Daniel Grabo
Chief of Trauma, NATO Role III Multinational Medical Unit, Kandahar Airfield, Afghanistan, 2014
Alec C. Beekley
Staff Surgeon, 102nd Forward Surgical Team, Kandahar Airfield, Afghanistan, 2002–2003
Chief of Surgery, 912th Forward Surgical Team, Al Mussayib, Iraq, 2004
Staff Surgeon, 31st Combat Support Hospital, Baghdad, Iraq, 2004
Director, Deployed Combat Casualty Research Team, 28th Combat Support Hospital, Baghdad, Iraq, 2007
“How varied was our experience of the battlefield and how fertile the blood of warriors in rearing good surgeons.”
Thomas Clifford Allbutt
BLUF Box (Bottom Line Up Front)
- 1.
Prepare for combat trauma surgery by reading, review of case scenarios, familiarization with JTS Clinical Practice Guidelines and visualization.
- 2.
Focus on one patient at a time. During multiple casualty events, stay with the casualty to whom you are assigned.
- 3.
In combat trauma C comes before A and B. Assess for and control hemorrhage immediately; it is what will kill most of your patients.
- 4.
Identify early on the patients who will require massive blood transfusion and would benefit from damage control resuscitation and surgery.
- 5.
Assessment of A and B should be rapid in combat casualties; it is generally an “all or nothing” phenomenon such as cricothyroidotomy or tension pneumothorax. Intubation can often wait until you get to the OR.
- 6.
Check tourniquets for adequacy and tighten or augment with pneumatic tourniquets, particularly for proximal amputations.
- 7.
Perform a FAST exam early. Obvious abdominal injury in unstable patients should prompt abandonment of the FAST and rapid movement to the OR.
- 8.
Portable chest and pelvis x-rays can be taken in the trauma bay and reviewed in the OR – they may provide valuable data.
- 9.
Get help in the OR, particularly for multisystem combat casualties. Do your damage control procedures in tandem, not in series.
- 10.
Intraoperative findings should match patient physiology – if they don’t, you need to conclude the operation you are doing and look for the real hemorrhage sources.
Multiple casualties have arrived. You can hear more Blackhawks landing on the helipad outside. The first casualty has rolled into the next trauma bed after being assigned to your colleague by the triage officer. You notice the exposed brain bulging from a jagged hole in the frontal bone. Omentum hangs from wound on his left flank. The left lower extremity is missing from about mid-thigh – two tourniquets are in place side by side. The area around the litter is a bustle of activity.
The next casualty is brought into you. You have an initial wave of anxiety . You haven’t been here long. Aside from an obvious open tibia/fibula fracture in his right leg, he is talking, telling you he is okay and to help his buddies first. Your cursory primary survey appears negative – airway intact, breath sounds clear, and palpable radial pulse. You begin to drift over to the first casualty. He is clearly going to need a lot of operations and your colleague is hard at work.
The scenario just described can happen any day at any surgical unit in Afghanistan, Iraq, or any other modern conflict. You may find yourself as the only surgeon or only one of two surgeons available to handle multiple severely injured casualties at once. Hence, any discussion on “initial management priorities” must take into account that these priorities may change based on the ratio of severely injured casualties to surgeons. One day, a casualty with a brain injury may get full resuscitative efforts; the next day, the same casualty may be made expectant due to the nature of the other casualties and the resources available. Triage and initial management priorities are not set in stone, but are dynamic processes that always take the local conditions and capabilities into account.
The process is triage, a simple sorting and prioritization that occurs with multiple casualties. This topic will be discussed further in another chapter. The process by which the surgeon approaches the individual multiply injured combat casualty, however, should also be thought of as a sorting and prioritization exercise . Every move you make, particularly in the first few minutes of the trauma evaluation, should be prioritized toward identifying life-threatening injuries and bleeding, followed by likely injuries that require immediate intervention, and lastly a detailed survey to identify occult or lower priority injuries. Even if the patient is “stable,” proceed like he could become rapidly unstable in the next minute. You don’t want to be shooting a femur x-ray when the patient becomes unstable and you realize you haven’t done a FAST exam or a chest x-ray yet. Like all operations surgeons perform, this exercise can be simplified by breaking it down into a series of steps.
