physiological status of patients on admission at Hospitals A and B; maybe prehospital care transport times differ such that the B patients despite more severe wounds still arrive at hospital in relatively better shape. But the ISS difference between the two populations is large; probably it is fair to accept higher rates of trauma deaths and post-operative complications in Hospital B compared to Hospital A. Critical comments on ISS For ISS calculation you only include one injury the most severe from each of maximum three body regions. If one patient has gunshot injuries to the small intestines, colon and also the liver, only one of these organ injuries is taken into the ISS calculation. Thus ISS may underestimate injury severity where there are multiple injuries concentrated in one body region as we typically find in penetrating wartime injuries to the abdomen. For this the New Injury Severity Score/NISS is suggested. Like ISS, the NISS is based on severity grading by AIS codes, but NISS calculation is based on the three most severe injuries regardless if all three are concentrated in one single body region. In a study of penetrating wartime injured the authors compared the accuracy of ISS and NISS to predict trauma death. As an overall severity predictor for entire patient populations they both performed well with equally high accuracy: ROC comparison of ISS and NISS accuracy: The Receiver Operating Characteristics analysis demonstrates that the area under both the ISS and the NISS curve is large; both tests have high accuracy. The accuracy is best where the curves come closest to the upper left corner, which is at intermediate levels of severity. However, the study population is small (n = 1,800). We can still not rule out that the NISS is the estimator of choice in severe wartime injuries, and that is why we recommend that both the ISS and the NISS should be used for Trauma Registry analysis (see p. 120). Warning: The anatomical severity scores are not universal, but context dependent. What is a critical or a moderate injury depends on where you are in a high-tech Level-1 Western trauma center, or in a low-resource hospital in the rural South. The severity rates of the AIS manual are set by consensus
104
Severity scoring
among US trauma surgeons and obviously depends on the capacity for trauma care in the US at any time. For further discussion of study contexts, see p. 107.
With increasing severity and reduced physiological capacity, the Pd increases. We therefore need a combined anatomical-physiological severity calculator to define the normal expected outcome in any individual patient. The international gold standard for probability of survival (Ps) calculation is the Trauma and Injury Severity Score (TRISS). The TRISS calculator uses RTS values for physiological severity and ISS values for anatomical severity. Also the patients age is taken into account. The question is whether the three risk indicators in the RTS RR, BP and GCS have the same impact, that they carry equal weights? Is it as bad to have low GCS ratings as low RR ratings? It is not. Of the three indicators GCS carries the most weight, then comes BP whilst RR is the risk indicator with the least impact. The exact weights for each of the three indicators are found by statistical analysis (logistic regression) on large trauma data bases. RTS vectors Actual RR rating (from 4 to 0) Multiplied by vector 0.2908 Actual BP rating (from 4 to 0) 0.7326 Actual GCS rating (from 4 to 0) 0.9386
RTS vected can thus take on values from minimum 0 to maximum (4 x 0.2908) + (4 x 0.7326) + (4 x 0.9386) = 7.848. TRISS is based on a probability distribution expressed by the equation: Ps = 1 (1 + e) b
105
The value of b is set by the regression equation: b = b0 + b1(RTS vected) + b2(ISS) + b3(AGE). AGE is defined as a dichotome variable: (AGE 55 years) = 0; (AGE >55 years) = 1.The values of regression factors b are set separately for blunt and penetrating injuries: TRISS regression factors for penetrating and blunt injuries Type of trauma Penetrating Blunt b0 0.6029 1.2470 b1 1.1430 0.9544 b2 0.1516 0.0768 b3 2.6676 1.9052
The regression equation for factor b in a given penetrating injury is thus: b = 0.6029 + 1.1430(RTS vected) 0.1516(ISS) 2.6676(AGE). We can now use the TRISS calculator to identify patients with a 50% chance of survival, Ps = 0.5. Such patients may have low ISS scores (moderate wounds) and low RTS scores (severe physiological impact), or high ISS scores with reasonable RTS scores, or they may have severe score of both severity indicators. Let us look at a graphic display of TRISS measurements in a real trauma patient population (land mine victims in Cambodia and North Iraq). In the graph the physiological indicator is listed on the Y-axis and anatomical indicator along the X-axis: Identifying the patients with unexpected outcome: Each patient in this data set is marked with a square. The line represents the Ps 0.5 isobar set by the TRISS calculator. According to TRISS estimates, the patients under the line have a chance of survival higher than 50%, those over the line have a chance of survival less than 50%.We can see that six patients survived despite their calculated chance of survival being less than 50%, indicating successful treatment. We can also see there were many trauma deaths in patients who should have survived according to the TRISS standard; four patients in reasonable physiological condition with ISS less than 20 died. Such cases with unexpected outcome need exploration.
TRISS as an Emergency Room triage tool: You can also use the TRISS calculator in clinical practice to estimate risks of trouble in individual patients:Your ER team plans the management of a blast injured victim of 55 years, RR 38/minute, BP 80 mm and a GCS of 8. He has been unconscious for at least 30 minutes, has a compound fracture to the skull with visible damage to the brain and also signs of hemo-pneumothorax. You estimate the ISS at 25. Now load the values in the TRISS computer. In this case the RTS score is 4.9 so the patient is highly out of balance and the expected probability of survival is estimated by the TRISS calculator as low as 43%.Why are such estimates useful? If the clinic ER, X-ray, laboratory, blood bank has free capacity, the team may well decide to mobilize all
106
resources and go for full life-saving treatment. However, in a mass casualty situation where other cases are already lining up for emergency surgery, the team may decide to give less priority to this patient.
Limitations to TRISS
Most textbooks and courses in trauma give the impression that the common severity indices are universal and apply in all settings.This is incorrect, universalistic diagnostic tests do not exist; they must all be calibrated for the actual study population at hand. We can sum up some critical arguments relevant for the TRISS: 1. ISS is context dependent: The AIS codes are based on what is moderate or critical in high-tech US urban trauma systems. A moderate injury becomes a severe one if the means to treat it are not present. 2. RTS is context dependent: The grades are derived from studies of well-fed, (mainly) healthy Westerners. 3. AGE is context dependent: People in different parts of the world are getting old at different ages. Old being defined as age >55 years does not apply to all trauma settings in the South. 4. The time factor is not included in the TRISS calculator: We know from recent advances in trauma physiology research that being briefly hypotensive (BP = 70, RTS code = 2) versus being hypotensive for three full hours (BP = 70, RTS code = 2) makes a massive difference. 5. Methodological failure I: The GCS parameter in RTS is inaccurate. The GCS scores are skewed toward motor response impact, patients with the same nominal GCS score may thus have a significantly different Ps. There are also observer failures, particularly for inexperienced observers and for scoring at intermediate levels of consciousness. The frequency of GCS scoring failures may be as high as 50%. 6. Methodological failure II: The TRISS equation is derived by logistics at regression analysis. One basic condition for such statistical methodology is that there is no co-linearity between the predictors. But RR, BP and GCS are co-linear, all three variables being indicators of oxygen starvation which may give false high TRISS values.
107
7. Methodological failure III: For comparison of separate populations and trauma systems, the actual distribution of predictor values is crucial. Goodnessof-fit of the TRISS calculator may be low in your study population if the distribution of predictors (ISS or RTS elements) differs significantly from the distribution in the US reference population. Warning There are no universal severity calculators with high accuracy in any setting. Use the PSS and TRISS with care when estimating survival probabilities and setting standards for comparison. We should revise the TRISS and develop specific severity calculators based on the specific theaters of land mines and war in the South where injuries are severe, technical resources minimal, evacuation sometimes impossible and the victims often malnourished and weakened by communicable diseases.
There are other comprehensive severity calculators: ASCOT, APACHE, Abdominal Trauma Index etc. They are all derived from US data sets of urban trauma and hardly fit wartime scenarios in the South.
Trauma Registries
Quality control of treatment takes a systematic effort where you analyze risk descriptors against outcome indicators for whole sets of patients treated. For that you have to gather the essential data on all patients, validate the data and load them onto a database, a registry. To set up a Trauma Registry is not hard; you simply need a small computer with Microsoft Excel software (or equivalent), a clear mind and well defined study questions which you want to explore. Essentially you need paramedics and doctors providing you exact medical information on patients managed. Finally you should have some very basic knowledge of statistics. This is a brief guide on how to do it yourself.
Trauma Registries
death, wound infection, organ failure and duration of hospital stay are commonly used to measure trauma outcome. 2. Explanatory variables (risk descriptors) describe the risk of getting a given outcome, e.g. the risk of trauma death. Physiological severity, ISS and time factors are examples of main explanatory variables. 3. Factors are used to analyze separate groups of patients for study such as age, gender, type of weapon causing the injury, name of surgical clinic etc.
109
Organ failure: Lung failure (Adult Respiratory Distress Syndrome/ARDS): yes/no. Four of the following signs must be present: Major injury/surgery; respiratory rate > 30/minute; hypoxemia; new patchy densities on chest X-ray; no signs of cardiac pump failure. Renal failure: yes/no. Two of the following signs must be present: Major nonrenal injury/surgery; urine production < 0.5 ml/kg/hour that does not respond to volume therapy; increasing serum creatinine. Cardiac failure: yes/no. All following signs must be present: Major non-cardiac injury/surgery; lung congestion; systolic BP <90 mm Hg without hypovolemia. Coagulation failure (Disseminated Intravascular Coagulation DIC): yes/no. All following signs are required: Prior injury/surgery; general tendency to bleed; reduced clotting time (clotting test); low platelet count; no hypothermia. Liver failure: yes/no. Two signs required: major non-hepatic injury/surgery and clinical jaundice. Multi-organ failure: yes/no. Two signs are required: Major injury/surgery and failure of two or more of organ systems (as defined above). Duration of hospital stay Register total in-hospital days (continuous variable). The duration of the hospital treatment may be an indicator of post-injury recovery. However, this variable may be inaccurate because other factors may affect in-hospital time such as actions of war, security measures, physical rehabilitation provided in the surgical clinic etc.
110
Trauma Registries
Anatomical severity We should register both ISS and NISS in order to compare accuracy between the two. For validation of ISS/NISS calculations the AIS diagnoses should be listed in each patient: ISS: register actual value between 1 and 75. NISS: register actual value between 1 and 75. Time factors: Time1, time from injury to first responder assistance: minutes Time2, time from injury to first paramedic contact in-field: minutes Time3, time from injury to hospital admission: hours and half-hours Time4, time from hospital admission to primary surgery: hours and half-hours of in-hospital delay.
increases the risk of bacterial wound infection and delays recovery. In malariaendemic areas parasite carriers are easily and accurately identified by rapid test at first encounter in-field (Paracheck dip-stick test). Register parasite status as soon as possible after injury. Laboratory data Fluid is shifted between blood vessels and the interstitial fluid space in the first hours after injury. Levels of hemoglobin after injury are therefore not an accurate indicator of trauma blood loss. Moreover, hemoglobin levels may be an indicator of chronic anemia and associated endemic diseases: Hb (hemoglobin) on hospital admission: g/ml (continuous variable) Hematocritis (hct) on admission (continuous variable). Pulse oxymetry measures the oxygen level in the peripheral circulation and is a precise indicator of oxygen starvation: PaO2: Oxygen tension in the peripheral circulation (continuous variable). Base Deficit (BD) is a rough indicator of oxygen starvation; it measures metabolic acidosis and correlates to serum lactate levels after blood loss. Samples for BD analysis can be taken from a peripheral vein. Normal BD values range from 3 to + 3 mmol/L. BD levels >15 indicate severe deficit and are a heavy risk factor for trauma death: BD: mmol/L (continuous variable). Malnutrition Malnutrition and starvation obviously affects the physiology. Chronic cases can be identified by measuring the Mid-Upper Arm Circumference (MUAC) and the thickness of the triceps skin fold. Rough assessments can also be done with considerable accuracy by experienced local health workers: MUAC: cm with one decimal (continuous variable) Triceps skin fold thickness: mm (continuous variable) Doctor-rated nutritional status (ranked variable): Critical malnutrition = 4; severe malnutrition = 3; some malnutrition = 2; no signs of malnutrition = 1.
Register factors
Patient identification We should be able to identify each patient in the Trauma Registry in a safe, simple and secure way: Mark each written patient chart with a genuine ID number and store charts in a locked steel shelf. The key to the ID shelf and ID numbers should be carried by trauma system coordinators only. Only genuine ID numbers, not names, are loaded into the registry. Date of injury In order to compare trauma system outcome over time, we have to register date of injury in all patients: year, month and date of injury. Age The physiological response to trauma is different in infants and children. Also old people can take less injuries.To analyze outcome we have to stratify groups by age.
112
Trauma Registries
Location and treatment responsible Districts may differ regarding poverty, means of transport and prevalence of endemic diseases. Also we like to compare quality of treatment between sectors and hospitals: District, where the injury happened: define relevant district by ID numbers (ranked) Paramedic who managed the patient: define by ID numbers (ranked) Hospital/surgeon who managed the patient: define by ID numbers (ranked). Category of injury Outcome probabilities are different in blunt versus penetrating trauma. It is useful to have one basic entry to separate the two main subsets for analysis: blunt versus penetrating trauma. Mass casualty Mass casualties (more than five patients injured simultaneously) are common in modern warfare and represent a big challenge for trauma care providers.We should not expect as good treatment results in mass casualties as in individual cases where resources can be used at their optimum. To take out the subset of patients injured in mass casualties, we should register numbers of patients injured in any single accident. Cause of injury This is a complex factor containing essential data for medical research as well as documentation of inhumane atrocities. To be able to take out maximum of information we recommend rather specific categories. The actual definitions of course depend on the actual war scenario. This is the list of codes used by the authors in a lot of different scenarios: Gunshot = 1 Land mine, blast type = 2 Land mine, fragmentation type or cluster bombie = 3 Artillery or rocket, conventional high explosive = 4 Mass Velocity Explosive/DIME = 5 Thermobaric, heat-generating explosive = 6 Improvised explosive device, road-side bomb = 7 Napalm, phosphorus, or equivalent = 8 Trapped in destroyed house/vehicle = 9 Torture = 10 Stab wound, other penetrating = 11 Traffic accident = 12 Fall from height = 13 Drowning = 14 Other injury = 15 Organ system injured The entries correspond to organ systems as defined in the AIS manual: Head and brain = 1 Face = 2 Spine = 3 Chest = 4
113
Abdomen = 5 Pelvic contents = 6 Upper limb = 7 Lower limb and pelvic girdle = 8 External, skin = 9 Burn = 10 Make it simple! There are many problems we would like to study, and you may feel tempted to set up a comprehensive Trauma Registry with lots of entries. But when data gathering forms are too elaborate, data gathering becomes a burden for your staff and the medical documentation becomes unreliable that is useless. What are you out for? We do not conduct research for the sake of research but for the sake of our patients: Define your main study aims carefully Design the registry and data forms accordingly.
In-field data
Fill in the chart there and then! The Field Injury Chart is filled in by the medic as he examines, treats and transports the victim to the hospital. The weapon history: The hospital needs to know the type of mine and how far away the victim was from the explosion. Delay after the injury: The risk of wound infection increases rapidly if the patient is not operated on within 8-10 hours after the injury. The hospital staff should know how much time has passed since the injury. Did a village first helper help the patient? You need this information to determine the effect of the training given to village first helpers. Tourniquet? If the victim had the tourniquet for several hours, fasciotomy should be done either by the medic or at the hospital. List all injuries: Mark all wounds on the drawing. Calculate the Physiological Severity Score before treatment starts! Measure and record three things: (1) The breathing rate. (2) The systolic blood pressure. (3) The mental state of the victim: Is he confused or drowsy? Is he unconscious, but responds when you talk to him? Is he unconscious and responds only when you pinch his skin? Or is there no response at all? 4 points is the best score, 0 points the worst score. Calculate the Severity Score by summing up the points for RR, BP, and the mental state. A total of 12 points means that the victim is in a good condition. Scoring 10 points or less means that the victim is severely injured.
115
Register the treatment: Write down all treatment given in the field and the time it was given. For example, if a victim is confused and drowsy on admission to hospital, it may be because he had ketamine and diazepam during transport. Or if he was not given any drugs, he may have severe oxygen starvation. This example shows that writing down information on all treatment given in the field is very important to the hospital staff. Position and warming is also part of the treatment and should be registered. Write down problems you had! A few words is enough. The Severity Score is registered twice: Once, when the medic examines the victim for the first time before starting to treat him that is on p. 1 of the Injury Chart. And again, when the victim arrives at the surgical center. Remember to mark the exact time for both the first and the last Severity Score. You can find out if the victim becomes worse or better by comparing the two scores. In this case the victim became better a score of 8 one hour after injury rose to a score of 11 on hospital admission.
116
End-point data
On clinic admission RR, BP and the level of consiousness are registered by the Emergency Room staff both to validate the registrations by the in-field medics and in case the patient arrives at the clinic without medical attention. Register the diagnosis based on Xray exam and findings during surgery. The information shuld be sufficiently detailed for anatomical severity scoring (ISS, NISS). Register the main result indicators: Infectious complications and mortality.
117
Patient ID
Year
Month
9 9 9
5 5 5
6 6 7
Category
Diagnosis region
Amputation
Time 2 Hours and half-hrs from injury to first medic contact 2.5 2.5
Time 3 Hours and half-hours from inury to end-point 4.0 4.0 5.0
Blunt = 1 Penetr = 2 1 1 2
(continued)
See codes 1 5 8
No = 0 Yes = 1 0 0 1
See codes
See codes
0.5
1.5
ISS
NISS
16 9 9
16 16 13
118
(continued)
In-field airway
In-field breathing
In-field warming
In-field IV infusion
In-hospital stay
No. of days 5 12 11
Infection
Death
Death site Before firstresp = 1 Before medic = 2 During medic treatment = 3 In-hosp = 4 After hosp = 5 4
Death time
See codes 1 0 0
No = 0 Yes = 1 1 0 0
This registry form has been used for years in mine and war victim assistance in Iraq and Afghanistan for running quality control by the trauma system coordinators as well as being used in several ground-breaking scientific studies.You may download the template at www.traumacare.no. Ethical considerations Especially in war personal information may be sensitive. Never enter non-anonymous information in the PC database. The hard copy forms with personal information should always be kept in locked steel shelves. Only trauma system operators should have access to non-anonymous data. In the database, each patient entry (row) is marked with an ID number corresponding to the ID number on the hard copy forms.
119
Load the proportions in the CIA statistical calculator and you find that the trauma mortality rate was reduced from 19.4% in year 1 to 13.0% in year 2.The reduction is statistically significant at the 95% level, the confidence interval for the difference being 1.1% to 11.7%. So there is a true improvement in trauma system outcome from year 1 to year 2, but the improvement is modest, maybe only 1%. So there is a question if the difference is significant also from a medical and not just a statistical point of view. For that, the computer software has no answers; it takes a doctors common sense. Comparison of trauma mortality by two different systems/hospitals Are the personnel at hospital X better life-savers than the staff at hospital Y? Far too often so-called scientific surgical papers compare crude success rates in percentages without giving confidence estimates for the outcome rates. You should know better. YEAR 1 Trauma System X Trauma System Y Patients treated 330 110 Fatalities 64 17
Do not trust statistical estimates if the study population is smaller than 25.
This year the System Y had the mortality rate at 15.5% as compared to 19.4% in System X. It seems that SystemY has the better quality of performance. However, the samples are small in numbers, therefore the estimates are statistically imprecise. Using the CIA calculator you easily find that the difference is not statistically significant; the 95% confidence interval for mortality rate differences contains zero, it ranges from 4.1% to 11.9%. In other words, we cannot be sure that there is a real difference between outcomes of System X and Y.
120
Effect of prehospital life support, comparison by year We can use variations in physiological severity score (PSS) as indicator of treatment effect, see p. 101. If there is a positive difference between PSS rated on hospital admission, PSS2, and the PSS rated at first paramedic contact in-field, PSS1, then the acual patients condition has improved during the prehospital phase. Negative value of (RTS2 RTS1) means that we did not succeed to improve that actual patients condition by our treatment; he deteriorated despite our efforts. From the trauma registry we can find the mean value and the standard deviation (SD) of the difference (RTS2 RTS1) for all patients managed within two years. To find out if the prehospital system improved or not during the period we will examine the prehospital treatment effect by year using RTS differences: Trauma System X RTS2 RTS1 Mean Year 1 Year 2 1.1 1.55 SD 0.65 0.8 330 440 Number of patients
The CIA calculator tells us: The difference is significant, 95% CI for difference 0.34-0.56. System X seems to have improved the prehospital performance during the period.
121
So, both the anatomical severity and prehospital transit times are clearly significantly different between the patient population treated in Year 1 and the patients treated in Year 2. That makes the two patient populations non-comparable regarding outcome indicators. So, our statistical comparisons on the previous page are simply not valid. Stratification = slice the study population Again you will notice with dismay that authors of surgical papers often do crude comparisons of treatment results without reflecting on differences in underlying risk factors. We should not, and therefore we have to stratify the two populations before doing outcome comparisons.We take out three slices/subsets of the two populations that have (approximately) the same distribution of the main risk factors: Subset 1 ISS Time 2 PSS Moderate: < 9 < 2 hours > 10 Subset 2 Serious: 9-15 2-4 hours 8-10 Subset 3 Major Trauma: > 15 > 4 hours <8
Now we are ready to compare outcome indicators (mortality, post-operative wound infection etc.) by year for each subset separately:YEAR 1 SUBSET 1 versus YEAR 2 SUBSET 1;YEAR 2 SUBSET 2 versus YEAR 2 SUBSET 2 etc. In this example we selected the stratification criteria ISS, transport time and RTS on qualified clinical guessing which is good enough for the in-field war surgeon. To do it properly with statistics the stratification criteria should be defined after careful studies of the distributions and the impact of each and every explanatory variable using scatter plots and Receiver Operating Curve (ROC) analysis.
The reality is complex: there are a lot of risk factors that cannot be registered by counts and numbers. People and personalities are different and react differently to the same treatment. Psychological depression and malnutrition weaken the immune system and patients capacity to endure injuries. Such factors are hard to measure but that does not mean that we have to leave them out. Use your head and common sense: statisticians and scientific papers operate with standard confidence intervals at 95%. But there are situations where it is enough to be 80% sure, and yet other circumstances where 99% confidence should be required. Be careful with the CIA calculator: The world is not normal even if statisticians rely on this assumption for their mathematical formulas. The normal distribution of variables is a condition for most statistical analysis. But there are surely variables in the real world that will never group nicely and symmetrically according to a normal distribution even if you gather samples of 100,000 observations. So, dont be quite sure even if the CIA calculator is 95% sure. Warning! Statistics is one thing, meaning another thing. So, there are several levels of significance. Having done the analysis, we should pose some questions: What now? What is the potent implication of the findings? How can I use the knowledge gained to change things for the better? The answers can be found only in critical thinking and careful team discussions not in trauma registry statistics.
123
124
Section
125
126
5 The weapon
Blast physics Blast injuries Land mines
......................................................................... ....................................................
........................................................................ ..............................................................
..........................................................................
Cluster weapons .................................................................... 150 Future trends laser and microwave weapons
...............................
127
5 The weapon
Billions of dollars are spent yearly on weapon development. Any cursory search on the Internet will reveal hundreds of newer, more destructive means available to aggressive, wealthy nations bent on destroying. Simply compare the weaponry used in the first and second Iraq war, or the invasions of Lebanon in 1982 and 2006; we are now facing a different scenario with weapons and types of injuries hitherto unseen. The war surgeon must have a working knowledge on the principles of all common weapons including the weapons we are going to face in wars to come and how they cause injuries. Respond to the atrocities! Always have a very high index of suspicion and report all abnormal injuries. People who use banned materials in bombs are potentially committing a war crime; report them and demand investigations.
Blast physics
Much has been focused on gunshots which continue to injure and kill a great proportion of people. However in the wars now going on in the Third World countries, bombs take an equal or even higher toll. As bombs become more powerful and lethal, only those in the periphery are fortunate to be wounded. Those in the center of the bomb blast are not only killed but often the bodies unrecognizably blown apart and incinerated. There are therefore no casualties on the site where large blasts occur, only an estimate of the dead by inference. Bomb survivors may have four types of injuries: 1. Blast wave injuries: The internal injury may be devastating and there is no external wound. Do not be misled by the lack of visible external injuries. 2. Fragment injuries: These are high-velocity fragments either from the bomb or from the surrounding debris gathered by the blast wave. They produce open wounds which have deep and extensive wound tracks. 3. Burns: Survivors close to the explosion normally have burn wounds. Additionally they may have burns in the airway and lung burns due to the extreme heat of the explosion. Burns may also be caused by added chemicals in the bomb like white phosphorus, napalm or their equivalents. 4. Crush injuries occur after victims are buried in collapsed buildings or thrown violently by the blast wave against walls. Explosives are described in TNT weight, thus a 1,000 kg bomb is the explosive equivalent of 1,000 kg of TNT. The high pressure wave is referred to as the Primary Blast Wave. Low order explosives like the Molotov produce subsonic wave velocity, while high explosives (HE) produce supersonic blast waves.
128
Blast physics
is high enough to split and fragment the bottle, sending out flying glass fragments as the bottle explodes; the burning gases escape, expand and lose pressure a principle used in the Molotov petrol bomb in rioting. Apply the simple concept of the Molotov to modern bombs, and despite the dimensions being now several times more, the components are there: The explosive: These are now many times more volatile therefore expanding so rapidly that the surrounding layer of air is compressed to create pressures of thousands of times atmospheric pressure, and forced to travel at several thousand meters per second. Atmospheric pressure is 14.72 pounds per square inch, approximately 1 kg/cm2. A temperature of several thousand degrees Centigrade, sufficient to melt metal and incinerate all organic matter, is the usual result of modern fuel-air explosives. The speed: Upon detonation, modern explosives reach nearly a 100% combustion within micro- or nano-seconds. This therefore increases the velocity of the pressure wave, not unusually to 6,000 to 8,000 meters per second. Compare this extreme speed to a high-velocity rifle bullet which travels 800-1,000 meters/second. The blast wave by its velocity propels all objects in its path. The blast wave, open space An explosion in open space creates a uniform blast wave extending rapidly outward. The pressure wave spreads radially and uniformly without disturbance. The peak (maximum) pressure of the blast wave will be reduced rapidly by the distance from the explosion. Blast wave reflection and engulfment When the blast wave strikes an object, parts of the wave are reflected back, parts of it propagate forward into the object and compress everything inside. Note: the blast wave also sneaks around corners thereby engulfing the body. Special damage will be caused where the wave enters the object by spalling and where it hits the rear side by tension. We will come back to these mechanisms of injury, but first see what happens when the explosion takes place in a confined space. The blast wave, confined spaces In open spaces, where the primary blast wave can travel unobstructed, its pressure will rapidly be dissipated.When the same explosive is detonated in the center of a room, the blast wave is reflected back by the walls hitting persons in the room not only once, but several times. Close to the corners, interaction of blast waves creates areas of very high pressures. Wave reflection and amplification thus result in more deaths and casualties when concrete buildings are blasted or large explosions occur in the streets among city blocks.
129
5 The weapon
Blasting shelters: An explosion in the opening of a tunnel, shelter or a concrete house can cause serious wave blast injuries even to people hiding at some distance from the entrance. As the blast wave travels around corners it also kills those hiding deeper inside unless there are several twists and turns plus steel doors in the corridor.
Some fuels used for FAE are highly toxic (ethylene oxide and propylene oxide). A weapon using such fuels is very dangerous even if the fuel fails to ignite; the device then becomes essentially a chemical weapon.
130
FAE versus conventional high-explosives (HE) The initial peak pressure may be higher from HE blasts, but the overpressure from FAE blasts has a longer duration. The vacuum generated the underpressure is worse in FAE blasts; the FAE weapons therefore shake buildings and people more than a conventional TNT explosion and consequently cause far more severe internal destruction. The vacuum also sucks in buildings burying all, ensuring that no one survives. The FAE blast wave travels at over 3 km/sec which leaves behind an extensive zone with vacuum. The vacuum damages in three ways: Crush: It sucks in walls of buildings, people and any loose objects. Burn: It draws burning vapor into all buildings and shelters within the blast radius and sets all life and objects on fire. Suffocation: Oxygen in the air is burned off and people die from oxygen starvation. When first deployed by Israel against Lebanon in 1982, this suction effect earned FAE bombs the name vacuum bombs. The blast wave duration. Compare the speed of the FA explosive to the bullet from a modern battle rifle, around 1 km/sec. Then keep in mind Newtons law: the energy of a moving object increases with the square of the speed.
FAE weapons
In crowded urban situations a variety of FAE grenades, missiles, rockets and cartridges of different calibers are available for infantry as well as the pilots and helicoper gunners. Let us look at a few examples to understand the kind of problems people on the ground and also the war surgeons now are facing. The XM1060 40mm Thermobaric Grenade: In 2004 the first small arms FAE grenade was fielded in Iraq. The US army claims that this 40mm grenade provides soldiers with a significantly greater probability of kill and incapacitation (= causing severe injuries) in close-quarter operations. The killing capacity results from the overpressure blast + vacuum rather than fragment injuries. The Urban Assault Weapon (UAW): This shoulder launched missile is now widely used by the ground forces in Iraq. The UAW has composite charges. The
131
5 The weapon
first break-in charge perforates brick or reinforced concrete wall allowing a follow-through FAE bomb into the building or shelter to detonate. The effect is extreme heat and also extreme overpressure because all the energy is concentrated inside a confined space. The UAW is effective at ranges of 30 to 300 meters. The Hellfire rocket has for years been the main air-to-ground weapon for unmanned aircraft and helicopters. The rocket is laser-guided and extremely precise. Since 2002 the Hellfire-II has been equipped with FAE warheads especially designed for urban warfare. This warhead is designed to inflict greater damage in multi-room structures, compared to the Hellfires blast-fragmentation warheads. The new warhead contains a fluorinated aluminum powder that is layered between the warhead casing and the explosive fill.When the explosive detonates, the aluminum mixture is dispersed and rapidly burns. The resultant sustained high pressure is extremely effective against shelters and other concealed targets and obviously also the people inside. Palestinian colleagues in Gaza report that blast injuries associated with extensive burns are common in those surviving the initial explosion.
The Urban Assault Weapon (UAW). Being criticized for breaking the Geneva Convention when using FAE-Hellfire rockets in Iraq, the British Ministry of Defense renamed the weapon enhanced blast weapon. The Norwegian DYNO company is the main supplier of RDX explosive for Hellfire rockets.
132
Anti-electrical carbon-graphite fiber bombs blanked out 80% of electric supply in Serbia (May 2nd 1999). Rumsfeld on JDAM bombs in Iraq, 2003: These are top performers.
of which 65% were hit by smart missiles within a short time span. The weapon of choice for such warfare is the Small Diameter Bombs (SDB), precision bombs of 250 pounds (113 kg). Being small, the aircraft can carry more of them and inflict more damage. Even being small, they are still terribly destructive: a 250 pound bomb can penetrate 1.20 meters of steel-reinforced concrete. There are a variety of SDBs: bombs to blank out electricity and communications; FAE bombs to burn, maim and suffocate people; and also DIME bombs (see below).
The typical IED scenario: Mass casualties, fire, chaos and fear.
Dense Inert Metal Explosive (DIME) giving momentum to the blast wave
Please, study this section carefully because DIME is a weapon of the wars to come. DIME weapons have been used by Israel in its 2006 war in Lebanon and also in the Gaza Strip. The crucial feature of the DIME technology is the explosive content: the explosive fill is mixed with a very dense powder of a heavy metal tungsten alloy (cobalt-nickel or iron). Note: When the bomb detonates the blast wave is not just
133
5 The weapon
made up of compressed air molecules as in ordinary explosive weapons, but a wave of heavy microparticles as well. The DIME technology thus gives the blast wave a lot more weight. It makes the difference between being hit by a fist and being hit by a truck. Also note: DIME explosives have a carbon fiber casing which turns into dust rather than creating dangerous fragments when the weapon detonates thus you will not find the typical shrapnel wounds. DIME injuries, Lebanon 2006: Lebanese surgeons report injuries consistent with DIME hits from the July 2006 Israeli invasion: Patients were admitted with discolored, dark skin (no burns) and massively swollen limbs (no fractures). There were no penetrating wounds, but fasciotomy revealed total necrosis of muscles and nerves with intima detachment and clotting of the arteries. In other patients exposed to the same air attacks and the same weapons, large portions of the limb soft tissues were torn off the bone like shark bites obviously by extreme shearing forces.
DIME also has a long term danger. In experimental animals exposed to DIME, 100% of the animals developed highly malignant sarcomas within 9 months. The long term effect in humans is yet unknown.
DIME injuries, Gaza 2009: Israel was the first foreign buyer of the DIME weapon GBU-39 developed by USAF, Boeing Corporation and University of Californias Lawrence Livermore National Laboratory in 2000. The US Congress approved a $77 million sale of 1,000 GBU-39s to Israel in September 2008 and Israel used the weapon extensively in Gaza on the Palestinians from December 2008 to January 2009. Study the photos: The dark discolored skin is a fingerprint of DIME. We note that the blast wave seems to be localized so that the victims torso may go without injuries while the legs are totally crushed. In the child victims, shearing forces have torn open the chest and abdominal wall. To understand and be able to treat such injuries, we should study the mechanism of blast injuries in more detail.
134
Blast injuries
Blast injuries
Three physical phenomena contribute to the patterns and types of tissue injury effected by blast waves: Engulfment, compression/tension, and spalling. Injury by engulfment: Just as pressure waves can sneak around corners, they also engulf the entire exposed body of a person. The maximum compression is on the side facing the explosion but also the sides and the rear surface becomes compressed. Lesson to learn: Examine all sides of the patient carefully. Compression tension + spalling 1 2
Car smashed by blast wave engulfment. Similar to concrete structures and buildings the human body is also more sensitive to tension (stretching force) than compression. 1 To the side of the explosion the torso becomes compressed. The blast wave travels through the torso and at the far side the stuctures become stretched. 2 Striking the far boundary of the lung, parts of the blast wave will again be reflected and as a consequence the pleura is pushed outwards, stretched and at the same time squeezed against the posterior chest wall. This is why we may find damage not only at the front side but also at the rear side. Injury by spalling: When the blast wave hits, the energy not reflected back from the body surface causes a compression of the chest wall. But it is what happens inside that should interest us: When energy passes into a less dense medium like the pleura/lungs from a denser medium such as muscles and bones of the chest wall, the wave is reflected. The reflection destroys the structures exactly at the point of reflection, much like a local explosion. Like rust flakes and pieces of metal will detach from inside the iron tube, blood vessels and the pleura are stretched and may rupture close to the chest wall. The effects of spalling from the ribs are clearly illustrated in this autopsy photo (Iraq 2006).
135
5 The weapon
Combined spalling-tearing of lung tissue: The blast wave then passes through the lungs, compressing the tissues as it passes. The lungs are elastic and take a lot of compression without being permanently damaged. 3 But spalling will occur also inside the lungs at points where the energy wave passes bronchi and air-filled alveoli, causing rupture of the alveolar lining, filling up the lung tissue with blood and edema much like a non-traumatic lung edema. 4 When the overpressure wave passes mediastinum, shearing forces may cause tears of bronchi and central vessels. Look for signs of subcutaneous emphysema at the neck and mediastinal shift (X-ray).
5 6
Due to spalling, persons wearing flak jackets and other body protective armor are at risk of getting more severe blast injuries.
Gunshots also injure by spalling: Damage by spalling and tension is not a feature of blast weapons only. As high-velocity bullets pass through the body, they create a wave of energy to the sides, causing a temporary cavity which rapidly compresses the tissues, see more on p. 142.Where this pressure wave enters a less dense tissue, the damage will be extensive: 5 The inner lining of the vessel, the intima, may be torn off the vascular wall and be further rolled off by the bloodstream. Intima roll-up makes the vessel narrow (this feature is often misinterpreted as artery spasms). 6 At narrow parts of the vessel there will be turbulence and blood clots will form. Intimal injuries to large and small arteries are common in blast cases, see reports from Lebanese colleagues on DIME weapons, see p. 133.
Blast injuries
Blast pressure chest injury signs may come later: Injury to the lungs: When alveolar walls are broken fluid collects and lung edema may develop. The blast compression of the abdominal wall lifts the diaphragm and causes damage especially to the inferior parts of the lungs. The physical signs are increasingly rapid and shallow respiration, and coughing of bloodstained mucus. Symptoms develop slowly and often after a symptom-free interval of 6-48 hours. Lung X-ray may show patchy infiltration 24-48 hours after the injury.
136
Blast injuries
Air embolism: Through broken alveolar septa, air bubbles can be taken by the blood to any organ. The effect may be anything from transient general unrest and confusion to sudden death. There is no specific treatment for blast lung injury or air embolism. The main stay is immediate and active supportive therapy: half-sitting position, oxygen support, and anxiety & pain relief. Assisted ventilation is mandatory in severe cases. Blast pressure abdominal injury early signs may be few
Peritoneal and intestinal tears: When blast waves enter the abdominal cavity and further pass into the lumen of the intestines, spalling and tension may cause tears of the peritoneum and the intestinal mucosa or even tear up the entire intestinal wall. In particular the distal ileum and the colon are at risk. The mesentery is sensitive to tensile forces: arteries may rupture and bleed into the abdomen. Or the vascular supply to the intestines may be partly blocked due to intima tears causing a silent and creeping necrosis of parts of the gut. Solid organ injury is less common: Solid organs are normally injured by penetrating fragments or crush forces, not by the blast itself. However, the liver is sensitive to compression causing intra-hepatic bleeds and even ruptures. Vascular tears, beware pelvis: Spalling occurs when the blast wave shakes the pelvic bones. The retroperitoenal vascular network lining the pelvic bone ring may rupture and cause massive bleeding. Control pelvic bleeds by packing, see p. 270. We recommend a high index of suspicion and repeated examination over 24-48 hours for all patients with a history of over-pressure exposure. Laparotomy should be done on discrete indications; do not wait until the intestines rupture! If the patient is multi-injured, staged surgery is best.
137
5 The weapon
Hematoma, but no fracture: The blast wave may pass through the skull bone without causing any fracture. However, at the inner side the spalling effect exerts strong tensile forces on the blood vessels which may cause a subdural hematoma or profuse bleeds from the arachnoidal vessels. Brain contusion Inside the brain tissue vessels may rupture causing intra-cerebral hematomas, or any degree of brain tissue contusion. Clinical signs vary from moderate signs of increased intra-cerebral pressure (edema) to early death. Glasgow Coma Scale (GCS) and increased intra-cranial pressure, see p. 241. Observe any blast-exposed patient for 24 hours. Repeated neurological exams with exact GCS registrations are crucial. Focal neurological signs may indicate subdural hematoma and immediate trephination. Diffused neurological signs may develop over hours and indicate brain edema: start active treatment at an early stage. Blast pressure damage to the limbs staged surgery! The main feature of limb injuries caused by extreme blast waves is disrupted blood perfusion: Vascular tears: Large and small vessels may tear completely, or be blocked by extensive roll-off of the intima. Compartment syndromes: Due to bleeds inside muscles plus swollen muscle tissue plus poor local blood perfusion due to vascular damage plus general oxygen starvation caused by blood loss the intra-muscular pressure builds up due to swelling inside a tight compartment formed by bone and dense fascia. This causes compartment syndromes in more than one muscle compartment. Patients with severely mangled limbs often have burns and injuries to other organs as well, these may be best managed by early primary amputation. In patients where limb salvage is an option we strongly recommend a staged surgical approach:
138
Blast injuries
1. Immediate extensive fasciotomies to decompress compartments and expose the injuries. Major artery tears should be managed by temporary shunts; the patient is probably too weak to undergo extensive vascular reconstructions at this stage. Fractures are roughly reduced and kept in place by splints or external fixators. 2. Provide intensive supportive therapy for 24-48 hours and constantly monitor the limb blood perfusion. 3. At the second operation blood vessles and broken bones are reconstructed or amputation is performed. Rupture of the eardrum The sign is acute deafness in one ear. The diagnosis is confirmed by otoscopy.Without infection the rupture will heal spontaneously. Note that blasts cause a complex interaction of reflection-interaction-spalling-tension inside all the exposed body: the colon may well be ruptured and the eardrums remain uninjured. The main challenge in blasts is to identify all patients at risk at the site of a mass casualty. Observe blast-exposed patients for 48 hours even if they have no clinical signs. Eardrum rupture is not a good indicator of internal blast injury.
Exploding bullets, see p. 146. Snipers may also use FAE munitions, destroying not only individuals but the entire neighborhood, see p. 133.
5 The weapon
3. Armed irregulars that are very difficult to detect except with a high index of suspicion. Sniper positions Battle damaged buildings with multiple broken windows and roofs with broken shingles are ideal sniper dens. Snipers can be holed up in the attics, basement, hiding in crawl space between floors shooting out through loopholes. Often there are dummy loopholes as decoy. Suspect stationary curtains as these are weighed down to minimise wind disturbance.
of its energy to tissue damage inside the body. The main question is therefore not how much energy was carried by the projectile, but how much of this energy was released within the body of your patient? This is a question of retardation: Energy for destruction: E = 0.5 x (MV12 MV22) where V1 is the velocity of the projectile at the entry wound and V2 is the speed of the projectile through the exit wound. Surgeons, please note: The optimal projectile has a high hit velocity and a low exit velocity. Maximal damage is done if it stops inside the body, V2 = 0. Surgeon, evaluate the entry velocity! What kind of weapon was used? Gather information about the weapons commonly used in your area and their projectile velocity. What kind of ammunition was used? The general trends in modern assault rifles and antipersonnel fragmentation weapons are reduction of projectile weight and increase in projectile velocity. And to use unstable bullets, see illustrations p. 144. What was the range of the hit? Due to air resistance a low-weight projectile (e.g. 5.56mm) will lose velocity during flight more rapidly than a heavy one (12.7mm). Thus the range of the hit (from the muzzle of the rifle, from the site of the explosion) affects the possibility of damage. How is the stability and penetration of the actual bullet? A low-weight projectile tends to become unstable during flight; uncontrolled tumbling will reduce its accuracy. So there is a lower limit of assault rifle projectile weight, even if calibers 4.85 mm and 4.6 mm are now ready for production. A heavy projectile has better stability in flight. In sniper fire and during jungle fighting you should still expect to find the traditional 7.62 mm projectile and heavy projectiles such as the .303 in (the Lee-Enfield Jungle carabine) and .30 in (US Garand) with a high inlet-velocity even at wide range hits. Pistol ammunition (less than 9 mm) is unstable in flight and of poor combat value due to the low muzzle velocity of pistol bullets. Then, evaluate the exit velocity! Is there an exit wound? Modern bullets are designed to break up and stop inside the body (V2 = 0). Are you sure it is not another entry wound? There may be multiple hits. Battle rifles often fire clusters of three and three bullets. Rifles with extremely rapid three-shot clusters (2,000 rounds/min.) are now in use. How extensive is the exit wound? If it is wide with extensive tissue damage close to the outlet surface, the projectile has left the body with considerable velocity; you can hope for less internal damage. Multiple small exit wounds indicate a projectile that fragmented inside the body, the internal damage is probably wide.
141
5 The weapon
Low-energy hit: The typical low-velocity wound track (9 mm pistol bullet, close range thigh hit with inlet velocity 450 m/s) is generally narrow. The energy output from the projectile is poor due to moderate inlet velocity.You should expect to find necrotic tissues not more than 2-3 cm from the bullets line of penetration. The exit wound, if any, will be small. According to Palestinian colleagues, such wounds may not need surgical debridement, but be managed by drainage only. High-energy hit
The typical high-velocity wound track (7.62 mm assault rifle bullet, close range thigh hit with inlet velocity 900 m/s) is both deep and wide. Due to its speed the energy output from the projectile is about four times that of a pistol bullet. As it passes through the bullet produces a shock wave in all directions in the tissues making a cavity which first expands and then immediately collapses behind the projectile. The cavitation effect is typical for high-velocity projectiles and causes tissue necrosis far from the line of projectile penetration, especially if the bullet breaks to pieces. The vacuum created by the cavitation sucks cloth, dirt and bacteria from the skin into the wound track.
142
Muzzle energy of common rifle bullets Ammunition Bullet weight Muzzle velocity Muzzle energy 5.45x39 3.42 g 900 m/s 1.4 kJ 5.56x45 4.0 g 915 m/s 1.7 kJ 7.62x51 9.3 g 840 m/s 3.2 kJ 7.62x54 R 9.65 g 850 m/s 3.9 kJ
Beware: We may misinterpret this table and think that the 7.62 bullet (NATO rifles or the famous Russian AK-47 Kalashnikov) is worse than the 5.56 ammo, muzzle energy being close to the double. But real life is another thing: When the 2nd generation Kalashnikov (5.45 mm rounds) were introduced in Afghanistan in 1984 there was shock at the extensive injuries it caused much worse than the 7.62 ammo. This is simply because the 5.56 bullets were very good in losing speed and delivered all its kinetic energy as damage.
Ammo fingerprints
At the point where retardation is maximal, the cavitation is also maximal and consequently the tissue damage.The most effective projectile causes maximum cavitation close to or within vital structures, that is not more than 5-10 cm after inlet. Each kind of rifle ammunition has its particular cavitation effect and particular wound track, its fingerprint.The war surgeon has a lesson to learn from veteran fighters: To know the fingerprints of common ammunition will make both triage and surgical performances better. We will look at some factors affecting the cavitation. The principles here illustrated by bullets are valid for any kind of high-velocity projectiles, be it from land mines, rockets, bombs or snipers.
Full Metal Jacket (FMJ): The lead core of this bullet is enclosed in a heavy copper jacket, which results in little or no expansion and deep penetration. 1 metal jacket; 2 lead core.
Soft Point (SP) and Hollow Point (HP): These are semi-jacketed bullets with exposed lead at bullets nose.The point of the bullet is deformed even by soft structures. The retardation is therefore maximal just inside the inlet wound, and this is the level where you find the most extensive injury. The deformation doubles the bullet diameter and hence increases the point surface area by a factor of four. 1 metal jacket; 2 lead core.
143
5 The weapon
Hollow Point makes a difference: Compare the effects of two thigh hits from an AK-47 Kalashnikov battle rifle using different types of ammunition. The Yugoslavian type hollow-pointed, 7.62-mm bullet turns unstable 10-15 cm inside the inlet wound. The fragmentation creates a wide outlet wound: You should prepare for a wide debridement of the medial thigh, in particular, the femoral artery (the outlet side) should be explored. The other ammunition, a standard 7.62-mm full mantled bullet will gradually turn unstable 15-20 cm after the hit. Inside an abdomen it may create considerable damage. But the wound track inside the thigh is too short for maximum destabilization and damage to occur:You should not expect to find wide soft tissue damage inside that wound track unless bone is hit (see illustration p. 145).
Steel jacket Empty Lead Steel penetrator
Empty Propellent
Retardation by rotation: This is the 2nd generation Kalashnikov, the most effective assault rifle from the former Soviet countries. What is particular about this 5.54 mm bullet is the air-filled space in its nose. On hitting the target, the heavy lead-antimony core is pushed forwards; the bullet becomes extremely unstable and starts rotating inside the wound track. In a thigh hit this causes a maximum cavitation close to the femur, the main nerves and vessels. Among the standard rifle ammunitions the destructive effect of the AK-74 is matched only by the new model 5.56 mm ammunition for the US rifle M16. Note from this illustration that the internal tissue loss may be extensive even if the outlet wound is small. The dogma of small outlet wounds less internal damage is not true.
M-16 A2 5.56
M-16 A1 5.56
Retardation by fragmentation: The US M16 rifles are operative in two models, both using 5.56-mm ammunition. The A1 is the old model ammunition. Its bullet is shorter than that of the new A2 model. The M16 is effective for limb injuries. The copper-nickel jacket of the M16 bullet is open at its base so that framents of the lead core are flung out when rotation starts.With this, the bullets break into fragments and create considerable cavitation before leaving the thigh. As a sign of fragmentation you may see several small outlet wounds; look for this informative sign when you plan the surgery. Oblique hit worse damage: Within 20 cm most types of bullets will turn unstable. In this case even the hit from an AK-47 FMJ bullet may tear up the femoral artery even without hitting it directly.
144
The range counts Drive any expanding bullet fast enough and it will come apart during penetration. Slow the same bullet down and it will not fragment at all. The way a bullet behaves at 100 m may have little resemblance to how it behaves at 500 m. Large variations Most rifle ammunition is not well standardized, variations of 30% are common. Within one and the same round one bullet may cause severe damage, the next may not. Armor Piercing bullets (AP): Armor-piercing ammunition is used to penetrate hardened armored targets such as body armor, vehicles, concrete, tanks and other defenses. AP bullets have a specific design with a hard and heavy penetrator inside the bullets lead core. When the bullet impacts armor, the nose flattens and the penetrator continues forward into the armored surface. A number of different materials are used for the penetrator, including tungsten and uranium alloys. AP bullets can be fired from traditional battle and sniper rifles: e.g the 5.45mm AP rounds from the AK-74 are capable of penetrating a steel slab 16 mm thick from 100 meters. The tissue damage in AP wounds is massive due to multiple lead fragments. 1 metal jacket; 2 lead; 3 hardened steel core, or tungsten, or uranium alloy. Bone hit causes retardation: Bone deforms or breaks most bullets. Consequently the surgeon finds maximum soft tissue damage exactly at this point close to the fracture. Also bone fragments are accelerated into the tissue as secondary projectiles thus increasing the cavitation effect. Energy shock waves may also travel along the bone and shake soft tissues far proximal and distal to the fracture site, see illustration of mine blast p. 149.
Shattered bone multiple wound tracks? Even tiny fragments of bone may penetrate deeply and cause extensive wound tracks when accelerated to the speed of a rifle bullet. When X-ray shows comminuted fractures there may well be more than one organ hit.
145
5 The weapon
The world record of successful anti-personnel sniping is held by a US soldier who claims to have killed Iraqis at 2,200 m with Nammo 12.7 in 2004.
Land mines
Land mines
On one hand land mines are defensive weapons, cheap and easy to produce. This has made mines popular in regional wars, and wide areas of the rural South are now mined without proper mine-mapping. But land mines are also used offensively, to deny local people access to roads, water and agricultural land. When the war is over, large territories are permanently occupied by the mines. Placing mines is easy, clearing irregular mine belts takes decades. Even if Anti-personnel (AP) mines do not belong to the armamentarium of modern wars, the surgeon should be prepared to manage mine injuries for generations to come. There are three main types: Fragmentation mines, blast mines, and anti-tank mines.The injuries and treatment differ between the types of mines. Land mine injuries are severe Anti-personnel mines carry 30-300 g high-explosives. Mine casualties are multi-injured. Examine all victims carefully. Fragmentation mines are located on a rod overground (POMZ), or they jump from ground level up to 1-2 m before they explode (PROM-1). They are released mechanically by trip-wires or by computer control. Improvised fragmentation mines are made by UXO (unexploded ordnance), artillery grenades released by trip wires. Fragmentation mines are often inter-connected in series of 3-6 mines in order to increase the fragment concentration. Up to a range of 50 meters the fragment wounds are severe due to high fragment speed, 800-1,000 m/sec.
Fragmentation mines.
Blast mines are buried in the ground or scattered on the surface by air or artillery. They are released by direct pressure (foot, vehicle). The injury is caused mainly by the blast pressure wave but also fragments are shot into the victims pieces of the mine case, stone and dirt from the ground, or amputated body parts from the victim. Type 72 is a small blast mine with 35 g high explosives (HE), enough to take off the foot.The 72C shown here also contains an anti-tilting device made to kill mine clearers. The PMN mine (left) carries 200 g HE, enough for a high double amputation. The PMNs work well also under water.
147
5 The weapon
Anti-tank (AT) mines contain 2-8 kg of high explosive. They are often deliberately placed to destroy civilian cars and tractors. In the 20th century wars in Southeast Asia and African countries there were a lot of AT mines available which were used also for anti-personnel purposes, placed in the villages and on small bush tracks. The release pressure of AT mines can be adjusted down to 50 kg, or they are booby-trapped with a small blast mine on top that will be released even by a childs foot and trigger the AT mine explosion, see photo. The injuries by AT mines are similar to IED injuries, see p. 133.
Mine amputation at the ankle: Amputations at this level are typically caused by 30-50 g blast mines. There may well be extensive injuries deep into the lower leg compartments so that the level of the surgical ampuation must be set at the proximal third of tibia, see illustration of the hidden wound on p. 149. Amputation techniques, see p. 383. Amputation by PMN blast mine: The PMN is the number one worldwide killer among anti-personnel mines. The mine contains 200 g high explosive and typically sets off the leg at mid-tibia level. The blast wave is strong and tears the muscle off the bone up to knee level; this leaves a very short below-knee stump and the surgeon must sometimes disarticulate at the knee joint or amputate above the knee. Beware the hidden wound in mine amputations: The mine limb amputation is an extremely high-energy injury and has features that make it different from amputations caused by shrapnels, entrapments etc. The extent of soft tissue injury is often underestimated by the surgeon infection, delayed healing and repeated amputations
148
Blast injury to the foot by light AP mine: There is obviously a compartment syndrome in the foot. Decompression by fasciotomy in all three muscle compartments is urgent, else the foot will be lost. Fasciotomy of the foot, see p. 685.
Land mines
being the result. The blast wave from a mine travels along the bones from the level of amputation into the limb above. To get an idea of how it works: put your ear to a long steel tube and let somebody hit the tube at the other end with a hammer it hurts! The blast wave shakes the soft tissues along the bone: the vascular network of periosteum is damaged and also the major arteries (the brachial, deep femoral and peroneal artery) which causes muscle compartment syndromes. Note: The skin over the hidden muscle wound may seem uninjured; the skin is elastic and can take the tension from the blast wave without tearing. Early fasciotomy and careful exploration proximal to the level of traumatic amputation is mandatory before you decide the level of surgical amputation. Beware the fragment injuries! The typical and most dangerous land mine injury is not the traumatic amputation but the fragment wounds.
Receiver Operating Characteristics, a statistical method to examine test accuracy. Study the publication at www.traumacare.no
The problem is fragment injuries rather than the amputation: A scientific study of 700 mine victims in the mine fields of North Iraq and Cambodia demonstrates that the fragment injury carries a far higher risk of death as compared to the amputation injury. The ROC curve shows death risk relative to injury severity: The area under the fragment curve (dotted line) is much larger than the area under the amputation curve (whole line). Conclusion: the real killers are the mine fragments. Compound fracture by mine fragments: In mine amputations there are always fragment injuries to the opposite leg, often with a compound fracture. The management of the associated mid-tibia fracture may in fact be the main challenge for the surgeon: the soft tissues at the medial side of the tibial bone as illustrated here may be so damaged that debridement leaves the bone and the fracture uncovered. Consider soft tissue flap transfer instead of making another amputation, see p. 329.
149
5 The weapon
Combined blast and fragment injury to the face: Beware, there may be airway burns here as well. Examine the eyes carefully; even tiny fragments may penetrate into the brain if the speed is high enough. In the presence of other injuries, airway burns increase the mortality rate by a factor of three.
Careful clinical examination! Behind this small entry wound are severe injuries to the colon and small intestine. Such small entry wounds are easily missed, especially if the Emergency Room is crowded with other casualties from the same mine accident.
Fragmentation mine injury: Large tear of the abdominal wall and evisceration by an old Russian POMZ fragmentation mine.
How much can he take? Land mine victims often are poor are landless suffer from malnutrition and anemia live where malaria and other devastating diseases are endemic. Staged surgery, see p. 234. If the pre-injury physiological capacity is poor, consider staged surgery.
Cluster weapons
Cluster bomb on the refugee camp: When the Sabra refugee camp in Beirut was bombed by Israel in 1982, a 12 year old Palestinian boy was hiding behind a Mercedes car just outside our hospital. An F-16 dropped a cluster bomb and the area was shattered by bomblets. The shrapnels penetrated the car and the boy. Cluster weapon = many bomblets (cluster submunitions) carried by one mother bomb/grenade. Palestinian boy hit by cluster fire, Beirut 1982. Cluster weapons are the cheapest and most efficient area-control weapon available. Because there is no international treaty prohibiting its use for military en-
150
Cluster weapons
gagement, they accompany almost every war in the 20th century and they also will in the 21st. There were 4 million cluster munitions dropped onto Lebanon immediately after the ceasefire by Israel. The deliberate use of cluster munitions against civilians is prohibited by International Humanitarian Law and no invading army will admit to its use of clusters for that purpose; civilian casualties are always described as unintentional and collateral. The table lists some of the examples: Date Location Details Soviet forces use air-dropped cluster munitions against German armor. German forces use SD-1 and SD-2 butterfly bombs aginst artillery on the Kursk salient. German aircraft drop more than 1,000 SD2 butterfly bombs on the port of Grimsby. US forces make extensive use of cluster munitions in bombing campaigns.The ICRC estimates that in Laos alone, 9 to 27 million unexploded submunitions remain, and some 11,000 people have been killed or injured, more than 30 percent of them children. An estimate based on US military databases states that 9,500 sorties in Cambodia delivered up to 87,000 air-dropped cluster munitions. Israel uses air-dropped cluster munitions against non-state armed group (NSAG) training camps near Damascus. Moroccan forces use cluster munitions against NSAG. Israel uses cluster munitions in southern Lebanon. Soviet forces make use of air-dropped and rocket-delivered cluster munitions. NSAG also use rocket-delivered cluster munitions on a smaller scale. Israel uses cluster munitions against Syrian forces and NSAG in Lebanon.
1943
USSR
1943 X-ray of the boys left leg shows extensive internal damage.
United Kingdom
1960s-1970s
1973
Syria
1975-1988 1978
1979-1989
Afghanistan
1982
Lebanon
151
5 The weapon
Date 1982
Details UK aircraft drop cluster munitions on Argentinean infantry positions near Port Stanley, Port Howard and Goose Green. French aircraft drop cluster munitions on a Libyan airfield at Wadi Doum. The US and its allies (France, Saudi Arabia, UK) drop 61,000 cluster bombs containing som 20 million submunitions. The number of cluster munitions delivered by surfacelaunched artillery and rocket systems during the Gulf War is not known, but an estimated 30 million or more DPICM submunitions were used in the conflict. Forces of Yugoslavia and NSAG use available stocks of cluster munitions during civil war. Used by unknown forces in civil war. Russian forces use cluster munitions against NSAG. On May 2-3, 1995, an NSAG uses Orkan M-87 multiple rocket launchers to attack civilians in Zagreb. Additionally, the Croatian government claimed that Serb forces used BL-755 bombs in Sisak, Kutina and along the Kupa River. Sudanese government forces use air-dropped cluster munitions in Southern Sudan. Nigerian ECOMOG peacekeepers use Beluga bombs on the eastern town of Kenema. Ethiopia and Eritrea exchange aerial cluster munition strikes, Ethiopia attacking the Asmara airport and Eritrea attacking the Mekele airport. Ethiopia also dropped BL-755 bombs in Gash-Barka province of western Eritrea.
1986
1991
1995
Croatia
1996-1999 1997
1998
Ethiopia/Eritrea
152
Cluster weapons
Date 1998-1999
Details Yugoslav forces launch cross-border rocket attacks and NATO forces carry out six aerial cluster munition strikes. The US, UK and Netherlands drop 1,765 cluster bombs, containing 295,000 bomblets. The US drops 1,228 cluster bombs containing 248,056 bomblets. The US and UK use nearly 13,000 cluster munitions containing an estimated 1.8 to 2 million submunitions in the three weeks of major combat. Israeli forces use surface-launched and airdropped cluster munitions against Hezbollah. The UN estimates that Israel used up to 4 million submunitions. Hezbollah fires more than 100 Chineseproduced Type-81 122mm cluster munition rockets into northern Israel.
1999
2001-2002
Whats shocking and I would say, to me, completely immoral is that 90 percent of the cluster bomb strikes occurred in the last 72 hours of the conflict, when we knew there would be a resolution ... Every day people are maimed, wounded and are killed by these ordnances. UN coordinator of humanitarian relief, Mr. Egeland 30 August 2006 on the Israeli attack on Lebanon.
2003
Iraq
2006
Lebanon
2006
Israel
Source: Human Rights Watch, Save Civilians: Ban Cluster Munitions By 2008
The Skeets and several CEM weapons are not included in the international convention to ban cluster weapons. Thats probably why NATO countries were happy to sign the convention.
5 The weapon
Conventional cluster bomb: The CBU-58 is a common cluster carrier. It contains 650 bombs, each of them filled with high-explosive and 600 steel fragments of 2-5 mm: each cargo thus carries 390,000 potentially lethal projectiles. The explosion is rapid and the fragment speed is high, 800-1,000 meter/sec close to the explosion. The cloud of steel fragments from one single cargo bomb covers an area as big as a football field. Unexploded clusters = land mines: In the Vietnam war the generation of cluster bomblets (BLU-72) had no self-destruct devices. Blanket bombing of Vietnam, Laos and Cambodia left tens of thousand bomblets unexploded and after a few years covered by a layer of soil. Till this day farming fields and forests are infested. Selfdestruct functions are built into modern cluster weapons so that munitions that do not hit the target automatically will be defused or explode after a preset time. However the self-destruct failure rate is high, up to 25%. Cluster weapons cause multiple and high-energy injuries Careful clinical examination: entry wound may be tiny still the internal damage massive.
154
Laser weapons
Until recently, the laser technology has mainly been used in a supportive role such as in communications, sighting targets, guiding and assisting delivery of bombs and missiles. Advances in chemical and solid state lasers have enabled laser weapons to be used to intercept and destroy ballistic warheads in mid-flight as in the Strategic Defense Weapons (Star Wars Programme). Solid state laser weapons are now becoming increasingly portable and can be powered by a gas powered jet engine or the turbine of a tank. Chemical lasers still take up too much space and would have to be tied up with huge energy generating sources. The range of laser weapons is in the order of thousands of kilometers, and destructive power above that of nuclear bombs without the hazard of radiation fallout.
Source: Richard J. Dunn. Operational Implications of Laser Weapons. Northrop Grumman, 2005. Feasible and ready for use: The illustration from the military manual from Northrop Grumman cleary demonstrates the wide range of potential applications of laser weapons.We can easily imagine that a moderately potent laser weapon able to break down the engine of a truck at long range will be a terrible weapon when used on urban living quarters. The weapon is more than ready for use; already during the Falklands war in 1982 the British used a ship based laser causing blindness to the Argentinian pilots.
5 The weapon
The ultraviolet fluorescence in some lasers the veiling glare Laser was thought to be eye-safe. However it is now known to destroy the retina and to be associated with long term eye damage and cataracts.
Victims will complain of seeing flashes of light, pain, reduction of visual acuity, eye discomfort and skin lesions. Examine the victims for skin burns; corneal burns; retinal hemorrhage and burns, with or without vitreous hemorrhage. Long term damage such as corneal scarring, and retinal damage may not be treatable, but some sight can be regained with vitrectomy for vitreous hemorrhage. Unexplained damage to optical instruments? Spontaneous fires? Suspect the use of laser weapons!
Microwave weapons
Microwaves are electromagnetic waves with wavelengths from 1 GHz to 300 GHz. Microwaves are absorbed by water, fats and carbohydrate the building stones of the human body which convert the microwave energy input into heat. But microwaves are not absorbed by plastic, glass and ceramics, and they are reflected by metal.These are the features that make microwaves readily applicable in warfare.
Boiling through walls: One can easily modify a normal microwave from the kitchen and create a prototype of a microwave weapon against persons inside buildings and behind walls, the degree of heating depending on the energy of the microwave source. Professional microwave weapons are already in use. Several countries have used them for riot control. The effect is said to be feeling an intensive heat so that persons immediately try to get out of the exposed area. The US army admittedly used microwave warheads to destroy Iraqi electronic systems during the 2003 invasion; there are no reports of what else the microwave weapons destroyed in the attack on Bagdad Airport or elsewhere on the ground in Iraq. High-power microwave bombs: Extremely potent and extremely imprecise Microwave sources may be packaged in several sizes, ranging in size from
156
artillery shells to scatterable mines. Microwave generating warheads are now also available for precision-guided rockets and bombs. According to US military reports microwave warheads have 50-times wider killing range compared to conventional blast/fragmentation warheads. Delivered by air missiles and charged by the missile explosive, the microwave output can hardly be precise or directed to avoid injuries to humans. As the American report on microwave weapons reads: ... an impact error of even several feet may make the difference between destruction and survival (USAF, 2002). Beware! There are good reasons to expect injuries hitherto unseen by microwave weapons. Especially beware unexplainable traumatic brain injuries and burns.
157
injury
surgery
Trauma surgery has made large advances in the last decade we are able to save more lives and limbs mainly because we have gained a better understanding of the physiological responses to trauma. Good surgical management is much more than skillful surgical handicraft. We now realize that good care in major trauma requires understanding of the cascade of physiological events triggered by the injury. Without such understanding, the surgical intervention may represent a second and devastating blow to the physiology of the patient. The main triggers of trouble, see p. 162. Responses Time is a critical factor in major trauma: there is a time for immediate interventions, and there is a time to bail out and close the incisions. Read the clinical signs of post-injury stress, see p. 165.
158
6 The injury
The local response to injury ...................................................... 160 Triggers of post-injury physiologic stress Organ failure
......................................
162 169
159
6 The injury
tissue damage blood loss oxygen starvation pain & fear coagulation failure infection immune depression Post-injury stress
Look at the title page of the book to see what our senior colleagues Trueta and Weigelt said about this.
A severe injury damaged tissues, blood loss, pain, dirty wounds triggers a massive physiological chain-reaction in the body.The body tries to protect itself. Some of the responses help it resist the injury, but other responses are devastating. They bring the physiology out of balance and act as agents of death. This complex response is called post-injury stress. It accelerates rapidly within hours after the injury. The body goes into overdrive the physiologists call it up-regulation. Postinjury stress cannot be prevented but it can be modified and partly controlled. To do that we have to understand what is going on inside the injured body. First we will see what happens at the wound site, how cells react when they are in trouble and try to survive. Then we will look at the body response in general.
Burns cause specific tissue responses, different from other injuries, see p. 696. 1
2 Regulation by the cell membrane pump: An active chemical pump inside the cell membrane regulates the concentration of sodium, potassium and hydrogen inside and outside the cell. 3
3 Regulation by osmotic pressure: The cell needs water and it produces water. The water volume inside the cell is regulated by passive osmotic pressure: Water is sucked into the cell when the concentration of sodium increases inside the cell. Then the cell will swell, and the salt inside the cell becomes diluted to the normal level, stopping further water inflow.
160
4 Any injury causes swelling of the tissues. 4 Oxygen starvation causes tissue edema: When the muscle is hit by a bullet, the local arteries are damaged and less blood reaches the muscle cell. Blood is lost from the circulation, the supply to the injured site is also less. Due to pain the breathing becomes less efficient, and the blood oxygen level goes down. The cell suffers oxygen starvation. This is the response of the cell: The energy production of the cell decreases due to lack of oxygen. The membrane pump slows down because of this lack of energy. Less sodium is pumped out of the cell and the levels of sodium and other molecules increase inside the cell. Consequently the salt-water concentration inside the cell increases. By osmotic pressure water is sucked into the cell cell edema. 5 5 Vascular obstruction accelerates edema: The neighboring cells also swell and the small veins become obstructed. The venous drainage becomes poor; fluid is retained in the tissues and accelerates the general swelling. Gradually the edema also obstructs the arteries, and the blood oxygen supply to the cell is further reduced increasing cellular edema. 6
7 6 Vascular injury further accelerates edema: Capillary vessels are also crushed by the bullet, and they leak fluid into the tissues. Increasing volumes of fluid between the cells further obstruct the local blood supply oxygen starvation tissue edema. 7 Leaking capillaries add to edema: Blood vessels and also the small capillaries are lined with endothelial cells. Endothelial cells regulate the vascular wall permeability. As with any other cell they need oxygen for their normal function. The tissue damage and the increasing local edema deprive them of oxygen and damage them the capillary wall starts leaking fluid into the tissues increasing edema. 8 The stress triggers are released: From the crushed, oxygen starved, dying cell several chemical agents are released into the bloodstream.These agents act like a signal to the endothelial cells to change the capillary wall permeability. White blood cells and immuno-proteins are let through the vascular wall into the injured tissue to eat bacteria, remove dirt and prevent infection. But water also leaks through the vascular wall increasing edema.
161
6 The injury
Prevent tissue edema: promote blood supply to the site of injury Stop the bleeding and get the blood pressure up to 90 mm Hg as soon as possible, 90 mm Hg is sufficient for limb perfusion. If the limb is swollen: do fasciotomy in-field or in the emergency room. Surgery in swollen tissues is dangerous The healing is poor and the risk of infection high. Surgery on cells in bad shape is like a second injury; it triggers more postinjury stress. Do fasciotomy to improve tissue perfusion, but delay surgical repair until the edema is less, see Damage Control surgery p. 234.
We reckon that 50% of severely injured initial survivors develop post-injury stress syndrome.
Obviously it must be most important for the trauma surgeon to control the triggers, so let us see briefy how the main triggers act. Trigger: Damaged tissue The sympathetic nervous system is activated by chemical substances from crushed and injured cells: breathing speeds up, the heart rate and cardiac output increases, blood is shunted from the periphery into the central circulation good pro162
tective measures. On the other hand the activation also releases cytokines, potent mediators that trigger the immune system and act on the endothelial cells. The capillary wall starts leaking which is very useful for white blood cells to pass through to the site of injury to catch and remove dead tissues and bacteria. This local clean-up response helps prevent infection, but on the other hand the activated phagocytes (white cells) further stimulate cytokine production. The more tissue damaged by the primary injury, the stronger the wound trigger. This is probably the reason why the post-injury stress response is stronger in blunt than sharp penetrating injuries. Trigger: Burns More than other tissue injuries, burns of more than 25% of total body surface area trigger a massive release of cytokines. This causes an immediate reduction in cardiac output and reduced blood flow through the lungs the first days post-burn and consequently global oxygen starvation which is another trigger of stress. The cytokine release also acts on the capillary wall and induces tissue edema, not only in the burn wound but also in unaffected tissues; edema means less blood perfusion = oxygen starvation = further triggering. The outcome of the massive triggering seen in major burns is pronounced depression of the immune system with high risk of post-injury infections and an enormous increase in energy requirement from the first week after injury.When severe injuries are associated with burns we should be especially aware of post-injury stress complications. Trigger: Oxygen starvation The definition of shock is: oxygen starvation at the cellular level.There may be many reasons for post-injury oxygen starvation: The blood supply at the site of injury is damaged; the global blood circulation is down due to blood loss; the cardiac output is low due to arrhythmia or cardiac infarction; there may be breathing failure due to pain or injuries to the chest and abdomen. Next to reperfusion syndrome (see below), a state of shock is the strongest trigger of cytokine production. The time factor is important here: most tissues (except the brain) can take 30 minutes of oxygen starvation without much damage being done, but if cells remain in a state of shock for more than 1-2 hours the trigger effect is very strong. Trigger: Reperfusion syndrome Reperfusion is what happens when the blood circulation is re-established after a period of poor blood supply. Reperfusion occurs in a patient when profuse bleeding eventually is stopped (e.g. by laparotomy) and circulation re-established by blood/fluid input, or it may happen when the local perfusion in a severely injured limb improves as a result of fasciotomy. Tissues that have been without blood flow or poorly perfused for a while then become re-perfused. This is obviously a gain in the long term, but in the short term reperfusion is a dangerous trigger. If reperfusion occurs after a period of two hours or more of low blood flow, chemical substances are washed out from the tissues and trigger a massive cytokine response which acts both locally and globally. In the injured tissues the endothelial cells become damaged and the capillaries become blocked by clots of blood cells. The all-body effect of this potent trigger is coagulation failure and immune depression.
163
6 The injury
The only way to estimate the gut perfusion is to measure the pH of the gastric/intestinal mucosa which is not feasible in low-resource settings. The best we can do is to keep up intensive resuscitation for at least 48 hours after injury even if BP, HR and UPH are normal. More on post-operative fluid resuscitation, see p. 725.
Hidden shock: Reperfusion after gut hypoperfusion In clinical practice we use blood pressure, heart rate and the urinary output as indicators of circulation and regard resuscitation to be effective when the blood pressure is up to 90 mm Hg, the heart rate down to 90/minute, and urinary output (UPH) per hour at 1 ml/kg after a period of circulatory shock. But despite these apparent indicators there may remain a state of low blood flow in the vascular bed of the guts after the initial resuscitation in a severely injured patient, a silent state of shock without clinical signs. With further good care and supportive therapy the blood flow to the guts gradually improves. However, reperfusion of the small intestines after protracted hypotension releases a strong cytokine response which may act as a hidden and protracted trigger. Trigger: Pain and fear Pain and fear are useful signals in the sense that they help activate the sympathetic nervous system. But when pain and fear persist over time, they act as permanent triggers that fire cytokines on the immune system and bring it out of balance. Pain also acts directly on the autonomous nerve system to upgrade the stress hormone response (adrenaline, cortisol). Trigger: Bacterial infection If the patient is in reasonable shape before the injury and does not suffer from endemic diseases or malnutrition, a moderate local infection is managed well routinely by the immune system. But there are infections that trigger the immune system so severely that it may get out of balance and eventually fail to remove the micro organism. Be especially aware of abdominal abscess, peritonitis and post-injury pneumonia.The gram-negative infections (E-coli, pseudomonas, klebsiella) are particularly dangerous; their membranes contain an endotoxin that acts on the endothelial system and triggers a general cytokine response which can cause coagulation and immune failure. Trigger: Extensive surgery
injury
surgery
The double hit hypothesis: Primary trauma surgery may take a patient in partial physiological imbalance to totally out of balance there are two assaults, not one. Surgery is seen by the bodys physiology as a trauma; you are cutting through viable soft tissues and placing screws into live bones. Anesthesia helps prevent the stress response, but extensive surgery (more than one hour) on patients on their way into a state of post-injury stress is by itself a trigger just like the primary tissue damage. This recognition lays the foundation for staged surgery in severely injured patients.
164
Trigger: Multiple blood transfusions Even when transfusions are carefully compatibility checked, replacement of more than 50% of the blood volume (five units of blood) is a risk factor for coagulation failure. Massive transfusions nearly always take the coagulation system out of balance. The pathway for the complication is connected to hypothermia, lack of platelets, dilution of coagulation factors, white blood cells and acidosis in banked blood are some of the contributory factors. Trigger: Malnutrition Failure in nutrition can act as a trigger in two ways. Firstly, persons with malnutrition have weak immune systems and consequently carry a risk for post-injury infections that may act as stress triggers. Additionally their immune system is already out of balance at the time of injury, so it takes less injury-released triggers to break it down. Thirdly, proper nutrition after injury and surgery is of vital importance to keep the immune system going. The lymphoid tissues in the intestinal mucosa is an immunological headquarters, especially for lymphocytes and antibody producing plasma cells. Surgeons should notice that the mucosa of the small intestine takes only 40% of its nutrition from the blood stream; 60% of the fuel for the headquarters is taken from the intestine by direct absorption. It follows that one of the main motors of the immune system will be starving if the post-injury nutrition is poor.
Three routes of stress: The stress response after a severe injury acts along three main axes. The first and immediate response comes by a down-regulation of the coagulation system. Then the immune system comes under stress, first by a brief overdrive period followed by protracted depression. The metabolism initially slows down, then after 48 hours it goes into a state of increased energy consumption. Let us study each of the three axes of stress response.
165
6 The injury
fibrin seal
plug resolution
The coagulation balance, unpredictable reactions: In blood there is thus a very delicate balance between processes enhancing coagulation and processes causing tendency to bleed. It does not take much to get the system out of balance. A severe injury causes multiple injuries to the vascular bed and therefore a massive immediate activation of platelets.There is also an early compensatory activation of fibrinolysis to prevent an over-clotting in the blood. However, when exposed to post-injury triggers especially oxygen starvation which causes acidosis either one or the other coagulation reactions may go astray. Then the coagulation system goes out of balance, the clinical effect being increased tendency to bleed, or increased tendency to clot. The clinical picture is unpredictable and varies from patient to patient. Do not rely on laboratory tests Several laboratory tests measure elements of the coagulation system. However, many tests may be misleading because they are done at calibrated temperatures and not at the actual body temperature of 37 C. The most important feature is the phys166
ical capacity of the clot and how fast it forms, for this bleeding time is a simple and very useful indicator: Bleeding time of 4-6 minutes indicates reasonable coagulation capacity. Another rough test can be done in-field or in the emergency room: In multi-organ failure (MOF) you may see both extreme clotting and extreme fibrinolysis in action at the same time. Organ failure, see p. 169 and p. 736. Bed-side clotting test Draw 5 ml of blood from the patient and place it into a clean glass tube. Place the tube in your arm pit to keep it warm. Turn it carefully upside-down every half minute. If a bloot clot forms within 5 minutes there is no significant coagulation failure. Factors that affect coagulation Hypothermia slows down platelet plug formation Acidosis (pH < 7.2) makes platelet plug fragile Dextran makes platelet plug fragile NSAID slows down platelet activation Tranexamic acid slows down fibrinolysis tendency to bleed tendency to bleed tendency to bleed tendency to bleed tendency to clot
A matter of half-hours! The coagulation failure sets in very soon after major injuries. The triad of death coagulation failure, acidocis and hypothermia The most common reason for uncontrollable bleeding is acidosis combined with low blood temperature. In-field and in the hospital before, during, and after surgery we should do everything possible to support the oxygenation and prevent loss of heat. See Life-saving surgery, p. 234.
The immune response acts by two different pathways Pathway 1, immediate, general (innate immune response): The immediate up-regulation of the immune response is the bodys first line of defense against infection.This response is very quick, however not well targeted.The Pathway 1 response is carried by phagocytes (granulocytes and macrophages) aiming to clean up the site of primary injury. The activation of pathway 1 releases cytokines that activate another pathway:
167
6 The injury
Pathway 2, delayed, (specific immune response): This response is gradually activated within 5-10 days after injury. Pathway 2 is carried by activated lymphocytes and antigen presenting cells. This pathway is well regulated. The negative feed-back inside the immune system is a beneficial self-regulatory mechanism which prevents over-heating of the immune response. The problem in patients with severe injuries, shock, pain and post-operative infections is that a massive and protracted triggering causes too much inhibition and also fragmentation of a nicely orchestrated pathway activation. Post-injury immune system failure may be either an ineffective response, or an overall depression of the exhausted immune system.
Organ failure
More on organ failure, see pp. 73038. When triggers keep on firing, one or several organ systems may start to fail; they become exhausted. Multi-organ failure (MOF) carries high mortality even in the best trauma centers. Here we just outline the main features of MOF for the war surgeon to recognize the complications at an early stage.
169
6 The injury
Risk factors for multi-organ failure Very high risk TBSA = Total Body Surface Area, see p. 697. Multiple severe injuries Burn > 50% of TBSA Circulatory shock > 2 hours Lung contusion Flail chest Aspiration Severe brain contusion Severe injury to colon or pancreas Crushed limb High-energy fractures of femur or pelvis Surgery > 1 hour on compromised patient Blood transfusion > 10 units Gram-negative sepsis Gram-negative pneumonia Peritonitis or abdominal abscess Blood transfusion > 5 units Severe injury to small gut, liver or kidney Other compound fractures High risk Single severe injury Burn 25-50% of TBSA Circulatory shock 1-2 hours Less risk
Post-injury lung failure is also called Adult Respiratory Distress Syndrome, ARDS.
Lung failure (ARDS) When the lungs are directly traumatized they produce many chemical factors which contribute to further downhill physiology and self-destruction. But even without obvious lung trauma, adult respiratory distress syndrome still develops. Eg. transfusion related lung injury is a feared complication to blood transfusion probably induced by antibodies present in the donor blood (HLA antibodies). The first two days after injury: Microemboli in lung capillaries with reduced blood perfusion. Defects in the alveolar membrane, low-grade lung edema. Clinical signs: Dyspnoea, respiratory rate > 25/minute, slight cyanosis. Rales on auscultation. There are few signs on the X-ray at this stage. Four or five days after injury: Massive clotting of lung circulation. Collapse of lung tissue with fibrosis formation = stiff lungs, atlectasis. Lung edema. Clinical signs: Increasing dyspnoea, respiratory rate and cyanosis. Pneumonia. Patchy infiltrates on X-ray.
170
Organ failure
Disseminated Intravascular Coagulation (DIC) At any time after injury: Multiple microemboli in the vessels throughout the body cause massive consumption of blood platelets. Increased fibrinolysis may occur simultaneously. Clinical signs: Total imbalance in the coagulation system: tendency of spontaneous bleeds plus tendency to clot. Tissue hypoxia and failure of specific organs due to artery emboli. Cardiac failure The cardiac output is not sufficient to meet the demands of the body. The reasons may be several: Immediate: Heart infarction and arrhythmia under circulatory shock Later: Inadequate oxygen supply during the hypermetabolic period causes reduced contractility and function of the myocardium. Renal failure after extensive contusions (crush syndrome), see p. 733. Renal failure The kidneys are very sensitive to oxygen starvation. Necrosis of the renal tissue may occur at any stage after a severe injury. Immediate: Kidney infarction under circulatory shock Days or weeks after injury: Infarction due to coagulation failure/DIC. Clinical signs: Low urinary output. Water retention causes pulmonary edema and heart failure. Retention of waste products (uremia) causes pericarditis, neurological symptoms/convulsions. Liver failure The liver is less sensitive to oxygen starvation. It has a large reserve capacity and can do the job as long as 50% of the organ is functional. The liver has a high capacity for regeneration when injured. The depression of the liver function after circulatory shock is seldom permanent and will improve spontaneously. However, the late liver failure may be serious. Clinical signs: Jaundice. Hypoglycemia. Chronic liver failure may cause reduced synthesis of proteins (albumin, acute phase proteins, coagulation factors).
171
172
............................................................. ......................................
A: Control the airway ............................................................. 180 Advanced life support for airways ........................................... 181 Airway cut-down ............................................................... 183 B: Support the breathing and give pain relief ................................. 185 Ketamine is the drug of choice ............................................... 186 Place a naso-gastric tube! ..................................................... 187 Advanced life support for the breathing: Chest tube drain ............. 188 C: Support the circulation ........................................................ 195 Stop limb bleeding, no tourniquets ......................................... 196 How to control internal bleeding ........................................... 198 Cold blood bleeds more keep patients warm ........................... 200 Intravenous cannulation ....................................................... 201 Venous cut-down ............................................................... 204 Volume therapy and nutrition ................................................ 206 Identify wounds and injuries Positioning of the patient Transport to hospital
.....................................................
.........................................................
173
Life support kits, see p. 74. Charts for in-field medical documentation, see p. 114. In-field rapid sterilization, see p. 75.
Never touch (what might be) an explosive device move around it!
174
One + one is more than two: Encourage and help each other!
with each other: How well did we do? How do we improve? Unload painful feelings: What did we feel on the site and afterwards? Can we support each other better? Do some of us soon need a week off? To make a good performance is not so much a question of individual skills, as regular training of team work, well prepared medical kits, and a caring team leader.
176
When a lot of blood is lost, pressure falls even if the pump works hard. If all lines of defense are broken, the blood pressure starts to fall This is a late and dangerous sign. Around 1/3 of the total blood volume has been lost, more than 1.5 liters in an adult. Even if the heart works as hard as it can, it is difficult to get enough blood supply to the brain and other main organs. The oxygen supply system can only work if all three parts work If the airway is OK and breathing is OK, but he is getting worse, he is probably losing blood. If the airway is OK and the heart rate less than 100 beats each minute, but he is getting worse, there is a breathing problem. Support all the way The oxygen supply system needs constant support and attention, outside hospital and in hospital, before, during and after surgery.
177
178
CPR in adults: 2 in 30 Give two rescue breaths. Immediately after this, press down on the chest 30 times. Continue in this way, giving 2 breaths for every 30 chest compressions. If you are alone, you have to change position from sitting beside the victims head to sitting beside his chest. If there are two first helpers, one does the rescue breathing, whilst the other compresses the chest. Assess every 2 minutes: are there signs of spontaneous breathing? CPR in children: 2 in 30 The rescue breathing: Place your mouth over the childs mouth and nose, and fill his lungs until you see the chest rising. (But do not fill the lungs too full!). The chest compressions: Use one hand for a child, or only two fingers for an infant. Press rapidly downwards approximately 100 times per minute. Check that the chest compressions make a pulse in the carotid artery at the neck, or in the femoral artery at the groin. Previously we recommended a rate of 2:15 in adults and 1:5 in children. Recent research documents that the oxygenation (rescue breathing) is more important than circulation (chest compressions); therefore the guidelines now recommend CPR rates of 2:30. Advanced CPR Ask an assistant to place an IV cannula and give an IV injection of adrenaline. But do not stop the CPR. These things should be done at the same time as the CPR! IV Ringer is useful for all victims with heart arrest. If the heart has stopped due to injury and blood loss, the victim has probably lost a lot of blood. Give a lot of infusion rapidly! As soon as the IV cannula is in place, give IV adrenaline 1 mg. Then do 10 cycles of CPR and give 1 mg adrenaline once more. Continue CPR until the heart starts beating, he starts breathing on his own, or wakes up. Stop when you and your helpers are too tired to go on. If you are this tired and the victim has not responded, the victim is dead and cannot be saved. Advanced CPR for adults and children in brief Examine the victim: Awake? Open airway? Breathing? Pulse? If none of these, there is heart arrest. Start CPR: 2 rescue breaths for every 30 chest compressions. Place IV cannula, and give adrenaline. Give 10 cycles of breaths-compressions. Then reassess. If no improvement, continue CPR and give more adrenaline. If there is still no response and you are too tired to continue, consider the victim dead.
179
If the patient initially survives aspiration to the lungs, the risk of late complications is high, see p. 730. Fuel-air explosives, see p. 130.
He is unconscious, the tongue is blocking the airway. Head tilt and chin lift opens the airway.
180
In unconscious victims contents of the stomach may block the airway. Recovery position prevents airway block.
Not talking? Not awake? Recovery position immediately: The recovery position will prevent the tongue from falling back to block the airway. There is less risk of vomit, blood and mucus running into the airway. Face injuries? Place with face down: Blood from injuries to the face, mouth or neck, may block the airway.This may even happen in the recovery position. Place the victim with their face down, and their head tilted backwards. Make a hole in the stretcher or the mattress. Place the victim on it with their face over the hole to drain the blood. Injured tongue? Pull it out of the mouth: When you pull out a bleeding tongue, the bleeding becomes less. The tongue will also swell less with less risk of a blocked airway during the evacuation. Get a good grip of the tongue between your fingers, using a piece of cloth. Pull it out of the mouth and downwards. Use a safety pin, towel clamp or a suture through the tongue to fix it to the skin. Airway burns: Take to hospital immediately. Pain relief is mandatory. Transport in half-sitting position and be ready for airway cut-down, see p. 184. Remember, the simple measures are most important In study of 3,800 Afghan war wounded, in-field endotracheal intubation was done in 12 patients only (0.3%); all others were safely managed by basic airway measures. See www.traumacare.no/publications
181
Age of patients Newborn 1-3 years 5-7 years 12 years Adult (small) Adult (large)
stylet
Place tip of stylet 2 cm from tube end and bend upper part of stylet so it doesnt slip down. Note: The stylet inside the tube should be slightly curved.
Place victim at on his back. Tilt head backward. Give two minutes of rescue breathing before intubating. Have a helper ready to apply cricoid pressure.
ep igl ot tis
vocal cords
Hold laryngoscope in left hand, slide it into right side of victims mouth.
Lift base of the tongue, and forward laryngoscope until you can see the epiglottis.
Now lift laryngoscope in direction of the handle do not bend it toward yourself. You should now see the vocal cords. If not, push the cricoid upwards and to the right.
You must see the vocal cords! Slide tube past the cords and remove stylet. Advance tube well below cords (in adults: 24 cm marking at victims lips). Hold tube steady and inate cuff.
If victim is breathing by himself: Check that warm breaths are coming on the tube, also check that the breathing sounds are equally strong over both lungs. If the victim does not breathe: Blow air into the tube, listen to breathing sounds and see that both sides of the chest rise. The abdomen should not rise. If you suspect tube in esophagus remove it immediately.
Fix the tube with gauze bands. Tie properly, tube displacement may kill. After tying, check tube position again. If breathing becomes difcult or victim becomes pale, withdraw the tube 2 cm and check breathing sounds again.
182
Endotracheal intubation
Failed intubation No attempt should last more than 30 seconds! Give 2 minutes of rescue breathing before you try again. Before trying again: Elevate the head a little.
If victim does not breathe himself: Attach self-inating bag and start assisted breathing immediately, at a rate of approximately 20 breaths per minute. Without bag: Start mouthto-tube rescue breathing.
Find the cricoid ring. Its the rst cartilage below the Adams apple.
Failed intubation? Tell the helper to push the cricoid upwards and to the right. Use a smaller tube, bend the stylet more. Not more than three attempts, edema and bleeding in the larynx may kill the patient! Not more than three intubations should be attempted, edema and bleeding in the larynx may kill the patient. If victim vomits: Place in recovery position immediately and clean up the airway with suction. Then place in supine position with cricoid pressure and try intubation again. Endotracheal intubation in brief Intubation gives a safe airway but it can be difficult and even impossible. Nobody should try intubation without having trained to do it at regular intervals. If intubation is difficult, consider airway cutdown. thyroid cricoid
lages of the larynx (the thyroid cartilage and the cricoid cartilage) called the cricothyroid membrane. First identify the cricoid cartilage: Find the top of the chest bone in the mid line. Let your finger run up the trachea exactly along the mid line. The first peak of cartilage you encounter is the cricoid. Then let your finger run further upwards along the mid line: Now you feel another, larger peak of cartilage, thats the thyroid (or Adams apple).The crico-thyroid membrane is the narrow hollow you feel between the cricoid and the thyroid. Fix the larynx and cut through the skin: The incision will bleed less if you stretch the skin over the larynx to the sides. Maintain your left-hand grip on the larynx all the time until you have cut through the membrane with your right hand. The patient is close to dying so there is no time for anesthesia or disinfection. Use any sharp knife at hand. Cut through the skin and the subcutaneous fat exactly along the mid line from the peak of the thyroid downwards a few cm. Cut through the membrane: Wipe the soft tissues off the larynx with some cloth and use your fingertip to locate the crico-thyroid membrane. The membrane is just 0.5 cm to1 cm beneath the skin. When you can see the membrane, make a decisive cut transversely through the membrane with the knife. This cut should not be more than 2 cm (one good fingertip) wide. Now you have entered the trachea and can hear air wheezing through the incision. Congratulations, you have saved a life. Insert a tube if you have one: Place one small fingertip or the handle of your scalpel knife inside the cut-down incision to keep it open. Then introduce a 5-mm endotracheal tube through the incision into the trachea, fix the tube with your hand and inflate the tube cuff. If you have no endotracheal tube, use any soft plastic tube about 0.5 cm in diameter. Or simply hold the cut-down incision open with your fingertip until a tube is found. Note: Dont push the tube more than 5 cm into the trachea! If the patient does not breathe: Start rescue breathing by either mouth-totube or bag-to-tube. If the patient breathes: Clear the upper airways with suction. Pack wounds of the mouth and pharynx with gauze to stop the bleeding. Fix the tube with a band of gauze or cloth tied around the neck of the patient. Close the skin with interrupted sutures if you find time for it. The sutures should be deep and include the soft tissues under the skin, but do not suture the crico-thyroid membrane or the cartilage. If there are no suture materials at hand, just cover the incision with some clean gauze or cloth. Airway cut-down in brief Cutdown should be done if equipment for endotracheal intubation is not at hand, or if intubation fails two times. Consider cutdown plus ketamine- diazepam sedation in airway burns. The cut-down is simple and causes far less harm than clumsy endotracheal intubation.
Fix the larynx and with one hand cut through the skin.
184
Place and carry the abdominal injured in a half-sitting position. Note how well the medic supports the airway.
185
186
The importance of an NG tube treatment in primary trauma care is not appreciated enough.
Open your mouth and breath deeply! Direct the tube along the oor of the nose, towards the ear.
When you see the tube in the throat stop! Tell him to swallow as you push the tube downward.
Equipment needed: NG tube, diameter 3-5 mm. Cup of water. Tape. Torch.
Mark 60 cm from the tube end (marker pen or tape). In adults 60 cm is the distance from the nose down to the stomach. Place the conscious victim in a sitting or half-sitting position. Tell him what you are going to do. Place the unconscious victim in a side position so that vomit can easily be drained by the mouth. Moisten the tube with oil or water. Introduce the tube through one nostril along the floor of the nose, directing it towards the ear. Pause for 10 seconds when you can see the tube in the throat and tell the patient to breathe well, that helps him to avoid vomiting. Now tell the patient to swallow and at the same time introduce the tube smoothly down into the esophagus. Let the patient swallow repeatedly (they may take sips of water) while you forward the tube stepwise to the stomach. Check that the tube is not bent inside the esophagus: Blow air through the tube (by mouth). Press your ear over the stomach to listen a bubbling sound over the stomach confirms that the tube is in the correct position. Fix the tube to the chin with tape. Problems? The victim coughs when the tube passes down the pharynx: This shows that the tube has entered the airway. Pull the tube back and try again. Vomiting during the introduction indicates that you are too rough; calm the victim and yourself.
187
Basic Life Support for the breathing in brief All victims severely injured and awake: Place them in half-sitting position. Count the breathing rate: RR more than 30/minute (adults) give IV ketamine pain relief and check again. RR > 30 after ketamine needs urgent follow-up. Calm the victim: Talk to them. Touch them. Place an NG tube in all patients with abdominal injury if they are far from the hospital. Signs of tension pneumothorax: Immediate needle puncture!
In small children chest tubes should be placed at a very early stage to safeguard the function of the other lung.
Hemo-pneumothorax in children: The volume of the chest cavity in children and infants is small compared to adults; the chest cavity rapidly fills up with blood and air. The mediastinum the mid-chest wall is soft in small children and will shift over and gradually also compress the uninjured lung.
188
Tension pneumothorax after blasts causes a very rapid collapse of the lung: The blast wave is transmitted through the airways causing extreme over-pressure in the lung tissue.This may cause tears of the lung surface. Additionally spalling at the inner surface of the chest wall may break the surface of the lung without breaking the chest wall itself. In this situation air will leak into the chest cavity by each breath but it will not find any way out. With increasing over-pressure the mediastinum will shift over and squeeze the uninjured lung also in adult victims. The clinical signs of blast tension pneumothorax are: Fear: The patient realizes that he is on the way to dying.You can read fear in his face. Distressed breathing: The breathing rate is very rapid and each breath superficial. The patient will normally sit or half-sit. Distended neck veins: The over-pressure inside the chest cavity blocks venous return to the heart. This is a dramatic and late sign. High heart rate: Due to poor venous input, the heart tries to maintain maximum output by an increased heart rate. Tension pneumothorax: There is no wait-and-see! Place chest tube immediately!
A tube drain stops the bleeding in 9 out of 10 patients with a bleeding chest injury; very few patients need surgical interventions for chest bleeds.
Chest drain prevents stiff lung. If blood is not drained, it clots and forms scar tissue. Non-elastic scar tissue attached to the lung makes the lung stiff. Undrained blood that is retained in the chest cavity for more than one week will cause the lung to shrink and it will stay dysfunctional for the rest of the patients life. Chest drain prevents chest infection. All fragment wounds are dirty and full of bacteria and so are chest wounds. Blood collecting inside the chest is excellent food for bacteria. An abscess will form unless the blood is drained. Examination of the chest Find all wounds in the chest wall: Undress the patient completely, wash off blood and dirt. The wound may be tiny yet it may be life threatening. Also check the rear of the patient. Compare breathing sounds over both lungs: Use a stethoscope or place your ear at the chest wall and compare the breathing sounds over both lungs. The injured lung is partially collapsed, so the breathing sounds are weaker over this side of the chest. Compare percussion sounds over both lungs: Over the non-injured lung the percussion sound is full and resonant; but where blood collects the sound is dull and weaker. Are you in doubt? Make a probe puncture: Insert a large-bore needle (IM size, no syringe attached) through the chest wall in the area where you think there may be a hematoma. Let the needle slide through the chest wall at the upper edge of a rib in order not to hit a rib artery. One of three things may happen: If air wheezes through the needle when you enter the chest cavity, you probably hit a pneumothorax: insert a chest tube! Or, if you can draw blood by the needle into a syringe, you probably hit the hemothorax: insert a chest tube! If neither happens: there may still be a hemothorax but probably so small that it can go without drainage. Tension pneumothorax Air collects at the top of the chest cavity. Puncture the chest wall with a large-bore needle in the 2nd or 3rd intercostal space immediately! The whistling of air out through the needle and immediate relief visible in the patients face confirms the diagnosis. Take action based on clinical signs.There is no time for chest X-ray examination. Place a chest tube well up in the axilla (and not in the front below the clavicle, where the access is more difficult). Hemo-pneumo thorax The blood will collect at the lower part of the chest cavity. The diagnosis is based on careful percussion and auscultation: dull percussion and weak breath sounds. The clinical signs of a 500 ml hemothorax may be discrete. If in doubt: make a probe puncture through the chest wall and see if you can draw blood through a syringe. If still in doubt: place a chest tube.
Wash off the blood! Fragment wounds at the back. Can the abdomen be injured?
Dont waste time by counting ribs to find the place of insertion. For tension pneumothorax the tube should be placed in the armpit, above the mammary level. To drain hemothorax the tube should be inserted a little lower, somewhere inside the area of one hand placed at the top of the patients armpit.
190
Prophylactic antibiotics, drugs and doses, see p. 744. Ketamine anesthesia, see p. 804. In-field disinfection, see p. 78.
Preparations Equipment you need: Soap and clean water Any soft plastic tube approximately 10 mm wide.You may also use an endotracheal tube Knife Large artery forceps Strong suture (1-0 or 2-0) on large curved cutting needle. Needle holder Suction apparatus or a bottle with soap solution (see water seal, below) Clean towels and sterile gloves Ketamine (vial 50 mg/ml) Antibiotics. Give ketamine anesthesia, and prepare the instruments: Cut the tube at 50 cm and cut 3 small side-holes in it. For disinfection, place the tube and instruments in 45% isopropanol for one minute, then rinse with water. Wash the site of insertion with soap-water for one minute. Place clean towels under the patient.
Make a 3-4 cm skin cut parallel to the rib at the level of the nipples (male, arm hanging down). Tension pneumothorax: Enter by the armpit, not in the front under the clavicle. But place the tube as high up in the armit as possible.
Push the forceps through the chest wall into the chest cavity. Let the forceps slide over the upper edge of a rib. Open and close the forceps when inside the muscles to make a wide channel. You hear a snapping sound when you penetrate the pleura. If you do not have a large forceps at hand use a pair of blunt scissors to make the channel for the tube. Do not cut with the scissors, but push it into chest closed and open it widely while inside the muscle to force the muscle fibers apart do not close the scissors until it is taken out of the chest. Note: You have to use some force, so support the forceps with one hand against the chest wall, or else you may slip into the lung by mistake.
191
Open the forceps and withdraw them to make a tunnel. Push your finger through the tunnel and feel inside the chest cavity. This is to make sure that the lung is off the inner chest wall (lung scarring from tuberculosis is common in many war injured). A wide channel is not dangerous: the wider the channel the easier the positioning of the tube.
Clamp the tube 15 cm from the tube end with the other forceps. Push the tube in through the tunnel while the finger/forceps slides out. Forward the tube 15 cm inside while you steer it towards the back and upwards towards the shoulder. Note: The tube is still clamped with the forceps to prevent a lot of air leaking into the chest cavity.
Set two deep skin sutures (size 2-0) in the skin cut, one suture on each side of the tube. Note: The sutures should catch all outer layers of the chest wall skin, muscle, and fascia so that the incision is tightly closed. You may use the sutures to fix the tube, or you can fix it with adhesive tape. Close the skin cut with additional deep sutures or tape. There may be some initial leaking of air around the incision but this will stop within an hour when the wound swells.
The chest tube will not drain if there are defects in the chest cavity: Use a separate incision for the chest tube. Do not use the bullet/fragment wound, it is infected already. Close chest wall wounds with deep sutures. If available, seal the suture line with a surgical drape. Sometimes the chest tube is trapped in the interlobar space when the lung is expanded and the drain stops working. Try to withdraw and manipulate the tube, or place an additional drain. Stylet prohibited! Do not use chest tube with pointed steel stylet/guide: Far too often the stylet will penetrate the lung. Prophylactic antibiotics! Chest tubes cannot be placed in a sterile manner in-field: give IV antibiotics, see p. 221.
192
glove. Then he must take deep breaths in and blow out forcefully. This is the best way to expand the lung rapidly but the excercises require proper pain relief. Monitor the drain: Is the bleeding increasing or decreasing? Check every 30 minutes HR, BP, and how much blood is drained: Bleeding by the tube + HR + BP = success. Bleeding by the tube + HR + BP = the patient is probably losing blood from another injury. If the tube drains a lot of blood + RR + HR : Speed up the IV infusion to keep BP around 90 mm Hg. If the BP gets higher than that, bleeding may increase. If severe bleeding goes on (> 500 ml/hour) and you cannot keep BP at 90 mm Hg, surgery (thoracotomy) is urgent. If no blood is coming by the tube: Leave the tube in place until the X-ray shows that the hemo-pneumothorax is completely drained and that the injured lung is fully expanded. If the hospital is far away and you cannot have X-rays done, the tube should be removed after 3 days but only if no more blood or fluid is coming out the tube. If the tube drains less than expected, it has probably clotted: Place another larger tube. Needle thoracostomy as treatment? No! Some doctors and textbooks recommend to drain pneumothorax by a needle with a split rubber glove finger tied to to it; this arrangement is said to make a valve so that air under tension is let out from the chest cavity. We discourage this approach for two reasons: 1. A thin needle with a rubber glove may easily be blocked by clotted blood and drainage becomes inhibited. The patient may then develop tension pneumothorax without drainage. 2. A rubbe glove is not an efficient one way seal. Air may still leak in. Then pull out the tube, and immediately tie the suture. Chest tube in brief Better to place one chest tube too many, than not to place chest tube in a patient in need of it. If you insert inadequate chest drainage, the patient may develop tension pneumothorax after you think you have finished the treatment. Place the chest tube soon after the injury, before the lung collapses and too much blood is lost. The patients position, ketamine pain relief and breathing exercises are vital.
Removing the chest tube: No air should be sucked into the chest when you pull out the tube. So, rst place one deep, double suture, but dont tie it yet.
194
195
4. Pressure dressing: Apply a tight dressing of elastic bandage (10 or 15 cm rolls) on the entire limb from the toes/fingers to the groin/armpit. Such a dressing will stop the bleeding, hold the packing in place and prevent swelling of the limb.
5. Check the effect for one minute: If it doesnt bleed through the dressing, you can gradually reduce the pressure on the artery but keep the limb lifted at all times. If the wound bleeds through the dressing, press on the main artery again and place another pressure dressing over the first one. If it still bleeds, the packing was not properly done: remove it, pack again and apply a proper pressure dressing.
