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Hero’s Highway shuts down. Airmen from the 332nd Expeditionary MedicalGroup carry a stretcher under theHero’sHighway flag during an aeromedicalevacuationtrainingexercise.ThehistoricalflagwasrecentlycasedinaceremonyonSeptember1,2011.

Photograph:USAirForcephotono.110707-F-GU448-007.

Photographer:SeniorAirmanJeffreySchultze.

EmergencyWarSurgeryFOURTHUNITEDSTATESREVISION

2013BordenInstitute

USArmyMedicalDepartmentCenterandSchool

FortSamHouston,Texas

OfficeofTheSurgeonGeneral

UnitedStatesArmy

FallsChurch,Virginia

“All the circumstances of war surgery thus do violence to civilian concepts oftraumaticsurgery.Theequalityoforganizationalandprofessionalmanagementisthe first basic difference. The second is the time lag introduced by themilitarynecessityofevacuation.The third is thenecessity for constantmovementof thewoundedman,and the fourth—treatmentbyanumberofdifferent surgeonsatdifferent places instead of by a single surgeon in one place—is inherent in thethird.Theseareallundesirable factors,andonthesurface theyseemtomilitateagainstgoodsurgicalcare.Indeed,whentheoverallcircumstancesofwarfareareaddedtothem,theyappeartomakemoreidealsurgicaltreatmentimpossible.Yetthiswasnot true in thewarwehave just finished fighting, norneed it ever betrue.Shortcutsandmeasuresofexpediencyarefrequentlynecessaryinmilitarysurgery,butcompromiseswithsurgicaladequacyarenot.”

—MichaelE.DeBakey,MDPresentedatMassachusettsGeneralHospital

Boston,October1946

THEFOURTHUNITEDSTATESREVISION

of

EMERGENCYWARSURGERY

ISDEDICATEDTOTHE

COMBATPHYSICIAN

DosageSelection:

The authors and publisher have made every effort to ensure the accuracy ofdosages cited herein. However, it is the responsibility of every practitioner toconsult appropriate information sources to ascertain correct dosages for eachclinical situation, especially for new or unfamiliar drugs and procedures. Theauthors, editors, publisher, and the Department of Defense cannot be heldresponsibleforanyerrorsfoundinthisbook.

UseofTradeorBrandNames:

Useof tradeorbrandnames in thispublication is for illustrativepurposesonlyanddoesnotimplyendorsementbytheDepartmentofDefense.

NeutralLanguage:

Unless thispublication statesotherwise,masculinenounsandpronounsdonotreferexclusivelytomen.

Theopinionsorassertionscontainedhereinarethepersonalviewsoftheauthorsand are not to be construed as doctrine of theDepartment of theArmy or theDepartment ofDefense. For comments or suggestionson additional contents inforthcoming editions, please contact the publisher(www.cs.amedd.army.mil/borden).

CERTAIN PARTS OF THIS PUBLICATION PERTAIN TO COPYRIGHTRESTRICTIONS.ALLRIGHTSRESERVED.

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PublishedbytheOfficeofTheSurgeonGeneral

BordenInstitute

FortSamHouston,Texas78234-6100

LibraryofCongressCataloging-in-PublicationData

Emergencywarsurgery(BordenInstitute)

Emergencywarsurgery.—FourthUnitedStatesrevision.

p.;cm.

Includesbibliographicalreferencesandindex.

I.BordenInstitute(U.S.),editorofcompilation.II.Title.

[DNLM:1.Emergencies—Handbooks.2.Woundsand

Injuries—surgery—Handbooks.3.MilitaryMedicine—Handbooks.WO39]

RD151

617.9’9—dc23

2013031557

PRINTEDINTHEUNITEDSTATESOFAMERICA

19,18,17,16,15,14,1354321

ContentsCOPYRIGHT

EDITORIALBOARDCONTRIBUTORS

ACKNOWLEDGMENTSFOREWORD

PREFACEPROLOGUE

Chapter1:WeaponsEffectsandWarWounds

Chapter2:RolesofMedicalCare(UnitedStates)

Chapter3:MassCasualtyandTriage

Chapter4:AeromedicalEvacuation

Chapter5:Airway/Breathing

Chapter6:HemorrhageControl

Chapter7:Shock,Resuscitation,andVascularAccess

Chapter8:Anesthesia

Chapter9:Soft-TissueandOpenJointInjuries

Chapter10:Infections

Chapter11:CriticalCare

Chapter12:DamageControlSurgery

Chapter13:FaceandNeckInjuries

Chapter14:OcularInjuries

Chapter15:HeadInjuries

Chapter16:ThoracicInjuries

Chapter17:AbdominalInjuries

Chapter18:GenitourinaryTractInjuries

Chapter19:GynecologicalTraumaandEmergencies

Chapter20:WoundsandInjuriesoftheSpinalColumnandCord

Chapter21:PelvicInjuries

Chapter22:ExtremityFractures

Chapter23:Amputations

Chapter24:InjuriestotheHandsandFeet

Chapter25:VascularInjuries

Chapter26:Burns

Chapter27:EnvironmentalInjuries

Chapter28:RadiologicalInjuries

Chapter29:BiologicalWarfareAgents

Chapter30:ChemicalInjuries

Chapter31:PediatricCare

Chapter32:CareofEnemyPrisonersofWar/Internees

Chapter33:BattlefieldTransfusions

Chapter34:CompartmentSyndrome

Chapter35:BattlefieldTraumaSystems

Chapter36:EmergencyWholeBloodCollection

Envoi

Appendix1:PrinciplesofMedicalEthics

Appendix2:GlasgowComaScale

Appendix3:DepartmentofDefenseTraumaRegistry

AbbreviationsandAcronyms

SignificantMilitaryMedicalTerms

ProductManufacturers

Index

EditorialBoard

Chair/SeniorMedicalEditorMiguelA.Cubano,MD,FACS

CAPT,MC,USNavyDeputyCommander

DefenseMedicalReadinessTrainingInstituteFortSamHouston,Texas

ExecutiveMedicalEditorMarthaK.Lenhart,MD,PhD,FAAOS

COL,MC,USArmy

MedicalCo-EditorsJeffreyA.Bailey,COL,MC,USAirForceGeorgeP.Costanzo,COL,MC,USAirForceBrianJ.Eastridge,COL,MC,USArmyJamesR.Ficke,COL,MC,USArmy

ChristopherM.Hults,CDR,MC,USNavyZsoltT.Stockinger,CAPT,MC,USNavy

________

BordenInstituteEditorialStaffDanielE.Banks,MD,MS,MACP

LTC,MC,USArmyDirectorandEditorinChief

TimothyK.Jones,DDSCOL(Ret),DC,USArmy

AssistantDirector

VivianMasonDouglasWise

VolumeEditorLayoutEditor

BruceMaston

Illustrator

ContributorsRomneyAnderson,COL,MC,USArmy

JaysonAydelotte,MAJ,MC,USArmy

MartinBaechler,COL,MC,USArmy

JeffreyA.Bailey,COL,MC,USAirForce

LindaBeltra,CAPT,MC,USNavy

JohnR.Benjamin,CDR,MC,USNavy

TerenceG.Benson,MAJ,BSC,USAirForce

AlanBerg,COL,MC,USAirForce

JohnBini,LTCOL,MC,USAirForce

IanH.Black,MAJ,MC,USArmyReserves

SharonBlondeau,CAPT,NC,USNavy

HaroldR.Bohman,CAPT(Ret),MC,USNavy

MarkE.Boston,COL,MC,USAirForce

MarkW.Bowyer,COL(Ret),MC,USAirForce

JosephBrennan,COL,MC,USAirForce

ChesterBuckenmaierIII,COL,MC,USArmy

FrankButler,CAPT,MC,USArmy

JeremyW.Cannon,LTCOL,MC,USAirForce

RamonF.Cestero,CDR,MC,USNavy

MichaelCharlton,LTCOL,MC,USAirForce

GeorgeP.Costanzo,COL,MC,USAirForce

TracyCotner-Pouncy,RN

JamesE.Cox,COL(Ret),MC,USAirForce

MiguelA.Cubano,CAPT,MC,USNavy

VirgilDeal,COL,MC,USArmy

SherrileeA.Demmer,RN,BSN

WarrenDorlac,COL,MC,USAirForce

DavidDromsky,CDR,MC,USNavy

JamesDunne,CAPT,MC,USNavy

BrianJ.Eastridge,COL,MC,USArmy

MaryEdwards,LTC,MC,USArmy

JamesR.Ficke,COL,MC,USArmy

StephenFlaherty,COL,MC,USArmy

RichardGonzales,COL,MSC,USArmy

KurtGrathwohl,COL,MC,USArmy

StevenHadley,COL,MC,USAirForce

DanR.Hansen,COL,MC,USArmy

KennethC.Harris,COL,MC,USArmy

ScottHelmers,CAPT,MC,USNavy

LindaHill,LCDR(Ret),MSC,USNavy

ChristopherM.Hults,CDR,MC,USNavy

JoelJenne,LTCOL,MC,USAirForce

JeffersonJex,MAJ,MC,USArmy

JasonJohnson,MAJ,MC,USArmy

TimothyK.Jones,COL(Ret),DC,USArmy

WarrenKadrmas,LTCOL,MC,USAirForce

JohnKeeling,CDR,MC,USNavy

JamesKeeney,LTCOL,MC,USAirForce

JessKirby,MAJ,MC,USArmy

KevinKirk,LTC,MC,USArmy

EricKuncir,CAPT,MC,USNavy

JulioLairet,MAJ,MC,USAirForce

RonaldA.Lehman,LTC,MC,USArmy

MarthaK.Lenhart,COL,MC,USArmy

HenryLin,CDR,MC,USNavy

MarkA.MacDougall,LTC,AN,USArmy

PatriciaMcKay,CAPT,MC,USNavy

AlanMurdock,LTCOL,MC,USAirForce

DavidNorton,LTCOL,MC,USAirForce

ShawnPassons,LCDR,NC,USNavy

JeremyPerkins,LTC,MC,USArmy

BenjaminPotter,MAJ,MC,USArmy

JosephRappold,CAPT,MC,USNavy

ToddRasmussen,LTCOL,MC,USAirForce

FranciscoRentas,COL,MC,USArmy

EvanRenz,COL,MC,USArmy

MarkRichardson,COL,MC,USAirForce

KeyanRiley,MAJ,MC,USAirForce

JohnR.Rotruck,CDR,MC,USNavy

ZsoltT.Stockinger,CAPT,MC,USNavy

JosephStrauss,CDR,MC,USNavy

DanielUnger,CAPT,MC,USNavy

TeunvanEgmond,COL,MC,RoyalNetherlandsArmy

GlennWortmann,COL(Ret),MC,USArmy

IllustrationContributorsE.Weissbial

JointTraumaSystem

SonoSite,Inc

IllustratorsBruceMaston

JessicaShull

DouglasWise

2004ContributorsWealsopaytributetothecontributorsofthe2004EditionofEmergencyWarSurgery:

EditorsRonaldF.Bellamy,COL(Ret),MC,USArmy

MatthewBrengman,MAJ,MC,USArmy

DavidG.Burris,COL,MC,USArmy

PaulJ.Dougherty,LTC,MC,USArmy

DavidC.Elliot,COL,MC,USArmy

JosephB.FitzHarris,COL,MC,USArmy

StephenP.Hetz,COL,MC,USArmy

JohnB.Holcomb,COL,MC,USArmy

DonaldH.Jenkins,LTC,MC,USAirForce

ChristophKaufmann,LTC,MC,USArmy

DaveEd.Lounsbury,COL,MC,USArmy

PeterMuskat,COL,MC,USAirForce

LawrenceH.Roberts,CAPT,MC,USNavy

ContributorsKeithAlbertson,COL,MC,USArmy

RoccoA.Armonda,LTC,MC,USArmy

KennethS.Azarow,LTC,MC,USArmy

RonaldF.Bellamy,COL(Ret),MC,USArmy

GaryBenedetti,LTC,MC,FS,USAirForce

WilliamBeninati,LTC,MC,USAirForce

MatthewBrengman,MAJ,MC,USArmy

DavidG.Burris,COL,MC,USArmy

FrankButler,CAPT,USNavy

MarkD.Calkins,MAJ,MC,USArmy

LeopoldoC.Cancio,LTC,MC,USArmy

DavidB.Carmacke,MAJ,MC,FS,USAirForce

MarenChan,CPT,USArmy

DavidJ.Cohen,COL,MC,USArmy

JanA.Combs,MAJ,MC,USArmy

PaulR.Cordts,COL,MC,USArmy

NicholasJ.Cusolito,MAJ,NC,USAirForce

DanielJ.Donovan,LTC,MC,USArmy

PaulJ.Dougherty,LTC,MC,USArmy

DavidC.Elliot,COL,MC,USArmy

MartinL.Fackler,COL(Ret),MC,USArmy

JohnJ.Faillace,MAJ,MC,USArmy

GeraldL.Farber,LTC,MC,USArmy

JosephB.FitzHarris,COL,MC,USArmy

StephenF.Flaherty,LTC,MC,USArmy

RomanA.Hayda,LTC,MC,USArmy

JohnB.Holcomb,COL,MC,USArmy

MichaelR.Holtel,CAPT,MC,USNavy

StephenP.Hetz,COL,MC,USArmy

JeffreyHrutkay,COL,MC,USArmy

AnnesleyJaffin,COL,MC,USArmy

DonaldH.Jenkins,LTC,MC,USAirForce

JamesJezior,LTC,MC,USArmy

ChristophKaufmann,LTC,MC,USArmy

KimberlyL.Kesling,LTC,MC,USArmy

ThomasE.Knuth,COL,MC,USArmy

WilmaI.Larsen,LTC,MC,USArmy

GeorgeS.Lavenson,Jr,COL(Ret),MC,USArmy

JamesJ.Leech,COL,MC,USArmy

DaveEd.Lounsbury,COL,MC,USArmy

ChristianMacedonia,LTC,MC,USArmy

CraigManifold,MAJ,MC,USAirForce

PatrickMelder,MAJ,MC,USArmy

AlanL.Moloff,COL,MC,USArmy

AllenF.Morey,LTC,MC,USArmy

DeborahMueller,MAJ,MC,USAirForce

PeterMuskat,COL,MC,USAirForce

MaryF.Parker,LTC,MC,USArmy

GeorgePeoples,LTC,MC,USArmy

KarenM.Phillips,LTC,DC,USArmy

RonaldJ.Place,LTC,MC,USArmy

PaulReynolds,COL,MC,USArmy

LawrenceH.Roberts,CAPT,MC,USNavy

DavidSalas,Msgt(Ret),USAirForce

JosephC.Sniezek,MAJ,MC,USArmy

ScottR.Steele,CPT,MC,USArmy

AllenB.Thach,COL,MC,USArmy

ReserveJohnnyS.Tilman,COL,MC,USArmy

JohnM.Uhorchak,COL,MC,USArmy

StevenVenticinque,MAJ,MC,USAirForce

IanWedmore,LTC,MC,USArmy

AdditionalContributorsChesterBuckenmaier,LTC,MC,USArmy

EskilDalerius,COL,SwedishArmedForces

MichaelDeaton,COL,MC,USArmy

WilliamDickerson,COL,USAirForce

PeterRhee,LTC,MC,USArmy

GlennWortmann,LTC,MC,USArmy

IllustratorsBruceMaston

JessicaShull

AcknowledgmentsSpecial acknowledgment to CAPT W. R. Dalton, Commander of the DefenseMedicalReadinessTrainingInstitute,forhisleadershipandoversightduringthisrevisionofEmergencyWarSurgery.

The information contained in this book reflects a generous collaborative effort.Thankyoutoallofthecontributorsandcontentreviewersfortheirvaluabletimeandcontributions.

Thanks to Donalda (Dee) Smith whose efforts and selfless service wereunprecedented.Deedeservesspecialrecognitionforperseveringandcommittingmore than 3 years to getting this book organized, connecting doctors withchapters,andprovidinguntiringservice to see it to its completion.Shewas thedriving force behind this book and spent countless hours making phone calls,sending multitudinous e-mails, and communicating with doctors all over thecountryandOCONUS.Withouther,thisbookwouldnothavebeenpossible.

TremendousgratitudetoColonelMarthaLenhartoftheBordenInstitutewhowasinstrumental in ensuring that this book was a priority, and who selflesslyprovided guidance and encouragement during all stages of its production.Wewould also like to express our sincere thanks toVivianMason,VolumeEditor,BordenInstitute,forherdedicationandtechnicalsupport.

Specialrecognitiontothefollowingindividualsforputtingforththatextraeffort:HaroldR.Bohman,CAPT(Ret),MC,USNavy;MarkW.Bowyer,COL(Ret),MC,USAirForce;RamonF.Cestero,CDR,MC,USNavy;WarrenDorlac,COL,MC,USAirForce;MaryEdwards,LTC,MC,USArmy;StephenFlaherty,COL,MC,USArmy;DanR.Hansen,COL,MC,USAirForce;KennethC.Harris,COL,MC,USArmy;LindaHill,LCDR(Ret),MSC,USNavy;JasonJohnson,MAJ,MC,USArmy;HenryLin,CDR,MC,USNavy;MarkA.MacDougall,LTC,AN,USArmy;Alan Murdock, LT COL, MC, US Air Force; Joseph Rappold, CAPT, MC, USNavy;andEvanRenz,COL,MC,USArmy.

MiguelA.Cubano,MD,FACSCaptain,MC,USNavyDeputyCommander

DefenseMedicalReadinessTrainingInstitute

ForewordItisanhonorformetoacknowledgethetime,efforts,andexperiencecollectedinthis fourth revisionofEmergencyWarSurgery.Onceagain, a teamofvolunteersrepresenting the Military Health System and numerous clinical specialties hascommitteditselftocompilingstate-of-the-artprinciplesandpracticesofforwardtraumasurgery.

War surgery and treatment of combat casualties at far-forward locations,frequently under austere conditions, continue to save lives. Military medicalpersonnelprovideoutstandinghealthsupporttothosewhoserveinharm’sway.As war has evolved, so has our medical support to those who fight. Today,American servicemembers face anew terrainofmobileurban conflict.Despiteadvances inpersonalandforceprotection,our forcesremainvulnerable toblastwounds, burns, and multiple penetrating injuries not usually encountered incivilian settings. This publication expertly addresses the appropriate medicalmanagementoftheseandotherbattleandnonbattleinjuries.

I congratulate contributors to this edition for drawing on the experiences ofcolleagueswhorecentlyreturnedfromtoursofdutyinSouthwestAsiatoprovidethemost currenthandbook. Iwish topubliclyextendmygratitude,and thatofthe American people, to the courageous men and women who serve in themedical departments of our armed services. I commendyourdedicated serviceandacknowledgeyoursacrifices,andthoseofyourfamilies, toprovidethebesthealthcare to thosewhoprotectournation.AllAmericansare indebted toyourservice.

JonathanWoodson,MDAssistantSecretaryofDefenseforHealthAffairs

DirectorofTRICAREManagementActivity

May2012

Washington,DC

PrefaceThemoraltestofanation’scharacterishowitscitizenscareforthosewhoareillor injured as a consequence of war. This edition of theEmergencyWar Surgerymanual (the 4th revision) exemplifies the continuing commitment of militaryhealthcare providers to Soldier well-being across the continuum of care fromremote battlefields to stateside evacuation. This resource epitomizes sharedknowledgefromhealthcareprovidersdedicatedtothedeliveryoflifesavingcare,which underpins our honored legacy of military medicine. The authors havedocumented our providers’ intellectual commitment and unwavering ability toadvance the practice of medicine under arduous combat conditions. Thebattlefieldexperiencehasalwaysinformedmedicine.Theincreasedexperienceofcombat and innovation resulting from the last decade of war will forever beetchedwithinthepagesofthismanual,notasamonumentforposterity,butasapracticalhandbooktoenhancetheworkingmedicalknowledgeandskillsofourfightingforce.

It is said that theGreekgodofmedicine,Asclepius,wasborn as a result of anemergency medical intervention. Heroic acts of courage by Soldiers, Sailors,Airmen,andMarinesareatestamenttoournation’sabilitytoovercomeadversityeven in the face ofmortal challenge.As enemy tactics in Iraq andAfghanistanevolved, with increased application of improvised and vehicle-borne explosivedevices, medical leaders at all levels questioned existing paradigms andconventional wisdom. They developed evidence-based Clinical PracticeGuidelines, changed or augmented existing treatment modalities, andspearheaded progressive alterations to ballistic survival gear. From theapplicationoftourniquetsatthepointofinjurytothedesignanddevelopmentofprosthetics during the rehabilitative phase of treatment, our medical teamscontinuetoconductnewresearchandchallengemedicaldogmatosolvecurrentproblems.

EmergencyWarSurgeryisatestamenttothecourageexhibitedbyourmilitarymenandwomeninthesedifficult times.Thismanualrepresentsthecollectiveeffortsofnumerousmilitaryscholarsandpayshomagetothosewhowillinglypaidtheultimatepriceoffreedom.Eachwordshouldbereadintheirhonor.

Withhonor,humility,andprofoundadmiration,wepresentthe4theditionoftheEmergencyWarSurgerymanualwiththeexpresshopethatwewillnotforgetthelessonswehavelearned.

PatriciaD.HorohoLieutenantGeneral,USArmy

SurgeonGeneral

CommandingGeneralUSArmyMedicalCommand

MatthewL.NathanViceAdmiral,USNavy

SurgeonGeneral

ThomasW.TravisLieutenantGeneral,USAirForce

SurgeonGeneral

April2013

Washington,DC

Prologue“Waristheonlyproperschoolforthesurgeon.”

—Hippocrates

Within the last century, ourwars have traveled from the hedgerows of EuropeandbeachesinthePacific,tothejunglesofVietnam,andnowtothedesertsandmountains of Southwest Asia. The common denominator of these conflicts isintensehumansufferinganddeathas a resultof injuryon thebattlefield.Mostrecently,afteradecadeofwar,whatisrecentpastisprologueforthiswork:morethan5,000deadandtensofthousandsofcombatcasualtieswithsignificantinjuryinthedecadefrom2001to2011.PerthephilosophyofHippocrates,“Whathavewe learned?”and,more importantly,howcanwepass thatknowledgealong tothosewhowill follow?As the conceptofmodernwarfarehas changed, so, too,hasmedical care evolvedon thebattlefield.The current contingencyoperationshaveproducedmedicaladvancesthatwillbeourlegacyandthenewfoundationsforthemilitarysurgeonsofthefuture.

Warsurgerytodayisaboutusingevidenceandbestpracticetooptimizecareofourwoundedwarriors. Although grounded in the fundamental training of thegeneral surgeonandsurgical specialist, itmustbeadaptive to the challengesofextremelyhighinjuryacuity,theburdenofoverwhelmingcasualtynumbers,longand unforgiving hours, environmental extremes, logistical austerity, and thereality that mission accomplishment may precede medical necessity. It is aconcept built on realistic experience and lessons learned over a decade ofcontinuousconflict.Warhaspredictablyproliferatedinnovationsinmedicineandsurgery.Moderntechnologyandcommunicationhaveyieldedsubstantialimpactonthebattlefield,inthatwearebetterabletousecontemporarylessonslearnedto disseminate, educate, and change practice to mitigate casualty outcomes inrelatively“realtime.”

Advancesincombatcasualtycareareassociatedwiththelowestcasefatalityrateinthehistoryofwarfare,afactrenderedevenmoreremarkablebythecomplexityofinjuryandexpeditedtranscontinentalevacuationofcasualtiesacrosstheglobe.Withinthisrealmofmedicalinnovation,oneofthemostimportantcontemporaryadvances tomilitarymedicine on the battlefieldhas been thedevelopment andimplementation of the Joint Trauma System, a systemwhose singular vision isthat every soldier,Marine, sailor, or airman injured on the battlefield or in thetheaterofoperationshas theoptimalchance forsurvivalandmaximalpotentialfor functional recovery. Themotto of the system is “Right Patient, Right Time,RightPlace,RightCare.”ThetraumasystemisbuiltontheinfrastructureoftheDepartmentofDefenseTraumaRegistry(DoDTR),inthatdataimprovemedical

care; thatdatadrivedoctrine,policy, anddecision-making; and thatdata createnew knowledge to further the evolution of battlefield care. Pertinent to thecasualtyandthesurgeon, themissionof the JointTraumaSystemis to improvetraumacaredeliveryandpatientoutcomesacrossthecontinuumofcare,utilizingcontinuousperformanceimprovementandevidence-basedmedicine.Valueofthetrauma system is evidenced by development of more than 36 evidence-basedbattlefield relevant Clinical Practice Guidelines (CPGs) that have decreasedmorbidityandmortalityfromcombatinjury.RelevantCPGsarecitedextensivelyinthisversionofEmergencyWarSurgery.

Furthermore,theantiquatedsystemofprehospitalcareespousedbyPre-HospitalTraumaLifeSupport(PHTLS)hasbeenubiquitouslysupplantedbytheparadigmofTacticalCombatCasualtyCare(TCCC),dividedintophasesdependingonthetacticalscenario.Ineachphase,thegreatestpotentialthreattolifeismanagedasapriority in thecontextofmissioncapabilityandmissioncompletion.Embeddedwithin the overarching concept of TCCC are hemorrhage control and airwaymanagement. Tourniquet utilization has become a fundamental pillar ofhemostasis in TCCC and has been shown to be associatedwith an attributablesurvivaladvantage.

Developersof the techniqueofbalanced resuscitation coined the term“damagecontrol resuscitation.” Itwasconceptualizedon thisbattlefieldandhas reducedthemortality rate ofmassive transfusion casualties from 40% to less than 20%.Further refinements of this resuscitation paradigm include the use of novelhemostaticagents,coagulopathytestingmodalities,andevenmobileresuscitativeteamstrategies.

Evenwithallof theadvancesthathavetakenplaceonthebattlefield inthe lastdecade, several challenges loomon thehorizon.Despite the lowest case fatalityrate in history, the “died ofwounds rate” remains largelyunchanged. The vastmajorityofcombatcasualtiesdieonthebattlefieldbeforeeverreachingamedicaltreatment facility.Therefore, thegreatest chance to impact combat casualty careoccurslongbeforethesurgeoneverhastheopportunitytostopthebleeding.Thecharge to the generation of surgeons reading this text is tomake this situationbetter.

ItistheearnesthopeoftheauthorsofthisEmergencyWarSurgeryhandbookthatitwillgatherdustontheshelvesoftomorrow’smilitarysurgeon,knowingalltoowellthatwithpredictablecertaintythatfartoosoonthe“balloonwillgoup”andmilitarysurgeonswillonceagainheedthecall.

There isnogreatercalling,norgreaterresponsibility,norgreatersenseofworththantocareforawoundedbrother-in-arms.

BrianJ.Eastridge,MD,FACSColonel,MC,USArmy

TraumaConsultant,USArmySurgeonGeneral

MiguelA.Cubano,MD,FACSCaptain,MC,USNavyDeputyCommander

DefenseMedicalReadinessTrainingInstitute

JeffreyA.Bailey,MD,FACSColonel,MC,FS,USAirForceDirector,JointTraumaSystem

May2012

SanAntonio,Texas

Chapter1

WeaponsEffectsandWarWounds

Introduction

Justaswithanymedicaltopic,surgeonsmustunderstandthepathophysiologyofwarwoundstobestcareforthepatient.Themostimportanttenetfollows:

TREATTHEWOUND,NOTTHEWEAPON

EpidemiologyofInjuriesPrimaryweaponsofwarcanbedividedintoexplosivemunitionsandsmallarms.

Explosive munitions: Artillery, grenades, mortars, bombs, rockets,mines,improvisedexplosivedevices,etc.Smallarms:Pistols,rifles,andmachineguns.

Threemajorepidemiologicalanalyseshavebeenconductedtoevaluatethecauseofbattlefieldinjury,aswellasoutcome:

During the Bougainville campaign of World War II (Table 1-1), amedical teamwas sent to gather data on the injured, including thecause of injury. This campaign involved primarily infantry soldiersandwasconductedontheSouthPacificislandofBougainvilleduring1944.USArmyandMarinecasualtiesfromtheVietnamWarwerecollectedby theWoundData andMunitionsEffectivenessTeam (WDMET) inVietnam(Table1-2).The Joint Theater Trauma System (JTTS) was developed andimplementedin2004,modelingthesuccessofciviliantraumasystemsintheUnitedStates.TheJTTSwasdevelopedtosupportoperationsinIraq andAfghanistan to ensure that everymilitary casualty has theoptimal chance for survival and maximal potential for functionalrecovery.

Table1-1.USCasualties:BougainvilleCampaign(WorldWarII),Vietnam,andOEF/OIFWeapon Bougainville(%) Vietnam(%) OEF/OIF(%)

Bullet 33.3 30 26

Mortar 38.8 19 3

Artillery 10.9 3 <1

Grenade 12.5 11 —

Boobytrap/IED 1.9 17 64

RPG — 12 3

Other 2.6 8 3

IED:improvisedexplosivedevice;OEF:OperationEnduringFreedom;OIF:OperationIraqiFreedom;RPG:rocket-propelledgrenade.

Table1-2.AnatomicalDistributionofPrimaryPenetratingWoundsConflict HeadandNeck(%) Thorax(%) Abdomen(%) Extremity(%) Other(%)

WorldWarI 17 4 2 70 7

WorldWarII 4 8 4 75 9

KoreanWar 17 7 7 67 2

VietnamWar 14 7 5 74 —

NorthernIreland 20 15 15 50 —

FalklandIslands 16 15 10 59 —

GulfWar(UK) 6 12 11 71 —

GulfWar(US) 11 8 7 56 18

Chechnya 24 9 4 63 —

Somalia 20 8 5 65 2

OEF/OIF 27 5 6 55 7

OEF:OperationEnduringFreedom;OIF:OperationIraqiFreedom.

Themost common battlefield injury pattern ismultiple fragmentwoundsinvolvingmultipleanatomicalsites.

Fig.1-1.Causeofinjury,OEF/OIF.GSW:gunshotwound;OEF:OperationEnduringFreedom;OIF:OperationIraqiFreedom.

MechanismofInjury(Fig.1-1)

Projectileinjuries(Table1-3).Therearetwoareasofprojectile–tissue interaction:permanentcavity

andtemporarycavity(Fig.1-2).Fig.1-2.Projectile–tissueinteraction,showingcomponentsoftissueinjury.

Permanentcavity:Localizedareaofcellnecrosis,proportionaltothesizeoftheprojectileasitpassesthrough.

Temporarycavity:Transientlateraldisplacementoftissue,whichoccursafterpassageoftheprojectile.Elastictissue(eg,skeletalmuscle,bloodvessels,andskin)maybepushedasideafterpassageoftheprojectile,butthenrebound.Inelastictissue(eg,boneorliver)mayfractureinthisarea.

Theshock(orsonic)wave(commonlymistakenforthetemporarycavity),thoughmeasurable,hasnotbeenshowntocausedamageintissue.

Table1-3.CommonMisconceptionsAboutProjectile

WoundsMisconception Reality

Velocityisthemostimportantdeterminantoftissuedamage.

Velocityisonefactorinwounding.Anincreaseinvelocitydoesnotincrease,perse,theamountoftissuedamage.Theamountoftissuedamageinthefirst12cmofaM-16A1bulletwoundprofilehasrelativelylittlesoft-tissuedisruption,similartothatofa.22longriflebullet,whichhaslessthanhalfthevelocity.

Projectilesyawinflight,whichcancreateirregularwounds.

Unlessaprojectilehitsanintermediatetarget,theamountofyawinflightisinsignificant.

Exitwoundsarealwaysgreaterthanentrancewounds.

Thisisuntrueandhasnobearingonsurgicalcare.

Fullmetal-jacketedbulletsdonotfragment,exceptinunusualcircumstances.

TheM-193bulletoftheM-16A1riflereliablyfragmentsatthelevelofthecannulureaftertraversingabout12cmoftissueinsoft-tissueonly.

Allprojectiletractsmustbefullyexcisedduetotheeffectsofthetemporarycavity.

Woundsshouldbewashedoutwithnecessarydebridementofforeignbodyandnecrotictissueonly.Woundsoftenrequiresubsequentexplorationanddebridementduetocontinueddevitalizationoftissue.

Explosiveinjuries(Table1-4).Explosiveagentsarematerialsthatundergorapidexothermicreactionwhen detonated. The degree to which this reaction occurs isdependentonthecharacteristicsoftheexplosiveagent.

Low-orderexplosivesreactbyrapidburningorconflagration.

High-orderexplosivesproduceextremeheat,energy,andapressurewaveknownasthe“blastwave.”Theblastwaveisreflectedandsustainedbyfixedstructuresandconfinedenvironments(eg,rooms,vehicles,etc)andmaypotentiatetheeffectsofblast-relatedinjury.Bythesamemechanism,water—anoncompressiblemedium—transfersmoreblastenergy,resultingingreaterinjuries.

Blastinjuriesaredividedintofourcategories:

Primaryblastinjuriesarecausedbytheblastwave.Themechanismofinjuryistheimpartationofblastenergytothebody,particularlyinair-filledorgans.Survivalandinjuryfromprimary

blastarecontingentonanumberoffactors,includingenergyoftheblast,confinedversusopenspace,anddistancefromtheexplosivesource.Casualtieswhosurvivemayhavetympanicmembranerupture,pulmonarybarotrauma,andbowelcontusionandperforation.Primarybraininjurymayalsooccur.

Secondaryblastinjuriesarecausedbyfragmentsfromthecasingandcontentsoftheexplosivedeviceandsecondarydebris(eg,dirt,rocks,bodyparts,etc).

Tertiaryblastinjuriesarecausedbyphysicaldisplacementofthevictim,resultinginbluntforcetrauma(eg,fractures,braininjury,solidorganinjuries,etc).

Quaternaryblastinjuriesarecausedbythermal,chemical,and/orradiationeffects(eg,burns,inhalationinjuries,etc).

Care of explosive-related injury is based on the same principles asstandard trauma management paradigms. The basic differencebetweenexplosive-relatedinjuryandotherinjurymechanismsisthatcasualtiescanhavealloftheabovemechanisms.

Ballistic.Fragmentsfromexplosivemunitionscauseballisticinjuries.Fragments are most commonly produced by mortars, artillery,grenades,andimprovisedexplosivedevices(IEDs).Fragments produced by these weapons vary in size, shape,composition, and initial velocity. They may vary from a fewmilligramstokilograms.Fragments fromexplodingmunitionshavegreatervariability in sizeandshapewhencomparedwithbulletsfromsmallarms.Althoughinitialfragmentvelocitiesof5,900ft/s(1,800m/s)havebeenreportedforsomeofthesedevices,thewoundsobservedinsurvivorsindicate that striking velocities were less than 1,900 ft/s (600 m/s).Unlikesmallarms,explosivemunitionscausemultiplewounds.

Fig.1-3.Theprobabilityofsustainingagiventraumaisrelatedtothedistancefromtheepicenterofthedetonation.

Blast.Theblastwaveeffectsrapidlydissipateasdistancefromtheepicenterincreases(Fig.1-3).

Table1-4.ClassificationofExplosiveInjuryCategory Characteristics BodyPart TypesofInjuries

Primary Uniquetohigh-orderexplosives;resultsfromtheimpactoftheblastwave

Gas-filledstructuresmostsusceptible:lungs,GItract,middleear

Blastlung(pulmonarybarotrauma)(uncommon)

Tympanicmembraneruptureandmiddle-eardamage(common)

Abdominalhollowviscusperforationandhemorrhage(rare)

Globe(eye)rupture(rare)

Secondary Resultsfromflyingdebrisandweaponcasingandcontentfragments Anybodypart

Penetratingfragmentsorbluntinjuries

Eyepenetration(canbeoccult)

Tertiary Resultswhenbodiesarethrownbyblastwind Anybodypart

Fractureandtraumaticamputation

Closedandopenbraininjury

Quaternary

Allexplosion-relatedinjuries,illnesses,ordiseasesnotduetoprimary,secondary,ortertiarymechanisms;includesexacerbationorcomplicationsofexistingconditions

Anybodypart

Burns(flash,partialthickness,andfullthickness)

Crushinjuries(buildingcollapse)

Asthma,COPD,orotherbreathingproblemsfromdust,smoke,ortoxicfumes

Angina

Hyperglycemia,hypertension

COPD:chronicobstructivepulmonarydisease;GI:gastrointestinal.

The ears aremost often affected by the blastwave, followed by thelungs and the gastrointestinal (GI) tract hollow organs. GI injuriesmaypresent24hourslater.Injury from blast is a pressure and time-dependent function. Byincreasingthepressureoritsduration,theseverityofinjurywillalsoincrease.

Thermobaric.Thermobaricdevices (eg, fuel-air explosions)workby increasing theduration of a blast wave. The device initially explodes and puts avolatile substance into the air (fuel vapor).A second explosion thenignites the aerosolized material producing an explosion of longduration.Theeffectsfromthisweaponaremagnifiedwhendetonatedinanenclosedspace.Airdisplacedafter the explosion creates ablastwind that can causetertiaryblastinjuries.

Thermal.Thermaleffectsoccuras theproductofcombustionwhen thedeviceexplodes.Patients wounded near exploding munitions may have burns inadditiontoopenwounds,whichmaycomplicatethemanagementofsoft-tissueinjuries.

Antipersonnellandmines.There are three types of conventional antipersonnel landminescommonthroughouttheworld:static,bounding,andhorizontalspray.

Staticlandminesaresmall,plantedlandmines(100–200gofexplosive)thataredetonatedwhensteppedon,resultingintwomajorareasofinjury(Fig.1-4).

Partialorcompletetraumaticamputation,mostcommonlyatthemidfootordistaltibia.

Debrisandothertissuearedrivenupalongfascialplaneswithtissuestrippedfromthebone.

Factorsinfluencingthedegreeofinjuryincludesizeandshapeoftheexplosive,pointofcontactwiththefoot,amountofdebrisoverlyingthemine,andthetypeoffootwear.

Boundingminespropelasmallexplosivedevicetoabout1–2metersofheightandthenexplode,causingmultiplesmallfragmentwoundstothosestandingnearby.Theselandminecasualtieshavethehighestreportedmortality.

Fig.1-4.Mechanismsofinjuriescausedbyantipersonnellandmines.

Horizontalsprayminespropelfragmentsinonedirection.Thislandminecanbecommand-detonatedordetonatedbytripwire.Asanexample,theUSClaymoreminefiresabout700steelspheresof¾grameachovera60°arc.Horizontalsprayminesproducemultiplesmall-fragmentwoundstothosenearby.

The IED is an unconventional weapon. Typically, another piece ofordnanceisused,suchasagrenadeoramortarshell,orthedeviceiscompletelyfabricatedoutoflocallyavailablematerials.

Smallarms.Pistols,rifles,andmachineguns.

TrendsforsmallarmssinceWorldWarIIincluderiflesthathaveincreasedmagazinecapacity,lighterbullets,andincreasedmuzzlevelocity.

Onthefollowingpagesaresomeexamplesofthecharacteristicsofcommonlyencounteredfirearms.Theillustrationsshowthepathofmissilesfiredfrom5to10metersintoordnancegelatinblocks.Variationsofrange,intermediatetargets(eg,bodyarmor),andbodytissuewillalterthewoundsseen.

TheAK-47rifleisoneofthemostcommonweaponsseenthroughouttheworld.Forthisparticularbullet(fullmetaljacketedorball),thereisa25-cmpathofrelativelyminimaltissuedisruptionbeforetheprojectilebeginstoyaw.Thisexplainswhyrelativelyminimaltissuedisruptionmaybeseenwithsomewounds(Fig.1-5).

Fig.1-5.IdealizedpathoftissuedisruptioncausedbyanAK-47projectile(10%gelatinasasimulation).FMC:fullmetalcase;Vel:velocity;Wt:weight.

TheAK-74riflewasanattempttocreateasmallercaliberassaultrifle.Thestandardbulletdoesnotdeforminthetissuesimulant,butdoesyawrelativelyearly(atabout7cmofpenetration).

Fig.1-6.IdealizedpathoftissuedisruptioncausedbyanM-193bulletfiredfromtheM-16A1rifle(10%gelatinasasimulation).Cal:caliber;FMC:fullmetalcase;Vel:velocity;Wt:weight.

TheM-16A1riflefiresa55-grainfullmetal-jacketedbullet(M-193)atapproximately950m/s.Theaveragepointforwarddistanceintissueisabout12cm,afterwhichityawstoabout90°,flattens,andthenbreaksatthecannalure(agrooveplacedaroundthemidsectionofthebullet).TheslightlyheavierM-855bulletusedwiththeM-16A2rifleshowsasimilarpatterntotheM-193bullet(Fig.1-6).

The7.62-mmNATO(NorthAtlanticTreatyOrganization)riflecartridgeisstillusedinsniperriflesandmachineguns.Afterabout16cmofpenetration,thisbulletyawsthrough90°andthentravelsbaseforward.Alargetemporarycavityisformedandoccursatthepointofmaximumyaw(Fig.1-7).

Fig.1-7.Idealizedpathoftissuedisruptioncausedbythe7.62-mmprojectile(10%gelatinasasimulation).FMC:fullmetalcase;NATO:NorthAtlanticTreatyOrganization;Vel:velocity;Wt:weight.

Armoredvehiclecrewcasualties.Sincethefirstlarge-scaleuseoftanksduringWorldWarI,injuriestothoseassociatedwitharmoredvehicles inbattlehavebeenadistinctsubsetofcombatcasualties.Examplesincludetanks,infantryfightingvehicles,armoredpersonnelcarriers,armoredsupportvehicles,and“light-armoredvehicles.”There are three main types of antiarmor weapons: shaped charge,kineticenergyround,andantitanklandmines.

Shapedcharge.

SeeFig.1-8a.

Theshapedchargeorhighexplosiveantitank(HEAT)roundconsistsofexplosivespackedaroundareverseconeofmetalcalledameltsheetoraliner.Thisistheprinciplebehindthewarheadoftherocket-propelledgrenade(RPG).

Shapedchargesrangeindiameterfromthe85mmRPG-7tothe6-inchdiametertube-launched,opticallytracked,wire-guided(TOW)missile.

Injuryeffectofshapedchargemunitions:

First,thereisthejetoftheshapedchargeitself.Thismaycausecatastrophicwoundstocasualtieswhoarehit,oritmayignitefuel,ammunition,orhydraulicfluid.

Second,thereisadebrisinjuryfactorcalledspall,whichismaterialknockedofffromtheinsidefaceofthearmoredplate.Thisproducesasprayofsmall,irregularlyshapedfragmentsinsidethecompartment(Fig.1-8b).

Fig.1-8.(a)Disruptivemechanismsoftheshapedchargewarhead.(b)Diagramtakenfromphotographofanactualdetonationofashapedchargewarheadagainstanarmorplatecausedbyantitanklandmines.

Kineticenergyround.

Thekineticenergyroundcontainsanaerodynamicpieceofhardmetal(eg,depleteduraniumortungsten)shapedlikeadart.Themetalisusuallyencasedinacarrierorsabotthatfallsawayfromtheprojectileafteritleavesthebarrel.Fragmentsofdepleteduraniumshouldbetreatedduringinitialwoundsurgeryasanyretainedmetalforeignbody.Thereisapotentialrisk,overtheyears,thatcasualtieswithretaineddepleteduraniumfragmentsmaydevelopheavymetalpoisoning.Thisconcernbyitselfdoesnotjustifyextensiveoperationstoremovesuchfragmentsduringinitialwounddebridement.

Injuriestothoseinsideavehiclearedue,inpart,tothedirecteffectsofthepenetratororfromfragmentsknockedofftheinsidefaceofthearmoredplate.Therangeoffragmentmassesmaybefromafewmilligramstooverakilogram.

Antitanklandmines.

Blastminesarethosewithalargeexplosivefillerof4–5kg.Injuriesareoftenfromblunttraumaduetocrewmembersbeingthrownaroundinsidethevehicleafteritdetonatesthemine.

Closed-headinjuriesandfracturesoftheextremitiesandspinearecommon.

Mechanismsofinjury(Fig.1-9).

Multipleinjuriestakeplaceastheresultofdefeatedarmor(asdescribedpreviously).

Thermal:Burnsoccurbecauseofignitedfuel,ammunition,hydraulicfluid,orasthedirectresultoftheantiarmordevice.

Twolargestudies,onefromBritishWorldWarIItankcrewmenandonefromIsraelicasualtiesinLebanon,showedthataboutone-thirdofliving,woundedcasualtieshaveburns.

Theseverityofburnsrangefromsuperficialtofullthickness.Mostburnsaresuperficialtoexposedskin,mostoftenoftheface,neck,forearms,andhands.Theseareoftencombinedwithmultiplefragmentwounds.

Blastoverpressurecanoccurfromthemunitionbreechingavehicle’sarmorandthenanexplosionoccurringinsideaconfinedspace.Duringexplosionsoutsideofavehicle,theblastwavehasbeenshowntobedissipatedbythearmor.

Toxicfumessecondarytophosgene-likecombustionbyproductscauseachemicalinhalationinjury(Teflon-coatedantispalllinersofarmoredvehicles).

Fig.1-9.Injuriessustainedasaresultofdefeatedarmor,(A)translationalblastinjury,(B)toxicgases,(C)blastoverpressure,and(D)penetratingmissilewounds.

TreatmentissupportiveandmayrequireIVsteroids(1,000mgmethylprednisolone,singledose).

Surgicaltriageconsiderations:Emergentifpulmonaryedema,expectantifhypotensiveandcyanotic.Reevaluatenonemergentpatientsevery2hours.

Inhalationinjury.Injuryexacerbatedbyretainedsootandchemicals.REMEMBER: Inhalation injury is primarily a chemical injury thatwillbenefitfromremovingthechemical.Supportivetreatment.

Unexplodedordnance.Unexplodedordnances(UXOs)areembeddedinthecasualtywithoutexploding.Rockets,grenades,mortarrounds.SomeUXOsmusttravelaspecificdistance(50–70meters)ornumberofrotationsinordertoarm.Fuses are triggered by different stimuli (impact, electromagnetic,laser).Notifyexplosiveordnancedisposalteamimmediately!Thirty-one of 31 victims and treating teams survived removal

(historicalreviewofUScasualties).The casualty should be triaged as nonemergent, placed far fromothers,andoperatedonlast.Preplanforhowtohandlebothtransportandoperation.Transport.

Ifbyhelicopter,groundthecasualtytotheaircraft(thereisalargeelectrostaticchargefromrotors).

Moveintoasafearea.

Revetment,parkinglot,orbackofbuilding.

Operateinasafearea,notinthemainORarea.Operativemanagement.

Precautionsforsurgeonandstaff.

Sandbagoperativearea,useflakvestsandeyeprotection.

Avoidtriggeringstimuli.

Electromagnetic(avoiduseofdefibrillator,monitors,Boviecauterizer,bloodwarmers,orultrasoundorCTmachines).

Plainradiographyissafe.Ithelpsidentifythetypeofmunition.

Anesthesia.

Regional/spinal/localpreferred.

KeepoxygenoutoftheOR.

Haveanesthesiologistleaveafterinduction.

Operation:Thesurgeonshouldbealonewiththepatient.

Employgentletechnique.

Avoidexcessivemanipulation.

Consideramputationifothermethodsfail.

Removeenblocifpossible.

The decision to remove a chemical/biological UXO is a command decision.Immediately after removal, hand the munition to explosive ordnance disposal(EOD)personnelfordisposal.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter2

RolesofMedicalCare(UnitedStates)

Introduction

Militarydoctrinesupportsanintegratedhealthservicessupportsystemtotriage,treat,evacuate,andreturnthecasualtytodutyinthemosttime-efficientmanner.The system begins with the casualty on the battlefield and ends in hospitalslocatedwithinthecontinentalUnitedStates(CONUS)andothersafehavens.Carebegins with first responder (self-aid/buddy aid and combat lifesaver), rapidlyprogressesthroughtacticalcombatcasualtycare(TCCC;careunderfire, tacticalfield care, and tactical evacuation care) and advanced trauma management tostabilizing surgery, followed by critical care transport to a higher taxonomy ofcarewheremoresophisticatedtreatmentcanberendered.

A basic characteristic of organizing modern health services support is thedistributionofmedicalresourcesandcapabilitiestofacilitiesatvariouslevelsofcommand,diverselocations,andprogressivecapabilities.Thisisreferredtoasthefourrolesofcare(Roles1–4).Asageneralrule,norolewillbebypassedexcepton grounds ofmedical urgency, efficiency, or expediency. The rationale for thisrule is to ensure the stabilization and survivability of the patient throughadvanced trauma management and far-forward resuscitative surgery prior tomovementbetweenmedicaltreatmentfacilities.Differentrolesdenotedifferencesincapabilityofcare.Eachhigherrolehasthecapabilityoftheroleforwardof itandinadditionexpandsonthatcapability.

Role1Role1ispointofinjurycare.

First responder care: first-aid and immediate lifesaving measuresprovided by self-aid, buddy aid, or a combat lifesaver (nonmedicalteam/squadmembertrainedinenhancedfirst-aid).CarebythecombatmedicorcorpsmantrainedinTCCC.Additionalbattlefield providers, with various levels of training, include theSpecial Forces medical sergeant, special operations combat medic,SEAL (SEa, Air, Land) independent duty corpsman, special boatcorpsman,pararescueman,andspecialoperationsmedicaltechnician.

Role1care—Army.Battalionaidstation.

Includestriage,treatment,andevacuation.

Careisprovidedbythephysician,physicianassistant,and/ormedic.

Goalsaretoreturntodutyortostabilizeandevacuatetothenexthigherrolemedicaltreatmentfacility.

Nosurgicalorpatientholdingcapability.

Role1care—USMarineCorps.Battalionaidstation.

Includestriage,treatment,andevacuation.

Careisprovidedbythephysician,physicianassistant,and/orcorpsman.

Goalsaretoreturntodutyortostabilizeandevacuatetothehighertaxonomyofcare.

Nosurgicalorpatientholdingcapability.

Shocktraumaplatoon.

SmallemergencymedicalunitthatsupportstheMarineExpeditionaryForce.

Includesstabilizationandevacuationsections.

Staffconsistsoftwoemergencymedicinephysiciansandsupportingstaff(totalstaffof25personnel).

Nosurgicalcapability.

Patientholdingtimelimitedto48hours.

Role2Includes basic primary care. May also include optometry; combat andoperational stress control and behavioral health; and dental, laboratory,radiographic,andsurgicalcapabilities(whenaugmented).Has increased medical capability over Role 1, but limited inpatient bedspace.100%mobile.Eachservicehasslightlydifferentunitsatthisrole.Role2care—Army.

Role2Armymedicalassetsarelocatedinthe:

Medicalcompany–brigadesupportbattalion,assignedtomodularbrigades,whichincludetheheavybrigadecombatteam,infantrybrigadecombatteam,Strykerbrigadecombatteam,andthemedicaltroopinthearmoredcavalryregiment.

Medicalcompany–areasupport,whichprovidesdirectsupporttothemodulardivisionandsupporttoechelonsabovebrigadeunits.

Role 2 medical treatment facilities are located in the treatmentplatoonsofmedicalcompanies/troops.Includesbasic/emergencytreatment(advancedtraumamanagement).Hascapabilitytodeliverpackedredbloodcells(liquid).Limited X-ray, clinical laboratory, dental support, combat andoperationalstresscontrol,andpreventivemedicine.Those patientswho can return to dutywithin 72 hours are held fortreatment.The Forward Surgical Team (FST) is assigned to the medicalcommandormedicalbrigadeandisattachedtotheCombatSupportHospital when not operationally employed forward with a medicalcompany.TheFSTprovidesarapidlydeployable immediatesurgicalcapability, enabling patients to withstand further evacuation. Itprovides surgical support in the brigade combat team. The teamprovidesdamage control surgery for those critically injuredpatientswho cannot be transported over great distances without surgicalinterventionandstabilization.

Provideslifesavingresuscitativesurgery,includinggeneral,orthopaedic,andlimitedneurosurgicalprocedures.

Consistsofa20-personteamwith1orthopaedicsurgeon,3generalsurgeons,2nurseanesthetists,andcriticalcarenursesandtechnicians.

Transportablebyground,fixedwing,orhelicopter;someFSTsareairbornedeployable.Operationalwithin1hourofarrivalatthesupportedcompany.

Canprovidecontinuousoperationsforupto72hours.

Hasa~1,000sqftsurgicalarea.

Includes2operatingtablesforamaximumof10casesperdayandatotalof30operationswithin72hours.

Canprovidepostoperativeintensivecareforuptoeightpatientsforupto6hours.

Thesupportingmedicalcompanymustprovidelogisticalsupportandsecurity.

X-ray,laboratory,andpatientadministrativesupportareprovidedbythesupportingmedicalcompany.

Requiresadditionalelectricity,water,andfuelfromthesupportingmedicalcompany.

TheFSTisnotdesigned,staffed,orequippedforstand-aloneoperationsorforconductingsick-calloperations.AugmentationrequirementsarediscussedinFM4-02.25,EmploymentofForward

SurgicalTeams:Tactics,Techniques,andProcedures.FSTshavebeensplittocreatetwoteamsduringOperationIraqiFreedom/OperationEnduringFreedom.

NOTE:TheRole2definitionusedbyNATO(NorthAtlanticTreatyOrganization)forces(AlliedJointPublication-4.10(A))includestermsanddescriptionsnotusedbyUSArmyforces.USArmyforcessubscribetothebasicdefinitionofaRole2medicaltreatmentfacilityprovidinggreaterresuscitativecapabilitythanisavailableatRole1.SurgicalcapabilityisnotmandatoryatRole2accordingtoUSArmydoctrine.TheNATOdescriptionofRole2care,however,includesdamagecontrolsurgery.

Role2care—AirForce.MobileFieldSurgicalTeam(MFST).

Consistsofafive-personteam(generalsurgeon,orthopaedist,anesthetist,emergencymedicinephysician,andanORnurseortechnician).

Canprovide10lifesavingorlimb-savingproceduresin24–48hoursfromfivebackpacks(350-lbtotalgear).

Designedtoaugmentanaidstationorflightlineclinic;noholdingcapacity.

Cannotstandalone;requireswater,shelterofopportunity,communications,etc.

IntegraltoremainderofAirForceTheaterHospitalSystem.

Small Portable Expeditionary Aeromedical Rapid Response(SPEARR)team.

Consistsofa10-personteam:5-personMFST,3-personCriticalCareAirTransportationTeam(CCATT;seeChapter4,AeromedicalEvacuation),anda2-personpreventivemedicineteam(flightsurgeonandpublichealthofficer).

Includesa600sqfttent;stand-alonecapablefor7days.

Canprovide10lifesavingorlimb-savingproceduresin24–48hours.

Designedtoprovidesurgicalsupport,basicprimarycare,postoperativecriticalcare,andpreventivemedicinefortheearlyphaseofdeployment.

Highlymobile,withallequipmentfittinginaonepallet-sizedtrailer.

ExpeditionaryMedicalSupport(EMEDS)Basic.

Providesmedicalandsurgicalsupportforanairbase,providing24-hoursick-callcapability,resuscitativesurgery,dentalcare,andlimitedlaboratoryandX-raycapability.

The25-memberstaffincludesaSPEARRteam.

Canprovide10lifesavingorlimb-savingproceduresin24–48hours.

Has4holdingbeds,2ORtables,and3climate-controlledtentstransportableonthreepallets.

Totalsizeis~2,000sqft.

EMEDS+10.

Adds6bedstoEMEDSbasic,fortotalof10beds.

Noadditionalsurgicalcapability.

Hasa56-personstaff.

Consistsof6tentstransportedon14pallets.

Role2care—Navy.CasualtyReceivingandTreatmentShip(CRTS).CRTSsarepartofanAmphibiousReadyGroup (ARG) and are usually comprised of oneMarine amphibious assault ship (Tarawa class) or landinghelicopterdeck Wasp-class ship, whose primary mission is the transport anddeploymentofMarinesandwhosesecondarymissionistofunctionasa casualty-receiving platform. An ARG typically comprises threeships,withsurgicalcapabilityonlyontheCRTS.

Shipshave45wardbeds,4ORs(withaugmentedstaff;seebelow),and17ICUbeds.

A176-personFleetSurgicalTeamconsistsof1surgeon,1certifiedregisterednurseanesthetist,1criticalcarenurse,1ORnurse,1generalmedicalofficer,and12supportstaff.

ACRTSandtheFleetSurgicalTeamcanbeaugmentedwith84additionalpersonneltoincreasecapabilityfromoneORtofour,aswellasprovidethefollowingspecialties:2orthopaedicsurgeonsand1oralandmaxillofacialsurgeon.

Shipshavelaboratory,X-ray,andfrozenbloodcapabilities.

Designedforreceiptandflowofcasualtiesfromhelicopterflightdeckandlandingcraftwelldeck.

Havetriageareasfor50casualties.

Doctrinalholdingcapabilityislimitedto3days.

Aircraftcarrierbattlegroup.

Includes1OR,52wardbeds,and3intensivecarebeds.

Staffincludes1surgeonand5additionalmedicalofficers.

Medicalassetsaboardaircraftcarriersareintendedforusebytheaircraftcarrieranditstaskforce.Aircraftcarriersarenotcasualty-receivingshipsandarenotincludedinmedicalassetsforsupporttogroundforces.

Role2care—USMarineCorps.Surgicalcompany.

ProvidessurgicalcarefortheMarineExpeditionaryForce.Basisofallocationisoneperinfantryregiment.

Providesstabilizingsurgicalprocedures(damagecontrolsurgery).

Doctrinallyconsistsof4forwardresuscitativesurgicalsystems,4shocktraumaplatoons,and4enroutecareteams.

Has20-bedcapability.

PortabledigitalX-rayandminimallaboratoryandbloodbankingcapabilities.

Patientholdingcapabilityupto72hours.

ForwardResuscitativeSurgicalSystem.

Basicsurgicalcapabilitymodule.

Rapidassembly,highlymobile.

Canprovideresuscitativesurgeryfor18patientswithin48hourswithoutresupply.

The8-personteamincludes2surgeons,1anesthesiologist,1criticalcarenurse,2ORtechnicians,and2corpsmen.

Holdingcapabilityof4hours.

Nointrinsicevacuationcapability.

Notastand-aloneorganization.

Enroutecareteam.

Two-personteamconsistingofacriticalcareregisterednurseandacorpsman.

Providestransportoftwocriticallyinjuredorill,butstabilized,postoperativecasualties.

Hasownequipmentpackage.

Capableoftransportingtwopatients,oneventilated.

Dependentonopportunelift.

Role3AtRole3, thepatient is treated inamedical treatment facility staffedandequipped to provide care to all categories of patients, includingresuscitation, initial wound surgery, damage control surgery, andpostoperativetreatment.ThisroleofcareexpandsthesupportprovidedatRole2.Patientswhoareunabletotolerateandsurvivemovementoverlongdistancesreceivesurgicalcareinahospitalasclosetothesupportedunitasthetacticalsituationallows.Thisroleincludesprovisionsfor:

Evacuatingpatientsfromsupportedunits.Providing care for all categories of patients in a medical treatmentfacilitywiththeproperstaffandequipment.Providingsupportonanareabasis tounitswithoutorganicmedicalassets.

Role3care—Army.Combat Support Hospital (248-bed). Provides hospitalization andoutpatientservicesforallcategoriesofpatientswithintheater.

Canprovidehospitalizationforupto248patients.Thehospitalincludesaheadquartersandheadquartersdetachment,andtwocompletelyfunctionalhospitalcompanies:one84-bedandone164-bed.Collectively,thehospitalhasfourwardsprovidingintensivenursingcareforupto48patientsand10wardsprovidingintermediatenursingcareforupto200patients.

Providesemergencytreatmenttoreceive,triage,andprepareincomingpatientsforsurgery.

Hassurgicalcapability—includinggeneral,orthopaedic,thoracic,urological,gynecological,andoralandmaxillofacial—basedonsixORtablesstaffedfor96operatingtablehoursperday.

Consultationservicesforinpatientsandoutpatientsincludeareasupportforunitswithoutorganicmedicalservices.

Alsoprovidespharmacy,psychiatry,publichealthnursing,physicaltherapy,clinicallaboratory,bloodbanking,radiologyandnutritioncareservices.

Theearly-entryhospitalizationelement(44-bed)providesupto72hoursstand-aloneoperations,withoutresupply.Canprovidehospitalizationforupto44patients,withtwowardsprovidingintensivecarenursingforupto24patientstotalandonewardprovidingintermediatecarenursingforupto20patients.Thehospitalizationaugmentationelement(40-bed)augmentstheearly-entryhospitalizationelement.Providesoutpatientspecialtyclinicservicesandintermediatecarehospitalbeds.Thetwoelementstogethercomprisean84-bedcompany.

Thehospitalcompany(164-bed)consistsoftwowardsthatprovideintensivecarenursingforupto24patientstotalandsevenwardsthattogetherprovideintermediatecarenursingforupto140patients.

Augmentation teams. The Combat Support Hospital may beaugmented by one or more medical detachments, hospitalaugmentationteams,ormedicalteams.Thesemayinclude:

Medicaldetachments–minimalcarecapableofprovidingminimal/convalescentcare,nursing,andrehabilitativeservicesinsupportofRole3hospitals.

FSTsavailabletoaugmentthesurgicalservicesoftheCombatSupportHospitalwithgeneralsurgeryandorthopaedicsurgerycapabilitieswhennotdeployedforwardwithmedicalcompaniestoprovideforwardresuscitativesurgicalcareanddamagecontrolsurgery.

Hospitalaugmentationteam–headandneckprovidesspecialsurgicalcareforear-nose-throatsurgery,neurosurgery,andeyesurgerytosupporttheCombatSupportHospitalplusspecialtyconsultativeservices.Thehospitalteam(headandneck)istheonlyorganizationauthorizedaCTscanner.

Hospitalaugmentationteam–specialcareprovidespathologysupporttotheCombatSupportHospitalclinicallaboratoryandspecialtyconsultativeservices.

Hospitalaugmentationteam–pathologyprovidespathologysupporttotheCombatSupportHospitalclinicallaboratoryandspecialtyconsultativeservices.

Medicalteam–renalhemodialysisprovidesrenalhemodialysiscareforpatientswithacuterenalfailureandconsultativeservices.

Medicalteam–infectiousdiseaseprovidesinfectiousdiseaseinvestigation,takesmeasurestocontrolthespreadofdisease,ensuresaccesstohealthservices,andprovidesconsultativeservices.Thisteammayincludeorpartnerwithspecialcareteamswithapreventivemedicine/publichealthnursewhenpublichealthmeasuresarerequired.

NOTE:Basedontheexperiencesofadecadeoftheateroperations,adraftArmyforcedesignupdate,ifapproved,willdramaticallychangethestructureoftheCombatSupportHospitalandaugmentationteamstoenhancefuturemedicalcapabilitiesintheaterandfurtherimprovemodularity.Itisalsoimportanttonotethatoperationalemploymentdoesnotalwaysmirrordoctrine.As

anexample,theonlyorganizationdoctrinallyauthorizedaCTscanneristhehospitalaugmentationteam(headandneck).However,uponoperationalemployment,aCombatSupportHospitalmayverywellbeprovidedwithaCTscannerevenifahospitalaugmentationteam(headandneck)isnotattached.

Role3care—AirForce.EMEDS+25.

25-bedversionofEMEDSbasic.

Has84personnel,2ORtables,9tents(600sqft),and20pallets.

Canprovide20operationsin48hours.

Additionalspecialtymodulescanbeadded,includingvascular/cardiothoracic,neurosurgery,obstetrics/gynecology,ear-nose-throat,andophthalmologyteams;eachcomeswithitsownpersonnelandequipmentmodules.

AirForcetheaterhospital.

Structuresandstaffingarecapabilities-basedandmodular.

RepresentsthelargestAirForcecriticalcareandsurgicallycapablemedicaltreatmentfacilityinthetheaterofoperations.

Canfunctionasatheateraeromedicalevacuationhub.

Role3care—Navy.Expeditionarymedicalfacility.

Standardconfigurationhas150beds,including40intensivecarebedsand4ORs.

Providesemergencytreatmenttoreceive,triage,andprepareincomingpatientsforsurgery.

Hassurgicalcapability,includinggeneral,orthopaedic,thoracic,urological,gynecological,andoralandmaxillofacial,basedonfourORtablesstaffedfor96operatingtablehoursperday.

Consultationservicesforinpatientsandoutpatientsincludeareasupportforunitswithoutorganicmedicalservices.

Alsoprovidespharmacy,psychiatry,publichealthnursing,physicaltherapy,clinicallaboratory,bloodbanking,radiology,andnutritioncareservices.

Stand-alone;fullancillaryservices.

Completebaseoperatingsupportavailable.

IncludesclassVIIIsupportuntiltheateris“mature”orapproximately60daysafteroperationscommence.

Largeholdingcapability.

NOTE:Basedontheexperiencesofadecadeofevolutionaryoperations,NavyExpeditionaryHealthServiceSupportisconsideringadramaticchangetothestructureofexpeditionarymedicalfacilities.Determinationswillbemaderegardingscalability,modularity,mobility,anddeployablecapabilitytoimproveandenhanceNavyMedicine’sflexibilityinprovidingmedicalsupportacrossthefullrangeofmilitaryoperations.

Hospitalships(currentlytheUSNSMercyandUSNSComfort).

Eachshiphas999bedsconsistingof88intensivecarebeds(68generalintensivecarebedsand20postsurgicalrecoverybeds).All88bedsareequippedwithpipedinoxygenandsuction,andcardiacmonitoringcapability.Onewardisconfiguredwith11respiratoryisolationbeds.

Inpatientwardcapabilityincludes400intermediatecareand500minimalcare/convalescencebeds.The500minimalcarebedsareupperbunks,unsuitableforinjurypatternsrelatedtofractures.Mostupperbunksaretypicallyusedbyescortsandpatientsreadytoreturntofullduty.

Eachshiphassupportservicesforupto12ORs.

Eachshiphas1,216medicalstaff(273officersand943enlisted).

ExtensivelaboratoryandX-raycapabilities,includingCTscan.

Largebloodbankwithfrozenbloodcapability.

Patientsarealloweda5-dayaveragestayinaccordancewithabaseline7-dayevacuationpolicy.

Role4Role 4 medical care is found in CONUS-based hospitals and other safehavens.Mobilizationrequiresexpansionofmilitaryhospitalcapacitiesandthe inclusion of the Department of Veterans Affairs and civilian hospitalbeds in the National Disaster Medical System to meet the increaseddemandscreatedbytheevacuationofpatientsfromtheareaofoperations.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter3

MassCasualtyandTriage

Introduction

Mass casualtieshave thepotential to rapidlyoverwhelmmultiple levels of careand evacuation. Because the Joint Theater Trauma System (JTTS) has beenadaptedtoproviderapidmovementofcasualtiesthroughthecontinuumofcare,mass casualty eventsmay occur atmilitary treatment facilitieswith little or noadvance notice. Asymmetricwarfaremay further complicate themass casualtyeventbyinclusionofcombatant,noncombatant,orthirdcountrynationalsamongthe injured. The mass casualty demands a rapid transition from routine tocontingency medical operations triggered by the earliest recognition of thisspecter within the fog of war. The transition will be eased by amass casualtyresponseplan thatmustbedesigned, exercised,andassessed to reflect relevantsiteandevacuationcapability.

A mass casualty event overwhelms immediately available medicalcapabilitiestoincludepersonnel,supplies,and/orequipment.

Effectivemasscasualtyresponseisfoundedontheprincipleoftriage,thesystemofsortingandprioritizingcasualtiesbasedonthetacticalsituation,mission,andavailable resources. It is the best means to establish order in a chaoticenvironment and the best hope to provide the greatest good to the greatestnumber within the limitations of time, distance, and capability. Triage is aconstantanddynamicprocessascasualtiesmovewithinandthroughthesystemofcare.

Theultimategoalsofcombatmedicinearethereturnofthegreatestpossiblenumber of warfighters to combat and the preservation of life, limb, andeyesight.

Thedecisiontowithholdcarefromacasualtywhoinanotherlessoverwhelmingsituation might be salvaged is difficult for any physician, nurse, or medic.Decisions of this nature are unusual, even in mass casualty situations.Nonetheless, theoverarchinggoalofprovidingthegreatestgoodtothegreatestnumbermustguidethesedifficultdecisions.Commitmentofresourcesshouldbedecidedfirstbasedon themissionand immediate tacticalsituationandthenbymedicalnecessity,irrespectiveofacasualty’snationalorcombatantstatus.

TriageCategories

Itisanticipatedthattriagewillbeperformedatalllevels.Traditionalcategoriesoftriageareimmediate,delayed,minimal,andexpectant.

Immediate: This group of injured requires attention within minutes to 2hoursonarrival toavoiddeathormajordisability.Theprocedures in thiscategory should focus on patients with a good chance of survival withimmediateintervention.Injuriesinclude:

Airwayobstructionorpotentialcompromise.Tensionpneumothorax.Uncontrolledhemorrhage.Torso,neck,orpelvisinjurieswithshock.Headinjuryrequiringemergentdecompression.Threatenedlossoflimb.Retrobulbarhematoma.Multipleextremityamputations.

Delayed:Thisgroup includes thosewoundedwhoare inneedof surgery,but whose general condition permits delay in treatment without undulyendangering life, limb, or eyesight. Sustaining treatmentwill be required(eg, fluid resuscitation, stabilization of fractures, and administration ofantibiotics, bladder catheterization, gastric decompression, and relief ofpain).Injuriesinclude:

Bluntorpenetratingtorsoinjurieswithoutsignsofshock.Fractures.Soft-tissueinjurieswithoutsignificantbleeding.Facialfractureswithoutairwaycompromise.Globeinjuries.Survivableburnswithoutimmediatethreattolife(airway,respiratory)orlimb.

Minimal: This group has relatively minor injuries (eg, minor lacerations,abrasions, fractures of small bones, andminor burns) and can effectivelycareforthemselvesorbewithminimalmedicalcare.Thesecasualtiesmayalso provide a resource for manpower to assist with movement orpotentiallyevencareoftheinjured.Whenamasscasualtyincidentoccursincloseproximitytoamedicaltreatmentfacility(MTF), it is likelythatthesewillbethefirstcasualtiestoarrive,bypassingorcircumventingthecasualtyevacuationchain.Suchcasualtiesmayinundatethefacilityleadingtoearlycommitment and ineffective utilization of resources. To prevent such anoccurrence,itisimperativetosecureandstrictlycontrolaccesstotheMTFimmediatelyuponnotificationofamasscasualtyevent.Expectant: This group has injuries that overwhelm current medicalresources at the expense of treating salvageable patients. The expectantcasualtyshouldnotbeabandoned,butshouldbeseparatedfromtheviewofothercasualtiesandintermittentlyreassessed.Thesecasualtiesrequireastaff capable of monitoring and providing comfort measures. Injuriesinclude:

Anycasualtyarrivingwithoutvitalsignsorsignsoflife,regardlessofmechanismofinjury.Transcranialgunshotwound(GSW)withcoma.OpenpelvicinjurieswithuncontrolledbleedingandclassIVshock.Burnswithoutreasonablechanceforsurvivalorrecovery.Highspinalcordinjuries.

