Mark W. Bowyer
Chief of Surgery/Trauma Czar, 332nd Air Force Theater Hospital, Balad, Iraq, 2006–2007
Peter Rhee
Chief surgeon, Charlie Medical Company, Forward level II facility, Ar Ramadi, Iraq, 2006
Joseph J. DuBose
Chief of Surgery/Trauma Czar, 332nd Air Force Theater Hospital, Balad, Iraq, 2009
Role 3, MMU KAF; Kandahar, Afghanistan 2010
Bagram Air Base Role 3 Air Force Theater Hospital 2011–2012
USSOCOM surgical support, Operation Inherent Resolve 2016
The surgeon is not yet born who does not think that he is the one who can close in war a gunshot wound primarily.
Philip Mitchiner, 1939
Bottom Line Up Front (BLUF) Box
- 1.
Maintain situational awareness. Don’t get distracted by the wound and miss other life-threatening injuries.
- 2.
Do it in the operating room. Big wounds benefit when you have good lighting, equipment, supplies, and anesthesia, and the operating room has these things.
- 3.
Trust your instincts and your physical exam.
- 4.
Closely examine every wound and the surrounding tissue.
- 5.
Bleeding, contamination control, diagnosis, and reconstruction are the priorities of trauma surgery.
- 6.
Prompt removal of devitalized tissue and debris is imperative to prevent local and systemic problems later.
- 7.
There will be more dirt, debris, and foreign bodies in these wounds than you’ve ever seen, and it may take several OR sessions to get them clean.
- 8.
Leave all wounds open initially. If someone else closed it, open it!
- 9.
Pulsatile pressure lavage systems are convenient, but they can hurt soft tissue and may promote rebound bacterial growth. Use simple irrigation.
- 10.
Vacuum therapy and frequent irrigation and debridement are good.
- 11.
Have low index of suspicion for compartment syndrome. If you think about it, you should do a fasciotomy.
- 12.
Complete full fasciotomies can save limbs and lives. There is no role for mini-fasciotomies.
- 13.
Closing wounds primarily is better than skin grafting, and taking patients to the operating room frequently will help achieve that goal.
When trying to describe to other surgeons the difference between the types of soft tissue wounds seen in combat and in peacetime, it is difficult to actually convey the complexity. Imagine the worst injured patient you have ever seen in your civilian practice while deployed to an active battle zone; you may see multiple patients in a single day with wounds that are bad or worse. Even otherwise well-trained trauma surgeons will find themselves initially uncomfortable caring for such injuries. These wounds are devastating, and we rarely see such extensive soft tissue injuries during our training or practice in the USA. The garden variety civilian stab wounds, slash wounds, and handgun injuries are incredibly minor compared to the wounds produced by things like a .50 caliber machine gun, an AK-47 round, or more commonly an improvised explosive device. No amount of reading can completely prepare you for some of these injuries, and you must adopt a different set of rules and strategies to optimize your patient’s outcome. Additionally, given that these wounds nearly always involve the extremities, it is essential that the combat surgeon be well versed in recognizing compartment syndromes and performing timely and complete fasciotomies. It is a travesty to have a young solider survive a multitude of potentially life-threatening injuries only to lose a limb or life due to a delayed or improperly performed extremity fasciotomy . The goal of this chapter is to help shorten the learning curve to care for the extensive soft tissue wounds of war and to reinforce the importance of both identifying compartment syndromes and treating them with correctly performed fasciotomies.
When caring for the extensive and complex wounds seen in combat, it is important to stick to basic principles and priorities. There are four principle steps in trauma and combat surgery:
- 1.
Hemorrhage control
- 2.
Contamination control
- 3.
Diagnosis
- 4.
Reconstruction
Whether you are doing a laparotomy or treating soft tissue injuries, the steps and priorities are not any different. The first priority is stopping the bleeding, and if available, bleeding wounds and big wounds should be taken to the operating room immediately. As a general rule of thumb, being in the operating room with wounds is easier on the patient, the hospital staff, and you. You get the best results by doing a good job, and the place to do the best job is in the operating room with proper equipment, lighting, and help.