The first step, and perhaps the most important one, is focus on your patient. One of my most senior surgeon mentors and friends used to say that the surgeon must develop the ability to block out distractions, both internal and external. The surgeon’s pounding heart, sweaty hands, and self-doubt are internal distractions. Each surgeon must figure out on his own how best to minimize and overcome the stress of caring for severely injured brothers and sisters in arms. Some surgeons do not suffer much from doubts (“often wrong, never in doubt”), but many of us do (if we are honest with ourselves). Some surgeons choose to mentally prepare by reading textbooks and others by presenting hypothetical surgical challenges and figuring out what to do with them. Choose a method and prepare ahead of time. Regardless of your background, prior deployments (or lack thereof), and civilian trauma experience (or lack thereof), you will be challenged by combat casualties. Mental preparation, study, and visualization can lessen the stress the first time. And always ask for help when needed – trauma is a team sport in the combat or disaster setting.
The casualty with exposed brain, evisceration, and a missing limb on the next litter is an external distraction. External distractions must be minimized in order for you to serve your patient best. The key point for surgeons new to the combat environment to learn is to STAY WITH YOUR PATIENT, particularly during multiple casualty events (which happen frequently). Focus on one patient at a time. The surgeon in the scenario at the beginning of the chapter is at risk for drifting away from his assigned casualty and missing important findings. If you are needed elsewhere, the triage officer will reassign you if your patient is truly stable. In the meantime, attend to your patient until you are confident that your work-up is complete or you have appropriately handed the casualty off to another provider.
Initial Management Priorities
Sick or Not Sick?
When the surgeon approaches a combat casualty for his initial evaluation, his first determination should be binary: Is this patient sick or not sick? In other words, is this patient at risk for dying? This should always be the surgeon’s first assessment, regardless if the patient was triaged into a delayed or minimal status. This determination can be the one that leads the surgeon down the path to success – or to failure if this determination is wrong. Simple techniques are right most of the time. They require hands-on engagement with the patient. Talk to him: “How are you doing, bud? What happened to you? Can you hold up 2 fingers?” While you are asking these questions, feel for the casualty’s radial pulse. A casualty who answers you, can hold up two fingers (GCS motor score of 6), and has an easily palpable radial pulse is usually not too sick.
Casualties that are initially deemed “not sick” can usually have a relatively thorough and detailed assessment, including CT scans and plain films for suspected injuries, or even be delayed in their management as the surgeon addresses the “sick” patient. Casualties that fail any of these initial assessments should immediately raise your level of concern and focus. They should be considered unstable and seriously injured until proven otherwise. Patients who fall into this category (unstable or “sick”) should prompt the surgeon to perform a rapid search to find the source of their illness and think about moving them expeditiously to the OR.
Identifying Triggers for Massive Blood Transfusion and Damage Control
Once the surgeon has deemed the casualty “sick” or unstable, he should consider early on if the casualty will likely require massive blood transfusion (>10 units PRBCs in 24 h) and likewise meets the criteria for damage control resuscitation and surgery. When initially presenting to the trauma bay, these patients are usually significantly injured and typically have these presenting physiologic parameters:
- 1.
SBP < 110 mmHg
- 2.
HR > 105 bpm
- 3.
Hematocrit <32%
- 4.
pH < 7.25
Patients with three of four above presenting factors have 70% predicted risk of massive transfusion; all four factors have 85% predicted risk. Additional risk factors for massive transfusion include: INR > 1.4 and St02 < 75%. Even in a combat theater hospital, there is increasing use of rotational thromboelastography (ROTEM). Although feasible in a combat environment, ROTEM should be used primarily in the fine tuning of management of coagulopathy in a combat casualty.
When confronted with the individual patient whom the combat surgeon determines damage control as the plan of action, the priorities shift to the following:
- 1.
Rapid hemorrhage assessment and control
- 2.
Minimal use of adjunctive tests such as radiographs and FAST only to help delineate sources of hemorrhage and recognize injury complex
- 3.
Controlled resuscitation: minimal crystalloids and preferred use of blood products in the proper ratios
- 4.