TriageManagement

Those previously classified asminimal injuries that are evacuated to a surgicalunitshouldnotbebroughtthroughtheresuscitationarea.Thesecasualtiesshouldbedivertedtoanareanearthefacilitywheretheyarereassessed,receivecare—and,conditionpermitting—beavailable toassistwithmovementof theseverelyinjured. The remaining casualties should be divided into three categories:emergent, nonemergent, and expectant. These categories are useful in dividingcasualties into those requiring further immediate surgical treatment (emergent),andthosethatarelessinjured,stillrequirecareinthenearterm(6–12hours),buthave low expected mortality (nonemergent). It is anticipated that 10%–20% ofcasualties presenting to a surgical unit will require urgent surgery, but this isincidentdependent.Thevastmajorityofthewoundedwillnotrequireintensivedecision-making,intervention,andcare.

Triage is a fluid process at all levels, with altered situations and resourcesrequiring a change in category at any time and in any setting. In the extremeexample,a casualtymaybe triaged fromemergent toexpectantduringsurgery,abruptlyterminatingtheoperation(“on-the-tabletriage”).

SpecialTriageConsiderations

Patientswhodonoteasilyfit intothestandardcategoriesorwhoposearisktoothercasualties,medicalpersonnel,or the treatment facilitymayrequirespecialconsideration.

Wounded contaminated in a biological and/or a chemical battlefieldenvironment: These casualties must be decontaminated prior to enteringthe treatment facility. Prehospital care may be provided outside of themedical facility by appropriately protected medical personnel prior todecontamination.Retained, unexploded ordnance: These patients should be segregatedimmediately and treated last. See Chapter 1, Weapons Effects and WarWounds,whichdescribesthespecialhandlingofthesewounded.Noncombatant local or third country nationals: Due to the asymmetricnature of modern warfare, these individuals may be brought into themilitary traumasystem for careduringamass casualtyevent thatmayormay not includeUnited States or allied forces.Although themission andtactical situation must be considered first, in most situations medicalnecessitywillguidetriagedecisions.Itiscrucialtorecognizethecapabilitiesof local national healthcare resources and to factor these limitations

prospectivelyintocareandtriagedecisions.Suchdecisionsmustbebasedonthebestandmosttimelyinformationavailable.Enemyprisonersofwar/internees/detainees:Althoughtreatment isbasedonmedicalnecessity,itisessentialthatthethreatof“suicidebombers”and“humanboobytraps”bepreventedbycarefullyscreeninganddisarmingallcasualties prior tomoving into treatment areas, including the triage area.SeeChapter32,CareofEnemyPrisonersofWar/Internees.US, allied, and third nation contractors: Although these individualswillalsoreceivecarebasedonmission,tacticalsituation,andmedicalnecessity,it should be recognized that less stringent predeployment healthassessments or requirements may permit a population with significantchronichealthco-morbiditytoenteratheaterofwarasapopulationatrisk.The effect of co-morbidity on survivabilitymay need to be considered intriage decision-making. (EXAMPLE: A casualty on antiplatelet therapywithlife-threateninghemorrhagic injury inasettingwhereavailabilityofbloodcomponentsislimited.)Combat stress: Rapid identification and immediate segregation of stresscasualties frominjuredpatientswill improvetheoddsofarapidrecovery.With expeditious care, these casualties can be returned to duty (80%).Donotusethemaslitterbearersbecausethismayincreasethetraumayouseektotreat.

Placepatientinoneoftwogroups.

Lightstress:Immediatereturntodutyorreturntounitorunit’snoncombatsupportelementwithdutylimitationsandrest.

Heavystress:Sendtocombatstresscontrolrestorationcenterforupto3daysreconstitution.

UsetheBICEPSmnemonicwhereresources/tacticalsituationsallow:

Brief:Keepinterventionsto3daysorlessofrest,food,andreconditioning.

Immediate:Treatassoonassymptomsarerecognized—donotdelay.

Central:Keepinoneareaformutualsupportandidentityassoldiers.

Expectant:Reaffirmthatweexpectreturntodutyafterbriefrest;normalizethereactionandtheirdutytoreturntotheirunit.

Proximal:Keepthemascloseaspossibletotheirunit.Thisincludesphysicalproximityandusingthetiesofloyaltytofellowunitmembers.Dothisthroughanymeansavailable.Donotevacuateawayfromtheareaofoperationsortheunit,ifpossible.

Simple:Donotengageinpsychotherapy.Addressthepresentstressresponseandsituationonly,usingrest,limitedcatharsis,andbriefsupport(physicalandpsychological).

Orrefer:Mustbereferredtoafacilitythatisbetterequippedorstaffedforcare.

If battlefield casualtiesdonothavephysical injuries,DONOT send themoutofthebattlearea,becausethiswillworsenstressreactions.

ResourceConstraints

Triagedecisionsareinfluencedbymultiplefactors.Areastoconsiderinclude:

Externalfactors:Thesurgeon/medicmayhavelimitedknowledgeofandnocontroloverexternal issues.Nonetheless,optimalcasualtycarerequiresatleastanassessmentofthesefactors.

Tactical situation and the mission: The decision to commit scarceresources cannot be based on the current tactical/medical/logisticalsituationalone.Oneseverelywounded,resource-consumingcasualtymaydepleteavailablesuppliesandthuspreventfuture,lessseriouslyinjuredcasualtiesfromreceivingoptimalcare.Liaisonwiththetacticalforce operating in your area is essential to making sound triagedecisions. Operational security may make this kind of informationdifficult to obtain in a timely fashion. Education of, andcommunicationwith, line commanders about the criticalnatureofthisinformationisessential.Resupply: Having a sense of how and when expended internalresourceswillberesuppliedmayprovecriticaltomakingthedecisiontotreatornottreattheindividualcasualty.Time:

EvacuationtotheMTF:Theshorterthetimeanddistanceintervalfrominjurytoarrivalwillincreasethevolumeandcomplexityoftriagedecisionsandincreasetheriskofthefacilitytobeoverwhelmedbythewalkingwounded.Securingthefacilityandstrictlycontrollingpointsofentryarekeystepsintheexecutionofamasscasualtyresponse.Longerintervalswillresultintheopposite,with“autotriage”ofthesickerpatientsfromtheemergentcategorytotheexpectant.

Timespentwiththeindividualcasualty:Inamasscasualtysituation,timeitselfisaresourcethatmustbecarefullymanaged.Allpatientsreceiveanevaluation,butonlysomereceiveimmediateoroperativeinterventions.TimeontheORtableisusuallythechokepoint.Applytheconceptsofdamagecontroltominimizethetimecasualtiesarerequiredtospendinsurgery.On-tabletriagetotheexpectantcategorymaybenecessaryduetodeteriorating

casualtyphysiologicalresponseand/orthepatternofinjury(aorta-venacavaGSW,dualexsanguinationsites,extensivepancreatic-duodenalinjury,etc).

Evacuationout:Casualtiesmustmoveexpeditiouslytothenextlevelofcare,otherwisevaluablelocalresourceswillbeconsumedinmaintainingpatients,therebypreventingadditionalpatientsfromreceivingcare.

Internal factors: These issues are known to all medical personnel andshouldbefactoredintotriagedecisions.

Medicalsupplies:Thesesupplies includeequipment,drugs,oxygen,dressings, sutures, sterilization capability, blood, etc. Immediateliaison with the logistics system in the MTF and the theater ofoperationisessentialtoensuretheavailabilityandtimelyresupplyofthese items, to include “surge” capabilities and local resourceavailability.Bloodproductsmaybescarce inan immature theaterorduring accelerated consumption in the case of mass casualty.Hemostaticordamagecontrolresuscitationmaybeprecludedbytheavailability of hemostatic transfusion components (plasma, platelets,cryoprecipitate).Transfusionmedicineinthetheaterofwarhasinthepastandwilllikelycontinueinthefuturetorelyonthewalkingbloodbank. It is crucial that expeditionarymedicalunits have a system inplace for effective and expedient execution of a fresh whole blooddrive. Early consideration of a fresh whole blood drive should beincludedintheresponsetoamasscasualty.Space/capability:ThiscategoryincludesthenumberofORtablesandICU beds (holding capacity and ward capacity), the availablediagnostic equipment—ultrasound, X-ray, CT—and laboratory tests.Forexample,ifyourMTFhastheonlyCTscannerintheater,planforan increased number of head-injured patients. Early in the masscasualty response, an assessment should bemade to clear occupiedbeds in the hospital, either by discharge or potential transfer ofpatients to other appropriate treatment facilitieswithin theater. Thisshould be accomplished in coordination with the theater medicalregulatorandoccurassoonaspossiblefollowingnotification.Personnel: This includes knowing the professional capability (typeand experience of individual physician/nurse/medic), and theemotionalstability,sleepstatus,etc,ofyourpersonnel.Thisperishableresource must be preserved; for example, 24 hours of continuousoperation may exhaust your only OR crew and may necessitatediversion of casualties to another facility. A response plan shouldinclude means to sustain and refresh the staff with hydration andenergy-dense foodsduringextendedperiodsofhighactivity.Robustandpractical plans for personnel recallmust be a component of the

mass casualty response plan. Also recognize that medicalprofessionalsmaypossessarangeofskillsetsthat isnotreflectedintheir deployment specialty (eg, the Reserve Component physicianwhoisageneralsurgeonincivilianpractice,butwhoisassignedasageneralmedical officer or flight surgeon). Identifying and includingtheseindividualsasappropriateinamasscasualtyresponseisaforcemultiplier.Stress: Soldiers, including medical personnel, are affected by theconsequences of war; individual and unit capabilities are degradedduringsustainedoperations.Thepersonalimpactofmilitarytriageonthe medical team cannot be overemphasized. It is extremelyemotional, and measures should be undertaken to minimize theseeffects. This is best provided by trained staff. Cohesive groupsmaytolerate stress better and assist each other in dealingwith traumaticeventswhenallowedtoprocesstheeventinagroupformataccordingtotheirowntraditions.

TriageDecision-Making

The complexity of decision-making in triage varies greatly, often depending onthe level of training and experience of the triage officer, aswell as the locationwhere the triage decision is being made. In the emergent treatment area, thesurgeon (ie, surgeon of the day; SOD) must make decisions about whethersurgeryisneeded,thetimingofthesurgery,andthepriorityofmultiplesurgicalpatients. Regardless of the type of triage decision needed, the followinginformationisofcriticalimportanceinreachingthatdecision:

Initial vital signs: Pulse (rate and quality), mentation, and difficultybreathing(eg,acasualtywithnormalmentationandradialpulsequalityisnonemergent). Respiratory rate alone is not predictive of the appropriatetriagecategory.Patternofinjury:Ahistoricalperspectiveaidsthetriagedecision-makerinunderstanding the distribution of wounds encountered on the modernbattlefield and the likely mortality associated with those wounds. Themajority of combatwoundedwill suffer nonfatal extremity injuries. Ingeneral,thesewillbetriagedasnonemergent.Response to initial intervention: Does the shock state improve, remainunchanged,orworsenwithinitialresuscitativeefforts?Apatientwhofailsto respond rapidly to initial resuscitation should be triaged ahead of apatient with a good response; alternatively, this nonresponder in a masscasualtysituationmayneedtobeplacedintheexpectantcategory.

Data from more recent American combat operations in Iraq (Operation IraqiFreedom) and Afghanistan (Operation Enduring Freedom), 2003–2004—indicating the spectrum of injury type (Table 3-1), mechanism (Table 3-2), andanatomicallocation(Table3-3)—arefoundinthetables.

Table3-1.TypeofInjury*TypeofInjury Frequency Percent

Penetrating 645 35.7

Blast 425 23.5

Blunt 410 22.7

Unknown 84 4.6

Crush 63 3.5

Mechanical 49 2.7

Thermal 48 2.7

Undetermined 21 1.2

Other 16 0.9

Chemicalagent 10 0.6

Bites/stings 8 0.4

Degloving 8 0.4

Electrical 7 0.4

Heatinjury 7 0.4

Inhalation 3 0.2

Multiplepenetrationsystem 3 0.2

TOTAL 1,807 100

*Acasualtymayhavemorethanonetypeofinjury.Thesenumbersarebasedon1,530Role3injuries.Datasource:EmergencyWarSurgery,ThirdUnitedStatesRevision.Washington,DC:DepartmentoftheArmy,OfficeofTheSurgeonGeneral,BordenInstitute;2004.

Setup,Staffing,andOperationofTriageSystemInitialtriagearea.

Allcasualtiesshouldflowthroughasingletriageareaandundergorapidevaluationby the initial triageofficer.Casualtieswill then bedirected toseparatetreatmentareas(emergent,nonemergent,andexpectant),eachwithits own triage/team leader. The expectant will have a medical attendant,ensuringmonitoringandoptimalpaincontrol.Thedeadshouldbesenttothemorgueandmust remain separate fromallother casualties, especiallythe expectant. Unidirectional flow of patients is important to preventclogging the system.Reverse patient flow in any treatment area is highly

discouraged.

Table3-2.MechanismofInjury*MechanismofInjury Frequency Percent

IED 310 18.4

MVA 207 12.3

GSW 188 11.1

Grenade(includesRPG) 170 10.1

Shrapnel/fragment 141 8.3

Unknown 119 7.0

Machineryorequipment 95 5.6

Fallorjumpfromheight 90 5.3

Mortar 84 5.0

Burn 53 3.1

Aggravatedrangeofmotion 31 1.8

Landmine 29 1.7

Other 27 1.6

Knifeorothersharpobject 21 1.2

Helicoptercrash 19 1.1

Bluntobject(eg,rockorbottle) 17 1.0

Pedestrian 16 0.9

Freefallingobjects 14 0.8

Bomb 12 0.7

None 12 0.7

UXO 10 0.6

Environmental 9 0.5

Exertion/overexertion 5 0.3

Flyingdebris 5 0.3

Buildingcollapse 2 0.1

Hotobject/substance 2 0.1

Altercation,fight 1 0.1

TOTAL 1,689 100

GSW:gunshotwound;IED:improvisedexplosivedevice;MVA:motorvehicleaccident;RPG:rocket-propelledgrenade;UXO:unexplodedordnance.*Acasualtymayhavemorethanonemechanismofinjury.Thesenumbersarebasedon1,530Role3casualties.

Datasource:EmergencyWarSurgery,ThirdUnitedStatesRevision.Washington,DC:DepartmentoftheArmy,OfficeofTheSurgeonGeneral,BordenInstitute;2004.

No significant treatment should occur in the triage area. Casualtiesshouldberapidlysenttotheappropriatetreatmentareaforcare.

Table3-3.AnatomicalLocationofInjury*AnatomicalLocation Frequency Percent

Multiplesites 761 49.7

Lowerextremity 248 16.2

Upperextremity 223 14.6

Head/face 174 11.4

Thorax/back 48 3.1

Neck 20 1.3

None 20 1.3

Abdomen 16 1.0

Unknown 9 0.6

Buttock 6 0.4

N/A 3 0.2

Genitalia 1 0.1

Softtissue 1 0.1

TOTAL 1,530 100

N/A:notapplicable.*Casualtieswithmorethanoneinjurylocationareincludedin“multiplesites.”Thesenumbersarebasedon1,530Role3casualties.

Datasource:EmergencyWarSurgery,ThirdUnitedStatesRevision.Washington,DC:DepartmentoftheArmy,OfficeofTheSurgeonGeneral,BordenInstitute;2004.

Qualitiesofanidealinitialtriageareashouldinclude:

Proximitytothereceivingareaforcasualties—landingzone,groundevacuation,anddecontaminationarea.

One-wayflowbothintoandoutofthetriageareathroughseparateroutestoeasilyidentified,marked(signs,colors,chemicallights,etc)treatmentareas.

Well-lit,covered,climate-controlled(ifpossible)areawithsufficientspaceforeasyaccess,evaluation,andtransportofcasualtiesinandout.

Dedicatedcasualtyrecorderstoidentify,tag,register,andrecordinitialtriage/disposition.

Usinganindeliblemarkertoplacenumbersonthecasualty’sforeheadisaneasy,fastwaytotrackpatients.Anymethodthatisreproducibleandsimplewillsuffice.

Ifresourcesallow,casualtytrackingmayincludestationingadministrativepersonnelateveryentry/exit.

Sufficientlitterbearers(controlledbyanNCO)toensurecontinuouscasualtyflow.

Initialtriageofficer.

Ideally,asurgeonexperiencedindealingwithcombattraumashouldbeusedinthiscapacity.

Itisessentialthatanotherphysicianwithclinicalexperiencebetrainedtoassumethisfunction(ie,EmergencyMedicinephysician).

Usingmasscasualtyexercisesorlimitedmasscasualtysituationsisonewaytotrain/identifytherightpersontofillthisroleintheabsenceofasurgeon.

Emergenttreatmentarea.Setup.

Closeproximitytoinitialtriageareawithdirectaccess.

Administrativepersonnelstationedatentryandexitdoorstorecordpatientflow.Ideally,adisplayboardoracomputershouldbeusedtorecordpatientidentity,location,anddisposition.

Seriesofresuscitationbays(numberdependsonavailableresources/personnel).

Allowsufficientroomforthree-personteamtowork.

Easyaccessinandoutofbay.

AvailabilityofequipmentneededforATLS(AdvancedTraumaLifeSupport)-styleresuscitation(Figs.3-1and3-2).

Staffing.

AtRole1facilities,themostexperiencedhealthcareprovidershouldserveasthemasscasualtyTeamLeader.AtRole2–4facilities,theChiefofTrauma(mosttrauma-experiencedsurgeon)isresponsibleforoverarchingclinicalmanagementofthemasscasualtyresponse.TheChiefofTraumaoradesignatedsurgeonservesastheChiefSurgicalTriageOfficeratRole2–4facilities.

Determinepriorityforoperativeinterventions.

Identifypatientswhorequireearlyevacuation.

Maintainclosecommunicationwiththeoperatingsurgeon(s).

Reassesspatientsawaitingsurgeryorevacuation.

Fig.3-1.Triagearea.ADMIN:administrativepersonnel;OR:operatingroom.

Fig.3-2.Resuscitationstation.IV:intravenous;NG:nasogastric;O2:oxygen;Resus:resuscitation.

Administrativeperson:Responsibleforregisteringandtrackingflowofpatientsthroughunit.

Resuscitationteam:Aphysicianorphysicianextender,nurse,andmedicaltechnician,ideally.

EachindividualresuscitationtreatmentteamwillcoordinatemovementofitspatientswiththeChiefSurgicalTriageOfficer.

Operation.

Manpowerteamdeliverspatient.

ChiefSurgicalTriageOfficerretriagespatientandassignsresuscitationteamtopatient.

Resuscitationteamtreatspatientandcoordinatesrequireddisposition(radiography,surgery,ICU,ward,andairevacuation).

ResuscitationteamcommunicatestoChiefSurgicalTriageOfficer

therecommendeddisposition.

ChiefSurgicalTriageOfficercoordinatesmovementofpatienttonextstop.

Administrativepersonrecordsdisposition.

Nonemergenttreatmentarea.

An emptyward, a cleared out supply area, or other similar space can beutilized. Appropriate medical and surgical supplies should be stockpiledand easily identifiable. A team consisting of a physician or physicianextenderandseveralnursesandmedical technicianscan formthenucleusof the treatment team. Lacerations can be sutured, fractures splinted, IVsplaced,andradiographstaken.Theteamleadershouldbealerttochangingvital signs,mental status changes, and nonrespondents to treatment.Anyevidenceofdeteriorationshouldpromptaretriagedecisionandapossibletransfertotheemergenttreatmentarea.

Expectantarea.

Ideally,expectantcasualtiesshouldbekept inanareaawayfromallothertreatmentareas.Theteamleadercanbeanyonecapableofgivingparenteralpainmedicationsandmonitoring thepatients.Thepatient shouldbekeptcomfortable.Afterallotherpatientshavebeentreated,aretriageofthesepatientsshouldbedoneandtreatmentinstitutedifappropriate.

AdditionalTriageOperationTipsDiversion of casualties to another facility should be considered. Triage ofinpatients should be done to identify patientswhomay be discharged ortransferredtopredeterminedfacilities.As the casualties finally clear the OR suites, the pace will slow for thesurgeons.ICUandwardcarewillsupplantoperativeprocedures.Casualtiesinitiallyundertriaged (~10%)willbediscoveredandwill require care.TherecoveryroomandICUswillbecomecrowded,nursingshiftswillhavetobeextended,andfatiguewillrapidlybecomeahospital-widefactor.Numerous authors have stated that, after the first 24 hours of a masscasualty ordeal, the activities of the care providersmust be decreased by50%, allowing for recovery and rest for the participants. A new rotationmustbeestablishedtosustainamodified,butcontinuous,effort.Oncetheacutephaseisover,personnelmustberequiredtorest.Priortoanactualmasscasualtysituation,alldeployedordeployableunitsshould exercise themass casualty responseplan to ensure smoothpatientflowandidentification.Theseexercisesshouldevaluatepatientregistryandtracking, personnel, supplies, and equipment. The practical value ofexercising and adapting the response plan to the changing facility,personnel,andtacticalsituationcannotbeoverstressed.Eachmasscasualtyeventorexerciserequiresdebriefing,withevaluationof

processandactionplantoimprovefutureresponse.Giventherotationalnatureofexpeditionarymedicine,lessonslearnedandafter-actionreportsshouldbereviewedwithincomingstaff.

Triage remains ourmost constant and effectivemethodof establishingorder inoverwhelming chaos. The organic integration of triage principles in tactical,logistical, and clinical decision-making remains the best hope forproviding thegreatestgoodtothegreatestnumber.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter4

AeromedicalEvacuation

Introduction

Evacuation of injured personnel using rotary or fixed-wing aircraft hasrevolutionized the rapid transportof casualties fromareaswhere there is eitherinadequate or no care available, to medical treatment facilities (MTFs) whereessentialand/ordefinitivecarecanberendered.Althoughuseofanaircraftcandecreasetransporttime,theaeromedicalenvironmentcreatesuniquestressesonthe injuredpatient.The followingare terms thatdescribeevacuationofpatientsusingaircraft.

Casualtyevacuation (CASEVAC) is themovement of a casualty from thepoint of injury tomedical treatment by nonmedical personnel. Casualtiestransported under these circumstances may not receive en route medicalcare.Typically,thisinvolvesahelicopterreturningfromthebattlefield.Medicalevacuation(MEDEVAC) is thetimely,efficientmovementandenroutecareprovidedbymedicalpersonneltothewoundedbeingevacuatedfromthebattlefieldtoMTFsusingmedicallyequippedvehiclesoraircraft.Examples include civilian aeromedical helicopter services and Army airambulances. This term also covers the transfer of patients from thebattlefield to anMTF or from oneMTF to another bymedical personnel,suchasfromshiptoshore.Aeromedicalevacuation(AE)generallyutilizesUSAirForce(USAF)fixed-wing aircraft to move sick or injured personnel within the theater ofoperations (intratheater) or between two theaters (intertheater), such asmovingacasualtyfromAfghanistantoGermany.Thisisaregulatedsystemin which care is provided by AE crewmembers. The AE crews may beaugmented with Critical Care Air Transport Teams (CCATTs) to provideICUlevelcare.Enroutecare is themaintenanceof treatment initiatedprior toevacuationandsustainmentofthepatient’smedicalconditionduringevacuation.

MedicalConsiderationsforPatientsEnteringtheMedicalEvacuationSystem

MedicalConsiderations/Requirements

Medicalevacuationrequestincludesrequirementforsurgicalequipmentand/orproviders.Patientissufficientlystabilizedfortheanticipatedmodeanddurationof

travel.Patient’sairwayandbreathingareadequateformovement.Patient’s IV lines, drainage devices, and tubes are fully secured andpatent.Patient at high risk for thoracic barotrauma should be considered forprophylactic chest tube placement before prolonged aeromedicalevacuation.Heimlichvalvesonchesttubesarefunctioning.Foleycathetersandnasogastrictubesareplacedandallowedtodrain.Patientiscoveredsecurelywithbothawoolenblanketandanaluminizedblanket for air transport, cold environment, or postoperativehypothermia.Threelitterstrapsareusedtosecurethepatienttothelitter.Personaleffectsandallmedicalrecordsaccompanythepatient.

Evacuation of a patient is initiated by the originating/sending physicianaccording to established procedures. Patient administration personnelnormally provide the administrative details and coordination required toaccomplish the evacuation. Due to differences in the type of evacuationassetsusedandtheireffectonthepatient’smedicalcondition(eg,flyinginthepressurized cabinof an aircraft), requests to transportpatientsvia theUSAF AE system must also be validated for evacuation by the theatervalidatingflightsurgeon.ForpatientsevacuatedfromRole2MTFsorForwardSurgicalTeams(FSTs),thebrigadesurgeon(ordesignee)determinestheevacuationprecedenceforall patients requiring evacuation from that facility. This is done inconsultation with the FST’s chief surgeon and/or senior nurse. When apatient is readied for evacuation from the FST by USAF assets, thesupporting Patient Movement Requirements Center (PMRC) should becontactedattheearliestpossibletime.ThisallowsthePMRCsufficienttimetocoordinateairliftandpatientmovementitemrequirements.

ImplicationsoftheAviationEnvironmentGeneralconsiderationspriortotransport.

Due to altitude effects, restrictedmobility, limited staffing en route,and unpredictable evacuation times, the referring physician shouldtailor vital signs monitoring requirements and frequency of woundandneurovascularchecks.Some therapies that might not be required in a fixed MTF areappropriateforAE.

Forexample,patientswithsignificantmedicalorsurgicalconditionsshouldhaveFoleycatheters,nasogastrictubes,provisionsforIVpainmedications,andextendeddurationIVantibiotics.

Considerliberaluseoffasciotomies/escharotomies.Considersecuringtheairwaywithaprophylacticendotrachealtube.Wounds dressed for delayed primary closure. Unless directedotherwise,theAEcrewdoesnotroutinelyredresswounds.However,if a patient develops fever or sepsis en route, wounds must beinspected.Casts must be bivalved. If the cast is over a surgical wound site,“window” the cast to allow for tissue expansion and emergencyaccess.Documentneurovascularcheckspriortoandfrequentlyduringflight.

Decreasedbarometricpressure.Thevolumeofagasbubbleinliquiddoublesat18,000feetabovesealevel. Cabin pressures in most military aircraft are maintained ataltitudesbetween8,000and10,000feet.Ifanaircrafthasthecapability,the cabin altitude can be maintained at lower levels, but this willsignificantlyincreaseflighttimeandfuelconsumption.

Considercabinaltituderestriction(CAR)forthefollowing:Penetratingeyeinjurieswithintraocularair.Freeairinanybodycavity.Severepulmonarydisease.Decompression sickness and arterial gas embolism require CAR atorigination field altitude. Destination altitude should not be higherthan origination altitude. Transport on 100% oxygen (by aviator’smaskifavailable).

Pneumothorax: Chest tube required for all pneumothoraces. A Heimlichvalve or approved collection system must be in place prior to patienttransfertotheflightline.AirSplints:Shouldnotbeusedifalternativedevicesareavailable.Becauseair expands with altitude, air splints require close observation andadjustmentsduringflight.OstomyPatients:Ventcollectionbagstoavoidexcessgasdislodgingthebagfromthestomawafer.Useastraightpintoputtwoholesinthebagabovethewaferring.DecreasedPartialPressureofOxygen:Ambientpartialpressureofoxygendecreases with increasing altitude. At sea level, a healthy person has anoxygensaturationof98%–100%.Atacabinaltitudeof8,000feet,thisdropsto90%,whichcorrectsto98%–100%with2L/minofoxygen.Neurosurgical Patients: Hypoxia may worsen neurological injury. Adjustventilatorsettingstomeetincreasedoxygendemandsataltitude.AccelerationStress:Traumaticbraininjurypatientscanexperiencetransientmarkedincreasesinintracranialpressureduringtakeofforlanding.Patientpositioningonboardtheaircrafthelpsminimizethisrisk(headforwardontakeoff,headaftonlanding).Thermal Stress: Plan for cabin temperature changes from 15°C (59°F) to

25°C (77°F) on winter missions, and from 20°C (68°F) to 35°C (95°F) onsummermissions.Normothermiashouldbemaintainedbyusingapproveddevices.Noise: Exposure to noise can produce problemswith communication andpatient evaluation (auscultation is impossible—use noninvasive bloodpressure monitoring and/or an arterial line). Provide the patient hearingprotection.Audiblemedicalequipmentalarmsareuseless.

Decreased humidity: Airplanes have very low cabin humidity ataltitude. Evaporative losses will increase; therefore, patients willrequireadditionalfluids,especiallythosewithlargeburnsandthoseatriskformucousplugging.

Patient movement in nuclear, biological, and chemical (NBC)environments:

Nuclear and chemical casualtiesmust be externally decontaminatedandtimeallowedforoff-gassingofresidualchemicalagent.Movementofbiologicalcasualtiesvariesbythenatureoftheagent,itsmechanismoftransmission,andtheperiodofcommunicabilityduringthecourseofillness.AnyNBCAEmovementmaybedelayedduetothefollowing:

Aircraftdecontaminationtime.

Availabilityofnoncontaminatedaircrew.

Cohortingofsimilarlyexposedpatients.

Quarantinablediseases(eg,plagueandsmallpox)requirespecialapproval(commandanddiplomatic)beforeAE.

ChemicallyorradiologicallycontaminatedcasualtiesmustbedecontaminatedbeforeenteringtheAEsystemunlessthetheaterandUSTRANSCOMcommandersdirectotherwise.

MedicalEvacuationPrecedencesDepending on the service, the type of evacuation assets used, and theevacuation environment, the timeframes for effecting evacuation differ.RefertoTable4-1.TheUSAFAEsystem:TheAirForce’sAEsystemrequirestheavailabilityofasecurelandingstrip,whichcansupportthefixed-wingplatformsthatareusedtomovecasualties.AEisaregulated,in-transitvisiblesystemutilizinga variety of opportune aircraft with dedicated medical crews andequipment,primarilyC-130,KC-135,andC-17.Themedicalcrewsaremadeupofflightnurses,aeromedicaltechnicians,andmedicalattendantstrainedtoperform routine care to stablepatientsduring transport.This system isnotdesignedasaprimary/sceneresponseteam.

AEpersonnelandequipmentforinflightsupportivepatientcareandflightlinesupportoperations.Organic communication network formedical facilities and airlift C2

agencies.

AeromedicalEvacuationLiaisonTeam(AELT):4-to6-personcommunicationteam,usuallyco-locatedwithanMTF,tocoordinaterequestswiththeAEsystem.

Table4-1.EvacuationPrecedences*

MovementPrecedence

Army,Navy,Marines(MEDEVAC)

AirForce(AE) Description

Urgent Within1h ASAP ImmediateAEtosavelife,limb,oreyesight

Priority Within4h Within24h Promptmedicalcarenotavailablelocally

MedicalconditioncoulddeteriorateandpatientcannotwaitforroutineAE

Routine Within24h Within72hornextavailablemission

Conditionisnotexpectedtodeterioratesignificantlywhileawaitingflight

AE:aeromedicalevacuation;ASAP:assoonaspossible;MEDEVAC:medicalevacuation.*Timelinemayvarybasedonpatientrequirementsandlogisticalconstraints.

Aeromedical Staging Facilities (ASFs), generally located at majortransit points, manage the administrative processing and staging,providinglimitedmedicalcareofcasualtiesenteringortransitingtheAE system. Patients are normally held only for 2–6 hours prior toevacuation.

ASFsrangeinsize/capabilityfromsmallunitsdeployedinsupportofSpecialOperationForcesto100-bedfacilities.

ReportingapatientforAE:Originatingphysicianconsultswithlocalflightsurgeontodeterminetheenroutecareplanandtimingofevacuation.

Duetothecomplexityoftheaeromedicalevacuationsystem,physiciansmustindentifypointsof contact (local flight surgeons, theAeromedicalEvacuationLiaison Team, aeromedical staging elements, and the Patient MovementRequirements Center), verify and test lines of communication, and rehearsepatientevacuationdrillsandproceduresbeforetheactualneedarises.

Patientstability:PatientsvalidatedfortransportbyAEmustbestabilizedascompletelyaspossiblepriortoevacuation(airwaysecured,hemorrhagecontrolled,shocktreated,andfracturesimmobilized).

Communicatethecondition,AEcategory(ambulatoryorlitter),andmovementprecedence(seeTable4-1)ofthepatienttothePMRC,as

communicationsassetsallow.SeeTable4-2.

Table4-2.PatientMovementRequirementsCenterContactInformation

PMRC CommercialTelephoneNumber

MilitaryTelephoneNumber

Global(ScottAFB,Illinois) 1-800-303-9301or1-800-874-8966 DSN779-4200or8184

EUCOMTheater(RamsteinAirForceBase,Germany) 011-49-6371-47-2264or2235 DSN314-480-2264or2235

PACOMTheater(HickamAFBHawaii) 808-448-1602 DSN315-448-1602

AFB:AirForceBase;DSN:DefenseSwitchedNetwork;EUCOM:EuropeanCommand;PACOM:PacificCommand;PMRC:PatientMovementRequirementsCenter.

Toensureoptimumcare,communicatewiththeacceptingphysician,andprovidediagnosis,carerendered,andsubsequentmedicalcareplan(next24–48hours).Ensure that the patient has adequate quantities of supplies andmedicationsfordurationoftransfer(atleast24hoursintratheaterand48hoursintertheater).Localflightsurgeonresponsibilities.

Authorityfordeterminingwhetherpatientsarephysiologicallyreadyforairtransport.Resource for AE system information, communication, andcoordination(Table4-3).

Request versus requirement: AE requests and patient movementrequirementsaredifferent.PhysiciansatoriginatingMTFssubmitrequestsformovement, timing, destination, suggested support therapies, etc.Onlythevalidatingflightsurgeon(usually locatedatPMRC;not the local flightsurgeon)andthePMRCcanvalidatethoserequests,whichthenbecomeAErequirements.

Table4-3.TheAeromedicalEvacuationProcessActivity LocationWheretheActivityOccurs

RequestforAEmission(seeendofchapterforformat) Originatingphysician

ValidationforAE PMRC(establishesAErequirement)

Clearancetomovebyair MTF(referringphysicianandlocalFlightSurgeon)

AE:aeromedicalevacuation;MTF:medicaltreatmentfacility;PMRC:PatientMovementRequirementsCenter.

ValidationversusclearanceforUSAFAE.AEclearanceisamedicalcareevent;validationisalogisticalevent.Clearance isadecisionbetweenthereferringphysicianandthelocalflightsurgeon,addressing:

Descriptionofthemedicalconditionofthepatient.

Probabilitythatthepatientcansurvivetransitthroughanaviationenvironment.

Whatthepatientneedstomakethetripsafely.

Enroutemedicalcapabilityrequirements.

KeystepsforUSAFAEpatientrequest.ContactlocalflightsurgeonandAEliaisonforclearanceconsultation.Determinethepatient’sAEcategory,basedondiagnosisandabilitytoself-helpinanemergencyduringflight.Determine need for CCATT (see next page). The CCATT adds anadditionallevelofsupporttotheAEsystemformovementofstabilizedpatientswho require ahigher level ofmedical therapyorwhohavethepotentialtoexperiencesignificantdeteriorationduringmovement.TheCCATTphysicianistheclinicalauthorityand,withtheotherteammembers,isresponsiblefordocumentingandprovidingcare.CCATTmembersmaybecalledontoconsultand/orassistinthecareofotherpatients.A five-person burn transport team can augment the AE system asrequiredforinhalationinjuryand/orsevereburns.Determine if special requirements exist for transport (eg, CAR andsplinting).Determine patient movement items required (eg, ventilators, pulseoximeters, among others). Flight surgeon must verify that all itemsaccompanyingthepatientareclearedforin-flightuse.Determinethepatient’smovementprecedence.Submitrequest.

SelectionoftheCCATTPatient

WhendecidingifacasualtyrequirestheexpertiseofaCCATT,theproviderneedstoassesswhatrequirementsthecasualtywillhaveduringtransport.

BasicDefinitionofaCCATTPatient

Patients requiring CCATT transport include those in need of intensivenursing care, constant hemodynamic monitoring, mechanical ventilation,frequenttherapeuticinterventions,orothermedicalorsurgicalinterventionsvital to sustain life, limb, and eyesight during movement of the patient

throughtheaeromedicalenvironment.Toensuremissionsuccess,aCCATTshouldbeusedtomovethepatientifanyofthecriterialistedbelowarepresent.

UseaCCATTifthepatient:isintubatedrequiresaggressivefluidadministrationorhasreceivedmorethan10unitsofbloodproductsinthepast24hoursrequiresbloodreplacementorvasopressorsupportrequiresinvasivehemodynamicorintracranialmonitoringrequiresfrequentsuctioningornebulizertreatmentshasanincreasingoxygenrequirementhasundergoneavascularreconstructionhasunstableanginahas a condition requiring the need to initiate/continue IV drips for painrelief,anticoagulation,etc,whileinflighthasanunstablespinefracturerequirestheVacuumSpineBoardformovementhasalteredmentalstatuswillrequireelectrolytereplacementandmonitoringinflight.

IfthereisaquestionaboutwhetherapatientwithoutanyofthepreviouslydescribedcriteriashouldbemovedviaCCATT,thesendingprovidershouldcontactthetheatervalidatingflightsurgeon.Consultationwithallprovidersinvolvedisfundamentalinensuringthattheappropriateresourcesareusedtomovethepatientsafely.

CriticalCareAirTransportTeams(CCATTs)

IntensivistPhysicianCapableofprovidingshort-termlifesupport,includingadvancedairwaymanagement, ventilator management, and limited invasive(nonoperative)procedures.Trained in critical care medicine, general surgery, anesthesiology, oremergencymedicine.

CriticalCareNurseExperienced in managing patients requiring mechanical ventilation,invasivemonitoring,andhemodynamicsupport.

CardiopulmonaryTechnicianExperienced in the management of patients requiring mechanicalventilationandinvasivemonitoring.Experienced in troubleshooting ventilatory support, portable laboratorydevices,andmonitoringsystems.

ABG:arterialbloodgas;AE:aeromedicalevacuation;AF:AirForce;AFI:AirForceInstruction;AOR:areaofresponsibility;CCATT:CriticalCareAirTransportTeam;DECON:decontamination;DOB:dateofbirth;ETT:endotrachealtube;hrs:hours;I&Os:intakesandoutputs;IV:intravenous;med:medicine;SSN:SocialSecurityNumber;w/:with.Datasource:JointTheaterTraumaSystemClinicalPracticeGuidelineforIntratheaterTransfer.

AfteritisdeterminedthatacasualtyrequirestheexpertiseofaCCATT,thenextstep lies in the preparation of that casualty for transport. The most importantaspect in ensuring that the movement of a critically ill or injured patient issuccessful lies in the preparatory phase. To accomplish this task, the sendingfacilitymustmakecertainthatallaspectsoftheIntertheaterTransportChecklistarefollowed(seepreviouspage).

UponarrivaloftheCCATT,aone-on-onereportshouldbegiventotheteam,thusensuring that any changesofpatient conditionhavebeenaddressed.Wheneverpossible, it ispreferredthatthesendingphysiciandirectlyspeakstotheCCATTphysicianprior todeparture.Thiswillensurethatasmoothtransitionofcare isaccomplished.

HumanitarianTransportRequestsThe process of arranging routine humanitarian evacuations out of theatercantakemorethan6months.Appropriatepatientselectioniscritical.Ideally,thesepatientshaveasingle,

fixable,stableproblem.The lackof suitablehostnationcaremustbe confirmedanddocumented.Regional care is preferred over transport to the continental United States(CONUS).Individualcasesforhumanitarianevacuationoutoftheaterareunlikelytobe successful without a passionate advocate. Personalizing the case withphotosandcompellingnarrativeiscrucialforsuccess.The approval process is complex and requires coordinationwith the localUSembassyorStateDepartment,hostnationmedicalofficials,andtransitnations’ministriesofforeignaffairsorequivalent.All evacuated children must have an attendant. Those needing militarytransportrequire“SecretaryofDefenseDesignee”status.Coordination also includes travel to the receivingmedical center once inCONUS, obtaining diplomatic transit clearance while waiting in a thirdcountry for ongoing transport and arrangements for return transport.Clearancesmustcoverboththepatientandthenonmedicalattendant.ContacttheservicingPatientMovementRequestCenterearlyforguidance.

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Chapter5

Airway/Breathing

Introduction

Skillful,rapidassessmentandmanagementofairwayandventilationarecriticaltopreventingmorbidityandmortality.Airwaycompromisecanoccurrapidlyorslowlyandmayrecur.Frequentreassessmentisnecessary.Preventablecausesofdeathfromairwayproblemsintraumaincludethefollowing:

Failuretorecognizetheneedforanairway.Inabilitytoestablishanairway.Failuretorecognizetheincorrectplacementofanairway.Displacementofapreviouslyestablishedairway.Failuretorecognizetheneedforventilation.Aspirationofthegastriccontents.

Initial airway management at any level, but especially outside of medicaltreatment facilities. Immediate goal:Move tongue, pharyngeal soft tissues, andsecretionsoutofairway.Untilaformalairwayisestablished,placepatientsinthelateralorproneposition(rescueposition),unlesscervicalspineprecautionsareappropriateintheparticularbattlefieldsituation.

Chin-liftandheadtilt.Place fingers under the tip of themandible to lift the chin outwardfromface.

Two-handedjawthrust.Place both hands behind the angles of the mandible and displaceforward.Thismethodcanbeusedonthepatientwithcervicalinjury.

Oropharyngealairway.Insert oral airway upright if a tongue depressor is used (preferredmethod).Keeptheairwayinvertedpastthetongue,thenrotate180°.Too small an airway will not alleviate the obstruction. Too long anairwaymayfoldtheepiglottiscaudally,worseningtheobstruction.Estimateairwaysizebydistancefromcornerofthemouthtotheearlobe.Oralairwaysarenotusedinconsciouspatients.

Nasopharyngealairway.Passlubricatednasalairwaygentlythroughonenostril.Notusedinsuspectedfacialorbasalskullinjuries.

Istoleratedbyconsciouspatients.Fieldexpedient.

Pull tongue forward and safety pin or suture it to the corner of themouth.

Cricothyrotomy.

VentilationVentilatepatientwiththebag-valvemask.

Bringthefaceintothemaskratherthanpushingthemaskontotheface.Thechinliftandheadtiltarealsousedduringmaskventilationunlesstheyarecontraindicatedduetocervicalspineprecautions.

Assess airmovement duringmask ventilation by observing therise and fall of the chest, auscultation, absence of amask leak,compliantfeelofself-inflatingbag,andstableoxygensaturation.

If air movement is not achieved, use two-person mask ventilation(Fig.5-1).

Onepersonliftsthejawaggressivelyattheanglesofthemandible;theotherholdsthemaskandventilates.Alternatively,onepersonmayliftandholdthemandiblewithbothhands,whileatthesametimeholdingdownthemaskonbothsides.Theotherpersonventilatesthepatient.

Ifairmovementisstillnotpresent,obtainadefinitiveairway.

Fig.5-1.Two-personmaskventilation.

Unsuccessful and aggressive attempts at ventilation may result ininflation of the stomach, placing the patient at increased risk forvomitingandaspiration.

Positivepressureventilationcanconvertasimplepneumothoraxintoatensionpneumothorax.

Perform frequent assessment and have equipment available forneedlechestdecompression.

OrotrachealIntubation

RapidSequenceIntubation—SixSteps

1. Preoxygenatewith100%oxygenbymask.2. Cricoid pressure—(Sellick’s maneuver) until endotrachealtubeplacementisconfirmedandballoonisinflated.

3. Inductionagent:etomidate0.1–0.6mg/kgIVpush.4. Musclerelaxant:succinylcholine1.0–1.5mg/kgIVpush.5. Laryngoscopyandorotrachealintubation.6. Verifytubeplacement.

Consider nasogastric or orogastric tube placement after securingairway.

Directlaryngoscopytechnique.Ensureoptimal“sniffing”positionisachievedunlesscontraindicatedbycervicalspineinjury.Openthemouthbyscissoringtherightthumbandmiddlefinger.Holdthelaryngoscopeinthelefthandandinsertthebladealongtherightsideofthemouth,slightlydisplacingthetonguetotheleft.

Macintosh(curved)blade:Advancethetipofthebladeintothespacebetweenthebaseofthetongueandtheepiglottis(ie,intothevallecula).Applyforceata30°–45°angle,liftingtheentirelaryngoscope/bladewithoutrockingitbackward(Fig.5-2).

Fig.5-2.Useofcurvedbladelaryngoscope.

Miller(straight)blade:Advancethetipofthebladeintotheposteriororopharynx,pickinguptheepiglottisandtonguebaseanteriorlyandlaterally,andapplyaforcevectorlikethatoftheMacintoshblade.Avoidrockingthelaryngoscopebackward(Fig.5-3).

Visualizethevocalcords.Consider the “BURP” (Backward Upward Rightward Pressure)

maneuverwhenthelaryngoscopicviewispoor(Fig.5-4).“BURP”ofthelarynxwasalsoreferredtoasexternallaryngealmanipulation.

Placethefingersofanassistantontothelarynxwithyourrighthandandmanipulatetheglotticopeningintothefieldofview.

Fig.5-3.Useofstraightbladelaryngoscope.

Assistantthenholdsthepositionforintubation.

EschmannstyletorGumElasticBougie(Fig.5-5).

Blindlyguidethetipofthestyletbeneaththeepiglottis,thenanteriorlythroughthevocalcords.

Advancethebougiedeeply.Placementintothetrachearesultsinthesensationoftrachealring“clicks”andturningofthestyletasitpassesairwaybifurcations.

Fig.5-4.BURP(BackwardUpwardRightwardPressure)maneuver.

Fig.5-5.Eschmannstyletinplace.

Thepatientmaycoughasthestyletpassesthroughtheairway.

Whenpassedbeyondthetrachea,thestyletwillstopataterminalbronchus.Ifplacedintotheesophagus,itwillpassindefinitelyintothestomachwithoutanytactilefeedback.

Theendotrachealtube(ETT)isguidedoverthestyletintotheairway,andtrachealintubationisconfirmed.

Advance the ETT between the vocal cords, withdraw stylet, andadvancetheETTto20–21cmattheteethforadultfemalesand22–23cm for adultmales.Deeperplacementmay result in rightmainstemintubation.ConfirmplacementoftheETTinthetrachea.Auscultateovertheaxillatoensurethatbreathsoundsareequal.

Avoid making more than three attempts at direct laryngoscopy. Excessiveattempts may result in airway trauma and swelling, potentially turning a“cannot intubate” urgency into a “cannot intubate–cannot ventilate”emergency.

DifficultAirway

After threeunsuccessfulattemptsatdirect laryngoscopy,abandonthetechniqueandtryalternatives.

Alternativeintubationtechniques.Lightedstyletor“lightwand”intubation.

Flexiblewand,lightedatthetip,isplacedthroughtheETT.

Wandisadvancedbytactileguidanceintothetrachea.

Positionintracheaisverifiedbytransillumination.TheETTisadvancedoverthewand.

Flexiblefiberopticoralornasalintubation.Retrogradewireintubation.Rigidfiberopticintubation(Bullardlaryngoscope).Video-assisted laryngoscopy (GlideScope Ranger) is currently a key

tool.Alternativeairways.

MayNOTbedefinitiveairways.

Allowforoxygenationandventilationwhenstandardairwayscannotbeplaced.

Supraglotticairway/laryngealmaskairway(LMA).

Esophageal–trachealcombitube.

Performasurgicalairway.

SurgicalCricothyrotomyIdentifycricothyroidmembrane(betweencricoidringandthyroidcartilage[Fig.5-6a]).Prepskinwidely.Graspandholdtracheauntilairwayiscompletelyinplace.MakeaverticalSKINincisiondowntothecricothyroidmembrane(ano.10

orno.11blade).

Fig.5-6.Stepsofsurgicalcricothyrotomy.(a)Identifycricothyroidmembrane.(b)Makeahorizontalmembraneincision.(c)Insertasmall,cuffedETTtojustabovetheballoon.

Bluntlydissectthetissuestoexposethemembrane.MakeahorizontalMEMBRANEincision(Fig.5-6b).Openthemembranewithforcepsorthescalpelhandle.Insertasmall,cuffedETT,6.0–7.0innerdiameter,tojustabovetheballoon(Fig.5-6c).Confirmtrachealintubation.SuturetheETTinplaceandsecureitwithtiesthatpassaroundtheneck.

LaryngealMaskAirway

Do NOT use in penetrating upper airway trauma or central airwayobstruction(foreignbody).

Insert blindlywithout a laryngoscope. The laryngealmask airway (LMA)restsoverthelaryngealinlet.Compared to an ETT, the LMA supports less airway pressures and offerslessaspirationprotection.Check theLMAcuff, thendeflate it until thedown side (inner) surface issmoothandflat;lubricatethepharyngeal(upper)sideoftheLMA.Thesniffingpositionworksbest,buttheLMAmaybeinsertedindifferentpatientpositions.

Insert LMA (3–4 for women, 4–5 formen) with upper (pharyngeal)side gliding along the hard palate, down and around into theposterior pharynx. This allows proper direction and reduces thechanceofcufffolding.DoNOTpush theLMAdirectlyback into themouth.This folds thecuffandprohibitsproperplacement.Inflatecuffwith20–30ccofairviasyringe.SlightupwardmovementoftheLMAtubingisseen.SecuretheLMA.

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Chapter6

HemorrhageControl

Thehemorrhagethattake[s]placewhenamainarteryisdividedisusuallysorapidandsocopiousthatthewoundedmandiesbeforehelp

canreachhim.

—ColonelH.M.Gray,1919

StoptheBleeding!Hemorrhageistheleadingcauseofpreventabledeathonthebattlefield.

90%ofcombatfatalitiesoccurforwardofamedicaltreatmentfacility.75% of combat fatalities have nonsurvivable injury and 25% havepotentially survivable injury. Of those with potentially survivablewounds,90%diefromhemorrhage.Although bleeding is a main cause of death, the vast majority ofwoundsdonothavelife-threateningbleeding.

UNDERFIRE

Getthepatientoutofthelineoffire—preventfurtherinjury.Controlobviousexternalbleedingonceoutfromunderfire.If you must remain under fire, stop external bleeding with use of atourniquet.Donotendangerthecasualtyoryourselfwithunnecessarytreatment.Stayengagedinthefirefightifnecessary.

KEEPYOURHEADDOWN

SitesofHemorrhageExternal.

Extremity injury(mostcommoncauseofmassiveexternalbloodlossincombat),scalp,andtorsowounds.Usuallyassociatedwithanopenfractureoramputation.

Internal.Chest,abdomen,pelvis,andclosedextremityfractures.High mortality if the casualty is not expeditiously transported andsalvagesurgicalproceduresperformed.Controlled (hypotensive) resuscitation should be implemented. (Seebelow;alsoseeChapter7,Shock,Resuscitation,andVascularAccess.)

InternalTorsoBleedingRequiresSurgicalControl

Treatment—FirstResponderExternalhemorrhagefromextremitywounds.

Directpressureatthesiteofinjuryisthemosteffectiveandpreferredmethodofhemorrhagecontrol.

Ifdirectpressurefailstostopthehemorrhage,itsignifiesdeep,massive,orarterialinjury,andwillrequiresurgeryoradvancedhemostaticagents.

Holdpressureforatleast5minutesbeforelookingtoseeifitiseffective.

Impaledforeignbodiesshouldnotberemovedbecauseprofusebleedingmayoccur.

Pitfall:ABandageDoesNotEqualDirectPressure!

Abandagemaywickbloodfromthewoundwithoutstoppingthebleeding.

Abandagehidesongoingbleeding.

Hemostaticbandagesareavailableonthebattlefieldtoassistin stopping bleeding. (See current TCCC [Tactical CombatCasualtyCare]Guidelines.)

Elevationoftheextremitywilldecreasemostbleeding.

Pointcompressionoftheproximalartery.

Mayhelpslowbleedingwhileattemptingtogainbettercontrolatthewoundsite.

Mayrequirecompressionatthepressurepointforupto20minutestoprovidehemostasis.

Table6-1showstherecognizedpressurepoints.

Noblindclamping.

Table6-1.RecognizedPressurePointsBleedingSite Hand Forearm Arm Leg Thigh

Artery Radial/ulnar Brachial Axillary Popliteal Femoral

Pressurepoint Wrist Innerupperarm Axilla Behindknee Belowgroincrease

Atourniquetshouldbeappliedifprevioustechniquesfail.

Useatourniquetearly,ratherthanallowongoingbloodloss.

Rapidmethodtosecurehemorrhagecontrol.

Doesnotrequireconstantattention;allowsfirstrespondertocareforothers—extendsresources.

Tourniquetsshouldnotberemoveduntilthehemorrhagecanbereliablycontrolledbyadvancedhemostaticagentsoruntilarrivalatsurgery.

TourniquetMayBetheFirstChoiceinCombat

Tourniquetplacementontheforearmorlegmaynotcompressthevessels,whichliebetweenthedoublelongbones.Tourniquetsontheupperextremityshouldbeplacedontheupperarm.Ifbleedingfromthelowerextremityisnotcontrolledbyatourniquetontheleg,itshouldbemovedtothethigh,wherethevesselmaybemoreeasilycompressed.

Asecondtourniquetmayneedtobeaddedtoprovidebetterhemostaticcontrol.

PitfallsoftheTourniquet

Risk–benefitDecision:Donotavoiduseofatourniquetinordertosavealimbandthenlosealife!

Clampingvessels:Ifthereiscontinuedbleedingandadamagedvesselcanbereadilyidentified,ahemostatmaybeusedtoclampthevisualizedvessel.

Limbsplintswilldecreasebleedingassociatedwithfracturesandsoft-tissueinjurybyaligning,stabilizing,andreturningthelimbtolength.

Scalpbleeding:Canbesignificantduetotherichvasculatureofthescalp.

Respondstodirectpressure.

Butdifficulttoapplyandmaintaindirectpressure.

Compressiondressingsmustbeappliedifyoucannotprovideongoingdirectpressure.

Requirescircumferentialheadapplication.

Verticalmattresssutureclosuresometimesisnecessarytocontrolbleedingscalpedges.

Areadilyidentifiedbleedingvesselcanbeclamped,butthewoundshouldgenerallynotbeexplored.

Avoidpushingfragmentsintothebrainwhenapplying

pressure,butcontrolhemorrhageevenattheexpenseofexposedbrain.

Protectionofexposedbrainwithnonadherentgauzeorplasticcanminimizeinjury.

Internalbleeding.

Bloodlossintotheabdomenorchestcannotbecontrolledinthefieldandrequiresimmediateevacuationforsalvageordefinitivesurgery.

Stabilizationofpelvicfracturewithapelvicbinderorwrappingthepelvistightlywithawidestrap(suchasafoldedsheet)mayreducepelvicbleeding.

Opentorsoinjuries:Ifdirectpressuredoesnotstopthehemorrhage,considerinsertingatamponadewithaballoon(Foley)catheterintothewound.Then,withtheballooninflated,pullbacktocompressthebleedingsite.

Dressings,Bandages,HemostaticAgents,andControlledHypotension

Dressings promote hemostasis, protect wounds from mechanical injury andcontamination, immobilize tissues, and provide physical and psychologicalsupporttothepatient.

Applicationofdressingsandbandages.Controlallbleeding.Assess neurological status and circulation of extremity before andafterapplyingadressingorbandage.Immobilizesuspectedfractures.Keepdressingascleanaspossible.Dressingsshouldcovertheentirewound.Bandagesshouldcovertheentiredressing.Avoidskin-to-skincontact.Leavefingersandtoesexposed.Reinforcement.

Ifatallpossible,DONOTremovethefirstdressing.

Ifthedressingbecomesthoroughlysaturated,reevaluatethewoundforasourceofbleedingamenabletodirectpressureandconsideradvancedhemostaticagentsoraproximaltourniquet.Bloodlossintothedressingcanbeestimated.

Coagulopathy:Blood loss,massive fluid resuscitation,andadrop inbodytemperaturemayleadtoaninabilitytoformclots.Keeppatientwarm(above34°C).

Usewarmfluids.

Usecrystalloidfluidssparingly.

TransfusewithcomponenttherapyorfreshwholebloodinaccordancewithcurrentClinicalPracticeGuidelines(CPGs).

Hemostatic agents: New products and bandages are available inseveralforms:

Dressings:Impregnatedwithhemostaticagents.

Injectables.

Intravenous:Augmentclottingcascadeofbody.

Intracavitary:Throughwoundstocontrolinternalbleeding.

Two-component“glues.”

Ifanadvancedhemostaticagentisusedafteratourniquethasbeenplaced,thetourniquetmaybecarefullyremovedaftertheagenthasachievedhemostasisandthewoundobservedforhemorrhage.Ifhemorrhagerecurs,returntothetourniquet.

SeecurrentCPGsforalistofhemostaticagents.

HemostaticAgents

Currently, TCCC (Tactical Combat Casualty Care) recommendsCombatGauze.SeecurrentTCCCguidelines.If standard measures, such as pressure dressings, do not controlbleeding,itisrecommendedthatatourniquetbeusedandthatthefirstagentbeCombatGauze.Ifthebleedingisexternalandnotatasitewhereatourniquetcanbeapplied, Combat Gauze can be used if conventional pressuredressingsfail.Thisproductistobeusedonlyonexternalsourcesofhemorrhage.Blood and clot should be wiped out of the wound prior toapplication.Remember, pressure must be applied for 3–5 minutes at thebleedingsite,afterapplicationofahemostaticdressing.

FieldHemostaticDressings—Considerations

Donotuseonminorinjuries.Useoninternalwoundsisnotyetrecommended.Mustapplypressuretothebleedingsiteafterapplication.Effectiveness is limited ifCombatGauze isnot incontactwith thebleedingsourceinadeepwound.

ControlledResuscitation(PermissiveHypotension).

Resuscitationisamethodofhemorrhagecontrol.Theneedsof

organperfusionmustbecarefullybalancedagainsttheriskofincreasedbleedingasbloodpressurerises.Excessivefluidresuscitationmayincreasebleedingandrebleeding.Priortodefinitivehemorrhagecontrol,alowerthannormalbloodpressuremaybeacceptable.Smallvolumesofresuscitationfluidarestillrequiredinthosecasualtieswithdecreasedmentationduetohypotension(ie,decreasedorabsentradialpulse).

Reference

Gray HMW. The Early Treatment of War Wounds. London, UK: Henry FrowdeHodder&Stroughton/OxfordUniversityPress;1919.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter7

Shock,Resuscitation,andVascularAccess

Introduction

Thegoalof resuscitation is tomaintainadequateperfusion.Resuscitationof thewounded combatant remains a formidable challenge on the battlefield.Routineinitial resuscitation using 2 L of crystalloid through two large-bore IVs is notappropriateinallsituations.Infact,bloodtransfusionsmaybepartoftheinitialfluid resuscitationof casualtieswhobledorwhowere at high risk for ongoingbleeding.ThevastmajorityofcasualtiesdonotneedanyIVfluidresuscitationpriortoarrivalataforwardmedicaltreatmentfacility.

This chapter will briefly address shock (including recognition, classification,treatment, definition, and basic pathophysiology), review initial and sustainedfluid resuscitation, summarize currently available fluids for resuscitation, anddescribevascularaccesstechniques.

RecognitionandClassificationofShock

Shock is a clinical conditionmarked by inadequate organ perfusion and tissueoxygenation, manifested by poor skin turgor, pallor, cool extremities, capillaryrefillgreaterthan2seconds,anxiety/confusion/obtundation,tachycardia,weakorthready pulse, and hypotension. Lab findings include base deficit >5 and lacticacidosis>2mmol/L.

Hypovolemicshock:Diminished volume resulting in poor perfusion as aresult of hemorrhage, diarrhea, dehydration, and burns. This is themostcommontypeofshockseenincombatcasualties(Table7-1).

Hypotensionisalatefindinginshock,occurringafter30%–40%bloodvolume loss. Earlier signs are tachycardia, decreased pulse pressure,andmentalstatuschanges.However,eventheseearliersignsmaynotbereadilyapparentinmilitarycasualtieswhogenerallyhaveagreaterpropensity for physiological compensation secondary to physicalconditioning.

Table7-1.ClinicalCorrelatesinHypovolemicShockSizeDesignation:BloodLoss(cc):

ClassI<750

ClassII750–1,500

ClassIII1,500–2,000

ClassIV>2,000

Bloodvolume* <15% 15%–30% 30%–40% >40%

Pulse <100 >100 >120 >140

BP Normal Normal ↓ ↓

Pulsepressure Normal ↓ ↓ ↓

RR 14–20 20–30 30–40 >35UOP(cc/h) >30 20–30 5–15 NegligibleCNS Normal Anxious Confused Lethargic

BP:bloodpressure;CNS:centralnervoussystem;RR:respiratoryrate;UOP:urineoutput.

*Bloodvolumeisapproximately7%(eg,a70-kgpatienthasabloodvolumeof4,900mL).

Cardiogenic shock: Pump failure from intrinsic cardiac failure orobstructive cardiac dysfunction from a tension pneumothorax (unilateralabsence breath sounds + distended neck veins) or cardiac tamponade(distendedneckveins).Distributiveshock:Poorperfusionduetolossofvasculartone.

Neurogenic shock: Bradycardia with hypotension, seen with spinalcord injury T6 and above due to loss of sympathetic tone andunopposedparasympatheticstimulationwithresultantvasodilation.Septicshock:Fever,hypotension, tachycardia,andwarmextremitiesfrommassivevasodilationrelatedtoinfection.

TreatmentofHypovolemicShock—ControlBleeding!

The goal in the treatment of shock is to restore tissue perfusion and oxygendelivery(dependentonhemoglobin,cardiacoutput,andoxygenation).

SecuretheairwayandadministeroxygenforSaO2<92%.Diagnoseandtreattensionpneumothorax.Controlobviousbleedingandassessforocculthemorrhage.AssesscirculationandestablishIVaccess.

Consider cardiac tamponade, even if there are no distended neckveins.

AdministerIVfluids.Hemorrhagicshock:Resuscitateinitiallywithanyfluidavailable.Butstrong consideration must be given for early blood producttransfusion, particularly in those casualties at risk for a massivetransfusion(>10unitsofPRBCs[packedredbloodcells]in24hours).Physiological/laboratorypredictorsofmassivetransfusioninclude:

Systolicbloodpressure<110.

Heartrate>105.

Hematocrit<32%.

pH<7.25.

3of4riskfactors=70%riskmassivetransfusion.

4of4riskfactors=85%riskmassivetransfusion.

Injurypatternsassociatedforriskofmassivetransfusioninclude:

Truncal/axillary/neck/groinbleedingnotcontrolledbytourniquetorhemostaticdressings.

Multipleamputations.

Largesoft-tissueinjurieswithuncontrolledbleeding.

Largehemothorax.

Largehemoperitoneum.

These patients should be immediately resuscitated with bloodproducts(redbloodcells:freshfrozenplasma:platelets)ina1:1:1ratioorconsiderfreshwholebloodiffullcomponenttherapynotavailable.

SeeJTTS(JointTheaterTraumaSystem)ClinicalPracticeGuideline“DamageControlResuscitation.”

TypesofIVfluids.

LactatedRinger’s(LR):1,000mLexpandsintravascularvolumebyonly~250mLwithin1hourafterinfusion.Normalsalineshouldbediscouraged.

Hextend(500mL,Hetastarch6%+aphysiologicalbalancedcrystalloidcarrier,includinglactatebufferandglucose)expandsintravascularvolumeby~800mLin1hour,isfunctionallyequivalenttothreebagsofLR,andissustainedforatleast8hours.Mayrepeatonceforatotalof1,000mL.

Hypertonicsaline(HTS)7.5%resultsinthesamephysiologicalresponsewithone-eighththevolumeofLRorsaline.Twoinfusionsof250cccanbeused.AlthoughthisrecommendationhasbeenmadebytheInstituteofMedicine(inWashington,DC)andtwomilitaryconsensusgroups,HTS7.5%isnotcommerciallyavailable.HTS3%andHTS5%canbeusedinsteadandareformularystockitems.

Caveat-Hextend and HTS are effective primarily by shiftingextracellular volume into intravascular space. Theymay be lesseffective if administrated in casualties with significantdehydration and require supplementationwith judicious use ofcrystalloid.

Isolatedneurogenicshock.

Intravascularresuscitationwithcrystalloidtomaintainsystolicmeanarterialpressure>80mmHgorsystolicbloodpressure(SBP)

>110.

Recommendthatcrystalloidfluidresuscitationbeusedjudiciouslyinthissituation,sincevolumeoverloadisassociatedwithincreasedriskofpulmonaryedema.

Add a vasopressor after appropriate intravascular volume challenge(generally2–3L)toaddressthelossinvasculartone.

Phenylephrine(50–300µg/min).

Ifbradycardic,considerdopamine(2–10µg/kg/min).

Septicshock.

Initialresuscitation(first12hours).

Targets:

Meanarterialpressure≥65mmHgorSBP≥90.

Centralvenouspressure8–12mmHg.

Urineoutput≥0.5mL/kg/h.

Centralvenousormixedvenousoxygensaturation≥70%.

Beginintravenousantibioticswithinthefirsthourofrecognitionofseveresepsiswithbroad-spectrumcoverage.

Addavasopressorafterappropriateintravascularvolumechallengeusuallyuntilcentralvenouspressurewas8–12(generallyupto5Lcrystalloidand/orcolloid).

Norepinephrineinitialdose8–12µg/min,thentitratetoeffectat2–4µg/min.(Sepsis[weight-baseddosing]0.01–3µg/kg/mincouldbeasmuchas0.7–210µg/minin70-kgpatient.)

Vasopressin0.04units/min(maytitratedownforeffect;donottitrateabovemaximum:0.04units/min).

Instituteearlyacutelunginjury/acuterespiratorydistresssyndromemechanicalventilationmeasureswithlowtidalvolumes(5–7cc/kgleanbodymass)andend-inspiratoryplateaupressures<30cmH2O.

Subsequenttherapy.

Overallfluidbalancetargetafter12hoursofresuscitationisbetween3–12L.Greaterthan12Lpositivebalanceassociatedwithincreasedmortality.

Considerbloodtransfusionifhemoglobin<7totargethemoglobinof7.0–9.0g/dL.

Reassessantimicrobialregimen48–72hoursafterstartingtreatmentwiththeobjectiveofnarrow-spectrumantibiotics.

Based on response to fluids, casualties will fall into three groups:responders,transients,andnonresponders.

Responders:Casualtieswithasustainedresponsetofluidsmayhavehadsignificantbloodloss,buthavestoppedbleeding.However,theymaystillrequiredefinitivesurgery.Transient and nonresponders are continuing to bleed. They needimmediatesurgicalintervention.

Startbloodproducttransfusionassoonaspossible,withatargetgoalratioof1:1:1(PRBCs:freshfrozenplasma[FFP]:platelets).

Fornonresponders,fluidsmaybegiventokeepthecasualtyalive,butoneshouldnotattempttorestorepressuretonormal.Considerationshouldbetakenintoaccountofthefutilityoftheresuscitation,dependingonthetacticalscenario.

Followcontrolledresuscitationguidelinesaspresentedinthischapter.

Exsanguinating hemorrhage is the cause of most preventabledeathsduringwar.Combatcasualtiesinshockshouldbeassumedtohavehemorrhagicshockuntilprovenotherwise.

VasopressorshaveNOroleintheinitialtreatmentofhemorrhagicshock.Resuscitationfluidselection.

The ideal fluid for resuscitation is still debated, despite decades ofresearchthatbeganduringWorldWarI(Table7-2).Blood product transfusions should be considered early in theresuscitation, particularly in patientswho have lost 30% ormore oftheirbloodvolume.Bloodproductsmayalsobenecessaryinpatientswho have not reached this threshold, but who have ongoing bloodlossorwhoareathigh riskofongoingbleeding.Freshwholebloodtherapyshouldbeconsideredatlevelsofcarewherecomponentbloodproduct therapy (ie,PRBCs,FFP,platelets) is inadequate tomeet thetargetgoalratioof1:1:1.

ConceptofControlledHypotensiveResuscitation/PermissiveHypotensionRaisingthebloodpressurewithfluidresuscitationmaydislodgeestablishedclots leading to continued blood loss. Prior to establishing definitivehemorrhage control, use controlled resuscitation to achieve and maintainadequate perfusion as demonstrated by at least one of the followingprioritizedgoals:

Table7-2.IntravascularResuscitationFluidsFluid/Initial

Dose Indication Advantages Cautions

Crystalloids

Saline

Ringer’slactate

Hypovolemia,hemorrhage,shock,burns

Easytostore,inexpensive,proveneffectiveness,isotonic

Weightratio—requires3:1forlostblood,dilution,edema,coagulopathy

Hypertonicsaline

3%–5%

7.5%*

HTS–colloid

combinations*

HTSdextran*

HTSHetastarch*

Hemorrhagicshock:

4cc/kgor250ccbolus,mayrepeatonce

Burns—onlyonedoseinitially

Lighterweight

Smallvolume=largeeffect

Increasedcardiaccontractility

LongerdurationofeffectthanplainHTS?

>500cc—riskofhypernatremia,seizures

Donotusefordehydrationfromvomiting,diarrheaorsweating,orheatinjuries

Donotrepeatwithoutadditionofotherfluids

Mustreplacedepletedextravascularfluid

Colloids

Albumin

Artificialcolloids

Dextran

6%Hetastarch(Hextend,Hespan)

10%Pentastarch*

Gelatin-basedcolloids*

Hemorrhagicshock(500–1,000mLbolus)

Burns?3rdday

Longerduration

1:1replacementforblood

Raisesplasmaoncoticpressure

Recruitsextravascularfluid

Weight/cubebetterthancrystalloids

Overusemayleadto“leak”intotissue

BindsimmunoglobulinsandCa2+

Mustreplacedepletedextravascularfluid

Artificialcolloids:coagulopathy,allergicreaction,osmoticdiuresis,interfereswithcross-matching

Hetastarch:↑fibrinolysis,↑amylase

Maximumdose:20mL/kg/d(about1.5L)

Oralrehydrationfluids

Dehydration-controlledhemorrhage

Burns

Fluidsofopportunity

Nonsterileingredients:4tspssugar,1tspsalt,1Lwater

Austereoptioninabdominalwoundsandunconsciouspatients,butusewithcaution

Storage,type,andcross-match

BloodHemorrhage—typeOuniversaldonor

Carriesoxygen

Autotransfusion

Walkingbloodbank

Transfusionreactions,infection,immunogenic

Artificialblood

Hemoglobin-based

Fluorocarbon-based

HemorrhageEasystorage

Notypeandcross-matching

Experimentalonly,notyetavailableforuse

Fluorocarbonsrequiresupplementaloxygen

Futureoption?

FDA:FoodandDrugAdministration;HTS:hypertonicsaline.

*NotFDAapproved.

Datasource:EmergencyWarSurgery,ThirdUnitedStatesRevision.Washington,DC:DepartmentoftheArmy,OfficeofTheSurgeonGeneral,BordenInstitute;2004.

Regainsconsciousness(followscommands).Palpableradialpulse.SBP~90mmHg.MAP(meanarterialpressure)~60mmHg.