In the current deployed setting, extensive soft tissue wounds are the norm requiring aggressive management and operative debridement and commonly require fasciotomy to prevent or treat compartment syndrome . While the techniques utilized for performing fasciotomies in theater are similar to that utilized in civilian practice, the indications and specific concerns may differ. It is essential that surgeons tasked with caring for these patients have a detailed understanding of the indications for and the anatomy and landmarks required to perform fasciotomies. Additionally, the austere environment of the deployed setting has afforded us a valuable experience with novel approaches to the subsequent closure of these wounds – experience that we hope to impart to you in this chapter.
Large Soft Tissue Wounds
The most important aspect of initial treatment of any soft tissue wound is to stick to your ABCs. Though it is important to ensure that an adequate airway is maintained, the vast majority of preventable deaths on the battlefield will be from uncontrolled hemorrhage, and the ABC mantra is adjusted slightly to C-ABC where the initial C refers to control of hemorrhage which should be done simultaneously (if possible) with evaluation and management of the airway. The wounds encountered in this setting are frequently overwhelming in appearance, and you will find that people have a tendency to focus on the wound and not the patient. Avoid the temptation to focus on what may be the most impressive wound of your life and miss other life-threatening issues. Prioritize as you would any trauma patient. If you have ample help and someone else can assess the airway and breathing, then you can address bleeding simultaneously. If you are running the team, then while someone else is trying to control the hemorrhage, you can ensure airway and breathing. While it is important not to miss a problem with an airway, you will save many more lives in combat medical care by controlling hemorrhage from a large soft tissue wound than you will by performing an emergent airway.
Once more pressing casualty issues have been addressed and emergent injuries excluded, attention should then be directed at the soft tissue wound. Bleeding from the wound is the first step. Direct pressure is the preferred method in civilian trauma, but in combat trauma, it is frequently inadequate and also requires a pair of hands that you usually need for other tasks. A well-placed and secured tourniquet is the preferred method for extremity hemorrhage control on the battlefield and in the combat hospital. If the patient arrives without one, put one on in the emergency room. For wounds distal to the elbow or knee, the tourniquet can be removed either in the operating room or in the resuscitation area. If there is uncontrollable arterial bleeding, pressure dressing can be applied, and the tourniquet should be retightened or reinforced with a second proximal tourniquet (Fig. 19.1). For many of the wounds seen in war time, the wounds are not suitable for tourniquets as they are very proximal (Fig. 19.2) and involve junctional areas where the extremities meet the torso. While it might seem tempting to simply irrigate these wounds in the emergency department or resuscitation area, we would advise you to avoid this temptation for all but the very smallest of wounds that do not need to be explored.
Fig. 19.1
Wounds where tourniquets were applied. Panel (a) bilateral tourniquets applied at groin, both legs amputated. Panel (b) tourniquet not applied due to lack of active blood loss. Panel (c) cloth tourniquet applied above wound
Fig. 19.2
Wounds that tourniquet cannot be effectively applied. Panel (a) wound created by rocket-propelled grenade. Panel (b) improvised explosive device
The wounds seen in combat must be assumed to be highly contaminated. Dirt and debris will always be present. Metallic fragments from the explosive device itself or surrounding objects may be present, particularly when the victim was in a vehicle that gets blown up. You may often find bone fragments in the wound but no bony fractures – these are fragments from bystanders or from the attacker in suicide bombing-type incidents (aka “bioshrapnel”). Decaying tissues and human or animal feces have also been found in explosive devices employed by insurgents to enhance wound infection rates. Everything imaginable can be found in the wounds (Fig. 19.3). In the least, the projectiles and fragmentation components of modern war wounds represent substantial risk for severe infection. Devitalized tissue, if not adequately debrided, will only fuel these infections and contribute to adverse outcome. One of the recurring lessons learned by newly deployed surgeons is that these wounds will need aggressive debridement, generally more extensive than one might initially expect.
