With the ongoing improvement in body armor and ballistic helmets as well as advances in modern combat casualty care, more and more combat casualties will survive following injury long enough to be resuscitated. As such, the severity of extremity injuries among survivors of combat injuries is increasing. Such injuries rarely occur in the context of civilian medicine, even at Level I trauma centers. So the first thing you have to do when you enter a combat zone is realize you are in a combat zone: the game is changed and you need to adapt to a different injury paradigm.

Rule number one is do not get distracted. Traumatic amputees can still die from an unsecure airway if you do. Prepare yourself for the inevitable emotional reaction to the graphic nature of blast injuries. Develop a plan of how to react, and then when you begin treating your first triple amputee, you and the casualty will be better prepared to meet that challenge successfully. Despite being at times massive injuries, familiar and effective treatment strategies can be adapted and used successfully in the combat zone. ATLS is your friend, so after identifying a significant extremity injury, return to the primary survey and manage it initially in that context.

Rule number two is to know where your tourniquets are and how to use them. Limb-threatening injuries due to blast will become life threatening the quickest through massive hemorrhage. This can be through characteristic pulsatile bleeding from an arterial injury or sustained low-pressure bleeding from venous sources, injured muscle, and fractures. As opposed to the civilian setting where tourniquets are generally used as a last resort, in the combat setting, they should be used early and often. Find out what kind of tourniquets you can expect to be available in your unit and which kinds the units you will be supporting are using – learn how to use them. Also become familiar with their unit SOPs – often you can find a tourniquet on the injured casualty himself in a predetermined pocket or pouch in their combat gear.

Once acute hemorrhage has been controlled, the casualty has an opportunity to respond to resuscitation, and the bleeding risk from the traumatic amputation is temporized; proceed as required to manage ongoing threats to life, but remain mindful of tourniquets that have been placed. Make note of when a tourniquet was applied, and be sure this information is passed on to higher echelons of care. Mark your casualty in an obvious way so all care providers know the presence and location of tourniquets and the time they were placed. Administer tetanus toxoid, a first-generation cephalosporin (typically cefazolin), an aminoglycoside (typically gentamycin – remain mindful of shock and the potential for renal impairment), and penicillin (or other agent to cover for anaerobic organisms). If you are in a mature theater, consider tailoring your antibiotic regimen according to historical infection and colonization rates. If the patient is stable enough to go to the OR, then proceed as indicated, if not then remove gross contamination and irrigate with copious amounts of sterile saline. In austere environments, consider a mild soap solution or clean water if sterile saline is not available. Lastly, be sure you have a clear understanding of the appearance of the wounds, and cover them with a clean dressing, which should be left in place until the casualty is in the operating room.

In civilian trauma, trauma surgery is generally done in series. The trauma surgeon does a laparotomy and then is followed by the orthopedics team to nail the femur. In combat trauma you must learn to operate in parallel! Prep the entire body, including all involved extremities, and all teams operate simultaneously. It is not uncommon to have four to six staff surgeons operating simultaneously on a severely injured patient. This will save time, resources, and get your patient off of the table and to the ICU rapidly. In the operating room, before removing field tourniquets, apply and inflate a pneumatic tourniquet proximal to the operative field if possible (Fig. 21.1). If needed, prep the tourniquet into the sterile field prior to removal in an attempt to minimize blood loss between the time of tourniquet removal and surgical control. The goal of the first operation is to control hemorrhage and to debride the wound, in that order. As a completion amputation can be considered in the context of both hemorrhage control and debridement, at this time, determine if an amputation is required for a mangled extremity. Such decision-making is covered under a separate chapter in this text.

Commonly accepted principles of amputation surgery apply in the combat zone; however, blast and other high-energy mechanisms often produce wounds where the zone of injury exceeds that which initially might be suspected. The guiding principles for combat amputations are similar to those of limb salvage: control of hemorrhage, debridement of nonviable tissue, stabilization for transport, and infection control.

One of the evolving management principles of wartime amputation surgery in the twenty-first century is the concept of the length-preserving amputation. The open circular amputation is no longer preferred or required. In the theater of operations, every attempt should be made to retain any viable soft tissue and bone (Fig. 21.2). With modern reconstructive amputation techniques, irregular skin flaps and soft tissue envelopes can often be augmented with rotational or free tissue transfer and skin grafting to preserve limb length and functional joints. The exposed bone should be left long to provide an internal splint for the soft tissues and to allow for maximum creativity and flexibility in the reconstructive process. You must resist the temptation to amputate at the level of a long bone fracture simply because it is there. Amputation can be combined with osteosynthesis of fractures to maximize limb length and function. A distal amputation may be combined with more proximal debridement and external fixation of fractures to effectively manage a complex injury.