Controlledresuscitation(permissivehypotension)isNOTasubstitutefor definitive surgical control. It is an attempt to keep a criticallyinjuredcasualtyaliveuntildefinitivetreatment.

Endpointsofresuscitation.Followingdefinitive hemorrhage control,more traditional endpointsofresuscitationinclude:

Bloodpressure:SBP>110–120mmHg,MAP>65–70mmHg.

Urineoutput:>0.5mL/kg/h(approximately30mL/h).

Correctionofacidosisbyachievingbasedeficit<2orserumlactate<2mmol/L.

Hypothermia: It is important tomaintain normal body temperature.Fluids, blood products, and casualty care areas must be warmed.Casualties frequently arrive to the facility hypothermic. Keepcasualties coveredwhen on litters, radiograph tables, and operatingtables.ExternalwarmersshouldbeusedinallcasualtycareareasfrominitialemergencyareathroughoperatingroomandICU.Hypothermiaismucheasier toprevent than it is to treat.See furtherdiscussionofhypothermia inChapter 12,DamageControl Surgery.Also see JTTSClinicalPracticeGuideline“HypothermiaPrevention.”

VascularAccessVascularaccessisacriticalearlystepinthemanagementoftrauma.Peripheral access should be attempted first; if unsuccessful, considerintraosseous (IO) device placement for initial resuscitation, followed byalternatives such as percutaneous central line (ie, subclavian, internaljugular,femoralveins)or“cutdowns”(saphenousveineitheratthegroinorankle).

SubclavianVeinAccessorInternalJugularVenipuncturePlacethecasualtysupineintheTrendelenburgposition(15°headdown).Prep anddrape subclavian/jugular area. Sterile glovesmust beworn.Usecentrallineaccesskit.

Subclavianline.

Withanindexfingerplacedatthesternalnotch,thethumbisplacedatthejunctionofthemedialandmiddlethirdoftheclavicle.

1%lidocaineisinfiltratedintotheskin,subcutaneoustissue,and

periosteumoftheclavicle.

Introducealargecaliberneedlewithanattached5-mLsyringeatthejunctionofthemiddletolateralportionoftheclavicle.Insertwiththebeveloftheneedleup,directingtheneedletowardthecontralateralclavicularhead.Keeptheneedlehorizontaltoavoidapneumothorax.

Whileaspirating,slowlyadvancetheneedleunderneaththeclavicle.

Jugularveinline.

Turnthecasualty’shead45°towardthecontralateralsidetoexposetheneck.Positionmustbealteredtoneutralpositionifconcernforcervicalspineinjury.

Identifytheapexoftheanteriorcervicaltriangleformedbytheheadsofthesternocleidomastoidmuscletolocatethecarotidartery.

Palpatethecarotidarteryandstaylateralwithyourvenipuncture.

Introducealarge-boreneedleona10-mLsyringeata45°angleintotheapexofthetriangle,lateraltothecarotidpulse.

Carotidpuncture:Immediatelywithdrawtheneedleandplacepressureonthesiteforaminimumof5minutes.

Advancetheneedlecaudally,paralleltothesagittalplaneandata30°posteriorangle(eg,towardtheipsilateralnipple).

Whenfreeflowofvenousbloodappears,advancetheneedleanadditional4mm(thelengthoftheneedlebevel),thenremovethesyringeandquicklycoverthehuboftheneedletopreventairembolism.

Ifairorarterialbloodappears,stopimmediately.Withdrawneedleimmediatelyandplacepressureatthesiteforatleast5minutes.

Ifnovenousbloodreturnsafteradvancing5cm,slowlywithdrawtheneedlewhileaspirating.Ifthisfails,redirecttheneedle.

Subclavianveinorinternaljugularveincatheterinsertion.

Oncetheneedleisinthevein,introducethe“J”wirethroughtheneedle(Seldingertechnique).Thewireshouldpasswithminimalresistance.Ifthewiredoesnotpasseasily,withdrawtheentireapparatusandreattemptlineplacement.

Removetheneedle.

Enlargethepuncturesitewithascalpelanddilator.

Passthecatheteroverthewirewhileholdingthewireinplacetoadepthof18cmontheleftand15cmontherightforsubclavian,andtoadepthof9cmontherightand12cmontheleftforjugularvein;thenremovethewire.

Aspiratefromallports,flushallports,sutureinplace,applyantibioticointment,dressarea,securetubing,andlabeldateofinsertion.

Chestradiographtoensurelinepositionandruleoutpneumothorax.

GreaterSaphenousVeinCutdownsContraindications.

Deepveinthrombosisorsevereipsilaterallowerextremitytrauma.Procedure.

Expose,prep,anddrapeankleorfemoralsite.For ankle, administer local anesthetic proximal to the medialmalleolus.Makeasuperficialtransverseincisionthroughtheskinovertheentirewidthoftheflattibialedge(~3cm)intheareaofthesaphenousvein.Usingacurvedhemostat,isolatethegreatersaphenousveinfromthenerveandunderlyingbone.Usingtheopenhemostatasaplatform,cuta1–2mmvenotomyintheanteriorsurfaceoftheveinwithano.11blade(Fig.7-1a).Placetheintravenoustubing(previouslybeveled)orangiocatheteratleast4cmintothevein(mayrequireuseofaveinintroducer)(Fig.7-1b).

Fig.7-1.Saphenousveincutdown.

Securethecatheterwithaproximalsilkligatureandtieoffthedistal

vein.Securethecatheterwithasuture.Applyacleandressing.The femoral procedure is essentially the same,with the site being ahandbreadthbelowtheinguinalligament,medialtothemidlineofthethigh.Afterskinincision,thefingerbluntlydissectsthroughthefattothefascia.Hookthefingerandlift,andtheveincomesupwithit.

Cutdowncanalsobeperformedonthecommonfemoralveins,thejugularveins,andonveinsoftheforearm.

IntraosseousInfusionContraindications.

Traumaorinfectionatinsertionsite.Excessivetissueorabsence/inadequateanatomiclandmarks.RecentIOdeviceatthesamesite.Fractureofinsertionbone.Recentsternotomy.

Devices/procedure.Proceduretechniquesvarybasedonmodelandcanbeeithermanualorpower-driven.

Manual:Cook,FAST1,sternalEZ-IO,Sur-Fast.

Semiautomatic:AdultandpediatricBoneInjectionGun(B.I.G.)—spring-loaded,adultandpediatricEZ-IO—battery-powereddrill.

AdultversuspediatricIOdevicesandneedlesareusuallyspecifiedonthepackaginglabeling.PediatricIOdevicesareonlyapprovedfortheproximalanddistaltibia.

Insertionlocation.

Tibia:B.I.G.,Cook,Sur-Fast,EZ-IO.

Proximalhumerus:EZ-IO.

Sternum(manubrium):FAST1,sternalEZ-IO.

DONOTUSEHUMERALORTIBIALIODEVICESONTHESTERNUM.

AllIVfluids(exceptHTSs)andmedicationscanbeadministratedviaIOinsimilarratestoIVinfusions.Confirmplacementof IObyaspiratingasmallamountofbloodandthenflushwith10mLofnormalsaline.

IO device placement is age and anatomically location-specific.CaremustbetakentoensureIOdeviceinsertioniscorrelatedtothepackaginglabelinginstructions(eg, tibialIOcannotbeusedonthesternumbecauseofthelengthoftheneedle).

The IOdevice shouldbe removedas soonaspossible afterother IVaccessisestablished,butdefinitelybefore24hours.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter8

Anesthesia

Introduction

Battlefield anesthesia primarily describes a state of balanced anesthesia usingadequate amounts of anesthetic agents to minimize cardiovascular instabilitywhile providing amnesia, analgesia, and a quiescent surgical field in atechnologically austere environment. Adapting anesthetic techniques tobattlefield conditions requires flexibility and a reliance on fundamental clinicalskills.Althoughmodernmonitorsprovideawealthofdata,thestethoscopemaybetheonlytoolavailableinanaustereenvironment.Thus,thevalueofcrispheartsounds and clear breath sounds when caring for an injured service membershouldnotbeunderestimated.

In addition, close collaboration and communication with the surgeon areessential to assist with aggressive resuscitation and a team approach todamagecontrolsurgerydecisions.

Airway

Many methods for securing a compromised airway exist, depending on theconditionoftheairway,theco-morbidstateofthepatient,andtheenvironmentinwhichcareisbeingrendered.Whenadefinitiveairwayisrequired,itisgenerallybest secured with direct laryngoscopy and an endotracheal tube (ETT) firmlysecuredinthetrachea.

IndicationsforaDefinitiveAirwayApnea/airwayobstruction/hypercarbia.Impendingairwayobstruction:facialfractures,retropharyngealhematoma,andinhalationinjury.Excessiveworkofbreathing.Shock(bloodpressure≤80mmHgsystolic).GlasgowComaScale≤8(seeAppendix2).Persistenthypoxia(SaO2<90%/PaO2<60mmHg).

SecondaryAirwayCompromiseCanResultFrom:Failuretorecognizetheneedforanairway.Inabilitytoestablishanairway.Failuretorecognizeanincorrectlyplacedairway.Displacementofapreviouslyestablishedairway.Failuretorecognizetheneedforventilation.

InductionofGeneralAnesthesiaTheanesthesiaprovidermustevaluatethepatientfor:

Concurrentillnessandcurrentstateofresuscitation.Airway—facial trauma, dentition, hyoid-to-mandibular symphysislength,extentofmouthopening.Cervicalspinemobility(preexistentandtraumarelated).Additionaldifficultairwayindicators:

Immobilization.

Children.

Shortneck/recedingmandible.

Facialhair.

Obesity.

Prominentupperincisors.

RapidSequenceIntubation(RSI)ChecklistEquipment.

Laryngoscope,blades,andbatteries(testeddaily).Suction,oxygensetup.ETTsandstylet.Airway adjuncts (oropharyngeal, nasopharyngeal, and LMA[laryngealmaskairway]).IVaccessitems.Monitors—pulseoximeter,ECG,bloodpressure,end-tidalCO2.Positive-pressureventilation(Ambubagoranesthesiamachine).

Drugs.Narcotics.Musclerelaxants.Anxiolyticsandamnestics.Inductionagentsandsedatives.Inhalationagents.

Narcotics.Fentanyl:1.0–2.0µg/kgIVbolus,thentitratetoeffect.Morphine:2–5mgIVbolusto load, then1–2mgevery5minutestoeffect.Dilaudid (Hydromorphone): 0.4–0.8mg IV to load, then 0.2–0.4mgevery5minutestoeffect.Use cautionwhen administering higher doses of opioids to patientswithrespiratoryorhemodynamiccompromiseorheadinjury.

Musclerelaxants.Depolarizing.

Succinylcholine.

1.0–1.5mg/kg.(NOTE:CandoublethedosetogiveIMifIVaccessisnotavailableanditisanemergency.)

Onset:30–60seconds.

Duration:5–10minutes.

Cancausebradycardia,fasciculations,elevatedintragastricpressure,elevatedintracranialpressure,potassiumrelease(especiallyin“chronic”burnorimmobilepatients),andprolongeddurationofactionpossiblewithpseudocholinesterasedeficiency.

Potenttriggerofmalignanthyperthermia.

Succinylcholine shouldNOT be used in patientswith burns orcrush injuries >24hoursoldor chronicneuromusculardisordersduetoriskforhyperkalemia.

Rocuroniumisthenextbestchoice.

Nondepolarizing.

Vecuronium:Inductiondoseof0.1mg/kg,withanonsetof2–3minutesandadurationofactionof30–40minutes.

Rocuronium:Inductiondoseof0.6mg/kg,withanonsetof1.5–2.5minutesandadurationofactionof35–50minutes.At1.2mg/kg,onsetissimilartosuccinylcholine,withadurationofactionthatcanexceed60–90minutes.

Pancuronium:Inductiondoseof0.1–0.15mg/kg(itwillcauseorexacerbatetachycardia),withanonsetof3.5–6minutesandadurationofactionof70–120minutes.

Cisatracurium:Inductiondoseof0.15–0.20mg/kg,withanonsetof2–3minutesandadurationofactionof30–40minutes.(Drugofchoiceforrenalorhepaticdisease.)

Anxiolyticsandamnestics.Versed(midazolam;0.5–2mgIVbolus).

Table8-1.InductionAgentsandSedatives

Agent RoutineDose* Characteristics Concerns

Ketamine1.0–2.0mg/kgIV

Dissociativeanestheticandamnestic

Sympathomimeticeffects(usefulinhypovolemia)

Potentbronchodilator

Varyingdegreesofpurposefulskeletalmovementdespiteintenseanalgesiaandamnesia

Onsetwithin30–60seconds

4.0–10.0mg/kgIM

Emergencedeliriumavoidedwithconcomitantbenzodiazepineuse

Increasedsalivation;consideranantisialagogue

Propofol1.0–2.5mg/kgIV

Mixedinlipid,strictsterilitymustbeensured

Rapidonsetandrapidlymetabolized

Onsetwithin30–60seconds

Contraindicatedinacutehypovolemicshockpatients

Etomidate0.2–0.4mg/kgIV

Onsetwithin30–60seconds

Duration:3–10minutes

Minimalcardiaceffects

Minimaleffectsonperipheralandpulmonarycirculation

Maintainscerebralperfusion

Maycauseclonus

Maycauseadrenalsuppression

*Allinductionagentscanbeusedforinductionofseverelyinjuredpatientsifreduceddosagesareused(eg,½ofthelowerrecommendeddose).However,therecommendedchoiceforhypovolemicpatientswouldbeketamine≥etomidate>>propofol.

Scopolamine: 0.4 mg IV. (For use in hemodynamically unstablepatients.)

Inductionagentsandsedatives(Table8-1).

RapidSequenceIntubation—6Steps

1. Preoxygenatewith100%oxygenbymask.2. Cricoidpressure(maintainuntilETTplacementisconfirmed).3. Inductionagent:etomidate0.2–0.4mg/kgIVpush.4. Muscle relaxant: succinylcholine 1.0–1.5 mg/kg IV push. 5.Laryngoscopy and orotracheal intubation (after 1 minute or seeingfasiculations).

5. Verifytubeplacement.

Considernasogastricororogastrictubeplacementaftersecuringairway.

NOTE:Forchildren,seeTable31-4.

Endotrachealintubation.Orotracheal.

Directlaryngoscopy60–90secondsafteradministrationofinductionagentsandneuromuscularblockade.

Firstattemptisthebestchanceforsuccess,buthaveabackupplan:

Optimizepositioningofpatientandanesthesiaprovider.

Haveadjunctsreadilyavailable(stylet,smallerdiametertubes,

alternativelaryngoscopeblades,suction,LMA,lightedstylet).

Nasotrachealintubationshouldgenerallynotbeperformed.Otherconsiderations.

Maintaincricoidpressureuntilballoonisinflatedandtubepositionisconfirmed.

Hypertensioncanbemanagedwithshort-actingmedications,suchasbetablockers(labetalol,esmolol).

Maytreatinduction-related(transient)hypotensioninitiallywithasmalldoseofephedrine(5–10mg),Neo-Synephrine(50µg),orepinephrine(5–10µg).But,ifhypotensionpersistsafterinductionagentsaremetabolized,usefluidstotreatthepersistenthypovolemia.Theanesthesiologistmustconveythissituationtothesurgeon,becausetheneedtocontrolbleedingbecomesurgent.

Asensitiveairwaycanbetopicallyanesthetizedwithlidocaine1.5mg/kg1–2minutesbeforelaryngoscopy.

VerifyETTplacement.Auscultatethelungs.Measuretheend-tidalCO2.EnsurethattheSaO2remainshigh.PalpatecuffofETTinsternalnotch.PlacethechemicalCO2sensorsintheairwaycircuit.

Verification of tube placement is VITAL. Any difficulty withoxygenation/ventilationfollowingRSIshouldpromptevaluationforimmediatereintubation.

TheDifficultAirway

(SeeChapter5,Airway/Breathing)

Initiallyprovideairwaymanagementwithjawthrustandfacemaskoxygenation.Assess the situation. Failed RSI may be due to inadequate time for inductionagents to work; inadequate time for muscle relaxation to occur; anatomicallydifficult airway; or obstruction due to secretions, blood, trauma, or foreignmaterial.

Resume oxygenation; consider placing a temporary oral and/or nasalairway.Repositionpatient.Callforhelp.ConsideralternativestoRSI.

Awakeintubation.LMA.Regionalanesthesia(RA)orlocalanesthesia.

Surgicalairway.

MaintenanceofGeneralAnesthesia

Generalanesthesiaismaintainedafterintubationwith:

Oxygen.TitratetomaintainSaO2>92%.Ventilation.

Tidalvolume:6–8cc/kg.Respiratoryrate:12–14/minute.Positive end-expiratory pressure: if desired at 5 cm H2O, titrate asnecessary.

Minimalalveolarconcentration(MAC).0.6 MAC: awareness reliably abolished, although 50% of patientsrespondtoverbalcommands.1MAC:50%ofpatientsdonotmovetosurgicalstimulus.1.3MAC:95%ofpatientsdonotmovetosurgicalstimulus.CommoninhalationagentMACs:

Halothane:0.75%.

Sevoflurane:1.8%.

Isoflurane:1.17%.

Desflurane6.00%.

Enflurane:1.63%.

Nitrousoxide:104%.

Additiveeffects(eg,60%nitrousoxidemixedwith0.8%sevofluraneyields1MAC).

Totalintravenousanesthesia.Mixmidazolam5mg,vecuronium10mg,ketamine200mg in50 ccnormalsalineandinfuseat0.5cc/kg/h(stop10–15minutesbeforeendofsurgery).Mix 50–100mg of ketaminewith 500mg of propofol (50 cc of 10%propofol)and250µgoffentanyl,andadministerat50–100µg/kg/minofpropofol(21–42mL/hfora70-kgpatient).

Balancedanesthesia(titrationofdrugsandgases)combine:0.4MACofinhaledagents.Versed:1–2mg/h.Ketamine:0.5–1mg/kg/h.Fentanyl:2–4µg/kg/h.

ConclusionofGeneralAnesthesiaIf the patient is to remain intubated, anesthetics may be terminated, butsedativesandpossiblymusclerelaxantsshouldbecontinued.Ifthepatientistobeextubated,controlledventilationisdecreasedtoallow

thepatienttospontaneouslybreathe.Anestheticagentsaretitratedtoallowforrapidrecovery.Muscle relaxation reversal is accomplishedwithNeostigmine (0.04–0.08mg/kgIVover3–5minutesandcanbemixedinthesamesyringeasGlycopyrrolate[Robinul0.01–0.02mg/kgIVover3–5minutes]).

Extubation criteria include reversal of muscle relaxation, spontaneousventilation, response to commands, eye opening, and head lifting for 5seconds.Whenindoubt,keepthepatientintubated.Amnestictherapywithmidazolamandanalgesictherapywithanarcoticareappropriate in small amounts so as not to eliminate the spontaneousrespiratorydrive.

RegionalAnesthesia

RA is a “field-friendly” anesthetic requiring minimal logistical support whileprovidingqualityanesthesiaandanalgesiaonthebattlefield.AdvantagesofRAonthemodernbattlefieldincludethefollowing:

Excellentoperatingconditions.Profoundperioperativeanalgesia.Stablehemodynamics.Limb-specificanesthesia.Reducedneedforotheranesthetics.Improvedpostoperativealertness.Minimalsideeffects.Rapidrecoveryfromanesthesia.Simple,easilytransportedequipmentneeded.

Recentconflictshaverevealedthatthemajorityofcasualtieswillhavesuperficialwoundsorwoundsof theextremities.RA iswell suited for themanagementofthese injuries either as an adjunct to general anesthesia or as the primaryanesthetic.TheuseofbasicRAblocksisencouragedwhentimeandresourcesareavailable.

Superficialcervicalplexusblock.Axillarybrachialplexusblock.IntravenousRA.Wristblock.Digitalnerveblock.Intercostobrachialnerveblock.Saphenousnerveblock.Ankleblock.Spinalanesthesia.Lumbarepiduralanesthesia.Combinedspinal-epiduralanesthesia.Femoralnerveblock.

Priortraininginbasicblocktechniquesisimplied,anduseofanervestimulator

orultrasound,whenappropriate, isencouraged toenhanceblocksuccess.Moreadvanced blocks and continuous peripheral nerve blocks are typically notavailable until the patient arrives at a Role 3 or higher level healthcare facilitywhere personnel trained in these techniques are available. A long-acting localanesthetic,suchas0.5%ropivacaine, isusedformostsingle-injectionperipheralnerveblocks.Peripheralnerveblockscanoftenbeusedtotreatpain(withouttherespiratorydepressionofnarcotics)whilepatientsarewaitingforsurgery.Donotperformaperipheralnerveblockforaninjuredextremitywithoutconsultinganorthopaedicorgeneralsurgeonregardingtheriskofcompartmentsyndromeandthepotentialtoobscureitsdiagnosis.

Neuraxialanesthesia.Subarachnoidblock.Epiduralblock.

When the patient’s physical condition allows the use of spinal or epiduralanesthesia,thosetechniquesareencouraged.Thesympathectomythatresultsisoften poorly tolerated in a trauma patient, and this must be factored into anydecision to use those techniques. Peripheral nerve blocks do not have thislimitation.

LocalAnesthesia

Whenlocalanesthesiawouldsuffice,suchasincertainwounddebridementsandwoundclosures,itshouldbethetechniqueofchoice.

FieldAnesthesiaEquipment

There are two anesthesia apparatuses currently fielded in the forward surgicalenvironment: (1) the drawover vaporizer and (2) a conventional portableventilatormachine.AschematicofthedrawoversystemisshowninFig.8-1.

Drawovervaporizer.Currently fielded model: Ohmeda Universal Portable AnesthesiaComplete(UPAC).Demand-type system (unlike the plenum systems in hospital-basedORs).

Fig.8-1.Drawoverapparatusincombinationwiththeventilator.

Whenthepatientdoesnotinitiateabreathortheself-inflatingbagisnotsqueezed,thereisnoflowofgas.Nodemandequalsnoflow.

Temperature-compensated,flow-overinlinevaporizer.Optimal oxygen conservation requires a larger reservoir (oxygeneconomizer tube) than is described in the operator’smanual—a 3.5-footoxygeneconomizertubeoptimizesFiO2.Maybeusedwithspontaneousorcontrolledventilations.Bolted-on performance chart outlines dial positions for somecommonlyusedanesthetics(eg,halothaneandisoflurane).

OhmedaUPACDrawoverApparatusinCombinationWiththeImpactUni-VentEagleModel754PortableVentilator

Currently, there is no mechanical ventilator specifically designed for usewith the UPAC drawover apparatus; but, use with various portableventilators has been studied in both the drawover and pushoverconfigurations.

Adding the ventilator frees the anesthesia provider’s hands whileproviding more uniform ventilation and more consistentconcentrationsoftheinhalationalanestheticagent.The drawover configuration places the ventilator distal to thevaporizer,entrainingambientairandvaporacrossthevaporizerinthesamemannerasthespontaneouslybreathingpatient.Donotattachacompressedsourceofair to the ImpactUni-VentEagleModel754 inthis configuration because the Uni-Vent Eagle Model 754 willpreferentially deliver the compressed gases and will not entrainair/anestheticgasesfromtheUPACdrawover.The pushover configuration places the ventilator proximal to thevaporizer, effectively pushing entrained ambient air across the

vaporizerandthentothepatient.The ImpactUni-Vent EagleModel 754 portable ventilator (Fig. 8-1) is notpartoftheUPACapparatus,butisstandardequipmentfortheUSmilitary.It has been used in combination with the Ohmeda UPAC drawoverapparatus.

The air entrainment (side intake) port is used to create thedrawover/ventilatorcombination.

Thesideintakeportoftheventilatorcontainsanonreturnvalve,preventingbackpressureonthevaporizerthatcouldresultinerraticandinconsistentanestheticagentconcentrations.

Thepatientair-outletportontheventilatoralsocontainsanonreturnvalve,preventingbackflowintotheventilatorfromthepatientside.Scavenging of waste gases can be accomplished by attachingcorrugatedanesthesiatubingtoeithertheoutletportoftheAmbuE-valve(inductioncircuit)ortheexhalationportoftheventilatortubing(ventilatorcircuit)ventingtotheoutsideatmosphere.The following items are added to the circuit to improve thisUPAC/ImpactUni-VentEagleModel754ventilatorcombination:

Smallandlargecircuitadapterstoaidinattachmentofvariouspieces.

PallHeatandMoistureExchangeFiltertoconserveheatandlimitpatientcontactwiththecircuit.

Accordioncircuitextendertomovetheweightofthecircuitawayfromthepatientconnection.

Oxygenextensiontubingtoattachsupplementaloxygen.

Two separate circuits should be constructed for use with theUPAC/Uni-Vent Eagle Model 754 combination: for induction andspontaneous ventilation and for controlled ventilation using theportableventilator.

Thisprocesscanbecomplicatedbecauseswitchingcircuitcomponentsrequiresseveraldisconnectionsandreconnections,creatingthepotentialforerror.(Practice.)

Conventionalplenumanesthesiamachine.Currentlyfieldedmodels:DragerNarkomedandFabiusTiroM.Compact version of standard OR machines, with comparablecapabilities.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter9

Soft-TissueandOpenJointInjuries

Allwarwoundsarecontaminatedandshouldnotbeclosedprimarily.

Introduction

The goals in the treatment of soft-tissue wounds are to save lives, preservefunction,minimizemorbidity,andpreventinfectionthroughearlyandaggressivesurgicalwoundcarefarforwardonthebattlefield.

PresurgicalCarePreventinfection.

Antibiotics.

Antibioticsarenotareplacementforsurgicaltreatment.

Antibioticsaretherapeutic,notprophylactic,inwarwounds.

Giveantibioticsforallpenetratingwoundsassoonaspossible.

Steriledressing.

Placeasterilefielddressingassoonaspossible.

Leavedressingundisturbeduntilsurgery.Aone-looksoft-tissueexaminationmaybeperformedoninitialpresentation.Infectionrateincreaseswithmultipleexaminationspriortosurgery.Initialwoundculturesunnecessary.

SurgicalWoundManagementPrioritiesLife-savingprocedureshavepriorityoverlimbandsoft-tissuewoundcare.Savelimbs.

Vascularshunt,bypass,orrepair.Compartmentrelease(seeChapter34,CompartmentSyndrome).

Preventinfection.Earlyantibioticadministration.Wounddebridementasearlyaspossible,preferablywithin6hoursofwounding.Steriledressing.Avoidwoundcareonmedical/surgicalward.Fractureimmobilization.

Superficialpenetratingfragment (singleormultiple) injuriesusuallydonotrequiresurgicalexploration.

Woundsshouldbeassessedforthepresenceofpressurizeddirt/debris

alongwithfragments.Limitedwoundextensionmaybereasonabletoremovedeepwoundcontamination.If thereisnosignificantdeepcontamination,superficialwoundsandskincanbecleansedwithantisepticandscrubbrush.Avoid“Swisscheese”surgery—connectionofmultiplesmallwoundsintoasinglesurgicalwoundispreferredoverthecreationofmultiplelargewounds thatwill result in prolongedhealing ormay limit theabilitytoaccomplishadelayedrepair.Maintainhighsuspicionforvascular injuryandconcurrent fragmentwoundingtohead,chest,abdomen,andpelvis.

WoundCare

PrimarySurgicalWoundCare

Limitedlongitudinalincisions.Excisionofforeignmaterialanddevitalizedtissue.Irrigation.LEAVEWOUNDOPEN—NOPRIMARYCLOSURE.Antibioticsandtetanusprophylaxis.Splintfortransport(improvespaincontrol).

Longitudinalincisions.Extendwounds parallel to the longitudinal axis of the extremity tofacilitatedeepexposure.Longitudinal incisions allow for proximal and distal extension formorethoroughvisualizationanddebridement.Avoidtransverseincisions;theydonotfacilitatesubsequentextensionifneeded.Inciseobliquelyacrossflexioncreasestopreventflexioncontracture.

Woundexcision(currentuseofthetermdebridement).Skin.

Performconservativeexcision(1–2mm)ofdamagedskinedges(Fig.9-1a).

Questionableareascanbeassessedatthenextdebridement.

Fat.

Damaged,contaminatedfatshouldbegenerouslyexcised.

Fig.9-1.(a)Skinexcision,(b)removaloffascia,(c)removalofavasculartissue,and(d)irrigation.

Fascia.

Damagetothefasciaisoftenminimalrelativetothemagnitudeofdestructionbeneathit(Fig.9-1b).

Shredded,tornportionsoffasciaareexcised,andthefasciaiswidelyopenedthroughalongitudinalincisiontoexposetheentirezoneofinjurybeneath.

Completefasciotomyshouldbeperformedforcompartmentsyndrome.

Limitedfasciotomyisreservedforlocalizedfascialinjurywithoutevidenceofcompartmentsyndrome.

Removal of dead muscle is important to prevent infection.ACCURATE INITIAL ASSESSMENT OF MUSCLE VIABILITY IS DIFFICULT.Tissue-sparing debridement is acceptable if follow-on woundsurgerywilloccurwithin24hours.Moreaggressivedebridementisrequiredifsubsequentsurgerywillbedelayedformorethan24hours.

Muscle.

Sharplyexciseallnonviable,severelydamaged,avascularmuscle(Fig.9-1c).

The“4C’s”(color,contraction,consistency,andcirculation)maybeunreliableforinitialassessmentofmuscleviability.Theyshouldbeusedtogethertoassistindeterminingtheextentofmuscledamage.

Color—Assessmentmaybeunreliablewhenusedindependently.Surfacemusclemaybediscoloredduetobloodunderthemyomysium,contusion,orlocalvasoconstriction.Muscleatthewoundmarginmayalsobetransientlyhypoperfusedinanincompletelyresuscitatedpatient.

Contraction—Assessedbyobservingtheretractionofthemusclewiththegentlepinchofforcepsoraresponsetoelectrocautery.

Consistency—Maybethebestpredictorofviability.Ingeneral,viablemusclewillreboundtoitsoriginalshapewhengraspedbyforceps,whereasmusclethatretainsindentationfromtheforcepshasquestionableviability.

Circulation—Assessmentviableedingtissuefromafreshwound.Transientvasospasm,commonwithwarwounds,maynotallowforotherwisehealthytissuetobleed.

Bone.

Fragmentsofbonewithvascularizedsoft-tissueattachmentsandlargefreearticularfragmentsarepreserved.

Removealldevitalized,avascularpiecesofbonesmallerthanthumbnailsizethathavenosoft-tissueattachment.

Removelargefragmentsofdiaphysealandmetadiaphy-sealbonethathavenosoft-tissueattachments,butconsiderretentionofosteoarticularfragmentsafterthoroughdebridementiftheywerenotgrosslycontaminatedfromthewoundingmechanism.

Delivereachoftheboneendsofanyfractureindependently,cleanthesurface,andcleanouttheendsofthemedullarycanal.

Nervesandtendons.

Debridement—Notnormallyrequiredexceptfortrimmingfrayededgesandresectinggrosslydestroyedportions.

Primaryrepairisnotperformed.Topreventdesiccation,usesoft-tissueormoistdressingsforcoverage.

Vessels.

(Refer to Chapter 25, Vascular Injuries, for a discussion ofconsiderationsinvascularshunting,bypass,andrepair.)

Debridement—Generallyonlyaminimaldebridementofthevesselisrecommendedforpurposesofdecreasedinfectionrisk.Priorityshouldbegiventorestorationofflowtominimizedistaltissueischemiaatthetimeofinitialdebridement.

Irrigation.

Irrigationshouldbeginafterthoroughsurgicaldebridementhasbeenaccomplished.

Irrigationshouldbeperformeduntilthewoundisvisiblyclean(Fig.9-1d).

Irrigationvolumebetween6and12Lisoftenutilizedforsignificantlycontaminated,largeopenwounds.

Low-pressureirrigationispreferredforacutewounds.Highpressuremayextendwoundcontaminantsdeeperintosofttissues.Mechanicalirrigationmaybenecessaryifwoundshavebeenchronicallycontaminated.

Sterilephysiologicalfluid(0.9%normalsaline)ispreferred.Potablewatermaybeusedasanalternativewhenresourcesarescarce.Mayconsideruseofmildsoapsolutiontopotablewater,aswellasterminalirrigationwithsterilesolution(1–2L).

Asterile,bulkydrydressingismostappropriateforpatientsbeingtransportedthroughandoutofthebattlefield.

Negativepressurewoundtherapy(NPWT).

NPWTdevicesmaybehelpfulincontainingthewoundenvironment.

NPWTdevicesmayenhancethelocalwoundenvironmentandvascularpermeabilityforwoundhealing.

NPWTdevicesmaybeplacedoversplit-thicknessskingraftstofacilitategraftadherence.

LossofoperationofNPWTdevicescancreateanenvironmentwithahigherriskofinfection.Whenutilized,NPWTdevicesneedtobecheckedfrequentlytoensureoperationalperformance.

MakeshiftandimprovisedNPWTdevicesperformunpredictablyandshouldnotbeusedinacombattheaterorduringaeromedicaltransport.

Antibioticbeads.

Antibioticbeadsarenotusedforthemajorityofopenwounds.

Antibioticbeadsmaybehelpfulinextendingtheperiodof

bacterialregrowthafterinitialdebridement.

Antibioticbeadsarenormallymadeusing1gofVancomycin/1.2gofTobramycinper40gofpoly(methylmethacrylate)(PMMA)cement.

MayconsideruseofPMMAantibioticbeadsbeneathNPWTdevices.

Localsoft-tissuecoverage.

Thedevelopmentandrotationofflapsforthispurposeshouldnotbedoneduringprimarysurgicalwoundcare.

Localsoft-tissuecoveragethroughthegentlemobilizationofadjacenthealthytissuetopreventdrying,necrosis,andinfectionisrecommended.Saline-soakedgauzeisanalternative.

NoPrimaryClosureofWarWounds

Dressing.

Cavitarywounds—Woundmaybegentlypackedwithgauzetoserveasawickforfluidegress.Donotplugthewoundwithpackingbecausethispreventswounddrainageandcreatesananaerobicenvironment.

Looselyapplycircumferentialbandagesinanticipationofswellingduringinitial72hourspostoperative.

WoundManagementAfterInitialSurgeryThewoundundergoesaplannedseconddebridementandirrigationin24–48hours,andsubsequentproceduresuntilacleanwoundisachieved.Thetimeintervalbetweendebridementsmaybeextendedto48–72hoursifNPWTdevicesareutilized,providedallnonviabletissuehasbeenremoved.Betweenprocedures,theremaybebetterdemarcationofnonviabletissueorthedevelopmentoflocalinfection.Earlysoft-tissuecoverageisdesirablewithin3–5days,whenthewoundisclean,topreventsecondaryinfection.Delayed primary closure (3–5 days) requires a clean wound that can beclosedwithoutunduetension.Thisstatemaybedifficulttoachieveinwarwounds.Soft-tissue war wounds heal well through secondary intention. This isespeciallytrueofsimplesoft-tissuewounds.Definitiveclosurewithskingraftsandmuscleflapsshouldnotbedoneintheater when evacuation is possible. These techniques may be required,however,forinjuredhostnationcasualties.

CrushSyndromeWhenavictim is crushedor trappedwith compressionon theextremities

for a prolonged time, there is the possibility for crush syndrome,characterizedbyischemiaandmuscledamageordeath(rhabdomyolysis).

With rhabdomyolysis, there is an efflux of potassium, nephrotoxicmetabolites, myoglobin, purines, and phosphorous into thecirculation,thusresultingincardiacandrenaldysfunction.Reperfusion injurycancauseup to10Lof third-space fluid lossperlimbthatcanprecipitatehypovolemicshock.Acute renal failure (ARF) can result from the combination ofnephrotoxicsubstancesfrommuscledeath(myoglobin,uricacid)andhypovolemia,resultinginarenallow-flowstate.

Recognition.History.

Suspectinpatientsinwhomthereisahistoryofbeingtrapped(eg,urbanoperations,mountainoperations,earthquakes,orbombings)foraprolongedperiod(fromhourstodays).

Clearhistoryisnotalwaysavailableincombat,andthesyndromemayappearinsidiouslyinpatientswhoinitiallyappearwell.

Physicalfindings.

Athoroughexaminationmustbedonewithattentiontoextremities,trunk,andbuttocks.

Physicalfindingsdependonthedurationofentrapment,treatmentrendered,andtimesincethevictim’srelease.

Extremities.

Mayinitiallyappearnormaljustafterextrication.

Edemadevelopsandtheextremitybecomesswollen,cool,andtense.

Mayhaveseverepainoutofproportionwithexamination.

Anesthesiaandparalysisoftheextremities,whichcanmimicaspinalcordinjurywithflaccidparalysis,buttherewillbenormalbowelandbladderfunction.

Trunk/buttocks:Mayhaveseverepainoutofproportionwithexaminationintensecompartments.

Laboratoryfindings.

Creatininephosphokinase(CPK)iselevatedwithvaluesusually>100,000IU/mL.

Theurinemayinitiallyappearconcentratedandlaterchangecolortoatypicalreddish-browncolor—theso-called“portwine”or“icedtea”urine.Urineoutputdecreasesinvolumeovertime.

Duetomyoglobin,urinedipstickispositiveforblood,butmicroscopywillnotdemonstrateredbloodcells.Theurinemaybesenttocheckformyoglobin,butresultstakedaysandshouldnotdelaytherapy.

Hematocrit/hemoglobin(H/H)canvary,dependingonbloodloss;but,inisolatedcrushsyndrome,H/Hiselevatedduetohemoconcentrationfromthird-spacingfluidlosses.

Withprogression,serumpotassiumandCPKincreasefurtherwithaworseningmetabolicacidosis.CreatinineandBUNwillriseasrenalfailureensues.Hyperkalemiaistypicallytheultimatecauseofdeathfromcardiacarrhythmia.

Therapy.Onscenewhilestilltrapped.

TheprimarygoaloftherapyistopreventARFincrushsyndrome.Suspect,recognize,andtreatrhabdomyolysisearlyinvictimsofentrapment.

Therapyshouldbeinitiatedassoonaspossible,preferablyinthefield,whilethecasualtyisstilltrapped.Ideally,itisrecommendedtoestablishIVaccessinafreearmorlegvein.

AvoidpotassiumandlactatecontainingIVsolutions.

Atleast1Lshouldbegivenpriortoextricationandupto1L/h(forshortextricationtimes)toamaximumof6–10L/dinprolongedentrapments.

Asalastresort,amputationmaybenecessaryforrescueofentrappedcasualties(ketamine2mg/kgIVforanesthesiaanduseofproximaltourniquet).

Hospitalcare.

Otherinjuriesandelectrolyteanomaliesmustbetreatedwhilecontinuingfluidresuscitation,asgivenpreviously,toprotectrenalfunction.

Foleycatheterforurineoutputmonitoring.

Establishandmaintainurineoutput>100cc/huntilpigmentshaveclearedfromtheurine.Ifnecessary,also:

AddsodiumbicarbonatetotheIVfluid(1amp/LD5W)toalkalinizetheurineaboveapHof6.5.

IfunabletomonitorurinepH,put1ampineveryotherIVliter.

Administermannitol,20%solution1–2g/kgover4hours(upto

200g/d),inadditiontotheIVfluids.

Centralvenousmonitoringmaybeneededwiththelargervolumes(mayexceed12L/dtoachievenecessaryurineoutput)offluidgiven.

Electrolyteabnormalities.

Hyperkalemia,hyperphosphatemia,hypocalcemia,andhyperuricemiamustbeaddressed.

Dialysis.

ARFrequiringdialysisoccursin50%–100%ofthosewithsevererhabdomyolysis.

Surgicalmanagementcentersondiagnosisandtreatmentofcompartmentsyndrome—remembertochecktorsoandbuttocksaswell.

Amputation:Considerincasualtieswithirreversiblemusclenecrosis/necroticextremity.

Hyperbaricoxygentherapy:Maybeusefulaftersurgicaltherapytoimprovelimbsurvival.

CompartmentSyndrome

(SeeChapter25,VascularInjuries,andChapter34,CompartmentSyndrome)

Compartmentsyndromeisanurgentsurgicalcondition.Combat extremity injuries are at an elevated risk of developing acompartmentsyndromewithin48–72hourspostinjury.Compartment syndrome may occur with an injury to any fascialcompartment:extremities,buttocks,ortrunk.Compartment syndromemay occurwith fascial defects or openwounds.Thedefectmaynotbeadequatetofullydecompressthecompartment.Compartmentsyndromeisaclinicaldiagnosis.Pressuremeasurementisnotnecessaryoradvisedinacombatsetting.All compartments within a surgical-treated extremity should be released.Do not perform single or selective compartment release, especially in thelowerlegandforearm.Mechanismsofinjuriesassociatedwithcompartmentsyndromeincludethefollowing:

Openfractures.Closedfractures.Penetratingwounds.Crushinjuries.Vascularinjuries.Reperfusionfollowingvascularrepairs.

Earlyclinicaldiagnosisofcompartmentsyndrome.

Painoutofproportionwithinjuryandtreatment.Tense,swollencompartment.Painwithpassivestretch.

Lateclinicaldiagnosis.Paresthesia.Pulselessnessandpallor.Paralysis.

Treatment:Emergentfasciotomy.Measurementofcompartmentpressures.

Notindicatedforpatientswithaclearexamination.May be considered for patients who cannot be accurately assessed(obtunded, intubated, and sedated body habitus), with low clinicalsuspicion,butenteringprolongedtransport.

Considerprophylacticfasciotomyforhighindexofsuspicionandlimitedcapacityforserialexamination.

Intubated,comatose,sedated.Closed-headinjuries.Vascularrepairindependentofischemiatime.Prolongedtransport.

FasciotomyTechnique

(SeeChapter34,CompartmentSyndrome)

Usefull-lengthincisionstoensurethatskinandsubcutaneoustissuesdonotconstricttheunderlyingmuscletissue.Keep fasciotomy wounds covered with moist dressing or an NPWTdevice. Do not use closure/approximation techniques during the initialfasciotomyifbeingtransported.Thesemaybeappropriatetoconsiderifthepatientisnottransportedandcanbeadequatelymonitored.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter10

Infections

Introduction

All wounds incurred on the battlefield are grossly contaminated withbacteria.Mostwillbecomeinfectedunlessappropriatetreatmentisinitiatedquickly.

Thebattlefieldenvironmentisconducivetowoundinfectionduetothe:

Absenceof“sterile”woundingagentsonthebattlefield.Allforeignbodies(wounding projectile fragments, clothing, dirt) are contaminated withbacteria.High-energyprojectilewounding:

devitalizedtissue,hematoma,andtissueischemia.

Delayincasualtyevacuation.

DiagnosisofaWoundInfectionThe four “-or’s”: dolor, rubor, calor, and tumor—pain and tenderness,redness,warmth,andswelling.Drainage or discharge, ranging from frank pus to the foul “dishwater”dischargeofclostridialinfection.Crepitus, radiographic evidence of soft-tissue gas, epidermal blistering,and/or epidermal necrosis are the hallmarks of necrotizing soft-tissueinfection(eg,clostridialgasgangreneornecrotizingfasciitis).Systemic effects: fever, leukocytosis, unexplained tachycardia, orhypotension.Confirm diagnosis by Gram stain and culture, if available, and/or tissuebiopsy.

CommonMicroorganismsCausingBattlefieldInfectionsGram-positivecocci:

staphylococci,streptococci,andenterococci.

Gram-negativerods:Escherichiacoli,Proteus,andKlebsiella.Pseudomonas, Enterobacter, Acinetobacter, and Serratia are common

nosocomial pathogens usually expected among casualtieswho havebeen hospitalized for an extended period, not those fresh off thebattlefield.

Salmonella, Shigella, and Vibrio should be suspected in cases of bacterialdysentery.Anaerobicgram-positiveandgram-negativerods:

Clostridia,Bacteroides,andPrevotellaspecies.

Fungal species: Candida species should be suspected in casualtieshospitalized for prolonged periods, those malnourished orimmunosuppressed, or those who have received broad-spectrumantibiotics,adrenocorticalsteroids,orparenteralnutrition.Empirictherapyshouldbeconsideredinappropriatepatientswithpresumptiveevidenceoffungalinfection.

CommonPatternsofInfectionSkin, soft tissue, muscle, and bone: Primarily due to staphylococcal,streptococcal,andclostridialspecies.Theseinfectionsinclude:

woundabscess,cellulitis,septicarthritis,osteomyelitis,necrotizingfasciitis,andgasgangrene.

Intracranial: Meningitis, encephalitis, and abscess—commonly fromstaphylococci and gram-negative rods—are difficult to treat due to theimperviousnatureofthemeningestocommonantibiotics.Orofacialandneck:Gram-positivecocciandmouthanaerobesaregenerallyresponsivetosurgeryandclindamycin.Thoracic cavity: Empyema (usually staphylococcal) and pneumonia(Staphylococcus,Streptococcus, andPseudomonas), especiallyamong thoseonprolonged mechanical ventilation or those casualties prone to aspiration(polymicrobial).Intraabdominal: Include posttraumatic or postoperative abscess andperitonitis due to Enterococcus, gram-negative rods, and anaerobic bacilli.Clostridium difficile is often responsible for a potentially severe diarrhealcolitis that occurs following the administration of even one dose ofantibiotic.Systemic sepsis: A syndrome caused by a bloodborne or severe regionalinfection resulting in a global inflammatory response (fever, leukocytosis,tachycardia,tachypnea,andpossiblyhypotension).

Asimilarinflammatoryresponsewithoutinfectioncanbecausedbyafocusof retainednecrotic tissueor themere act of sustaining severetrauma.

Culprit microorganisms will not be recovered in all cases of sepsissyndrome.Although typically associated with gram-negative organisms, anybacterialorfungalagentcancausesepsis.

Prompt surgical source control, including debridement anddrainage,arethecornerstonesofprophylaxis/treatmentofallwarwoundinfections.

Treatment

GeneralPrinciplesSurgicalandantibiotic treatmentshouldbeginasearlyaspossible, ideallywithin3hoursafterinjuryandberepeatedintheprophylaxisofwarwoundinfection.Optimally, surgical debridement should be achieved within 6 hours ofinjury.Following initial exploration and debridement, the wound should besufficiently irrigated to ensure that all dead material, bacterialcontamination,andforeignmaterialhavebeenwashedfromthewound.

Table10-1.RecommendationstoPreventInfectionsAssociatedWithCombat-RelatedInjuriesBasedonLevelofCareLevelofCare* CareCategory Recommendations

Role1field Initialcareinthefield

Bandagewoundswithsteriledressings(avoidpressureovereyewounds)

Stabilizefractures

Transfertosurgicalsupportassoonasfeasible

Postinjuryantimicrobials

Providesingle-dosepoint-of-injuryantimicrobialsifevacuationdelayedorexpectedtobedelayed

Role1treatmentfacility/Role2withoutsurgicalsupport

Postinjuryantimicrobials

ProvideIVantimicrobialsassoonaspossible(within3h)

Providetetanustoxoidandimmuneglobulinasappropriate

Enhancegram-negativecoveragewithaminoglycosideorfluoroquinolonenotrecommended

Additionofpenicillintopreventclostridialgangreneorstreptococcalinfectionnotrecommended

Redoseantimicrobialsiflargevolumeofbloodproducesresuscitation

Useonlytopicalantimicrobialsforburns

Debridement

Irrigatewoundstoremovegrosscontaminationwithnormalsaline,sterile,orpotablewater,underlowpressure(bulbsyringeorequivalent)withoutadditives

andirrigation Donotattempttoremoveretaineddeepsoft-tissuefragmentsifcriteriamet;†provideCefazolin2gIV×1dose

Role2withsurgicalsupportandRole3

Postinjuryantimicrobials

ProvideIVantimicrobialsassoonaspossible(within3h)

Providetetanustoxoidandimmuneglobulinasappropriate

Enhancegram-negativecoveragewithaminoglycosideorfluoroquinolonenotrecommended

Additionofpenicillintopreventclostridialgangreneorstreptococcalinfectionnotrecommended

Redoseantimicrobialsiflargevolumeofbloodproducesresuscitation

Useonlytopicalantimicrobialsforburns

Antimicrobialbeadsorpouchesmaybeused

Providepostsplenectomyimmunizationsifindicated

Debridementandirrigation

Irrigatewoundstoremovecontaminationwithnormalsalineorsterilewater,underlowpressure(5–10PSI;eg,bulbsyringeorgravityflow)withoutadditives(use3LforeachtypeI,6LforeachtypeII,and9LforeachtypeIIIextremityfractures)

Donotattempttoremoveretaineddeepsoft-tissuefragmentsifcriteriamet;†provideCefazolin2gIV×1dose

Donotobtainculturesunlessinfectionsuspected

Surgicalwoundmanagement

Surgicalevaluationassoonaspossible

Onlyduralandfacialwoundsshouldundergoprimaryclosure

NPWTcanbeused

Externalfixation(temporaryspanning)offemur/tibiafractures

Externalfixation(temporaryspanning)orsplintimmobilizationofopenhumerus/forearmfractures

Role4 Postinjuryantimicrobials

Completecourseofpostinjuryantimicrobials

Antimicrobialbeadsorpouchesmaybeused

Providepostsplenectomyimmunizationsifindicated

Debridementandirrigation

Irrigatewoundstoremovecontaminationwithnormalsalineorsterilewater,underlowpressure(5–10PSI;eg,bulbsyringeorgravityflow)withoutadditives(use3LforeachtypeI,6LforeachtypeII,and9LforeachtypeIIIextremityfractures)

Donotattempttoremoveretaineddeepsoft-tissuefragmentsifcriteriamet;†provideCefazolin2gIV×1dose

Donotobtainculturesunlessinfectionsuspected

Surgicalwoundmanagement

Woundsshouldnotbecloseduntil3–5dpostinjury

Onlyduralandfacialwoundsshouldundergoprimaryclosure

NPWTcanbeused

Externalfixation(temporaryspanning)offemur/tibiafractures

Externalfixation(temporaryspanning)orsplintimmobilizationofopenhumerus/forearmfractures

IV:intravenous;NPWT:negativepressurewoundtherapy;PSI:poundspersquareinch.

*Roleofcare,levelofcare,andechelonofcareareconsideredsynonymouswithrole,currentlythepreferredUSmilitaryterm.Role1—self-aid,buddyaid,combatlifesaver,andcombatmedic/corpsmancareatthepoint-of-injury;physician/physicianassistantcareatbattalionaidstation(USArmy)orshocktraumaplatoon(USMarineCorps[USMC]);nopatientholdingcapacity.Role2—medicalcompany(includesforwardsupportmedicalcompany,mainsupportmedicalcompany,andareasupportmedicalcompanyinUSArmy)orexpeditionarymedicalsupport(USAirForce[USAF]);72-hpatientholdingcapacity,basicbloodtransfusion,radiography,andlaboratorysupport.Maybesupplementedwithsurgicalassets(Level2b)(forwardsurgicalteam,USArmy;mobilefieldsurgicalteam,USAF;forwardresuscitativesurgicalsystem,USMC).Role3—combatsupporthospital(USArmy),AirForcetheaterhospital(USAF),orcasualtyreceivingships(USNavy);fullinpatientcapacitywithintensivecareunitsandoperatingrooms.Role4—regionalhospital(LandstuhlRegionalMedicalCenter,Germany)orUSnavalhospitalships,typicallyoutsideofthecombatzone;generalandspecializedinpatientmedicalandsurgicalcare.Role5—carefacilitieswithintheUnitedStates,typicallytertiarycaremedicalcenters.†Criteriaforallowingretainedfragmentstoremainbehind:entry/exitwounds<2cm;nobone,joint,vascular,andbodycavityinvolvement;nohigh-risketiology(eg,mine);noobviousinfection;andassessiblebyX-ray.ReprintedwithpermissionandminorchangesfromHospenthalDR,MurrayCK,AndersenRC,etal.Guidelinesforthepreventionofinfectionsassociatedwithcombat-relatedinjuries:2011update(endorsedbytheInfectiousDiseasesSocietyofAmericaandtheSurgicalInfectionSociety).JTrauma.2011;71(2):S210–S234.

Table10-2.PostinjuryAntimicrobialAgentSelectionandDurationBasedUponInjuryPattern*Injury PreferredAgent(s) AlternateAgent(s) Duration

Extremitywounds(includeskin,softtissue,andbone)

Skin,softtissue,noopenfractures Cefazolin2gIVq6–8h†,‡

Clindamycin(300–450mgPOTIDor600mgIVq8h) 1–3d

Skin,softtissue,withopenfractures,exposedbone,oropenjoints

Cefazolin2gIVq6–8h†,‡,§ Clindamycin600mgIVq8h 1–3d

Thoracicwounds

Penetratingchestinjurywithoutesophagealdisruption

Cefazolin2gIVq6–8h†,‡Clindamycin(300–450mgPOTIDor600mgIVq8h) 1d

Penetratingchestinjurywithesophagealdisruption

Cefazolin2gIVq6–8h†,‡+metronidazole500mgIVq8–12h

Ertapenem1gIV×1doseormoxifloxacin400mgIV×1dose

1dafterdefinitivewashout

Abdominalwounds

Penetratingabdominalinjurywithsuspected/knownhollowviscusinjuryandsoilage;mayapplytorectal/perinealinjuriesaswell

Cefazolin2gIVq6–8h†,‡+metronidazole500mgIVq8–12h

Ertapenem1gIV×1doseormoxifloxacin400mgIV×1dose

1dafterdefinitivewashout

Maxillofacialandneckwounds

Openmaxillofacialfractures,ormaxillofacialfractureswithforeignbodyorfixationdevice

Cefazolin2gIVq6–8h†,‡ Clindamycin600mgIVq8h 1d

Centralnervoussystemwounds

Penetratingbraininjury

Cefazolin2gIVq6–8h†,‡;consideraddingmetronidazole500mgIVq8–12hifgrosscontaminationwithorganicdebris

Ceftriaxone2gIVq24h;consideraddingmetronidazole500mgIVq8–12hifgrosscontaminationwithorganicdebris;forpenicillinallergicpatients,vancomycin1gIVq12h+ciprofloxacin400mgIVq8–12h

5doruntilCSFleakisclosed,whicheverislonger

Penetratingspinalcordinjury

Cefazolin2gIVq6–8h†,‡;ADDmetronidazole500mgIVq8–12hifabdominalcavityisinvolved

Asabove;ADDmetronidazole500mgIVq8–12hifabdominalcavityisinvolved

5doruntilCSFleakisclosed,whicheverislonger

Eyewounds

Eyeinjury,burn,orabrasion

Topical:ErythromycinorBacitracinophthalmicointmentQIDandPRNforsymptomaticrelief

Systemic:Nosystemictreatmentrequired

Fluoroquinolone1dropQID

Untilepitheliumhealed(nofluoresceinstaining)

Eyeinjury,penetrating

Levofloxacin500mgIV/POoncedaily;beforeprimaryrepair,notopicalagentsshouldbeusedunlessdirectedbyophthalmology

7doruntilevaluatedbyaretinalspecialist

Burns

Topicalantimicrobialswithtwicedailydressingchanges(includemafenideacetate¥or

Superficialburns silversulfadiazine;mayalternatebetweenthetwo),silver-impregnateddressingchangedq3–5d,orBiobrane

Silvernitratesolutionappliedtodressings

Untilhealed

Deeppartial-thicknessburns

Topicalantimicrobialswithtwicedailydressingchanges,orsilver-impregnateddressingchangedq3–5d+excisionandgrafting

Silvernitratesolutionappliedtodressings+excisionandgrafting

Untilhealedorgrafted

Full-thicknessburnsTopicalantimicrobialswithtwicedailydressingchanges+excisionandgrafting

Silvernitratesolutionappliedtodressings+excisionandgrafting

Untilhealedorgrafted

Point-of-injury/delayedevacuation¶

Expecteddelaytoreachsurgicalcare

Moxifloxacin400mgPO×1dose;ertapenem1gIVorIMifpenetratingabdominalinjury,shock,orunabletotoleratePOmedications

Levofloxacin500mgPO×1dose;Cefotetan2gIVorIMq12hifpenetratingabdominalinjury,shock,orunabletotoleratePOmedications

Single-dosetherapy

CSF:cerebrospinalfluid;IM:intramuscular;IV:intravenous;PO:orally;PRN:asneeded;QID:fourtimesdaily;TID:threetimesdaily.

*Postinjuryantimicrobialagentsarerecommendedtopreventearlyposttraumaticinfectiouscomplications,includingsepsis,secondarytocommonbacterialflora.Selectionisbasedonnarrowestspectrumanddurationrequiredtopreventearlyinfectionsbeforeadequatesurgicalwoundmanagement.Thisnarrowspectrumisselectedtoavoidselectionofresistantbacteria.Theantimicrobialslistedarenotintendedforuseinestablishedinfections,wheremultidrug-resistantorothernosocomialpathogensmaybecausinginfection.†Cefazolinmaybedosedbasedonbodymass:1gifweight≤80kg(176lbs),2gifweight81–160kg(177–352lbs),and3gifweight>160kg(>352lbs);dosesupto12gdailyaresupportedbytheFoodandDrugAdministration(FDA)-approvedpackageinsert.‡Pediatricdosing:Cefazolin,20–30mg/kgIVq6–8h(maximum:100mg/kg/d);metronidazole,7.5mg/kgIVq6h;clindamycin,25–40mg/kg/dIVdividedq6–8h;ertapenem,15mg/kgIVorIMq12h(childrenupto12years)or20mg/kgIVorIMoncedaily(childrenolderthan12years;maximum:1g/d);ceftriaxone,100mg/kg/dIVdividedq12–24h(dosingforcentralnervoussysteminjury);levofloxacin,8mg/kgIVorPOq12h(levofloxacinisonlyFDA-approvedinchildrenforprophylaxisofinhalationalanthraxinchildrenolderthan6months,butthisdoseiscommonlyusedforotherindications);vancomycin,60mg/kg/dIVdividedq6h(dosingforcentralnervoussysteminjury);andciprofloxacin,10mg/kgIV(or10–20mg/kgPO)q12h.§Theseguidelinesdonotadvocateaddingenhancedgram-negativebacteriacoverage(ie,additionoffluoroquinoloneoraminoglycosideantimicrobials)intypeIIIfractures.¥Mafenideacetateiscontraindicatedininfantsyoungerthan2months.¶PostinjuryantimicrobialtherapyassuggestedbytheTacticalCombatCasualtyCareCommittee.

ReprintedwithpermissionandminorchangesfromHospenthalDR,MurrayCK,AndersenRC,etal.Guidelinesforthepreventionofinfectionsassociatedwithcombat-relatedinjuries:2011update(endorsedbytheInfectiousDiseasesSocietyofAmericaandtheSurgicalInfectionSociety).JTrauma.2011;71(2):S210–S234.

Woundsshouldbeirrigatedtominimizegrosscontaminationwithsalineorsterilewaterbybulbsyringeorgravityflowfromirrigantbag.The skin is left open, and a lightly moistened sterile gauze dressing is

applied.For largerwounds,placementofavacuum-assistedclosuredevicemaybeindicated.Antibiotics should be started as soon as possible after wounding, thencontinued for 24 hours, depending on the size, extent of destruction, anddegreeofcontaminationofthewound.

Table10-3.SpecificAntibioticCoverageforTheater-SpecificConcerns:CultureSpecificRecommendationsCulture Recommendations

Carbapenem-resistantAcinetobacter

1stLine(ifsensitive):Tobramycin5–7mg/kgqd×10–14days(monitortroughsifcapable;goal,2.0;otherwise,proceedto2nd-linedrugifCrincreases>0.5)

2ndLine:Colistin2.5–5.0mg/kg/din2–4divideddoses

3rdLine:Tigecycline100mgload,then50mgqd×10days

MRSApneumonia

1stLine:Linelozid600mgIV/POBID(literaturesuggestslinelozidoffersatreatmentadvantageovervancomycin)

2ndLine:Vancomycin15mg/kgq12h×10–14days(maintaintroughlevelof15–20µg/mL)

ForSEPSIS(EmpiricTreatment):

Performempiriccultures.Theninitiateantibioticswithin4hours.1stLine:Carbapenemwithantipseudomonalcoverageimipenem1gq6hormeropenem1gq8hPLUSAmikacin15–20mg/kg/dorgentamicin5–7mg/kg/d.Consideraddingvancomycin15mg/kgq12hifVAPsuspected.

CRITICAL:Butthisshouldbebasedonindividualsiteantibiotigram.

BID:twiceaday;Cr:creatine;IV:intravenous;MRSA:methicillin-resistantStaphylococcusaureus;PO:peros(bymouth);qd:everyday;VAP:ventilator-associatedpneumonia.Datasource:Reprinted,withminormodifications,fromAppendixC,SpecificAntibioticCoverageforTheater-SpecificConcerns,ClinicalPracticeGuidelines(AgencyforHealthcareResearchandQuality,Rockville,MD).

Iftimefromwoundingtoinitiationofantibioticsis>6hours,ortimefrom wounding to surgery is >12 hours, give an antibiotics-usingregimenforestablishedinfection.

Thechoiceofempiricantibioticisdependentonthepartofthebodyinjured(Tables10-1to10-3).Once a battlefield wound has become infected, treatment is two-fold:surgicalandmedical.

Surgicalstrategyremainsthesame:Openthewound,removeinfectedandnecrotictissue,andinspectforforeignmaterial.Drainage is generally used in abscess cavities to prevent prematureclosureandreformation.

Empiric broad-spectrum antibiotic therapy is initiated against likelypathogensandcontinuedfor7–10days.Ideally, obtain cultures and tailor therapy to cover the actualpathogensrecoveredonGramstainandculture.Routinebacteriologyisoftennotavailableinforwardmedicalfacilities.Because Bacteroides and Clostridia are difficult to culture, tailorantibiotictherapytocovertheseorganisms.If the debridedwound still has possibly ischemic tissue or retainedforeignmaterial,thepatientisreturnedtotheORevery1–2daysforredebridement, until absolute assurance of healthy, clean tissue isachieved.

SpecificInfectionsTetanus.

Battlefield wounds are “tetanus-prone” due to high levels ofcontaminationwithClostridiumtetani.Bacteria grow anaerobically and release a CNS toxin that results inmusclespasm,trismus,neckrigidity,andbackarching.In addition to surgical debridement of war wounds, additionalprophylacticmeasuresfortetanus-pronewoundsinclude:

Administrationof0.5mLIMoftetanustoxoidifpriortetanusimmunizationisuncertain,lessthanthreedosesoftetanusvaccineor>5yearssincethelastdose.

Administrationof250–500UIMoftetanusimmuneglobulininaseparatesyringeandataseparatesitefromthetoxoidifpriortetanusimmunizationisuncertainorlessthanthreedoses.

Treatmentforestablishedtetanusincludes:

IVantibiotics(penicillinG,24millionU/d;ordoxycycline,100mgbid;ormetronidazole,500mgq6hfor7days).

Tetanusimmuneglobulin.

Wounddebridementasneeded.

IVdiazepamtoamelioratethemusclespasm.

Placepatientinadark,quietroomfreeofextraneousstimulation.

Maywarrantendotrachealintubation,mechanicalventilation,andneuromuscularblockade.

Soft-tissueinfections.Cellulitis ismanifestedbylocalizedskinerythema,heat, tenderness,andswellingorinduration.Treatment:IVantibioticsagainststreptococcalandstaphylococcalspecies(IVnafcillin,Cefazolin,or,inthepenicillin-allergicpatient,

clindamycinorvancomycin).

Postoperative wound infections become evident by wound pain,redness, swelling, warmth, and/or foul or purulent discharge, withfeverand/orleukocytosis.

Treatment:Openthewound,draintheinfectedfluid,anddebrideanynecrotictissuepresent.

Thewoundisleftopenandallowedtocloseviasecondaryintention.

Necrotizing soft-tissue infections are the most dreaded infections,resulting from battlefield wounding. These include clostridialmyonecrosis(gasgangrene)andpolymicrobialinfectionscausedbyStreptococcus,Staphylococcus,Enterococcus,Enterobacteriaceae,Bacteroides,andClostridia.

Theorganismscreatearapidlyadvancinginfectionwithinthesubcutaneoustissuesand/ormusclebyproducingexotoxinsthatleadtobacteremia,toxemia,andsepticshock.

Alllayersofsofttissuecanbeinvolved,includingskin(blisteringandnecrosis),subcutaneoustissue(panniculitis),fascia(fasciitis),andmuscle.

Clinicalmanifestationsbeginlocallywithseverepain,crepitus,andwithClostridia—athin,brown,foul-smellingdischarge.

Theskinmaybetenseandshiny,showingpallororabronzecolor.

Systemicsignsincludefever,leukocytosis,mentalobtundation,hemolyticanemia,andhypotension,progressingrapidlytomultipleorganfailureanddeathinuntreatedorundertreatedcases.

Thediagnosisismadebyahistoryofsevereunexpectedwoundpaincombinedwithpalpableorradiographicsoft-tissuegas(airinsubcutaneoustissueand/ormuscle).

Absenceofsoft-tissuegasdoesnotexcludediagnosisofnecrotizinginfection.

Treatmentissurgical,includingearly,comprehensive,andrepeated(every24–48hours)debridementofalldeadandinfectedtissue,combinedwithantibiotics.

Excisionofaffectedtissuemustbeasradicalasnecessary(includingamputationordisarticulation)toremoveallmusclethatisdiscolored,noncontractile,nonbleeding,orsuspicious.

Identificationofcausativeorganismsisoftenproblematic:

treatmentmustbeaimedatallpossibleorganisms.

IVantibiotictherapy.

Clindamycin,900mgq8h;pluspenicillinG,4millionUq4h;plusgentamicin,5–7mg/kgqd.

Asasubstituteforclindamycin:Metronidazole,500mgq6h.

Asasubstituteforpenicillin:Ceftriaxone,2.0gq12h,orerythromycin,1.0gq6h.

Asasubstituteforgentamicin:Ciprofloxacin,400mgq12h.

Alternativeregimen:Imipenem,1gIVq6h.

Intraabdominalinfections.Prevention.Regimens(startassoonaspossibleandcontinuex24hourspost-op):

Singleagent:cefotetan,1.0gq12h;orampicillin/sulbactam,3gq6h;orcefoxitin,1.0gq8h.

Tripleagent:ampicillin,2gq6h;plusanaerobiccoverage(metronidazole,500mgq6h;orclindamycin,900mgq8h);plusgentamicin,5–7mg/kgqd.

Establishedintraabdominalinfection(peritonitisorabscess).Sameregimenasabove,exceptcontinuefor7–10days.Drainallabscesses.

Pulmonaryinfections.Empyema (generally streptococcal) following penetrating thoracictrauma is typically due to contamination from the projectile, chesttubes,orthoracotomy.Diagnosis:loculations,air/fluidlevelsonradiograph,pleuralaspirate.Treatment.

Chesttubeinitially,andthoracotomyifunsuccessful.

Cefotaxime,orceftriaxone,orcefoxitin,orimipenem.

Pneumonia is most frequently due to aspiration (eg, patients withheadinjury)andprolongedmechanicalventilation.The diagnosis is made through radiograph finding of a newpulmonary infiltrate that does not clear with chest physiotherapy,combinedwith:

Feverorleukocytosis.

Sputumanalysisshowingcopiousbacteriaandleukocytes.

Empirictherapyisdirectedtowardlikelypathogens.

Aspiration:Streptococcalpneumonia,coliforms,andoral

anaerobesarelikely.IVantibiotics—suchasampicillin/sulbactam,clindamycin,orcefoxitin—havebeenproveneffective.

Ventilator-associatedpneumonia:Staphylococcus,Pseudomonas,andothernosocomialEnterobacteriaceae.Broadcoverageisbestwithsuchagentsasimipenem,ceftazidime,orpiperacillin/tazobactamplusciprofloxacin.Vancomycinshouldalsobeinitiatedifconcernformethicillin-resistantStaphylococcusaureus.

SystemicSepsis

Sepsis can be defined as infection combined with a prolonged systemicinflammatoryresponsethatincludestwoormoreofthefollowingconditions:

Tachycardia.Feverorhypothermia.Tachypneaorhyperventilation.Leukocytosisoracuteleukopenia.

Progression to septic shock is manifest by systemic hypoperfusion: profoundhypotension,mentalobtundation,orlacticacidosis.Treatmentisathree-prongedapproach:

Identifyanderadicatethesource.Administer broad-spectrum intravenous antibiotics for the most likelypathogens.Use intensive care unit support for failing organ systems, such ascardiovascularcollapse,acuterenalfailure,andrespiratoryfailure.

It is oftendifficult to identify the sourceof sepsis, but it is themost importantfactorindeterminingtheoutcome.Potentialsourcesofoccultinfectioninclude:

Anundrainedcollectionofpus,suchasawoundinfection,intraabdominalabscess,sinusitis,orperianalabscess.Ventilator-associatedpneumonia.Urinarytractinfection.Disseminatedfungalinfection.Centralintravenouscatheterinfection.Acalculouscholecystitis.

Intensive care support for sepsis involves vigorous resuscitation to restoreperfusion to preventmultiple organ dysfunction. This requires optimization ofhemodynamicparameters(pulmonaryarteryocclusionpressure,cardiacoutput,and oxygen delivery) to reverse anaerobic metabolism and lactic acidosis.Endpointsof resuscitation—suchasurineoutput,basedeficit,andblood lactatelevels—guide successful treatment.Until the source for sepsis is identified andactual pathogens isolated, empiric therapy with broad-spectrum intravenousantibioticsiswarranted.Suitableregimensmightincludethefollowing:

Imipenem,1gIVq6h.

Piperacillinandclavulanate(Zosyn),3.375gq6h;orceftazidime,2.0gq8h;orcefepime,2.0gq12h;plusgentamicin,5–7mg/kgqd (basedonaonce-daily dosing strategy and no renal impairment); or ciprofloxacin, 400mgq12h.Addition of vancomycin, 15 mg/kg q12h, if methicillin-resistantStaphylococcusaureusisalikelypathogen.Additionoflinezolid,600mgq12h,ifvancomycin-resistantenterococcusisalikelypathogen.

Battlefieldcasualtiesareathighriskforinfection.Inparticular,warwoundsarepredisposed to infection due to environmental conditions on the battlefield,devitalizedtissue,andforeignbodiesinthewound.Thekeytoavoidingwoundinfection is prompt and adequate wound exploration, removal of all foreignmaterial,andexcisionofalldeadtissue.Allbattlefieldwoundsandincisions,toinclude amputations, should have the skin left open. Antibiotics play anadjunctiveroleintheprophylaxisofwoundandotherinfectionsinthebattlefieldmedicaltreatmentfacility.Knowledgeoflikelypathogensforparticularinfectionsandsites,aswellasoptimalantibioticstoeradicatethosepathogens(Table10-4),willaidthebattlefieldclinicianinavertingandtreatinginfections.

Table10-4.SpectrumandDosageofSelectedAntibioticAgentsAgent AntibacterialSpectrum Dosage

PenicillinG Streptococcuspyogenes,penicillin-sensitiveStreptococcuspneumoniae,clostridialspp.