196
Blind clamping prohibited! Do not try to stop external bleeds by placing vascular clamps inside the wound: It damages vessels and nerves making surgical repair difficult. It is not necessary; you can stop any external bleed by proper deep gauze packing.
They say tourniquets are acceptable if you release them briefly every hour. We have seen hundreds of tourniquet cases, but nobody had dared to release them. And if they had done, a massive rebleeding would have occurred.
197
Then stabilization: Fractures open as well as closed are common in wartime mass casualty events and you cannot carry ready-made splints for all. Make it simple: Under constant manual traction, the injured leg is tied to the uninjured leg by turns of elastic bandage. The fractured arm is tied to the body and the thigh. The fractured finger is taped to its neighbor.
No BP apparatus? You can feel the wrist pulse: BP = 90 mm Hg. You can feel the groin pulse but not the wrist: BP = 80 mm Hg. You can feel the carotoid pulse only: BP = 70 mm Hg.
Keep the patient warm: Most liver bleeds stop spontaneously if the blood is warm enough for the platelets to form blood clots. Warm IV infusions are mandatory. Support the breathing: When there is less blood in circulation it is even more important to load it as much as possible with oxygen. Give pain relief! Place in half-sitting position (if still awake)! Keep BP at not more than 90 mm Hg (hypotensive fluid resuscitation): If you push the infusion hard, the blood pressure will rise and blood clots already formed will be flushed out and rebleeding starts. Several liters of infusion will dilute the blood so much that it cannot clot at all. If you can feel the radial pulse, the blood circulation is good enough also to support the internal organs and the brain. Abdominal bleeds The old guideline of getting BP up to normal levels (120 mm Hg) as soon as possible after injury has proved to be wrong. Recent studies document that hypotensive fluid resuscitation reduces mortality in patients with traumatic brain injury plus abdominal bleeds. If the surgeon is less than hour away, dont give volume therapy at all!
Manual compression of the aorta is a useful temporary measure that also reduces bleeds after delivery. Extra-peritoneal pelvic packing, see p. 270.
Control pelvic and proximal thigh bleeds by aorta compression There is a vast network of arteries and veins inside the pelvic cavity close to the bones. Open as well as closed fractures of the pelvis therefore bleed a lot. In very high thigh injuries it may be impossible to apply proximal pressure on the artery. In such cases bleeding is reduced by external compression of the abdominal aorta: 1. Instruct one helper to push down his fist exactly in the midline just below the umbilicus in order to squeeze the aorta against the spine. 2. Check the femoral pulse beat: push so hard into the abdomen that the groin pulse cannot be felt. 3. Keep up the aorta compression steadily for at least 20 minutes while you warm the patient.
199
Prevention of cooling is most important: Due to the laws of physics it takes 4-6 times as long to rewarm compared to the time of cooling the human body. The lower the temperature, the slower will the rewarming be. Remove wet clothes immediately. Place blankets under and over the patient. Protect against wind (plastic sheets) during transport in open vehicles. Two ways to warm patients Warming from outside: Buddy warming: Let one helper sit/lie close to the patient holding around him. Place plastic bottles with hot water in the armpits and groins of the patient.
Warming from inside: If at all possible, use warm IV infusions. Boil water and put the IV infusion bags into the hot water; 5 minutes in water for 1 L infusion at 20C raises the temperature to 40C which is perfect. In cold weather: keep the IV bags in your own armpit during the transport.
200
Let the patient sip warm drinks if he can talk and is without injury to the abdomen. Central warming by enema: Explore the rectum with your finger; if there is no blood on the glove, you can use enemas. Introduce one liter of warm water (warmer than your skin). Empty after five minutes and repeat. Central warming by the bladder (in emergency room): Instill, drain, and reinstill warm sterile saline repeatedly via the bladder catheter. Special for burns: Burn patients lose a lot of heat through the large burn wounds: Cover the burn wounds with several layers of clean cloth. Cover the victim with blankets. IV infusions, drinks, and food should all be warm.
201
The infusion bag, IV set and IV cannula are all sterile as long as the protective cover is not broken. If it is broken, dont use it. Bacteria must not enter the bloodstream! Dont touch these parts with your fingers: the connections between the IV bag and the IV set, the connections between the IV set and the IV cannula, the IV cannula itself.
tap
Remove covers and caps on IV bag and IV set. Close the tap before twisting the stylet into the bags outlet.
The plastic stylet is in place. Squeeze the drip chamber several times till it is half-lled with infusion.
Air inside the IV set must be let out. Open the tap and let the infusion run to ush out air bubbles.
Use a large IV cannula and a large vein If you use thin-bore cannulas in small veins you cannot give the victim a large volume of infusion even if you squeeze the infusion bags. We recommend cannulas of diameter 1.8 or 2.0 mm in adults.
stylet
cannula
Prevent the vein from rolling off the cannula by stretching the skin with your thumb.
202
Blood is entering the cannula (arrow). The stylet is inside the vein but not yet the cannula.
Dont withdraw the stylet yet. Slide the cannula a little further into the vein.
STEADY
Now slide the cannula forward (use left hand) without moving stylet (right hand).
Fix the cannula with tape before you remove the stylet.
Press on the vein (left hand) to prevent back-ow of blood. Remove stylet, connect IV set, and open tap to start infusion.
Make the vein swell: Place a band around the limb above the cannulation site. Let the limb hang down, and tell the victim to clench his fist (or foot) ten times. Slap the vein gently to make it contract. Cold and blood loss make the veins collapse. If so, warm the limb by wrapping a warm wet towel around it for two minutes. Fix the IV cannula well: Adhesive tape does not stick well on wet and bloody skin. Patients in stress and confusion may pull out the IV lines or some helper may tear them out by accident. Before rough transports, always fix the cannulas with sutures to the skin. In cold climate, prevent freezing in the IV tube by taping the tube to the skin under his clothes. Or put the bag and infusion set under the patient, let his weight flush the infusion.
IV cannulation common mistakes You did not take your time to let the vein swell properly. You selected a thin vein far down on the arm look at the elbow region! You pulled the stylet back too soon; the cannula was not yet inside the vein. Try once more, then go for the external jugular.
Ketamine pain relief, see p. 186. Ketamine anesthesia, see p. 804. In-field disinfection, see p. 77.
In adults and children older than 10 years: Make a cut-down of the saphenous vein. It is always located two fingers in front of the medial bone at the ankle.
Place a venous stasis (BP cuff at 50 mm Hg) mid-thigh. Wash the skin well with soapy water, and make a 3-cm cut through the skin but not deep: the vein is immediately under the skin.
Find the vein. Use a small artery forceps to clear the vein of soft tissues.
204
Place two sutures under the vein. Tie the lower suture, but not the upper one.
Make a small cut through the veins wall (less than half the circumference). Stop the bleeding by lifting the vein by the suture.
Use the sterile IV set tube as IV catheter. Cut the tube end obliquely, and make a few small side-holes. In children less than 10 years: place an IV catheter (at least 1.8 mm) into the vein without cutting the vein open.
Introduce the tube carefully 20-30 cm into the vein. It should slide upwards inside the vein smoothly and without resistance. If it does not, the tube is not properly inside the vein. When the tube is in place, tie the upper suture tightly around the tube to fix it. There is not time to close the skin cut, just cover it with clean dressing and start volume treatment. Temporary venous cut-down in small children In children older than 10 years a cut-down at the ankle works well. Smaller children have more fat under the skin, and it is difficult to identify the saphenous vein at the ankle when the vein is collapsed. Better do the cut-down of the superficial femoral vein at the groin.
Make the cut-down at the superficial femoral vein at the groin. The femoral vein is never collapsed. It is always located immediately to the medial (inner) side of the femoral artery.You can exactly locate the femoral artery by finding the pulse beat with your finger.
205
Make a 4-cm cut through the skin. Use your fingertip inside the wound to find the pulse beat of the artery. Note the anatomy: The saphenous vein coming from the ankle is located inside the fat, but outside the muscle fascia. The femoral vein is one level deeper, you have to split the fascia to identify it.
Place one or two IV catheters (minimum 1.6 mm) inside the vein(s). Hold the catheters steady while you squeeze the infusion bag. When enough IV infusion is given to compensate for the blood loss, the limb veins will fill up. Then you can do a standard IV cannulation and pull out the femoral vein catheters.
The last option: rectal infusion Electrolytes and drugs are absorbed by the rectal mucosa into the blood stream. Use double IV doses for placement of vital drugs, and leave the syringe in the anus for a few minutes to prevent leaking. For infusion of electrolytes: Place a bladder catheter into the rectum, inflate the balloon and pull the catheter back until the balloon rests inside the anal ring. Connect the IV line to the catheter and let the infusion drip slowly, approximately one liter per hour.
206
Patients differ.Young, healthy adults can take a blood loss of 1-1.5 liters and still have normal BP. Older patients have poor reserve capacity and lose BP after moderate losses. Clinical signs in children are different, see p. 408.
How much fluid should you give (unburned patients)? As a rough rule you need three liters of fluid to replace one liter of blood lost. The reason for the 3-factor is that the small blood vessels (capillaries) in the entire body start leaking after a severe injury so much of the fluid put into the blood stream will soon escape into the tissues and make them swell. This reaction is inevitable and cannot be prevented. So we have to stick to the rule of 1 unit blood = 3 units of electrolyte fluid. But how can you find out the liters of blood lost on the ground or inside the abdomen? Thats impossible; we have to estimate on clinical signs and for that we have to know how the body reacts to blood loss: First signs: HR speeds up to more than 100/minute.The body protects the vital organs by shunting blood away from the skin and the limbs into the central circulation: The skin (first the nose) becomes pale, clammy, and cold. The patient is thirsty and does not pass urine. Signs of major blood loss: The patient tries to load more oxygen on the blood left in circulation: RR increases > 30/minute. BP falls below 90 mm Hg.The brain is short of oxygen making the patient confused or unconscious. When you have stopped the bleeding: Start volume treatment if HR is > 100/minute! IV volume treatment is urgent if BP is less than 90 mm Hg! Internal bleeds, hospital not far: No volume treatment at all!
Beware: Patients on beta blockers are not able to increase their heart rate after blood loss and the BP will simply collapse with a regular HR.
Colloids make the kidneys retain sodium water accumulates lung edema increased death risk.
Urine production 100 ml/hour in adult patients means normal blood volume.
5. No improvement despite 4 L Ringer in 20 minutes:The victim is bleeding somewhere! See if limb wounds are bleeding through the dressing. Have you looked between the legs, around the anus and the back of the patient? Is he bleeding inside from a blast injury? The aim of volume treatment in non-burn adults: Get the BP up to 90 mm Hg and HR < 100/minute within 30 minutes! But if the hospital is near: Go for the surgeon not for the IV infusions!
blood loss should be done by IV infusions. But for moderate losses and for maintenance during long evacuations oral treatent may be the best option also it can provide nutrition. Too much salt is dangerous: Half a teaspoon of salt per liter is enough. With more salt, the absorption from the intestines slows down. Beware of ready-made ORS (oral rehydration solution) packets: they cost money, they are not readily available, the absorption is slower than drinks made from local cereals and the content of salt is too high. How? The drink should contain carbohydrate.You may simply mix table salt in water, but the absorption of salt (sodium chloride) from the intestines is 3-10 times faster if the drink also contains carbohydrates. So you can add sugar, but too much sugar may create an osmotic pull that draws water back from the blood stream into the intestines and the absorption slows down. Therefore it is safer to use other carbohydrate sources such as rice, maize, wheat, millet or whatever staple there is around. Make soups or dilute traditional porridges with water to make a thin drink that is easy to swallow.You can reduce the risk of stomach problems if you make the drink from yogurt or soured porridges (porridges made from fermented grain). The acidity that comes with the fermentation by lactic-acid producing bacteria delays growth of harmful bacteria, even if you use unclean water for dilution. How much? Non-burn patients need 3-4 liters by mouth to replace one liter of blood lost. If the hospital is far away, the drinking should also cover the bodys daily need of fluid which makes another three liters/day. The guideline is: Start out carefully with repeated small sips, not more than liter/hour. Let the patient drink until he voids but not so much that he vomits. Burn patients need nutrition from day one No other type of injury requires that much energy input. Patients with large burns need high-energy nutrition from the first day after the injury. If the victim is awake and without injuries to the abdomen: give parts of the volume required as soup or porridge. Long evacuations (days): volume + energy + protein Insufficient energy input after a severe injury may cause physiological collapse.Within 24 hours the carbohydrate stores in the patients liver (glycogen) will be empty. Within 48 hours the repair processes start: the energy required/day may be doubled as compared to non-injured persons and the severely injured also need extra protein. Find out what kind of foodstuffs are available where you are. Locals especially traditional midwives can advise you on traditional recipes for high-energy feeding. Advantages of home-made drinks: Rapid absorption Nutritious at the same time Treatment can start immediately Low cost, more self-sufficiency Focus in on people, local knowledge and education.
209
Content of nutrients in some common foodstuffs (per 100 g) carbohydrate (gram) Energy sources Lentils, beans, chickpeas Flour (wheat, maize, rice) Groundnuts Coconuts Coconut milk Seeds of melon, sesame, cotton Whole milk powder Butter, ghee, vegetable oils Carbohydrate sources Sugar and honey Banana Fruit juice Protein sources Meat Dried meat Fish Dried fish Eggs Milk Cheese (low fat) Cheese (fat) protein (gram) 30 10 25 5 20 25 energy (kcal) 400 300 600 400 250 600 500 800 400 100 100 20 50 20 50 20 5 20 20 200 500 100 300 150 100 100 400
80 80 60 40
100 25 25
210
Land mine victims: Entry wounds to the abdomen and the brain.
There is no minor head injury until the level of consciousness is repeatedly examined. Life-saving surgery in head trauma, see p. 239.
Signs of extensive brain injury, probably too much for surgery Dilated pupil/pupils with slow reaction to light Irregular respiration General convulsions. If you are in doubt, manage the case as a spinal injury until X-ray examination is done. One assistant should be at the head end and keep the head and neck stable under slight manual traction (5 kg) until the hospial team takes over.
Note: Any projectile or foreign body located deep inside a spinal wound should be left for surgical removal.
212
Remember the landmarks: C4 the shoulder girdle T4 the nipples T6 the lower end of sternum T10 the umbilicus L1 the groin/pubic bone S1 the lateral toes. Signs of spinal fracture or cord injury: Lift in one piece Four people should assist in turning and lifting the patient. Keep up traction in the feet and head/shoulders until the examination concludes whether there is an unstable spinal fracture.
5 Press the chest between both your hands. Indirect pain indicates chest wall fracture. 6 7
6, 7 Percussion: Your right 3rd finger is the drum stick, your 3rd left finger on the chest is the drum plate. Always compare one side with the other at the same level, and seek any difference between the two sides. Over the uninjured part of the lung the drum sound is resonant (plus see diagram). Over the hemothorax the drum sound is dull (small plus). Over the pneumothorax the drum sound is hyperresonant, that is a drum sound of greater volume than normal (big plus). 8 8 Auscultation: Again compare the sounds of both lungs at equal levels. Over the uninjured parts you can hear the normal respiration sounds (big plus). Over the pneumothorax and over the hemothorax the sounds are weak or absent (small plus). Dull drum sound and weak stethoscopic lung sounds: Hemothorax insert chest tube! Hyper-resonant drum sound and weak stethoscopic lung sounds: Pneumothorax insert chest tube! Hyper-resonant drum sound at top level, dull drum sound at the lung base and weak stethoscopic lung sounds: Combined hemo-pneumothorax insert chest tube!
10
10 Then palpation. Tell the patient to relax and breathe deeply. Perform superficial palpation of every part of the abdomen. Gently press the abdominal wall with one hand. Deep palpation: Use both hands, one superimposed on the other. Palpate every abdominal organ, including the deep structures. In children: The child will relax when you use the childs hand for your palpation. 11 11 Withdrawal pain. During the palpation, press the abdominal wall slowly then suddenly remove your hand. The withdrawal pain is a main sign of peritonitis, or peritoneal irritation due to leaking from intestinal tears. 12 Then exploration of the rectum. This is the only route to the deep pelvic structure. It is mandatory in all cases with abdominal or pelvic injury. Collections of fluid in the pouch between the rectum and the bladder or uterus may be felt. Also search for retroperitoneal hematomas inside the pelvic walls. When finished: Is there blood on the glove? 13 Diagnostic bladder puncture or suprapubic bladder catheter should be a routine procedure. If there is hematuria, collect urine in glasses at regular intervals to see if the bleeding is increasing or receding. Never force the bladder catheter: Resistance in urethra may indicate urethral tear and the catheter may tear it more. In that case, perform a diagnostic bladder puncture (infiltration anesthesia) with (spinal) needle in the midline just above the pelvic bone. Check the femoral artery pulse volume. Reduced pulse volume on one side may indicate iliac artery injury. That indicates risk of injury to neighboring structures: ureter, colon and rectum. Referred pain: Hematomas under the diaphragm may cause pain at the shoulder girdle on either side. Hematomas from a liver injury may cause referred pain to the right shoulder, hematomas from a splenic injury to the left shoulder.
12
13
14
Surgery within 8 hours All penetrating and possibly penetrating abdominal injuries should be explored surgically within eight hours after the time of injury.
15
wound with a gloved finger, fecal smell from the wound track, or bruising above the pubic bone, in the scrotum or perineum. 16 16 Pelvic fractures. Suspect pelvic fractures after crush injuries, heavy blast wave injuries and in entrapped patients. The typical case is one with pelvic pain and circulatory shock (the fracture hematoma may contain 2 liters or more). Bone fragments may tear the bladder, urethra, rectum or major vessels. The examination: Bladder catheter or suprapubic puncture Rectal examination Femoral pulse examination Unequal length of the limbs? Stability of the pelvic bone ring. 17, 18 Test for stability of the pelvic ring: Is there indirect pain? Buttock missile injuries risk of gas gangrene Inside the large buttock muscles you often find wound tracks more than 10 cm long. That implies extensive deep necrosis after most types of high-velocity projectile hits, in particular when there is also a compound fracture. A small inlet wound makes favorable conditions for gas gangrene. Explore buttock wound tracks with your finger to roughly estimate the extent of tissue damage.
17
18
216
19
19 The sites for pulse volume testing: These are also the pressure points where you control distal bleeding. The carotid artery The brachial artery The radial artery The femoral artery The popliteal artery The posterior tibial artery The dorsal foot artery. Test and compare both limbs The capillary circulation is slow fingerprint test: Press your finger against his skin for a few seconds, then let go. Study the time for blood to refill the white fingerprint (an early sign). Test the function of the fellow nerve: On most levels, the main arteries are accompanied by one main vein and one main nerve. Damage to the nerve indicates risk of artery injury (an early sign). Nerve function test, the upper limb, see p. 628 and p. 643. Nerve function test, the lower limb, see p. 659.
217
Airway problem Cannot talk/cough Head/face/neck injuries Vomits Airway burn Breathing problem Chest injuries Hemo/pneumothorax Circulation problem All patients losing blood also lose temperature.
Support airway Recovery position, tilt head and lift chin. Protect the cervical spine. Support breathing Half-sitting position Support circulation Buddy warming: Sit behind the victim and let him lean against you. In this position you easily observe his breathing and check the neck pulse. At the same time you warm and comfort the victim. The blood still in circulation should be pooled in the vital organs and not in the limbs: Lift arms and legs for 2 minutes. Then apply very tight compressive dressings with elastic bandages from toes to groin, from fingers to arm pit.That squeezes at least one liter of blood into the central circulation. Protect spine Four helpers: Lift the patient in one piece One helper: Support the neck by pulling slightly on the head at all times (also during the transport) until Xray examination shows that there is no unstable spinal fracture. You may extend the neck but never bend it.
Major blood loss Head injured: If not vomiting let them sit, then the brain swells less.
Spinal injuries Deep wounds over the spine Paralysis/numbness/radiating sensation to arm or leg Pain when moving neck/spine
Pregnant patients left side down The fetus is very vulnerable to oxygen starvation. Many pregnant women are anemic prior to the accident and cannot tolerate much blood loss without risking the fetus. The fetus will be in distress before the mother. Lying on the left side gives the best blood supply to the womb and the fetus. Children (awake) Let them lie or sit as they like. Children will find the best position themselves.
218
Who is responsible? The team leader on-site should give clear orders for positioning before transport starts.
Transport to hospital
Test yourself: How would you arrange the transport in this case? A 10-year-old girl has been hit by a fragmentation mine. She has two injuries: a fragment wound to the chest and a below-knee amputation. Assisted by village first helpers you have stopped the limb bleeding by compression of the femoral artery, gauze packing and a long compressive dressing. One infusion of warm IV fluid is running and her BP is now up to 90 mm Hg, but the HR is still high, 130/min. She is breathing rapidly, RR > 30/minute, and probably has a hemothorax but you have not yet been trained to place a chest tube drain. The villagers have arranged for a taxi car and you have got your backpack medical kit.The hospital is six hours away.
219
No BP apparatus and no watch? Assess the circulation by talking to the patient: the brain gets enough oxygen if if the patient is able to talk to you and you can feel the radial pulse beats. That would imply BP at least at 80 mm Hg. Bleeding from the amputation? No, the compressive dressing is dry and clean not one single blood cell gets through. Will the IV line take the transport? She has only one line but it is large bore and works well. After the ketamine dose, suture the IV cannula to the skin so that the line is not accidentally pulled out if trouble occurs. Anything more to be done before you leave? Missed any injuries? One single bounding fragmentation mine shoots out 400 tiny shrapnels at very high speed (> 1,000 m/sec).The entry wounds are normally very small and easily missed during the primary assessment: Check the head and eyes, the back, the groin and between the limbs again. Antibiotics?Yes, she has a chest injury and should have one high IV dose of ampicillin. Nutrition? She is from a poor farmer family and she is skinny. It is already four hours since the injury and it takes at best another six to get to the hospital. Additionally in the hospital it will probably take hours before she gets fed. She definitely needs some carbohydrate input. On the other hand there may be injuries to the abdomen.You are in a dilemma here, but nobody would blame you for giving small sips of ricewater with salt at intervals. If that doesnt make her vomit, the abdomen is probably okay. Comfort: Talk to the girl: It is a long way to go, but you can make it, be strong! Tell us if you feel cold or have pain. We are staying with you at all times, and if we help each other we will for sure make it.
Transport to hospital
Transport to hospital in brief Many avoidable complications some of them fatal occur during transport. Common transport failures are incorrect positioning, poor pain relief and no warming. Transport is not transport but a long intensive care stage.
221
Two points often forgotten 1. Antibiotics can only reach the wound site when the area has a blood supply. 2. Antibiotics are carried by the blood and the bacteria live mainly in tissue without blood supply. So, antibiotics do not at all reach the main target, they only reach the area around the bacteria. More on bacteria and infections, see p. 742. A few hours after injury all penetrating war wounds are infected. Antibiotics do not stop the infection, at best they may help prevent it from spreading. Watch out for allergy Some patients are allergic and cannot take certain drugs. If they by mistake get such drugs they rapidly get skin rash, swelling in the mouth and breathing problems. If the patient is awake and clear ask if he is allergic. If you suspect allergy dont give antibiotics at all.
Treatment of sudden allergy: Give IM adrenaline 0.5-1.0 mg to adults; 0.1 mg/10 kg body weight to children. Be ready for airway life support.
Drug
Antibiotics Penicillin G
Standard drug for infections of limbs, airways and skull. In high doses effective against anaerobic bacteria. Standard drug for infections of abdomen (together with metronidazole or chloramphenicol) and airways. For anaerobic infections such as tetanus, gas gangrene, peritonitis and deep wound infection. Standard drug against amebic dysentery. In combination with penicillin G for several types of severe infections, including some anaerobic infections. For several types of infections, but no effect on anaerobic infections unless combined with metronidazole or chloramphenicol. Same action as oxytetracycline.
Prevent: IV 8-12 million IU one time. Treat: IV1-5 million IU every 6 hours. Prevent: IV 2 g one time. Treat: IV 0.5-2 g every 6 hours. Prevent: IV 1.500 mg one time (infusion for 30 minutes). Treat: IV 500 mg every 8 hours (infusion for 20 minutes). Prevent: IV 1.5 g one time. Treat: IV 500 mg every 6 hours.
Ampicillin
Metronidazole
Chloramphenicol
Oxytetracycline
Prevent: IV 1 g one time. Treat: IV 0.5-1 g every 12 hours. Prevent: IV 200 mg one time. Treat: IV 100 mg every 12 hours.
Doxycycline
222
Antibiotic treatment For deep wounds and burns only: Infection is rare in wounds to the face and wounds that do not enter the muscles except for burn wounds. IV only: Antibiotics are only slowly absorbed from the muscles into the bloodstream after an IM dose. IM antibiotics are hardly absorbed at all if the victim has lost a lot of blood. Antibiotic ointments applied to the wound have no effect at all. Which type of antibiotic should you use? Different types of antibiotics kill different types of bacteria. There are no evidencebased guidelines here; we have to consider efficacy, side effects and costs. We recommend: Head and limb injuries: Benzyl-penicillin, one single IV dose of 8-10 million IU. You need a high dose to prevent anaerobic infections like gas gangrene. Chest injuries: Ampicillin or doxycycline. Abdominal injuries: Ampicillin or doxycycline. If feasible you may add 1.5 grams metronidazole as an IV infusion to help prevent anaerobic and streptococcus infection.
Side-effects
Prevent: IV 200,000 IU/kg one time. Treat: IV 25,000/kg every 6 hours. Prevent: IV 100 mg/kg one time. Treat: IV 25 mg/kg every 6 hours. Prevent: IV 20 mg/kg one time. Treat: IV 7.5 mg/kg every 8 hours. Prevent: IV 25 mg/kg one time. Treat: IV 10 mg/kg every 6 hours.
Moderate
Allergic reactions (seldom). Prevent diarrhea by drinking sour milk or yogurt, do so also if other antibiotics below are used. Vomiting and diarrhea (common). Headache and convulsions (seldom).
Cheap
Very expensive
Vomiting and diarrhea (common). Damage to the production of blood cells in the bone marrow: Stop treatment immediately if hemoglobin or platelet counts fall. Vomit and diarrhea (common). Do not use in children less than 12 years (damage to teeth). Side-effects as for oxytetracycline.
Moderate
Prevent: IV 15 mg/kg one time. Treat: 10-15 mg/kg every 12 hours. Prevent: IV 3 mg/kg one time. Treat: 1.5 mg/kg every 12 hours.
Very expensive
Very expensive
223
Drug
More antibiotics Doxycycline Cloxacillin Dicloxacillin Gentamycin
Same action as oxytetracycline. To treat severe limb infections if penicillin does not work. To treat severe infections in combination with penicillin G or cloxacillin.
Prevent: IV 200 mg one time. Treat: IV 100 mg every 12 hours. Treat: IV 1-2 g every 6 hours. Treat: IV 120-240 mg every 8 hours (see: side-effects).
Drugs for pain relief Ketamine for pain relief Ketamine for anesthesia Pentazocine Morphine Buprenorphine Paracetamol Alcohol (ethanol) Drugs for malaria Quinine Drug of choice to treat malaria crisis and severe falciparum malaria. In combination with oxytetracycline or doxycycline (above) to treat (not prevent!) malaria that did not respond to chloroquine. As for meoquine. Treat: 1,000 mg quinine in 500 mL glucose 5% as infusion for 2 hours. Then IV 10 mg/kg every 8 hours. Treat: Tablets 750 mg initially, 500 mg after 6 hours, and 250 mg after 6 more hours. Treat: Tablets 1.5 g sulphadoxine with 75 mg pyrimethamine, a one-time dose. For severe pain, especially in victims with blood loss. For surgical anesthesia in victims of injury. For moderate to severe pain. For severe pain. Synthetic morphine-like drug for severe pain. For moderate pain, especially in the limb injured. For moderate and severe pain where no other analgesic is available. IV 0.2-0.3 mg/kg in repeated doses (every 30 minutes-1 hour). IM 2-3 mg/kg. IV 1-2 mg/kg. IM 10-20 mg/kg. IV 30-60 mg every 2-4 hours. IV 5-10 mg every 2-4 hours. IV 0.3-0.6 mg every 6 hours. P.o. tablets 0.5-1 g every 4-6 hours. P.o. 25-50 mL 45% ethanol (brandy, whiskey, etc.) every 1-2 hours.
Meoquine
Pyrimethaminesulphadoxine
224
Side-effects
Prevent: IV 3 mg/kg one time. Treat: 1.5 mg/kg every 12 hours. Treat: 25 mg/kg every 6 hours. Treat: IV 2 mg/kg every 8 hours.
Side-effects as for oxytetracycline. Diarrhea (common). Allergy (seldom). Pain and swelling at the site of IV injection. Damage to the brain if dose is higher than recommended. Give every 12 hours only to persons older than 60 years.
Positive side-effect: Increases BP. Negative side-effects: Hallucinations and unrest (reduced with diazepam). Poor breathing or temporary stop of breathing if given fast IV Allergy (common). Vomiting and poor breathing (but less than morphine). Vomiting (common). Low BP and poor breathing Vomiting and poor breathing, but less than morphine. Allergy (seldom). Drowsiness and vomiting (common).
Expensive
Dose: as for adults. IV 0.3-0.5 mg/kg every 4 hours. IV 0.1 mg/kg every 4 hours. Should not be used in children. 10 mg/kg every 6 hours. Should not be used in children.
Treat: 10 mg/kg quinine in glucose 5% as infusion for 2 hours. Repeat every 8 hours. Treat: Tablets 20 mg/kg one time.
Dizziness, vomiting, headache (common). Diarrhea is common after high doses. Allergy (seldom). Dizziness, vomiting, diarrhea (common). Hallucinations and nervous disorders (seldom). Allergy to sulphadoxine (common).
Cheap
Expensive
Moderate
225
Drug
More drugs for malaria Artesunate Drug of choice to treat malaria Falciparum. Not for prophylaxis, only to patients with positive rapid test (see p. 436). 3.2 mg/kg initially, then 1.6 mg/kg every 6 hours.
Local anesthetics Xylocaine, Lidocaine Local anesthesia as inltration, nerve block, IV regional anesthesia or pleural anesthesia by chest tube. Maximum doses: Lidocaine: 5 mg/kg Lidocaine with adrenaline: 8 mg/kg.
Bupivacaine
Other drugs Adrenaline 1 mg/mL Atropine To treat severe allergic reactions. For advanced CPR (heart arrest). To reduce salivation and risk of vomiting during ketamine anesthesia and analgesia. To treat toxic reactions to local anesthetics (see above). To reduce mental side-effects of ketamine. Reduces anxiety. To treat convulsions (brain injury, malaria crisis and toxic reactions to local anesthetics). To reduce vomiting during transport, especially during morphine analgesia. Allergy: IV 0.1-0.2 mg (dilute 1 mg in 9 mL Ringer, give 1-2 mL of this solution). Heart arrest: IV 0.5-1 mg. IV 0.5 mg every 2 hours during ketamine anesthesia. IV 2.5-5 mg in repeated doses. Convulsions: IV 10-20 mg.
Diazepam
Metoclopramide
226
Side-effects
As for adults.
Few
Moderate
Allergy (seldom). Toxic reactions (normally due to overdose): Drowsiness, convulsions: Open airways. IV diazepam 0.1 mg/kg Low BP: Limbs up! IV Ringer rapidly Low HR: IV atropine 0.5 mg. Allergy (seldom). Toxic reactions: as for lidocaine.
Moderate
Expensive
Allergy: IM 0.1 mg/10 kg. Heart arrest: IV 0.1 mg/10 kg. IV 0.1 mg/10 kg every 2 hours during ketamine anesthesia and analgesia. IV 0.2-0.5 mg/kg. Convulsions: IV 0.5-1 mg/kg.
Unrest, dizziness, high HR, increased BP (common). Irregular heartbeats (after high doses). Dry mouth, blurred vision (common). Irregular heartbeats (high doses). Allergy (seldom). Drowsiness, confusion (common). Warning: Diazepam may accumulate and cause severe side-effects after repeated doses: low RR and BP in patients with oxygen starvation and blood loss, circulatory collapse in severely injured children. Unrest and convulsions, mainly in children (seldom). Allergy (seldom).
Cheap
Cheap
Moderate
Expensive
227
228
Register the treatment: Write down all treatment given in the field and the time it was given. For example, if a victim is confused and drowsy on admission to hospital, it may be because he had ketamine and diazepam during transport. Or if he was not given any drugs, he may have severe oxygen starvation. This example shows that writing down information on all treatment given in the field is very important to the hospital staff. Position and warming is also part of the treatment and should be registered. Write down problems you had! A few words is enough. The Severity Score is registered twice: Once, when the medic examines the victim for the first time, before starting to treat him that is on p. 1 of the Injury Chart. And again, when the victim arrives at the surgical center. Remember to mark the exact time for both the first and the last Severity Score. You can find out if the victim becomes worse or better by comparing the two scores. In this case the victim became better a score of 8 one hour after injury rose to a score of 11 on hospital admission.
Most prehospital forms are too complicated and you risk incorrect registrations. This is the form we have used for years in wartime trauma systems in Iraq, Afghanistan and South-East Asia. Download the data gathering forms at www.traumacare.no
Medical documentation is obligatory! We need it for treatment The hospital staff has to know the in-field condition and treatment. Is the patient improving or going down? We need it for learning and research Without records of what we found and what we did, we cannot recall the details when we want to re-examine the case.
229
Circulation Stop chest bleeding: Chest tube drainage. Stop abdominal bleeding: Damage Control laparotomy. Stop pelvic bleeding: Extraperitoneal pelvic packing. Core re-warming by urinary bladder or rectum. External jugular cannulation. Venous cutdown. Hypotensive volume therapy: warm IV electrolytes. IV volume therapy in burn victims.
230
231
232
8 Life-saving surgery
Two kinds of surgery: Damage Control versus repair Staged surgery: Head injuries Staged surgery: Chest injuries Temporary abdominal closure Staged surgery: Limb injuries Multi-injured burn cases Feeding tube-gastrostomy Staged surgery: Vascular injuries
.......................
.................................................... ................................................
...................................................
....................................................
.......................................................... ........................................................
233
8 Life-saving surgery
234
Damage Control
What characterizes a limb so injured that it cannot take lengthy primary surgery? 1. Global indicators: Orthopedic surgeons do well to understand that limbs in fact hang on to the body. The overall condition of the total physiological fabric also sets the physiological frames for how much of surgery the limbs can take after severe injury: In unstable, multi-injured patients any extensive surgery including that on the limbs is risky. Save life before limbs! 2. Local indicators: If the microcirculation in the limb soft tissues has collapsed due to isolated vascular injuries or severe blast/crush injuries with compartment syndromes and the tissues have suffered oxygen starvation for two hours or more, then lengthy efforts of limb repair will not only fail but also increase the risk of trauma death. Often a severely damaged and ischemic limb is contributing to physiological triggers to destabilize a multi-injured patient. Would a fasciotomy send even more triggers into the general circulation causing more damage? In the context of mass casualties early amputation could be life-saving. Children are different! Children compensate well for bleeding until a certain point, when the circulation suddenly collapses if bleeding continues. In the severely injured child damage control interventions should be done before the BP starts falling. Characteristics of Damage Control surgery: Urgency! Somebody has to take on the responsibility and decide: This patient needs life-saving surgery and he needs it now! The decision is made on purely clinical grounds, there is no time to hide in the X-ray department. Time is the critical factor. Make it simple! Life is at stake so there is no time for elaborate preparations. Getting to and preparing the Operating Room may take time; Damage Control operations are therefore done there and then, in the Emergency Room, in any village or at a forward tent clinic. Ketamine anesthesia and one simple surgical set is all you need to get started. There is only one main problem. Solve it NOW! The surgeons one and only aim is to control the damage which is the main threat to survival: Abdominal bleed stop it! Crushed and swollen limbs decompress the muscle compartments; no time for debridement, place draines only! Torn major arteries place temporary shunts! Compound and bleeding fractures to the face intubation and packing! Maximum 45 minutes! What cannot be done in 45 minutes should not be done. You have now solved the main problem; the patient is no any longer on the way down but will be able to profit from intensive resuscitation (Stage 2, see p. 237). Non-traumatic anesthesia! Good support during the operation helps prevent some of the devastating side-effects of surgery: Give oxygen if available. Cover the patient well to reduce heat loss. Place bottles of warm water under the blankets. IV infusions and blood transfusions must be warm (40C). Use auto-transfusion if possible. Stop-orders: There are some key physiological indicators of physiology coming close to collapse after injury.The most important warning signs are: (1) Hypo235
8 Life-saving surgery
thermia: core temperature less than 34C. (2) Coagulation failure: the surgeon reports it bleeds from everywhere; bed-side clotting test reveals coagulation failure. (3) Severe oxygen starvation, pH < 7.2.The anesthetist should watch these signs carefully and tell the surgeon to bail out immediately if one of them occurs. Stop talking of the golden hour! There is no fixed 60 minutes window of opportunity for life-saving. Sometimes ten minutes is too much. Other patients can take hours of post-injury stress. Read the clinical signs in each and every patient! Damage Control = staged trauma care The injury
Stage 1: Primary assessment and life support in-field Stage 2: Secondary assessment after initial life support Unstable physiology Stage 3: Damage Control (max. 45 minutes) Stage 4: Intensive resuscitation 24-72 hours Stage 5: Surgical repair (hours) Postoperative monitoring + rehab Stable physiology Stage 3: Damage Control + repair (hours) Postoperative monitoring + rehab
Damage Control
Stage 2, skillful assessment of initial life support effect; and Stage 4, skillful postoperative care. Stage 2, the secondary assessment Are we able to identify soon enough the unstable patient, the patient on the way to trauma death? The first assessment of the trauma victim is done on-site, outside hospital by the paramedic team. They provide initial life support according to the primary assessment and monitor the treatment effect all the way through the evacuation. At some point either in the ambulance, in a village along the road or in the hospital Emergency Room a definitive secondary assessment must be done: Is this patient improving or deteriorating? Is this a case for Damage Control surgery? When under fire or in a mass casualty setting with extreme loads on the forward clinic or the hospital discreet signs of physiological instability may be missed with dire consequences for the patients. Secondary assessment of major trauma victims in-field or in the Emergency Room, should be done by the most experienced paramedic/doctor. Stage 4, resuscitation after Damage Control surgery The main problem is solved by the surgeon (Stage 3) and it should now be possible to re-oxygenate the patient and re-perfuse the damaged tissues. Blood lost should be replaced. There may be a hidden state of circulatory shock in the vascular bed of the intestines which takes time to treat, see p. 164. Cooling is simple, re-warming takes time and systematic efforts, see p. 200. Pain relief, comfort and a good nights sleep are crucial for the patient to regain strength. The patient now needs high-energy nutrition, at best by the enteral route, see p. 766. Note: All this supportive treatment is provided within a pressing time frame: the patient definitely needs another operation to reconstruct arteries, debride dirty wounds, suture intestinal tears etc. and he needs it soon. The longer the wait for surgical repair, the higher the risk of sepsis and other complications.The decision of timing and aims for Stage 5 operations (reconstruction) depends on close cooperation between the operating surgeon and the post-operative care providers. Not only the operating surgeons, but also post-operative care providers are life-savers in major trauma. Stage 5, 6, 7 ... However we know that reality is more complex than flow-charts: many staged procedures are necessary in major trauma thus damage control surgery is not a single operation but a series of operations each one addressing separate problem or problems. Primary life saving laparotomy needs to be followed by second look laparotomy where packs are removed, hematomas drained and gut wounds closed. Likewise in open limb fractures, the first operation would take the form of fasciotomy and drainage, further surgeries would involve a second look and further debridement of dead muscles until it is safe enough to close the wound with or without skin graft/flaps and the fracture stabilised definitively.
237
8 Life-saving surgery
Life-saving surgery: Where the patient needs it not where the surgeons by tradition are based
Life support goes on In-field life support Secondary assessment In-field damage control surgery Most traditional systems for war surgery would assume that the wounded was evacuated to a field hospital with a setup for further assessment and treatment.The second assumption is also that evacuation time is short and indeed in the Western or well equipped modern armies invading the Third World, evacuation by helicopter is the standard. In Third World war zones this is not the case for the locals. No way can we get around the fact that time is the critical factor in major trauma. For this reason forward clinics or mobile teams must be equipped with capacity to carry out life saving surgery in line with the strategy of early damage control. Blood on the floor is lost for ever The coagulation starts failing very soon after major injuries. The best life-saver is the one who stops bleeding at a very early stage. Surgical hospital
Study models from previous wars, especially the Cambodian model, see p. 36.
238
Head injuries
It is irresponsible to let non-surgeons do advanced surgery: Not correct. Knowledge and training are not the privilege of surgeons. It is our experience and also well documented in scientific reports from Africa and South-East Asia that experienced paramedics after proper training can perform chest drainage, emergency laparotomies, fasciotomies and autotransfusion just as well as hospital surgeons. There is no anesthesia service to support the field surgery: Not correct.The anesthesia for urgent life-saving surgery is not a question of central IV lines or advanced monitoring equipment the patient may die while those facilities are being arranged. Damage control surgery is done under IV ketamine anesthesia. The factors to monitor are (1) the airways, respiratory rate and body temperature which is monitored by any paramedic trained in basic anesthesia; and (2) the central organ blood flow and blood clotting capacity which is monitored by the paramedic/doctor doing surgery to restore it.
8 Life-saving surgery
The Cerebral Perfusion Pressure (CPP) determines the blood perfusion of the brain. CPP = Systolic BP minus ICP The minimum CPP to keep up brain persusion is probably around 40 mm Hg. If you suspet elevated ICP: Do all you can to get BP > 70 mm Hg if you suspect elevated ICP! Half-sitting position reduces ICP by 50%!
Multi-injured head case, Gaza 2009: There is a head-brain injury that may need life-saving surgery but he is also bleeding from external and abdominal injuries. The Glasgow Coma Scale (GCS) is our main tool to assess the severity of brain injuries, but the GCS rating is not only affected by the brain injury but also by poor breathing and blood loss. Consequently we must resuscitate the multiinjured head trauma patients before evaluating the brain function. Do not even consider craniotomy if there is an abdominal bleed go for damage control laparotomy immediately, and then reassess the brain function.
240
Head injuries
Then assess the damage to the brain: Glasgow Coma Scale (GCS) after resuscitation
The GCS is an accurate test to assess the brain damage, especially where we do not have access to X-ray or CT scans. We use the GCS for repeated examinations to find out if the patient is deteriorating (ongoing intracranial bleeding or increasing intracranial pressure) or stable/improving. The GCS test is simple and can be taught to medics and also to by-standers (family members) to be used in mass casualty situations. The Glasgow Coma Scale RESPONSE STIMULUS No stimulus, observe only Talk to patient Eye opening Looking around 4 Verbal function Oriented 5 Motor function
Opening eyes
Obey command 6
Pain stimulus
2 1
Score 1 Eye
Score 2 Verbal
The GCS must be applied exactly and it is hard to remember the GCS by heart. Have a GCS card in your pocket at all times, see pocket at the back cover.
Standardize the GCS stimuli! Register responses carefully! For accurate GCS scoring it is essential that the stimuli we use the voice, talking to the patient, and the pain stimulus are well standardized. Female as well as male must give the voice stimuli talk to the patient in a strong and clear voice: Look at me! Also the pain stimulus should be the same all the time. If the patient cannot point at their mouth (motor response = 6), we should use the pain stimulus: Squeeze the shoulder muscle (trapezius) of the patient forcefully and read the signal: the GCS requires that the patient should move the opposite hand across the midline towards the pain inflicted on the other shoulder to get a GCS motor score of 5; or the patient should just try to withdraw or try to get away from the pain to get a GCS motor score of 4.
241
8 Life-saving surgery
13
15 GCS
GCS screening: find out what is too much. GCS < 7 indicates severe TBI.There may be intra-cerebral damage and deep bleeds, extensive brain contusion or a very high ICP. Do not start on craniotomy on cases with GCS < 7 unless you have a trained neurosurgeon with CT services at hand. GCS > 13 indicates moderate brain damage, there may be no need for craniotomy. Note: The GCS may fall rapidly to scores < 13; repeated exams are obligatory. GCS 7-12: this is the window of life-saving brain surgery. Indication for urgent surgery: The GCS goes down Check the GCS every 10 minutes for the first hour- and further if the scores are going slowly down. A reduction in GCS scores of two points indicates a significant elevation of the ICP; surgical decompression of the brain is urgent. Note: Re-assess the entire patient before you decide to operate; missed injuries to the chest or ongoing internal bleeds may also push the GCS scores down. GCS score falling 2 points in an otherwise stable patient: surgical decompression is urgent! Children are different! The brain of the child is especially sensitive to trauma. Post-injury breakdown of the membranes causes rapid elevation of the ICP in children. Monitor children closely, check the GCS often. A child may slip down from GCS 14 to GCS 10 in a very short time. Go for surgical decompression if you are sure the GCS score in a child is on its way down. Indication for urgent surgery: lateralization of clinical signs Be it a gunshot or a blast injury, hematomas may collect anywhere. Without CT scans we cannot localize the hematoma exactly. It may be outside or inside the dura; or deep inside the brain beyond reach for the surgeon in the field. We have to set indications for surgery on clinical signs only: First, the hematoma increases the ICP: GCS scores are going down.
242
Head injuries
Never say too late! Even in massive herniation the patient may recover when the hematoma is evacuated if there are no other injuries to the brain.
Then, the hematoma expands further, and the brain herniates towards the opposite side: At the site of the hematoma, the pupil of the eye becomes dilated and reacts slowly to light. GCS scores are falling. Finally, full herniation: Arm and leg at the contralateral side (opposite to the hematoma) become weak and finally paralytic. The GCS scores go further down. Sum-up: Indications for urgent surgical decompression Either Other bleeding injuries are controlled, BP > 70 mm Hg and GCS score is < 13 but > 6. Or There are lateralizing clinical signs and GCS score is > 6 and other bleeding injuries are controlled, BP > 70 mm Hg. Patients with GCS score < 7: give palliative treatment only. Fractures can wait but not the brain injury Any open fracture must be debrided soft tissues and bone as also skull fractures. The debridement should be done within 8 hours after the injury else the bacterial infection becomes established and may spread into non-injured tissues. So, surgery for compound skull fractures can wait for some hours unless there are clinical signs of elevated ICP (use the GCS) or bleeds under the fracture (lateralizing signs).
243
8 Life-saving surgery
There are two indications for staged surgery on brain injuries Cut down operating time: The patient is in poor condition due to other injuries and cannot take extensive surgery. Elevated ICP: It is not possible to close the dura due to brain edema.
244
Head injuries
Elevating a bone flap: Use a dissector to tear dura off the inner table of the skull bone before you pass the Gigli saw guide. Pass the Gigli wire from hole to hole. Lift the bone flap carefully off the dura. Note: In children there will be adhesions between the dura and the bone at the suture lines. Control bleeding from the bone edges: Squeeze the skull bone with a large artery forceps or needle holder both the inner and the outer table in one bite. Do not apply a lot of bone wax; it may cause wound infection.
Gauze packing for diffuse epi/subdural bleeds: If it bleeds in the epidural space from under the skull bone and you cannot control the source of bleeding by cautery, place small pads of gauze soaked in diluted adrenaline carefully into the epidural space. The subdural space may also be packed in the same way. The packs are removed during second-look craniotomy after 48 hours. At that time the brain edema has probably sealed off the bleeding points. Debridement of the brain wound Wash with saline and debride by gentle suction. Do not debride blindly into wound tracks and deep injuries. Leave embedded bone or metal fragments unless you can see them and remove them in a controlled way. Temporary storing of bone fragments/bone flap? The soft tissues of the skull have rich blood perfusion and heal well after proper debridement. The main cause of post-operative wound infection is bone fragments without blood supply. Remove all loose bone fragments without compromise. If there is a severe injury with elevated ICP and swelling of the brain tissue, the bone flap should not be replaced during the first stage of surgery. It may be stored sterile in saline solution in the refrigerator or embedded in a subcutaneos pocket in the abdominal wall. The bone flap may be replaced at the second-look operation 4-5 days later if the wound is clean, soft tissues well perfused, and the ICP is down to normal.
245
8 Life-saving surgery
No time/not possible to close the dura: If time and conditions allow, we close the dural incision carefully with or without a fascia flap. If you want to spare operation time, or the swollen brain tissue protrudes through the craniotomy: Excise the fascia off the temporal muscle (or any other muscle) and nest it with a few sutures to cover the dural defect. Place an extra-dural drain and close the wound just with the skin-muscle flap. There may be some initial leaking of cerebrospinal fluid (CSF), but within 48 hours the fascia flap will stick to the wound and seal off CSF leaks. Close the wound with a skin-flap only, not galea: After debridement of a wound to the skull there may be a soft tissue defect too large to be closed by the galea aponeurosis. The skin of the skull sticks to the galea aponeurosis and galea is non-elastic. Better than making extensive galea relief incisions to approximate galea to fill the defect, is to dissect the skin with subcutaneous fat off the galea and use this elastic skin flap to cover the defect.
Most avoidable TBI deaths are due to secondary brain injury. Prevent secondary brain injury: Keep up the cerebral perfusion pressure: BP at 90 mm Hg, half-sitting position to reduce the ICP.
246
Vascular injuries
Register GCS scores: Start mannitol treatment if GCS scores do not improve. A fall in GCS score of two points indicates urgent need for re-operation if the GCS is still > 6. Seizures elevate the ICP. Treat post-operative convulsions immediately with high doses of IV diazepam or IV phenytoine (diphenylhydeantoine) 5-10 mg/kg (very slow IV injection). In patients reported to have had convusions immediately after the injury, prophylactic phenytoine treatment is mandatory: give a loading dose of 15 mg/kg in Ringer over 30 minutes; then maintenance by 5 mg/kg/day until GCS is normalized. CSF leaking from the wound after 48 hours increases the risk of infection and dictates re-operation with proper closure of the dural wound. Signs of bacterial wound infection: Re-operate, remove bone fragments and bone wax. Planned second-look craniotomy Gauze packs placed for bleeding control at the first-stage operation should be removed after 48 hours. Large bone fragments from a fracture, or the crainotomy bone flap may be replaced after 4-5 days on the definite condition that the ICP is normalized and the soft tissues over the bone defect are sound and healthy. However it is worth noticing that the patient may live well for months with a large bone defect as long as the skin has healed, so reconstructive surgery can wait. A strategic problem: The surgeon is scared Many TBI patients suffer avoidable deaths because the surgeon does not dare to access the injury. However bleeding control in head injuries is simple compared to major abdominal bleeds. And the treatment of skull fractures is simple compared to limb fractures. Dura should be treated like any other fascia and the brain wound debrided like any other wound. There is nothing magic about a traumatic brain injury!
8 Life-saving surgery
atively narrow and the flow in the tube is very fast. The next stage of surgery for definitive surgical vascular repair can be delayed for 48-72 hours.
Temporary shunt in place. Mark the dressing to inform other care providers: Artery shunt (date and time). Handle with care!
Temporary vascular shunts: We use ordinary soft plastic tubes, diameter 510 mm, in major artery shunts; the IV set tube for smaller arteries.We have a tight time frame in such cases and the shunt should be in place in minutes. First control the artery proximal and distal to the injury (silicon slings or bulldog clamps) and debride the vessel.There are two technical key points regarding the technique: 1. Forcing the tube into the lumen, the intima rolls up and the artery gets closed. Cut the ends of the artery obliquely, and place three stay sutures to open the entry before you carefully insert the shunt. 2. When the shunt is in place it may slip out by pulsations when you open the clamps even if it is tied by double ligatures. Prevent this by one additional suture fixing the shunt to the adjactent tissues.
Shunting or ligature?
We should place shunts where ligature carries a high risk of distal necrosis. That risk of course depends not only on the actual anatomy but also the physiological condition of the patient. How long has he been in circulatory shock already? And it depends on age, children have an impressive capacity to regenerate blood supply, elderly patients do not. There are no fixed rules here, just guidelines. Emergency surgery in vascular trauma Injured blood vessel Carotid artery Mesenteric artery, main branch Hepatic artery Risk of distal necrosis after ligature 30-50% > 50% > 25% if the portal vein is not damaged Advice shunt shunt ligature if the portal vein is not damaged
248
Chest injuries
Injured blood vessel Renal artery Splenic artery Common iliac artery External iliac artery Superficial femoral artery Popliteal artery Brachial artery, proximal part Brachial artery, distal part
Risk of distal necrosis after ligature > 50% > 50% > 50% 25-50% 25% > 50% 50% 25%
Advice ligature/clamp and secondary nephrectomy ligature/clamp and secondary splenectomy shunt shunt shunt or ligature shunt shunt shunt or ligature
249
8 Life-saving surgery
Chest wall wounds must be closed initially, otherwise chest tube drainage is inefficient. In major trauma there is no time for wound debridement and the wound is closed by deep skin sutures. There will be some leaking of air initially, sealing off the suture line with surgical drape helps reduce initial leaking. The suture line is normally tight when wound edema develops within 24 hours. Place chest tube by a separate incision.
Omental flaps may also be used for reconstructions of chest wall injuries, see p. 269.
Skin flaps for major chest wall wounds: This is an emergency; just make a rough debridement to remove bone fragments and devitalized soft tissues. Approximate the ribs by towel clamps and tie them together by any thick suture.The chest wall defect is then selaed off by two sliding flaps of skin with subcutaneous fat. Such flaps take the blood supply from perforator arteries from the costal vessels. To be well perfused, each of the flap should be as wide as three ribs (7-10 cm). Seal off the plasty by adhesive surgical drapes if available. Flail chest Three or more rib fractures with intermediary fragments will cause instability of the chest wall a flail chest: The fractured area will move out and in with expiration and inspiration. The condition is very painful and the pain prevents effective respiration.The main problem is that pneumonia develops in those parts of the lung not inflated during respiration. Fixation of unstable rib fractures is not an option: Effective pain relief is mandatory: Either pleural bupivacaine analgesia directly by the chest tube or intermittent IV ketamine pain relief, see p. 186. Start chest tube drainage if you suspect hemo/pneumothorax. Encourage active respiratory exercises (blow gloves) from day one and continue for three weeks to prevent lung collapse and post-injury pneumonia. Cardiac injury Suspect cardiac injury in penetrating injuries to the central chest and all high-pressure blast cases. The clinical signs of heart contusion and cardiac tamponade may develop gradually, monitor patient closely for 24 hours: HR and arrhythmia Look for congestion of the neck veins, increasing RR or cyanosis Falling BP Do repeated chest X-ray exams: Changes in the contour of the pericardial sac.
250
8 Life-saving surgery
so it wasnt the pain, Nasi Gul was bleeding inside. Wares bent over her: We have to operate on you, you are bleeding from wounds inside the belly. Be strong and dont fear, your father will stay with you all the time. Wares was nervous, but still he felt confident: he had done life-saving laparotomies before, in the tent clinics during the Battle of Jalalabad. Last year Wares had trained his wife to assist him. Now he told her: Place 5 bags of Ringer in a pot of warm water, and prepare the drugs. The starting dose will be 1 mg atropine, 2.5 mg diazepam, and 50 mg ketamine, all IV. Wares called Neaz, a young farmer, and told him to assist during the surgery. He explained to him the details of the operation while he prepared small and large gauze packs and placed the boiled instruments on a clean towel next to the bed. They both washed their hands in boiled water and soap for 10 minutes. Wares washed the abdomen with soapy water, and cut through the skin exactly along the mid line from the tip of the breastbone to 10 cm below the umbilicus. He split the peritoneum told Neaz to pull open the incision with his hands and entered the abdominal cavity. Blood was pooling to the left of the stomach.Wares removed five full cups of blood, clamped two arteries with small artery forceps and the bleeding stopped. One bleeding source stopped he said to his wife. Heart rate 130 mm Hg, blood pressure still at 90, she answered. He examined the spleen: no injury. Wares placed one large gauze pack in the upper left quadrant, and went for the upper right quadrant. Here Wares found a 5-cm tear in the liver. It was not bleeding now, but he removed several cups of blood that had collected beneath the liver. Dont touch that liver tear, Neaz, it may start bleeding again. Wares carefully placed a lot of large gauze packs under and over the liver, around the tear. The IV Ringers must be warm, he told his wife. They are, she replied. In the lower left side Wares found the inlet wound from the second fragment just in front of the colon. No blood there. No wounds in the colon. 2 liters of Ringer are finished, what now? Wares son asked. Good boy! One more liter, moderate speed, Wares replied. He checked the right side: no free blood and no blood collecting under the peritoneum. I think we have stopped the bleeding. Lets see if the gut is leaking, Wares said. He felt confident now. They found two tears in the small intestine, and tied gauze band proximal and distal to the wounds. Before closing the abdomen,Wares again checked the liver tear, it was not bleeding now. In the left side the gauze pack was still dry and white. Heart rate 130, BP 100, his wife said. Your daughter will survive, Wares told the father. He left the gauze packs and the two artery forceps inside the abdomen and closed the mid-line cut. They had taken 40 minutes altogether. Wares observed Nasi Gul closely for three hours after the laparotomy. With one Ringer infusion running slowly, the blood pressure was stable at 110-120 mm Hg, and the heart rate at 100-120/minute. They placed Nasi Gul covered with blankets upon mattresses on a tractor-trailer. Wares sat at her head with his backpack full of infusions, ketamine, antibiotics and his set of surgical instruments. Nasi Guls mother held her hand firmly. Sixteen hours and 300 mg ketamine later, they arrived at the surgical hospital. Three weeks later they went back home again, Nasi Gul sitting beside her mother on the trailer.
252
Correction: In the 1st edition of WS we wrongly recommended thoracotomy with compression of thoracic aorta to control massive abdominal bleeding, as one step in emergency laparotomies. However, clinical studies conclude that very few patients were saved by the procedure and adverse effects were many. Today we can say that the technique has no place in a war setting with long in-field response times. Massive abdominal bleeding is controlled by direct manual compression of the abdominal aorta as soon as the the abdomen is opened, before gauze packing. Indications for urgent laparotomy The patient is in constant need of IV volumes to maintain BP above 80 mm Hg. The RR increases above 30/min despite free airways and good pain relief. The urine production is less than 0.5 ml/kg body weight/hour (25-50 ml/hour for adults). The patient has been in grave circulatory shock for one hour or more and there is probably hypoxic damage to the kidneys. Is peritoneal lavage helpful? Diagnostic lavage can be done under local infiltration or low-dose ketamine anesthesia through a small midline incision under the umbilicus. Enter through the rectus sheath exactly in the midline. Insert a soft catheter (the infusion set tube with side holes). Tie a purse-string suture around the tube and close the incision tightly. Flush 1 liter of saline from the infusion bag. Let the fluid out again immediately by putting the infusion bag on the floor. If you can read a newspaper through the bag of pink water emerging, there is no major bleeding in the abdominal cavity. Peritoneal lavage. The problems with peritoneal lavage: Firstly, the technique is very sensitive in detecting abdominal bleeds. It may be useful for assessment in a controlled situation in a stable patient who maybe has some internal bleeding, where you consider to operate now or wait until the next morning. But we are out to identify the patients with major ongoing blood loss, and for that we use clinical indicators; peritoneal lavage is a waste of time. Secondly, the technique has low specificity: peritoneal lavage only detects free bleeds in the abdominal cavity and not blood collecting outside the peritoneum. Large retroperitoneal bleeds may be fatal, but such conditions will not be detected by a diagnostic lavage. One of three abdominal cases also has injuries outside the abdominal cavity! Associated chest injury is most common: The chest injury has priority and should be managed before laparotomy is done. In most cases chest tube drainage is the only management necessary. Wounds of the diaphragm are sutured from the abdominal side. Associated pelvic injury: Unless major pelvic vessels are damaged and this is the main bleeding source, the abdominal injuries have priority. See extra-peritoneal packing for pelvic bleeds, p. 270.
253
In trained hands ultrasound and CT scans are sensitive tools to identify abdominal bleeds. CT has low sensitivity in identification of bowel injuries.
8 Life-saving surgery
Associated spinal injury: The abdominal injury has priority.The abdomen must be closed before the spinal injury is explored.You may delay spinal surgery for 48 hours unless there are increasing neurological signs. The decision to do Damage Control laparotomy is based on clinical assessment: BP is 80 mm Hg and going down or, the patient is in constant need of transfusion to maintain BP > 80 mm Hg.
Waiting for surgery: External compression of the abdominal aorta in the emergency room. Bleeding in the lower abdomen, pelvis and lower extremities is reduced by compression of the abdominal aorta. Place a fist in the midline and compress the aorta against the vertebral column. Keep the pressure steadily until the time of laparotomy. Check the effect by the groin pulse; there should be no pulse in the femoral arteries when the compression is done correctly. Note: The aorta branches into the iliac arteries at the level of the umbilicus; the pressure should thus be placed above the umbilicus. Minimum laparotomy set Scalpel, 6 artery forceps (16-18 cm long), and a small cup to remove blood 20 gauze packs 10cmx10cm 10 gauze packs 20cmx20cm 12 towel clamps, or very thick skin suture, or plastic band to close the midline cut For anesthesia: ketamine 50 mg/ml, large bore IV cannulas, warm IV infusion, blankets Ampicillin/doxycycline and metronidazole. Wash off the blood! There are fragment wounds at the back. Can the abdomen be injured?
254
Plan the approach: Examine the front, back, and groin carefully. Identify all possible entry and exit wounds; mentally work out where the main bleeding source may be and go directly for it when you have opened up the abdomen.
Warm infusions! Two IV lines! The patient loses a lot of heat when the abdomen is opened during the laparotomy. So the IV infusions must be warmed (42 C). When you cut open the abdomen, the pressure inside the abdomen suddenly falls. This may cause rapid bleeding. Have two large-caliber IV lines running. Bladder catheter and stomach tube in place: Even if there is no blood in the urine, there may be injuries in the urinary tract, eg. transection of the ureter. Similarly no blood during suction by the stomach tube shows there is no stomach injury. Explore the rectum with one finger up the anus. Blood on the glove means injury to the rectum. From these examinations we have gained a lot of information. You need three assistants: One assistant looks after the airways, gives ketamine and IV infusions and controls body temperature; another retracts the abdominal wall; number three assists you during the surgery. Give all three exact instructions before you start.
Wash the abdomen for 5 minutes with soapy water from the nipples to the groin. Cut precisely along the midline from the tip of the sternum, around the umbilicus and 5 cm further down. Cut down to, but not through the muscle fascia. Bleeding from small vessels under the skin stops spontaneously.
Wipe the fat off the fascia above the umbilicus.You can easily see where the fibers from the left and right meet. This is the midline. Cut through the fascia in the midline.You can now see the peritoneum or the abdominal lining bulge towards you.
The intestines are immediately beneath the peritoneum. You have to lift the peritoneum up before you can cut it open otherwise you may cut into the intestines. Then put one hand into the abdominal cavity, lift the abdominal wall, and cut through the fascia and peritoneum from the upper to the lower end of the skin cut.
255
8 Life-saving surgery
Compression of the abdominal aorta during laparotomy. When the abdomen is cut open, the intra-abdominal pressure falls abruptly and abdominal bleeds may explode. To prevent this event, let the assistant press one hand firmly against the aorta immediately below the diaphragm. The access is best from the right side, sneaking in behind the lesser omentum towards the midline behind the stomach. To prevent backflow from below, the distal abdominal aorta should also be compressed: you may enter from either side behind the omentum and loops of the small intestine. Keep a steady pressure until the surgeon had identified the bleeding sources and controlled them.
The right upper quadrant: Push the liver upwards, the stomach to the left, and the colon downwards. Blood in this quadrant indicates injury to the liver or the right kidney.
The left upper quadrant: Push the liver and the ribs upwards, the stomach to the right and the colon downwards. Blood in this quadrant indicates injury to the liver, the spleen, or the left kidney.
The right lower quadrant: Lift the entire small intestine out of the abdomen to the left. Blood in this quadrant indicates injury to the blood vessels at the posterior abdominal wall. Note: Manipulation of the intestines affects the heart. Beware when the small intestine is delivered during the exploration.
256
The left lower quadrant: Lift the entire small intestine out of the abdomen to the right, and push the sigmoid colon downwards. Blood in this quadrant indicates injury to the vessels at the posterior abdominal wall.
The pouch in front of the rectum: With the small intestine still outside the abdomen, push the sigmoid colon upwards, and the urinary bladder (the uterus in females) forward. Blood in this pouch indicates injury to the iliac vessels, or the organs in the pelvic cavity.
Gauze packs to control bleeding. Pack liver or kidney tears with gauze even if the bleeding has stopped. Bleeding may start again if BP rises. First pack into the tear, then pack around the injured organ and fill up the entire quadrant with gauze. Press on the packing for 5 minutes to stop bleeding. If it bleeds despite the packing, clamp the artery for 10 minutes finger clamping (arrow), not by forceps!
Leave clamps in place. If the spleen is torn, clamp the artery and vein with one large artery forceps. Pack around the spleen and the forceps until the entire quadrant is filled with gauze. Leave the forceps inside the abdomen.
Tie off all holes in the intestine to prevent leaking. Tunnel a hole through the mesentery, pull a gauze band through, and tie firmly. Clamp bleeding vessels in the mesentery with artery forceps, pack gauze around the forceps and leave the forceps inside the abdomen. Note: Examine every centimeter of the small intestine and the colon to identify all tears.
257
8 Life-saving surgery
Temporary closure with 12-15 towel clamps: Close the skin only, do not include fascia and muscle layers. Push intestines down so they dont get trapped.
Temporary closure with plastic ties (from the market): Tunnel holes through the skin; you may include the outer fascia but not the muscle. Be careful not to trap intestines. Danger: Abdominal compartment syndrome! If the intestines are swollen due to extensive injuries and protracted oxygen starvation before surgery, it may be hard to close the midline incision. Closure under tension may cause increasing pressure inside the abdomen, further reducing the blood perfusion in the abdominal organs, further swelling and a vicious cycle of increasing intra-abdominal pressure ending in organ failure and organ death. The first clinical signs of abdominal compartment syndrome are subtle: Increasing RR and decreasing urinary output despite reasonable BP and warm skin. Re-operate and release the tension urgently! Note: The complication may occur days after the laparotomy due to a slow edema of the bowel or intra-abdominal abscess or peritonitis. Prevent high intra-abdominal pressure after extensive abdominal injuries Place naso-duodenal tube for decompression of the upper bowel. Place wide-bore rectal tube to decompress the colon. Do not suture the fascia, close the midline incision by deep skin sutures only. If in doubt: Use Bogota Bag or Vacuum Dressing for temporary closure. Bogota Bag for temporary closure. The midline incision should not be closed under severe tension; that may cause a compartment syndrome. One simple way to get around this problem is to split a sterile 1,000 ml IV bag and interpose it in the incision, fixed by tight skin sutures. One problem with the Bogota Bag is drying out of abdomial contents. Cover the plastic bag with moist paddy dressings. Another problem is leaking of abdominal fluid between the sutures. If you have access to sterile surgical drapes, vacuum closure is the method of choice, see p. 259.
258
Vacuum dressing for temporary closure A better way to prevent abdominal compartment syndromes is to make a sliding two-layer dressing. The inner layer: Wrap up a surgical towel in sterile surgical plastic drape and place inside the midline incision outside the omentum; the towel should extend 10 cm to all sides of the incision. The outer layer: First place two suction tubes by separate incisions through the abdominal wall. Then cover the midline incision and make the suction tubes airtight with another sheet of surgical drape. Connect the two tubes to suction; that will keep the inner plate in place. If the abdominal content swells, the inner layer of the dressing will slide on the abdominal wall; thus, the abdomen may expand while the dressing is still in place. Ready for next stage: intensive post-operative life support Good pain relief is essential for good breathing. Keep patient warm, 38C is the best temperature for the coagulation system. Do not over-load with IV infusions, it may cause re-bleeding. BP at 90 mm Hg is optimal (hypotensive fluid resuscitation). Leave naso-gastric tube in place to decompress the stomach and prevent high intraabdominal pressures. Danger, if it starts bleeding again: Monitor skin temperature, HR, BP, RR, and urinary output closely. Do not hesitate to take a second-look with better packing if it bleeds! Danger, if high intra-abdominal pressure: The abdominal wall gets tense, RR increases and the urinary output falls. Re-operation with IV bag or vacuum closure is urgent!
259
8 Life-saving surgery
One team! The surgeons with the post-operative care providers should monitor the patient hour by hour. Plan next stage! Based on the clinical finding the first 12 hours the team sets the time schedule, aims and site for the next stage of surgery: repair of the abdominal organs.
Liver emergencies
Be conservative! Heroic primary liver surgery with extensive debridements, resections and lobectomies increases the mortality rate even in experienced hands. The only aim for damage control laparotomy is temporary control of liver bleeds. Like muscle tissue, the tissues of the liver are not elastic and high-energy injuries (penetrating and blasts) may cause wide tears and also hematomas at some distance from the liver wounds. However, the liver tissue is very well vascularized and even major tears heal without primary debridement. Autotransfusion, see p. 419. Collect blood for autotransfusion if there are no injuries to the ileum or colon. Warm and fresh platelets are more important than surgery to control major liver bleeding. Control liver bleeding, step 1 In moderate liver tears the bleeding would normally have stopped spontaneously by the time of surgery. If it still bleeds, reduce bleeding by the Pringles maneuver: Let your assistant control the hepatic artery and the portal vein at the hilum of the liver by finger clamping, see p. 257. Note that the clamping effect may be delayed, the bleeding coming down slowly due to backward venous bleeding.You may keep the vessels finger-clamped as long as 30 minutes while the gauze packs are being placed. Permanent ligature of the hepatic artery is safe if the portal vein is not damaged.
260
Liver injuries
Control bleeding, step 2 Pack carefully into the liver wounds with loose gauze swabs or ribbon gauze. Then place large gauze packs under and over the liver. If liver veins are torn and it bleeds from behind the liver: cut the falciform ligament at the top of the liver to get better access to the backside and place large gauze packs over and behind the liver. Then fill up the entire upper right quandrant with large packs. Note that the Pringle finger-clamping is kept all the time while the packs are placed. Control bleeding, step 3 Do not leave the upper right quadrant yet! The assistant maintains the Pringle clamping, and you compress the packed liver carefully and steadily between two hands for five minutes. Take your time to look up and ask the anesthesia assistant how the patient is doing, breathing, temperature etc. Then let the Pringle clamping go slowly while you compress the packs for another minute and observe if bleeding has stopped. In case of re-bleeding: repeat the procedure and pack better. If bleeding stops, report to the team. Gunshot tunnels through the liver: Due to cavitation effect, most fragment and gunshot injuries disrupt the liver and cause open tears. But in some cases you may find a deep penetrating wound track that bleeds. In such cases gauze packing may be difficult. Either, mobilize an omental flap, pull it into a soft plastic tube and use the tube to guide the flap through the wound. Pull out the tube when the flap is in place. The flap will stop bleeding, drain the wound and accelerate healing. Or, place two Foley catheters into the tunnel and fill up the balloons with 30 ml. The next stages: Post-operative life support: Regarding the liver injury there is no problem to delay the second-look laparotomy for 72 hours as long as it does not rebleed. However high intra-abdominal pressure or intestinal injuries may dictate less delay. If there is no injury to the intestines, start enteral feeding, see p. 778. In the multi-injured patient, consider gastrostomy feeding, see p. 274. Second-look laparotomy: The packs are carefully removed under Pringle finger-clamping. Repair of liver tears, see p. 550.
8 Life-saving surgery
Control bleeding: If the situation is critical and blind finger clamping of the splenic vessels has reduced the bleeding, you may place two large artery forceps on the vascular bundle without dissecting the peritoneum. A safer approach is to split the peritoneum between the stomach and the spleen to isolate and control the artery and the vein with two separate clamps. If time is critical, better leave the clamps without ties until the second-look laparotomy; pack carefully into the splenic tear, around the spleen, and also around the clamps. Note: Brisk bleeding may also come from accessory arteries between the stomach and the upper pole of the spleen (arrow). In that case, clamp with artery forceps both on the splenic and the gastric side of the tear, then pack. There is neither time nor reason for complete splenectomy in a critical case: Leave that for the second-look laparotomy 48-72 hours later. The next stages: Post-operative life support: You may delay the splenectomy for 72 hours as long as it does not bleed. Increasing intra-abdominal pressure or intestinal injuries may dictate less delay. In the multi-injured, consider enterostomy feeding, see p. 274. Second-look laparotomy: Perform standard splenectomy, see p. 557.
262
Exposure Bleeding may restart the moment you open the midline cut and the intra-abdominal pressure falls. Let the assistant be ready for immediate compression of the aorta under the diaphragm and also in the lumbar region, see p. 256. Go in from the right side and retract the transverse colon downwards: Now you have access to the proximal part of the duodenum including the superior mesenteric artery (large black arrow). To access the back of the duodenum and the head of the pancreas, split the peritoneum along the outer curvature of the duodenum (black arrows) and lift it off the abdominal wall (Kocher maneuver). Kocher maneuver with exposure of the bile duct, pancreas and the right kidney gives good access also to the caval vein (white arrow).
Access the body of the pancreas and the superior mesenteric artery by splitting the omentum between the stomach and the transverse colon. (C, caval vein; A, aorta; SA, splenic artery) Temporary artery shunts, see p. 248. Vascular anatomy of the intestines, see p. 526. The mesenteric artery Place a shunt if possible; ligature on the proximal segment of this artery will inevitably cause necrosis of parts of the small intestine and colon. In that case the second-look laparotomy with resection-anastomosis should not be delayed for more than 24 hours. The stomach Wounds to the stomach seldom bleed much. If there is time for it, close the wounds roughly with one-layer continuous suture on large curved needle. If time is critical, just place large curved artery forceps which you leave inside. Note: In penetrating injuries there will normally be wounds to the back of the stomach. Split the gastro-colic ligament for full exposure. Note: Juices and gases will inflate the stomach and break the seals unless the stomach is decompressed. Ensure at the time of surgery that the naso-gastric tube is nicely located in the proximal part of the duodenum. Active suction of the tube should be practiced also during this laparotomy.
263
8 Life-saving surgery
Duodenum and the proximal jejunum In most cases with duodenal injury there are associated injuries to major vessels. In the initial survivors you will often find a retroperitoneal hematoma. The backwall of the duodenum may also be torn with a risk of retroperitoneal abscess formation. Do not open any retroperitoneal hematoma at this stage! The bleeding will explode and surgical control is technically difficult. Controlled duodenual fistula or early repair? The total physiological secretions passing into the duodenum from the stomach, pancreas and the biliary duct amount to 4-5 liters per 24 hours. To tie off tears in duodenum or the proximal loops of jejunum as we do in the small intestine, is therefore not an option. Primary suture is risky due to the massive secretion and because the lumen of the duodenum is narrow unqualified repair of duodenal wounds may cause permanent stenosis. If second-look laparotomy can be done within 48 hours: Leave the intestinal tear untreated, concentrate on naso-gastric suction and pack the area for bleeding control. If the surgical center is far and the second-look laparotomy will be late: Place a large-bore Foley catheter inside the tear and pack around the catheter for bleeding control. The drain is left for 2 weeks, then the Foley balloon is deflated and the catheter pulled out stepwise, a few centimeters every day. In this way a controlled fistula will form which can later be managed by expert surgeons. The physics of blast wave, see p. 135. Special for blast victims Blast waves may cause massive blow-out tears of both the duodenum and stomach. The proximal jejunum contains less gas, is more mobile and less prone to such injury. Severe blast cases are multi-injured and cannot sustain extensive repair. Stick to the 45-minute rule and make it simple: Approximate tears of the stomach roughly with continuous sutures in one layer and leave the duodenal tears untreated. Decompression is crucial: see to it that the nasogastric tube is placed well into the duodenum. Then pack the entire region with large gauze pads to control bleeds and restrict/absorb leaking of intestinal fluids. In other blast cases you may find that the organs are not torn up but there may be large hematomas inside the intestinal wall. Such hematomas may cause necrosis and eventually rupture, but leave them untreated at this stage: pack carefully and re-explore after 24-48 hours. Pancreas The superior mesenteric artery runs through the body of the pancreas and injuries to this artery should be shunted or ligated and then the entire region filled up with large gauze pads. The problem in injuries to the pancreas itself is not bleeding as much as highly irritating pancreatic juice leaking into the abdominal cavity. If the second-look laparotomy has to be postponed for more than 48 hours, the pancreatic wound should be drained at first-stage laparotomy: Place a soft tube drain at the site, pack gauze pads well around the drain and take out the drain through a separate incision. The drain may be left in place for 2 weeks, then slowly pulled out to form a pancreatic fistula.
264
Renal injuries
Injuries to the central upper region, the next stages: Post-operative life support: The main measure is continuous gastric decompression. Apply suction on the gastric tube every 15 minutes. Place the patient in the position where the gastric tube drains best, normally left-side down. If the nasogratric tube does not produce well, replace it with a new tube. In the multi-injured, consider gastrostomy feeding, see p. 274. Second-look laparotomy: If there is injury to the mesenteric artery or duodenum, the second-look laparotomy should be done by an expert surgeon not later than 48 hours. If intestinal tears were managed by drain initially, the drains should be left for fistulas to form. However all gauze packs should be out within 72 hours. Special for the pancreas: the organ has no separate independent blood supply but is supplied from the gastric, duodenal and splenic circulation. Injuries to these organs may therefore cause secondary necrosis of the pancreas. If there are injuries to the stomach, duodenum and spleen, the pancreas should therefore be explored during the second-look laparotomy.
8 Life-saving surgery
packs for five minutes, then observe for re-bleeding while you gradually reduce the pressure.
Extensive injury, stable patients, experienced surgeon: First control the renal artery and vein by full exposure of the kidney but be prepared for circulatory collapse at the time you split the peritoneum. Consider primary nephrectomy resections and suture of the kidney wounds are more bloody and time consuming. If time is critical, tie the renal vessels, pack the quadrant and do nephrectomy at the second-look laparotomy. The next stages: Post-operative life support: Retroperitoneal hematoma? Handle the patient with extreme care: keep warm, give transfusions of fresh warm blood if at all possible. Monitor HR and BP closely: If BP suddenly drops, the hematoma has ruptured and another operation is urgently needed. In the multi-injured, consider gastrostomy feeding, see p. 274. Second-look laparotomy: The packs and also a kidney waiting for nephrectomy can be left in place for 72 hours and then removed. Renal tissue blood perfusion is excellent and most kidney wounds can be left for spontaneous healing without secondary debridement/resection and suture, just place drains at the second-look laparotomy.
266
Intestinal injuries
In the unstable hypovolemic multi-injured patient, stick to the 45-minute rule regardless of extent of intestinal injury Clamp bleeding points in the mesentery and leave forceps inside. Tie off wounds to the small intestine and colon with ribbon gauze. Pack gauze pads around each and every intestinal wound to absorb leaking. High-dose antibiotics with metronidazole. Second-look laparotomy for reconstruction by expert surgeon within 48 hours. Blast injury: conservative strategy Where it bleeds, clamp bleeding points. Tie off open tears according to the standard procedure, see p. 257. There may also be multiple heamatomas in the mesentery; obviously these segments of the intestine are poorly perfused, may necrose and rupture later. In multiple segments of the small and large gut you may find swelling and bleeds inside the intestinal wall without the wall being completely broken yet. Where there are multiple injuries to the gut, the patient must have been exposed to a very high over-pressure wave; there are probably blast wave damages also to lungs and other structures. Therefore the abdominal surgery should be as non-traumatic as possible at this stage: Pack gauze pads carefully around each injured segment so that leaks can be absorbed if rupture occurs before the time of second-look laparotomy. If the surgeon is far: Make a primary proximal relief enterostomy In gut injuries, as a general rule the second-look laparotomy with intestinal repair should be done at 24 hours and not later than 48 hours after injury. There may be situations where this is not possible, patients are stuck under fire and cannot be evacuated, or there are simply no expert surgeons within two days reach. In that case fecal leaks and distention of the intestines should be diverted by making a proximal relief stomy.The most proximal injury on the small intestine or colon is taken out through a separate incision as stomy:
There is injury to the small intestine: Make a loop ileostomy. Take out the most proximal injured loop through a 7-8 cm separate cut. Fix the loop to the skin with a few sutures before you cut open the wound enough to invert it. Then suture the mucosa to the skin with interrupted sutures. Check with your finger that both legs of the stomy are open. Extend the abdominal wall incision some cm if the lumen is narrow.
267
8 Life-saving surgery
No injuries to the small intestine, only to the colon: Make a loop colostomy. Make a separate incision and take out the most proximal segment where there is a colon tear. The loop should not be under tension, if the injury is on the right or the left side you may have to mobilize the gut, see p. 516. Support the loop on a rod of rubber/plastic, extend the wound enough to invert the mucosa, and fix it carefully by interrupted skin sutures. Other enterostomy options, see p. 528. Where evacuations may be long: Train paramedic teams to make relief enterostomy! The next stages: Post-operative life support: Cover the patient with broad-spectrum antibiotics including metronidazole. Patients with intestinal injury cannot take enteral feeding at this stage. This is one main reason why the second-look laparotomy should be done at least within 48 hours so that high-energy feeding can start. Second-look laparotomy: First remove packs and inspect each and every injured segment of the intestine. Then plan repairs and resections. Relief enterostomies should be used deliberately in blast cases where large segments of the intestine are still poorly perfused, swollen and may necrose. Note: Reconstructions of multi-injured intestines take hours and cause blood loss. The patient should be well transfused and have more blood packs ready before undergoing reconstructive surgery.
age Control laparotomy is urgent. Wash off the intestines with warm water and deliver into the abdominal cavity. Loops with perforations should be tied off before they are replaced. Cover the defect with any clean sheet of plastic until the time of laparotomy. Skin transposition flap for major defects: The aim at this stage of surgery is not to reconstruct the abdominal wall but re-establish continuity. For this we should use skin- or fascia-skin flaps based on perforator arteries. There are numerous perforators from the costal and lumbar arteries. Raise broad flaps over the rectus muscle on one or on both sides and transfer to close the defect. Take care not to undermine the flaps, this may damage the perforators. Apply broad bands of adhesive plaster to support the abdominal wall for better breathing. Implantation of synthetic materials (silicone, Silastic) in dirty war wounds causes infection and should not be used for permanent closure of large defects in the abdominal wall. Large wall defects: Use the omentum. Blast injuries may cause extensive necrosis of muscle, fascia and skin. The blood supply to the abdominal wall is broken, any dissection or primary reconstruction will cause more harm than good. First stage: There is no time for debridement at this stage. Just replace the intestines and cover the entire defect with one large clean plastic sheet (towels wrapped in sterile surgical plastic drape is nice). Secure with broad bands of adhesive to support the breathing.Then wrap the entire torso in blankets for hypothermia prevention. For the initial survivors, emergency laparotomy should be done within 24 hours. At that stage the extent of necrosis is clear and options for reconstruction can be considered. Next stage, omental flaps for reconstruction: The omentum carries stem cells and is therefore very helpful in wound protection and healing functions. The blood supply to the omentum is rich and comes from the gastric artery, see p. 541.There are anastomosing branches between the omental arteries so you can safely split full-length flaps to either side.You may also mobilize the omentum through a separate incision into the abdominal wall defect and fix it to the
269
8 Life-saving surgery
wound edges as a floor to cover the intestines. Place large saline-wet gauze pads outside the omentum and close the entire defect water-tight with a large plastic sheet as above. After one week the omentum will be covered with granulation tissue and may take split-skin grafts.
Pelvic injuries
Study the complex anatomy of the pelvis, see p. 593 and p. 614. Gunshots through the pelvis often cause massive fracture bleeds and will normally also tear up the rectum, bladder, loops of the small intestine and any female organs. High-energy blasts may also cause retroperitoneal bleeds as well as ruptures of the bladder and/or rectum. A deadly combination: retroperitoneal hematoma + (anaerobic) retroperitoneal infection. Surgery stage one: Control bleeding At the inner side of the pelvic bone ring is an extensive network of arteries and veins embedded in loose connective tissue. Any high-energy fracture causes immediate and massive bleeding. The particular problem in retroperitoneal pelvic bleeds is that there is hardly any counter-pressure: A hematoma will dissect through the loose tissues along the pelvic wings and also down towards the pelvic diaphragm in between the pelvic organs. In this way half the amount of circulating blood can be lost unless extraperitoneal packs are placed.
While waiting for surgery: Reduce pelvic bleeds by external manual compression of the aorta, see p. 254.
Packing for extra-peritoneal bleeds: Access the retroperitoneal space by midline incision from the umbilicus down to the pubic bone. Wipe off the fatty tissue to each side and identify the peritoneum but do not cut through it. By blunt finger dissection in the posterior direction along the peritoneum you can enter the site of bleeding. Now place large gauze pads as far posterior towards the sacrum as you get, then fill up the entire extraperitoneal space with more pads. Note: To make an effective counter-pressure both sides of the pelvic cavity should be packed. If you suspect injury to the urinary bladder or urethra (hematuria): place a Foley catheter through a small incision at the top of the bladder before you close the incision.
270
Pelvic injuries
Intra-peritoneal pelvic bleeds The iliac artery: Midline laparotomy. Tears of the common iliac artery should be managed by shunts. One internal iliac artery may be ligated, but not both of them. Tears of the uterus: Midline laparotomy, pack into the tear; consider ligation of the uterine artery, see p. 598. Tears of the pregnant uterus: In 1st and 2nd trimester give priority to the mother: pack the tears or ligate the uterine artery. In the 3rd trimester give priority to the baby: do Caesarean section, see p. 598, then control bleeding. Bleeding from the ovaries: Clamp the tube and the broad ligament, see p. 599. Tears of the urinary bladder: Close the tear roughly by continuous suture and place gauze packs inside and outside the pertitoneum. Insert suprapubic bladder catheter before closing the laparotomy. Often there are associated fractures: Wrap the pelvic ring tightly in a figure-of-8 broad sheet for 24 hours. Bed-side clotting test: Draw 5 ml of full blood directly into a standard glass tube (not coated, no chemicals added). Keep the tube inside your shirt in the axilla for 3 minutes. If a clot is formed in the glass tube, there is no significant coagulation failure. If there is no clotting, the coagulation system is out of balance. Surgery stage two: Prevent abscess formation The gauze packs should be removed and organs reconstructed within 72 hours. Re-warm the patient and give fresh warm blood-transfusions to restore optimal coagulation. Do not over-load the patient. Restrict IV volumes to keep BP at maximum 90 mm Hg. All transfusions and infusions must be warm. If extraperitoneal bleeding goes on you may use the clotting test to see if there is coagulation failure, but there is not more you can do with surgery. If the clotting test is normal and there are no signs of ongoing bleeding, we shift the focus to prevent abscess formation: Remove the hemostatic packing if any and place drains. Dilate the anus to drain the rectum of feces. You may at the same time place a large bore tube drain in the anus. Give broadspectrum antibiotics and metronidazole.
Perianal drainage + diversion colostomy: Between the floor of the pelvis (the pelvic diaphragm) and peritoneum are compartments of loose connective tissue. Here blood, feces and urine will collect and form perfect conditions for aerobic or anaerobic infections. In most cases it is impossibe to access extraperitoneal tears of the rectum. It is a life-saving effort to prevent pelvic infections by drainage. Both the anterior and posterior compartment should be drained (corrugated drains or tubes with side holes). Make a 3-5 cm incision through the skin
271
8 Life-saving surgery
just outside the anal ring. Use a large artery forceps to make one tunnel along the rectum, and one tunnel into the anterior compartment. If both the extra- and intraperitoneal parts of the rectum and/or bladder are injured, the pouch of Douglas (black arrow) should also be drained. Note: Keep one finger inside the rectum when you place the drains so that the rectum is not torn accidentally. Sigmoidostomy, see p. 534.
Limb injuries
273
8 Life-saving surgery
Problem 2: Loss of temperature The extreme loss of temperature in major burn cases makes them vulnerable to surgery. More temperature is lost during laparotomy and fracture surgery.The operation time on associated injuries should therefore be as short as possible:The objective is not definitive repair, but exclusively to manage the main problem at that time. Dont break the 45-minute frame for damage control surgery! Warming at all times is extremely important! Problem 3: Immune defenses break down There are no injuries like burns to depress the immune capacity. The immune depression does not occur immediately, but develops gradually during the first week after injury and it affects all injuries not just the burn wounds. In major burns even aggressive antibiotic treatment and optimal surgical care cannot prevent wound infections. Dont start on elaborate reconstructive surgery in the multi-injured with burns; it will probably fail due to bacterial infections. Make it simple especially if there is also airway burn! Problem 4: Nutrition More than any other type of injury, burns trigger the metabolism and consume a lot of energy. In patients with burns of more than 25% of total body surface area the basic energy expenditure is doubled; in very large burns it is tripled! It is not possible to supply that much high-energy nutrition by the mouth, and definitely not by the IV route. Large burns: Consider making a feeding tube-gastrostomy at the first stage of surgery.
Feeding tube-gastrostomy
Why not intravenous feeding? Oral and enteral feeding are more effective, cheaper, safer, and the nutrients can be found everywhere. The commercial IV solutions are too expensive: A complete feeding program for one patient costs US$ 100-200/24 hours. The feeding solutions and additives (minerals, trace elements and vitamins) are not readily available in a field wartime setting. IV feeding is risky: The complete program includes mineral additives; if used incorrectly they may cause serious complications. Close laboratory monitoring is necessary. Finally, IV lines do become infected, a big problem.
274
Feeding tube-gastrostomy
Why not naso-gastric catheter feeding? The method is safe, but the preparation of diets elaborate: Tube-feeding solutions must have low viscosity and cannot be bulky if you use fine-caliber tubes of 3-5 mm. Larger tubes (5mm) will be painful and cause pressure wounds of the nose.
Gastrostomy tube feeding: We recommend tube gastrostomy at the time of Stage-1 surgery in all major trauma cases. The gastrostomy operation is rapid, simple, and done under ketamine anesthesia. Gastrostomy feeding is well tolerated and it can be practiced also outside hospital. Insert a large-bore Foley catheter through a stab incision in the abdominal wall and into the stomach.The small stomach incision is closed by a circular suture and the catheter balloon is inflated. Some sutures between the stomach serosa and peritoneum will fix the stomach to the abdominal wall. Within a few days adhesions have formed to keep the stomach in place. Tape the catheter over a roll of gauze under slight traction. The diet should be a blend of any local foodstuff with high energy content. Jejunostomy tube feeding The proximal loop of jejunum is intubated in the same way as the gastrostomy is done. Make a separate small stab incision in the abdominal wall and a very small stab incision through the jejunal wall. Introduce a Foley bladder catheter size 18 and inflate the balloon with not more than 5 ml of water. There are several technical complications to jejunal-tube feeding: Leaking along the catheter may cause stoma infection or fistula formation. The catheter may withdraw spontaneously. The catheter may become displaced or obstructed inside the intestine, or obstruct the intestinal lumen.
275
Percutaneous needle jejunostomy can be done: It has less complications, but the fine-caliber tubes can only take specially prepared fluid solutions. The equipment is expensive.
276
..................................................................
277
Of these patients around 20% may also have burn injury. The table gives no information on the degree of injury, and on how serious it is. Unlike what is listed in the table, triage is sorting injuries on a quality basis. Everybody, military and medical staff, should know the four triage groups Type 1 T1: Urgent! This patient needs urgent life support and life-saving surgery. Type 2 T2: Can wait! This patient needs life support and surgery, but can wait until all T1 cases are managed without danger to life. Type 3 T3: Must wait! This is a light case and needs simple treatment only (walking and talking). Type 4 T4: Too much! This patient has injuries so extensive that surgery cannot save him, or surgery is too time consuming with the resources at hand. Triage classification is relative There are no fixed rules for how this or that injury should be classified by triage. The actual classification depends upon the load of patients at the moment, the capacity of the clinic, and the skills of the staff. Eg. a skilled surgeon may well manage
278
an open thoraco-abdominal injury at a forward clinic on a quiet day (T1), whereas the same case admitted among ten mass casualties may be classified as T4.
Lessons to draw In four out of five war casualties you are in no hurry. Life support and evacuation should be arranged smoothly. But first find the one where time is critical!
279
Consider as T2: No airway problems No respiratory problems Stable circulatory state Head injured, semi- or fully unconscious Penetrating chest and upper abdominal injuries High-pressure blast wave injuries Penetrating abdominal and pelvic injury Fractures (open and closed) Burns less than 30% Vascular injuries under control but in need of vascular reconstruction
Consider as T3: Moderate and light injuries Injuries for minor debridements and dressing Face injuries for debridement and primary suture Eye injuries without sign of brain injury Minor fracture cases Blast wave injuries for observation
Consider as T4: Very extensive injuries Head injuries with clinical signs of brain death Multiple T1 injuries in one patient Large open thoraco-abdominal lesions Serious injuries with multiple organ failure Burns > 60% of body surface area.
280
Second round: IV infusions and ketamine Antonio: He can not survive this extensive burn, Julio thought. But he needs something for his pain. Julio gave him 75 mg ketamine IM. Roberto was still crying. His arms and legs were warm. He is strong, hell make it, Julio said. Maria looked anxiously at him. Youll make it sister, he said. Her arms and legs were cold. Julio placed two IV cannulas, each with 1,000 Ringer, and told two of his helpers to stay with her and squeeze the infusion bags. Call me when the bags are empty, he told the helper. Andres, the boy was crying quietly. Julio felt the tip of his nose, it was cold, and so were the arms. Julio placed a large bore cannula in an arm vein and started flush infusion of 1 L of Ringer. Well take you out soon, he told the boy as he gave him 10 mg ketamine IV. Third round: Find patient no. 1 Julio paused, looked at the five victims, and made this decision: Patient no. 1 is Maria: She is bleeding inside. If we push the infusions, the hospital may at least save her baby. Patient no. 2 will be Andres: He has lost a lot of blood inside the fractured legs.Well get him out and send him with Maria to the hospital first. Roberto seems strong, breathing and circulation OK he can wait. Antonio will probably die after some days, but needs pain relief. Documentation and transport Maria: Julio started another 2 L of Ringer infusions and gave her 10 mg ketamine IV. He wrote on a piece of paper: Maria, 20 yrs. Pregnant 8 months. Internal bleeding. 9:45 a.m.: HR 140, BP 80, Ringer 2 L + 2 L, 10mg ketamine. They took Maria to the ambulance. Julios note was taped to her dress. Andres was calm now although still trapped. Heart rate 160 after 1 L of Ringer. 160 is too much for his age, he has lost a lot of blood, Julio said. Andres got another 500 ml Ringer and 10 mg ketamine IV before they got him out of the wreck. He left with the ambulance together with Maria. Roberto was still awake and crying. Julio examined his wounds, they all seemed to be superficial. Lets take him to the hospital for observation, Julio said. He made a written report on Roberto too. Roberto went with the ambulance when it returned. Antonio: Julio tried to place an IV line, but failed. He had never felt this tired. He took Antonio to the hospital when the ambulance returned for the second time. The head surgeon honored Julio for his job. Could Julio have done better? Could you? The outcome Maria died on the operating table during the Cesarean section, but her baby survived. Andres is now playing football. Roberto left the hospital the next day. Antonio died one week after the accident.
282
Organize! Managing mass casualties at a forward clinic, the Battle of Jalalabad, Afghanistan 1992.
283
Now Patient no. 1 is ready for evacuation. Again stop, get an overview to identify Patient no. 2, the victim who is the second most injured after the first. Reassess Patient no. 2 the airway, breathing, and circulation. Then do the same for Patient no. 3, and so on. Documentation The accident scene will be chaotic. Therefore it is especially important to fill in the Injury Charts for all the mass casualties. Register carefully for each patient the weapon history, the time of injury, the wounds you identified, RR-HR-BPconsciousness, and the treatment you gave. Transport Give exact orders for the evacuation of each patient the position, infusions, and drugs each should have during the transport.You yourself should follow the evacuation of the most seriously wounded victim. Triage in mass casualties in brief You have to be extremely cool and concentrated. Prepare yourself well, see p. 174. Work systematically, no short-cuts: Complete rounds no. 1 and 2 before you identify Patient no. 1. Do not allow any non-medical staff buddies or military commanders to interfere with the triage decisions.
284
285
286
Section
287
288
10 Surgical technique
Non-traumatic technique Choice of incisions Control of bleeding Surgery on bone Dissection and retraction
.........................................................
................................................................. .........................................................
................................................................
.................................................................... ........................................................
289
10 Surgical technique
Non-traumatic technique
Handle the tissues carefully! Your surgery should assist the tissues heal, not fight them. Gentle and and non-traumatic surgery depends on two factors: How to train surgical techniques on animal models, see p. 70. Finger-skill required! Surgery is like playing piano; it takes trained fingers. Train both hands in tying knots and managing instruments like scissors, forceps and vascular clamps. Knowledge of surgical anatomy required! Study how the tissues differ in blood supply, elasticity and capacity for regeneration. There is only one way to prevent accidental damage to vessels and nerves during surgery: learn the anatomy. 1 1 Note the architecture of the tissues: The tissues are arranged sheet upon sheet the skin, subcutaneous fat, the main muscular fascia, layers of muscles with thin fascia in sheet in relation to the sheet above and beneath it. During exploration and dissection, try to move within the space between the sheets, not across them. Also during wound closure, try to re-establish the exact architecture of the tissues layer-by-layer to reduce deep scarring and promote limb mobility. Consider the tissue blood supply: Fatty tissue has poor blood supply; tension and pressure may cause tissue necrosis, and tense subcutaneous sutures are risky. The blood supply to muscle tissue is good. But where muscles are affected by edema and close to a wound track, the blood supply is less: Avoid rough manipulation. Sutures will always strangle some blood vessels and further reduce a poor blood supply. The skin is well vascularized, in particular the skin of the face and male organs. The bone blood supply is carried by the periosteum: Handle it carefully! Consider the age of the patient: The soft tissue elasticity and vascular supply will decrease with increasing age. The viability after injury of a childs tissues is far greater than that of an old patient. Be conservative in debridements on children; make narrow excisions. 2 3 2, 3 Avoid careless tension and pressure on the tissues: A surgeon struggling inside a tiny incision to perform the exploration will damage the soft tissue micro-circulation with his instruments. Deliberate use of wide explorative incisions is less traumatic to the patient. If you cannot close the wound with 3-0 sutures due to ten-
290
Non-traumatic technique
sion, do not ask for 1-0. Better leave the wound partly open for spontaneous granulation. Or close it with skin grafts, see p. 398. Sutures under tension will obstruct the micro-circulation, cause wound necrosis and infection. Many interrupted sutures of fine caliber with short intervals between them produce less tension on each suture than a few sutures of rough material. Cross-taping may further reduce the tension. Do not let the tissues dry Wet the operation field with NaCl every five minutes. Tendons, nerves and subcutaneous fat will necrose when dry. Instruments and sutures: Use blunt retractors wherever possible: The gloved fingers are the kindest retractors. They are also the instrument of choice to explore deep wounds. If you pad gauze under the retractors, the retraction is even more non-traumatic and at the same time hemostatic. Never clamp tissues with artery forceps, unless that tissue is to be excised. Surgical scissors and blades must be sharp. Maintain the instruments well; careless washing and storing will damage them. Blunt scissors and blades will crush the tissues instead of cutting them. Be restrictive with absorbable sutures (Dexon,Vicryl, catgut etc): They create some irritation inside the tissues during the period of absorption (within 10-20 days). This is an unnecessary additional trauma to the tissues. In tissues whose viability is at risk better use fine prolene or silk sutures (3-0, 4-0) for the soft tissue approximation. 4 Use temporary traction during fracture surgery: The traction will ease the bone alignment, and help reconstruct the soft tissue architecture. Manual traction by one assistant or some sort of improvised plaster traction will do.
Choice of incisions
5 5 Use the standard incisions if possible: To be able to explore all parts of a wound track and make an exact debridement, you have to extend the wound into an exploratory incision. Plan your incisions well. In Chapters 40 and 41 are listed the standard incisions for exploration of regional injuries.Try to include the wound track into one of the standard incision.Your incisions should not cross the joint flexion lines, but run parallel to them or at least cross them obliquely in a Z-incision. Otherwise the wound may heal with excessive scarring and joint contracture. Be liberal in your use of additional incisions for exploration. The second incision may be useful for counter-drainage, see p. 309, and to decompress the muscle compartment, see p. 304. Improper exploration through one small incision is far more traumatic than adding another exploratory incision.
291
10 Surgical technique
6 Sharp dissection with scissors: The scissors must be really sharp in order to cut and not to chew the tissues. First use the scissors to spread open a tunnel into the tissues. Then use it as a cutter.
7 Sharp dissection with knife: Use the blade and not the bladepoint for cutting. Stretch the actual tissue when cutting it. Here the incision is through the wall of uterus during Caesarean section.The arrow points to the head of the fetus which is protected by the surgeons fingers.
8 Blunt dissection should be performed neatly without tearing the tissues. The gloved finger is a good tool, here during laparotomy with mobilization of the rectum from the pelvic cavity.
9, 10 Stay sutures better than retractors: Stay sutures are eg. inserted before debridement and exploration of a bladder tear. And in exploration of a shoulder joint injury before cutting the muscles. At wound closure the stay sutures will enable approximation of muscles which might otherwise retract. Take care! No sharp retractors on muscles and nerves! No vascular clamps to pull on muscle or skin! Cut through muscle by sharp knife not by scissors! Do not let exposed muscle or fascia dry keep wet by saline! 10
Control of bleeding
The debridement in deep wounds is often insufficient, for two reasons: Poor knowledge of the anatomy and the localization of the main vessels make the surgeon defensive and fearful of deep excision. Also an inappropriate technique for control of bleeding causes insufficient debridements. Some basic and simple techniques make you able to control any bleeding:
292
Control of bleeding
Proximal tourniquet as backup: Most bleeding limb injuries are controlled by packing and pressure directly onto the wound. If not, apply the BP-cuff as tourniquet. Note:The cuff pressure should exceed 220 mm in order to obstruct the main arteries.When you expect grave bleeding during surgery, better apply the BP-cuff (without inflating it) proximal to the operating field as an in-case measure.You may deflate the cuff at intervals during the debridement to identify bleeding points, to evaluate tissue circulation and the extent of necrosis. Note: Never use a tourniquet if you suspect there is a vascular injury, increased local vascular pressure may tear a partial injury completely. One-minute tamponade: At intervals during the surgery, pack gauze into every corner of the wound. Apply pressure upon the gauze pack for 1-2 minutes before you proceed with the debridement.You may soak the tampons with diluted adrenaline for better hemostatic effect. Proximal control of the bleeding vessel study the anatomy: In Section 4 the main surgical anatomy is listed for each regional injury. Study the localization of the main vessels and the blood supply to main structures and organs. It is too late to consult the manual when the surgery is going on. When you know the anatomy you can extend the incision in the proximal direction and find the main vessel. Or expose the vessel through a small separate incision proximal to the bleeding point. Now control the bleeding by finger clamping or rubber slings on the main vessel. 11 Permanent control by ligature: Ligature is the main method for permanent control of any bleeding vessel. Clamp the vessel with the curved side of the artery forceps. Make one knot, and tie it while your assistant releases the forceps slowly. Add two or more knots. Use double ligatures on major vessels. If you fear the ligature will slip off the vessel, apply a ligating stitch. The materials used for vessel tie are mersilene or silk (3-0, 4-0) on major vessels. On minor vessels you may use resorbable ligatures (catgut, Dexon, Vicryl).