Rapid assessment and correction of airway and breathing problems
- 5.
Focused disability assessment and neurologic intervention
- 6.
Control for hypothermia
- 7.
Effective communication of the plan and early decision-making
Hemorrhage Control Über Alles
Although the A of the Advanced Trauma Life Support ABCDE algorithm stands for “airway,” in the combat casualty the airway is rarely the source of threat to life. This is particularly true if they have survived the evacuation process to reach you with an intact airway. When there is a significant airway issue, it is usually quite obvious and will be apparent that this has to be dealt with first. The biggest threat to a combat casualty’s life is usually from hemorrhage, so in combat trauma the C should come first. Hence, the initial evaluation in the unstable casualty, while still involving a primary survey, must rapidly move to finding and treating the hemorrhage sources. These include external hemorrhage sources and intracavitary hemorrhage: into the chest, into the abdomen, and into the pelvis. In the end, these sources can all be found fairly quickly, usually in a matter of minutes with a focused physical exam augmented with basic and rapid imaging or interventions as needed. Figure 3.1 outlines the basic initial management algorithm and targeted priorities in the combat casualty.
Fig. 3.1
Algorithm for initial management and prioritization in combat trauma
One advantage of combat trauma is 95% of the mechanisms are penetrating. Casualties have holes in them. Their injuries are frequently obvious and often dramatic. Hence, unstable casualties with limbs missing, blood draining, abdominal evisceration, or large holes in the chest should pretty much go to one place – the OR. These obvious injuries should prompt the surgeon to establish intravenous lines, begin resuscitation, and activate the OR, but should not keep him from fully evaluating the casualty. Combat casualties may also suffer blunt or blast mechanisms (which may not create holes in the body), or they may have holes from head to toe. So, after a RAPID primary survey, at a minimum, these casualties should have the following :
- 1.
Inspection of the entire body surface : Casualties must be exposed and their body surfaces examined. The critical part of this is the logroll. This step is easily overlooked, which can have grave consequences for the patient. A casualty may present with a normal-looking anterior and have a devastated posterior, the extent of which is only known once he is rolled. These wounds are seen with increasing frequency due to explosions going off under vehicles or behind foot patrols. Profoundly hypotensive patients may have stopped bleeding from posterior wounds, which can then re-bleed under the surgical drapes once the patient gets some resuscitation. Knowledge of these posterior wounds can be critical for the operating surgeon. For example, findings on abdominal exploration that are not compatible with the casualty’s level of shock should prompt the surgeon to reexamine the posterior wounds. Additional attention should be paid to the axillae, groins, and perineum, so as not to miss a penetrating bullet or fragment wound.
- 2.
Tourniquets , both limb and junctional, may have been applied after the patient had already become hypotensive. Less force than normal may have been required to stop hemorrhage, or if the hemorrhage had stopped spontaneously, the medic would have no cues to tell him how tight to make the tourniquet. Resuscitation may precipitate re-bleeding, so all tourniquets should be checked and consideration given to supplementing them with pneumatic tourniquets. Assurance of tourniquet adequacy should be done early – it will allow you to focus on finding and treating other non-compressible sources of hemorrhage.
- 3.
FAST exam : This study can also be done almost immediately on casualty arrival and allows assessment of the abdominal, pericardial, and with proper training, the thoracic cavity. Usually, the FAST can be done directly after a quick evaluation of the airway and auscultation of the chest. Unstable casualties with positive findings on FAST exam need rapid transfer to the OR. For equivocal FAST images, a diagnostic peritoneal aspiration (DPA) with a 20-gauge needle can be performed in unstable patients if the source of hemorrhage is not yet clear. DPA can help rule out major hemorrhage into the abdomen.
- 4.
Portable chest x-ray : This study can be done within minutes of arrival and the digital image viewed immediately. With auscultation of the chest cavity, life-threatening tension pneumothorax or massive hemothorax is easily ruled out. Add the evaluation of the chest by portable chest x-ray, and potentially life-threatening problems like simple pneumothorax and hemothorax are identified. If your unstable patient has a clear chest x-ray – they are NOT dying from intrathoracic hemorrhage. Look elsewhere.
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