4mUIVq4h

Ampicillin Enterococcalspp.,streptococcalspp.,Proteus,someEscherichiacoli,Klebsiella

1–2gIVq6h

Ampicillin/sulbactamEnterococcalspp.,streptococcalspp.,Staphylococcus,*Ecoli,Proteus,Klebsiella,clostridialspp.,Bacteroides/Prevotellaspp.

3gIVq6h

Nafcillin Staphylcoccalspp.,*streptococcalspp. 1gIVq4h

Piperacillin/clavulanateEnterococcalspp.,streptococcalspp.,Staphylococcus,*Ecoli,Pseudomonas,andotherenterobacteriaceae,clostridialspp.,Bacteroides/Prevotellaspp.

3.375gIVq6h

ImipenemEnterococcalspp.,streptococcalspp.,Staphylococcus,*Ecoli,Pseudomonas,andotherenterobacteriaceae,clostridialspp.,Bacteroides/Prevotellaspp.

1gIVq6h

Cefazolin Staphylococcalspp.,*streptococcalspp.,Ecoli,Klebsiella,Proteus

2gIVq8h

CefoxitinStaphylococcalspp.,*streptococcalspp.,Ecoliandsimilarenterobacteriaceae,clostridialspp., 1–2gIVq6h

Bacteroides/Prevotellaspp.

Ceftazidime Streptococcalspp.,Ecoli,Pseudomonas,andotherenterobacteriaceae

2.0gIVq8h

CeftriaxoneStreptococcalspp.,staphylococcalspp.,*Neisseriaspp.,Ecoli,andmostenterobacteriaceae(NOTPseudomonas),clostridialspp.

1gqd

Ciprofloxacin Ecoli,Pseudomonas,andotherenterobacteriaceae 400mgq12h

Gentamicin Ecoli,Pseudomonas,andotherenterobacteriaceae5–7mg/kgqd(basedononce-dailydosingstrategyandnorenalimpairment)

Vancomycin Streptococcal,enterococcal,andstaphylococcalspp.(includingMRSA,notVRE)q12h

15mg/kgq12h

Erthromycin Streptococcalspp.,clostridialspp. 0.5–1.0gq6h

Clindamycin Streptococcusspp.,Staphylococcusspp.,*clostridialspp.,Bacteroides,andPrevotellaspp.

900mgq8h

Metronidazole Clostridialspp.,Bacteroides,andPrevotellaspp. 500mgq6h

MRSA:methicillin-resistantStaphylococcusaureus;spp.:species;VRE:vancomycin-resistantenterococci.NOTE:Dosageanddosageintervalsareaveragerecommendations.Individualdosingmayvary.

*NotMRSA.

References

Conger NG, LandrumML, Jenkins DH, et al. Prevention and management ofinfectionsassociatedwithcombat-relatedthoracicandabdominalcavityinjuries.JTrauma.2008;64(3Suppl):S257–S264.

HospenthalDR,MurrayCK,AndersenRC,etal.Guidelinesforthepreventionofinfectionsassociatedwithcombat-related injuries:2011update (endorsedbytheInfectious Diseases Society of America and the Surgical Infection Society). JTrauma.2011;71(2):S210–S234.

MurrayCK,HsuJR,SolomkinJS,etal.Preventionandmanagementofinfectionsassociated with combat-related extremity injuries. J Trauma. 2008;64(3Suppl):S239–S251.

Wortmann GW, Valadka AB, Moores LE. Prevention and management ofinfections associated with combat-related central nervous system injuries. JTrauma.2008;64(3Suppl):S252–S256.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter11

CriticalCare

Introduction

Theeffectiveapplicationofbasiccriticalcareconceptsinatimelyfashionisvitaltothesurvivalofthewoundedwarrior.Atafundamentallevel,mostofthecarerequired by patients in the combat care environment after a traumatic injurycenters around the adequate delivery and utilization of oxygen. An organizedorgansystemapproachtocareintheintensivecareunitshouldfocusongoalsofresuscitationandtheidentificationoffactorsthatcanthreatentheseefforts.

Shock/EndpointsofResuscitation

Shock is an acute physiological state characterized by inadequate oxygenavailability to support cellularmetabolicneeds.Uncompensatedshock is easilyidentifiedatthebedsideandischaracterizedbydecreasedurineoutput,alteredmental status,hypotension,poor capillary refill, and tachycardia.Compensatedshock is much more difficult to discern clinically because patients may looknormal on examination, but, in fact, have organ hypoperfusion that is notappreciated.Resuscitationisnotcompleteuntiladequateoxygendelivery(DO2)anduptakehavebeenensuredforallcellsthroughoutthebody.

DO2=C.O.×1.34×Hgb×SaO2+0.0031×PaO2,

where C.O. = cardiac output,Hgb = hemoglobin, SaO2 = percentage of oxygensaturationofhemoglobin,andPaO2=partialpressureofoxygenintheblood.

Hypovolemicshock is themost common formof shock in the combat casualtycare settingand is characterizedbydecreased intravascularvolume (IVV)as itsprimary abnormality. The resulting decrease in cardiac output leads todiminishedDO2.Inthecaseofhemorrhage,thereisalsooftenanaccompanyingdecreaseinhemoglobinthatalsocontributestoinadequateDO2.

Distributiveshockisproducedbyaninappropriatedecreaseinsystemicvasculartone,leadingtoanabruptdecreaseinbloodpressuretoalevelthatcannotensureadequate organ perfusion. Neurogenic shock, septic shock, and anaphylacticshockareexamplesofthisprocessthatmaybeseenwithreasonablefrequencyinthecombatsetting.

Cardiogenic shock results from a primary defect in the generation of cardiacoutput. Myocardial infarction leading to heart wall or valve function

abnormalities and cardiac tamponade are commonly seen examples. Manyconsiderobstructive shock a related disorder. Processes that cause obstructiveshockultimatelyresultinaninadequatecardiacoutput,althoughthemechanismsby which this occurs are variable. Pulmonary embolism (PE) and tensionpneumothoraxaretwoillustrativeexamples.

DefineGoalsofShockResuscitationMean arterial pressure (MAP) > 60mmHg (assumingno traumatic braininjury[TBI]).Urineoutput>0.5mL/kg/h.AdequateDO2tomeettheneedsoforganfunction.

ManagementofUncompensatedShockDefinethetypeofshockanditsetiology;eliminatethecauseoftheshockaspossible.VigorouslyrepletetheIVVifMAPorurineoutputis inadequatetargetingcentralvenouspressure8–10mmHg.

Centralvenouspressure:8–10mmHg.Pulsepressurevariation<13%.

Pulsepressure=systolicbloodpressure(SBP)–diastolicbloodpressure(DBP).

Use vasopressor agents to support the MAP after adequate volumerestoration.

Vasopressinisthefirst-lineagentinburnresuscitation.Norepinephrine is the first line in most other nonhemorrhagicsituations.Considerepinephrineinanaphylaxis.Consider dopamine in cardiogenic shock associatedwith low bloodpressure.

DetectionofCompensatedShockandSubsequentManagementInadequate DO2 relative to oxygen uptake (VO2) leads to increasedanaerobicmetabolism.Anaerobicmetabolismleadstoincreasedlactateproduction.Increased lactatemay lead to thedevelopmentofananiongapmetabolicacidosis.Anincreasedbasedeficitsuggestsinadequateresuscitation.

Basedeficit=numberofmmoLofbicarbonatethatmustbeaddedtoaliterofplasmatomakethepH=7.4,assumingthepartialarterialgaspressureofCO2(PaCO2)isnormal.

Central venous oxygen saturation (ScvO2) < 65% suggests inadequateresuscitation.

Thebodyshoulduse<25%–35%ofoxygendelivered.IncreasedutilizationbycellssuggestsinadequateDO2.

ScvO2 < 65% suggests inadequate DO2 and an implied need tooptimizeSaO2,hemoglobin,orcardiacoutput.

OptimizeSaO2andIVV.

Considertransfusion>10mg/dL.

Considerinotropictherapy.

FluidManagement

IntravenousfluidsaregiventopatientstoeitherrepleteadeficitinIVVorpreventthedevelopmentof suchadeficit in apatientunable to accomplish thesegoalswithoutassistance.Thechoiceoffluiddependsonwhichofthesegoalsisbeingaddressedandtheoverallclinicalcontext.

Total body sodium is directly proportional to extracellular fluid volume(ECFV).IVVgenerallyrepresents15%–20%ofECFV.IVVrepletion,therefore,isdependentonsodiuminfusion.

LactatedRinger’s(LR)solution:130mEq/Lsodium,pH5.5–6.0.0.9%normalsaline(NS):154mEq/Lsodium,pH4.5–5.5.

In most clinical contexts, colloid infusion confers no benefit duringresuscitationrelativetoisotoniccrystalloidsolutions,suchasLRandNS.

However,equivalent IVVrepletioncanbeaccomplishedusing lowervolumesofcolloidsolutions.

Anonaniongapmetabolicacidosisfrequentlyresultsfromtheuseoflargevolumes of NS during resuscitation; continued resuscitation can be thenaccomplishedusingotherisotonicfluidcombinations.

0.5 L of ½ NS with 75 mEq sodium bicarbonate (NaHCO3):approximately152mEq/Lsodium.1 L of D5W (5% dextrose in water) with 150 mEq NaHCO3:approximately150mEq/Lsodium.

SpecialFluidConsiderationsHypertonicsalineshouldbeconsideredinpatientswithTBI.½NS (±D5 [or 5% dextrose]) should be used formaintenance of IVV tocounteractinsensiblelosses.½ NS (±D5) can be used to replete IVV for the rare patient with bothhypernatremiaandIVVdepletion(postosmoticdiuresis,etc).Albuminshouldbeconsideredinthefollowingpatients:

Complicated burn resuscitation expected to result in >6mL/kg/24 hresuscitation.

RefertoChapter26,Burns,forfurtherguidance.

Severely malnourished patients with serum albumin concentration<1.0.Cirrhoticpatientswhopresentwithspontaneousbacterialperitonitis.

SerumElectrolyteManagement

SerumsodiummanagementdependsprimarilyontherecognitionthattheserumsodiumconcentrationisnotnecessarilyindicativeofIVVstatus.AlthoughIVVisdirectlyproportionaltoECFVand,therefore,totalbodysodium,abnormalserumsodium concentrations usually represent abnormalities in free water handling.Notable exceptions include hypovolemic hyponatremia (diuretics, etc) andhypervolemic hypernatremia (hypertonic saline administration, etc). Two keyquestions are important to consider in all patients with an abnormal serumsodium:

WhatistheIVVstatusofthepatient?Istherefreewaterexcess(hyponatremia)ordeficit(hypernatremia)?

Hyponatremia(Na<135mEq/L)Euvolemichyponatremia.

Differential diagnosis (Ddx): Antidiuretic hormone (ADH) release(syndrome of inappropriate ADH, pain, anxiety), adrenalinsufficiency,hypothyroidism,andseverepolydipsia.Management:Freewaterrestriction,correctunderlyingcause.

Hypovolemichyponatremia.Ddx:Diureticuse,cerebralsaltwasting.Management:IVVrepletionwithNS.

Hypervolemichyponatremia.Ddx:Severecongestiveheartfailure(CHF),cirrhosis,orrenalfailure.Management:Treatunderlyingcondition;considerdiureticuse.

Relative“saltdeficit”(mEqNa)=0.6×weightinkg×(140–Na).Rate of serum sodium correction should be <1 mEq/L/h and <12mEq/L/24h.Freewaterrestrictionforeuvolemicandhypervolemichyponatremia.NS(154mEq/L)or3%saline(513mEq/LNa)infusion.

Reservedforseizures,severementalstatuschanges,etc.

Hypernatremia(Na>145mEq/L)Euvolemichypernatremia.

Ddx:Sameashypovolemichypernatremia.Management:Treatunderlyingcause,freewaterrepletion.

Hypovolemichypernatremia.Ddx: Renal water loss (osmotic diuresis [mannitol, hyperglycemia,etc]), impaired thirst/water intake, and central/nephrogenic diabetesinsipidus.Management: Treat underlying cause, replete IVV, and free waterrepletion.

Hypervolemichypernatremia.Ddx:Iatrogenic(hypertonicsalineadministration).Management:Freewaterrepletion.

Relative“freewaterexcess”(inliters)=0.6×weightinkg×(Na–140)/140.Rate of serum sodium correction should be <1 mEq/L/h and <12mEq/L/24h.

Serumpotassium concentration is frequently abnormal in critically ill patients.Similar to the case with serum sodium concentration disorders, the serumpotassiumlevelmaynotbeindicativeoftotalbodypotassiumstores.Inthecaseof potassium, the vast majority is contained in the intracellular fluid volume(ICFV) space, and only a small portion is found in the ECFV or intravascularspaces.PotassiumshiftsbackandforthbetweentheECFVandICFVwithrelativeease, leading to potentially large swings in serum concentrations. Total bodypotassiummaybequicklydepletediflostthroughrenalornonrenalexcretion.

Hypokalemia(K<3.5mEq/L)

Serumhypokalemiamaybesecondary to redistributionofpotassium from theECFV to the ICFV, as is commonly seenwith significant acidemia or increasedbeta-2 agonist utilization. Total body potassium depletion may also lead to adecrease in serum potassium concentration through renal (diuretic use,postobstructive diuresis, osmotic diuresis, metabolic alkalosis, andproximal/distal renal tubular acidoses) and nonrenal (diarrhea, sweat, andfasting)mechanisms.

Total body potassium deficits range from 150 to 400 mEq for each 1 mEq/Ldecreaseinserum:

Potassium supplementation must be carefully monitored to avoidhyperkalemiadevelopment.Repletion of potassium is made more difficult if total body magnesiumstoresarelow.The pace of potassium repletion depends on the presence or absence ofclinicalmanifestationsmorethantheabsoluteserumconcentration.

ProminentUwaves,T-waveflatteningonEKG.Paralysis,respiratorymuscledysfunction,andrhabdomyolysis.

Supplementationisbestaccomplishedwithenteralsupplementationandispreferredifpossiblewhenthepatientisclinicallystable,becauseit isbothsaferandresultsinfasterrepletionrelativetoIVinfusion.

IVinfusionratesarelimitedto10mEq/hthroughaperipheralIVand20–40 mEq/h through a central line, and these higher rates requirecontinuouscardiacmonitoring.

UseKClforreplacementinmostsituations;potassiumcitrateorpotassiumbicarbonate is more appropriate when hypokalemia is associated withmetabolicacidosis(especiallyrenaltubularacidosis).Oral repletion: KCl elixir or tablet 30–60mEq qid until serum potassiumconcentrationnormal.EmergentIVrepletion:KClviaacentralline20–40mEq/huntilpotassium>3.0mEq/L, then switch to oral as above or a lower infusion rate of 10–20

mEq/huntilserumconcentrationisnormal.Avoid IV fluids containing dextrose during emergent repletion,because the dextrosewill result in the intracellular redistribution ofpotassiumandcomplicaterepletionefforts.

Hyperkalemia(K>5.5mEq/L)

Hyperkalemia may present as a result of several different mechanisms.Pseudohyperkalemia resultswhen largeamountsofpotassiumarespilledfromthe intracellular space duringmeasurement and subsequentlymeasured in theextracellularspace.Themeasuredserumpotassiumlevelisnotindicativeoftrueserum concentration in the patient (eg, severe thrombocytosis [>1,000,000] orleukocytosis [>200,000]). Redistribution hyperkalemia is seen in the traumacritical care setting most frequently as a result of academia, succinylcholineutilization, or hypertonic states (hypertonic saline or mannitol use). Finally,hyperkalemia may result from renal failure, hypoaldosteronism, andmedications (penicillin potassium, salt substitutes, and exogenous potassiumsupplementation).

Chronic hyperkalemia of a given value is generally better tolerated thanacutepresentations.Acute hyperkalemia should be regarded as a life-threatening medicalemergency.Pace of treatment is generally dictated by EKG abnormalities (seen, ingeneralorder,as):

PeakedTwaves,flattenedPwaves,andprolongedPRinterval.Idioventricularrhythm,widenedQRSinterval,sinewavepattern,andventricularfibrillation.

Treatmentoptionsforhyperkalemiainclude:50mEqofNaHCO3(1standardampuleofa7.5%NaHCO3solution).Repeatevery30minutesuntilQRSimproved;oftenineffectiveifrenalfailurehascausedthehyperkalemia.10 mL of calcium chloride of a 10% solution (standard calciumchloride ampule) over 1–3 minutes; can repeat every 5 minutes, aslongassevereEKGchangespersist.ConsiderdialysisassoonaspossibleifQRSwideninghaspresented.

TreatmentwithmildEKGchanges(noevidenceofQRSwidening):Beta-2agonists(albuterol)20mgin4mLofsalinenebulizer.50mLof50%dextrose/glucose,10Uofregularinsulin;followglucose,repeatasneededEKGchanges.Loop or thiazide diuretic—use only in patients known to beintravascularlyreplete;willbeineffectiveinanuricrenalfailure.Sodium polystyrene sulfonate (Kayexalate) 20 grams orally every 6hoursor50gramsasanenemaevery2–4hours.

TreatmentwithnormalEKGconsistsofidentificationandcorrectionofthecause, as well as 15 grams of sodium polystyrene sulfonate (Kayexalate)

orallyevery6hoursor30–60gramsasanenemaevery2–4hours.Intestinal necrosis can result, especially when given orally within aweekofmajorsurgery.

Serummagnesiumisoftennotgivensignificantpriorityinthecareofthecriticalcare patient. Serum magnesium represents only a fraction of the total bodymagnesium stores, similar to the case with potassium balance. A significantdifferencewith respect tomagnesium is that itdoesnot transition readily fromthe ICFV to ECFV.Low serummagnesium levels indicated severe total bodymagnesiumdeficits.Normalserummagnesiumlevelsdonotcorrelatereliablywithtotalbodymagnesiumstores.

Hypomagnesemia(Mg<2.0mEq/L)

Hypomagnesemia usually results from inadequate intake (NPO status,malnutrition prior to admission) or excessive loss, usually via renalmechanisms(diuretics,osmoticdiuresis).

Magnesium < 1.0 mEq/L may be associated with central nervous system(CNS)excitabilityandtorsadesdepointesonEKG.Establishing and correcting the cause of hypomagnesemia is the ultimatekeytothemanagementofthisdisorder.Totalbodymagnesiumdepletion(withorwithoutserumhypomagnesemia)isfrequentlyassociatedwithbothhypokalemiaandhypocalcemia.

Successful repletion of potassium and calciumwill not generally bepossibleuntiltotalbodymagnesiumstoreshavebeennormalized.

In the absence of CNS excitability or life-threatening hypokalemia orhypocalcemia,magnesiumrepletionshouldbegivenas4gramsIVevery24hoursfor72hoursbeforeserummagnesiumlevelsarerechecked.If CNS excitability or life-threatening hypokalemia or hypocalcemia ispresent, 2 grams of magnesium should be given as an immediate push,followedby4–6gramsin6hours,andfollowedby4–6gramseachdayforthenext2–3days.Checking serummagnesium levels during repletion is not useful becausemildly elevated magnesium levels do not indicate successful total bodyrepletion, and clinically significant hypermagnesemia is not seenwith theaforementionedratesofrepletionunlesssevererenalfailureexists.

Serumcalcium disorders are seen frequently in the combat critical care setting.Hypocalcemia is seenwithmuch greater frequency than hypercalcemia in thissettingandwillbegivengreater emphasishere. Serumcalcium levels areoftencorrected for serum albumin levels since negatively charged proteins, such asalbumin, bind positively charged calcium cations. Ionized calcium is thephysiologically relevant portion of total calcium. Adjusting total calcium formeasuredalbuminvalues isusefulonly if ameasurementof ionizedcalcium isnotavailable.Inthecombatcasualtycaresetting,ionizedcalciummeasurementscanbeobtainedquicklyusinghandheldpoint-of-caretestingdevices,suchasthe

i-STATBloodGasAnalyzer(withanEG7+orEG8+cartridge).

Hypocalcemia(iCa<1.10)

Hypocalcemiainthecombatsettingisseenmostfrequentlyaftermassivebloodproducttransfusion(calciumisboundbycitrateusedasananticoagulant)orasaresultofassociated totalbodyhypomagnesemia.QT interval prolongation canresultfromseverehypocalcemia,anditspresencedictatesthepaceofrepletion.

10%calciumchloride10mLvialcontains272mgofelementalcalcium.10%calciumgluconate10mLvialcontains93mgofelementalcalcium.Administerone10mLvialof10%calciumchloridein50–100mLofD5inwaterfor>10–15minutesifQTprolongationisnoted.

Follow this with 1–2mEq/h of elemental calcium infusion until QTprolongation has been resolved or >1.00–1.10 grams of calcium arecorrectedtowithinnormalrange.

HypocalcemicpatientswithoutQTprolongationcanberepletedasfollows:Oralsupplementationof1.5–2.5gramsofelementalcalciumperday.If oral supplementation is not possible, initiate an infusion of 0.5mg/kg/hofelementalcalcium>1.10.

If hypocalcemia is difficult to correct, consider total body magnesiumdepletion (with or without serum hypomagnesemia); an associatedhypokalemiamaybeacluetothepresenceofatricationdeficiency.

PulmonaryMedicine

BasicsofMechanicalVentilation

Patientsareplacedoninvasivemechanicalventilationmostcommonlyforairwayprotection, respiratory failure (hypoxemia), or ventilatory failure (hypercapnialeading to acidemia). Another relatively common indication is in the setting ofshocktooptimizeDO2.Complianceofthechestwall/lungunitisdefinedbythechange in volume associatedwith a given change in pressure. Inherent in thisdefinition is the concept that a volumegiven to thepatient by a ventilatorwillresult insomechange inpressure,whereasapressuregivenwill result insomechangeinvolume.

Volume control modes of ventilation (assist-control [A/C], synchronizedintermittentmandatory ventilation [SIMV]) providemandatory breaths as a setvolume(asetflowisgivenuntilapredefinedvolumeisachieved)andgeneratesomeresultingpressure.

Pressure control modes of ventilation (pressure control ventilation) providemandatorybreathsasasetpressure,generatingsomeresultingvolume.

Ventilation (elimination of CO2) is necessary to achieve a target pH that isphysiologicallyacceptabletothebody(7.35–7.45inmostpatients).

PaCO2ismanipulatedbymechanicalventilationmostreliablybyaltering

respiratoryrate (RR)or tidalvolume(VT) inorder tochange theminutevolume(Ve).

Oxygenation/respiration (intake of oxygen) is necessary to support adequateDO2tothepatient.GoalSaO2inmostpatientsrangesbetween92%–100%.Thereis generally little physiological benefit from attempting to manipulate theventilatortoachievevalueshigherthan92%–94%.

Usingpositivepressureventilation, increasedoxygenation/respirationoccursbyincreasing the fractionof inspiredoxygen (FiO2) or increasing themeanairwaypressure(positiveend-expiratorypressure[PEEP]).

AlowPaO2/FiO2(<300),intheabsenceofveryseverehypercapnia,suggestsshuntphysiologyasthemostlikelycauseofhypoxemiainapatient.Increased mean airway pressure may be a useful adjunct (increase thePEEP).FiO2 manipulation alone will be unlikely to correct hypoxemia in thissetting.

Initial ventilator settings for most patients should strive to optimizeoxygenation and ventilation while at the same time serve to minimizebarotrauma (pneumothorax, subcutaneous emphysema, etc, due to excessivetransalveolar pressures), volutrauma (lung damage due to excessive stretch),atelectotrauma (lung damage due to repetitive opening and closing of alveoli),andbiotrauma(releaseofcytokinesrelatedtotheapplicationofpositivepressureventilation).

Mode:VolumeCycled(A/CorSIMV)SIMVisnotrecommendedbecause it isassociatedwith increasedworkofbreathingwhenusedforprolongedperiods.Inaddition,whenSIMVisused,itisbesttousepressuresupportventilationtoaugmentanyspontaneousbreaths.

Thestandardmilitarytransportventilator(Impact754)doesnotallowpressuresupportventilationtobeusedwhentheSIMVmodeisused.

FiO2=100%;titratedowntolowestamounttokeepSpO2orSaO2>92%.SaO2 = saturation of hemoglobin asmeasured by arterial blood gassampling.SpO2=noninvasivepulseoximetry;aroughestimateofSaO2.

VT=5–7mL/kgidealbodyweight.Idealpredictedbodyweightinkilogramsinmales=50+2.3(heightininches–60).Idealpredictedbodyweightinfemales=45.5+2.3(heightininches–60).Adjusttokeep<8mL/kgandplateaupressures<30cmH2O.

RR=16.AdjusttokeepRR×VTadequatetomanipulatePaCO2toachievegoal

pH.Inspiration:expiration(I:E)ratio=1:2to1:3.PEEP=5cmH2O.

IncreasePEEPifPaO2/FiO2<300(shuntphysiologyexpected).IncreasePEEPto10–12cmH2Oifshuntphysiologypresent.

IncreaseasnecessaryabovethisleveltokeepSpO2>92%.

WithincreasedPEEP,VTmayneedtobedecreasedtokeepplateaupressures<30cmH2O.

AcuteRespiratoryDistressSyndrome/AcuteLungInjury

Both acute respiratory distress syndrome (ARDS) and acute lung injury (ALI)representthesamediseaseprocess,andtheirdefinitiondiffersonlyonthedegreeofshuntasestimatedbythePaO2/FiO2:

Acutepresentationofhypoxemicrespiratoryfailure.Bilateralinfiltratesonchestradiography.No clinical evidence of left heart volume overload; pulmonary capillarywedgepressure<18mmHgifmeasured.PaO2/FiO2<200(ARDS),PaO2/FiO2200–300(ALI).

ARDS can be caused by direct (inhaled toxins, aspiration) or indirect (trauma,burns,anycauseofsystemicinflammatoryresponsesyndrome)mechanisms,butthebasicmanagementissimilar.

Basic ventilatory strategies are designed to minimize barotrauma by avoidingexcessive alveolar pressures, volutrauma by limiting delivered VT andatelectotrauma by keeping alveoli open using increased mean airway pressureventilatorstrategies.Aventilatorstrategyencompassingthesefeatureswasfoundby the ARDSNet investigators to lead to an improved mortality relative tostandardofcarein2000andshouldbefollowedwherepossible(Table11-1).

Adjunctive therapies forARDS have been studied for decades and have beendemonstratedtohavevariableclinicalbenefit.Eachcanbeconsideredinagivenpatientdependingontheclinicalscenarioandavailabilityofresources.

High(>16cmH2O)vsmoderate(10–16cmH2O)PEEP.Possible benefit using higher levels in patients with more severehypoxemia.

Pronepositioning.Improvesoxygenationinpatientswithseverehypoxemia.Nodefinitivemortalitybenefit.Can be accomplished with a Stryker frame in the combat supportsetting.

Devicecanbeusedincombatmedicalfacilities,aswellasgroundandairtransportvehicles.

Table11-1.MechanicalVentilationProtocolSummaryINCLUSIONCRITERIAAcuteonsetofthefollowing:

1. PaO2/FiO2≤300(correctedforaltitude).2. Bilateral(patchy,diffuse,orhomogeneous)infiltratesconsistentwithpulmonaryedema.3. Noclinicalevidenceofleftatrialhypertension.

PARTI:VENTILATORSETUPANDADJUSTMENT

1. CalculatePBW.Males=50+2.3(height[inches]–60).

Females=45.5+2.3(height[inches]–60).2. Selectanyventilatormode.3. SetventilatorsettingstoachieveinitialVT=8mL/kgPBW.4. ReduceVTby1mL/kgatintervals≤2hoursuntilVT=6mL/kgPBW.5. Setinitialratetoapproximatebaselineminuteventilation(not>35bpm).6. AdjustVTandRRtoachievepHandplateaupressuregoalsbelow.

OxygenationGoal:PaO2,55–80mmHgorSpO2,88%–95%

UseaminimumPEEPof5cmH2O.Consideruseof incrementalFiO2/PEEP combinations, such as shownbelow(notrequired)toachievegoal.

LowerPEEP/HigherFiO2

FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7PEEP 5 5 8 8 10 10 10 12

FiO2 0.7 0.8 0.9 0.9 0.9 1.0

PEEP 14 14 14 16 18 18–24

HigherPEEP/LowerFiO2

FiO2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5PEEP 5 8 10 12 14 14 16 16

FiO2 0.5 0.5–0.8 0.8 0.9 1.0 1.0

PEEP 18 20 22 22 22 24

PlateauPressureGoal:≤0cmH2O

CheckPplat(0.5-secondinspiratorypause),atleastq4handaftereachchangeinPEEPorVT.

IfPplat>30cmH2O:decreaseVTby1mL/kgsteps(minimum=4mL/kg).IfPplat<25cmH2OandVT<6mL/kg,increaseVTby1mL/kguntilPplat>23cmH2OorVT=6mL/kg.IfPplat<30andbreathstackingordyssynchronyoccurs:mayincreaseVTin1mL/kgincrementsto7or8mL/kgifPplatremains≤30cmH2O.

pHGoal:7.30–7.45

Acidosismanagement:pH<7.30IfpH7.15–7.30:IncreaseRRuntilpH>7.30orPaCO2<25.

MaximumsetRR=35.IfpH<7.15:IncreaseRRto35.

IfpHremains<7.15,VTmaybeincreasedin1mL/kgstepsuntilpH>7.15(Pplattargetof30maybeexceeded).

MaygiveNaHCO3.

Alkalosismanagement:pH>7.45(decreaseventrate,ifpossible)

I:E:RatioGoalRecommendthatthedurationofinspirationbelessthanorequaltothedurationofexpiration.

PARTII:WEANINGA.ConductaSpontaneousBreathingTrialDailyWhen:

1.FiO2≤0.40andPEEP≤8.

2.PEEPandFiO2lessthanorequaltothevaluesofthepreviousday.

3.Patienthasacceptablespontaneousbreathingefforts.(Maydecreaseventrateby50%for5minutestodetecteffort.)

4.SystolicBP≥90mmHgwithoutvasopressorsupport.

5.Noneuromuscularblockingagentsorblockage.B.SpontaneousBreathingTrial

Ifalloftheabovecriteriaaremetandthesubjecthasbeeninthestudyforatleast12hours,initiateatrialofUPTO120minutesofspontaneousbreathingwithFiO2≤0.5andPEEP≤5:

1.PlaceonT-piece,trachcollar,orCPAP≤5cmH2OwithPS≤5.

2.Assessfortoleranceasbelowforupto2hours.

a.SpO2≥90;and/orPaO2≥60mmHg.

b.SpontaneousVT≥4mL/kgPBW.

c.RR≥35/min.d.pH≥7.3.

e.Norespiratorydistress(distress=2ormore).i.HR>120%ofbaseline.

ii.Markedaccessorymuscleuse.iii.Abdominalparadox.

iv.Diaphoresis.v.Markeddyspnea.

3.Iftoleratedforatleast30minutes,considerextubation.4.Ifnottolerated,resumepreweaningsettings.

DEFINITIONOFUNASSISTEDBREATHING(DifferentfromtheSpontaneousBreathingCriteriaBecausePSIsNotAllowed)

1.Extubatedwithfacemask,nasalprongoxygen,orroomairOR

2.T-tubebreathingOR

3.TracheostomymaskbreathingOR4.CPAP≤5cmH2OwithoutPSorIMVassistance.

ARDS:acuterespiratorydistresssyndrome;BP:bloodpressure;bpm:breathsperminute;CPAP:continuouspositiveairwaypressure;FiO2:inspiredoxygen;HR:heartrate;I:E:inspiration:expiration;IMV:intermittentmandatoryventilation;NaHCO3:sodiumbicarbonate;PaCO2:partialarterialgaspressure(tension)ofcarbondioxide;PaO2:partialpressureofoxygenintheblood;PBW:predictedbodyweight;PEEP:positiveend-

expiratorypressure;Pplat:plateaupressure;PS:pressuresupport;q4h:every4hours;RR:respiratoryrate;SpO2:noninvasivepulseoximetry;trachcollar:tracheostomycollar;VT:tidalvolume.ReprintedwithpermissionandwithminorchangesfromtheARDSClinicalNetworkwebsite(www.ardsnet.org)andtheNationalInstitutesofHealthandtheNationalHeart,Lung,andBloodInstitute.

ConservativeIVVmanagement.Improved outcomes relative to liberal strategy, as tolerated byphysiologyandinjurypatternofthepatientinquestion.

Pulmonaryarterycathetervscentralvenouspressuremonitoring.No benefit to using a pulmonary artery catheter to guide fluidmanagement.

Specialdietaryformulations.No single proprietary formula has been demonstrated to improveoutcomes.

Corticosteroids.NoconsistentbenefitfortheuseofcorticosteroidsinARDS.

Inhalednitricoxide.Improvedoxygenationnoted.Nomortalitybenefit.

Pressurecontrolventilation.NosignificantoutcomesbenefitrelativetovolumecontrolA/Cmode.Ifused,effortsmustbemadetocontinuetolimitVTasoutlinedintheARDSNetprotocol.

Airwaypressurereleaseventilation.NosignificantoutcomesbenefitrelativetovolumecontrolA/Cmode.Equivalent mean airway pressures can be obtained using loweramounts of sedation, and patients are less likely to requireneuromuscularblockade.Ifused,effortsmustbemadetocontinuetolimitVTasoutlinedintheARDSNetprotocol.

High-frequencyoscillatoryventilation.Nobenefittostandardofcaredemonstratedinthe1990s.HasnotbeendirectlycomparedwithARDSNetlowVTstrategy.Technologyandexpertiseunlikely tobeavailable incombat supportoperations.

Extracorporealmembraneoxygenation.Improvedoxygenation.Nomortalitybenefit.Technologyandexpertiseunlikely tobeavailable incombat supportoperations.

Extracorporealcarbondioxideremoval.Maybe a useful adjunct with carbon dioxide elimination is severelylimited.HasnotbeendirectlycomparedwithARDSNetlowVTstrategy.

Patientswith PEEP > 14 cmH2Oorwho appear clinically unstable andwhorequireimmediatetransportshouldbeconsideredcandidatesforactivationofspecialized lung teams, where available. Such a team is based at LandstuhlRegional Medical Center to support EUCOM (US European Command),AFRICOM(AfricaCommand),andCENTCOM(USCentralCommand)missions.

PulmonaryContusion

Pulmonary contusion is frequently seen in the combat setting,most commonlybeingassociatedwithblunt,nonpenetratingtraumawithorwithoutribfractures.ThedisorderissimilartoARDS,inthatitmaypresentwithasignificantdegreeofhypoxemiaduetoshuntphysiologyrequiringincreasedmeanairwaypressure,aswell as decreased compliance requiring limited VT. A significant distinctionbetween the two clinical syndromes is the profoundly asymmetric nature ofpulmonary contusion. Excessive mean airway pressure delivery may lead tooverdistension of healthy lung,whichhas the effect of shuntingblood awayfromwell-ventilatedalveoli(increasingdeadspacefraction)andtowardpoorlyventilated contused regions (increasing shunt). Each patient may have adifferent mean airway pressure where this happens that is clinically hard topredict. If an increase in PEEP is associatedwith a significant fall in oxygensaturation, an increase in shunt physiology due to excessive mean airwaypressure should be suspected, and PEEP should be decreased to its previouslevel.PulmonarycontusionisgenerallymanagedinasupportivefashionusingalowVTstrategyandoccasionalbronchoscopytofacilitatepulmonarytoilet.

PulmonaryEmbolism

PE ispartofabroaderdiseaseprocess that includesdeepvenous thrombosis(DVT)knownasvenousthromboembolicdisease.DVTisverycommoninthetrauma setting and associatedPEmay be a life-threatening result.Diagnosis ofDVTcanbemadeinthecombatsupportsettingusingduplexultrasoundorCTchest/PEprotocolwithlegvenousrunoffsifavailable,butmayneedtobetreatedempirically if clinically suspected; however, technology is unavailable forconfirmation.PEdiagnosisisdifficultinthebestofcircumstances,butitisvitaltosystematically define pretest probability before ordering any studies. Availablestudies to confirm PE in the combat support setting are largely limited to CTchest/PE protocol performance at higher echelon facilities. If pretest clinicalsuspicion (see next page) ismoderate or high, treatment should be given untilconfirmatorytestinghasbeenaccomplished.

DiagnosisofDVTDefinepretestclinicalsuspicion.Iflowpretestclinicalsuspicion,donotworkupfurther.If moderate or high pretest clinical suspicion, perform duplexultrasonography.If clinical suspicion ishigh in theabsenceofultrasonographyhighpretestclinicalsuspicion,butnegativeultrasonography,considerempirictreatment

withfurthertestingatahigherechelonofcare.Considerempirictreatmentwithfurthertestingatahigherechelon.

Considerserialultrasonography(atotalofthreetimesover3–5days).TreatmentofDVT.

Lowmolecularweightheparin(Lovenox1mg/kgsubcutaneouslybid)Consider removable inferior vena cava filter placement if there is acontraindication toanticoagulation.Examplesof contraindications toanticoagulation common to the combat casualty include TBI, solidvisceralinjury,pelvicfracture,etc.

DiagnosisofPEDefinepretestclinicalsuspicion.Iflowclinicalsuspicion:

Obtain duplex ultrasonography of bilateral lower extremities (ifavailable).Perform portable chest X-ray (pCXR) (PA/LAT CXR[posteroanterior/lateral chest X-ray], if possible) to exclude easilyidentified mimics of PE (pneumothorax, hemothorax, ARDS,pulmonarycontusion,andpneumonia).Do not work up further if ultrasound is negative (or if studyunavailable).

Ifmoderateorhighclinicalsuspicion:Initiatetherapywithlowmolecularweightheparin(Lovenox1mg/kgsubcutaneouslybid).PerformpCXR(PA/LATCXR, ifpossible) toexcludeeasily identifiedmimics of PE (pneumothorax, hemothorax, ARDS, pulmonarycontusion,andpneumonia).Obtain duplex ultrasonography of bilateral lower extremities (ifavailable).

IfDVTidentified,continuefull-doselowmolecularweightheparinanddonotperformfurtherdiagnosticstudiestoevaluateforPE.

ObtainCTchest/PEprotocolifultrasoundisnegative(orunavailable).If CT chest/PE protocol was performed and was negative for PE,therapyforPEcanbediscontinued,andnofurtherdiagnosticstudiestoevaluateforPEarenecessary.Full-doseanticoagulationshouldbecontinuedunlesstheCTchest/PEprotocol was normal or another obvious source for the patient’ssymptomsisidentified.

Furtherdiagnosticevaluationshouldbeperformedathighermedicaltreatmentfacilitiesinthiscase.

Removable inferior vena cava (IVC) filter placement should beconsidered in patients with PE pretest clinical suspicion who haveDVT or PE diagnosed, or in whom PE cannot be excluded by CT

chest/PEprotocol,andinwhomthereisasignificantcontraindicationtotherapeuticanticoagulation.

Placementofsuchendovasculardeviceswillnotbepossibleatmostcombatsupportmedicalfacilities.

Ifhighpretestclinicalsuspicion:Initiatetherapywithlowmolecularweightheparin(Lovenox1mg/kgsubcutaneouslybid).PerformpCXR(PA/LATCXR, ifpossible) toexcludeeasily identifiedmimics of PE (pneumothorax, hemothorax, ARDS, pulmonarycontusion,andpneumonia).Obtain duplex ultrasonography of bilateral lower extremities (ifavailable).

IfDVTidentified,continuefull-doselowmolecularweightheparinanddonotperformfurtherdiagnosticstudiestoevaluateforPE.

ObtainCTchest/PEprotocolifultrasoundisnegative(oravailable).Full-dose anticoagulation should be continued regardless of the CTchest/PE protocol results in the setting of high pretest clinicalsuspicionunlessanotherobvioussourceforthepatient’ssymptomsisidentified.

Furtherdiagnosticevaluationshouldbeperformedathighermedicaltreatmentfacilitiesinthiscase.

RemovableIVCfilterplacementshouldbeconsideredinpatientswithhighpretestclinicalsuspicionwhohaveDVTorPEdiagnosed;or inwhomanotherobviousdiagnosisisnotprovidedbyCXR,ultrasound,or CT chest/PE protocol; and in whom there is a significantcontraindicationtotherapeuticanticoagulation.

Placementofsuchendovasculardeviceswillnotbepossibleatmostcombatsupportmedicalfacilities.

HemodynamicallySignificantPE

ThemajorityofpatientswhodiefromPEdieofrightheartfailureassociatedwithacute pulmonary hypertension rather than hypoxemia. A high pretest clinicalsuspicionforPEinthesettingofhypotensionandevidenceofrightheartfailureonexamshouldbeconsideredamedicalemergency,becausethisdefinesapatientpopulationwith a very high rate of mortality. Patient instabilitymay precludemaking a formal diagnosis of hemodynamically unstable PE. Bedsidetransthoracicechocardiogramdemonstratingevidenceofrightheartfailureinthesetting of a high pretest clinical suspicion for PE may assist in making areasonableclinicaldiagnosis.Thefollowingshouldbeconsidered:

Start therapy immediatelywith lowmolecularweightheparin (Lovenox1mg/kgsubcutaneouslybid)orunfractionatedheparin.

Use of this agent must be considered carefully in the multisystemtraumapatient.Protaminecanbeusedtoreversetheeffectsoflowmolecularweightheparin,althoughdosingmaybemoredifficulttopredictthanwhenusedtoreversetheeffectsofunfractionatedheparin.Do not give fluid boluses for hypotension if significant evidence ofrightheartfailureexists.Jugularvenouspressureelevationnotedorcentralvenouspressure>18mmHgifbeingtransducedfromacentralvenouscatheterwithatipknowntobeinthesuperiorvenacava.

Support blood pressure (MAP > 60mmHg,DBP > 40–45mmHg) usingepinephrineordopamine.Norepinephrine is also acceptable, although reflex vagal stimulationmayresult in a decreased cardiac output relative to what is seen withepinephrine.ConsidertheadditionofMilrinoneorDobutamineifpersistentshocknoted.

Milrinone may be a superior choice due to an improved ability todirectlylowerpulmonaryvascularresistance.Considertheuseofthrombolytictherapyifhypotensionispersistentorcardiopulmonaryarrestdevelops.Absolute versus relative contraindications to the use of such agentsmustbeconsideredcarefullyinthemultisystemtraumapatient.

PreventionofVenousThromboembolism

Given the high risk of venous thromboembolism complications associatedwithmultisystem trauma patients (especially those with orthopaedic and spineinjuries),preventionremainsthekeytoavoidingadverseconsequences.

All trauma patients should receive chemical prophylaxis for venousthromboembolismdisease.

Lowmolecularweightheparin (Lovenox30mgsubcutaneouslybid)shouldbeadministered.Highest risk patients (spine injury, expected prolongedimmobilization,andorthopaedicinjury)shouldalsohaveintermittentpneumaticcompressiondevicetherapyinitiated.

Trauma patients with a significant clinical contraindication to chemicalprophylaxis should receive intermittent pneumatic compression devicetherapy.

Highest risk patients (spine injury, expected prolongedimmobilization,andorthopaedicinjury)shouldalsobeconsideredforremovableintravenousvenacavafilterplacement.

AspirationPneumonitis

In patients with compromised pulmonary status secondary to aspiration, theyshould bemanaged supportively,with positive pressure ventilation and a lung

protectivestrategyasdescribedpreviouslyinthischapter.EmpiricantibioticsareNOT indicated for isolated aspiration. Antibiotic therapy should be based onconcomitantinjuries.Witnessed,orclinicallysuspected,aspirationusuallyresultsin a chemical pneumonitis and does not commonly lead to an infectiouspneumonia. Aspiration pneumonitis generally presents with an infiltrate in adependentportionofthelungs(especiallytherightlowerlobe,leftlowerlobe,orthesuperiorsegmentsoftherightorleftupperlobes)andmaybeassociatedwithanimpressivefever,moderateleukocytosis,worseningoxygenation,andevidenceof consolidation on physical exam. Antibiotics are not recommended for thisprocess in the first 24 hours after a suspected aspiration event. Failure todemonstratesomeimprovementafterthistimeshouldpromptconsiderationofasecondarybacterialpneumoniainfectiousprocess.

Empiric antibiotic therapy with a broad-spectrum agent (meropenem,pipericillin/tazobactam,andcefepime)shouldthenbeinitiatedduetoahighrateororalcolonizationwithmultidrug-resistantorganismsinthecombatcriticalcaresetting. Specific coverage targeting anaerobic organisms is not necessary in theabsence of poor dentition, although anaerobic coverage will be included withmost of the empiric broad-spectrum agents discussed previously. Specificcoverage formethicillin-resistant Staphylococcus aureus (MRSA) is not necessaryunless the patient is believed to be previously colonizedwith this organism. Ifavailable,bronchoscopywithdirectedbronchoalveolarlavageorblindaspirationthroughanendotrachealtubecanbeusedtodeterminethedurationofantibiotictherapy. Bronchoscopy should be performed in any case where foreign bodyaspiration (teeth, etc) is suspected.Antibiotics shouldbe stopped at 72hours ifculturesdonotdemonstrateadominantorganism.Ifadominantorganismexists,antibioticscanbediscontinuedat5–7days.

Combat-AssociatedHealthcarePneumonia

Combat-associated healthcare pneumonia denotes a healthcare-associatedpneumoniathatisobtainedbyapatientwhilebeingtreatedinacombatmedicalfacility. The distinction is important, becausemany combatmedical facilities inIraqandAfghanistanareassociatedwith increased ratesofpatient colonizationwithmultidrug-resistantbacteria.Patientswhodeveloppneumoniaafterbeinginthe combat medical system for at least 72 hours should be considered to becolonized with multidrug-resistant organisms, and empiric therapy shouldincludemeropenem,doripenem,pipericillin/tazobactam,orcefepime.ErtapenemisnotrecommendedduetopoorcoverageofPseudomonasaeruginosa.

Vancomycin or Linezolid should be added if MRSA is clinically suspected (aknown history of MRSA colonization), and double coverage for PseudomonasshouldbeincludedifassociatedPseudomonasbacteremiaissuspected.Antibioticcoverage should be tailored to the narrowest spectrum possible based onrespiratoryandbloodcultureresults,anddurationoftherapyshouldcontinuefor5–7days if clinical improvement is noted. Failure to improveby 7days should

prompt a reconsideration of the diagnosis, repeated efforts to obtain cultures,consideration of other infectious organisms, and a search for defects in theimmunesystem(neutrophilnumber/function,B-cellfunction,T-cellfunction).

CardiacConsiderations

CardiacTamponade

Acutecardiactamponadeisseeninthecombatsettingasaresultofeitherbluntorpenetrating thoracic trauma.Cardiac tamponade in thesettingof trauma isasurgicalemergency.Hemodynamicallysignificantpericardialeffusionsassociatedwithtraumagenerallymaybesmallvolumecollectionsofbloodthatresultinthecollapseofthecardiacchambers;however,anypericardialeffusioninthesettingof trauma requires immediate surgical evaluation. Tamponade physiology,initially, may be subtle and vary with respiration, but eventual cardiovascularcollapsecanquicklydevelop.

Beck’sTriadsuggeststhediagnosisofcardiactamponade.Hypotension,jugularvenousdistention,muffledheartsounds.

Thediagnosiscanbeconfirmedwithtransthoracicechocardiogram.Assessment of cardiac enzymes has no role in the diagnosis of cardiactamponade.Urgentpericardialdrainageisnecessary.Inthesettingoftrauma,emergentpercutaneous pericardial drainage may be considered as a temporizingmethodintheabsenceofimmediatelyavailablesurgicalcare.

Viaanunguidedsubxyphoidneedledirectedtowardtheleftnippleinanemergency.Echocardiographicallyguidedneedleinsertionforpigtaildrainage,ifavailable.

IVV may need to be aggressively supported to ensure adequate cardiacfilling.Inotropic therapy with Dobutamine may temporize the condition untileliminationofthepericardialfluidcollectionhasbeenaccomplishedoutsidethesettingoftrauma-associatedtamponade.Proximal aortic dissection should be strongly considered in patientswithblunttraumawhodevelopacutecardiactamponade.

BluntCardiacInjury

Bluntcardiacinjurypresentsasaclinicalconsequenceofbluntthoracictraumainthe combat setting. It is likely underdiagnosed because the vast majority ofpatientswithcardiaccontusionhaveminimal-relatedsymptoms,andsignificantconsequencesareuncommon.Severebluntcardiac injurysymptomsareusuallythose referable to musculoskeletal pain, although CHF may be present if thedegree of injury was significant enough to result in myocardial wall or valvedysfunction. When valve dysfunction occurs, it usually represents improperlyfunctioningchordaetendinaebecauseofmyocardialwalldysfunction.Diagnosisis usuallymade by demonstrating focal cardiac wall or valve dysfunction in a

patientwithrecentbluntthoracictrauma.Cardiacenzymesdonothavearoleinthediagnosisormanagementofbluntcardiacinjury.Managementissupportiveand centers around cardiacmonitoring to detect the rare patientwhodevelopssignificant arrhythmias or mechanical heart dysfunction (severe acute valveregurgitation,freewallrupture,andventricularseptalwallrupture).

AcuteCoronarySyndrome

ST elevation myocardial infarction (STEMI) is usually caused by the rapidaccumulationoffibrinatthesiteofapreviouslystableatheroscleroticplaqueinacoronaryarterythatresultsinsignificant(oftentransmural)cardiacmuscledeath.Topreventfurtherdamage,managementcentersonopeningthevesselasquicklyaspossible;decreasingoxygendemandbytheheart;andmonitoringclosely forthe development of mechanical complications, CHF, and potentially lethalarrhythmias,suchasventriculartachycardiaandfibrillation.

Aspirin81mgPO,chewedasquicklyaspossibleanddailythereafter.Plavix300mgloadfollowedby75mgPOdaily.Aglycoprotein2B/3Ainhibitorshouldbeconsidered(Eptifibatide).SupplementaloxygentomaintainSpO2>96%–98%.Sublingualnitroglycerin(sprayortablet)asnecessaryforpain.

Rapid hypotension development with nitroglycerin suggests right-sideddisease.

MorphineIVasnecessaryforpain.Thrombolytic therapy (Tenecteplase,Reteplase) shouldbegiven ideally in<1hour(within3hoursisideal,12hoursisacceptable).Ifan invasivecardiaccatheterizationlaboratory isavailablethat is favoredoverthrombolytictherapy.Betablocker(Lopressor5mgIVinitially)ifnoevidenceofacuteCHF.Beta blocker per the current American Heart Association guidelines(Lopressor5mgIVincrementallyorEsmololdrip)totargetheartrate<60–70andSBP<110.If heart rate target met with beta blocker, but SBP is >110, consider thefollowingadjuncts:

Nitroglyceringtt(dosemaybelimitedbyheadacheorthepresenceofright-sideddisease).Nicardipinegtt.Nitroprussidegtt.

IfevidenceofCHF:Startnitroglyceringtt.Lasixq6hIVversusgtttoaffectdiuresis/preloadreduction.Consider nicardipine versus nitroprusside gtt to titrate bloodpressure/afterloadreduction.DopamineorMilrinonecanbeconsideredifSBP<90.Dobutamine can be considered; however, this agent will increasemyocardialoxygendemand.

Aorticballoonpumpisfavoredinthissetting,ifavailable.Continuous cardiac and hemodynamic monitoring (arterial line, centralvenous catheter with central venous pressure monitoring) should becontinueduntiltransferredtoahighermedicaltreatmentfacility.AnACE(angiotensin-convertingenzyme)inhibitorshouldbestartedwithin24hoursoftheindexsymptoms.Astatinanticholesterolmedicationshouldbestartedassoonaspossible.

Non-STEMI (NSTEMI) and unstable angina are closely related processeswhereby a platelet-rich clot forms in the region of a previously existingatherosclerotic plaque. Symptoms associated with NSTEMI/unstable anginausuallyrepresentsupply/demandmismatchinthesettingofaslowlyprogressiveclot,althoughtheclotmayprogressquicklyinsome.Itshouldberegardedasamedical emergency.NSTEMI and unstable angina are physiologically the sameprocess and are only distinguished by the presence of myocardial damage, asevidencedbycardiacenzymeelevation,inthesettingofNSTEMI.Managementissimilar to STEMI; however, fibrinolytics plays a less prominent role, andantiplatelet therapy plays a more prominent role due to the relativepredominance of platelets over fibrin in coronary vessel clot associated withNSTEMI/unstableangina.Goalsremaintoimprovecoronarybloodflowrapidly,decrease myocardial oxygen demand, and monitor for complications of thediseaseprocess.Progression toSTEMIneeds tobe carefullywatchedbecause itcouldaffecttherapy.

Aspirin81mgPO,chewedasquicklyaspossibleanddailythereafter.Plavix300mgload,followedby75mgPOdaily.Aglycoprotein2B/3Ainhibitorshouldbeconsidered(Eptifibatide).SupplementaloxygentomaintainSpO2>96%–98%.Sublingualnitroglycerin(sprayortablet)asnecessaryforpain.

Rapid hypotension development with nitroglycerin suggests right-sideddisease.

MorphineIVasnecessaryforpain.Thrombolytic therapy (Tenecteplase,Reteplase) shouldbegiven ideally in<1hour(within3hoursisideal,12hoursisacceptable).Beta blocker per the current American Heart Association guidelines totargetheartrate<60–70andSBP<110.If heart rate target met with beta blocker, but SBP > 110, consider thefollowingadjuncts:

Nitroglyceringtt(dosemaybelimitedbyheadacheorthepresenceofright-sideddisease).Nicardipinegtt.Nitroprussidegtt.

IfevidenceofCHF:Startnitroglyceringtt.Lasixq6hIVvsgtttoaffectdiuresis/preloadreduction.

Consider nicardipine vs nitroprusside gtt to titrate bloodpressure/afterloadreduction.DopamineorMilrinonecanbeconsideredifSBP<90.

Continuous cardiac and hemodynamic monitoring (arterial line, centralvenous catheter with central venous pressure monitoring) should becontinueduntiltransferredtoahigherechelonofcare.AnACEinhibitorshouldbestartedwithin24hoursoftheindexsymptoms.Astatinanticholesterolmedicationshouldbestartedassoonaspossible.Aspirin81mgPO,chewedasquicklyaspossibleanddailythereafter.Plavix150mgloadfollowedby75mgPOdaily.Aglycoprotein2B/3Ainhibitorshouldbestarted(Eptifibitide).

Most important in patients with recurrent pain, ST segmentdepressionordynamicSTsegmentchanges.

SupplementaloxygentomaintainSpO2>96%–98%.Sublingualnitroglycerin(sprayortablet)PRNpain.

Rapid hypotension development with nitroglycerin suggests right-sideddisease

MorphineIVPRNpain.Betablocker(Lopressor5mgIVinitially)ifnoevidenceofacutecongestiveheartfailure.Beta blocker (Lopressor 5mg IV incrementally or Esmolol drip) to targetheartrate<60–70andSBP<110.If heart rate target met with beta blocker, but SBP > 110, consider thefollowingadjuncts:

Nitroglyceringtt(dosemaybelimitedbyheadacheorthepresenceofright-sideddisease).Nicardipinegtt.Nitroprussidegtt.

IfevidenceofCHF:Startnitroglyceringtt.Lasixq6hIVversusgtttoaffectdiuresis/preloadreduction.Consider nicardipine vs nitroprusside gtt to titrate bloodpressure/afterloadreduction.DopaminecanbeconsideredifSBP<90.Dobutamine can be considered; however, this agent will increasemyocardialoxygendemand.

Aorticballoonpumpisfavoredinthissetting,ifavailable.

Continuous cardiac and hemodynamic monitoring (arterial line, centralvenous catheter with central venous pressure monitoring) should becontinueduntiltransferredtoahighermedicaltreatmentfacility.AnACEinhibitorshouldbestartedwithin24hoursoftheindexsymptoms.Astatinanticholesterolmedicationshouldbestartedassoonaspossible.

CongestiveHeartFailure

CHFrepresentsaclinicaldiagnosisdescribingtheinabilityofthehearttopumpadequately relative to a given preload. Resulting clinical signs and symptomsreflect left-sided heart failure (pulmonary edema, pleural effusions), as well asright-sidedfailure(jugularvenousdistention,dependentedema,liverandspleenengorgement).SystolicanddiastolicdysfunctioncanbothcauseCHFwhenIVVbecomes relatively excessive, as can acute or chronic valve dysfunction. Acutevalve dysfunction can be seen in the setting of blunt cardiac contusion injury.GoalsofCHFmanagementcenteraroundpreloadreduction,afterloadreduction,andimprovedinotropicfunction.

PreloadReductionDiuretictherapy.

Loopdiuretic(Furosemide,Bumetanide).

ConsiderIVtherapyforsevereCHF;continuousgttforrefractoryCHF.

Minimizesaltintakeasextracellularfluidvolumeisdirectlyproportionaltototalbodysalt.

Totalsaltintakeshouldbe<1.5–2.0g/d.Nitroglycerindrip.

Vasodilatesvenoussystem.Nitroprussidedrip.

Relativelybalancedarterialandvenodilator.Atrialnatriureticpeptidetherapy(Nesiritide).

Vasodilatesarteries,butalsoaffectssignificantnatriuresis.ForrefractoryCHF,nomortalitybenefit.

AfterloadReductionGoalSBP<100–110mmHg.Beta-blockertherapy:

Carvediololfavored.LongactiveLopressorcanalsobeconsidered.DonotstartanewbetablockerinthesettingofacuteCHF.

Patientsalreadyonabetablocker,whodevelopnewCHF,shouldhavethedosedroppedinhalf,BUTNOTCOMPLETELYDISCONTINUED.

Nicardipinegttintheacutesetting.ACEinhibitortherapyshouldbestartedearlyandtitratedaggressively.Consider the addition of Hydralazine, Clonidine, or Minoxidil if bloodpressuredifficulttocontrol.NitroprussideorNesiritide canbeused transiently in the acute setting asdescribedinthesectiononPreloadReduction.

InotropicTherapyThere is no mortality benefit to using inotropic therapy in the setting of

acuteCHFwhencomplicatingunderlyingsystolicdysfunction.However, it canbe considered as a temporizingmeasureuntilmoredefiniteevaluationandcareareavailable.

DobutamineorMilrinonecanbeconsidered inacuteCHFwithSBP>100mmHg.DopamineshouldbeconsideredifSBP<90mmHg.Anaorticballoonpumpshouldbeused,ifavailable,whenCHFcomplicatestheperiod surrounding thepresentationof an acutemyocardial infarctionorwhenaorticormitralvalvedysfunctionisthecauseoftheCHF.

OtherAspectsofTherapyFollowelectrolytesclosely.

Normalizeserummagnesiumandpotassium.Phosphorouslevelsbelow1.0mg/dLshouldberepleted.Hyponatremia is a marker for increased mortality in the setting ofCHF, but there is no benefit in correcting the hyponatremia as aspecifictherapeuticaim.

ItwillcorrectonitsownasCHFimproves;thekidneyseesbetterforwardflow,andfreewaterretentiondecreases.

Watchforevidenceofarrhythmias.Patients with an ejection fraction < 30%–35% should be consideredcandidates for automated implantable cardioverter defibrillatorplacementunlesslifeexpectancyis<6–12months.

NeurologicalConsiderations

TraumaticBrainInjury

ThemedicalmanagementofTBIwillbebrieflyreviewedandcanbeexploredingreater detail in Chapter 15, Head Injuries. There is nothing about medicalmanagement thatcanreverseprimarybrain injurycausedbya traumaticevent,but aggressive critical care management can greatly decrease the subsequentevolution of secondary brain injury. The critical care management of TBIcasualtiesfocusesuponthetenetsofadequateoxygenationandadequatevolumetominimizetheriskofsecondarybraininjury.

CerebrovascularAccident/StrokeManagement

Two questions are vital to answer immediately when a patient presents withsymptoms suggestive of a cerebrovascular accident (CVA), because theydictatethetherapeuticapproach:

Whendidthestrokeoccur?Iffibrinolytictherapyisgoingtobeconsidered,itshouldbedeliveredwithin 6 hours of symptom onset (better outcomes associated withearly<3-hourtherapy).

Isthestrokehemorrhagicornonhemorrhagic?

Ifnonhemorrhagic,thereisariskofhemorrhagicconversion(maybeseen in up to 10%–15% of patients with middle cerebral arteryterritory strokes)? Document and follow serial neurological examsclosely.

Assess airway patency serially and have a low threshold to place onmechanicalventilationifnecessary.AVOIDHYPOXEMIA(keepSpO2>90%andPaO2>60mmHg).Avoidhyperglycemiaandhypoglycemia(keepglucose90–140mg/dL).

Utilizeinsulindripifnecessary.Keep head of bed flat unless aspiration risk is present, patient has beenplaced on mechanical ventilation, stroke territory is large, or there isevidenceofelevatedintracranialhypertension.

Ifsuchrelativecontraindicationstoflatpositioningexist,placepatientin30°head-of-bedelevation.

Start therapy with aspirin within 24 hours if no evidence of intracranialhemorrhage.CAUTION: THROMBOLYTICS SHOULD ONLY BE GIVEN INACCORDANCEWITHCURRENTAMERICANHEARTASSOCIATIONGUIDELINES REGARDING TIMING FROM THE ONSET OFSYMPTOMSANDSTROKESEVERITY.Thrombolytics (Tenecteplase, Alteplase, Reteplase) should be given if nosignificant contraindications exist, the stroke is associatedwith significantclinicaldeficits,andthereisnoevidenceofintracranialhemorrhage.

Ensure that it ispossible to lowerSBP<185mmHgandDBP<110mmHg.

Hypertensionmanagement.Hypertension in the setting of CVA usually reflects either baselineblood pressure levels or a reaction to the stroke itself and may bedangeroustonormalizeintheacutesetting.

SBP>220mmHgorDBP>140mmHgshouldbetreatedusingshort-acting,titratableIVmedications,suchasLabetalolorNicardipine,withagoalofproducinga15%dropinbloodpressurevalues.

Previouslyusedoutpatientantihypertensivesshouldbeinitiatedwithin24–48hoursoftheCVAandgoalbloodpressuresofSBP<130mmHgandDBP<80mmHgachievedslowlyoverdaystoweeks.

Other conditions thatmay coexist with the CVA thatmay dictate amore aggressive approach to rapid blood pressure titration (evennormalizationofbloodpressure)usingshort-actingIVagentsinclude:

Unclippedcerebralaneurysmsassociatedwithsubarachnoidhemorrhage.

Aorticdissection.

Acutemyocardialinfarction.

Bodytemperatureregulation:MAINTAINNORMOTHERMIA.Effortstonormalizebodytemperatureareappropriate.Temperatureregulationbythepatientsmaynotbenormal.Hyperthermia is associated with worse outcomes and should beavoided.AcetaminophenPOorrectummaybebeneficialinthissetting.TherapeutichypothermiainthesettingofCVAisnotsupportedbytheliteratureatthistimeoutsideofclinicalresearchprotocols.Otheradjunctiveagents.Nimodipine has been associated with improved clinical outcomeswhenusedinthemanagementofacutesubarachnoidhemorrhage.Freeradicalscavengershavebeensuggested tohavesomebenefit inCVA,butarenotrecommendedforroutinecareatthistime.

GastrointestinalConsiderations

StressGastritis

Indicationsforstressgastritisprophylaxisincludeseveralfactorscommoninthecombatcriticalcaresettingthatpredisposepatientstodevelopstressgastritis,ofparticular note coagulopathy, mechanical ventilation greater than 48 hours,shock,multisystemtrauma,andburn>35%ofthetotalbodysurfacearea.Sincemostpatientsinthecombatsettingwhohaveaneedforcriticalcaresupporthaveat leastoneof these risk factors,prophylaxis against stress gastritis shouldbeconsiderednecessaryinallsuchpatients.

Pantoprazole40mgIVDailyorRanitidine50mgIVorSubcutaneouslyEvery8Hours

Sucralfateisnotrecommendedinthissetting.

AcalculousCholecystitis

Trauma patients have several potential risk factors for the development ofacalculous cholecystitis, significant among them multisystem trauma,hypotension,andburns.Thediagnosiscanbeverydifficult tomakeatbedside,butisextremelyimportanttomakeinatimelyfashion,becauseadelayintherapycanresultinsignificantmorbidityormortality.

Diagnosis suspected with new fever, vague abdominal discomfort, andleukocytosis.

Mildalkalinephosphotaseelevation.Conjugatedhyperbilirubinemia(elevatedTbili;Dbili/Tbili>0.5).

Confirmation of the diagnosis can be made with RUQ (right upperquadrant)ultrasound.

Ifnormal,butconditionsuspected, laparoscopicoropen laparotomy

shouldbeperformed.AHIDA(hepatobiliaryiminodiaceticacid)scancanbeperformedatmajormedicalcenterspriortosurgeryifclinicallystable,butthiswillnotbeavailableinthecombatcaresetting.

Empiric antibiotic therapy should be started when the diagnosis issuspected.

Imipenem, pipericillin/tazobactam, ampicillin/sulbactam, or a third-generation cephalosporin with metronidazole are all reasonablechoices.VancomycinorLinezolidshouldbeaddedonlyifthepatientisknowntobecolonizedwithMRSA.

Urgentconsultationforoperativemanagementorinterventionaldrainageofthe condition shouldbe obtainedbefore franknecrosis andperforation ofthegallbladderoccurs.

RenalConsiderations

The most relevant forms of renal abnormalities in the combat setting includeprerenal azotemia, acute tubular necrosis (ATN), rhabdomyolysis,nephrolithiasis, and iatrogenic complications of medications. Most of theseentities do not involve permanent kidney damage if recognized and managedappropriately.Forthosethatdodevelopsignificantazotemia(eithertransientlyorpermanently),thereusuallyexistsareasonablewindowofatleast24–36hourstofacilitate evacuation out of the theater of operation. In general, a reliablemechanismforprovidingdialysisdoesnotexistinthewartimeenvironmentuntilRole4isreached.Earlyrecognitionofrenalcomplicationsandappropriateearlymedical management are key to avoiding significant life-threateningcomplications.

PrerenalAzotemiaandAcuteTubularNecrosis

Although these twoentities are separate clinical conditions, theyare commonlyrelatedinthecombatpatient.Prerenalazotemiarepresentsthedevelopmentofrenal failure (marked by a decreasedCrCl and complications such as elevatedBUN,acid-baseabnormalities,hypervolemia,andelectrolytedisturbancessuchashyperkalemia)duetohypoperfusionofthekidneys.ATNdevelopsusuallyasaresultofhypoperfusionwithresultantdamagetorenaltubulecells,especiallyintheregionof the thickascendingloopofHenle.Damaged tubulecellsmayform “muddy brown casts” that can be seen on urine microscopy and mayobstructtubules,leadingtoseverallocalhemodynamicconsequences.

Prerenalazotemiadiagnosis.Decreasedurineoutput,elevatedCre,BUN/Cre>20,UNa<10mg/dL.FeNa(%)=(UNa/SNa)/(SCre/UCre)×100.

FeNa<1%isconsistentwithaprerenaletiologyofrenalfailure

(whereBUN=bloodureanitrogen,Cre=creatinine,UNa=urinesodium,FeNa=fractionalexcretionofsodium,SNa=serumsodium,SCre=serumcreatinine,andUCre=urinecreatinine).

ATNdiagnosis.Decreasedurineoutput,elevatedcreatinine,BUN/Cre10–20,UNa>20mg/dL.FeNa(%)=(UNa/SNa)/(SCre/UCre)×100.

FeNa>1%isconsistentwithanon-prerenaletiologyofrenalfailure.

Muddybrowncastsonurinemicroscopy.PrerenalazotemiaandATNmanagement.

EnsureadequateIVV.Thereisnosignificantclinicalbenefittoconvertinganuricrenalfailureto oliguric failure, although patients who present in anuric renalfailuredoworsethanthosewhoareoliguriconpresentation.IfIVVrepletionisensuredandurineoutputislow,diureticusecanbeconsidered in thepatientwith lowurineoutput if IVVoverload isaconcern.In the case of ATN, a period of 1–3 weeks may pass before renalrecoveryisnoted.

AnincreaseinurinevolumeoccursthatprecedesanytrueimprovementinCrCl.

Watchcloselyfor thedevelopmentofhyperkalemia,acidemiaduetoananiongapmetabolicacidosis, IVVoverload,pericardial rubs,andextremeuremia.

Theseareindicationsforemergenthemodialysis.

Rhabdomyolysis

Rhabdomyolysis results in the setting of crush injury that causes significantdestruction of skeletal muscle. CKT (creatinine kinase), heme-pigmentedmyoglobin, and phosphate elevations are all released in significant amounts.Heme-pigmented proteins may result in an ATN. One unique feature of thisform of renal failure is that it is associated with hypocalcemia. Prevention ofrenal failureand its consequences isoneof the fundamentalprioritiesof themanagementofrhabdomyolysis.

Diagnosis: Red/brown low volume urine, positive urine dipstick formyoglobinintheabsenceofredbloodcellsonurinemicroscopy,andCKTelevation(maybe>50,000–100,000).AggressivelyensureadequateIVVrepletion.

Repletewithisotoniccrystalloid(0.9%NSorLRmayalsobeutilized,butconsidertheriskofhyperkalemiainthesettingofrhabdomyolysis

andassociatedrenalfailure).Goalurineoutput150–300mL/h;considerdiureticifIVVhasbeenrepleted.Bicarbonatetherapycanbeconsidered—titratetoaurinepHof6.5–7.

Dose:150mEqNaHCO3 (3 standardamps) in1LD5Wat100mL/hinitially.Nodefiniteclinicalbenefittothisapproachhasbeendemonstrated.

Mannitol diuresis is not recommended in the peritrauma setting due topossibleIVVdepletion.Follow serumelectrolytes closely, especially potassium,phosphorous, andionizedcalcium.

Nephrolithiasis

Nephrolithiasisrepresentsoneofthemostcommonreasonsforsoldierstobeevacuated from the combat theater in both Operation Iraqi Freedom andOperationEnduringFreedom,andsurgeryofrenalstoneswasthemostcommonelective surgery performed in theater. Risk factors related to the combatenvironmentincludelowurinevolumeduetoIVVdepletion,aswellasadietthat may be high in protein. The majority of stones are calcium based(approximately 80%) and are therefore easy to visualize with radiographicstudies.Manywill eventuallypass on their own, but patientswith a history ofrecurrent stones, family history of stones, or complicating anatomical featuresleadingtorenalfailuremaynecessitatesurgicaltherapybyaurologist.

Diagnosisofnephrolithiasissuggestedbywaxing/waningpain(radiatingtothe flank or scrotum, generally depending on level of obstruction) andmicroscopichematuria.The stone may be visualized on KUB, CT/nephrolithiasis protocol, orultrasound.

StartwithKUB;subsequentstudiesbasedonavailability.Adequateintravascularhydrationisextremelyimportant.Parenteralintravenousmedicationsarefrequentlyneededforpaincontrol.Medicaltherapycanbeconsideredwithanalpha-blockingmedication,suchasTamsulosin(0.4mgPOdaily).Consultationwithaurologistearlyisimportantandevacuationtoamedicaltreatmentfacilitywheresurgerycanbeperformedifthestonedoesnotpasscanbeconsidered.