11
12
12 Hemostatic sutures will control oozing of blood where you are not able to identify one single bleeding source. Bleeding from tears of the inner organs (here: the liver) is also controlled by deep hemostatic sutures. Use a large and wellcurved needle.
293
10 Surgical technique
Bed-side clotting test Is the patient cold? Do you suspect coagulation failure? Draw 5 ml of blood from the patient and take into a clean glass tube. Place the tube in your arm pit to keep it warm. Turn it carefully upside-down every half minute. If a blood clot forms within 5 minutes there is no significant coagulation failure. Electro-cautery controls bleeding points and minor vessels. Cautery spares the operation time for the benefit of the patient, and increases the surgical capacity. Cautery may also be applied directly to the cutting knife, but only when cutting through tissues where you expect considerable oozing of blood (scalp, lung etc.). On medium and main arteries, cautery cannot control the bleeding so ligate these vessels. Note: As nerves usually accompany the vessels, do not damage them with the cautery.
Surgery on bone
13 14 15
13 Elevate the periosteum carefully. The periosteum carries the blood supply to the bone, it is vital for protection against infection and for bone regeneration. Do not elevate more periosteum than strictly necessary to expose the fracture.
14 The nibbler is a bone-cutting instrument. A blunt nibbler is a bonecrushing instrument and should not be used. Eg. enlarge the drill holes by minor repeated bites by the nibbler during exploration of a skull injury. If you have no bone file, you may also use a sharp nibbler to trim the end of an amputated bone.
15 The saw, be it a straight one or a Gigli saw as illustrated here, may damage the soft tissues. Protect the tissues during sawing. A fine and light chisel may also do the job in amputations. Drive it forwards with multiple frequent light blows with the hammer. The chisel must be sharp; a blunt or heavy chisel may fragment the bone.
A Gigli wire saw is a versatile saw that can be used in amputations and also in lifting cranial bone flaps in evacuating intracranial hematoma, see more on p. 245.
294
16 The standard surgical knot: In tying the knot, pull the two ends of the suture parallel to the wound in order to locate the knot at one side of the wound, not over the wound line. Notice: The first knot is straight and double, the second one reversed and single, the third one is straight and single. 17
17 The sliding knot: Make both the first and second knots straight. Then both knots will slide down together and form a knot that will not slip. The third knot is a reversed one. Use the sliding knot technique in sutures and ligatures deep inside the wound where access is difficult. 18 The one-hand-knot: Learn this procedure well.You need it to apply ligatures deep inside the wound. If you are right-handed, your left hand is doing the tying. Keep your right hand steady. Ensure that the long end of the suture is taut all the time.
18 First knot
10 Surgical technique
Second knot
Third knot
Suture techniques
The surgeon does well to keep in mind that every single suture represents a small trauma to the tissue. Consequently we should always consider carefully the type of needles and suture materials we use, and how we place sutures and knots: Round pointed needles makes less damage to soft tissues like subcutaneous fat, muscle, vessels, liver, intestines etc. Cutting triangular-point needles should be used only for the skin, fascia, joint capsule and other hard types of tissue. Resorbable suture materials always cause some local irritation of the tissues; a better use inert material (silk, nylon and equivalents) if you fear the wound healing is at danger or you want a neutral and good-looking scar. Do not tie sutures hard! After the injury and surgical manipulation of the tissues, the tissues will always react with some edema. Take this wound edema into consideration when you tie the suture: This welling will increase the tension on the sutures, and may strangle the blood supply to the wound edges. 19 Forward the needle with grace: Grasp the needle between the distal two thirds and the proximal one third, then it slides smoother through the tissues. Make it a habit to apply a correct grasp on the needle holder like the violin artist controls the bow on his instrument.
19
296
20
20 The plain interrupted suture: Drive the needle at a 90-degree angle to the skin surface. If not, the suture will depress the suture line and create a pouch inside the wound where hematomas and infection will collect.
21
22
23
21 The cross suture is a steady suture for closure of fascia and joint capsule incisions.
22 Subcutaneous sutures should always be interrupted absorbable sutures. Be restrictive with subcutaneous sutures in war wounds as they obstruct the blood perfusion of the wound. In most cases a deep mattress non-absorbable suture causes less tissue reaction. 25
23 Mattress sutures close deep wounds. They also evert the skin edges nicely. The superficial part of the mattress suture should just take a tiny bite of the skin.
24
26
24 Simple over-and-over continuous suture: Your assistant keeps a steady pull on the preceding stitch while you apply the next one. Close the continuous suture by a standard surgical knot on the last stitch. Note: Where there is tension on the suture line, the wound healing is at risk better use interrupted sutures.
25 Continuous inter-locking suture is an alternative to the overand-over suture. The wound edges are nicely elevated, but the suture obstructs the wound blood supply to some extent.
26 Continuous S-suture is a standard suture for wounds of the gut. The wound edges are nicely adapted as long as each stitch does not include too much tissue.
297
10 Surgical technique
27
27 The Donati suture is a non-traumatic suture, well fit for cosmetic closure and for fixation of skin grafts. Take care to apply the sutures quite superficially and just to take small bites of the tissues.
28
28 The intracutaneous suture for cosmetic closure of face wounds. The suture runs inside the skin (dermis) all the way. Notice the small step backwards between each stitch.
298
299
300
301
Fasciotomy-debridement-drainage is a three-in-one surgical procedure that is the foundation of war surgery.The procedures are technically simple, but the assessment of the tissue viability is difficult, and can only be learnt from experience. Step one fasciotomy Split the muscle fascia by wide longitudinal incisions. The reason is to improve the venous drainage from the wound area and prevent collapse of the arterial blood supply. Perform fasciotomy on all high energy limb injuries as soon as possible and within six hours after injury. There are few exceptions to this rule. When in doubt do fasciotomy. Step two debridement Surgically remove all necrotic tissue from a war wound. Debride all missile wounds as soon as possible and within six hours after the time of injury. There are no exceptions to this rule. Step three drain All wounds that penetrate the muscle fascia must be drained to let blood and dirt out and oxygen in. There are no exceptions to this rule. Staged surgery in severe cases: Delay debridement! Fasciotomy + drain only as stage one, see p. 273. Delayed primary suture Leave war wounds open for at least four days after debridement before wound closure. Except for injuries to the face and the male organs, there are no exceptions to this rule.
302
Antibiotic routines, see p. 743. Details often make the difference between success and failure. Even experienced surgeons have to to study surgical manuals before they enter the operating room. See the bottom-black marked section in this manual, in particular the landmarks of the surgical anatomy.
Is the case too late for surgery? Is it a multi-injury case? Will surgery take more than two hours? Consider antibiotics before and during surgery. Is it a high-risk case regarding thrombosis? Consider anti-thrombotic therapy before and during surgery if there is no associated skull injury or internal cavity bleeding. Do you need muscle relaxation during surgery? Decide the method of anesthesia. Which incisions do you plan to use? Order the extent of operation field to be washed. Decide the position of the patient on the operation table. Arrange padding to prevent pressure damage on nerves, joints or bony prominences during prolonged surgery. Is the case already hypothermic? Do you expect prolonged surgery with loss of temperature? Cover the patient with extra clothes during surgery. Arrange a warmer for the infusions and transfusions. Fractured limbs: Arrange temporary (plaster) traction before surgery. Which instruments do you need, other than the general surgical set?
303
When injured, all tissues in our body start swelling including the muscles. But limb muscles are enclosed in groups between the non-elastic muscle fascia and bone. Hence, they cannot expand when they start to swell. Instead the pressure inside the muscles increases. The effects of increased muscle pressure First, the veins inside the muscle collapse. Thus less blood is drained from the muscle: The pressure in the muscle increases. Then, the small arteries collapse due to the pressure. This means local oxygen starvation: It adds to the injury and further increases swelling and pressure. Eventually, the bigger arteries collapse. The trapped muscle is shut off from the blood supply: The muscle starts to die.
3. Pressure increases, also the arteries collapse. The muscle is entrapped inside the fascia.
304
Proximal segment fasciotomy: As a rule the blast wave crosses joint and enters proximal compartments. Make a 10 cm skin cut, wipe the fat off the fascia and split the fascia lengthwise, upwards and downwards with scissors. The total length of the fasciotomy should be at least 2/3 the length of the actual limb segment (e.g. the thigh).
Debridement
The disinfection
The missile wound is always contaminated as patients are admitted from the combat area with dirty clothes, dirty dressings and dirty wounds. In emergencies: Take the patient directly to the operating room. Ignore the dirt. When there is time for it: Remove dirty clothes before taking the patient to the operating room. But leave on clothes and foreign bodies stuck or burned in the wounds. They should be removed only during surgery. Instill dilute soap solution into the wounds (50-ml syringes) on admission. Leave it for 10 minutes or more, then rinse with abundant boiled water or NS. Wash the operation field with soap solution. In all disinfection, time is the important factor, not the kind of antiseptic solution you use. Wash a wide operating field for at least five minutes. Debridement takes time The challenge is to perform a full debridement of the deep structures close to bone, vessels and nerves. A proper debridement of an open high-energy fracture takes at least one hour in experienced hands. Hurried debridements invariably cause damage and set the stage for infection. The debridement is diagnostic Only a complete debridement tells you the extent of tissue damage and the risk of complications. Debridement of the skin: The skin is elastic and resists the shock wave well. Excision of the skin edges should be limited, in most cases 5 mm is enough. In the face and neck the skin blood supply is rich and the excision even more limited. If in doubt you can make a small slit on the skin next to the wound does it bleed?
305
The longitudinal exploratory incision: Extend the skin wound in the proximal and distal direction to form an exploratory incision. In Section 4 the standard regional incisions are illustrated. As the blood supply to the subcutaneous tissues is poor the debridement of fat should be more extensive. Necrotic fat tissue is not shiny, but dull. It has no bleeding points when you cut it. Debridement of the muscle fascia and fasciotomy: Only ragged edges of the fascia should be excised. Then make a fasciotomy: Extend the fascia wound along the fibers proximally and distally to explore the muscles. If this is a high-energy injury, and if the underlying muscle is swollen and tense, extend the fascia incision proximally and distally to make a regular fasciotomy.
306
Debridement
Do not trust the four Cs Capillary bleeding, contractility, colour and consistency are said to be the four indicators of viable muscle tissue. It is not that simple. Capillary bleeding, a good indicator Viable muscle has multiple bleeding points when you cut it; necrotic muscle does not bleed from the capillaries. This is a safe and early sign of nonviable tissue. Contractility? Necrotic muscle is flaccid, while viable muscle may contract when you pinch it with the forceps. However, a swollen but still viable muscle may also contract poorly or not contract at all. Colour? Necrotic muscle is said to be dark, viable muscle said to be red. But a cyanotic muscle is also dark even if it is not necrotic. Consistency? The muscle consistency is also unreliable as an early indicator: Local edema can make necrotic muscle tense soon after injury. In cases late for surgery and in infected wounds the necrosis may be soft. The debridement of bone: The healing of any open fracture depends mainly on skilful soft tissue surgery and not on the debridement of bone itself. The main points of bone debridement are: Periosteum is the key to bone regeneration. Debride it very carefully; only necrotic tags should be excised. Bone fragments attached to the periosteum should be re-aligned. Minor bone fragments without soft tissue attachment should be removed. Major lose bone fragments may be removed, washed with soap and NS and replaced in the fracture as a bone graft on one condition: that you cover the fracture with viable soft tissue when the debridement is finished. Otherwise, that bone graft will not take, and it acts as a source of infection. It is often safer to remove devitalised fragments and bring the healthy bleeding bone ends together to acutely shorten to limb and obtain early bone union. With a few interrupted sutures adapt viable muscle loosely to cover the fracture. Hematomas are sources of infection; deep drainage is crucial. Soft tissue flaps for bone healing, see p. 329. Staged surgery in severe limb injuries, see p. 272. End-point assessment: Limb salvage or amputation? Never compromise on the muscle debridement in extensive injuries in order to salvage a limb. If you cannot cover the fracture when the debridement is done, either prepare a soft tissue flap or consider if this is a case for primary amputation.
307
Gauze drainage: The gauze has good suction capacity as long as it is loosely packed into the wound. It should be soft, clean and fine meshed. If it is tightly woven, pull some threads from it. A sheet of gauze is placed over the wound and put carefully into all deep pockets.The wound is thereafter filled up to surface level with loosely packed gauze before a circular dressing or plaster cast is applied. Do not worry about the gauze drain being difficult to remove. A major dressing 3-5 days after the debridement should be performed under some kind of anesthesia anyway. During repeated dressing you may soak the wound with soap solution to release the gauze drains. Dependent tube drainage: Fluid will run through the tube by the force of gravity and from the pressure of the fluid collecting inside the wound. You may use any soft tube, but not so soft that the tube becomes obstructed by bends. With a diameter at least 8 mm the tube will not clot. Cut some side holes in the tube. Make a separate incision for the tube and railroad it through that incision. Put the tube ends into the deepest and most proximal pockets of the wound. Secure the tube drain: Either close the drain incision around the tube with a suture, and tie the tube with that same suture. Or fix the tube with a suture or a needle through the tube wall. Or secure it with adhesive tape.
308
Counter-drainage: In deep wounds one drain is not sufficient. A counterincision will ease the debridement of the deep parts of the wound track and also improve the drainage. Warning Suction drains are not efficient in major war wounds. The caliber of the suction tube is small and will clot. Dependent drainage has proved more efficient. Suction drain systems are definitely more expensive than water tubes bought in the local hardware store. The method of Trueta the plaster cast as suction drainage The method is named after the English war surgeon Joseph Trueta who joined the republican side during the Spanish Civil War 1937-39. He developed this simple and very efficient drainage system. In addition to drainage, the Trueta method provides fracture fixation, pain relief and makes the patient fit for further evacuation. We recommend the method for major soft tissue injuries as well as open fractures. The wound is filled up to the surface with gauze drain. Except for small cotton pads over the bony prominences, the plaster is wrapped directly on the skin without padding. The limb is elevated. After some days the cast becomes increasingly coloured as the plaster continuously sucks the fluid through the gauze drain by capillary action. Note: There is one absolute condition for the Trueta method to work: The debridement must be complete and the gauze drainage very exact. The Trueta plaster cast in fracture management, see p. 345. VAC: Vaccum-Assisted Closure VAC is a very efficient method to drain large and infected wounds. Cut a pad of rubber foam so it exactly fits into the wound cavity, sterilize it in isopropanol, insert one or two suction drains, cover with surgical drape (thin, adhesive plastic film) - and apply intermittent suction on the drains for 2-3 days. Commercial VAC devices are very expensive, but local improvizations work well. In emergencies: Leave the debridement, but never the drain! You may be in a hurry or under military pressure. If there is no time for a full debridement, do not make a 50% debridement. When there is blood supply to the wound, the defences of the body are able to discharge a lot of necrotic tissue provided you arrange a way out for the excretions: Perform fasciotomies to improve the local blood perfusion. Insert fluffy gauze, corrugated drains or large tube drains deep into the wound tracks.
309
310
311
3 Blood clot formation is a problem in vascular surgery: The blood contains a sophisticated chemical system that forms a blood thrombus (blood clot). This clotting system is activated by injury and surgery. The main risk factors for thrombus formation are: Prolapse of the intima due to the injury Unsuccessful artery repair with narrowing of the artery and turbulence distal to the narrowing Incomplete repair of the intima causing turbulence and clot formation in the lumen Poor soft tissue cover, the artery anastomosis dries out Infection and hematoma at the site of artery repair.
312
4 The open vascular injury may be one with a side hole, parietal tear or total rupture. It is caused by direct hit of a penetrating projectile or bone fragments acting as secondary missiles. In most cases there is a major hematoma. Even if the condition is stable at the time of surgery, heavy re-bleeding will start when you enter the hematoma: Always control the vessel proximal to the injury before you explore the site of injury, see p. 315.
There is considerable loss of soft tissue; the artery has no soft tissue cover when the debridement is done: The reconstruction will probably be complicated by infection, thrombus formation or secondary rupture of the artery with sudden heavy bleeding. Consider primary amputation. Avoid vascular reconstructions in an infected field. It may be primary infection in cases late for surgery. Or secondary infection after the vascular repair is done. There are mass casualties arriving at your clinic, many of them serious. Vascular reconstructions are time consuming, and other patients may die while you try to save one limb. Consider ligature or primary amputation.
Injury to veins Veins are reconstructed in the same way as arteries. Sufficient venous drainage is particularly important during the first three days after injury. If both the artery and vein are damaged, first reconstruct the vein. The lateral arm vein (brachiocephalic) and the femoral vein should always be reconstructed and therefore explored even if there are no signs of artery injury. Four options for severe artery injuries at the limbs Temporary vascular shunting, see p. 248. Buying time by temporary vascular shunt: By shunting you can delay decision-making and vascular surgery for 48 hours till the patient is resuscitated and expert surgery can be done. Primary amputation: The risk of complications is low, the period of hospitalization short, and the load upon clinic minimal. But the decision may be difficult to take, see p. 380.
314
Artery ligature: In the brachial, femoral and popliteal arteries the risk of secondary amputation is considerable. With close monitoring and secondary amputation in due course, the risk of complications is low. The period of hospitalization is short. Unsuccessful vascular reconstruction: Repeated operations increase the risk of serious complications. The period of hospitalization is increased 3-4 times, and the load upon the clinic is high.
Exploration
Preparations to surgery
The diagnosis is mainly set on clinical grounds: X-ray arteriography has limited place in primary management of wartime vascular injuries. It is time consuming and the injuries must anyhow be explored and debrided. The pocket-size Doppler apparatus is handy and may guide you to injuries that do not bleed out, eg. roll-ups of the intima. Still, a careful clinical examination sets the ground for surgery: We should only intervene if the distal circulation is less than normal. If you are in doubt, make fasciotomies and re-examine after one hour. Prophylactic therapy: Give prophylactic antibiotic and antithrombotic therapy during and after vascular reconstructions. Consider subcutaneous injections of heparin 5,000 IU every eight hours for one week. Note: Do not give heparin to head injuries and cases with internal cavity bleeding or hematoma formation. 5 5 The operation field: Wash a wide field, since during surgery you want to check the pulse volume proximal and distal to the injury. As a routine, wash the opposite lower leg in case you need a venous graft from the great saphenous vein. If both legs are injured, a vein graft may be taken from the lateral arm vein.
damaged area. Note: Do not use ordinary hemostatic forceps on the main vessels. They cause permanent damage to the vascular wall.
316
Exploration
Is there good back-flow from the artery? If not, there may be one distal injury that you did not recognize. Or there is already extensive thrombus formation that occludes the micro-circulation distal to the injury. In any case there is a high risk of unsuccessful repair. Can the anastomosis be covered with vital soft tissues? If not, infection and thrombosis will develop.
Reconstruction
8 8 Debride the artery: An intimal tear may be sutured directly with single stitches through all layers of the vessel, tied on the outside. If there is crushing of the vascular wall debridement is necessary: With knife or sharp scissors excise maximum 0.5 cm of viable artery proximal and distal to the injury. Cut both ends obliquely to prevent narrowing at the suture line.
End-to-end anastomosis
The artery ends may be anastomosed without interposing a vein graft if the excised artery segment is short (less than 2 cm).There must be no tension along the suture line!You may mobilize the artery ends to some extent by soft tissue dissection along the artery in both directions. But extensive dissection will damage collateral vessels and the nutrition to the artery wall itself and increase the risk of secondary rupture of the anastomosis. If you are in doubt, it is safer to use graft-anastomosis. 9 Two stay sutures: The sutures should catch all three layers of the vessel. 10
10 The vascular anastomosis: In major- and medium-sized vessels close the anastomosis with continuous over-and-over-sutures 1-2 mm from the edge, and 1-2 mm between each suture. Include all layers of the wall in each suture, or the intima will escape and prolapse into the lumen.Take care that the needle penetrates 90 degrees to the artery wall, and apply each stitch at very regular intervals. Use two separate sutures: one for half the circumference, the next one for the other half. Wash the artery and remove all clots before you close the anastomosis, tying the two sutures together with at least five knots so that they do not slip. Control the suture line: Release the clamps slowly, first the distal one, then the proximal one. Some leaking in the suture line is not uncommon. Compress slightly with dry gauze for two minutes. If it still leaks, add some interrupted sutures at the leaking points.
317
11
11 Anastomosis of small-caliber arteries: Continuous sutures will cause constriction at the suture line. Better use interrupted sutures, either plain or mattress sutures as illustrated. Drain and cover the anastomosis: A hematoma will cause infection as well. Some leaking at the suture line is common; you should drain the site of vascular repair separately. Place a soft tube drain at level with the vascular suture, but take care that it does not press directly upon the vessel. Avoid gauze drains as they may tear the sutures when you remove them. Adapt the deep layer of muscles in the exploratory incision with a few interrupted sutures to cover the anastomosis. Leave both the wound track and the superficial part of the exploratory incision open. If there is loss of soft tissues, soft tissue flaps should be mobilized to cover the vessel.
12
13 Preparation of the vein graft: The opposite legs great saphenous vein is suitable for a variety of arteries. The small saphenous vein and the lateral arm vein may also be used. Isolate the vein by careful dissection, identify and ligate all small side veins. Take care that the ligatures are applied correctly. Before you remove the vein graft, tie a long mark suture to its distal end to secure that this end is for the proximal anastomosis. Test the vein graft by clamping each end and injecting normal saline into the graft lumen (do not distend it too much). Tie the side veins that are leaking. 14 14 The grafting technique: The suture technique is identical with that of direct anastomosis (ill. 11, 12 above). When the proximal anastomosis is done, remove the proximal clamp to check the blood flow.Wash blood clots from within the graft. Local heparinization: Instil heparin-saline solution (50 IU/ml) proximal to the graft. Before you proceed with the distal anastomosis, release the distal clamp and check the back-flow. If it is poor, use the embolectomy catheter, see p. 316.
318
Reconstruction
15
15 Matching the graft caliber: If the graft caliber does not fit the artery, you can adjust the circumference of either by cutting the end obliquely. The more oblique the cut, the bigger the circumference. Synthetic grafts? Artificial vascular grafts are available (Gortex or Dacron). They need no preparation and will reduce the time of operation. But they are expensive, and they have a higher rate of occlusion than venous grafts in medium- and small-caliber arteries. Dacron grafts should be avoided in infected areas. Gortex grafts resist infections as well as the vein grafts.
16
17 Major side-hole injuries reconstruction by vein patch: A more than minor side hole should be reconstructed either by excision and end-to-end anastomosis, or by vein patch. First debride the edges of the artery tear. Check that the intima is in position; any prolapse of intima should be debrided and the edges of intima fixed by sutures. Then collect a short vein graft and split the vein at a segment where there are no valves. Trim the patch to roughly fit the tear, and insert the first suture in the corner of the tear. Fix one side of the patch by the first suture. Trim the patch again, and fix it by a second continuous suture.
prolapse. If fasciotomy of all muscle compartments was not done during primary surgery, do it bed-side and observe the distal circulation. If it improves within 30 minutes, compartment syndrome was the reason for circulatory collapse. If it does not improve, embolectomy is indicated. 18 18 Embolectomy: Re-open the incision and control the artery proximal and distal to the anastomosis. Make a small arteriotomy. Insert the embolectomy catheter and remove clots in both directions until you get good re-bleeding. If you feel some resistance inside the lumen when you insert the catheter, do not force it.There may be an intimal prolapse partly obstructing the lumen. Extend the arteriotomy or make another, explore the lumen and fix the intima with some interrupted sutures. Then close the arteriotomy incision, release the distal and the proximal clamp and watch the circulation in the distal part of limb for some minutes. If the distal circulation now improves, adapt the soft tissue cover. If not, re-explore the vessel in both directions until you have identified and managed the cause. If that is not possible, this is a case for amputation. Note: Transverse arteriotomy incisions should be used on limb arteries to prevent stenosis. Another thrombosis? Continue close monitoring after embolectomy. A second thrombosis event is a reason to amputate.
320
Massive re-bleeding It may happen within 4-14 days after the primary surgery. It often starts suddenly and may be fatal. The reason is local bacterial infection. The management is emergency amputation do not even consider vascular repair.
321
322
324 325
Healing of fractures
Soft tissue flaps ..................................................................... 329 Muscle flaps ...................................................................... 332 Perforator flap surgery ......................................................... 337 In-field management ............................................................... 340 Plastercraft
.......................................................................... .......................................................
The Trueta plaster method Protect the joints External fixation Traction
................................................................... ...................................................................
.............................................................................. .....................................
323
Types of fractures
The medic first seeing the patient should do an exact documentation at the site of injury. Information on the actual soft tissue damage, the degree of bone fragmentation and the position of the bone fragments is essential for further surgery. The best front-line report may be a simple sketch and some words for explanation. Physics of the weapon, see p. 135 and p. 140. 1 Describe: High- or low-energy injury. The extent of soft tissue injury is determined by the energy. What kind of weapon? How far was the patient from the gun/explosion? Traffic accidents: what was the speed? 1 Open or closed fracture: The closed fracture: The skin and subcutaneous tissue in the fracture area remain intact. The closed fracture poses no serious problem regarding infection and usually heals well. However in crush injuries, the fracture is just incidental, since the soft tissue injuries are what causes morbidity and death. The open fracture: The skin and soft tissue covering the fractured bones are damaged either by the missile or by protrusion of bone fragments. Classify the fracture as open if some bone fragment presses upon the skin and thereby causes discoloration of the skin even if there are no open wounds of that area. In such cases the skin is dying or dead and therefore not able to protectively cover the fracture. Avoiding infection and salvaging fractured limbs in open fractures during wartime remains one main challenge for the surgical team. 2 A simple transverse fracture. 3 An oblique fracture. 4 A segmental fracture with one large intermediary fragment. 5 A comminuted fracture. This type of fracture is a sign of high-energy missile hit. The more comminuted it is, the higher the energy absorbed from the missile and the more extensive the soft tissue damage close to the fracture. 6 7 8 6 Fragments overlap or impaction. 7 Angulation side view: Describe the angulation of the distal fragment seen both from the side and from the front. In this case: femur shaft fracture with angulation of 20 degrees, apex (the opening) posterior. Note: By describing the direction of the apex, the confusing situation of dorsal/volar/medial/lateral can be avoided. 8 Angulation frontal view: Distal tibial fragment with angulation of 30 degrees, apex medial.
324
Types of fractures
9 Describe: The rotation of the distal fragment. In this femur fracture the distal fragment is in 30 degrees externally rotated. 10 10 In this 3rd finger fracture the distal fragment is in radial rotation of 20 degrees.
You cannot assess the degree of rotation by X-ray films, but by clinical examination. Compare to the opposite limb.
11 11 Most important: Estimate the loss of bone. The exact degree of bone loss can only be determined by a careful surgical debridement. If the bone end does not bleed, it is dead. Bite off bone until you can see it bleed (the paprika sign). If bone fragments are attached to the periosteum they still have blood supply and may survive, but loose fragments are lost and should be removed. Circumferential loss of bone may break the internal blood supply to the fracture (see Healing of fractures, below). If more than 4 cm bone is lost, the entire limb is in danger.
Healing of fractures
The fracture = a large soft tissue wound + some broken bones 12 The bone is not a dead or static structure. It is instead in a continuous process of resorption and new bone formation is going on in all parts of the skeleton all the time. The bone tissue is continuously resorbed into the bone marrow by bone-eating cells (osteoclasts) lining the inner side of the long bones. On the outer side, under the periosteal sheath, the bone-producing cells (osteoblasts) continuously form new bone. By this absorption-formation balance, the internal architecture of each and every bone is formed and maintained. The bone forming process consumes a lot of energy and requires good blood supply. 12 Blood supply to the bone: The internal and the external route. There are nutrient arteries and veins penetrating the cortex of the bone to support the blood flow in the bone marrow. Some bones have several nutrient arteries, others have just a few. The nutrient arteries with the bone marrow make up the internal route of blood supply. The periosteal sheath carries an extensive vascular network which takes its blood supply from the muscles surrounding it. The periosteal network is the external route of blood supply to the bone.
325
Major fractures break the internal route of blood supply to the injury. The external blood supply is therefore the key to fracture healing. Thats why the soft tissue management is the key to success.
13
13 Forming new bone from stem cells: There are particular types of mother cells in the tissues of the body that are multi-potent, they can differentiate and form several types of cells. For example, from the blood-stem cells in the bone marrow all types of blood cells arise. The periosteum and the muscle fascia carry stem cells that can start the formation of osteoblasts, the bone producing cells necessary to heal a fracture and also cells forming new capillary vessels. This is why well vascularized periosteum is the foundation for fracture healing, and why fascia-skin flaps enhance the healing of large open fractures. This is why orthosis is an excellent tool in the healing of fractures, see p. 352. 14 Stimulate bone formation by careful weight-bearing Moderate stress (oscillation < 1mm + compression) on the site of fracture triggers the formation of blood vessel and new bone. 14 Healing of fractures: At the time of injury the continuity of the periosteum and bone marrow is broken. There is a fracture hematoma from which new bone will develop. 15 Within one month the callus stage: The edges of a fracture bleed and form a hematoma. Non-mineralized waxy bone called callus is formed by boneproducing cells that enter the fracture hematoma. Gradually the callus transforms the hematoma into a waxy bridge. Callus formation increases and forms a callus tumor which you may identify through the skin. The fracture fragments become welded together inside the callus tumor. The fracture is not yet rigid, but elastic when you bend it carefully. The callus stage may last from 1-3 months depending on which bone is broken. In cases of delayed union it may last up to one year. Especially during the early stages of callus formation, partial weight-bearing accelerates the bone formation. The periosteum is well innervated. The weight-
15
326
Healing of fractures
bearing load should therefore be regulated by the pain signal: A too heavy load will produce periosteal pain reduce the load then. 16 16 Within 2-3 months the bony consolidation starts: The callus is gradually mineralized and transformed into solid bone. Now that the fracture is stable and not elastic by manual testing, increase the training load. Around this time the patient becomes painfree on weight-bearing. 17 During 1 year remodelling of the bone: The bone-eating and the boneproducing cells will gradually remodel and approximate the bone to its former shape. The internal architecture of the bone is also partly restored. This reconstruction process is finished 12-18 months after the injury.
17
Do not use non-steroid antiinflammatory drugs (NSAID) in difficult fracture cases. NSAIDs slow down bone healing.
lap of 1-2 cm at the time of injury in a femur fracture in a young child is acceptable. The child will regain the overlapped length after two years and end up with both femoral bones of equal lengths. In a child around 16 years, the growth activity is less; do not allow fracture overlap in that child.
328
19 18 Mobilize and adapt surrounding muscles: If the debridement has left just a moderate defect, you could adapt the muscle bellies from each side to cover the bone or the vascular anastomosis. This works well where the muscles are bulky (arm, buttocks, thigh) and should be done at the time of primary surgery. 19 Local muscle flap: The flap is hinged on an artery with a vein at the proximal end. The method requires good knowledge of the local vascular anatomy. In the forearm you may also base the flap at the distal end due to the communication between the radial and ulnar arteries, see p. 334. Obviously, this type of flap is not feasible to cover artery repairs. For this you should consider distally based flaps (see below). Free flap transfers include one complete muscle with artery, vein and nerve e.g. the latissimus dorsi muscle which is cut free and anastomosed into the fracture wound anywhere in the body. The method requires microsurgical skills and equipment beyond the scope of this manual.
329
20
20 Local fascia-skin flap, based at the proximal end: The flap is based on an artery with a vein.The method is technically simple, but study the anatomy carefully so as not to cut the supporting artery! Such flaps have a wide range and are a good option in below-elbow and below-knee open fractures. 21 21 Local fascia-skin flaps, based at the distal end (perforator flaps): This is a new technique, especially useful in fractures of the distal forearm/wrist and the tibia/foot where proximally based flaps cannot reach. The source arteries for the distally based flaps are tiny perforator branches of one of the main limb arteries. Perforator flaps can be raised without microsurgical equipment. Good glasses (from the local market, strength +3) and a careful hand is all that is needed, see pp. 33639.
22
22 If you cannot make flaps: Drill holes + split-skin grafts. This is an alternative to cover denuded bone in the proximal part of the ulna and the medial surface of the tibia. When debridement is done, drill several 3-4 mm wide burr holes through the cortex of the bone; cover with wet saline dressings (hypertonic saline is best) for 5-6 days until granulation tissues from the bone marrow come up through the burr holes. Then cover the area with split-skin grafts to enhance bone growth.
330
Staged surgery in major open injuries Debridement + definitive fracture fixation + flap dissection and transfer takes hours even in the best hands. In patients with severe injuries long primary operations are harmful. Better use a staged approach: First: Debridement. Temporary fixation of fracture Then: Supportive treatment. Plan the flap transfer After 3-4 days: Definitive fixation. Flap dissection and transfer if the wound is clean.
23
24
23 Direct perforator arteries are passing through the septa between the muscles (septo-cutaneous perforators), penetrate the muscle fascia, and branch to supply the subcutaneous fat and the skin. The septo-cutaneous perforators are the main source for distally based fascia-skin flaps, see below.
24 Indirect perforator arteries are passing through the muscles before they enter the fascia and the skin.
Take care not to sacrifice the main perforators when you raise muscle flaps or fascia-skin flaps. Work slowly and carefully.
331
Muscle flaps
The blood supply to long muscles comes by two routes by the main source artery at the proximal end and by several perforator arteries at distal levels. The standard muscle flap (e.g. the gastrocnemius flap) is based at the proximal end and relies on the main source artery. But if you raise the flap carelessly and elevate too much of the proximal part of the muscle belly you may compromise the flap.We will look at a few common muscle flaps to illustrate the key features of the surgical technique. 25
If there is a defect of the knee joint or the patella tendon, one half of the Achilles tendon can be included in the gastrocnemius flap for reconstruction of the joint.
26
25 The gastrocnemius muscle flap for the upper third of the tibia: The medial and the lateral head of the muscle are each supplied by one solid branch of the popliteal artery but also by perforators from the posterior tibial artery (medial head) and the peroneal artery (lateral head).You may mobilize either head of the muscle to cover soft tissue defects at the knee joint and the proximal third of the tibia. 26 Medial gastrocnemius flap the elevation: Split the skin and fascia by a long midline incision. It is not necessary to control the proximal artery. The two heads of gastrocnemius are split by blunt dissection and the head cut at the distal end at the muscle-tendon junction. The crucial point is to raise the bed from the underlying soleus muscle very carefully, observing the direct perforator artery coming through the soleus muscle (arrow). Do not elevate the flap higher than 5 cm below the knee joint (dotted line) in order not to damage the strong proximal perforators.
332
27
27 Medial gastrocnemius flap the mobilization: To safeguard the circulation, the muscle flap must not come under tension or be squeezed when mobilized.To transpose the flap to cover defects at the medial surface of the tibia we therefore recommend doing so by separate incision and not by subcutaneous tunneling.The flap is fixed to the site by interrupted sutures. The incisions can normally be closed by direct suture.
28
28 The anterior tibial muscle flap for the middle third of the tibia: Open fractures of the middle third of the tibia are common in wartime and land mine injuries. To provide soft tissue cover on defects at the medial surface of the bone remains a challenge for the surgeon. For a moderate defect the anterior tibial muscle flap is feasible; for larger defects the sural perforator flap is recommended (see below). The vascular anatomy of the anterior tibial muscle is unique: perforators from the anterior tibial artery enter the muscle at intervals to form a circular network. It is thus possible to slice the muscle and turn the upper part over the anterior rim of the tibial bone to cover defects. Beware two technical key points: Firstly, you may mobilize the belly of the muscle some centimeters to the medial side but do not squeeze the perforator arteries by applying too much tension to the muscle. Secondly, do not cut both arms of the arterial circle slice not more than 2/3 into the muscle belly.The muscle flap is fixed to the wound by interrupted sutures. The incision is then closed by direct suture (plus split-skin grafts).
333
Muscle flap with an island of skin You may include an island of fascia and skin with the muscle flap for two aims: 1. To reconstruct the skin defect over open fractures. 2. You may also let a small island of fascia-skin hang onto the muscle flap in order to monitor flap circulation: the skin is supplied by perforators from the muscle, so you know the muscle flap is well circulated as long as the skin island remains warm and well colored. 29 29 Flaps at the forearm the anatomy: Special features of the vascular anatomy make it possible to design a variety of forearm flaps. Firstly, the two main arteries communicate by a double distal network at the hand, the superficial and the deep vascular arc.You may thus ligate either the radial or the ulnar artery at a distal or proximal level and use it as a source artery for a pedicle flap, e.g. the radial forearm flap or the ulnar flap. The axes for the radial and the ulnar flaps are marked in the drawing. Secondly, both arteries send off direct and indirect perforators to the fascia and the skin. There are individual variations of perforator anatomy, but normally you will find sets of reliable perforators from both the radial and the ulnar artery at three levels: 45 cm below the elbow, midway between the elbow and the wrist and 4-5 cm proximal to the wrist joint. Consequently you may design perforator flaps based at the proximal end for proximal injuries, or distally based flaps for defects at the lower third of the forearm. Note: In older patients it may be risky to ligate one of the forearm arteries; better to use perforator flaps.
334
30
30 Proximal flaps based on the main artery: The radial musclefascia-skin forearm flap. The area and shape of the flap depend on the fracture wound: When the fracture wound is well debrided, place a gauze pad over the wound and copy with ink pen onto the donor site, see ill. 36 below. Cut out the skin-fascia island, letting a brim of subcutaneous fat and fascia extend 2 cm outside the skin island. Then extend the incision along the axis for the radial flaps, see ill. 29, to isolate and ligate the radial artery at the distal end. It is not necessary to isolate the proximal part of the radial artery, better transfer the artery with a fascial band. The flap should include the brachio-radialis muscle and the radial extensor muscles which are cut distally and proximally at levels necessary for the flap to fill the actual defect. The flaps should not be tunneled but be transferred by a separate incision, see ill. 27. The donor area is covered by meshed skin grafts either at the time of flap transfer, or delayed. 31 31 Distal based flaps supplied by the main artery: The ulnar muscle-skin-fascia flap. The flap size and shape is designed according to the fracture wound, the axis set along the ulnar artery, see ill. 29 and 32. First the skin and the fascia are cut out with a brim of fascia extending 2 cm outside the edges of the skin. Then the ulnar artery is isolated and set off at the proximal level. The flap includes the ulnar extensor muscle which is cut at the appropriate level for the flap to reach the target area. Identify the ulnar nerve so as not to damage it when you raise the muscle. The flap may be transferred in any direction to the radial or the ulnar side. The distal ulnar forearm flap is a robust flap, useful in defects of the wrist and hand.
335
32
33
32 The ulnar forearm perforator flap dissection to the radial side: The flap is based on the middle set of perforators from the ulnar artery. The flap length should not exceed 10 cm, the width not exceed 6 cm. Mark the axis of the ulnar artery (from 2 cm medial to the epicondyle of the humerus to the pisiform bone of the hand) and cut out the skin flap over this axis; let the skin retract and then cut out the fascial brim. Then isolate the ulnar artery and control it by a silicone sling. Take care to identify the ulnar nerve at all times during the further dissection. Now comes the crucial point of surgery: Lift the fascia on hooks and dissect carefully (sharply and bluntly) from the radial side towards the axis of the flap to identify the perforator arteries. Coming close to the axis you will see several perforators (arrows); choose the largest one (or two if they are close to each other) as the source artery for the flap. Minor perforators are sacrifced (electro-cautery). Now shift over to dissection from the ulnar side. 33 The ulnar forearm perforator flap dissection to the ulnar side: Isolate the ulnar nerve and dissect carefully in the direction of the source perforators. There is no point in isolating the source perforator (arrow); better leave a mesenteric band containing the
336
source artery (arteries) at the root of the flap. The flap can now be transposed in the ulnar direction to cover defects at the dorsal side, or to the radial side of the forearm. The donor site is closed by direct sutures plus a meshed skin graft.
Note: This illustration is meant to explain the concept of pivot points and flap range estimation only; you should not raise four perforator flaps simultaneously in any limb.
337
35
36
35 Distal lateral perforator flaps on the lower leg anatomy and landmarks: Open fractures with soft tissue defects at the medial distal third of the tibia are common and remain a challenge to the surgeon. This flap (also called the sural perforator flap) is robust and has a sufficient range to cover medial defects at the tibia and the ankle. The flap is based on direct (septocutaneous) perforators from the peroneal artery. The perforators emerge by the fascial septum between the extensor muscles (in front) and the peroneal muscles (to the dorsal side).You will regularly find sets of robust perforators around 5 cm and also 12-15 cm above the tip of the lateral malleolus. The axis of the flap is from the groove between the malleolus and the Achilles tendon up to the head of the fibula (dotted line). 36 Distal lateral perforator flap on the lower leg tentative flap design: Place a sheet of gauze over the soft tissue defect and copy the pattern of the wound onto the donor site. Draw up the flap and the pivot point with a marker pen. The flap will shrink somewhat when you elevate it, so mark the flap length a few centimeters longer than the gauze copy. Note: This is just a tentative design; the definitive pivot point cannot be set before the source perforators are identified; also the flap length depends on the capacity of the source perforator. 37 Distal lateral perforator flap on the lower leg definitive flap design: First you have to identify the source perforator and decide the pivot point level. Cut out the base of the flap 3 cm wide, and start careful dissection from the dorsal side towards the axis of the flap to find the perforators. In this case two solid perforators are identified 7 cm above the tip of the malleous, so this should be
338
37
a good pivot point. Such good perforators can well support a flap with length/basewidth ratio 1:4, so now you can set the definitive length of the flap. If you cannot identify any perforators the pivot point should be set at 5-7 cm, assuming that the flap will take its blood supply from the mesenterial vascular plexus above the malleolus. At the proximal end the sural nerve and the lesser saphenous vein are identified and retracted. 38
Other flaps: Rectus flap for abdominal wall injury, see p. 269. Triceps flap for shoulder and arm injuries, see p. 636.
38 Distal lateral perforator flap on the lower leg mobilization of the flap: The flap is elevated by careful dissection from the dorsal and the frontal side. Proximal perforators (arrow) have to be sacrificed. Take care not to damage the distal perforators when the dissection is coming close to the base of the flap. The flap is transposed to the site of injury through a separate incision not by tunneling. Most of the donor site can be closed by direct suture; since grafts may be necessary at the proximal end.
339
In-field management
Immediate reduction! Every fracture, open as well as closed, should be reduced as soon as possible after injury. Mal-position of bone fragments during evacuation will add to the soft tissue injury caused by the missile. Moreover, a fracture is a very painful injury. Early fracture reduction improves the local circulation, reduces pain and improves the general condition. During the first few minutes after the injury, manipulation of the fracture is less painful, and any fracture may be aligned without anesthesia. Reduction more than two minutes after the time of injury should be done under local anesthesia (10-20 ml lidocaine injected into the fracture hematoma; or low-dose IV ketamine anesthesia). 39, 40 Fracture reduction: The only safe procedure for fracture reduction is manual traction. Pull the distal fragment (foot or hand) in the limb direction. In most cases this traction alone will reduce the fracture roughly. A major bone fragment dislocated through the wound should be grasped and repositioned directly. Do not worry about sterility the wound is dirty already. However, extruded loose fragments without any soft tissue connection should not be inserted back into the wound. If the fracture is more than a few hours old there may be a considerable overlap in the fracture. Let one assistant pull steadily for one minute. Then, still under traction, reduce the fracture by moulding it. 41 Stabilize the fracture with any means at hand use the body as a splint!
39
40
41
Plastercraft
Never treat an open wartime fracture with internal fixation This includes plate and screws or bone pins through the fracture area. Internal fixation causes wound infection and osteomyelitis. Intra-medullary nails not recommended The technique requires absolutely sterile conditions which is hardly an option in low-resource settings. Additionally the nail breaks down the internal route of blood supply to the fracture; see principles of fracture healing on p. 325. The safe and simple method is external fixation The alternatives are many: plaster cast, plaster cast combined with bone pinning, traction, external fixation apparatus or orthosis.
340
Plastercraft
42
42 The essentials for plastercraft: Plaster shears both small and large. (You may make it with a knife.) Cast-bending forceps. Plaster of Paris, rolls of 10 and 15 cm. Water. Cotton for padding. A greasy ointment to fix the padding to the skin. At least one skilled assistant and lots of training. Before you start: Instruct your assistant about the actual plaster, the direction of traction, the joint position, the moulding of the plaster etc. Wash the actual limb as dirt or small particles of gypsum under the plaster may damage the skin. Then take measurement and prepare all the plaster slabs and plaster rolls you will need. All materials must be ready and at hand before the application starts. The padding: The main point of plaster immobilization is moulding of the plaster so that it fits the limb like an elastic stocking with even pressure against the soft tissues all along the limb. Too much padding prevents good moulding! 43 A well-fitting plaster: Thin padding just over the bony prominences. 43 44 An ill-fitting plaster: The padding creates an uneven pressure against the soft tissues. This actually obstructs the venous circulation and may cause limb edema.
44
45
YES!
NO!
45 The soft tissue pressure controls the fracture: If the cast is wide with thick padding the pressure is not evenly distributed along the shaft of the bone and the fracture will displace. Mould the cast to fit the contours of the muscles like a stocking. To control fracture rotation, include the joint above and below the fracture. 46
46 Correct padding: Ointment on the skin over the bony prominences will fix the cotton pads. Thin strips of filter or cotton are sufficient padding provided that the cast is well moulded to fit every contour of the limb.
341
47
47 The slab: The plaster bandage is made out of slabs and circular turns. For additional strength, two layers of slabs with circular turns between them may be applied.Measure the length of the slab on the limb. Add 5-10 cm for the expected shrinkage of the slab when wet. 48 48 The application: Warm water (37 C) makes the plaster of Paris harden quickly. Cold water makes it harden more slowly(after 5-10 minutes).When applying a sophisticated plaster bandage, use cold water. The unskilled craftsman should also use cold water. Pull the slab through the water once. Hold it up at one end and let it drip water. Let your assistant carefully wipe off the excess water from the slab. Stretch the slab ends until they are in the correct position. Then mould the slab onto the skin. Note: No bends and folds on the slab! 49 Warning: From now on until the cast is stiff, the joints must not change position in order to avoid bends inside the plaster that may create skin damage or obstruct the venous circulation. The assistant should not leave fingerprints on the plaster, for they will cause pressure wounds under the plaster.
49
50
50 The circular turns are made of plaster rolls 10 or 15 cm wide. Put the roll into water. Keep it there until air bubbles do not leak out from the roll. Then take the roll out of water and press it slightly for water. Too much pressure will remove the plaster from the gauze. Work clockwise (if you are righthanded) from the distal towards the proximal part of the limb. Stretch each turn with your left hand. Avoid folding of the bandage by smoothing the surface between each roll applied. Plaster strength mainly depends on even application and good moulding of the plaster. A thick and heavy plaster bandage is not necessary and will create problems during the rehabilitation.
342
Plastercraft
51
51 Before the cast hardens: The plaster hardens by a chemical reaction inside the plaster. After a few minutes feel the plaster will become warm. Before the temperature rises, smooth the outer surface of the cast. The smooth surface makes the plaster stronger and more resistant to damp and water that could soften and damage the cast. Smooth and lift slightly the edges of the cast so that they do not press upon the skin when edema develops. Test the joint movement proximal and distal to the cast; check that the joints not immobilized are really free. Note: The hardening process lasts for 24 hours. During this time the plaster should not carry any load or be covered by blankets and clothes that may prevent its drying. 52
52 Mould the cast to prevent limb rotation: A Sarmiento patella-bearing cast is illustrated. Notice the cross section through the proximal tibia with its triangular form, and the quadrate form of the cross section through the ankle. Mould the cast carefully to fit these forms.
The problem of swelling inside the plaster cast information for your patients
Edema always develops after injury and rises to a peak 2-3 days after the injury or surgery. Inside a circular plaster cast edema will create a compartment syndrome. Increased soft tissue pressure may obstruct the limb veins, gradually also the minor arteries. Serious damage to the limb nerves may develop due to lack of oxygen. If the pressure is not relieved in due time, a permanent condition reflex dystrophy may develop. For reflex dystrophy there is no effective treatment. Concentrate on prevention: avoid edema and high pressure inside the cast. 53 The signs of increasing edema inside the cast Swelling and cyanosis distal to the cast Sign of alarm: Increasing pain inside the cast at even slight movement of fingers/ toes. Prevent edema complications by 53 Longitudinal splitting of the plaster bandage in patients where much edema is expected. Split down to skin: often the plaster is split but tight bandages are left to form constrcting bands. At the end of splitting, you should be able to see exposed skin. Alternatively take out a strip 1cm wide from the entire length of the plaster. Delaying the plaster application until the 3rd-4th day after the injury. Initial splintage of the fracture can be with a plaster slab.
343
54
54 Elevation of plastered limb Active exercises with isometric muscle training inside the plaster help provide efficient analgesia! Cyanosis and/or increasing pain: Split the cast immediately! If the edema does not recede: Remove the cast and consider fasciotomy! If you act too late these are the signs of reflex dystrophy: Pain far exceeding the normal, lasting for days and weeks The skin gradually becomes glossy, thin and painful at the slightest touch The limb become edematous The joint movements are restricted and painful. Danger: pressure wounds under the plaster! A well-fitting plaster should relieve the patient of much of his pain and generally improve his condition. If the patient complains about localized pain under the plaster, this may be a sign of localized pressure on the skin from a bad-fitting plaster: Release that plaster look for pressure injury. A pressure wound may induce the reflex dystrophyhence. We should never ignore the complaints from our patients. Ask if they feel lasting and localized pain under the plaster. Plaster with window If you want to monitor an open fracture, make a wound window in the plaster cast Mark the exact location of the window, and cut it with a knife when the plaster is hardened. Fix the window with crepe bandage between the dressings. Note: The window weakens the plaster cast, and makes it less efficient as fracture fixation. Consider the Trueta plaster as an alternative, see p. 345.
Walking plaster?
55 Early partial weight bearing upon the fracture will promote the healing of the fracture. You may apply a walking heel or boot 3-6 weeks after injury depending on the actual fracture. Test the fracture: Does it resist manipulation? Is it stiff? Is there no pain when the fracture line is pressed? Then bony consolidation has started, and weight-bearing up to the limit of fracture pain can start. 55 Walking heels ready-made ones are available.You may as well use sections of a tire applied as a boot (pad inside the tire). Or a tire patch fixed to a small wooden plate as a walking heel.
344
57 56
56 Applying the walking heel: Locate the heel exactly its center should be slightly in front of the axis through the tibia. Look at the foot end on and locate the heel under the tibia, that should be slightly to the medial side of the center of the foot.
57 Fill the foot profile with plaster to a level. Make a short split slab for the heel. Fix the heel with additional circular turns of plaster. The problem with plaster casts outside of hospital Plaster casts are useful for treatment in controlled settings. But in out-patient management of villagers and soldiers plaster casts become soft and fall into bits and so does the fracture. For out-patient management: consider plastic orthosis, see p. 352.
you leave the limb without cast until 4-5 days after injury; then re-explore the wound to make sure that the debridement is complete before the Trueta cast is applied. The cast should not be removed until the fracture has some callus stability, that is 3-5 weeks after injury. When the wound is cleaned you will find healthy granulations. The gauze drain is often attached into the soft tissues. By soaking the wound for 5-10 minutes with hydrogen peroxide the drain is removed. If the granulations are still not ready for grafting, another Trueta plaster may be applied for 1-2 weeks or the wound dressed 2-3 times daily with slightly hypertonic saline solutions to accelerate the granulation process.
58
The neutral position is the position with the least risk of permanent joint damage through capsule-ligamentum contracture.
External fixation
Even the best plaster cast cannot fix unstable fractures fractures with considerable loss of bone, very comminuted fractures and fractures with extensive loss of soft tissues. Some method of external fixation is then indicated: The plaster-and-pins method provides good external fixation. The method is cheap, simple and rapid. It may also be combined with the Trueta method, making it very suitable for forward management of wartime fractures.
346
External fixation
The external fixation apparatus provides effective fracture fixation whilst allowing the surgeon to simultaneously work on the soft tissue injury. But the equipment is expensive, unless you persuade the local blacksmith to make it for you. Traction is also a type of external fixation. The procedure is simple, but has the drawback of fixing the patient to his bed. Thus it makes exercises and active physical rehabilitation difficult as well as evacuation when under military pressure. Do not underestimate the mental complications of total immobilization in traction for an exhausted war victim. Resorption of bone is a problem! At the fracture site there will always be some resorption of old bone before formation of new bone begins. Bone resorption Less compression/stress of the bone ends 59 Slower formation of new bone Risk of failed healing Shift from ex-fix/traction to orthosis treatment as soon as the fracture starts becoming elastic, after 6-8 weeks. 59 Plaster-and-pins. Equipment needed: Steinmann pins (2, 3 and 4 mm) or Kirschner wires (1.5 and 2 mm). Drill with a chuck (a drill from a hardware store will do it).You may use a hammer on the Steinmann pins; the Kirschner pins must be drilled. Wooden plates approximately 3x10 cm. 60 60 The procedure: The pins must be inserted through viable soft tissues, outside the wound area. Wash the pinning area! Sterile gloves! The entire procedure may be done under local anesthesia: Infiltrate the pinning points on both sides with local anesthesia, including the periosteum. Often pin insertion results in fracture motion with increased pain in which case it is better to use ketamine anesthesia. 61 61 The pin insertion: Drill (or drive with careful hammering) the pin through the proximal main fragment from the lateral to the medial side perpendicular to the bone axis. (Watch the peroneal nerve!) Pin the distal fragment in the same way. Note: Never insert the pins at an oblique angle.
347
62
62 The pin fixation: Drill holes in each wooden plate to fit the pins. Then apply the slab and the first circular turns of plaster. Put the wooden plates in position and cut the Kirschner wires 1 cm outside the plates. Fix the wooden plates with small plaster slabs and another circular turn of plaster to make a standard plaster cast supporting the pins. Warning! When the pins are applied under sterile conditions we seldom see suppuration from the pins. But pinning into cancellous bone (trochanter or calcaneus) often creates some irritation and even bone infection. Pins in these areas should be removed within four weeks. Never insert pins/wires through damaged or infected soft tissues. Do not insert pins through the bone growth zones (epiphyseal plates) in patients less than 18 years old. Temporary external fixation: multiple bone pins with orthopedic cement-filled tubings as frame/ connecting rods. Expired Simplex cement can be bulk purchased cheaply. Also see local copies of surgical instruments, p. 90. 63
63 Transfixing, self-drilling bone pins. Couplings and universal ball joints. Plain and adjustable connecting rods.
348
External fixation
65 64
64 The pin insertion: The pins must be inserted only through viable soft tissues. Drill the pins in series of three. Use the holes in the coupling plate to find the exact distance between the three pins. The entire procedure may be done under local anesthesia (ill. 60 above). 66
65 Fracture reduction and fixation: Before reducing the fracture, mount the universal ball joints and insert the connecting rods.Then reduce the fracture, maintain the fracture position while your assistant fixes the universal joints tightly. Note: There will always be some bone resorption in the fracture area during the first month after injury. To avoid fragment distraction, adjust the compression stirrup (if any) on the two connection rods or slightly release the rods, compress the fracture manually and re-tighten the universal joints. 66 Improvise! Depending upon which bone is fractured, and the location of the soft tissue wound, you may use penetrating pins or half-pins.You may use two, three or four connecting rods.
Traction
The problem: Traction inactivates the patient; his general condition will soon deteriorate. Alternative 1: Short-time traction only Use traction for only 1-2 weeks until the soft tissue problems (edema, wounds for skin grafting, vascular injury) are managed. Then apply plaster/orthosis or external fixation and get the patient out of the bed. Alternative 2: Use dynamic traction where possible It does not immobilize the joints proximal and distal to the fractured bone. It stimulates the blood circulation and soft tissue healing, and thereby accelerates the bone healing. It stimulates the patients general condition. Indications for dynamic traction All fractures without severe displacement of the fragments All fractures where the bone growth zones (epiphyseal plates) are not displaced.
349
Traction on spinal fractures is not discussed here. Management of spinal fractures, see p. 468. 67
Warning! Pins and wires inserted through damaged or infected soft tissue may cause bone infection. 67 Traction the principle: The traction force should be strong enough to counteract the muscular tension working upon the fracture. The traction weights differ depending upon the bone fractured, the age of the patient and his body feature. The traction weight for a femoral fracture is approximately 10% of the body weight. For a pelvic fracture (larger mass of muscles) the weights are somewhat higher. For an arm fracture (less muscle mass) the weights are less than 10%. Note: Traction is active therapy! Monitor the traction weight so that it exactly balances the muscle tension. Too light traction weights the fracture will overlap. Too heavy traction weights the fracture becomes distracted. 68 68 Monitor the direction of the traction: Angulation of the fracture is corrected by adjusting the axis of the traction and by putting pillows under the fracture.
69
69 Unstable fractures of the pelvic ring are managed by longitudinal tibia traction with 30 degrees abduction in the hip joint or a combined traction of the tibia and eye screw trochanter traction. Femoral shaft fractures are managed by dynamic traction upon the tibia. Pin insertion points are 2 cm below and 2 cm behind the tubercle of the tibia. Fractures of the upper two thirds of the tibia are managed by traction through the lower tibia or calcaneus. In the calcaneus the pin insertion point is slightly above and behind the center of the calcaneus. Forearm fractures are managed by traction through the 2nd and 3rd metacarpal bones.Wire insertion 2 cm proximal to the finger joints. Multiple metacarpal fractures are managed by finger traction. Wire insertion 1 cm proximal to the finger joints.
350
Traction
70
71
70 The practical procedure: The Steinmann pin is best fitted for leg traction. Locate the traction point exactly and working under sterile condition, apply local anesthesia and insert the pin, see ill. 60 and 61. Split bandage at each pinning point. The standard Boehler stirrup is applied, but improvisations are as effective. 72 73
71 The Kirschner wires are too thin to support the traction weights unless they are stretched with this particular instrument.
72 Static traction: The fractured limb is elevated upon pillows. Active ankle and foot exercises are done, but the knee joint is immobilized.
73 Dynamic traction: Exercises should start as soon as possible after injury, 15 minutes in repeated intervals under analgesia. For femur fractures the bed is arranged to allow knee flexion. This is best done by splitting the bed. If it is not possible to remove the end of the bed then with an assistants manual support of the fractured femur, moderate flexion-extension exercises of the knee and hip joint are done. Gradually, as pain recedes, the range of knee and hip motion is increased and so are the training periods. 74 Adhesive plaster traction is used in children of less than 12 kg to avoid damage to the growth zones. Also as temporary traction the plaster traction is useful during surgery, for post-operative monitoring after vascular surgery etc. Shave the leg. Apply a strong plaster sling exactly along the axis of the limb. Fix the sling with circular turns of crepe bandage. Arrange traction upon a small wooden plate in the end of the plaster sling. Illustrated here is the plaster gallows traction. It is used in femur fracture management of children younger than three years. Even if just one femur is injured both legs are set on traction. The traction weight should be just enough to lift the buttocks of that child slightly from the bed. Note: There is danger of ischemia in the legs of that child. For the first 48 hours the feet must be continually observed for their skin color and temperature. On suspicion, release the circular strapping, or shift to plaster spica treatment, see p. 620.
74
351
Expect callus to develop within four weeks after injury.The signs of callus formation are: The patient can exercise with increasing range of motion without pain The fracture is elastic on testing. No clinical signs of callus formation after four weeks suspect: The patient did not exercise Distraction of the fragments reduce the traction weights. A slight overlap of fragments is not a problem Muscle is interposed betweens the fragments consider surgery Fracture infection consider surgery. When there are signs of callus formation (the fracture is elastic when you manipulate it carefully): Either apply a well-moulded orthosis or a long plaster cast, see below Or, reduce the traction weight stepwise to zero within four weeks under continuous exercises. Then mobilize (on crutches) with careful and increasing weight-bearing.
Increasing pain and reduced motion when the traction is reduced indicate lack of callus.
352
The orthosis can be made from a variety of synthetic light plastic materials. Such materials are resistant to water, easy to keep clean and therefore the method-of-choice for out-patient treatment. 75
76
75 Making the plaster mold: 1 Remove the fixation (ex-fix or traction) and wrap up the limb in a a circular patella-bearing plaster cast. Apply vaseline or grease on the skin to prevent the plaster sticking to the skin. The orthosis must fit exactly at the patella tendon and to the bony contours at the proximal and distal end of the limb segment; at these points you must mould the cast very carefully.When the cast is half-dry (after 15-20 minutes) split it (dotted line), remove it carefully and let it dry overnight. 2 Close the lower end with some turns of plaster and fill up the cylinder with plastic plaster (POP powder in water). Put in a rod, and leave to dry. 3 When dry, wrap off the circular plaster and smooth the mold nicely. 76 Making PWC orthosis: Heat PWC (plastic) sewage tubes to 150 C in an oven. Adapt one lateral and one medial slab on the mold (use protective gloves). Again take special care to fit the proximal and distal ends at the bony prominences. The slabs are cut so that they overlap over the margin of the tibia in the front. Let there be some space at the back to adjust the pressure of the posterior leg muscles (it is the muscle pressure that supports the fracture).Take special care to adjust slab length at the knee and ankle joints to allow flexion/extension. The two slabs are fixed by velcro straps which makes it easy for the patient to adjust the compression. Drill multiple small holes in the orthosis to ventilate the skin. Note: In fitting the orthosis you have to cooperate closely with the patient; re-heat and adjust the PWC slabs until the patient is happily bending knee, ankle and walking easily on moderate weight-bearing. Consider gluing thin sheets of rubber foam inside the slab ends to prevent pressure sores from the bone. Cut holes over wounds that have still not healed (arrow).
353
77
77 Making Orthoplast orthosis: There are several types of synthetic plaster like Orthoplast on the market.They are easy to apply, but expensive.The proximal, middle and distal diameters of the limb are measured while wearing an elastic stocking.The semi-soft material is cut with a knife and heated in 70-80 C warm water for some minutes. When the material is soft it is applied and moulded to fit the limb profile exactly.
78
78 Moulding the orthosis: When stiff, the final form is drawn with a pen, the orthosis removed and the edges trimmed. Additional strips are heated for fixation of a heel cast and the transverse straps.
354
Why not antibiotics, but surgery? 1. The source of infection is necrotic tissue. Necrotic tissue is tissue without blood supply. So, neither antibiotics nor white blood cells can reach the site of trouble. 2. Certain bacteria especially staphylococcus and pseudomonas produce biofilm. Biofilm is a polysaccaride matrix that wraps up the colonies of bacteria so that antibiotics and white blood cells hardly can penetrate. The biofilm in wound infection can only be removed mechanically by the knife and by washing.
Check out the risk factors for fracture infection and poor healing
Poor oxygenation: Is there a missed vascular injury proximal to the fracture? Additionally check the local muscle compartments: Unless decompressed at an early stage, compartment syndrome may stay on for weeks with few clinical signs. Is the patient anemic? Give blood transfusion if Hb is less than 9 g/dl. Poor immune capacity: Is the patient undernourished or malnourished? How much weight did they lose after admission? Evaluate their nutrition after injury, did they get a high-calorie diet, and did they eat? Did they spend weeks in bed while under traction, wasting muscles and becoming depressed and inactive? Associated diseases delay healing: Did the patient suffer from some endemic disease before the injury? Especially check for malaria; asymptomatic carriers of P. Falciparum have a higher risk of bacterial wound infection and wounds heal slower. Re-think your treatment strategy Ganga Score, see p. 328. MESS score, see p. 381. Did you underestimate the extent of soft tissue destruction? If so, consider secondary soft tissue flap transfer. Multi-trauma did you underestimate the total severity of the injuries? If so, consider secondary amputation.
355
The re-assessment: time to decide the further strategy Bone loss? Place small chips of bone chiseled from the pelvic wing as grafts in the fracture site. Note that bone grafts will turn out to be food for bacteria unless the site is covered with well perfused soft tissue. Bone distraction? In cases of delayed healing, bone resorption in the fracture line may cause distraction of a fractured tibia or ulna. In that case, make an oblique osteotomy (chisel or Gigli saw) to remove a 1-cm long segment of the fibula or the radial bone. Then consider orthosis treatment with partial weight-bearing to stimulate bone formation. Indication for secondary soft tissue flap? Because osteomyelitis basically is a soft tissue problem, muscle or fascia-skin flaps make most infected fractures heal provided the debridement is good. Even ten or more years after the primary injury, soft tissue flaps help cure post-injury osteomyelitis. Place external fixator apparatus when the flap is in place.
356
357
358
14 Joint injuries
Evaluation of joint function The soft tissue problem
......................................................
360 361
...........................................................
359
14 Joint injuries
be decreased by more than 30% without causing instability and chronic pain. For displaced intra-articular fractures the treatment of choice may be arthrodesis (ill 12) or amputation. A non-weight-bearing joint may be treated with excision of the fractured bone end, see p. 364. Extensive capsular and ligamentous injury? In a weight-bearing joint stability is essential to function. An unstable joint will cause chronic pain. If the patient after a successful primary treatment still needs elaborate reconstructive surgery to stabilize the joint, a primary arthrodesis may be the treatment of choice. A nonweight-bearing joint has far less demands for stability and should be reconstructed. In-field management of penetrating joint injuries Wash the joint with large amounts of NS through the inlet and outlet wounds. Instill soap solution into the joint and leave it there during the evacuation. Wrap the joint in a well padded crepe bandage and immobilize it on a long splint. Staged surgery If the limb can survive and you are in doubt whether to reconstruct the joint or not, you can safely delay your decision: Concentrate on vascular repair and a proper soft tissue debridement at the first stage. Re-explore the joint after 4-5 days and then decide the management strategy for that joint.
Children have a healing capacity far better than adults. As a general rule you should always try to save a childs joint.
14 Joint injuries
Standard exploratory incisions: shoulder: p. 632 elbow: p. 640 wrist: p. 647 hip: p. 620 knee: p. 675
the soft tissues around the fracture; better use double or triple longitudinal incisions to handle the fragments rather than extensive dissection and rough traction through one incision. 5
5 Closure of joints: Close synovium tightly with a continuous over-and-over suture. Instill penicillin (5-10 mega IU) in normal saline (40 ml for a knee joint) into the joint, and close the fibrous capsule with interrupted strong sutures. Leave the skin incision open for delayed suture. 6 Continuous joint washing in high-risk injuries: In open-joint injuries with extensive tissue damage, injuries more than eight hours old or joints containing dirt and debris arrange a continuous antibiotic washing of the joint for 1-3 days. Cut the tube of an IV infusion set, cut some side holes in it, and put it through a separate stab incision into the joint before closing synovium. For dependent drainage, a urinary catheter (small caliber) with side holes are put into the distal part of the joint through another separate low incision. Then close synovium tightly. Small leaks will close spontaneously. Let the washing run slowly, 5 mega IU penicillin to each liter NS.
joint, in particular the compartments and extensions of the main joints. Eg. the superior compartment of the knee joint extends more than 5 cm above the top of the patella. Thus fractures and deep soft tissue wound of the lower third of the thigh may well enter the joint. In all penetrating injuries close to major joints: Do diagnostic needle aspiration of the joint, see p. 365. Aspiration of blood indicates openjoint injury: That joint has to be explored during surgery. Note: With X-ray examination minor fracture lines that enter the joint may not be seen. Still they are big enough to act as an entry for bacteria. Also injuries of the cartilage cannot be seen in X-rays. 8 8 Fractures of the cartilage: Free fragments of the cartilage are removed.Wash the joint thoroughly in order to find all free fragments; otherwise they become loose bodies that obstruct joint movement. Trim the edges of ragged cartilaginous wounds with a knife. 9
9 Intra-articular fracture fragments are they rotated? Minor bone fragments may be excised if they are not located in the central weight-bearing part of the joint surface. The actual fragment displacement may be difficult to assess from the X-rays. Explore the joint and align the fragments. See to it that no soft tissue is interposed between the fragments, see below. Arrange dynamic traction or plaster cast immobilization. 10
10 Comminuted intra-articular fractures: Steps more than 2-3 mm between fragments of the joint surface should not be tolerated, especially in weightbearing joints. The fracture here illustrated must therefore be explored and reduced. Apply traction (manual, plaster or pin traction) before you start surgery. In particular look for soft tissue interposition maybe some torn muscle is crammed inside the fracture and prevents reduction of the fragments. In very comminuted
363
14 Joint injuries
fractures with multiple small fragments exact surgical reduction is impossible: Remove minor fragments and soft tissue interposition; close the joint and arrange dynamic traction. Order effective analgesia and start active and passive exercises with careful movements of the joint in an intermediate position from the first day after surgery. The joint motion will mould the joint ends and further reduce the fracture. The defect left can often fill up with fibrous cartilage thus achieving secondary congruence. Primary bone grafting into open missile fractures carries a high risk of fracture infection. Bone grafting should be delayed until the soft tissues have healed without infection. 11 11 Destroyed joints consider primary resection: Resect all free bone fragments. Mobilize a capsule/muscle flap into the joint space as padding. After 6-8 weeks immobilization in a plaster cast, weight-bearing is started.The end result will be a joint with fair movement but poor load resistance. This is often useful in non-weightbearing joint in the Upper Limb, but in the Lower Limb a delayed joint fusion can be considered. 12 12 Destroyed joints consider primary arthrodesis: Resect the bone ends to get good contact of raw bone surface with the joint in functional position. Immobilize for 3-4 months in plaster cast, cast with pinning, or external fixation apparatus. The end result will be a stiff, but painless joint capable of weightbearing. But in cultures in which kneeling and squatting is very important, it is better not to carry out primary arthrodesis of the knee joint. Joint excision with soft tissue interposition can be carried out, and if necessary a delayed arthrodesis.
Infected joints
A joint may become infected through the bloodstream from some other local infections. Multi-injured and cases in poor general condition carry a particular risk of this complication. More often infectious arthritis is a result of poor primary management:Tiny high-velocity missile injuries are missed, fracture lines that enter the joint are not diagnosed or the debridement was insufficient. The signs of joint infection: Increasing pain on joint movement. Gradually the joint is left in a contracted position and the patient will not let you move it. Swelling of the joint. The local tissues are reddish and warm. Fever and poor general condition. On the slightest suspicion: Perform diagnostic aspiration of the joint! Aspiration of infected joints is very painful; use anesthesia for full accees.
364
Infected joints
13
Treating joint infection: Open that joint immediately and explore for missed injury. In particular look for bone fragments without blood supply and abscess formation in some deep wound pocket next to the joint. Wash the joint with dilute soap solution and large amounts of NS. Arrange continuous washing with antibiotics. Drain the soft tissues next to the joint well. Total immobilization of the infected joint. IV antibiotics. 13 Joint aspiration the shoulder joint: Work sterile! Use a large-bore needle and infiltrate local anesthetic on your route towards the joint. The normal synovial fluid is yellow, smooth and clear. In joint infection the fluid becomes thick and cloudy with debris. The shoulder joint: Rotate the arm outwards. Direct the needle towards the lower part of the joint. Here the joint space is wider. 14 The elbow joint: Flex the joint. From the lateral side you can identify the head of radius. Direct the needle just proximal to the head of radius into the joint.
14
15 16
15 The wrist joint: The inlet point is just radial to the index extensor tendon, 1cm distal to Listers tubercle. The needle is directed not 90 degrees but 60 degrees to the skin, and in the proximal direction. 16 The hip joint: Use a long (spinal) needle. Rotate the femur outwards. The inlet point is in front of (not medial to) the femur, at a level of the lower part of trochanter. Forward the needle until you feel the base of the neck of the femur on the needle point; then walk the needle along the neck of the femur, step-by-step switching the direction of the needle towards the medial and lower part of the joint.
17
17 The knee joint: The inlet point (on either the lateral or the medial side) is 1 cm proximal and 1cm posterior to the upper corner of the patella. From here, forward the needle in a horizontal direction. 18 18 The ankle joint: Palpate the space between fibula and tibia. The inlet point is just lateral to the toe extensor tendons.
365
366
15 Tendon injuries
Primary management .............................................................. 368 Secondary reconstruction
........................................................
368
367
15 Tendon injuries
Primary management
Tendons heal well The tendons have great capacity to heal after injury on two conditions: That the tendon blood supply and nutrition remain undamaged That the tendons are covered by viable soft tissue. Two-step surgery: First debridement and soft tissue cover Then surgical reconstruction after 3-6 weeks. 1 The tendon blood supply: All tendons are covered by a thin sheet of loose connective tissue. In this sheet runs a fine network of blood vessels that enter the tendon. Close this sheet when the debridement is done exposed to air tendons cannot heal. 2 3
2 The tendon synovium: In some areas the tendons are protected by aspecialized synovium here the handflexor and extensor synovium. 4
4 The tendon synovium contains a clear yellow viscid fluid that lubricates and provides nutrition for the tendon. Inside the synovium is a delicate network of blood vessels. For protection and nutrition the synovium should always be closed after exploration and debridements. The assessment Nerve function tests may indicate tendon injury as the main limb nerves run close to the tendons. Tests for the upper limb, see pp. 628-629; the lower limb, see p. 659. Associated vascular injury? Both vascular and nerve injury has priority over tendon injuries. Assess the degree of soft tissue injury. Plan the skin or muscle-skin flaps you intend to use to cover the injured tendons, see p. 329.
368
Primary management
5 The primary surgical exploration: Due to muscle tension, the tendon ends retract, especially the proximal ends of the flexor tendons will retract considerably after injury. Extend the wound into a wide exploratory incision. Dissect the soft tissues carefully and identify the injured tendons one by one. Note: Are you sure what you identify as a tendon is not a nerve, see p. 375? Pull the proximal ends of the tendons towards the level of injury, debride only the most ragged parts of the tendons, and fix them with some suture to the soft tissues to prevent retraction. (A thin steel suture is convenient for later X-ray identification.) 6 Cover and drain the tendons: Wet the tendons with normal saline every five minutes during surgery. Mobilize viable soft tissues from the side of the wound, and anchor them with interrupted sutures over the tendons. Drain well through separate stab incisions. If there is major soft tissue deficit, design a local full thickness skin or muscle-skin flap, and rotate it onto the wound to cover the tendons. If you cannot cover the tendons with local flaps, make normal saline-wet dressings for some days:That will promote a bed of granulations for secondary splitskin grafts.
7 Free tendon movement: Excessive scarring will destroy tendon function as the tendons become attached inside the scar tissue. The tendons may also become entrapped in the callus of an underlying fracture. Do not let a wound over a tendon heal by spontaneous granulation. Do not apply free skin grafts directly onto tendons. Start active and passive exercises (analgesia!) from the first days after primary surgery to prevent tendon attachment and contractures.
Secondary reconstruction
Reconstruction should be undertaken as soon as possible after the injury. But four conditions should be fulfilled: The skin is healed There is no local infection There are no contractures in the distal joints up on which the tendons shall work There is not extensive scarring in the field. Any reconstruction inside a scar-filled wound is useless: The scar will invade the tendons and prevent their free movement.
369
15 Tendon injuries
8 No mans land: Reconstruction of hand flexor tendons inside their synovial sheath is difficult even in experienced hands. Tendon injuries inside this shaded area should be exactly debrided as soon as possible after injury. Concentrate on proper soft tissue cover (flaps in hand surgery, see p. 335). Refer the case to an experienced surgeon for reconstruction as soon as the soft tissues have healed without infection.
9 Tendon suture: Mobilize the proximal and distal ends of the tendon, free them from scar tissue and adhesions. Atraumatic technique not to damage the tendon blood supply! Apply double mattress sutures. You may add some interrupted sutures for approximation. Silk 3-0 to 5-0 is convenient. Cover the anastomosis with viable soft tissues. Immobilize for two weeks in a position where the anastomosis is not under tension. After two weeks start exercises within a narrow range of motion. 10 10 Tendon graft the palmaris tendon: Never suture tendons under tension, the anastomosis will give in. If there are loss of tendon tissue due to injury and debridement, better interpose a small tendon graft. The palmaris tendon can be removed from the wrist with no loss of function. 11 11 Tendon graft the plantaris tendon: The plantaris tendon makes a long graft.You find it on the medial side of the Achilles tendon. 12 12 Tendon graft one of the index extensors: There are two extensor tendons to the index finger. You may excise one of them without loss of function.
370
Secondary reconstruction
13
13 Graft reconstruction: The grafts are trimmed and sutured without tension. Notice the needle inserted during surgery to prevent retraction of the proximal tendon stumps. Immobilize for two weeks before intensive exercises start.
371
372
16 Nerve injuries
Diagnosis and exploration
........................................................
374
373
16 Nerve injuries
Nerve function test for the upper limb, see p. 628. Nerve function tests for the lower limb, see p. 659.
mobilize a soft tissue rotation flap, see pp. 329-39. Drain well; secondary hematomas may cause infection and excessive scarring. Immobilize the site of injury for two weeks, but order active exercises of the distal motor units controlled by the injured nerve. 3 3 Tinnels sign for nerve regeneration: The nerve fascicles regenerate from the level of injury in the distal direction. The growth is slow, maximum 1 mm per day.You may test the level of regeneration with Tinels sign: Tap your finger distal to the site of injury. If the response is distal-radiating sensations along the nerve, some regeneration of the nerve fascicles is under way. Prepare for the the reconstruction! Information:You need active participation from the patient, explain him why, how and when the second operation will take place. Order active exercises: Most nerve injuries are not total active exercises help maintain the function of the nerve fascicles not injured. Order passive exercises: Why reconstruct the nerve if his joints turn stiff? Maintain joint and tendon function by passive exercises.
Children have great capacity for nerve regeneration: Do not rush with the secondary surgery.
5 Are you sure it is a nerve and not a tendon? The end of a cut tendon is smooth; at the end of a nerve you can see the fascicles protruding. Pull carefully in the distal end: If it moves a finger, it is a tendon.
375
16 Nerve injuries
6 The nerve anastomosis: When you approximate the proximal and distal end of the nerve, see to it that there is no tension on the anastomosis. Flex the neighbouring joints, but do not mobilize the nerve by wide dissection as this will damage its blood supply. Better perform nerve grafting if there is too much tension. If the anastomosis cannot hold a 8-0 suture due to tension, a graft is indicated. Identify some vessel in the epineurium on both ends. Use this vessel as a landmark to avoid rotation at the anastomosis. Apply two holding sutures. The sutures are interrupted 6-0 to 8-0 non-irritating suture (prolene is best, silk is acceptable). The sutures should just grasp the epineurium, not the fascicles. Provide soft tissue cover. Drain well. Immobilize for six weeks, but order active and passive exercises distal to the level of injury. Note: The rehabilitation is protracted. After six months of active post-operative training you will see the end-result. Nerve grafting The sural nerve just lateral to the Achilles tendon is suitable as graft.You may mobilize the nerve through some small transverse incisions. The nerve graft is anastomosed with interrupted sutures through the epineurium. Note: As the graft will retract, estimate an additional length of 20-30% to allow for retraction. Ruptures of major nerves may be repaired with several parallel sural grafts.
376
377
378
17 Amputations
Amputation or limb salvage? Land mine amputations
.....................................................
...........................................................
Techniques for the primary amputation (first stage) ......................... 383 Techniques for the definitive amputation (second stage) Get going again: Early Temporary Prosthesis Fitting
................... ........................
379
17 Amputations
380
Mangled Extremity Severity Score (MESS) Factors influencing lower limb salvage after injury 1 The degree of tissue damage Low energy (minor soft tissue damage, simple fractures) Medium energy (moderate soft tissue damage, multiple simple fractures) High energy (close-range gunshot wounds, crush injuries, compound fractures) Very high energy (avulsion of soft tissue and heavy contamination) 2 The degree of circulatory shock Systolic BP 90 mm Hg or more all time Systolic BP less than 90 mm Hg in periods Systolic BP less than 90 mm Hg all time 3 Patients age (years) Less than 30 30-50 More than 50 4 The degree of limb ischemia Pulse reduced, but capillary circulation normal Pulseless limb with diminished capillary refill Cool limb with neurological signs 5 The duration of limb ischemia If the limb has been ischemic for more than six hours, the ischemia scores (section 4 above) are doubled Also see the Ganga Score, p. 328. Sum the points to predict the chance of limb salvage: A MESS score of 7 points or more normally indicates that primary amputation should be done; despite the best limb salvage surgery that limb will probably be lost, or at best end up useless, prosthetic, and with chronic pain. Use severity calculators with care: Associated injufies? The MESS score may be a good guide where the limb injury is the main injury; in unstable multi-injury patients you must decide which injury represents the main risk, an injured limb with scores less than 7 may have to be amputated to save life. The physiological cpacity: Several factors that influence the outcome are not included in the MESS score factors sus as malnutrition, chronic diseases and the patients mental state and motivation. Arms and legs are different! An arm with permanent nerve injury and partial loss of skin sensation may well be useful, a leg is not. An arm with bone loss and/or contracted joints may well be useful, a leg of that kind cannot bear weight and is useless.
381
Points 1 2 3 4 1 2 3 0 1 2 1 2 3
17 Amputations
Mechanics and farmers are different! A mechanic may loose their job and income if you amputate his right thumb, but not a farmer. Discuss indications for amputation and the level of amputation with your patient. Mass casualties makes a difference! Attempts to salvage seriously damaged limbs are time- and staff-consuming; in mass casualties an over-load of the clinic capacity may be one reason to do primary amputations more readily.
Beware the fragment wounds. A tiny fragment can kill at close range.
Behind this small entry wound is a massive injury to the right colon.
382
Wartime amputation staged approach The modern high explosive weapons (DIME and fuel-air-explosives) typically causes extensive limb injuries. Amputations must often be done on life-saving indications, especially when there are associated burns, see pp. 272-74. Consider immediate fasciotomy of the stump in the emergency room on admission. Perform the primary surgical amputation, stump fasciotomies included. Leave the wound open with good drainage. After 4-5 days: If the wound is clean, make the definitive amputation and close the wound. If not clean, make re-debridement and see if you can close the stump after another 3 days. Get the patient up and going: Early temporary prosthesis fitting!
If there is time for it: harvest some split-skin grafts from the amputated limb and store in refrigerator.You may need it later if the wound does not heal well.
17 Amputations
approximate the muscle and skin flaps with a few deep interrupted sutures over drains. Apply bulky dressing with light compression, and elevate the limb (higher than the level of heart). 2 2 Amputation stump fasciotomy: We should keep in mind that most wartime amputations are consequences of high-energy injuries and that the soft tissues have been exposed to massive pressure. Even in very short amputation stumps compartment syndrome with increased intramuscular pressure will develop within 24 hours unless the exploratory incisons are extended as fasciotomies up to the proximal joint. Make this a routine in wartime amputation surgery.
3 Disarticulation (the knee joint): This method is rapid, simple and less traumatic. It is indicated in entrapped limbs, emergency amputations in multi-trauma, and for extensive joint injuries. It is said that the disarticulation results in amputation stumps unsuitable for prosthesis. This is not true. The disarticulated stump is suitable for any modern prosthesis. Design the skin-fascia flaps according to the injury: The standard method is a short anterior-long posterior flap. Note: The postetior flap should be at least as long as the diameter of the knee.You may also use medial-lateral flaps. The incision is carried through skin and fascia in one incision.Control the vessels before you amputate: Make a wide incision from the amputation level downwards along the main nerves and vessels. Retract the nerves and cut them at the highest possible level; apply local anesthesia nerve block. Ligate the vessels doubly. Then the joint capsule with ligaments and tendons are cut. Notice that some synovium will be left on the amputation stump. It will produce fluid, so better drain the stump well. There is no problem with soft tissue retraction after disarticulation. 4 4 Ray amputation on the hand/ foot: Compared to a transverse amputation, the ray amputation is less traumatic as the incision runs parallel to and inside the space between the muscles, vessels and nerves. The functional and cosmetic result is also satisfactory. The wound is explored proximal to the level of injury through longitudinal incisions. In high-energy injuries the shock wave may cause muscle necrosis inside the compartments of the calf/forearm: Extend the exploratory
384
Shoulder and forearm amputations: p. 637. Elbow and forearm amputations: p. 642. Hand and finger amputations: p. 651. Thigh amputations: p. 670. Lower leg amputations: p. 688.
incisions above the ankle/wrist. Particularly explore the lateral compartment of the lower leg. Leave these incisions open as fasciotomies. Resect the metatarsal/metacarpal bones through the joint, through the fracture, or take them off by sawing close to their base. The amputation wound will ooze considerably: Drain well. 5
5 Guillotine amputation on special indications only: This method may be useful for patients trapped in destroyed buildings, under vehicles and in situations where the amputation must be hurried (serious multiple-injury patients, military emergencies). Make circular skin and fascia incision at the most distal level possible. Incise the muscles at the same level and let them retract. Identify the main arteries and veins and ligate them, major vessels with double ligature. Pull the main nerves and cut them at the highest possible level; let them retract into the soft tissues and inject 5-10 ml local anesthetic as nerve block along the nerve truncks. Note: If one muscle belly is necrotic at the level of amputation, make an exploratory longitudinal incision and amputate this muscle at a more proximal level. 6 Level of bone amputation: Retract the soft tissues and cut off the bone as proximal as possible without dissecting the muscles off their bony attachment. The oozing of blood from the medullary bone is controlled by compression for five minutes by a crammed wet gauze compress. The profile of the guillotine stump should be like an inverted cone. The problem with guillotine amputations The skin is elastic and will retract many cm within two weeks. The muscles will also retract progressively and thus pull the fascia and skin further into retraction. Thus the bone may protrude after 1-2 weeks and further bone amputation may be necessary in order to close the stump. Many sophisticated kinds of skin traction are developed in order to prevent soft tissue retraction. However, they are elaborate, time consuming and not very effective. Better to restrict the use of the guillotine method. If it is used, apply a well-fitting and tight Trueta plaster cast onto the stump at the time of primary surgery. The Trueta cast will not only provide drainage and prevent edema, but will also reduce the soft tissue retraction.
385
17 Amputations
7 Dressing the amputation stump is a part of surgery and should be done by the surgeon. Good dressing prevents stump edema, prevents soft tissue retraction, prevents joint contracture and allows good drainage.You may use either crepe bandage or a Trueta plaster cast. Apply dry fluffy gauze to drain all deep spaces and compartments of the stump, including the fasciotomy incisions. Pad the bony prominences, and apply a compressive dressing that exerts an even pressure on the soft tissues. Long slings of adhesive plaster secure the dressing/cast and counteract contractures. Intensive post-operative care! Amputation wounds are painful: Give intermittent IV ketamine pain relief for 24 hours until the next operation. Amputees are depressed: Let family or friends be close at all times. Amputees are confused: Parts of the body are gone for ever; the body image has to be reconstructed. Inform patient that he will be up and going again within 10 days (temporary prosthesis). Let the patient meet other amputees walking on temporary prosthesis. This will help him rebuild a positive body image.
386
9 Myoplasty for better muscular control: To secure the bone in center with good muscular control, myoplasty should be done when the amputation stump is closed: The skin is not separated from the fascia flaps, but retracted as one thick flap. The mass of muscles is divided along the natural septa into four main bundles. The bone is cut and trimmed for sharp ends.The opposite muscle bundles are fixed to each other by deep interrupted sutures without tension. Thus the bone becomes well centered and well padded. Note: If the myoplasty results in a clumsy stump, the muscles should be thinned before the plasty is made. 10 10 The skin problem: 4-5 days after the primary amputation the stump should be dressed and closed if it is clean and well circulated. Do not delay stump closure more than 10 days: The soft tissue retraction will increase and loss of valuable limb length may be the result. Trim the skin-fascia flaps so that the skin-fascia suture is located off the weightbearing area of the stump. Central suture lines will create pain inside the prosthesis. Note: Amputation flaps have a maximum length approximately like the base of that flap. If the length exceeds the base distance, the blood nutrition may be insufficient and the end of the flap may become necrotic. Be careful during the dissection of the skin-fascia flaps not to damage their blood supply. Skin graft for closure? Where the soft tissues have retracted, you may save several centimeters of stump length by closing the stump with skin grafts instead of re-excision of the bone. However, the grafted stump has poor tolerance for weight-bearing and should be used only for upper limb stumps and amputations in children. Use meshed thick partial thickness grafts, see p. 399. Nerve entrapment and neuromas After they are cut, nerve ends may swell and become invaded by scar tissue. Thus a neuroma is formed which may produce chronic pain and excessively tender amputation stumps. Nerves under tension and pressure may cause painful amputation stumps. During primary surgery identify each main nerve, pull them downwards and cut them as high as possible, let them retract into the soft tissues. Apply a nontraumatic technique; use a sharp knife when you cut them. See to it that the soft tissues around the main nerves are viable, that the nerve end is well padded by soft tissues, not under pressure and that no hematoma may collect around the nerve.
Nerve block during surgery: Apply 5 ml local anesthetic along each main nerve to reduce post-operative pain.
387
17 Amputations
Prevent post-injury disability! When the amputation wound is closed, the stump is swollen and sensitive; it takes 2-3 months before you can fit a definitive prosthesis. Dont let the patient stay in his house waiting to get a prosthesis; he may become permanently disabled by depression and pain. We need an active rehabilitation plan: Definitive amputation After 4 days: Fit a temporary prosthesis Wrap the stump twice daily. Walk and work After 2 months: Take mould and fit definitive prosthesis.
388
Pain-killers or other drugs have no effect on post-injury chronic pain. Consequently, our response should go along three lines: 1. Physical rehabilitation: Fit temporary prosthsis as soon as possible when the amputation wound is closed. Seeing and walking on the artificial limb forces the amputee to think in positives, not in negatives. 2. Help the patient take charge of his own rehabilitation: Information is crucial, especially explaining the features of phantom limb pain to the patient. It is a particular pain felt in the amputated limb in the limb that has been actually removed. As many as 75% of mine amputees have some problems with phantom pain a few of them so intensely that they cannot bear it. Some patients do not feel pain, but a phantom sensation: They feel the amputated limb is still there, and often in a wrong position. The phantom problem should be foreseen, your patients and staff prepared on how to handle it: Inform your patients that they probably will get some trouble with phantom pain or sensations, that this is a normal complication that will gradually recede. Discuss the plan for further treatment; information builds trust, and thereby coping and less pain, or coping despite the pain. 3. Socio-ecconomic support: Start vocational training for a new job or give the amputated family a cow or some sheep; they can pay back a calf or some lambs after 2-3 years. Or hire out farming land to a landless family.
389
17 Amputations
The plastic holster is carefully fitted at the upper thigh and buttock. Double steel bars run down to the foot device; the bars may be hinged at the knee joint. The trans-tibial amputation stump thus hangs freely supported by a sling of canvas and velcro straps without being exposed to any stress. Take mould of the upper thigh: Apply vasaline or grease on the skin and make a circular plaster cast of the upper thigh with a few slings around the pelvis. Take special care to fit the cast at the lower rim of the buttock, and to fit the triangular shape of the upper thigh. Split the cast open when half-dry and cut off the pelvic sling.When dry, make a floor in the cast form and fill it with
390
plastic plaster (POP powder in water). You may also use mud armored with grass. Split open and remove the outer form when the content has hardened. Smooth over the plaster mould and here you have the exact copy of the upper thigh.
Make the ischial tuberosity-bearing holster If there is lymphedema at the thigh, use end-bearing rather than tuberosity-bearing prosthesis.
Split PVC sewage tubes, heat in an oven to 170 C, and wrap the PWC sheet onto the mould to make an exact copy of the plaster form.
Fit the prosthesis: Work closely with the patient; good cooperation depends on their understanding.Take exact measures to fit the side bars. The bars with the foot device is fixed to the holster by steel nails. Let the patient test the prosthesis to see how it fits; any painful points must be re-moulded. This is easily done in the village by slight heating by a blow-torch or in the fire.
Up and going three weeks after the mine amputation. This Cambodian farmer stepped on a PMN while farming. Three weeks after the inury he is again working with a temporary prosthesis made in a small workshop at the local district hospital by local rehab workers using local technology only.
391
17 Amputations
11
13
12 Make a negative copy of the stump: When the stump is well shaped, wrap a plastic sheet over the stump. Pull a stockinette elastic bandage tightly over the plastic sheet and form a well-molded plaster cast. When dry, remove the plaster carefully in one piece. Fill the plaster form with plastic plaster or mud/grass around a wooden pin. When the content has hardened, remove the outer plaster holster and you have an exact copy of the amputation stump upon which the prosthesis shall fit. 13 Make the inner prosthesis holster: There must be some padding between the skin and the outer prosthesis holster: Tubigrip stocking is desirable, but homemade elastic textile stocking will do as well. Put this padding upon the stump copy. Then make the inner holster from Orthoplast (or some equivalent type of synthetic plaster) or from thin leather.
392
14
14 Make the outer prosthesis holster: With padding and the inner holster on the stump copy, another sheet of Orthoplast or PVC is applied to form the outer holster. To the outer holster you attach the walking device, a carpenter-made hand, a hand hook, a nice foot etc.
15
15 Adjust the prosthesis: Folds and ridges cause pain and pressure sores. Cooperate closely with the patient; adjust and mould the padding and holsters until they fit optimally.
393
394
18 Wound closure
Monitor the wounds
............................................................... ............................................
..................................................
...........................................................................
395
18 Wound closure
The protocol
When: Inspect the wound 4-5 days after the primary debridement. If the primary debridement is suspected to be inadequate, the wound should be looked at no less than 48 hours later. How: Undress it completely. If gauze drains and debris stick to the wound, soak the wound with hydrogen peroxide solution. Or better still, put the entire limb/patient in soap solution for 15 minutes, and undress it/him there. By whom: The first dressing should be done by the surgeon or a surgical team member who made the primary operation. From then on daily dressings are done by experienced staff. Accurate problem shooting: For each major wound, the main risk factor should be identified at any time. Eg.: Especially watch the drain at the lower left abdomen! Does it stink? Or: Wash the deep wound pocket at the backside of the thigh.
396
Anesthesia/analgesia: Do not let pain prevent a proper exploration! Extensive injuries should be dressed in the operation theater under anesthesia. Small and moderate necroses should be excised immediately bedside under intermittent IV ketamine analgesia.
397
18 Wound closure
3 Relief incisions to prevent tension: Make parallel relief incisions on each side of the wound (here closure of a fasciotomy), approximately 5 cm from the wound. The relief incisions should not be sutured let them heal spontaneously. Some practical points You may close the muscle, fascia, subcutaneous fat and skin in four separate layers of suture. But note that all suture materials particularly the absorbable ones cause some chemical irritation to the tissues. In risky wounds better close all layers of the wound in one deep suture, eg. interrupted mattress sutures. To reduce the tension on each suture, set the sutures at maximum 1 cm intervals. Deep pockets inside the wound may be closed separately with a few absorbable sutures. But a safer procedure is to delay the DPS until such pockets have filled up with granulations. Control all bleeding points before you close the wound. And place drains by separate incisions. Hematoma formation invariably causes wound infection. Apply thick dressings of dry gauze under slight compression. Paddy dressings protect against bacterial superinfection. Local antibiotic ointments creams or impregnated nets do not prevent infection, but only slow down healing. Do not let anybody open the dressing for four days as that may contaminate the wound. If the wound should turn infected, you will not see the signs before the 4th or 5th potoperative day.
Skin grafts
Skin grafts have no blood supply and they are not innervated. Skin flaps have blood supply and innervation. Types of free skin grafts: The thin partial thickness graft includes only the most superficial layer of the skin. It has good take, but the skin of the grafted area becomes thin and fragile. The donor site will granulate and heal rapidly. The thick partial thickness graft includes 2/3 of the skin; only the deepest layer of the skin is left at the donor site.This graft has impaired take and parts of it may become necrotic. But the final result is a nicer and more resistant skin. The full thickness graft includes all layers of the skin down to the subcutaneous fat. This graft gives the best final result. But there are problems with the take: Graft necrosis often occurs in more than minor full thickness grafts. Minor grafts to a well-vascularized bed (the face) may succeed when there is no infection. Conditions for skin grafting: The wound has healthy granulations The wound is without infection The grafted area must be immobilized for 5 days after grafting.
398
Skin grafts
5 The instruments for skin grafting: Either a large dermatome (15 cm), adjustable for any thickness of skin grafts. Or a small dermatome with standard razor blades (Silver), adjustable for any graft thickness. Convenient and sufficient for most grafting procedures. A plain wooden plate 15x10 cm, to stretch the skin when the grafts are excised. Fine non-toothed forceps. 7
6 Anesthesia of the donor area: If you fix the partial thickness grafts with sterile adhesive plaster, the entire grafting operation can be done with infiltration anesthesia of the donor area only. Spinal needles are convenient for the subcutaneous infiltration.
7 Harvesting the graft: Adjust the dermatome to excise exactly the graft thickness needed. Stretch the donor site between the wooden plates. Pick up the graft with the forceps so it does not become entrapped in the dermatome. Note: Grafts wider than 5x10 cm are difficult to handle.
8 The graft preparation: Put the grafts with the skin side down on a sheet of vaseline gauze that makes them more easy to handle. Trim their edges and mesh them: Cut some short incisions in each graft to prevent fluid from collecting under the graft and lifting it off its bed. Note: Do not let the grafts dry; wet them with normal saline until they are applied.
9 The grafting: Put the grafts, a few mm apart the bed of granulation, their flesh side down. You may fix them by some interrupted sutures, but it is easier done with thin strips of sterile adhesive.
399
18 Wound closure
Dressing
Either closed treatment: Dress the wound with normal saline-moist gauze, thick gauze padding and good fixation with broad crepe bandage. Or open treatment: Apply no dressing at all; let the graft be exposed to the suns heat during the day, or dry it carefully at intervals with a fan or hand heater (hair dryer). Open treatment improves the graft take and should be applied for full thickness grafts and face wounds. It is contraindicated in dirty and infected areas. Grafts as dressing Thin partial thickness skin grafts is the best dressing material possible they stimulate healing and help prevent wound infection. Bank grafts Take some thin partial thickness grafts during the primary debridement, and put them on vaseline gauze moist with sterile normal saline in a sterile closed glass inside the refrigerator. You may apply the bank grafts for that same patient when the wound is examined 4-5 days after surgery either to close parts of the wound or as dressing until definitive wound closure is done. Allografts You may use the bank grafts on some other extensively injured patient, that is as allografts. Allografts will not take, but become necrotic after 5-7 days. But during these days they are an excellent dressing.
Skin grafts
the take is partial do not remove the graft: New skin will develop from elements of the skin tissue even in areas where the take is only partial. 11 11 Pinch grafts: The pinch grafts have good take, but poor cosmetic result. Lift a small skin cone and cut it (knife blade horizontal). Each pinch is thin at the edge while the center is thicker containing skin germ cells. New skin will develop between the pinch islands from these germ cells. Dressing with vaseline gauze, moist gauze and slight compression. The donor site will heal by spontaneous granulation. 12 Corachan grafts: Dissect a full thickness skin band and remove all subcutaneous fat. Cut the graft in small stripes and place these side down on the granulation bed, side by side.The corachan grafts have better take than the pinch grafts. Close the donor site by direct suture. Skin grafts upon bone Small areas of raw bone may also be grafted with free grafts provided the area is without infection: Drill multiple holes through the cortical bone into the marrow. Dress the area with gauze wet with hypertonic NS solution for some days. Granulations will develop from the marrow through the drill holes, and make a bed for grafting. Apply a thick partial thickness free graft or corachan grafts, see p. 330.
12
Skin flaps
Stimulate healing You can design the flaps to include subcutaneous fat and fascia. These tissues contain stem cells that may accelerate the healing of deep wounds. Re-establish skin sensation All skin flaps are based on one or more source arteries. As the arteries are accompanied with nerves, skin flaps can also re-establish skin sensation to damaged areas which is useful especially in reconstruction of injuries to the face, hand, and foot. Consider flap closure in these cases: Full thickness skin loss on the palmar side of the hand, fingers and foot Full thickness skin loss close to the eyes and mouth Large wounds where tendons, nerves and vessels are exposed without soft tissue cover Skin deficit or poor soft tissue padding on amputation stumps, bony prominences, and deep scalp wounds.
401
18 Wound closure
13
13 Simple fat-skin flap: Plan and design the flap before the dissection starts. Good venous drainage from the flap is important. Design the flap along the veins of that area so that the flap drains well through its base. The flap will shrink when it is raised from its bed. Allow 20% shrinking into account when you design the flap size. Note: The cm length of the flap in relation to its base should not exceed 2:1. Otherwise the end of the flap may become necrotic. A face flap may be somewhat longer because of the good blood supply. Raise the flap by careful sharp dissection towards the muscular fascia. Do not damage the superficial veins. The base of the flap should be thicker than its end. Rotate the flap, trim its size and fix it well with fine non-traumatic sutures. If too much tension arises along the long axis of the graft, make a very short transverse relief incision at its base. The donor site is covered by free skin grafts. 14
14 Fascia-fat-skin flap: You may of course cut the bone of this thumb stump, and close it by direct suture. But then you lose length and the important grip function of the hand. Fascia-skin flaps are useful to save length in finger amputations. A flap is raised composed of skin, subcutaneous fat, vessels, nerves, fascia and the short intrinsic muscle to the 2nd finger. The flap is trimmed and sutured to the defect. It provides good soft tissue padding for the bone, complete sensation and the grip function is saved. 15
15 Flap transfer the cross finger flap:You may transfer skin flaps from one area to another distant flaps. This full thickness skin injury on the volar aspect of the index finger will cause joint and tendon contracture by spontaneous heal402
Skin flaps
ing. A broad-based flap of skin and subcutaneous tissue not including the volar nerves and vessels is raised from the lateral aspect of the 3rd finger. The flap is trimmed and sutured to cover the defect on the index finger. The donor area on the 3rd finger is covered by thin split-thickness grafts, and the two fingers are immobilized together. After 10-12 days the flap will take its blood supply from the index finger, and you may cut it through its base on the 3rd finger, trim the cut edge and close the index finger wound. 16 16 Local fascia-skin flaps, hinged at the distal end (perforator flaps): This is a new technique, especially useful in fractures of the distal forearm/wrist and the tibia/foot where proximally hinged flaps cannot reach. The source arteries for the distally hinged flaps are tiny perforator branches of one of the main limb arteries. Perforator flaps can be raised without microsurgical equipment; good glasses (from the local market, strength +4) and a careful hand is all what is needed. See more, pp. 336-39. Staged flap transfer if you doubt the blood perfusion! First step: Dissect the flap, but leave it in place. Dress with moist NS gauze under the flap. The second step: The next day inspect the capillary circulation at the tip of the flap. If its skin is warm with good color, transfer the flap. If there is edema, pale and cool skin the flap will turn necrotic within days: Replace it to its bed and find another strategy for wound closure.