Fig. 19.3
Foreign objects found in wounds. Panel (a) cover of an M4 rifle. Panel (b) dirt and rocks in wounds. Panel (c) unknown object found in tissue after improvised explosive device
General guidance for initial operative intervention consists of three main components: irrigation, debridement, and leaving wounds open. Antibiotics should be given right away as empiric therapy. The choice of antibiotic should cover gram-negative bacteria (particularly Acinetobacter) as they are much more prominent than in civilian trauma practice. We advise wide coverage for gram-positive and gram-negative organisms in your perioperative choice. Next you should then focus on irrigation. While high-pressure pulsatile lavage (HPPL) systems are commonly utilized in civilian practice, it is the current recommendation by the Joint Theater Trauma System Clinical Practice Guidelines (JTTS CPGs) that the employment of these devices be avoided. While these devices make the irrigation process easier, there is concern that the use of HPPL is associated with additional trauma to the tissues, creating an environment with a greater abundance of devitalized tissue and setting the stage for more aggressive bacterial regrowth. Several studies have shown higher wound infection and complication rates with pulse lavage compared to standard irrigation. Antibiotic-resistant Acinetobacter has also been associated with the HPPL. These devices are also relatively expensive and may not be available at all medical treatment facilities in the area of conflict. For these reasons, the use of bulb suction or gravity-fed systems should be utilized to provide for high-volume irrigation of all wounds in a more gentle fashion. Normal saline, sterile water, and potable tap water all have similar usefulness, efficacy, and safety for this purpose. How much irrigation to utilize depends on the size of the wound. As bacterial loads in the wound will drop dramatically with increasing volumes of 1, 3, 6, and 9 L of irrigation, we advise (as does the current JTTS CPG on the topic) that the following be utilized as a rule of thumb: 1–3 L for small volume wounds, 4–8 L for moderate wounds, and 9 or more liters for large volume wounds or wounds with evidence of heavy contamination. If the HPPL system is used, it can be made gentler by putting your fingers over the injecting end and to let the fluid fall into the wound. This turns the HPPL into a high-flow low-pressure system. Remember to use warm fluids, as hypothermia can rapidly develop with these large volumes.
After effective irrigation of the wound has removed all loose debris, you should turn your attention to debridement. Remove all remaining foreign material that is readily visualized or palpated through the wound – do not routinely extend wounds to “chase” a fragment that you might have seen on radiography – it will only create new potential spaces for infection, and you may injure another structure in the process. While the degree of debridement will require you as the operating surgeon to utilize your own judgment, take care to ensure that all devitalized tissue is removed while at the same time attempting to preserve as much soft tissue as possible for reconstruction at a higher level of care or later operations. For the muscle, purple or black tissue that does not move with the electrocautery should be removed, but when in doubt, you can leave it for the next time the wound is debrided if the wound is left open. There is a widely propagated surgical fallacy about the need for massive wide debridement of high-velocity missile wounds. This is based on erroneous assumptions and distortions regarding the size and extent of injury related to the sonic wave and temporary cavity created, with some authors advocating debridement of a cavity 30 times the size of the projectile. Do not do this; you will only create significant morbidity and cosmetic defects. This has been refuted by both ballistics data and combat surgical experience. As all of these wounds should be left open after the initial operation, it is reasonable to leave some tissue that you think may survive with the express understanding that this patient should be returned to the operating room for another look and additional debridement within the next 24 h. A common experience downrange was to receive a casualty at the role three who had had a debridement further forward and upon return to the OR find significant devitalized tissue. The initial reaction was to assume that the first operation was inadequate, but subsequent experience proved that some of these wounds (especially blast wounds) are wounds in evolution, in which tissue that looked viable at the initial operation was no longer so on second look. This underscores the need to avoid the temptation of closure at the initial operation, as there remains the strong possibility that the damage to the tissues has not fully declared itself and that additional debridement will be required at subsequent operation.
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