IatrogenicComplicationsofTherapy(Medications,ContrastDye)

Severalmedicationsmaycauseorcontributetotheworseningofrenalfunctioninthe multisystem trauma patient. The most common offenders are medicationssuch as diuretics that may be used before IVV repletion has been ensured,resulting in prerenal azotemia or even ATN. Nonsteroidal antiinflammatorymedications used for pain management may result in renal failure by alteringlocal glomerular perfusion pressure. Penicillin medications may be associatedwithacuteinterstitialnephritis.Themostimportantsingleagenttobeawareof

with respect to the kidneys is intravenous contrast dye,whichmay cause anassociated ATN (contrast dye-associated nephropathy). These agents areiodinated and either ionic or nonionic. Most contrast dye used currently arenonionic,whichhasdecreasedtherateofrenalfailure.

ATN resulting from intravenous contrast dye generally resolves withindays, in contrast to the 1–3week recovery expected from other causes ofATN.AssuranceofadequateIVVismostimportantforthepreventionofcontrastdyenephropathy.Themostimportantaspectofcontrastdye-associatednephropathyisaimedatpreventionwithprecontrasthydration.NobenefithasbeenshownwitheitherbicarbonatetherapyofN-acetylcysteine(Mucomyst).

DisseminatedIntravascularCoagulation/ThromboticThrombocytopenicPurpura

Disseminatedintravascularcoagulation(DIC)usuallyidentifiespatientswithahigherlikelymortalitybothduetounderlyinginjuryandpossiblyDICitself.Theprocessresultsfromaprothromboticstatewhereinfibrinisdepositedthroughoutthebody,resultingintheconsumptionofcoagulationfactors,hemolyticanemia,and thrombocytopenia. This leads to an inability to clot blood effectively, andpatients are noted to have petechiae and frank bleeding from IV sites, surgicalwounds, and mucosal barriers of the body. Thrombotic thrombocytopenicpurpura(TTP)iscausedbyabnormalactivityofvonWillebrand’sfactor,resultingin activation and aggravation of platelets. Laboratory abnormalities includethrombocytopenia and hemolytic anemia. The classic clinical pentad includes:fever,anemia,renalfailure,thrombocytopenia,andneurologicalabnormalities(especiallyseizures).

DICdiagnosis:Hemolytic anemia, thrombocytopenia, and fibrinogen decrease(usually<100).INRelevation (KEYDISTINCTIONFROMTTP—THERE ISNOINRELEVATIONWITHTTP).

DICmanagement:Largelysupportive;correctthecauseofDIC.Cryoprecipitate, fresh frozen plasma, platelet, and red blood celltransfusionIFCORRECTABLEETIOLOGYFORDICISIDENTIFIED.

TTPdiagnosis:Hemolyticanemia,thrombocytopenia,andfibrinogendecrease.INRISUSUALLYNORMAL.Clinicalpentadoffever,anemia,thrombocytopenia,renalfailure,andneurologicalabnormalities.

TTPmanagement:Bloodproductsarelargelywithoutbenefit.

High-dosecorticosteroids.Plasmaexchangetransfusions.Unrecognized and untreated TTP can have an extremely highmortality.

Heparin-InducedThrombocytopenia

Heparin-inducedthrombocytopenia(HIT)iscausedbyantibodiesdirectedattheheparin-plateletfactor4complex.Itusuallypresentsapproximately4–5daysafterthe initiation of heparin products, but can present suddenly in susceptiblepatientswhohavereceivedheparinwithintheprevious3months.Theriskofthedevelopmentis1%–5%withunfractionatedheparinand<1%withlowmolecularweightheparin.Thediagnosis is suspectedwhen theplatelet count suddenlydropsby50%ortoavalueof<100,000(ifplateletcountwasnormalinitially).Confirmationof thediagnosiswill generallynot bepossible in the combat caresetting, but higher medical treatment facilities can confirm the diagnosis bysendingHITantibodystudiesintheappropriateclinicalcontext.

Suspected HIT should prompt immediate discontinuation of all heparinproducts(includinglowmolecularweightheparin).Therapeutic anticoagulation should be initiated in full anticoagulationdoses,ifpossible.

Thrombosisoccursin>50%ofHITpatients.Antithrombin agents that can be used in the combat environmentrequiretitrationbasedonactivatedpartialthomboplastintimelevels:

Argatroban.

Hirudin.

Fondaparinuxisananti-XainhibitorthatcanbeconsideredatRole4facilities that have access to onsite anti-Xa level measurementcapability.

WarfarinshouldNOTBEUSEDinthemanagementofHITpatientsunlessanantithrombinagentisinuseatfulltherapeuticanticoagulationdoses.

EndocrineConsiderations

Themajorityofendocrineemergenciesthathappeninthecombatsettingoccurinpatientswithpreexisting conditions (knownornot)whoundergoa clinicaldecompensationrelatedtoeitherastressintheenvironmentorlackofaccesstomaintenance medical care (insulin in the case of the diabetic patient). Whileinfrequently seen, the most likely endocrine emergencies to be aware of arediabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, and adrenalinsufficiency.

DiabeticKetoacidosis/HyperglycemicHyperosmolarSyndromeDiagnosisofdiabeticketoacidosis(DKA):

Elevated glucose (200–600); long-standing DKA may have normal

glucose.Aniongapmetabolicacidosis;elevatedserumandurineketoacidosis.Glucosuriaifserumglucoseiselevated.Dehydration(generally<6–8Loftotalbodywaterdeficit).

Diagnosisofhyperglycemichyperosmolarsyndrome(HHS):Severelyelevatedglucose(600–1,500).Severeintracellulardehydrationduetoextremeosmoticshifts.Mild anion gap metabolic acidosis may be present, but is not adominantclinicalfeature.Severeglucosuria.Severedehydration(>8–10Loftotalbodywaterdeficit).

ManagementofDKAandHHS:CorrectthecauseofDKA/HHSdevelopment(infection,trauma,etc).Managementissimilarinmanyways;differenceswillbehighlighted.Bolus 10 units of regular insulin IV; start insulin drip at 5 units ofregularinsulinIVperhour.

Holdonbolusifpotassium<3.0;donotgiveinsulinuntilserumpotassium>3.0.

Donotcorrectglucose>100perhouror1,200in24hours.

Bolus2Lof0.9NSinthefirsthour.

Repletionofvolumeisvitalforbothconditions;HHSwillrequiresubstantiallymoreisotoniccrystalloidtoaccomplishthis.

Give4–6Lof0.9NSinthefirst6hoursforDKA.

Give6–8Lof0.9NSinthefirst6hoursforHHS.

Subsequent0.9NSrequirementswillbedeterminedbyassessmentoftheadequacyoftheIVVstatus.

AfterrepletionoftheIVV,changebasefluidfromisotoniccrystalloid(0.9NS)tohypotoniccrystalloid(½NS).Check glucose hourly using point-of-care testing while adjustinginsulindrip.Measureserumelectrolytesevery1–2hoursuntilpotassiumstablefor>4hoursandglucosestablefor>4hours.When potassium < 4.5 mg/dL, add 20 mEq KCl/L to currentintravenousfluid.

Additionalsupplementationwillbeneeded(orallyasaKClelixir)aswell.

Potassiumreplacementneedsareusuallyprofoundduetototalbodylossofpotassiumandmagnesiumduetodiuresis,aswellastranscellularshiftsassociatedwithinsulinutilization.

When serum glucose drops below 250 mg/dL, add D5 to whatever

fluidisbeingutilized.WHEN TREATING DKA, DO NOT STOP INSULIN INFUSIONUNTIL THE ANION GAP IS CLOSED—HYPOGLYCEMIA ISTREATED WITH THE ADDITION OF DEXTROSE AND ADECREASE IN INSULINDOSE, BUT CESSATIONOF INSULINWILLRESULTINTHERETURNOFDKA.

AdrenalInsufficiency

Adrenalinsufficiencyshouldbeanticipatedinpatientsrequiringsurgerywhoaretakingcorticosteroidsatdosesinexcessoftheequivalentofprednisone10–20mgdaily.Itisalsoseenclinicallyinpatientswhohavetakensuchdosesformorethan5–7days at anypoint in theprevious year.Rarely, adrenal insufficiency resultsfrominfarctionofthebilateraladrenalglandsassociatedwithhypovolemicshockstates.Unfortunately,thereisnouniversalagreementonthelaboratorydiagnosisofadrenalinsufficiency,soahighindexofclinicalsuspicionshouldbepresentinpatientswithaknownhistoryof steroiduse.Oneclinical scenario that canbesuggestive of adrenal insufficiency is a patient with a history of steroid usewhoishypotensive(sepsis,hemorrhage,etc),whoisnotresponsivetopressortherapy, andwho does not have an appropriate tachycardia. The presence ofhyponatremiaand/orhyperkalemiamayalsosuggestadrenalinsufficiency.

Treatment of acute adrenal insufficiency:Hydrocortisone 200mg IV, then100mgIVq8h.If hyponatremia and/or hyperkalemia persists despite hydrocortisonetherapy,addfludrocortisone0.1mgPOeverymorning.

ICUProphylaxis

Ventilator-AssociatedPneumonia/Combat-RelatedVentilator-AssociatedPneumonia

Assessdailytheneedforcontinuedmechanicalventilationanddiscontinueasquicklyaspossible.Use a Hi-Lo Tracheal Tube to allow removal of subglottic secretions thatcollect above the endotracheal tube cuff in all patients expected to beintubated>96hours.Provideoralcarewithchlorhexidinesolutionq4h.Donotroutinelychangeoutventilatorcircuitryunlessmechanicalfailureispresentorvisiblecontaminationisnoted.Keep head of bed 30°–45°at all times while intubated (unless absolutecontraindicationexists).Perform regular surveillance cultures of respiratory secretions in the ICUandregularlyupdatethebiogramdescribingorganisms/susceptibilitiesthathavebeenisolated.Minimizetheempiricuseofantibiotics.Whentreatingasuspectedcombat-relatedventilator-associatedpneumonia(CRVAP):

Treat aggressively with broad-spectrum antibiotics based on localbiogram(seesectiononPulmonaryMedicine).Culture respiratory secretions, as well as blood; tailor antibioticregimenbasedoncultureresults.Discontinue all antibiotics if cultures are negative at 72 hours andpatientisimproving.Continue CRVAP therapy for 7 days total if cultures demonstrate adominantorganism,andaGramstainshowedasignificantnumberofleukocytes.

When a multidrug-resistant organism is isolated, consider cohortingpatients with similar isolates to one area of the ICU away from otherpatients.ConsiderterminalcleaningofapartoftheICUafteramultidrug-resistantorganismhasbeenisolatedandthepatienttreated.

DeepVenousThrombosisProphylaxis

Seepreviouscontentwithinthischapter.

GlucoseControlMost critical care patients in the combat setting should have glucosetargetedbetween140–200mg/dL.Insulin drips should be initiated in any critically injured patientwho hastwoormoreconsecutiveglucosereadings>180mg/dL.

NutritionEnteralnutritionisfavoredovervenousroutes,ifpossible.Duodenaltubeplacementisfavoredovergastrictubeplacement,butgastricisacceptableaslongasresidualsremain<500mL/4h.

TotalparenteralnutritionmaybeavailableatsomeRole3facilitiesiffull-doseenteralnutritionisnotabletobeusedby72hours.The risk of infection related to totalparenteral nutritionusemaybedrivenmorebythedurationofcentralvenousaccessandnumberoftimes theport is accessed than the actual content of total parenteralnutrition.

Glutaminecanbeaddedtotraumapatientnutritionregimens.Albuminshouldbegiveniftheserumalbumis<1.Specialtyformulaswithspecificadditivesgenerallyofferlittlebenefitintheacutesetting.

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Chapter12

DamageControlSurgery

Introduction

Historically,theapproachtothevictimofseveretraumafromcombatwoundingwas surgical exploration with definitive repair of all injuries. This approach issuccessful when there are a limited number of injuries, the patient is notphysiologically impaired, and if there are adequate resources. Extensiveexperience inboth civilianandmilitary traumadictates anabbreviated surgicalapproachinpatientswithextensiveinjuriesdirectedatcontrolofhemorrhageandcontamination, followed by resuscitation to normal physiology with definitiverepairinadelayedfashion.Thisapproach,termeddamagecontrolsurgery(DCS),is designed to restore normal physiology prior to normal anatomy. It is wellestablished thatpatientswhodevelop the lethal triadof coagulopathy, acidosis,and hypothermia have significantly increased mortality. DCS is designed toprevent or limit the triad through rapid control of bleeding and shortenedoperativetime.

DAMAGE CONTROL SURGERY is defined as the rapid initial control ofhemorrhageandcontamination, temporaryabdominalclosure, resuscitationto normal physiology in the ICU, and subsequent reexploration anddefinitive repair after normal physiology has been restored. DAMAGECONTROL TECHNIQUES can also be applied in extremity, thoracic, and headtrauma.

A decision to apply damage control should be made early, and, in manycircumstances,evenbeforetheoperationisbegun.

GeneralConsiderationsPhilosophyofdamagecontrolis“alivepatientaboveallelse.”

Avoidhypothermia.Rapidlyachievehemostasis.Perform initial bowel resections without anastamosis. Controlcontamination and reconstruct at the second operation after thepatienthasbeenstabilizedandcantolerateaprolongedoperation.

Whentoemploydamagecontrol.Use damage control in patients who present with or are at risk fordeveloping:

Multiplelife-threateninginjuries.

Acidosis(pH<7.25).

Hypothermia(temperature<34°C).

Shockonpresentation.

Combinedhollowviscusandvascularorvascularizedorganinjury.

Coagulopathy(INR>1.4).

Masscasualtysituation.

The use of specific physiological criteria/lab values to determine when toemploy damage control is of questionable utility because these representborderline physiological states in which the patient may already beunsalvageable. The earlier DCS is applied in patients at risk, the better theoutcomes.

Take into account ability to control hemorrhage, severity of liver injury,andassociatedinjuries.Packbeforemassivebloodloss(10–15unitsofpackedredbloodcells)hasoccurred.Injuriesthattypicallyrequiredamagecontroltechniques:

Upperabdominalinjuriesthatarenotisolatedspleeninjuries(duodenal,largeliverinjuries,pancreas,etc).

Penetratingpelvicinjurywithvascularinvolvement.

Anyretroperitonealvascularinjury.

Thegoalofdamagecontrolistorestorenormalphysiologyratherthannormalanatomy. It is used for the multiply injured casualty, with combinations ofabdominal, vascular, genitourinary, neurological, orthopaedic, and/or thoracicinjuryinfourseparateanddistinctphases.

Phase0(Ground0):PrehospitalandEarlyResuscitation

The emphasis of Phase 0 is the early recognition of patientswho are at risk ofdevelopingthelethaltriadandthoseinwhomdamagecontroltechniquesmaybeindicated.Phase0includesthefollowingsteps:

Stopbleedingusingtourniquetsordirectpressure.If the patient has noncompressible bleeding, practice permissivehypotension.Rapidtransfertothemedicaltreatmentfacility.Initiatedamagecontrolresuscitation.Preventhypothermia.Measurebloodgases.RapidtransfertotheOR.

Phase1:PrimaryDamageControlOperationControlofhemorrhage.Explorationtodetermineextentofinjury.Controlofcontamination.Therapeuticpacking.Temporaryabdominalclosure.

GeneralPointsControlofhemorrhage.

Hemorrhage from blood vessels can be controlled by ligation,shunting,orrepairofinjuredvesselsastheyareencountered.Theinitialgoalishemorrhagecontrol,notmaintenanceofbloodflow.For thepatient inextremis, clampingor shuntingofmajorvessels isrecommendedoverrepair.

THINK:⇒fasciotomy.Additionalmethods of hemorrhage control include balloon cathetertamponadeofvascularorsolidviscusinjuries.

Explorationtodetermineextentofinjury.Damagecontrollaparotomy.

Performonlyessentialresectionsorpacksolidorganstodiminishbloodloss.

Rapidlyterminatetheproceduretominimizehypovolemia,hypothermia,acidosis,andcoagulopathy.

Performdefinitivereconstructiononlyduringsubsequentoperation(s)afterthepatienthasstabilizedandcantolerateaprolongedoperation.

Assessmentandstabilization/externalfixationofmajorextremityandpelvicfractures.

Includingvascularinjuriesandfasciotomy.

Controlofcontamination.Contamination control also proceeds as injuries are encountered,utilizingclamps,primaryrepair,orresectionwithoutreanastomosis.Withmultiple enterotomies, if the area of injury represents <50% ofthelengthofthesmallbowel,asingleresectioncanbeundertaken.

Temporarypacking.Temporary packing provides tamponade of liver, pelvic, andretroperitonealbleeding.Donotusethe“pack-and-peek”technique.Oncepackedandbleedingcontrolled,leavealoneuntilsecond-lookoperation.Definitivepackingisbasedontwobasicprinciples:

Pressurestopsbleeding.

Pressurevectorsshouldre-createtissueplanes(attempttore-createthepressurevectorscreatedbythecapsuleofasolidorganorfillthespaceofthatorgan,notrandompackplacement).

Laparotomypadsarethebestcommonlyavailablepackingmaterial.An intervening layer—suchasabowelbag,steriledrape,absorbablemesh,oromentum—canbeplacedbetweenpacksandthetissuetoaidineasypackremovalatrelaparotomy.

Temporaryabdominalclosure.Multipletechniquesemployed:

Bogotábag—sterileIVbag(3liters)sewntoskin.

Vacuumpack—constructedfromavailablematerialsinOR(seenextpage)andthereforecommonlyusedincurrentcombatcasualties.

WoundVAC—commercialdevicenotuniversallyavailableindeployedsetting.

Towelclipclosure—ofhistoricalinterestonly;NOTRECOMMENDEDbecausethereisahighincidenceofassociatedabdominalcompartmentsyndrome(ACS).

Keyconceptsfortemporaryabdominalclosure.

Musthaveanonadherentlayer(eg,IVbag,sterileX-raycover,Mayostandcover,bowelbag)ontopofthebowelandtuckedundertheperitoneumasfarlateralaspossible.

Perforateor“piecrust”theabovelayerpriortoplacementtoallowfluidtodrainout.

Adequatedrainagetubes(eg,chesttube,Jackson-Pratt)thatareinterposedbetweengauzeortowelsandbroughtoutthroughthetopofthewound.

Water-tightsealoverthetopadherenttotheskin.

Donotsewtothefascia.

Useadequatesedation.

BeawarethatACScanoccureveniftheabdomenisleftopen.

The vacuum pack technique (easy, keeps patient dry, allows forexpansion):

Withfasciaopen,placeanORtowelthatisfullyplastic-coveredwithabowelbag,X-raycassettebag,orIobandrape,etc,wellundertheperitoneumtocovertheviscera.Placeasmallnumberofcentralperforationstoallowfluidtoegresstothedrains.Alternatively,placeasterile,nonadherent,perforatedplasticdrape

(asabove)completelyoverthevisceraandundertheperitoneumandcoverthiswithasterileORtowel.

Placeclosed-suctiondrains(Jackson-Pratt,modifiedFoley,smallchesttube)abovethetowelatthelevelofthesubcutaneoustissuebroughtoutthroughseparatestabwoundsortheinferiororsuperiorportionofthewound.

Placelapspongesoranothersteriletoweltofillinthewoundandsandwichthedrain(s).

Covertheentirewoundwithalargesticky(Ioban)drape.

Placedrainsonlowsuction.

Skinclosureisnotrecommended.

Phase2:CriticalCarePhysiologicalsupportinthepost-opDCSpatientisparamounttosurvival.

Corerewarming:Warmedresuscitativefluids,blankets,ventilatorair,and environment, or commercially available products, such as BairHugger,ChillBuster.Reversalofacidosis:Appropriate resuscitationwithbloodproducts,colloids,and/orcrystalloid.Reversalofcoagulopathy:Factorreplacement.Ventilatory support: Using ARDSNet low tidal volume supportavoidingbarotrauma.Injuryidentification:Performatertiarysurveyof thepatient,obtainCTscansandangiographyasindicated.MonitorforACS(seebelow).

ACS.ACS is a condition in which increased intraabdominal pressureadversely affects the circulation/ventilation, and threatens thefunctionandviabilityoftheviscera.Measurementisperformedusingurinarybladderpressure(normal=0).

Measurementofbladderpressureisagoodvariabletotestandfollow;however,interventionforACSshouldoccurwhensuspectedorclinicallyindicated.

Occurs in abdominal trauma accompanied by visceral swelling,hematoma,orabdominalpackuse.PhysiologyofACS.

Cardiacoutputandvenousreturnaredecreased.

Reductioninbloodflowtotheliver,intestines,andkidneyscanresultinanuria.

Thetwohemidiaphragmspushupward,decreasingthoracic

volumeandcomplianceleadingtoelevatedpeakairwaypressures.Centralvenous,pulmonarycapillarywedge,andrightatrialpressuresincreasewithintraabdominalpressure(canleadtofalsepulmonaryarterycatheterpressures).

PO2isdecreasedduetoincreasesinairwaypressuresandventilation/perfusionabnormalitiesthatworsenwithpositiveend-expiratorypressure.

AbdominalPressure DegreeofElevation ClinicalEffect10–20mmHg Mild Insignificant20–30mmHg Moderate Oliguriaandorgandysfunction>30mmHg Severe Requiresimmediateattention

Phase3:PlannedReoperationPacksshouldbeleftinplaceuntilthepatient’shemodynamicsarestableandallmajorsitesofhemorrhagehavehadtimetoclot.Whenremoved,packsshouldbetakenoutslowlywithplansforvascularcontrol.Reoperation should be scheduled when the probability of achievingdefinitiveorganrepairandcompletefascialclosurearehighest,althoughanestimation that the fascia cannot be closed should not preclude initialreexploration(s).Reexploration must occur after correction of hypotension, acidosis,hypothermia, and coagulopathy. It typically occurs 24–48 hours followingtheinitialoperation.Timingcan,however,bedictatedbyotherpressingclinicalconcerns, suchas ACS, limb ischemia, and suboptimal control of spillage at primaryoperation.Incasesofapackedanddrainedduodenum,pancreas,kidney,bladder,orliver injuries with gross bowel contamination, packs should be retrievedwithin36–48hours.This surgery may occur (and in many cases should occur) at the nextechelonofcare.

STRATEVAC (strategic evacuation) should be weighed carefullybecausesurgeryisnotavailableintransit.

ConductofRelaparotomyItistobepresumedthatinjurieswereunrecognized.Acompleteexplorationmustbeperformed.Feeding tube placement, either transabdominal or nasoenteric, should beperformedatthistime.Repackingmaybereemployedifothermeasuresfailtocontrolhemorrhage.Radiographicimagesshouldbeobtainedthatvisualizenipplestomid-thightoensurethatallpackshavebeenremovedfromtheabdomen.

Spongecountsareunreliableinthissituation.Unplannedreexploration.

Emergent, unplanned reexploration should be considered in anypatientwhoremainsunstable,persistentlycoagulopathic,oracidoticdespitecontinuedresuscitationorevidenceofACS.

DamageControlintheChest

ThoracicInjuriesThegoalofabbreviatedthoracotomyistostopthebleedingandrestoreasurvivablephysiology;contaminationisusuallynotaproblem.In the exsanguinating patient, nonanatomical wedge resection to rapidlyachievehemostasisandcontrolofairleaksusingalargestaplerispreferredoverformallungresection.In pulmonary tractotomy, the lung bridging the wound tract is openedbetweenlongclampsorwithalinearstaplerallowingdirectinspectionandselectivecontrolofbleedingpointsandairleaks.GreatvesselinjuriescanbetemporizedwithintraluminalshuntsorFogartyballoonstoachievedistalcontrolininaccessibleareas.Tracheal injurycanbe temporizedwithairwaycontrolplaced through thesiteofinjury.Extensive bronchial repairs are not feasible in the patient in extremis;therefore,rapidresectionoftheaffectedlobewouldbebest.When dealing with esophageal injury, diversion and wide drainage, notdefinitiverepair,arethebestinitialcoursesofaction.Asinglelayerenmassesutureclosureofthechestwallshouldbeused.

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Chapter13

FaceandNeckInjuries

Introduction

Immediaterecognitionandappropriatemanagementofairwaycompromiseis critical to survival. The best method to quickly evaluate airwaycompromise is to ask the patient to speak. If the patients can speakintelligibly,thentheairwayisintact,theyhaveenoughpulmonaryreservetogeneratesound,andtheirGlasgowComaScalescoreismostlikely>8.Ifthepatientcannotspeak,theairwayneedstobeemergentlysecured.

Faceandneck injuries canbe immediately life-threateninganddifficult tomanage.FocusonABCpriorities.Duringairwaycontrol,maintaincervicalspineimmobilizationinpatientswithheadandneckinjuries.Control of bleeding begins with direct pressure. If bleeding cannot becontrolled with direct pressure, immediate operative intervention isnecessary.DONOTblindlyclampvesselsintheneck.Complete assessment of remaining injuries (fractures, lacerations,esophagealinjury,ocularinjuries,etc)occursonlyaftertheABCshavebeenaddressed.

ImmediateManagementofFacialInjuriesAirway.

The most common site of airway obstruction in the trauma patientwith head and/or neck injuries is at the base of tongue and upperpharynx. These patients typically present with obstructed breathingmarked by stertor, a coarse snoring noise most pronounced oninspiration. Blunt or penetrating neck injuries may also result inlaryngeal trauma that can present with inspiratory stridor, a harsh,high-pitchedsound. Ineither case,anoisyairway isa compromisedairway, and steps must be taken immediately to relieve theobstruction.Commoncausesoftraumaticairwayobstructioninclude:

Bloodorsecretions.

Soft-tissueedema.

Collapseofthetonguebaseagainsttheposteriorpharynx.

Afractured,free-floatingmandiblemayobstructtheairwaydueto

tonguebaseretrodisplacement.

Displacedtoothfragmentsmaybecomeforeignbodies.

Maneuverstorelieveupperairwayobstruction:

Chinliftorjaw-thrustmaneuver.

Removeforeignbodies(strongsuction,Magillforceps).

Placeadjunctiveairwaydevice(nasaltrumpetororopharyngealairway).DONOTusenasaltubesinpatientswithsuspectedskullbasefractures.

Endotrachealintubation.

Cricothyroidotomy(preferredemergentsurgicalairwaytechnique)orurgenttracheotomymaybecomenecessary.

Cervicalspine.Up to 10% of patientswith significant blunt facial injurieswill alsohaveacervicalspineinjury.

Theneckshouldneverbehyperextended.

Intubationshouldonlybeperformedwithin-lineneckstabilization.

Vascularinjury.Injuriestothefaceareoftenaccompaniedbysignificantbleeding.Controloffacialvascularinjuriesshouldprogressfromsimplewoundcompression forminor bleeding to possible vessel ligation formoresignificantbleeding.

Vessel ligation should only be performed under directvisualization and after careful identification of the bleedingvessel. Blind clamping of bleeding areas should be avoidedbecausecriticalstructures,suchasthefacialnerveorparotidduct,aresusceptibletoinjury.

Woundpackingwithapressuredressingmaycontrolactivecraniofacialbleeding.Hemostaticgauzemayalsobeused.

Intraoralbleedingmustbecontrolledtoensureasafeairway.

Donotpacktheoropharynxinanawakepatientduetotheriskofairwaycompromise.Firstsecuretheairwaywithanendotrachealtubeorsurgicalairway,ifnecessary.Moistened,rolledgauzeisexcellentmaterialforpackingtheoropharynx.

Irrigationandgram-positiveantibioticcoverage(eg,clindamycin)shouldbeusedliberallyforpenetratinginjuriesoftheface.

Evaluation.

Oncethecasualtyisstabilized,gentlycleansedriedbloodandforeignbodiesfromwoundsitestoevaluatethedepthandextentofinjury.Thebonyorbits,maxilla,forehead,andmandibleshouldbepalpatedforstepoffsormobilesegmentssuggestiveofafracture.Acompleteintraoralexaminationincludesinspectionandpalpationofall mucosal surfaces for lacerations, avulsions, ecchymosis, bonystepoffs,malocclusion,anddentalintegrity.Intheawakepatient,malocclusionindicatesaprobablefracture.Perform a cranial nerve examination to assess vision, gross hearing,facial sensation, facial muscle movement, tongue mobility, andextraocularmovements.Consultanophthalmologistfordecreasedvisionongrossvisualfieldtesting,diplopia,ordecreasedocularmobility.If the intercanthal distance measures >40 mm (approximately thewidthofthepatient’seye),thepatientshouldbeevaluatedwithaCTscanandtreatedforapossiblenaso-orbital-ethmoid(NOE)fracture.

IfanNOEfractureissuspected,donotinstrumentthenose.Theremaybeatear in the dura, and instrumentationmay contaminate the cerebrospinalfluid(CSF)viatheskullbasedefect.

FacialBoneFractures

Facialbonefracturesshouldberealignedandfixedincorrectanatomicalpositionwithdentalwiresortitaniumplatesandscrewstorestorenormalappearanceandfunctionofthefaceandsurroundingstructures.

With the exception of fractures that significantly alter normal dentalocclusionorcompromisetheairway,repairoffacialfracturesmaybedelayedforupto10daysafterinjury.Openfracturesmaybedebrided,irrigated,andclosedtemporarilyshouldtimenotpermitimmediaterepair.

Mandiblefractures.Secondmostcommonlyfracturedboneoftheface(afterthenose).Subcondylarfracturesaremostcommon.Multiplemandiblefracturesarepresentin50%ofcases.Patientstypicallypresentwithlimitedjawmobilityormalocclusion.Panorexisthesinglebestplainfilm(butisusuallyunavailableinthefield environment); a plain film mandible series serves as a lessreliable, but satisfactory, study (might overlook subcondylarfractures).Finecut(1–3mm)CTscanwilldelineatenearlyallmandiblefractures.Treatment is determinedby the location and severity of the fractureandtheconditionofexistingdentition.

Removeonlyteeththatareseverelylooseorfracturedwithexposedpulp.

Teethinthelineofafracture,ifstableandnotimpedingthe

occlusion,shouldbemaintained.

Nondisplacedsubcondylarfracturesinpatientswithnormalocclusionmaybe treated simplywitha softdiet and limitedwearof aKevlarhelmetandprotectivemask.Immediate reduction of the mandible fracture and improvement ofocclusion (and patient comfort) can be accomplished with a bridlewire(24or25gauge)placedaroundatleasttwoteethoneithersideofthefracture.More severe fractures may require immobilization with maxillary-mandibularfixation(MMF)for6weeks.Place commercially made arch bars onto the facial aspect of themaxillaryandmandibularteeth.

Archbarsarefixedtotheteethwithsimplecircumdental(24or25gauge)wires(Fig.13-1).

Afterproperocclusionisestablished,themaxillaryarchbarisfixedtothemandibulararchbarwithwiresorelasticbands.

Ifportionsofthemandiblehavebeenavulsedorthefragmentsareextremelycontaminated,anexternal,biphasesplintshouldbeplacedtomaintainalignment.

WirecuttersmustalwaysbewiththepatientwhoisinMMF.

Fig.13-1.Archbarapplications.

The airway must be closely monitored in the patient with maxillofacialtraumawhoisplacedintoMMF.Considertheabilitytomonitorpatientswith MMF during aeromedical evacuation before placing a patient inMMF.

Open reduction and internal fixation with a mandible plate acrossfracturesitesmayobviatetheneedforMMF.

Nasalfractures.

Mostcommonfracture.

Controlofepistaxis:Gauzeorspongepackingorballoon.Hemostaticgauzemayalsobehelpfulforbriskepistaxis(Fig.13-2).

Diagnosed clinically by the appearance and mobility of the nasalbones.

The patient’s septum should be evaluated for the presence of aseptalhematomathat,ifpresent,mustbeimmediatelydrainedbyincision,followedbypackingtopreventdelayedcomplications.

Treat by closed reductionof the fracturedbones and/or septum intotheircorrectanatomicalpositionsupto7daysafterfracture.

Placeabluntelevator(Sayre)intothenasalcavitytoelevatethedepressedbonysegmentwhilesimultaneouslyrepositioningthebonewiththesurgeon’sthumbplacedexternally.

The nose may then be fixed with tape or a splint to maintain thereduction.

Maxillofacialfractures.Includes orbital, zygomaticomaxillary complex, frontal bone, andLeFortfractures.Potentially life-threatening due to loss of airway, hemorrhage, orspinalinjury.Fragmentwoundsofthemaxillarysinusarecommonlyseenandmayrequire surgical removal of retained fragments (can delay until

specialistavailable).Fig.13-2.(a)Anteriorand(b)posteriorpackingofthenose.

Midfacefractures(LeFort).

Requires“significant”trauma.

Highincidenceofassociatedspine,brain,andorbitalinjuries.

Significanthemorrhagefromlacerationsoftheinternalmaxillaryarteryanditsbranches.

Canbedifficulttocontrol.

Maybelife-threatening.

Treatbyprotectingtheairway,controllinghemorrhagewithpressuredressingsorpacking,andreducingfractures.

Asurgicalairwayissometimesnecessary.Edemamaycauseimmediateordelayedairwaycompromise.

Canbedifficulttodiagnose.

Manipulatethehardpalateandmidfacewhilestabilizingtheskull.Placethethumbandforefingerofonehandonthenasalbridgetostabilizeand,withtheotherhand,determinemobilityofthemaxillabyplacingthethumbonthealveolusandforefingeronthepalateandattemptgentledistractioninananterior-posteriordirection.

PenetratingfacialinjuryfracturesmaynotfollowclassicLeFortpatternsandoftenhavesignificantassociatedexternalandinternalsoft-tissueinjuries.

Systematicallypalpatetheheadandfacelookingfordeformities,crepitus,tenderness,ecchymosis,orsubconjunctivalhemorrhagesthatmightsuggestfractures.

ClassificationoffacialfracturesbyLeFort(Fig.13-3).

I—Fractureseparatestheentirealveolarprocessfrommaxilla.

II—Separationofmidface,includingthenasalbone,fromtheorbit(pyramidal).

III—Detachmentofthefacefromtheskull(craniofacialdisarticulation).

Treatment.

ABCs.

Ifnasalintubationisnecessary,extremelycarefulplacementismandatorytoavoidcribriformplateoranteriorcranialfossapenetration.

Fig.13-3.LeFortfacialfractureclassifications.

CheckCNSandvision.

Canimmobilizethemaxillabyusingthemandibleasasplint(wires/archbars,withwirecuttersatbedside).ItismucheasiertoplacepatientintoMMFifeitheranasalairwayortracheostomyisused.

Controlnasopharyngealand/ororopharyngealhemorrhagebytamponadeaspreviouslydescribed.

Definitivesurgicalrepair.

Notanemergencyoncetheairwayandhemorrhagearecontrolled.

RequiresexpertiseinENT,oralandmaxillofacialsurgery,plasticsurgery,and/orophthalmology.

Repairisoftentime-consuming.

Openfracturereductionsrequiretitaniumplatingsystemsandequipmentthatareusuallyunavailableinthefield.

Soft-TissueInjuriesGeneralprinciples.

Avoid injury to surrounding structures, such as the facial nerve orparotidduct.Wounds should be gently cleansed with saline and light scrubsolutions; foreign bodies should be meticulously cleaned fromwoundspriortoclosure.Profuseirrigationisindicated.Sharplydebridedevascularizedwoundedgesminimally.Facial lacerations should be closed in layers within 24 hours ofinjuryunlessseverelycontaminated.Heavilycontaminatedwoundsand large avulsion injuries may be treated with packing, regulardebridement, localwoundcare,andclosedinadelayedfashion.Theuseoflocalflaps,skingrafts,orfreevascularizedtissuetransfersmaybenecessarytocoverlarge,soft-tissuedefectsofthefaceandneck.

Use4-0or5-0absorbablesutureforsubcutaneous/dermallayers.

Use5-0or6-0nonabsorbablesuturesonfacialskin.

Removesuturesin5–7days.

Facialnerveinjuries.

Facial nerve branches that are lacerated at a site anterior to a verticallinedrawndownfromthelateralcanthusoftheeyedonotneedtobesurgically reapproximated because these branches are very small andwillspontaneouslyregeneratewithgoodreturnoffacialfunction.

Carefullyexamineforfacialnervefunctioninallfivebranchesassoon

aspossibleafterinjury(Fig.13-4).Fig.13-4.Branchesofthefacialnerveparotidductinjury.

The severed ends of the nervemay be located in thewoundwith anervestimulatorforupto3daysafterinjury.Cutnerveendsshouldbeprimarilyreapproximatedwiththreeorfourfine(9-0)nylonsuturesplacedthroughtheepineurium.If a gap exists between the severed ends of the facial nerve due totissueloss,aninterpositiongraftmaybeplacedusingasectionofthegreatauricularnervetobridgethegap.Inheavilycontaminatedwoundsthatcannotbeclosedprimarily, thesevered ends of the nerve should be located and tagged foridentificationandrepairatalatertime.

Parotidductinjuries.Evaluatepenetratingwoundsoftheparotid/buccalregionsofthefaceforsalivaryleakageduetoalaceratedparotidduct(Fig.13-5).

Thewoundmaybemanuallycompressedandinspectedforsalivaryleakage.

Iftheparotidductisinjuredbyafaciallaceration,thedistalendoftheductmaybeidentifiedbyplacingalacrimalprobethroughtheintraoralopeningoftheductlocatednearthemaxillarysecondmolar(seeFig.13-4).

Theproximalendmaybeidentifiedbycompressingthewoundandlookingforsaliva.

Repairwithabsorbable(6-0)sutures(seeFig.13-5).Astentmaybeplaced into theduct to facilitate closureandprevent

stenosis.Fig.13-5.Repairoftheparotidduct.

Possiblestentsincludelacrimalstents,large(size0)polypropylenesutures,orlongangiocaths.

Stentsmaybesuturedtothebuccalmucosaandremovedafter7days.

Auricularinjuries.Strongly consider antibiotic coverage for Pseudomonas andStaphylococcusinfectionswithexposedcartilage(especiallyinburnsoftheauricle).Preserve skin and soft tissue for maximal coverage of exposedcartilage.Cartilage should be preserved unless severely damaged. Minimizeuseofsutureincartilageorperichondrium.Auricular hematomas should be incised and drained to preventcartilagedestruction.Adrainorbolstershouldbeplacedfor48hoursafterincisionanddrainage.

PenetratingNeckTraumaIntroduction.

Vascularinjuriesoccurin20%andaerodigestivetractinjuriesin10%ofcases.Immediate mortality is primarily due to exsanguination or airwaycompromise.Esophageal injury,whichmay result inmediastinitis and intractablesepsis,isasignificantcauseofdelayedmorbidityandmortality.

Anatomy.

Theneck isdivided into threezones toaiddecision-making fordiagnostic testsand surgical strategy. In each zone, the primary structures at risk of injury aredifferent(Fig.13-6).

ZoneI(clavicletocricoid):Thestructuresofconcernincludelargevesselsofthethoracicoutlet(subclavianarteryandvein,commoncarotidartery),

thelung,andthebrachialplexus.ZoneII (cricoidtoangleofmandible):Structuresofconcernincludethecommoncarotidartery,internaljugularvein,esophagus,andtrachea.Zone III (angleofmandible tobaseof skull): The structure ofprimaryconcernistheinternalcarotidartery.

Fig.13-6.Zonesoftheneck.

Immediatemanagement.ABCs.Obtain chest, soft-tissue neck radiographs, and CT angiography ifpatientisstable.Addresstetanusstatusandantibioticprophylaxis.

Operativestrategy.Neck wounds with suspected platysma violation should only beprobed or explored in the operating room. An approach via anincisionalongtheanteriorborderofthesternocleidomastoidmuscleispreferred(Fig.13-7).Iftheplatysmaisnotviolated,surgicalinterventionisnotindicated.If the patient with penetrating neck trauma (PNT) is symptomatic,neckexplorationis indicated.If thepatient isasymptomatic,workupto include CT angiography, panendoscopy (direct laryngoscopy,bronchoscopy, and esophagoscopy), and a water-soluble contrastswallowstudyshouldbeconsidered.Neckexplorationisindicatediftheworkuprevealspathology.Selectivemanagement basedon clinical signs and symptoms shouldbe considered for all patients with PNT, regardless of the zonesinvolved.NonoperativemanagementofzoneIIinjurieswithplatysmaviolationisacceptableinthestablepatientwithanegativeworkupasdescribed previously. Selective management of PNT can only beperformedatfacilitieswiththeresourcestocompletetheworkupandobservethepatient.SurgicalexposureofzonesIandIIIisdifficultandrequires a high degree of surgical expertise. Nonoperative

managementofPNTinstablepatientswithzoneIorzoneIIIinjuriesis preferred.

Fig.13-7.NeckexposureofzoneII.

PNTpatientswithoutclinicalsignsofinjury(seebelow)maybeevacuatedwithoutoperativeinterventioniftheappropriateworkup(CTA,panendoscopy,orswallowstudy)isnegative.

Important clinical signs indicating probable injuries (pertinent to allthreezones).

Signsofvascularinjury:

Currentorhistoryofsignificantbleeding.

Expandinghematoma.

Bruitorthrillintheneck.

Hypotension.

Dyspnea,hoarseness,orstridor.

Absentordecreasedpulsesinneckorarm.

Focalneurologicaldeficitormentalstatuschange.

Chestradiographfindingsofhemothoraxormediastinalwidening.

Signsofaerodigestiveinjury(esophagus,trachea,larynx):

Crepitusorsubcutaneousemphysema.

Dyspneaorstridor.

Airbubblingfromwound.

Tendernessorpainovertrachea;odynophagia.

Hoarseorabnormalvoice.

Hematemesisorhemoptysis.

SurgicalPrinciplesThegroinandupperthighshouldbesurgicallypreppedforpossiblegreatersaphenousveininterpositiongraftorpatchangioplasty.Exsanguinating hemorrhage from injured vessels at the base of the skull(zoneIII)maybecontrolledwithinflationofadirectedcatheter(FogartyorFoley).RepairesophagealinjuriesintwolayersandplacepassivePenrosedrains.Amuscleflapshouldbeinterposedbetweenrepairedesophagealandtrachealinjuries to prevent a fistula.Obtain a contrast swallow study 7 days afterrepairandbeforefeeding.Repair laryngotracheal injuries with either absorbable or nonabsorbablesuture, stainless steel wires, or microplates. It is important to search forconcomitantesophagealinjuriesaswell.Major (significant segmental loss or >50% diameter loss) tracheal injuriesshould be managed with an endotracheal tube placed through the distaltrachealopeningandplacementofpassivedrains.Vertebralarteryinjury.

Suspect if bleeding continues from a posterolateral neck wounddespitepressureonthecarotidartery.Preoperative angiography localizes the site of injury and establishestheexistenceofapatentcontralateralvertebralartery.Exposure of the vertebral artery may be difficult. When thecontralateralvertebralartery is intact, ligationproximalanddistal totheinjurywilllikelybenecessary.Bone wax or surgical clips may be useful for controlling vertebralartery bleeding. May require removing the lateral aspect of thetransverseprocessforaccess.

Intraoralinjuries.Occult internal carotid artery injury should be suspected in patientswith penetrating intraoral injuries LATERAL to the tonsillar fossa.Neurologicaltestingandmonitoringarecritical,andaCTscanand/orangiography should be considered. A “sentinel” bleed should beconsideredif,afterapenetratinglateraloralinjury,thepatientbleedsasmallamountonlytostop.Acarotidarteryblowoutorocclusionmayfollow. Carotid artery intimal dissectionmay occur in patients withblunt lateral oropharyngeal traumaor in patientswith high-velocitypenetratinginjuryneartheskullbasethatdoesnotdirectlyviolatethecarotidartery.

Internalcarotidarteryinjury.Should be surgically repaired unless there is profound hemiplegiawithcoma(GlasgowComaScalescore<8),inwhichcasethecommonorinternalcarotidarteriesmaybeligated.Theexternalcarotidarteryanditsbranchesmayalwaysbeligated.

Mortalityishighinpatientswithsevereneurologicaldeficits;carotidligationisjustifiableincompleteocclusionoftheentirecarotidsystemanddependingonthetriagesituation.Small carotidperforations shouldbeminimallydebridedand closedwith6-0polypropylene.Veinangioplastyisrequiredwithlossofvasculartissue.Ifthereisextensivedestruction,segmentalresectionandrestitutionofflowareestablishedby:

End-to-endanastomosis(ifthevesselissufficientlyelastictopermit).

Interpositionveingraft.

Externalcarotidswing-overandinterposition.

Temporary(24–48hours)shuntaspartofadamagecontrolmaneuver.

Adistalclotmayberemovedbygentleuseofaballooncatheterpriortoshuntinsertionorrepair.

Internaljugularveininjury.Preferablyrepairedwithsuture.Ligationisacceptableifthecontralateralinternaljugularispatent.

Larynx.Afterimmediatecontroloftheairwayhasbeenachievedbyintubationor tracheotomy (not through thewound in the larynx!), a completeairwayevaluationbydirectlaryngoscopyandbronchoscopymustbeperformed.Debridement of laryngotracheal injuries must be careful andconservative. A fragmented larynx or trachea should bereapproximated and sutured with extraluminal sutures for trachealinjuriesandnonabsorbablesuturesormicroplatesusedfor laryngealfractures. All exposed laryngeal cartilage should be covered withmucosa.Abuccalmucosagraftmaybeusedwhenlargeintraluminalmucosaldefectsarepresent.Management of laryngeal trauma includes accurate reduction andstabilization of fractures; mucosa-to-mucosa closure of lacerations;and use of a soft stent if there is extensive cartilaginous damage,structural support is decreased, or the anterior commissure isinvolved.Thestentmayneedtobetemporarilyplacedfor4–6weeksto maintain correct anatomical architecture and requires acomplementarytracheotomy.Excessiveremovalofcartilageandmucosamustbeavoidedtopreventtrachealorlaryngealstenosis.

Laryngotrachealinjuries.If laryngotracheal separation is suspected (massive crepitus over the

larynx/trachea) in an otherwise “stable” airway, endotrachealintubationshouldnotbeundertakenbecausethismaycauseapartialseparationtobecomeacompleteseparation,and/ortheendotrachealtubemayenterthemediastinumandoccludethedistalairway.Awake tracheotomy/cricothyroidotomy under local anesthesiawithout paralysis is preferable in patients with laryngeal trauma.Adequate local anesthesia can be achieved with a 4% (40 mg/cc)lidocainenebulizer,2ccin3ccofsaline,anddirectadministrationof4%lidocaineintothetracheaforanawaketracheotomy(inadditiontolocal anesthetic infiltration into the skin and subcutaneous tissues).Wheninstillinganesthesiaintotheairway,aspirateandensurethatairentersthesyringebeforeinjecting.

Trachealinjuryandreconstruction.Atracheostomytubemaybeplacedthroughsmallanteriorwoundsofthecervicaltrachea.Repair simple lacerations with absorbable suture. Care should betakentoavoidconstrictingtheairwaywhenclosingdefects.Pedicledmusclemaybeusedtocoversmalltrachealdefects.End-to-end tracheal anastomosis should be performed withinterrupted,extraluminal4-0nylonorpolypropylenesuture.The anterior cricoid ring does not need to be closed, and carelessreapproximation of a fractured cricoid may result in subglotticstenosis.Up to 5 cm of trachea can be resected with proximal and distalmobilization.Mobilizeanteriorlyandposteriorlytopreservelateralbloodsupply.Asuprahyoidreleasemaybehelpful.Removeanoralendotrachealtubeassoonaspossiblepost-op.Considerchin-to-chestsutures(2-0nylonsuturesthroughmandibularperiosteumandclavicularperiosteum)for10dayspostoperativelytoavoid accidental wound separation with head extension in patientswithtrachealseparationrepairs.

Esophagealandhypopharyngealinjuryandrepair.Commonlyassociatedwithinjuriestotheairwayandgreatvessels.Subcutaneous emphysema, pneumomediastinum, saliva in the neck,hemoptysis or blood-tinged saliva, odynophagia, and dysphagia arepossible signs and symptoms of hypopharyngeal and esophagealinjury.However,25%oftheseinjuriesmaybeasymptomatic.Missedinjuryisamajorsourceoflatemorbidity/mortality.Chest radiographandesophagogramwithwater-solublecontrastareindicated in patients with suspected hypopharyngeal or esophagealinjuries, but without a definitive indication for exploration.Esophagograms may have a false-negative rate as high as 20%. Anegativewater-soluble contrast studymay be followed by a barium

studytoincreasethetestsensitivity.Insufflationwithair inanopenneck floodedwithsalinemayaid inidentificationduringexploration.Rigid and flexible esophagoscopy are complementary in theidentificationofhypopharyngealandesophagealinjuries.Debridedevitalizedtissue.Closeesophagealwoundsintwolayerswithabsorbablesutures.Pedicledmuscleflapshelptobolsterrepairs.DrainwoundswithPenrosedrains.Contrastswallowstudyat7dayspost-opandpriortooralintake.Leave drains in place until swallow study performed and oral dietresumed.Extensive injuriesmay require lateral cervical esophagostomyand ispreferredtoclosureundertension.

Combinedinjuries.Esophageal injuriescombinedwithairwayorvascular injuryrequireseparationwithhealthytissue.Strapmusclesareideal,buttheuseofapedicled sternocleidomastoid muscle is an alternative if the strapmusclesaredevitalized.

Esophagealfistula.10%–30%incidence.Due to inadequate debridement, devascularization of remainingesophagealwall,closureundertension,orinfection.Treatment.

NPO.

Maintainnutritionwithtubefeeds.

Ensurefistulacontrolwithdrains.

Weeklywater-solublecontraststudytoassessclosure.

Resumeoralintakepriortoremovingdrains.

SkullBase,TemporalBone,andOtologicalInjuryAllpatientswithsuspectedtemporalbonefracturesoracousticbarotrauma,with or without tympanic membrane perforation, should undergoaudiometric testing (with an audiometer) as soon as feasible. In addition,thesepatientsdeservespecialconsiderationbecauseofthehighincidenceofother neurological and cognitive problems that may occur with theseinjuries.Documentationoffacialnervefunctionisperformedonallawakepatientsand as early as possible in a patient who has regained consciousness.Delineationbetweendelayedversussuddenonsetfacialparalysisiscriticalfordeterminingtheprognosisandmanagementoffacialnerveinjuries.Alsocritical is the delineation between a distal and proximal nerve injury. If aproximal injury is present, one or more facial nerve branches may be

affected.Be as complete as possible in describing facial motion, even if nottechnically accurate. Accurate documentationmay spare the patientfromunwarrantedsurgicalinterventiontoexploretheentirelengthofthe facial nerve. It is desirable to accurately describe the motion ofEACH branch of the facial nerve. An injury of themain trunkwillmost likely result in all branches being equally affected. Eyelidmovement does not ensure that the facial nerve is intact, since thelevatorpalpebraemuscle is innervatedby theoculomotornerveandwillremainintactdespitefacialnerveinjury.Intheabsenceofmedicalcontraindications,systemicsteroidsshouldbeadministeredforsuspectedfacialnerveparalysis.Crushinjuriestothe facial nerve may present with delayed-onset paralysis, and theseverity and course of the paresis may be improved with systemicadministrationofsteroids.

Skull base fractures are often occult. Assess the patient for evidence ofbasilar skull fractures (Battle’s sign, raccoon eyes, CSF rhinorrhea orotorrhea). Any patient with blood or CSF in the ear canal should bepresumedtohaveatemporalbonefracture.Carefullyexaminetheexternalauditorycanal,butdonotinstrumentthecanalifthereisCSForbloodinthecanal.Ifatemporalbonefractureispresentandtheduraisnotintact,instrumentationmayintroducebacteriaintotheCSFwithresultingmeningitis.Sterileinstrumentsmaybeusedtosuctionanddebridetheearcanalwithmicroscopicvisualization.Atearintheliningoftheexternalauditorycanalsuggestsatemporalbonefracture.

Whenatemporalbonefractureissuspected,facialnervefunctionandhearingmustbeassessed.

Drytympanicmembraneperforationscanbeobserved.Thevastmajorityofthem will heal spontaneously, but the patient should be followed forpotential complications or failure to heal.Wet or contaminated tympanicmembraneperforationsshouldbe treatedwithototopicalantibiotics foratleast 10 days (4 drops twice daily of ofloxacin are adequate). The patientshouldbeinstructedtokeeptheearsdry(avoidwatercontamination).Hemotympanum may be seen with acoustic and temporal bone trauma.These patients will have hearing loss. If available, perform a grossaudiological evaluation with tuning forks. Hemotympanum-associatedhearinglossshouldresolveitselfinabout6–8weeks.

Examination of hearing can be accomplished with a single 512-Hztuningfork.

Thehandleofavibratingtuningforkisplacedonthemastoidtipandthenalternatelythetuningforkisheldintheairoutsidetheexternalcanalwhileaskingthepatientwhichisheardlouder(Rinnetest).DocumentationasA>B(air>bone)orB>Ais

sufficient(donotreportas“positive”or“negative”):

Airconductiongreaterthanboneconductionwitha512-Hztuningforkisnormal.

Boneconductiongreaterthanairissuggestiveofaconductivehearinglossintheaffectedear.

Placethe512-Hztuningforkonthefrontalbone/nasaldorsumorcentralincisors(Webertest).

Thesoundwillbeheardloudestintheearwithaconductivehearinglossorintheearcontralateraltoanearwithsensorineuralhearingloss.

IftheRinnetestsuggestsaconductivehearingloss(ie,boneconduction>airconduction),thetuningforkshouldbeheardlouderonthesidewiththeconductiveloss.

Any otological blast injury or injury to the temporal bone may result intinnitus. Management is expectant because tinnitus following acoustictrauma usually resolves spontaneously. Hearing should be evaluated anddocumented.Any patient with acoustic trauma should be removed from noisyenvironments and have serial audiograms performed over 14–21 days toassessrecovery.Recoveryofmosttraumatichearinglossisexpected,exceptin cases of temporal bone fractures, very large tympanic membraneperforations,orpenetratingtemporalboneinjuries.Steroidsshouldbeconsideredifsensorineuralhearinglossissuspectedanddocumented after a blast injury or acoustic trauma.Adose of 1mg/kgofprednisone is appropriate. If there is no improvement after 5 days oftherapy,steroidsmaybediscontinued.Ifimprovementisnoted,ataperover3–4weeksisindicated.Bemindfulthatsteroidsmayalterapatient’saffect,impairjudgment,orimpairwoundhealing.Dizziness and vertigo may result from acoustic trauma. If true vertigo(observednystagmus)existsafteranotologicalinjury,thepatientmayhaveaperilymphaticfistulafromdepressionofthestapesintotheovalwindoworruptureoftheroundwindow.Thesepatientsmayalsohavetinnitusandhearing loss. If a perilymphatic fistula is suspected, the patient should beseenbyanotolaryngologistassoonaspossibletopreventfurtherdamagetotheinnerear.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter14

OcularInjuries

Introduction

The preservation of the eyes and eyesight of service personnel is an extremelyimportantgoal.Despitecomprisingaslittleas0.1%ofthetotalbodysurfacearea,injuriestotheeyehavebeensustainedin6%ofallcombatcasualtiesinOperationIraqiFreedom/OperationEnduringFreedom.IntheVietnamWar,almost50%ofcasualtieswithpenetratingeyewoundseventuallylostvisionintheinjuredeye.Improvementsinophthalmiccareinthelast30yearsofferhopethatblindnessincombatcasualtieswillbeincreasinglylesscommoninfuturewars.

TriageofPatientsWithEyeInjuriesAdvancedTraumaLifeSupportprotocols:Afterprimarysurveyiscompleteandthepatientisstable,identifyandtreatocularinjuriesinthesecondarysurvey.Casualtieswithmildeyeinjuriesmaybetreatedandreturnedtoduty.Casualtieswithmoresevereinjuriesshouldbeevacuatedtosavevision.Distinguishingmajorocularinjuriesfromminoronesmaybedifficult.AtRole1/2,due to timeandequipment restraints,medicalpersonnelwilllikely “shield and evacuate.” If an open globe is suspected, cover the eyewithashieldmadewithadevicethatappliesforcestothebonyorbitareainsteadoftotheeye.

IdentifyingSevereEyeInjuriesAssociatedinjuries.

Fragmentationwoundsoftheface—thinkintraocularforeignbody.Lid laceration—open the eyelids and check for underlying globelaceration.

Vision.Use book print, medication labels, finger counting, etc, to evaluatevision.Comparesightintheinjuredeyetotheuninjuredeye.Severevisionlossisastrongindicatorofseriousinjury.

Eyeballstructure.Obviouscornealorsclerallacerations.Subconjunctivalhemorrhage(SCH)—mayoverlayanopenglobe.Dark uveal tissue presenting on the surface of the eye indicates anopenglobe.

Foreignbody—diditpenetratetheeye?Blood in the anterior chamber (hyphema) indicates severe blunttraumaorpenetratingtrauma.

Proptosis—may indicate a retrobulbar hemorrhage, which is an ocularemergency.Pupils.

Pupillarydistortion—maybeassociatedwithanopenglobe.Motility.

Decreasedmotilityononesidemaybecausedbyanopenglobe.Other causes include muscle injury, orbital fracture, and orbitalhemorrhage.

OpenGlobeMayresultfrompenetratingorblunteyetrauma.May cause loss of vision from either disruption of ocular structures orsecondaryinfection(endophthalmitis).Biplanar radiographs or a CT scan of the head may help to identify ametallic intraocular fragment in a casualty with severe vision loss, atraumatic hyphema, a large SCH, or other signs suspicious for an openglobewith an intraocular foreignbody. Fine orbit cuts at every 1mmarerequiredtoproperlyviewtheglobe.Routinehead4-mmCTcutsmaymissahighnumberofglobemetallicforeignbodiesorinjuries.

ImmediateTreatmentofanOpenGlobeTapearigideyeshield(NOTapressurepatch)overtheeye.Donotapplypressureonormanipulatetheeye,includingultrasound.Applyshieldtooppositeeyetolimitmotionofinjuredeye.Donotapplyanytopicalmedications.StartquinoloneantibioticPOorIV(eg,Levoquine500mgqd).Scheduleanurgent(within24–48hours)referraltoanophthalmologistwithsurgicalcapabilities.Administertetanustoxoidifindicated.Preventemesis(Phenergan50mgorCompazine10mgIM/IV).

TreatmentofOtherAnteriorSegmentInjuries

SubconjunctivalHemorrhageSmallSCHsmayoccurspontaneouslyor inassociationwithblunttrauma.Theselesionsrequirenotreatment.SCHsmayalsooccurinassociationwitharuptureoftheunderlyingsclera.Warning signs for an open globe include a large SCH with chemosis(conjunctivabulgingawayfromtheglobe)inthesettingofblunttrauma,oranySCHinthesettingofpenetratinginjury.Casualtieswithblastinjuryandnormalvisiondonotrequirespecialcare.Suspectedopenglobepatientsshouldbetreatedasdescribedpreviously.

TreatmentofChemicalInjuriesoftheCornea

Nonsterilewatermaybeusedifitistheonlyliquidavailable.Use topical anesthesia before irrigating, if available (tetracaine orproparacaineophthalmic).MeasurethepHoftearstoensurethat,ifthereiseitheracidoralkaliintheeye, the irrigation continues until the pH returns to normal. Do not usealkalinesolutionstoneutralizeacidityorviceversa.Removeanyretainedparticles.Usingthefluoresceintest,lookforepithelialdefect(ie,cornealabrasions):

Ifnone,thenmildchemicalinjuriesorforeignbodiesmaybetreatedwithartificialtears.If an epithelial defect is present, use a broad-spectrum antibioticophthalmicointment(Polysporin,erythromycin,orBacitracin)4timesperday.

Noncausticchemicalinjuriesusuallyresolvewithoutsequelae.Moreseverechemicalinjuriesrequireophthalmologicalevaluation.Monitor (daily topical fluorescein evaluation) for a corneal ulcer untilepithelialhealingiscomplete.Severe acid or alkali injuries of the eye (recognized by pronouncedchemosis, limbal blanching, and/or corneal opacification) can lead toinfectionof thecornea,glaucoma,andpossible lossof theeye.Refer toanophthalmologistwithin24–48hours.Treatmustardeyeinjurieswithophthalmicointments,suchas5%boricacidointment, to provide lubrication and minimal antibacterial effects. Applysterilepetrolatumjellybetweentheeyelidstoprovideadditionallubricationandpreventsealingoftheeyelids.Treat nerve agent ocular symptoms with 1% atropine sulfate ophthalmicointment;repeatasneededatintervalsofseveralhoursfor1–3days.

CornealAbrasionsDiagnosis.

Bealertforthepossibilityofanassociatedopenglobe.The eye is usually very symptomatic, with pain, tearing, andphotophobia.Visionmaybediminishedfromtheabrasionitselforfromtheprofusetearing.Diagnosewithtopicalfluoresceinandcobaltbluelight(Wood’slamp).A topical anesthetic as abovemaybeused fordiagnosis, but shouldNOTbeusedasanongoinganalgesicagent—thisdelayshealingandmaycauseothercomplications.

Treatment.Applybroad-spectrumantibioticointment(Polysporin,erythromycin,orBacitracin)qid.Optionsforpainrelief.

Diclofenac:0.1%dropsqid.

Largerabrasionsmayrequireamildcycloplegicagent(1%MydriacylorCyclogyl).

Moreseverediscomfortcanbetreatedwith0.25%Scopolamine1dropbid,butthiswillresultinpupildilationandblurredvisionfor5–6days.

Smallabrasionsusuallyhealwell.Iftheeyeisnotshielded:

Antibioticdrops(fluoroquinoloneoraminoglycoside)maybeusedqidinlieuofointment.

Sunglassesarehelpfulinreducingphotophobia.

Casualtieswhowearcontactlensesshouldhavethelensremovedandnotbereinserteduntilsymptom-freeandnormaleyeexam.Abrasionswillnormallyhealin1–4days.Initial treatmentof thermalburnsof the cornea is similar to that forcornealabrasions.

Allcornealabrasionsneedtobecheckedonceadayuntilhealingiscompletetoensurethattheabrasionhasnotbeencomplicatedbysecondaryinfection(cornealulcer,bacterialkeratitis).

CornealUlcerandBacterialKeratitisDiagnosis.

Cornealulcerandbacterialkeratitisareseriousconditionsthatmaycauselossofvisionorevenlossoftheeye!Ahistoryofcornealabrasionorcontactlenswear.Increasingpainandredness.Decreasingvision.Persistentorincreasingepithelialdefect(positivefluoresceintest).Whiteorgrayspotonthecorneaseenonexaminationwithapenlightordirectophthalmoscope.

Treatment.Quinolone drops (eg, Ocuflox), 1 drop every 5 minutes for 5 dosesinitially, then 1 drop every 30minutes for 6 hours, and then 1 drophourlyaroundtheclockthereafter.Scopolamine0.25%,1dropbid,mayhelprelievediscomfortcausedbyciliaryspasm.Patching and use of topical anesthetics for pain control arecontraindicated(seepaincontrolmeasuresdiscussedpreviously).Expedited referral to an ophthalmologist within 3–5 days, sooner ifocular injury is deteriorating. Infection may worsen, leading topermanentinjury.

ConjunctivalandCornealForeignBodiesDiagnosis.

Abruptonsetofdiscomfortand/orhistoryofsuspectedforeignbody.Ifanopenglobeissuspected,treatasdiscussedpreviously.Definitive diagnosis requires visualization of the offending object,whichmaysometimesbequitedifficult.

Ahand-heldmagnifyinglensorpairofreadingglasseswillprovidemagnificationtoaidinthevisualizationoftheforeignbody.

Staintheeyewithfluoresceintocheckforacornealabrasion.

Thecasualtymaybeabletohelpwithlocalizationifaskedtoindicatethe perceived location of the foreign body prior to instillation oftopicalanesthesia.Eyelid eversion with a cotton-tipped applicator helps the examineridentifyforeignbodieslocatedontheuppertarsalplate.

Treatment.Superficial conjunctival or corneal foreign bodies may be irrigatedaway or removed with a moistened sterile swab under topicalanesthesia.Objects adherent to the cornea may be removed with a swab or asterile22-gaugehypodermicneedlemountedonatuberculinsyringe(holdtheneedletangentialtotheeye).If no foreign body is visualized, but the index of suspicion is high,vigorous irrigationwith artificial tears or sweeps of the conjunctivalfornices with a moistened cotton-tipped applicator after topicalanesthesiamaybesuccessfulinremovingtheforeignbody.Ifanepithelialdefectispresentafterremovaloftheforeignbody,treatasdiscussedpreviouslyforacornealabrasion.

Hyphema:BloodintheAnteriorChamberTreatment(topreventvisionlossfromincreasedintraocularpressure):

Be alert for a possible open globe and treat for that condition ifsuspected.Avoidanceofrebleedsisamajorgoalofmanagement.

Avoidaspirinornonsteroidalantiinflammatorydrugs.

Nostrenuousactivity(bedrestwithheadofbedelevated)for7days.

Noreadingfor7daystominimizerapideyemovements.

Prednisolone1%—1drop4timesaday.Scopolamine0.25%—1droptwiceaday.Covereyewithprotectiveshield.Elevateheadofbedtopromotesettlingofredbloodcells inanteriorchamber.Providea24-to48-hourreferraltoanophthalmologisttomonitorfor

increasedintraocularpressure(whichmaycausepermanentinjurytotheopticnerve)andtoevaluateforanassociatedopenglobe.Ifevaluationbyanophthalmologistisdelayed(>24hours),treatwitha topical beta-blocker (Timolol or Levobunolol) bid to help preventintraocularpressureelevation.Ifintraocularpressureisfoundtobemarkedlyelevated(above30mmHg)withatonopenorotherportabletonometrydevice,otheroptionsforloweringintraocularpressureincludeacetazolamide500mgPOorIVandmannitol1–2g/kgIVover45minutes.

Retrobulbar(Orbital)HemorrhageKeys to recognition:Severeeyepain,proptosis,vision loss,anddecreasedeyemovement.

Marked lid edema may make the proptosis difficult to appreciate.Inabilitytoopenthelids,evenwithcottonswabs,ishighlysuspiciousforthis.Failure to recognize may result in blindness from increased ocularpressure.

Performanimmediatelateralcanthotomyandcantholysis.Provideanurgentreferraltoanophthalmologist,within24–48hours.If evaluation by an ophthalmologist is delayed (>24 hours), treat with atopical beta-blocker (Timolol) bid to help lower intraocular pressureelevation.If intraocular pressure is found to be elevated (>30 mm Hg), treat asdiscussedpreviously.

LateralCanthotomy/Cantholysis

The indication for lateral canthotomy/cantholysis is orbital compartmentsyndrome. Do not perform such procedures if the eyeball structure has beenviolated. If there is apenetratingglobe injury, applyaFox shield forprotectionandseekimmediateophthalmicsurgicalsupport.

Inject2%lidocainewith1:100,000epinephrineintothelateralcanthus(Fig.14-1a).Crush the lateral canthuswith a straight hemostat, advancing the jaws tothelateralfornix(Fig.14-1b).Usingstraight scissors,makea1-cm-longhorizontal incisionof the lateralcanthaltendon,inthemiddleofthecrushmark(Fig.14-1c).Graspthelowereyelidwithlargetoothedforceps,pullingtheeyelidawayfromtheface.Thispullstheinferiorcrus(bandofthelateralcanthaltendon)tight so it can be easily cut loose from the orbital rim (Fig. 14-1d). Itwillhavea“banjostring”feelagainstthetipofthescissors.

Useblunt-tippedscissorstocuttheinferiorcrus.Keep the scissors parallel (flat) to the face with the tips pointingtowardthechin.

Place the inner blade just anterior to the conjunctiva and the outerbladejustdeeptotheskin.The eyelid shouldpull freely away from the face, releasingpressureontheglobe.(Fig.14-1e)Cutresiduallateralattachmentsofthelowereyelidifitdoesnotmovefreely.Donotworryaboutcutting½cmofconjunctivaorskin.Thelowereyelidiscut,relievingorbitalpressure.Iftheintactcorneaisexposed,apply,hourly,copiouserythromycinophthalmicointmentorophthalmic lubricant ointment to prevent devastating cornealdesiccationandinfection.Reliefoforbitalpressuremustbe followedbylubricatingprotectionofthecorneaandurgentophthalmicsurgicalsupport. Do NOT apply absorbent gauze dressings to the exposedcornea.

Fig.14-1.Lateralcanthotomyandinferiorcantholysisareindicatedforcasualtiespresentingwithseriousorbitalhemorrhage.

OrbitalFloor(Blowout)Fractures

Thesefracturesareusuallytheresultofabluntinjurytotheglobeororbitalrim,often associated with head and spine injuries. Blowout fractures may be

suspected on the basis of enophthalmos, diplopia, decreased ocular motility,hypoesthesia of the V2 branch of the trigeminal nerve, associated SCH, orhyphema. Immediate treatment includes pseudoephedrine 60 mg q6h and abroad-spectrumantibioticfor7days,icepacks,andinstructingthecasualtynottoblowhis/hernose.DefinitivediagnosisrequiresCTscanoforbitswithaxialandcoronalviews.Indicationsforrepairincludesevereenophthalmosanddiplopiainthe primary or reading gaze positions. Not an urgent matter, surgery may beperformed1–2weeksaftertheinjury.

LidLacerations

TreatmentGuidelinesforLidLacerationsNotInvolvingtheLidMarginExcellentbloodsupply—delayedprimaryclosureisnotnecessary.Eyelidfunction(protectingtheglobe)istheprimaryconsideration.Begin with irrigation, antisepsis (any topical solution), and a check forretainedforeignbodies.Superficiallacerationsoftheeyelid,notinvolvingtheeyelidmargin,maybeclosedwithrunningorinterrupted6-0silkormonofilament.Horizontal lacerationsshouldincludetheorbicularmuscleandskin intherepair.Ifskinismissing,anadvancementflapmaybecreatedtofillinthedefect.Forverticalorstellatelacerations,usetractionsuturesintheeyelidmarginfor7–10days.Antibioticointmentsqid.Skinsuturesmayberemovedin5days.

TreatmentGuidelinesforLidLacerationsInvolvingtheLidMarginRepairofamarginallowereyelidlacerationwith<25%tissueloss(Fig.14-2a).

The irregular laceration edges may be freshened by creating apentagonalwedge;removeaslittletissueaspossible(Fig.14-2b).A4-0silkornylonsutureisplacedintheeyelidmargin(throughthemeibomian gland orifices 2 mm from the wound edges and 2 mmdeep)andistiedinaslipknot.Symmetricsutureplacementiscriticaltoobtainpost-opeyelidmarginalignment(Fig.14-2c).The slipknot is loosened, and approximately 2 or 3 absorbable(VICRYL or gut) 5-0 or 6-0 sutures are placed internally toapproximatethetarsalplate.Theskinandconjunctivashouldnotbe

includedinthisinternalclosure(Figs.14-2gand14-2h).Fig.14-2.Lidmarginrepair.