403
404
406 410
405
Airways
Small children breathe through the nose, not by the mouth. If the nose is blocked they may become desperate. Blood in the nose: suck it out Dressing: leave the nose uncovered Insert naso-gastric tube by the mouth, not by the nose. Head tilting in children: Tilt the head to open the toungue block but dont tilt as much as you do in adults; its more like placing the neck in neutral position, not bent and not extended. Airway cutdown, use needles! Upper airway obstructions are best managed by insertion of 2-3 large-bore needles into the larynx between the cricoid and thyroid cartilages. Avoid bronchial intubation locate the end of the tracheal tube: The trachea of small children is short, the distance from the vocal cord to the main bronchus is only 6 cm in a one-year-old child. Make sure that the endotracheal tube does not enter one main bronchus, leaving the opposite lung without ventilation. In children the tube is palpated through their soft trachea:The end of the tube should not be located below the level of the clavicular heads. As a routine, chest X-ray is done after intubation to check the tube position.
406
Tracheal tube size for children Age (years) Newborn 1 2 2-10 10-15 Internal tube diameter (mm) 3.0 3.5-4 4.5 AGE + 16 4 6.0-7.5 no cuff no cuff no cuff no cuff cuffed
A rough guide: The childs 5th finger corresponds approximately to the endotracheal tube size for that child.
407
Look for critical signs of lung injury: Anxiety in the eyes Wide nostrils Retractions over the clavicles and the upper abdomen when breathing High RR. Perform fine-needle diagnostic pleural puncture on the slightest suspicion aspiration of blood is diagnostic.
Dont use diazepam, morphine or pentazocine after blood loss in children: the peripheral blood vessels dilate and the circulation may collapse.
408
Volume therapy Dont underestimate the blood loss. An injured child with a cold nose and increased HR may already have lost 1/3 of the blood volume. 1. Give warm Ringer as rapid infusion: Infants: 200 ml Young children: 400 ml Older children: 600 ml 2. Assess the response: Check skin temperature and HR. If it is still not normal: Give one more rapid infusion of half the first dose. 3. Again reassess: If there is still no improvement, the child is probably bleeding inside. Give no more infusions but hurry to the hospital.
Nutrition
Small children have very small stores of carbohydrate in the body and have to eat often. If the injury is severe and the hospital far they may run out of blood glucose and collapse unless they get nutrition: Best: Breast milk Second best: Warm rice soup or sweet fruit juice by mouth or by stomach tube Or: Glucose 500 mg/kg as slow IV infusion. Mix the glucose with the electrolyte infusion, or give it by a separate IV line.
Surgery on children
Head injury The brain of the child is especially sensitive to trauma. Post-injury breakdown of the membranes makes the intracranial pressure raise rapidly after trauma. Monitor children closely and check the Glagow Coma Scale (GCS) at close intervals for the first 6 hours after injury. A child may slip down from GCS 14 to GCS 10 in a very short time. Do immediate surgical decompression if you are sure the GCS score in a child is on its way down. Chest injury Beware lung contusions! The chest wall of children is soft and multiple rib fractures are not common after crush injuries. Blunt injuries may cause lung contusions without the ribs being fractured. Children rescued from entrapment situations and children with contusion marks on the chest should be kept for 1-2 days for respiratory monitoring even if their respiration may seem easy on admission.
409
Abdominal injury Diagnosis, exploration and management of specific organ injury in children follow the guidelines in Chapters 28-36 with some exceptions: Exploratory laparotomy on ready indications: The chest cage is short and the abdomen wide in small children: High abdominal organs such as the stomach, duodenum, the small gut, liver and spleen are more exposed to injuries than are adult organs. Poor respiration, internal bleeding or bloody drainage from the stomach even after minor blunt injuries are indications for surgical exploration of the upper abdomen. Conservative primary surgery? Bleeding from the liver and spleen may stop spontaneously in children. Contrary to injured adults, splenic injuries in children may thus pass without diagnosis. The capsule of the spleen in small children is thick compared to adults, and may take sutures. Tears of the spleen may therefore be managed by debridement and careful suture on the condition that you are able to montor the child closely for five days after surgery.
Breathing
Watch out for hypoxemia Ageing causes increased lung stiffness and reduced vital capacity. In old patients the respiration may be marginal before injury and even a minor depression of their respiration may cause poor tissue oxygenation. Aspiration into the airways is more common in old patients. Aspiration regularly cause pneumonia. Watch out for pneumonia Gram-negative pneumonia is a common fatal complication after injury in the elderly. Aging and alveolar dilatation cause emphysema with retention of airway secretion and increased risk of atelectasis and pneumonia after injury.
Circulation
Poor response to hypovolemia start volume therapy early The old heart cannot respond to hypovolemia by adequate increase of the heart rate therefore the cardiac output will fall more rapidly than in younger patients. Neither are the peripheral vessels fully capable of constriction and shunting of blood to the vital organs as a response to bleeding. As a consequence volume therapy should be started early before the circulation collapses.
410
Support the cardiac function Cardiovascular disease is common in old people and there is an increased risk of heart arrhythmia and coronary infarction during surgery and the first post-injury days. Oxygen support and good pain relief are important to prevent the complication. Note: It is not uncommon to find an elderly patient with low blood pressure and also slow heart rate. This can be due to failure of the heart to beat faster such as previous heart disease, or the effects of beta-blockers in the treatment of hypertension.
Surgery on elderly
Ceep the patient warm! Cold blood bleeds more. Old patients have less capacity to stop bleeding by vascular contraction and blood clot formation. Prevent avoidable deaths! Early primary surgery is especially important in the elderly. Delayed surgery increases the risk of post-operative complications and trauma death. Old victim of an anti-tank mine explosion in Cambodia. Infections Poor peripheral tissue perfusion and a general low resistance to bacterial infections make old patients a risk group regarding wound infections. Two measures will reduce the rate of infections: Prevent oxygen starvation: Restore the tissue blood blood perfusion by early and active volume therapy. Prevent local edema, the threshold for emergency room fasciotomy should be low. Make debridement as soon as possible: The old patients have less responsive immune defences, and wound infections develop soon after the time of injury. It is a sad fact that old injured patients are often the last ones to be evacuated after mass casualties and accidents. Head injuries Old patients have increased risk of skull hematoma formation after a head injury; even a minor blunt head injury may cause a subdural hematoma. Monitor closely for 2-4 days after head injury. Chest injuries A penetrating chest injury is managed by early chest drainage.The mortality of blunt chest injuries is much higher in patients older than 65 years. Blunt injuries may cause multiple rib fractures or sternum fracture with flail chest formation. Early diagnosis and respiratory support are essential: analgesics, costal nerve block, tracheal suction, coughing exercises, early ambulation. Increasing RR and hypoxemia are indications for intubation or tracheostomy and assisted ventilation.
411
Limb and pelvic injuries Due to osteoporosis (bone demineralization), the elderly are prone to get fractures of the spine, the pelvic ring or the long bones even after moderate injuries. The fracture hematoma may be considerable after pelvic fractures due to laceration of the pelvic veins, even life threatening. The fractures of the old patient heal slowly and there is increased risk of non-union and osteomyelitis.The debridement after missile fractures should be done soon after injury with meticulous exploration, not leaving any necrotic tissue in the wound field. Due to the poor tissue blood perfusion in the elderly, consider primary amputation after open high-energy fractures in particular if there are associated injuries.
412
413
414
....................................................
415
Beware: If a patient is on Beta blocker antihypertensive therapy the heart rate can remain low even with much blood loss.
416
Uncross-matched blood
Consider to blood-type and give blood-type cards to the resistance and key personell in your area. Cross-matching, see p. 831. Blood packs are marked with donor ABO- and Rh-type. In most trauma cases you have time to analyse the ABO-Rh blood type of your patient and make a cross-match between donor and recipient. In emergency cases you may safely use compatible blood without cross-matched.You will just have to wait the 10 minutes it takes to identify the blood type of the injured patient. If his blood type is already identified, you may start transfusion without delay on admission. If mismatched blood
417
is transfused, intravascular haemolysis will take place with risk of renal failure and acute shock in the patient. The reaction is life-threatening.
Type-O blood
The distribution of ABO types varies between regions and ethnic populations. In most areas the O-type is common. Check the distribution of ABO blood types of the population in which you work.You may draw 5-10 packs of O-Rh negative blood and store them in a plain refrigerator in the emergency room of your clinic. In general you may use O-Rh negative blood for transfusion to any blood type without cross-matching. A blood sample from the patient is taken for blood-type identification immediately upon arrival, and before the transfusion is started. If more than 5 units of O-negative blood are given to a non-O patient, there may be problems with later cross-matching of type-specific blood transfusion for that patient. Precautions for blood group O transfusions: If more than 5 units of blood group O blood are transfused to a non-O patient, transfusion reactions may occur and you have to discontinue the transfusion. If less O-blood units are given, those reactions are not common. If you have the blood bank facilities available, the O-negative blood should be analysed regarding anti-A and anti-B antibodies. Preferably only O-negative blood with low antibody-titres should be used for emergency transfusions, as that will further reduce the risk of transfusion reactions. Or you may let the drawn O- blood sediment, pour out the plasma and just use packed red blood cells for emergency transfusion.
Improvised direct blood transfusion: When standard equipment for transfusions is not available you may improvise direct transfusion in emergency cases. Use a blood group O donor or blood type compatible blood. Double large-bore IV cannulas are inserted in the donor veins from which blood is taken with ordinary 20-ml syringes. The blood is administered directly through IV cannulas to the actual patient.With double cannulas, two officers may transfuse 500 ml blood during 15 minutes in this way. Note: There is a certain risk of air embolism with this procedure. Let the blood fill the syringes slowly to avoid air bubbles. If the blood is transfused immediately and within seconds, it will not coagulate inside the syringe. If available infuse the blood through blood filters.
418
Autotransfusion
With autotransfusion there is no risk of transmitted blood-borne diseases or transfusion reactions due to incompatible blood products. In autotransfusion blood from the wounds, abdomen, chest or drains of the injured patient is collected, anticoagulated and re-infused to the patient. Cases suitable for autotransfusion are Heavy internal bleeding Heavy chest tube bleeding Dependent drains producing much blood after surgery. The practical procedure Blood is collected from the abdominal cavity or chest by a large syringe, by a metal cup or directly by the chest tube. Leave the blood clots. Filter the blood through a blood filter or through sheets of sterile gauze into a sterile bottle. Add 20 ml sodium citrate to each 100 ml blood for anticoagulation.The blood may either be transferred to an ordinary blood bag and transfused, or you may store it in the blood bank as whole blood or packed red blood cells. Or it may be directly transfused with syringes as citrate-blood from the bottle. Re-infuse through 200 micro-mm blood filters to reduce the risk of complications.
If there are no blood packs: Cut open a bag of electrolyte infusion, poor out some of the content, mix the elctrolyte solution with citrate-blood and transfuse.
Some kind of transfusion reaction occurs in 5% of all transfusions. Keep emergency drugs ready at any time!
419
Dirty blood-bags and IV catheters There is a certain risk of bacterial contamination of the blood bags. The risk is increased during rough transport and storage. Also processing of whole blood upon production of plasma and red blood cells etc. may induce contamination. Staphylococcus, pseudomonas and klebsiella are the most common responsible agents. The IV catheters in long-term patients may contain multi-resistant staphylococcus (MRSA) which may also contaminate the transfusion. Transfusion-transmitted infections Malaria, hepatitis B, hepatitis C, and HIV may cause disasters after transfusion. Screening of donors is imperative. Note: Several rapid tests for donor screening recommended by WHO have proved to be inaccurate in certain areas (e.g. SouthEast Asia). Also ELISA tests yield low accuracy (false-negative rates of 5-10%) in certain populations. Adverse effects on the physiology: Hypothermia: Transfusion of cold blood from the blood bank may cause a considerable fall in body temperature. This hypothermia may cause a serious general bleeding tendency. Avoid hypothermia by running the transfusion tube through a cup with warm water (40 C) before it enters the patient. Coagulation problems: Extensive transfusion of bank blood may cause low platelet counts, dilution of coagulation factors and spontaneous bleeding.The complication is avoided by alternating bank blood and fresh whole blood. Hypercalemia: Old whole blood from the blood bank contains increased amounts of serum potassium. In patients with major tissue damage, the serum level of potassium is generally increased. After several transfusions of old whole blood (stored for 30 days), hyperkalemia may arise in these trauma patients. Hypocalcemia: Citrate is used as blood anticoagulant. Citrate binds calcium. The normal liver in a well-circulated patient is capable of regulating the citrate and calcium level. But after liver disease, liver failure or major liver injury, multiple transfusions of bank blood may cause low serum calcium and cardiac arrhythmia. Prevent this complication by injection of 1 g calcium chloride for every 4 units of blood transfused in a separate intravenous line.
Diseases complicating surgery and transfusions, see pp. 431-32. Coagulation system failure, see pp. 734-36.
420
421
422
424 426
423
Management of hypothermia
This is hypothermia: A central body temperature (temperature of rectum or esophagus) below 35 C. In severe hypothermia the central body temperature may be below 30 C. Hypothermia as trigger of post-injury stress, see p. 234. Hypothermia is a serious complication It may cause oxygen starvation with acidosis and severe coagulation failure. Volume therapy may have no effect until the temperature is corrected. Early diagnosis is essential Cooling occurs rapidly, but re-warming takes time and a lot of energy. Even in tropical countries hypohermia is common after long evacuations. See www.traumacare.no/publications Hypothermia is common in major injuries even in hot climate: Patients rescued after long-time entrapment Patients undergoing prolonged evacuation after extensive injuries Patients with major burns Patients loosing blood, treated with high volumes of IV infusions Patients operated in cool/airconditioned operating theaters, in particular laparotomies lasting more than one hour Small children and old people are generally at risk.
424
Management of hypothermia
Avoid exposure to heat: Surface rewarming causes increased skin blood flow, circulatory failure and should be avoided.
Careful rewarming! A sudden rise in central temperature may cause cardiac arrhythmia. Making warm infusions: Place a one liter bag of Ringer (20 C) in hot water for 5 minutes. Then the infusion temperature will be around 40 C.
425
Manage shivers: Give IV or rectal diazepam. Do not mistake temperature shivers for muscular spasms: Muscular spasms may be due to electrolyte disorders if the hyperthermia has developed after prolonged heat exposure. In cases of unconsciousness and signs of brain edema, dexamethasone 10 mg i.v may be useful. Give oxygen to prevent asciosis.
427
428
............................................................................ ............................................................................
429
Types of anemia
Anemia and surgery Moderate anemia will seldom cause complications. In chronic anemia surgery may be done with hemoglobin level as low as 7 g %. Patients with acute, grave anemia due to blood loss carry increased risk of circulatory failure, wound infections, sepsis and secondary organ failure due to poor tissue oxygenation. Beware particular forms of anemia Sickle cell anemia, thalassemia and anemia due to malaria may all cause serious complications during surgery even if the anemia is moderate. Routines: Test hemoglobin on all patients before primary trauma surgery In some areas blood smear examination is imperative.
430
Types of anemia
Spontaneous abortions in female patients Complications during deliveries in women. Sickle cell anemia, clinical signs Short and stunted fingers Bone and joint deformation Enlarged spleen and heart. Before surgery Avoid hypotension: Start aggressive volume therapy with electrolytes and plasma expanders. Avoid hypoxemia: Give respiratory support and oxygen. Give sodium bicarbonate if the patient is admitted with hypoxemia or hypovolemia. Avoid hypothermia: Keep the patient warm. Start exchange transfusions if his hemoglobin level is below 6-7 g %: Take venous blood from the patient and exchange step by step with normal fresh red packed blood cells until 1,500 ml. During surgery Use local anesthesia (infiltration, nerve block or epidural anesthesia) wherever possible general anesthesia causes more complications. Give oxygen via mask. Monitor his circulation closely. Avoid excessive blood loss. Replace blood loss immediately with transfusions. But beware: Transfusion reactions are common in sickle cell patients. Do not use tourniquets and do not clamp vessels temporarily: Local hypoxemia may provoke sickle cell crises. After surgery Sickle cell patients are a high-risk group regarding secondary organ failure and require active resuscitation. Especially monitor the respiration and the circulation.
432
Sprue and surgery: Anemia and vitamin deficiencies increase the risk of wound infection and protract healing. Hypokalemia may cause cardiac symptoms during and after surgery. Hypocalcemia may cause cardiac symptoms and spasms after injury and surgery. Hypoproteinemia may cause circulatory failure after injury and surgery. The sprue patient cannot utilize post-operative high-energy nutrition.
Nutritional deficiencies
Primary lactase deficiency Many Africans and Asians are lactase deficient: Milk and milk-made diets cause diarrhea they cannot utilize milk as a basic nutrient. The state is chronic in contrast to secondary lactase deficiency which is common in all patients after acute or chronic enteritis. The disorder may spoil enteral nutrition after surgery unless recognized. Vitamin A deficiency The main sources of vitamin A are liver, dark green vegetables and orange fruits. Vitamin A deficiency is endemic in certain areas as a common result of prolonged malnutrition, enteritis and malabsorption. The main clinical sign of deficiency is corneal ulceration and ultimately blindness. Vitamin A deficiency causes general weakness and increases the rate of complications after surgery. The therapy: Injections IM of vitamin A 100,000 IU per day for three days, and diets rich in vitamin A. Vitamin B deficiency Vitamin B deficiency or beri-beri is common in Indonesia and the East Asia. The condition may have many clinical manifestations: neurological signs with paresis of the limbs, general edema and circulatory changes with cardiac failure. Particularly in children circulatory disorder with cardiac failure and fluid congestion in the lungs may arise secondary to injury and surgery. The emergency therapy is i.v injection of Benerva or aneurine. Consider venesection of 200 ml blood from a peripheral vein in cases with cardiac complications. Vitamin D deficiency Vitamin D is formed by action of the sun upon the skin. Even in tropical areas vitamin D deficiency may be seen in the big cities. The clinical signs are bone pain and sudden fractures due to poor mineralization of the bones. Pelvic, rib and femur deformities may be seen. Fractures heal slowly and the risk of non-union is increased. Serum calcium is low and cardiac disorders due to hypocalcemia may be seen after trauma and tranfusions.The therapy: vitamin D or cod liver oil together with adequate oral calcium intake.
433
Schistosomiasis
Surgery and schistosomiasis: Urinary tract schistosomiasis may mimic an acute injury. There is high risk of intestinal complications after abdominal surgery. Schistosomiasis (bilharziasis) is a chronic disease of the urinary tract and large gut caused by different strains of the schistosoma parasite. The disease affects 5% of the worlds population and is most common in Africa, South America, Thailand, Burma, China, and in the mountainous areas of the Middle East. The parasite lives in water, using snails as intermediate hosts. Certain village populations may be universally infected. The parasite lives and mates inside minor blood vessels in man before they enter the walls of the urinary tract or colon, or follow the bloodstream to cause infection in some other body organ. Diagnosis by identification of schistosoma eggs in the urine or feces by direct microscopy.The diagnosis may be confirmed by serological tests, rectal biopsy or cystoscopy. Clinical features The clinical picture is complex and depends upon the stage and site of infection: Blood in the urine: After physical exhaustion, but also after major injuries in organs other than the urinary tract. Urinary tract stenosis may cause partial obstruction and renal failure. Suprapubic catheter or ureter catheter may be indicated. Bladder contracture: Extensive ulcerations and scarring of the urinary bladder may make bladder surgery difficult. Abdominal complications: Ulcerations and granuloma of the walls of the rectum, colon and lower ileum may cause intestinal bleeding imitating rupture of the intestine. The infection may cause rupture of intestinal anastomosis, and paralytic ileus after abdominal surgery. Liver failure and spontaneous bleeding from the gastric mucosa may complicate rehabilitation. Several drugs are available for specific therapy: Niridazole, metrifonate or praziquantel are all effective against most strains of schistosoma.
Ascariasis
Be worm-conscious! Ascariasis is common in most Third World countries. The infection may be universal in moist areas. Even patients carrying a few worms may develop serious complications after abdominal injury and surgery.
434
Surgery and ascariasis: The worm searches the gut injuries and may cause rupture of intestinal sutures. Worms may block naso-gastric tubes and tube drains. Worms may obstruct the intestinal blood supply, cause necrosis and spontaneous gut perforations after surgery. The ascaris worm is 10-30 cm long, 2-5 mm broad and whitish-pink in colour. Ascaris infection may cause inflammation of the gut and formation of adhesions. In extreme cases a bolus of worms may obstruct the small intestine and cause ileus and gut perforation (arrow). In many African countries ascariasis is the most common cause of bile duct obstruction. The specific therapy is simple and effective: Piperazine citrate in one single dose of 4 g will cure most cases.
Amebiasis
Amebiasis = trouble! Amebiasis may cause problems at all stages of wartime surgery in pre-operative care, during surgery, and in the post-operative phase. Amebiasis is a worldwide disease found in most tropical, subtropical and temperate areas where the hygienic conditions are poor. The parasite, Entamoeba histolytica, is ingested with contaminated food or water. The disease is most common in patients of 30-50 years of age. The parasite invades the gut wall and causes enteritis with ulcerations mainly in the colon.The diagnosis should be suspected in patients with chronic mild diarrhea. The diagnosis is confirmed by identification of amoeba in the stools, or in smears of mucus from the gut ulcerations. The stool smear is examined by direct microscopy. Repeated smears may be necessary since some stool productions are free from parasites. Note the nucleus of the parasite compare the size with the red blood cell ingested by the parasite (arrow). Amebiasis and surgery: Poor capacity at the time of injury: Chronic diarrhea may cause hypovolemia and electrolyte deficiencies. Technical problems during surgery: In advanced amebiasis the entire colon may be deformed by strictures and scarring.The gut wall becomes thin and brittle and may not take sutures. Post-operative infection: Abdominal and other extensive injuries may cause a spread of amebas through the gut wall. Fistulas, peritonitis and abdominal abscess may develop.
435
Post-operative bleeding: Aggressive amebic enteritis with massive bleeding may arise secondary to abdominal injury. Secondary organ failure: In patients with poor general condition after extensive injuries and surgery, the amebiasis may spread from the intestine and cause liver abscess, lung empyema or cardiac failure. The specific therapy consists of metronidazole 1,500 mg for 2-5 days as tablets, suppositories or infusion.
Malaria
Post-injury malaria is a common complication In areas where malaria falciparum is endemic, as many as 1/3 of trauma patients may develop symptomatic malaria as a complication to injury and surgery. Post-injury immune depression, see p. 167. Injury + surgery immune depression malaria break-through Major injuries depress the immune capacity. Extensive surgery further takes the immune system out of balance which enables the hidden Falciparum parasites to break through the defenses:Within 24-48 hours after surgery the patient develops the typical clinical signs of malaria high fever, shivering and extreme weakness. Post-injury malaria is a serious complication Post-injury malaria falciparum increases the risk of bacterial wound infection and delays healing. Antimalarial drugs, see p. 224. Always screen for Falciparum before surgery! In parasite carriers: Start antimalaria treatment before surgery. Make surgery brief and simple: Long operation time is a risk factor or postoperative malaria relapse. Plasmodium falciparum the most potent of the malaria parasites may cause severe complications after injury and surgery. Malaria Falciparum is common throughout Central Africa, South East Asia, and the northern parts of Latin America. Infected but no clinical signs In endemic areas the inhabitants are continuously infected by the malaria parasite by mosquito bites. Persons surviving the age of 3-5 years develop partial immunity to the disease: they carry the parasite in the blood stream, but they have no clinical symptoms of malaria. It is essential to identify Falciparum carriers as soon as possible after injury at least before surgery: In-field: In endemic areas all serious trauma cases should undergo dip-stick testing in-field. Dip-stick positive cases should get immediate IV artesunate treatment. On admission: Confirm dip-stick diagnosis by microscopy of thick blood smear.
Since 2004 a new strain of malaria, Plasmodium Knowlesi, is reported in persons in South-East Asia. The parasite is carried by monkeys, but can cause clinical signs similar to P. Falciparum in humans. Treat as P. Falciparum.
436
Malaria
Malaria and surgery Postoperative malaria: The malaria relapse further takes the immune system out of balance, especially the defences against bacterial wound infections. Take blood smears for microscopy and start immediate artesunate + mefloquine treatment s soon as the diagnosis is confirmed. Note: Postoperative malaria fever may mislead you to look for bacterial infections. Then keep in mind that postinjury malaria normally occurs within 24-48 hours after injury, bacterial wound infections trigger clinical symptoms from day 3-4 onwards. Severe malaria: Left untreated, the Falciparum relapse may develop into fullblown severe malaria including cerebral infection with unconsciousness and respiratory failure. Grave anemia due to hemolysis. Renal and liver failure, and coagulation system failure similar to the DIC disorder.
Typhoid fever
Diagnostic problem Patients without symptoms may carry the infection. Surgical problem Weak patients develop abdominal complications. Risk of cross-infection in the ward! The sources of infection are urine, feces, vomiting and wound discharge from infected patients. Even after specific therapy, the patient may pass salmonella bacteria in his excretions for 3-6 months. Typhoid fever is caused by bacteria of the salmonella group. It is widespread throughout Third World countries. The salmonella bacteria are spread with contaminated water or foodstuffs, particularly milk where the hygienic conditions are poor.The clinical signs are stepwise increasing fever, respiratory symptoms, headache with some mental confusion and enlargement of the spleen.The definite diagnosis is done by blood and stool culture, but these tests take too long. In emergency management better do the diazo reaction which is positive in 90% of all infected cases. Bed-side diagnosis The diazo reagent is made from two solutions: Solution A: sulfanilic acid 0.5 g, concentrated hydrochloric acid 5 ml and 100 ml water Solution B: sodium nitrite 0.5 g and 100 ml water. One part of solution B is mixed with 40 parts of solution A to form the diazo reagent. Five ml urine and 5 ml reagent are mixed with a few drops of 30% ammonia and shaken in a glass tube. A pink or red coloration of the froth implies a postitive reaction indicating typhoid infection all other colors are negative.
437
Typhoid and surgery The clinical symptoms may be complex. In weak patients several organ systems may be infected: The typical typhoid fever may erupt secondary to injury and surgery: The temperature is rising gradually to very high fever with cerebral confusion and eventually coma. Abdominal complications: Ulcerations of the intestines may cause spontaneous perforation of the distal parts of the small gut. Typical is peritonitis and abscess formation in the right lower part of the abdominal cavity. The management is urgent laparotomy with drainage, suture of the perforations or resection-anastomosis. Increased risk of paralytic ileus after abdominal surgery: The treatment is gastric decompression and chloramphenicol by the gastric tube. Distant infection: In cases with poor general condition salmonella may spread aggressively and cause lung abscess, arthritis or typhoid fracture infection. The management is urgent debridement and drainage. The specific therapy consists of chloramphenicol 500 mg every six hours. In serious cases add metronidazole.
438
Prevent spreading HIV during surgery: Do not use the same instruments on two patients without proper sterilization. Simple boiling or isopropanol sterilization will kill the virus. Exclude HIV in all blood donors. Do not use skin allografts without knowing if the donor is HIV positive. Always use gloves during surgery and wound care in high-risk areas.
439
440
Section
441
442
.......................................................................... ...............................................................
................................................................... .............................................
Skull hematoma after closed injury Complications of skull surgery Management of neck injury
..................................................
......................................................
Staged surgery in major head trauma ........................................... 239 Fractures of the neck Head injury chart
..............................................................
465 841
..................................................................
443
Surgical anatomy
1 1 The main arteries of the neck: The two internal carotid arteries carry the brains blood supply. Note that the internal carotid artery starts as low as the level of the thyroid cartilage. Note the superficial, vulnerable position of both carotid arteries just under the jaw. Note the vertebral artery running through the transverse vertebral processes. 2 2 The main nerves of the neck: Note the level of the brachial nerve plexus the superior branch is located at the level of the cricoid cartilage. Just above the clavicular bone the plexus runs rather superficially: Blunt and penetrating injuries may damage the plexus at this level. Note the vagus nerve (regulating heart and intestinal functions) running close to the carotid arteries (white arrow). Also the external jugular vein is illustrated (black arrow); the site for IV cannulation is where the vein rides on the sternomastoid muscle.
3 3 The scalp anatomy: Nerves and a rich capillary network run in the subcutaneous tissue. This is where the local anesthesia should be infiltrated to control bleeding during surgery. Under the subcutaneous tissue is the galea a strong, non-elastic fibrous sheet. Hematomas may collect under the galea (as illustrated) or between periosteum and the skull bone. 4 4 The brain and its main arteries: Note the deep course of the anterior and posterior cerebral arteries. Branches of the middle artery run superficially and may be torn by fracture fragments in temporal injuries. 5 5 The venous sinuses are the main venous drainage of the brain.The smaller cerebral veins empty into the sinuses. The sinuses are located inside the dural sheath, closely attached to the skull bone and are easily torn in fracture injuries. Note the sagittal sinus running exactly in the midline: Take care in the debridement of skull injuries towards the midline not to tear the sinus.
444
Surgical anatomy
445
Before surgery
Prepare normal saline: During surgery the open skull injury is washed with saline, by a large syringe or directly from the infusion set. Suction is used for debridement of brain tissue. Any suction may be used, a hand or foot pump suction is useful. Suction is done through a fine-caliber plastic tube, a naso-gastric tube cut short will do. The operating field: If there is time for it you may cut and shave the hair around the injury but it is not documented that shaving reduces risk of post-operative infections. In emergencies there is no time and need for shaving. Do not manipulate with skull fracture fragments or deep foreign bodies: Leave that for the surgeon. Position the patient: Tilt the table feet downwards to increase the venous drainage and decrease bleeding. A small pillow under the head eases the access for the surgeon. Anti-edema management: If the brain is swollen from hematoma and edema it may protrude through an open skull injury.The patient is probably unconscious: make an an airway cutdown and ventilate the patient aggressively (hyperventilation) before surgery. Note that hyperventilation has a temporary effect only; it may be repeated in sequences of 2-3 minutes. Flush infusion of 500 ml mannitol 150 mg/ml helps reduce the brain edema and make surgery simpler. Prevent convulsions: Some patients with elevated intracranial pressure get general convulsions soon after the injury. Convulsions further add to the brain edema. Patients reported to have had convusions immediately after the injury, should have prophylactic phenytoin treatment before surgery: give a loading dose of 15 mg/kg in Ringer over 30 minutes; then maintenance dose by 5 mg/kg/day until GCS is normalized. Surgeon, prepare yourself! Many head injured have died because the surgeon did not dare to access the injury. There is nothing magic with a brain injury The brain wound is to be debrided like any other war wound. Bleeding control is simple compared to major abdominal injuries. Dura is to be managed like any other fasacia. An open skull fracture should be treated like any other fracture. So, tell yourself: I am good, I can make it!
Anesthesia
Local anesthesia The brain tissue carries no pain receptors. Most skull injuries can thus be managed in local infiltration anesthesia of the skull: Infiltrate anesthetic with adrenaline deep subcutaneously to reduce bleeding from the scalp capillary network.The craniotomy is normaly painless, but manipulations with the basal parts of the dura may be painful; infiltrate local anesthesia towards the skull base.
446
Ketamine anesthesia Ketamine is said to increase the brain pressure and contribute to edema and elevated ICP in traumatic brain injuries. In our opinion, this warning is not justified: Ketamine improves the cardiac output and also the perfusion pressure in the brain. Ketamine thus helps prevent further oxygen starvation and edema. Only in cases where the drainage of cerebrospinal fluid is obstructed (severe herniation) may ketamine have negative side-effects but those are cases with GCS scores < 7 who should not undergo craniotomy in a wartime makeshift clinic. Thus we advocate the use of ketamine as anesthetic in closed as well as open skull injuries.
Scalp injury
8 9 10
8 Debride the scalp wound: Let the assistant press the scalp just lateral to the incision to control bleeding. Control bleeding by infiltration of a diluted adrenaline-saline at bleeding points, electro-cautery or ligature on small needle. The blood supply to the scalp soft tissues is rich. Small scalp wounds should be closed at the time of injury (delayed suture is not necessary).
9 Explore the skull: Do not hesitate to extend the scalp wound, elevate the galea and periosteum to get a full view of the skull injury. Control the scalp bleeding carefully, otherwise you will be hindered by constant bleeding into the operating field.
10 Closure of scalp wounds: The blood circulation is rich and scalp wounds can be closed by immediate primary suture if the wound is well debrided. Let mattress sutures include the deep layers (galea). If the tissue loss makes suture impossible even with lateral relief incisions, apply vaseline gauze and thick gauze padding (spontaneous granulation). Or split-thickness skin graft or rotation flap graft for closure, see pp. 398-401.
447
11 Depressed fracture without open brain injury: Even if the outer surface of the skull is just slightly depressed, some fragments may be pressed through the dura into the brain tissue. Careless manipulation of a depressed fragment may cause serious bleeding: First drill a hole with the perforator in sound skull bone just lateral to the fracture area until you can see the light blue dura in the hole. Enlarge the hole with the burr. Stop drilling before the burr slips inside! Then lift the dura off the skull bone with the elevator, and nibble the skull bone until you reach the fracture area. 12 12 Debride the fracture and examine the dura: Remove all loose bone fragments carefully; they may stick to the dura, so use the dissector to lift them carefully out. Major bone fragments well attached to the periosteum/galea should not be removed, but elevated as a bone flap. Remove the depressed fragment last. If the dura under the fracture is completely normal, yuo may close the wound. If the dura under the fracture is undamaged but dark blue or bulging, there is an injury under the dura. Then incise the dura and explore the brain. If the patient has signs of serious brain damage (GCS < 13), the dura should anyway be incised for exploration.
448
Do not replace loose bone fragments after the debridement! The most common reason of post-operative wound infections is necrotic bone. At this stage our sole aim is debridement and primary healing of the wounds. Any defect of the skull bone may be reconstructed later.
13
14 15
13 Exploration of the brain: A ragged dural tear is debrided. Otherwise incise the dura cross-wise avoiding the dural vessels. Take care if you are close to the venous sinuses, see p. 444.
14 Debride the brain tissue: Wash with abundant NaCl and use suction to remove blood clots. Remove bone fragments and dirt from inside the brain, only fragments deeply buried should be left. If you find the missile itself, remove it. If not, do not search for it. Damaged brain tissue is soft and pulpy: Remove it by careful suction and continuous washing with NS. Control every bleeding point, see below.
15 Close the dural incision after exploration (silk or Dexon 3-0). Here a graft from the temporal muscle fascia is used for closure. There may be some initial leaking of cerebrospinal fluid (CSF) by the wound. However, if the skin and subcutaneous tissues are healthy, leaking normally stops after 48 hours. Persistent leaking of CSF may cause brain infection and abcess formation and indicates reoperation. If the patient is cirtically ill and time is short, we do not spend time on dural closure, see more on p. 246.
Skull wounds: Primary skin suture is OK The blood perfusion of the skin of the face and the skull is rich. You may close the wound by direct primary suture if the skin wound is well debrided and not closed under tension. Do not close the wound of the galea, but the skin only.
449
Control bleeding
16 Increase the venous drainage: Tilt the operating table to keep the head well above the level of the heart. 16 Control bleeding from the skin-muscle flap: The skin flap may bleed briskly and make access difficult. Wrap the flap in gauze, fix the gauze with stay sutures or a few towel clips through the flap, and use an elastic rubber band to pull on the everted flap. The six crosses mark burr holes in case a bone flap has to be raised. 17
17 Control bleeding from the bone edges: Approximate and squeeze the skull bone slowly with a large artery forceps or needle holder both the inner and the outer table in one bite. Do not apply a lot of bone wax; it may cause wound infection. 18
19
18 Gauze packing for diffuse epi/subdural bleeds: If it bleeds in the epidural space from under the skull bone and you cannot control the source of bleeding by cautery, place small pads of gauze soaked in diluted adrenaline carefully into the epidural space. Also the subdural space may be packed in the same way. The packs are removed after 10 minutes. Or you may leave the packs for a second-look craniotomy after 48 hours when the brain edema has sealed off the bleeding points 19 Hitch sutures for epi/subdural bleeding: Tie up the dura to galea or periosteum with hitch sticthes to control oozing from under the skull fracture.
450
Control bleeding
20
20 Cautery: Do not use artery forceps on the delicate brain vessels. They may tear the vessels and increase the bleeding. Grasp the vessel carefully with small forceps and coagulate with low-grade bipolar cautery current. If it bleeds from the brain tissue: Punch one leg of the pipolar forceps one cm through the brain surface (the pia mater sheath), and burn the circumference of the punch wound at lowcurrents. Note: Clean the forceps and the bipolar between each cauterization, else it does not work well.
21
22
21 Clips for bleeding control: Vessels of medium size are best controlled with clips. 23
22 Control by manual pressure: Apply gentle finger pressure for one minute on a gauze pack soaked in diluted adrenaline against the bleeding point.
23 Muscle patch for bleeding control: Take a small piece of muscle (eg. from the temporal area) and crush it between your fingers into a thin sheet, about the size of a postage stamp. Apply the muscle patch upon the bleeding area under gentle finger pressure. Within minutes, the bleeding vessel will clot. Bleeding from deep inside the brain Pack the bleeding pocket with a warm wet ribbon gauze tampon soaked in diluted adrenaline. Make up a solution of 1:200,000 or 1:100,000 strength. Leave it for 10 minutes, then withdraw it stepwise. If it still bleeds from deep inside the brain, go for staged surgery: 1. Leave the hemostatic gauze tampon inside the brain and cover the wound with heavy well-fixed gauze dressing. Give anti-edema treatment and reoperate within 48 hours. 2. Re-operation: Soak the gauze tampon well with isotonic saline, and remove it. The bleeding would have stopped. Finish the debridement and close the wound. Bleeding from the venous sinuses Even major tears in a sinus are controlled by a muscle patch and very gentle digital pressure. The wall of the sinus is thin, and should not be grasped with forceps. The sagittal sinus may be ligated in the frontal area (the anterior 1/3). Ligature of its posterior parts or of the transverse sinus is usually fatal.
451
Fractures of the base of the skull (bilateral retrobulbar hematomas): Bed rest, half-sitting position. Monitor GCS. Antibiotics are not indicated. 24
Complex injuries In high-energy blast injuries you will often find combined epi-sub-dural bleeds, see p. 239. On which side is the hematoma? Probably on the side of the dilated/slowly reacting eye pupil. But maybe (also) on the opposite side.
452
26
26 Exploration through burr holes is rapid, simple and life saving. The hematoma is usually located in the area where the skull was hit: If there are signs of crush injury, make the first burr hole in that area. If there are no visible signs of injury, the first burr hole (1) is made midway between the ear and the eye on the side with the most dilated pupil. This is the site where most subdural hematomas collect. If the first burr hole is dry (no signs of hematoma), make the second and third burr holes (2 and 3) in the posterior part of the skull approximately 6 cm from the midline. And a fourth hole (4) in the frontal area. If all holes are dry, repeat the same procedure on the other side of the skull.
27
27 Burr holes the procedure: Infiltrate the area of incision with lidocaine with adrenaline to reduce bleeding. Make a rapid 5-cm-long incision through the skin and galea down to the skull bone in one cut while your assistant applies constant pressure to the wound edges to reduce bleeding. Free the periosteum from the bone, place dry gauze on the wound edges and apply the self-retaining retractor firmly to control bleeding from the scalp. Make the bone hole with perforator and burr (ill 11).
It may be difficult to evacuate large subdural hematomas by burr holes, especially if they come late for surgery. If so, elevate a bone flap, see p. 245.
If you are sure there is a hematoma inside the skull Do not stop making burr holes even if the patient seems to be dying in your hands! Identification and evacuation of a hematoma may still save him.
454
In abscess formation there are also signs of localized brain damage (pupil reactions, paresis, rapidly increasing brain pressure). Re-operate on ready indcations: Explore the wound, evacuate the abscess, wash with abundant saline, remove loose bone fragments if any, debride the necrotic brain tissue that was left over from primary surgery. Close the wound over a soft drain from inside the skull. Cover with broad-spectrum antibiotics and metronidazole. Post-operative acute hyperthermia The body temperature may rise rapidly to well above 40 C due to brain edema and damaged brain tissue. Such acute post-injury hyperthermia is caused by injury to the heat-regulating center in the brain, and is not a sign of infection. Cool with cold water. Consider sedation. Convulsions may be a sign of persisting brain edema. Management: Manage the brain edema (see above). Control the convulsions else they increase the brain edema: IV diazepam 10-50 mg or IV phenytoine (diphenylhydeantoine) 5-10 mg/kg mixed in Ringer infusion. In serious cases: Continuous therapy with phenytoin 5 mg/kg/day as infusion. If the patient seems to recover, gradually reduce the dose. Enteral feeding programs, see pp. 778-81. Gastrostomy for enteral feeding, see p. 274. Problems of nutrition Optimal nutrition is necessary for the healing of serious head injuries. In comatose or semi-comatose patients, naso-gastric tube feeding is used from the first day after operation. Beware deeply comatose patients also may have lost the intestinal motility: Start slowly with small doses of carbohydrate solution. Extensive brain injury? If you expect a prolonged recovery, make a feeding tube-gastrostomy at the time of primary surgery. Bed sores and joint stiffness These are serious complications which further depress the general condition of a severely injured patient. The only preventive measures are continuous intensive nursing, passive exercises and joint protection. That program is time consuming and presents too big a load upon the professional staff: Better train friends and relatives in a complete nursing program.
455
456
28 The lateral incision. The incision runs along the anterior border of sternocleidomastoid muscle and gives good access to the main vessels and the esophagus. For exposure of the brachial plexus the incision is extended along the clavicular bone: The external jugular vein is ligated, the triangular flap elevated and the neck muscles separated by blunt dissection. Do not hesitate to detach the sternomastoid muscle. To explore the carotid artery and the espohagus: Extend the incision up behind the ear. Work with your finger on the carotid pulse beat, split the vascular sheath carefully to explore the carotid vessels. The subclavian vessels is best accessed by resection of 5-10 cm of the clavicle, the medial or the lateral part depending on the injury: Strip off periosteum, resect the bone by Gigli saw, and cut through the posterior periosteal sheet to expose the artery and vein. Beware that the vessels are located immediately behind the bone. 29
29 The midline incision for airway injuries. Air bubbles with a missile wound means perforation of the larynx or the trachea. Injuries to the upper airway is best explored through a long incision exactly in the midline. Stretch the skin to the side and clean subcutaneous tissue off the larynx by gauze finger. For complete access to the trachea, the thyroid gland is separated between ligatures. Control the airway place endotracheal tube by crico-thyrotomy before you start debridement and repair. Wound to the wall of the larynx and trachea are closed
457
by sutures through the cartilage. If the defect in trachea is too big to be closed, place the endotracheal tube by the tracheal wound and close soft tissues around the tube as best possible. Injury to the esophagus Blood aspirated from the stomach in neck injuries may be a sign of missile tear of the esophagus. Explore the missile track through the standard lateral incision, see p. 457. Close the esophagus wound with fine interrupted sutures. Implement enteral feeding for two weeks to avoid fistula formation. Injury to the carotid vessels Such inuries carriy high early mortality. Still, cases with intimal injury or minor partial tears may survive hours of evacuation. Even if there is no bleeding out or pulsating hematoma, the carotids should be explored in high-energy blunt and in deep penetrating injuries. There may well be intimal injuries with few early clinical signs.The reconstruction follows common procedures. In emergencies the internal jugular vein or the carotid artery on one side may be ligated for life-saving reasons. The brain is well perfused through the other side. Some neurological problems may follow ligature of a bleeding carotid artery, but in most young and healthy perons the blood supply from one carotid artery is sufficient to supply the brain. Injury to the brachial plexus Routine neurological test on admission should reveal injury to the brachial plexus, see pp. 628-29. Explore the plexus, control the bleeding, debride the surrounding soft tissues carefully.The nerve injury itself is not debrided but left for secondary reconstruction some weeks later.
458
459
460
.................................................................
.....................................................................
Complications of injury and surgery ............................................ 471 Rehabilitation after spinal injury
................................................
.........................................
461
Surgical anatomy
The main questions regardless of open or closed injury: Neurological signs: Is the cord already damaged? Spinal stability: Is the cord at risk because of unstable fractures of the spine? Prevent secondary cord injury Assume all spinal injuries to be unstable: Manage unstable fractures carefully! Prevent hematoma formation and infection by early debridement, good drainage and careful control of bleeding. Beware during the evacuation: Most secondary cord injuries happen during field manipulation and evacuation. Careless lifting of the patient may convert an incomplete cord injury to a complete one. Complete or incomplete cord injury? Diagnose carefully: The definitive diagnosis can only be made after days of observation of reflexes and function.Young patients have great capacity to regain function after serious cord injuries provided the injury is not complete. A complete cord injury will never recover: Concentrate on preventing secondary complications from the airways, the urinary tract, bedsores and joints.
1 Close relation between the spine and the cord: Note how small hematomas or slightly displaced fractures will put pressure onto the cord or nerve roots. The management is surgical.
2 Stable: A compression wedge fracture if the loss of vertebral height is less than one third. 3 Stable: Fractures of transverse processes. 4 Normally unstable: Side-displacements. 5 Unstable: Displacements on X-ray side-view. 6 Uncertain: Compound penetrating fractures may be stable or unstable. Manage them as if they were unstable.
462
Surgical anatomy
The cord ends at the 2nd lumbar vertebra. The horse tail below L2 is seldom torn by penetrating missiles.
The effect of steroids in spinal cord trauma is not well documented. Steroids increase the risk of bacterial wound infection in open spinal injuries.
8 Do not miss associated injuries: Missile inlet through the abdomen the spinal injury is often missed. Suspect spinal damage when there are signs of posterior wall injury.
463
Combined abdominal-spinal injury: First manage the abdominal injury, close intestinal tears Then explore and debride the spinal injury. Combined limb-spinal injury Missing the double diagnosis is a common mistake. Limb paralysis indicating cord injury is often missed in cases with major limb injuries.
In-field treatment
Field triage identify cord injuries: Motor function roughly: Raise your arms! Raise your legs! It is the tempo of movements that best indicates the cord function: Slow movements = poor function = suspect cord injury Sensory function roughly: Pain response in arms, perineum and legs (pinch the skin) Rectal exploration: Check the function of the anal sphincter muscle Palpate the bladder: Distended bladder insert bladder catheter before evacuation. Field triage identify spinal injuries that may be unstable: All high-energy missile wounds close to the spine Posterior gap? Turn the patient to his side in one piece (with two assistants). Unwrap clothes and run your finger down the spine: If a gap is felt between the vertebrae assume there is an unstable fracture Knock the spinal vertebra with your fists: Painful vertebra may be fractured. All fractures are instable until Xray exam proves otherwise. Prevent secondary injury Move head, body and lower limbs in one piece. You need at least two assistants during examination and transport.
464
In-field treatment
10
11
9 Unstable neck fractures must be supported all the way by manual traction of the head. Do not let the traction go until some other support is applied.
10 Improvised neck collar: A broad roll of clothes wrapped around the neck. Wrap some turns of plaster outside the clothes. Or make a plastic collar cut the top of a plastic bucket and shape it on the fire or in an oven at 170 C. 13
11 Traction upon a cloth/canvas halter: The pull should not exceed 5 kg. Replace this traction within 24 hours by proper skull traction or neck plaster cast.
12
13 Double stretchers for prolonged evacuations: One stretcher has holes for his face and urine, the other has one hole for stools. Turn the patient every 2-4 hours (change stretcher like a sandwich) to avoid skin pressure sores.
465
16
16 Standard position for spinal surgery: Flex the spine slightly over two pillows. For better respiration do not apply pressure against his abdomen. Note: In incomplete cord injury the spine should not be flexed. Anesthesia: Extensive injuries with derangement of the spine: general anesthesia with muscle relaxation is recommended. Most other injuries: Ketamine anesthesia or local infiltration anesthesia combined with low-dose ketamine analgesia will do. Adrenaline for bleeding control: During surgery, infiltrate down to the spinal processes along the exploratory incision with anesthetic with a dilute adrenalinesaline solution (1:100,000).
Do not use spinal or epidural anesthesia in open spinal injuries as dural tears may cause unexpected side-effects.
17 The midline incision for spinal exploration and laminectomy: Probe the direction of the wound track with your finger. If you suspect spinal injury, debride without delay: Either extend the inlet wound into the standard midline incision, or debride the wound track separately. And then make the midline incision to explore and debride the deep parts of the wound track. Extend the mid-line incision through the fascia down to the spinous processes as illustrated.
18 Isolate the spinous processes: Strip the long extensor muscles off the spinous processes with the chisel to expose the posterior arch of the injured vertebra. Insert gauze packs on both sides and apply the retractors firmly to control bleeding.
19 Laminectomy for exploration: In this case where one vertebrae is fractured by the missile, you should explore the dura. To prevent accidental dural tears during surgery, perform laminectomy of the two neighboring vertebrae before you expose the dura: Remove through its neck the fractured spinous process, and the neighboring spinous process with a nibbler.
466
20
21
22
20 Expose the dura: Carefully incise the ligament between the vertebrae exactly in the midline. Note: Immediately outside the dura, in the epidural space, hematomas may collect after open and blunt injuries. The epidural hematomas may spread along the space, extend 3-4 vertebrae and cause cord compression with increasing volume. Evacuate the hematomas completely, control bleeding meticulously. Then explore the dura for tears. Dural tear even small: Open the dura and explore the cord; the internal damage may be extensive. Also nerve roots may protrude through dural tears and become gradually damaged.
21 Complete the laminectomy: Do not remove directly a fragment penetrating the dura you may damage the cord. First extend the laminectomy, then open the dura to fully expose the fragment: With nibbler and punch the rest of the spinous process is removed together with the posterior arc. Work slowly, small bites only, so as not to damage the underlying dura. Take particular care close to the apophyseal joints (arrows on ill. 20) to prevent bleeding. Control bleeding points carefully: Infiltrate the adrenaline solution and pack the field with gauze packs under slight pressure for five minutes.
22 Open the dura with fine scissors between dura hooks (the cord and nerve roots are just underneath it). Use stay sutures on dural edges. Now remove the fragment carefully. The damaged nerve root cannot be repaired. Inspect the cord and control bleeding points (electro-cautery, tampon or muscle patch, see p. 451). If you cannot see the missile, do not search for it. Debride the ragged dural tear and close the dura tightly (silk 4-0). Do not suture dural injuries under tension better take a fascia graft for closure, see p. 449. Then cover the dura by adapting viable muscles or a rotation muscle flap over a soft drain. Be careful that the drain does not press directly upon the dura. The debrided missile track is left open for delayed suture.
After surgery: Monitor spinal post-operative patients every six hours for two days after surgery: Increasing neurological signs indicates cord edema or hematoma formation, see p. 212. Patients with laminectomy have a stable spine no need for traction or plaster. Let them rest in bed with careful exercises for three days. Then mobilize them. Unstable spinal missile fractures need traction or plaster casts for stabilization, see pp. 468-71.
467
Spinal fractures
Closed spinal fractures are common among blast victims and persons entrapped during heavy city warfare. Indications for surgical exploration: X-ray examination shows unstable fracture with fragments that may damage the cord: urgent surgery. The patient has signs of partial cord damage, and his neurological signs worsen rapidly: urgent surgery. Signs of complete transection of the cord with rapid onset: lumbar injuries should be explored. Surgery at cervical and thoracic level is seldom indicated. Moderate neurological signs persist after the period of post-traumatic edema (one week): The reason may be herniation of nerve roots through dural tears, or an epidural hematoma. Consider surgery. All other closed spinal injuries are managed with traction, plaster cast, or simply by bed-rest.
468
Spinal fractures
24
24 Wire traction the procedure: Make two burr holes with a 2-cm bone bridge between them. Elevate the dura underneath. Pass a steel wire over a dura guide, or pass a big curved needle (the rounded point forwards) under the bone bridge, tie the wire to the suture and pull the wire through.Tie the two wires together and connect them to the traction equipment. Cut small skin cross-incisions to prevent the wires from pressing on the soft tissues.
25
25 Skull traction with tongs: There are lots of sophisticated tongs for skull traction. The Gardner-Wells tongs are safe and simple. The instrument is equipped with a spring-loaded nipple upon one of the screws.When you tighten the screws, the nipple will protrude. When the nipple protrudes 1 mm from the screw, the tension is correct. Thus you may apply the Gardner-Wells apparatus without making scalp incisions. For locally made copies without the load-nipple this is the procedure: The insertion is done at the line from 1 cm in front of the ear to the top of the skull. Shave the area, infiltrate anesthetic, and make a 3-4-cm incision, just enough to inspect the skull. Apply the tongs exactly symmetrical. Tighten the screws so they penetrate 4 mm into the skull bone. That is, they do not penetrate the inner table of the skull bone and do not reach the dura. Close the incisions. Skull traction management: Analgesia prevents muscular spasm and makes the traction more effective. The direction of the traction is strictly neutral neither cervical flexion nor cervical extension. Arrange counter-traction by simply elevating the head end of the bed. The skull traction weight (adults): 4-7 kg. Monitor the fracture whle increasing the weight stepwise, 2 kg every 4-6 hours. Take X-ray side-views to control the effect of each step. The derangement of the spine will gradually become reduced under traction. Within 24 hours most fractures are brought to a correct position. The traction weights are then gradually reduced under X-ray control. Displaced neck fractures more than one week old: Reduction by traction may take some days. Displaced neck fractures more than three weeks old: Traction may be without effect stabilize the fracture in cast or collar.
469
If you do not have X-ray facilities, you should still use skull traction. Follow the plan outlined above. Monitor the patient closely with neurological examinations every six hours. If there is radiating pain or increasing neurological signs, adjust the weights and/or the direction of the traction slightly.
26
27
28
26 Reduction of fractures under traction: Note the displacement of the 6th cervical vertebra, it is hooked on the 5th and 7th (arrows) and must be disengaged.
27 The fragments are disengaged and the position is good except for the gap between the 6th and 7th vertebrae. 28 The traction weights are gradually reduced, the gap disappears, and the reduction is complete. The correct curved axis of the cervical spine must be maintained all the way through the reduction procedure. Now leave him in traction for six weeks, gradually reducing the weights during the last weeks.Then apply a cervical plaster cast, and remove the traction. Let him wear the plaster cast for another six weeks.If you do not have X-ray facilities, you should still use skull traction follow the plan outlined above. Monitor the patient closely with neurological examinations every six hours. If there is radiating pain or increasing neurological signs, adjust the weights and/or the direction of the traction slightly. Problems with the skull traction method Mental strain on the patient Security problem under military pressure Inactivation makes depression: Exercises and high-energy nutrition are essential High load upon the clinic staff: The patient must be turned in his bed every two hours to avoid pressure sores. At least three persons must turn him one of them supporting his head so that his neck is not twisted. Train his family and friends in the nursing procedures. 29
29 Neck plaster cast: The cast must extend the cervical spine it must have a broad weight-bearing base over the shoulders and support the jaw and head
470
Spinal fractures
You can make neck collars from plastic materials (PWC). Study the technique on p. 391.
(occiput).You need two assistants, one must maintain continuous manual traction, the other assist with the plastercraft. If the patient is under skull traction, do not remove the traction until the plaster is set. Pad the shoulders, jaw and occiput. Apply two broad plaster slabs one frontal, one in the back. Apply circular turns and mold the cast well.
471
Wound infection: Superficial infection in a penetrating spinal injury may be the first step towards a tragedy deep spinal infection with permanent loss of function and chronic back pain. Re-debride the wound track without delay. Start early intensive antibiotic therapy. Deep infection outside the dural sac: The signs normally develop after 48 days. The infection may run without much fever the main clinical signs are those of a hematoma: increasing pain and worsening of the neurological signs. Sudden development of paralysis may be the first sign of infection. The management is urgent exploration with re-debridement and decompressive laminectomy. Support the surgery with potent antibiotic therapy. Infection inside the dural sac: The main sign is meningitis high fever and stiff and painful neck on flexion. Start aggressive antibiotic therapy but delay surgery. If there is no response to the therapy, suspect a deep necrotic focus: Reexplore the wound track.
Automatic bladder: When the bladder is filled up with urine, tell the patient to stroke his penis or the inside of his thigh while he press his bladder just above the pubic bone. After weeks of this manoeuver, the bladder may respond with contraction an automatic bladder. After his urine is delivered, the automatic bladder must be catheterized for the remaining urine. Continue the catheterization until the remaining urine volume is less than 75 ml. (Teach the patient to catheterize himself.) Intermittent catheterization: If the patient is not able to develop an automatic bladder after weeks of training, start intermittent selfcatheterization. Tell him to use the catheter often, as the bladder should not be allowed to become distended with urine. On the condition he empties his bladder completely (by manual pressure above the pubic bone) during each catheterization, this method will not create urinary infection even if the catheterization is not quite sterile.
473
474
475
Surgical anatomy
1 2 1, 2 Airway obstruction? Reduce the fracture immediately! Displaced midface fractures may occlude the upper airways, the nose as well as the pharynx. Also watch for backwards displacement of the tongue in doublesided lower jaw fractures. Fracture bleeding or aspiration of foreign bodies (teeth, prosthesis fragments) will further contribute to airway obstruction. If you suspect fracture fragments are blocking the airways, make rough reduction immediately in the field. If the fracture is unstable, try to keep it in place with your fingers until clinic admission.
3 Associated brain damage? Note the close relationship between the frontal sinus and the brain. Also high-energy fractures of the midface may include fractures of the base of the skull. Fracture hematomas inside the skull are usually spontaneously drained through the skull base fracture into the pharynx. If not drained, hematomas may collect inside the skull and compress the brain: Explore through frontal burr holes if there are lateralizing signs or GCS scores are going down, see p. 241 and p. 452. 4 4 Facial nerve injury: The nerve branches run through the parotid salivary gland. The nerve innervates the muscles of the face and eyelids. Examine the facial nerve function in all lower face injuries. Take care not to damage the nerve during debridements of the parotid area. Tears of the nerve behind the dotted line should be repaired by secondary nerve suture. In front of that line, one may see spontaneous nerve regeneration. 5 Standard incisions for exploration and drainage: Note the easy access to the maxillary sinus and floor of the orbit through the mucosa of the mouth. The face structures have a rich blood supply, and proper drainage is important.
476
Surgical anatomy
In-field treatment
Face injuries is an airway problem: Bleeding into the airway Airway obstruction by displaced fracture fragments Brain injury unconsiousness tongue block and aspiration. Airway bleed, conscious patient If the patient can talk, he is able to protect the airway himself. Place in sitting position or face down. Airway bleed, unconscious patient: Immediate endotracheal intubation or airway cutdown Clear the airway by suction Pack the pharynx and mouth with gauze packs The surgical exploration can wait 24 hours.
7 Deep wounds into the cartilage (nose and eyelids): Take care to identify and suture each layer of the tissues separately and exactly. Here, the interrupted sutures in debrided cartilage.
8 Deep wounds into the salivary glands: The parotid and submandibular ducts are at risk in lower face injuries. If the duct from the glands is damaged, a salivary fistula may form through the skin or into the mouth. Drain these injuries well by primary surgery. Do not try to reconstruct a torn duct at primary surgery, arrange good drainage. A fistula is managed in a secondary operation if it does not close spontaneously within one month.
478
9 Extensive loss of soft tissue: Do not try to close the wound under tension. Debride the defect and suture skin to mucosa of the mouth or nose. Leave the defect for secondary reconstruction. Major soft tissue wounds elsewhere are left open for 5-10 days and then closed by grafting or flap reconstruction.
Fracture management
Examine before surgery: The airways: Backwards displacement of the tongue? Free nasal airway on both sides? The eye function: Tell him to look wide to the sides, up and down is there double vision? If so, suspect a fracture of the eye orbit with entrapment of eye muscles. Blurring of vision? If so, suspect a penetrating eye injury (the splinter may be tiny, see p. 211 and p. 486). Leaking of brain fluid: Put a urine test strip into his nose and pharynx to examine for glucose. Positive glucose indicates skull base fracture (the cerebrospinal fluid contains glucose). Alignment of the teeth: Fractures of the mandible and maxilla may cause malocclusion. The alignment of the teeth is your best guide for field reduction. Debridement and fixation: Make a limited debridement of the soft tissues, particularly of the mucosa. Reduce the fracture to correct position. Save as many bone fragments as possible. With the good blood supply, bone fragments without soft tissue attachment are washed and replaced into the fracture as free bone grafts within 48 hours after the time of injury. In the meantime, store the bone grafts in normal saline in refrigerator. Massive swelling? If so, consider a staged approach: Stabilize the fracture by packing the area (nose, maxillary or frontal sinus) with saline-wet gauze bands and external slings of elastic bandage. Re-operate within two weeks when the soft tissues have healed and the swelling receded. Alternative 1, fixation by wire: Reduce and stabilize fractures of the lower and middle face by interdental wire fixation. Refer the case for secondary miniplate internal fixation if such service is available. Alternative 2, fixation by primary miniplate: Under sterile conditions and antibiotic prophylaxis, you may manage facial fractures by primary internal fixation (miniplates) even in high-energy wounds. Never leave the fracture open: Either suture mucosa to the skin to cover the bone ends (see ill. 9 above), or raise a soft tissue flap for rotation onto the fracture.
479
10 Interdental wire fixation of lower jaw fracture: Use his teeth for wire fixation and the opposite non-fractured jaw as splint for the fractured jaw. Use soft steel wire (0.3-0.4 mm). Tie the steel wires around six teeth of the upper jaw and six teeth of the lower jaw. Twist the wires but do not tie them yet. Alternative method: Place two small screws in the upper and the lower jaw as anchors for wire or rubber band fixation. 11 11 Reduce the fracture: When the teeth are well aligned, the fracture is in correct position: Tie the wires first the lateral ones on both sides, and work your way towards the midline. Tie them loosely at first, then gradually tighten them. In toothless cases: Use drill-holes through the upper and lower jaw. Precaution: Instruct the patient and his family how to cut the wires if the patient needs to vomit. Instruct the patient to wash and clean his mouth several times a day. The dental wire fixation is removed after 6-8 weeks.
12
12 Lateral lower jaw fracture: The interdental wire fixation will not stabilize this type of fracture. First step: Debride and provide soft tissue cover for the fracture.Second step: After 1-2 weeks (if the soft tissues are clean), carry out wire fixation through drill-holes. The simplest method is drilling through the upper border of the jaw bone through the mouth. Or a 5-cm incision is made through the skin from the angle of the jaw bone (note the facial nerve). Reduce the fracture and tighten the wire. Support the fixation with a vertical bandage for 3-4 weeks or interdental wire fixation. If available, miniplate fixation is done at the time of primary surgery.
480
Fracture management
Midface fractures
13 13 Upper jaw fracture eyelet wiring: Minor and stable fractures of the upper jaw are immobilized with teeth wire fixation between the upper and lower jaws. In major and double-sided fractures, use the zygoma as anchor for upper jaw dental eyelet wires. Consider supplementing the zygoma suspension with interdental wire fixation to the lower jaw (if there is no lower jaw fracture). Fractures with a major central fragment engaging the eye orbit are supported with Kirshner wire drilled from one zygomatic bone to the other as illustrated. 14
14 Zygoma suspension: The main wire is passed around the zygoma and delivered through a large-bore cannula. If you have miniplates, the upper jaw fracture is managed with open reduction and plate fixation at the time of primary surgery either through the eyelids or the vestibulum. Also miniplate fixation should be supported with zygoma suspension. 15
15 Nose fractures bleed briskly during debridement and reduction: Use intermittent packing of the nose with adrenaline-saline-wet gauze.The reduction is done with specially designed forceps (Walsham forceps). But wrapped with gauze or rubber tubes, major artery forceps will do. Grasp the nose septum and wings: Mobilize the fragments by traction and careful twisting. Model the nose into normal configuration. Thereafter the nose is packed on both sides with saline-wet gauze bands for one week to stabilize the fracture and control bleeding.
481
16
16 Midfacial fractures the eye orbit: The floor of the orbit and the wall between the orbit and the nose is very thin even blunt injuries may cause fractures. Soft tissues of the eye (fat, eye muscles, the eye bulb itself) may then herniate through the fracture; the main clinical sign will be double vision. Reduction of even minor fractures of the orbit is important to maintain eye function. Twostep surgery:You may debride and reduce an open fracture through the wound or through the mouth and maxillary sinus. Note the subciliary incision below the eye to control fracture reduction. Replace the eye tissues into the orbit, remodel the floor as best as you can, and pack the maxillary sinus with saline-wet gauze pack for one week. Take care not to elevate the eye too much. Re-explore and reduce the fracture after one week. Definitive primary surgery: With alloplastic materials you may reconstruct the eye orbit at the time of primary surgery through a subciliary incision.
GCS < 7 indicates massive brain damage too much for surgery, see p. 242. Prophylactic antibiotics are not indicated in closed fractures to the base of the skull.
17
482
483
484
......................................................................
485
Surgical anatomy
Do not miss the penetrating injuries: tiny fragments can make severe damage! Examine every head and face injury for possible eye injury Examine every eye wound for possible penetrating eye injury Examine every penetrating eye injury for associated skull and brain injury. Staged surgery? In combined skull-face-eye injuries, the eye surgery can/should wait. It may be delayed for 3-5 days, provided you give continuous local and systemic antibiotics. In this way you may buy time for evacuation to an experienced surgeon. 1 Anatomy of the eye side-view: Bleeding inside the eye will obscure the vision. Thus, no vision does not necessarily mean a lost eye the deep structures may be undamaged hidden behind a blood clot. The illustration shows a hematoma inside the bulb. Note the anterior chamber in front of the iris (arrow) where blood may collect in penetrating eye injuries. More common than hematomas is diffuse bleeding: When an examiners light through the pupil is seen as a beam through smoke, it means that blood is dispersed inside the eye. 2 The anterior chamber: When blood collects in the anterior chamber, the injury is definitely penetrating! Look for the entry wound: Evert the upper eyelid over a pin or forceps. Wounds of conjunctiva may hide a penetrating injury through the sclera into the eye globe. The inlet wounds of high-velocity shrapnels may be very small and hard to see, and the penetration almost painless. Also see photo p. 211. Exact primary examination The first clinical examination after the injury is the most important examination. Within a few hours swelling will make further examinations difficult. The first examination should thus be exact, the results written in the injury journal. Use topical anesthesia and be careful: You cannot examine a painful eye properly apply topical anesthesia, solution of tetracaine 1% Do not apply pressure on the bulb: In penetrating injury, pressure may cause protrusion of the eye content through the wound. Work systematically: Test the vision four levels: Can the patient see strong light, see hand movements, count your fingers, read? Test for double vision: Double vision may imply hematoma inside the orbit, or a fracture of the orbit with entrapment of eye muscles.
486
Surgical anatomy
Blood inside the eye: With flashlight, moderate bleeding is seen as light beam through smoke. Look for blood collection in the anterior chamber. Increased tension of the bulb: If there is much blood inside the eye, apply gentle fingertip pressure upon the injured eye and compare the tone of that globe with that of the other eye. If the tension undoubtedly is increased, reduce it by acetazolamide 250 mg tablets every six hours. Wounds of cornea, sclera and conjunctiva: Even tiny wounds or blood points may hide a serious penetrating injury. If you suspect corneal wounds, apply topical fluorescein upon the cornea: The dye colors corneal lesions yellow-green.
Before surgery
Napalm / white phosphorus: When burning particles or small circular wounds are found on the eye bulb, remove particles immediately with any instrument a plain knife or wooden pin. Do not wash napalm/ phosphous burns with water or IV fluids! Management of chemical burns, see p. 711. In-field management: Analgesia and sedation: The patient with a serious eye injury should not move around. Fear will always accompany loss of vision consider tranquilizers in addition to IV analgesia. Occlusion: Cover the eye with soft gauze packs. Do not cover both eyes in semicomatose or confused patients they turn nervous and restless if they cannot see. Penetrating injury: Do not extract penetrating shrapnel and foreign bodies before surgery. Do not replace protruded eye content into the eye globe. Apply chloramphenicol eye ointment every three hours. If available, get an ophthalmologist. Bleeding inside the eye: Let the patient sit or half-sit. Tell him not to move much.
We recommend ketamine anesthesia in major trauma. But in eye injured ketamine have some disadvantageous effects: Ketamine causes rapid eye movements disturbing surgery. Also it is reported though not documented that ketamine increases the pressure inside the eye globe: Use with caution in penetrating eye injuries (protrusion of eye content) and in cases with already increased eye tension (increased bleeding).
Eyelid injury
Primary suture of eye injuries Due to excellent blood supply and rapid healing, eye injuries are debrided and closed with suture at the time of primary surgery. Cases late for surgery Swollen tissues make surgery difficult/impossible. Give systemic and local antibiotics, apply eye occlusion and do delayed primary debridement and closure within 3-4 days. 3 3 Eyelid injury without loss of tissue: Limited debridement, 1-2 mm is sufficient. Suture of conjunctiva is not important. Note the eyelid structure:The suture must be accurate, layer by layer to avoid excessive scarring and lid contracture. Suture the fibrous plate with interrupted sutures, absorbable 5-0. A torn muscle (levator palpebrae) should be closed with separate interrupted sutures. 4
4 Eyelid injury with loss of tissue: Study the wound edges carefully to reconstruct the lid structure. Note the single suture in the mucosa-skin line of the upper lid, and the suture for retraction of the lower lid. 5
5 Routine stay sutures: In every more-than-minor lid injury, apply stay sutures between the hair-rim and eyebrow skin to relieve wound tension.
488
Eyelid injury
6 Extensive eyelid damage flap closure: To prevent scar contractures, major superior lid wounds are closed with free skin graft. Inferior lid wounds are closed with a lateral flap. 7
7 Mobilize the flap by careful dissection in the space between subcutaneous fat and the tarsal plate. Note the stay suture from the lower eyelid to the eyebrow. 8
8 Prevent drying of the eye by tarsorrhaphy: If the eye remains partly open with the cornea exposed to air, it may dry and the cornea becomes permanently damaged. Conjunctiva is the best cover: Close the eye with stay sutures over small plastic tubes (IV catheter tubes are fine). In eyelid burns and major corneal injuries, early tarsorrhaphy should be done. 9
9 Extensive damage refer for secondary reconstruction: To prevent drying of the eye during the evacuation, incise the remnants of the lid in the hair-line, and dissect out conjunctival tissue flaps on both eyelids. Adapt the conjunctival flaps to close the eye. Reconstruction is done within 2-3 weeks.
489
11 Enucleation mobilize the eye bulb: Incise the conjunctiva along the limbus and dissect bluntly until you identify the eye muscle attachment upon the globe. Incise the fibrous capsule between each of the muscles, hook the muscles and cut them as far posterior as possible.
490
12
12 Remove the eye: Retract the bulb forwards under partly blunt, partly sharp dissection along the bulb. Identify and clamp the optic nerve and vessels, and cut them. Remove the eye. Pack the orbit with saline-wet gauze for 10 minutes to control bleeding. Explore the walls of the orbita for fractures. Either insert an eye prosthesis (diameter 15-18 mm, adults) or close the incised capsule and conjunctiva over drain.
Subconjunctival antibiotics: inject 1 ml lidocaine 0,5% immediately beneath conjunctiva before the antibiotic is injected.
491
Delayed reaction of the other eye 1-2 months after injury/surgery, the other, normal eye may become painful, red and partly lose its vision. This is a sort of immune response to the injury. The condition is rather resistant to treatment and much of his vision may be lost.The management: Analgesia Topical steroids Eye occlusion. Late effects of metal bodies inside the eye Even tiny metallic foreign bodies inside the eye may create blurring and gradual loss of vision. This process usually starts 6-12 months after the injury. If an X-ray examination makes you suspect some metal body inside his globe, refer the case to an ophthalmologist for metal body extraction.
492
493
494
...................................................................
Exploratory thoracotomy ......................................................... 501 Cardiac injury ....................................................................... 503 Complications of injury and surgery ............................................ 504 Chest tube management
..........................................................
188
495
Surgical anatomy
1 1 The chest wall is made up of the thoracic part of the spine, the sternum, the ribs, the intercostal muscles, and the external muscles of the chest and the back. Below each rib pass the intercostal vein, artery and nerve. The intercostal vessels are one main source of hemothorax. Each lung is lined by a thin sheath the pleura. The pleura consists of a visceral part fixed to the lungs, and a parietal part fixed to the chest wall. Between the two layers, a small amount of fluid is continuously excreted and absorbed, creating a slight vacuum between the two pleural layers. This vacuum attaches the lungs to the chest wall and keeps them expanded. If air (pneumothorax) or blood (hemothorax) enters the pleural space, the lung will collapse. 2 The internal mammary arteries run along the edges of the sternum. They are another common source of bleeding inside the thoracic cavity. Ligate them carefully in thoracotomy incisions close to the sternum. 3
3 Note the extent of the abdominal cavity: One out of four wartime chest cases also has abdominal injury. The floor of the chest cavity is made up of diaphragm. During expiration the diaphragm reaches as high as the nipples (black points in the illustration). The abdominal injury is easy to miss as tears of diaphragm and hematomas on the posterior abdominal wall are often silent with few clinical signs the first hours after injury. 4 4 X-ray features: The esophagus, trachea (T), the arch of aorta (AA) and the decending aorta, the superior (SCV) and inferior caval veins are all located between the two lungs in the mid-wall, the mediastinum of the chest. The main X-ray indicator of injury and hematoma formation in the midline structures is a wide mediastinum. Also look for blurring of the aortic arch, of the decending aorta, of the hilum of the lung (HI), deviation of trachea (or a gastric tube) to the uninjured side, and hematoma at the top of the lung. The illustration also indicates hemothorax and/or contusion of the left lung.The heart is wrapped inside a fibrous tissue sheath the pericardial sac. The pericardium has no elasticity: Even small amounts of fluid inside the pericardial sac will compress the caval veins inside the sac and the atrium of the heart, and cause cardiac tamponade. A wide contour of
496
Surgical anatomy
the pericardial sac (P) indicates pericardial hematoma. Note: Chest X-ray in bed: Mediastinum is wider and diaphragm at higher level compared to the upright position.
497
Thoraco-abdominal injury
Combined injuries are common in high-energy injuries. Bullets and shrapnels hitting the bones of the chest wall may deform and change direction. Also fragments of the ribs and sternum may be accelerated through the diaphragm as secondary projectiles. The abdominal structures at risk are: Injury to the diaphragm: Tears of the diaphragm prevents efficient breathing. The injury may pass with few clinical signs unless bowel sounds are heard inside the chest. X-rays may show disturbed contour of the diaphragm or the lower part of the lung. There are probably injury to other abdominal organs as well. Laparotomy is indicated, the tear of diaphragm is normally sutured from the abdominal side. The spleen: Suspect splenic tear in circulatory shock cases and left-sided injury. Do urgent laparotomy. The stomach and esophagus: Gastric tube is diagnostic. The liver and posterior abdominal wall: Retroperitoneal hematomas and minor liver tears may have few clinical signs. Consider peritoneal lavage, see p. 253. Highvelocity hits on the right side in circulatory shock: Suspect tears of the liver. Thoraco-abdominal injury The abdominal injury has priority: Place chest tube, then do laparotomy.
498
499
500
Exploratory thoracotomy
Out of ten major chest injuries reaching the clinic alive, one or two may need exploratory chest surgery. Reasons for primary thoracotomy: Continued bleeding inside the chest despite effective chest tube management: 1,500 ml or more on the first tube inserted. Or 500 ml/hour for three hours. Bone fragments and dirt buried inside the lung tissue: The risk of wound track infection, pneumonia and lung abscess formation is high unless the major fragments are removed. Open chest wall injury: The thoracotomy is already done by the missile. Debride and extend the inlet wound, explore the lung and close the chest wall defect as tightly as possible.
Secondary thoracotomy
Patients staying for days with insufficient breathing and oxygen starvation carry high risk of organ failure. Exploratory thoracotomy should be done sooner than too late: A clotted hemothorax: If not drained within one week the hematoma clots. Gradually it becomes organized, and some sort of a capsule will form around it. Even if you drain most of the blood and pleural effusion, the lung will not expand the respiration and the chest wall movement become poor, the risk of respiratory failure is high. Thoracotomy with surgical excision of the capsule (decortication) should be done within one week after the injury before the hematoma is completely organized: Wash out the hematoma with warm saline, release the visceral pleura with careful blunt dissection, controlling bleeding with elector-cutery. Late decortication of an organized hemothorax is technically difficult and carries high mortality. Lung abscess or fistula formation: Try to drain the abscess with one or two chest tubes. If tube drainage proves ineffective, thoracotomy must be done with decortication of the abscess capsule. Also identify and manage the focus of infection such as deeply embedded rib fragments or infected rib fractures, see more on p. 504. 8 Standard thoracotomy the procedure: The level of incision depends upon the injury, commonly an incision below the 5th or 6th rib. The incision should be at least 20 cm long to give good access into the chest. It may extend from 2 or 3 cm lateral to the spine, pass two fingers below the scapula bone until the breast bone. Cut the muscles in the axillary fold with a knife or electro-cautery knife. Incise the intercostal muscles mid-way between two ribs, or along the upper edge of the 6th or 7th rib to avoid bleeding from the intercostal vessel.
501
9 Control the bleeding: Puncture the pleura with knife. You now enter the hematoma; the lung collapses and you may open the pleura wide. Note: Take care not to cut the internal mammary artery just lateral to the sternum. Evacuate the hematoma; consider autotransfusion if the bleeding is extensive, see p. 419. Identify the bleeding source: Minor bleeding points in the lung tissue are controlled by deep U-sutures. Bleeding points in the chest wall are controlled by ligature or electro-cautery.You may have to tie ligatures tightly around the rib to control bleeding from the costal vessels. 10
If you identify a diaphragmatic tear during thoracotomy, laparotomy is indicated. There will probably be other abdominal injuries as well.
10 Lung resection may be done to control profuse bleeding from the lung.You may finger-clamp the major vessels at the lung hilum to control bleeding during the resection. Make a wedge-resection between long clamps, close the lung with deep Dexon 2-0 (or silk) interrupted or continuous interlocking sutures on a big curved needle. Double rows of suture helps prevent air leaks. Lobectomy is seldom necessary. Note: The lung tissue is has rich blood perfusion and is not debrided unless there is extensive destruction. 11 11 Closure of the thoracotomy: Before closure, apply two chest tubes, one towards the top of the lung, the other towards the diaphragm. Pull the ribs together (large towel clamps) and close the chest wall tightly in one layer including pleura, intercostal muscles and ribs with strong interrupted sutures (Dexon no 2, silk no 1 or steel suture). For lateral incisions, the muscles of the axillary fold are closed in separate layers. Close the skin. Also close the missile wound track after debridement, but leave the skin wound open. Post-operative care: Half-sitting position in the bed improves the ventilation of the lower parts of his lung. Effective analgesia is essential for effective respiration: Bupivacaine pleural analgesia by the chest tube and intermittent IV ketamine pain relief. Repeated respiratory exercises to inflate the operated lung: Expiration against resistance by blowing surgeons gloves. Intermittent suction on the chest tubes. Note the volumes drained to monitor the total blood loss. Consider autotransfusion. Get the patient out of bed with support the first day after surgery, or at least bedside sitting, with respiratory exercises.
502
Exploratory thoracotomy
Cardiac injury
Close monitoring Suspect cardiac injury in midline injuries and all high-energy chest injuries. The clinical signs of heart contusion, penetrating injury and cardiac tamponade may develop gradually monitor closely for 24 hours: The heart rate and arrhythmia The venous pressure, venous congestion The respiratory rate, cyanosis The blood pressure Repeated chest X-ray exams if possible. 12 12 Cardiac tamponade paricardial drainage: The clinical signs of tamponade are increased HR, increased central venous pressure with congestion (visible) in the superficial veins of the neck, and falling blood pressure. Evacuation of hematoma in the pericardial sac is an emergency procedure to be done there and then in the field, during the evacuation or immediately at admission.You may try to aspirate the hematoma through a large-bore needle (subxiphoidal puncture). There are some problems with this method: It is difficult to decide whether aspirated blood is from the heart or from the pericardial sac. And the needle aspiration is dry if the hematoma has become organized. Pericardial drainage by subxiphoidal incision: The procedure is done under local or ketamine anesthesia. Make a short incision from the xiphoid process downwards; incise the superficial abdominal fascia exactly in the midline. Identify the pericardial sac by blunt finger dissection behind the costal margin close to the bone. Incise the pericardium with a knife. An organized hematoma is washed out with warm saline. For the experienced surgeon: Sternum split gives the best access to the heart and mediastinum. Definitive surgery Both ventricles are reached through a left anterior thoracotomy, see p. 499. Split the pericardium in front of the left phrenic nerve and expose the heart. Bleeding from minor tears is controlled by finger pressure until the sutures are tied. Atrial and caval injuries: Apply exclusion clamp to control bleeding. Repair by continuous suture (4-0 Prolene or silk). Ventricular injuries: Repair by interrupted U-sutures (4-0 Prolene or silk). The heart muscle is easily torn, and direct suture may cut through the muscle. If so, cut two strips of pericardium and set the suture through the strips. Note: Identify the coronary arteries; they are normally seen on the cardiac surface do not close them with the sutures.
503
ized abscess capsule, excise it. What is the reason for abscess formation? It may be piecs of bone or other foreign bodies embedded in the lung. Consider wedge resection of non-healty lung tissue. Osteomyelitic ribs should be resected. When the debridement is complete, insert drains and leave them until they are non-productive (it may be months). Lung fistula An abscess may rupture spontaneously through the chest wall and form a fistula. In some cases the fistula will dry and close after potent long-term antibiotic treatment. In most cases a small thoracotomy and decortication must be done. Osteomyelitis Open chest wall fractures may get infected and osteomyelities may develop in the sternum or ribs. The management consists of surgical excision of necrotic bone and damaged soft tissues, drainage and long-term antibiotic therapy. Mobilize local soft tissue flaps if the debridement leaves a soft tissue defect.
505
506
510
Abdominal wall injury ............................................................. 512 Exploratory laparotomy ........................................................... 513 Decompression drainage closure Staged life-saving surgery
...........................................
521 254
.........................................................
507
508
2 The penetrating injury may be silent. The abdominal cavity is lined with a mucosal sheet, the peritoneum. The intestines are covered with a fat tissue apron, the omentum. The peritoneum and omentum are the abdominal surgeons: They try to cover and close any wound inside the abdomen the penetrating injury may be silent and rather painless at the time of examination. In particular tiny perforations of the small intestine are often missed at the time of injury. But within 4-5 days the seal is broken, peritonitis develops, and makes you recognize the full extent of the injury. A missed intestinal injury carries a high risk of complications and death. I am not sure if the injury is penetrating Low-energy injury: Consider peritoneal lavage, see p. 253. Abdominal ultrasound is a sensitive technique to identify free blood in the abdomen in skilled hands. If you still are in doubt: carry out laparotomy. High-energy injury Manage the case as if the injury is penetrating if there are entry wounds: do laparotomy without further delay.
The incidence of negative wartime laparotomies (where no injury is found) should be about 20%.
509
Associated injuries
Wounds of the diaphragm is sutured from the abdominal side. One out of four abdominal injuries also has injuries outside the abdominal cavity: Associated chest injury is most common. The chest injury has priority and should be managed before the laparotomy is done. In most cases chest tube insertion is the only management necessary. Associated pelvic injury: Unless major pelvic vessels are injured and the patient is unstable, the abdominal injury has priority. Close or resect intestinal wounds before the pelvic injury is explored. Most pelvic injuries are managed by gauze packing (bleeding) or drainage (tears of the rectum, bladder and female organs). Associated spinal injury: The abdominal injury has priority. Intestinal injuries must be repaired before the spinal injury is explored.You may delay spinal surgery for 48 hours (unless there are increasing neurological signs) if that is necessary to repair the abdominal injury.
Ask patient/relatives: Did you have any abdominal illness? Chronic dysentery (amebiasis)? Schistosomiasis? Typhoid fever? Ascariasis? These diseases may all cause serious complications during and after abdominal surgery Make a list of all surgical instruments and the exact number of gauze packs before surgery starts. Check the list before closure of the abdomen: Make sure that no items are left inside Wash the field from the nipples to the mid-thigh Make sure the operating table tilts: Surgeons access to the upper abdomen is better with the patient tilted with head up, feet slightly down. Tilt the table the other way for access to the lower abdomen. Antibiotics before surgery a one-time dose: Alternative 1: IV ampicillin 2-4 g Alternative 2: IV penicillin 10 mega IU and doxycycline 400 mg. Alternative 3: IV chloramphenicol 1g For all cases: Infusion or suppositories of metronidazole 1.5 g.
Anesthesia
Relaxation of the abdominal wall muscles is essential for precise exploration of the abdomen, and for repair of major abdominal wall injuries: General anesthesia with controlled ventilation is the best method: Muscle relaxation makes the surgery easier, and the tracheal tube prevents aspiration of gastric contents to the lungs. Bupivacaine spinal anesthesia is a safe method. The anesthetic level should at minimum reach Th6, at best Th4 (the nipples).You may supplement a low spinal anesthesia (below Th6) with intercostal nerve block (observe the maximum doses) or IV ketamine anesthesia. Ketamine anesthesia in emergencies: Ketamine does not provide muscle relaxation. But intermittent IV ketamine anesthesia is simple and rapid it may be the method of choice in emergencies with temporary gauze packing of abdominal bleeding through a wide midline incision. For recontructive surgery inside the abdomen, muscle relaxation is necessary. Be ready for problems with anesthesia in abdominal bleeds: The surgeon should be present and ready for lparotomy at the time of anesthetic induction: Stable but hypovolemic patients may develop circulatory shock immediately when the anesthesia is given. Flush the infusions and enter the abdomen without delay:When surgery starts and there is some manipulation with peritoneum, the blood pressure will rise. Distended abdomen beware when the abdomen is entered: Major bleeding inside abdomen may stop spontaneously due to increasing pressure inside the abdominal cavity tamponade effect.When the surgeon enters the abdomen, the intraabdominal pressure falls abruptly due to the loss of the tamponade effect and the bleeding may explode. Compress the aorta, see p. 513, and flush the IV infusions! Monitor the heart: Much manipulation with the intestines affects the heart. Beware when the small intestine is delivered out of the abdomen during the exploration.
511
The intestines themselves are insensitive. The main source of pain is the skin, and manipulation of peritoneum and the mesentery.
Synthetic materials (silicone, Silastic) cause infection, and should not be used for permanent closure of large defects in wartime injuries.
512
length flaps to either side.You may also mobilize the omentum through a separate incision into the abdominal wall defect and fix it to the wound edges as a floor to cover the intestines. Place large saline-wet gauze pads outside the omentum and close the entire defect water-tight with large plastic sheet as above. After one week the omentum will be covered with granulation tissue and may take split-skin grafts. Skin transposition flap for major defects: The aim is not to reconstruct the abdominal wall but re-establish continuity. For this we should use skinor fascia-skin flaps based on perforator arteries. There are numerous perforators from the costal and lumbar arteries. Raise broad flaps over the rectus muscle on one or on both sides and transfer to close the defect. Take care not to undertmine the flaps, this may damage the perforators. Apply broad bands of adhesive plaster to support the abdominal wall for better breathing.
Exploratory laparotomy
Technical details of the laparotomy incision, see p. 255. Always midline incision in war: Wartime injuries are multi-organ injuries. By extending the midline incision from the sternum to the pelvic bone, you can explore and manage every abdominal and pelvic organ. The incision is rapid, simple and heals well. Bleeding explodes compress the aorta: When the abdomen is cut open, the intra-abdominal pressure falls abruptly and abdominal bleeds may explode. To prevent this event, let the assistant press with one hand firmly against the aorta immediately below the diaphragm. The access is best from the right side, sneaking in behind the small omtentum towards the midline behind the stomach. To prevent backflow from below, also the distal abdominal aorta should be compressed: you may enter from either side behind the omentum and loops of the small intestine. Keep a steady pressure until the surgeon has identified the bleeding sources and controlled them.
First, clean up Take out blood from the abdomen using the cup or your hands as a cup. Suction does not work here. Wipe out the rest of the blood with gauze packs. Normally more than one abdominal organ is injured, so you have to explore the entire abdominal cavity in a systematic way.
The right upper quadrant: Push the liver upwards, the stomach to the left, and the colon downwards. Blood in this quadrant indicates injury to the liver or the right kidney.
The left upper quadrant: Push the liver and the ribs upwards, the stomach to the right, and the colon downwards. Blood in this quadrant indicates injury to the liver, the spleen, or the left kidney.
The right lower quadrant: Lift the entire small intestine out of the abdomen to the left. Blood in this quadrant indicates injury to the blood vessels at the posterior abdominal wall. Note: Too much manipulation of the intestines affects the heart. Beware when the small intestine is delivered during the exploration.
The left lower quadrant: Lift the entire small intestine out of the abdomen to the right, and push the sigmoid colon downwards. Blood in this quadrant indicates injury to the vessels at the posterior abdominal wall. The pouch in front of the rectum: With the small intestine still outside the abdomen, push the sigmoid colon upwards, and the urinary bladder (the uterus in females) forward. Blood in this pouch indicates injury to the iliac vessels, or the organs in the pelvic cavity.
514
Exploratory laparotomy
5 Omental flaps control bleeding: In most injuries of the upper abdomen, a part of the omentum may be separated, mobilized and tied inside the tear.The omentum has a formidable hemostatic effect and accelerates healing (stem cell function). False bleeding control If the patient is hypovolemic during surgery, the bleeding control may be deceptive.When the circulation is restored after proper volume therapy, the bleeding may start again: When you assume to have controlled the bleeds: Give warm volume therapy until BP is up to 90 mm Hg. If it still not bleeds, you may close the abdomen. The best prevention:Transfusions of fresh warm whole blood with platelets.
515
6 The small intestine: Examine every cm methodically both sides of the intestine and the mesentery. Perforations are tied off with gauze bands when identified, see p. 257, and sutured if there is time for it, see p. 530. Control bleeding mesenteric vessels with vascular clamps or finger clamping and observe the blood supply to the intestine: Cyanosis around the perforation after vascular clamping indicates resection and end-to-end anastomosis of the intestine, see p. 531. 7
7 The right colon, the right kidney and ureter: Cover the small intestine with large saline gauze packs and retract them to the left.You may deliver the whole pack of small intestine outside the abdomen for better exposure. Retroperitoneal hematoma or local swelling close to the colon indicates a tear of the colon (or the right kidney) behind the peritoneum mobilize the colon: Incise the peritoneum along the dotted line in the bloodless area just lateral to the colon. Mobilize the colon by blunt finger dissection, lift it towards the midline for inspection. This is also the best access to the right kidney. 8 8 The transverse colon is inspected by retraction of the small intestine to the right, and lifting the colon with the omentum upwards.You also have access to the posterior abdominal wall with the main vessels. The dotted line (arrow) represents the incision for exploration and control of the left kidney, also see ill. 15, p. 519. 9 9 The transverse colon may also be explored by splitting the gastro-colic ligamentum the part of the omentum located between the colon and the stomach. Clamp and ligate the ligamentum stepwise (the technical procedure in detail, see p. 528). Explore the posterior side of the transverse colon, stomach and pancreas, see p. 518.
516
Exploratory laparotomy
9 The left colon, the left kidney and ureter: Retract the small intestine to the right or out of the abdomen. Examine the left colon, sigmoid and rectum. In case of swelling or hematoma on the posterior abdominal wall, do not hesitate to mobilize the colon: Incise the peritoneum in the bloodless field lateral to the colon and mobilize the colon off the posterior abdominal wall by blunt dissection. This is also the standard access to the left kidney. 10
10 Rectum and the rectovesical pouch: For exploration of the retroperitoneal part of the rectum, ureters and bladder, incise the peritoneum in the recto-vesical (female: rectovaginal) pouch. With careful traction on the rectum, it is mobilized upwards from the pelvic cavity by blunt dissection. Note: In major pelvic hematomas, do not enter the hematoma without first taking control of the main proximal vessel (the iliac artery or aorta) the bleeding may be heavy once the peritoneum is opened. Rather consider extraperitoneal packing, see p. 270. 11 11 The liver: Examine the right part of the diaphragm and search carefully with your hand over the liver for tears and hematomas. Note: Rough manipulation of the liver may cause heavy bleeding from clotted liver wounds. Traction of the liver may cause bleeding from partial tears of the liver veins on the posterior side of the liver. The management: Pringles maneuver, see p. 515 and 48 hours gauze packing.
517
12
12 The liver hilum: Retract the transverse colon downwards, apply soft clamps / forceps on the gall bladder and inspect the hepatic artery, portal vein and main bile duct.They are located altogether behind the peritoneum. Hematoma, swelling, discoloration or bile leaking indicates exploration: Incise the peritoneum and identify the main structures by careful blunt dissection. The dotted lines are incisions for mobilization of duodenum (Kochers maneuver, see below) and the right colon (for hemicolectomy). 13
13 The stomach and pancreas: In upper abdominal injuries and blood on the naso-gastric tube, also the posterior side of the stomach must be explored. Split the gastro-colic ligament, see p. 516, and lift the stomach forwards. The head of pancreas is explored by Kochers maneuver, see below. Retroperitoneal hematomas in this area indicate tears of aorta (A), the caval vein (C) or the splenic artery (SA). Hands off! Do not enter a retroperitoneal hematoma unless it is expanding. Never enter a retroperitoneal hematoma before you have controlled the proximal artery (manual compression or vascular clamp). 14 Duodenum Kochers maneuver: Retroperitoneal hematoma or swelling along the duodenum, or blood on the naso-gastric tube indicates exploration of the duodenum. Retract the transverse colon downwards, and split the peritoneum along the lateral border of the duodenum (a bloodless area). By careful soft dissection the duodenum is lifted off its bed. The bile duct running through the head of pancreas is inspected. Note the superior mesenteric artery (small arrow) carrying the blood supply to the small intestines. Also the access to the kidney vessels and the caval vein (big arrow) is excellent.
14
518
Exploratory laparotomy
15
15 The spleen, the left kidney and ureter: To explore the spleen retract the ribs upwards, the stomach towards the midline, and the left colon flexure downwards. To control the splenic artery, mobilize the spleen and expose the tail of the pancreas: Split the peritoneum lateral and proximal to the left colon flexure (the proximal part of the dotted line). Further mobilization of the left colon will expose the left kidney, the kidney vessels and ureter (arrow). A more rapid access to control the kidney vessels is the medial incision, see ill. 8, p. 516. 16
16 The bladder: In cases with hematuria, the bladder must be explored. This is best done from the inside: Open the bladder between two stay sutures. Monitor the function of both ureters: On a mucosal ridge some 3 cm to each side of the midline the ureters are emptying flushes of urine. Monitor each orifice until you see clear urine flowing from both ureter openings.
519
17
17 The female organs are easily accessible. Injuries below the peritoneum are explored by incising the peritoneum in front of the uterus or behind it in the rectovaginal pouch.
Drainage of the abdominal cavity Dependent tube drainage is more effective and less expensive than the small-caliber suction drains. Small-caliber drains may block by blood clots or pus. Also the drain may become obstructed by the omentum or loops of the intestine: Use two drains, minimum 10 mm wide.You may use any plastic tube not too soft, cut side holes in it. Make a small stab incision through the far lateral abdominal wall for the tube. Consider the gravity in order to achieve effective drainage: The patient should eg. be half-sitting to drain the lower part of the abdomen. Or put him in a half-side position at intervals to improve the drainage. Early respiratory exercises and effective analgesia improves the drainage.There are many pockets where blood, bile or urine may collect and give rise to secondary infection. Illustrated is the standard drainage of the four abdominal quadrants. In addition drainage should be done close to intestinal sutures and anastomosis. Make sure that the drain does not damage the suture line. Also note the extraperitoneal drain lateral to the bladder in pelvic injury. Decompression of the gastro-intestinal tract The tract is paralytic for some days after injury and surgery. Fluids and gas will collect inside the intestines and stomach causing them to expand and anastomoses to burst. To relieve this pressure, the intestinal sutures and the midline incision suture, decompression must always be done for 48-72 hours after the laparoto521
my there are no exceptions to this rule. Either insert a naso-gastric or naso-duodenal tube guided by the hand during surgery. In major injuries, multiple-injury cases and other cases carrying a high risk of secondary complications, do a tube gastrostomy for both decompression and enteral feeding.
Tube gastrostomy for enteral feeding: For patients in need of long-term highenergy feeding (poly-trauma and major burns) we strongly recommend a large calibre feeding tubes which can take home-made diets. Insert a large-bore Foley catheter through a stab incision in the abdominal wall and into the stomach. The small stomach incision is closed by a circular suture and the catheter balloon is inflated. Some sutures between the stomach serosa and peritoneum will fix the stomach to the abdominal wall. After a few days adhesions will form to secure the fixation. Tape the catheter over a roll of gauze under slight traction. In most cases tube feeding can start the first post-operative day, unless there is abdominal distension due to paralytic ileus.
522
Closure of the midline incision: Grasp the peritoneal edge with clamps and close the peritoneum by continuous over-and-over sutures (absorbable 3-0). Take care not to tie up any intestinal loops. Close the muscle fascia with cross-wise strong sutures (no 1, absorbable or silk). Then close the skin. Before closure: Are you sure no instruments or gauze packs are left inside? Count, and compare with the list made up before surgery.
Relief sutures: In cases late for surgery the intestines may be distended and swollen. To relieve tension in the midline sutures and to reduce the risk of wound infection and rupture, a few sutures (no 1 or 2) are inserted 5-7 cm from the incision before you close the incision. Tie the relief sutures in rubber tubes to avoid pressure sores on the skin. Also some broad bands of adhesive plaster across the dressing will relieve tension upon the midline suture. Warning: abdominal compartment syndrome! If the intestines are distended and the abdomen also packed with gauze pads, direct suture of the midline incision may cause high pressure inside the abdomen = compartment syndrome. The cardinal signs of abdominal compartment syndrome: High respiratory rate Low urinary output Circulatory shock due to venous obstruction. Untreated abdominal compartment syndome is fatal: Release the midline suture immediately! Close the incision by Bogota bag or vacuum dressing, see p. 258.
523
524
526 527 530 532 536 537 251 513 539 603
Debridement and enterostomy Injury to the small intestine Injury to the colon Injury to the rectum
......................................................
...................................
.......................................................... ..............................
...........................................
525
Surgical anatomy
1 1 The structure of the intestine: The small intestine, the transverse and sigmoid colon are indirectly attached to the posterior abdominal wall through a mesentery. The mesentery is covered by peritoneum, and contains fat and the vascular supply to the intestine. The vascular network in the mesentery is rich in collaterals and may endure moderate injuries without necrosis of the intestine. The duodenum and large intestine are far more vulnerable to vascular injury. The wall consists of three layers. From inside out: the mucosa, the muscular layer and the serosa. The intestinal sutures should include all three layers.
2 The blood supply for the intestine: The superior mesenteric artery runs through the body of pancreas in front of the duodenum and supplies the small intestine, the right colon and the transverse colon. The inferior mesenteric artery runs behind and below the duodenum and supplies the left colon, sigmoid and rectum. Ligature of the main branches of these arteries will invariably create hypoxia/necrosis of parts of the intestine: Intestinal resection is necessary.
3 Anatomy of the rectum: The blood supply is rich; there are collaterals from the internal iliac artery, and the rectal tears normally heal well. The main problem is hematoma and abscess formation in the spaces of fat and loose connective tissue inside the pelvic cavity (arrows). Effective drainage is essential. Note the close relationship to the bladder: Hematuria indicates exploration and suprapubic drainage of the bladder.
526
Surgical anatomy
4 5
4 Multiple injuries are common in penetrating as well as blunt trauma. Note the close relations in the upper abdomen. Study the techniques for exploration of the upper quadrants, see pp. 514-19.
5 Associated injuries in the lower abdomen: Especially note the close relationship between the colon and the ureters and the iliac arteries both on the left and right side. Many injuries to the ureter are made by careless surgery. Do not mobilize the right or left colon unless you first identify the ureter.
7 Resection may be the best debridement: Major tears or double perforations through a loop or flexure are managed by resection and end-toend anastomosis. Hematoma in the mesentery: Examine carefully the circulation of that part of the intestine. If in doubt, do resection-anastomosis.: Clamp the intestine with soft intestinal clamps. Do stepwise ligature of the mesentery along the dotted line. 8 Spare the vessels to the anastomosis: Inspect the cut ends of the intestine to see if they are well vascularized. Change the knife blade after cutting the intestine.
11
12
11 Injury to the right colon: The distal ileum is used for enterostomy. Note: There are particular problems injuries to the right colon, see p. 535. 12 Injury to the ileum: A loop of ileum just proximal to the injury is used for enterostomy.
528
Loop enterostomies of the small intestine, see p. 532. Colostomies, see pp. 533-35.
In-field enterostomy if the hospital is far Uncontrolled leaking from intestinal tears for 8-10 hours may cause fatal peritonitis. If the hospital is far or you do not feel competent to repair intestial injuries, or it is too time consuming a diversion enterostomy should be made as soon as possible after injury: Either the intestinal perforation is brought out of the abdominal cavity as a stoma, see p. 534, or a loop-enterostomy is done using uninjured intestine proximal to the injury. The quadrant with the intestinal perforation is then gauze packed to restrict leaking. The enterostomy is done through a small midline incision under IV ketamine anesthesia. For trained staff the complete procedure takes 30 minutes. Decompress the intestines: Naso-gastric tube is inserted before surgery. Before you close the laparotomy, guide the tube into the duodenum and start suction. Continue intermittent suction for 2-4 days until the bowel function re-starts. Dilatation of the anus is done in teafs of the colon and rectum to prevent retention of fluid inside the intestine. Dilate the anus till it takes 4-6 fingers and place a large bore tube drain for 48 hours.
13
529
Extensive injury? Use omental flaps to secure the suture lines, see p. 269 and p. 515. 15 The suture technique: The longitudinal wound is transformed into a transverse one using stay sutures. Longitudinal sutures cause narrowing of the intestine, increased pressure on the sutures, and rupture of the suture line.The suture line should not cause a narrow lumen. For small wounds we recommend interrupted S-sutures (absorbable or silk 3-0 or 4-0). Each suture must include all three layers of the intestinal wall. See to it that the wound edges are well invaginated into the intestine all the way in the suture line. If you doubt the patency of your suture, apply interrupted sutures from serosa to serosa to invaginate the primary suture line.
530
16
16 End-to-end anastomosis suture no 1: Is the blood circulation of the intestine ends sufficient? Let your assistant approximate the clamped intestine ends. Suture no.1 starts at the midline with continuous S-sutures. Invaginate each suture carefully at the corners, where the rupture tends to occur. Continue the suture to the midline. Note the sutures at the front: They are not over-andover. Make sure that each suture takes all three layers of the intestine. 17 17 End-to-end anastomosis suture no 2: Start at the midline, and repeat the procedure from inside the intestine towards the opposite side. Let sutures no 1 and 2 meet at the front and tie them. Control the patency of the anastomosis with your fingers: The anastomosis should admit your thumb. Remember: Close the split in the mesentery with over-and-over continuous sutures else loops of the small intestine may be caught and strangulated.
531
18
18 Loop ileostomy: Make a separate incision 7-8 cm wide just lateral to the rectus muscle. Control bleeding inside the incision, pull the intestinal loop through the incision, and secure its position with some forceps, etc. Check with your finger that the intestine is not strangulated in the incision. Fix the loop to the abdominal skin with some interrupted serosal sutures. Now finish your surgery inside the abdominal cavity and close the midline incision before you proceed with the enterostomy. Cover the midline incision and the stoma incision with gauze packs before you open the intestinal loop with a transverse knife incision. Use suction to avoid intestinal contents contaminating the wound. Interrupted all-layer sutures fix the intestine to the skin.
ed and includes only the serosa. Tags of the omentum fixed to the serosal sutures help protect the suture line. Three alternative methods for primary management 1. Suture and diversion enterostomy for rectal injuries and minor injuries of the colon 2. Bring the perforation forward as enterostomy in cases that cannot tolerate extensive surgery 3. Resection and double end-enterostomy in major injuries to the colon. 20
20 Method 1 suture the wound and do a proximal diversion colostomy: The perforation is debrided and closed (two-layer suture). In this case with a left transverse colon perforation, the right transverse colon is used for enterostomy. A separate incision for the colostomy is made on the right-hand side over the transverse colon. Before the transverse colon can be delivered, free the omentum from the lower border of the colon for 15 cm. 21
21 The loop-colostomy: The transverse colon is delivered through the incision and fixed over a rod of plastic or a stiff rubber drain. Check that the colon is not under tension through the incision. The right and left colon has to be mobilized from the posterior abdominal wall to be delivered for colostomy, see pp. 516-17: A colostomy under tension invariably causes complications, see p. 609. Close the enterostomy incision, but do not open the colostomy until the midline incision is closed. Then incise the enterostomy along one of the white fibrous bands to reduce bleeding. Fix the edges of the colon to the skin with interrupted sutures at short intervals.
533
22
23
22 Method 2 deliver the perforation itself as enterostomy: The method is particularly suited to injuries of the transverse and sigmoid colon. The injured segment of the intestine is delivered through a separate incision and fixed over a rod. When the midline incision is closed, the enterostomy is completed. 24
23 A combinations of methods 1 and 2 is indicated in multiple injuries of the colon. Debride and close the distal perforations (method 1), in this case a sigmoid tear. Deliver the proximal perforation as enterostomy (method 2), in this case a left colon tear. Note: Close the space between the enterostomy and the lateral abdominal wall with some interrupted sutures to prevent entrapment of the small intestine.
24 Method 3 resection and double end-enterostomy: The method is suitable for high-energy injuries with extensive intestinal tears. In this case the distal left colon and the sigmoid is mobilized by a peritoneal incision lateral to the left colon, and isolated with soft clamps at the (dotted) line of resection. The sigmoid mesentery carrying the vascular supply to the damaged section is ligated stepwise. 25
25 The end-colostomy: After resection, the two intestinal ends are delivered without tension through two small separate incisions in the abdominal wall. The colostomy incisions should be located well away from the pelvic bone, from the midline incision and any other skin wounds. The intestine is fixed by some sutures from the serosa to the deep abdominal fascia. Without these sutures, loops of the small intestine may herniate along the colostomy into the abdominal wall. The mucosa is sutured with close interrupted sutures to the skin.
534
27
28
27 Recommended: resection of right colon. Colostomy of the right colon normally creates skin problems, abdominal wall infection and abdominal abscess formation at the site of the stoma. The experienced doctor should manage major injuries to the right colon with resection of the right colon (right hemicolectomy) and enterostomy of the ileum. The simplest alternative is to deliver the resected colon as a mucous end-colostomy as illustrated here. The resection starts with a long peritoneal incision along the lateral wall. The colon with its arteries is lifted off its bed by blunt dissection.Take care not to damage the ureter (white arrow). The right colon with 10 cm of ileum is resected along the dotted line. A left transversostomy and an end-ileostomy is arranged. Close the space (black arrows) between the end-ileum and the abdominal wall. 28 For the less experienced surgeon: Foley catheter enterostomy. Hemi-colectomy requires some surgical training. The not so experienced doctor should debride and suture the perforation. Supplement an omental tag to protect the suture line.Then mobilize the cecum towards the abdominal wall making a peritoneal incision lateral to cecum. Cut the end of a large-bore Foley urinary catheter
535
and insert it into the cecum through very short stab incisions in the cecum and abdominal wall. Inflate the catheter balloon and close the cecum tightly around the catheter with a purse-string suture. Fix the cecum up to the abdominal wall with some sutures between the cecum serosa and the peritoneum. When the catheter is deflated and removed after two weeks, the fistula will close spontaneously after some days on the condition there is no abscess formation inside. An alternative to Foley catheter stomy is a distal loop-ileostomy.
29
30
30 Reconstruction of end-colostomies: First the two barrels of the colostomy are released from the abdominal wall. Clamp the intestinal ends with soft intestinal clamps and mobilize them so that they can be approximated without tension. Extend the colostomy incisions to mobilize the intestines under direct vision. The posterior outer suture is done while your assistant is approximating the clamps steadily. The suture is interrupted and includes serosa only. The inner suture is similar end-to-end anastomosis of the small intestine: a continuous suture using two needles including all three layers of the wall. Take care to invaginate the edges properly, particularly at the corners. The anterior outer suture is interrupted and includes only serosa. Drain the anastomosis: Gastric decompression and external tube drains are arranged before both enterostomy incisions are closed.
537
538
540 542
Stomach injury ...................................................................... 541 Injury to the duodenum and upper jejunum
..................................
Complications of injury and surgery ............................................ 544 Staged surgery in major abdominal injuries Exploration of the upper abdomen Complications of abdominal surgery
...................................
............................................. ...........................................
539
The injuries may be initially silent! In high-energy blast injuries, both the duodenum and stomach may rupture in a blow-out fashion with wide tears of the wall and obvious clinical symptoms of abdominal bleeding and peritonitis. But in other cases hematomas may form in wall of duodenum causing gradual obstruction and rupture. In such cases it can take days before a retroperitoneal duodenal rupture produce clinical signs of peritonitis/abscess.
Surgical anatomy
The structure of the stomach and duodenum is identical to that of the intestine:The wall consists of three layers mucosa, the muscular layer and serosa, see p. 526. Injuries to the stomach Both diagnosis and surgery are simple: Blood with gastric suction indicates surgical exploration. As the blood supply to the stomach is abundant, tears heal well after moderate debridement and suture.The main problem is retention of duodenal and gastric acid content in the stomach after surgery which may cause rupture of the sutured wound. Gastric decompression with intermittent suction via naso-gastric tube is important. Injuries to the duodenum In nine out of ten cases with duodenal injury there are associated injuries, often to major vessels. Most high-energy injuries die before they reach surgery. Often the initial survivors pose diagnostic problems: Problem 1: Blunt injuries and missile injuries with posterior inlet may cause tears of the posterior wall, that is, retroperitoneal perforations of the duodenum.There is no leaking into the peritoneal cavity and the early clinical signs may be few. Problem 2: Blunt injury and heavy blast waves may cause hematomas in the duodenal wall with swelling and partial/total obstruction of the duodenum, a condition seldom seen elsewhere in the gastro-intestinal tract. Except for gastric retention of fluid, the early clinical signs may be few. A missed and unmanaged hematoma of the wall may rupture within a few days. Also the surgical repair of duodenal injuries is not straightforward: Problem 1: The total physiological secretions passing into the duodenum from the stomach, pancreas and the biliary duct amount to 4-5 liters per 24 hours. This causes pressure upon the suture line, and high risk of rupture of the suture line with peritonitis and fistula formation. Proximal as well as distal drainage is mandatory. Enteral feeding should be considered due to the prolonged recovery. Problem 2: As the lumen of duodenum is narrow, suture of even small tears may cause partial or total obstruction of the intestine. Injuries to the upper part of the jejunum The surgical problems with these injuries are nearly identical to those of the duodenum, and the same management procedures should be applied.
540
Surgical anatomy
1 The vascular supply: There is a rich anastomosing network between the main arteries along the greater and lesser curvature of the stomach (white arrows). As these arteries are not end-arteries, you may ligate them without risk of stomach wall necrosis. Note the artery for duodenum along the inner curvature of duodenum. Along the outer curvature there are few vessels the duodenum and the head of pancreas are therefore mobilized (Kochers maneuver) by bloodless dissection from the outer curvature (black arrows). Always explore the pancreas in injuries to the stomach, duodenum and spleen: The pancreas has no separate independent blood supply; it is supplied from the gastric, duodenal and splenic circulation. Injuries to these organs may cause partial necrosis of the pancreas as well. 2 Anatomy of the duodenum: In this illustration the gastro-colic ligamentum, see p. 518, is not drawn. Note that the main portion of duodenum lies behind the peritoneum, directly fixed to the posterior abdominal wall without any mesentery. Below the ligament of Treitz (white arrow) the jejunum starts, with loops lying free inside the abdomen connected to the posterior abdominal wall by the mesentery. Consequently, most perforations of the duodenum do not cause the typical acute peritonitis seen after more distal intestinal injuries. If you recognize a duodenal injury by its peritonitis, you are probably too late and will face difficulties during surgery. Note the superior mesenteric artery (big black arrow) carrying the main blood supply for the small and large intestine. The artery runs through the body of pancreas, and crosses the duodenum at its distal third. The small black arrows indicate the area with few blood vessels that should be divided for exploration of the posterior wall of the duodenum.
Stomach injury
Look for the other perforation! Isolated wounds of the stomach are uncommon in missile injuries. Split the gastro-colic ligamentum and explore the posterior wall. 3 3 Transverse suture of stomach perforations: The perforation is roughly debrided and stay sutures applied. In the distal part of the stomach, longitudinal wounds should be transformed into transverse ones to prevent narrowing.The wound is closed with two layers of sutures as described for tears of the colon. The inner continuous over-and-over suture is applied with a close interval between each suture to control mucosal bleeding. The outer suture is interrupted, contains just the serosal layer and must invaginate the inner suture. A strand of omentum
541
may be used to protect the suture line (ill. 5). Before you close the stomach wound, guide a tube into the duodenum for decompression. Start suction on the operating table and continue intermittent suction for 3-5 days. Arrange dependent drainage of the space between the stomach and transverse colon, and of the lesser sac if the wound is on the posterior wall. Even wide tears of the stomach are managed by direct primary suture. Major resections and gastro-jejunostomy are rarely indicated. Diets for enteral feeding, see p. 786. Enteral feeding In extensive stomach injuries, give enteral feeding by a duodenal tube for one week after surgery to avoid pressure upon the suture line or place the feeding tube by a loop enterostomy, see p. 543.
well. A tag of the omentum may be fixed to the suture line with some interrupted serosal sutures, see below. Deliver a proximal loop of jejunum through a separate left lateral incision, and arrange a loop jejunostomy, see p. 532. Before you close the midline incision, pass a soft tube guided with your hand through the jejunostomy into the duodenum for decompression. Pass the distal tube through the jejunostomy into the small gut for enteral feeding. A naso-gastric tube is applied for decompression of the stomach for 5-10 days. At least one large-bore tube with side holes should drain the area close to the duodenal suture. By this tube drain you can monitor the patency of the suture. Also the tube will make the track for the duodenal fistula that develops in case of wound rupture. Take the tube out through a far lateral separate stab incision. 5
5 The emergency alternative: a controlled duodenal fistula. In multiorgan injuries, during emergency laparotomies and in cases late for surgery, it may be a hazard to do extensive primary duodenal surgery. Also if you are inexperienced in abdominal surgery, the controlled fistula is a safe alternative: Make two side holes in a wide-bore Foley catheter and insert it through a separate far lateral stab incision in the abdominal wall and into the duodenal perforation. Inflate the balloon slightly. Adapt the wound edges around the catheter as best you can, and fix a strand of the omentum to the area with some interrupted sutures. Proximal and distal decompression is essential, see ill. 4 above. High-energy enteral feeding through a loop jejunostomy is a must as the rehabilitation will be protracted. Two weeks after surgery the duodenal balloon is deflated and the catheter withdrawn stepwise, a few centimeters every day. Probably a duodenal fistula will form.
543
Blunt injury without perforation Explore the retroperitoneal duodenum to be sure there is no perforation. Also explore the pancreas: Leaking of pancreatic juice may cause perforation in a hematoma in the duodenal wall. The management of the duodenal injury is conservative: Concentrate on proximal decompression with intermittent gastric suction for 5-10 days. 6 6 Extensive duodenal injury: In cases with loss of tissue and extensive tears, wound suture will invariably cause obstruction of the relatively small lumen of the duodenum. Duodeno-jejunostomy is indicated: Close the duodenum distal to the tear with a two-layer suture. Anastomose the proximal part end-to-side on a proximal loop of the jejunum. See suture techniques for entero-entero-anastomosis, p. 531. Injury to the proximal part of jejunum The perforation is debrided and closed minor perforations with plain suture, major or multiple perforations with resection-anastomosis, see pp. 528-31. Then the jejunal loop distal to the perforation is delivered through a separate incision as a loop jejunostomy. Two soft catheters are inserted one into the duodenum for decompression, the other into the small gut for enteral feeding. Supplement with intermittent gastric suction for some days.
complications. In a catabolic and weak patient the fistula will probably not close spontaneously reconstructive surgery is indicated, preferrably before the catabolism becomes too advanced. Duodenal stenosis The patient recovers, but complains of constant vomiting: Suspect narrowing of the injured part of the duodenum. If X-ray facilities are available, examine the degree of obstruction after peroral barium contrast. Continue gastric suction and enteral feeding. Most cases of partial stenosis recover without reconstructive surgery. Complete obstructions 10 days after the surgery will normally not recover: Reconstruction is indicated (gastro-jejunostomy or duodeno-jejunostomy, see above).
545
546
.......................................................................... .....................................
Injury to the biliary tract .......................................................... 552 Staged surgery in major abdominal injuries Exploration of the upper abdomen Complications of abdominal surgery
...................................
............................................. ...........................................
547
Surgical anatomy
1 1 The blood circulation of the liver: By upwards retraction of the edge of the liver, and downwards retraction of the large intestine, you can identify the liver hilum, the inlet to the liver, see p. 518. Note the three structures of the liver hilum (inside the ring): The portal vein (1) carrying nutrition absorbed from the intestines for metabolism inside the liver. The liver artery (2) is a branch of the celiac artery, and carries oxygenated blood from the aorta (4) to the liver tissues. The main biliary duct (3) carrying the bile into the duodenum. The surgeon may temporarily clamp all three structures (Pringles maneuver) to reduce bleeding from a liver tear. If it still bleeds after hilum clamping, the bleeding source may be the liver veins (5). They are controlled by tamponade of the posterior side of the liver. The liver arteries are not end-arteries. They communicate with the portal circulation.You may thus permanently ligate a liver lobe artery with little risk of liver necrosis if the portal blood supply is undamaged. 2 Associated injuries are common: In serious cases, when liver bleeding is controlled, do not waste time on further liver surgery. Concentrate instead on exploration of the duodenum, pancreas and colon as these injuries cause peritonitis and infect the liver tears. Note the position of the left lobe of the liver: It is often injured by missiles penetrating the midline from the left side. Combined injuries of the right kidney and the right lobe of the liver are common as they are located at the same level. 3
3 Abscess formation after liver injury: Hematomas not drained may form abscesses. The arrows show where blood and bile normally collect. Note especially the pocket behind the stomach and the gastro-colic ligament and downwards to the transverse colon (the lesser sac). And the space between the ribs and the right lobe (black arrow). Two or more large-bore dependent drains through the lateral abdominal wall (right or left side) will prevent abscess formation. The liver is lined by a capsule, and hematomas may also form under the capsule if liver tears are tightly sutured.
548
Surgical anatomy
4 The biliary tract: The bile ducts from the liver, the gall bladder and the main bile duct together form the biliary tract.When the free flow of bile down to the duodenum is impaired, jaundice arises. Biliary tract decompression after injury is done either by drain into the gall bladder or by T-drain from the main bile duct. Note that as the distal part of the main bile duct is covered by peritoneum, you have to incise it to explore the duct, see p. 518. The duct runs behind the duodenum, through the head of pancreas before it enters the duodenum. To explore the distal part of the bile, you must therefore mobilize the duodenum, see p. 518. The gall bladder may rupture by the spalling effect of blast waves, see p. 137. Minor tears of the gall bladder are more common. They heal well after moderate debridement, suture and effective bile drainage. As missile injuries of the main bile duct are normally associated with major vascular injury, most patients die before surgery.
Liver injury
Conservative surgery! Like muscle tissue, the tissue of the liver is not elastic; high-energy injuries may cause wide wound tracks. But the liver tissue is very well vascularized; even extensive liver wounds heal well without being debrided. Moderate tears, the bleeding has stopped Place hemostatic sutures. An omental flap inside the tear reduces the risk of re-bleeding. Note that hypotension may be the reason why the liver wound does not bleed at the time of surgery: Get the blood pressure up to 90 mm and check the liver suture before you close the abdomen. Re-bleeding indicates staged surgery with gauze packing. Collect blood for autotransfusion if there is no associated intestinal injury. The platelets are more important than surgery to control liver bleeds, see p. 419. Major tears that bleed Heroic primary liver surgery with extensive debridements, resections and lobectomies increase the mortality rate even in experienced hands. Rather go for staged surgery: Pack the tear and pack the upper right quadrant, see p. 257. Prevent peritonitis! When the liver bleeding is under control, concentrate on associated injuries of the intestine and pancreas to prevent peritonitis. Infection is a common cause of re-bleeding from liver wounds. Surgical access A long midline incision with retraction of transverse colon downwards and the ribs and diaphragm upwards gives good access to the liver. Sternum split or extensive thoraco-abdominal incisions are seldom necessary. Injuries to the liver veins and the posterior side of the liver should be managed with packing and drainage only, which is well done through the midline incision. For better access to the posterior side, the falciform ligament at the top of the liver may be cut.
549
Temporary bleeding control Hilum compression (Pringles maneuver) may be done by direct finger clamping, see p. 515. Or you may split the peritoneum and clamp the structures of the liver hilum all-in-one with a vascular clamp. You may maintain clamping of the hilum vessels continuously for 30 minutes, and even up to 60 minutes in emergencies. Fresh whole blood is important to control liver bleeding in hypovolemic and hemodiluted cases, blood transfusion should start once the bleeding is under control. Note: Venous bleeding from a liver tear may continue for minutes after the hilum clamping is done. 5 Debridement of ragged liver tears: Only the obviously necrotic liver tissue is cut, pinching it between the fingers.You will feel the major bile canals and vessels when you fracture the liver tissue with your fingers. Clamp them with forceps, and tie them with ligature. Minor vessels are controlled by el-cautery.
6 Suture liver tears: Moderate bleeding is controlled by deep hemostatic sutures with big curved non-cutting (round) needle. Do not tie the sutures tightly as they may tear the liver tissue and cause necrosis. If the tear is deep, mobilize an omental flap into the tear and and tie the sutures over the flap. 7
7 Deep wound tracks: Due to cavitation effect, most fragment and gunshot injuries disrupt the liver and cause open tears. But in some cases you may find a deep penetrating wound track. Mobilize an omtal flap, pull it into a soft plastic tube, and use the tube to guide the flap through the wound. The flap will stop bleeding, drain the wound and accelerate healing.
550
Liver injury
Drainage Drain the spaces where hematomas normally collect with large-bore tube drains with side holes, see p. 521 and p. 548. Also apply drains close to, but not into, the liver tears. For better dependent drainage, tae the drains out far lateral through the abdominal wall, in the anterior axillary line. Register in the Patient Chart or with marker on the skin which tube drains which space. Monitor the drains closely for signs of re-bleeding when you restore the blood volume. And for signs of infection 4-6 days after the injury.
551
The simle and rapid alternative: Resect the bladder distal to the tear and close the remaining part of the bladder around a small-caliber tube drain.You may use a tag of omentum to supplement the bladder suture.
9 Major gall bladder injury: cholecystectomy if you feel competent. Split the peritoneum at the hilum, and identify the liver artery and the main bile duct by careful blunt dissection. First tie the gall bladder artery (two ligatures), then the gall bladder duct. Note: The anatomy of this area is not constant the gall bladder artery may be single or double, it may leave the hepatic artery at different levels. Despite the small caliber of the artery, it may bleed considerably and be difficult to control if once lost. Then free the bladder from its attachment to the liver by blunt dissection. Keep a steady pull upon the bladder during the dissection. Dependent drainage.
552
10
NO!
10 Injury to the main bile duct: During cholecystectomy, take care not to tie the main bile duct. A careless ligature of the gall bladder duct may cause stricture upon the main duct, and jaundice. The management is drainage by T-tube or a plain soft plastic tube for two weeks. Missile tears and total ruptures of the main duct are also managed by primary bile duct drainage, and secondary reconstructive surgery.
553
554
556 557
Complications of injury and surgery ............................................ 558 Staged surgery in major abdominal injuries Exploration of the upper abdomen Complications of abdominal surgery
...................................
............................................. ...........................................
555
Surgical anatomy
Always supect injury to the spleen The spleen consists of loose connective tissue covered by a thin capsule. Even low-energy crush or blast wave injuries may cause ruptures of the spleen. In children the capsule is thicker and can take higher pressure before it breaks. Massive bleeding The blood circulation through the spleen is considerable, even minor tears may cause massive bleeding. Remove the injured spleen! In the war scenario with multi-inured patients and few resources for close post-operative follow-up, injuries to the spleen are as a rule managed by spenectomy. In children, splenic injuries may be repaired, but that takes skilled postoperative monitoring which is hard to undertake in war. Beware associated injuries! Isolated wartime injury of the spleen is uncommon. Always explore the diaphragm, stomach, colon, pancreas and the right kidney and rule out injury to the right lung.
1 Relationship to other organs: The spleen is located behind the stomach. To expose it, the stomach with omentum is retracted to the right, and the transverse colon downwards. Note the close relation to the diaphragm and the left lung. The splenic artery and vein (dotted) are located inside the broad peritoneal sheet (the
556
Surgical anatomy
small omentum, the gastro-colic ligament) between the stomach and the transverse colon. The black arrow points to some branches of the splenic artery supplying the stomach (short gastric arteries).These arteries may be damaged during careless exploration of the spleen; they are a common source of bleeding in upper abdominal injury. From the lower part of the spleen down to the transverse colon runs a strand of omentum (white arrow). It contains some vessels and may also bleed if torn. 2
2 The splenic artery and vein (black arrow) are exposed by blunt dissection after splitting the peritoneal ligament between the stomach and the spleen. The two vessels run together at the upper border of pancreas and slightly behind the pancreas. In order to finger clamp the splenic vessels to control bleeding, the surgeon must thrust his fingers posterior to the tail of the pancreas. Observe that the pancreas may be torn during this maneuver. The dotted line illustrates the lateral peritoneal incision used to mobilize the spleen for exploration or splenectomy.
the stomach and the spleen, and finger clamp the splenic vessels for some minutes while transfusions/infusions are flushed. Let your assistant maintain the finger clamping, while you mobilize the spleen to identify the anatomy and the injury exactly. 4 5 6
4 Mobilize the spleen: In cases with heavy abdominal bleeding, you may ligate the splenic vessels before you mobilize and remove the spleen. If the bleeding is moderate, the spleen is first mobilized from the abdominal wall by incision of lateral peritoneum (the dotted line, ill. 2, p. 557). By blunt finger dissection it is gradually lifted forwards into the midline incision. Pack the space between the spleen and the lateral abdominal wall with gauze packs to control oozing of blood before you continue the operation.
5 Control the splenic vessels: The spleen is gently lifted forwards from its bed by gauze packing. Split the peritoneum between the stomach and the spleen, and isolate the splenic artery and the splenic vein by careful blunt dissection. First the artery and then the vein is ligated doubly and cut. Note the ligature upon the cut strand of omentum from the lower pole of the spleen.
6 Avoid pancreatic tears: The spleen is carefully lifted from its bed. Adhesions to pancreas are carefully wiped off. Careless dissection may tear the tail of the pancreas (arrow). Pancreatic tears leak pancreatic juice which may cause serious complications, see p. 562. Bleeding in the splenic bed is controlled by 10 minutes compression upon gauze packs.
Drain! Large-bore dependent tube drains are inserted through a stab incision in the anterior axillary line: To find out if bleeding starts again when the blood circulation is restored To prevent abscess formation.
558
Lung complications Left-sided hemothorax may develop during 24 hours after the injury. The reason is probably suction of blood from the splenic bed through a minor diaphragmatic injury. Re-examine for signs of hemothorax after surgery even if the chest was cleared before surgery. Atelectasis (partial collapse) of the left lung is common unless early active respiratory exercises are done under analgesia. One out of four cases develops pneumonia. Those who form atelectasis are especially at risk. Abscess A hematoma under the left diaphragm (insufficient drainage) and a missed colon injury (insufficient exploration) may cause abscess formation inside the abdominal cavity, under the left diaphragm. Injury of the tail of the pancreas may cause retroperitoneal abscess formation.The clinical signs of abscess formation are a worsening general condition, spiking intermittent temperature peaks (abscess temperature) and sometimes a dull pain referred to the left shoulder area. The management is urgent exploratory laparotomy. Wash out the abscess with warm normal saline. Inspect the pancreas and drain pancreatic wounds. Arrange double dependent tube drainage from the infected area. Tendency to attract infections The spleen is part of the body immune system. Pneumococcal and other infections may rise after splenectomy. Give prophylactic antibiotics for one month after splenectomy. If available, give pneumococcal vaccination to all splenectomy cases.You may prevent such immune system defect by saving some splenic tissue and bury it in a subcutaneous pocket at the abdomen or thigh. The lymphoid tissue sometimes survive to help in the defence system.
559
560
562
Pancreatic injury .................................................................... 563 Complications of injury and surgery ............................................ 564 Staged surgery in major abdominal injuries Exploration of the upper abdomen Injury to the duodenum and upper jejunum Complications of abdominal surgery
...................................
............................................. ..................................
...........................................
561
Surgical anatomy
The pancreas consists of glandular tissue covered with a thin fibrous capsule. The hold for sutures in the capsule is poor, especially if surgery is delayed. The entire organ is located behind the peritoneum on the posterior abdominal wall. The pancreas produces digestive enzymes. The pancreatic juice is highly irritating to the tissues, and leaking from pancreas will create local inflammation, soft tissue necrosis and formation of local abscess, fistula or cyst. Leaking of pancreatic juice into the peritoneal cavity may cause erosion and damage to other structures as well. Retroperitoneal tears may cause retroperitoneal abscess on the posterior abdominal wall. The mortality rate after pancreatic injury is high one out of five dies mainly due to associated injury to major vessels. Another factor contributing to the high mortality rate is diagnostic difficulties: Retroperitoneal location: late clinical symptoms! The most common mistake in pancreatic management is to miss the injury initially. The clinical signs from associated injuries dominate the picture, the early signs indicating the pancreatic injury are few. The pancreas is covered by peritoneum, and located inside the lesser sac. Minor and moderate injuries may therefore grumble with poor clinical signs for days, before signs of pancreatic rupture develop: Central abdominal pain Referred back pain Vomiting Worsening general condition Peritonitis. Explore the pancreas on suspicion If the stomach, duodenum, spleen or left kidney is injured, make it a routine to also explore the pancreas: Early drainage of pancreatic tears is simple and efficient Late surgery is often unsuccessful. 1 1 The anatomy: The central duct of the pancreas empties into duodenum together with the main bile duct (short black arrow). Note the multiple side ducts inside the pancreas. Torn pancreatic ducts should be carefully ligated to avoid free leak of the pancreatic juice. Lacerations of the main duct: Resect the part of pancreas to the left of the tear. The splenic artery (white arrow) runs at the upper border and the vein behind the pancreas. As both splenic vessels give several branches to the pancreas, splenectomy should be done as a routine in resections of the pancreatic tail. The superior mesenteric artery (long arrow) runs through the body of pancreas. The main blood supply for the pancreas is from branches of the duodenal artery. The pancreatic blood circulation is thus based on a rich network of collaterals: So only major tears and obviously necrotic areas should be debrided.
562
Surgical anatomy
Pancreatic injury
Associated injuries Most patients with injury to the pancreas have associated serious injury to other abdominal organs. Often the associated injury has priority over the pancreatic injury: Injury to major vessels: Control bleeding. Consider shunting or reconstruction The colon: Close perforations and divert the fecal stream The spleen, liver, kidneys: Control the bleeding. Then you are ready to explore the pancreatic injury. The exploration Retract the transverse colon downwards and the gastro-colic ligamentum to the left.You can then inspect the duodenum and the head of pancreas. To inspect the body and tail of pancreas, split the gastro-colic ligamentum, see p. 518. To explore the posterior surface of the pancreas, use Kochers maneuver to mobilize the duodenum together with the head of pancreas, see p. 518.You may also mobilize the body of pancreas by splitting the peritoneum along the lower border, and lift the organ off the posterior abdominal wall by very careful blunt dissection.
If large parts of the pancreas is resected, the patient can develop hypergycaemia and diabetes. Monitor blood glucose and consider insulin therapy.
3 Extensive injury: wedge resection. Resect the part of pancreas to the left of the tear. Note the ligatures on the splenic artery and vein: you have to mobilize and remove the spleen in order to do the pancreatic dissection. The pancreatic incision is done in a fishtail fashion. The main pancreatic ducts are ligated and the incision closed by just capsular sutures. Fashion a strand of omentum with a few sutures to cover the pancreatic suture line, see p. 543.
Consider enteral feeding Protracted recovery and a long periode of intestinal paralysis are common after a major pancreatic injury. Cases with associated injury to the stomach and duodenum especially profit from high-energy enteral feeding and duodenal decompression from the first day after surgery.
564
565
566
Complications of injury and surgery ............................................ 573 Staged surgery in major abdominal injuries Exploraton of the upper abdomen Complications of abdominal surgery
...................................
.............................................. ...........................................
567
Surgical anatomy
Wide wound tracks and heavy bleeding The renal tissue is solid and non-elastic. It responds to penetrating injuries as do muscle tissue: Low-energy missiles cause narrow wound tracks. High-energy missiles or heavy blunt injuries may cause extensive and bleeding tears deep into the renal tissue. The main concern in emergencies is to control bleeding the exploration and wound management should be left for a second-look laparotomy. Surgery should be conservative The necrosis after high-energy missiles is not as extensive as you may see in muscle wounds. The kidney blood perfusion is copious and wounds normally heal well after major injuries. Blunt injury As the kidneys are well protected inside the renal compartment, blunt injuries are seldom extensive: Collect urine every hour for 24 hours and monitor the degree of hematuria. Only circulatory unstable cases and cases with increasing hematuria should be explored. Do not miss the injury, there may be few clinical signs: No hematuria: Hematomas may form under the renal capsule without leaking into the collecting system. In one out of five kidney injured there is no hematuria. Negative peritoneal lavage: The kidneys are packed with fatty tissue inside a compartment where the walls consist of the peritoneum and the abdominal organs in front, and the abdominal wall lateral and posterior. Major hematomas may collect inside the renal compartment with few early clinical signs except increasing circulatory shock. Often the peritoneal lavage is negative. Midline incision! The exploration of the kidneys is always done through the midline laparotomy incision.The lateral approach common in elective renal surgery is risky: You may enter a bleeding retroperitoneal hematoma without being able to control the renal vessels at the hilum of the kidney.
568
Surgical anatomy
1 Exploration of the right kidney: Major bleeding: Do not enter the kidney compartment without first taking control of the renal vessels. Mobilize the duodenum by Kochers maneuver and identify the hilum of the kidney with the renal artery and vein, see p. 518. Then explore the kidney as illustrated here. Note: If there is a large retroperitoneal hematoma at the kidney it may be impossibe to identify the renal vessels by a midline approach. In that case, enter by a separate incision in the flank, lift out the kidney and clamp the renal vessels from behind the kidney. Stable case: The exploration starts with mobilization of the right colon through the standard lateral peritoneal incision. Extend the incision along the duodenum (dotted line) to free the hilum of the right kidney. 2 2 Exploration of the left kidney: Retract all the small intestine to the right. In case of bleeding renal injury, first control the renal vessels, see p. 519.The kidney is normally explored by mobilizing the left colon flexure by the standard lateral peritoneal incision. By blunt dissection the colon is retracted medially and downwards. Note: Careless dissection may tear the peritoneal ligaments between the spleen and the left kidney and cause bleeding. The kidney is covered by a fascia and a pad of fat.The upper part is covered by the tail of pancreas take care not to tear it. 3 Major bleeding first control the renal artery and vein: The arteries leave the aorta just proximal to the veins. Note the right renal artery running behind the caval vein. The incision for direct exposure of the left renal hilum: ill. 8 on p. 516. By rubber bands or finger clamping you can control the circulation to either kidney. Temporary occlusion of the renal vessels should not last for more than ten minutes then release the occlusion for some minutes before you repeat the procedure. Black arrow: the inferior mesenteric artery.White arrow: the superior mesenteric artery.
569
4 Exploration of the ureter: Both ureters are located on the posterior abdominal wall just medial to the right/left colon. A rupture of the ureter (arrow) is exposed by mobilization of the (right or left) colon. An ureter catheter inserted from the bladder helps locate the ureter. The anatomy of the pelvic part of the ureters, see pp. 526-27.
570
Extensive injury, stable patient, experienced surgeon First control the renal artery and vein by full exposure of the kidney but be prepared for circulatory collapse at the time you split the peritoneum. Consider primary nephrectomy resections and suture of the kidney wounds are more bloody and time consuming. If time is critical, tie the renal vessels, pack the quadrant and do nephrectomy at the second-look laparotomy. The packs and also a kidney waiting for nephrectomy can be left in place for 72 hours and then removed. 5 Stable case: Debridement and primary suture. Surgical manipulation of the tear may provoke re-bleeding. If you are inexperienced, the best alternative may be the simplest: Drain only. During the debridement, major vessels and urinary ducts are tied with ligature upon small curved needle. Provided all necrotic tissue is debrided, the wound is closed with deep, interrupted hemostatic mattress sutures. If the sutures do not control the bleeding, release them and apply a tag of omentum into the wound before closure. In major injuries, decompress the kidney by nephrostomy, see p. 573. Replace the colon, close the peritoneal incision, and apply dependent drain from the renal compartment and also from inside the abdominal cavity. 6
6 Partial resection: Renal resections are bloody, and should not be done in unstable cases. Nephrectomy is technically simpler and safer. For safety, first control the renal vessels at the hilum. The resection is done by stepwise sharp incision and ligature/cauterization of the vessels and urinary ducts. Arrange a tube nephrostomy before the resection is closed.
571
Few signs missed diagnosis The early clinical signs of primary injury to the ureter are few or none. Only days after the injury the retroperitoneal leaking of urine may cause low abdominal swelling, pain and visible urinary phlegmon. At that time the kidney may be lost due to urinary obstruction. Ureter or a torn vessel? Pinch the structure and see if it contracts as the ureter will. Surgical exploration on suspicion! As the management of ureteral injury is technically simple, missing the diagnosis is a catastrophe. X-ray urography is an unreliable diagnostic tool: The X-ray performance of the ureters is often poor and non-continuous. Also a partial obstruction of the ureter the day of injury may gradually become complete when the urinary phlegmon and hematoma add to the obstruction. The only safe strategy is surgical exploration in all cases where the wound track is close to the ureter. 7 7 Moderate injury: Reconstruct the ureter. Close intestinal wounds before you expose the ureteral tear. First open the bladder, see p. 519, and pass a ureter catheter (you may use a thin plastic suction tube) up the ureter to the site of injury. Incise the peritoneum, debride the wound track and trim the ragged ends of the ureter. A transverse anastomosis may cause secondary stenosis: Make a short longitudinal split at both ends of the ureter to achieve an oblique anastomosis. Bring forward the catheter across the tear up to the kidney. Apply one anterior and one posterior stay suture, and fulfill the anastomosis with one-layer interrupted or continuous sutures (4-0 absorbable, silk or polypropylene). Do not perform the anastomosis under tension: Mobilize the ureter proximal and distal to the anastomosis. Ensure that the wound edges are everted all the way round the anastomosis. Apply a tube drain beside the anastomosis and close the peritoneum. The ureter catheter is delivered through the urethra together with a Foley bladder catheter. The bladder incision is closed. Leave the ureter catheter for two weeks, then pull it out carefully and stepwise. 8 Extensive injury:Temporary ureterostomy. The ureter should not be anastomosed under tension. If the defect is extensive, better insert a soft plastic tube (fine caliber suction or infant feeding tube) into the proximal ureter and take the tube out through a separate flank incision.The tube should have side holes and reach the renal calyx. The distal end of the ureter should be ligated. Alternatively you may tie the ureter proximal and distal to the injury and drain the urine by a temporary catheter nephrostomy (see below).
572
9 Decompression of the collecting system: Catheter nephrostomy. Wound edema, hematomas and ureter obstructions may impair the flow of urine and increase the pressure inside the collecting system. Suture lines may rupture and urine penetrate renal tears. The indications for nephrostomy are: All more than minor renal tears Tears of the ureter that cannot be reconstructed In cases where you may suspect injury to or compression of the ureter from retroperitoneal hematoma or abscess Nephrostomy as drainage in cases with renal infection and abscess formation after injury. Expose the kidney and control the renal vessels before you open the renal compartment. Cut several side holes in a small-caliber Foley catheter and insert it through a stab incision in the lateral abdominal wall. Make a small incision in the renal pelvis. Guide thin forceps carefully through the inferior urinary duct (calyx), through the renal tissue towards the renal capsule. Make a small stab incision in the capsule and railroad the Foley catheter into the renal pelvis. Thrust it well into the ureter, but see to it that there are several side holes draining the pelvis. Fix the catheter well: The patient may carry it for weeks unless it slips out. Note: Pass the catheter through the inferior calyx as that track bleeds less, and the direction lets you take out the drain below the costal arc.
573
Renal abscess Tenderness and swelling of the lateral abdominal wall, worsening of the general condition, and peaks of fever indicate abscess formation. Re-operate without delay: Identify the abscesses: There may be more than one, see p. 607. Also consider retroperitoneal abscess formation inside the pelvic cavity. Mobilize and explore the colon, including the posterior intestinal wall. Probably a perforation of the colon was missed during the primary surgery. Explore the kidney for localized swelling under the renal capsule indicating abscess formation. Or areas of soft consistency indicating renal necrosis. If nephrostomy was not done during the primary surgery, do it now. Wash out the abscesses with warm normal saline. Drain both the peritoneal cavity and the retroperitoneal space with several large-bore dependent drains. Poor renal function If X-ray facilities are available, control urography should be done 24-48 hours after the primary surgery. Normally the function of an injured kidney is temporarily reduced. The reason is edema of the tissues due to the injury itself, and due to hypoxia/circulatory shock. If the other kidney is normal, do not bother. No function of the injured kidney indicates surgical exploration. Several reasons should be considered: The nephrostomy is not functioning. A bend on the catheter may be managed by pulling the catheter slightly. If the nephrostomy still does not produce urine re-operate without delay. A missed injury to the ureter: Reconsider the wound track could the ureter be damaged? Reconsider the surgery could the ureter be torn or entrapped in a ligature? Stenosis to the ureter: A partial stenosis of the ureter after reconstruction is not uncommon. Try to pass a fine-caliber ureter catheter from the bladder through the stenosis. If that does not succeed, do nephrostomy. Renal necrosis due to hypoxia: 30-60 minutes without blood perfusion may permanently destroy the kidney. In cases with multi-organ injury and grave circulatory shock that do not respond to volume therapy, hypoxia may destroy a kidney. The more so if the kidney itself also was injured.
574
575
576
......................................................................
Complications of injury and surgery ............................................ 584 Staged surgery in major abdominal and pelvic injuries ...................... 260 Complications of abdominal surgery Pelvic anatomy and injuries
...........................................
603 613
......................................................
577
Surgical anatomy
A common combination: Injury to the small intestine, the rectum and the bladder. Mine injuries: Even tiny shrapnels may penetrate deep into the pelvic cavity. The lower limb injuries dominate the picture, and urinary tract injuries are often missed at the time of primary management. Blast victims: High-energy injuries may cause wide blow-out like tears of the bladder. Blunt pelvic injuries: Fracture fragments may tear the bladder and the posterior parts of the urethra. The main problem: retroperitoneal abscess formation Three factors contribute to the high risk of abscess formation: The bladder and urethra are retroperitoneal organs. In most cases urine and blood leak into the retroperitoneal space and not into the abdominal cavity. Inside the pelvic cavity are several retroperitoneal spaces and compartments where considerable amounts of urine and blood may collect with few early clinical signs. Hematomas and urine phlegmons become infected from associated rectal injury or from outside through the skin inlet wound. Key points in primary surgery: Drain the retroperitoneal space: Study the pelvic anatomy carefully to find the compartments where abscesses normally form. Drain these compartments with large-bore dependent drains. Decompress the urinary tract: Increased urinary pressure causes leaking of urine. Even a partial obstruction causes damage to the kidneys. Routine: suprapubic bladder catheter plus urethra catheter. 1 1 Compartments inside the pelvic cavity: The lower part of the abdominal cavity is located inside the pelvis. Thus missiles penetrating the pelvic wings may cause injury to the small intestine, colon and rectum. Peritoneal hematoma and abscess often collect in the rectovesical/rectovaginal pouch (black arrow). The pouch may be drained via the vagina in women or by drains along the rectum to the perineum, see p. 271 and p. 593. Outside the peritoneum hematomas may collect in the loose connective tissues in front of and lateral to the bladder (white arrows), and lateral and posterior to the rectum up along the spine to the posterior abdominal wall. Abscesses often sink down and collect above the muscular diaphragm that constitutes the floor of the pelvic cavity. Note: The upper parts of the bladder are covered by peritoneum.You may thus enter the bladder either through the abdominal cavity, or by blunt dissection outside the peritoneum behind the pubic bone, see pp. 580-81.
578
Surgical anatomy
2 Compartments outside the pelvic cavity: Hematomas and abscesses inside the pelvis may penetrate through several windows along with vessels and nerves into the buttocks and thigh. Through the pelvic diaphragm they may penetrate into the perineum, penis and scrotum. Local swelling of these structures may be the first indication of complications.
Types of injury
Always use a midline incision for exploration. First: Control bleeding and start volume therapy. Then: Close intestinal leaks. Then: Manage the urinary tract injury. Penetrating injuries The main problem is associated injuries, not the urinary tract injury. In cases with upper thigh, perineal, pelvic or lower abdominal missile wounds, the indications for laparotomy are: Internal bleeding circulatory shock: The common source of heavy bleeding is the pelvic venous network. This form of bleeding often can only be controlled by packing, see p. 270. Loss of the femoral pulse beat: Suspect injury to the iliac artery, see p. 621. Rectal tear: Identify the tear by manual exploration by the anus. Primary diversion sigmoidostomy reduces the risk of pelvic abscess formation, see p. 534. Hematuria: Identify and countrol the source of bleeding. If you are unable to pass the bladder catheter: Check if there is a high-riding prostate by finger exploration of the rectum. There is probably a posterior tear of the urethra, see p. 582. Exploration and suprapubic drainage are mandatory. Blunt injuries In circulatory unstable cases, urgent laparotomy is done to control bleeding, see p. 254. If the circulation is stable, unless there are signs of rectal injury, you may delay the primary surgery: Collect samples of urine every hour to monitor if the bleeding persists or decreases. Brownish coloration normally indicates less bleeding. X-ray cystography: Instil 200 ml contrast through a bladder catheter, shoot one film before voiding and one after. Explore urethral tears or obstructions. Minor tears of the bladder may close spontaneously within 48 hours. Minor leaks persisting after 48 hours may be managed by suprapubic bladder catheter and retroperitoneal dependent drains outside the bladder. Major leaks should be explored, debrided and closed.
579
Collect blood for autotransfusion even if there is some leaking of urine, but not when faeces is leaking.
3 Exploration of the bladder: The standard exploration of the bladder is done from the abdominal cavity through a longitudinal bladder incision. Note the relatively thick bladder wall, consisting of three layers: Innermost is the mucosa, rich in blood vessels even small tears may bleed considerably. Then the thick muscular layer, and outside a thin capsule. In this case a missile bladder wound is debrided between stay sutures. As the bladder blood circulation is copious, the debridement is generally moderate. Brisk bleeding during the debridement is controlled by a tight bladder suture when the incision is closed. As double wounds are common (inlet-outlet) the wound is extended to make an exploratory incision. Insert retractors, and inspect the base of the bladder. Note the triangle with the urethral outlet (black arrow) and the openings for both ureters (white arrows). Verify by direct vision that clear urine is pouring from both ureteral openings: Flush the infusion for some minutes to increase the urine production. A dry ureteral opening indicates injury to the ureter: it should be managed and a ureter catheter passed before you close the bladder,
580
see p. 572. In this case the other bladder wound is located on the anterior retroperitoneal surface of the bladder. It should be explored and drained from outside the bladder the dotted line represents the exploratory incision.
4 Extraperitoneal exploration of the bladder: Extend the midline abdominal wall incision until it reaches the pubic bone. Split the peritoneum in front of the bladder. By blunt dissection, wipe the fatty tissues in front of the bladder off the bladder wall. You have now entered one of the retroperitoneal compartments of the pelvis where hematomas and abscesses may form, see p. 578. Do not explore deep hematomas in this compartment (arrows) as deep dissection may cause heavy bleeding. Insert large-bore tube drains with side holes through separate lateral stab incisions in the abdominal wall; guide the drains outside the peritoneum into this compartment. The bladder is explored with one hand inside, one hand outside the bladder wall. In this case there is a tear of the bladder at its neck. Close the bladder wounds with continuous interlocking sutures that include all three layers of the bladder wall (absorbable 3-0 on a well-curved needle). Most bladder wounds are best closed from outside the bladder as blind deep sutures from inside the bladder may entrap the ureter or urethra. 5 5 Drainage and decompression of bladder injuries: More than minor tears should have double decompression of the bladder suprapubic drainage in addition to the urethral bladder catheter: Despite intermittent flushing through the catheters with normal saline, bleeding may clot one catheter. Use a large-bore Foley bladder catheter also for the suprapubic decompression. Insert it through a separate stab incision of the lower abdominal wall and the bladder wall (not through the exploratory incisions). A purse-string circular suture around the catheter prevents urinary leak. Also tube drains are inserted well down along both sides of the bladder and brought out through separate lateral incisions. In uncomplicated cases the urethral catheter and the dependent drains are removed after 4-5 days, but the suprapubic bladder catheter is left for two weeks.
581
Posterior Anterior
7 Anterior injury primary repair: The urethra is exposed through a perineal midline incision and sharp dissection through the spongious body of penis. Insert a urethral catheter up to the level of injury to identify the urethra during the dissection. Carefully mobilize the urethra proximal and distal to the injury, and guide the catheter into the posterior part of the urethra and into the bladder. If you succeed in passing the catheter, close the urethral wound with a few interrupted sutures (absorbable 4-0). Debride and close the skin incision. Note:Wounds of the penis, scrotum and external female organs may be closed by primary suture or grafting due to the copious blood circulation.
582
8 Marsupialization a controlled urinary fistula: If you do not succeed in passing the catheter, make a urinary fistula by suturing the skin edges to the urethral wound edges with a few interrupted sutures.The procedure is technically simple, and should be the standard procedure for management of urethral injuries for inexperienced surgeons. Also in injuries late for surgery, marsupialization is the safest alternative. Reconstructive surgery can be done after 3-6 months.
9 Posterior injury railroad catheter: If you cannot pass an urethral catheter easily, use the railroad-technique to establish a continuous urinary tract: Get access by a low abdominal midline incision and exploratory incisions into the bladder and extraperitoneal anterior to the bladder, see p. 519. A small-caliber Foley catheter is passed through the urethra into the tear.The tip of the catheter is picked up by the surgeon and brought into the operating field. Another and larger Foley catheter is inserted from inside the bladder down the urethra into the tear, picked up by the surgeon and likewise pulled into the operating field. The tip of the larger catheter is cut and the small one is inserted into the larger one; let one suture secure the catheter anastomosis. Pull the distal catheter into the bladder and inflate the balloon. Supplement with suprapubic bladder catheter and largebore retroperitoneal drains. The urethral catheter is left for one month, then carefully removed. Do not remove the suprapubic catheter: Clamp it at intervals and see if the patient can void the bladder.
583
Bed-side clotting test, see p. 271. Fresh whole blood transfusion, see p. 417.
584
585
586
587
One out of three male land mine victims has injury to the male organs. Still the diagnosis is often missed because all attention concentrates on the extensive injuries to the lower limbs. 1 1 The structure of the penis: The penis consists of two lateral blood-filled bodies, and one central spongious body carrying the urethra. Note the central vein with one main artery on each side. Inside the scrotum the testicular artery runs close to the testicular duct there is seldom a torn duct without the testicular artery also being damaged. The scrotal veins form a network around the duct and artery. As the blood circulation of the penis and scrotum is copious, most injuries should be managed with moderate debridement and primary closure of the wound. 2 2 The structure of the scrotum: The testicular pocket consists of a multi-layer capsule. Large amounts of blood or urine may collect inside this pocket. Collections of fluid inside the scrotum always resorb spontaneously.
588
589
590
Preparations for surgery in the pregnant patient Injury to the non-pregnant woman
................................................... .............................................
Complications of injury and surgery ............................................ 601 Staged surgery in major abdominal and pelvic injuries ...................... 260 Surgical exploration
............................................................... ...........................................
........................................................
591
592
1 The non-pregnant woman relationship to important pelvic structures: Note the uterine artery (UA) riding on the ureter (UR) just lateral to the uterus. In this area the ureter may be damaged during uterine surgery unless you work close to the uterus.The uterine artery is a branch of the internal iliac artery; it is a main source of pelvic hematomas and may bleed briskly.You may control the iliac vessels distal to the sigmoid mesentery. Note the close relation between the external iliac artery and vein (EAV) and the pelvic organs.The ovarian (OA) and uterine arteries carry the blood supply to the ovary, tube and uterus.The arteries anastomose inside the broad ligament between the uterus and the pelvic wall, see illustration p. 599. The two round ligaments (RL) between the uterus and the anterior abdominal wall carry no major blood vessels.
2 Pelvic infection and drainage: Infection may ascend into the retroperi-toneal pelvic space through vaginal tears. (The pelvic bone is shown cut for reasons of illustration.) Do not close a vaginal tear use it for dependent drainage by largebore soft tubes. Also in cases without vaginal injury, the vagina may be used to drain both the retroperitoneal compartments and the abdominal cavity. 3 3 Exploratory puncture of the rectovaginal pouch: By manual examination through the vagina and rectum you can identify hematoma and abscess formation in the pouch between the uterus and rectum. Collection of fluid is confirmed by puncture with a long wide-bore needle in the midline just behind the uterus (local anesthesia of the vaginal wall). Aspiration of blood indicates laparotomy.
4 The pregnant uterus: After three months of pregnancy, the uterus rises above the pelvic bone. From the 3rd-6th month the uterus contains much amniotic fluid which provides a certain protection of the fetus from blunt injuries. During the last third of pregnancy the uterus is of formidable size, and most penetrating abdominal injuries will also hit the uterus. During the end of pregnancy, the wall of uterus is thin: It may rupture after blunt injuries.
593
5 Placental separation after blast and blunt injury: The placenta carries the blood supply to the fetus. Even moderate blunt injuries can separate the placenta from the uterine wall. Normally, but not always, there is vaginal bleeding after placental separation. Also the separation may be gradual, and the clinical signs develop 48 hours after the injury. The fetus may survive a moderate separation, while a major separation is fatal to the fetus. Due to the blood loss placental separation may even be fatal to the mother unless operative delivery is done early. During the first three months of pregnancy spontaneous abortion follows placental injury and fetal death. Fetal death late in pregnancy normally provokes spontaneous labour and delivery within two days after injury.
594
Most preterm babies have low blood glucose at delivery. Give enteral or IV glucose.
595
Fetal death
In nine out of ten cases the dead fetus is delivered spontaneously within two weeks. Parts of the fetal or placental tissues retained inside the uterus may cause uterine infection and coagulation system failure. Early abortion: During the first three months of pregnancy, curettage should be done as a routine after the delivery. Late abortion: From 15 weeks of pregnancy curettage carries a high risk of uterine bleeding and perforation. Give IV Oxytocin 10 IU in repeated injections or misoprostol tablets 400 microgram every four hour until the fetus is expulsed. Delay the curettage until most of the placental tissues are delivered spontaneously. Missed abortion before the 7th month of pregnancy: The dead fetus is not delivered spontaneously, but there may be few clinical signs. The diagnosis should be done carefully. Examine the mother at intervals for six weeks. If the fetal heart rate cannot be identified and the uterus does not increase in size, there is a missed abortion: Start the delivery (see below) and do curettage unless there are signs of infection. Missed abortion with infection carries a high risk of septicemia and severe bleeding. Give broad-spectrum antibiotics and metronidazole. Delay the
delivery (terbutaline-glucose infusion stops the uterine contractions) and the curettage until the infection recedes. Fetal death after the 7th month of pregnancy: There is a high risk of severe spontaneous bleeding if the fetus is retained more than two weeks inside the uterus. Start delivery immediately when the diagnosis is confirmed. Procedures to start spontaneous delivery Mix oxytocin 10 IU in 1,000 ml glucose 50 mg/ml infusion. Start infusion rate: 5 ml/hour. Increase the infusion rate stepwise until effective. Maximum dose: 120 ml/hour. Or give misoprostol tablets, 600 microgram as one single dose. Dilate the cervical canal with the fingers to stimulate uterine contractions. 6 Uterine curettage: The uterine mucosa including all necrotic fetal remnants are removed. Curettage is done under low-dose ketamine anesthesia. The uterus is pulled downwards by clamping the superior lip of cervix while an assistant retracts the posterior vaginal wall. The cervical canal into the uterine cavity is dilated stepwise by gently inserting Hegar steel dilators from size 6 mm until 8 or 9 mm. The curette is inserted through the dilated cervical canal, and the uterine mucosa and fetal remnants are removed from every part of the uterine cavity. Even small amounts of necrotic tissues left may cause serious infection. After the curettage, the uterus will contract and bleeding will recede. Gauze tampons are left inside the vagina for 12 hours. Major uterine bleeding is managed by inj. Oxytocin 10 IU i.v and tranexamic acid (Cyclokapron) 0.5-1 g IV. Note: Curet carefully, do not penetrate the uterine wall. Minor penetrations heal spontaneously covered by antibiotics. Explore by laparotomy if you suspect abdominal perforation with bleeding or intestinal injury.
Complex injuries
Diversion enterostomy, see p. 528. Prevent infection: Associated injuries to the intestines: Unless the fetal state is critical, close all intestinal wounds and do diversion enterostomy before you enter the female organs. Extensive perineal or vaginal injuries carry high risk of secondary wound infection with sepsis. A temporary diversion sigmoidostomy (see p. 534) helps avoid fecal contamination. Injuries to the pregnant uterus: Minor tears of the uterus without fetal or placental damage are debrided and closed by two-layer suture. Major uterine damage with bleeding: Use aorta compression to identify bleeding sources. Take out the fetus / deliver the baby by Caesarean section. Ligate one or both uterine arteries to control bleeds from the uterine body. If it still bleeds: pack the uterus and the pelvic cavity and reoperate after 24-48 hours.
597
7 Control bleeding: Ligate the uterine artery! The artery divides just below the peritoneum and sends off a major branch up on the lateral side of the body of uterus (see illustration p. 593). Place the ligature blindly by a large round curved needle. There are numerous collateral arteries, so the uterine artery on both sides can safely be ligated. 8
8 Caesarean Section: Surgical delivery of the fetus. The uterus is exposed through a low midline incision. (For reasons of illustration the incision shown is more extensive than standard).You may extend an uterine tear for access to the uterine cavity. Or close the tear and use a standard transverse or longitudinal (dotted line) incision through the frontal uterine wall. In this case, a low transverse incision is done just above the bladder. The peritoneum is incised and the bladder peritoneum is swept downwards by blunt dissection.The uterine muscular wall is incised carefully the head of the fetus is just underneath the wall (arrow). Once the uterine cavity is reached, continue the incision with fingers inside the uterine cavity to protect the fetus. 9
9 The delivery: The head of fetus is delivered, and the rest of the body under manual compression at the top of the uterus. Start immediately basic life support to the fetus. Give IV Oxytocin 10 IU to the mother, and mobilize the placenta from the uterine wall under slight traction and very careful blunt dissection. Clean the uterine cavity of blood clots, count the gauze pads, and close the uterine incision by two-layer continuous muscular suture and separate suture of the peritoneum.
598
11 Major resections due to extensive injury: There are no rigid rules whether reconstruction or resection should be done assess each injury carefully. Attempts to reconstruct and close extensive injuries at the time of primary surgery carry increased risk of wound infection. Most probably tube stenosis will follow the attempt to reconstruct a torn tube. And the uterus here illustrated cannot carry a fetus after debridement and repair. But if you are in doubt, apply a conservative strategy at the time of injury: Complete the debridement, control bleeding and drain the injury during the primary surgery. Decide whether to repair or do resection at a second-look laparotomy. The standard line for resection of ovary, tube and supravaginal amputation of the uterus are shown (dotted line). Note the two main branches of the uterine artery: The proximal branch (arrow) is cut and ligated during uterus amputation; the distal branch is left to supply the uterus stump after amputation. Also note the vascular network along the lateral wall of uterus: Do not carry the dissection too close to the uterus as that will increase bleeding.
599
12
12 Supravaginal amputation of the uterus. Step one mobilization of the uterus: Keep the ureters in mind (black arrows). (1) Insert stay sutures at the top of uterus to pull the uterus into the operating field. (2) The round uterine ligament in front of the tube (see p. 593) is cut between clamps and tied. (3) The tubes and the broad ligament are cut stepwise between clamps and tied (see p. 599). (4) Split the broad ligament between clamps along the lateral uterine wall. Proceed stepwise and do not include too much tissue inside each clamp, or else the ligatures may slip. Stay away from the ureters (black arrows).
13
14
13 Step two the amputation: Control the uterine artery before the amputation is done. Careless dissection and clamping of the artery may damage the ureter (black arrow). (5) First split the peritoneum anterior and posterior to the uterus. Wipe the peritoneum downwards by blunt dissection. (6) Identify the uterine artery immediately under the peritoneum, clamp the proximal branch of the artery close to the uterine wall, tie the artery well. Then decide the level of amputation (palpate the top of the vagina). The neck of uterus is cut sharply in a conical fashion. Bleeding is moderate if the uterine artery is properly tied. The uterine stump is closed by interrupted cross sutures (absorbable 2-0). 14 Step three dependent drainage: The peritoneum is closed over the uterus stump by continuous suture. Drain both the retroperitoneal space at the top of the uterus, and the abdominal cavity by separate large-bore soft tube drains with multiple side holes. The drains are inserted through separate stab incisions close to the groin.
600
601
602
623 717
..........................................
603
Post-operative care
Good organization is crucial Post-operative care and rehabilitation is as important as the surgery. Under high casualty load the quality of the post-operative monitoring deteriorates unless it is strictly organized. And unless the surgeon in charge also monitors the monitoring system. Normally the capacity for surgery is not the limiting factor, but the capacity for post-operative treatment and rehabilitation. That is why the staff-training program is a continuous and integral part of wartime surgery. One case one responsible: The surgeon who did the primary surgery should be the one responsible day-to-day for the patient. Also among the bed department staff, one paramedic is day-to-day responsible for the case. The same goes for the family if they take part in the nursing. Identify risks: Monitoring means continuous and exact examination of the vital functions, the wounds, and the nutrition and the rehabilitation. In each case the surgeon responsible should identify the main risk in that patient, e.g.: Risk of suture rupture. Watch the drain to the left. Written documentation all the way: The results are continuously written in the Patient Chart. Without a written chart, early and minor but important signs of complications cannot be identified. The chart follows the patient everywhere. Beware the first week: Most complications arise either during the first 24 hours (re-bleeding) or in day 4-6 (ruptured sutures, peritonitis). The monitoring should be particularly intensive during the first week. Mobilize the patient and the relatives: Form a confident relationship with the patient. Often the patient and his relatives know better than the medical staff when complications are about to develop. Listen to their information. Instruct them carefully on the signs and symptoms they should watch for.
Respiration The respiratory rate: A rate of 35/minute (dog-like respiration) and a rate below 10/minute both indicate serious complications. Revise the analgesia. Rule out missed chest injury. Intensify the respiratory support.
Post-operative care
Painful and devastating hiccups may develop after high abdominal injuries, especially injuries or abscess formation close to the diaphragm. Eliminate the cause of the hiccup by re-operation, or give a mixture of morphine-chlorpromazine for symptomatic treatment.
The respiratory effort: Is the respiration free, or does he use accessory muscles? Rule out distension of the stomach and injury to the diaphragm. Circulation Heart rate and systolic blood pressure are the main indicators of post-operative bleeding. Skin temperature: A warm nose indicates well balanced circulation. Cool and clammy skin indicates pain or bleeding. Monitor the abdomen: Distention, swelling in the flanks or perineum indicate bleeding or hematoma formation. Monitor blood loss through the drains. Fluid and electrolyte balance The urinary output should be at least 1 ml/kg/hour the first post-operative day. If less, the patient is hypovolemic or there is renal failure. Check the fluid-in-fluid-out balance every 12 hours, and revise the fluid program: 3,000-4,000 ml fluid intake is the basic daily need of an adult. Add 1,0002,000 ml in all major abdominal injuries. Add for estimated blood loss. Add for estimated increased evaporation. The basic daily need of potassium is 40-60 mmol.There is increased loss of potassium in abdominal injuries, add 60-80 mmol potassium daily. Body temperature Monitor the rectal temperature. Does he have attacks of cold shivering? If so, monitor his temperature every 30 minutes to identify septicemia or abscess temperature peaks. The abscess-temperature curve: In a patient whose state is deteriorating or does not improve, this temperature curve strongly indicates abdominal abscess formation. Typically the temperature rises 4-6 days after surgery (the most common time for intestinal wound rupture). The peaks of fever represent output of bacteria and toxins to the blood circulation, the patient is in a state of septicemia. Septicemia may trigger organ failures: Start aggressive broad-spectrum antibiotic treatment without delay if you suspect septicemia: Combination therapy with ampicilline + gentamycine + metronidazole. Re-explore the abdomen without delay. Antibiotics are no substitute for surgical evacuation of the abscesses, see p. 607.
The normal 2,000 ml per day evaporation of an adult is increased up to 3,000 ml in hot climate. Fever further increases the evaporation.
Do laparotomy, identify the abscesses! But note that some patients develop abdominal abscess without the typical peaks of fever.
605
606
Post-operative care
The drains and bandages The smell: Sniff on drains and dressings. Fecal smell indicates intestinal wound rupture or infection or a missed injury. The volume of the discharge: Increasing production indicates wound rupture or fistula formation. The enterostomy Watch carefully the blood perfusion of the stomal mucosa: An enterostomy under tension tends to retract; the mucosa may become cyanotic, necrotic or separate at the skin suture. The production: Poor production may indicate a narrow stoma. Test with your finger inside the stoma.
Then find out why the abscess formed: Explore the intestinal sutures and anastomosis. If the intestinal wall is necrotic, resect it leaving viable tissue. If the intestinal wall is red and swollen around a suture, better resect that part and make another anastomosis. Attempts to repair an infected suture line will probably fail. If the intestinal suture line is not that swollen, additional serosa sutures and a tag of omentum will do. Abscess on the posterior abdominal wall: Mobilize the colon and duodenum close to the abscess site. The tear may be on the posterior intestinal wall. Explore the gall bladder, the common bile duct and the hilum of the liver: Leaking of free bile may cause local peritonitis. If you still cannot find the source of infection, explore the pancreas. Leaking of pancreatic juice may erode the intestines or cause retroperitoneal tissue necrosis. Take your time! There may be more than one abscess: Especially explore the sites where the omentum and small intestines pack together. There may be more than one leaking perforation: Explore every cm of the intestine for a missed perforation.
Paralytic ileus
Prevention is the best treatment: Get the patient out of bed the first day after surgery. Leave the naso-gastric tube for decompression until there are bowel sounds. Start peroral or enteral nutrition as soon as there are bowel sounds. The management of paralytic ileus is non-surgical: Gastric decompression. Check the position of the gastric tube Analgesia and sedation Rectal rubber tube Get the patiet out of bed: The intestinal function will improve unless there is also mechanical obstruction. If the general condition is worsening: do exploratory laparotomy before he is too weak to allow surgery.
Mechanical ileus
Do not let the sun set over an obstructive ileus! The treatment is surgical. When the diagnosis is set, there is no wait-andsee. Use a mid-line incisions and locate the site of obstruction. The most common reason for obstruction is herniation of a loop of the small intestine either through an incision of the mesentery (the surgeon forgot to close the mesenteric incision
608
Massive ascariasis, amebomas and intestinal tuberculosis may also cause strangulation or stenosis of the intestine.
after resection-anastomosis), or herniation behind the intestines delivered for enterostomy (the surgeon forgot to close the space lateral to the enterostomy). Patients with previous infectious abdominal disease may have peritoneal adhesions, that is, tissue strings that may strangulate the small intestine. Manipulate the intestines carefully and without force. If the intestine is very distended, deflate it by needle aspiration of gas and fluids. Cut the adhesions causing the obstruction and leave the abdomen: The more you manipulate, the more adhesions tend to develop.
Enterostomy complications
There are particular problems with enterostomies of the right colon, see p. 535. A poor enterostomy needs surgery. The management depends on the source of the complication. The stoma is necrotic: The stoma may retract or become necrotic if the intestine is under tension. The complication is common in colostomies of the fixed parts of colon when the colon is not sufficently mobilized from the posterior abdominal wall. Open the midline incision, release the necrotic stoma and resect the necrosis. Convert a necrotic loop-stoma to a double-barreled endstoma. Mobilize the colon well before the stoma is arranged. The stoma is retracted, but not necrotic: Mobilize the colon through wide peritoneal incisions. If the stoma is still under tension, arrange a distal ileostomy. Stenosis of the enterostomy: Extend the abdominal wall incision under local anesthesia. Separation or infection around the enterostomy:The reason may be poor nursing. Or hematoma or abscess formation in the abdominal wall close to the stoma, in which case you extend the stoma incision and evacuate the infection.
sive than imagined. Evacuate the hematoma and debride necrotic tissue carefully. Search well to the sides for abscess formation. If the intestines are distended and paralytic, consider gastrostomy with tube decompression of the duodenum. Close the incision with all-in-one interrupted sutures (non-absorbable no.1 or 2) at close intervals. Tie the sutures over rubber tubes (pieces of IV catheter) or over a roll of gauze. Note: Do not close the incision under tension: Either make lateral relief incisions, or interpose split infusion bags until the intestines are decompressed, and definitive closure can be done. Ventral hernia Permanent defects of the abdominal wall are not uncommon after abdominal injury and surgery. The reasons may be the following: Injury with loss of abdominal wall muscle and fascia. The temporary closure with skin grafts or skin-muscle flaps leaves defects in the wall where the peritoneum and abdominal contents may protrude under the skin. Unmanaged ruptures of the midline incision (due to infection or poor surgical technique) cause a gap between the two rectus muscles where the hernia protrudes. Fat patients carry an increased risk of post-operative ventral hernia. Also severe vomiting and coughing after surgery, or rough evacuations may cause ruptures of the midline incision, especially if relief sutures, see p. 523, are not applied. Necrotizing infections may necessitate excision also of the abdominal wall muscles. The management differs depending on the localization and size of the hernia, and the state of the patient: Narrow hernias with entrapment of the small intestine: Urgent surgery and repair, else obstructive ileus may develop. Broad-based hernias above the umbilicus:The hernias are seldom painful, and surgical repair is often unsuccessful. A broad compressive belt is the treatment of choice. Hernias below the umbilicus should be operated on. Reconstructive surgery often fail in fat patients, patients with chronic coughing or obstructive lung diseases, and in the presence of enterostomies or infected wounds.
610
611
612
39 Pelvic injury
Surgical anatomy Surgical strategy Hip joint injury Pelvic fractures
................................................................... ..........................................................
.....................................................................
Complications of injury and surgery ............................................ 623 Staged surgery in major pelvic injuries ......................................... 270
613
39 Pelvic injury
Surgical anatomy
Pelvic injuries are common wartime injuries Entrapment in bombed houses, vehicle accidents, fall from 3-4 meters: Blunt pelvic injuries are common. High-energy shrapnels: Bullets and fragments can take any course inside the body. Look for signs of pelvic injury, also in cases with penetrating wounds at the back, abdomen and thigh. Especially examine between the legs. Blast injuries may cause massive reroperitoneal bleeds and blow-out injuries of the pelvic organs even if the bone ring is not broken, see p. 137. Pelvic injuries are complex Bleeding: The vascular network inside the pelvis bone ring is rich. Blood loss of 2-3 liters is not uncommon after blunt trauma. There are numerous spaces and compartments inside the pelvic cavity where hematomas may form. The pelvic cavity may contain 2,000 ml of blood with few local clinical signs. Multi-organ injuries are common: The bladder, female organs, small intestine and rectum are at risk. Infected hematomas: Both internal and external hematomas are sources of abscess formation unless they are properly drained. The sources of infection may be perforations of the intestine or contamination through inlet wounds in the perineum. Associated neurological injuries may complicate the rehabilitation. First things first! First: Control the bleeding. Do not enter a retroperitoneal hematoma from the abdominal side, the bleeding may explode. Retroperitoneal bleeding normally stops spontaneously when the hematoma has reached a certain size. Extraperitoneal packing is the method of choice, see p. 270. If the blood supply to one limb is lost, the iliac artery should be explored. Control the common iliac artery/aorta proximal to the injury and the femoral vessels distal to the injury before you enter the pelvic hematoma. Note: Due to the many collaterals between the internal and external iliac arteries, the early signs of external iliac artery injury may be few. Second: Prevent secondary infection. Close intestinal wounds and divert the fecal stream. Close bladder tears and decompress the bladder (suprapubic catheter). In major wounds of the perineum, buttock and upper thighs, diversion sigmoidostomy should be considered, see p. 528. Third: Stabilize pelvic fractures. In unstable fractures through the pelvic ring, early external fixation will reduce the blood loss. Stable fractures can wait. 1 Associated injuries: In the upright position, the pelvis is filled with loops of the small intestine. The pelvic bone wings offer no protection against high-energy missiles. Bone fragments may be propelled by the missile into the pelvic cavity.
614
Surgical anatomy
2 The pelvic vascular network: The iliac artery divides into the internal (encircled) and external iliac arteries just below the pelvic wing. The ureters cross the arteries approximately at this level. The branches of the internal iliac artery to the bladder and uterus are common sources of pelvic bleeding. Do not hesitate to ligate the internal iliac artery if the external artery is undamaged there are copious communications between the right and left internal arteries. Note the deep femoral artery (black arrow) rising from behind the main artery: Tears of the deep artery may form hematomas deep in the proximal part of the thigh, but the injury is often missed initially. 3 3 The vascular network of the buttocks: The superficial muscles of the buttocks are retracted to expose the arteries. There is a communicating network between branches from the internal iliac artery (i) and the external iliac and femoral arteries (E). These collaterals are one reason why some limbs may be viable despite ligature of the external iliac artery. The arrows point out the compartments where hematomas may form: between the superficial and deep layer of the buttock muscles, and in the canal of the sciatic nerve (S). 4 The windows of the pelvis: Hematomas and abscesses inside the pelvis may penetrate through several windows along with vessels and nerves into the buttocks and thigh. Through the pelvic diaphragm they may penetrate into the perineum, penis and scrotum. Local swelling of these structures may be the first indication of internal complications. 5 5 Deep hematomas of the groin and upper thigh: Hematomas of 1-2 liters may collect superficially under the strong muscle fascia of the buttock and thigh. The superficial hematomas are seldom missed, but the deep ones are: hematomas in the deep compartments are smaller, but are still the main reason for the high rate of infected upper thigh and groin injuries. Note especially the compartments close to the hip joint: Outside the joint capsule is a fat pad (not shown in this illustration) which makes an excellent medium for infected hematomas. Also note the space between the adductor muscles (the most medial arrow), and the compartment along the femoral artery inside the adductor canal.
615
39 Pelvic injury
6 The pelvic bone ring: The ring may sustain one single fracture, and still be stable. Double fractures as this vertical shear are unstable. In high-energy fractures the bone missiles from the pelvic fractures may tear the vessels and organs deep inside the pelvic cavity. In this case the internal iliac artery is damaged. 7 7 Pelvic nerve injury: The nerve roots of the sacral bone form the pelvic nerve plexus. The nerve plexus is located close to the pelvic bone ring, and may be damaged by bone fragments. The main nerves from this plexus are the femoral nerve (F) to the extensor muscles of the thigh, and the sciatic nerve (S). From the hypogastric plexus of sympathetic nerves (HP) in front of the spine run the nerves for urine and stool control. 8 8 Routine: Make neurological examination of pelvic injuries! Do pinprick sensory testing of the perineum and lower limb in pelvic injuries, and test the contraction of the anal ring muscles. Loss of the sensory function of the sacral nerve roots indicates neurological damage to the bladder. Management of neurological damage to the bladder, see p. 472.
Heavy bleeding? Manual compression of the abdominal aorta is a simple measure to reduce internal and external bleeds. Keep a constant pressure on the aorta all time until the patient is on the operating table. High risk of anaerobic infections! Give one IV dose of antibiotics (penicillin or dicloxacilline) plus metronidazole before surgery on all high-energy injuries. On the operating table Wash a wide operating field from the mid-thigh to the sternum. Cases with perineal injury, bladder and rectal injury are managed in the gynecological position. The abdominal exploration and repair should be done before you access the pelvic structures.
Anesthesia
Ketamine is the anesthetic of choice unless there are major abdominal injuries. Spinal anesthesia theoretically works well in pelvic injuries and low midline laparotomies. The level should reach Th6-8 (between the umbilicus and sternum) to prevent pain during manipulation of the peritoneum. The problem with spinal anesthesia is the hypovolemia often present in major pelvic injuries:The blood loss may be underestimated, and spinal anesthesia may cause circulatory collapse if the hypovolemia is not compensated for. With associated abdominal and spinal injuries it is rarely feasible in a collapsed war injured patient. Penetrating injuries of the upper thigh and buttocks: The injury is normally more extensive than expected, proper exploration cannot be done under local anesthesia.
Surgical strategy
Systematic approach! Major pelvic injuries are complex. Good knowledge of anatomy and a systematic staged approach is required: Aim no. 1: Control the bleeding. Aim no. 2: Prevent wound infection. There is high risk of cross infection from intestinal injuries with abscess formation in deep penetrating wound tracks.
39 Pelvic injury
ator or figure-of-eight compression sling, see p. 271 and p. 623. Then flush electrolyte infusions. If you cannot stabilize the circulation, the case is one for exploratory surgery. Exploration of the iliac and femoral vessels, see p. 621. Check the lower limb circulation: If one leg is cool, suspect injury to the common iliac artery or the external iliac artery. Make a low midline laparotomy, tilt the head end downwards and retract the small intestines, see p. 622. Compress the distal aorta against the spine or clamp the iliac artery. Venous and backward artery bleeding is reduced letting assistants apply manual pressure to the groin vessels. If the bleeding is heavy and you cannot identify and control the bleeding sources, pack the entire pelvic cavity with large gauze pads. Close the abdomen and concentrate on warming and volume therapy. If both legs are cold there is probably not an isolated injury to one of the main vessels, but a large retroperitoneal hematoma. Control the bleeding by extraperitoneal packing on both sides, see p. 270.
618
Surgical strategy
9 Penetrating injuries of the buttock: The muscle volume is massive and necrotic tissue left over deep in the wound track often causes infections, also anaerobic infection (gas gangrene). Thus all deep wounds of the buttocks even after low-energy missiles should be fully explored. Extend the inlet wound in a wide longitudinal exploratory incision through the muscle fascia. Explore and drain the compartments between the superficial and deep muscles well.This do not close the fascia incision, but leave it wide open with gauze drainage to prevent anaerobic infection. Do not manipulate depressed fracture fragments as that may cause severe bleeding from the venous network lining the inside of the pelvic bone ring. Control fracture bleeding: Apply a long ribbon gauze tampon through the fracture to control bleeding. Let the tampon out through the fascia incision. Leave the tampon for two days, then withdraw it stepwise as you watch the patient for signs of re-bleeding. 10 10 Exploration of the sciatic nerve: Primary nerve repair is not done in wartime injuries, but debridement of the nerve and surrounding tissues must be done to prevent infection. The standard incision for sciatic exploration is just behind the trochanter of femur. Split the fascia along the fibers and split the superficial layer of the buttock muscles immediately behind the trochanter, retract the muscle and identify the nerve by careful blunt dissection. Note: A branch of the internal iliac artery runs together with the sciatic nerve hematoma in the sciatic nerve canal indicates nerve injury. Split the epineurium to decompress the nerve bundles.
Extensive wounds and burns of the buttocks, perineum and upper thigh get infected unless you arrange diversion sigmoidostomy.
The degree of cavitation depends on the length of the wound track, see p. 144.
39 Pelvic injury
11
11 Exploration of the hip joint antero-lateral approach: This is the easiest access to the joint. The incision is done through the skin from below the pelvic spine and in front of the trochanter. Sweep away the fat, incise the muscle fascia, and split the muscles by blunt longitudinal dissection. You now enter the compartment surrounding the anterior part of the joint where deep infections may form. Take particular care to resect necrotic fat tissue, and drain this compartment well.You may inspect the joint through a cross-wise incision through the fibrous capsule (dotted line).
12
12 Exploration of the hip joint posterior approach: Missile injuries entering the joint from behind are best explored by a posterior approach. The skin and fascia are split, and stay sutures tied through the deep muscles close to their attachment on the trochanter. Split the muscles close to the bone, retract them and expose the joint capsule (for reasons of illustration the fat pad outside the capsule is not drawn). Enter the joint through a cross-wise incision through the capsule (dotted line). 13 13 Trueta plaster for open hip joint injuries: The Trueta method, see p. 345, provides both drainage and fracture fixation. The half pant spica here illustrated stabilizes fractures of the proximal femur, the hip joint and pelvic fractures. Applied early, it prevents the flexion contracture that often develops after hip joint injuries, and makes early mobilization and evacuation of the patient possible. The procedure: Extend the inlet wound, explore and debride the joint / the fracture. Leave the fascia incision open as fasciotomy; fill the wound/incision with fluffy dry gauze from the deepest compartment up to the skin surface. Pad the bony prominences of femur and pelvis. With the hip joint at about 15 degrees flexion, three
620
14
slabs one anterior, one posterior and one circular are applied. Then the circular plaster is applied and the spica moulded well. 14 Primary Girdlestone operation for compound fractures of the femoral head and neck: The vascular supply to the head and neck of femur is poor. Some weeks after femoral neck fractures, the femoral head may become soft and waxy. X-ray films may show the destruction of the head of femur 1-3 months after injury. Missile fractures of the hip joint with major derangement of the head and neck of femur are therefore best managed with primary resection the Girdlestone operation: Do the surgery with leg traction for better exposure of the joint. In this case the fracture is exposed through an antero-lateral incision. Remove bone fragments and resect the neck of femur (Gigli saw or chisel). Cover the resected end of femur with a flap of capsule or muscle. Drain well. Either tibial traction is applied for 4-6 weeks, or the Trueta method is applied and the patient is mobilized the next day. With early and active physical training, the Girdlestone hip joint will become surprisingly stable and painless. Hip joint disarticulation or short femur stump? High-energy amputations at the thigh are common in modern warfare. From a functional point of view a femur stump even a short one is preferable to hip joint disarticulation. But a femur stump shorter than 10 cm cannot control a prosthesis, and is of little value. Hip joint disarticulation may be the treatment of choice in cases with traumatic high thigh amputations, and in anaerobic infections of the upper thigh and groin region. However, disarticulations at the hip joint are bloody, technically difficult, takes long time and may be devastating in severely injured patients. Hence we recommend surgical amputation of the femur as primary management even if the stump is very short. Reconstructive surgery can be done later.
15 Exploration of the lower part of the iliac artery: The skin incision is S-shaped. Identify and divide the superficial veins. Then extend the fascia incision in the distal direction and proximally through the inguinal ligament and the
621
39 Pelvic injury
abdominal muscles (dotted line). Divide the minor vessels in front of the femoral artery. Approximately 5 cm below the inguinal ligament, the deep femoral artery rises from the posterior side of the femoral artery. Identify and tie the circumflex vein running between the superficial and deep femoral artery (big black arrow). Also identify the circumflex arteries (CA) they may bleed considerably. Temporary vascular shunt may salvage the limb, see p. 248. 16 The risk of secondary gangrene after ligature of the iliac arteries depends on the level of ligature, the age of the patient and the duration of the circulatory shock. For details, see p. 520. 16 Exploration of the upper part of the iliac artery: Abdominal midline incision. Mobilize the (left or right) colon p. 516). Identify the ureter (black arrow) before you split the peritoneum: it crosses the iliac vessels approximately where the artery divides. If the bleding is severe or there is a large retroperitoneal hematoma, compress or clamp the aorta / the common iliac artery proximal to the injury before you enter.
Pelvic fractures
Control bleeding and intestinal leaks before you enter the fracture. Pubic bone fracture urethral tear: If there is blood in the opening of urethra, you cannot pass a urethra catheter. Explore the urethral injury, see p. 582, before you manipulate the fracture. Pubic bone fracture bladder injury: Hematuria and urine phlegmon indicate a bladder tear. Explore the injury through a low midline incision. Split the peritoneum in front of the bladder, see p. 581, and identify the fracture. Reduce the fracture under direct vision. Note: Pelvic fractures may temporarily block the bladder function even if the bladder itself is not damaged. Leave an indwelling bladder catheter for 3-5 days in all major pelvic fractures. Injury to the rectum: Rectal exploration is routine. Blood indicates intestinal injury. Sciatic nerve injury must be explored and the fracture reduced under direct vision if there is a significant loss of nerve function on admission. Evacuation of unstable and bleeding pelvic fractures: Double IV lines Insert bladder catheter Reduce the fracture roughly by manual traction on both legs.The wrap the pelvic ring tightly in a figure-of-eight sling, see p. 271.
622
Pelvic fractures
17
18
18 Fractures with hip joint displacement combined traction: Unequal length of the legs, and pain on hip joint rotation indicate penetration of the acetabulum or displacement of the acetabular fragment. Even minor derangements in the acetabulum should be reduced by traction: Apply tibial traction. Then make a small incision over the trochanter; make a hole in the bone with an awl, and insert an eye screw at least 3 cm into the trochanter. Combined tibial (10 kg)-trochanter (5 kg) traction is used for 3-4 weeks. Then a high hip plaster spica including his thigh and lower chest is applied, see illustraion 13 p. 620, and he is mobilized.
39 Pelvic injury
lization and rectal rubber tube stimulate the bowel function. If the bladder and bowel function does not improve within 4-5 days after injury/surgery, suspect pelvic nerve damage or a missed organ injury: Consider exploratory laparotomy. Continuous bleeding, re-bleeding or hematoma formation Infection may cause re-bleeding; the risk period is 5-10 days after the injury. Moderate re-bleeding: Explore the wound tracks to identify, debride and drain the necrotic tissues left over from the primary surgery. The re-bleeding may be massive: Emergency laparotomy with compression of the distal aorta must be done. The mortality rate is high. Infection and abscess formation The clinical signs arise 5-10 days after the injury: Worsening of the general condition Abscess temperature, see p. 605 Local swelling of the groin, above the pubic bone or in the perineum and scrotum Manual examination of the vagina and rectum may identify local swelling Consider diagnostic puncture of the rectovaginal pouch: Aspiration of pus through a large-caliber needle is diagnostic, see p. 593 Test the femoral pulse beat and the neurological function of the legs: A major abscess may compress iliac vessels or nerve roots. There is only one management: Midline exploratory laparotomy. Urine phlegmon Bruising and swelling above the pubic bone, in the perineum or scrotum may be a sign of urinary tract tear with free leaking of urine. Repair the tear and decompress the bladder. Buttock abscess and gas gangrene may develop in deep wound tracks. The reason is poor primary debridement and drainage.After missile injuries buttock abscesses may be formidable, and the patient may deteriorate rapidly. 19 19 Exploration of the deep structures of the buttock: Wide dissection is necessary. Release the buttock muscles from the pelvic wing through a V-shaped incision. By blunt and chisel dissection the muscles are detached from the pelvic bone, retracted and the deep segments of the wound track exposed. Now do the debridement and drainage that should be done during the primary surgery. Do not compromise on the debridement the risk of gas gangrene and other aggressive anaerobic infections is high: Do extensive excisions of all non-viable muscle and leave the wound wide open. Hip joint arthritis and abscess formation Pain originating in the hip joint is normally referred to the groin area. Increasing groin pain, flexion contracture of the hip, pain on passive rotation of the femur and fever all indicate hip joint infection:There may be an abscess in the compartments close to the joint or infection inside the joint. In any case exploration and evacuation of the infection should be done immediately.
20
20 Adduction contracture of the hip joint may be the result of poor training after surgery, and protracted and painful rehabilitation. Palpate the tendons while you force the leg into passive abduction: If you feel the tendons as tight strings under the skin, first do adductor tenotomy. The adductor tendons are cut close to the pubic bone under extension and abduction of the hip joint. Cut the muscle close to the pubic bone to avoid damage to branches of the obturator artery.
21
21 Extensor tenotomy: If adductor tenotomy did not release the joint, extensor tenotomy is also done: Split the muscle fascia and cut the extensor close to the attachment on the pelvic bone. After tenotomy, the tendons will re-attach without suture and the patient will gain full strength after some months of training. Note: Without effective analgesia and intensive passive and active exercises after the tenotomy, the contracture will soon re-develop.
625
626
628
Shoulder and arm injury .......................................................... 631 Surgical anatomy ................................................................ 631 Exploration of shoulder injuries .............................................. 632 Shoulder fractures .............................................................. 634 Extensive shoulder injury ..................................................... 635 Exploration of arm injury ..................................................... 635 Open arm fractures ............................................................. 636 Above-elbow amputations ..................................................... 637 Elbow injury ........................................................................ 638 Surgical anatomy ................................................................ 638 Exploration of elbow injury ................................................... 639 Elbow fractures .................................................................. 640 Extensive elbow injury ......................................................... 642 Forearm and hand injury .......................................................... 642 Surgical anatomy ................................................................ 642 Exploration of the forearm and hand injury ............................... 646 Fractures of the forearm and hand ........................................... 648 Extensive hand injury .......................................................... 649 Amputations at the forearm and hand ...................................... 651 Complications of injury and surgery ............................................ 653 Staged surgery in major limb injuries
..........................................
272
627
628
3 The ulnar nerve: From below the elbow the nerve runs together with the ulnar artery. The nerve is particularly at risk close to the elbow and distally in the forearm where the soft tissue protection is poor. Loss of motor function: He cannot spread his fingers. The sensory function: Both the dorsal and volar skin of the 5th and the ulnar part of the 4th finger are always innervated by the ulnar nerve. 4 4 The median nerve: From the axilla to below the elbow, the median nerve runs close to the brachial artery. Loss of motor function: Loss of finger flexion force (2nd and 3rd fingers).The opponens function of the thumb is always controlled by the median nerve. Tell him to press his thumb against the tip of the 5th finger, and check the force.
The limb wound is more extensive than you imagine The shock wave from a high-energy missile travels proximally and distally along the muscle bundles of the upper limb. The shock wave may even cross the joints. Wide fasciotomies and exploratory incisions are necessary: Wash the whole limb from the neck to the fingers, but do not drape the hand: During surgery you have to monitor the skin color and temperature of the fingers to control the blood perfusion of the limb. If you suspect vascular injury: Prepare for vein grafting. Wash the donor area on an uninjured leg. Staged surgery for major injuries Cases with lengthy circulatory shock and limb hypoperfusion carry high risk of wound infection and a poor ultimate result. Reduce the primary limb surgery to a minimum: Do fasciotomy, reduce and splint fractures, drain the wounds, place vascular shunts but delay the debridement for 24 hours when the patient is stable. Multiple major injuries: Consider primary amputation, see p. 380.
Before surgery
Surgical equipment General debridement set Bone nibbler, chisel, hammer, Gigli wire saw Drill, Steinmann pins, eye screws, soft steel wire
629
Plaster of Paris (rolls of 10 cm and 15 cm) If available: external fixation set Instruments for vascular surgery, see p. 83. Soap washing on admission! Most limb cases have low priority for surgery. In a mass casualty situation there may be a delay of hours between the admission and surgery. But the disinfection should not be delayed:Wash the wound field on admission. Also instill dilute soap solution into deep wounds. The position on the operating table Shoulder surgery: The patient is in half-side or side position with a sandbag under the scapula. Work under arm traction manual or plaster traction: It helps realign the anatomy in major injuries. Arm/forearm/hand surgery: The patient is in the supine position with the arm in abduction on a separate arm table. Work under traction in major cases. Hand surgery: As the fingers flex spontaneously, the access to the palm is difficult without an assistant. Make a lead hand: Cut a hand with five broad fingers from a thin plate of lead (20 cm x 20 cm). By bending the lead fingers around the fingers of the patient, you get a steady assistant. Prepare bloodless field A back-up tourniquet may be useful during the surgery. Apply a BP-cuff on the arm before you wash the operating field. Inflate it to 220 mm Hg if bleeding occurs during the surgery. Tourniquet for finger surgery: Tie a thin plastic catheter tightly around the base of the finger, fix it with a clamp. Anesthesia Major and urgent cases are done under ketamine anesthesia. Add diazepam for muscle relaxation during fracture management. Non-urgent fracture cases: Consider brachial plexus or axillary nerve block for better muscle relaxation.You may add ketamine if the surgery is done above the anesthetic level. Isolated finger injuries are managed under finger nerve block anesthesia. IV regional anesthesia is not recommended in primary surgery and debridements: The bloodless field makes it impossible to assess which tissue is necrotic and which is viable. In secondary procedures, reconstructive hand surgery, wound closure etc., the method is useful.
630
631
8 Identify vascular injury by neurological examination Together with the main arteries run the nerves. Loss of nerve function after missile injury thus indicates the track of that missile inside the tissues. If the nerve is damaged, there is also risk of vascular injury: Axillary injury: The three main nerves run close to the main vessels. If there is loss of nerve function, explore of the axillary artery. Medial arm injury: The median and ulnar nerves are close to the brachial artery. Loss of nerve function from these nerves indicates brachial artery damage. Dorsal/lateral arm injuries:The deep arm artery (PA) runs together with the radial nerve close to the bone. Loss of radial nerve function indicates that the missile track is close to the deep artery. Danger zones There are two levels where nerve injuries are common: Above the axilla the nerve bundle passes between the first rib and the clavicle lying just 2 cm under the skin. It may be hit by the missile, bone fragments or compressed by displaced clavicular fragments. Also in humerus shaft fractures the radial nerve (RN) may be torn by the missile, bone fragments, or compressed by hematoma and fracture callus.
9 Artery ligature or reconstruction? The risk of distal necrosis after artery injury and ligature depends upon the level of artery obstruction: The first part of the artery (subclavian): Several collateral arteries carry blood to the arm. Ligature of the subclavian artery in young patients normally does not lead to gangrene. The second part of the artery(axillary): The collaterals have a small caliber and cannot carry the arms blood supply. One out of four patients develops arm gangrene after ligature of this part of the artery. Notice the two arteries together with the axillary nerve running around the neck of humerus; they contribute to the hematomas forming around the neck of humerus. The third part of the artery(brachial): Artery injury proximal to the deep artery should be reconstructed if possible.The risk of distal gangrene after ligature is high. The fourth part of the artery: Ligature of the brachial artery distal to the deep artery causes arm gangrene in one out of four patients.
to their attachment on the humerus and retract them. Split the fascia under the muscles along the dotted line. Beware: The subclavian vein and top of the lung are just underneath the fascia. Push the vein downwards and the nerve plexus upwards by blunt dissection. Run rubber bands around the artery and control it. Injuries close to the midline: Cut and retract the clavicle to expose the central part of the artery. Before splitting the bone, drill two holes 2-3 cm apart, and cut the bone with Gigli saw between the drill-holes. Exploration towards the axilla: Extend the skin incison along the border of the deltoid. Closure: Repair the clavicle with steel wire through the drill-holes. Drain the compartments deep to the breast muscle, and repair the muscle by tying the stay sutures.
11
11 Exploration of the shoulder joint anterior approach: The skin incision follows the border of the deltoid muscle.You may extend the incision across the acromion bone to the posterior side of the joint, see below, and distally through the breast muscle to the medial or lateral side of the arm. (1):The fascia is split from the acromion downwards.The deltoid muscle is retracted to the lateral side. (2): Stay sutures are inserted, and the flexor muscles are cut close to the coracoid bone and retracted downwards. (3): The joint capsule is exposed by splitting the muscles in front of the joint. Control the small artery crossing the capsule, incise the capsule (dotted line) and enter the joint. Closure: Drain the compartments close to the joint, see p. 631. Close the joint capsule and the deep muscle layer (3) with close, interrupted sutures. Re-attach the flexors (2) to the coracoid process with stay sutures. 12 12 The shoulder joint posterior aproach: Start the skin incision 4-5 cm medial to the end of acromion, and turn it along the posterior border of the deltoid muscle towards the medial or lateral side of the arm. (1): The posterior part of the deltoid muscle is cut between stay sutures 2 cm from its acromion attachment. (2):The posterior rotator muscles of the shoulder are cut between stay sutures 2 cm from their humerus attachment (dotted line), and you look onto the joint capsule lateral to the elbow extensors (3).
633
Shoulder fractures
Fractures of the clavicle Even compound clavicular fractures heal well. Explore the subclavian vessels in compound fractures, se previous page. Remove or trim protruding bone fragments to prevent vascular damage. Fractures of the lateral 2-3 cm of the clavicle are best managed with resection of the lateral part of the clavicle provided the ligament between the clavicle and the coracoid process of scapula is not injured. We do not recommend the traditional figure-of-8 traction bandage for fractures of the clavicular shaft; if the patient is mobile, he should wear a broad arm sling with a cushion in the axilla, in bed the clavicular fracture is reduced by putting a pillow between the scapular bones. Effective analgesia is important to prevent lung complications. Fractures of the scapula heal well. The main point is early active exercises under analgesia to avoid adhesions that may freeze the scapula to the chest wall. Trizeps soft tissue flap, see p. 636. Surgical techniques in joint injuries, see p. 360. Soft tissue flaps, see p. 329. 13 Fractures to the shoulder joint Reconstruct fractures of the glenoid to form a smooth joint surface. Fractures of the cartilage are trimmed with a knife. The patient with glenoid fracture should start pendulum exercises within one week after the injury under effective analgesia. The exercises help reduce displaced fracture fragments. Fractures of the head of humerus heal well provided the fracture is covered by viable muscle. Try to save the head of humerus even in comminuted fractures. Replacement, resection arthroplasty or arthrodesis can be done later.
13 Fractures to the neck of humerus: The pull of the deltoid muscle will rotate the head fragment. Also the breast muscle will pull the shaft fragment in the medial direction. Manipulate the fracture with care, and watch the distal blood circulation: The axillary artery may be damaged. The neck fractures heal well provided they are well debrided and drained. Simple fractures are immobilized for 2-3 weeks in a collar and cuff bandage. Let the weight of the arm reduce the fracture by traction. If the fracture is displaced or comminuted, consider elbow traction with an olecranon eye screw for 2-3 weeks.
634
14
Note the strut between the forearm and the trunk cast.
16
cia septum proximal on the arm, and can be identified by blunt exploration into the posterior compartment. The ulnar nerve (UN) is located in both fascia compartments. Note: The level of the deep artery is not constant it may leave the main artery close to the shoulder joint, or at the mid-arm.
17
18 17 Triceps fascia-skin flap: The support artery for the triceps flaps runs exactly in the posterior midline. The flap has a wide range because the blood suply is solid; the flap width-length ratio can be up to 1:4. 18 The biceps muscle flap: The tendon and aponeurosis of the biceps are cut at the elbow (dotted lines).The biceps belly (1) is released by blunt dissection from the brachial muscle (2). To mobilize a proximally hinged posterior flap, the tendon and muscle belly of the triceps are split in the dotted line, released from the fascia septum (black arrow) by sharp dissection, and one half of the muscle transposed either laterally or medially. 19 Prevent angulation of shaft fractures: The shaft fractures tend to be pulled into angulation by the strong extensor muscle, especially so if much of the flexor muscles are excised during the debridement. Use the extensor muscle as a splint: Immobilize the shaft fractures in an elbow flexion slightly more than 90 degrees
636
19
(collar-and-cuff or plaster cast). In this position the extensor muscle is stretched and acts as a dynamic splint for the fracture. 20 20 External fixation: Fractures of the shaft of humerus are well suited for plaster-and-pin fixation.Watch the radial nerve! Plaster-and-pin fixation in detail, see p. 347.
21
21 The arm plaster cast: The inexperienced may apply the cast in two steps first the arm part, then add the forearm part. A long slab from well above the acromion is fixed with circular turns. Note the traction on the fracture: Maintain constant traction until the cast is finished. Mold the plaster well (medial-lateral compression) to fit the arm contour.The cast should reach the acromion and fit the deltoid muscle snugly. The elbow should be in slight flexion and neutral position (no forearm rotation, the thumb pointing upwards) when the forearm part of the cast is applied. Mold the forearm cast well, see p. 648, and support the cast in a collar-and-cuff sling.
Above-elbow amputations
Principles of amputation surgery, see p. 380. Save stump length! Design anterior-posterior flaps, or medial-lateral flaps depending on the wounds. Normally the medial and anterior flaps of the arm have the best blood supply: They can be rather long without turning necrotic. Extend the medial skin incision to explore the brachial artery proximal to the level of amputation. Then carry out fasciotomy of the two fascia compartments. Both flexor and extensor muscles retract when you cut them: Save all length possible of the muscle bellies. Ignore for skin defects:You may cover them with split-skin grafts later, as the upper arm stump does not carry weight. At the time of closure: Split the muscle bellies on the flexor and extensor side to form four muscle bundles. Do myoplasty for better muscle control of the stump.
637
Elbow injury
Surgical anatomy
As the elbow area is well vascularized, soft tissue injuries and fractures heal well. The two main problems are: Hematoma and abscess formation: There is considerable effusion and bleeding from injuries at the elbow. Fluid and blood collect in several spaces and compartments close to the joint. Unless the deep compartments are explored and drained, the joint is at risk: Study the anatomy carefully. Nerve and vascular damage: The main vessels and nerves have poor soft tissue protection at the elbow area. Both the missile, the shock wave and bone fragments may cause combined vessel-nerve injury. Repairs often require mobilization of soft tissue flaps, see pp. 634-37. 22 22 The vascular network at the elbow: Because of the rich network of collateral arteries, the debridement of the soft tissues may be limited. Ligature of the brachial artery at the elbow level in young patients will result in distal gangrene in one out of four patients provided the collateral arteries are not damaged. If you consider ligating the brachial artery, note that the anterior radial collateral artery runs together with the radial nerve (RN). Loss of radial nerve function of the forearm/hand indicates damage to this collateral artery.The main ulnar collateral artery runs together with the ulnar nerve (UN). 23
23 The volar compartments to be drained at the elbow the superficial compartment: There are two separate fascia compartments on the volar side of the forearm.The superficial compartment contains the superficial set of hand flexor muscles, the radial artery, the radial nerve (RN), the ulnar artery and the median nerve (MN). The roof of the compartment consists of the strong superficial forearm fascia, the somewhat thinner deep fascia makes up the floor. To prevent compartment syndrome, a complete fasciotomy of the superficial forearm fascia (along the dotted line down to the wrist) should always be done in high-energy
638
Elbow injury
elbow injuries. The deep forearm fascia separates the superficial (2) and the deep (3) groups of forearm muscles. In extensive elbow injuries also the deep fascia should be split and the deep compartment drained to prevent a deep compartment syndrome.To explore the deep compartment: Cut the biceps aponeurosis (1) along the dotted line. Insert stay sutures and cut the flexor muscles (2) close to their attachment on the medial epicondyle. By downwards retraction of the flexor muscles and lateral retraction of the extensors, you enter the space where the main arteries and nerves are located. Identify and retract them carefully and expose the deep fascia by blunt dissection. 24 24 The deep volar compartment: Hematomas may also form under the deepest muscle groups (3) along the interosseous membrane between the ulnar (U) and radial bones. To reach this space, retract the radial artery to the radial side, the ulnar artery to the ulnar side. Insert a tube drain with side holes through a separate stab incision. 25 25 The ulnar nerve: Of the three main nerves at the elbow level, the ulnar nerve (arrows) is most vulnerable to injury. Shock waves may stretch the nerve between the epicondyle and its crossing of the upper arm septum. Displaced bone fragments in low humerus fractures may tear the nerve. Poor padding of the elbow during protracted surgery may cause pressure damage to the nerve on the operating table. Below the elbow, the nerve is located close to the ulnar artery, well protected under the flexor muscles (2).
26 26 The elbow joint consists of two joints Flexion-extension:The joint between the ulna and humerus is a hinge joint. Fractures of the medial humerus condyle may cause instability and block flexionextension of the elbow. Take special care to preserve the medial condyle and reduce fractures in the medial part of the joint accurately. Rotation: The joint between radius and humerus is for rotation of the forearm. Forearm rotation is essential to good hand function, and every effort should be taken to preserve maximum rotation in this joint. That is mainly a matter of early post-operative training you may resect the lateral condyle of humerus as well as the head of the radius (black arrows), and rotation is still possible.
27
27 Exploration: The lazy-S anterior incision. The missile wound track is extended into an S-shaped incision. Tie the superficial veins, split the aponeurosis of the biceps muscle and the superficial forearm fascia, see p. 645.You can now identify and control the brachial artery. Identify the median nerve, then retract the extensor muscles (Ex) and the biceps (Bi) to the lateral side, and the flexors (Fl) to the medial side. Split the brachial muscle (Br) and the joint capsule by a transverse incision (dotted line). 28 28 The lateral exploratory incision provides the easiest access to the elbow joint. The skin incision is 2 cm in front of the lateral epicondyle of the humerus. Split the extensor muscles along the fibers, insert stay sutures and cut the muscles sharply close to the attachment. Note: Do not damage the deep branch of the radial nerve (DRN) with retractors; it is located deep inside the extensor muscles. Enter the joint through a transverse incision of the capsule (dotted line) without cutting the ring ligament around the neck of the radial bone (black arrow).
29
29 The posterior exploratory incision is used to expose fractures of the lower part of the humerus, and as counter-incision to explore and drain inlet-outlet missile injuries. The skin incision follows the posterior midline of the upper arm to the medial or the lateral side of the elbow bone (olecranon). Beware of the ulnar nerve (UN, white arrow). To expose the distal part of humerus: Split the triceps muscle in the midline and release it from the bone by blunt and sharp dissection. To expose or enter the posterior part of the elbow joint: Cut the triceps muscle along the dotted line and deflect the distal part of the muscle to expose the joint.