Anteriorandposteriormarginalsutures(6-0silkornylon)areplacedintheeyelidmarginjustinfrontandbehindthepreviouslyplaced4-0

suture(Fig.14-2e).The middle and posterior sutures are left long and tied under theanteriorsuture.Ensurethatthewoundedgesareeverted(Fig.14-2f).Skin is closed with 6-0 silk or nylon sutures. The lid is placed ontractionforatleast5days.Skinsuturesareremovedin3–5days,andthemarginal suturesare removed in10–14days (Figs.14-2gand14-2h).

AdditionalPointsinLidLacerationRepairTissueloss>25%willrequireaflaporgraft.Bestmanagedbyeyesurgeon.If there is orbital fat in the wound or if ptosis is noted in an upper lidlaceration,damagetotheorbitalseptumandthelevatoraponeurosisshouldbesuspected.Iftheeyelidisavulsed,themissingtissueshouldberetrieved,wrappedinmoistened Telfa, and preserved on ice. The tissue should be soaked in adiluted antibiotic solution prior to reattachment. If necrosis is present,minimal debridement should occur to prevent further tissue loss. Theavulsedtissueshouldbesecuredintheanatomicallycorrectpositioninthemannerdescribedforlidmarginrepairasdescribedpreviously.

Damage to thecanalicular systemcanoccurasa resultof injuries tothe medial aspect of the lid margins. Suspected canalicular injuriesshould be repaired by an ophthalmologist to prevent subsequentproblemswithteardrainage.Thisrepaircanbedelayedforupto24hours.

LaserEyeInjuriesBattlefield lasersmaybedesigned to cause eye injuries ormaybepart ofotherweaponsorsensorsystems.Prevention is the best option! Wear eye protection designed for theappropriatelightwavelengthsifthereisaknownlaserthreat.Thetypeofoculardamagedependsonthewavelengthofthelaser.Retinalinjuriesaremostcommon.The primary symptom of laser injury is loss of vision, which may beprecededbyseeingaflashoflight.Painmaynotbepresent.Immediate treatment of corneal laser burns is similar to that for cornealabrasions.Laser retinal burns have no proven immediate treatment, althoughimprovementwithcorticosteroidshasbeenreported.Routineevacuationforevaluationbyanophthalmologistisrequired.

Enucleation

Ageneralsurgeoninaforwardunitshouldnotremoveatraumatizedeyeunlessthe globe is completely disorganized. Enucleation should only be considered ifthepatienthasaverysevereinjury,nolightperceptionusingthebrightest lightsource available, and is not able to be evacuated to a facility with an

ophthalmologist.Sympatheticophthalmiaisaconditionthatmayresultinlossofvisioninthefelloweyeifaseverelytraumatized,nonseeingeyeisnotremoved;however, it rarely develops prior to 21 days after an injury. Thus, delayingenucleationuntil thepatient is in thecareofanophthalmologist is relativelysafe.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter15

HeadInjuries

Introduction

Themotorexamisoneofthemostimportantaspectsfordeterminingprognosisand role for surgical intervention in head-injured patients. Those patientswhofollow commands have the best prognosis; however, a subsequent neurologicaldeterioration may indicate an enlarging intracranial hemorrhage or increasedintracranialpressure (ICP)withbrainstemcompression.Thosepatientswho failto followcommands,but localizeorwithdrawtostimuli,mayalsobenefit fromneurosurgical intervention. The worst category of patients who demonstrateflexionorextensorposturinglessfrequentlybenefitfromsurgicaldecompressionunless done quickly and appropriately. One such example would be if a largemass lesion, such as an epidural hematoma, can be rapidlyevacuated/decompressed.

Any subsequent neurological improvement may indicate salvageability andshouldprompt reevaluation. In theater, survival of combat-relatedhead-injuredpatients has been better than expected, compared with traditional civilianliterature. This is likely related to the rapid on-site airway and hemorrhagecontrol, with rapid evacuation to in-theater neurosurgeons. Currently,US/coalitionmilitarypatientspresentingwithaGlasgowComaScale(GCS)scoreof 3–5havea 35%survival; thosewithaGCSof 6–8havea 90%survival,withaggressive multimodality care. One-year outcomes of casualties sustaining agunshotwound to the head inOperation Iraqi Freedom andpresentingwith aGCS of 3–5, who were treated with aggressive operative decompression andadvanced critical care, have been significantly better than reported in civilianliterature.Ofsurvivorsinthisgroup,55%ofthesepatientshada1-yearGlasgowOutcomes Score (GOS) of >4. (TheGOS is a functional outcomes score rangingfrom1to5,with1beingdead;aGOSof4isindependent,butdisabled.)Amotorexamination of the most salvageable severely brain-injured patients willdemonstrate localization to central stimulation. Immediate intubation withadequate ventilation (PaCO2 of 35) and oxygenation and restoration ofintravascularvolumearethemostcriticalfirst-linetreatmentforaseverelyhead-injured patient. Evacuating to the nearest neurosurgeon, avoiding diagnosticdelays, and initiating cerebral resuscitation allow the best chance for ultimatefunctional recovery.A properly trained surgeon at Role 2may, at times, find itnecessary to surgically intervene should the situation dictate. However, the

neurotrauma patient’s care should be ideally centralized in the theater ofoperations, where a neurosurgeon, CT scanner, and fixed air transport areestablished.

Neurosurgical damage control includes early intracranial pressure control(whichmayincludesurgicaldecompression);cerebralbloodflowpreservation;and prevention of secondary cerebral injury fromhypoxia, hypotension, andhyperthemia.

CombatHeadInjuryTypesBlunt(closed-headinjury).Penetrating.

Penetratingfromfragments.Penetratingfromagunshotwound.Guttering(groovingtheskull).

Primaryblast(overpressurecentralnervoussysteminjuries).A direct injury to the brain or via a force transmitted by the greatvessels of the chest to the brain; associated with unconsciousness,confusion, headache, tinnitus, dizziness, tremors, increased startleresponse, andoccasionally (in themost severe forms) increased ICP.Bleedingmay occur frommultiple orifices, including the ears, nose,andmouth.Alternatively,ablast-injuredpatientmayhavenoexternalsigns of injury and only subtle signs of cognitive dysfunction inattention,concentration,reactiontime,andbalance.

A combination of multiple injury types is typically involved in combat-relatedbrain injuries. Those injuries generally involve the face, neck, and orbit; entrywoundsmaybethroughtheupperneck,face,orbit,ortemple(Fig.15-1).

Fig.15-1.Commonvectorsofpenetratinginjury.CourtesyofE.Weissbial.

Thesubocciput,occiput,andretroauricularregionsareoftenoverlooked.Injuriestotheseareascanindicateunderlyinginjurytotheposteriorfossa,majorvenoussinus, andvertebralor carotidartery, as fragmentspass through the skull base.ReconstructingthefragmentpathbasedonacombinationofplainfilmsandCTscan can be challenging, butmay be beneficial in triage. In transorbital, lateraltemporal, orpenetrating injuries that cross themidline, anunderlying injury tointracranial vessels should be suspected with associated pseudoaneurysms,dissections,orvenoussinusinjury.

Explosion results in penetrating fragment injury, as well as blunt injury to thebrain. Depending on proximity to the explosion, a blast overpressurephenomenonmay also result. In a severely brain-injured patient,more deficitsthanindicatedbytheCTscanmaybeduetounderlyinginjurytobrachiocephalicvessels, shear injury, or the late effects of blast overpressure, with resultingdelayedcerebralvasospasm.Plainfilms,moreusefulinpenetratingthaninblunttrauma,mayrevealaburstfractureoftheskullindicatingthetremendousforceofa penetratingmissile. Transventricular bihemispheric fragment tracts portend apoorprognosis.However,bilateral injuriesabovethe levelof theventriclesmaybebettertoleratedandrespondtobifrontaldecompressivecraniectomies.

Severe head injuries are often seen in combination with significant chest,abdomen, and extremity injuries. Rapid hemorrhage control, utilizing damagecontrolconcepts,istheprioritytominimizesecondarybraininjury.Additionally,many combat penetrating or severe blast injuries include head and neck

structures. It is critical for a coordinated plan that includes oral maxillofacial,ENT,andophthalmology.

TraditionalClassificationofHeadInjuriesOpeninjuriesaremorecommonincombat-injuredversusciviliantrauma.Closed injuries are still very common in blunt trauma sustained duringcombatoperations.Blastinjurymaypresentasaclosed-headinjury.Scalp injuries may be closed (eg, contusion) or open (eg, puncture,laceration,oravulsion).

Any scalp injury may be associated with a skull fracture and/orunderlyingbraininjury.Openscalp injuriesbleedprofusely,eventothepointof lethalbloodloss,butusuallyhealwellwhenproperlyrepaired.

Skull fractures may be open or closed, and are described as linear,comminuted,ordepressed.

Skullfracturesareusuallyassociatedwithsomedegreeofbraininjury,varying frommild concussion, todevastatingdiffusebrain injury, tointracranialhematomas.Openskullfracturesarepronetoinfectionifnotproperlytreated.

NOTE: The previous descriptions remain a generalized broadclassification that does not always correlatewith the prognosis, rolefortreatment,orlevelofconsciousness.Massiveamountsofbleedingandsoft-tissueinjurycanoccurinthescalpandsuperficialcortexwithrelatively little significant injury to the deep structure of the brain.Alternatively,noexternalsignsoftraumamaybepresentinapatientwithasevere“shear”injurytothebrainstem,diencephalon,orcorpuscallosumwithaseverecomatousstatethatmaypersisttoavegetativecoma.

MechanismsofInjuryPrimaryinjury is a functionof theenergy transmitted to thebrainby theoffendingagent.

Very little can be done by healthcare providers to influence theprimaryinjury.Enforcementofpersonalprotectivemeasures(eg,helmet,seatbelts)bythecommandisessentialprevention.

Secondaryinjuryresultsfromdisturbanceofbrainandsystemicphysiologybythetraumaticevent.

Hypotensionandhypoxia are the twomost acute andeasily treatablemechanismsofsecondaryinjury.

Other etiologies include seizures (seen in 30%–40% of patientswithpenetratingbraininjuries),fever,electrolytedisturbances(specificallyhyponatremiaorhyperglycemia),andinfection.Allofthepreviouslydescribedconditionscanbetreated.

Elevations of ICPmay occur early as a result of a space-occupyinghematoma or develop gradually as a result of brain edema orhydrocephalus.Normal ICP is 5–15mmHg,with normal CPP (CPP =MAP – ICP)usually>70mmHg(whereCPP=cerebralperfusionpressure;MAP=meanarterialpressure).Decreasesinperfusionpressure,asaresultofsystemichypotensionorelevated ICP, gradually result in alteration of brain function(manifested by impairment of consciousness), and may progress toglobalbrainischemiaanddeathifuntreated.

PatientAssessmentandTriageThemostimportantassessmentisthevitalsigns.Nextisthelevelofconsciousness,bestmeasuredandrecordedbytheGCSscore(Table15-1).

Table15-1.GlasgowComaScaleComponent Response Score

Motorresponse(bestextremity)

Obeysverbalcommand 6

Localizespain 5

Flexionwithdrawal 4

Flexion(decortication) 3

Extension(decerebration) 2

Noresponse(flaccid) 1

Subtotal 1–6

Eyeopening

Spontaneously 4

Toverbalcommand 3

Topain 2

None 1

Subtotal 1–4

Bestverbalresponse

Orientedandconverses 5

Disorientedandconverses 4

Inappropriatewords 3

Incomprehensiblesounds 2

Noverbalresponse 1

Subtotal 1–5

TOTAL 3–15

NOTE:GlasgowComaScaleinintubatedpatientsisfollowedbya“T,”withamaximumscoreof11T(ie,E4M6V1).

Duringthesecondaryassessment,attentionshouldbeplacedonacompleteexamination of the scalp and neck. Fragments that enter the cranial vaultwith a lateral, transorbital, crossing themidline trajectory or bridging thecranial–cervical junction should be suspected as having associatedneurovascular injuries.Woundsare typicallycontaminated.Thesewoundsshouldbedebridedwithremovalofforeignmaterial;however,thisshouldnot delay definitive neurosurgical intervention for an underlyinghematoma, brainstem compression, or depressed skull fracture that mayexist.Thescalpshouldbecopiouslyirrigatedcleanwithcontrolofongoingscalphemorrhage.Thiscanbeaccomplishedwithaheadwrap,scalpclips,or surgical staples; a meticulous plastic surgical closure beforeneurosurgicalevaluationisnotappropriateandshouldnotdelaytransfer.Triagedecisions inthepatientwithcraniocerebral traumashouldbemadebased on first available GCS score (admission or prehospital), pupillaryreactivity,andavailableresources.

A GCS score of ≤5 indicates a poor prognosis; however, withaggressivecomprehensive treatment, thecombatcasualtycanhaveahigher survival than standard civilian neurotrauma patients (up to35%)andhigherGOSs.Thisisparticularlytrueforpatientswhowillhave access to further rehabilitative care and higher treatmentfacilities. If triaged to an expectant category, they should bereassessed.AGCSscoreof≤9 indicates thata casualtymaydowell ifmanagedappropriately.

Ingeneral,neurologicallystablepatientswithpenetratingheadinjurycanbemanagedeffectivelyintheICUwithairwayandventilatorysupport,antibiotics,andanticonvulsantswhileawaitingsurgery.

Anexceptiontothiswouldbeaclinicallydeterioratingpatient(ie,asuspectedlargehematoma—thisshouldbeconsideredasurgicalemergency).

CasualtieswithaGCSscoreof6–8canbethemostreversible,within-theaterneurosurgicalmanagement involvingcontrolof ICPandpreservation of cerebrospinal fluid. Treatment decisionsmayhaveto take intoaccountaccess to further rehabilitativeandsupportivecare.Casualties requiring evacuation to neurosurgical care should not

have transportation delayed for surgical management of injuriesthatarenotlife-threatening.

Pupillaryreactivity.Be aware that eye injuries are common with associated intracranialinjuriesandcanthereforeaffectpupillaryexam.A single dilated or nonreactive pupil adds urgency and implies thepresenceofaunilateralspace-occupyinglesionwithsecondarybrainshift.Immediatesurgerymaybeindicated.The presence of bilateral dilated or nonreactive pupils is a dismalprognosticsigninthesettingofprofoundalterationofconsciousness.

Asingledilatedornonreactivepupiladdsurgencyandimpliesthepresenceofaunilateralspace-occupyinglesionwithsecondarybrainshift.Immediatesurgerymaybeindicated.Transportationtoneurosurgicalcareshouldnotbedelayedfortreatmentofinjuriesthatarenotlife-threatening.

Radiographicevaluation.CTscannersareoftenavailableatRole3medicaltreatmentfacilities.

NoncontrastCTisthedefinitiveradiographicstudyintheevaluationofacuteheadinjury,andshouldbeusedliberally,asitgreatlyimprovesdiagnosticaccuracyandfacilitatesmanagement.ACTangiogramshouldbeperformedafternoncontrastCTinthosecaseswhereinamajorneurovascularinjurymayhaveoccurred,includingduralvenoussinusinjury,traumaticpseudoaneurysm,ordissection.

Skull radiographs still have a place in the evaluation of head injury(especiallypenetratingtrauma).

IntheabsenceofCTcapability,APandlateralskullradiographshelptolocalizeforeignbodiesincasesofpenetratinginjuriesandcanalsodemonstrateskullfractures.

Thiscanhelpdirectotherwise“blind”surgicalinterventioninitiallytothesideoftheheadwherethefractureisidentified.

Closed-headinjurycanbeassociatedwithinjuryofthecervicalspine.

Survivablecervicalspineinjuryoccursinlessthan2%ofisolatedpenetratingheadinjuryincombattrauma.

Inblunttrauma(blastinjuryincluded),assumethepresenceofcervicalspineinjuryandkeepthecervicalspineimmobilizedwitharigidcollaruntilastandardCTofthecervicalspinecanbeobtained.TheCTscanshouldbeoffinecuts(3mm),andwithsagittalandcoronalreconstructions.AP,lateral,andopen-mouthradiographsdonotdefinitivelyclearaspineforbonyinjuryintheobtundedpatient,butmaybeofassistancewhenaCTscanisnot

available.(SeeJointTheaterTraumaSystem[JTTS]ClinicalPracticeGuidelines.)

Inpenetratingheadtraumathatmayinvolvethecervicalspine,CTscanshouldalsobeperformedwhenthepatientisobtundedorpresentswithmotororsensorydeficits.

ManagementMedical.

Primarytenetsarebasic,butvital:protecttheairway,ensureadequateventilation, and assess and treat for shock (excessive crystalloidadministrationshouldbeavoided).Ingeneral,patientswithaGCSscoreof≤13shouldbemanagedinamonitoredsetting.Managementshouldbedirectedtowardpreventingsecondarybraininjury.

AvoidhypoxiabymaintainingthePaO2>80mmHgoroxygensaturation>93%.

AvoidvasoconstrictionorvasodilationbymaintainingthePaCO2between35and40mmHg.

Theheadofthebedshouldbeelevated>30°.(UsereverseTrendelenburgpositionofthebedifthethoracolumbarspineisunabletobecleared.)

Theneckshouldbepositionedinthemidlineandthecervicalcollarloosenedtopreventocclusionoftheinternaljugularveins(andsubsequentelevationoftheICP).AvoidplacementoftheinternaljugularveincentrallinethatmayinducejugularveinthrombosisandsubsequentincreasedICP.

Sedatetheseverelybrain-injuredpatientwithshort-actingagents(toallowfrequentneuroexams)tolimitstimulationandtoavoiddyssynchronywiththeventilator—bothleadingtoICPelevation.(Propofolhasbeenthepreferedearlysedatingagent.Becautiousofhypotensionwithitsuse.)

Earlyinitiationofhyperosmolartherapywith3%normalsalineisrecommendedforaGCSscoreof<12.Maybegivenasa250-mLbolus,followedbyaninfusion.Thegoalisserumsodiumof154–160mEq/LwithserumOsm<330mmol/L(SeeJTTSClinicalPracticeGuidelinesonSevereHeadTrauma.)

AdministerCefazolin2gramsevery6–8hoursfor5daysinpatientswithpenetratinginjuries.(Vancomycinisasecond-linealternate.)

Administer5daysofMetronidazoleforgrosslycontaminated

woundsorthoseopenwoundswhosetreatmenthasbeendelayedmorethan18hours.

Phenytoinshouldbeadministeredinpatientswithpenetratingheadinjuryorthosewithsuspectedordemonstratedsignificantintracranialbloodvolume(>1cm)onCTscan.Usea17-mg/kgload,inanormalsalinepiggybackandgivenover20–30minutes(nomorethan50mg/min,becauserapidinfusionmaycausecardiacconductiondisturbances).

Amaintenancedoseof300–400mg/day,eitherindivideddosesoroncebeforebedtime,shouldbeadequatetomaintainaserumlevelof10–20µg/L.

Alternatively,aLevetiracetam(Keppra)loadof1,500mgIVwith1,000mgbidhasbeeneffectivewithalowercross-reactivitywithothermedications,includingantibiotics,andlessside-effectprofilethanphenytoin.

Measureserumchemistriesdailytomonitorforhyponatremiaorseverehypernatremia(>160mEq/L).Thisshouldbedoneq6hif3%NaClormannitolhasbeingutilized.

Treatinitialcoagulopathyaggressively(goalINR<1.4).

Hyperglycemiaandhypoglycemiashouldbetreated.

Blastoverpressurecentralnervoussysteminjuries.

Supportivemedicaltherapyisusuallysufficient.OnlyinrarecasesisanICPmonitor,ventriculostomy,orcranialdecompressionnecessary.Delayedintracranialhemorrhageshavebeenreported.Additionally,thesepatientshaveahighersusceptibilitytosubsequentinjuryandshouldbeevaluatedataRole4medicaltreatmentfacility.Repetitiveinjuryandexposuretoblastoverpressuremayresultinirreversiblecognitivedeficits.

MonitoringofICPisrecommendedforallpatientswithaGCSscoreof≤8orforthosepatientsundergoingintertheateraeromedicalevacuation,whereinserialneurologicalexaminationisneeded(inessence,itisanadjuncttoaneurologicalexamination).

AnintraparenchymalICPmonitor(ICPEXPRESSbyCodmanistheUSAirForceaeromedical-approveddevice)canbeplacedwithrelativeeaseintothebrainparenchymaandgivesanaccuratereflectionoftheICP.Cerebrospinalfluidisnotabletobewithdrawn.

AventriculostomyispreferredinacomatosepatientataRole3medicaltreatmentfacility,sinceboththemeasurementand

treatmentofincreasedICPcanbeperformed.(Asimple,fluid-coupledmonitorensuringthatnopressurizedbagispairedwiththetransducer.)

Administerprophylacticantibiotic(Cefazolin2grams)priortoinsertion.

Makeanincisionjustatoranteriortothecoronalsuture,approximately2.5–3cmlateraltothemidline(Fig.15-2a,b).

Atwistdrillcraniostomyisperformed,theunderlyingduraisnicked,andaventricularcatheterisplacedintothefrontalhornofthelateralventricle(encounteredatadepthof5–6cm)(Fig.15-2b,c).Cathetershouldbedirectedtowardthemedialepicanthisonthecoronalplaneandtowardthetragusinthesagittalplane.

Evensmallventriclescanbeeasilycannulatedbyaimingthetipofthecathetertowardthenasioninthecoronalplane.

Antibiotic-impregnatedventricularcathetersarehighlypreferable;acceptablesubstitutesarean8FrRobinsoncatheterorpediatricfeedingtube.

Akeyfeatureofthistechniqueistotunnelthedrainoutthroughaseparateincision2–3cmfromtheprimaryone,thusreducingtheriskofinfection.

Fig.15-2.Placementoftheintracranialventricularcatheter.

AsustainedICP>20mmHgshouldbetreated(Fig.15-3).(SeeJTTSClinicalPracticeGuidelines.)

OnceanICPmonitorisinplace,calculateaCPP(CPP=MAP–ICP).

ThegoalofmanagementistomaintainaCPPof>60mmHg.

Intravascularvolumestatusshouldbeassessed,witheuvolemiabeingthegoal.Thisisdifficultinthedeployedsettingandonereasontoavoidmannitol.Acentralvenouspressure(CVP)of8–10mmHginayoungpatientonnormallevelsofpositiveend-expiratorypressure(5cmH2O)shouldbesuggestiveofanadequatevolume.Valueslessthanthismayindicateaneedforadditionalfluidresuscitation.Ifadditionalbloodiswarranted,ensurethatthepackedredbloodcellunitisthefreshest

availabletofacilitatebraintissueoxygenation.

IfCPPremainslowafteradequatefluidresuscitationandreassessmentforothersourcesofhypotension(bleeding,pharmacological,etc),initiateavasopressininfusionat0.04units/min.IfCPPremainslow,beginavasopressor,suchasphenyephrineornorepinephrine(norepinephrineshouldbeginat5µg/kg/minandtitrateasneeded;maximumdosebeing20µg/kg/min).IfCPPislow,theinitiationofavasopressortosupportCPPiswarrantedwhiletheothermeasurespreviouslymentionedcanbeperformed.

Fig.15-3.LevelsofinterventiontoreduceICP.CSF:cerebrospinalfluid.

Sedation,headelevation,neckmidline,andcervicalcollarloosened.

CerebrospinalfluiddrainagetoanICPof20mmHgifaventricularcatheterisinplace.

MildhyperventilationtoaPaCO2of30–35mmHgONLYASABRIDGINGMANEUVERuntilothermeasurestakeeffect.(Prolongedlevelsbelowthisaredeleterious,asaresultofsmallvesselconstrictionandischemia.)OncetheacuteICPelevationistreated,ventilationshouldthenbetitratedtoaPaCO2of35–40mmHg.

Hyperosmolartherapyshouldbeinitiatedwitha250-mLbolusof3%NaCl,followedbyaninfusionof50mL/h.If3%NaClhasalreadybeeninitiatedandserumsodiumlevelsremainbelow150,considerasecondbolusatthistime.(SeeJTTSClinicalPracticeGuidelines.)

Normothermiashouldbeobtained.Uncoverthepatient,use

fans,applyicetothegroinandaxilla.Feverwillleadtoincreasedmetabolicactivityofthebrain,increasedICP,andincreasedvasospasm.AtRole3/4,thiscanbeperformedwithsurfacecoolinggelpadswithaclosed-loopautomatedsystemcalibratedwithaFoleycatheterthermistor.

Utilizepharmacologicalparalysisifheavysedationisnoteffectiveorasneededfortransport(Vecuronium5–10mgIVPRNorasadripforlongeractinguse).Maintainparalysisbyassessingwithaneurostimulationdevicetoa“trainof4”(1/4)topreventovermedicationorundermedication.

AnypatientwhodevelopsintracranialhypertensionordeterioratesclinicallyshouldundergopromptrepeatCT.Adequatecraniectomyshouldbeconfirmed.

Refractoryintracranialhypertensionmaybemanagedwithaninitialbolusof1g/kgofmannitolandintermittentdosingof0.25–0.5g/kgq4hasneeded.

AggressivetreatmentwithmannitolshouldbeaccompaniedbyplacementofaCVPlinebecausehypovolemiamayensue.

Serumosmolalityisnotabletobemeasuredinthedeployedsetting,makingmannitol’susecomplexandfurthermanagementmoredifficult.Itcanbeusedto“buytime”enroutetotheneurosurgeon.

Donotusemannitolinhypovolemicorunderresuscitatedpatientsbecauseitwillproducehypotension.

PentobarbitalcomacanbeusedinrefractoryICPelevation,buthasbeenessentiallyreplacedbydecompressivecraniectomy.PentobarbitalcomarequiresaCVPmonitorandislimitedto72hoursmaximumtherapy.(Load:2.5mg/kgq15min×4doses,10mg/kg/hggt×3hours;Maintenance:1.5mg/kg/h;ideally,onewouldcheckalevelanddecreasemaintenanceif>5mg%orbecomeshypotensive.)Thepulmonary,infectious,andcardiacadverseeffectshavelimiteditsutilityandrecentapplication.

AtRole4,mildhypothermia(32°–34°C)maybeconsideredinisolatedheadinjury,unresponsivetoothermeasures.Itshouldbeavoidedinthemultisystemtraumapatient.

Surgical.Goals: Stop hemorrhage, prevent infection, and relieve/prevent

intracranialhypertension.ROLE2: Indications for emergent explorationandadamage controlcraniectomy (must be done in consultation with regionalneurosurgeon, if available). These may be “presumed” at a Role 2medicaltreatmentfacility,becauseCTscanwillnotbeavailable.

Presumedspace-occupyinglesionswithneurologicaldeterioration(eg,acuteepiduralhematoma).Thismaybesuspectedwithanunreactive/dilatedpupil,especiallywhenassociatedwithcontralateralhemiparesis.

Compounddepressedfracturewithsignificantneurologicaldeterioration.

Penetratinginjurieswithsignificantneurologicaldeterioration.

ReliefofICPwithhemicraniectomy.

Alargetraumaflapshouldbeplannedfortheevacuationofamasslesionwithsignificantunderlyingedemainthesupratentorialspace.

Thecommonmistakesarefailuretomaketheboneflaplargeenoughduetoamisplacementoftheburrholes,notanteriorenough,notposteriorenough,orinadequatetemporalboneremovalattheskullbase(Fig.15-4).

Shavehairwidelyandscrubandpaintthescalpwithbetadine.Generalanesthesia.Administerempiricantibiotics(Cefazolin:2grams).Positioningcanbeadequatelymanagedwiththeheadinadoughnutorhorseshoe-typeheadholder.Theheadwillbeturnedawayfromthesideofthecraniectomy.Makeagenerousscalpincisiontocreateanadequateflap(Fig.15-5a).The flapshouldextendaminimumof4cmposterior to theexternalauditory canal and 2 –3 cm off midline. Exposing the frontal,temporal,andparietallobesallowsforadequatecerebralswellingandavoidsbrainherniationatthecraniectomyedge.Ensuring that decompression in adults measures 15 cm in the APdimension and 12 cm from themiddle cranial fossa to the vertex isessential.

Theflapshouldhaveanadequatepedicletoavoidischemia;preservationofthesuperficialtemporalarteryshouldbeperformed.

Scalphemorrhagecanbecontrolledwitharunning,lockingsutureorRaneyclips.

Retractionofthescalpflapoverarolledlaparotomyspongewill

avoidkinkingtheflap,whichalsomayleadtoischemia.Avoidplacementofthespongeovertheglobe,however,sincethiscanresultinincreasedintraocularandthereforeICPand,inrarecases,blindness.

Fig.15-4.Craniallandmarksandlocationofstandardburrholes.CourtesyofE.Weissbial.

Fig.15-5.Craniectomyflap.CourtesyofE.Weissbial.

Burrholesaloneareinadequatetotreatacutehematomas,butareofdiagnosticutilityintheabsenceofaCTscanner.Exploratoryburrholesmaymisssubfrontalorinterhemispherichematomas(Fig.15-6).

Fig.15-6.Hematomasmissedwithroutineexploratoryburrholes.

TheboneworkmaybedonewithaHudsonbraceandGiglisaw(passedbeneaththecraniumwiththehelpofaGiglisawpasserortonsilclamp),thoughapowercraniotomeiscertainlypreferableifavailable(seeFig.15-5a).

Alargeduralopeningshouldbecreated,usingtheentireexpanseofthecranialopeningwithenoughedge(~5mm)lefttoclosetheduraatalatertime.

Thebaseoftheduralopeningshouldbeonthesidenearanyneighboringmajorvenoussinustoavoidinjurytolargedrainingveinsandaggravationofcerebraledema.

Forthedamagecontrolcraniectomybythegeneralsurgeon,removalofdevitalizedtissueshouldbedeferredtotheneurosurgeon,aslongasbleedingcanbecontrolled.

Thehematomashouldbegentlyevacuatedwithacombinationofirrigationandmechanicalremoval.Copiousirrigationwillhelpto“float”bonefragmentstothesurfaceforeasierremoval.

Thrombin-soakedgelfoammaybethebestandeasiestadjunctmeasureforbleedingcontrol.Bipolarcauteryisideal,orunipolarelectrocauterywithforceps,clips,andsuturemaybeused.Avoidinjurytothelargemidlinesagittalsinus.

Thedurashouldbeleftopen.

Thescalpcanbeclosedfullthicknesswitharunningnylonsuture.

Skull flap (the removed portion of the skull)management has beenevolving.

Forlocalnationals—washaggressivelyandplacetheskullflapintheabdominal-wallfatpocket.

DiscardtheflapinUSpatients.Reconstructioncanbeperformed

usingtitanium,methylmethacrylateoracrylicatalaterdate.

Applyaloosedressingusingrollerbandagesaroundtheentirehead.Evacuatepatienttoneurosurgicalcareassoonaspossible.ROLE 3: Indications for emergent exploration by neurosurgeoninclude:

Space-occupyinglesionswithneurologicalchanges(eg,acutesubdural/epiduralhematoma,abscess).

Intracranialhematomaproducinga>5mmmidlineshiftorsimilardepressionofcortex.

Compounddepressedfracturewithneurologicalchanges.

Penetratinginjurieswithneurologicaldeterioration.

A similar procedure will be followed, but with the addition of thefollowing:

ReliefofICPwithwidehemicraniectomy/duraplasty/ventriculostomy.

AcapaciousduraplastyshouldbeconstructedwithasubduralICP/ventricularcatheterinplace,allowingmonitoringanddrainagefromtheinjuredhemisphere.

Forunusualpositioningofthehead,soastogainaccesstothesubocciput,useastandard3-pointMayfieldfixationdevice.

Approachtopenetratinginjurywithneurologicalchanges is aimedatremovalofdevitalizedbrainandeasilyaccessibleforeignbodies.

Performcopiousirrigationwithanantibioticsolution(eg,Bacitracin)andaconcertedattemptmadetoachievewatertightduralclosure(ie,pericranium).

Tension-freescalpclosureisalsoessential,butreplacementofmultipleskullfragmentsinanattempttoreconstructtheskulldefectisnotappropriateifotheroptionsforreconstructionareavailable.

Excellentresultscanbeachievedwithcranioplastyafterevacuationfromtheaterandasufficientdelaytominimizeriskofinfection.

A duraplasty should always be performed. A commercial duralsubstitutemaybeavailable;otherwise,pericranium,temporalisfascia,ortensorfascialatamaybeused.Tack-up sutures should be placed around the periphery (no centraltack-upsintheabsenceofaboneflap)oftheduralexposuretoclosethe dead space and discourage postoperative epidural hematoma

formation.Thegaleaofthescalpshouldbeclosedseparatelywithanabsorbablesutureandstaplesusedtoclosetheskin.

Asinglelayerclosurewithheavymonofilamentnylonisacceptable,butshoulddefinitelyincludethegalea,withthesuturesremaininginplaceforatleast14days.

Asubgalealorepiduraldrainshouldbeusedatthediscretionofthesurgeon.

Apply a noncompressive dressing using roller bandages around theentirehead.ObtainapostoperativeCTscan.

NOTE: Injuries that include the frontal sinus,anterior skullbase,andorbitalroofshouldundergoearlyrepair,whichincludesfrontalsinusexenteration; cranialization of the frontal sinus; obstruction of thenasofrontal duct; and a multilayer closure with pericranium, fat,fascia,andautologoussplit-thicknessbone.

EvacuationoftheHead-InjuredPatientA postoperative craniotomy/craniectomy patient should ideally first beobserved for 12–24hoursprior to transport. Evacuating immediatelymaylead to the inability to treat delayed, postoperative hematomas that mayoccur.

All patients with a GCS score of <12 are likely to benefit withintubation.PatientswithaGCSscoreof<8Torpatientswhocannotbeawakeneden route by the transport team (each hour) will require ICPmonitoring.ArterialcatheterizationisnecessaryinpatientswhereCPPmonitoringiscritical.Patients with intracranial pathology should be neuro-surgically“optimized” on the ground prior to departure (eg, placement of aventriculostomy,widecraniectomy,orevacuationofahematoma).The ICPmonitor shouldbeplaced,positionconfirmed, secured,andworking prior to departure. A ventriculostomy gives the transportteam the therapeutic option of cerebrospinal fluid drainage for anelevatedICP.The critical care evacuation teammust be confident in its ability tomedicallytreatincreasedICP,treatrelatedcomplications(eg,diabetesinsipiduswith DDAVP [Desmopressin]; hyperthermia; and seizure),andtroubleshoottheventriculostomy.Inadditiontoallstandardpreevacuationpreparation(seeChapter4,AeromedicalEvacuation):

Draintheventriculostomy;avoidlayingitdownflatbecausethe

ventfiltermaybecomemoistandleadtoan“air-lock.”Ventingthetubingfiltercanbeperformedwithaclean21-gaugeneedle,ifneeded.

Ifahead-injuredpatientdeterioratesinflightandisnotalreadyintubated,intubationshouldbeconsidered.

MedicalmanagementofICPinflightshouldfollowthesamealgorithmaspreviouslydescribed;however,repeatCTscanningorreturntotheoperatingroomarenolongeranoption.

Loadingapatienthead-of-bedtowardthefrontoftheaircraftlimitstheeffectoftakeoffanda“noseup”attitudeoftheaircraftwhileinflight(3%intheC-17)onICP.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter16

ThoracicInjuries

Introduction

About 15% of war injuries involve the torso. Those injuries involving thevasculatureof themediastinum(heart,greatvessels,andpulmonaryhilum)aregenerally fatal on the battlefield. Injuries of the lung parenchyma (the vastmajority) can be managed by the insertion of a chest tube and basic woundtreatment.Althoughpenetrating injuries aremost common, blunt chest traumamayoccurandcan result indisruptionof the contentsof the thorax, aswell asinjury to thechestwall itself.Blast injuriescanresult in theruptureofair-filledstructures(thelung),aswellaspenetratinginjuriesfromfragments.

The immediate recognition and treatment of tension pneumothorax is animportant life-saving intervention in the treatment of chest injuries incombat. Distended neck veins, tracheal shift, decreased breath sounds,hyperresonanceintheaffectedhemithorax,andhypotensionarethecardinalsigns, BUT may not be identified in the presence of otherinjuries/hypotension/hypovolemia.Immediatedecompressionislifesaving.

Theprotectionaffordedbybodyarmorgreatlyreducestheincidenceofthoracicinjuries, compared with extremity or head/neck injuries. Unfortunately, not allindividuals have such protection; some tactical situations limit the use of bodyarmor and some sustain chest injuries despite protection. In addition, militarysurgeonsroutinelytreatinjuredcivilians.

AnatomicalConsiderationsSuperiorborderisattheleveloftheclaviclesanteriorlyandthejunctionofthe C7–T1 vertebral bodies posteriorly. The thoracic inlet at that levelcontains major arteries (common carotids and vertebrals), veins (anteriorandinternaljugulars),trachea,esophagus,andspinalcord.Within or traversing the container of the chest itself are the heart andcoronary vessels, the great vessels—including arteries (aortic arch,innominate, right subclavian, common carotid, left subclavian, anddescendingaorta),veins(superiorandinferiorvenacava,azygousvein,andbrachiocephalic vein), and pulmonary arteries and veins—distal trachea,andmainstembronchi,lungs,andesophagus.Theinferiorborderisdescribedbythediaphragm,attachedanteriorlyattheT6levelandgraduallyslopingposteriorlytotheT12level.

Penetrating thoracic injuries below the T4 level (nipple line) mandateevaluation for abdominal injuries due to the variable position of thediaphragmduringtherespiratorycycle(Fig.16-1).

EvaluationandDiagnosis

Knowledgeof themechanismof injury (eg,blast, fragment,amongothers)mayincrease the index of suspicion for a particular injury.A complete and accuratediagnosisisusuallynotpossiblebecauseofthelimiteddiagnostictoolsavailablein the setting of combat trauma.Nonetheless, because injuries to the chest canprofoundlyaffectbreathingandcirculation(and,onrareoccasion,theairway),acompleteandrapidassessmentofeachinjuryismandatory.

Fig.16-1.Thoracicincisionofabdominalcontents.

If the casualty is able to talk without hoarseness or stridor, there isreasonableassurancethattheairwayisintact.

Life-ThreateningInjuries

Injuries requiring urgent intervention, include tension pneumothorax,massivehemothorax,andcardiactamponade.

Tensionpneumothorax.Apatientwithaknownchest injurypresentingwithanopenairwayand difficulty breathing has a tension pneumothorax until provenotherwise.Itrequiresrapiddecompressionandtheinsertionofachesttube.Needledecompressionaloneisinsufficient.

Massivehemothorax.Thereturnofbloodonchesttubeplacementmayindicateasignificantintrathoracic injury. Generally, the immediate return of 1,500 cc ofbloodmandates thoracotomy.When initial blood loss is <1,500mL,but bleeding continues such that ongoing blood transfusions arerequired and all other sources of hemorrhage are eliminated, thenthoracotomy may be indicated. Needle decompression will notidentifyhemothorax.Casualtieswithmassivethoracichemorrhagerequiredamagecontroltechniques(seeChapter12,DamageControlSurgery).

Cardiactamponade.Distended neck veins (may be absentwith significant blood loss) inthe presence of clear breath sounds and hypotension indicate thepossibilityoflife-threateningcardiactamponade.Fluidresuscitationmaytemporarilystabilizeapatientintamponade.Performanultrasoundiftimepermits.

Ifpositive,proceedtotheOR(pericardialwindow,sternotomy,thoracotomy).Anypericardialbloodmandatesmediansternotomy/thoracotomy.

Anegativeultrasoundrequireseitherrepeatultrasoundorpericardialwindow,dependingonthelevelofclinicalsuspicion.

Pericardiocentesisisonlyastopgapmeasureonthewaytodefinitivesurgicalrepair.

Openpneumothorax (holeinchestwall) istreatedbyplacingachesttubethroughaseparate incisionandsealingthehole.Alternatives includeone-wayvalvechestdressingsorasquarepieceofplasticdressingtapedtothechestonthreesidesasa“flapvalve.”Flailchest (entire segment of the chestwall floatingdue to fractures of ablockofribs,with twofracturesoneachrib) iscommonlyassociatedwithpulmonary contusion under the flail segment. Patients with flail chestshouldbemonitoredcloselyforrespiratorydistress.Paincontrolisessentialandmayrequire intercostalnerveblocksorepiduralcatheters tooptimizepulmonarymechanics.Patientswithevidenceof respiratorydistress,pooror marginal oxygenation, or ventilation should be intubated andmechanicallyventilatedpriortoairevacuation.

SurgicalManagement

Most penetrating chest injuries reaching medical attention are adequatelytreatedwithtubethoracostomy(chesttube)alone.

TubeThoracostomy(ChestTube)Indications.

Knownorsuspectedtensionpneumothorax.Pneumothorax(includingopen).Hemothorax.

Procedure(Fig.16-2).Incasesoftensionpneumothorax,immediatedecompressionwithalargeboreneedlemaybe lifesaving.An IVcatheter (14gauge,3.25inches in length) is inserted in themidclavicular line in the secondinterspace (approximately2 fingerbreadthsbelow the clavicleon theadultmale).Donot placemedial to the nipple to avoid cardiac orvascular injury. Entry is confirmed by the sound of air passingthrough the catheter, if a pneumothorax was actually present.Thismust be rapidly followed by the insertion of a chest tube.

Fig.16-2.Procedurefortubethoracostomy.Numbersindicateribsites.

In a contaminated environment, a single gram of IV Cefazolin(ANCEF)isrecommended.Iftimeallows,preptheanteriorandlateralchestontheaffectedsidewithpovidone-iodine.Identify the incision site along the anterior axillary line, intersectingthe 5th or 6th rib. This is at nipple level in males and at theinframammarycreaseinfemales.Injectalocalanestheticintheawakepatient,ifconditionsallow.Makeatransverseincision,3–4cminlength,alongandcenteredovertherib,carryingitdowntothebone(Fig.16-2a).Insertacurvedclampintheincision,directedoverthetopoftherib,and push into the chest through the pleura. A distinct pop isencounteredwhenenteringthechest,andamoderateamountofforceis necessary to achieve this entry.A rushof air out of the chestwillconfirm a tension pneumothorax. Insertion depth of the tip of theclamp shouldbe limitedby the surgeon’shand toonly 3or 4 cm tomake sure that the clamp does not travel deeper into the chest,resultingindamagetounderlyingstructures.

Spread the clamp gently and remove. The operator’s finger is theninsertedtoconfirmentry(Fig.16-2b,c).Insertachesttube(24–36Frgauge) intothehole.Allchesttubesideholesmustbeinthepleuralspace(ie,notjustbelowskinlevel).Ifnochesttubesareavailable,anadultendotrachealtubemaybeused(Fig.16-2d).AttachachesttubetoaHeimlichvalve,sealedPleurovac,orbottles.Ina resource-constrained environment, a cutoff glovewith a slit in theend,oraPenrosedrainmaybeattachedtotheendofthechesttube(Fig.16-2e).Secure the tube with sutures, if possible, and dress to preventcontamination.

ResuscitativeThoracotomy

Only indicated in penetrating injury in extremis or with recent loss ofvitalsigns.11%survivalreportedfromcombatcasualtiesinIraq/Afghanistan.Ifperformed,arapidassessmentofinjuriesshouldbemade;and,inthecase of unsalvageable injuries, the procedure should be immediatelyterminated.

ProcedureWith the patient supine, make an incision in the left inframammary foldstartingatthelateralborderofthesternumextendingtothemidaxillaryline(Fig. 16-3).

Fig.16-3.Incisionforresuscitativethoracotomy.

Theprocedureshouldbeabandonedupondiscoveryofdevastatinginjuriestotheheartandgreatvessels.Animmediaterightchestthoracostomyshouldbeperformedconcurrently.If bleeding is identified, a rapid extension across the midline should bedone, crossing through the sternum with a Lebsche sternum knife andperformingamirror-image thoracotomy.Whendoing thisprocedure, youwillcutacrossbothinternalmammaryarteries,whichwillbeasignificantsourceofbleedingandmustbeclampedassoonaspossible.Elevating the anterior chest wall will expose virtually all mediastinal

structures.Open the pericardium and assess the heart. Use an anterior longitudinalincisiontoavoidphrenicnerveinjury.Prioritiesaretostopbleedingandrestorecentralperfusion.

Holes in the heart and/or great vessels should be temporarilyoccluded.

Temporaryocclusioncanbeachievedwithfingers,side-bitingclamps,orFoleycatheterswith30ccballoons.Anyothersteriledeviceofopportunityisacceptable.Afingerisusuallysufficient,andlesstraumatic.

Majorpulmonaryhilarinjuriesshouldbecross-clampedenmasse.Distal thoracic aorta should be located, cross-clamped, and cardiacfunctionrestoredviadefibrillationormassage.(Makesuretoopenthemediastinal pleura over the aorta to securely apply the vascularclamp.)Ifunabletorestorecardiacfunctionrapidly,abandontheoperation.

With successful restoration of cardiac function, injuries should be moredefinitivelyrepaired.

SubxiphoidPericardialWindow

Subxiphoid pericardial window should not be attempted in an unstablepatient. Unstable patients with penetrating injuries suspicious for cardiacinjuryshouldundergoimmediatemediansternotomy/thoracotomy.

ProcedureWith the patient supine,make a 4–5 cm longitudinal incision just on andbelowthexiphoidprocessthroughtheskinandfascia.Bluntlydissectsuperiorlytowardtheheartexposingthephrenopericardialmembranebelowtheheart.Sharply incise pericardium with care to avoid the heart, opening thepericardialsac,andexposingtheunderlyingbeatingheart.Presenceofpericardialbloodmandatessternotomytoassess/repaircardiacinjury.

MedianSternotomyIndications.

Suspectedcardiacinjury.Positivepericardiocentesis/subxiphoidpericardialwindow.Suspectedinjurytothegreatvesselsinthechest.Suspecteddistaltrachealinjury.

Procedure.In thesupineposition,makeamidlineskin incisionfromthesternalnotchtojustbelowthexiphoid.Through blunt/sharp dissection, develop a plane for severalcentimetersbothsuperiorlyandinferiorlybeneaththesternum.

DividethesternumwithasternalsaworLebscheknife.Keepthefootoftheknife/sawtilteduptowardtheunder-surfaceofthesternumtoavoidcardiacinjury.Bonewaxcanbeusedtodecreasebleedingonthecutedgesofthesternum.Separatethehalvesofthesternumusingachestretractor.Carefullydividethepericardiumsuperiorly,avoidingtheinnominatevein,andexposingtheheartandbaseofthegreatvessels.

Ingeneral,exposuretotheheartandgreatvesselsisbestachievedthroughamediansternotomy.Forproximalleftsubclavianarteryinjuries,additionalexposure(trapdoor)maybenecessary.

Close with wire suture directly through the halves of the sternum,approximately2cmfromtheedge,oraroundthesternumthroughthecostalinterspacesusingwiresutures.Large,permanentsuturescanbeusedifwireisunavailable.Place one or two mediastinal tubes for drainage, exiting through amidlinestabwoundinferiortothemediastinalskinincision.

OtherApproachesSupraclavicular(Fig.16-4).

Indication.

Mid-todistalsubclavianarteryinjury.

Procedure.

Makeanincision2cmaboveandparalleltotheclavicle,beginningatthesternalnotchandextendinglaterally8cm.

Trapdoor(Fig.16-5).Indication.

Proximalleftsubclavianarteryinjury.

Procedure.

Performsupraclavicularapproachaspreviouslydescribed.

Performapartialmediansternotomytothe4thintercostalspace.Atthe4thintercostalinterspace,incisetheskinlaterallyinthesubmammaryfoldtotheanterioraxillaryline.

Dividethesternumlaterallyandcontinueinthe4thintercostalspacetotheanterioraxillaryline.Theinternalmammaryarterywillbedividedandmustbecontrolled.

Itmaybenecessarytoeitherfractureorremoveasectionoftheclavicletogainadequateexposureoftheproximalleftsubclavianartery.

Fig.16-4.Supraclavicularapproach.

Approachdistalleftsubclavianarteryinjuriesthroughasupraclavicularincision.

Thoracoabdominal.Indication.

Combinedthoracicandabdominalinjuries.

Procedure.

Theresuscitativethoracotomycanbecontinuedmediallyandinferiorlyacrossthecostalmarginintotheabdominalmidlinetocompleteathoracoabdominalincision.

Fig.16-5.Trapdoorprocedure.

Alternatively,aseparateabdominalincisioncanbemade.

Withright-sidedlowerchestinjuries,theliverandretrohepaticvenacavacanbeexposedwellusingarightthoracoabdominalapproach.

SpecificInjuriesVascular.

Initially, holes in vessels should be digitally occluded. Stopgapmeasures include placing Fogarty or Foley catheters, side-bitingclamps,or—inthecaseofvenousinjuries—spongesticks.Total occlusion or clampingmay temporarily be necessary to allowresuscitationtocontinueandrestorecardiacfunction.If cardiac function cannot be restored within 5 to 10 minutes, theprocedureshouldbeabandoned (on-the-table triage)and thepatientmanagedexpectantly.Repairofvesselsshould followtheprinciplesdetailed inChapter25(VascularInjuries),withshuntingorrepairbyautogenousorsyntheticgraftsasindicated.

Heart.

The usual result of high-velocity injuries to the heart is irreparabledestructionofthemuscle.

Isolated punctures of the heart should be exposed (opening thepericardium)andoccludedbyfingerpressure.OthermethodsincludetheuseofaFoleycatheterorskinstaples.Use pledgeted horizontal mattress sutures (2-0 PROLENE) on atapered needle for definitive repair. Care must be taken to avoidadditionalinjurytocoronaryvessels.Extremecaremustbetakentoavoidtearingthecardiacmuscle.Autologouspericardiumcanbeusedifcommercialpledgetsarenotavailable(Fig.16-6).Atrialrepairsmayincludesimpleligature,stapledrepair,orrunningclosures.Temporaryinflowocclusionmayprovehelpfulinrepair.Morecomplexrepairsareimpracticalwithoutcardiacbypass.

Lung.Tube thoracostomy alone is adequate treatment for most simplelungparenchymalinjuries.Large air leaks not responding to chest tubes or that do not allowadequate ventilation will require open repair (see section on“TracheobronchialTree”).Posterolateral thoracotomy is preferred for isolated lung injuries.Anteriorthoracotomymayalsobeused.Controlsimplebleedingwithabsorbablesutureona taperedneedle.Alternatively,staples(eg,TA-90)maybeusedforbleedinglungtears.

Fig.16-6.Repairofpenetratingcardiacinjury.

Tractotomy: Open any bleeding tracts (through-and-through lungpenetrations)withaGIAstaplerorbetweenstraightvascularclampsandligatebleedingpoints.

Donot simply close the entrance and exit points of penetratingtractsinthelung.Withpositivepressureventilation,theriskisairembolism.Themorecentraltheinjury,thehighertherisk.

Resection for bleeding may be indicated with severe parenchymalinjury. Anatomical resections are not indicated, and simple stapledwedgeexcisionsarerecommended.Uncontrolled parenchymal/hilar bleeding, or complex hilar injurieswithmassive air leak, shouldbe controlledwithhilar clamping andrepair attempted. Pneumonectomy is performed as a last resort,becausesurvivalisverylow.

Tracheobronchialtree.Suspect the diagnosiswithmassive air leak, frothy hemoptysis, andpneumomediastinum.Confirmbybronchoscopy.Airwaycontrolisparamount.Mediansternotomyisbestapproach.Repair over endotracheal tubewith absorbable suture—may requiresegmental resection. Bolster with pleural or intercostal muscle flap,especiallybetweenthetracheaandesophagus.Temporizingmeasuresinclude:

Singlelungventilation.

Controltheairwaythroughthedefect.

Esophagus.Isolated thoracic esophageal injuries are exceedingly rare. Theywillusuallybediagnosed incidentallyassociatedwithother intrathoracicinjuries.Diagnostic clues include pain, fever, leukocytosis, cervicalemphysema,Hamman’ssign,chestX-rayevidenceofpneumothorax,mediastinal air, andpleural effusion.Contrast swallowmay confirmthediagnosis.StartIVantibioticsassoonasthediagnosisissuspected,andcontinuepost-op until fever and leukocytosis resolve. This is an adjunctivemeasureonly.Surgeryisthedefinitivetreatment.For stable patients in a forward location, chest tube drainage and anasogastric tube placed above the level of injury are temporizingmeasures. Ideally, primary repair is performedwithin 6–12 hours ofinjury. Beyond 12 hours, isolation of the injured segment may benecessary.

The preferred approach for intrathoracic esophageal injuries is

posterolateralthoracotomy:rightfortheupperesophagusandleftfortheloweresophagus.

Locatetheinjurybymobilizingtheesophagus.Primarilyrepairwithasinglelayerortwolayersof3-0absorbablesuturesandcoverwiththepleuralorintercostalmuscleflap.Drainagewithchesttubes(oneapical,oneposterior)isrecommended.Ifunabletoprimarilyrepair(aswithalargesegmentallossorseverelycontaminated/old injury), staple above andbelow the injury, place anasogastrictubeintotheupperpouches,andplaceagastrostomytubeinto the stomach. Drain the chest as indicated previously. Complexexclusionproceduresarenotindicatedinaforwardoperativesetting.An alternative when the esophageal injury is too old for primaryrepair is to close the injury over a large T-tube, which converts theinjurytoacontrolledfistula.Themediastinumisthenwidelydrainedusing chest tubes or closed-suction catheters placed nearby. After amaturefistulatractisestablished,slowlyadvancetheT-tube;later,themediastinaldrainscanbeslowlyadvanced.

Diaphragm.Allinjuriesofthediaphragmshouldbeclosed.

Lacerationsshouldbereapproximatedwithnonabsorbable0or2-0runningorinteruptedsutures.

Careshouldbeexercisedinthecentraltendonareatoavoidinadvertentcardiacinjuryduringtherepair.

Ifthereissignificantcontaminationofthepleuralspacebyassociatedenteral injuries, anterior thoracotomy and pleural irrigation anddrainage with two well-placed chest tubes should strongly beconsidered.

Inadequateirrigationanddrainage,suchaswhenattemptedthroughthediaphragmaticdefectviatheabdomen,canleadtoahighincidenceofempyema.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter17

AbdominalInjuries

Introduction

Changing patterns of warfare coupled with improvements in protective bodyarmorhavecombinedsynergistically todecrease truncalandabdominal traumain contrast toprevious conflicts.Despite themany advances inprotective bodyarmor, penetrating abdominal trauma remains an inevitable component ofwarsurgery.Rapidrecognitionandtreatmentofintraabdominalinjuriesarenecessarytoensuremaximalsurvivalwiththeminimumamountofmorbidity.

Traumatotheabdomen,bothbluntandpenetrating,canleadtooccultinjurythatcanbedevastatingorfatalifnotrecognizedandtreatedinatimelymanner.Inanunstablepatientwhopresentswithanabdominalinjury,thedecisiontooperateisusuallystraightforward. In thiscircumstance,exploratory laparotomyshouldbeperformed as soon as the diagnosis is made. In a few rapidly hemorrhagingpatients with thoracoabdominal injuries, a rapid decision must be made as towhichcavitytoenterfirst.Thischapteraddressessomeoftheseissues.

Penetrating injuries below the nipples, above the symphysis pubis, andbetween the posterior axillary lines must be treated as injuries to theabdomenandmandatefurtherworkupand/orexploratorylaparotomy.

Posterior truncal penetrating injuries from the tip of the scapula to thesacrum may also cause retroperitoneal and/or intraabdominal injuries. Alow threshold for exploratory laparotomy in these patients is warrantedwhenlimiteddiagnosticmodalitiesareavailable.

DiagnosisofAbdominalInjuryDocumentafocusedhistorytoincludetimeofinjury,mechanismofinjury,previoustreatmentsemployed,andanydrugsadministered.Inspectionofthefullyexposedchestandabdomenwillbethemostreliablepartofthephysicalexamination,especiallyregardingpenetratinginjuries.The most important determination is whether or not a patient requiresurgentlaparotomy.Donotfocusonmakingaspecificdiagnosis.

IndicationsforLaparotomy

Themostimportantdecisionistodeterminewhoneedssurgery.

Patientswhomandateexpeditiousabdominalexplorationarepatientswiththefollowingsignsandsymptoms:

Physiological instabilityonpresentationwithanobviouspenetratingabdominalinjury.Penetratingabdominalwoundsinthezonesasdescribedinthezoneofinjuryexplainedabovewhennomeanstoexcludeanintraabominalinjuryareavailable.Present with other penetrating truncal injuries with potential forperitonealpenetrationandclinicalsigns/symptomsof intraperitonealinjury.Presentinshockwithpotentialforbluntabdominalinjuries.

When aeromedical evacuation is uncertain and will involve substantialdistance, unstable patients with life- or limb-threatening circumstancesshouldundergolaparotomyatthenearestfacilitythatcanprovidesurgicalcare.Laparotomy may be delayed if necessary, depending on the operationalsituation.Thesecircumstancescanbegenerallymanagedby the followingguidelines:

Stablepatientswith intraperitoneal injuryandnosignsof shockcanbemanagednonoperativelyforseveralhours.Initiateresuscitation.Startbroad-spectrumantibiotics.Arrange for transport as soon as possible to the next higher role ofcare.

Whenthetacticalsituationpermits,aeromedicalevacuationiseffective,andthe distance betweenRole 2 (Forward Surgical Team) andRole 3 (CombatSupportHospital)orhigherlevelhospitalsisshort,allcriticallyillcasualtiesshouldbemedicallyregulatedtothehigherrolewhenpossible.

DiagnosticAdjuncts

Nonoperative adjuncts todiagnosing intraabdominal injuries—suchasCT scan,ultrasound(US),anddiagnosticperitonealaspiration(DPA)—havebeenusedtodecrease the negative laparotomy rate in stable patients with blunt abdominaltrauma. Some of the aforementioned modalities have been used in lieu oflaparotomy to evaluate patients with penetrating injuries when the clinicalsuspicion is low for an intraabdominal injury. The practice of nonoperativemanagement of penetrating abdominal trauma and reliance on diagnosticmodalitiestoruleoutintraabdominalinjuryhavethepotentialofmissinginjuries,particularly in the resource-constrained environment with limited diagnosticmodalities.TheuseofCT,DPA,andUSinpenetratingabdominaltraumashouldbe reserved for stable patients with a mechanism of injury suggestingintraabdominal injury, but who lack obvious operative indication. Thesediagnosticmodalitiesshouldbereliedononlywhengoodfollow-up ispossibleandpatientswillnotrequirelongtransportswhererapidsurgicalinterventionisnot possible. US andDPA have some utility in unstable patients to help guidewhich cavity, thoracic or abdominal, should be entered first when planning

operativestrategy.USandDPAmayalsoserveastriagetoolsinthemasscasualtysituation.

FocusedAbdominalSonographyforTrauma(FAST)Hasbecomeanextensionofthephysicalexaminationoftheabdomen,andshouldbeperformedwheneverindicatedandavailableinthesettingofanabdominalinjury.SonoSiteisthecurrentstandardUSmilitarydeviceused.

A3.5–5MHzcurvedprobeisoptimal.The abdomen is examined through four standard sonographicwindows:rightupperquadrant,subxiphoid,leftupperquadrant,andsuprapubic.

Advantages:Noninvasive, may repeat frequently, quick, easy, identifies fluid in theabdomenreliably.AidsinprioritizationofpenetratinginjurypatientsfortheOR.Helpsidentifywhichcavitytoopenfirstinpatientswiththoracoabdominalinjuries.Identifies pericardial fluid and may assist in the diagnosis ofhemopneumothorax.

Disadvantages:Operator-dependent,maymiss small amounts of fluid and hollow viscusinjuries.Assiststhesurgeonindeterminingtheneedforlaparotomyinpatientswithbluntabdominalinjury,butdoeslittletoidentifyspecificinjuries.DOESNOTidentifyorstagesolidorganorhollowviscusinjury.

FASTViews

A typical portable sonography device is shown in Fig. 17-1. The standardlocationsfor“sonographicwindows”areshowninFig.17-2.ExamplesofpositiveandnegativesonographicexaminationsareshowninFigs.17-3through17-6.

Fig.17-1.Typicalsonographydevice.CourtesyofSonoSite,Inc,Bothell,WA.

Fig.17-2.Thestandardfourlocationsforsonographicwindows.(a)Subxiphoid.(b)Suprapubic.LUQ:leftupperquadrant;RUQ:rightupperquadrant.

Fig.17-3.(a)Rightupperquadrant.(b)Normaland(c)abnormalnegativesonographicexaminationsfortherightupperquadrant.

Fig.17-4.(a)Subxiphoid.(b)Normaland(c)abnormalnegativesonographicexaminationsforthecardiacwindow.LA:leftatrium;LV:leftventricle;RA:rightatrium;RV:rightventricle.

Fig.17-5.(a)Leftupperquadrant.(b)Normaland(c)abnormalnegativesonographicexaminationsfortheleftupperquadrant.

Fig.17-6.(a)Suprapubic.(b)Normaland(c)abnormalnegativesonographicexaminationsforthepelvicwindow.Abd:abdomen;BL:bladder.FF:freefluid.

DiagnosticPeritonealAspiration

Historically,diagnosticperitoneallavageplayedaroleinbluntabdominaltraumadiagnosis;however,theutilityofthelavagecontinuestodecreaseinthesettingofimprovementsinbothUSskillsandtechnology,coupledwiththewidespreaduseof CT scan. Far-forward combat medical units are not routinely outfitted withappropriate equipment, such as microscopic and laboratory functions thatprovide cell counts or fluid enzyme determinations. Thus, the only reliableinformationobtainedfromalavageistheaspirationofgrossbloodorDPA.

Advantages:Quicklyascertainintraperitonealblood.Mayhelpdeterminewhichbodycavitytoenterfirstinanunstablepatientwithtruncalinjury.

Disadvantages:Invasive,oftennotreproducible,significantlyslowerthanFAST.MaybeusefulwhenUSand/orCTarenotavailable,orastriagetool.ThefollowingrepresentpositiveDPA:

Aspirationof10ccofgrossblood.Aspirationofentericcontents.

DPAisNOTrecommendedforpenetratingabdominaltrauma.Basictechnique:

Opentechniqueusingasmall,verticalinfraumbilicalincisionandanytubing(IV,Foley,straight,orballooncatheter).Aspirateperitoneum.

CTScan

Advantages:

Defines injured anatomy in stable patients and provides a modality thatmaypreventunnecessarylaparotomyinappropriatelyselectedpatients.WhenavailableandinSTABLEpatients,CTscanmaybeusefulfor:

The workup of penetrating abdominal injuries where there is aquestion of whether or not the projectile traversed the peritonealcavity.The evaluation of isolated penetrating retroperitoneal and posteriorinjuries.

WhenusingCTscantoevaluatepenetratingretroperitonealinjuries,triple-contrastCTscan(oral,IV,andrectal)remainsimportanttoruleoutinjuries.

Disadvantages:Slow.Requirescontrastuseandequipmentavailability.Maymisssmallholloworganinjury.Requirestransportawayfromtheresuscitationarea.Operator-/interpreter-dependent.

There isNOROLE forCTscan in theevaluationofanunstablepatientwithobviousabdominaltrauma,regardlessofthemechanismofinjury.

WoundExplorationBlastinjuriesandimprovisedexplosivedevicescreatemanyfragmentsthatmay penetrate the skin, but not the abdominal cavity. Operative localwound exploration in the stable patient with a normal or equivocalexamination may help determine the need for formal exploratorylaparotomy.When possible, wound exploration should be performed in the OR withadequateinstrumentsandlighting.Finding of an isolated fragment in the abdominal wall superficial to theanteriorfasciamayobviatetheneedforformallaparotomy.Ifthereisanydoubtthatthefragmentpenetratedtheabdominalcavity(eg,thetractoftheprojectileisnotadequatelyidentifiedorthefragmentcannotbeseenonplainfilmradiograph),formallaparotomyshouldbeperformed.CTscan,whenavailableandusedasanadjuncttowoundexploration,mayalso be helpful in determining the trajectory of fragments and help planwoundexploration.

OperativePlanningandExposureTechniquesAdministerbroad-spectrumIVantibioticpriortosurgeryandcontinuefor24hours.

Redose short half-life antibiotics intraoperatively and considerredosingantibioticswithlargeamountsofbloodloss.

Laparotomyshouldbeperformedthroughamidlineincision.When wide exposure is needed, extend the incision superiorly justlateraltothexiphoidprocessandinferiortothesymphysispubis.

Quicklypackallfourquadrantswithlapspongeswhilelookingforobviousinjuries.Controlhemorrhagewithpackingorclampingofbleedingvessels.Oncepackedandhemorrhagecontrolled,assessphysiologicalstatus.

Consideringcasualtyphysiology,yourcurrentresources,andlocation,create an operative plan to control hemorrhage, contamination, andtruncatetheoperationifnecessary.Attempttolimitinitialexploratorylaparotomyto<60minutes.ALWAYS consider damage control principles throughout theprocedure(seeChapter12,DamageControlSurgery).If the patient is stable, consider definitive surgery. In general,definitive surgical procedures should be limited to procedures oncethe patient has been resuscitated and at a level of care with thegreatestdiagnosticandtherapeuticresourcesavailableforpatientcare(ie,Role3facility).

Identifyallsolidorganandhollowviscusinjuries.Evisceratethesmallboweltoincreaseworkspace,ifneeded.

If needed, divide both the left and right triangular ligamentousattachments of the liver to improve exposure in the right upperquadrantoruppermidline.

Foldthe left lateralsegmentof the liverdownandtotheright to improveexposureatthegastroesophagealjunction.Improve exposure to the liver by extending the incision into the inferiorsternumand/oracrossintothelowerrightchest(thoracoabdominal).

GastricInjuriesThestomachisavascularorganandwilldowellaftermostanyrepair.Theentirestomachmustbevisualized.

When exploring the stomach, enter the lesser sac by dividing thegastrocolicligamentandreflectingthestomachuptowardtheheadtoevaluateforposteriorwallinjuries.

Encircle thedistalesophaguswithaPenrosedraintoprovidetractionandimprovevisibilityforhighmidlineinjuries.Once all gastric injuries have been identified, minimally debride andprimarilyclosestomachdefectsin1or2layerswithpermanentsutures.Placethenasogastrictubeandconfirmpositionwithpalpation.

Consider use of a large gastrostomy tube (a large Foley orMalecotmayworkifnogastrostomytubesareavailable).Remember tohave thenasogastric tube or gastrostomy tube irrigatepostoperativelywith30mLofsalineevery2hourstoensurethatthetubedoesnotbecomeclogged.

DuodenalInjuries

Injuriestotheduodenumaretypicallyassociatedwithmassiveupperabdominaltrauma. Thus, early consideration for damage control surgery should be

considered(seeChapter12,DamageControlSurgery).

Missedinjuriesoftheduodenumhavedevastatingmorbidity.Bile staining or hematoma in the periduodenal tissues mandates fullexplorationoftheduodenum(Kochermaneuver).Minor injuries can be primarily repaired in two layers and closed-suctiondrains(JP[Jackson-Pratt]drains)placedaroundtherepair.Major injuries should be primarily repaired if they do not involve theampulla,andluminaldiameterwillnotbenarrowedby>50%.Optionsforclosinginjuriesof>50%:

Closeduodenalwallaroundatubeduodenostomy.

Useano.2-0absorbablesuture(VICRYL).

UsethelargestMalecotcatheterordrainagetubeavailable.

Performapyloricexclusionprocedure.Throughagastrotomy,ligatethepyloruswithanabsorbablesutureorbyusinganoncuttingTAstaplingdevice.Staplebutdonotdividethepylorus.Closetheduodenalinjury.Create a gastrojejeunostomy anastomosis between the jejeunal limbandthegastrotomy(Fig.17-7).Remembertoplaceafeedingjejunostomyfornutrition.TheprocedureofLASTRESORTispancreaticoduodenectomy.Intheacuteanddamagecontrolsettings,thereisNOroleforreconstructionduring the initial procedure in patients with traumaticpancreaticoduodenectomy.

Duodenalinjurycaveats.Widelydrainallinjurieswithclosed-suctiondrains.Anymethodused to close the pyloruswill typically last only 14–21days.Thepossibilityofinjurytothebiliaryandpancreaticductsshouldbeconsideredwheninjuriesinvolvethesecondportionoftheduodenumorthepancreatichead.

Fig.17-7.(a)Pyloricexclusion.(b)Duodenalinjuryrepair.(c)Gastrojejeunostomy.

PancreaticInjuriesAnyinjurytothepancreas/ductrequiresdrainage.Even ifductal injury isnot identified, it shouldbepresumedanddrainedwithmultipleclosed-suctiondrains.

Resectclearlynonviablepancreaticbody/tailtissue.

Major injuries to the head of the pancreas may requirepancreaticoduodenectomy. If pancreaticoduodenectomy isperformed as part of damage control surgery, reconstructionshould be delayed until the patient has been resuscitated.Consideration for reconstruction should be given if definitivesurgery will take more than 72 hours from time of injury. Ifreconstruction isnotpossible, thenwidedrainagewithmultipleclosed-suctiondrains shouldbeusedand thepatient’s abdomenleftopentofacilitatereconstruction.

Transectionornear-transectionofthepancreaticductcanbetreatedby:Drainage.Distalpancreatectomy(typicallyrequiressplenectomy).

LiverInjuriesMost liver injuries can be successfully treatedwithdirect pressure and/orpacking, followed by aggressive resuscitation and correction ofcoagulopathy.If packing is not successful, generous exposure is required and should begainedearlyandaggressively.

Mobilize triangular, falciform, and coronary ligaments for fullexposure.Useextensionintothepericardiumand/orrightchest,ifneeded.Placeseverallaparotomypadsabovethedomeofthelivertodisplaceitdownintothefieldofview.

Short duration clamping of the hepatic artery and portal vein (Pringlemaneuver)mayberequiredtoslowbleedingwhilegainingothercontrol.IfbleedingcontinuesdespitethePringlemaneuver,especiallyfrombehindthe liver, this indicatesa retrohepaticvenous injuryora retrohepaticvenacaval injury. These injuries carry an extremely high mortality. If theretrohepatichemorrhageiscontrolledwithpacking,thebestmechanismtodealwith these injuries is tomaintain tamponadebyaggressivelypackingtheliverandICUresuscitation.Ifnecessary,theseinjuriesmaybeaddressedoncethepatienthasbeenmoreadequatelyresuscitatedandtransferredtoahigherroleofcarewiththeresourcestocareforthepatient.Asalastresort,considercross-clampingtheaortaintheleftchestorupperabdomenifallothermodalitiesfailtocontrolhemorrhagetotheliver.Usefingerfractureofliverparenchymatoexposedeepbleedingvesselsandoversewdirectly.Large exposed injuries of the liver parenchyma can be controlled in anumberofways:

Exposedlargevesselsandductsshouldbesuture-ligated.Overlappingmattresssuturesofno.0chromiconabluntliverneedleisfastandeffectiveforcontrollingrawsurfacebleeding.Placement of SURGICEL on the raw surface and high-powerelectrocauteryisalsoeffective.

BleedingtractsthroughthelivercanbecontrolledbytyingofftheendofaPenrosedrain,placingitthroughthetract,and“inflating”itwithsalinetotamponadethetract.Urgentsurgicalresectionisstronglydiscouraged:

Indicatedonlywhenpacking/pressurefails.Followfunctionalorinjurypattern,notanatomicallines.