Elbow fractures
Staged surgery for open high-energy fractures Step one soft tissue care: There is no time for elaborate fracture surgery during the first operation. Instead reduce the fracture roughly. Fracture fragments that may hurt main vessels and nerves are reduced or resected under direct vision. Concentrate on debridement, fasciotomy and drainage. Stabilize by plaster slab. Step two fracture care: After 4-5 days, re-explore the soft tissues, redebride if necessary. Reduce, fix, and cover the fracture. 30 Fracture displacement due to muscular pull: The muscles working on the elbow joint may displace fractures of the epicondyles and olecranon.The degree of fragment rotation in epicondylar fractures is difficult to evaluate on the X-ray
640
Elbow injury
30
films. Interposition of muscle in the fracture makes closed reduction impossible: Explore the fracture; retract the interposed muscle to reduce the fracture. Resist the temptation to do primary Kirschner wire fixation if the fracture is open: The inevitable result will be osteomyelitis and a lost joint. In this case, flex the elbow to reduce the pull of the extensor muscles. Consider releasing the muscles partly from the fragment. Immobilize the fracture at about 100 degrees in flexion in the joint, see p. 637. If the fragment again becomes displaced, leave it till the soft tissues have healed. Then reconstruct the joint and pin the fragment with Kirschner wire or resect the fragment. 31 Primary resection of fragments in lateral elbow fractures: Try to preserve the medial, hinge part of the elbow joint. The lateral part of the elbow joint with the forearm rotation is less vulnerable to bone resections. Comminuted fractures of the head and neck of the radial bone are best managed by primary resection. Mobilize viable soft tissue to close the joint. Drain well. Start active rotation exercises within one week after surgery. 32
31
32 Olecranon fractures affect the hinge function of the elbow joint. Reduction is complicated by the strong triceps muscle pulling upon the fragments. A minor fragment of olecranon (less than one third of the joint surface) can be resected, and the flexion-extension stability still maintained. Some holes are drilled through the ulnar bone rim and the triceps tendon re-inserted with strong silk sutures. 33
33 Olecranon fractures major fragments: Resection of fragments including more than half of the joint blocks the flexion-extension and causes joint instability. The standard method of pinning across the fracture line cannot be used in open fractures. We recommend external fixation on double Kirschner wires: Expose the fracture and the triceps tendon through a posterior midline incision. Cut the central part of the triceps tendon close to the bone (arrows) to reduce the
641
pull upon the fragment. Drill one heavy Kirschner wire through the skin and the fragment, and another through the ulna well outside the wound. Reduce the fracture with the elbow at not more than 45 degrees in flexion, and fix the fracture with steel wire bars around the Kirschner wires. A plaster splint, the elbow at a maximum of 45 degrees in flexion, is worn for 6-8 weeks.
The more distal the level of amputation, the better is the rotation of the forearm stump and the prosthesis.
642
Assess the nerve-muscle function From a functional point of view we separate the anatomy of the forearm and hand into three functional units defined by the three main nerves to the hand. 34 35 36
34 The functional unit of the median nerve: The radial grip. The median nerve controls the motor function of the radial flexor muscle of the wrist, the flexors of 1st, 2nd and 3rd fingers and the sensory function of those fingers. The nerve runs down the forearm in company with the muscles it controls. The thumb-index pinch is a median nerve function, as is the tripod pinch.
35 The functional unit of the ulnar nerve: The ulnar grip. The ulnar nerve controls the motor function of the ulnar flexor muscle of the wrist, the ulnar flexors of the fingers (4th and 5th fingers), the interosseous muscles and the sensory function of 4th and 5th fingers. The nerve runs down the forearm in company with the muscles it controls. Spreading the fingers and the ulnar part of the hand grip are the functions of the ulnar nerve.
36 The functional unit of the radial nerve: Hand and finger extension. The deep branch of the radial nerve controls the motor function of the posterior compartment of the forearm the two wrist extensors and the extensors to all fingers.The superficial branch controls the sensory function on the radial extensor side of the fingers correspondingly. Also the branches of the radial nerve run together with the muscles they control.
Lessons for the surgeon Take special care to save the median nerve unit. It is the thumb-index pinch that makes the mans hand differ from that of the ape. Study the cooperation and balance between the three nerve units:You want to save the median nerve unit. Save the radial nerve unit also: what is the use of the flexor muscles if the extensors are paralysed, and the joint cannot be extended? Why save injured 4th and 5th fingers if the ulnar nerve function is lost? Without innervation the fingers are useless. Assess the tendon-joint function To save the nerve-muscle units is just half the job.The nerve-muscle units are working on tendons, ligaments and joints:The rest of the job is to reconstruct these struc643
37
tures by surgery, and restore their smooth function by post-operative training.When you have tested the three nerve-muscle units, assess the mechanical functions of the wrist and hand: To what extent will it be possible to maintain/reconstruct the tendons and joints. There is no rotation in the hand itself. The rotation is based in the joint between the radius and humerus where the radius rotates around the axis of ulna, see p. 639. 37 The hand ball joints: The wrist of the hand consists of several small joints. Take particular care to save the first (radial) ray of the small hand bones and joints (black arrows): The first ray carries the important rotation of the thumb. Without it, you cannot oppose the thumb to the other fingers, and the hand grip is more or less lost. Note: The radius and ulna are connected by a strong ligamentous membrane (white arrows) that separates the forearm flexor compartment from the extensor compartment. Both compartments must be decompressed and drained separately in extensive forearm injuries. 38
PIP DIP MCP
38 Incorrect immobilization is a common cause of hand and finger contractures. The MP joints of the fingers are stabilized by side ligaments (white arrow). The ligaments will contract and cause joint stiffness if the MCP joints are immobilized in extended position. The capsule of the PIP and DIP joints and the wrist and finger flexor tendons will also contract during immobilization in flexion. Thus the correct positions for immobilization: The wrist joint extended The MCP joints flexed The PIP and DIP joints extended.
39
39 The tendon apparatus of the hand: There are two flexors and one extensor to each finger. On each finger are small muscles the lumbricals (LU) and interosseous muscles (IO) that connect the extensors and flexors. This complicated tendon apparatus is very sensitive to infection and contractures: Concentrate on good primary debridement, prevent infections, avoid prolonged immobilization, encourage early post-operative finger exercises. The flexor tendons run protected in sheaths deep in the palm. Infection inside the sheaths will spread rapidly and cause adhesions and stiff fingers. As the extensor tendons lie just beneath the skin, the main problem is soft tissue cover and scar contractures. Note the metacarpal fracture: The extensors may also be trapped inside the callus tissue unless active and early finger exercises are done.
644
40
40 Finger fractures rotation deformities: Control the alignment of the finger nails by looking at them end on. In this case a fracture of the 3rd finger has healed in malposition: When flexed, the 3rd finger will disturb the 4th finger function. Normally the flexed fingers should point to a common point at the wrist. If one of them does not, there is a finger fracture that needs reduction. Prevent infection drain all spaces and compartments The hand is well vascularized. Still infections are common in penetrating hand injuries whether they are high- or low-energy injuries. The reasons: There are several compartments and spaces in the forearm and hand where hematomas may form. Unless the knowledge of anatomy is good and those spaces are systematically explored and drained, hematomas will form from which abscesses develop. Forearm decompression by fasciotomy is generally accepted as part of the primary management. But the fasciotomies are often incomplete: The deep compartments are not decompressed, and the palm of the hand is not decompressed. The result of poor venous drainage is increased risk of local necrosis and infection.
41
42
41 Fasciotomy of the forearm the volar compartments: The superficial and the deep volar compartments are separated by the deep forearm fascia. Both compartments should be drained in high-energy injuries.Through a long volar midline skin incision the superficial forearm fascia is divided from the level of the elbow until the level of the wrist joint, and you look into the superficial flexor compartment (1). The muscle inside the superficial compartments is split by blunt dissection and retracted to each side:You can then see the deep forearm fascia. It is incised in the midline from the elbow to decompress the deep forearm compartment (2). 42 Fasciotomy of the forearm the dorsal compartment and the fascia sheaths: Through a long dorsal midline skin incision the forearm fascia is split from the elbow to the wrist joint. Now you are looking into the common extensor compartment, (1). Inside this compartment, each muscle belly is surrounded by a separate fascia sheath. Edema inside the fascia sheaths may obstruct the local blood circulation. In high-energy injuries, also split the fascia surrounding each extensor muscle belly, (2).
645
43
44
45
43 The two volar compartments of the hand: Under the thick palmar fascia are located the ulnar (UC) and the radial (RC) compartment of the hand. Through these compartments run the flexor tendons, the main nerves and vessels. Here blood and pus collect from both proximal and distal directions. The two compartments should be explored and drained as a routine in extensive hand injuries. Note that the compartments are separated by a wall a double fasciotomy is thus necessary to decompress and drain completely.
44 Fasciotomy of the hand: The volar forearm fascia continues as the strong fascia of the palm. Split the fascia through a standard angular skin incision, see illustration opposite page. Beware of the median nerve located immediately under the fascia. Work exactly in the midline at the wrist level so as not to damage the palmar branch of the ulnar nerve (UN). Open the ulnar compartment (UC) widely and explore the flexor tendon sheaths and the median nerve (MN). Also split the fascia over the flexor to the 2nd finger (dotted line) to enter the radial compartment (RC).
45 The hand and finger blood supply: There are two arches of arteries of the hand; one is located superficial, another deep to the flexor tendons. There are four arteries to each finger, the volar ones being the most important. In young persons one volar finger artery may carry enough blood to save the finger provided the venous drainage is good.
646
46
46 The volar exploratory incisions: The wound is extended to one of the standard incision for exploration. Use the volar incision to explore the main vessels and nerves. For fracture exploration, use the dorsal exploratory incision. Note that the incisions should cross the creases at the wrist and hand obliquely to avoid excessive scarring. The incisions are done on the ulnar or radial side depending on the injury. Do not hesitate to use two parallel longitudinal incisions to explore completely. Ligate the superficial veins, split the superficial fascia and retract the superficial flexor muscles (1) to expose the radial (RN) and median nerves (MN). To explore the the mid-portion of the median nerve, you have to cut the superficial flexors just distal to their epicondylar attachment, see illustration p. 638. Split the deep flexors (2) to reach the ulnar bone and the interosseous membrane. 47 47 The dorsal exploratory incisions: Incise the skin just radial to the ulna. Release the extensor muscles from the ulna with a chisel, and retract them to expose the ulna, radius and the interosseous membrane. 48 48 Exploration of the palm: The angulated palmar incision may be extended to Z-incisions of the fingers. By careful sharp dissection on the fingers, the skin with subcutaneous fat is lifted off the flexor sheaths.
49
49 Exploration of the back of the hand: Several longitudinal incision rather than one transverse incision should be used for dorsal exploration.The incision may be extended to finger Z-incision. Vascular injury In high-energy injuries we often see intima detachments in the brachial artery close to the elbow: Do arteriotomy on suspicion. Reconstructions of the radial or ulnar artery are seldom indicated: Tie one artery if the other is undamaged. If both arteries are torn, normally two or more main nerves are also damaged this might indicate primary amputation. Vascular reconstructions at the hand and fingers have no place in wartime surgery.
647
Tendon injury Explore and identify all tendon injuries at the time of primary surgery and report exactly in the Injury Chart which tendons are injured, at which level. Cut extensor tendons will not retract, cut flexor tendons will. Leave the proximal stumps of the tendons in the retracted position.
50
50 Plaster cast for stable forearm fractures: This radius fracture is relatively stable as the undamaged ulna acts as an internal splint (vice versa for single isolated ulnar fractures).The wrist joint is included in standard forearm casts.The plaster is applied under continuous manual traction until the cast has set. Mold the forearm part of the cast by volar-dorsal compression: Increased soft tissue pressure and the traction from the interosseous membrane will help stabilize the fracture. 51 51 Plaster cast with pinning for unstable forearm fractures: Fractures of both the ulna and the radius are unstable, especially if the fracture is comminuted. Pin the upper and lower main fragments with double Kirschner wires and apply a standard forearm cast for external fixation (for details, see p. 347).
52 Metacarpal traction for comminuted forearm fractures: Traction has some advantages in extensive forearm injuries: It is simple, allows effective elevation and free finger movements, and allows monitoring of the wounds and circulation. The pin is drilled through the neck of the 2nd and 3rd metacarpal bones;
648
52
compress the hand side-to-side to raise the two metacarpals (arrows). A countertraction of 1-3 kg is applied on the upper arm. When the fracture has entered the callus stage (within 3-4 weeks), a plaster cast is applied: Do not remove the pin, but include it in the plaster and apply the plaster cast under traction. Thus the pin helps maintain traction on the fracture also inside the cast.
53
53 Bone resection in comminuted fractures: Make every effort to save the hinge joint of the elbow (circle) and the radial part of the wrist joint (circle).You may resect bone fragments of compound fractures of the upper radius and lower ulna affecting the joints (shaded parts) and still maintain a reasonable function and stability of those joints.You may do the bone resection during the primary surgery, or later on. The strategy mainly depends on the primary soft tissue management: If you are unable to get soft tissue cover for the important parts of the joint, better do primary bone resection. 54 54 Plaster with traction for finger fractures: Comminuted fractures of the metacarpal bones and fingers tend to overlap or angulate.Traction should be applied at the time of primary surgery: A soft metal splint is fixed inside the cast with circular turns of plaster. The actual finger is fixed to the splint in an extended position by adhesive plaster (or a strong silk suture through the edge of the nail tied to the spint). The splint with the finger is flexed to exert traction on the finger. Note: Look at the nail bed is there any rotation deformity? See p. 645.
649
The basic principles of hand salvage Concentrate on the radial part of the hand: Save every cm possible of the thumb and index finger. Save all viable skin and soft tissue for secondary reconstruction. Mobilize fascia-skin flaps to cover vessels, nerves, joints and fractures, see pp. 334-37. Tendons and nerves are reconstructed when the soft tissues have completely healed without infection 2-6 months after the injury. Take care of the joint function: A schedule for post-operative active and passive joint exercises is an essential part of the surgery. 55 56
55 Watch this area hand surgeons call it The No Mans Land: Flexor tendons injured in the shaded area are particularly difficult to reconstruct. Take particular care to prevent hematomas and infection in this area of the hand.
56 Tunnel flap for the finger: The tunnel flap is a safe and rapid method to cover stripped tendons and bone; you may use it at the time of primary surgery, or delay it until there are healthy granulations in the wound. A bridge of skin with some subcutaneous tissue is raised from the forearm, chest or abdomen. The skin proximal and distal to the tunnel is undermined along the fascia, and the defect inside the tunnel is closed by sutures. The finger is embedded in the tunnel for 1012 days, then one edge of the flap is cut (dotted line), trimmed and sutured to the finger wound. After 5-10 more days the other edge of the flap is cut, trimmed and sutured to the finger.
57
57 The groin flap is useful in cases with extensive loss of soft tissue in the palm or at the back of the hand. The flap is designed according to the site and size of the injury. Note: The venous drainage from the flap is most important.Watch the subcutaneous veins when you raise the flap.The ratio of the flap length: flap base should not exceed 1.5:1. The flap is raised by sharp dissection (along the abdominal fascia in slim patients), the base thicker than the free end. The groin defect is covered with split-skin grafts. The flap is trimmed and sutured to the wound edges. Pad the area well, and fix the injured arm to the groin by adhesive plaster or external fixation apparatus.Within 10-12 days the flap should take its blood supply from
the hand: Test by clamping the flap base, and study the circulation at the flap end. If the circulation after clamping is still good, split the flap at the base, trim it and suture it to the hand wound.
59 Amputations at the hand: The dotted lines represent amputation levels. The radial part of the hand is most important.You may save 1-2 cm of the stump length if you cover the stripped bone end with a full thickness skin flap (tunnel flap or groin flap, see below).The 2 cm saved may be the difference between a grip function or none.
651
60
60 Ray amputations of the hand: Amputations close to the MP joint leave an open space between the fingers that impairs the hand function. Ray amputation gives a more functional hand: Make a dorsal incision and expose the metacarpal bone by blunt/sharp dissection. Cut it obliquely close to its base. Leave the incision open with gauze drainage. After 5-7 days the wound is re-explored, trimmed and closed. 62 61 63
61 Long volar flaps: The skin viability determines the length of the bone stump. Try to save at least 1 cm of the bone distal to a finger joint, it will serve as a useful hook. Design long volar flaps: The volar flap carries the main sensory function and the best blood supply.
62 Thenar flap for the index finger: The flap is raised along the muscle fascia of thenar. The donor bed is closed by sutures. The flap is trimmed and sutured to the index stump. Pad well and fix the index under flexion with adhesive tape. Test the circulation of the flap graft after 10-12 days (clamp the base): If the flap takes its blood supply from the finger, cut and trim the flap and close the amputation.
63 Palmar flap for the thumb: The flap is raised along the palmar fascia.Test the circulation of the flap after 10-12 days: If the flap takes its blood supply from the finger, cut and trim the flap.
652
64
64 Tube flap for the stripped finger: For an adult thumb, the flap should be 9 cm broad. It is raised from the forearm, chest or abdomen. A tube is formed to fit the amputation stump. Note that the tube flap will swell during the early days after surgery: Design the tube wide enough to take that swelling. Normally the flap can be cut free and adapted to the finger after 10-12 days.
653
66
67
66 Counter-drain the palm: Drain infected soft tissues before the palmar abscess develops. Through small stab incisions of the volar and dorsal skin, tunnels through the soft tissues between the metacarpal bones are made using forceps to pull gauze through the incisions. 67 Draining the flexor sheath: Explore a swollen and painful finger without delay. The reason is probably a missed injury, a tiny shrapnel etc. Infection inside or around the flexor sheath will cause a stiff finger unless the sheath is drained at an early stage. Open the sheath through a short lateral incision.Wash out the infection, and insert an IV plastic tube for continuous antibiotic washing for 1-2 days. Arthritis and osteomyelitis The management is immediate surgery antibiotics are supportive but cannot control the infection. Remove all bone fragments without soft tissue attachment. The most common reason of infection is poor soft tissue perfusion at the joint / the fracture: At the primary surgery, the surgeon tried to save what was not possible to save. Now resect all non-viable soft tissue and mobilize a well-circulated soft tissue flap to close the joint / the fracture. Or do amputation. Scarring and contracture Soft tissue scars always contract, especially if the wound has been washed with iodine solutions. The result may be joint deformities. The treatment is surgery: Excise the scar and graft the defect before joint capsule, ligaments and tendons also contract. If the joint is already contracted, release it by tenotomy.
654
655
656
658
Thigh injury ......................................................................... 661 Surgical anatomy: Case studies of thigh gunshot wounds ................ 661 Fasciotomy and exploration ................................................... 665 Thigh vascular injury: Repair, shunt, or ligature? ......................... 667 Fracture management .......................................................... 667 Crush injuries .................................................................... 670 Amputations at the thigh ...................................................... 670 Injury to distal thigh and knee ................................................... 671 Surgical anatomy ................................................................ 671 Preparations for surgery ....................................................... 674 Penetrating injuries ............................................................. 674 Exploration ....................................................................... 675 Extensive joint injury ........................................................... 676 Open joint fractures ............................................................ 676 Fractures of the plateau of tibia .............................................. 678 Amputations at the knee joint ................................................ 679 Lower leg injury .................................................................... 680 Surgical anatomy ................................................................ 680 Fascia compartments of the lower leg and the foot ....................... 683 Fracture management .......................................................... 686 Amputations at the lower leg and foot ...................................... 688 Complications of limb injury and surgery Staged surgery in major limb injuries
.....................................
.......................................... .....................................
657
1/4 of on-site survivors have lower limb injuries Initial gunshot survivors often present with thigh injuries: DIME and other high explosives in particular damage the lower limbs, see p. 134. Most mine victims have traumatic amputations and open fractures below knee. Patients trapped in bombed houses often have the lower limbs crushed.
658
Pairs of nerves and arteries On most limb levels one main nerve is close to some main vessels.The diagnostic landmarks of the lower limb are: The femoral nerve with the femoral artery The sciatic nerve with femur shaft fractures The posterior tibial nerve with the popliteal artery The peroneal nerve and the lateral lower leg compartment with the anterior tibial artery. 2 3
1 The femoral nerve: At groin level the nerve runs close to the common femoral artery, and loss of nerve function indicates vascular injury. The nerve spreads out like a horse tail in the anteromedial parts of the upper leg. It is located subcutaneously and is not affected by compartment injuries. Loss of motor function: He cannot extend his knee or contract the quadriceps muscle. The sensory function: The nerve innervates the anterior and medial parts of the thigh.
2 The sciatic and peroneal nerves: The sciatic nerve runs close to the femur. It may be damaged by fracture fragments. The peroneal nerve is at risk in lateral injuries at knee joint level. It runs down the lateral leg compartment together with the anterior tibial artery, and is an important indicator of lateral compartment problems. Loss of motor function: Dorsal flexion of the foot and 1st toe is weak or lost.The sensory function: The shaded area is alway innervated by the peroneal branch of the sciatic nerve.
3 The posterior tibial nerve: The nerve, which runs together with the popliteal artery, is an indicator of artery injury at knee joint level. Most injuries of the popliteal artery injury are partial with slowly increasing artery obstruction. Increasing loss of tibial nerve function (ischemic) is indicative. Further down the nerve runs with the posterior tibial artery. They are at risk in all deep injuries to the lower leg. Gradual loss of nerve function may indicate posterior compartment syndrome. Loss of motor function: He cannot flex his toes. The sensory function: The nerve always innervates the medial volar part of the foot.
659
Anti-thrombotic therapy.
On the operating table Wash the limb from the groin to the toes, especially between the toes. If you suspect vascular injury, wash and prepare a vein donor area on the opposite leg. Note: Normally more than one incision is necessary for proper exploration. Wash the whole circumference of the limb. Apply traction before surgery on fracture injuries:Traction makes exploration and fracture reduction easier. Adhesive tape, bone pins or manual traction may be used. Apply a deflated BP-cuff proximal on the thigh: When the fascia is incised and the soft tissue pressure diminishes, heavy re-bleeding may start inflate the cuff to 300 mm Hg until the bleeding source is identified. Avoid stretch or pressure to the joints, bony parts of the body and on nerves (beware of the peroneal nerve below the knee, see p. 659) as this may cause serious damage in operations lasting more than 30 minutes. The access for the surgeon is improved by abduction of the injured limb. Note the traction. Access to the posterior thigh by half-side position supported by sandbags and rotation of the thigh. Anesthesia Ketamine anesthesia is suitable for most major lower limb injuries. As ketamine does not affect muscle relaxation, reduction of femur fractures may be difficult. Give IV diazepam or use spinal anesthesia. Spinal anesthesia: Do not underestimate the large hematomas that collect around a femur fracture or under a tense thigh fascia.The patient may respond to the anesthesia with severe hypotension caused by vasodition of distal vessels, unless the blood loss is restored by volume preload of 1-2 liters Ringer before the anesthesia. Superficial injuries of the thigh: Consider femoral nerve block combined with infiltration anesthesia and/or ketamine pain relief. Ankle nerve block is useful for all injuries to the foot. Staged surgery for limb salavage in severe injuries The risk of venous thrombosis, reperfusion syndromes, soft tissue infection, and osteomyelities is higher in the lower limb compared to the upper limb injuries. These complications are all triggers of post-injury stress.
Staged surgery with short primary interventions reduces the risk of organ failure: First stage: Control bleeding. Place temporary shunts in femoral artery injuries. Make wide fasciotomies. Drain all deep wounds. Stabilize fractures roughly by external fixators or plaster slabs. Second stage: Active resuscitation. Third stage, re-operation after 24-48 hours: Vascular repair. Full debridement. Definitive fracture management.
660
Thigh injury
Thigh injury
Two important problems Long wound tracks extensive necrosis: Normally the extent of necrosis depends on the type of ammunition used. But in the long thigh wound tracks most types of rifle ammunition are retarded and cause extensive necrosis. Simply due to the large diameter of the thigh, the injury and the surgery of the thigh are more extensive than in other limb segments injured. Drainage is difficult: Blood and fluids easily collect in numerous spaces and compartments between the muscles. Unless you know the anatomy, explore, and drain these spaces, deep pockets of infection and abscess will develop.
6 Heavy and light mantled 7.62-mm bullets: Compare the effect of these two hits, both from the same standard NATO 7.62 rifle. The standard bullet has a heavy copper mantle. It will not break into fragments. The bullet starts to rotate 15-20 cm after the inlet wound and continues back-to-front. Its damaging effect in a thigh hit is moderate.The German produced light mantled 7.62-mm bullet turns unstable 10 cm after the hit. It breaks into fragments and will create maximum cavitation and soft tissue damage 10-15 cm inside the inlet. This light mantled unstable ammunition is as effective as the hollow-pointed AK-47 bullets. 7
M-16 A2 5.56
M-16 A1 5.56
7 The US M16 rifles are operative in two models, both using 5.56-mm ammunition. The A1 is the old model ammunition. Its bullet is shorter than that of the new A2 model. The M16 is effective for limb injuries. Both types of bullets start to rotate in their track soon after the hit. Both break into fragments and create considerable cavitation before leaving the thigh. As a sign of missile fragmentation you may see a wide outlet wound with additional small outlet wounds after the fragments. Look for this informative sign before you start your surgery.
8 Oblique hit long wound track worse tissue damage: In oblique hits most types of bullets will turn unstable. Thus all common battle rifles may create extensive tissue damage in wound tracks more than 20 cm long. Compare this hit from an AK-47 standard ammunition with the effect of that same ammunition in ill. 4.
9 Drain the deep spaces! The superficial femur fascia is strong. More than one liter of blood may collect inside the muscles under the fascia without much swelling of the thigh. Normally there is no distinct hematoma formation, but the blood collects deep in the spaces between the many muscle bellies. The only clinical sign is a tense fascia, the injured limb feels hard (compare to the opposite limb). Study the cross section of the mid-thigh carefully to know the compartments and spaces where fluid collects: The three main compartments: The fascial septa divide the thigh into three compartments: one frontal (anterior) compartment for the extensor muscles (E); one medial compartment for the adductor muscles (A); one posterior compartment for the hamstrings/flexor muscles (F). In high-energy missile injuries, fasciotomy and drainage should be done for all three compartments. Then explore the deep spaces: Between and along the long muscle bellies blood and fluid may collect (black arrows). Also along the main vessels and nerves are
662
Thigh injury
10
spaces filled with loose connective tissue (white arrow). Here collection of fluid often causes minor foci of infection. If not drained, even the best debridement will not prevent wound infection. (SV the saphenous vein. DFA the deep femoral artery. SFA the superficial femoral artery. SN the sciatic nerve.) 10 The superficial femoral artery carries the main vascular supply to the lower leg. It runs together with the femoral vein under the medial head of quadriceps, through the adductor canal (AC) into the popliteal fossa behind the knee. Then the artery runs superficially and artery injuries are common after missile hits. The deep femoral artery runs deep inside the adductor muscles close to the bone. The multiple small perforating branches of the deep artery are the main source of the large fracture hematomas of the thigh (1-2 liters). 11 11 Hematomas along the main arteries: The canal for the femoral artery (white arrow) should be explored in deep medial injuries. The canal is drained by simply splitting the roof of the canal. Access to the canal is achieved by forward retraction of the sartorius muscle as illustrated. Note the deep femoral artery running into the adductor compartment. 12 12 The deep femoral artery a source of deep hematomas: Deep hematomas often collect along the deep femoral artery, the sources are the multiple, small but deep perforating arteries running from the deep artery. Here the main adductor muscle is shown to be cut to illustrate the space deep between the adductor muscles that should be explored and drained. The canal for the main femoral artery (also cut) through the adductor muscles into the popliteal area is shown (AC).
13
Fracture fixation: Consider the biomechanics! Femur fractures heal well provided they are covered by viable soft tissues and well aligned. The alignment may be difficult due to the strong pull on the femur from strong muscle groups. The muscle forces must be counterbalanced by the fixation you apply be it traction, plaster cast or external fixation of the fractures. 13 Displacement of trochanter fractures: Strong buttock and adductor muscles act upon the proximal fractures. Observe the pull in the medial direction upon the femoral shaft from the adductor muscles. To reduce and counter this medial pull with plaster cast management, trochanter fractures should be immobilized in abduction and flexion of the hip joint, see p. 668.
663
14
15
14 Displacement of shaft fractures: The quadriceps muscle in front of the femur and the hamstrings muscles posterior to the femur exert a balanced pull upon fractures of the shaft. If the fracture is not exactly reduced during primary surgery, the displacement will soon increase and result in angulation. In major mid-thigh injuries with extensive loss of either the quadriceps or the hamstring volume, a muscular imbalance will arise that may displace the fracture. 16
15 Displacement of distal third fractures: Note the traction from the strong gastrocnemius muscle upon the distal fracture fragment. The fragment will rotate backwards unless the pull from the strong calf muscles is counterbalanced by traction upon the tibia. Also flexion of the knee joint (pillow) will shorten the calf muscle, and reduce its force on the fracture.
16 Two networks of veins one superficial, one deep: The superficial veins run superficially to the thigh fascia inside the subcutaneous tissue. The superficial veins are not essential to the general venous drainage of the limbs, unlike the deep veins. Thus superficial venous bleeding is controlled by simple ligature of bleeding points. However, avoid damaging the saphenous vein (SV) by your incisions. Grafts from this vein are used for artery reconstructions. The small saphenous vein (SSV) drains the posterior lower leg and flows into the popliteal vein (PV). The major deep veins run together with the respective main arteries. They carry the main drainage from the limb. If damaged, the main femoral vein (FV) should be reconstructed.
664
Thigh injury
17
17 Muscle pump drainage of the lower limb: Many small communicating veins connect he superficial to the deep venous network. By mechanical pressure from the muscles during walking or exercises, venous blood is pushed through the ommunicating veins from the superficial into the deep network. The valves of the veins (circle) stop the blood from flowing in the opposite direction.This muscle pump should be actively used in anti-edema programs from the first post-operative day: Flex your ankle extend your ankle 500 times every day!
19
Exploration and debridement: double incisions We expect the tissue necrosis to be moderate on the bullet inlet side: The debridement is done by simply extending the inlet wound upwards and downwards. But close to a gunshot fracture and at the bullet outlet side there will normally be extensive soft tissue damage. Use one of the standard exploratory incisions for complete access to the wound track, including the deepest parts of it. 20 20 The medial exploratory incision is used for exploration of vascular injury, for fasciotomy of the adductor compartment and as counter-incision for debridement and drainage of fractures. The skin incision is done along the superficial femoral artery in front of the sartorius muscle. The thigh fascia is split, the sartorius muscle (S) retracted backwards, the rectus femoris head (RF) of the quadriceps muscle retracted forwards. The roof of the canal for the femoral artery may be carefully split along the dotted line. 21 21 The frontal (anterior) exploratory incision: By sharp dissection the lateral head of quadriceps is split from the rectus femoris, and retracted to expose the deep head of the quadriceps muscle. The deep head is also split sharply along the dotted line, and lifted off its femur attachment with rasps. Note: The frontal incision thus does some damage to the quadriceps muscle; it impairs the knee function and makes rehabilitation difficult. Be restrictive with the use of the frontal incision. 22 22 The lateral exploratory incision is the standard incision for management of femoral shaft fractures. The fascia is split longitudinally. The lateral head of the quadriceps muscle is split by blunt dissection and the bone exposed. For wider exposure of the bone, the deep head of the quadriceps muscle is cut along the dotted line and lifted off the bone with a rasp or chisel. For exposure of the distal part of the shaft, the short head of biceps is released from its femoral attachment with a chisel.
23 23 The posterior exploratory incision is used for exploration of the sciatic nerve and the hamstring muscles. The skin and fascia are incised in the midline and the posterior compartment entered. The hamstring muscles are separated by blunt dissection and the sciatic nerve exposed between them. The nerve rests upon the roofs of the extensor compartment (E) and the adductor compartment (A). Note the popliteal fat pad posterior to the knee joint (arrow): Resect all crushed and necrotic fat tissue to prevent infection.
666
Thigh injury
Fracture management
The treament strategy depends on the level Fractures of the trochanter area: These fractures heal well; the main problem is fragment displacement. Fractures of the shaft: The main problem is the soft tissue injury. Fractures of the distal third: The fracture may enter the knee joint with risk of arthritis. 24 24 Fractures of the trochanter area: As the trochanter has good blood supply, the debridement of bone is conservative. Only minor bone fragments without soft tissue attachment are removed. Regarding soft tissue cover: The sartorius and tensor fascia lata muscles may be mobilized as rotation flaps in cases of soft tissue loss. The fractures through and just below the trochanter heal well. The main problem is fracture displacement:The buttock muscles retract and rotate the proximal fragment outwards, while the adductor muscles displace the shaft fragment in the medial direction. The muscular forces are reduced by abduction and flexion of the hip joint. If traction is used for fracture immobilization, we recommend dynamic traction: Arrange tibial traction with the hip joint in 30degree flexion and 30-degree abduction (see below). Pillows should support the thigh. Start quadriceps and knee joint exercises from the first day. Check the fracture position frequently and adjust the axis of traction according to the X-ray films. When the fracture has entered the callus stage after 6 weeks if there is no infection apply plaster spica.
667
25
25 Plaster spica management: Fractures of the trochanter area may also be managed by primary plaster spica without prior traction management. Use the plaster method of Trueta (p. 345). Apply two plaster slabs on the leg and one circular slab for the pelvis (ill. 28). Immobilize the fracture under constant manual traction, the hip joint in 30-degree flexion and 30-degree abduction.The condition for effective immobilization is careful molding of the cast (white arrows) to make it fit the contours of pelvis, thigh and lower leg.The spica should reach the rib level, but not include the ribs. The total time of immobilization is 10-12 weeks. The limb should not bear weight inside the spica until 6-8 weeks after injury. Triangular molding of the thigh cast: The cast must fit the triangular shape of the thigh, see the cross section. The triangular molding will prevent rotation of femur inside the cast, and make isometric quadriceps training more effective (muscle pump training, see p. 665). 26 26 Fractures of the shaft: Associated vascular injury is common. In cases with damage to the deep femoral artery and extensive muscle necrosis, the bone blood supply is poor: Healing is slow and the risk of fragment necrosis and osteomyelitis is high. Do not compromise on the debridement of the soft tissues; close to the bone the debridement should be very careful. Drain the fracture field through medial and lateral fasciotomies. Where the debridement leaves the fracture with poor soft issue cover: Mobilize local muscle flaps. 27
Dr. Trueta reported excellent results of primary plaster cast management of all open fractures of the femur, see p. 345.
Dynamic traction, see p. 351. 28 27 Dynamic tibia traction: If external fixation is not available, also shaft fractures may be managed with primary plaster cast (the method of Trueta). Another alternative is some weeks in dynamic tibia traction before the plaster cast is applied. The patient is encouraged to perform quadriceps exercises and move the knee joint at intervals (under analgesia) from the first day after surgery. Monitor and adjust the direction of the traction, the traction weights and the pillows supporting the thigh in order to achieve good alignment of the fracture within one week following injury. Note the slight curvature of femur in side view: Support with pillows. As soon as the fracture has entered the callus stage (4-6 weeks), a hip plaster spica is applied. 28 Hip plaster spica for shaft fractures is applied under constant manual traction. Use two long plaster slabs for the leg and one circular slab for pelvis. The hip joint is immobilized in a neutral position, the knee joint flexed at 15-20 degrees. Mold the cast in a triangular fashion, see above.
668
Thigh injury
29
29 Plaster cast with bone pinning for unstable fractures: For good immobilization inside a plaster cast, a balanced soft tissue pressure and a wellmolded cast is necessary. If the debridement ends up with extensive loss of muscles, the pressure inside the thigh is not longer balanced, and the fragments will displace. If there is also loss of bone after the debridement, the fracture is even more unstable. Double Steinmann pins proximal and distal to the fracture fixed in a well-molded plaster cast are a good method for unstable shaft fractures if a proper external-fixation apparatus is not at hand.
30
For out-patient treatment, orthosis is better than plaster casts, see p. 352.
30 Fractures of the distal third: The bone blood supply is rich and the bone debridement normally narrow. There are two main problems with distal fractures of the femur: Knee joint injury does the fracture enter the knee joint? Even the best X-ray film may miss a fine fracture line entering the joint. Do sterile diagnostic puncture of the knee joint, see p. 365. Blood aspirated from the joint is diagnostic the fracture enters the joint. Debride the soft tissues carefully, cover the fracture with viable soft tissue flaps, consider continuous joint washing (see p. 362) to prevent infection and late arthritis. Fragment reduction and fixation may be difficult: If the fracture is well above the knee joint level, primary plaster cast with 2x2 bone pins may fix it. To reduce the pull of the calf muscle on the distal fracture fragment, the knee joint is immobilized in the cast with 40-degree flexion. Manage displaced distal fractures in dynamic tibia traction for 4-6 weeks before an orthosis is applied. 31
31 Multiple lower limb fractures: Combined plaster-traction management may be useful.The tibial fracture is debrided and a Steinmann pin is inserted through the tuberosities of tibia.The fracture is reduced and immobilized in a standard lower leg plaster cast, see p. 687. Dynamic traction is applied on the thigh fracture from the first day after injury. After 4-6 weeks, a long foot-to-hip plaster spica should be applied and the patient mobilized.
669
Crush injuries
The primary management of crush injuries differs from that of missile injuries. The patient often presents a swollen cold limb. The main reason for poor nerve function and low blood perfusion is a combination of multi-compartment syndromes plus crush injuries to vessels and nerves. Polytruma: Consider primary amputation. The wide necrotic fields of the limb contribute to organ failure especially after blood perfusion is restored (reperfusion syndrome, see p. 163). Immediate amputation may be life-saving. Maybe the limb can be salvaged: Fasciotomy and observation. Immediately do wide fasciotomies of the three compartments of the thigh. If the evacuation is long, make the fasciotomies on-site before the evacuation starts. Monitor the distal circulation on the operating table for 10-20 minutes. If the muscle bellies bulge through the fasciotomies and the blood perfusion of the muscles gradually improves, the patient had a compartment problem. Delay the definitive surgery with debridement and fracture management for 24 hours. Artery exploration reconstruction or amputation: If the distal circulation does not improve within 10-20 minutes after the fasciotomy, there is probably one or more tears or intimal injuries in one of the femoral arteries. Explore the actual artery. If the damage is localized, consider vascular shunting. If the vascular damage is extensive and includes several segments of the vessel and affects minor as well as major arteries this is a case for primary amputation.
Reperfusion syndrome, see p. 163. Crush cases carry high risk of thrombotic complications. Consider anti-thrombotic therapy. There is risk of renal failure: Flush IV infusions to get urinary output up to 2 ml/kg/hour as soon as possible, see more on p. 733.
670
Distal femur amputation Hinged knee prosthesis:The ideal bone amputation level is 12-15 cm above the knee joint. For a non-hinged prosthesis, save maximum stump length. Use immediate temporary prosthesis until the definitive prosthesis is fitted.
32
33
671
34
34 The soft tissue problem: The knee joint is well vascularized by a network of collateral arteries. Generally the debridement of skin and subcutaneous tissues is limited. Beware of wounds of the lower anterior aspect of the joint (shaded): In this area the skin blood supply is poor, no muscles protect the joint, healing may be delayed unless soft tissue flaps are mobilized for joint closure. 35
35 The complex knee joint mechanism: Principally the knee is a hinge joint, but there is also some rotation and a slight sliding of femur on tibia during flexion-extension. The wide range of motion makes the joint stability a problem. 36 Knee joint stability: To stabilize the complex motion, the supportive mechanism has to be complex as well. Here the joint is shown to be disarticulated and the femur removed for reasons of illustration: The quadriceps muscle is the single most important stabilizer. It works on the patellar tendon (PT), but is also connected directly to the capsule through its medial and lateral tendinous expansions. Defects of the main ligaments may be partly compensated by strong quadriceps action. Handle the quadriceps muscle with care during surgery: Choose your incisions so you do not interfere with the quadriceps joint function. The medial and lateral collateral ligaments (MCL and LCL) are external ligaments that stabilize the joint against stress from the sides. The ligaments are interwoven in the tendon-capsule apparatus. The anterior and posterior cruciate ligaments (ACL and PCL) are internal ligaments stabilizing the sliding motion. The medial and lateral meniscus (MM and LM) are semi-lunar cartilaginous structures exactly fitting the contour of the femur condyles. Injury to the semilunar cartilage may block the hinge movement of the joint, resulting in a locked knee.
36
672
37
37 Testing the cruciate ligaments: A torn cruciate ligament or a fracture through its bony attachment will produce a draw instability of the joint, a forward or backward draw depending upon which of the cruciate ligaments are torn. Test all joint injuries for draw instability. 38 38 Testing the collateral ligaments: Injuries to the collateral ligaments cause side instability. In this case the injuries to the medial capsule and the collateral ligament are diagnosed by side-stability testing. 39 39 Associated popliteal artery injury: Intimal detachment or tears of the popliteal artery (PA) or vein (PV) are common in penetrating and blunt high-energy injuries. There is a close relationship between the femur condyles, the posterior joint capsule and the popliteal artery. Fracture fragments may tear the vessels. More common are intimal injuries: The artery is fixed proximal and distal to the popliteal area in the adductor channel (A) and crossing through the sartorius muscle (S) together with the tibial nerve (TN). Between these points, the artery may be stretched in posterior dislocations of the femur condyles, causing rupture of the arterys intima and partial occlusion of the artery.
40
40 Watch the peroneal nerve! The nerve (PN) runs under the biceps muscle (B), subcutaneously around the neck of the fibula into the lateral muscle compartment of the leg. Close to the fibula (circle) the nerve may be damaged by careless surgery, by pressure damage on the operating table or pressure from a poor plaster cast. The signs of peroneal nerve injury, see p. 659. TN: the tibial nerve.
673
Penetrating injuries
Use the Ganga and MESS scores to assess indications for primary amputation, see pp. 328 and p. 381. Treatment protocol Examine the vascular and nerve function: If both the tibial nerve and the popliteal artery are torn, primary amputation may be indicated, especially in a mass casualty situation. Reconstruction of the popliteal artery has priority before the joint injury. The blood supply to the soft tissues of the knee joint is rich. The debridement should generally be moderate. Synovium and the synovial fluid are the main protection against joint infection, a dry and open joint will become infected: Leave enough healthy synovium and/or skin to close the joint after the debridement. Wash all joint compartments thoroughly with normal saline. Also wash with soap solution if the joint is very dirty. Be careful to excise all crushed and non-bleeding fat tissue inside and outside the joint. Excise tags of the cartilage and meniscus, but leave tears of the main ligaments for secondary reconstruction. Mark them with a silk suture for easy identification later. Smooth tears and fractures of the joint cartilage with a knife. If the joint injury is less than eight hours old, close synovium with continuous sutures. Instill penicillin (10 mega ill IU) in the joint. Close the capsule and skin. If the joint injury is old and infected, arrange continuous antibiotic washing of the joint, see p. 362.
674
Explore popliteal injuries The popliteal groove is the gate for blood vessels and nerves to the lower leg and the foot. In crushed limbs and high-energy injuries the popliteal structures should be explored especially if the foot is cold, or there is a comminuted fracture at the knee joint. Intimal injuries to the popliteal artery are common, but may have few clinical signs initially: At the knee joint the collateral small knee arteries can support the distal circulation to some extent but with progressive tear-off of the intima the lower leg becomes cool and gradually paralytic. Ligature of the popliteal artery causes secondary gangrene in one out of two cases: Try to reconstruct the artery or place a temporary shunt, see p. 248.
Exploration
41 41 Exploration of the popliteal structures: Use a lazy-S shaped skin incision to avoid excessive scarring. Follow the superficial veins by careful dissection into the popliteal fat pad: The veins will guide you to the popliteal vein (arrow). By careful dissection explore the popliteal artery and the tibial nerve under the vein. Beware that the retractors may damage the tibial (TN) and peroneal nerve (PN). Isolate the artery between clamps and do a short arteriotomy if you suspect arterial damage. For further exploration of the vessels, the incision is extended in the proximal direction through the medial hamstring muscles, or into the lower leg by splitting the calf muscle.
42
43
42 The medial exploratory incision: Incise the skin, subcutaneous fat and capsule 1-2 cm medial to the patella. The synovium is lifted between clamps, split and retracted (blunt retractors). Identify the medial meniscus, the anterior cruciate ligament and the medial femur condyle. Wash all compartments of the joint.You may extend the incision proximally into the quadriceps tendon expansion, retract the patella and explore the superior compartment (SPC). 43 Double exploratory incisions: To explore the posterior joint compartment, the capsule is split longitudinally at the posterior medial (and/or lateral) corner behind the collateral ligament.
675
45
If you find it impossible to close the joint, the case is probably one for arthrodesis or amputation.
676
46
46 The exploration: The bone and soft tissue blood supply to the distal thigh is rich and the debridement is generally moderate. On the X-ray films the fracture position may seem reasonable, you should still explore the fracture closely: Fragments of bone may have torn the joint capsule, and muscle may interpose in the fracture line making reduction impossible. Expose the fracture through a long lateral incision: retract the lateral head of quadriceps (LQ) and the biceps muscle. Often, as in this case, the short biceps muscle (B) is interposed in the fracture release it. More on traction mangement, see p. 349. Dynamic traction Arrange dynamic tibial traction on comminuted fractures: Start careful flexionextension motions of the knee joint (mean flexion 30 degrees) from the first day. The range of motion should be restricted during the first four weeks. Start orthosis treatment after 5-6 weeks. Note: The gastrocnemius muscle will displace the distal fragment, see p. 664. To prevent angulation, both traction and plaster cast fixation must be done on a flexed knee. 47
47 Plaster cast management: Pad the bony prominences. Apply anterior and posterior slabs under constant manual traction on the foot, the knee joint flexed at 15-20 degrees, the ankle in a neutral position. Circular turns of plaster fix the slabs and finish the cast. The cast should be worn for 8-12 weeks depending upon the fracture. After 6-8 weeks careful weight-bearing is allowed. Let the fracture pain adjust the weight load. Note some points regarding the plastercraft:
677
The cast should reach from ankle joint level to the femur trochanter. Slab application is easier if you apply one layer of circular plaster (rolls of 15 cm) inside the slabs to which the slabs will stick. Mold the cast triangular at the thigh level to fit the adductor muscles (A). Mold it quadratic above the joint to fit the medial and lateral quadriceps (M, L) and the hamstring tendons. Mold it triangular below the joint to fit the triceps surae muscle (TS). Mold it quadratic above the ankle to fit the malleolar contour. In tibial condylar fractures, the cast should also include the ankle joint. 48
49
48 Fractures of the patella: If the patient is able to raise a straight leg, the patellar fracture is stable, and the treatment is simply debridement and a standard knee plaster cast with the knee in full extension for six weeks. Is the fracture complete or not? If the inner table of the patellar bone is not fractured, the fracture will not displace. Is the quadriceps tendon expansion (QE) torn or not? If undamaged, the expansion will fix the fracture, and you do not need to wire the patella. If the fracture is complete and the quadriceps expansion torn, the fracture is reduced and fixed with strong non-absorbable sutures or soft steel wire. The wires are applied through the tendon and capsule as close to the bone as possible. One of the wires should be located deep, the other more superficial to compress both the inner and outer patellar table. A standard knee plaster cast is worn for 6-8 weeks. 49 Comminuted fractures excision of the patella: The excision is done close to the bone, inside the quadriceps expansion. When the bone is completely removed, the expansion and the patellar tendon is approximated and sutured with strong silk sutures with full extension of the joint. Steinmann pins through the tendon proximal and distal to the patella may be used to relieve the tension on the tendon suture. The pins are fixed in the plaster cast which is worn for six weeks.
fracture field has poor blood perfusion and necrotic soft tissues are present. Instead, we recommend a two-step procedure for open comminuted plateau fractures. 50
51
50 Open plateau fractures First stage: Exploration and soft tissue cover. Debride the soft tissues carefully. Reduce the fracture fragments roughly, and mobilize muscle or full thickness skin flaps to cover the fracture field with well-vascularised tissue. Arrange for continuous joint washing with antibiotic solution. Arrange for dynamic traction (calcaneus or lower tibia pin): Encourage continuous but careful flexion-extension exercises for 5-15 days. Dynamic traction will assist in reducing the fracture fragments. Second stage: Reduce the fracture and reconstruct the joint. Reexplore the fracture as soon as the soft tissues have healed without infection. Reduce the fragments so that no steps in the joint surface exceed 2 mm. Insert bone chips from the pelvic wings in the fracture line to stabilize the fragments. Insert gauze drains and apply a long plaster cast, the knee joint flexed at 15-20 degrees. Shift to orthosis threatment with careful weight-bearing after 6 weeks.
52
53
53 Knee joint disarticulation is less traumatic, and should be used in multi-injury cases, where the operation time must be short, on old patients, and to free trapped limbs. The skin flaps are designed with a long anterior flap, or with medial-lateral flaps. A posterior midline incision below the amputation level makes the popliteal dissection easier. Carry the incision straight through the capsule and the patellar tendon. Cut the cruciate ligaments through their tibial attachment. Identify the vessels and nerves in the popliteal area; ligate the vessels doubly, and cut the nerves at the highest possible level. Then the biceps muscle (B), the medial hamstrings, the medial and lateral gastrocnemius muscles all close to their attachment to bone. After 5-10 days the stump is clean and closure is done: Suture the patellar tendon to the posterior cruciate ligament and capsule, the hamstrings to the anterior joint capsule. (There is no need to fix the patella to the femur condyles). The skin-fascia flaps are trimmed to locate the skin suture line posterior to the weightbearing surface of the stump. Skin and fascia are closed over drains by all-in-one deep interrupted sutures.
54
The middle 1/3:Tibial shaft fractures are the main problem. Concentrate on careful soft tissue debridement and drainage of deep compartments. Always cover the fracture with healthy soft tissue flaps, e.g. anterior tibial muscle flap, see p. 333. The lower 1/3: Distal tibial fractures normally heal well. Reduce the fracture immediately after injury to prevent nerve and vascular damage. If the fracture enters the ankle joint, concentrate on preventing joint infection. Distally hinged perforator flaps are useful for fracture cover. 55 55 Assess the stability of the tibia fracture: Between the tibia and the fibula is a strong fibrous membrane, the interosseous membrane, assisted by thick cords of ligaments.Through this membrane the undamaged fibula acts as external fixation on the tibial fracture. A comminuted or segmental fracture of the fibula breaks this ability to fix the tibia. Delayed healing: Within weeks there is always some resorption of bone at the fracture site. In isolated fractures of the tibial shaft, the fibula and the interosseous membrane may distract the fracture fragments: Even weight-bearing inside an orthosis will not compress the fracture. In that case the fibula must be cut to accelerate the fracture healing (fibular osteotomy, see p. 692). Notice the hole in the interosseous membrane for the anterior tibial artery (ATA); where the artery penetrates the membrane it may be damaged directly by fracture fragments, and indirectly by shock wave from bullets or blasts, see p. 136. 56 56 Anterior-posterior displacement: The strong triceps surae muscle and the anterior tibial muscle tend to displace the distal fragment in the posterior direction. The displacing force is reduced when the knee joint is flexed: Apply plaster casts on unstable fractures with the knee flexed at 90 degr. Also flex the knee under traction management for better fracture alignment.
57 57 The biomechanics of the foot: The two arches of the foot carry the total body weight, and are essential to walking. Save the main structures during debridements and resections; support them during plaster cast immobilization. The longitudinal arch of the foot carries the total body weight. It consists of the calcaneus (C), talus (T) and the metatarsal bones (MT).The flexor tendons (FL) on the medial side, the peroneus tendon on the lateral side together and the short plantar muscles suspend the arch. Note that the space close to the calcaneus under the fat pad of the heel (white arrow) is a common site for abscesses to form in open fractures of the heel area.
681
58
58 Immobilization of the ankle: An incorrect position may cause permanent damage to the ankle/foot and displace ankle joint fractures. Immobilized in flexion, the load through the tibia hits the talus off center: A painful ankle and posterior fragment displacement will be the result. Immobilized in supination, fractures of the lateral malleolus will displace and the ankle will contract in equinus mal-position. 59
Study these illustrations carefully. A lot of complications would be avoided if the surgeons understood the particular features of the antero-lateral compartment at the lower leg.
59 Vascular injuries: The popliteal artery (and vein) splits into three main arteries of the lower leg: two in the posterior fascia compartment, the peroneal artery (PA) and the posterior tibial artery (PTA) both located close to the bones. And the anterior tibial artery (ATA) passing through the interosseous membrane to enter the anterior compartment. Vascular injury differs at various locations:
682
At the knee joint: Suspect intimal injury to the popliteal artery after high-energy injuries, see p. 136 and p. 673. Tibial shaft fractures: Bone fragments may tear the arteries. The anterior compartment: High-energy shock wave may cause isolated and total necrosis of the anterior compartment. The necrosis may develop in two ways: (1) Fasciotomy was not done, and the blood supply collapses due to increased compartment pressure. (2) Or the anterior tibial artery is blocked by intimal detachment and thrombus at the point where it penetrates the interosseous membrane. Note: Isolated anterior compartment necrosis is seen also in cases where the injury is below ankle level, as injuries from light anti-personnel mines and high-energy bullet wounds through the calcaneus or talus. Ankle fractures: Displaced bone fragments may damage the arteries and nerves located close to the malleolar bones. Nerve function tests indicate vascular injury The three main nerves follow the main arteries in the lower leg. Loss of function in one nerve thus indicates probable injury also to the artery following that nerve: The two peroneal nerves and the anterior tibial artery: All are located deep inside the anterior fascia compartment. They may be damaged by bone fragments in comminuted fractures, and by compartment syndrome in the anterior compartment. The nerves supply the skin on the dorsal side of the foot. Do nerve function tests as routine, see p. 659. The tibial nerve and the posterior tibial artery: Both are located deep inside the posterior compartment. Shaft fractures and posterior compartment syndrome, but ankle fractures may also damage the tibial artery and nerve: Displaced fracture at the medial malleolus may tear or stretch (intimal rupture) the vessel. As the nerve supplies the plantar structures of the foot, sensory loss indicates vascular injury.
683
Double incisions for complete fasciotomy below-knee For the posterior and deep compartment the medial incision is recommended: make a longitudinal skin incision just posterior to the posterior margin of the tibia. Fasciotomy of the anterolateral compartment is done with an incision lateral to the anterior margin of tibia. 61
62
61 Spaces to drain Split the superficial (1) and the intermediate layer (2) of the calf muscles by blunt dissection: Hematomas from the popliteal area may collect along the vessels in this space. Release the intermediate layer of the calf muscles (2) from its attachment to the fibula and tibia; retract it to enter the space where the two posterior arteries are located (PTA the posterior tibial artery. PA the peroneal artery). Note the communication from the popliteal area down into this space (white arrow). The deep fexor compartment can also be accessed from the lateral side: Split the fascia over the deep layer of calf muscles (3).To drain fracture hematomas: Retract the deep layer and drain along the interosseous membrane (IM). 62 The anterior exploratory incision: Both anterior fasciotomy and exploration of tibia fractures may be done by this incision. But note: As the medial standard incision is less traumatic to the soft tissues, it should be the standard incision used to explore tibial fractures. Make the anterior incision to the skin and fascia at minimum 3 cm lateral to the edge of the tibia.You may extend the incision to one of the standard incisions for exploration of the knee joint. Release the muscles from the lateral surface of tibia and expose the interosseous membrane with the anterior tibial artery. In high-energy hits you may find complete necrosis of all muscles inside the anterior compartments even if the posterior compartment (P) is not injured: In that case, excise all necrotic muscle without compromise, leave the incisions wide open, use a gastrocnemius muscle flap for closure, see p. 332.
684
63 Never split the skin over the medial surface of tibia: that incision will not heal.
63 The medial exploratory incision: This is the standard incision to decompress both flexor compartments, and to explore tibia fractures. Make the skin and fascia incision at least 3 cm behind the posterior edge of the tibia posterior to the saphenous vein.You may extend it behind the medial malleolus of the ankle, to the ankle, or into the popliteal area to manage vascular injuries. Release the intermediate layer of the calf muscle (2) from its attachment to the tibia, retract it together with the gastrocnemius muscle (1), and enter the space next to the deep compartment (D): Identify and explore the two posterior arteries. To expose the posterior surface of the tibia, you also have to release the long toe extensors (3) from the tibia. Note the arrows: Be careful not to damage the soft tissues at the posterior edge of the tibia with retractors. 64 64 The fascia compartments of the foot do not communicate with the compartments at the lower leg. This cross section through the base of the metatarsals shows the four separate fascia compartments of the foot: The medial compartment contains the flexor muscles for the 1st toe. The lateral compartment contains the flexors for the 5th toe. Between them, the central compartment containing the flexor muscles for the 2nd-4th toes. The dorsal compartment between the metatarsal bones that contains the interosseous muscles and the nerves and vessels for the toes. 65 Fasciotomy of the foot: The first sign of a foot compartment problem is deep plantar pain on dorsal motion of the toes, especially the first toe. All four compartments should be decompressed by fasciotomies in high-energy blast and penetrating injuries. In the medial compartment the edema and muscle necrosis may be especially extensive. The fasciotomies are always done from the dorsum of the foot. By three separate incisions all four compartments are decompressed and drained.The fasciotomy incisions are closed by split-skin grafts within one week after the surgery: The medial incision is done at the lower edge of the first metatarsal through the skin and the thick plantar fascia. The spaces between the muscle bellies are opened by finger dissection. For full exploration of the medial and central compartments: Extend the fasciotomy incision towards the medial malleolus.
685
65
The lateral incision is done from the dorsal side between the 4th and 5th metatarsals. By blunt dissection (artery forceps) close to the the 5th metatarsal, the wall of the lateral compartment under the bone is split and the compartment opened. The central incision is done between the 2nd and the 3rd metatarsals. By blunt dissection deep to the metatarsals the central compartment is entered. Make sure that the forceps split all muscles of the deep central compartment down to the plantar fascia.
Fracture management
The main problem: delayed healing and infection in open tibial shaft fractures To cover the fracture with well-circulated soft tissue is the most important measure to prevent fracture infection. Staged surgery in high-energy injuries First, re-establish the soft tissue perfusion by immediate fasciotomy and drainage. Reduce the fracture roughly and stabilize by plaster slabs or externa fixator. Place drains but delay the debridement. This is a 20 minutes intervention. Elevate the limb and resuscitate the patient. After 24 hours, manage the fracture: Make a complete debridement of soft tissues and bone. Now decide if the limb should be amputated or salvaged. If salvagable: Reduce and fix the fracture. Cover the fracture wound by viable soft tissues.This is an extensive operation that takes a least two hours. If you use soft tissue flaps: Watch the circulation of the flap carefully the first 12 hours. Immediately evacuate hematoma collecting under the flap. After 4-6-8 weeks as soon as the fracture is semi-stable shift to orthosis treatment: Weight-bearing stimulates bone formation and fracture healing. Warning: Long-term traction management is a hazard The complications are well known: delayed healing, secondary infections and deteriorating general condition of the patient. Particularly in the tibial shaft fractures where the bone nutrition is generally poor due to anatomical reasons, traction management should be used with care: Apply traction only if the soft tissue injuries need monitoring, dressing and repeated surgery and you have no external fixation apparatus. Use traction management only during the period of soft tissue managment: Apply plaster cast or orthosis and mobilize the patient as soon as the soft tissues have healed and the fracture is closed. If the healing is slow, do not extend the traction management: Shift to orthosis treatment. If there is distraction to the fracture site, make osteotomy of the fibula, see p. 692. If the fracture does not start to heal after 2 months of orthosis treatment, there is probably a low-grade infection and necrotic bone inside: Consider re-debridement with bone grafting.
There is no antibiotic treatment to cure a fracture osteomyelitis, the bacteria hides in a biofilm. More on osteomyelitis and biofilm, see p. 743.
686
Closed tibial fractures Almost all closed fractures heal without surgery if the plaster cast is well done, if weight-bearing starts soon enough, and the patient is healthy without malnutrition. 4-6 weeks after the injury: Callus develops start careful weight-bearing 6-10 weeks after the injury: Shift to orthosis to accelerate healing. 66 66 Patella-bearing cast for fractures at the lower 1/3: The cast is moulded carfully to fit the tibial condyles and the patella. Note the cross section through proximal tibia with its triangular form, and the quadrate form of the cross section through the ankle.
67
67 Long cast for fractures of the upper 1/3: The cast should reach from below the trochanter to the base of the toes. Outside a one-layer circular plaster, apply two long slabs. Fix them with turns of 15 cm rolls. Note some details: Do not pad too much, especially at the fracture level, as padding makes the cast support the fracture less. You need two assistants: one should maintain traction on the foot, the ankle joint in neutral position.The other supports the thigh, the knee joint 15-30 degr. flexed. Mold the cast well to fit the contour of the leg in each section. Mold the distal cast to support the arches of the foot. Open ankle injuries As the bone and soft tissues at the ankle are well supplied from a rich network of collateral blood vessels, injuries generally heal well. The main points of management: Decompress the leg: A high-energy hit to the ankle area may cause shock-wave injury with artery obstruction and muscle necrosis up to the level of the knee joint. The anterior lower leg compartment and the medial foot compartment are at special risk: Fasciotomy may help the fracture healing. Close the fracture with healthy soft tissue: Either use fascia-skin rotation flap, perforator flap, or primary Trueta plaster and secondary skin grafting.
687
The fracture management: Bone fragments without soft tissue attachment should be removed. Minor deranged fragments of the articular surface of tibia or talus are also removed, or else they may cause steps of the articular surface and secondary progressive joint pain. Maintain the integrity of the malleolar bones they are essential to the stability of the ankle joint. Primary amputation depends mainly on the soft tissue state: If the ankle joint is extensively deranged, still apply a conservative strategy if the vascular and nerve function of the foot is good an ankle with some joint function is better than nothing. Extensive loss of soft tissues and nerve function normally indicates amputation. 68 68 A particular problem: fractures of the calcaneus and talus. High-energy open fractures in these bones tend to develop a low-grade osteomyelitis: The cancellous bone becomes soft and waxy, the suppuration from the wound channel of the bone persists even if the fracture is well debrided and soft tissues healthy and without infection. A similar state of calcaneus bone necrosis may develop after high-temperature deep burns to the foot. In our experience, early bone grafting, soft tissue rotation flap, and application of a Trueta plaster at the time of primary surgery are the management of choice for these injuries: Debride deliberately the fractured cancellous bone (orthopedic curette) until there is fresh bleeding from the bone. Small chips of bone (chiseled from the tibia or the pelvic wing) fill up the wound track inside the calcaneus. Debride the soft tissues and mobilize a local full thickness skin flap. Cover the donor site with a splitskin graft. Drain the fracture into a plaster cast and mobilize the patient. Expect suppuration for some weeks; another debridement of the fracture is of no use. If the fracture is still suppurating after two months, excise the posterior fragment or the whole calcaneus; suture the Achilles tendon to the plantar fascia.
688
69
69 Amputation levels: Note the critical minimum length:The tibia stump should be at least 8 cm long to control a hinged prosthesis. The best length is 15-20 cm. 70
71
70 Below-knee amputation Do not dissect the soft tissues separately, but make an all-in-one posterior flap that consists of skin, fascia and muscles. To do that, the dissection of the posterior (or the medial) flap is done from inside out: Mark the flaps on the skin with marker pen. Isolate the anterior skin-fascia flap, identify and control the anterior tibial artery, and amputate through the anterior compartment. Saw off the tibia, and the fibula 1-2 cm proximal to the tibia stump. Then identify and control the posterior vessels: the posterior tibial artery close to the tibia, and the peroneal artery with two veins behind the fibula. Now isolate the posterior soft tissue flap from inside out: Cut the inner and intermediate muscles (soleus) flush with the tibia amputation to thin the flap. Cut the superficial muscle (gastrocnemius) at level with the fascia-skin incision. Extend the incisions towards the knee joint as fasciotomies, and explore the muscles carefully: Necrotic patches and necrotic muscle bellies are excised and the incisions left open for decompression. Drain with gauze and apply a Trueta plaster cast to mid-thigh, the knee joint flexed at 10-20 degrees, to prevent flexion contracture at the knee. 71 Stump closure: The closure is done 5-10 days after the amputation. We do not use myoplasty in lower leg amputations. The thick muscle-fascia-skin posterior flap is sutured fascia-to-fascia to the anterior flap. The shaded areas illustrate where the soft tissues of the stump are vulnerable to pressure inside the prosthesis holster. There are some points to consider for a good stump: Trim the bone ends nicely. Apply local anesthesia nerve block along the main nerves. Handle with care the skin along the anterior edge of tibia. Design the flap size so as not to suture the flaps under tension. Do not make a clumsy stump:You may thin the flap more by cutting more of the soleus muscle at the flap base. And make a wedge-resection in the gastrocnemius in the midline. Suture the flaps over double-tube drains, and again apply plaster cast to prevent knee joint flexion contracture. Pad the cast well over the bony prominences. Let the cast reach the groin: Fix a training prosthesis to the cast and start walking within five days after stump closure under effective analgesia.
689
72
73
72 Symes amputation for ankle and foot injuries: The Symes stump is well padded by soft tissues, it tolerates weight-bearing well, and is a good alternative where there is no prosthesis service. A condition for a good Symes stump is a heel fat pad without major damage (black arrows). The wounds decide the flap design (dotted lines). The incision is carried directly through the skin, subcutaneous fat, fascia and tendons. The calcaneus bone is released by sharp dissection close to the bone to protect the vascular supply to the heel pad. The tibia and fibula are cut just above the ankle joint, and the bone edges trimmed with a rasp. After 5-10 days the stump is clean and without infection: The heel flap is then trimmed and sutured to the fascia and skin in front. 73 Amputations at the foot: Partial traumatic amputations are magaged by ray amputation of one or two metatarsals, see p. 384. In larger injuries either amputate through the metatarsal shafts 1, or do disarticulation through the tarsometatarsal joints 2. For mid-foot amputations we recommend long and thick allin-one plantar flaps of skin, fascia and muscles.
74
74 Toe amputation is done through any joint of the toe, or through the metatarsal bone as ray amputation. Take care to cut the nerves as proximal as possible.
690
The main problem with plaster casts: They break when wet. Use orthosis of PWC materials for out-patient management, see p. 352.
The exudation from extensive thigh and leg injuries may be considerable. If you use the Trueta plaster method, the staining and smell from the plaster may be a problem. Explain to your patient that the more staining there is, the better the drainage and the better the prognosis. If you drape the plaster in cloth bags, the smell is reduced to an acceptable level. Soft tissue infection In most cases secondary infection is the result of poor primary debridement and/or drainage. Re-operate without delay with wide exploratory incisions; excise the necrosis left over from the primary surgery. Hesitation to do another debridement may put both limb and life at risk. Especially explore the anterior lower leg compartment: The clinical signs of complete compartment necrosis may be few warm skin over a tender anterior compartment indicates exploration. Necrotizing fasciitis is a condition seen sometimes after extensive crush injuries of the lower limb: A few days after injury, widespread necrosis of the skin, subcutaneous tissues and fascia develops very rapidly and affects wide wound fields much like a deep burn wound. In most cases the fasciitis is caused by streptococcal strains. The management is aggressive debridement with excision of all necrotic skin, subcutaneous fat and fascia, followed by saline or potassium permanganate baths and secondary skin grafting. In cases where the infection and necrosis are quite resistant to treatment, amputation must be done. Arthritis The reason is poor primary surgery debris, dirt, foreign bodies or necrotic tissues were left inside the joint. Or the joint was infected through an open fracture, missed at the time of primary surgery. Re-operate without delay with wide exploration of the joint and resection of all necrotic bone fragments. If you are able to close the joint after the re-debridement, arrange continuous antibiotic washing of the joint. If the joint cannot be closed, the case is one for amputation or arthrodesis. Post-operative fracture infection The management is surgical, there is no wait-and-see: Re-explore the fracture, and remove all necrotic bone fragments without compromise. Most important: Clean up the soft tissues and close the fracture by healthy muscle or muscle-skin flaps. If this is not possible, the case is probably one for amputation.
Delayed healing of fractures Despite good soft tissue management, no evident local infection and early weightbearing, some tibial shaft fractures heal very slowly:There are no signs of bony union in X-rays three months after the injury, and by clinical testing the fracture remains just elastic for months. Then consider three possible reasons: Missed infection? A low-grade osteomyelitis prevents bony union. Vascular injury? A missed vascular injury may cause poor fracture nutrition and delayed healing. Poor nutrition poor general condition? In patients immobilized for weeks in a catabolic state, fractures heal slowly/do not heal even under optimal local conditions.
691
75
75 Osteotomy of the fibula and weight-bearing accelerates healing After bone resorption in the fracture line, the uninjured fibula distract the fracture fragments. Do oblique fibular osteotomy (chisel or Gigli saw) and remove a 1-cm long segment of the fibula. Then apply a Sarmiento plaster cast or orthosis, and tell the patient to load the fracture close to the pain limit. He may have to wear the orthosis for one year, but sooner or later the fracture will heal. Scarring and contractures Excessive scarring with contracture of joints will interfere with the rehabilitation. Contracted scars of the skin and subcutaneous tissue are managed with Z-plasty, or scar excision with skin grafting at an early stage. Sometimes the knee is stuck in extension. This is often due to shortening of the quadriceps or it being tethered to the fracture site. Consider manipulation under anaesthetic to restore flexion, followed by intensive mobilization in the first instance. If the mobilization is successful, the joint will contract again if it is not moved 4-6 times a day for 2-3 weeks under effective analgesia. In refractory cases surgical release and quadriceplasty has to be considered. 76
76 Knee joint contracture lateral tenotomy: Secondary tendon contractures are managed by tenotomy. Intensive active exercises and passive movements of the joint are necessary to prevent re-contracture. The lateral tenotomy is done through a short skin incision posterior to the lateral collateral ligament of the knee (LCL). Note: The peroneal nerve is located close to the skin identify and isolate it. Do a Z-plasty (dotted line)on the lateral hamstring tendon. The elongation of the tendon should be about 4 cm. 77 77 Medial tenotomy at the knee: The sartorius muscle (S) is retracted forwards, and the tendons cut close to their attachment (G the gracilis tendon, H the medial hamstring tendons). Raise an anteriorly based flap of the periosteum at the femur condyle, and suture the tendons under this flap. MCL the medial collateral ligament of the knee.
692
78
78 Z-plasty elongation of the Achilles tendon is done through a skin incision lateral to the tendon. Poor amputation stumps The lower leg amputation stumps should be well designed to be able to take the weight load and control the prosthesis. Painful points may be due to bone fragments or foreign bodies left over from the primary surgery or neuroma formation; do surgical exploration sooner rather than later to prevent chronic pain syndrome. If the stump is clumsy or the amputation level is inconvenient for prosthesis adaptation, better do a secondary elective amputation and revise the stump. Localized chronic skin sores and minor areas with poor soft tissue padding are managed by excision and full thickness skin flaps. 79
79 Excision and sliding graft: The actual skin area is excised, and a broad flap of skin with subcultaneous fat is carefully raised from the fascia. The flap is mobilized for direct suture to the excised area. Unlike the free skin graft, the sliding graft contains sensory nerves.
693
694
42 Burns
The physiology of burn injuries Fluid therapy
................................................. ........................................
........................................................................
Life support and life-saving surgery Wound care and burn surgery Some special burn wounds Complications of burns
...................................................
.......................................................
...........................................................
...................................................
695
42 Burns
Burn fever: Due to the hypermetabolism, the regulation of body temperature is adjusted. The normal body temperature in a major burn case is around 38 C, that is, fever does not necessarily indicate infection.
696
Assess the depth of the burn wound Exact early diagnosis of depth is difficult, but an approximate assessment should be done for triage and planning of surgery. The burns are classified as superficial (S), partial thickness (P), deep partial thickness (DP) and full thickness / deep burns (F): The superficial burn heals without further therapy. The loss of fluids is minimal. A partial thickness burn leaves the deep layer of the skin (dermis) uninjured. Dermis produces the skin cells: A partial thickness burn may heal within 2-6 days. If it is deep (DP) and only some islands of the dermis remain undamaged, it will
697
42 Burns
heal within 2-3 weeks, and leave some scarring in the wound field: Close deep partial thickness burns with skin grafts. A full thickness burn (F) does not leave any skin producing elements in the wound. The wound will be covered with a stiff plate of dead skin elements the eschar. The full thickness wound heals by scar tissue proliferation from the wound edges. The final result will be a massive scar field, painful, with risk of contracture formation. Clinical signs of burn depth Partial thickness burn wound: There are skin blisters filled with clear fluid. Prick test with needle: There is some sensation of pain in the wound field. Full thickness burn wound:You can see mall thrombosed blood vessels deep in the burn wound (the vessels are located under the dermis). The wound is painless on needle testing (the skin sensory nerve ends just beneath the skin).The skin appears stiff and non-elastic, hairs can easily be pulled out. Danger: Eschar formation in deep burns! After some days, the full thickness wound forms a dark and stiff plate of necrotic tissue called eschar. The eschar is a typical sign of the deep burn wound. It may include the subcutaneous tissue down to the muscle fascia, main nerves, vessels and tendons. Eschar and surgical decompression, see p. 709. Compartment syndrome, see p. 303. Under the eschar the soft tissues become swollen. If the eschar takes much of the circumference of a limb, a compartment problem develops: The veins collapse; the soft tissue pressure further increases, and may obstruct also the limb arteries. As burn cases are already hypovolemic, the compartment problem in burns develops at a lower tissue pressure. Repeated exams! The depth of skin burns is often underestimated at first sight. Close monitoring for some days by experienced staff may identify areas of full thickness injury. Airway injury Early airway complications after the inhalation injury may be due to thermal irritation or burns to the airway mucosa, chemical irritation due to inhalation of irritant or toxic smoke and gases or both. Signs of thermal damage: Examine the face and pharynx burn wounds around the mouth, nose or inside the pharynx indicate airway burn. Wheezing during inspiration indicates upper airway injury. Unrest, high respiratory rate, and wheezing during the expiration indicate damage to the lower airways. Signs of chemical damage: Suspect a combined thermal-chemical problem in casualties injured inside a closed space, with inhalation of heavy smoke from burning furniture, oil etc. Carbon monoxide (CO) and/or cyanide poisoning may cause loss of consciousness and death: Give 100% oxygen to comatose cases. Order bedrest and monitor his condition for 48 hours after injury even if he is without early symptoms.
698
Do not miss the inhalation injury The early clinical signs may be few. In all cases with burns around the mouth and nose, and patients with high RR despite good pain relief: Bed-rest in half-sitting position Monitor the respiration for 48 hours.
Fluid therapy
As the loss of fluid is massive during the first 24 hours postburn, the patient needs aggressive fluid therapy in the initial phase. The Parkland formula has been used for 35 years to estimate the initial fluid requirements. The original Parkland regime and also Brooks and other formulas included colloid/plasma/albumine infusion in addition to electrolytes. Recent meta-studies document that there is no gain in colloid treatment for major burns. The Parkland calculator, see pocket folder at back cover. A rough guide for in-field care providers, see p. 208. The New Parkland Formula: Electrolytes for the first 24 hours 4ml x kg body weight x burn area in % of TBSA Give at least half the dose during the first 12 hours after injury. The Parkland calculator in practice Take a burn case, body weight 50 kg, burn area 35% of TBSA. Fluid needs for the first 24 hours postburn: 4 ml x 50 x 35 = 7,000 ml Ringer. The first 12 hours: Give at least half the total day volume, 3,500-5,000 ml Ringer. The next 12 hours: Give the rest of the total day volume. The next days Give enough fluids to keep up the urinary production at 1 ml/kg/hour. Oral fluid therapy Minor burn cases should be given per oral fluid and nutrition. Adults with burns less than 20% TBSA, children with burns less than 10% TBSA: Give sodium bicarbonate and salt in water. Add sugar from the second day postburn. One teaspoon sodium bicarbonate (4 g NaHCO3) is mixed with one teaspoon salt (5 g NaCl) in one liter of water. After 48 hours: Add nutrients, see next page. Blood transfusion Normally there is a slight increase in the hemoglobin level due to hemoconcentration the first days postburn even when the volume therapy is well run and matches the loss of fluids. This can mislead us to miss the burn anemia. Patients with full thickness burns of more than 10% TBSA regularly lose red blood cells and platelets during the first days. Also patients with extensive partial thickness burns may develop post-burn anemia.
699
42 Burns
Falling hemoglobin level as early as the first day postburn indicates associated bleeding injury: Identify the bleeding source and control it!
The volume of blood transfusion needed is indicated by a standard formula: % deep burn x 50 = ml blood transfusion. Monitor the hemoglobin level for one week; additional transfusions may be needed. aggressive fluid therapy supports blood circulation tissue edema poor blood perfusion Good for vital organs Bad for burn wound
The difficult balance: Vital organs versus the burn wounds. Around the burn wound is a rand zone of partly damaged skin. One aim of burn wound care is to prevent necrosis of this zone. But capillary leaking makes fluid slip from the vessels into the interstital space which causes edema of nonburnt skin and poor blood perfusion of the rand zone. The result will be tissue necrosis, extension of the burn wounds, and increased post-injury stress. On the other hand, if the loss of fluids remains uncompensated, the blood perfusion of vital organs will fail. The resuscitation of major burns is therefore a careful balance between local and central needs. Formulas are guidelines only The loss of fluid and blood elements varies from case to case: Inhalation injury with airway burn invariably increases the need for fluid and volume therapy. The Parkland formula has tendency to over-estimate the fluid requirements. Still, we should use it as a starting point. The best indicators for the volume therapy Urine production of 1 ml/kg body weight per hour Hematocrit of 20-25.
Nutrition
The metabolism after burn injuries is increased by 50-200% in relation to the normal condition. In burns of more than 20% of the TBSA, high-energy nutrition is essential to prevent weight loss, reduce the rate of infections, and prevent secondary organ failure.
700
Nutrition
Basic Energy Expenditure BEE is the energy used by the resting and healthy human body to maintain the vital functions. BEE is given in kilocalories (kcal). Calculate the need for nutrition BEE kcal = 66 + body weight (kg) x 13.7 + height (cm) x 5 - age (years) x 6,8 Needs for nutrition after injury and surgery, see p. 768. The metabolism of a burn case increases with the extent of area burnt. The actual energy requirement may be BEE x 2 or BEE x 3 depending on the extent of the burn, and associated injuries. The feeding procedure The metabolism is depressed for the first 24 hours postburn. But from the second day on high-energy nutrition is needed. Moderate cases can take per oral and nasogastric feeding. Major cases where the rehabilitation will be lengthy benefit from gastrostomy tube feeding: Start enteral feeding infusion at 50 ml/hour and increase gradually to a maximum of 200-250 ml/hour. High protein diets:There is loss of protein in extensive burns, especially if the burn is deep. The feeding diet should contain at least 100 g protein/day for an adult. Low salt concentration: There is some retention of sodium during the first 48 hours postburn. Hypernatremia is increased after high volumes of Ringer infusion. The enteral diet should thus have a low content of salt. No salt should be added to the diet unless serum electrolytes are monitored.
Enteral feeding procedures, see p. 778. Make diets of local foodstuffs, see pp. 782-89.
42 Burns
range blast injury from shelling may cause combined thermal burn-shrapnel injury. Fuel-air-explosives may cause very deep burns combined with blast as well as penetratig injuries. Circulatory shock: Even moderate blood loss in any type of associated injury may cause circulatory shock within a few hours due to the burn hypovolemia. Thus a burn more than 20% of the TBSA also increases the priority of the associated injury be it an abdominal injury or a fracture. Respiratory problems: Blast pressure injury to the lungs may complicate the inhalation injury. Both types of injury may be free of symptoms during the first 24-48 hours after the injury. Wound infection: Burn wounds with shrapnel and dirt after close-range explosions are contaminated and infected from the time of injury. The time factor affects the triage: The 8-hour limit The evacuation of patients may be delayed due to entrapment or heavy military pressure. Cases with burns more than 30% TBSA have high risk of secondary organ failure if the volume therapy is delayed more than eight hours postburn. The capacity of the medical network affects the triage Consumption of materials: A 30% TBSA burn may need 60-80 liters of fluid and 5-10 liters of blood/plasma expander during 10 days. Consumption of time and staff: A 30% TBSA burn may need dressing one or twice a day (60 minutes for one or two paramedics) for 2-3 weeks. And 5-10 surgical operations under anesthesia. A high risk of complications in burns of more than 30-40% TBSA further adds to the load.
42 Burns
Airway obstruction: Analgesia and sedation. Repeated tracheal suction. Aminophylline for bronchospasm. Consider intubation/tracheostomy and assisted ventilation. Consider tracheostomy. Patients with airway burns carry 3 times the mortality compared casualties without airway involvement. Breathing Analgesia is essential for effective breathing. Wide deep burns of the chest and abdomen: Escharotomy incisions improve the respiration, see p. 709. Inhalation injury: Give oxygen and broad-spectrum antibiotics. There is risk of paralytic ileus: frequent suction on naso-gastric tube. Circulation Examine the forward therapy and assess the fluid balance so far: Compensate for fluid deficit immediately. Circulatory shock on admission: Control bleeding from associated injuries. Control the fluid therapy strictly Estimate again fluid requirements by the Parkland formula. Check the fluid balance every 6 hours by the two main indicators: 1. Urinary output 1 ml/hour/kg body weight 2. Hematocrit round 25. Nutrition Estimate the actual energy requirement in kcal, see p. 769. Start high-energy nutrition on day 2 postburn: Make a glucose-protein solution of local foodstuffs. Give 50 ml/hour peroral or by naso-gastric tube, increase gradually to 200 ml/hour. Burns 30% TBSA or more: Consider gastrostomy or jejunostomy tube feeding.
704
The first 12 hours Airways:Tracheal suction. Postural drainage: alternate the position left-side position right-side position Breathing: half-sitting position. Ketamine analgesia (repeated IV doses of 40 mg). Oxygen. Chest tube: 500 ml blood is drained immediately. Naso-gastric tube. Volume therapy: 1. Requirement due to the burn: 4 x 70 x 40 = 11,200 ml the first 24 hours, of which approximately 7,000 ml should be given during the first 12 hours. There is thus a deficit of 7,000 - 3,000 = 4,000 ml Ringer on admission. 2. The fluid requirement is increased in cases with inhalation injury: Add 1,0002,000 ml Ringer. 3. Requirement due to 1,500 ml blood loss: 2,500 ml Ringer compensates 1 liter blood loss. This patient needs approximately 4,000 ml Ringer to compensate the blood loss. Better give 1,000 ml blood transfusion and add 1,000-2,000 ml Ringer. 4. Conclusion: The initial fluid therapy is thus flush infusion of 4,000 + 3,000 = 7,000 ml Ringer and 1,000 ml blood/plasma expander by double large-caliber IV lines or venous cut-down with large calibre IV catheter. Further volume therapy depends on the urine production and chest blood loss. Staged surgery: The risk of airway complications and circulatory collapse is high. Stabilize and drain the femur fracture, but delay debridement and fracture fixation until the patient is in stable circulatory state and nutrition is established (day 3 or 4 postburn). 12-24 hours postburn The rest of the first days total volume makes 11,200 - 7,000 = 4,200 ml Ringer. Add for increased loss due to the inhalation injury. Add for chest blood loss. Day 2 postburn Fluid therapy: Give around 2 ml x 70 x 40 = 5,600 ml electrolytes for the burn injury and add electrolytes or blood according to losses by the chest injury and the fracture. The only solid guide for the volume therapy is to keep the urinary output around 70 ml/hour. Start high-energy nutrition: His basic nutritional needs are 66 + (70 x 13.7) + (180 x 5) --- (50 x 6.8) = 1,585, that is 1,600 kcal/day. Consider him a stress level-3 case due to multiple injuries and extensive burns: That makes the actual energy requirement 1,600 x 2 = 3,200 kcal/day. This patient carries high risk of complications, the rehabilitation will take time, so enteral feeding should be arranged: Make gastrostomy with large-caliber feeding tube under ketamine anesthesia. Start feeding with a glucose-protein solution 1,500 ml per day of blood or plasma expander. Enteral fluid therapy plus nutrition: Give a high-energy diet made of local foodstuffs, 200-300 ml per hour.
705
42 Burns
706
707
42 Burns
No prophylactic antibiotics! The burn wound infections are best prevented by proper debridement, topical antimicrobial creams, early skin grafting and early high-energy nutrition. Broad-spectrum antibiotics are reserved for inhalation injuries, and secondary infections when a specific bacterial diagnosis is established.
is removed every 1-2 days for wound monitoring, soap washing and repeated bedside debridements. Closed wound management is the method of choice in outpatient cases, under dirty field conditions and during evacuation. For prolonged evacuations and outpatient treatment of limb burns, the Trueta plaster method may be used: The plaster protects the wound during transport; it reduces the pain and effects continuous good wound drainage. The Trueta plaster is also the method of choice in limb burns combined with extensive soft tissue injuries or fractures. Note: A tight vaseline gauze causes fluid retention and wound infection: Pull some threads from the gauze.
For years, silver sulfadiazine (SSD) burn cream has been the treatment of choice for partial thickness burns. The agent has a a wide antibacterial action. However, recent studies document that SSD delays healing of deep burns as it has toxic effects on keratin-producing cells.
Burn creams The use of special burn creams will reduce the risk of burn wound infection. Sulfamylon burn cream (mafenamide acetate) has a potent antibacterial action including Pseudomonas, but there are resistent strains of Staphylococcus aureus.The drug penetrates even deep burns.The application of Sulfamylon is painful in partial thickness burns. The cream causes hypersensitivity reactions in one out of ten cases. Honey is a cheap and efficient dressing alternative. It is well documented that honey accelerates the healing of partial-thickness burns. Warm the honey before application and cover under clean plastic wraps.
Burn surgery
Skin grafts, the technical procedure, see p. 398. Deep partial thickness burns: early skin grafting Thin split-thickness skin grafts reduce the evaporation and exudation through the burn wound. Also skin grafts are the best possible dressing, and help prevent wound infection. Start grafting as soon as the patient is in stable circulatory state. The main problem in extensive burns is lack of donor areas: Better take very thin grafts to be able to re-use the donor areas every 2-3 weeks. Meshing enlarges the grafts and improves drainage through the grafts. Use meshing machine or cut numerous small incisions in each graft. Full thickness burns: early escharectomy and skin grafting The eschar plate poses two problems: 1. The eschar is non-elastic.When edema builds up under the stiff escharplate, the eschar of a circumferential limb burn may cause a compartment problem.Wide eschar fields on the chest and abdomen may restrict the breathing and cause abdominal compartment syndrome. 2. Fluid collecting under the eschar of full thickness burns makes a base for local infection. Emergency escharotomy: Escharotomy may be done bed-side without anesthesia as the eschar itself is insensible. One or more longitudinal incisions are made through the eschar into bleeding subcutaneous tissue. The soft tissue pressure will widen the incisions and confirm that escharotomy was necessary.
709
42 Burns
Escharectomy Excise the eschar as soon as the patient is in a stable state. After echarectomy, the area is covered by saline-wet dressing for some days. Skin grafting is done as soon as healthy granulations have developed. Alternative 1 escharectomy to the fascia: The eschar is excised together with the subcutaneous tissues down to the muscle fascia. The excision is done by blunt and sharp dissection along the fascia. Bleeding vessels are carefully clamped and tied, the blood loss is moderate.Then apply split-skin grafts on the fascia; the take is normally good. Alternative 2 tangential escharectomy:The eschar is excised layer-by-layer until you reach healthy tissue. One-step complete tangential escharectomy bleeds much and requires bipolar electro-coagulation and blood transfusion service. Scar excision at the limbs can be done in a bloodless field which makes it difficult to assess tissue viability as you cannot see the bleeding from capillary vessels. Another alternative is adrenaline injection under the eschar plate: Dilute 1 mg adrenaline in 500 ml normal saline and inject the soluton fanwise with a long needle as the excision progresses. Two-step escharectomy is also an option: First do a partial excision, then apply burn cream (mafenamide acetate), and await the demarcation of the eschar (1-2 weeks) before the definitive escharectomy is done. Lack of graft donor areas: Use human allografts Lack of suitable skin donor areas is a problem in extensive burns. Synthetic and biologic skin substitutes are available, but very expensive. Human allografts may solve the problem: Harvest split-skin grafts from relatives or friends of the patient, or from volunteers. Collect many grafts and store them under sterile conditions in refrigerator. The allografts will primarily stick to the patients burn wound as his own skin grafts. But within 1-2 weeks they will become detached and should be removed at the dressings. In the meantime they serve as a valuable biological wound dressing for many days, restricting fluid loss and preventing local infection.
Soft tissue flaps for the hand and foot, see pp. 335-39.
Burns to the cartilage Deep burns of the nose and ears may cause necrosis of the local cartilage with chronic suppuration. Excise the necrotic cartilage at an early stage to prevent infection. Reconstructive surgery is done later. Thermal bone necrosis The heat exposure from modern heat-generating missiles is intensive. Also the subcutaneous tissue and muscles may be damaged. Where the bone has poor soft tissue padding (hands, feet) the heat exposure may cause extensive vascular damage and thrombosis:Within some days postburn, the bones become soft, waxy and start to suppurate. Osteomyelitis will develop unless all dead bone is excised, and the wound covered by healthy soft tissue (local or distant muscle-skin flaps). Burns to the perineum There is risk of secondary infection from urine and stools. Use exposure wound management. Insert bladder catheter. Consider temporary diversion sigmoidostomy in extensive perineal wounds.
Chemical burns
Particles or droplets of phosphorus or napalm cause circular deep skin burns. If the chemical is not removed immediately, it gradually penetrates deep into the tissues until all the active agents are burned out. Shrapnels from grenades and cluster weapons may also contain burning agents and cause extensive internal injury.
711
42 Burns
The essential treatment for chemical wounds is done at the site! The burning chemical must be removed as soon as possible. Use any knife at hand to cleanse/excise the wounds. White phosphorus Do not pour water in the wound. White phosphorus ignites on contact with water at 32 C, giving off phosphoric acid fumes, and spreads inside the wound field making debridement more difficult. Phosphorous particles have to be mechanically and meticulously removed. If left, they spontaneously burn and the fumes consume the water in the tissue to form phosphoric acid, in the process burning all tissues. The fumes are highly acidic and toxic. The effects of the fumes are that they dissolve to produce a massive acidosis and also to corrode the respiratory tract, eyes and mucous lining. Survivors of the early sytemic effects often succumb to later respiratory failure, liver and kidney failure. In theory, topical copper sulfate solution and potassium permanaganate solution will neutralize phosphorus and napalm inside chemical burns. In real life the neutralizing solutions are not very useful:They are not available in the fighting area; on clinic admission the active agent normally would have burned out. Also copper sulphate poisoning has been reported when used extensively to treat phosphorus burns.We recommend that all paramedics, village health workers and fighters be instructed to do surgical cleansing of the chemical war wound. Neutralise the acidosis with sodium bicarbonate infusion. Give respiratory support.
Complications of burns
Burn wound infection Let experienced staff dress and monitor extensive and deep burn wounds to diagnose wound infections as early as possible. The signs of infection: Increased wound discharge, foul smelling or change in color of the discharge. Healthy granulations turn pale and degenerate. Separation or poor take of thin split-skin grafts (normally due to beta-hemolytic streptococci). Secondary spontaneous bleeding from the wound. Cellulitis or formation of small abscesses in healthy skin around the burn wound. The management: Explore other sources of infection: a missed injury from penetrating shrapnel, thermal necrosis of cartilage or bone, and infection in a long-term IV catheter. Burn wound infections are primarily managed by frequent (three times a day) soap or saline baths with debridement and application of burn cream. Consider systemic antibiotics: Early infections (first week postburn) are mainly caused by gram-positive bacteria, and respond to penicillin. After 1-2 weeks gram-negative bacteria dominate (E.coli, pseudomonas): Tobramycin and cephalosporines may be effective.
The bacterial diagnosis of burn wound samples is uncertain as the bacterial population is usually mixed.
712
Complications of burns
Infection in deep burn wounds Discharge and bleeding from under the eschar, and early separation of the eschar are signs of deep burn wound infections. Note that anaerobic infections may develop under the eschar. Escharectomy: Remove all eschar by excision down to the muscle fascia. If for some reason complete escharectomy is not possible, inject broad-spectrum antibiotics fanwise under the eschar plate twice daily. Give metronidazole IV to prevent anaerobic infections. Acute renal failure in extensive burn cases The main cause of renal failure in burns is hypovolemia the patient has fluid deficit. To prevent permanent renal failure, early diagnosis of low urinary output and immediate volume therapy is essential: Monitor the overall fluid balance and calculate the urinary output per hour for every 8-12 hours. If the urinary output becomes low, flush a bolus of IV fluid. If the urinary output does not increase, give mannitol or diuretics.
Organ failure Gastro-duodenitis secondary to major burns may be fatal due to massive spontaneous bleeding from the stomach. The risk is reduced if oral or enteral feeding is used. Major burn cases should have prophylactic antacid every four hours. Respiratory faiure and coagulation system disorders are common in extensive burns, and may develop as late as 1-2 months postburn.
713
714
Section
715
716
......................................................................... .....................
Cardiac complications
Renal failure and crush syndrome ............................................. 732 Coagulation system complications
..............................................
Multi-organ failure ................................................................. 736 Monitoring and complications after abdominal surgery
....................
603
717
Simple, but good enough Good post-operative care does not depend on monitors and ventilators, but close clinical monitoring. This manual is written for low-resource settings where there are few drugs and little or no laboratory service.
718
Normally the capacity for surgery is not the limiting factor, but the capacity for post-operative care and rehabilitation. That is why the staff-training program is a continuous and integral part of wartime surgery.
Wound care
The daily dressings are diagnostic To reduce the risk of septicemia and secondary organ failure, early identification of wound necrosis, infection and abscesses is essential. That can only be done by experienced staff monitoring all major war wounds at daily dressings. One and the same nurse/doctor should be resonsible for the patient. Train your staff in wound care The open debrided war wounds are like windows through which the physiology of repair can be studied at close range. Spend time to train your staff in essential clinical signs: to identify necrotic tissue, to distinguish healthy granulations from deteriorating granulations, to use the color and smell of the wound discharge as indicators of secondary infection, to explore causes of delayed healing. The surgeon should take part during daily dressings of major war wounds for training. Strict organization The post-operative management of war wound makes a heavy demand on the clinics. Organising the post-operative care should be the concern for the senior surgeon: The war wounds are many, but not all of them need expert care. Identify the patients with risky wounds and give them special attention. Expert wound monitoring and an aggressive approach to re-debridements reduce the rate of secondary complications and increase the turnover of patients. Implement strict routines to make the daily dressings less time consuming. Do not transmit infection between the patients: Strict hygienic routines. Separate equipment and wards for the infected cases. Disinfection and sterilization, see p. 760. Disinfection There are lots of chemical disinfectants. Most of them are expensive, some of them cause toxic or allergic reactions in the wound field. Medical staff tend to rely upon the claimed bactericidal effects of super-solutions: but no disinfectant takes effect within seconds, the result is hurried and poor disinfection. Soap is good enough For several reasons we recommend solutions of plain soap (without additives) in boiled water as the standard disinfectant: The disinfectant capacity of soap is as good as most chemical agents provided you use the time needed for disinfection. Plain soap is always and universally available at low cost and in sufficient amounts. Standard soap solutions of varying concentration may be used as the general disinfectant: washing of hands before surgery, washing operating fields before surgery, personal hygiene, wound toilet, instillation into joints and deep instil wounds, and washing of beds and clothes. There are few toxic and allergic side effects of plain soap solutions.
719
Topical antibiotics and concentrated chemical solutions have no place in wartime wound management. NaCl solutions NaCl-wet gauze for dressing has a particular effect in speeding up the growth of wound granulations. Dressing with meshed gauze wet with NaCl 0.9% is used directly upon the raw wound surface; change the dressing 3-4 times a day. Slightly concentrated NaCl solutions will further stimulate the wound granulations, and may be used the last 2-3 days before skin grafting. Do not apply iodine solutions in open wounds; it may trigger excessive scaring and keloid formation. Hydrogen peroxide solution Small amounts of the 2.5% or 4% solution are used to clean a wound where there is much debris, dirt and blood clots. Let the solution act for half a minute. The peroxide solution may also be used where gauze drains are stuck deep inside the wounds. The problem of pain during dressing Painful dressings should be avoided: Pain interferes with the physiology of repair and delays the recovery. Pain and unrest during dressings make the dressing hurried thus the wound exploration and bed-side debridement suffer. Pain is not necessary you have the means at hand to prevent it: Give a small dose of IV ketamine 2 minutes before major dressings start (0.2 mg/kg).
Wound care
Major necrosis or possibility of abscess formation is a definite indication for surgical re-debridement on the operating table that same day. Drain the wound: Dry fluffy gauze has excellent draining capacity.The more exudate there is, the more frequent the dressings. Introduce the gauze carefully into every deep wound pocket. Do not press the gauze tightly into the wound: That causes tamponade and fluid retention. Suction dressing: Where you expect much discharge, make a dressing with several layers of cotton between layers of meshed gauze.
Study the bacteriology of common wartime wound infections, see pp. 746-53.
721
Poor venous drainage If the wound edges are swollen and the limb edematous, a bandage applying pressure to the wound edges may accelerate the healing: Cut a hole in a soft rubber plate corresponding to the wound edges. Place the rubber plate onto the wound and apply compressive bandage outside it. Elevate the limb and mobilize the muscle pump by active isometric exercises. Poor nutrition Inadequte feeding in major injuries causes protein breakdown and delayed healing: Weight loss is a sensitive indicator Vitamin and/or mineral deficiency may cause delayed wound healing. Malaria Falciparum increases the risk of wound infection and slows down healing. See p. 437. Mental depression, pain, lack of sleep Anxiety, pain and sleeplessness depress the immune system and also cause inactivity. The result is protracted healing of wounds.
722
Decentralized surgery reduces risk of post-operative infections. Study the experiences from previous wars, especially the Tripoli model, see p. 36.
Preventive measures High turnover of patients: Early mobilization out of bed, and early transfer to rehabilitations centers reduce the risk of cross-infection. Most patients staying for more than 10 days in the clinic, attract secondary cross-infection. Village surgery is better: Mobile field clinics carry less risk of hospital infections than the in-house stationary clinics. Hospital infections are less likely to develop under sunny, dry conditions. Consider moving the clinic frequently during the rainy season. Special ward/room/house for infected and chronic cases. Personal hygiene among the medical staff and the patients is not a personal matter: Set a strict standard and monitor it closely. Having a clean bed, a clean patient and a clean paramedic are efficient preventive measures. Organize washing routines for patients, beds, clothes, furniture and instruments. The consumption of soap and water will be tremendous. Organize the production side The consumption of basic materials for post-operative care issystematically underestimated. Engage ambulant patients, their families and the local population: Arrange a production unit and a dry store for dressing materials: Large quantities of gauze, bandages, soap solution, clean bedclothes and patients clothes must be available for mass casualties. Access to clean water may be a limiting factor. So, where there is lack of clean water, decentralize the clinic system.
723
Compare the rates of early and late infections in different groups of patients: An increasing rate of late infection in moderate cases indicates a hospital infection problem. The more so if the rate of infection also increases for the short-term patient group.
724
Respiratory work Is the respiration laboured, the patient exhausted? The reason may be respiratory failure with increasing stiffness of his lungs. Fatigue is a poor prognostic sign. Measures: Elevate the head end, half-sitting position Oxygen Consider gastric decompression: naso-gastric tube suction. Respiratory rate Frequency higher than 35/minute and thoracic (shallow and dog-like) respiration? The reason may be anxiety, pain, abdominal complications, or respiratory failure. Measures: Oxygen Rule out distension of the stomach and abdominal abscess formation Intensify analgesia, consider intercostal nerve block or pleural anesthesia through the chest tube. Lung auscultation One-sided poor respiratory sounds 2-3 days after surgery indicate collapse of one lung segment. Within 2-3 more days fever will arise as a sign of pneumonia. Pleural rubbing sounds and localized poor respiratory sounds indicate emboli of one lung artery branch. Moist dependent rales indicate fluid retention in the lung tissue (a total fluid overload or congestive heart failure). Measures: Rule out congestive heart failure Re-assess the intake-output balance: Fluid overload? Rule out pulmonary vascular embolism Start intensive respiratory exercises to prevent pneumonia Atelectasis/pneumonia: Start or intensify the antibiotic therapy.
Rule out cardiac failure Rule out septicemia Increase fluid intake. Monitor all drains. Estimate post-operative blood loss Note the volume from each separate drain, whether it increases or not. Increasing limb and abdominal circumference indicates internal bleeding. Spontaneous hematuria, delayed clotting after venous puncture, continuous or secondary bleeding after surgery may indicate coagulation system failure. Measures: Rule out poor bleeding control during surgery: Ask the surgeon responsible if something could have gone wrong. Do a simple bed-side clotting test, see p. 271. Hypothermia causes coagulation failure: monitor body-core temperature, consider central warming to 38 C. Input-output balance. Urine production per hour (UPH) Make a separate list of total fluid intake and output each day for each patient. The list is stuck to the bed and filled in continuously. Check the intake-output balance every 8-12 hours. Calculate the mean UPH at least every eight hours. UPH should be a least 50-70 ml for an adult (1ml/kg body weight). Less than 0.5 ml urine/kg body weight per hour indicates low circulating volume, renal failure, cardiac failure, or urinary tract obstruction. Measures: Rule out urinary tract or bladder catheter obstruction. Flush a bolus of IV fluids (1,000 ml) and monitor the urinary response. Poor response: Try diuretics (frusemide). Fluid over-load? No! Previously we thought that too much IV fluids would cause lung failure. Now we know that post-operative lung failure mainly is an effect of circulatory shock. A 70 kg person has 15 L of extracellular water, 4 L of plasma and 11 L in the interstitial fluid space (ISF). If he is short of circulating volume, fluid is shifted from the ISF into the circulation. Therefore post-operative fluid restriction does not prevent respiratory problems, but it may kill the kidneys. Persisting hidden shock Hypoperfusion and hypoxia may persist in the gastro-intestinal tract for 12-24 hours even if the skin is warm, and HR and BP is normalized. Intestinal hypoperfusion is a trigger of complications, see p. 164. UPH is the main indicator of what is the correct fluid input in each patient.
726
727
Stools Diarrhea and mucus with the stools indicate intestinal inflammation, side effect of broad spectrum antibiotics or fat overload Measures: Rule out endemic intestinal disease Consider stopping broad-spectrum antibiotics Revise the enteral diet. Feeding Monitor the quality of nutrition by three simple indicators: Body weight: Major injury and surgery normally cause water retention and some increase in body weight during the first 3-5 days after injury. Thereafter weight loss indicates protein and fat breakdown. No loss of muscle: We do not expect trauma victims to gain in weight and strength. The aim is to prevent loos of body protein. Measure mid-arm circumference every week in long-term cases. Wound-healing time: Delayed healing and poor resistance to infections indicate trace element, vitamin or protein deficiency.