Useapedicleofomentuminalargedefecttoreducedeadspace.

Prevention and treatment of coagulopathy, hypothermia, and acidosisare essential in the successful management of major liver injuries.APPLYDAMAGECONTROLTECHNIQUESEARLY.

Retrohepatic vena cava and hepatic vein injuries require a tremendousamount of resources (blood products, operating room time, equipment)typicallyunavailable in a forward surgery setting (on-table triage inmasscasualty).

Packingisthemostsuccessfuloption.Ifpackingfails,considerhemorrhagecontrolbytotalhepaticvascularisolationoratriocavalshunt(Fig.17-8)inordertoeffectinjuryrepair.

Providegenerousclosed-suctiondrainagearoundmajorliverinjuries.

BiliaryTractInjuriesInjuriestothegallbladderaretreatedbycholecystectomy.RepaircommonbileductinjuriesoveraT-tube.

Ano.4-0orsmallerabsorbablesutureisusedonthebiliarytree.Extensive segmental loss requires choledochoenterostomy or tubecholedochostomy(dependingontimeandpatientphysiology).Drainwidely.

SplenicInjuriesIntraoperativesplenicsalvagehasNOROLEincombatsurgery.Empiric left subphrenic drains should not be routinely placedpostsplenectomyifthepancreasisuninvolvedintheinjury.Splenic injury should prompt exploration for associated diaphragm,stomach,pancreatic,andrenalinjuries.Theater clinical practice guidelines exist to help guide protocols forpostsplenectomy immunization. All postsplenectomy patients should beimmunizedwith pneumococcal, hemophilus, andmeningococcal vaccine.

Fig.17-8.Atriocavalshunt.(A)Proximalclampocclusion;(B)purse-stringsuture,rightatrium;(C)fenestrationsmadeintube;(D)suprahepaticinferiorvenacavacontrol;(E)Pringlemaneuver;and(F)endotrachealtube,ballooninflatedaboverenalveins.

SmallBowelInjuriesBasictenets:

Debridewoundedgestofreshlybleedingtissue.Closeenterotomiesin1or2layers(skinstaplerisarapidalternativefordamagecontrol).

Withmultipleenterotomiestoonesegmentof<50%ofsmallbowellength,

perform single resection with primary anastomosis. Avoid multipleresections.

ColonInjuries

Simple, isolated colon injuries are uncommon. In indigenous populations andenemycombatants(eg,patientswhocannotbereadilyevacuated),diversionwithcolostomyshouldbetheprocedureofchoice.

Simple,isolatedcolon(nonrectal)injuriesshouldberepairedprimarily.Debridewoundedgestonormal,noncontusedtissue.Performtwo-layerclosureoranastomosis.

For complex injuries, strongly consider damage control followed bycolostomy/diversion,especiallywhenassociatedwith:

Massivebloodtransfusionrequirement.Ongoinghypotension.Hypoxia(severepulmonaryinjury).Reperfusioninjury(vascularinjury).Multipleotherinjuries.High-velocityinjuries.Extensivelocaltissuedamage.Distalcolon(ie,distalsigmoidandrectal)injuriesshouldberesectedand ostomy formed due to the high incidence of leak fromanastomosis.

Potential breakdown of a repair or anastomosis is high in the setting ofconcomitantpancreaticinjury.Damagecontroltechniqueforcoloninjury:

Controlcontaminationwithligation/staplingofbowel.ResuscitationintheICU.Creationofastomaduringthedefinitivereconstruction.Intestinal continuity shouldbe restoredorostomyperformedwithin72hoursoforiginaldamagecontrolprocedure.

Clearlydocumenttreatmentforoptimalfollowupthroughoutrolesofcare.Atthetimeofformation,acolostomyshouldbematured.

RectalInjuries

Rectalinjuriescanbedifficulttodiagnoseunlessverydramatic.Anyquestionofan injury raised by proximity of another injury, rectal examination, or plainabdominal film radiographyMANDATES proctoscopy. Gentle distal washoutwith dilute Betadine solution may be required to be able to perform rigidproctoscopy.

Findingscanbedramaticdisruptionsoftherectalwall,butmorecommonlyare subtle punctuate hemorrhages of the mucosa. All abnormal findingsshouldpromptcorrectiveintervention.

Diversion,Debridement,Distalwashout, andDrainage (the 4D’s ofrectal injury).Diversion is themost importantaspectof rectal injury

management.

Transabdominalsigmoidcolostomyiseasiest.

Iftheinjuryhasnotviolatedtheperitoneum,explorationoftheextraperitonealrectumshouldNOTbedoneatlaparotomyunlessindicatedforanassociatednonbowelinjury.Thisavoidscontaminatingtheabdominalcavitywithstool.

Debridementandclosureofsmall-tomedium-sizedrectalwoundsareunnecessaryinpatientswhohavebeendivertedanddrained.Distal washout may be necessary to assess the injury. Use gentlepressurewhen irrigating tominimizecontaminationof theperirectalspace.Routine use of presacral drains is discouraged unless grosscontamination and infection are present at the time of surgery. Thecreationofaspacetoplacedrainsshouldbeavoided.

Ifneeded,presacraldrainsareplacedthroughtheperineumintotheretrorectalspace(Fig.17-9).

Fig.17-9.Presacraldrain.

Peritonealized rectal injuries are easily accessed transabdominally andshouldberepairedandprotectedwithdiversion.

RetroperitonealInjuriesLeftmedialvisceralrotationmovesthecolon,pancreas,andsmallboweltoexpose the aorta rapidly. Proximal aortic control can be rapidly obtainedwith compression or a clamp on the aorta at the esophageal hiatus, orthroughtheleftchest.Right medial visceral rotation (colon + Kocher maneuver to elevateduodenum)exposesthesubhepaticvenacava.Threezonesoftheretroperitoneum(Fig.17-10):

ZoneI—central,supracolic:exploreforallinjuries.ZoneII—lateral:blunt trauma,avoidexploration ifpossiblebecauseexploration increases the likelihood of opening a stable hematomaand,thus,precipitatingnephrectomy.Exploreforpenetratingtrauma.

Fig.17-10.Threezonesoftheretroperitoneum.

ZoneIII—pelvic:blunttrauma,donotexplore,likelyassociatedwithpelvicfracture.Exploreforpenetratingtrauma.

Gainproximalvascularcontrolbeforeenteringthehematoma.

AbdominalClosureMassive swelling associated with large amounts of blood loss andresuscitation and large injuries may necessitate temporary closures (seeChapter12,DamageControlSurgery).

Avoidclosingthefasciaunderthefollowingcircumstances:

Furtherabdominalproceduresareanticipated.

Entericvisceraleftindiscontinuity.

Damagecontrollaparotomy.

A few penetrating battlefield wounds are isolated, small, and withoutvisceralcontamination,anditisperhapssafetoclosetheskin.Mostarenot,andthesepatientswillbepassedquicklyfromonesurgeontothenext,sotheriskofmissedandcatastrophicinfectionisincreased;theskinshouldnotbeclosed.Retentionsuturesshouldbeconsidered,butshouldbereservedforpatientsundergoingdefinitivesurgicalrepair.Thereisnorolefortheplacementofretention sutures if a patient is going to return to the OR for scheduledrepeatlaparotomy.

ForClinicalPracticeGuidelines,goto

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Chapter18

GenitourinaryTractInjuries

Introduction

Genitourinary injuries constitute approximately 5% of the total injuriesencounteredincombat.Theirtreatmentadherestoestablishedsurgicalprinciplesofhemostasis,debridement,anddrainage.Proper radiographicevaluationpriorto surgery may replace extensive retroperitoneal exploration at the time oflaparotomyinthediagnosisofseriousgenitourinaryinjuries.

Genitourinary wounds, aside from injuries of the external genitalia, aretypicallyassociatedwithseriousvisceralinjury.

RenalInjuriesMostrenalinjuries,exceptforthoseoftherenalpedicle,arenotacutelylife-threatening. Undiagnosed or improperly treated injuries, however, maycausesignificantmorbidity.Although the vast majority of blunt renal injuries will heal uneventfullywith observation and conservative therapy, a significant number of renalinjuries in combat will come from penetrating wounds and requireexploration.

The evaluation of a suspected renal injury is based on the type ofinjuryandphysicalexamination.

Hematuria is usually present in patients with renal trauma, and grosshematuria in the adult patient is concerning for a significant injury.Theabsence of hematuria, however, does not exclude renal trauma. Renalinjury must be suspected in patients who have sustained significantconcurrent injuries, such as multiple rib fractures; vertebral body ortransverse process fractures; crushing injuries of the chest or thorax; orpenetratinginjurytotheflank,chest,orupperabdomen.

BluntTraumaAllpatientswithgrosshematuria(regardlessofinitialSBP)andthosepatientswithmicroscopichematuria,whoseinitialSBPis<90mmHg,shouldundergocontrast-enhancedCTscanif/whentheybecomehemodynamicallystable.

RenalInjuryGrading

RENALINJURYPenetratingrenalinjury

=Abdominalexploration

Grade1:Subcapsularhematoma.Grade2:Smallparenchymallaceration.Grade3:Deeperparenchymallacerationwithoutentryintothecollectingsystem.Grade4:Lacerationintothecollectingsystemwithextravasation;vascularinjurywithcontainedhemorrhage.Grade5:Shatteredkidneyorrenalpedicleavulsion.Hemodynamicallystablepatientscanusuallybemanagedwithoutoperation.Vascularrepairisindicatedforsalvageablekidneyswithrenalarteryorveininjury(seevascularCPGsformoredetails).Ureteralstentmayneedtobeplacedforpersistenturinaryextravasation.

CPGs:ClinicalPracticeGuidelines;SBP:systolicbloodpressure.

Adultpatientswhopresentwithgrosshematuriarequirefurtherevaluationoftheirkidneys.CT provides excellent staging of renal injuries and aids in the decisionwhetherornottoexploretheinjuredkidney.Renaltraumaiscategorizedbytheextentofdamagetothekidney.

Minorinjuries.

Consistofrenalcontusionsorshallowcorticallacerations.

Mostcommonafterblunttraumaandusuallyresolvesafelywithoutrenalexploration.

Majorinjuries.

Consistofdeepcorticallacerations(withorwithouturinaryextravasation),shatteredkidneys,renalvascularpedicleinjuries,ortotalavulsionoftherenalpelvis.

Thereisan80%incidenceofassociatedvisceralinjurieswithmajorrenaltrauma.Mostcaseswillrequirealaparotomyforevaluationandrepairofconcurrentintraperitonealinjuries.

Operativeinterventionincludesdebridementofnonviablerenaltissue(partialnephrectomy),closureofthecollectingsystem,anddrainageoftheretroperitonealarea.

Kidneypreservationshouldbeconsideredifatallpossible,althoughtotalnephrectomymayberequiredfortheseverelydamagedkidneyortheunstablepatient.Anattemptforverificationofthepresenceofcontralateralkidneybypalpationshouldbeattemptedpriortonephrectomy.

Vascular control of the renal pedicle can be obtained prior to opening theperirenal fascia, when control of hemorrhage from the kidney requiresexplorationoftheretroperitoneum.

Operativetechnique.

Totalnephrectomyisimmediatelyindicatedinextensiverenalinjurieswhenthepatient’slifewouldbethreatenedbyattemptedrenalrepair.The preferred approach in these situations is mobilization of thekidneybymedialvisceralrotation.Thisapproachhasbeenshowntobe faster and is associated with less blood loss, compared withattemptingvascularcontroloftherenalpediclepriortoexploration.When partial or complete renal salvage is planned, obtain vascularcontrolfromaperiaorticapproachtotherenalvascularpedicle.

Thesmallintestineisretractedlaterallyandsuperiorly,andtheposteriorperitoneumisincisedovertheaorta.

Fig.18-1.Exposureoftheleftrenalhilum.

Theleftrenalvein,crossinganteriortotheaorta,mustbemobilizedtogaincontrolofeitherrenalartery.

Atraumaticvascularclampsareusedtooccludetheappropriateartery.

Although vascular control in this fashion may provide the safestapproach against renal hemorrhage and reduce the likelihood ofnephrectomy, it is not a commonly performed maneuver by eitherurologistsorgeneralsurgeons.Directreflectionofthecolontoexposethe kidney is feasible (Fig. 18-1). A kidney pedicle clamp should bereadilyavailableforthisapproach.

Damaged renal parenchyma can be locally debrided (Fig. 18-2),excised in a partial nephrectomy (Fig. 18-3), or removed in a totalnephrectomy,dependingonthedegreeofinjuryandtheconditionofthe patient.

Fig.18-2.Stepsinrenaldebridement.

Damagecontrolmanagementmayrequirenephrectomyformajorrenalinjuriesasalife-savingmeasure.

Watertight closure of the collecting system with absorbable suturepreventsthedevelopmentofaurineleak(Fig.18-3b).

Urinarydiversionistypicallyunnecessaryifformalrenalreconstructionisaccomplished.

Forthesakeofexpedienceorinthepresenceofassociatedinjuriesoftheduodenum,pancreas,orlargebowel,diversionmayberequired.

Tubenephrostomy,ureteralstent,orureterostomymaybeutilized.

Fig.18-3.Stepsinpartialnephrectomy.

The reconstructed kidney should be covered by perirenal fat,omentum,orfibrinsealant(seeFig.18-3c).

Aclosed-suctiondrainshouldbeleftinplace.

UreteralInjuries

Ureteral injuries are rare, but are frequently overlooked when notappropriately considered. They are more likely in cases of retroperitonealhematoma and injuries of the fixed portions of the colon, duodenum, andspleen.

Isolated ureteral injuries are rare and usually occur in conjunction withothersignificantinjuries.Theycanrepresentadifficultdiagnosticchallengeinboththepreoperativeandintraoperativesettings.

Hematuriaisfrequentlyabsent.Blast injury to the ureter may produce significant delayedcomplications even when the CT is normal and the ureter appearsvisibly intact.Placementofan indwellingstent is reasonablewhenahigh-velocityorblastinjuryoccursinproximitytotheureter.If a ureteral injury is initially missed and presents in a delayedfashion, urinary diversion with a nephrostomy tube and delayedrepairat3–6monthsisasafeapproach.

Operativetechnique.Intraoperative localization of the ureteral injury is facilitated by IVinjectionofindigocarmine/methyleneblueordirectinjectionintothecollectingsystemunderpressure.Basicprinciplesofrepair.

Minimaldebridementandmobilization.

Primarytension-free,1-cmspatulatedanastomosisusinganinterruptedsingle-layerabsorbablesuture(4–0or5–0)closuretechnique.

Internal(doubleJureteralstent)andexternaldrainage.

Lengtheningmaneuvers.

Ureteralmobilization.

Kidneymobilization.

Psoashitch(Fig.18-4).

Boariflap.

Fig.18-4.Thepsoashitch.

Fig.18-5.Ureteroureterostomy.

Isolaterepairswithomentumorposteriorperitoneum.

Thetypeofrepairisbasedonthefollowing:

Anatomicalsegmentofthetraumatizedureter(upper,middle,andlowerthird).

Extentofsegmentalloss.

Otherassociatedinjuries.

Clinicalstabilityofthepatient.

Upperormiddleureteralinjuries.

Shortsegmentloss/transaction:Performaprimaryureteroureterostomyoverstent(Fig.18-5).

Longsegmentloss:Mayrequireatemporizingtube/cutaneousureterostomywithstentplacementorureteralligationwithtubenephrostomy.

Lowerureteralinjuries.

Whentheinjuryoccursnearthebladder,aureteroneocystostomyshouldbeperformed(Fig.18-6).Thisistypicallycompletedbyfixingthebladdertothefascialcoveringofthepsoasmuscleusingpermanentsuture,suchas2.0or3.0PROLENE.Atransversecystotomyassistsinelongatingthebladdertothatlocationandfacilitatestheconstructionofatension-freeanastomosis.

Fig.18-6.Ureteroneocystostomy.

Whenadistalureteralinjuryisassociatedwitharectalinjury,ureteralreimplantationisnotrecommended;temporarydiversionshouldbeperformed.

Ureteralinjuriesinthecombatsettingmaybebestmanagedwithtemporarytube drainage with a small feeding tube or ureteral stent, followed bydelayedreconstruction.

BladderInjuries

Bladder wounds should be considered in patients with lower abdominalgunshot wounds, pelvic fractures with gross hematuria, or those patientsunabletovoidfollowingabdominalorpelvictrauma.

Bladder disruptions can occur on the intraperitoneal or extraperitonealsurface of the bladder. The location may change the symptoms,complications,andmanagementofthisinjury.Afterensuringurethralintegrityinappropriatecases(seeUrethralInjuries,p. 286), evaluation of the bladder is performed radiographically with acystogram.

Cystographyisperformedusingathree-filmtechnique:scoutorplainfilm KUB concentrating on the pelvis, full-bladder radiograph after

retrograde filling of the bladder with contrast, and a postdrainageradiograph.Technique:Fill thebladderbygravitywithaurethralcatheterusingradiopaquecontrastmediumelevated20–30cmabovetheleveloftheabdomen.At least 300 cc (5–7 cc/kg in children) are required for anadequatestudy.Takeafull-bladderradiograph.Drain the bladder using the catheter and take a postdrainageradiograph. Small extraperitoneal areas of extravasation may beapparent only on the postevacuation film. CT cystogram is thepreferredstudywhenavailable.

Operativetechnique.Intraperitonealinjuries.

Cystographyrevealscontrastmediuminterspersedbetweenloopsofbowel.

Managementconsistsofimmediateexploration,multilayerrepairoftheinjurywithabsorbablesuture,suprapubictubecystostomy,anddrainageoftheperivesicalextraperitonealspace.Consideropeningthebladdertoallowmorethoroughinspectionforinjuriesandrepairbladderthroughcystotomy.

Extraperitonealinjuries.

Bladderlacerationismostoftentheresultoflacerationbybonyfragmentsfromapelvicfracture.

Cystographyrevealsadense,flame-likeextravasationofcontrastmediuminthepelvisonthepostevacuationfilm.

Thebladderusuallyhealswith10–14daysofFoleycatheterdrainagewithouttheneedforprimaryrepair.Iftheurineisclear,catheterdrainagealoneispreferredfortreatmentofmostextraperitonealruptures.

Incasesofabdominalexplorationforotherinjuries,primaryrepairanddrainagearenecessaryiftheextraperitonealspaceisentered.Repaircanbecompletedfrominsidethebladderthroughacystotomytoavoiddisturbinganypelvichematoma.Patientswithconcurrentrectalinjuriesshouldbemanagedmoreaggressivelyandmaybenefitfromhematomaevacuationandprimarybladderrepair.

UrethralInjuries

Aurethral injuryshouldbesuspectedinpatientswithascrotalhematoma,blood at the meatus, or a floating/high-riding prostate. Catheterization iscontraindicated until urethral integrity is confirmed by retrogradeurethrography.

Retrograde urethrography is performed to evaluate the anatomy of theurethra.

Takeobliqueradiographsofthepelvistoavoid“end-on”imagingthatobscuresthebulbarurethra.Inserttheendofasterilecathetertipsyringe(60cc)intotheurethralmeatuswhilegraspingtheglanstopreventleakage.Alternately,insertan unlubricated Foley catheter into the fossa navicularis(approximately3cm)andinflatetheballoonwith3ccofwater.Gently instill 15–20 cc of water-soluble contrast. The radiograph istakenduringinjection.Contrastmustbeseenflowingintothebladdertocleartheproximalurethra of injury. Posterior urethral injuries seen in pelvic fracturesmaybemissedotherwise.Ifnoinjuryisidentified,carefullyplaceaFoleycatheter.

If anydifficulty inpassing the catheter is encountered, theurethra shouldnot be instrumented, and a suprapubic tube cystostomy should beperformed.

Operativetechnique.Theurethraisdividedintoanteriorandposterior(prostatic)segmentsbytheurogenitaldiaphragm.

Anteriorurethralinjuriesmayresultfromblunttrauma,suchasresultsfromfallswhenastrideanobject(straddle)orfrompenetratinginjuries.

Blunttraumaresultinginminornondisruptiveurethralinjuriesmaybemanagedbygentleinsertionofa16FrFoleycatheterfor7–10days.

Penetratingwoundsshouldbemanagedbyexplorationandjudiciousdebridement.

Small,cleanlacerationsmayberepairedprimarilybyreapproximationoftheurethraledgesusinginterrupted4-0chromicsuture.

Donotmobilizetheentireurethraforaprimaryanastomosis,becausetheshortenedurethrallengthinthependulousurethramayproduceventralchordeeandananastomosisundertension.

Instead,marsupializetheinjuredurethralsegmentbysuturingtheskinedgestothecutedgesoftheurethra.Marsupializationshouldbeperformeduntilhealthyurethraisencounteredbothproximallyanddistally.Closureofthemarsupializedurethraissubsequentlyperformedat6monthstoreestablishurethralcontinuity.

Posteriorurethraldisruptioncommonlyoccursfollowingpelvicfractureinjuries.

Rectalexaminationrevealstheprostatetohavebeenavulsedattheapex.

Improvedcontinenceandpotencyratesareattainedwhensuprapubictubecystostomyisusedastheinitialmanagement.

Suprapubicurinarydiversionismaintainedfor10–14days,andurethralintegrityisconfirmedradiographicallypriortoremovalofthesuprapubictube.

Withexpectantobservation,virtuallyalltheseinjurieswillhealwithanobliterativeprostatomembranousurethralstricture,whichcanberepairedsecondarilyin3–6monthsafterreabsorptionofthepelvichematoma.

Initialexplorationofthepelvichematomaisstrictlyreservedforpatientswithconcomitantbladderneckorrectalinjury.

ExternalGenitaliaInjuries

(SeeChapter19,GynecologicalTraumaandEmergencies)

Management of wounds to the penis, scrotum, testes, or spermatic cordshould be as conservative as possible, and consists of hemorrhage control,debridement,andearlyrepairtopreventdeformity.

InjuriestothepenisthatdisruptBuck’sfasciashouldbesuturedtopreventfurther bleeding and avoid future penile curvature with erection. Whenextensive penile skin is lost, then cover exposed corpora with remainingskinandsterilemoistdressing.The scrotum is highly vascularized, and extensive debridement is usuallynotnecessaryforscrotalwounds.

Most penetrating scrotal injuries should be explored to evaluate thetesticleforinjuryandreducetheriskofhematomaformation.Mostpartialscrotalavulsionsarebesttreatedbyprimaryclosurewithabsorbable3-0suturesintwolayers.Primary closure is selected for patients without associated life-threatening injurieswho sustained injury less than 8 hours prior. APenrosedrainorsmallcloseddraincanbeplacedtoreducehematomaformation.

It is essential,when dealingwith testicularwounds, to conserve asmuchtissueaspossible.

Herniated parenchymal tissues should be debrided, and the tunicaalbugineaclosedbyabsorbablemattresssutures.Thetesticleisplacedinthescrotumorwrappedinmoistgauze.A testicle should never be resected unless it is hopelessly damaged

anditsbloodsupplydestroyed.ForClinicalPracticeGuidelines,goto

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Chapter19

GynecologicalTraumaandEmergencies

Introduction

Thecurrentactivedutypopulation consistsof 14%women,manyofwhomaresubject to thesamerisksofcombat injuryas theirmalecolleagues.Thischapterdeals with OB/GYN emergencies that may present to a deployed medicaltreatmentfacility,particularlyinmilitaryoperationsotherthanwar.

GynecologicalTrauma

VulvaVulvarinjuriesincludelacerationsandhematomas.

Lacerationsthataresuperficial,clean,andlessthan6hoursoldcanbeprimarily closed with absorbable suture. Debridement of obviouslydevitalizedtissueisrecommended.

Deeplacerationsshouldbeexaminedandexploredtoruleouturethral,anal,rectalmucosa,orpericlitoralinjuries.

Placingaurethralcatheterwillassistindetermininginjury.Iffound,single-layerclosurewithfine(4-0orsmaller),absorbablesutures,leavingthecatheterinplace,isrecommended.Rectalandpericlitoralinjuriesareclosedinasimilarfashion.

Anallacerationsshouldberepairedbyapproximatingthecutendsoftheanalsphincterwithsize0or1absorbablesuture.Considerationfordiversionoffecalstreamshouldbeincludedinthesettingofanorectalinjury.

Antibiotics(second-generationcephalosporin)arerecommendedwithcontaminatedwounds.

Vulvar trauma may cause infrafascial (below the pelvic diaphragm)hematoma.

Becausethedeeperlayerofsubcutaneousvulvarfasciaisnotattachedanteriorly to the pubic rami, hematoma can spread freely into theanteriorabdominalwall.Mostvulvarhematomasaretreatedconservatively.External compression and ice packs should be applied untilhemostasisisensuredbyserialexaminationofthevulva,vagina,andrectum.

Hematoma may preclude adequate urination, and an indwellingcathetermayneedtobeplaced.Largehematomasmayneedtobeincisedandbleedingvesselsligated(usuallyvenous)toavoidskinnecrosis.Signs of shock in associationwith a decreasinghematocrit shouldpromptconsiderationofanextraperitonealexpansion.UltrasoundorCTisusefulfordetectingextraperitonealexpansionnotdiagnosedbyclinicalexam.

VaginaTraumatothevaginacancauselacerations,andlesscommonly,suprafascial(abovethepelvicdiaphragm)hematoma.Vaginal traumahasbeenreported inapproximately3.5%ofwomenwithtraumatic pelvic fractures. Concomitant urological trauma, most ofteninvolvingthebladderand/orurethra,hasbeendescribedinabout30%ofpatientswithvaginaltrauma.Thoroughinspectionandpalpationofthevaginaandrectovaginalexamarenecessary to detect vaginal trauma and to determine the need for furtherurologicalevaluation/imaging.Duetopelvicinstability(infracturecases)orpain,examinationundersedationoranesthesiamaybenecessary.Patientswithvaginallacerationstypicallypresentwithbleeding,sometimesprofusely,fromthewell-vascularizedvagina.Lacerations are repaired using the guidelines given previously for vulvarlacerations.Vaginalhematomaisusuallyaccompaniedbysevererectalpressureandisdiagnosed by palpation of a firm, tender mass bulging into the lateralvagina. Vaginal hematoma should be treated by incision, evacuation,ligation,andpacking.Unrecognizedvaginaltraumacanresultindyspareunia,pelvicabscess,andfistulaformation.

Uterus/CervixTrauma to the uterus and cervix is most commonly found in associationwith pregnancy, but may be seen as a result of penetrating vaginal orabdominaltrauma.Noninfected simple cervical lacerations should be repaired to optimizerestoration of normal anatomy (and possibly decrease the risk of cervicalincompetence or stenosis with dysmenorrhea from poor healing).Absorbablesize0gradesuturecanbeused.Acutepenetratingtraumainvolvingtheuterinefundususuallycauseslittlebleeding and can bemanaged expectantlywithout repair. Damage to theuterinewallwithbleedingcanberepairedwithsize0absorbablesuture.Trauma involving the lateral wall of the uterus may cause significantbleeding, but can usually be controlled by successive ligation of theascendinganddescendingbranchesoftheuterinearteryasdescribedinthe

obstetricalsectionUterineAtony.

Hemorrhagenotrespondingtoligation,orextensivemutilatingdamagetothecervixoruterus,shouldbetreatedbyhysterectomy.

Prophylacticantibioticsshouldbegiven.

AdnexaFallopiantubes.

Damage to the wall of the fallopian tube by ruptured ectopicpregnancy or penetrating abdominal trauma should be treated bysalpingectomy, if there is significant damage to the tube, due to theriskofsubsequentorrecurrentectopicpregnancyifleftinsitu.Ifthedamage is equivalent to a linear salpingotomy, achieve hemostasis,thenallowhealingbysecondaryintention.Themesosalpinxisligatedorcauterized,thenthetubeisligatedandcutatitsconnectionwiththeuterinefundus.

BasicStepsforPerforminganEmergentTotalAbdominalHysterectomy

Ligate/cauterizeroundligaments(Fig.19-1).Incise anterior leaves of broad ligaments bilaterally, thencontinueacrossthemidlinetoincisethevesicouterinefold.Mobilize bladder downward by blunt dissection (and sharpdissection if necessary) from the lower uterine segment andcervix.*To retain adnexa, clamp/cut/ligate utero-ovarian ligamentsand fallopian tubes near their connections to the uterinefundus(Fig.19-2).Adnexashouldberetainedunlessthereisanindicationforremoval.To remove adnexa with the uterus, clamp/cut/ligateinfundibulopelvic ligaments after making windows in theposteriorleavesofthebroadligamentsabovetheureters.Incise posterior peritoneum to mobilize adnexa either awayfrom (if being retained) or toward (if being removed) theuterus.Inciseperitoneumoverlyingrectovaginalspace,thenmobilizerectum downward and away from the posterior vagina bybluntdissection(Fig.19-3).*Clamp/cut/ligate uterine arteries along the lateral surface oftheuterusattheuterocervicaljunction,stayingwithin1cmoftheuterustoavoiddamagingureters.Clamp/cut/ligate the remainder of the cardinal ligaments,paracervical tissue, and uterosacral ligaments by takingsuccessive inferior bites until the cervicovaginal junction is

reached; each bite should be placed medial to the previousbitetoavoidinjuringtheureterandbladder.Cross-clampthevaginabelowthecervix.Transect vagina, removing uterus (and attached adnexa, ifapplicable).Suture vaginal cuff closed, ensuring that the bladder is notincorporated.

_________________*Incaseofdenseadhesionsbetweenthecervixandbladderorrectuminanemergentsetting,orongoinghemorrhagewithpoorvisualization,supracervicalhysterectomycanbeperformed.Aftermobilizingthebladderandrectumfromtheuterusandligatinguterinearteries,theuterinefundusistransectedfromthecervixwithaknife.Thecervixisthenoversewnwithabaseballstitch,stayingmedialtotheligateduterinearteries.

Fig.19-1.Abdominalhysterectomy—anteriorview.

Unruptured ampullary/isthmic ectopic pregnancy can be treated bylinearsalpingotomy,withextractionoftheectopicgestation.Thetubalincisionisleftopentohealbysecondaryintention.An unruptured or ruptured corneal/interstitial ectopic pregnancyrequireswedgeresectionoftheuterinecornuwithsalpingectomy.An ectopic pregnancy spontaneously aborted into the abdominalcavity through the endof the tube shouldbe removed,but the tubemaybeleftinsituifhemostasisisattained.

Ovaries.

Fig.19-2.Abdominalhysterectomy—adnexalview.

Fig.19-3.Abdominalhysterectomy—posteriorview.

Arupturedovariancystshouldbetreatedviacystectomybyshellingthecystwalloutoftheovary,thencauterizingorligatinganybleedingvessels,usuallyatthebaseofthecyst.Torsion of an ovarian mass is first treated by assessing the ovary.Untwist the ovary and or fallopian tube. If it appears healthy, withsome continuing blood supply, it can be left in situ. If the ovarycontains a large (>4 cm), simple-appearing cyst, the cyst can bedrainedand the cystwall removed. Interrupted suturesusing a finemonofilament or electrocautery can be used to obtain hemostasis. Ifthe ovary appears dark and dusky after untwisting, perform asalpingo-oophorectomy by ligating the infundibulopelvic ligamentfirst(afteridentifyingtheureter),thentheutero-ovarianligamentandfallopiantube.Hemorrhage from an infundibulopelvic ligament, as a result ofpenetrating abdominal trauma, is best treated by ligation withsalpingo-oophorectomy.

RetroperitonealHematomaLaceration of an arterial branch of the hypogastric artery can cause a

retroperitonealhematoma.A large amount of blood may collect in the broad ligament with fewsymptoms. Dissection of the hematoma can extend up to the level of therenalvessels.Thehematomamaybediscoveredduringemergencysurgeryfor trauma or during reoperation or postpelvic surgery, or suspected bysignsofshocksuggestinginternalbleeding.Retroperitonealhematomacanbetreatedbyhypogastricarteryligationontheaffectedside.Bilateralhypogastricarteryligationmaybenecessaryforhemostasis.Theuterus,tubes,andovariesmaybeleftinsituifviableandwithoutotherindicationforremoval.

Gynecological/ObstetricalEmergenciesAcutevaginalhemorrhageunrelatedtotrauma.

Brightredvaginalbleedingfillingmorethanonelargeperinealpadper hour is considered vaginal hemorrhage. A pregnancy test andpelvicexamdirectinitialtherapy.

Ifthepatientisnotpregnant,hormonalmanagementwith25mgIVPREMARINor50µgestrogen-containingoralbirthcontrolpillsshouldbegivenevery6hours.

Ifbleedingrespondstohormonalmanagement,oralbirthcontrolpillsshouldbecontinuedqidfor5–7days,whilemoredefinitivediagnosisandmanagementplansaremade.

Ifbleedinghasnotdecreasedsignificantlywithin24hours,dilatationandcurettagearereasonable.Ifheavybleedingcontinues,imagingstudiesandpossiblycoagulationstudieswillbeneededtohelpdirectfurthertherapy.

Inthepregnantpatient,heavybleedingfromthecervicaloswithuterinesize<20weeks(fundusat/orbelowthelevelofpatient’sumbilicus)suggestsspontaneousabortion.Dilatationandsuctioncurettageshouldbeperformed.

Ectopicpregnancyuncommonlypresentswithacutehemorrhage,butshouldbeconsideredifthepatienthasanacuteabdomenorifscanttissueisobtainedoncurettage.

Inapregnantpatientwithuterinesizeconsistentwithathirdtrimestergestation(>4cmabovetheumbilicusinasingletonpregnancy),vaginalhemorrhageisusuallyanindicationofplacentalabruptionorplacentaprevia.

Emergentcesareansectionwillbenecessaryiftheuterinehemorrhagedoesnotspontaneouslyresolvewithinseveralminutes.

Afterdeliveryofthefetusandplacenta,persistenthemorrhage

unresponsivetomoreconservativemeasuresmayrequirehysterectomy(seeEmergencyCesareanSectionandUterineAtony).

Pregnantpatients(mothers)withacutevaginalhemorrhagewhohaveRh–bloodtype,oriftheirRhstatusisunknown,shouldbegivenRhoGAM300µgIM.

Ahemorrhagingmass in the vagina ismost likely cervical cancer.Thevaginashouldbepackedtotamponadethebleedingafterplacingaurethral catheter.Placingsutures isgenerally futileandmaymakethebleedingworse.

PrecipitousVaginalDeliveryPreparation.

Suppliesneededforthedelivery,includepovidone-iodinesponges,a10-ccsyringe,lidocaine,twoKellyclamps,ringforceps,drytowels,abulbsyringe,andscissors.Themothershouldbeplacedonherleftsideforlabor.The fetal heart rate should bedetermined every 15minutesprior topushing and following each contraction during the pushing phaseusingavascularDoppler.Normalfetalheartrateisbetween120–160beatsperminute.Theheartrateoftendropswiththecontraction,butshouldrecovertonormalpriortothenextcontraction.

Ifthefetalheartratedropsbelow100andstayslowformorethan2minutes,acesareansectionshouldbeconsidered.

When the patient presents, the cervix should be examined todetermine dilation and fetal position. For the woman to beginpushing, the cervix should be completely dilated (10 cm), and nocervixshouldbefeltoneithersideofthefetalhead.Ifthebaby’sheadisnotpresenting,movetocesareansectionimmediately.Ifthereisanyquestion,andultrasoundisavailable, itshouldbeusedtodeterminethepresentation.

Delivery.Once thepatientbeginspushing, flex thehips tooptimallyopen thepelvis. The patientmay be on her back or tilted slightly to the left.Assistants should support the legs during pushing and relax thembetweencontractions.Clean the perineum with sterile Betadine solution. If this is thepatient’s first delivery, the perineum should be anesthetized withlidocaine in case an episiotomy isneeded.There is little support forprophylacticepisiotomy,butmaybenecessaryif thefetusis largeortearingisanticipated.Thefetalheaddeliversbyextension.Pushingupwardonthefetalchinthrough the perineum can assist this process. Additionally, it is

extremely important to control the rate of delivery of theheadwiththeoppositehand.If an episiotomy isneeded, it shouldbe cut in theposteriormidlinefromthevaginalopeningapproximately½thelengthoftheperineumandextendabout2–3cmintothevagina.Afterdeliveryof thehead, themouthandnose shouldbe suctionedand theneckpalpated for evidenceof anuchal cord. Ifpresent, thisshouldbe reducedby looping itover the fetalhead,orby clampingtwiceandcuttingifitwillnotreduce.Next,theoperator’shandsareplacedalongtheparietalbones,andthepatient is asked to push again to allow delivery of the anteriorshoulder. Gentle downward traction should allow the shoulder toclear the pubis, and the fetus should bedirected anteriorly to allowdelivery of the posterior shoulder. The remainder of the body willnormallyfollowrapidly.Wrapinfantindrytowels.Oncethe fetusdelivers, thecordshouldbedoublyclampedandcut.Theplacentausuallydeliverswithin15minutesofdelivery,butmaytakeupto60minutes.Deliveryoftheplacentaisheraldedbyuterinefundalelevation,lengtheningofthecord,andagushofblood.Whilewaiting,gentlepressuremaybeplacedonthecord;however,vigorousuterinemassageandexcessivetractioncanleadtocomplications.Followingdeliveryoftheplacenta,thepatientshouldbestartedonaninfusion of lactated Ringer’s with 20 units of oxytocin (Pitocin).Oxytocin canalsobegiven IM if there isno IVaccess. If there isnooxytocin available, alternatives are administering methylergonovinemaleate(Methergine)0.2mgIMorallowingthepatienttobreastfeedthe infant. The placenta should be inspected for evidence offragmentationthatcanindicateretainedproductsofconception.

Inspectionandrepair.Following delivery of the placenta, the vagina and cervix should beinspectedforlacerations.Downwarddigitalpressureontheposteriorvaginaandfundalpressure(byanassistant,ifavailable)willfacilitatevisualization of the cervix.A ring forceps is thenused to grasp andvisualizetheentirecervix.Thevaginashouldbeinspected,withspecialattentiontotheposteriorfornix.Theperineumandperiurethralareasshouldalsobeinspected.Vaginalandcervicallacerationsmayberepairedwith3-0VICRYLoranequivalentsutureinrunningorinterruptedlayers.Iftheanalsphincterislacerated,itshouldbereapproximatedwith2-0absorbableinterruptedsingleorfigure-of-eightsutures.If the tear involves the rectum, the rectal-vaginal septum should berepaired with interrupted sutures of 3-0 VICRYL. A second layerimbricatingtheunderlyingtissuewilldecreasetheriskofbreakdown.Care shouldbe taken topreserveaseptic technique. If a large tear is

noted,asaddleblockorspinalanestheticmaybenecessary.Patientswithaperiurethraltearmayrequireurethralcatheterization.In addition to lacerations, hematoma in the vulva, vagina, orretroperitoneum may occur. See Gynecological Trauma formanagement.

EmergencyCesareanSectionIndications.

Fetal heart rate drops below 100 and stays down for more than 2minutes.Acute uterine hemorrhage persisting for more than a few minutes(suggestiveofplacentalabruptionorprevia).Breechortransversefetalpresentation.

ThepatientshouldbeplacedinthelefttiltpositionwithanIVbagortoweldisplacingtheuterustotheleft.Sheshouldundergoaquickprepfromjustbelowthebreaststothemidthigh.Amajorabdominalequipmentsetshouldhavemostoftheinstrumentsthatyouwillneed.BasicstepstoperforminganemergencyC-section(Fig.19-4).

Entertheabdomenthroughthelowermidline.Identifyandincisetheperitonealreflectionofthebladdertransverselyandcreateabladderflaptoretractthebladderoutofthefield.Using a scalpel, carefully incise the uterus transversely across theloweruterinesegment(wheretheuterinewallthins).Once the amniotic membranes are visible or opened, extend theincisionlaterally,eitherbluntlyorbycarefullyusingbandagescissors.Avoid the uterine vessels laterally. If necessary, the incision can beextendedatoneorbothofitslateralmarginsinaJ-fashionbyverticalincision.Elevate the presenting fetal part into the incision, with an assistantprovidingfundalpressure.Upondeliveryofthefetus,suctionthenoseandmouthandclampandcutthecord.Handtheinfantoffforcare.Direct the anesthetist to administer 2 grams of Cefazolin (ANCEF)oncethecordisclamped.Allowtheplacentatodeliverbyprovidinggentletractiononthecordandperforminguterinemassage.Beginoxytocin,ifavailable,aspreviouslydescribed.Usingasponge,cleantheinsideoftheuterus,andvigorouslymassagethefundustohelptheuteruscontract.Quickly close the incision with 0 VICRYL. A single layer (running,locking)isadequate, ifhemostatic, fortransverseincisions.Takecareto avoid the lateral vessels. If the incision has a vertical extension,closeitintwoorthreelayers.Oncehemostasisisensured,closethefasciaandabdomenintheusualfashion.

Fig.19-4.EmergencyC-section.(a)Uterineincision.(b)Deliveryoffetus.(c)Deliveredinfantonabdomen.(d)Uterinefundusexteriorized.

Intherarecaseofcontinueduterinehemorrhage,evaluateandtreatasoutlinedinUterineAtony.

UterineAtonyThe majority of postpartum hemorrhage is secondary to uterine atony(failureofuterinecontracture).

When the uterus fails to contract following delivery of the placenta,bleedingmaybetorrentialandfatal.

Initialmanagementshouldincludemanualuterineexplorationforretainedplacenta.Withoutanesthesia, thisprocedure ispainful.Anopenedspongeis placed around the examiner’s fingers. Place the opposite hand on thepatient’suterinefundusandapplydownwardpressure.Gentlyguideyourfingers through the open cervix and palpate for retained placenta. Theinsideoftheuterusshouldfeelsmooth,andtheretainedplacentawillfeellikeasoftmassoftissue.Thismayberemovedmanuallyorbyusingalargecuretteifavailable.

If no tissue is encountered, use both hands to apply vigorous uterinemassagetoimprovetheuterinetone.Medicationsshouldalsobeusedifavailable.OxytocinmaybegivenbyIVbolususing40unitsin1,000cc,orupto10unitsIM,butneverbyIVpush.Althoughunlikelytobeavailable,othermedicationsthatcanbeconsideredareMethergine,Dinoprostone(Prostin),andMisoprostol(Cytotec).Ifnomedicationisavailable,thepatientshouldbeencouragedtobreastfeedthe infant or to do nipple stimulation to increase endogenous oxytocinrelease.

If conservative measures fail to arrest the postpartum hemorrhage,laparotomy (if the hemorrhage is occurring postvaginal delivery)shouldbeperformed.

Intraoperativemassageoftheuterinefundusmaybetried.Ifthemassagefailstoimproveuterinetone,theuterinearteriesshouldbeligated in a stepwise fashion. Begin with the ascending branch at thejunctionoftheupperandloweruterinesegment.Using0orno.1chromic,place a stitch through themyometriummedial to the artery from front toback. The stitch is then brought out through the adjacent broad ligamentand tied. If bilateral ligation of the ascending branch does not controlbleeding, the descending branch should be ligated at the level of theuterosacral ligament. If this fails, consider bilateral hypogastric arteryligation. If this fails, proceed to hysterectomy as outlined in thegynecologicalportionofthischapter.

NeonatalResuscitationImmediatelyfollowingdelivery,everyinfantshouldbeassessedforneedfor resuscitation. Equipment that may be needed includes warm towels,bulb syringe, stethoscope, flow-inflating or self-inflating bagwith oxygensource, laryngoscope and blade, suction catheter, and endotracheal tube.The two medications that may be needed are epinephrine 1:10,000 andNaloxone(Narcan)0.4mg/mL.Nearly90%oftermbabiesaredeliveredwithoutriskfactorsandwithclearfluid,requiringthattheyonlybedried,suctioned,andobserved.

Ifthebabyis<36weeks,orifthereismeconiuminthefluidatdelivery,thebabywillneedtobeobservedmoreclosely.

In the first 30 seconds after delivery, dry and stimulate the baby,positionittoopentheairway,andgivefreeflowoxygenifthecolorispoor.At30seconds,evaluatetheheartrate.If it is<100,begintoprovidepositivepressureventilation.After30secondsofventilation,rechecktheheartrate.Ifitis<60,thenchestcompressionsshouldbestarted.After30secondsofchestcompressions,againreevaluate.Iftheheartrateremains<60,youshouldadministerepinephrine.Epinephrinecan

begiven either through theumbilical vein or the endotracheal tube.Thelevelofexperienceoftheteampresentshoulddictatewhichrouteshouldbeused.Thedoseis0.1–0.3mL/kgofthe1:10,000solution.Iftheheartraterisesover100,stopthepositivepressureventilations,butcontinuetoprovidefreeflowoxygen.Ifthemotherhasbeengivena dose of narcotics in the 4 hours prior to delivery, and positivepressureventilationhasresultedinanormalheartrateandcolorbutpoor respiratory effort, then Naloxone is indicated. AdministerNaloxonebyIV,IM,orendotrachealrouteatadosageof0.1mg/kg.

Ifatanytimeduringresuscitationtheheartrategoesabove100—withgoodrespiratoryeffort, tone,andcolor—thebabymaybemovedtoobservationstatus.

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Chapter20

WoundsandInjuriesoftheSpinalColumnandCord

Introduction

Combat injuries of the spinal column, with or without associated spinal cordinjury,differfromthoseencounteredincivilianpractice.Theseinjuriesareoftenopen,contaminated,andusuallyassociatedwithotherorganinjuries.

Following the ABCs (airway, breathing, circulation) of Advanced Trauma LifeSupport,managementprinciplesinclude:

Initialspinestabilizationtopreventneurologicaldeterioration.Diagnosis.Definitivespinalstabilization.Functionalrecovery.

Incompleteinjuries,thelikelihoodofneurologicalrecoveryisminimalandisnotinfluencedbyemergentsurgicalintervention.Incompleteinjurieswithneurological deterioration, however, may benefit from emergent surgicaldecompression. One must assume, until spinal shock has abated, thatpatients with a significant spinal column injury have the potential for aconcomitant neurological deficit, and should be treated and transportedaccordingly.

Classification

Four discriminators must be considered in the classification and treatment ofspinalinjuries.

Istheinjuryopenorclosed?Neurologicalstatus:completevsincompletevsintact.

Complete injury demonstrates no neurological function below thelevelof injuryafter theperiodofspinalshock(usually48–72hours,evidencedbythereturnofthebulbocavernosusreflex).

Locationoftheinjury:cervical,thoracic,lumbar,orsacral.Degreeofbonyandligamentousdisruption:stablevsunstable.

PathophysiologyofInjurytotheSpinalCordInjury to the spinal cord is the result of both primary and secondarymechanisms.

PRIMARY: The initialmechanical injurydue to local deformation andenergytransmission(primaryinjurycascade).Thisphaseoftheinjury

ismostoftenunpreventable.

High-velocitymissilewoundsintheparavertebralareacancauseinjuriesevenwithoutdirecttrauma.Stretchingofthetissuearoundthemissile’spathduringformationofthetemporarycavity,orfragmentationoftheprojectileandboneresultinginsecondarymissiles,causesinjurywithoutanydirectdestructionofthespinalcolumn.

The destructive nature of high-velocity wounds explains thefutility of decompressive laminectomy in the management ofthesewounds.

SECONDARY: The cascade of biochemical and cellular processesinitiatedbytheprimaryprocessthatcausescellulardamageandevencelldeath(secondaryinjurycascade).

Critical care of spinal cord injury patients includes attempts tominimize secondary injury from hypoxia, hypotension,hyperthermia,andedema.

MechanicalIntegrityoftheVertebralColumn

Thevertebralcolumniscomposedofthreestructuralcolumns(Table20-1):

Anterior.Middle.Posterior.

Table20-1.SupportoftheSpinalColumnColumn BonyElements Soft-TissueElements

Anterior Anteriortwo-thirdsofvertebralbodyAnteriorlongitudinalligament

Anteriorannulusfibrosus

MiddlePosteriorone-thirdofvertebralbody

Pedicles

Posteriorlongitudinalligament

Posteriorannulusfibrosus

Posterior

Lamina

Spinousprocesses

Facetjoints

Ligamentumflavum

Interspinousligaments

Injuriesoccurbyeitherdirectpenetratingforcesoracombinationofflexion,axialloading,rotation,anddistractionforces.Instabilitymayoccurfromeitherbluntinjuryofthevertebralcolumnorgunshot/ fragmentation wounds. The incidence of instability issignificantlyhigherinexplosion-relatedinjuries.Cervicalinstabilitybylateralradiograph(mustincludetheC7/T1junction)

issuggestedby:3.5mmorgreatersagittaldisplacementortranslation.Angulationof11°ormoreonthelateralview.Theaccuracyand, therefore, the roleof flexionandextension lateralradiographs to assess for cervical stability are limited in the acuteinjurysetting.Ifcervicalstabilityremainsinquestionfollowinginitialassessment, thesafest courseofaction is toprovideexternalcervicalimmobilizationuntilstabilitycanbedefinitivelyestablished.

CT is very effective in demonstrating spinal morphology and has becomeavailableinsomefieldenvironments.

Instabilitymustbepresumed(andthespinestabilized)inanypatientwith:

Complaintsofasenseofinstability(holdsheadinhands).Vertebralcolumnpain.Tendernessinthemidlineoverthespinousprocesses.Neurologicaldeficit.Alteredmentalstatus.SUSPECTED,butNOTPROVEN,injury.

PatientTransport

On the battlefield, preservation of the life of the casualty andmedic is ofparamountimportance.Inthesecircumstances,EVACUATIONTOAMORESECUREAREA TAKES PRECEDENCEOVER SPINE IMMOBILIZATION.Data do not support the use of cervical collars and spine boards forPENETRATINGspineinjuriesonthebattlefield.

ExtricationCervicalspine.

Theneckshouldneverbehyperextended.Ifanairwayisneeded.

Ifappropriate,attemptendotrachealintubationwithin-lineneckstabilization.

Cricothyroidotomymaybenecessaryifintubationfails.

Theheadshouldbemaintainedinalignmentwiththebody.

Requiresseveralpeople,includingonedesignatedtostabilizetheneck.

Logroll,withthemostexperiencedpersonstabilizingtheneck.A stiff cervical collar and sandbagsprovide stabilizationof theneckduring transport. The head and body should be secured to theextricationdevice.

Thoracicandlumbarspine.Usethelogrollortwo-mancarry.

Thetwo-mancarryalonedoesnotprotectthecervicalspine.EnsureC-spineprotection.

In the absence of a spine board, makeshift litters can be fashionedfromlocalmaterials.

AnatomicalConsiderations

CervicalSpine

Allpotentiallyunstablecervicalspineinjuriesshouldbeimmobilizedinacervicalcollar,unlesshaloimmobilizationisrequired.However,halodevicesshouldnotbeplaceduntilthepatientisevacuatedtoatheaterassetwhereaneurosurgeonororthopaedicspinesurgeonisavailableforhaloplacementandreductionoftheseinjuries.

Indicationsforhalouse:The role of halo immobilization in the acute combat setting is quitelimited. In nonpenetrating trauma to the cervical spine,immobilizationwith a cervical collar or sandbags is preferable untilarrivalatadefinitivetreatmentsite.Shouldtractionbeindicatedforcervicalspineinjuries(eg,facet jointdislocationsorburstfractureswithatenuousneurologicalstatus),theGardner-Wells tongs should be applied and sufficient weight(generally10–20lbs)placedinlinewiththespine(Fig.20-1;Table20-2). If traction is applied, radiographsmust be obtained to be certainthatnoundiagnosedligamentousinjuryhasbeenexacerbatedbytheweight.Donottreatinjuriestotheoccipitocervicalarticulationwithtractionbecausethiscouldresultindisarticulationoftheheadfromthecervicalspine.Theroleofcollarimmobilizationinpenetratinginjuriestothecervicalspine is lesswell established.Soft-tissuecare is compromisedby thecollar’s position and, in general, penetrating injuries coupled withosseousinstabilityshouldbemanagedinGardner-Wellstraction.

ThoracicandLumbarSpineAlthoughthethoracicribcagecontributesconsiderablerotatorystability,itdoesnotprotectcompletelyagainstinjuries.Thevascularsupplyof thespinalcord ismostvulnerablebetweenT4andT6,wherethecanal ismostnarrow.Evenaminordeformitymayresult incord injury.

Fig.20-1.Gardner-Wellstongs.

Themost commonplace for compression injuries is at the thoracolumbarjunction between T10 and L2 in the civilian population.However, a veryhighpreponderanceoflowlumbarburstfractures(L3andbelow)occursinthemilitarypopulation.These injuries are quitedistinct in that thepelvicbrimconnotes“inherent”stabilityforthesefractures.Most burst fractures result from an axial load and occur at thethoracolumbarjunction.Thesefracturesareassociatedwithcompromiseofthe spinal canal and progressive angular deformity. They are oftenassociatedwithsignificantneurologicalinjury.Evaluationforsurgicalstabilizationandspinalcorddecompressionshouldbedonewithadvancedimaging,suchasCTand/orMRI.

Whencomplexwoundsinvolvingthehead,thorax,abdomen,orextremitiescoexistwithvertebralcolumninjuries, lifesavingmeasurestakeprecedenceover the definitive diagnosis andmanagement of spinal column and cordproblems.During these interventions, further injury to the unstable spinemustbepreventedbyappropriateprotectivemeasures.

Table20-2.ApplicationofGardner-WellsTongsSteps Procedure Comment

1

InspectInsertionSite:

1cmsuperiortopininlinewiththeexternalauditorymeatus.

Ruleoutdepressedskullfractureinthisarea.

2 ShaveandPrepPinInsertionSite

InjectLocalAnesthetic:

Inject2–3ccof1%

3Xylocaineorequivalentagent1cmaboveeachearinlinewiththeexternalauditorymeatus.

Mayomitifpatientisunconscious.

4

AdvanceGardner-WellsTongPins:

Insertpinsintoskullbysymmetricallytighteningtheknobs.

Aspring-loadeddeviceinoneofthetwopinswillprotrudewhenthepinsareappropriatelyseated.(Adataplateonthetongsprovidesadditionalinformation.)

5

ApplySkeletalTraction:

Useapulleyfixedtotheheadofthelitterorframetodirecthorizontaltractiontothetongs.

Usethe5-lbrule(ie,5lbsofweightforeachlevelofinjury).Highcervicalfracturesusuallyrequireminimaltractiontoreduce.Monitorwithseriesradiographs.Thetong-pinsiterequiresanteriororposteriorpositioningtoadjustforcervicalspineflexingorextensionasindicated.

6

ElevateHeadofLitter:

Useblockstoprovidebodyweightcountertraction.

Theknotinthecordshouldnotbepermittedtodriftupagainstthepulley.Shouldthisoccur,tractionisnolongerbeingapplied.

7

DecreaseTractionWeight:

Whenradiographsconfirmthatreductionisadequate,decreasetractionto5–15lbs.

Unreducibleorunstablefracturesshouldbemaintainedinmoderatetractionuntilsurgicalintervention.Ifneurologicaldeteriorationoccurs,immediatesurgicalinterventionmustbeconsidered.

8 DailyPinCareCleansetractswithsalineandapplyantibioticointmenttothepinsites.Maintainpinforce(seestep4)bytighteningasnecessarytokeepspring-loadeddeviceintheprotrudedposition.

9

TurnPatientAppropriately:

UseStryker,Foster,orsimilarframeandturnpatientevery4hours.

Wheninitiallyproned,obtainradiographstoensurethatthereductionismaintained.Ifreductionisnotmaintainedwhenthepatientisproned,rotatethepatientonlybetweenthe30°rightandleftquarterpositions.Useofacircleelectricbediscontraindicatedwithinjuriesofthespinalcordorcolumn.

10

IfSatisfactoryAlignmentCannotBeObtained,FurtherWorkupIsNecessary

Considermyelogram,CTscan,tomograms,andneurosurgical/orthopaedicconsultations.

EmergentSurgery

Emergentspinesurgeryforpenetratingorclosedinjuriesofthespinalcordisindicatedonlyinthepresenceofneurologicaldeterioration.

Penetratingspineinjuries.Injuriesassociatedwithahollowviscusshouldundergoappropriate

treatment of the viscus injurywithoutextensive debridement of thespinal injury, followedbyappropriatebroad-spectrumantibiotics for1–2 weeks. Inadequate debridement and irrigation may lead tomeningitis.Removalofafragmentfromthespinalcanalisindicatedforpatientswithneurologicaldeterioration.Inneurologicallystablepatientswithfragmentsinthecervicalcanal,delayingsurgeryfor7–10daysreducesproblemswithduralleakandmakesduralrepairmorestraightforward.Casualties not requiring immediate surgery may be observed withspine immobilization and treated with 3 days of IV antibiotics.Surgicalstabilizationcanbeperformedfollowingevacuation.

GeneralManagementConsiderations

NeurogenicShockTraumaticallyinducedsympathectomywithspinalcordinjury.Symptomsincludebradycardiaandhypotension.Treatment:

Volumeresuscitationtomaintainsystolicbloodpressure>90mmHg.May use phenylephrine (50–300 µg/min) or dopamine (2–10µg/kg/min) to maintain blood pressure. (First treat with fluidresuscitationandoxygenbeforestartingpressorsupport.)

GastrointestinalTractIleusiscommonandrequiresuseofanasogastrictube.Stressulcerpreventionusingmedicalprophylaxis.Bowel training includes a schedule of suppositories andmay be initiatedwithin1weekofinjury.

DeepVeinThrombosisStartmechanicalprophylaxisimmediately.Initiatechemicalprophylaxisafteracutebleedinghasstopped(seeChapter11,CriticalCare).

BladderDysfunctionFailuretodecompressthebladdermayleadtoautonomicdysreflexiaandahypertensivecrisis.Thebladderisemptiedbyintermittentorindwellingcatheterization.Antibioticprophylaxisfortheurinarytractisnotadvised.

DecubitusUlcersSkinbreakdownbeginswithin30minutesintheimmobilizedhypotensivepatient.Forprolonged transport, the casualty shouldbe removed from thehardspineboardandplacedonalitter.Frequentturningandpaddingofprominencesanddiligenceonthepartof

caretakersareessentialtoprotecttheinsensatelimbs.Allbonyprominencesareinspecteddaily.Physicaltherapyisstartedearlytomaintainrangeofmotioninalljointstomakeseatingandperinealcareeasier.

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Chapter21

PelvicInjuries

IntroductionInjuries of the pelvis are an uncommon, but potentially lethal battlefieldinjury.Blunt injuries may be associated with major hemorrhage and earlymortality.Deathwithinthefirst24hoursofinjuryinthesepatientsismostoftenduetohemorrhage.Civilianmortalityrateshaverangedfrom18%to40%.Penetrating injuries to the skeletal pelvis are usually associated withabdominopelvicorganinjury.Key issues in the management of pelvic fractures are to identify if thepatientishemodynamicallystableandifthepelvicfractureismechanicallystable.

If the patient is not hemodynamically stable, it is imperative toidentifyallsitesofhemorrhage,becausepelvicfracturesoftenoccurinconjunctionwithotherlife-threateninginjuries.Appropriate evaluation of the abdomen, chest, and other potentialsitesofinjuryandhemorrhagecannotbeoverstressed.

Additionally, a thorough examination of the pelvis and perineum isrequired to rule out associated injuries to the rectum andgenitourinary/gynecologicalsystems,whichmayrenderthefractureopen.Open injuries require early recognition and prompt treatment to preventhighmortalityduetoearlyhemorrhageandlatesepsis.Themortalityrateofopenpelvicfracturesis>50%.Diagnosis.

Leg-length discrepancy, scrotal or labial swelling/ecchymosis, orabrasionsoverthepelvisraisesuspicionforpelvicringinjury.

Theperineum,rectum,andvaginalvaultmustbeevaluatedforlacerationstoruleoutanopeninjury.Assesspelvic stability by applying aposteriorlydirected force to the iliaccrestsattheleveloftheanteriorsuperioriliacspine.Ifthesymphysisopens>2.5 cm, or the hemipelvis shifts posteriorly, the pelvis is unstable. Thisexamination should be completed only once by the most experiencedprovider available, because additional manipulation can exacerbatehemorrhaging.

Bladder and urethral injuries are suspectedwhen blood is present at

themeatusorintheurine,orwhenaFoleycathetercannotbepassed.Retrogradeurethrogramandcystographyconfirmthediagnosis.

Radiographs (anterior-posterior pelvis and,whenpossible, inlet andoutletviews)confirmthediagnosis.CTdefinesthelocationandextentof injury more accurately, but is not necessary in the immediateevaluationofthesepatients.

BluntInjuriesPatterns and mechanisms are the same as those seen in civilian blunttrauma.

Lateral compression injuries are marked by internal rotation ormidlinedisplacement of the hemipelvis. Bydefinition, these injuriesmaintain an intact pelvic floor and are at least partially stable.Radiographic hallmarks include oblique ramus fractures anteriorlyand vertically congruent sacroiliac joints posteriorly. Closed-headinjuriesareassociatedwith thismechanism.Generally, these injuriesinfrequentlyrequiresignificanttransfusion.Vertical shear injurieshave cephaladdisplacementof thehemipelvisand are mechanically unstable. Radiographic hallmarks include awidened symphysis or vertical ramus fractures anteriorly and avertically disrupted sacroiliac joint posteriorly. These injuries have ahigh incidence of retroperitoneal hematoma formation andconsumptive coagulopathy. These injuries have a predilection forhemorrhage and may require significant transfusion of blood andbloodproductsforresuscitation.Anterior-posterior (openbook) injuriesdemonstrateexternal rotationof the hemipelvis. Radiographic hallmarks include a widenedsymphysis or vertical ramus fractures anteriorly and wide butvertically congruent sacroiliac joint(s) posteriorly. These injuries areassociated with hollow viscus and solid organ injury and life-threatening hemorrhage. These injuries have a predilection forhemorrhage and may require significant transfusion of blood andbloodproductsforresuscitation.

Combinedmechanismscanoccur.

Increasing degrees of displacement in any direction are associated withgreaterriskofhemorrhage.

Anterior-posterior injuries with complete disruption of all sacroiliacligamentsrepresentaninternalhemipelvectomyandhavethegreatestpotentialforhemorrhage.

Immediate pelvic stabilization (pelvic binders, sheets, externalfixation,C-clamp) can control hemorrhage and reducemortality.This is particularly true in an austere environmentwith limitedbloodreplacementproductsandothertreatmentresources.

Treatment.Hemorrhagecontrol.

Whenpelvicfracturescausehemorrhage,thebleedingoccursfromthreemajorsources:arterial,venous,andcancellousbone.Morethan70%ofthehemorrhageassociatedwithbluntpelvictraumacausingpelvicfractureisvenous,andmaybecontrolledwithmaneuversthatreducethepelvicvolumeandstabilizethepelvis.

Volumereduction/mechanicalstabilizationcanbeobtainedby:

Tyingasheetorplacingabinderaroundthepelvisatthelevelofthegreatertrochanters.

Manuallyreducingthepelvisandplacingbeanbagsorsandbagsatthelevelofthetrochanters.

Positioningthepatientinlateraldecubituswiththeaffectedsidedown.

Tyingtheanklestogetherininternalrotationprovidesadditionalvolumereduction.

Pelvicbindersorsheetsarethemostexpeditiouswaytocontrolhemorrhageand provide pain relief through pelvic stabilization and reduction ofintrapelvic volume. External fixators can provide longer term stabilization,butaredifficulttoplaceandhaveahigherincidenceofcomplications.Skinnecrosiscanoccurwithlong-termapplicationofpelvicbindersandsheets.

The other nearly 30% are associated with an arterial source and often requireproceduralinterventions,suchassurgicalpackingand/orembolization.

Angiographyisausefuladjunct,butisnotusuallyavailableinthedeployedenvironment. When available, angiographic exploration with earlyembolization for the hemodynamically unstable patient with intrapelvichemorrhagemaybebeneficial.GiventhatthiscapabilityisrarelyavailableoutsideofaRole3facility,thenextmostbeneficialmaneuver is retroperitonealpackingviaasuprapubicincision.Attempts at opening a retroperitoneal pelvic hematoma (as a result of apelvicfracture)frominsidetheabdomenshouldberesistedatallcostsandattemptedonlyasalastresort.None of these interventions should delay the necessary acute surgicaltreatmentforconcomitanthemorrhagicinjuries.

Openbluntinjuriesrequire:

Immediatehemorrhagecontrolbypacking.

Aggressiveandthoroughdebridement.

Pelvicstabilizationbyexternalfixation.

Divertingcolostomyinthepresenceofwoundsatriskforfecalsoilage.

Definitive internal pelvic stabilization (plates, screws, etc) is doneoutsideofthecombatzone.

Missileandfragmentationwoundscancausepelvicfractures.

Thepelvisusuallyremainsmechanicallystable.Thecolon,smallintestine,rectum,andthegenitourinarytractsmustallbeassessedforassociatedinjury.Majorhemorrhagecanresultfrominjurytotheiliacvessels.

PenetratingInjuriesEvaluation.

Diagnosisofassociatedinjuriesmayrequireexploratorylaparotomy.Fractures should be assessedwith radiographs andCT scans,whenavailable,toruleoutextensionintothehipandacetabulum.

Treatment.Controlhemorrhageandresuscitatewithbloodandbloodproducts.Controlhollowviscusinjury.Thoroughlydebridewoundsandfractures.

For combined hollow viscus and acetabulum/hip joint injuries,the joint is contaminated and must be explored and treated asdescribedinChapter9,Soft-TissueandOpenJointInjuries.

Techniqueofsheetorpelvicbinderapplication.Slide the folded sheet (30–40 cm wide) or binder under the supinepatient,centeredatthelevelofthegreatertrochanters.Withasecondindividualontheoppositesideofthetable,overlaptheends of the sheet (or Velcro straps of the binder) circumferentially,applyingcompressionacrossthepelvis.Secure the sheet in place with large Kelly clamps, or, alternatively,tightenthedrawstringonthebinder.Binderscanbeleftinplacefor24–48hours,butrequirefrequentskinchecksforlongerperiodsofuse.Confirm reduction of the pelviswith an anterior-posterior pelvis X-ray.

Techniqueofpelvicexternalfixatorplacement(Fig.21-1).Preptheiliaccrests.Placea2-cmhorizontalincisionovertheiliaccrest,2–3cmposteriortothe anterior-superior iliac spine.

Fig.21-1.Pelvicexternalfixatorplacement.

Bluntly dissect to the iliac crest, taking care to identify theintermuscularplanebetween the external obliqueand iliacus,whichwilllessenbleeding.Todetermine theangleof thepelvis, first slide aguidepinbetweenthemuscle and the bone along the inner table of the iliac wing nodeeperthan3–4cm.

Failuretoproperlydeterminetheangleoftheiliacwingleadstoinadequatefixationandmaycausesignificantcomplications.

Locatethejunctionofthemiddleandmedialthirdsofthethicknessoftheiliaccrestwiththetipofa5-mmexternalfixatorpin.Parallelingtheguidepin,begindrillingthepinintothecrest.Drill between the inner and outer tables to a depth of about 4 cm,aiminggenerallytowardthegreater trochanter.Onlygentlepressureshouldbeappliedoncethepinthreadshaveengagedtoallowforthepintoguideitselfbetweenthetables.Asecondpinisinserted1–2cmmoreposteriorlyonthecrest.Checkthestabilityofeachpin.Ifunsatisfactory,attemptreinsertionbyaimingbetweenthetables.Placepinsinthecontralateraliliaccrestinthesamemanner.Reduce thepelvisbyapplyingpressureon thepelvis (not thepins!)andconnect theexternal fixatorpinswithbar(s)across theabdomenandpelvistomaintainreduction.

Techniqueforretroperitonealpacking.Prep the abdomen and make an 8-cm midline incision extendingproximally from the level of the symphysis pubis toward theumbilicus.Dividethefasciaoftherectusabdominusinitsmidline,takingcaretoavoidpenetratingtheunderlyingbladder.Retract thebladder toonesidewith theuseofamalleable retractor,

and identify thepelvicbrimbeginningat the levelof the symphysispubisandextendingposteriorly.To the greatest extent possible, quickly identifywhether the bulk ofthe bleeding encountered is venous or arterial in nature. If arterial,considersubsequentembolizationprocedures.Taking care to avoid disruption of anomalous vascular connectionsbetween theobturatorand iliacsystems (coronamortis), identify thepelvicbrimandplace the firstof three laparotomyspongeswith theaid of a sponge stick posteriorly to the level of the sacroiliac joint,belowthelevelofthepelvicbrim(truepelvis).Asecondsponge ispackedat themidportionbelowthepelvicbrim,with the third sponge placed below the bladder anteriorly into thespaceofRetzius.The bladder is retracted to the other side, and the procedure isrepeatedfortheoppositehemipelvis.Therectusfasciaisclosed,withasinglelayerrunningsutureandtheskinclosedwithstaples.Exploratory laparotomy, if required, should follow closure of theretroperitoneal fascia to allow for the continued tamponade of thevesselsintheretroperitoneum.Packingshouldbecarefullyremovedwithin24–48hours.

Technique of pelvic C-clamp placement (Fig. 21-2). (For markedlyunstable injuries—ie, internal hemipelvectomy and shock unresponsivetofluidresuscitation.)

Extend a line along the axis of the femur curving proximally andposteriorlyabovethelevelofthegreatertrochanter,alongthelateralaspectofthepelvis.Extend a second line perpendicular to the floor at the level of theanterior-superior iliac spine so that it intersects the first line.

Fig.21-2.PlacementofapelvicC-clamp.Intersectionoflinesindicatesthecorrectentrypoint.

Preptheareaandmakea2-cmincisionattheintersectionofthetwolinesabove.Dissectwithabluntinstrumenttothelevelofthepelvicgrooveformedbyangulationofthelateralcortexoftheiliacwing(atthemarginbetweenthetrueandfalsepelvis).Insert the first pin with the disengaged arm of the C-clamp to the

grooveontheuninjuredsideofthehemipelvisfirstandimpactgentlywithamallet.Engage the pin on the opposite injured side in a similarmanner bysliding the arms of the clamp together. Further tightening of thethreads can provide definitive compression of the posterior pelvicring.Confirmreductionwithananterior-posteriorpelvisX-ray.

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Chapter22

ExtremityFractures

Introduction

Thischapterdiscussestwotechniquesforsafetransportationofwoundedservicememberswithalongbonefracture:transportationcastsandtemporaryexternalfixation.Bothof thesemethodsareacceptable for initial treatmentofacasualtywhowillbeevacuatedoutof theater.Precise indications forexternal fixatoruseversuscastinghavenotbeenestablished.

Both transportationcastsandexternal fixatorsareacceptablemethods for theinitial management of long bone fractures. In the end, the choice of initialfracture stabilization must be made on a case-by-case basis by the treatingsurgeon.

Ingeneral,indicationsforexternalfixatoruseincludewhenthesofttissuesneedtobeevaluatedwhileenroute,suchaswithavascularinjury;whenotherinjuriesmake use of casting impractical, such aswith a femur fracture and abdominalinjury; orwhen the patients have extensive burns. The advantages of externalfixation are that it allows for soft-tissue access, can be used for polytraumapatients, andhas aminimal impact on thepatient.A splint andbulkydressingmaybeaddedforbettersoft-tissuesupport.