Vitamins and trace elements in local foodstuffs, see p. 774 and p. 782.
Psychological support
Mental reactions to injury tend to follow a basic pattern The initial psychological shock reaction lasts for some days after injury.The patient is not able to understand information given to him. Indifference and mental depression are common in the shock period. Management: Show patience and kind care. The period of confusion: Anxiety, aggression and psychotic reactions are common 1-2 weeks after the injury. Consider these reactions normal. A protracted state of mental depression and indifference is a poor prognostic sign. The management: Start active mental stimulation. Physical exercises may stabilize mental reactions. Consider drug therapy (sedation or psychotropics) in serious cases only. The period of re-orientation: This period may start 1-3 weeks after injury. The patient starts accomodating himself to the new situation after the injury.The management: Work out a plan together with the patient for his mental and long-term physical rehabilitation. Demand his active participation in daily duties in the clinic and care for fellow patients. Excessive and permanent confusion with no signs of rational re-orientation may indicate organ complications. Rule out: Missed head injury, or post-operative skull hematoma formation Renal failure with electrolyte disturbances and increasing blood urea Septicemia, or bacterial embolus to the brain with brain abscess formation Depression of the central nervous system as part of a multi-organ failure syndrome Drug side effect after repeated anesthesia and analgesia The patient may be a drug addict or an alchoholic Some endemic diseases (malaria and typhoid fever) may cause mental disturbances.
728
physical capacity of the clot and how fast it forms. For this we can use two simple bed-side tests: Bleeding time of 4-6 minutes indicates reasonable coagulation capacity. Also check the blood-clotting time: Draw 5 ml blood from the patient into a clean glass tube. Place the tube in your own arm pit to keep it warm. If it takes more than 5 minutes for a blood clot to form, suspect coagulation failure: Low platelet counts, or platelet dysfunction (hypothermia). A rapid dissolution of the blood clot (within less than 20 minutes) suggests coagulation system dysfunction (DIC).
Lung complications
Early Within one week after injury/surgery: acute respiratory failure, lobar atelectasis, pneumonia. The risk factors are: aspiration, chest trauma, patients undergoing laparotomy. The physiology of organ failure, see p. 162. Late One week to three months after injury/surgery: lung failure (ARDS). The risk factors are: lung contusion, poly-trauma, cases late for surgery, patients with peritonitis and/or abdominal abscess, major fractures of pelvis and long bones, multiple blood transfusions (more than 10 units). Lung atelectasis and pneumonia Atelectasis is a state of collapse of the lung tissue in one or several segments of the lung. The common cause is mucus and fluid obstructing the airways. Most often the dependent segments of the lung are affected. Atelectasis normally develops 13 days after surgery.The only early sign is localized dull percussion sounds and harsh breath sounds on auscultation. Chest X-rays may give the diagnosis. After some days the collapsed segment is invaded by bacteria and the pneumonia with fever becomes a fact. Preventive measures: Sitting/half-sitting position improves the ventilation of the dependent lung segments. Get the patient out of bed the first day after surgery if possible. Instruct all risk cases to expire against resistance: blow balloons or surgeons gloves. The positive alveolar pressure thus created helps prevent atelectasis formation. Give effective analgesia and assist the patient with respiratory exercises and coughing to prevent mucus obstruction of the lower airways. Perform frequent tracheal suction in patients with poor coughing capacity. When the atelectasis is already established: Analgesia with intensive respiratory exercises and repeated tracheal suction may prevent pneumonia formation. At this point extend the antibiotic regime to include gram-negative strains.
Do not use potent antibiotics for preventive reasons! Side effects of potent antibiotics, see p. 758.
730
Lung complications
Lung failure adult respiratory distress syndrome (ARDS) Risk case: the patient with labored respiration, respiratory rate higher than 3035/minute, and increasing fatigue. Monitor him closely. Confirmed diagnosis: Gradually the heart rate increases, and the patient becomes cyanotic. Chest X-rays show a typical picture of snowstorm patchy densities in both lung fields. Imbalance of arterial blood gases with hypoxemia and retention of carbon dioxide confirms the diagnosis. The optimal management consists of intubation and assisted ventilation on volume-controlled respirator with positive end-expiratory pressure. In a field setting such intensive care is not possible: The management will consist of oxygen, half-sitting position, respiratory exercises and analgesia. The mortality of ARDS is high concentrate on preventive measures Early and intensive life support and damage control surgery A complete regime for respiratory support after surgery: analgesia, early ambulation, respiratory exercises, physiotherapy, tracheal suction and drainage Early high-energy enteral feeding to major injuries Aggressive approach to complications: Re-operate and control bleeding before the circulation collapses; re-debride necrotic wounds before an abscess forms, do re-laparotomy for intestinal leak before peritonitis develops, identify and drain abscesses before the general condition worsens.
Cardiac complications
Cardiac arrhythmia, infarction, or myocardial depression may develop at the time of surgery and early in the post-operative period. Or late, as part of a state of multi-organ failure. Acute cardiac failure (1-7 days after surgery) Risk factors: Lasting circulatory shock and hypoxemia Chest injury with heart contusion Grave imbalance of electrolytes. Late cardiac failure Risk factors: Septicemia Multi-injury cases Extensive soft tissue crush injuries Extensive burns Acidosis Protracted recovery with chronic pain and anxiety.
731
Myocardial infarction The main risk period is during surgery and the first post-operative week. The signs may be chest pain and typical patterns of ischemia on the ECG. Note: The acute infarction may be camouflaged by post-operative pain and fatigue: The only clinical symptom may be arrhythmias and congestive cardiac failure. The management aims at reducing the load on the heart and securing optimal oxygen supply for the heart muscle to minimize the damage. The management consists of effective analgesia, oxygen, respiratory support, early diagnosis and treatment of arrhythmias, and very careful fluid load. The mortality is close to 50% even in the best hands. Myocardial depression pump failure Chemical agents (myocardial depressant factors, MDF) are released from the tissues into the blood circulation after extensive tissue damage, tissue ischemia and acidosis. Pain and anxiety further contribute to MDF release. MDF depresses the myocardial function and reduces the pump effect of the heart. Arrhythmia adds to the pump failure. The clinical picture is congestive heart failure: peripheral edema and dependent moist fine rales on lung auscultation. The management consists of the following: Acute failure with circulatory collapse: Repeated IV doses of ephedrin 0.2-0.3 mg/kg may help maintain the blood pressure. Digoxin 0.25 mg every six hours for 24 hours increases the myocardial performance. In cases with poor drug effect, consider glucose-insulin-potassium infusion: Give glucose 1g/kg + regular insulin 1 unit/kg + 20 mmol KCl as infusion over 10 minutes. The cardiac-stimulating effect lasts for one hour, and the infusion may be repeated. Beware of fluid overload: Maintain the hematocrit at between 30 and 35. Anemia due to bleeding is managed with packed red blood cell transfusion. Monitor the fluid intake-output balance closely: Fluid retention is managed by reduced fluid load and intermittent low IV doses of diuretics. Beware fluid underload: Poor cardiac output may also be due to low cardiac preload, that is a too small circulating blood volume. Documented fluid deficiency (fluid intake-output calculation) and high hematocrit (hemoconcentration) are indicative: Increase the fluid load carefully and see if the blood pressure increases. If not, reduce the fluid load. Diagnose and treat arrhythmias early.
Myocardial-stimulating drugs are available, but should not be used by inexperienced staff.
Renal failure
Acute renal failure Causes: necrosis of kidney tissue after hypoxemia or injury to the kidneys Risk cases: protracted circulatory shock, clamping of aorta or the renal artery during emergency laparotomy, urinary tract or catheter obstruction Diagnosis: decreasing urinary output per hour despite effective volume therapy.
732
Renal failure
Late renal failure Causes: septicemia, or a state of multi-organ failure Risk cases: septicemia, multi-organ failure, renal artery thrombosis Diagnosis: increasing serum creatinine above 1.5 mg/100 ml/day. Note: the urinary output per hour may be normal or increased. Standards Optimal urinary output: 1 ml/kg body weight per hour Oliguria low urinary output: less than 15 ml per hour (adult) Anuria no urinary output: less than 50 ml urine per 24 hours (adult).
Renal failure after extensive soft tissue injuries (the crush syndrome)
This special type of renal failure is common but often not recognized after extensive soft tissue injuries: mine amputations, major burns, and muscle crush injury. The kidneys are damaged by a particular muscle protein (myoglobin) released from crushed muscle tissue. More than 200 g muscle crushed predisposes to renal failure. The serum concentration of myoglobin reaches a maximum 12 hours after the injury, and signs of renal failure normally develop the first day after
733
Do not use frusemide: it acts on the loop and makes the urine acidic.
injury: red-brown pigmentation of the urine, and decreasing urinary output. Diagnostic: Urine test stix indicates hematuria (myoglobin is a hemoprotein), but urine microscopy shows no red blood cells. The management consists of increased production of alkaline urine: Start intensive volume therapy at the site of injury, see p. 207. At the clinic, give a mixed infusion of saline-sodium bicarbonate-glucose:The standard infusion is made of 100 ml NaCl 0.9% + 200 ml NaHCO3 500 mmol/l + 700 ml glucose 50 mg/ml. The infusion rate is 6-7 ml/kg/hour. Monitor the urinary response: The objective is to maintain a high urinary output of 5 ml/kg/hour, and alkaline urine with pH above 6.5 for 48-72 hours. Give mannitol infusion 1 g/kg if the urinary production decreases despite the fluid load. Monitor the circulation: There is a risk of fluid retention and congestive heart failure, but the risk is small in young patients with normal respiratory and cardiac capacity. Monitor the serum potassium there is a risk of hyperkalemia: To prevent arrhythmia, give IV calcium-cloride 10 mg (adults) in hyperkalemia higher than 6.5 mmol/l.
734
After injury the coagulation normally dominates After injury the coagulation system is modified: The clotting system becomes predominant. Acidosis and tissue hypoxia further increase the clotting tendency. But the injury also activates the fibrinolysis the more extensive the injury, the bigger the increase in the fibrinolysis. Hypothermia (body-core temperature below 34 C) and grave acidosis (pH below 7.2) may cause general clotting failure. Monitoring Clinical monitoring of the circulation, and the bed-side clotting test are sufficient for our use: Leave a venous blood sample for clotting in a plain glass tube bed-side. A clotting time of 5 minutes indicates that the clotting system is at a normal level. Clot dissolution within 20 minutes indicates increased fibrinolytic activity: suspect a state of DIC (see below). Thrombosis after surgery Peripheral venous thrombosis: Clinical signs are localized deep pain, edema and pale-bluish skin.The most common sites for venous thrombosis are the deep veins of the leg, thigh and pelvis. Artery thrombosis: Early clinical signs are pale and cool skin and decreased capillary circulation distal to the occlusion. Partial loss of neurological function is a late sign. Lung embolus: Sudden chest pain and respiratory distress are indicative. Rubbing pleural sounds may be heard on auscultation, blood stained tracheal mucus may be present. Note that the clinical signs may be few in patients in poor general state. Antithrombotic therapy Preventive: Active exercises from the first day after surgery. Get operated patients out of bed the first day after surgery if possible. There is no well documented effect of preventive drug therapy in injury surgery at reasonable costs. Clinical signs of thrombosis immobilize the patient and start the antithrombotic regime immediately: Give standard heparin 150 IU/kg body weight as an IV booster dose. Then a continuous infusion of heparin 300 IU/kg/day in in glucose 50 mg/ml. Monitor the tendency to bleed: Stop the infusion in case of bleeding, the heparin effect soon diminishes.
Protamine sulfate is the antidote to heparin, 1 mg neutralizes 100 IU heparin. Protamine sulfate is seldom needed.
Tendency to bleed
The clinical signs are bleeding from everywhere during surgery, re-bleeding after surgery, delayed clotting after venous puncture or spontaneous hematuria. Consider several causes: Low platelet counts: Low platelet counts are normally a sign of increased platelet activation and consumption. A sudden fall in platelets after surgery indicates serious complications: septicemia, abscess formation, DIC, multiorgan failure. Low platelet counts are also seen after multiple blood transfusions, specially where transfusion reactions occur: Expect disturbances in the coagulation system after transfusion of more than the total blood volume (adults: 45 liters). Normal platelet counts, but poor platelet function: Extensive surgery (especially laparotomies) and major wounds (especially major burns) cause loss of tem735
perature: hypothermia with body-core temperature below 34 C causes platelet dysfunction. Platelet dysfunction may also be seen secondary to renal failure, and as side effect of drugs (sulfa antibiotics, quinine, quinidine, aspirin and indomethacin). Specific therapy is transfusion of fresh whole blood containing normal platelets. Protein deficiency: After prolonged starvation, chronic intestinal diseases, liver injury and liver failure, the synthesis of proteins essential to normal coagulation may be impaired.The result is increased fibrinolysis and bleeding tendency. The specific therapy consists of transfusion of fresh plasma or fresh frozen plasma. Infections:Vascular wall damage and spontaneous bleeding are often seen in septicemia, meningococcal infections, typhoid fever, and advanced cases of AIDS. Vitamin K deficiency: Vitamin K is an essential factor in the clotting system. As a fat-soluble vitamin, the intestinal absorption of vitamin K is impaired in malnutrition, after bile obstruction, bile fistula, and major liver injury/liver failure. Specific therapy: 25 mg vitamin K IM for three days.
Multi-organ failure
The physiology of multi-organ failure, see p. 169. Serious injury cases that survive early complications as circulatory shock, acute renal failure and pneumonia, are the risk cases for multi-organ failure. Note: Also the organs which were not damaged at the time of injury may fail. One cannot predict when, which, or how many organ systems will be involved. The multi-organ failure syndrom may develop one week to three months, most often 1-2 weeks, after primary surgery. High risk cases to develop multi-organ failure Patients with septicemia Patients with post-operative peritonitis or abdominal abscess formation Burn polytrauma.
736
Multi-organ failure
Common signs of multi-organ failure Early increased capillary permeability: general edema, increased body weight, and high demands for fluid therapy. Within some days hypermetabolism and circulatory signs: increasing heart rate, falling blood pressure. Then come the signs of organ failure which may be two or more of the following: Lungs: respiratory distress, hypoxemia, pulmonary congestion and edema Kidneys: increasing serum creatinine Coagulation system: tendency to bleed, DIC Liver: jaundice, failure of the protein synthesis, catabolism The gastro-intestinal tract: spontaneous ulceration and bleeding The immune system: delayed healing of wounds, less resistance to infections, erruption of infection and abscesses in healthy tissue The central nervous system: semi-consciousness or coma. The best management is preventive The mortality of multi-organ failure is above 50% in advanced trauma centers; in a wartime field setting it is close to 100%. Factors that decrease the risk of multi-organ failure: Correct early triage of casualties: Identify the cases with high risk of organ failure. Basic life-saving support and surgery: Control bleeding by forward surgery to prevent lasting circulatory shock and hypothermia. Aggressive monitoring and surgery: Re-operate immediately to debride persistent necrotic tissue, prevent peritonitis, and drain abscesses. Intestinal hypoperfusion the motor of multi-organ failure Lenghty circulatory shock causes hypoperfusion of the abdominal organs. Acidosis of the stomach and intestinal mucosa increases the risk of secondary infections, and triggers organ failure. Note that hypoperfusion and hypoxia may persist in the gastro-intestinal tract even when the circulation seems well restored after intensive basic life support. Early normalization of the gastro-intestinal function is important to prevent multi-organ failure that is: oral or enteral feeding, and mobilization of the patient. We recommend as preventive measures: Reduce the duration of acute phase intestinal hypoperfusion: Apply staged surgery in major injuries. Optimal volume therapy: The objective is not only to restore the blood pressure, but to re-establish the peripheral circulation early. Only when the skin is warm and well circulated, and the patient is eating/taking enteral feeding, the perfusion of the abdominal organs is also under way to become re-established. Optimal oxygenation: A normal respiratory rate is not good enough. Only when the patient is sitting or half-sitting with painless deep respiration of oxygenated air, can you assume that the blood level of oxygen is suffcient. Start enteral feeding the first post-operative day in risk cases: Early intestinal motility and function improve the intestinal blood circulation. And it prevents secondary infections better than do heavy antibiotics.
737
Do not use routine antacids to prevent gastric stress bleeding: The acids of the stomach help maintain the normal bacterial flora and function of the intestines. Sitting/half-sitting position and early ambulation drain the stomach and help prevent gastric bleeding. Restrict the use of broad-spectrum antibiotics: They make it impossible to restore normal intestinal function.
738
739
740
Bacteria important in surgery .................................................... 746 Common infections and common antibiotics Resistance to antibiotics
................................. ..........................................................
Disinfection and sterilization ..................................................... 760 Gram stain and microscopic examination
.....................................
833
741
What is bacteria
Bacteria are one-celled organisms. To survive and multiply, they need nutrition like other cells. Most bacteria manage that without harming other organisms, like the billions of bacteria that live in the soil. But the others, the medically important ones, feed on human tissues. For example, the enterobacteria are necessary for human digestion, but when they spread outside the intestine they are destructive.The dead and damaged muscles in war wounds are especially excellent food for diseaseproducing bacteria. Here they produce poisons toxins or enzymes which destroy the host tissues locally, and may injure vital organs when distributed by the bloodstream. 1 The bacterial cell consists of the cell wall (CW) which is different for each strain of bacteria; many bacteria also have a capsule outside the cell wall. All bacteria have cytoplasm and a nucleus which houses the chromosome (CH) with its specific genes. Some bacteria have many tails flagella (F). Under difficult conditions, like the lack of food, or too much / too little oxygen, some bacteria (bacillus and clostridium) form spores. Spores are granules of genetic material housed in a thick capsule. Spores are tough and can survive hard conditions for long periods, sometimes years. Once conditions improve, the spores spring to action again, start to multiply, and produce enzymes and toxins. 2 Classifying bacteria: Bacteria can only be seen with the help of the microscope. They can appear round (cocci), or like small rods (bacilli). These cocci and bacilli can be arranged in clusters, in chains, singly, or in pairs.With the simple Gram stain, they can either stain purple gram-positive, or fail to stain, thus appearing pink gram-negative. With Gram stain we can identify the type of bacteria in wounds and circulating in the bloodstream. We can thus predict their behaviour a condition to control them. Aerobic and anaerobic bacteria Some bacteria die in the presence of oxygen: The strict anaerobes. Others need oxygen to live: the aerobes. Several bacteria can live both with and without oxygen. They thrive on dead tissues which have little or no oxygen, and cause spreading gangrene. Such bacteria are often found in war wounds.
F
1
CW
CH
What is infection
Bacteria are everywhere: Throughout the human gut, skin, and various orifices like nose, ear and anus, bacteria live in large numbers, without causing damage. This is why broad-spectrum antibiotics may cause systemic damage, see p. 759.
742
Bacteria are friendly most times: The bacilli in the intestines produce vitamins and help digest food. They protect the intestines from being invaded by other unfriendly and destructive bacteria.
What is bacteria
Injury and surgery can make friendly bacteria become destructive: Let normal gut bacteria like E. coli from the colon multipy in the kidneys or brain and a most nasty infection results. Or let staphlococci, which the skin normally is full of, get a foothold in open fractures and hematomas and you get the familiar osteomyelitis and abscesses. The presence of bacteria does not equal infection! This is infection: When alien bacteria become established in a local organ or tissue and multiply effectively and destroy tissue either locally or destroy remote organs through circulating toxin. There is evidence that once there are 100,000 bacteria per gram of tissue, the infection is established. Infection is a clinical not a laboratory diagnosis A bacterial culture or the microscope may tell you which type of bacteria is responsible for the infection. But only you can decide whether there is an infection or not. And this you do by examining the patient locally for signs of wound infection and the overall state for signs of septicemia.
Bacterial exams may be inaccurate because culture swabs might be negative as the organisms in biofilms are deeply embedded in their matrix.
743
Prevent infection
All wounds are contaminated with large numbers of bacteria. They multiply exponentially (by the power of two in each generation) in damaged tissues. The preventive measures are: Wash bacteria from the wound: Remove dirt and clothes. Wash with large quantities of soap and boiled water to remove all visible contamination anesthesia may be necessary. Remove what bacteria feed on: Excise all necrotic tissue as soon as possible after the injury. Wash out hematoma, drain to prevent hematoma from forming. As hydrogen peroxide removes blood clots effectively, wash with peroxide after debridement. Do not let other bacteria get to the patient or his wounds: Use aseptic surgical techniques, maintain good personal hygiene among staff, remove all dirty clothes, wash and scrub the operating field with large quantities of soap and water. Early intervention! Most war wounds are very heavily contaminated, and wound infection is established 4-6 hours after the injury. Reduce the rate of wound infections and post-operative infections by a single massive dose of recommended antibiotics as prophylaxis as soon as possible after the injury radical excision of all necrotic tissue leave the wound wide open to prevent anaerobic infection If the patient is not seen until 8-12 hours after the injury, the infection would have been fully established by then. Radical debridement and washout is mandatory. In such cases antibiotics should be given for days. Prophylactic therapy: High-dose antibiotics given for no more than 24 hours and only before and/or during surgery. These are the basic antibiotics for wartime surgery.You can treat most cases without the more advanced and often expensive antibiotics listed in the table on pp. 754-59. Recommended prophylactic antibiotics (doses for adults) Superficial wound (not penetrating the muscle fascia): No antibiotics Deep injury (penetrating the muscle fascia): One single dose of IV penicillin 8-12 mega-IU, or IV dicloxacillin 2 g Penetrating chest injury: One single dose of IV penicillin 8-12 mega-IU, or IV cephalotine 2 g Penetrating abdominal injury: IV ampicillin 2-4 g plus IV metronidazole 1.5 g as one single dose Penetrating skull injury: IV penicillin 8-12 mega-IU, or IV chloramphenicol 1.5 g, or IV cephalotine 2 g. Prolonged infection Look for a cause do not simply give antibiotics: Has he got an abscess? Necrotic tissues left behind? A non-viable limb? Leaking intestinal anastomosis? An infect744
Persistent infection? Simply prolonging antibiotic treatment will just increase resistance to antibiotics.
ed collapsed lung segment? Urinary tract infection? Or is he so weak that his body defences have simply given up? Remove the cause: Re-operate before the general condition further deteriorates. Support his defences: Help him breathe effectively. Support the blood circulation. Give high-energy nutrition. Septicemia The patient is ill, and his temperature chart shows typical peaks of fever. Early and aggressive intervention is essential: Most important, identify and control the source of the septicemia where the circulating bacteria and/or toxins come from. Give high IV doses of two (or more) antibiotics based on a qualified guess: What is the probable bacteria causing septicemia? Take a blood culture if possible.
Septic shock
If the early management of septicemia fails, the probable result is septic shock. The mortality rate of final-stage septic shock is high. The clinical signs of septic shock are totally different from circulatory shock: The blood pressure is normal, heart rate increased, extremities warm and dry during the first stages. During later stages of septic shock, the blood pressure falls and the heart fails, unless effective treatment is given. During early stages, the kidney function is normal. During later stages the kidneys, liver, intestines and coagulation system may fail. During early stages the temperature is increased, during late stages the endocrine system collapses and the temperature may fall to hypothermia.
745
Streptococcus
Gram-positive bacteria arranged in pairs or chains. Streptococci (beta-hemolytic) produce a wide number of potent enzymes and toxins. They are potent and cause
746
a variety of aggressive infections such as meningitis, infections after skull surgery, post-operative pneumonia, wound infections with cellulitis and necrotizing fasciitis, and post-operative septicemia. Danger! Streptococci are principally aerobic bacteria, but some strains grow better under anaerobic conditions. They may cause aggressive deep wound infection, often with cellulitis, and lung abscess. Pneumococcus are paired cocci bacteria living in the upper airways. Important source of lobar pneumonia, upper airway infections, and meningitis. Antibiotic sensitivity streptococcus: 1st choice penicillin 2nd choice clindamycin (expensive, poor enterococcus effect) Penicillinase-stable antibiotics (eg. cloxacillin) cover both streptococci and staphylococci, but have poorer streptococcus effect than penicillin Tetracycline resistance is common. Enterococcus Gram-positive cocci of the family of streptococcus (Streptococcus faecalis). Living in the intestines, bile ducts and urinary tract, they may be a source of post-operative abdominal and pelvic infections. They grow under aerobic as well as anaerobic conditions. Antibiotic sensitivity enterococci: 1st choice ampicillin Sensitive to penicillin G in very high doses Resistant to cephalosporins.
Enterobacteria (coliforms)
A large group of gram-negative bacteria normally living in the intestine of man and animal. All strains have an exceptional ability to develop resistance to antibiotics and to transfer the resistance from one strain to another. Coliforms are the most important source of abdominal infection after intestinal and urinary tract injury, often with abscess formation and septicemia. They are a common cause of hospital infections. Escherichia coli (E.coli) and klebsiella may cause peritonitis, abscesses and septicemia after abdominal and pelvic surgery, especially in clinics where much ampicillin is used. The infection may form gas. Proteus may cause infection after burns and in pressure sores.
747
Enterobacter may cause abdominal infections and peritonitis. It is resistant to many antibiotics, and develops when heavy antibiotics have been used for some time. Salmonella is known as the cause of the epidemic salmonella enteritis, but may also form abscesses in muscles, arthritis and osteomyelitis. Sensitivity unpredictable Antibiotic sensitivity of enterobacteria cannot be predicted these are the drugs of choice: Ampicillin effective against proteus, but klebsiella and often E.coli are resistant Gentamycin and other aminoglycosides 1st choice drugs against klebsiella and enterobacter Cephalosporins but enterobacter may develop resistance Chloramphenicol is effective against most strains but the drug may cause serious adverse effects during long-time treatment Trimethoprim-sulfa 2nd choice drug against klebsiella and proteus. Pseudomonas also belong to the coliform group.They are normally found in the human intestines. Pseudomonas grows in moist climate, and may even proliferate in dilute antiseptic solutions. Being resistant to most common antibiotics, pseudomonas infections are often seen after irresponsible use of broad-spectrum antibiotics. Pseudomonas is a common cause of infections in weak patients, major burns, extensive soft tissue injuries, and in patients with indwelling bladder catheter.The smell of pseudomonas infections is often fruit-like (of strawberries) and the discharge is greenish. Antibiotic sensitivity pseudomonas: Aminoglycosides (gentamycin, tobramycin) combined with piperacillin Colistin (neurotoxic, nephrotoxic) Ciprofloxacin (for adults only) Imipenem (expensive) Some 3rd generation cephalosporins (ceftazidime, expensive).
Anaerobic bacteria
Bacteroides, fusobacteria and anaerobic cocci This composite group of anaerobic bacteria all live in the colon and and genital tract. They are important sources of abdominal and gynecological wound infections often combined with coliforms, and of anaerobic abscesses. The strain bacteroides fragilis is especially a potent cause of abdominal and pelvis infections after injury; this strain is resistant to penicillin, even in high doses. Antibiotic sensitivity bacteroides and anaerobic cocci: 1st choice metronidazole (all strains are sensitive) 2nd choice chloramphenicol, trimethoprim-sulfa Clindamycin Bacteroides fragilis may be resistant, most other strains are sensitive All strains are resistant to gentamycin and often to cephalosporins.
748
Clostridium This group contains gram-positive, sporing, anaerobic bacilli that live in the intestines, in soil and dirty water.They are a main source of anaerobic wartime infections. Clostridium tetani produces a potent neurotoxin that causes tetanus. Clostridium perfringens and other strains cause gas-producing aggressive infections in necrotic war wounds. Antibiotic sensitivity clostridium: 1st choice penicillin G in very high doses 2nd choice metronidazole, erythromycin Resistant to gentamycin and most cephalosporins. Surgery rather than antibiotics! Clostridium infections are never managed by antibiotics alone surgery is essential. Haemophilus influenzae The small, gram-negative coccoid rod lives in the upper airways. It is an important cause of pneumonia. In infants it also causes osteomyelitis and arthritis, often with septicemia. Antibiotic sensitivity haemophilus influenzae: 1st choice ampicillin Also sensitive to trimethoprim-sulfonamide, and cefuroxine.
749
The normal bacterial flora Skin Airways staphylococcus coliforms staphylococcus streptococcus haemophilus influenzae enterobacteria enterococcus bacteroides anaerobic coccus Clostridium perfringens pseudomonas enterobacteria coliforms enterococcus
Colon
Urinary tract
Type of bacteria
Gram classification
positive positive positive positive negative negative positive negative negative negative positive
Type of infection
Infected burns
beta-hemolytic streptococcus
positive positive negative negative positive negative negative positive, but poor staining
Osteomyelitis
Brain infection streptococcus (aerobes and anaerobes) bacteroides yellow staphylococcus Eye infection Superficial wounds Penetrating injuries staphylococcus pseudomonas enterobacteria positive negative negative
751
Type of infection Abdominal and pelvic infection Peritonitis and intestinal injuries
Type of bacteria
Gram classification
normally mixed infection: enterobacteria (seldom pseudomonas) enterococcus bacteroides yellow staphylococcus negative positive negative positive
normally mixed infection: enterobacteria pseudomonas enterococcus negative negative positive negative positive negative
Airway infection Post-operative pneumonia Streptococcus pneumoniae Haemophilus influenzae Aspiration pneumonia yellow staphylococcus bacteroides anaerobic streptococcus Infected deep chest wounds Lung abscess yellow staphylococcus anaerobic streptococcus anaerobic coccus bacteroides klebsiella
752
positive negative positive negative positive positive positive mixed negative negative
Type of infection
Type of bacteria
Gram classification
Septicemia: The bacterial strains depend on the source of infection Infected wounds, burns yellow staphylococcus streptococcus pseudomonas enterobacteria Infected fractures/bone yellow staphylococcus pseudomonas Abdominal infection enterococcus enterobacteria Urinary tract infection Infected IV cannulas white staphylococcus enterobacteria pseudomonas Multi-injury cases, weak patients, immune system failure yellow staphylococcus streptococcus pseudomonas positive positive negative negative positive negative positive negative enterobacteria positive positive negative negative positive positive negative
753
Ampicillin
cheap
Anti-staphylococci (penicillinase-resistant penicillins) Cloxacillin Dicloxacillin Flucloxacillin Methicillin Nafcillin IV 1-2 g every 4-6 hours IV 1-2 g every 4-6 hours IV 1-2 g every 4-6 hours IV 1-2 g every 4 hours IV 1-2 g every 4 hours cheap cheap moderate moderate moderate
Antipseudomonas penicillins Carbenicillin Piperacillin IV 5 g every 4 hours (as infusion over 2 hours) IV 3-5 g every 4-6 hours (as infusion over 30 minutes) expensive very expensive
Second-generation cephalosporins Cephoxitin Cefuroxine IV 1-2 g every 4-8 hours IV 0.75-1.0 g every 6 hours expensive expensive
Third-generation cephalosporines Cephotaxim Ceftazidime Ceftriaxone IV 1-2 g every 6-8 hours IV 1-2 g every 8-12 hours IV 1 g every 24 hours expensive very expensive very expensive
754
Antibacterial spectrum Gram-positive bacteria Most anaerobic bacteria Not Bacteroides fragilis
Principal use Limb infections Streptococcal and pneumococcal infections Clostridial infections Skull infections Preventive routine (not abdominal and pelvic injuries) Abdominal and pelvic infections Airway infections Systemic infections (combined with other drugs) Preventive routine (drugs of choice against enterococcus)
Better activity against gram-negative bacteria than penicillin. Better against Haemophilus influenzae and most coliforms except klebsiella. Poor effect against anaerobes
Good effect against anaerobes and intestinal gram-negatives. Less active against gram-positive cocci. Less staphylococcal effect than 1st generation. No effect against enterococci
Effective against a broader spectrum of gram-negatives. No staphylococcal effect. Variable effect against pseudomonas and Bacteroides fragilis. Resistance develops rapidly
755
Drug
Drug dosage adults (60-70 kg) Poor kidney function: Reduce the doses!
Aminoglycosides Gentamycin Tobramycin Netilmycin Tetracyclines Doxycycline Oxytetracycline IV 100 mg every 12-24 hours IV 0.5-1 g every 12 hours very expensive very expensive IV 120-280 mg every 8 hours IV 120-280 mg every 8 hours IV 160-320 mg every 8 hours moderate expensive expensive
Metronidazole
very expensive
IV 0.5-1 g every 6 hours IV 300-900 mg every 6 hours IV 600 mg every 8 hours IV 1 g every 8 hours
Chloramphenicol
moderate
756
Antibacterial spectrum
Principal use
Gram-positive and some gram-negative bacteria. Resistance to sulfonamides develops rapidly, thus thus sulfonamides should be combined with trimethoprim enterobacteria
Urinary tract infections Infections inside the skull Liver abscess negative
Active against coliforms, pseudomonas and staphylococcus. Note: nephrotoxic and neurotoxic in doses close to the therapeutic level
Serious systemic gram-negative infection Urinary tract infection Combined with other antibiotics in staphylococcal infection Infected burns
Wide anti-bacterial spectrum, gram-positive and gram-negative. Proteus and pseudomonas are resistant Anaerobic bacteria including cocci, bacteroides and clostridia. No effect on aerobic bacteria
As resistance develops rapidly, tetracyclines are not drugs of choice in serious infections Can be used as preventive routine For patients older than 12 years only All anaerobic infections Abdominal sepsis Deep wound infection Necrotizing fasciitis Preventive routine Alternative to penicillin in pneumococcal and streptococcal infections in patients allergic to penicillin Serious infections Staphylococcal infections where penicillins (also methicillin) and cephalosporins have no effect Anaerobic infections Necrotizing fasciitis, combined with metronidazole or a third-generation cephalosporin Local application for eye injuries Serious systemic infections Infections inside the skull Salmonella infections
As penicillin, but less effective on anaerobes. Staphylococcus may rapidly become resistant Staphylococcus, streptococcus, clostridium, most anaerobes
Broad spectrum, but the effect against gram-negative rods may vary. Often effective against clostridia and bacteroides. No effect against pseudomonas
757
Drug dosage adults (60-70 kg) Poor kidney function: Reduce the doses!
very expensive
Aztreonam Ciprofloxacin
Resistance to antibiotics
Resistance is man-made!
Potent antibiotics used for preventive measures, broad-spectrum antibiotics used on unqualified-guess basis, irregular administration, too low drug doses all produce drug-resistant strains of bacteria: Initially sensitive bacteria become resistant to antibiotics. Resistance can develop in three ways: The antibiotic fails to bind at the normal target site at the bacterial cell wall. The bacterial membranes change permeability and cannot be penetrated by the antibiotic. Bacteria may start producing enzymes that inactivate the antibiotic agent. Multi-resistance Bacteria may develop resistance to more than one antibiotic they become multi-resistant. Resistance and multi-resistance to antibiotics can be transferred from one bacterium to another. MRSA is a scaring example of how microorganisms can adapt to resist mans misuse of useful drugs. Stop the irresponsible use of antibiotics The more you use broad-spectrum antibiotics in a clinic, the more difficult strains will cause the hospital infections. Soon we are out of antibiotics that work at least for low-resource settings.
758
Resistance to antibiotics
Antibacterial spectrum
Principal use
Wide anti-bacterial action. Resistance may develop rapidly. Some strains of yellow staphylococcus, streptococcus and pseudomonas are resistant Effective against many gram-negative aerobes. No effect against gram-positives and anaerobes Wide anti-bacterial action. Effective against most enterobacteria, several strains of staphylococcus and pseudomonas. No effect on pneumococcus. Poor effect on anaerobes
Second-choice antibiotic in serious infections and septicemia where other antibiotics are not effective
Second-choice antibiotic in serious infections where other antibiotics are not effective Osteomyelitis with gram-negative rods Necrotizing soft tissue infections
Gut failure is a trigger of multiorgan failure Another complication of overtreatment with broad spectrum antibiotics is the destruction of normal friendly gut bacteria such as lactobacillus. The result is diarrhoea and gut ulceration. The intestines then become colonised by pathogenic bacteria such as Costridium difficiles.
Correct antibiotic treatment reduces the risk of drug resistance Are antibiotics really necessary? Antibiotics cannot penetrate an abscess or necrotic tissue perhaps the patients need surgery, not antibiotics. In most cases he needs both. Are broad-spectrum antibiotics really necessary? The best bacteriological diagnosis is given by microscopy or culture. Without laboratory facilities, choose the drugs based on qualified guess.There are no standards to follow; each case must be assessed separately. Combine two or more antibiotics in serious infections. That may prevent drug-resistance and increase the effect of both drugs. Give the drugs in adequate doses: Partly resistant bacteria may survive low doses (and even develop resistance), a few high doses will kill them. Give the drug in correct time: Uncomplicated infections: 1-2 weeks. Prolonged infections: up to 6 weeks. Osteomyelitis: 3-6 months. Use intravenous antibiotics in all seriously ill patients: In bleeding injuries drugs are not absorbed after IM injections, the muscular blood flow is too low. Drugs are hardly absorbed from the intestines in weak patients, after abdominal injury, and under circulatory shock.
759
Iodine solutions may cause extreme scarring and keloid formation. Do not use in open wounds!
Heat as disinfectant
Heat is more effective as a disinfectant than chemicals: At 80 C most bacteria (but not their spores) are destroyed within a few minutes.Washing instruments in soap solution and boiling for some minutes in water is an effective routine for disinfection. Washing-machines for surgical instruments should work at 85 C.
760
Disinfection by boiling Do not let debris and dirt dry before disinfection wash instruments in cold water immediately after use, then disinfect them. The disinfectant must work over some time no disinfectant is effective within seconds of action. Washing with soap and boiling for 20 minutes is a simple and safe method of disinfection.
Sterilization
Sterilization implies complete destruction of all bacteria and spores. There are several methods for sterilization: moist heat, dry heat, isopropanol, formaldehyde vapor, gaseous sterilization and gamma irradiation. For our use, moist heat or isopropanol is the method of choice. 4 3
3 Sterilization by moist heat pressure boiling: Under pressure, steam will increase its temperature with increasing steam pressure. The figure shows the relationship between steam pressure and steam temperature. The common range of sterilization is 120140 C, that is, between 1.0 and 2.7 kg/cm2 (above 15 lb per in2).
4 TDT in relation to steam temperature: The time needed to destroy completely all bacterial spores is called Thermal Death Time (TDT). The TDT depends upon the steam temperature: The figure shows that all spores are destroyed by 120 C within 15 minutes, or by 115 C within 40 minutes.
5 The autoclave: Note the separate double steam inlet to the jacket and chamber and a separate air inlet with filter. The thermometer is located at the bottom of the autoclave, the pressure gauge at the top.
761
6 The pressure boiler: The instruments are lifted above water upon a grid.This pressure boiler does not have a thermometer, the temperature must thus be calculated from the pressure gauge. Add some time to the TDT due to the dry air content inside the pressure boiler (see text below). Several factors affect the sterilization: Air inside the pressure boiler reduces the temperature of the steam: In autoclaves air may be let out from the bottom of the autoclave (air being heavier than steam), that cannot be done in the pressure boiler. When sterilization by pressure boiling is used, steam pressure must be increased and at least 30 minutes added to the TDT to ensure a safe sterilization. If instruments or cloth packs are kept in metal boxes, the boxes must have multiple holes in the bottom to let the dry air run out of the box. The articles for sterilization must be clean: Dirt or oil film on the instruments will prevent the steam from penetrating to every bacterium or spore. Surgical instruments should not be closed. The pressure boiler and autoclave must not be heavily packed: The steam must be able to circulate and penetrate every pocket. This is particularly important when cloth packs are sterilized. Drying is done by letting the steam out of the chamber while the steam still circulates inside the jacket. The pressure boiler is unlocked to let the packs dry by evaporation. Handling of moist cloth packs causes contamination. Recommendation Pressure boiling at 120 C for 15 minutes is a good standard for sterilization of surgical instruments. Bacteria have different resistance to sterilization Least resistance: staphylococcus, streptococcus, E. coli Moderate resistance: Mycobacterium tuberculosis and related Most resistance: spores formed by clostridium strains and bacillus species. Sterilization in a field setting Double boiling If an autoclave or pressure boiler is not available, a thorough disinfection is done by double boiling: Wash instruments in soap, rinse well, and boil them for 30 minutes. Let the instruments cool, and boil another 30 minutes.
Chemical and biological indicators are commercially available which may control the effect of the sterilization program.
Isopropanol is easily available. It is used in auto workshops to remove condensed water from the fuelling system.
Isopropanol Place clean instruments on a grid in a box of steel. Fill with isopropanol 45% so that the instruments are covered by the fluid. After one minute 60 seconds the instruments are sterile. Pour out the isopropanol and let the instruments dry.
762
763
764
766 767 770 773 777 780 782 786 790 791 162
.....................................
............................................... ...............................................
.............................................................
Common foodstuffs and their nutrient values Home-made diets for enteral feeding Field standards of volume and weight
..........................................
.....................................
765
766
The complete feeding program 1. Before surgery Assess the amount of calories needed to fullfill the daily requirements for repair after surgery in each patient. 2. Decide the feeding strategy for each patient Oral, naso-gastric tube, gastrostomy tube, or jejunostomy tube feeding. 3. Prepare the feeding solutions Oral feeding: study the basic diets for high-energy oral feeding. Prescribe exact diets, the volumes and frequency of meals based on local available foodstuffs. Tube feeding: study the basic diets for enteral feeding. Compose your own standard solutions from foodstuffs available. The viscosity problem: Bulky solutions cannot pass through the feeding tube. They may also cause airway obstruction in oral feeding of children and weak patients. Special methods of food processing solve the viscosity problem.
767
Factors that stimulate hypermetabolism Remaining necrotic tissue after debridement Infections and abscess formation Pain and anxiety. The best high-energy feeding cannot compensate for these factors. The patient who stays catabolic despite proper feeding, probably needs redebridement, better analgesia, and improved post-operative care.
To plan the feeding program: Calculate the Basic Energy Expenditure (BEE) for the actual patient. Assess the stress level: Add to the BEE the energy required due to the degree of injury and/or complications. The basic energy expenditure BEE The amount of energy necessary to maintain vital functions respiration, circulation, function of the brain etc.The BEE depends on body size and age, and is measured in kilocalories (kcal) per 24 hours. The factor 66 is a constant to be included for all patients. BEE = 66 + (body weight x 13.7) + (body height x 5) - (age x 6.8)
Worked example
You are planning a program for post-operative feeding of a patient 20 years old, with a weight of 70 kg, and 175 cm height. BEE = 66 + (70 x 13.7) + (175 x 5) - (20 x 6.8) = approximately 1,700 kcal/24 hours Add for the actual stress level Stress level 1: moderate injuries without secondary complications, smooth secondary surgery in uncomplicated cases. The actual energy expenditure = BEE x 1.3. Stress level 2: extensive injuries and extensive surgery. The actual energy expenditure = BEE x 1.5. Stress level 3: multiple injured, serious burns, repeated surgery, serious infections and sepsis. The actual energy expenditure = BEE x 2.0. Our patient in the example above has an extensive soft tissue injury; repeated skin grafting is done. Consider him a stress-level 2 case: The actual energy expenditure is 1,700 x 1.5 = 2,550 kcal/24 hours. Add for exercises and temperature So far we considered the patient to be staying in bed, doing nothing, in a temperate climate, with a normal body temperature. Add to BEE: The energy used for exercises or working: 1,000-1,500 kcal. For fever/hyperthermia:The BEE is increased by 7% for each centigrade the body temperature rises above 37 C. In the example above: Our patient has an extensive soft tissue injury, the body temperature is normally about 38 C in non-infected major injuries. He is doing daily exercises. Add: 1,000 kcal + (1,700 kcal x 0.01 x 7) = 1,120 kcal/24 hours. So the total energy consumption is: 2,550 + 1,120 = about 3,700 kcal/24 hours until the wounds have healed.
769
Alternatively, instead of calculating the degrees of fever and activity, you may just add 25% to the actual energy requirement. In this case that makes 2,550 kcal + (2,550 x 0,01 x 25) kcal = 3,200 kcal/24 hours which should be the minimal content of energy in his diet.
770
The typical kwashiorkor patient, a result of prolonged state of protein deficiency 1 thin hair 2 general edema 3 thin upper arm (muscle wasting) and swollen forearm (edema) 4 big belly (large liver and intraperitoneal fluid). Protein deficiency is easily recognized in children. But in adults the clinical signs are few, and a serious condition protein deficiency may be missed unless you make it a routine to look for it. The mid-upper arm circumference (MUAC) indicates muscle wasting. The normal values of the MUAC for males Age (years) 1-2 3-4 5-6 7-8 9-10 11-12 13-14 MUAC (cm) 12.7 13.7 14.7 16.0 17.0 18.3 21.1 Age (years) 15-16 17-18 19-30 30-40 40-50 50-60 60-70 MUAC (cm) 23.7 25.8 27.5 28.3 28.3 28.0 27.0
The normal values of the MUAC for females: Age (years) 15-16 17-18 19-30 30-40 40-50 50-60 60-70 MUAC (cm) 20.2 20.5 21.0 21.5 22.0 22.5 22.5
Until 15 years of age, the MUAC is identical for boys and girls.
The triceps skinfold: The thickness of the triceps skinfold indicates loss of subcutaneous fat. Measure it with standardized calipers. The normal values of the triceps skinfold for males Age (years) 1-2 3-4 5-6 7-8 9-10 11-12 13-14 Skinfold (mm) 10 10 9 9 10 11 10 Age (years) 15-16 17-18 19-30 30-40 40-50 50-60 60-70 Skinfold (mm) 9 8 11 12 12 11 11
771
The normal values of the triceps skinfold for females Age (years) 1-2 3-4 5-6 7-8 9-10 11-12 13-14 Skinfold (mm) 10 11 10 11 13 13 15 Age (years) 15-16 17-18 19-30 30-40 40-50 50-60 60-70 Skinfold (mm) 17 19 19 22 25 25 24
Standard weight-to-height relation for children, both sexes combined Laboratory examination may reveal malnutrition and mineral deficiencies. If available, check as a routine the hemoglobin, serum electrolytes, serum creatinine, serum albumin, the liver function. See more on p. 729. Height (cm) 75 80 85 90 Weight (kg) 9.8 10.9 12.0 13.1 Height (cm) 95 100 110 120 Weight (kg) 14.3 15.6 18.4 22.0
Weight for height indicator A weight below 80% of the standard indicates that a child is undernourished.
Surgery in patients with chronic anemia, see p. 430. Where transport times are long, prehospital feeding is an integral part of life support, see p. 209.
772
Protocol for starving adults: Consider starving patients at least as stress level-2 cases: The actual energy consumption is BEE x 1.5. Glucose: Give 400-500 mg for the first 3-4 days, then reduce the glucose intake to the normal level of 200-300 mg per day. Protein: The daily intake should be 100-120 g/day. Fat: The rest of the energy needed is covered by intake of fat. Treat imbalances of electrolytes immediately. Give vitamins and trace elements from the first day after injury. Consider blood transfusion if the hemoglobin is less than 6-7 g%.
ileostomy case loses much sodium. Patients with intestinal fistula or renal failure may develop a complex picture of electrolyte/mineral imbalance. Concentrate on sodium (Na), potassium (K), calcium (Ca), and chloride (Cl). When enteral nutrition is used, the body absorbs minerals from the intestine according to its requirements. This makes enteral feeding more effective and less risky than intravenous infusion of minerals. Daily basic requirement of minerals (adults) Na K Ca Trace minerals: minerals needed in very small amounts. The most important are iron (Fe), magnesium (Mg), copper (Cu), zinc (Zn), and iodine (I). Vitamin deficiencies may be endemic, see p. 432. 2-3 g 2-4 g 800 mg 86-129 mmol 26-52 mmol 11.2 mmol
Vitamin and trace mineral requirements Normal levels of vitamins and trace minerals are essential to the patients rehabilitation after injury. In some areas as certain vitamin deficiencies are endemic, the requirements may thus vary much from one population to another. Most deficiencies of vitamins and trace minerals develop 1-3 weeks after injury/surgery. Of the trace minerals, iron is essential to hemoglobin synthesis and zinc seems to play a role in connective tissue metabolism and wound healing. Daily requirements of vitamins and some trace minerals (adults) Thiamine Riboflavin Nicotinamide Vit B6 Folic acid Vit C Vit A Vit D Vit K Magnesium (Mg) Iron (Fe) Zinc (Zn) Iodine (I) Copper (Cu) 2.8 mg 4.2 mg 28 mg 4.6 mg 0.4 mg 140 mg 0.7 mg 2.8 picog 0.15 mg 3-400 mg 10-20 mg 15 mg 150 picog 2-3 mg
Enteral feeding better than tablets In oral and enteral feeding, the requirements are fulfilled using a balanced diet of vegetables, cereals, animal protein and fat. Give tablets of iron as soon as the intestinal function is restored.
774
Step 1 calculate the BEE BEE = 66 + (70 x 13.7) + (175 x 5) - (20 x 6.8) = approximately 1,700 kcal/day Step 2 assess the stress level and calculate the total energy requirement Our patient is a multi-injury case with double open femur fractures and penetrating chest injury.The primary operation was time consuming, and you plan another operation for fixation of the fractures within 4-5 days.You consider him a stress level3 case. The actual energy requirement is 1,700 x 2 = 3,400 kcal/24 hours. As a rule we add another 25% to this value (for hyperthermia, physical activity):Total energy requirement = 3,400 + (3,400 x 0.01 x 25) = about 4,300 kcal/24 hours Step 3 calculate the daily glucose requirements As he is not undernourished, the daily need is 4 g glucose/kg = 70 x 4 g = 280 g glucose/24 hours. Step 4 calculate the daily protein requirements He is not undernourished, the daily protein requirement (major injury) is 1.4 g/kg = 1.3 g x 70 = 100 g protein/24 hours. Step 5 calculate the calories from glucose and protein Both glucose and protein yield about 4 kcal/g in metabolism: 280 g glucose 280 x 4 = 1,120 kcal/24 hours 100 g protein 400 kcal/24 hours. Thus the total amount of energy from glucose and protein is 1,120 kcal + 400 kcal = about 1,500 kcal/24 hours. Intravenous nutrition? This case would daily need 1,500 ml 20% fat emulsion a daily cost of US$ 100-150 for the fat nutrition only! Step 6 calculate the fat requirements He needs a total of 4,300 kcal/24 hours, and 1,500 of these are fulfilled by glucose and protein administration. Thus 4,300 1,500 = 2,800 kcal/24 hours must come from fat. Metabolism of 1 g fat yields 9 kcal. Thus he needs: 2,800 - 9 = about 300 g fat/24 hours to meet the extreme energy requirements. Conclusion a plan for the post-operative nutrition In this case the nutrition must contain 280 g glucose, 100 g protein, and 300 g fat per 24 hours. This will give a total energy output of about 4,300 kcal/24 hours. Study the tables on pp. 786-88 and compose the diet he needs.
Intestinal dysfunction due to side effects of broad-spectrum antibiotics is common: Stop the misuse of potent antibiotics, see p. 758.
Short-bowel syndrome after surgery Short bowel occurs after a stoma of the small intestine or of the proximal part of the large intestine that exclude the distal parts of the intestine. Electrolyte deficiencies: Sodium, magnesium and calcium are lost through the stomy in amounts giving rise to clinical symptoms of deficiency. Loss of water and water intoxication: The colon normally plays a role in the regulation of the body fluid balance, water is absorbed from the colon into the circulation. In short-bowel syndrome, the water absorption is partly lost: The short-bowel patient feels thirsty, drinks more and more water which causes dilution of serum sodium. A state of weakness, drowsiness and serious electrolyte imbalance called water intoxication may develop. Early intake of salt and protein is preventive. Cannot utilize fat: In cases with the stoma proximal on the small intestine, the fat absorption is poor. Deficiency of the fat-souble vitamins (A, D, E and K) may develop unless vitamin supplements are given. Cannot tolerate fat: Patients with short bowel develop diarrhea on high-fat diets. The diarrhea may add to the electrolyte disturbances. Reduce the fat intake to less than 100 g/day or completely exclude fat from the diet. Gut perforations, peritonitis and intestinal fistula formation These complications have in common the fact that electrolytes, water and protein are lost from the intestines. The daily losses are moderate, but the long-term total losses may be considerable. There is no predictable pattern regarding the deficiencies: Assume that sodium, potassium and chloride are lost from the intestines. You may safely increase the sodium, potassium and chloride intake with 50100% above the standard. Vomiting The main problem is fluid loss: Note the approximate volumes of fluid lost, and make an intake-output card for each 24 hours. Chloride is lost, often in considerable amounts: If you do not have laboratory facilities, increase the intake of sodium and chloride.
Burns of 20% body surface area or more The metabolic requirements in major burn cases differ somewhat from other injuries: The hypermetabolism develops slowly The hypermetabolism may last for months Considerable fluid and electrolyte imbalance may develop Large amounts of protein are lost through the wide wounds. Protracted recovery Repeated surgery, elaborate secondary and reconstructive surgery, long-term immobilization in bed, chronic pain, psychological depression causing inactivity there are all factors that prolong the period of catabolism and increase the losses of body fat and protein.
As a rough rule: Continue highenergy nutrition until all wounds have healed and the patient is out of bed.
776
Infection and septicemia The metabolic changes associated with septicemia are profound. Due to the fever, the energy expenditure is increased by 7% for each centrigrade of hyperthermia. The septicemia itself causes further hypermetabolism: The actual energy expenditure is approximately 100% higher than BEE. Organ failure, see pp. 730-38. Post-operative organ failure The metabolic response to secondary organ failure is complex, and differs from case to case. The main guidelines to follow: Renal failure: The capacity of fluid and electrolyte regulation is impaired. Reduce the overall fluid load. Reduce the intake of sodium and potassium. Reduce the protein load. Liver failure and multi-organ failure: The capacity of fat metabolism is reduced. Reduce the intake of fat to 100 g/24 hours, or less. Respiratory failure:The lung excretion of carbon dioxide is reduced. Acidosis may develop unless the total energy load is generally reduced.
777
Aim Within one week after the primary surgery, the patient should stabilize the weight and gradually gain weight if the nutrition is appropriate. Muscle strength muscle sustainability Strength: Monitored daily by the same paramedic, it is possible to note whether the patients muscular strength increases or decreases. Just as important is the muscular sustainability: Let him do repeated simple exercises and note how many times he is able to perform them. Poor performance reflects a poor general condition/catabolism. The central body temperature Intolerance to nutrients may cause fever. Patients on long-term, high-energy nutrition may develop intolerance to nutrients. Urinary output of 1 ml/kg/hour indicates good balance. See more on p. 726. The fluid balance Register the total fluid output: urine, loss from wounds, bandages, drains, fistula and stoma. Fever increases fluid loss by evaporation. Make a 24 hours intakeoutput card for each patient to monitor the fluid balance and urinary output. The circulation Check for fluid retention: Do daily lung auscultation to identify pulmonary fluid retention. Soft tissue edema of the legs is another indicator. Check the heart rate and regularity: Calcium and potassium disturbances may cause arrhythmia. Fat overload? The most common sign is diarrhea and vomiting. Check the serum: Take a blood sample six hours after feeding. Centrifuge it (1,200 rounds per minute) and study the supernatant: If it is milky and opalescent, the fat content is too high.
Lack of phosphate and magnesium deficiency may cause blurred vision, mental confusion and trembling.
Enteral feeding
Why not intravenous feeding Oral and enteral feeding is more effective, cheaper, is safe, and the nutrients can be found everywhere. The commercial IV solutions are too expensive: A complete feeding program for one patient costs US$ 100-200/24 hours. The feeding solutions and additives (minerals, trace elements and vitamins) are not readily available in a field wartime setting. IV feeding is risky: The complete program includes mineral additives; if used incorrectly they may cause serious complications. Close laboratory monitoring is necessary. IV lines do become infected, a big problem.
778
Enteral feeding
Types of enteral feeding Oral feeding should be the standard method for low-risk cases. It is the safest method. The preparation of diets is simple. Naso-gastric tube-feeding should be the standard method for cases that need early high-energy nutrition, where you reckon the recovery to be uncomplicated and rapid. The method is safe, but the preparation of diets elaborate: Tube-feeding solutions must have low viscosity and cannot be bulky. Gastrostomy with gastric tube-feeding should be the standard method for highrisk cases that need early high-energy nutrition, where you suspect the recovery to be slow and/or complicated. The preparation of tube-feeding solutions is elaborate. Jejunostomy tube-feeding should be used in high-risk cases where gastric feeding cannot be done due to upper abdominal injury and surgery. Jejunal tube-feeding carries higher risk of medical and technical complications.
779
Naso-gastric feeding is superior to naso-duodenal feeding Contamination: The gastric acid acts as a protective barrier against bacteria and infection. So a slightly contaminated gastric meal does not necessarily cause enteritis. Duodenal or jejunal feeding is vulnerable to infection and enteritis: The meals must be prepared under very clean conditions, stored well and not be contaminated. Overload: In gastric feeding, the pylorus regulates the duodenal load, letting only small intermittent volumes of food pass into the intestine. Feeding directly into the duodenum/jejunum may cause vomiting, intestinal distention and diarrhea if the load is too high. Gastrostomy tube feeding Do the tube gastrostomy at the time of primary surgery in all cases with high risk of post-operative complications, protracted recovery or malnutrition, see p. 274. Do secondary gastrostomy in patients who come up with complications, where the post-operative recovery will be slow: The gastrostomy operation is rapid, simple, and done under ketamine anesthesia. Normally gastrostomy feeding is well tolerated and convenient for the patient as well as for the nursing staff. There are no objections to outpatient management. Precautions: Initial confusion may make the patient withdraw the tube: Fix it well with adhesive tape. Jejunostomy tube feeding The proximal loop of jejunum is intubated in the same way as the gastrostomy is done. Make a separate small stab incision in the abdominal wall, and a very small stab incision through the jejunal wall: A wide intestinal incision may leak along the catheter. Introduce a Foley bladder catheter size 18; inflate the balloon with not more than 5 ml of water. Take care that the balloon does not obstruct the intestinal lumen. There are several technical complications to jejunal-tube feeding: Leaking along the catheter may cause stoma infection or fistula formation. The catheter may withdraw spontaneously. The catheter may become displaced inside the intestine, become obstructed/angulated, or obstruct the intestinal lumen. The complications are more common in patients whose general condition is poor: If you decide jejunal feeding, make the jejunostomy early and before the general condition worsens best during the primary operation.
Percutaneous needle jejunostomy can be done: It has less complications, but the fine-caliber tubes can only take specially prepared fluid solutions.
780
Objections to commercial solutions for enteral feeding: The composition: The energy from carbohydrate constitutes about 50% of the total energy which is not optimal for major trauma cases. The cost: Complete nutrition for one patient costs about US$ 150/24 hours. Intermittent enteral bolus feeding Intermittent feeding can be done through naso-gastric, gastrostomy or jejunostomy tubes. Intermittent feeding is safe and simple: Prepare volumes of feeding solution for 24-48 hours use, store them cold to prevent contamination (in refrigerator). Collect only a minor sample before feeding hours, warm it to reduce the viscosity. Inject the feeding solution in the tube with a large syringe, the patient in half-sitting position, left side elevated. The day of surgery: Start careful feeding with orange juice-water, 50 ml every hour. Add 4-6 g salt/24 hours. Post-operative day 1: Give dilute high-energy solution 50-100 ml every hour, increase the concentration and volumes stepwise. Within 2-4 days meals of 200-600 ml concentrated high-energy nutrients are injected 6-12 times a day. Monitor the intake-output balance: Additional IV infusions of electrolytes and fluid may be needed. Continuous enteral feeding Fine-caliber naso-gastric or jejunal tubes can only take low-viscosity, commercial solutions. Precautions: Irrigate the tube frequently with water to prevent obstruction. The infusion set is changed each day to avoid contamination. The bottle containing the nutrients should not be kept in room temperature for more than six hours in order to reduce the risk of contamination. Contents of a commercial solution for enteral feeding, per 100 ml Osmolality Energy content Protein Fat Carbohydrate Vit A Vit D Vit E Thiamine Riboflavin Vit B6 Niacin Folic acid Vit B12 200 100 kcal 4.5 g 3.5 g 12 g 60 picog 0.5 picog 1.5 mg 0.1 mg 0.1 mg 0.12 mg 1 mg 20 picog 0.3 picog Pantothenic acid Vit C Calcium Phosphorus Sodium Potassium Magnesium Iron Copper Iodine Zinc Manganese Chloride 0.5 mg 5 mg 90 mg 75 mg 95 mg 160 mg 15 mg 1.1 mg 0.1 mg 7.5 picog 0.8 mg 0.2 mg 160 mg
Vomiting and diarrhea: Consider over-load, tube displacement, too concentrated solutions, or contaminated nutrients.
The first infusions should not exceed 50 ml/hour, the rate being gradually increased to 200 ml/hour.
781
The locally made feeding solutions should also be used in village health care, in the management of malnutrition and chronic diseases.
All fresh legumes contain a certain amount of toxins which are destroyed after boiling or soaking.
Legumes (beans and peas) important sources of energy Legumes are among the main sources of both protein and energy. Being easily available and often included in local cooking traditions, they should be the basic ingredients in home-made diets for enteral feeding. They may be stored after drying and ground to flour. Legumes with high-fat content (soy beans, ground-nuts) may produce oil with high-energy content. Legumes are important sources of vitamin B, folic acid, calcium and iron. The young sprouts are also rich in vitamin C. Oilseeds and nuts alternative energy sources These foodstuffs are rich in fat, some of them also in protein (melon seed, sesame seed). Use flour made from seeds and nuts as additive to the basic diets in cases that need very high-energy intake. For example, ground white coconut may be mixed with white cereal flour to increase the energy content as well as digestibility. Vegetables and fruits sources of vitamins and trace elements In most areas some kinds of vegetables or fruits are available. The darker the color of the fruits (green or yellow), the higher is the content of vitamin A. Dark green vegetables also contain iron and vitamin C. Fruits are the main source of vitamin C. Sweet juice is an alternative carbohydrate source. Fish and meat protein sources Fish and meat are protein sources and important sources of vitamin B. Clear boiled soups of fish or meat may be used as a fluid base for the tube-feeding suspensions. Well-dried fish and meat are safely stored also in hot climate, and may be ground and used in tube diets. Ground dried fish including fish bones is a concentrate of calcium and trace elements. Some types of fish (sardines) are fatty; fish oil is a valuable source of energy and vitamins A and D.
Oil from melon and sesame seeds is used in commercially made suspensions for enteral feeding.
Milk contains lactose that contributes to diarrhea in high-energy enteral tube feeding. Some populations lack intestinal enzymes necessary for the digestion of lactose.
Milk a fluid base for tube diets Milk contains protein, calcium and vitamins. Milk from camel, buffalo and sheep is especially rich in fat and is a source of energy. Fresh milk is easily contaminated. Soured and fermented milk has the same nutrient value, but it is easier to digest, and carries less risk of contamination it should be used as the milk base. Soft or hard cheese made of milk keeps well in storage and is an important source of energy. Donated powder from whole milk or skimmed milk, and milk substitutes made from full-fat soy powder are alternative bases for tube-feeding suspensions.
783
5 Milling of cereal grains removes the outer layers of the grain. Important vitamins and protein are lost in this process: The germ (G) and the scutellum (S) contain most of the protein and vitamin B which are lost when the aleurone layer (A) and the germ coat (GC) are removed during the milling process. The end-product is a flour of good digestibility, but of poor nutrient value. Rice grain is rarely milled into flour. But the grinding of rice represents no technical problem, rice flour is an important and well-digestible carbohydrate source. Fermentation In many areas there is a tradition to soak the grain in water before grinding. In a hot climate soaking starts a process of fermentation that breaks down the starch of the grain and reduces viscosity of the flour suspensions. There is a risk that soaking or damping the grain contaminates the flour: Diets made from flour after fermentation should be cooked well before use. Parboiling Parboiled rice and parboiled wheat (bulgur wheat) store better than ordinary rice or wheat. The flour made from parboiled rice also has better nutrient values than plain rice flour. Drying Meat and fish are slightly salted before drying to prevent contamination. Dried vegetables may be ground and the powder stored.
Use lime water to soak maize before grinding: That increases the calcium content of maize flour.
784
6 The viscosity problem: The viscosity of cereal flourwater suspensions increases during cooking. The starch granules swell when heated, and create a gel. The gelatinization process continues when the boiled suspension is cooled. 7
9 Fat reduces the viscosity of flour suspensions: Increasing amounts of fat added to the flour suspension reduce the viscosity correspondingly. 10
10 Sugar reduces, and salt increases the viscosity of flour suspensions: Sugar reduces the swelling of starch granules and the gelatinization during cooling. Salt added to cereal grain flour has the opposite effect. 11
8 The degree of gelatinization differs with the various types of cereal flour, but all flours containing starch follow the basic pattern.
11 The definitive solution to the viscosity problem is fermentation or malting of the cereal flour: The grain is soaked in water or dampened, then exposed to heat (in the sun or in a heater, 40-60 C) for 6-24 hours to start the fermentation process, then dried and milled. The fermentation breaks the starch granule, and reduces the viscosity of the flour suspension without reducing its nutrient value. The reduction of viscosity is about 75% the reduction is permanent and not affected by heating or cooling later on.
785
Add dark green vegetables, orange fruit and 4 g salt to each 1,000 ml solution. Taste it: The solution should not be more saltish than your own tears. This diet corresponds to the energy demand of a moderately severe adult injury case. Add or reduce fat depending upon the calculated total energy requirement for each patient. Standard diet 2 Cereal flour as carbohydrate base, vegetables as protein base From Tables 9-12 you find the nutrient values of the foodstuffs per 100 g: Cereal flour Beans (dried and ground) Oil (any oil) 10 g protein 80 g glucose 25 g protein 350 kcal 350 kcal 900 kcal
Fermented flour is cooked with oil and salt, cooled, and the final suspension filtered through a screen or clean cloth.
786
Nutrient 1,000 ml water 100 g flour 100 g beans (dried and ground) 30 g oil/fat 1,000 ml contain 3,000 ml contain
kcal
350
970 2,910
Add dark green vegetables, orange fruit and 4 g salt/1,000 ml. Taste the suspension. Compared to a milk-based diet, this suspension produces less vomiting and diarrhea. It is also more resistant to contamination. The diet fulfills the requirements of most post-operative adult cases.The content of fat should vary from patient to patient according to calculations done. Nutrient value of protein sources (values per 100 g foodstuff) protein (gram) Legumes in general (lentils, chickpea, kidney bean, mungo bean, soy bean etc.) Eggs Fish, raw Fish, dried Meat Meat,dried Milk cow, goat, camel Milk buffalo, sheep Soft cheese Hard cheese Yogurt Milk powder 25 15 20 50 20 50 3-4 5 15 30 4 25 kcal 350 150 80 270 150-250 400-700 70 100 100 400 90 500
Nutrient value of carbohydrate sources (values per 100 g foodstuff) glucose (gram) Sugar Honey Banana Apple juice Grape juice Grapefruit juice Orange juice 100 75 25 30 30 20 20 kcal 400 300 115 120 120 80 80
787
Nutrient value of energy sources (values per 100 g foodstuff) protein (gram) Melon seeds Sesame seeds Butter Ghee (butter oil) Red palm oil Vegetable oils 25 20 kcal 600 600 700 900 900 900
Nutrient value of protein-energy sources (values per 100 g foodstuff) glucose (gram) Flour wheat, maize, rice Soy bean, flour Ground-nut,flour Coconut Coco milk Melon/cotton seed Bulgur wheat Bulgur wheat (soy fortified) Corn soy milk Faffa (full-fat soy) Dubbe Whole milk powder Skimmed milk powder 80 80 60 protein (gram) 10 35 25 5 20 11 17 20 17 11 26 36 fat (gram) 20 45 kcal 350 400 600 375 260 600 350 350 380 370 360 500 350
66 73 40 40
Fat: The rest of the energy needed (3,000 1,000 400) = 1,600 kcal/24 hours should come from fat intake That is (1,600 - 9) = approximately 180 g fat/24 hours Fluid: about 3,000 ml fluids/24 hours depending upon the circulatory state Electrolytes, vitamins and trace elements. A diet is composed of available foodstuffs rice flour, ground beans, fruits and oil: protein (gram) glucose (gram) 80 25 kcal 350 100 350 225 1,025 3,075
Rice flour, 100 g Fruit juice, 75 ml Ground beans, 100 g Oil, 25 g Water 1,000 ml 1,000 ml contain 3,000 ml contain
10 25
35 105
105 315
Additives: Table salt, ground whole dried fish, ground dark green vegetables. Make the diet example 2 An adult (70 kg) with abdominal injury and perforations of the large intestine, has fever 38.5 C.You classify him as a stress-level 3 case. He needs About 3,400 kcal + 10% = 3,750 kcal/24 hours (Add 7% for each degree C of fever) About 300 g glucose/24 hours. That is 1,200 kcal from glucose About 100 g protein/24 hours. That is 400 kcal from protein Fat: 2,150 kcal/24 hours. That is about 240 g fat Fluid: about 4,000 ml/24 hours Electrolytes, minerals and trace elements. Assume increased losses of sodium, chloride and potassium due to the abdominal injury. A diet is made from available foodstuffs, for example, maize flour, whole milk powder, orange juice, ground beans and oil: protein (gram) Maize flour, 50 g Milk powder, 50 g Orange juice, 100 ml Ground beans, 50 g Oil, 25 g Water 1,000 ml 1,000 ml contain 4,000 ml contain 5 13 glucose (gram) 40 20 20 15 kcal 175 250 80 200 225 930 3,720
33 132
80 320
Additives: Table salt, ground dried fish or meat, ground dark green vegetables.
789
790
Examples: 150 ml sesame seeds x 0.65 = 97.5 g sesame seeds. 1,000 ml ground nuts x 0.75 = 750 g ground-nuts
791
792
Section
Anesthesia
793
794
46 Wartime anesthesia
Airway obstruction Circulatory collapse
................................................................ ............................................................... ........................................................
Sympathetic hyperactivity
Which anesthesia to use? .......................................................... 799 Anesthesia to the pregnant woman Anesthesia chart
.............................................
595 843
....................................................................
795
46 Wartime anesthesia
Avoidable anesthesia deaths Deaths during trauma surgery may occur from failures in the management of the anesthesia procedures, or side-effects of the anesthetic drugs. Many of these deaths could have been avoided, eg. oxygen starvation due to inadequate breathing when under anesthesia, or fatal post-operative pneumonia after airway aspiration. We reckon that the rate of avoidable anesthesia deaths may be as high as 1% for wartime general anesthesia. Training anesthesia on animal models, see p. 54. Quality control requires exact documantation. See anesthesia chart p. 843. Ether inhalation general anesthesia (EMO apparatus) is simple, inexpensive and safe. But the EMO apparatus is heavy and does not fit into a backpack. Chaos, high casualty loads, and severe injuries increase the risk of avoidable deaths. Thats why wartime anesthesia technicians should be well trained, the routines simple and robust, and anesthesia protocols followed strictly at any time. Especially when managing mass casualties no short-cuts should be accepted. In-field anesthesia The medical procedures are simple. The technical equipment is easy to use, durable, and inexpensive. The equipment is small in volume and weight. The methods are fairly safe as long as basic precautions are followed. The procedures provide effective anesthesia for all kinds of surgery.
Airway obstruction
Aspiration More on airway management, see pp. 180-84. Patients for wartime primary surgery usually have full stomachs. There is a general high risk of vomiting with aspiration of gastric content into the airways. Aspiration to the airways is a serious complication: It may cause respiratory failure at the time of anesthesia and it increases the risk of secondary organ complications. Cases at risk of vomiting: Patients undergoing rough off-road evacuations Poor analgesia: Pain stimulates vomiting Morphine-type analgesics increase the risk of vomiting Abdominal injuries: Retention of fluid and gas in the stomach Patients in circulatory shock Hypotension during anesthesia: Spinal anesthesia on hypovolemic patients Head injuries. Risk cases due to poor swallow reflex: General weakness due to extensive injuries and evacuations Patients in circulatory shock Head injuries Hypothermic patients
796
Airway obstruction
Drowsiness due to analgesics and tranquilizers given during evacuation and anesthesia. Ways to prevent aspiration: Gastric aspiration (empty the stomach with gastric tube and suction) in non-urgent cases, see p. 187. Suction apparatus and suction tubes at hand during all anesthesia procedures. Emergency management: Know the procedure for applying cricoid pressure. Be prepared to do endotracheal intubation at any time during any anesthesia procedure. IV metoclopramide and atropine as premedication reduce the risk of vomiting and aspiration, but only to some extent. Note: Give metoclopramide as premedication before you give the atropine, as otherwise it has no effect. Morphine may cause vomiting in abdominal cases low-dose ketamine analgesia is safer. Obligatory for the anesthesia technician Training airway management, see pp. 53-65. He must know the head-tilt and jaw-thrust procedure. He must know rescue breathing for children and adults. He must be able to make endotracheal intubation and airway cutdown. He must have and know how to use airway suction. He must be good at assisted ventilation by self-inflating bag.
Circulatory collapse
Why anesthesia may be dangerous: The normal response of the sympathetic nervous system: Injury and pain cause shunting of blood from the skin and muscles into the central organ circulation, increased heart rate, and increased blood pressure. All the drugs discussed in this chapter except ketamine block the sympathetic injury response to some degree, and causes increased blood circulation in muscles and skin, with rapid fall in blood pressure. The common mistake a case study of spinal anesthesia One patient is admitted with a lower limb mine amputation. As analgesia given during the evacuation was poor, he is in much pain. His primary blood loss was 1,500 ml; he got no volume therapy during the evacuation. But he arrives in a seemingly stable circulatory state: no bleeding, blood pressure 100 and pulse rate 130. His skin is cool and clammy, which you reckon is due to pain.Without further volume therapy he gets spinal anesthesia.Within five minutes his circulation collapses: blood pressure 60, pulse rate 140. The reason: He had hypovolemia, but his hypovolemia was hidden by the sympathetic response a temporary blood pressure increase. The spinal anesthesia made his hypovolemia evident, but only too late.
797
46 Wartime anesthesia
Volume pre-load in serious cases Prevent circulatory collapse by flush infusion of 1,000-2,000 ml Ringer before anesthesia starts. Use ketamine and not spinal anesthesia in hypovolemic patients.
Sympathetic hyperactivity
The total load upon the war wounded severe pain and physical exhaustion, anxiety, strenuous evacuation creates an over-reaction in the normal sympathetic nervous reponse to injury: Gastric irritation, spasms and vomiting Heart irritability, tendency to heart arrhythmia Increased risk of post-operative organ complications. Measures to reduce the sympathetic hyperactivity Block the sympathetic response: Atropine blocks the vagus stimulation of stomach and heart. Thus atropine premedication reduces the risk of aspiration and arrhythmias during anesthesia. Prevent a continuous sympathetic stimulation by early and effective analgesia. 5-10 mg morphine IV as premedication will also reduce the post-operative pain. Calm down the sympathetic triggers: Give psychologial support to the patient during the evacuation, and before surgery. Inform the patient, family and friends of your plans for surgery and post-operative care, gain his confidence and active cooperation. Encourage his family and friends to stay close. Good mental support increases patientscoping capacity and reduces the rate of post-operative complications. Hypoglycemia? Low blood glucose increases the risk of blood acidosis, heart arrhythmia and circulatory collapse. In poor areas patients may arrive for surgery after prolonged evacuations with hypoglycemia and livers empty of glycogen. Also patients with chronic diseases at the time of injury, and exhausted fighters are risk cases. Risk cases: Start infusions with dextrose 5% High-risk cases: Consider 500-1,000 ml 10-12% glucose infusion in addition to electrolytes during the anesthesia. Diseases causing anemia, see pp. 430-33. Anemia? Hemoglobin levels below 6-7 g% due to acute bleeding imply tissue hypoxia and risk of cardiac complications during surgery. Consider autotransfusion or blood transfusion. Note that cases with grave chronic anemia due to diseases or starvation carry less risk of complications.
Atropine may increase the risk of acute hyperthermia in hot countries. Analgesics and tranquilizers, doses and side effects, see pp. 224-27.
798
Sympathetic hyperactivity
In infants and children ketamine premedication can be given nasal, oral or rectal, see p. 186.
The complete premedication IV ketamine 0.5 0.3 mg/kg plus IV diazepam 5 mg. Or IV morphinetype drugs Pre-load volume therapy Gastric aspiration and i.v metoclopramide to risk cases Adults: IV atropine 0.5 mg. Children: IV atropine 0.1 mg/10 kg Autotransfusion or blood transfusion in hemoglobin levels below 8 g% Information and psychological support.
799
46 Wartime anesthesia
Local infiltration anesthesia is a very useful supplement to spinal and nerve block anesthesia. But we should not forget that operations like craniotomy, laparotomy, moderate debridements, flap surgery, and skin grafting can be done with local infiltration as the only anesthesia. Infitration of the anesthetic-adrenaline solution is often useful when bleeding control is tricky, eg. during craniotomies. Combine two or more anesthesia methods Regional nerve blocks may take incompletely; the operation may come to last longer than expected; and the patient may have more than one painful injury. This is why combined anesthesia procedures should be considered: Eg. limb surgery under nerve block anesthesia combined with local infiltration anesthesia and/or low-dose ketamine analgesia. Eg. abdominal surgery under spinal anesthesia combined with costal nerve block and/or ketamine anesthesia. Eg. NSAID drugs as supplement to local anesthesia. Painful surgery is inhuman, traumatic and always avoidable.
800
801
802
47 Ketamine anesthesia
803
47 Ketamine anesthesia
Ketamine is the standard wartime general anesthetic. Advantages A potent analgesic effect Rapid action No effect on the reflexes of pharynx and larynx (swallowing and coughing), no increased risk of airway aspiration The patient breaths himself also under deep anesthesia, and does not need concentrated oxygen to maintain sufficient levels of blood oxygen It increases the HR, the BP and the cardiac output, a positive effect in circulatory shock cases It can be given by all routes: IV, IM, oral, by the nose, and rectal It stores well at room temperature The cost is reasonable (cheap brands are available) It is safe, especially for the inexperienced, and in chaotic settings:You may by accident give ten times too much of ketamine without causing harm. Disadvantages Mental side effects are common Ketamine does not give muscle relaxation. Misjudgements Ketamine is not contraindicated in brain injuries. It does not increase the intracranial pressure, rather it helps keep up the brain blood perfusion, see p. 244. Ketamine does not cause circulatory collapse after prolonged hypovolemia. Indications for ketamine anesthesia All kinds of surgery that do not require full muscle relaxation, especially when time is short and the setting chaotic. Doses Ketamine is available in solutions of 10 mg/ml (for IV use) and 50 mg/ml (for IM use). For logistic reasons we use the concentrated solution of 50 mg/ml but we should dilute it to a concentration of 10 mg/ml to better control the accuracy of injections: Ketamine dilution and doses, also see pocket folder at back cover. 1 ml ketamine solution is diluted in the syringe with 4 ml NaCl 0.9% to a ketamine solution of 10 mg/ml. IV anesthesia: Ketamine 1-2 mg per kg body weight IM anesthesia: IM ketamine 5-10 mg per kg body weight Oral: Ketamine 6-10 mg per kg body weight Nasal: Ketamine 6-10 mg per kg body weight Rectal: Ketamine 10 mg per kg body weight.
804
Ketamine anesthesia
Intermittent IV doses is better You may mix ketamine in electrolytes and give as continuous infusion, but you can better control the level of anesthesia with intermittent IV doses. The response to ketamine varies: One IV dose may act for 10-20 minutes.
Precautions
Do not give diazepam to hypovolemic child patients: It may collapse the circulation. See more on p. 408. Premedication IV diazepam 5 mg and IV atropine 0.5-1 mg (adult dose) should be given in one syringe together with the ketamine start dose. Note: Midazolam may be used as premedication, but may cause padaroxical reactions like agitation and aggression in combination with ketamine. Flush IV infusion Atropine increases the heart rate, but not the blood pressure. Ketamine also increases the heart rate. As the heart rate is affected by both drugs, it is no longer a good early indicator of blood loss. Be on the safe side: give a lot of IV Ringer during the anesthesia. Always be ready for trouble Keep emergency drugs, suction device, face mask, self-inflating bag, and endotracheal intubation set at hand. Monitor continuously during the anesthesia: The level of analgesia: Unrest and increasing blood pressure indicates pain increase the dose of anesthetic. Most patients make some sounds and have involountary movements of the mouth and tongue during ketamine anesthesia. This is normal and does not indicate insufficient anesthesia. Free airway: The uncomplicated ketamine patient maintains spontaneous respiration and the reflexes, but not necessarily a free airway. Especially child patients salivate a lot during ketamine anesthesia. Use the suction frequently. The breathing: IV ketamine may cause some respiratory depression if the start dose is not given slowly (one minute). If there is respiratory arrest: Stay cool! Do not try to intubate! When the patient becomes cyanotic, respiration will restart spontaneously. The circulation: Monitor closely the blood pressure. Under atropine treatment the heart rate is not a good indicator of hypovolemia. Insufficient anesthesia may be dangerous Any kind of superficial anesthesia may cause spasm of the larynx and heart arrythmia. There are no side-effects of very deep anesthesia except it takes some more minutes for the patient to wake up after surgery.
805
47 Ketamine anesthesia
Worked examples
Case study intermittent IV ketamine anesthesia Double lower limb amputation for primary surgery, body weight 60 kg. Premedication: IV diazepam-atropine Start-dose ketamine: 60 kg x 2 mg/kg = 120 mg IV Maintenance dose: 60 mg ketamine as intermittent injections. Case study IM ketamine anesthesia A ten year old child, limb crush injuries with multiple fractures, body weight 30 kg. Premedication: IV diazepam 5 mg and atropine 0.5 mg Start-dose ketamine: 30 kg x 6 mg/kg = 180 mg IM. The anesthesia is complete within three minutes The duration of one IM dose is 10-25 minutes. Signs of pain: Maintenance dose IM 50% of the start dose, 90 mg. Or establish an IV line after the IM start dose and continue with intermittent IV anesthesia. Circulatory shock cases: Muscle blood circulation is poor, absorption of IM drugs slow and the effect of IM ketamine unpredictable. Use IV drugs!
806
807
808
48 Local anesthesia
Infiltration anesthesia
.............................................................. ........................................................
Brachial plexus nerve block Axillary nerve block Nerve block of the hand Nerve block of the foot
............................................................... ..........................................................
...................................................
809
48 Local anesthesia
Multimodal anesthesia is better The anesthesia must be complete in the sense that surgery should be painless. Painful surgery is another insult to the patient and increases the risk of post-operative complications. Then we have some problems: Nerve blocks may not take completely The operation may last longer than anticipated Also the patient may have more than one painful injury. Combine regional anesthesia with ketamine analgesia and/or NSAIDs.
Infiltration anesthesia
Drugs and equipment Lidocaine 0.5% plain or with adrenaline (1:200,000) Needles: 0.5-0.8 mm Spinal needles (25 G) for extensive or deep infiltration. 1 2 1 The technique: As the sensory nerves run subcutaneously, the superficial parts of any wound are anesthetized by two subcutaneous injections.
2 Infiltration anesthesia for minor debridements: The tissues are infiltrated layer by layer as the debridement proceeds: infiltration for the skin incision. Then fanwise through the muscle fascia and along the wound track into the muscles. Anesthetic with adrenaline makes it bleed less but makes the assessment of tissue necrosis more difficult. Fracture hematoma anesthesia The method is effective for field reduction of fractures and evacuation analgesia. The hematoma is punctured. Aspirate blood from the hematoma into the syringe to verify correct position of the needle.Then 10-20 ml lidocaine 1% without adrenaline is injected slowly into the hematoma.
810
Infiltration anesthesia
Do not exceed the maximum doses Better add ketamine 0.25-0.5 mg/kg body weight as repeated IV injections. Or dilute lidocaine to 0.3% (with NaCl 0.9%) to affect a wider area not exceeding the toxic dose. Maximum doses Lidocaine: 5 mg/kg Lidocaine with adrenaline: 8 mg/kg Bupivacaine: 2 mg/kg Bupivacaine with adrenaline: 3 mg/kg.
811
48 Local anesthesia
4 The site of injection: The block is best applied through a posterior approach, three fingers lateral to the spine. A block at this level causes total anesthesia of the chest wall. Or the block may be applied in the mid-axillary line. 5
5 The injection: In a groove on the underside of each rib run the nerve, artery and vein for that segment.Wash the area, palpate the rib and infiltrate a little anesthetic in the skin at the lower border of the rib. Forward the needle until it reaches the rib. Walk the needle down the rib until it reaches the lower border. From this position forward the needle not more than 5 mm. Aspirate to avoid intravascular injection, and inject 3 ml anesthetic slowly. Problems with this method Note the maximum doses: Use anesthetic with adrenaline in extensive blocks to reduce the systemic absorption and the risk of side effects. A sharp chest pain is a sign of pleural puncture or pneumothorax. The fine-caliber needle reduces the risk of significant pneumothorax. Clinical examination for pneumothorax should be routine when the block is done.
812
Pleural analgesia
Indication Analgesia for chest-injured with chest tube. Drugs and equipment Lidocaine 1% or 2% with adrenaline or bupivacaine 0.5% Chest tube management, see pp. 188-94. Intrapleural anesthesia/analgesia may also be applied by using a fine-caliber catheter inserted percutaneously into the pleural space however, that procedure is not for field use. The procedure The anesthetic solution is applied through the chest tube. The tube is clamped, and 20 ml anesthetic is flushed through the chest tube into the pleural space.You may dilute the anesthetic with 20 ml saline for better distribution. After five minutes the clamp is released. Analgesia is rapid and effective. Problems with this method None significant.
48 Local anesthesia
Infiltrate a little anesthetic in the skin and seek the first rib posterior to the artery with your needle. The distance down to the rib is approximately 2-3 cm. If you let the needle walk upon the rib all the time, the risk of pneumothorax is minimal. Let the needle walk forwards upon the rib, while you aspirate the syringe. Tell the patient to inform you when he feels radiating sensations down his arm: That sensation indicates that the needle point touches one of the nerves, you can start the injection. Inject 30 ml lidocaine 1% slowly fanwise towards the rib. If you cannot exactly locate the nerves, seek the artery with your needle. If you aspirate blood, you have hit the artery (fine-caliber needle, no problem). Then walk 1 cm in the posterior direction and start the injection of 40 ml anesthetic. After 10-20 minutes the anesthesia is complete. Problems with this method Poor anesthesia of the ulnar nerve is common. You may add ulnar nerve block at the elbow. Pneumothorax due to perforation of the top of pleura (especially in patients with pulmonary tuberculosis).The risk is reduced when you use short fine-caliber needles. Routine: Clinical chest examination or X-ray after the nerve block. Horners syndrome (dilation of one pupil) and recurrent laryngeal nerve block (hoarse voice) is not serious and the patients condition returns to normal within 2-4 hours.
Better use axillary block if you cannot monitor the patient properly.
814
Problems with this method Approach through the artery: The radial nerve runs behind the artery, and the anesthesia of the radial part of the forearm may be poor. In that case you may repeat the radial block in the axilla through the artery: Locate the artery, and forward the needle through it until you cannot aspirate blood into the syringe. In that position, immediately behind the artery, inject 10-15 ml anesthetic without adrenaline. Or you may supplement a poor block with local infiltration or ketamine low-dose IV anesthesia. In fat patients the location of the artery may be difficult. Then go for radiating sensations with your needle to locate the nerve bundle.
11
11 Hand block radial nerve: Just proximal to the wrist the branches of the radial nerve spread fanwise. Inject 5-10 ml anesthetic as a subcutaneous wall. The latency before the take is 10 minutes.
815
48 Local anesthesia
12
12 Hand block median nerve: The nerve runs together with the finger flexor tendons under the palmar tendon approximately 2 cm under the skin. The site of injection is between the palmar tendon and the radial flexor of the wrist. Inject a little anesthetic in the skin and seek fanwise with your needle for sensations radiating into the 2nd and 3rd fingers. Inject 5 ml anesthetic at the nerve. Problems with this method None in particular.
13
816
15
15 The procedure: The main femoral nerve is located just lateral to the femoral artery, 1-2 cm deeper than the artery.Wash the field. Palpate the artery pulse beat. Infiltrate the skin with a little anesthetic, and forward the needle just lateral to the artery. Remove the syringe: If the needle pulsates with the pulse beat, the position is correct. Forward the needle another 1-2 cm, and infiltrate fanwise 20 ml of the anesthetic. Aspirate repeatedly to avoid intravascular injection. If the artery is punctured, apply manual pressure for five minutes to prevent hematoma formation then repeat the procedure. The lateral cutaneous nerve of the thigh is located under the inguinal ligament 1-2 cm medial to the anterior iliac spine, and under the muscle fascia of the thigh (fascia lata). Wash the field and infiltrate the skin. Forward the needle slowly, you will feel the resistance of the fascia lata when you penetrate it. Infiltrate 10 ml anesthetic fanwise in medial direction. Problems with this method Perforation of the femoral artery is no problem as long as it is recognized, and a fine-caliber needle is used. Manual pressure for five minutes prevents hematoma formation. If the anesthesia is poor in the deeper structures, supplement with ketamine lowdose anesthesia.
17
48 Local anesthesia
With a careful technique you should make the total ankle block with 30 ml anesthetic. Problems with this method Incomplete anesthesia in some areas: Supplement with toe nerve block or local infiltration anesthesia.
19
19 The anesthesia: Unwrap the arm. Tell one of your assistants to watch the BP apparatus continuously and maintain the cuff pressure at 200 mm. Inject slowly 50 ml anesthetic in the IV cannula. After 10-15 minutes the anesthesia is complete. Do not remove the IV cannula until the anesthesia is complete:You may have to add another dose of anesthetic. Lower limb regional anesthesia may be difficult due to insufficient tourniquet despite high cuff pressure: Insert the cannula in a foot vein or distal in the saphenous vein. Take care to apply the BP-cuff well distal to the knee joint to avoid
818
pressure damage on the peroneal nerve. In muscular males a cuff pressure of 300 mm and more than 50 ml anesthetic may be needed (leaking of anesthetic into the intraosseous space). Otherwise the procedure is identical to that of upper limb regional anesthesia. Problems with this method Bloodless fields increase the risk of thrombosis. Maximum duration is two hours: A bloodless field standing more than two hours will cause local necrosis due to hypoxemia. Not fit for debridements:You cannot assess tissue viability. Side effects are common when the cuff is released, but they recede rapidly without intervention. Note: Never release the cuff during the 15 minutes after the injection of anesthetic. As the cuff pressure is painful, either add a low-dose ketamine anesthesia or use the two-cuff method: A second cuff below the first is inflated to 200 mm once the skin is anesthesized, and the first cuff deflated. Delay of onset: Anesthesia of periosteum is not complete until 20 minutes after injection of the anesthetic.
819
820
49 Spinal anesthesia
The anesthetics The procedure
..................................................................... ......................................................................
822 823
821
49 Spinal anesthesia
Spinal anesthesia is a type of nerve block The anesthetic is injected into the dural sac where it mixes with the spinal fluid. The nerve roots are thus blocked inside the dural sac. Indications Spinal anaesthesia is NOT suitable for emergencies and mass casualties in forward clinics. Its use should be limited to a controlled and clean setting. Requirements 1. Sterile conditions 2. Never give spinal anesthesia unless the BP value is higher than the HR value. Eg: Blood pressure 90, heart rate 100: High risk of circulatory collapse, use ketamine anesthesia. Eg: Blood pressure 100, heart rate 90: You may give spinal anesthesia, but give IV ephedrine 5-10 mg immediately before the anesthesia.
The anesthetics
Both lidocaine and bupivacaine may be used as spinal anesthetics. Their onset time is approximately the same (5-10 minutes). The spinal anesthetics are available as two different solutions with different action: Heavy solutions: Both heavy lidocaine 5 mg/ml and heavy bupivacaine 5 mg/ml are available. Glucose 5 mg/ml is added to the anesthetic to make a solution with specific gravity higher than the spinal fluid. (You may make the heavy solutions yourself by simply adding 5% glucose.) The heavy solutions do not spread by diffusion inside the spinal fluid. Their localization and the nerve roots affected is determined by the position of the patient.The anesthetic area is therefore easier to predict compared to the plain solutions. Heavy bupivacine 5 mg/ml is the spinal anesthetic of choice for abdominal surgery. Plain solutions: Bupivacaine 0.5% (without glucose) spreads inside the spinal fluid by osmotic gradient. It is the spinal anesthetic of choice for all pelvic and lower limb surgery. But the upper level of anesthesia is too unpredictable for abdominal surgery. Bupivacaine is better As the duration of lidocaine anesthesia is one hour compared to the 3-4 hours with bupivacaine our advice is to use bupivacaine as the standard spinal anesthetic in wartime surgery. Wait 20 minutes before surgery starts to stabilize the anesthetic effect. 1 Spinal needles: Fine-caliber spinal needle with introducer. (You may equally use a 25 G spinal needle and an ordinary 22 G injection needle as introducer). And a standard spinal needle diameter 22 G with stylet.
822
The anesthetics
Premedication Drugs: IV diazepam 5 mg. Or IV morphine 5 mg plus i.v or IM atropine 0.5 mg Fluid pre-load: Give one flush infusion of 500-1,000 ml Ringer immediately before the anesthesia to prevent circulatory collapse Emergency drugs, suction device, and intubation set at hand. Dose and anesthetic level by injection at L3-L4 Intended level Skinny patients need higher doses of plain spinal anesthetic. Fat patients manage with less. Th12 Th4 Lidocaine/bupivacaine heavy 5 mg/ml 1.5-2 ml 2.5-4 ml Bupivacaine plain 0.5 mg/ml 3-4 ml unpredictable
Anesthetic level and surgery Type of surgery Abdominal surgery under lowspinal anesthesia (below Th6) increases the risk of bradycardia and arrhythmias. Abdominal Pelvic Thigh Lower limb Perineal Minimum level of anesthesia Th4 Th10 L1 L3 (the knee) S2 (perineum)
Notice the landmarks: Th4 the nipples Th6 the lower end of sternum Th10 umbilicus Th12 the pubic bone (midline)
The procedure
2 2 The anatomy: The spinal cord with the spinal fluid is located inside the dural sac. At each vertebra two nerve roots of the cord leave the spine. The dural sac is well protected inside the bony spinal canal, and by a strong ligament (the yellow ligament) between the spinous processes of each vertebra (you may feel this ligament when you penetrate it with the spinal needle). Immediately outside the dural sac in the epidural space is a venous network. Slightly bloody spinal fluid by the needle indicates that you have accidentally hit one of the small veins. The bleeding stops spontaneously and is not regarded as a complication. Note: Let the puncture of the dural sac be as non-traumatic as possible to avoid leaking of spinal fluid a cause of post-spinal headache.
823
49 Spinal anesthesia
C7
3 Spinal landmarks: The spinal cord ends at L2, and the level of puncture is below the L2 vertebra to avoid needle damage to the cord. Below L2 is a horse tail of spinal nerves that slip off the needle point without being damaged. A common site for the injection is between the 3rd and 4th lumbar vertebrae (L3-L4): A line between the top of his pelvic wings intersects the spine approximately at this level. The end of the dural sac (conus) is within the sacrum. Serious complications arise if the anesthetic reaches his cervical spine C7. 4 4 The procedure: The patient in sitting position, his spine well curved, not moving (support him). This position gives the most easy access between the lumbar vertebrae. Or the patient may lie on his side, his spine maximally curved. Good light is essential. Locate his pelvic wings and identify and mark the level between L3 and L4 exactly in the midline. Wash well and work sterile from now on.
5 5 For the inexperienced: With an ordinary needle infiltrate local anesthetic in the skin at the injection site, and into the interspinal ligament. By fanwise injections you can feel with the needle the spine of the vertebrae and thus identify the correct track for the spinal needle. 6 6 The puncture: The spinal needle with the stylet (or fine-caliber needle with introducer) is driven exactly in the midline in a slightly cranial direction. If you hit bone, withdraw and change the direction slightly. Perforation of the thick yellow ligament immediately outside the epidural space may be felt like a small snap. 7 Correct position of the spinal needle: When you are inside the dural sac, withdraw the stylet and wait some seconds for the clear, yellow, 37degree warm spinal fluid to drip from your needle. If it does not drip, insert the stylet and drive the needle in about l mm more, and try again. The structures passed by the needle from the skin inwards: the subcutaneous tissue, the supraspinous ligament, the intraspinous ligament, the yellow ligament, the epidural space and the dural sac.
824
The procedure
8 Choosing drug and dose case 1: Let us say you have a penetrating pelvic injury for exploration. The anesthesia should reach the lower abdomen, Th10-12. The patient is an adult of medium weight. Aspirate 4 ml plain bupivacaine 0.5 mg/ml in a syringe, withdraw the stylet from the spinal needle, connect the syringe and aspirate a little spinal fluid to check the correct position of the spinal needle. Inject the anesthetic slowly, remove the needle, apply a small bandage and let the patient lie down. Note: If you let the patient sit for 2-4 minutes after the anesthetic is applied, the anesthetic area increases. Choosing drug and dose case 2: A penetrating abdominal injury for exploration. The anesthesia should reach Th4. Inject 4 ml heavy bupivacaine 5 mg/ml using the same procedure. Lay the patient in the supine position immediately after the injection, tilt the table slightly head down but check that his neck is flexed on a pillow so the anesthetic cannot flow up to the cervical spine. Monitor closely after the injection: The circulation: Heart rate and blood pressure every two minutes for 15 minutes. Normally the blood pressure will fall somewhat within 25 minutes, then begin to rise when surgery starts. The breathing: In high thoracic anesthesia (anesthetic level above Th6) the patient feels discomfort due to paralysis of the intercostal muscles the thoracic respiration becomes weak. If the anesthesia reaches the cervical level, also the voice becomes weak he may not even be able to whisper as he cannot force air to pass between the vocal cords. The upper level of anesthesia: Ask the patient if he feels his legs becoming hot.This is a first sign of effective anesthesia. Identify the exact upper level of anesthesia by needle prick test.
825
49 Spinal anesthesia
Post-spinal headache It may develop the first 24 hours after anesthesia. The reason is leaking of spinal fluid through the dural puncture/punctures. The headache occurs mostly in patients where you had several dry taps, withdrawing and re-inserting the spinal needle and in young patients. Preventive: Fine-caliber spinal needles with introducer will reduce the risk of post-spinal headache. A careful technique of puncture good premedication is essential. An old dogma says 24 hours strict bed-rest after spinal anesthesia should reduce the risk of post-spinal headache that is not so. The management: Bed-rest:The supine position reduces the headache when it is already established. Effective analgesia. Fluid load: Per oral or IV 3,000 ml/day. All cases with post-spinal headache, even the bad ones, recover spontaneously within two weeks. The epidural blood patch procedure is not indicated unless the anesthesiologist is experienced and the conditions very clean. Spinal infection This infection is a catastrophe that may cause permanent cord damage. Preventive: Never make spinal puncture in a wound field or through damaged skin. Spinal anesthesia is not the method of choice in a hurried, chaotic and unclean emergency setting. Careful sterilization of instruments and strictly sterile procedures are mandatory. The management consists of high-dose broad-spectrum antibiotics on suspicion. Anesthesia chart Spinal anesthesia is an invasive procedure with serious potential complications. The documentation in the chart should be exact, and include the following information: The level of spinal puncture Puncture problems, if any The anesthetic drug and volume The upper level of anesthesia All side effects and complications.
826
827
828
Blood grouping
Blood given to a patient is a foreign substance, and may cause transfusion reaction: Antibodies in the patient are activated when foreign blood antigens are introduced some antibodies immediately, others after one or several contacts with foreign blood. The most important blood antigen-antibody system of the immediate kind is the ABO system. The most powerful system of the delayed kind is the Rhesus system. The ABO system There are four different blood groups in the ABO system. Each person has only one of the four: Blood type A Blood type B Blood type AB Blood type O. To prevent transfusion reaction with full-blood: Patients of blood type A should have A blood or O blood Patients of blood type B should have B blood or O blood Patients of blood type AB should have AB blood or O blood Patients of blood type O must have O blood. Emergency blood transfusion, see p. 417. In an emergency when you dont know which ABO group the patient has, give type O blood until the blood grouping is done. Remember to take a blood sample for typing before you start the O-blood transfusion. Monitor closely for transfusion reactions when O blood is used without typing and cross-matching, see p. 419.
829
The Rhesus system Each person has antigens of either Rhesus D+ or Rhesus D--- type.
830
Agglutination on a test spots always indicates that an antigen (A, B, or AB) and the antibody against that antigen (anti-A or anti-B) are both present on that test spot: If the patient has blood group A, spots 1 and 4 will agglutinate: On spot 1 the anti-A antibody solution reacts against the A cells. On spot 4 the A serum reacts against the known B cells. If the patient has blood group B, spots 2 and 3 will sediment: On spot 2 the anti-B antibody solution reacts against the B cells. On spot 3 the B serum reacts against the known A cells. If the patient has blood group AB, spots 1 and 2 will sediment: On spot 1 the anti-A antibody solution reacts against the AB cells. On spot 2 the anti-B antibody solution also reacts against the AB cells. On spot 3 and 4 no reaction will appear. If the patient has blood group O, spots 3 and 4 will sediment: The patients serum contains anti-A and anti-B antibodies that react against the known A and B cells. In the ABO-system a person has naturally occurring antibodies against the antigens the person is missing (ex blood type A has antibody B in plasma) . How to do the Rhesus D grouping Put one drop of anti-D solution in a test tube. Add blood cells from the patients cell concentrate with a stick (or 1 drop of 5% red cell solution in 0.9%NaCl). Set the mixture aside for five minutes in 20-25 C. Shake the tube, then spin it in the centrifuge for 1 minute at 3,000 rpm. Look for agglutinations with the magnifying mirror: Agglutinations indicate Rhesus D+ group, no agglutination indicates Rhesus D--- group. Note: The test is more accurate if you simultaneously mix the anti-D antibody solution with a control D--- blood sample that you know will not sediment, and compare the patients tube with the control tube.
Cross-matching
This is to test if the patients blood reacts against the donor blood you plan to use for transfusion. Simple cross-matching is to test the actual donor blood cells against the patients serum and is a control of ABO compatibility. How to do simple cross-matching Put two drops of NaCl 0.9% in a test tube. Make a blood cell concentrate of the donor blood (see above), dip a stick in the blood cell concentrate, and mix the donor cells with the saline to obtain a 5% solution. Wash the mixture by filling the tube with saline, and spin it in the centrifuge for one minute at 3,000 rpm. Remove the saline with pipette. Add two drops of the patients serum to the washed donor blood cells. Set the donor-patient mixture aside for five minutes in 20-25 C. Spin the mixture in the centrifuge for one minute at 3,000 rpm.
831
Read the agglutination with magnifying mirrors: No agglutination indicates that the donor blood may be used for transfusion (ABO-compatible). Agglutinations indicate that antibody-antigen reaction of some sort has happened, and the donor blood should not be used for that patient.
Blood banking
More on blood transfusion, see p. 415. If the resources are few and the forward clinic mobile, we recommend a walking blood bank for field use: Blood group the local population, soldiers and clinic staff. Take special care to identify a certain number of blood type O donors. Make blood group cards that the donors should always carry around their neck. Make a calling system so you can scramble donors rapidly in emergencies. The donors themselves will profit on being grouped in case they themselves become wounded.
832
Preparation of the smear Wear gloves. A tissue sample: Roll swabs with the material with firm pressure over a small area on the glass slide. A thin fluid sample: Place one drop of the fluid in the center of the slide, let it dry without being spread. A thick, viscous sample: Place one drop of the material on the glass slide, cover it with a second slide. Press the slides together, and pull them apart. Air-dry the sample. Then heat-fix by passing the slide three times (about one second each) through a flame. The slide should be warm, but not hot. Cool the slide before staining. The gram-stain procedure Flood the thin, air-dried, and heat-fixed glass slide smear with crystal violet solution (dark blue) for 30 seconds. Then wash gently under running water. Flood with iodine solution (brown) for 30 seconds. Wash gently under running water. Critical step: Remove excess color by letting ethanol 95% flow over the slide until the runoff becomes clear, or the thinnest parts of the smear are colorless. Counter-stain by flooding the slide with safranin solution (red) for 30 seconds. Wash gently under running water. Air-dry the smear. It is ready for microscopic examination. The microscopic examination: Control smear quality Examine the smear in the microscope under an oil immersion objective: Check if the smear really contains infectious material: Examine the smear under low power, look for inflammatory cells close to bacteria a main sign of infection. Check the technical quality of the smear: Use the oil-immersion lens. The nuclei of inflammatory cells should stain red or purple. If the cell nucleus stains blue or the background is blue, the excess color has not been sufficiently removed (see critcal step above).
834
Problems with the gram-stain smear The infectious material must contain about 100,000 bacteria per ml to make possible a microscopic diagnosis.You can hardly draw any conclusions if the number of bacteria is small, and no inflammatory cells are present. In acute infections, the smear usually contains one (or two) types of bacteria. But different types of bacteria may appear identical in the gram-stain procedure: Always compare the microscopical picture with the clinical facts, and with a gross examination of the infectious material. Gram-positive bacteria may appear rather gram-negative if they are old or treated with antibiotics. Draw conclusions with care, accuracy depending on training and skill: Artefacts, such as particles of crystal violet, may be misinterpreted as cocci or bacilli. You may have lost material from the smear during staining: The smear has been too thick, or the heat-fixation poor. You may check the gram-stain technique by staining your own sputum, which contains both gram-positive and negative bacteria, as well as epithelial cells. We recommend additional staining procedures for pus where no bacteria are observed (eg. acid-fast stain). Study laboratory manuals for further information, see p. 848.
835
836
The forms below are very simple and they should be; there is no time for elaborate documentation in the war zones. If you ask for a lot of detailed information you will surely end up with incomplete and unreliable data. Even though simple, these forms have been used by the authors and our partners during twenty years of trauma studies in mine fields and wars, resulting in quite a few useful scientific publications. You may download the forms at www.traumacare.no. More on data gathering and quality control, see chapter 4.
837
844
www.traumacare.no Our own web page with scientific publications and wiki on trauma care and trauma training in low-resource settings. You can also find trauma registry templates and a simple confidence interval calculator for free download. www.trauma.org A non-profit site with a good library of articles, images and case presentations of trauma patients in high-resource settings. The site has useful trauma severity calculators. www.aast.org The website of American trauma surgeons has images, videos and articles on trauma care including guidelines for surgery and critical care according to high-tech Western standards. www.braintrauma.org The site has updated guidelines for management of traumatic brain injuries, including combat-related trauma. www.nbc-med.org You can download: Medical aspects of chemical and biological warfare. In: Zaitchuk R, Bellamy RF. Textbook of Military Medicine. US Army.
845
Nessen SC et al: War surgery in Afghanistan and Iraq: A series of cases, 2003-2007. Department of the Army. USA, 2008. Illustrated and detailed study of war victims managed by the US and NATO surgical teams in the war theaters. The book reports and discusses frankly success cases as well as treatment failures.
General surgery
Zollinger and Zollinger: Atlas of surgical operations. McGraw-Hill. NewYork, 2002. An instructive atlas for the new surgeon. In a large format, it may be too heavy for field use. Sabiston: Textbook of surgery. The biological basis of modern surgical practice. WB Saunders Company, USA, 2001. Offers basic principles in a readable way. Weigelt JW, Lewis FR: Surgical critical care. WB Saunders Company, US, 1996. A must for the doctor who wants to understand and manage the complex physiological responses to injury.
847
Vascular surgery
Ascher E et al: Haimovicis vascular surgery. Principles and techniques. Appleton & Lane. New York, 2004. A basic and comprehensive book on vascular surgery. Good explanations of technical details. Useful in the library if you have to treat vascular problems.
Orthopedics
McRae R: Practical fracture treatment. Churchill Livingstone. London, 2008. A recommended book for field-work, readable with good illustrations.
Plastic surgery
Mc Gregor AD: Fundamental techniques of plastic surgery and their surgical applications. Churchill Livingstone, 2000. A short, instructive, and basic book on plastic surgery. Blondeel PN et al: Perforator flaps. Anatomy, technique, and clinical applications. Quality Medical Publishers. St. Louis, 2005. The first comprehensive textbook on perforator flaps. The details of the operative technique are still a matter of discussion.
Nutrition
Whitney EN, Hamilton EMN: Understanding nutrition. West Publishing Company. Minnesota, USA, 1984. An instructive, comprehensive, and readable introduction to basic nutrition.
Tropical medicine
Manson-Bahr PEC, Apted FIC: Mansons tropical diseases. Bailliere Tindall. London, 1982. The classic textbook on tropical diseases.
Laboratory medicine
World Health Organization (WHO): Basic laboratory procedures in clinical bacteriology. WHO. Geneva, 2003.
848
Anesthesia
Dobson: Anaesthesia at the district hospital. World Health Organization 1988. Jaypee Brothers. New Delhi, 1989. A well-illustrated and instructive introduction to life support, general and local anesthesia, and diseases that may complicate anesthesia. Brown DL, Clifford JA: Atlas of regional anaesthesia. Saunders. USA, 1999. An illustrated guide to regional nerve blocks.
Rehabilitation
Hobbs L et al: Life after Injury. A rehabilitation manual for the injured and their helpers. Third World Network. Penang, Malaysia, 2002. A goldmine of comprehensive information for assessing needs and carrying out rehabilitation where resources are few.
Staff training
Werner D, Bower B: Helping health workers learn. Hesperian Foundation. Palo Alto, USA, 1992. A basic and instructive book, recommended for everybody engaged in medical staff training.
849
850
Acknowledgements
The models and recommendations in this book draw on studies conducted under difficult conditions, and could not have come about without support, advice, and protection provided by popular movements and institutions in the South. The authors are especially indebted to the paramedics and doctors of Mujahed Medical Center Afghanistan, Trauma Care Foundation of Iraq and Cambodia, the Civil Defense of Islamic Health Society Lebanon, and the Palestinian resistance in Gaza who treated war victims and gathered data in the teeth of power. We acknowledge the honored members of the Ningarhar Shura, the late commander Qari Baba, governor of Ghazni Province, Afghanistan and Dr. Sann Aung, Minister of Health, NCGUB, Burma and the late Hallvard Kuloy, founder of the Norwegian Burma Committee. We also want to thank a few outstanding war surgeons and care providers for generously sharing knowledge and skills: the late professor Choenn Choun, head surgeon of the Khmer revolution; Prak Bun Hay, surgeon, Malay Hospital, Cambodia; the late HM Singh, consultant surgeon, Karen Base Hospital, Burma; Pierre Bwale, surgeon, Congo; Gino Strada, chief surgeon, Emergency; and Chris Paul Giannou, former consultant surgeon, Palestinian Red Crescent Society. We also acknowledge inspiration and guidance from professor Fernando Vaz, Eudardo Mondlane University, Mozambique; professor Moosa Zargar, Sina Trauma Center, Tehran; professor Eng Hout, Deputy Minister of Health, Cambodia; professor Rebecca Jacob, Vellore Medical University, India; the professors Mads Gilbert,Anne Husebekk, and Dag Soerlie at the University Hospital North Norway; and professor Torben Wisborg, Hammerfest Hospital, Norway. Without the commitment from these friends, we would not have been able to develop and test the models for forward wartime surgery presented in this book. We also want to thank the following persons for their assistance and advice: V Arnulf MD J Beavis MD S Bergstrm MD B Bjoerkvoll C Davoung MD LJ Garvik K Gargesh MD PA Gulowsen MD S Gustafsson RN K Hassanally MD B Heger MD E Hem MD F Jerve MD D Johansen MD
851
Acknowledgements
F Khoo IM Pinder MD T Lund MD A Lyslo MD M Mikkelsen B Nicolaissen MD PT Nilsen HK Nordby MD U Pedersen L Salemark MD A Skagseth MD P Skjelbred MD SRS Smith MD K Solheim MD
PA Steen MD J Stevens MD KE Stroemskag MD K Stroemsoe MD M Sundet MD PO Sundnes MD A Sundsfjord MD N Soerheim MD M Taksdal, RN TW Wadsworth MD JA Weigelt MD D Werner P Worlock MD O Ugland MD
The production War Surgery, first edition was sponsored by the Asmund Laerdal Foundation for Acute Medicine Inc; Norwegian Air Ambulance; the Norwegian Ministry of Foreign Affairs, Section for Human Rights and Humanitarian Relief; the Norwegian Board of Health; Norwegian Church Aid; Norwegian Peoples Aid; Save the Children Norway; Mediq Norway AS; Norwegian Aid Committee; and Norwegian Non-fiction Writers and Translators Association. The production of the second and revised edition of War Surgery is sponsored by the University Hospital North-Norway, the University of Tromsoe, and humanitarian grants from the Norwegian Ministry of Foreign Affairs.
852
Glossary
Listed here are medical terms commonly used.Words in bold are all listed as separate entries in the glossary. If you cannot find some terms in the glossary, look them up in the Index, they may be explained or illustrated in the text.
853
abdomen
A
abdomen the cavity in the body trunk between the diaphragm and the pelvis, above the diaphragm is the chest abdominal cavity that part of the abdominal cavity which is inside the peritoneal lining.This lining divides the abdominal cavity into the abdomen proper, and outside the lining is the true pelvis abduction moving a limb away from the central (midline) line of the body abortion expulsion, or removal of the early contents of pregnant womb. A miscarriage is a natural abortion, while abortion can also be achieved by scraping out the pregnant womb abscess a cavity or space filled with pus absorb to suck up, take into absorbable (sutures) material which when placed in the body will dissolve in the body with time. Thus absorbable stitches do not need to be removed. Catgut, Dexon, and Vicryl are examples of suture materials which are absorbed by the body tissue accelerate to increase in speed Achilles tendon the strong heel tendon by which the calf muscles flex the ankle joint acidosis too much acid in the blood.The degree of acidosis is measured in units of pH. Normally the blood pH is between 7.2 to 7.4.The pH may vary as stress or exhaustion increases the production of acid. Or the acid production may be normal, but the body is unable to get rid of the acid because the kidneys or the lungs are not working properly acromion the point of the shoulder blade acute sudden adduction to bring a limb or digit towards the midline adhesion early or late scar tissue that makes the body linings and organs stick to each other. In the abdomen, adhesions may form between intestines and peritoneum. In the joints, adhesions may form between the lining of the joints, between tendons and the surrounding soft tissues adventitia outside layer of the intestines, blood vessels, and nerves.Adventitia consists mainly of loose fibrous tissue aerobic infection infection by bacteria which flourishes in the presence of oxygen. Also see anaerobic infection airway the whole air passage from the nostrils to the lung tissue. It consists of the nostrils, nasal cavity, the pharynx, larynx, the trachea, bronchus, small bronchial branches and the air sacs
854
albumin a protein found in the blood, which is important for keeping the water molecules inside the circulating blood volume through osmotic pressure. Loss of albumin results in water being drained from the circulating blood to the tissues, which then swell (edema) allergy/allergic the bodys way of over-reacting to certain substances. It can be mild like a local skin rash (skin allergy), hay fever (the upper airways reacting to substances in the air), or severe when the blood forms allergic complexes to drugs like penicillin, or a different type of blood. allograft tissue graft from another person, like skin graft or bone graft.The commonest allograft is blood transfusion alloplasty/allplasic surgery with synthetic graft alveolus/alveolar alveolus is the terminal part of the airway where the branching small bronchi end in sacs.These sacs are very rich in blood supply, and being thin-walled, allow the blood to come into contact with the breathed-in air.The blood takes up oxygen, and at the same time carbon dioxide is given out into the sacs and is breathed out ambulation to make mobile, eg. to get out of bed, to walk, to move with a wheelchair ameba a single-cell parasite which invades the large intestine and feeds on red blood cells amino acid the molecule units which makes up proteins amniotic fluid the fluid which surrounds the fetus anabolism absorbing food and building up body stores of carbohydrate, protein and fat anaerobic infection infection by bacteria which grow in conditions with little or no oxygen analgesia without pain, to remove or decrease pain with the use of drugs and injections analgesic painkiller, it may be simple, like aspirin tablets, or complicated like intercostal nerve blocks and ketamine anesthesia anastomosis a joining of two tube ends together surgically anemia low hemoglobin of less than 10 g/100 ml anesthesia, local local injections of substances which abolish all sensations, making an area numb anesthesia, general injection or breathing of anesthetics which knocks off the brain centers temporarily so that a state of unconsciousness and unawareness results anesthesiology the science of effecting and reversing anesthesia anesthetic substances which produce anesthesia antacid alkaline substances taken to neutralize the acid fluids in the stomach anterior to the front
bulb of eye antibody a protein produced by the body to neutralize unfriendly agents, like bacteria, viruses, toxins. Sometimes the body makes a mistake and starts producing antibodies to common substances like food, pollens, and allergy results, or to its own tissues auto-antibodies antidepressant drug drugs which elevate mood, and therefore help counter psychological depression antihistamine histamine is a substance important in bringing about an allergic reaction, antihistamine is a drug to block the action of histamine antiseptic against sepsis substances which kill bacteria and other organisms which cause infections anuria not producing urine; real anuria indicates the kidneys have packed up, but most clinical anuria is due to the urinary outflow being blocked for instance, a blocked catheter anus/anal the end of, normally refers to the bottom end of the intestinal canal, where the rectum meets the outside aorta/aortic the main blood vessel of the body. It leaves the heart with fresh blood and runs upwards curving down to descend into the chest and abdomen where it finally divides into the two main arteries for the lower limbs. All along the way, it gives out branches to various organs like the heart muscle, the lungs, the liver, the neck, the kidney, the intestines, and the limbs arrhythmia wrong rhythm referring to the heart rhythm being abnormal in speed and regularity arteriography an X-ray technique to outline the arteries by injecting dye (contrast) into them arteriotomy to make an opening into an artery arthritis joint inflammation which may be caused by infection, chemicals, injury, or wear and tear arthrodesis joint fusion:The joint cartilage is removed, and the bone ends compressed together, the resulting bony union thus abolishes all joint movement arthroplasty surgical creation of a new joint:This can be done by resecting the old deformed joint and allowing the remaining bone ends to move freely between soft tissues, eg. a resection arthroplasty like the Girdlestone hip arthroplasty. Alternatively, replacemement arthroplasty is where a synthetic joint is inserted into the bone ends replacing the old joint ascend to go up, to increase aspiration/aspirate to draw up, also refers to the backflow or vomiting of stomach contents and then breathing them into the lungs atelectasis collapse of lung tissue atrium/atrial the chambers of the heart which receive blood from the veins:Thus the right atrium receive venous blood from the caval vein, and the left atrium receive blood from the lung veins auscultation to listen with a stethoscope autotransfusion transfusion with own blood autoclave a machine, not unlike a sophisticated oven, where bacteria and disease-producing organisms are destroyed by heat, either moist or dry heat autonomic nervous system part of the nervous system that functions without the control of our will. It regulates the functions of internal organs as well as circulation, breathing, metabolism. See also vagus nerve axilla the armpit
B
biceps the muscle on the front of the arm which flexes the elbow. Also one of the muscles (hamstrings) on the backside of the thigh which flexes the knee bile/biliary yellowish-green, bitter digestive juice secreted by the liver, and stored in a pouch called the gallbladder biologic living biomechanics the study of the mechanics of skeletal motion in living things blast an explosion releasing a lot of energy causing high pressures (the blast wave) and high temperatures blood gas the oxygen and carbon dioxide carried in the blood blood smear (diagnostic) spreading blood on a glass slide and staining it so that details can be examined under a microscope blunt (injury) injury caused by blunt agents (as opposed to penetrating injury). Blunt injuries typically involve ill-defined, large areas which are crushed, deep and with internal bleeding bolus ball, thus food bolus, bolus injection is a one-shot dose as opposed to continuous infusion BP blood pressure brachial arm bradycardia slow heartbeat brain stem the lower part of the brain, joining the top or forebrain to the spinal cord. It is the most important part of the brain controlling vital functions like breathing, heart, temperature broad-spectrum (antibiotic) effective against a large spectrum, or many types of bacteria bronchus/bronchial the branches (or bronchi) arising from the trachea bulb of eye eyeball
855
C (centigrade)
C
C (centigrade) when measuring temperature, the Centigrade scale is divided into 100 units or degrees 0 being the freezing point of water, and 100 being the boiling point of water, the human body temperature is 37 degrees Centigrade C (cervical) neck, C1 means the first cervical vertebra or segment, C2 the second and so on cadiac output the volume of blood pumped out by the left side of the heart (left ventricle) into the aorta every minute. It is the volume of blood rich in oxygen that the heart sends to all parts of the body every minute cal calorie, a unit for measuring heat, where one calorie raises the temperature of one gram of water by one degree Centigrade calcaneus the heel bone callus soft new bone, which is formed during the early part of fracture healing calorie, see cal cancellous (bone) spongy bone rich in marrow and blood supply.The vertebral bodies, the ends of long bones are all cancellous cannula a tube for inserting into blood vessels or body ducts and tubes, so that infusions and drugs could be given capillary the terminal branch of the artery and vein. It is small with thin walls so that blood gases and nutrients could be exchanged between the tissues and the blood, and in the case of the lung alveoli, between the atmosphere and the body carbohydrate chemical substances containing carbon, hydrogen and oxygen, the unit of which is the sugar molecule, such as starch or glycogen carbon element which commonly exists as coal, or rarely as diamond. It is the basic element of organic compounds from which living things are made carbon dioxide when carbon is burnt in oxygen (air), the molecules of carbon and oxygen join to form carbon dioxide.To produce energy, the body slowly burns carbohydrate, which forms carbon dioxide that is carried to the lungs and out to the air cardiac heart carotid the main arteries to the head and neck catabolism breaking down of body tissues resulting in weight loss and wasting catheter a hollow tube which can be inserted into the bladder to drain urine out, through the nose into the stomach to drain gas and fluid, into the blood vessels to give infusions and drugs, or used as a drain for a hematoma
856
cautery burning, used mainly to burn small vessels during surgery so that bleeding stops caval vein the main vein of the body which carries used blood back into the heart so that the blood low in oxygen and high in carbon dioxide could be directed to the lungs to be re-oxygenated and decarbonized cavitation to form a cavity cecum the beginning of the large intestine cellulitis local inflammation due to infection without welldefined boundaries in subcutaneous and connective tissue cereal seeds of the grass family; common cereals are barley, rice and wheat cerebral the forebrain, which is responsible for higher intellectual functions and memory cervical neck cervix of uterus the junction of the vagina and uterus chain-of-survival an organized network of trained lifesavers outside hospital where first helpers, paramedics and doctors give life-support to the patient all the way from the site of injury until hospital admission cholecystectomy removing the gall-bladder choledochus bile duct chronic long-term circulation an overall term describing the function of the blood, heart and vessels citrate salt form from citric acid, which is in citrus fruits clavicle collar bone cluster weapon air-dropped or ground-launched explosive weapons that eject smaller bomblets or rockets cm (centimeter) one hundredth of a meter coagulation blood clotting coccyx the tail end of the spinal column; in animals it is the tail bones. In humans, the coccyx is very small and lies buried in the natal cleft collagen a protein of connective tissue that forms strong fibers as in tendons collateral (vessel) parallel blood vessels colon large intestine coma a state of unconsciousness comatose to be in coma comminuted fracture broken bone, where there are more than two fracture fragments compound (fracture) open fracture, where the skin is breached and the fracture communicates with the outside environment.This means bacteria from the outside can get into the bone and infect the fracture consciousness wakefulness condyle knuckle, an expanded end of a bone congestion over-accumulation of fluid, eg., blood in the lungs, heart, liver, legs
displacement congestive heart failure the heart failing as a pump. There is backlog of fluid, since fluid is not pumped on conjunctiva the lining of the exposed part of the eyeball, and the inner side of the eyelid connective tissue usually consists of fiber cells, muscle cells, fat cells and collagen bundles conservative a preserving attitude.When a debridement is described as conservative, it means to save as much tissue as possible.The opposite is radical, meaning to get rid of as much as possible contamination the presence of bacteria or infectious substances contracture describes a state where the joint capsule and ligaments are permanently shortened (contracted) thus limiting full movements of the joint convulsion fits cord (spinal) the large nerve tube running in the spinal canal cornea the clear lining of the eye over the pupil coronary vessels the blood vessels supplying the heart muscle corrugated (drain) drains made from flat, wavy rubber cortical (bone) strong, dense laminated bone such as the shaft of long bones costa/costal rib counter-traction opposing pull against primary traction counter-incision additional incisions which will help in the exploration craniotomy a surgical operation in which a bone flap is removed from the skull, to access the brain crepitation fine bubbling of the lungs due to the alveolar sac being filled with fluid cricoid the Adams apple cross-match technique used to identify blood that may be used for transfusion curettage scraping with a curet a surgical spoon cutis/cutaneous the visible part of the skin cyanosis when blood loses much of its oxygen, it becomes dark and loses its red color, and this gives a bluish, purplish color when seen through the transparent structures like the nails, the under-surface of the tongue, the conjunctiva. cyst a fluid-filled sac lined by a body membrane cystography X-ray technique of visualizing a cyst by filling it with contrast media, eg. X-ray examination of the urine bladder
D
damage control brief surgical operation on severely injured or weak patients for temporary stabilization until the injuries can be repaired debridement removing debris. It refers to the surgical technique of cutting away damaged and dead tissue and mechanically removing dirt particles from a wound debris dirt, rubbish and foreign fragments decompression to reduce pressure. It can be done by draining fluid and gas by naso-gastric tube. Or by removing a constricting roof as in fasciotomy where pressure is released by splitting the roof of the tight canal formed by fascia and bone. Or in spinal decompression, where the bony ring of the vertebra is deroofed to reduce the pressure on the spinal cord, also see laminectomy decortication removing the outer layer of.To remove the roof of a pleural abscess, or one cortex of a osteomyelitic bone. Decortication opens up an infected cavity and allows free drainage of pus dehydration reduction of the water content of the body, as when losses by diarrhea are not compensated for by drinking more fluid dental teeth dependent drainage to drain (fluids) by gravity dermatome an area, segment of skin supplied by one spinal nerve root dermis/dermal the deep layer of the skin diabetes excessive output of urine. Diabetes mellitus is a condition with hyperglycemia and excessive output of sweet urine diaphragm the transverse dome-shaped muscular layer which separates the chest from the abdomen; the diaphragm is also the main muscle for breathing diastolic relating to the relaxation of the heart ventricles digitalization to treat with digitalis, which is a drug increasing the force of heart muscle contraction dilation increase in circumference and size, to stretch DIME, dense inert metal explosive an explosive containing small particles of heavy metal (tungsten or nickel-cobalt) mixed with the explosive material, causing very heavy pressure waves disarticulation to remove through a joint disinfect to kill bacteria and micro-organisms by chemicals, heat or radiation disinfectant substance which disinfects dislocation joint surfaces becoming dissociated, out of joint displacement refers to fractures when the two ends are shifted in relation to each other
857
dissect dissect to cut up surgically dissection, sharp to surgically cut using a sharp technique, classically with a scalpel dissection, blunt to open up tissue surgically using a blunt or round instrument, such as the finger tip, a gauze swab distal away from the head distraction (of fracture fragments) to pull apart distress, respiratory b re athing difficulty from mechanical problems like fractured ribs, pneumothorax distress, fetal the unborn child in distress in the womb, usually due to lack of oxygen; this shows up as slowing down of the fetal heart rate diuretic substance to increase the production of urine diversion stoma interrupting the flow of intestinal content by diverting it outside through the abdominal wall.This is usually done by making an opening in the intestine stoma proximal to an injury to let the fecal stream drain out through the abdominal wall donor the area or the person from whom grafts are taken dorsal the back duct a hollow body tube conveying fluid, juices duodenum the first 12 inches of the small intestine dura/dural the sac which lines the brain dynamic permitting movements and flexibility emphysema a lung disease characterized by partial small and medium airway obstructions resulting in the lungs being over-expanded, with diminished gas exchange, and the adjacent walls of the alveoli breaking down empyema pus in the pleural cavity endemic local, coming from within the community endocrine glands without ducts, secreting hormones directly into the blood endotracheal (intubation) into the trachea endotracheal intubation is to put a non-collapsible tube into the trachea so that oxygen can freely enter the lungs energy the work or force within a system enteral the stomach and intestines enteritis inflammation of the intestines through infection, allergic reactions, damage enterostomy a stoma, opening of the intestine leading to the outside for either diverting the intestinal contents from the distal intestine, or for introducing nutrients into the proximal intestine for feeding purposes enucleation removal of a round structure, such as taking out the eye enzyme a biological substance that speeds up a chemical reaction epicondyle (of humerus) the enlarged distal ends of the humerus where the muscles of the forearm find origin epidural the space inside the spinal canal and skull superficial to the dural sac epigastrium overlying stomach area epineurium the outer covering of a nerve epiphysis the growing cartilage at the ends of a bone in children, it becomes calcified and stops growing on their reaching adulthood eschar the thick scab which forms over full thickness burns escharectomy surgical removal of an eschar escharotomy incising an eschar so that it is split down to the deep soft layers esophagus the gullet, that part of the upper gut tube from pharynx to stomach evaporation changing from water in the fluid state to water vapor or gaseous state to dry out eversion lifting of the outer rim of the foot excise/excision to surgically cut out expiration to breathe out exploration surgical searching and examination extension increase what is already existing, eg., an incision, an infective process.When used to describe joint movements, it means the straightening out of a joint extensor muscle producing extension
E
ECG electrocardiograph, tracing of the electrical activity which takes place in each cardiac cycle -ectomy surgical removal, eg. nephrectomy removal of one kidney edema diffuse swelling due to accumulation of tissue fluid electro-cautery to burn with electricity electrolyte substance which when disssolved in water produces charged particles. Salts and elements in the blood and body tissue are electrolytes unless they are chemically attached to other substances elevation to raise up.When referred to a limb, it is to raise it up beyond the heart level embolectomy remove an embolus, blood clot by arteriotomy or specially designed embolectomy catheters embolism the process of throwing up blood clots, clumps of bacteria, air, tumor into distant blood vessels embolus/emboli blood-borne particles, such as, clots formed inside the bloodstream, particles of tumor, bacteria etc. which break lose and travel with the blood to other parts of the vascular tree, see also thrombus
858
guillotine exteriorization bringing out from inside the body to the outside like exteriorization of a loop of intestine external fixation a technique for stabilizing bone fractures by external devices. Popularly referring to the external fracture fixators using pins and bars like the Hoffman, the Orthofix, the ASIF frame, but any pins in the proximal and distal fragments could also be held together with plaster of Paris, or tubes of orthopedic cement; see also transfixion pins extra outside, extraperitoneal means outside the peritoneum fuel-air explosive the initial explosion releases a flammable vapor cloud which is ignited, making a flame front of high temperature and pressure
G
g (gram) a unit weight, one ml of water weighs one gram G (gauge) needle and cannula sizes, the larger the Gvalue the thinner the needle standard intramuscular injection needles are between 19 + 21 G, large IV cannulas should be at least 14 or 16 G, for blood transfusion. Conversion table G/mm, see pocket folder at back cover gangrene dead tissue, organ necrosis gastric stomach gastrostomy a surgical opening made between the stomach and skin, so that food solution could be given to the stomach, bypassing the mouth and esophagus gelatin a protein derived from boiling collagen, after cooling the liquid sets to form a jelly-like material gelatinization the process of making gelatin-like substances genital reproductive organs, sex organs Gigli (saw) orthopedic chain saw globe of eye the eyeball glucose a six-carbon sugar formed from breaking down carbohydrates. Glucose is the form of fuel used in the body to produce energy gluteus/gluteal the large buttock muscles, or describing the buttock area glycerol a chemical produced by chemically splitting fat glycogen animal starch. Glycogen is the form in which carbohydrate stored in the liver and muscles graft tissue or synthetic material used to cover or make good a defect. It could take the form of skin graft or bone graft. Blood transfusion is also a graft Gram (classification of bacteria) by using the Grams stain technique, bacteria are divided into those which retain iodine-treated, crystal violet stain even after washing with alcohol gram-positive; and those which do not retain the stain gram-negative. granulation pinkish buds of healing tissue rich in capillaries seen growing in excised and healthy wounds left open.When granulations are seen, the wound can be skin grafted, if left alone, granulation tissue becomes transformed into scar tissue in due course guillotine an apparatus for beheading.When used to describe an amputation, it refers to the cutting off all tissues of a limb at the same level
859
F
facial the face fasciitis inflammation of fascia, usually due to infection fascia muscle fascia is the fibrous layer that separates the muscles from the subcutaneous layer; fascia can be very thick like the thigh fascia, or so thin that it is scarcely visible in some parts of the body fascicle (of nerve) small bundles of nerve fibers which together form a nerve fasciotomy dividing and splitting open the fascia, so as to decompress a muscle compartment of a limb fatal leading to death feces stools femur/femoral the thigh bone, or describing the region relating to the thigh bone fermentation the process where yeast acts on carbohydrates, breaking them into smaller sugar molecules, a process which uses oxygen and produces carbon dioxide fetus/fetal the unborn baby fibrinolysis clot dissolution fibrous a structure is said to be fibrous if it contains an abundance of fibers fibula/fibular the outer and thinner bone of the leg fistula a track leading from a body cavity, organ, tube, sac, to the skin surface flechette projectile with dart-type steering devices flexion bending a joint so that the distal part comes towards the proximal part flexor muscle that brings about flexion Foley (catheter) urethral catheter named after its inventor. It has an inflatable balloon at its tip to prevent it slipping out and is therefore self-retaining French (size) a system of sizing the diameters of catheters and tubes frontal the forehead
hallucination
H
hallucination to hallucinate is to see or hear people or things which are not present; hallucination is a psychotic state halo large ring over the head hamstring (muscles) the muscles at the back of the thigh, they flex the knee and extend the hip hematocrit also called packed cell volume, it measures the proportion of red blood cells in relation to the fluid of the blood, and should be about 34 normally hematoma collection of blood, blood clot outside the blood vessels hematuria blood in the urine hemi- half hemicolectomy removing part of the colon, eg. the ascending colon as in right hemicolectomy, or the descending colon as in left hemicolectomy hemithorax half the thorax, either to the left of the mediastinum or to the right of it hemoconcentration increasing proportion of blood cells in relation to the plasma, as in dehydration. Blood becomes more viscous, and there is increased tendency to clot hemodilution blood becomes more fluid as the proportion of blood cells decreases, as in Ringer infusion hemoglobin the iron-containing protein in red blood cell which carries oxygen and gives the blood its red color hemolysis under certain conditions, the cell walls of the red blood cells rupture, and their contents escape into the plasma hemostatic ability to stop bleeding hemothorax bleeding into the pleural cavity hepar/hepatic liver heparinization giving of heparin to prevent thrombus formation inside the vascular tree hernia protrusion of an organ or tissue through an abnormal opening or a weak point, eg. the peritoneal sac and abdominal contents pushing out through a weakness in the abdominal wall herniation forming a hernia high explosive (HE) an explosive creating a pressure wave moving at speed higher than the speed of sound (343 m/sec) hilum the eye, a gap or opening in an organ where vessels enter and leave, such as hilum of kidney, liver, lungs horizontal parallel to the horizon hormone biologically active agents secreted by endocrine glands and released into the bloodstream so that they could be carried to exert effects on distant target organs
860
HR heart rate hyper- increased hypermetabolism increased metabolism hyperosmolar increased osmolarity, increased molecular concentration hypertension increased blood pressure hyperthermia body core temperature above normal hypertonic (solution) more concentrated than blood hypertrophy increases in size of an organ hyperventilation to overventilate, drawing in large volumes of air, or increasing the speed of breathing hypo- decreased hypoglycemia decreased glucose in the blood hypo-osmolar decreased molecular concentration hypoperfusion decreased blood flow through an organ hypotension low blood pressure hypothermia central body temperature below normal hypotonic (solution) less concentrated than blood hypovolemia decreased blood volume hypoxemia low oxygen content in blood hypoxia low oxygen tension
I
IM intramuscular, into muscle i.o. intraosseous, into bone IV intravenous, into vein ileum the distal part of the small intestines where maximal absorption of food nutrients takes place ileus, paralytic a state where the intestines become paralyzed and non-functional, resulting from non-mechanical causes ileus, obstructive a state of non-functioning of the gut resulting from prolonged overactivity of the gut to overcome an obstruction; after some time, the gut packs up from fatigue and enters a paralytic state iliac the ileum or the pelvic walls immobilization to keep still, to prevent motion immune system the system which defends the body against infection and includes the white blood cells, the lymph nodes and reticulo-endothelial system which produces the cells forming antibodies against bacteria, virus and toxins immuno-protein an antibody implosion to suck in, collapse inwards incision a surgical cut infarction tissue death through the blood supply being cut off inferior below
malnutrition infiltration (X-ray) this refers to the tissue of an organ becoming solid, dense on X-ray appearance. It can occur with infection, hematoma, injury, tumor infiltration spread, eg. to spread a drug by injection into a layer of tissue inflammation tissue reaction to infection, injury or allergy, consisting of redness, swelling, increased temperature and pain inflate/inflation to blow up with air or fluid, as inflating a balloon inorganic describing objects derived from non-living sources inspiration to breath in, draw in air inter- between internal inner, inside a surface internal fixation holding a fracture together by fixing it internally with nails, screws and plates inside the limb interosseous between bone intestinal the gut from below the stomach, consisting of the small and large intestines intra inside intramedullary inside the medullary canal of long bones intramuscular inside muscles intraosseous inside bone intraperitoneal inside peritoneum intravenous inside veins intubation to insert a tube invaginate (suture line) to close over ischemic decreased blood flow iso- same as isometric same length isotonic same concentration as blood Kirschner wire stiff pointed wire which can be drilled directly into bone or bone fragments kwashiorkor protein-calorie malnutrition, starvation where the deprivation of protein is worse than that of calorie
L
L (lumbar) the loin, the part of the trunk linking chest to the pelvis lactase enzyme which converts lactose into user-friendly glucose lactose milk sugar laminectomy removing the posterior arch or lamina of the vertebra (to decompress the spinal cord and nerves within the spinal canal). See also vertebra laparotomy surgical opening into the abdominal cavity laryngoscope an endoscope with light source and a blade to direct an endotracheal tube into the larynx and trachea laryngotomy an emergency procedure, to make an opening through the skin into larynx to let air into the lungs larynx the voice box, at the beginning of the trachea laser light of a certain wavelength is concentrated into a non-divergent beam. Laser has the ability to cut and burn tissues precisely lateral to the outside of, away from the midline legume beans, peas and other seeds of the family of plants which are nitrogen fixing lesion a diseased area ligament a fibrous band which strengthens a joint, either outside or on the joint capsule ligate to tie ligature a tie, a knot lobe a part of an organ like a lobe of the lung, the liver, the brain, the kidneys logistics organization and delivering of supplies and services longitudinal lengthwise
J
jejunostomy opening into the jejunum for the purposes of feeding, or diverting intestinal contents jejunum proximal small intestine beginning just after the duodenum, and extending to the beginning of the ileum
M K
kcal (kilocalories) 1,000 calories keloid hypertrophic scar kg (kilogram) 1,000 grams kilocalorie 1,000 calories m (meter) 100 centimeters mm (millimeter) one thousandth of a meter malabsorption impaired absorption of food nutrients from the intestine malleolus the knuckles, the eye of the ankle malnutrition insufficient nutrition
861
mamma/mammary mamma/mammary breast mantle (on bullets) the metal case which coats bullets marasmus protein-calorie malnutrition, starvation where there is deprivation of both calorie and protein maxilla/maxillary the cheek bone media (of an artery) the muscular middle layer of artery medial towards the midline median central mediastinum the midline structures between the right and left hemithorax, consisting of heart, aorta, caval vein, the trachea and the lung hilum medulla (of bones) the central cavity of long bone, containing marrow, sandwiched between two layers of cortical bone mega- one million, 5 mega-IU penicillin means 5 million IU penicillin mental describing the mind mesentery the peritoneal fold which suspends the small intestines and parts of the large intestines from the abdominal wall mesh (skin graft) passing a skin graft through a machine which produces multiple, small, longitudinal cuts on it, allowing the skin graft to be stretched to twice or even seven times its size hence 2:1 or 7:1 mesher.The cuts also allow drainage through the graft to the outside metabolism chemical processes in the body which produce energy to sustain life metacarpal (bone) the small long bones of the palm metatarsal (bone) the small long bones of the foot mg (milligram) a thousandth of a gram micro- one millionth of, in popular term: tiny, very small micro-circulation the blood circulation through the capillary vessels micropore (filter) a filter used to filter particles and clots from blood during transfusion mineralization (of bones) the deposition of calcium crystals in bones, a process which gives bone its strength mobilization to move a patient or a limb molecule a basic unit of atoms held together, each molecule then forming a unit of a chemical monitor to watch, to observe mortality death rate mortar a grenade launcher motor function muscular and skeletal function resulting in movements MUAC stands for mid upper arm circumference mucosa the mucus membrane lining body tubes like the urinary collecting system, the vagina, the oral cavity, the inner lining of intestines which secretes digestive juices, and carries out nutrient absorption
862
mucus a thick and slimy secretion of the mucosa myocardium/myocardial the heart muscle myoplasty an operation using muscles for reconstruction, such as closing an amputation stump using a muscle flap
N
n.p.o. nil per orum, meaning to take nothing by mouth naso-gastric nose to stomach.This is one way of introducing a tube into the stomach so that the stomach contents could be sucked out, or feeding could be carried out through the tube in patients who are unable to swallow necrosis tissue death necrotizing spreading necrosis nephrectomy removal of kidney nephrostomy surgically making a hole into the kidney pelvis so that urine could be drained out, eg., via a tube to the outside nerve block anesthetic technique where the entire area innervated by a sensory nerve is made numb by injecting anesthetic at the nerve to temporarily block its ability to conduct impulses to the brain neurology the study of the nervous system neuroma a benign nerve tumor. Neuroma can form after an injury by numerous nerve bodies regenerating in unorderly fashion; it can be very tender and painful nibbler an instrument developed to take bites out of bone nitrogen element found in all living organisms.The amino acids from which protein is made, all contain nitrogen.The excretion of nitrogen by the urine reflects the degree of body protein breakdown non-traumatic usually known as atraumatic. It applies to surgical techniques aiming to cause as little injury or trauma to the tissues as possible.This is achieved by careful handling of tissues, dissection with sharp blades, avoidance of tissue crushing, preservation of blood supply to the operated tissues nucleus (of cell) a rounded, membrane-bound compartment of the cell which contains the chromosomes (genetic material)
O
olecranon the upper end of the ulna bone of the forearm. It forms part of the elbow joint, and the other side is for the attachment of the powerful triceps muscle tendon oliguria decreased production of urine
periosteum omentum the peritoneal fat fold hanging down from the stomach and transverse large intestine in front of the small intestines ophthalmology specialized medicine and surgery of the eye ophthalmoscope an instrument with a light source for looking into the back of the eye, so that the retina, the optic nerve and the blood supply to the eye could be seen oral mouth oral airway an airway put into the mouth to ensure clear passage of air into the pharynx and larynx. It is designed to put the tongue out of the way orbit/orbital the eye socket organic originating from living matter orthopedic surgery of the musculo-skeletal system orthosis appliance worn as splints for fractures or joints osmosis the passive transfer of water molecules across a permeable membrane dividing two compartments with different solute concentrations.Water will pass from the less concentrated solution to the more concentrated one until the concentration finally becomes equal on both sides of the membrane osmotic pressure the pressure exerted across a membrane by the solutes; the more concentrated the solution, the higher the osmotic pressure osseous bone osteomyelitis bone and bone marrow infection osteoporosis reduction in quantity and quality of bone osteotomy incision or cutting bone with a saw or chisel to produce a surgical break otoscope/otoscopy an instrument for looking into the external ear canal and eardrum ovary female gland which secretes the female hormones as well as releases ovum (female reproductive cell) oxygenation process of adding oxygen paralysis loss of motor function, usually due to nervous system damage like a central stroke, or a nerve being out of action paramedic traditionally means a health-care worker who works in adjunct to medical practitioners parasite an animal, plant or micro-organism which lives in and/or off another creature (host), and draws its nourishment from it. Parasites range from worms to bacteria, to some insects parboil partly cooked by boiling with water parenteral the giving of drugs, nutrients and vitamins by routes other than the enteral (the intestine and mouth).Thus parenteral could be through the veins, intramuscular, intraosseous paresis motor weakness, incomplete paralysis patella kneecap pediatric refers to medical treatment of children pelvic cavity the lower part of the trunk which is enclosed by the pelvic bone. It therefore contains loops of intestines, the rectum, bladder, prostate in males, the female organs, and the large pelvic vessels and nerves pelvis the large bone ring where the lower limbs meet the spine and trunk pelvis (of kidney) the proximal part of the urinary collecting system penetrating (injury) injury caused by outside sharp object penetrating the skin into the body gunshot wounds and missile injuries. See also blunt injury penis male copulatory organ, which also contains the urethra per- for/by percussion to strike quick, light blows onto hollow airfilled organs which produce a drum-like sound. If the organs or cavity becomes filled with fluid like bleeding into the peritoneal cavity, or becomes solid like lung infection the percussion note becomes dull, and a clinical diagnosis could be made perforation a hole through the full thickness of a wall, eg., of the stomach wall, intestinal wall, blood vessel wall perforator a tool for making a perforation perforator artery small branch of a deep artery which penetrates the fascia and supplies the skin and subcutaneous tissue perfusion the passage of blood through an organ or a limb pericardium the covering of the heart perineum the lower end of the trunk which lies outside the pelvic outlet. It consists of the genitalia, the anus and the soft tissues bounded laterally by the ischial bones periosteum the outer lining covering bones. Periosteum is thick and well developed in the young, and becomes
863
P
palmar the palm of the hand palpation to feel pancreas gland behind the stomach which secretes digestive juices to the gut, and the hormone insulin to the blood paradoxical breathing breathing which contradicts normal pattern. It refers to a segment of fractured chest wall which moves in the opposite way to the rest of the chest wall with each cycle of breathing in and out
peritoneum/peritoneal thinner with age. It becomes very important in the formation of bridging callus after fractures peritoneum/peritoneal the lining of the abdominal cavity which covers most of the abdominal contents. At places it doubles up on itself forming a mesentery peritoneal cavity the cavity lined by the peritoneum peritonitis inflammation of the peritoneum, which may be infective or chemical permanent lasting permeability porosity, describes the readiness with which membranes allow water and other molecules to pass through peroneus the lateral leg muscles responsible for foot extension and eversion peroperative during the operation phantom (pain) ghost, describes pain felt in a limb which has already been amputated pharynx back of the nose and oral cavity leading down to the larynx phlegmon pus forming infection and thickening of skin and subcutaneous tissue, usually caused by staphylococcus bacteria phrenic nerve the nerve to the diaphragm, with roots from cervical 3, 4, and 5 physical relating to the musculo-skeletal system, or to physics physiology the study of body functions in living things physiotherapy treatment with physical measures like heat, ultrasound, massage, changes in temperature and physical activity placenta a blood-rich organ developed in the pregnant uterus to carry out nutrition, exchange of oxygen and carbon dioxide for the fetus plantar the sole of the foot plasma expander solutions of large molecules which increase the the circulating volume of the blood by increasing its osmotic pressure, thus drawing in fluid from the tissues outside the blood vessels plasma the fluid part of the blood which contains proteins and salts, excluding the blood cells plaster of Paris also called Gypsona, the active chemical substance is calcium sulphate dihydrate. When mixed with water, it becomes creamy and can be molded into any shape conforming to the body contours. It sets into a hard mass during a chemical reaction forming a conforming cast platelet (blood) small fragments of large cells called the megakaryocytes. Platelets circulate in the bloodstream and are important in stopping bleeding by causing blood to clot, as well as small vessels to constrict pleura the lung membrane, the inner part of it lines the
864
lung, the outer part lines the chest cavity. The two layers of pleura are held together by vacuum between them pleural chest pleural cavity the two (right and left) lungs-containing cavities of the chest lined by pleura, separated by the mediastinum and the heart plexus (cervical, lumbar) a network of nerves pneumonia lung infection pneumothorax air in the pleural cavity, often resulting in lung collapse p.o. post-operative popliteal the back of the knee portal vein vein carrying blood from the intestines to the liver post- after postburn after burn posterior the back of post-operative after operation postural drainage drainage by position pre- before prehospital outside the hospital premedication medication given before adminstering an anesthetic, which usually helps to calm the patient down and decrease secretions pre-operative before operation pronation to turn the forearm so that the palm faces downwards prone position to lie face downwards prostate male gland situated round the outside of the bladder neck and the pelvic urethra prosthesis an artificial limb proximal towards the head psychological mental, also mood psychosis mental illness, where patient has no insight into his own condition pubic (bone) the front of the pelvis
Q
quadrant (of abdomen) one of the four quarters of the abdomen quadrate four-cornered shape quadriceps the extensor of the knee joint, the quadriceps muscle is composed of four bands of muscle meeting at the patella and patellar tendon
spectrophotometer
R
radiate to spread outwards in a radial fashion radical treatment which aims to do as much as possible; thus radical surgical excision means excising as much tissues as possible with a wide margin radius/radial one of the two forearm bones, and in the supinated position is the lateral of the two raspatorium bone file ray (of hand/foot) the metacarpus/metatarsus and its corresponding digit forms one ray receptor a tissue or cell target on which hormones and enzymes can exert their action recto-vesical pouch the space between the rectum behind and the bladder in front rectum/rectal the last 10 inches of the large intestine terminating in the anus reduce/reduction (fracture management) to straighten and restore to correct position a broken bone reflex, of nerves automatic nerve action in response to certain stimuli regeneration (of tissue) recovery, re-growth of tissues rehabilitation to restore function to a limb, to return a person to his full before-injury status to his community renal kidney reperfusion to re-establish blood flow to an organ or a limb after a period of very poor blood supply resection to cut off a section of respiration breathing resuscitation life-support to a lifeless or severely injured person retard to slow down retention (of fluid) keeping back of fluid resulting in swelling of cell, limb or organ. It may be localized to an organ or cavity as in ascites of the abdomen, or collection of fluid in the alveoli of the lungs, or it may be generalized as in edema caused by heart, liver or kidney diseases retina the inner lining of the inner part of the eye bulb consisting of specialized nerve ends capable of reading light signals retraction (of tendons) after a tendon is cut off, the proximal end is still attached to the muscle which therefore pulls the cut tendon end proximally retraction (during surgery) to hold tissues away from the operative field so that they do not get in the way of dissection or surgery retractor instrument for retraction during surgery retro- behind retroperitoneal behind the peritoneum
Ringer a solution of electrolytes which is isotonic to human blood RR respiratory rate rupture to burst, tear
S
S (sacrum) the pelvic part of the spinal column saline/normal saline salt solution, normal saline describes saline which is isotonic to blood, and is 9 mg NaCl/ml fluid scapula the shoulder blade sciatic sciatic nerve is the large nerve from the sacrum which runs down the back of the thigh and supplies the muscles and skin of the leg and foot sclera the thick fibrous wall of the eyeball scrotum the sac and skin covering the testes section (gynecology) to deliver a baby through an incision through the wall of uterus sedatives drugs which calm sensor function touch, pain, temperature, vibration and position sense are all sensor functions sepsis/septic infection septicemia bacteria and their toxins f rom a septic source entering and multiplying in the bloodstream produce septicemia. Apart from local sepsis, the patient also becomes generally feverish and ill septum a partition wall sequestrectomy removal of infected, dead bone serosa (of the intestine) the outermost layer of the intestine merging with the peritoneum serum the non-cellular part of the blood shunt divert SIB (ventilation) self-inflating bags sigmoid S-shaped section of the descending large intestines silicon an inert material which has rubber qualities, but does not provoke the reaction to rubber, hence its usefulness as indwelling catheter, joint spacers sinus, of the nose the large air-filled spaces in the bones around the nose sinus, of the brain the venous channels inside the skull; they are thin walled and easily damaged in surgery or fractures, resulting in massive bleeding spasm sustained muscular contraction spatula spoon spectrophotometer an instrument which measures the intensity of the light transmitted by a substance in different part of the light spectrum, thus allowing its identification and analysis, eg. hemoglobin analysis
865
spica (plaster) spica (plaster) a special plaster cast for the hip where the affected leg as well as the opposite leg are immobilized to control hip and thigh fractures; it is like plaster pants spinal vertebral spine the backbone splenectomy removing the spleen static motionless Steinmann (pin) special 3-5 mm pin used for transfixing bones stenosis narrowing sterilization the process of rendering free of microorganisms, bacteria sternomastoid muscle the muscle on both sides of the neck attached to the mastoid process, the clavicle and the sternum sternum the longitudinal piece of bone attached to the ribs in the front of the chest, behind which lies the heart with its pericardium steroid corticosteroids, hormones secreted by the adrenal cortex which are important for coping with stress stethoscope an instrument for listening to the heart, lungs and bowels stirrup a metal loop which could be fastened to a pin, and traction applied stoma intestinal opening to the outside stricture narrowing stylet a metal tube or needle with a sharp end inserted through a soft cannula to help its easy insertion, once the object is cannulated, the stylet may be removed sub- under subclavian describes the large vessels under the clavicle destined for the upper limbs subconjunctival underneath the conjunctiva subcutaneous the layer of tissue just under the skin, it is usually fat, with some fibrous tissue superior above supernatant the top fluid left after mixtures are left standing for some time, heavy particles sink to the bottom supination to place the forearm so that the palm faces upwards supine position to lie on the back suppuration infection with pus formation supra- above suprapubic above the pubic bone sympathetic nervous system see autonomic nervous system syndrome a clinical complex synovial fluid joint fluid
866
synovium the membrane which lines the joint and secretes the joint fluid synthesis to make synthetic artificial systolic during the contraction of the heart ventricles
T
tachycardia fast heart rate tampon a gauze pack or ribbon tucked into a bleeding space tamponade inserting a tampon to stop bleeding tangential parallel to the surface, thus tangential excision means excising parallel to the surface.Tangential hit means the bullet impact is parallel to the surface tarsorrhaphy stitching the eyelids together so that the eye is closed tarsus of eye the eyelid plate TBSA total body surface area temporal the temple on the side of the face and skull temporary for the time being only tenotomy to divide a tendon tension in describing solids, it refers to the state of being stretched, pulled apart, tautness.With reference to gases, it means the pressure exerted by the gas Th (thoracic), thorax that half of the trunk above the diaphragm and below the neck thermobaric weapon explosions causing high temperatures and high pressures, also see fuel-air explosive thoraco-abdominal chest and abdomen thoracotomy to open into the chest thrombosis formation of a blood clot inside the blood vessels thrombus a blood clot forming inside a blood vessel.The thrombus will not only obstruct blood flow, but it may become detached and, in the case of venous thrombus, carried centrally with the venous blood flow into the lungs, where it then causes lung tissue death by blocking pulmonary vessels pulmonary embolus thyroid (gland, cartilage) endocrine gland in the front of the neck which secretes the hormone thyroxine tibia/tibial the shin bone tone (of muscles) strength of contraction. Contraction of muscles produces its tone; muscle relaxation abolishes its tone topical local tourniquet a band, cuff, tubing tied round a limb intended to stop the blood flow into the rest of the limb toxic poisonous
vagus nerve toxin a substance produced by bacteria that is poisonous to other cells or organs trace mineral trace minerals refer to a group of elements which are essential to body functions, but needed in minute quantities only trachea/tracheal the large wind-pipe from larynx leading into the chest, when it branches into the main bronchus to the right and left lungs tracheostomy a surgical opening made in the wind-pipe so that a breathing tube could be inserted traction pull, stretch.To put a fractured limb on traction is to pull on its distal end, steady its proximal end either by gravity or counter-traction.Traction overcomes the muscle pull, allowing the fracture ends to reduce tranquilizer a drug which calms a person down transfixion (bone pins) transfixion pins, like the Steinmann pins, strong Kirschner wires, have sharp ends so that they can perforate through cortical bones. See also external fixation transfusion to give fluids directly into the blood, fluids can be Ringer, nutrient solutions, whole blood, plasma transplant to take tissues from one part of the body (donor area), or from some other person (donor) and graft it onto another area (recipient area or recipient). Examples of autotransplant (same person) are blood autotransfusion, skin grafts, flaps, bone grafts. Examples of tissues and organs from a different donor are cross-matched; blood transfusion, cadaveric corneal grafts, kidney and heart transplant from live donors transverse to lie across the the body at right angles to the longitudinal axis trauma insult, injury trephination technique of drilling holes in the skull triage sorting out casualties into groups those in need of immediate treatment, those whose treatment is less urgent, those who need minimal or no treatment, and those whose injuries are so severe that they have to be allowed to die comfortably triangular three-cornered triceps (of the arm) the large muscle at the back of the arm inserting into the olecranon; it has three muscle bellies which merges into a tendon triceps (of the lower leg) the group of muscles at the back of the lower leg (gastrocnemicus and soleus) that makes up the Achilles tendon and flex the ankle (and the knee) trochanter at the junction of the neck of the femur with its shaft, the bone becomes enlarged into two prominences:The larger one is the greater trochanter into which the large hip abductors are attached; the smaller is the lesser trochanter to which the ilio-psoas, the hip flexor is attached turbulence (of the bloodstream) disturbance, uneven movement. Ideally blood should flow in a smooth streamlined manner inside blood vessels, but if there is narrowing or kinking of the vessel, this smooth flow becomes disturbed, hence turbulence occurs
U
u.p.h. urinary output per hour ulcer a hole. Skin ulcer is a hole in the skin, duodenal ulcer is a hole in the mucosa of the duodenum; when ulcers become deeper and deeper, to reach the other side of the wall, perforation results ulna/ulnar the medial of the two forearm bones, when the forearm is placed in supination umbilicus the navel uremia when the kidneys are not functioning properly, nitrogenous waste products are not excreted via the urine.They therefore accumulate in the blood producing a state of uremia with high blood nitrogen in the form of urea. Isolated raised blood urea (uremia) may not be due to the kidneys malfunctioning, it may also be due to excessive nitrogen production due to tissue breakdown after injury ureter the tube or duct leading urine from the kidney to the bladder urethra the tube leading urine from the bladder to the outside urography X-ray examination the kidneys, ureters and bladder by IV injection of contrast that becomes excreted by the kidneys USP (dimension of sutures) USP stands for United States Pharmacopeia uterus the womb
V
VAC, vacuum-assisted closure a technique to drain wounds by suction through rubber foam vacuum a void, an empty space. A term also used for spaces that do not contain air vagina female passage linking the uterus to the external genital opening vagus nerve the tenth cranial nerve, it is part of the autonomic nervous system and is a parasympathetic nerve. Its secretions oppose the effects of the sympa867
vascular thetic nervous system hence if the sympathetic nerves to an organ cause the vessels to contract, the parasympathetic will cause them to relax vascular relating to blood vessels vascularize to bring blood vessels into tissue vasoconstriction blood vessels have muscle walls, and when they contract, the vessels become thinner vasoconstruction vasodilation the opposite of vasconstriction, the blood vessel muscle wall relaxes, and the vessel opens up and expands their inner size veins blood vessels which bring blood from the tissues and organs back to the heart venesection to draw blood from a vein ventilation the mechanical part of breathing consisting of inspiration (inhalation) drawing air into the lungs, and expiration (exhalation) the process of pushing air from the lungs to the outside ventricle/ventricular the muscular chamber of the heart which pumps blood into the arteries.The right ventricle pumps blood out to the lung artery and the lungs; the left ventricle pumps blood into the aorta vertebra a unit bone of the spine.The spine is formed of multiple vertebral bones all linked to each other. Each vertebra has a body in front, facet joints behind and to the sides, and a spinous process towards the skin vertical upright vesica cyst, also commonly means the bladder viability ability to survive viscosity fluid thickness vital functions the functions essential to life like breathing, heart beat, heat regulation vital essential for life vitality life, energy vitamin chemical substances needed in small quantities in everyday food for metabolism and health vocational professional, career, job volar the palmar aspect of the hand volume therapy treatment by giving fluids to replace fluid lost from the blood circulation
W
wedge resection to take out a wedge of organ due to injury or disease wedge fracture a compression fracture of the vertebral body resulting in the anterior edges of the body being pressed together, so that side X-rays show a wedge shape
X
xiphoid the terminal part of the sternum. It is usually a flexible separate piece of cartilage shaped like an arrow head
Z
zygoma malar, the bony cheek prominence
868
Index
Abbreviated Injury Scale (AIS). See Injury Severity Score Abdomen, injury 508-23 See also individual abdominal organs abdominal wall injury 268-70, 512-13, 610-10 anesthesia 511 blast 137, 509 bleeding, control of 198-201 child patient 410 clinical examination 214-15 gastric decompression 521-22 laparotomy, damage control 71-72, 254-68 laparotomy, standard technique 510-23 peritoneal lavage 253 post-operative care 604-10 temporary abdominal closure 258-59 vascular injury 247-48 Abdomen, post-operative complications 604-10 ABO, blood type 416-20 Abortion, after injury 596-97 Abscess abdominal 559, 605, 607-08 brain 454 hip joint 624 liver 551 lung 504 palmar 653-54 pancreatic 564 pelvic 271-72, 536 renal 574 Acidosis 167, 234-36 Adrenaline 226-27 to control bleeding 244 Adult Respiratory Distress Syndrome (ARDS). See Respiratory failure. Afghanistan 38-40 AIDS. See HIV Airway, life support. Also see Life support airway cut-down/emergency laryngotomy 183-84 aspiration 183 burn injury 180, 703 child patients 406-07 cricoid pressure 183 endotracheal intubation 181-83 head tilt-jaw thrust 180 recovery position 181 AIS. See Injury Severity Score Alcohol analgesia 224-25 disinfection 758 Allograft burn wound care 710 Amebiasis 435-36 Ammunition. See Bullet; Weapon Ampicillin. See Antibiotics Amputation 380-93, 693 See also Limb injury above-knee 670-71, 679 arm 637 below-knee 679, 689 disarticulation, nee joint 384 fasciotomy of the stump 304-05, 384 finger 652 foot 690 forearm 642 hand 651-52 mine injury 148 - 49, 382-83 myoplasty 387 prosthesis fitting 388-93 severity assessment in severe injury 272, 381 Syme 690 toe 690 Amputation, uterus 599-600 Anaerobic bacteria 740 Anaerobic infection 740 See also Bacteria; Infection necrotizing fasciitis 691 Analgesia 185-86 pleural 811 post-operative care 724 Anatomical severity Injury Severity Score (ISS) 103-05, 121-22, 149 New Injury Severity Score (NISS) 104 Anemia 430-32 See also Bleeding; Circulatory shock chronic 430 endemic diseases 430 sickle cell anemia 431-32 thalassemia 431 Anesthesia 796-826 anesthesia chart 843 brain injury 244, 446-47 intravenous regional 818-19 ketamine 799, 804-06 local infiltration 799, 810-11 nerve block, intercostal 799, 812 nerve block, lower limb799, 816-18 nerve block, upper limb 799, 813-16 premedication 823 spinal 799, 822-26 Ankle injury 681, 690 diagnostic aspiration of joint 365 Ankle, nerve block 817-18 Antibiotics 221-23, 743-45 antibacterial spectrum 754-58 biofilm 743 drug resistance 746, 758 prophylactic 744 septic shock 745 ARDS. See Respiratory failure Arm, injury 631-37 See also Limb, upper Artery 247-49, 312-21 aorta, abdominal 518, 520 axillary 628 brachial 628, 635, 638-39 carotid 458 869
Artery
duodenal 541 femoral 615, 663, 665-67 finger 646 iliac 520, 526, 615 intercostal 496 internal mammary 496 liver 548 mesenteric 520, 526, 541, 562 ovarian 593 peroneal 682-85 popliteal 673 radial 628, 638-39 renal 520, 569 splenic 518, 541, 562 subclavian 457, 628 tibial 682-85 ulnar 628, 638-39 uterine 593, 598 Artery, injury 312-19 clinical signs 216-17 embolectomy 320 intima injury 136, 148-49, 312 ligature, risk of gangrene 248-49, 314 vascular shunt 72, 248-49 Artesunate 226-27 Arthrodesis 364 Ascariasis 434-35 Atropine 226-27 anesthesia premedication 823 consumption estimate 91 ketamine analgesia 186 ketamine anesthesia in children 805 Autoclave 761 Autotransfusion 419 Axillary artery 628 Back. See Spinal Bacteria 746-49, 750-53 See also Infection aerobic and anaerobic 742 anaerobic coccus 748 bacteroides 748 biofilm 743 clostridium 749 coliforms 747-48 enterococci 747 Eschericia coli 747 Gram stain 742, 833-35 hemophilus influenzae 749 microscopic examination 833-35 pneumococci 747 proteus 747 pseudomonas748 resistance, antibiotics 221, 746, 758 salmonella 748 staphylococcus 743, 746 streptococcus 746-47 Bacteroides 748 Ballistics. See Weapon 870
Basic energy expenditure (BEE) 768-70 Basic life support airway management 180-81 bleeding 195-199 cardio-pulmonary resuscitation (CPR) 178-80 child patients 406-09 hypothermia prevention 200-01 oral rehydration 208-10 positioning of patient 217-19 rescue breathing 178-80 BEE. See Basic energy expenditure Beirut 36 Belgrade 130, 131 Bile tract, injury 548-50, 552-53 mobilization of duodenum (Kocher maneuver) 263, 266, 518 Bilharziasis. See Schistosomiasis Biofilm 743 Bladder. See Urinary bladder Blast wave, injury 128-39, 148-49 See also individual organs brain 138 ear drum rupture 139 intestines 137 lung 135-36 spalling 135 Bleeding, control. See also individual organs abdomen, gauze packing 254-57 artery, proximal control 196 brain 244-45, 450-51 chest and lung 189-94, 249-50 compressive dressing 196-97 kidney 265-684 ligature, risk of gangrene 248-49 liver 260-61 manual compression of abdominal aorta 199, 254 pelvis, extra-peritoneal packing 270-71 retroperitoneal 265, 270 surgical techniques 292-94 tourniquet, side-effects of 194 Blood bank Walking rural blood bank 417, 832 Blood circulation. See Circulation Blood donor. See Blood transfusion Blood pressure. See also Shock head injury 239-40 normal values in children 102, 406, pocket folder at back cover Blood smear malaria 436-37 sickle cell anemia 431-32 thalassemia 431 Blood transfusion 416-20, 829-32 autotransfusion 419 blood typing 829-31 coagulation system disorders 165, 420, 734-37
cross-matching 417, 831-32 donor screening 417, 420 exchange transfusion, sickle cell anemia 431 O-negative blood 418 Blood transfusion reaction 419 in sickle cell anemia 431 in thalassemia 431 Blood volume normal values 406 Bogota bag 258, 523 Bomb blast wave physics 128-39 cluster weapons 151-54 Dense Inert Metal Explosives (DIME) 129-34 fuel-air explosive (thermobaric) 130-32 Improvised Explosive Dvices (IED) 133 Joint Direct Attack Munition (JDAM) 132 Small Diameter Bombs (SDM) 132-33 Bowel sound post-operative 727 Brachial artery 628, 635, 638-39 ligature, risk of gangrene 248-49 Brachial nerve plexus 457-58 nerve block anesthesia 813-14 Brain edema. See Intra-cranial pressure Brain, injury 239-47, 444-55 anesthesia 244, 446-47 control bleeding 244-45 craniotomy 244-46, 448-53 dural repair 449 fracture to the skull 448-49 Glasgow Coma Scale 98-99, 239-43 head injury chart 841 intra-cranial pressure 239-40, 454 life support outside hospital 178-84 perfusion pressure 240 post-operative infection 454-55 surgical anatomy trephination 448, 453 Breathing, life support 178-79, 185-94 child patient 407-08 rescue breathing 178-79 respiratory rate, normal values 99-100, 406, pocket folder at back cover Bullet. See also Ammunition; Weapon energy output 140-43 expanding (sniper weapon) 146 pistol 142 rifle, wound tracks 144-46, 661-62 Bupivacaine 226-27, 811, 825 See also Anesthesia consumption estimate 88 Buprenorphine 224-25 Burma 41-42 Burn, chemical 711-12 Burn, electrical 711 Burn, inhalation 180, 698-99, 703-4
Burn, thermal 696-711 burn creams 709 chart for burn patients 706 clinical examination 697-99 escharectomy 710 escharotomy 709 fluid therapy, Parkland formula 699-700 immune system dysfunction 163, 696 life support outside hospital 208-09, 703-07 major injuries 272-73, 707 nutrition 209-11, 700-01 triage 701-02 wound care 707-11 Calcaneus, fracture 688 Calcium blood transfusion 420 daily requirement 774 hypocalcemia 420, 729 sprue 433 Callus 326, 354-55 See also Fractures Cambodia 36, 44 Cannula. See Intravenous cannula Carbapenem. See antibiotics Carbenicillin. See antibiotics Carbohydrate. See nutrition Cardiac. See also Heart Cardiac arrhythmia 732 hyperthermia 426 hypothermia 425 Cardiac failure 110, 171, 731-32 amebiasis 435-36 myocardial infarction 732 old patients 411 septic shock 745 sickle cell anemia 431-32 thalassemia 431 Cardiac injury 503 Cardiac output 731-32 Carotid artery 557-58 ligature, effects on brain 248-49 Cartilage, injury. See Joint injury Catabolism 768. See also Post-injury stress; Nutrition Catheter diameter, mm-French conversion table Pocket folder at back cover Cavitation by projectiles 142-44 Ceftazidime. See antibiotics Ceftriaxone. See antibiotics Cefuroxine. See antibiotics Cephalosporine. See antibiotics Cephalotin. See antibiotics Cephotaxim. See antibiotics Cephotoxin. See antibiotics Cervical spine injury 457-58, 465, 468-71 neurological examination 212-13 Cesarian section 598
Chart anesthesia chart 843 burn case chart 842 field chart 115-16, 228-29, 838-39 head injury chart 841 hospital chart 117, 840 Chemical burn 711-12 Chest, injury 496-505 See also Heart; Lung blast wave injury 135-36 cardiac tamponade 503 chest tube management 188-94, 501 chest wall injury 249-51, 500 child patient 188 clinical examination 190, 213-14 damage control 249-51 heart injury 496-97 post-operative care 504-05 thoracotomy 499- 02 training 71 X-ray features 496-97 Chest tube 188-94, 501 consumption estimates 88 Child patients 406-10 circulatory shock 408-09 CPR 178-80 endotracheal intubation 182, 406-07 head injury 242 normal values 406, pocket folder at back cover pain relief 186 venous cutdown 205-06 Chloramphenicol. See antibiotics Chlorhexidine 758 Cholecystectomy 552 Ciprofloxacin. See antibiotics Circulatory shock 163, 176-77, 206-08, 234-36 See also Bleeding child patient 408-09 old patients 410-11 Clavicle, injury 634 Clindamycin. See antibiotics Clostridium. 749, 750-53 Clotting of blood. See Coagulation; Thrombosis Cloxacillin. See antibiotics Cluster weapons 150-54 Coagulation system 166-67 bed-side clotting test 167 damage control 234-36 DIC 171, 736 Hypothermia 200-01 post-operative failure 734-36 Cocci. See Bacteria Coliform bacteria 747-48, 750-53 Colon, injury 516-18, 527, 532-36. See also Enterostomy; Rectum; Sigmoid
blast wave injury 137, 509 colostomy 528, 533-35 post-operative care 604-10 Compartment syndrome. See also Fasciotomy abdomen 523, 609 burns 698 limb 303-05 lower leg 682-86 Consumption, medical materials 88-89, 278 Contracture, joint 346. See also individual joints Contracture, scar tissue 397 Copper, daily requirements 774 Corachan skin grafts 401 Cornea. See Eye CPR 178-79 Craniotomy 242-46, 448-54 Creatinine in serum 729, 733, 737 Cricoid pressure 183 Cricothyroid membrane 183 Cross-matching of blood 417, 831-32 Curettage, uterus 597 Cut down. See Venous cut down; Airway cut down Cytokines 163, 167-68 Damage control 30-32, 39-40, 234-75 abdominal wall 268-70 brain 239-47 burns 272-73 chest 249-51 duodenum and pancreas 264 feeding 274-75 intestines 265-68 kidney 265-66 laparotomy 71-72, 254-60 limb 196-98, 272-73 liver 260-61 pelvis 71, 270-72 spleen 261-62 temporary abdominal closure 258-59 training 53-58, 70-73 vascular 72, 247-49 Debridement 305-07 See also individual organs burn wound 708-09 damage control 273 fracture 325-28 Decompression brain 243-44 duodenum 187-88 fasciotomy 303-05 kidney 573 spinal cord 466-67 stomach 187-88 Decortication 501 Delayed primary suture (DPS) 397-98 871
Delivery after injury 597 Dermatome, neurological 213 Diameter of catheter mm-French conversion table See pocket folder at back cover Diaphragm, injury 498, 502, 510 Diazepam 226-27 consumption estimate 88 Diazo reaction, typhoid diagnosis 437 Disseminated intravascular coagulation (DIC) 171 malaria 437 Dicloxacillin. See antibiotics Diets. See Foodstuffs; Nutrition Disarticulation. See also Amputation foot 690 ankle joint (Symes amputation) 690 knee joint 384 Diseases interfering with surgery 430-39 Disinfection 758-60 in-field 77-79 Displacement. See Fracture Diversion stoma. See Enterostomy Documentation, medical 114-19 anesthesia chart 843 burn case chart 842 field chart 115-16, 228-29, 838-39 head injury chart 841 hospital chart 117, 840 trauma registry 108-119 Doxycycline. See antibiotics Drainage 308-09, 273 See also individual organs Trueta plaster 309 Dressing of wounds. See Wound care Drugs analgesics 186. 224-25 anesthetics 799 antibiotics 221-43, 743-45 consumption estimates 88-89 medical kit 76-77 Duodeno-jejunostomy 544 Duodenum, injury 518, 540-45 damage control 264 blast wave injury 137 Kochers procedure 263, 266, 518 Dura, injury 246, 449 Edema of brain. See Intra-cranial pressure Elbow, injury 638-42 See also Limb, upper puncture, diagnostic 635 soft tissue flaps 334-38 Electrical burn 711 Electrolytes, serum 605, 729 renal failure 171, 732-34 Embolectomy 320 872
Emergency laparotomy. See Damage control; Laparotomy Endotracheal intubation 181-83 child patient 406-07 Energy. See Weapon; Nutrition Entamoeba histolytica 435-36 Enteral feeding. See nutrition Enterobacteria 747-48, 750-53 Enterostomy, diversion 528-29, 532-35 damage control 267-68 failure of 607, 609 pelvic injury 271, 614 reconstruction after 537 Enucleation of eye 490-91 Erythromycin. See Antibiotics Escharectomy 710 Escharotomy 709 Escherichia coli 747, 750-53 Esophagus, injury 457-58 Evacuation of patients 719-21 mass casualty 281-84 Evisceration 268-69 Examination, clinical 211-17 See also individual organs and body regions brain injury 239-44 child patients 406-08 fractures 324-05 mass casualties 281-84 normal values for children See pocket folder at back cover old patients 410-11 Exploratory laparotomy. See Laparotomy Explosion. See Blast; Weapon External fixation of fractures 90, 346-49, 637, 648 pelvis 623 face 480 External iliac artery 520, 615 effects of ligature 248-49 External jugular vein, cannulation 203-04 Epidural hematoma 239, 452-54 Eye, injury 486-92 fracture of orbit 482 Evisceration 268-70, 512-13 Extremity. See Limb Face, injury 475-82 Burn 180, 698-99, 703-05 fractures 476, 479-83 life support outside hospital 181 Facial nerve 476 Falciparum. See Malaria Fascia compartment. See Compartment syndrome; Fasciotomy Fasciotomy 303-04 amputation 305
arm 635 artery injury 320 burn 711 damage control 273 foot 685 forearm 645 hand 646 lower leg 683-86 thigh 665-66 Fat, in nutrition. See Nutrition Feeding. See Nutrition Female sex organ, injury 592-601 See also Fetus; Placenta; Pregnancy anesthesia 595 damage control 271 recto-vaginal pouch, exploratory puncture 593 Femoral artery 615, 663, 665-68 effects of ligature 248-49 Femoral nerve neurological examination 659 Femoral vein 205-06, 314 Femur, injury 661-71 See also Limb, lower Fetus, injury 593-598 damage control Fibrinolysis 166 See also Coagulation Fibula, injury 680-90 See also Limb, lower Finger, injury 642-53 Finger, nerve block anesthesia 816 First helper 230 basic life support 180-81, 185, 195-201 CPR 178-79 Fistula bile 552, 736 duodenal 543 pancreatic 563 Flail chest 250, 500 Flap. See Soft tissue flap Flucloxacillin. See Antibiotics Fluid balance burn 699-700 post-operative 725-26 Fluid therapy. See Circulatory shock; Volume therapy Foley catheter. See also Urinary bladder colostomy 535 duodenostomy 543 feeding gastrostomy 275 urethra injury 581-83 Folic acid anemia 430 Foodstuffs 209-11, 773-90 diets, home-made 210, 786-90 energy contents 782-83, 773 processing 783-85 weight-volume relation 791
Infusion
Foot, injury 680-90 burn 710 Forearm, injury 642-53 soft tissue flaps 336-39 Fracture 324-56 See also individual bones and body regions damage control 272-73 external fixator 73, 346-49 orthosis 352-54 soft tissue flaps 329-39 Fragment. See Bullet; Weapon Fusobacteria 748 Galea, injury 447 Gall bladder, injury 548-49, 552-53 Ganga Severity Score 328 Gangrene after artery ligature 248-49 anaerobic infection 691, 713, 748-49 Gas gangrene 713, 748-49 Gastric. See Stomach Gastro-intestinal function burn 696 post-operative 606, 740 Gastrocnemius muscle flap 333 Gastrostomy 522 feeding 274-75, 780 Gauze packing. See Damage control; Limb injury; Tamponade Gaza 46-47, 134 Gentamycin. See Antibiotics Girdlestone operation 621 Glascow Coma Scale 98-99, 239-43, pocket folder at back cover Graft fascia, for dural repair 246 nerve 376 skin 308-401 tendon 370 vein, saphenous 318-19 Gram classification 742, 833-35 Growth retardation normal height-weight relation 772 thalassemia 431 Gustilo-Anderson classification 328 Gunshot. See Bullet; Weapon Hand, injury 642-53 Burn 710 soft tissue flaps 336-39 Head, injury 444-55 See also Brain injury; Skull injury anesthesia 244, 446-47 child patients 242, 409 damage control 239-47 head injury chart 841 life support 180-81, 211 neurological examination 98-99, 239-43,
pocket folder at back cover old patients 411 training 70-71 Head tilt-jaw thrust 180 Heart. See also Cardiac Heart, arrhythmia 425, 426, 732 Heart compression. See Cardiopulmonary resuscitation (CPR) Heart, failure 110, 171, 731-32 old patients 411 septic shock 745 sickle cell anemia 431-32 Heart, injury 496-98, 503 cardiac tamponade 503 Heart rate. See also Circulatory shock child patients 406, pocket folder at back cover fetal distress 596 normal values 99 Hegar rod 597 Hemaccel. See Plasma expander Hematocrit 729 Hematoma mediastinal 497 pelvic 271-72 pericardial 503 renal 265-66, 570 retrobulbar 846 retroperitoneal 563 skull 239, 452-54 Hemicolectomy 535 Hemoglobin, disorders sickle cell anemia 431-32 thalassemia 431 Hemolysis malaria 437 sickle cell anemia 431 Hemophilus influenza 749, 750-53 Hemostasis. See Bleeding control Hemothorax 497 blast wave injury 135-36 damage control 249-51 life support outside hospital 188-94 Heparin 316, 318 Hepatitis blood transfusion 417, 420 Hernia, ventral 610 High-explosive ammunition. See Bomb Hip joint, injury 619-21, 623 diagnostic joint puncture 365 HIV 438-39 Hookworm (ankylostoma) 430 Hospital infection 722-24 See also Bacteria Humerus, fracture. See Arm, injury; Fracture Hypercalcemia 420 Hyperkalemia 420, 729 Hypermetabolism 168-69, 768
Hyperthermia 426-27 brain injury 455 malaria 437 Hyperventilation, for intra-cranial pressure 454 Hypocalcemia 420, 729 sprue 433 Hypoglycemia child patients 409 fetal 595 malnutrition 772 Hypokalemia sprue 433 Hypometabolism 168-69, 768 Hyponatremia hyperthermia 427 short bowel syndrome 729 Hypothermia 200-01, 424-25 blood transfusion 420 child patient 408 damage control surgery 234 physiology 167 prevention 200 Hypovolemia. See Circulatory shock Hypoxemia 163, 176-77, 234-38 child patient 409-10 old patient 410-11 Ileostomy 528, 532, 535 Ileum 530-32 See also Intestine Ileus, obstructive 529, 606, 608-09 Ileus, paralytic 544, 606, 608 schistosomiasis 434 typhoid fever 438-39 Iliac artery 623-24 effects of ligature 249 Imipenem. See Antibiotics Immune system, failure 160, 167-69 burns 163, 274, 696 Improvised Explosive Devices (IED) 133 Incision, exploratory. See individual organs and body regions Infant. See Child Infection 742-59 See also Bacteria anaerobic 742 anemia 430 antibiotics 754-58 bacteria, types of 746-49, 750-53 burn 712-13 definition 109, 743 hospital infection 722-24 quality control program 723 septic shock 745 septicemia 745 Inferior mesenteric artery 520, 526 Infusion colloid 207 873
Inhalation injury
consumption estimates 88-89 electrolyte/crystalloid 206-08 rectal 91 Inhalation injury. See Burn Injury chart 115-16, 228-29, 838-39 See also Chart Injury. See also individual organs or body regions Injury severity 31-32, 97-108 anatomical severity 103-06 child patient 102 limb injury 328. 381 physiological severity 98-102 TRISS 105-108 Injury Severity Score (ISS) 103-105, 121-22, 149 Insulin with glucose-potassium 732 with glucose 733 Intercostal artery 496 Intercostal nerve block 799, 812 Internal iliac artery 520, 526, 615 Internal mammary artery 496 Interosseous membrane forearm 647 lower leg 681-82 Intestine, injury 526-37, 540-45 blast wave injury 137, 509 colon 532-36 damage control 264-68 duodenum 540-45 evisceration 268-70, 512-13 exploration 516-17 ileum 530-32 jejunum 530-32 rectum 271-72, 536 Intima, detachment 312 See also Vascular injury blast wave injury 136 mine injury 148-49 anterior tibial artery 683 popliteal artery 673 Intra-cranial pressure 239-40, 454 Also see Brain injury Glasgow Coma Scale 98-99, 239-43, pocket folder at back cover malaria 437 Intravenous cannula 201-04 caliber 202 consumption estimates 88 external jugular 203 medical kit 76-77 Intravenous catheter 91, 205 Intravenous fluid colloid 207, 699 electrolyte/crystalloid 206-08 Intravenous regional anesthesia 818-19 Intubation. See Endotracheal intubation 874
Iodine daily requirement 774 Gram stain 833-35 Iraq 29, 42-43, 47-48, 131-32, 141, 146, 156 Iron, daily requirements 774 Isopropanol, disinfection 78, 762 ISS. See Injury Severity Score IV See Intravenous Jalalabad 39-40 Jejunostomy decompression of duodenum 544 feeding 780 Jejunum, injury 540, 544 See also Intestine Joint, injury 560-65 See also individual joints diagnostic puncture 364-65 fracture of joints 362-64 Jugular vein, cannulation 203 Keloid 397 Ketamine, anesthesia 799, 804-06 See also anesthesia brain injury 244, 446-47 Ketamine, pain relief 186-86, 224-25 brain injury 244, 446-47 consumption estimates 88 post-operative 724 Kidney. See also Renal Kidney, injury 518-19, 568-74 damage control 265-66 Klebsiella 748, 750, 752 Knee joint, injury 671-80 diagnostic puncture 671 soft tissue flaps 333 Knots, surgical technique 295-96 Kochers maneuver 263, 266, 518, 569 Kwashiorkor 771 Laboratory blood cross-matching 831-32 blood grouping 831-32 blood smear 430, 431, 437 clotting test 167 creatinine 729, 733 electrolytes 729 Gram stain 833-35 hematocrit 729 platelet count 735 stool smear 435 Lactase deficiency 433 Lactated Ringer. See Infusion Laminectomy 466-67 Land mine 42-44, 147-51 amputation stump fasciotomy 304-05 Laparotomy 512-25 See also Abdomen
abdominal wall injury 268-70 anesthesia 511 damage control 71-72, 254-68 drainage 521-22 exploration 256-57 peritoneal lavage 253 temporary closure 258-59 Laryngoscope 182 improvised 92 Laryngotomy 183-84 Larynx, injury 457 Laser, weapon 155 Lebanon 36, 45, 134, 153 Leg. See Limb, lower Leishmaniasis 430 Lidocaine 226-27, 809 See also Anesthesia Life support 174-230 airway 180-84 breathing 185-94 burn 208, 699-700, 703-07 circulation 195-210 clinical examination 176-77, 211-18 CPR 178-79 documentation 228-29 drugs 221-27 mass casualties 281-84 nutrition 209-10 pain relief 185-86 positioning 217-19 transport 219-21 triage 278-80 Limb injury 628-93 blast wave 134, 138 life support 195-198 severity assessment 273, 328, 381 staged surgery 272-73 Limb, lower 658-93 femur 661-71 knee 671-80 lower leg and foot 680-90 mine injury 148-49 soft tissue flaps 332-33, 338-39 Limb, upper 628-54 elbow 638-42 forearm and hand 642-53 shoulder and arm 631-38 soft tissue flaps 334-37, 634 Lincomycin. See Antibiotics Liver, artery 548 Pringles maneuver 257, 515 Liver, failure 171 definition 110 malaria 437 schistosomiasis 434 Liver, injury 517-18, 548-51 damage control 260-61 Local anesthesia. See Anesthesia Lung, abscess 504
amebiasis 435 typhoid fever 438 Lung, failure 170, 504, 730-31 definition 110 Lung, injury 497, 502 See also Chest blast wave 135-36 damage control 249-51 life support outside hospital 188-94 Macrodex 207 Magnesium daily requirements 774 post-operative loss 729 Malabsorption 732-33 Malaria 436-37 blood transfusion 417, 421 post-operative 96, 111-12 drugs 224-27 Male organs, injury 588-90 urethra 582-84 Malnutrition 770-73 See also Nutrition Mandible, fracture 480 Mangled Extremity Severity Score (MESS) 381 Mannitol brain injury 454 renal failure 734 Marasmus 770 Marcaine. See Anesthesia, local Marsupialization 583 Mass casualty 133, 281-84 Materials. See Medical materials Maxilla, fracture 476, 481-82 Median nerve block 816 Median nerve, injury 646 neurological examination 629, 643 Mediastinum 696-97 Medical materials 76-89 consumption estimates 87-89 life support kit 76-77 maintenance 89-90 surgical sets 80-86 Mesenteric artery 520, 526, 541, 562 Mesentery 526 resection 528-29 sigmoid colon 534 transverse colon 533 MESS (Mangled Extremity Severity Score) 381 Metabolism physiology 168-69 post-operative nutrition 767-69 Metacarpal. See Hand Metatarsal. See Foot Methicillin. See Antibiotics Metoclopramide 226-27 consumption estimates 88
Metronidazole. See Antibiotics Microbiology 742-59 See also Bacteria; Infection Microscopy blood cross-matching 831-32 blood smear 430, 431, 438 Gram classification 833-35 stool smear 435 Microwave, weapon 156-57 Mid upper arm circumference (MUAC) 771 Mine. See Land mine MOF. See Multi-organ failure Morphine 186, 224-25 anesthesia premedication 823 consumption estimates 88 Mortality avoidable deaths 28-32 medical documentation 105-06, 109 trauma registry analysis 120-23 MRSA (multi-drug resistant staphylococcus aureus) 746 MUAC. See Mid-upper arm circumference Multi-organ failure 170, 736-38 definition 110 Muscle flap. See Soft tissue flap Myocardial infarction 732 Myoglobin, renal failure 711 Myoplasty, amputation 387 NaCl, dressing 400, 720 NaCl, infusion 207 consumption estimates 88-89 Nafcillin. See Antibiotics Napalm, burn 711-12 Naso-gastric tube 187-88 post-operative feeding 725, 727, 780 Neck, injury 456-58 cervical fracture 465, 468-71 Necrotizing fasciitis 693. See also Bacteria Nephrectomy 265, 571 Nephrostomy 573 Nerve block anesthesia 799, 812-18 Nerve injury 374-76. See also individual nerves Netilmycin. See Antibiotics Neurological examination head injury 241-42, pocket folder at back cover limb, lower 659 limb, upper 628-29, 643 pelvic injury 616 spinal injury 213 Neuroma 387 New Injury Severity Score (NISS) 104 Normal saline. See NaCl Nose, injury 478, 481
Nutrients. See Foodstuffs Nutrition 208-10, 766-91 burn 209-10, 700-01 enteral 274-75, 542, 764, 778-81, 786-89 food processing 783-85 foodstuffs 782-83 metabolism after injury 767-70 monitoring 777-78 oral 208-10, 790 requirements 773-77 Old patients 410-12 Olecranon, fracture 641 Oliguria. See Renal failure Omentum, tags of abdominal wall injury 269-70 intestinal injury 262, 543 Organ failure. See also Post-operative care cardiac 110, 171, 731-32 coagulation 110, 166-67, 170, 734-36 liver 110, 171 lung 110, 730-31 multi-organ failure 736-38 physiology 169-71 renal 110, 171, 732-34 Organization wartime clinics 34-49, 76-89 post-operative care 604, 718-19 life support in-field 174-76 Orthosis 326, 352-54 Osteomyelitis 354-56, 505, 743, 755, 751 Osteotomy, fibula 692 Oxygen starvation 163, 176-77, 234-38 See also Hypoxemia; Acidosis Oxytetracycline. See Antibiotics Oxytocin 597 Pain physiology 30-32, 162-65 analgesics 185-86 phantom 389 Pain relief. See Analgesia Palestine 46 Palmaris tendon, graft 370 Pancreas, injury 518, 549, 557-60, 562-64 damage control 264 exploration, Kochers maneuver 263, 266 Pancreatitis 564 Paralytic ileus 606 Paramedic life support 33-34, 174-230 medical kit 76-77 training 52-68 Parkland formula, burns 699-700 Patella, injury 658 Patient chart. See Chart Pediatric. See Child Pediatric Trauma Score (PTS) 102-03 875
Pelvis, injury
Pelvis, injury 614-25 abscess 624 blast wave injury 137 buttock injury 619 damage control 71, 254, 270-72, 614, 617-18 female organs 592-603 fracture 622-23 hip joint 619-21 male organs 588-89 retroperitoneal hematoma 270-71 urethra 582-893 urinary bladder 578-81 Penicillin. See Antibiotics Penis, injury 588 Pentazocine 224-25 consumption estimates 88 Pericardial drainage 503 Peritoneal lavage 253 Peritonitis 164, 607-08, 730, 738 amebiasis 435 ascariasis 434 definition 109 typhoid fever 437 Peroneal nerve, injury 673, 682-84 neurological examination 659 Phantom pain 389 Phenytoine 247, 455 Phlegmon, urinary 578 Phosphorous burn 711-12 Physiology cellular 160-62 circulatory shock 30-32 coagulation 166-67 immune system 160, 167-68, 274 metabolism 168-69 nutrition 767-70 organ failure 169-71, 730-38 Physiological severity 98-102 Piperacillin. See Antibiotics Pitocin. See Oxytocin Placenta, separation 596 Plantaris, tendon graft 370 Plasma expander 207-08 Plasmodium falciparum. See Malaria Plaster cast 340-45 See also Fractures consumption estimates 88-89 reflex dystrophy 344 spica 470, 471 Trueta method 345-56 Platelet coagulation system failure 167, 195, 199 post-operative monitoring 735 Pleural analgesia 811 PMN, land mine 147-48 Pneumococcus 747, 750-53 Pneumonia, post-operative 500, 504, 725, 730 876
See also Infection definition 109 Pneumothorax 189, 497 child patient 188, 407 diagnosis 190, 213-14 life support 188-90 tension 135-36, 498 POP. See Plaster cast Popliteal artery 673 effects of ligature 248-49 intima detachment 675 Portal vein 518, 548 Post-injury immune depression 160, 167-68, 274 Post-injury organ failure 110, 730-38 Post-injury stress 30-31, 162-69, 234-38, 765-67 Post-operative care 718-38 See also Antibiotics; Infection; Nutrition abdomen 604-10 burn 700 coagulation 730 fluid balance 725-26 hospital infection 722-24 organ failure 730-38 pneumonia 730 psychological 728 septic shock 743 septicemia 743 wounds 719-24 Post-operative nutrition. See Nutrition Post-traumatic. See Post-injury Potassium, serum blood transfusion 420 daily requirement 774 heart arrhythmia 729 loss of, intestinal injury 776 Pregnancy, injury abortion 596-97 anesthesia 596 life support 218, 271 separation of placenta 596 surgical delivery 598 Premedication, anesthesia 823 anesthesia chart 843 Pressure boiler 761-62 Pringles maneuver 257, 515 Projectile. See Weapon; Bullet Prosthesis. See also Amputation definitive 392-93 immediate temporary 388-91 Proteus 747, 750-53 Pseudomonas 743, 748, 750-53 Pulse 199 carotic 178 circulatory shock 176-77 infants 179, 408 Pulse rate. See Heart rate
Pupil reaction eye injury 486-87 head injury 241-43 Quality control 96-123, 723-24 avoidable deaths 29-31 medical documentation 114-19, 228-29 trauma registry analysis 43-44, 120-23 Quinine 224-25 Radial artery 628, 638-39 effects of ligature 249 Radial nerve, injury 635, 638, 640, 646-47 neurological examination 628, 643 Receiver Operating Characteristics (ROC) 100, 104, 149 Recovery position 181 Rectal infusion 91 Recto-vesical pouch 618, 624 drainage 593 Rectum, injury 526-27 damage control 271-72 Reflex dystrophy 344 Regional intravenous anesthesia 818-19 Renal. See also Kidney Renal artery 520, 569 damage control 266 Renal failure 171, 732-34 definition 110 malaria 437 septic shock 745 Renal function burn 700 post-operative care 729 Reproductive organ. See Female; Male Rescue breathing 178-79 Resistance of bacteria 746, 758 See also Infection Respiration 185-94 See also Breathing normal values 406, pocket folder at back cover Respiratory failure 730-31 definition 110 Retrobulbar hematoma 482 Retroperitoneal hematoma 563 compression of abdominal aorta 199, 254 kidney 265-66, 570 pelvis 270-71 Revised Trauma Score (RTS) 98-99 Rhesus D blood grouping 829-32 emergency blood transfusion 418 Rib injury. See Flail chest Rifle. See Bullet; Weapon Ringer lactated 207-08 burn 699-700, 705 consumption estimates 89 Rocket . See Weapon
Tibial, arteries
Rockwell, steel quality 89 Rule of nine in burns 697 Salivary gland injury 478 Salmonella 748, 750-53 Saphenous vein 664-65 Sarmiento plaster cast 687 Savlon 760 consumption estimates 89 Scapula fracture 634 Scar burn eschar 709 contracture 397 Schistosomiasis 434 Sciatic nerve, injury 619, 666 neurological examination 616, 659 Sclera. See Eye Scrotum, injury 589 Section, cesarean 598 Sensitivity. See Antibiotics; Bacteria Septic shock 743 Septicemia 743 Severity. See Injury severity Shock, physiological circulatory 162, 164, 176-77, 737 septic 743 Shock wave, weapon energy output, blast wave 128-31 energy output, land mine 148-49 energy output, projectiles 140-43 Short bowel syndrome 776 Shoulder, injury 631-37 diagnostic joint puncture 635 Shrapnel. See Bullet; Weapon Sickle cell anemia 431 Sigmoid colon, injury 532, 534 See also Colon Silver sulfadiazine 709 Sinus, frontal 482 Skeet 153 Skin flap. See Soft tissue flap Skin graft 398-401 amputation stump 387 corachan graft 401 Skull fracture 448-49 See also Brain; Face; Head blast wave injury 138 damage control 243 neurological examination 98-99, 239-43 Skull traction 465, 468-70 Small intestine. See Intestine Sniper. See Bullet Soap, disinfection 78, 191, 193, 760 Sodium bicarbonate alkalinization of urine 711 hypothermia 425 sickle cell anemia 431-32 Sodium, serum 729 See also Hyponatremia
Soft tissue flaps 325-26, 329-39 abdominal wall injury 269 chest wall injury 250 finger 402-03, 652-53 groin 650 muscle flaps 73, 329, 332-35 penis 588 perforator 73, 331, 336-39 skin flaps 330, 401-03 Spalling 135. See also Blast wave abdomen 136 chest 135-36 head 138 intima detachment 136 pelvis 137 Spinal anesthesia 822-26 anesthesia chart 843 Spinal cord, injury 463, 466-67 neurological examination 212-13 Spinal fracture cervical 465, 468-71 life support 218 lumbar 462-71 neurological examination 212-13 thoracic 471 Spleen, injury 556-59 child patient 410 damage control 361-62 typhoid fever 437-38 Splenectomy 557-58 Spore, bacteria 742, 760-62 Sprue 430, 432 post-operative nutrition 433 Staged surgery. See Damage control Staphylococcus 743, 746, 750-53 Starvation. See Malnutrition Steel maintenance of instruments 89-90 Stem cell, fracture healing 326 Sterilization 760-62 in-field 77-79 Stoma. See Enterostomy; Nephrostomy Stomach, injury 540-42 decompression 187-88 schistosomiasis 434 Stool, smear 430, 435, 437 Streptococcus 746-47, 750-53 Stress. See Post-injury stress Subclavian artery 457 Subdural hematoma 239, 452 Sulfa. See antibiotics Sulfadiazine 709 Sulfamylon 709 Superior mesenteric artery 520, 541, 562 effects of ligature 526 Supraclavicular nerve plexus. See Brachial nerve plexus Suprapubic bladder catheter 581, 583 Suprapubic bladder puncture 215
Sural nerve, graft 376 Surgical instruments consumption estimates 87-89 improvisations 90-92 maintenance 89-90 standard sets 79-86 sterilization 77-79, 760-62 Suture improvisations 92 primary delayed 397-98 relief suture 523 technique 290-91, 295-98 Synovial fluid 360 Synovium joint 360 tendon 368 Talus, injury 687, 690 Tamponade, gauze abdominal bleeding 256-57 limb bleeding 196 liver bleeding 261, 550 pelvic bleeding 270 Tarsorrhaphy 489 TBSA (total body surface area) 208, 697 See also Burn TDT (terminal death time) 761 See also Sterilization Team work 174-76 Temperature. See Fever; Hyperthermia; Hypothermia Temporary abdominal closure (TAC) 258-59 Tendon injury 368-71 hand flexor 370 soft tissue flaps 337-39 Tendon plasty 370-71 Tenotomy hip joint 625 knee joint 692 Testis, injury 589 Tetracycline. See antibiotics Thalassemia 431 Thermal burn. See Burn Thermal death time 759 See also Sterilization Thigh injury 661-71 Thoracotomy 499-502 damage control 249-51 Thrombocyte. See Platelet Thrombosis 735 See also Coagulation coagulation system failure 166-67, 734-36 vascular surgery 315, 320 Tibia, injury 680-90 See also Limb, lower soft tissue flaps 332-33, 338-39 Tibial, arteries 682-85 land mine injury 148-49 877
Tibial nerve injury 684-85 neurological examination 659 Tinnels sign 375 Tobramycin. See antibiotics Total body surface area (TBSA) 208, 697 See also Burn Tourniquet, complications 197 Toxin, bacteriology 743, 746, 749 Trace minerals 774 Trachea, injury 456-58 Traction 349-52 See also Fractures cervical spine fracture 465, 468-69 Training 52-73 damage control 53-57 first helper 66-70 paramedic 57-65 surgery 70-73 Transfusion. See Blood transfusion Transplantation. See Graft Trauma. See also Injury Trauma registry 108-23 Trauma system 33, 120-23 models in previous wars 34-47 Trephination 448, 453 Triage 278-84 burn 273-74, 701-02 documentation 282 mass casualty 281-82 Triceps, soft tissue flap 636 Triceps skinfold, malnutrition assessment 771-72 Trimethoprim-sulfonamide. See antibiotics Tripoli 36-37 TRISS 105-08 Tropical diseases. See Diseases Tropical sprue. See Sprue Trueta plaster 309, 345-46 amputation 390 burn 709 Trypanosomiasis 430 Tube, uterine 593, 599-600 Tuber ischii, temporary prosthesis 390-91 Tuberculosis 430, 751, 762 Typhoid fever 437-38 Ulna, injury 644, 648 Ulnar artery, injury 628, 638-39 effects of ligature 249 Ulnar nerve block 815
Ulnar nerve, injury 635, 639, 646 neurological examination 629, 643 UPH (urine per hour). See Urinary output Upper limb. See Limb Ureter, injury 519, 570-73 accidental damage during surgery 527, 571 Urethra, injury 578, 582-83 Urinary bladder catheter consumption estimates 88 suprapubic 581 urethral injury 582-83 Urinary bladder, injury 519, 578-81, 584 schistosomiasis 434 Urinary output burn 700 post-operative monitoring 729 renal failure 729 Urine per hour. See Urinary output Urine phlegmon 578 Uterus, non-pregnant, injury 519 Uterus, pregnant, injury 596-98 See also Female sex organ damage control 271 Vagina, injury 593 Vacuum-Assisted Closure (VAC) 309 Vancomycin. See Antibiotics Vascular injury 312-21 See also Artery; Vein abdomen 520 blast wave injury 136-37 clinical examination 216-17 damage control 72, 216-17, 247-49, 520 embolectomy 320 ligature, risk of secondary gangrene 248-49, 314 vascular shunt 72, 248-49 Vein, injury 314. See also Vascular injury venous sinus of brain 444, 451 Venous cut-down 204-06 Ventral hernia 610 Ventricular fibrillation. Sere Cardiac arrhythmia Vietnam 35 Vital function documentaion, injury chart 115-16, 228-29, 838-39 normal values See pocket folder at back cover physiological severity 98-102
Vitamin deficiency 432-33 requirements 774 Vitamin K, coagulation failure 736 Volume therapy burns 699-700 child patient 408-10 consumption estimates 88 life support 195, 206-10 old patient 410-11 post-operative 725-26 septic shock 745 sickle cell anemia 431-32 Weapon 128-57 See also Ammunition; Blast; Bullet blast 128-39 bullets 139-47 cluster weapon 150-54 dense inert metal explosive (DIME) 133-34 fuel-air explosive (FAE) 130-32 land mine 147-50 laser 155 microwave 156-57 sniper 139-40, 146 Weight of body post-operative care 728 relation to height 772 Worm. See Ascariasis Wound care 396-403 burn 707-11 delayed primary closure 397-98 disinfection 760 hospital infection 746 infection, bacterial pattern 749-59 malaria 436 skin flaps 336-39, 401-03 skin graft 398-401 Wound closure 396-403 burn 707-11 soft tissue flaps 329-39 Wound infection. See Bacteria; Infection Wound track 140-47, 661-62 Wrist joint injury 644, 649, 651 diagnostic puncture 365 Xylocaine 226-27 See also Anesthetics consumption estimates 88 Zinc, daily requirement 774
878
Talk to patient
Pain stimulus Opening eyes No response 2 1 Sounds only No response 2 1 Localize pain Withdrawal Flexion Extension No response 5 4 3 2 1
STIMULUS
Penicillin 0.2 mio IE/kg mio IE Atropine 0.02 mg/kg mg Adrenaline 0.01 mg/kg mg
Normal systolic BP mm Hg
Ketamine 2 mg/kg IV mg
Normal HR beats/min
Endotracheal tube mm
Fluid 20 ml/kg ml
Metronidazole mg
Weight kg
Normal RR/min
Age years
If you dilute
you get
years
kg
mm Hg min ml mm mg
beats/ min
mg
mg
mg
mio IE
mg
mg
Newborn 1 2 3 4 5 6 7 8 9 10 11 12 13 14 3.5 10 12 14 16 18 20 22 24 27 30 33 36 39 42 80 80 80 90 90 90 90 100 100 100 100 110 110 120 140 120 120 110 100 100 90 90 90 80 80 80 75 70 40 40 30 25 20 20 18 18 18 16 16 15 14 12 200 240 280 320 360 400 440 480 520 600 660 720 780 840 80 160 60 70 3.0 4.0 5.0 5.0 5.0 5.0 6.0 6.0 6.0 6.0 6.0 6.0 7.0 7.0 7.0
1 2-3 3-4 3-4 3-5 3-5 4-6 5-7 5-7 6-8 7-9 8-10 8-11 9-12 10-13
7 20 24 28 32 36 40 44 48 54 60 66 72 78 84
0.1 0.2 0.2 0.3 0.3 0.4 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.8 0.8
0.04 0.1 0.1 0.1 0.2 0.2 0.2 0.2 0.2 0.3 0.3 0.3 0.4 0.4 0.4
1 2 2 3 3 4 4 4 5 5 6 7 7 8 8
0.1 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.8 0.9 1 1.1 1.2 1.3
70
5 6 7 8 9 10 11 12 14 15 17 18 20 21
200 240 280 320 360 400 440 480 540 600 660 720 780 840
Ketamine pain relief IV Ketamine anesthesia IV Ketamine anesthesia IM Pentazocine Atropine Penicillin Ampicillin Metronidazole Adrenaline
Ketamine is available in three different concentrations: 10 mg/ml, 50 mg/ml, and 100 mg/ml. Check the vial before use.
4 6 12
5 8 15
6 10 18
7 12 21
8 14 24
9 16 27
10 18 30
11 20 33
12 22 36