ADVANTAGES of transportation casts are that they preserve the maximumnumberofsurgicaloptions,thesofttissuesarewellsupported,andthecastsarerelativelylowtech.

DISADVANTAGESoftransportationcastsarethattheycoversofttissues,maynot be suitable for polytrauma patients, and are more labor-intensive thanexternalfixators.

Althoughstandardinciviliantraumacenters, intramedullarynailingofmajorlongbone fractures is contraindicated in combat zonehospitals because of avariety of logistical and physiological constraints. Thismethodmay be usedonce apatient reachesRole 4or other sitewheremoredefinitive care canbeprovided. Intramedullary nailing has been performed successfully at Role 3facilities on local nationals after appropriate initial damage control surgeries.However,thisisanexception.Literaturesupportingthispracticehasveryshortfollow-upwithlowpatientfollow-up.Localnationalsurgeonsmustbeabletocare for patients with orthopaedic implants, particularly in the event theybecome infected. Historically, infected intramedullary devices have posed a

significantmanagementproblem.

In this chapter, the term“castingmaterial” is used todescribe eitherplaster orfiberglassforconstructingcasts.Bothareacceptabletousefortransportcasts.

GeneralConsiderationsofWoundManagementInitialmanagement.

Treat by debridement and irrigation as soon as feasible to preventinfection.Tibiafracturesareathighriskforinfectionfollowinginternalfixation(about40%,historically).Biplanarradiographsshouldbeobtainedwhenpossible.Neurovascular status of the extremity should be documented andcheckedrepeatedly.Internalfixationiscontraindicatedinthefaceofgrosscontamination.BeginIVantibioticsassoonaspossibleandmaintainthroughouttheevacuation chain. Use a broad-spectrum cephalosporin (Cefazolin 1gramq8h).

Woundincision/excision.GuidelinesasperChapter9,Soft-TissueandOpenJointInjuries.Uselongitudinalincisionstoobtainexposure.Fascia is incised longitudinally to expose underlying structures andfacilitate compartment release.

Fig.22-1.Woundincision/excision.

All foreign material in the operative field must be removed, alongwithdeadboneandnonviablemuscle(Fig.22-1).Bone fragments should be retained only if they have a viable soft-tissueattachmentorarepartofajointsurface.Detachedbonefragmentsarediscarded.Irrigationisessential(Fig.22-1d).Pulsatilelavageshouldbeavoided.

Closureofwounds.Primary closure is NOT indicated in these contaminated wounds.Loose approximation of tissues with one or two retention suturesMAYBEappropriatetocovernerves,vessels,andtendons;but,theremustbeaprovisionforsubstantialfreedrainage.Skin grafts, local flaps, and relaxing incisions are contraindicated intheinitialmanagement.

Delayedprimaryclosuremaybeattempted,asdescribedinChapter9,Soft-TissueandOpenJointInjuries.Thisshouldbeaccomplishedinastableenvironment.Negative pressure wound therapy is a useful adjunct in soft-tissuewoundmanagement.

BivalvingCasts

Whenbivalvingacast,splittingitintoanteriorandposteriorhalvesispreferred.Thepurposeofbivalving is toaccommodate soft-tissue swelling, thus lesseningthe chance of postcasting compartment syndrome. It is important that theunderlying cast padding also be completely split underneath the cast cuts;otherwise, the cast padding can restrict swelling and a compartment syndromecouldstilldevelop.Inanacutesetting,IFalimbiscasted,itissafesttobivalvethecastorsimplyimmobilizewithasplint.

ExternalFixationGeneral technique: the surgeon should be familiar with four standardconstructs of external fixation for use in the initial care of bone and jointinjuries:femur,tibia,knee,andankle.Externalfixationcanalsobeappliedforhumerusandulnafractures,asneeded.

A thoroughunderstandingof the anatomyof the lower extremity isessentialforsafeinsertionoffixatorpins.The external fixator for military purposes should be modular andallowformodificationashealingprogresses.Application of the external fixator may be done without the use ofplainfilmsorfluoroscopy.Pinscanbeinsertedwithoutpowerinstruments.Enoughpinsshouldbeplacedtoadequatelystabilizethefracturefortransport.Thisisusuallytwoperclamp,butthreemayoccasionallyberequired.Thepresentexternalfixationsystem(Hoffmannframe)allowsfortheuse of either singlepin clamps ormultipin clamps. Both clamps areacceptabletouseinstandardconstructs.Multipinclampsprovidegreaterstabilityandarethecurrentfixatorsfielded. Dual pin placement (with multipin clamps) is describedbelow.Thetechniqueforsinglepinplacementissimilar.

Femurdiaphysealfracturetechnique.Theentirelimbispreparedforsurgery,fromtheanteriorsuperioriliacspinetothetoes.AstandardORtableorportablefracturetablemaybeused.Anassistantshouldapplycounterpressurewhilepinsareinserted.Precisereductionisnotnecessary.Apadded“bump”underthethighwillhelpreducethefracture(Fig.22-2).Thepositionoftheproximalfemurshouldbeidentifiedbypalpation.A 1-cm longitudinal stab incision is made over the midaxis, or

midlateralaxis,ofthefemur(Fig.22-3).Thepinclosesttothefractureshould be outside of the fracture hematoma and at least 3

fingerbreadthsfromthefracture(Fig.22-4).Fig.22-2.Placingatowelunderneaththethighhelpstoreproducethebowofthefemur.

Spreadsofttissuebluntlydowntothebone.Insertapinthroughthisopeningandwhenreachingthebone,assessitsmidpointbysweepingthe pin anteriorly and posteriorly (Fig. 22-5). Your assistant shouldprovidestabilityandcounterpressure.Twotapsontheendofthebitbracewill indent the bone and stabilize the pin for insertion. Apexpinsareplacedbyhandorpower.Use5-mmhalf-pins.Insertthepininthemidportionoftheboneandadvancethroughboththenearandfarcorticesofthebone(Fig.22-6).Thepinwillmoveeasierasitenterstheintermedullarycanalandthenbecomesmoredifficulttodriveasitenters the far cortex.

Fig.22-3.Placea1-cmlongitudinalincisioninlinewiththemidlateralaxisofthefemur.

Placeamultipinclampover the insertedpin. Ideally, thepin shouldoccupyoneoftheendpositions(eg,position1or5;Fig.22-7).Usingtheclampasaguide,insertasecondpinthroughtheclamp.Anassistantshouldholdtheclamp.Ensurethattheclampisalignedwiththeboneandthatbicorticalpurchaseisobtained.Thesecondpinmustbeparalleltothefirstpin.Toensuretheyareparallel,itcanbehelpfultouse the clamp as a guide for placing the secondpin.Use thepinsites that are the farthest apart on the clamp as possible forbiomechanicalstability(clamppositions1and5arebest;seeFig.22-7).Athirdpinmaybeinsertedifneededforadditionalclampstability.

Fig.22-4.Pinsshouldbeplacedoutsideofthefracturehematomaandatleast3fingerbreadthsfromthefracture.

Fig.22-5.Femoralpinplacement.

Fig.22-6.Bicorticalplacementof5-mmhalf-pin.

Fig.22-7.Multipinclampshowingpositions1–5.

Repeatthistechniquewheninsertingpinsandapplyingthemultipin

clamptothedistalfemoralfracturefragment.

Fig.22-8.Frameappliedandfracturegrosslyreduced.Lateralplacementofstabilizingrodispreferred.Consideruseofmultiplerodsforincreasedstability.

Connect the two clamps with elbows, bar-to-bar clamps, and twolongitudinalbarsplacedparalleltoeachother(Fig.22-8).Reduce the fracture with longitudinal traction. Manipulating thefracture fragments using the clampsmay be helpful.Once adequatereductionisachieved,tightenalloftheconnections.Precisereductionisnotnecessary.

Tibiashaftfracturetechnique.Place a 1-cm longitudinal incision over the midportion of theanteromedial tibia (Fig. 22-9). The pin closest to the fracture siteshouldbeoutsidethehematomaandatleast2–3fingerbreadthsawayfrom the fracture site (Fig. 22-10).

Fig.22-9.Palpationoftheanteriorandposteriormarginsofthemedialfaceofthetibiawherea1-cmincisionhasbeenmademidwaybetweenthesetwopoints.

Insertthefirstpinintoeithertheproximalordistalfragment.Placethepinperpendiculartothesubcutaneousborderofthetibiaandcenteredacross the width of the tibia. Ensure that pins engage both cortices(Fig.22-11).Usingtheclampasaguide,insertasecondpinthroughtheclamp.Anassistant shouldhold the clamp.Align the clampwith theboneandadvancepinthroughbothcortices.Thesecondpinmustbeparalleltothe first. Use the pin sites as far apart on the clamp as possible forbiomechanicalstability(positions1and5inFig.22-7).Thesecondpinshould be through the opening farthest away from the fracture site.

Fig.22-10.Theanteromedialsurfaceisthesafestlocationfortibialpins.Pinsshouldbeaminimumof2or3fingerbreadthsfromthefracturesite.

Applyasecondmultipinclampandtwopinsinthesamemannertotheothermainfracturefragment(Fig.22-12).Connectthetwoclampsviatwoelbows,bar-to-barclamps,andasinglebar(Fig.22-13).Most combat-related fractures are comminuted. Therefore, a secondbar should be added for increased fracture stabilization (Fig. 22-14).Useasinglebarforstablefracturesonly.Confirmreductionwithavailablemeans.

Techniquetospanknee.Indications are proximal tibia fractures, distal femur fractures orextensive knee injuries, or vascular repairs in the popliteal fossa.

Fig.22-11.Bicorticalplacementoftibialpins.

Fig.22-12.Applicationofthesecondmultipinclampandtwopins.Add30-degreeelbowstothetwosetsofmultipinclamps.Pointtheelbowsinadirectionthatwillpositionthebar(s)awayfromopenwoundsandallowforthebestaccess.

Check the distal vascular status of the limb prior to and after theprocedure. If there is avascular injury, refer toChapter25,VascularInjuries.An assistant will be required to help apply the frame.

Fig.22-13.Additionofthecross-barandtwobar-to-barclamps.Applylongitudinaltractiontoreducethefractureandthentightentheframeinalignment.

Fig.22-14.Thetwo-barapparatusisamorestableconstructfortypical,unstabletibialfractures.Thisrequirestheuseoftwokits.

General reduction maneuver should be longitudinal traction withslight(10°–15°)flexionattheknee.Pinsareplacedanteromedialon theproximal tibiaandanterolateralon the distal femur. Pin placement should be outside the zone ofinjury, at least 3 fingerbreadths from a fracture site and outside theknee joint. A longitudinal stab incision is made over the mid-anterolateral aspectof the femurand thepin insertedat a45-degreeangle to the long axis of the bone. Depending on the fractureconfiguration, itmayalsobeplaceddirectlyanteriorly,althoughit isgenerally better to avoid pin placement through the quadricepstendon.Bluntdissectionisusedtocreateacorridortothebone.Asinglepinisinsertedbyhandorpowerthroughbothcorticesofthebone.Amultipinclampisusedasaguideforasecondpin.Thesecondpinmustbeparalleltothefirstpinandalsobebicortical—careshouldbetaken to maintain pin alignment. The proximal tibia should bepalpated on the anteromedial surface, and the anterior-posteriorborder should be identified. Midway anterior-posterior, a 1-cmlongitudinal stab incision should be made, followed by blunt, soft-tissuedissectiontothebone.Amultipinclampshouldbeusedasaguidetoinsertasecondpinintheproximaltibia.The two pin clusters (femur and tibia) should be connected via 2elbows,2bar-to-barclamps,and1bar.Thekneeshouldbealigned.Asecondbarshouldbeaddedinthemannerdescribedpreviously.

Techniquetospanankle.Anassistantwillberequiredtohelpapplytheframeandreducetheankle.Generalindicationsareforopendistaltibiafracturesandopenanklewounds.Pinsshouldbeinsertedontheanteromedialsurfaceofthetibiaandonthemedialaspectofthecalcaneus.Checkthedistalvascularstatuspriortoandaftertheprocedure.Markwheretheposteriortibialanddorsalispedisarterypulsescanbefelt.Palpatetheanteromedialborderofthetibia.Makea1-cmlongitudinalincision midway between the anterior-posterior border of the tibia.Insertthemostdistalpinonthetibiaoutsidethezoneofinjury,atleast3fingerbreadthsfromthefracturesite.Using amultipin clamp as a guide, insert a second pin in the tibiaproximaltothefirstpin.Thepinmustbeparallelandalignedwiththelongitudinalaxisofthefirstpin.Palpate the medial border of the calcaneus. Make a longitudinalincision over the calcaneus avoiding the posterior neurovascular

structures:dissecttothebonewithabluntinstrumentandinsertthepin.When available, insert a centrally threaded pin frommedial tolateral.Thepininsertionpointshouldbethejunctionofposteriorandmiddle one-third distance between medial malleolus and posteriorcalcaneus tuberosity. If using two half pins, then apply in posteriorhalfofthisline.Using a multipin clamp as a guide, insert a second pin in thecalcaneus.Connectthe2clampsvia2elbows,2bar-to-barclamps,and1bar.

Skeletaltraction.Skeletaltractionprovidesaquickmeanstoimmobilizefractureswithaminimumoftechnicalsupport.External fixation is preferred because it is more manageable in thetransportenvironment.Currently,tractionequipmentishardtofindatfieldhospitals.Indications.

Patientswhoareexpectedtohavemorethanoneprocedureinthesameforwardhospitalpriortoevacuation.

Largecasualtyload.

Technique.

Large,threadedSteinmannpinsareusedtoobtainskeletaltractionofafemurortibia.

Asepticpreparationofapinsiteisnecessarypriortoplacement.

Applylocalanesthetictoplannedpinsite.

Inciseskinanddissecttobonebluntly.

Forfemurfractures,incisionismade2cmposteriorandlateraltothetibialtuberosity(deeptothetibialtuberosity,asinFig.22-15).Placepinfromlateraltomedialcompletelythroughtheproximaltibia.Placethethighandlegonthebed,andapplylongitudinaltractionof20–40lbs.

Fig.22-15.Appropriatesiteforplacementofproximaltibialtractionpin.

ApplyaThomassplintwithaPiersondevice,withweightappliedmidthigh(10–20lbs),totheleg(10–20lbs),andtothetractionpin(20–40lbs)toobtainbalancedskeletaltraction.

Fortibialfractures,incisemedially2cmanteriorand2cmcephaladfromtheposteriorcalcaneus.Placethepinfrommedialtolateralacrossthecalcaneus.Placethelegonthebedbalancedandapplytractiontothecalcanealpin(10–20lbs).

Waitatleast30minutesafterapplyingtractiontoobtainradiographs.

Careintheevacuationchain.When planning procedures, consider the potential for complicationsduringairevacuation.Considermedicationsupplyfortransport(seeChapter4,AeromedicalEvacuation).Skeletaltractionshouldnotbeusedfortransportation.Casts should be bivalved. Monitor extremity neurovascular statusduring transportbecausecastsmayactas tourniquetsdue to tissueswelling.All documentation, including radiographs, should accompany thepatient.Well-padded splints can be usedwith andwithout external fixationwith large open wounds, such as blast injuries. Circumferentialdressingsshouldbeavoidedbecausetheycanbeconstricting.

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Chapter23

Amputations

Introduction

Battlecasualtieswhosustainamputationshavethemostsevereextremityinjuries.

Historically,1in3patientswithamajoramputation(proximaltothewristorankle)died,usuallyofexsanguination.Although complete andnear-complete traumatic amputations arevisuallydramatic, attention must be focused on the frequently associated life-threatening injuries, including control of ongoing hemorrhage from thedamagedlimb(s).

Goalsforinitialcarearetopreservelife,preparethepatientforevacuation,andleavethemaximumnumberofoptionsfordefinitivetreatment.

Indicationsforamputationfollowingtrauma:

Partialorcompletetraumaticamputation.Irreparable vascular injury or failed vascular repair with an ischemiclimb.Life-threateningsepsisduetoseverelocal infection, includingclostridialmyonecrosis.A patient in extremis with severe soft-tissue and bony injuries to theextremityprecludingfunctionalrecovery.

Thesurgeonmustbalancetherealistic likelihoodofultimatereconstructionofafunctionalextremityagainsttheriskofdeathassociatedwithattemptstopreservea limb. It is always desirable to secure the opinion of a second surgeon beforeamputating. The tactical situation or the patient in extremis may requireamputationincaseswherethelimbmightotherwisehavebeensalvaged.

Battlefieldamputationsareunique.Most commonly due to explosive munitions, with penetration andblasteffects(seeChapter1,WeaponsEffectsandWarWounds).Involve a large zone of injurywith a high degree of contamination,which may affect the level of amputation and/or reconstructiveoptions.Require staged treatment, with evacuation out of the combat zonepriortodefinitiveclosure.

Amputations should be performed at the lowest viable level of

soft tissues, in contrast to traditional anatomical amputationlevels(eg,classicabovetheknee,belowtheknee,etc)topreserveasmuch limb as possible. In general, a longer residual limb isdesirableforfinalprostheticfitting,andinitialpreservationofallviabletissuesmaximizesthereconstructiveandcoverageoptionsavailableathigherlevelsofcare.

Theopenlengthpreservingamputationprocedurehastwostages:initialandreconstructive.

Initial—Completetheamputationatthelowestpossiblelevelof bone and prepare the patient for evacuation to the nextlevelofcare.Reconstructive—Involves final healing of the limb to obtaintheoptimalresiduallimb.NOTE:ThefinallevelofamputationanddefinitivetreatmentoftheresiduallimbshouldoccurinthestableenvironmentofaCONUShospital,notinthecombatzonehospital.Inthecaseofhostnation casualtiesor enemycombatants,whereinevacuation is not an option, several debridement andirrigation procedures are generally indicated prior toattemptingdefinitiveamputationandclosuretopreventhighwoundfailureandinfectionrates.

All viable skin and soft tissues distal and proximal to the indicatedlevelofboneamputation shouldbepreserved foruse in subsequentclosure of the amputation stump. These tissues may be considered“flaps of opportunity” and can add length to the stump. This isespeciallytrueforamputationsbelowtheknee.Short tibia limbscanbesavedwithposteriorlybasedflapsbecausethegastrocnemiusandsoleusarefrequentlypreservedfollowingblastinjury.Tosavelength,anyshapeorformofaviablemuscleorskinflapshouldbepreserved.Preservation of even oblique or irregular soft-tissue flaps or viablebonelackingdistalsoft-tissuecoveragemaximizesthereconstructionoptions at higher levels of care. Late free tissue coverage cansometimes salvage functional joint levels. Therefore, residual viabletibia (if distal to the tibial tuberosity) should be preserved initially,even if the remaining soft tissueswould not initially permitwoundclosure.

TechniqueofAmputationSurgicalpreparationoftheentirelimb:toallowforevaluationofplanesofinjury thatmaybemuchhigher than initially evident andallowaccess tothepotentialneedforproximalvascularcontrol.Tourniquet control is mandatory. If a tourniquet was placed in theprehospitalsettingforhemorrhagecontrol,itispreppedentirelywithinthe

surgicalfield.Excisenonviabletissue.

Necrotic skin and subcutaneous tissue or skin without vascularsupport.Muscle that is friable, shredded, grossly contaminated, ornoncontractile. (This muscle is usually at the level of the retractedskin.)Bonethatisgrosslycontaminatedordevoidofsoft-tissueattachmentfor blood supply. Bone is transected at its lowest viable level,regardlessoftheresidualsoft-tissuecoverage.

Identifyandsecurelyligatemajorarteriesandveinstopreventhemorrhageintransport.Identifynervesandtransectthematthelevelofavailablemuscularcoveragetominimizepatientpaindue todressingchanges.Moreproximal tractionneurectomy is best reserved for thedefinitive closureprocedure at higherlevels of care. Initial traction neurectomy may preclude furtherreconstructiveoptionsatdefinitiveclosureas the final levelofamputationmaybewellproximaltotheinitiallevelofviabletissuedebridement.Ligatethemajornerves if theyarebleeding (eg, sciatic); taggingofmajornerveswithcoloredsutureisreasonable,butnotmandatory.Preservedmuscle flaps shouldnotbe sutured,but shouldbeheld in theirintendedpositionbythedressing.Flaps should not be constructed at the initial surgery to facilitate laterclosure.

In blast injuries, particularly landmine injuries, the blast forces drive debrisproximally along fascial planes. It may be necessary to extend incisionsproximally parallel to the axis of the extremity to ensure adequate surgicaldebridement of the wound. Each successive debridement should explore allintermuscularandfascialplanestoavoidmissingareasofpurulenceornecrosis,withoutdevascularizingtheremainingskinflaps.

Theresiduallimbisneverclosedprimarily.

Specialconsiderations.Primary Symes (ankle disarticulation) has a high failure rate due toheel pad necrosis during transport. The wound should simply bedebrided,retainingthecleanhindfoot(talusandcalcaneus).Primary knee disarticulation is problematic due to skin and tendonretractionnecessitatingreamputationatahigher,oftenlessfunctionallevel. It is preferable to leave even a very short (1–2 cm), cleantranstibialstump—eventhoughnonfunctional—topreventretraction,aswell as to preserve asmuch patellar tendon, gastrocnemius, anddistalskinaspossible.Fractures,whenpresentproximaltothemangledsegment,shouldnotdetermineamputation level,butmustbe treatedappropriately (cast,

external fixator) to preserve maximal length and salvage functionaljointlevels.Plan the initial amputation solelyon thequalitiesof thewoundandsurroundingtissues,neveronthehopeofachievingaparticularlevelorflappatternasafinalresult.Thecombatsurgeon’sgoalsarepatientsurvival, hemostasis, and a thorough and complete debridement.Tryingtopreservemarginaltissueinthehopethatabetterstumpcanbeconstructedmayleadtosubsequentinfectionandamoreproximalamputationlevel.For high transfemoral and more proximal amputations (ie, hipdisarticulation or hemipelvectomy), particularly when bilateralinjuries are present, proximal vascular control via exploratorylaparotomy and temporary clamping of the common iliac vesselsand/orinfrarenalaortaandinferiorvenacavacanbelifesaving.Whenthis is performed for bilateral proximal amputations, completeproximal fecal diversion with distal colonic washout should bestronglyconsideredconcurrently, independentofabdominal injuries,topreventfecalcontaminationofwounds.

DressingsandPreventionofSkinRetraction

Becauseamputationsmustbeleftopen,skinretractionislikely,causingthelossofusablelimblengthandmakingdefinitiveclosuredifficult.Thisisparticularlytrueofapatientwhoisintheevacuationchainforaprolongedperiod.

SkinTraction

Ideally,skintractionshouldbemaintainedthroughoutthecourseoftreatment.Ifevacuationtimesarereliablyveryshort(1–3days),skintractionmaybeomitted.If there is thepossibilityofanydelay,useskin traction topreserve limb length.When tactical conditions or resources are not available for application of casts,skin tractionmaybeapplied throughweightsoff theendof thebedbeforeandaftertransport.

Dry, fine mesh gauze is loosely placed over the open wound. Preservedflapsarenotsuspendedfreely,butareheldintheirintendedpositionbythedressing(Fig.23-1).Absorbentdressingisplacedovertheresiduallimb.Tinctureofbenzoinisappliedproximallyontheskinupto2cmfromthewoundedge,butnotincludingthepreservedflap.Astockinetteforskintractionisapplied.Wrapthestockinettewithafigure-of-8elasticwrap.2–6poundsoftractionareappliedthroughthestockinette/wrap.Thismaysimply involve a weight attached via parachute cord to the stockinette.However, during transport, hangingweights are problematic andmay besubstituted with light elastic, such as surgical tubing or elastic exercisetubingappliedthroughatransportationcastasdescribedbelow.

Atransportationcastmaybeapplied topreventcontractureandallowforcontinuous traction.

Fig.23-1.Skintraction.

Vacuum-assistedsubatmosphericwound therapydressingsmaybeplacedpriorto evacuation only if reliable maintenance of suction can be expected duringtransport and on arrival at the next level of care. If a subatmospheric wounddressing is used, skin traction and countertraction can be achieved via acombination of negative pressure from the device and opposing skin tensionusingrunning tiedvessel loopsover thereticulatedopencell foamandsecuredundertensiontotheskinedgeswithstaples.

PostoperativeManagementPreventionofcontracture.

Below-the-kneeamputationsareatriskforkneeflexioncontractures.Thesecontracturesarepreventablebyusinga longlegcastorsplint.Splintinginextensionrequiresclosermonitoringandmeticulouscastpaddingplacementandcutoutsoverthepatella.Pillowsshouldneversupportthekneebecauseoftheincreasedriskofflexioncontractures.Above-the-knee amputations are at risk for hip flexion contractures.Prone positioning and active hip extension exercises will avoid thiscomplication. When the casualty is supine, sandbags may be alsoappliedtotheanteriordistalthigh.

Prevention of hemorrhage: a tourniquet should be readily available atbedsideorduringtransportforthefirstweekfollowinginjury.Pain control: patient comfort is paramount following amputation,particularlyifdressingchangesarerequired.Adequateanalgesiashouldbeavailable, and the patient should be counseled regarding phantom limbpain/sensations.

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Chapter24

InjuriestotheHandsandFeet

Introduction

Combat injuries to thehandsand feetdiffer fromthoseof thearmsand legs interms of mortality and morbidity. The hands and feet have an importantcommonality: an intricate combination of many small structures that mustfunction smoothly together. Because these terminal appendages are extremelyspecializedandrepresenttheinterfaceofthepersontotheoutsideworld,aminorwound—causingno lasting impairment if inflicted, for example, on the thigh—canresultinlife-longdisabilitywhenitoccursonahandorfoot.

TypesofInjuryNonbattleinjuriesresultinginlaceration,contusionorsprainofthehandorfoot, and crush injuries involving either the hands or feet from heavyequipment are common. Such crush injuries may result in compartmentsyndrome.Missile, blast, andhigh-energyordnance injuries involving thehands andfeet are common in combat andmay result in mutilating injuries with apermanent loss of function, innervation, or distal extremity tissue(amputation).

TheHand

Evenapparentlyminorwoundsdistal to thewrist creasemayviolate tendonsheaths and joints, resulting in a serious deep space infection. Suchwoundsrequireahighindexofsuspicionfor injuryandalowthresholdforoperativeexploration.

EvaluationandInitialManagementThecasualty’supperextremitiesshouldbeexposed.Rings,watches,andotherpotentiallyconstrictivematerialmustberemovedimmediately.A preliminary neurological examination should be performed anddocumented.Vascular status of the hand should include an assessment of radial andulnarpulses,andperfusiontoeachfingertipasassessedbycolor,warmth,andcapillaryrefill.

TreatmentofHandCompartmentSyndromeThe hand has 10 separate fascial compartments (4 dorsal interossei, 3

palmar interossei, the thenar muscles, the hypothenar muscles, and theadductor pollicis; Fig. 24-1).

Fig.24-1.Compartmentsofthehand.

Acompletehandfasciotomyconsistsoffourincisions(showninFig.24-2):

Thefirstincisionisplacedalongthethumbmetacarpalattheradialaspectofthehandtoreleasethefasciaofthethenarmuscles.

Thesecondincisioniscentereddorsallyontheindexmetacarpal.Ontheradialsideofthisbone,thefasciaofthefirstdorsalinterosseousandtheadductorpollicisareincised.Ontheulnarsideofthisbone,thefasciaofthedorsalandpalmarinterosseiisincised.

Thethirdincisioniscentereddorsallyontheringmetacarpal.Fromthiswound,thefasciaofthedorsalandpalmarinterosseiisreleasedonbothsidesofthisbone.

Thefourthincisionisplacedalongthesmallmetacarpalontheulnaraspectofthehandtoreleasethefasciaofthehypothenarmuscles.

Althoughcompartmentsarenotwelldefinedinthefingers,fingersthatareseverelyswollenmayrequirereleaseofdermalandfascialconstriction;careshould be taken to place the skin incision away from the neurovascularbundles (Fig. 24-3).

Fig.24-2.Handfasciotomyincisions.

Fig.24-3.Incisionforfingerfasciotomy.

SurgicalTechnique

Do not blindly clamp bleeding tissues because nearby nerves may beinjured. If unable to control the bleedingwith pressure, isolate the vesselundertourniquetcontrolandtieofforclampunderdirectvision.

General or regional (block) anesthetic is required; local infiltration ofanesthetic is inadequate. Epinephrine is never injected into the hands orfingers.Either the radial or ulnar arterymay be ligated if necessary.Never ligateboth.Debridementremovesembeddedforeignmatteranddeadtissue.Tissue, including skin, with marginal or questionable viability is left forsubsequentevaluationtoimprovechancesforoptimaloutcome.Thefingersarenotamputatedunlessirretrievablymangled.

Viable tissue, but potentially nonfunctional, is retained and stabilized for laterreconstructiontoincludeotherlocations.

SpecificTissueManagementBone:Provisionalstabilizationof fractureswithKirschnerwires(K-wires),

when skillfully done, may enhance patient comfort. Do not compromisefuturereconstructiveeffortswithoverzealousinitialmanagement.Aplastersplintmaybethebestoption.Tendon:Minimalexcisionof tendonsshouldbeperformed.Noattemptatrepairshouldbemadeinthefield.Nerve:Donotexcisenervetissue.Noattemptatrepairshouldbemadeinthefield.Onemaytagthecutendsofnervesandtendonsifskillfultofacilitatelaterrepair. Monofilament nonabsorbable suture (6.0 or smaller) should beplacedthroughtheepineuriumonlyofcutnerveends.

Closure of wounds is delayed. However, exposed tendon, bone, and jointshouldbecoveredwithviableskin,ifpossible,topreventdesiccation.

DressingandSplinting

Splintthehandinthesafeposition(Fig.24-4).Thewristisextended20°,themetacarpophalangealjointsareflexed70°–90°,andthefingers(proximalanddistalinterphangealjoints)areinfullextension.

Fine-meshgauze is first laidon thewoundsandcoveredwithagenerouslayeroffluffedgauze.The entire wound should be covered, but the fingertips left exposed, ifpossible,tomonitorperfusion.Asplint isapplied, immobilizingall injuredpartsandextendingoneboneor jointbeyond.Apalmarplaster slab is routine,butadorsalonemaybeadded for additional stability.

Fig.24-4.Handsplintposition.

TheFoot

Penetrating injuries of the foot frequently result in prolonged morbidity anddisability. Crush injuries and injuries from blast aremore likely to result in anunsatisfactory result than arewoundsmade by low-velocity bullets or isolatedfragments.This is especially truewhen there is loss of theheelpad, significantneurovascularinjury,orwhenthedeepplantarspacehasbeencontaminated.Theultimate goal of treatment of these injuries is a relatively pain-free, plantigradefootwithintactplantarsensation.

EvaluationandInitialManagementThezoneof injury,withbothopenandclosed injuriesof the foot, isoftenmore extensive than is apparent with the initial inspection, and a lowthresholdforextensiledebridementusing longitudinal incisionsshouldbeobserved.Allclothingandbootsshouldberemovedandtheentirefootexposed.The vascular status of the foot should be assessed by palpation of thedorsalispedisandposteriortibialpulsesorwithuseofaDopplerdeviceifavailable.Anassessmentofcapillaryrefillinthetoesshouldalsobemadetoassessperipheralperfusion.Transectedmajorbloodvesselstothefootshouldbedoublesutureligatedto include plantar and dorsal pedal arteries and veins. Transected nervesmaybetaggedwithsutureforsubsequentidentification.At the time of debridement, small, contaminated, nonarticular bonefragmentswithoutsoft-tissueattachmentshouldberemovedanddiscarded.High-volume, low-pressure irrigation for all openwounds is important asanadjuncttothoroughsurgicaldebridement.Vessellooptissuetensioningtechniquemaybeusedtopreventwoundexpansionduringtransport.

Allwoundsshouldbeleftopen.

Sterilewet-to-drydressingsornegativepressurewounddressingsshouldbeplacedfortransport.

InjuriestotheHindfootSeverely comminuted, open fractures of the talusmay require talectomy;butthisdecisionshouldbelefttohigherlevelsofcare.The talus is best debrided through an anterolateral approach to the ankleextendedtothebaseofthefourthmetatarsal.Penetrating wounds into the plantar aspect of the heel pad can beapproached through a heel-splitting incision to avoid excessiveunderminingofthisspecializedskin.Transverse gunshot wounds of the hindfoot are best managed bymedialand lateral incisions, with the majority of surgery performed laterally toavoidmedialneurovascularstructures.

InjuriestotheMidfootTarsal and metatarsals are best approached through dorsal longitudinalincisions. Dorsal incision interosseous fasciotomies do not improveoutcomesfrompotentialcompartmentsyndromes.Contamination of the deep plantar compartments of the foot is bestmanagedthroughaplantarmedialincisionthatbegins1inchproximaland1inchposteriortothemedialmalleolusandextendsacrossthemedialarchending on the plantar surface between the second and third metatarsalheads.Themedialneurovascular structuresmustbe identifiedduring thisapproach.A full compartment release can alsobeperformed through this

incision.

InjuriestotheToesEveryeffortshouldbemadetopreservethegreattoe.Amputationofthelateraltoesisgenerallywell-tolerated.

FootCompartmentSyndromeThereareninecompartmentsinthefoot.

The four interosseouscompartmentsareboundedby themetatarsalsmediallyandlaterallybythedorsalinterosseousfasciaandtheplantarinterosseousfascia.The lateral compartment is bounded by the fifth metatarsal shaftdorsally, the plantar aponeurosis laterally, and the intermuscularseptummedially.The central compartment is bounded by the intramuscular septumlaterallyandmedially,theinterosseousfasciadorsally,andtheplantaraponeurosisplantarly.Themedialcompartmentisboundedbytheinferiorsurfaceofthefirstmetatarsal dorsally, the plantar aponeurosis extensionmedially, andtheintramuscularseptumlaterally.Thecalcanealcompartmentcontainsthequadratusplantaemuscle.

There is no evidence that a double dorsal incision and interosseouscompartment release alter outcomes, and, in fact,may increase infectiousandpainfulcomplications.Tosparethedorsalsofttissueandreducesubsequentriskforinfectionandcomplex regionalpainsyndrome,a single incisionmedial fasciotomymaybeused.Amedial approach to the foot ismade through themedial compartment,reachingacrossthecentralcompartmentintotheinterosseouscompartmentdorsallyandlateralcompartmentreleasingall thewayacrossthefoot (seedescriptioninthischapter’ssectiononInjuriestotheMidfoot;alsoseeFig.24-5).

Aswithallbattlewounds,thefasciotomyisleftopenandiscoveredwitha steriledressing. Jacob’s laddervascular loopsmaybeused toavoidwoundexpansionduringtransport.

Fig.24-5.Centralcompartmentreleasesthroughmedialapproach.

StabilizationK-wires can be used for temporary stabilization following reduction.Alternatively,forlargersegmentalinvolvement,aspanningexternalfixatormaybeplacedtoregainoverallanatomical lengthandalignment.Plateorscrew fixation in the combat zone should usually be deferred to Role 4facilities.Abivalvedcastorsplintisadequatefortransporttoasiteofmoredefinitivecare.

Takecaretoavoidiatrogenicpressuresoresbyprovidingadequatepaddingto includebulky cottonpadding.External fixation “kickstands” areuseful,butonlywhenexternalfixationisusedforstabilizationandnotasaprimarytreatment.

Reference

Fuenfer MM, Creamer KM, eds. Pediatric Surgery and Medicine for HostileEnvironments.Washington,DC:Departmentof theArmy,OfficeofTheSurgeonGeneral,BordenInstitute;2010.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter25

VascularInjuries

IntroductionHistory.

World War II: Popliteal artery injuries were routinely ligated andassociatedwitha73%amputationrate.KoreanWar:Formalrepairofperipheralarterialinjuriesinstituted.VietnamWar:Furtherrefinements inarterial repair;amputationrateforpoplitealarteryinjuriesisreducedto32%.IraqandAfghanistan:ForwardRole2carerefinesuseof temporaryvascular shunts, and Joint Theater Trauma System (JTTS) advancesrecodingofinjury.

Therearevarioustypesofwoundsseenincombat.Low-velocitymissile/fragmentdamagesabloodvessel lyingdirectlyinitspath.High-velocitymissile/fragmentwoundswithblastcauseswidespreaddamage,includingvascularinjuryatadistance(remoteinjury).Blunt trauma, often resulting from sudden deceleration in motorvehicleaccidents,falls,andrailandairdisasters.Poplitealarteryinjuryassociatedwithposteriorkneedislocations.

EpidemiologyofVascularInjury1 in 5 (20%) battle injuries (nonreturn toduty) is codedwithhemorrhagecontrolnototherwisespecified.Rateofvascularinjuryinmoderncombatis12%,whichishigherthanthe1%–3% reported inWorldWar II, Korea, and Vietnam. Rate of operativevascularinjuryis9%,withhalfbeingligationsandhalfrequiringrepair.Extremityvesselsaccount for70%–80%ofvascular injuries,whereas10%–15%areinthecervicalregionand5%–10%areinthetorso.

RolesofCareandtheManagementofVascularInjury

Eachrolehasuniqueapproachestothemanagementofvascularinjury:

Role1.Hemorrhagecontrol(directpressure,tourniquet,ortopicalhemostaticagent)andotherlife-savinginterventions/evacuation.

Role2.Operationsatforwardoperatinglocationsareabbreviated(preferably

<1hour).Interventiononextremityvascularinjuryisimportantandmaymakethedifferenceinmeaningfullimbsalvage.Primaryamputationor ligation isalsoanacceptabledamagecontroltechniquewhenotherlife-threateninginjuriesarepresent.Iflimbsalvageistobeattempted,tourniquetremoval,explorationandcontrol of vascular injury, thrombectomy, and administration ofheparinized saline through the inflow and outflow vessels arerecommended.Restorationofflowcanthenbeestablishedusingatemporaryvascularshunt followed by fasciotomy andMEDEVAC (medical evacuation).Definitive repair at this level can be considered with caution,dependingonavailableequipmentandthetacticalsituation.

Role3.Removal of tourniquet(s) and temporary vascular shunts placed asforwardlocationsfollowedbydefinitivevascularrepair.Saphenous vein is preferred as a conduit for extremity vascularinjuries.Extremity evaluation will be difficult during AIR EVAC (airevacuation) out of theater, and Role 3 must ensure adequacy ofperfusion,fasciotomy,anddebridement.Primary amputation or ligation is acceptable damage controltechniquewhenotherlife-threateninginjuriesarepresent.

Role4(SafeHaven).Surveillanceofrepair, includinganassessmentofsoft-tissuewoundsandtissuecoveragepriortocontinuingAIREVAC.

Role4(CONUS).Surveillance of vascular repair with duplex or CTA (computedtomographyangiography)andassessmentofsoft-tissuewoundsandadequacyoftissuecoverage.Revisionofrepairswithstenosisorinadequatetissuecoverageleavingthempronetoinfectionandblowout.Delayed revascularizationof viable, butpoorlyperfused, extremitiesinwhichligationwaschosenastheinitialmethodofcare.

EvaluationandDiagnosisHardsigns.

Activehemorrhageorexpandinghematoma.Bruitorthrill.Ischemia—definedas theabsenceofDoppler signal in the extremityon multiple attempts over time after resuscitation—warming, andreductionoffractures.Hard signs require management in the operating room with wideexposureandexplorationoftheinjury(ie,controlofvascularinjury).Unlike civilian vascular trauma, there can be multiple injuries in a

singlevessel.There is limited need for other diagnostic tests (ie, CTA orangiography)thattaketimeandoftenprovideunclearfindings.

Softsigns.Proximity to vessel, fracture/injury pattern (eg, knee dislocation),hematoma,orquestionregardingpalpablepulse.Often require another diagnostic test, such as continuous waveDopplerwithorwithoutcalculationoftheinjuredextremityindex.CTAorangiographyisusefulasadiagnosticadjunctinthepresenceofsoftsignsofvascularinjury.

Theinjuredextremityindex.Similar to theankle–brachial indexand is calculatedusingamanualbloodpressurecuffandacontinuouswaveDoppler.First step is todetermine thepressure atwhich the arterialDopplersignaloccludesintheinjuredextremity(numerator).Cuff and Doppler moved to uninjured extremity and occlusionpressureofDopplersignalrecorded(denominator).Injuredextremityindex>0.90isnormalandhasahighspecificityforexcludingextremityvascularinjuryintheabsenceofhardsigns.

Angiography.Limitedutility in thediagnosisofwartimeextremityvascular injuryand,inthepresenceofhardsigns,preferenceisgiventoincisionandexposureofsegmentinquestion.Limitations related to the availability and quality of imagingtechnologyinaustereenvironments.Extremity vasoconstriction with shock and hypothermia in youngtroopsmayleadtoconfusingorfalse-positivefindings.Angiography has the greatest utility in the setting of multiplepenetratingwoundsatvariouslevelsofthesameextremity.Angiographymaybedoneviacutdownusingasmallgaugeneedleorcathetertoinjectcontrastminimizingcomplications.Advantagetoangioisitslowvolumeofcontrast,especiallyusefulinpatientsatriskforrenalfailure.

CTA.Increasinglyavailableinamaturetheaterofwarandhasthegreatestutilityinthediagnosisandtriageoftorsoandneckwounds.CTAisoftenusedasascreeningtoolforsuspectedvascularinjury.Thismodalitytakesadditionaltime,contrast,andtechnicalexperiencetoprovideaccurateandmeaningfulimages.

ManagementAspects:ExtremityVascularInjury

UpperExtremity

Consider prophylactic distal fasciotomies in all patients with prolongedischemiatimes.

Subclavianartery.Recommendations: Shunt or ligate as damage control, or definitiverepair.Utility of temporary shunt: High, but difficult due to technicaldifficultyofexposureandplacement.Method/conduit: Interposition graft/6–8 mm ePTFE (expandedpolytetrafluoroethylene)orDacron.Pearls:

Proximalsubclavianvesselsandinnominateareapproachedthroughamediansternotomy.

Alternatively,aproximalleftsubclavianarterycanbeapproachedusingahigh(thirdintercostalspace)anterolateralthoracotomysupraclavicularapproachthroughtheclavicularheadofthesternocleidomastoid,sternothyroid/hyoidmusclestothescalenefatpadwithretractionofthephrenicnerve,anddivisionoftheanteriorscalene;mayresecttheclavicularhead.

Themid-anddistalsubclavianarteriesonbothsidescanbeexposedthroughcombinationsupra-andinfraclavicularincisions.

Avoidinjurytothephrenicnerve,internalmammary,thyrocervical,andvertebralarteries.

Axillaryartery.Recommendations: Shunt or ligate as damage control, or definitiverepair.Utilityoftemporaryshunt:High.Method/conduit:Interpositiongraft/reversedsaphenousvein.Pearls:

Supra-andinfraclavicularincisionsallowproximalcontrolanddistalexposure.

Prepaxilla,arm,andhandintooperativefield.

Infraclavicularexposureincludesdivisionoftheclavipectoralfasciaandthepectoralismajormuscle.

Theproximalaxillaryarteryisthenvisibleunderthepectoralisminormuscle,whichcanberetractedlaterallyordivided.

Avoidthebrachialplexus,whichwillbedeeporlateraltotheaxillaryartery.

Brachialartery.Recommendations: Shunt or ligate as damage control, or definitiverepair.Utilityoftemporaryshunt:High.Method/conduit:Interpositiongraft/reversedsaphenousvein.

Pearls:

Medialapproach;adjacenttothemediannerveinbrachialsheathinbiceps/tricepsgroove.

Elasticarterywithredundancy;flexarmslightlyforinterpositiongraftstoavoidkinking.

Ligationmaybetoleratedifcollateralsareintact.

Radial/ulnararteries.Recommendations:Selectiverepair (maintainat leastonevessel flowtohand).Utilityoftemporaryshunt:Lowpatencyrate.Method/conduit: Ligation or interposition graft/reversed saphenousvein.Pearls:

PerfusiontothehandshouldbeassessedwithDopplerbeforeandafterocclusionorligation.

ThepresenceofanarterialDopplersignalinthehandobviatestheneedforarterialrepair.Repairwithsaphenousveinininstanceswherethereispersistentabsenceofanarterialsignal.

Themajorityofindividualshaveulnar-dominantperfusion;whenpossible,repair/reconstructtheulnarartery.

LowerExtremity

Consider prophylactic distal fasciotomies in all injuries with prolongedischemiatimes.

Commonfemoralartery.Recommendations:Shuntasdamagecontrolordefinitiverepair.Utilityoftemporaryshunt:High.Method/conduit: Interposition graft/saphenous vein or 6–8 mmprosthetic.Pearls:

Injurytothecommonfemoralarteryisoftenfatalbecausehemorrhagecontrolinthefieldisdifficult.

Exposearteryattheinguinalligamentforproximalcontrol(2–3cmlateraltothepubictubercle)(Fig.25-1).

Fig.25-1.Inguinalanatomy.

Proximalcontrolcanbeobtainedintheretroperitoneum(ie,externaliliac)throughtheproximalextensionofthisgroinincisionorbyusinganincisioninthelowerabdomen.

Attempttomaintainflowintheprofundafemorusartery.Coverwithtissue(femoralsheath),thesartoriusmuscle,ortherectusflap(Role4).

Profundafemorusartery.Recommendations:Selectiverepair.Utilityoftemporaryshunts:Lowduetodifficultexposure.Method/conduit:Ligationorinterpositiongraft/saphenousvein.Pearls:

Exposureofproximalprofundaisthesame(distalextension)asthecommonfemoral.

Ifsuperficialfemoralisinjured,repairoftheprofundaisnecessarytohealamputations.

Ifsuperficialfemoralispatent,ligationofmid-todistalprofundainjuriesisacceptable.

Proximalprofundainjuriesshouldberepairedwithreversedsaphenousveininterposition.

Superficialfemoralartery.Recommendations:Shuntasdamagecontrolordefinitiverepair.Utilityoftemporaryshunts:High.Method/conduit:Interpositiongraft/reversedsaphenousvein.Pearls:

Medialincisionwith“bump”undercalf.

Exposureoftheproximal⅓belowthesartoriusanddistal⅓abovethesartorius.

Bewaryoftheadjacentvein(maybeadherenttoartery)andgeniculatebranchesatthedistalartery(Hunter’scanal).

Poplitealartery.Recommendations:Shuntasdamagecontrolordefinitiverepair.Utilityoftemporaryvascularshunts:High.Conduit:Reversedsaphenousvein.Pearls:

Medialincisionwith“bump”undercalfforabovekneeandunderthighforbelowknee.

Naturaldissectionplanesexistinexposingtheabove-kneepoplitealartery(ie,poplitealspace)withtheexceptionoftheneedtodividethefibersoftheadductormagnusthatenvelopesthedistalsuperficialfemoralartery(Hunter’scanal)(Fig.25-2).

Tocompletelyexposethepoplitealspace,themedialattachmentsofthesartorius,semitendinosis,semimembrinosis,andgracilistothemedialcondyleofthetibiacanbedivided.Distalexposurebydivisionofthegastrocnemiusandsoleusfromthetibiaallowsdissectiontotheanteriortibialoriginandthetibial-peronealtrunk.Extraanatomicalbypasscanalsobeperformedwithouttheneedtoexposetheinjuredsegment(Figs.25-3and25-4).

Fig.25-2.Exposureofdistalfemoralandpoplitealvessels.

Fig.25-3.Medialapproachtopoplitealvessels.

Fig.25-4.Posteriorapproachtopoplitealvessels.

Tibialarteries.Recommendations:Selectiverepair.Utility of temporary vascular shunts: Lowdue to difficult exposure,smallcaliber,andlowpatencyrates.Method/conduit:Ligationorinterpositiongraftwithsaphenousvein.Pearls:

IfaDopplersignalispresentattheankle,indicatingthatoneormoretibialarteriesarepatent,thereisnoneedforadditionaltestsorrepair.

Dopplerexamshouldberepeatedaspatientisresuscitatedandwarmed.

Exposureoftheposteriortibialarteryinthedeepcompartmentofthelegisthroughamedialincisionwithaliftor“bump”underthekneeorthigh.RepairwithveinifthreetibialarteriesareinjuredandanabsenceofaDopplersignalpersists.

Extremityvenousinjury.Recommendations:Selectiverepair.Utilityoftemporaryvascularshunts:Moderateforlargevessels.Method/conduit:Ligation,repair,orsaphenousinterpositiongraft.Pearls:

Repairofproximalveinsisindicatedtoreducevenoushypertensionandcongestion.

Shuntsinproximalveinswillusuallyremainpatentuntilformalrepaircanbeperformed.

Techniquesoflateralvenorrhaphyareacceptable,althoughpatchangioplastyoraninterpositiongraftusingsaphenousveinfromtheuninjuredlimbisoftennecessary.

Considerremovingthrombusfromthedistalvenoussegmentswithcompression(eg,ACEwraporEsmarkbandage)priortorepair.

Pneumaticcompressiondeviceondistalextremitytoaugmentvenousflowafterrepair.

Limbsalvagebenefitofveinrepaircomparedwithligationhasbeenshown2yearsafterinjury.

Repairofextremityvenousinjuryshouldonlybeconsideredinstablepatients.

ManagementAspects:TorsoVascularInjury

Aorta.Pearls:

Withsmallpenetratinginjuriestotheaortaofthechestorabdomen,primaryrepaircanbeattempted.

Whennotamenabletorepair,ashuntcanbeplaced(eg,chesttube).

Recognizethatpenetratinginjurymayinvolveentranceandexitwoundstotheaortathatmaynotbeobvious.

Managementofpenetratinginjurytotheaortaisveryrare,giventheprehospitallethalityofthisinjury.

Managementofbluntinjurytothethoracicaorta(partialtransectionorpseudoaneurysm)israre.

Mostsurvivorscanbemanagedmedicallywithcontrolofheartrateandbloodpressureusingbeta-blockersandpermissivehypotension.

EndovascularrepaircanbeattemptedatsomeRole3facilities.

Venacava.Pearls:

Establishresuscitationlinesabovethediaphragmforabdominalvenacavainjuries.

VenacavainjuriesshouldbeexposedusingtheCattell-BraaschandKochermaneuvers.

Lateralrepairisacceptable,understandingthatthelumenmaybecomprised.

Ifocclusionofthecavaresultsinhypotension,clampaortatosupportcentralperfusion.

Retrohepaticandretroperitonealhematomasshouldnotbedisturbedifnotactivelybleedingorexpanding.

Attempttoidentifylargelumbarveinsfeedingtheinjuredsegmentthatcanbleedprofusely.

PatchangioplastyorresectionandinterpositiongraftusingePTFEarereconstructiveoptions.

Ligationofthecavaisacceptableasadamagecontrolmaneuver.Ifairtransportisgoingtobeutilized,thenprophylacticbilaterallowerextremityfasciotomiesshouldbeperformed.

Portalveinandhepaticartery.Pearls:

Pringlemaneuvershouldprecedeexplorationoftheportaltriad.

Ligationofhepaticarteryinjuriesisacceptable,iftheportalveinispatent.

Lateralvenorrhaphyispreferred.

Damagecontrolligationoftheportalveinisanoption;itresultsinhepaticischemia,splanchniccongestion,andsystemichypervolemia.

Cholangiographythroughthegallbladderorwithasmallbutterflyneedleinthecommonbileductshouldbeconsideredinordertolookforassociatedinjuriesoftheextrahepaticbiliarysystem.

Mesentericarteries.Pearls:

PresentassupramesocoliczoneIhematoma.

Repairproximalmesentericarteryandveininjuries,includingportalvein.

Repairoptions:primarypledgetedrepair,veinpatchangioplasty,orreplacementoftheinjuredsegmentwithinterpositionsaphenousveingraft.

Ligationcanbeperformedfordistalarteryandveininjuriesorasdamagecontrol.

Renalarteries.Pearls:

ExplorezoneIIexpandinghematomasfrompenetratinginjury;90%ofexploredkidneysresultinnephrectomy.

Establishstatusofcontralateralkidneybycontraststudyormanualpalpationpriortonephrectomy.

Damagecontrolmayrequireearlynephrectomy.Devascularizedkidneythatisnotbleedingmaybeleftinsitu.

Iliacarteries.Recommendations: Ligate or shunt as damage control, or definitiverepair.Utilityoftemporaryvascularshunts:High.Method/conduit: Interposition graft/ePTFE or Dacron or saphenousvein.Pearls:

ExplorezoneIIIhematomafrompenetratingwoundafterestablishingaorticcontrol.

Distalcontrolisobtainedattheinguinalligament(forexternaliliacarteries).

Ifthereisprimaryinjuryto,orbackbleedingfromtheinternaliliacartery(hypogastric),itmaybeligated.Trytoavoidligatingbothinternaliliacsduetoriskofglutealischemia/necrosis.

ManagementAspects:CervicalVascularInjury

Carotidartery.Recommendations: Ligate or shunt as damage control, or definitiverepair.Utilityoftemporaryvascularshunts:High.Method/conduit:Veinpatchorveininterpositiongraft.Pearls:

ZoneIinjuriesbestapproachedwithmediansternotomyforample

proximalexposure.

Earlycontrolofcommoncarotid.

3FrFogartycatheterwiththree-waystopcockisusefultooccludeinternalcarotidbackbleeding.

Duringcarotidrepairconsidertemporaryshuntandaugmentationofmeanarterialpressure.

CTAaidsinthetriageforurgentoperation,improvesoperativeplanning,andimagesthebrainasabaseline.

AselectiveapproachtoexplorationofzoneIIneckwoundsisacceptableinapatientwithouthardsignsofvascularinjuryoraerodigestiveinvolvement.

PenetratingneckwoundsthatarenotselectedforexplorationshouldundergoCTAtofurtherevaluateforvascular,tracheal,oresophagealinjury.

Exposureofthecarotidarteryisthroughastandardanteriorsternocleidomastoidneckincision.

Vertebralartery.Recommendations:Ligate.Utilityoftemporaryvascularshunts:None.Method/conduit:Notapplicable.Pearls:

Bleedingvertebralarteryinjuriesareligatedwithnoroleforreconstructionintheater.

Vertebralarteryocclusionsaremanagedwithanticoagulation,ifitisnotcontraindicated.

Endovascularembolizationisanoptionifinjuryisnotaccessiblebystandardexposure.

Exposureusuallyrequiresrongeurtoopenvertebralforamen;temporaryocclusionwithbonewaxcanbehelpful.

Jugularvein.Recommendations:Ligationorselectiverepair.Utilityoftemporaryvascularshunts:None.Method/conduit:Lateralvenorrhaphy,veinpatch,orsaphenousvein.Pearls:

Significantjugularveininjuriescanbeligatedwithoutadverseeffects.

Repairofjugularinjuriesshouldbeconsideredinthesettingoftraumaticbraininjurywithelevatedintracranialpressure.

Largeveininjuries.Pearls:

Initialcontrolcanbeaccomplishedbyoneormorefingersonthebleedingsegment.

Useofclampsforcontrolmayinjuretheveinfurther.

Avoidtoosmallofaneedleandsuture,whicharedifficulttomaneuverinblood.4-0PROLENEonanSH-taperedneedleisasubstantivesutureonaneedlelargeenoughtosee.

ManualdirectpressurecanbereplacedwithasmallspongestickorKittner.

Hemorrhagecontrolwithligationispreferabletopatencywithdeathfromexsanguination.

Bewaryofriskofairembolismwithlargeveininjuries.

Ligationofvessels.Pearls:

Acceptabledamagecontrolmaneuver,especiallyforsmall,moredistalarteriesandveins(Table25-1).

Table25-1.VesselsAmenabletoLigationVeinsThatCanBeLigatedRoutinely ArteriesThatCanBeLigatedRoutinely

Internal/externaljugular Digital

Brachiocephalic Radialorulnar,butnotboth;preserveulnarwhenpossible

Infrarenalinferiorvenacava Externalcarotid

Leftrenal Brachialdistaltoprofundiandadequatewrist;Dopplersignal

Internaliliac Subclavianbranches

Subclavian Internaliliacs

Mesenteric Profundafemoris

Tibialis Hepatic

Temporaryvascularshuntingtorestoreperfusionshouldbeconsideredbeforeligation.

ContinuouswaveDopplershouldbecheckedbeforearterial

ligationtojudgeperfusion/viability.

Fogartythrombectomycatheters.Pearls:

Sizedat2–7Frcatheters;maximumballoondiameterofthe2and3Frcathetersis4and5mm,respectively.

Inflatewithsalineusinga1cctuberculinsyringe(0.2–0.75cc)whilewithdrawingfromthevessel.

Goalisclot,notintima,removal;so,donotoverinflateor“drag”toomuch.

Maybeusedtocontrolbleedingwithuseofathree-waystopcocktomaintaininflation.

Proximalanddistalthrombectomiesshouldbeperformedpriortoperformingrepair.

Temporaryvascularshunts.Pearls:

Inlineshuntsrestinthevessel(“insitu”),whereaslongexternalshuntsaredesignedtoloop.

InlineArgylshuntscomeinacylindercontainerwithsizes8,10,12,and14FrFogartycatheters.

InlineJavidshuntsarelongerandindividuallypackaged.

Sundtshuntsaredesignedwithshort(15cm;inline)andlong(30cm;external)profiles.

EqualsuccesshasbeenhadwithArgyl,Javid,andSundtshuntswithoutsystemicanticoagulation.

Securedwithsilkligaturesandpatentforupto6hours;reportsoflongerdurationexist.

Shuntsshouldberemovedwithformalrepairin-theaterpriortoAIREVACtoRole4.

Temporaryvascularshuntsareeffectiveandshouldbeconsideredinthemanagementofnearlyallextremityvascularinjurypatterns,includingproximalvenousinjuries.Theirmainadvantageisprovisionofearlyrestorationofflowandmitigationofthedamagingeffectsofarterialischemiaandvenoushypertension.Asanabbreviatedprocedure,comparedwithformalvascularrepair,shuntingextendsthewindowofopportunityforlimbsalvageinsomepatternsofvascularinjury.Althoughthepatencyat3–4hoursishigherinlarger,moreproximalvessels(axillary/brachialandfemoral/popliteal),shuntshavebeenusedeffectivelyinsmaller

(distalbrachial/forearmandtibial)vessels.Outcomesofextremityvascularinjurymanagedwithtemporaryshuntshavebeenrecorded,demonstratingnoadverseeffectofthistechniqueandalimbsalvageadvantageinthemostseverelyinjuredlimbs(MangledExtremitySeverityScore[MESS]≥8).

Considerdistalfasciotomies.

Pediatricvascularinjuries.Pearls:

Lessthan10yearsold:interventionshouldbeavoidedinthosegivenapropensityforspasm.

Ligationismorewelltoleratedininfantsandtoddlers,giventheabilitytorecruitcollaterals.

Performinterruptedsuturelines(6-0PROLENE)toallowexpansionwithgrowthofthechild

Endovascularcapabilityandinferiorvenacavafilters.Pearls:

Techniquesshouldbeusedinasmallsubsetofinjuriesanddirectedinconsultationwithatraumasurgeon.

Placementofvenacavafiltersshouldbeconsideredinpatientswhohavecontraindicationsforanticoagulation.

Useofprostheticgraftmaterial.Pearls:

ePTFE(GORE-TEX)orDacronusedforcentraltorsovascularinjuries(aorta,greatvessels).

Prostheticconduitacceptableasalastresortinextremitieswhenveincannotbeharvested.

Ifprostheticusedinextremityinjury,notifyhigherlevelsofcaretofacilitatesurveillance.

Harvestinganduseofautologousvein.Pearls:

Ifpossible,usereversedgreatersaphenousveinfromtheuninjuredextremity.

Exposeatsaphenofemoraljunctionoranteriortomedialmalleolus(consistentlocations).Besuretomarkanatomicallydistalendas“inflow,”ensuringreversalofveinconduit.

Introduce18-gaugeplasticveinormetallicolivetipcannulatodistendwithheparinsaline.

Nearlyalwaysinthesettingoftrauma,theveinappearsinsituas“toosmall”or“notadequate”duetovasoconstrictionorspasm.Bestassessedafterhydrodistention.

Soft-tissuecoverageandanastomoticdisruption.Pearls:

Covervascularrepairswithavailable,viablelocaltissue(muscleandadipose).

Ifnosofttissuetocover,routegraftsoutofthezoneofinjury.

Poorlycoveredvascularanastamosiscan“blowout.”

Avoiddirectplacementofnegativepressurewoundtherapyspongeonvascularstructures.

If no tissue is available to cover the vascular repair, route an interpositiongraft out of the zone of injury through another myocutaneous or evensubcutaneouspath.

Anticoagulation.Pearls:

Heparinsalineistypically1,000U/1L,althoughothermixtureswithorwithoutpapaverine(60mg/1L)areacceptable.

Systemicanticoagulationisachievedwith50U/kgofIVheparinwith1,000unitsrepeatedat1hour.Repeatdosesarenotrecommended,giventhepropensityforbleedinginwartimeinjury.

“Regionalanticoagulation”istheuseofheparinsalineflushintheinflow/outflowvessels.

Post-opcare.Palpable pulses obtained in the operating room should remainpalpablepost-op.Pulse changes, even if Doppler signals remain, may indicate graftthrombosisandshouldbeinvestigated.Considerlow-doseheparinasdeepveinthrombosisprophylaxis.Usewithcautioninmultiplyinjuredandhead-injuredpatients.Slightelevationofinjuredextremityimprovespost-opedema.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter26

Burns

Introduction

Burnssustainedduringmilitaryoperationsconstitutearelativelysmall,butveryrealpercentage(5%)ofcombat-relatedinjuries.Evenburnstoasmallsurfaceareacan be incapacitating for the casualty and strain the resources of deployedmilitarymedical units. It is crucial to remember that burnsmay represent onlyone of the casualty’s traumatic injuries, particularly when an explosion is themechanism of injury. Optimal treatment includes management of homeostaticchangesrelatedtotheburnandassociatedtraumaticinjuries.Resuscitationoftheburncasualtyisgenerallythemostchallengingaspectofcareduringthefirst48hoursfollowinginjury,andoptimalcarerequiresaconcertedeffortonthepartofallprovidersinvolvedduringtheevacuationandtreatmentprocess.

Point-of-InjuryCare

Keystepsintheinitialtreatmentofburncasualtiesinclude:

Stop the burning process. Extinguish flames.Move the patient to a safelocation.Removeall burned clothing. Safely separate thepatient from thepower source related to electrical injury. Remove chemical agents usingcopiousamountsofcleanwater.Provide emergency resuscitative care. Control hemorrhage and protectairway.Removeallconstrictingarticles.Removeitemssuchaswristwatches,rings,belts,andboots.Removeallcontaminatedclothingandequipment.Coverthepatient.Docoverthepatientwithaclean,drysheettominimizefurther contamination during transit. Place saline-soaked dressings overwoundsinvolvingwhitephosphorustopreventignitionofthephosphorusoncontactwithair.Protectagainsthypothermia.Utilizeblanket(s)orotherwarmingdevicestomitigate hypothermia. Patients with large surface area burns are atincreasedriskofhypothermia.Establish IV access. Through unburned skin if possible, through burnedskinifnecessary,andsecure(sewin)IVlines.Begin resuscitation. Use lactated Ringer’s (LR) solution or a similarsolution,andcontinueduringevacuation.

PrimarySurvey

Donotbedistractedbytheburninjuryitself!Theprioritiesofmanagementforburncasualtiesarethesameasthoseforotherinjuredpatients,withtheaddition of burn pathophysiology. The burn may not be the most life-threateninginjury.

Theprimarysurveyincludeshemorrhagecontrol,airwaymanagementwithprotectionofthecervicalspineasappropriate,basedonthemechanismofinjury, diagnosis, management of any breathing dysfunction, and rapidcirculatoryassessment.Intheburnpatient,specialattentiontoexposure,removalofmaterialsthatmaycontinuetoburnthevictim,andpreventionofhypothermiaareveryimportant.

Inhalation injury may be manifested by stridor, hoarseness,cough, carbonaceous sputum, or dyspnea. Airway obstructionmayresultfrompluggingoftheendotrachealtubeandshouldbesuspectedifacutechangesinpulmonarystatusoccur.Patients who may have sustained inhalation injury should becloselymonitored;withoutintubationifminimallysymptomatic.Preemptively intubate patients with symptomatic inhalationinjurypriortotransport.Endotrachealandnasogastrictubesshouldbedefinitivelysecuredwith cloth umbilical tape that can be adjusted based onprogressionof facialedema.Securing theendotracheal tube toapremolartoothusingstainlesssteelwireshouldbeconsideredinpatientswithfacialburnsorotherfacialtrauma.

Airway.Considercervical spine injury inpatients injured inexplosions, falls,orbycontactwithhigh-voltageelectricity.Burns are a “distracting injury,” pain secondary to burns, and thetreatment of painwith narcoticsmaymake the clinical diagnosis ofspinalinjurydifficult.

Breathing.Inhalationinjuryisnotcommon,butismorecommoninpatientswithextensive cutaneous burns, a history of injury in a closed space (eg,buildingorvehicle),andthepresenceoffacialburns.Patients with major burns and/or inhalation injury requiresupplementaloxygen,pulseoximetry,chestradiography,andarterialbloodgasmeasurement.Circumferentialburnsofthechestmaypreventeffectivechestmotion;for patients with circumferential full-thickness burns, performimmediatethoracicescharotomyasalife-savingproceduretopermitadequatechestexcursion(Fig.26-1).Definitive diagnosis of lower airway injury requires fiberoptic

bronchoscopy.

Fig.26-1.Dashedlinesindicatethepreferredsitesforescharotomyincisions.Boldlinesindicatetheimportanceofextendingtheincisionoverinvolvedmajorjoints.Incisionsaremadethroughtheburnedskinintotheunderlyingsubcutaneousfatusingascalpelorelectrocautery.Forathoracicescharotomy,beginincisioninthemidclavicularlines.Continuetheincisionalongtheanterioraxillarylinesdowntothelevelofthecostalmargin.Extendtheincisionacrosstheepigastriumasneeded.Foranextremityescharotomy,maketheincisionthroughtheescharalongthemid-medialormidlateraljointline.

Carbon monoxide poisoning causes cardiac and neurologicalsymptoms. Patients with carbon monoxide poisoning require 100%oxygenforatleast3hoursoruntilsymptomsresolve.

Circulation.Secureall IVcathetersand lineswithsutureorsurgicalstaples; tapewill not adhere to burned skin, and circumferential wrapping mayleadtosevereconstriction,edema,andpossiblevascularcompromise.Manual blood pressure measurements utilizing a cuff may beinaccurate in patients with burned or edematous extremities;therefore,arterialbloodpressureispreferredwhenpossible.

EstimationofFluidResuscitationNeedsforAdults

InitiateresuscitationwithlactatedRinger’sbasedonthepatient’sburnsize.Utilizeurineoutput as theprimary indexof adequacyof resuscitation (seebelow). It is equally important to avoid both overresuscitation andunderresuscitation.

DeterminetheburnsizebasedontheRuleofNines(Fig.26-2).Apatient’s

hand(palmandfingers)isapproximately1%ofthetotalbodysurfacearea(TBSA). Only second and third degree burns are included in burn sizecalculations.

Overestimationiscommonandmayleadtooverresuscitation.EstimateinitialhourlyrateforcrystalloidresuscitationutilizingtheRuleofTensandadjusthourlybasedonresponse.

InitialHourlyRate=%TBSABurn×10mL/h

Example:40%TBSABurn

InitialHourlyRateofLactatedRinger’s=400mL/h

Anyformula-basedcalculationisonlyaninitialestimateoffluidneeds.Patientsweighingmorethan80kgorwithinhalationinjury,predominantlyfull-thickness burns, and a delay in resuscitation will have higher fluidrequirements. The rate of infusion of LR must be adjusted based onphysiological response, primarily urine output. Avoid abrupt changes inrateofinfusion;avoidbolusinfusionofcrystalloids. Increaseordecreaseinfusion rate by approximately 25% of current rate as needed, based onresponse.For patientsweighing >80 kg, add 100mL/h for each 10 kg above 80 kg.However,remembertoadjustbasedonmonitoredresponseinurineoutput.If LR is not available, use other crystalloids such as normal saline. Ifcrystalloidsuppliesareseverelylimited,considerstartingcolloidasearlyas12 hours after injury. Resuscitation requires close monitoring of urineoutput.

Fig.26-2.RuleofNinesshowingthedistributionofbodysurfaceareabyanatomicalpartintheadult.

FluidResuscitationforChildrenWithBurnsFluidresuscitationforpediatricpatientswithburnsinvolving20%ormoreTBSA may be initiated using the Modified Brooke formula (2 mL/kg ×%TBSAburn×weight[kg]administeredover24hourswith½administeredin the first 8 hours) and adjusted based on response as measured byglucose-negative urine output, targeted at 1 mL/kg/h. As with adultpatients,frequentmonitoringandindividualtitrationareessential.Peripheral or intraosseous access may suffice initially; however, centralvenousaccessismorereliableandusuallyrequiredforfluidresuscitation.Children with burns over 20% TBSA should have a Foley-type catheterplaced (size 6 Fr catheter for infants and size 8 Fr catheter for olderchildren);diapersmaybeweighedtoaccountforurineoutputifFoleyisnotavailable.Childrenwith burns under 20% TBSA or those presenting for care 24–48hours after injury generally do not require a formal fluid resuscitation,ratherfluidshouldbeadministeredbasedonclinicalneed.Childrenmaybeprovidedoralnutrition/hydrationiftheyareabletosafelytolerate it;however,gastricdecompressionwithanasogastric tubeduringtheresuscitationphasemustalsobeconsidered.Stressulcerprophylaxisisessential.Resuscitationtargetsincludeanalertsensorium,fullperipheralpulses,andwarmdistalextremities.Serumsodiumshouldbemonitoredevery8hoursduringthefirst72hoursifburnsare>20%.Hypotonicresuscitationfluidshouldbeavoided.

MonitoringtheBurnPatientTwoIVcatheters,aFoleycatheter,continuousECG,pulseoximetry,acorethermometer, and anasogastric tube areneeded for ICU care of apatientwithburnsof20%TBSAorgreater.Vitalsignsandfluidinput/outputshouldbeaccuratelyrecordedhourlyonaflowsheet.Nasogastricdecompressionisessentialforallpatientswithburnsover20%TBSA,duetopotentialgastricileus.Placement of a Foley-type catheter is an essential part of the resuscitationprocess. Even full-thickness burns to the glans or penis itself should notpreventintubationoftheurinarymeatus.Debridementofescharanduseofasmallhemostatmaybenecessarytofacilitateurinarycatheterplacement.Suprapubic catheter placement is rarely, if ever, necessary because ofperinealburnsandshouldbeavoided,especiallyifthepatienthasburnstotheabdomen.

SecondarySurveyPerforma thoroughhead-to-toe secondary survey, looking fornonthermalinjuries, to include fractures, dislocations, corneal abrasions, and/ortympanicmembranerupture.

Ocular examination for corneal laceration and/or globe trauma should beperformed early before resuscitation-related edema makes examinationmoredifficult.If there is a question of intraabdominal injury, diagnostic peritonealaspiration,throughburnedskinifnecessary,isappropriate.

BurnResuscitation—First24Hours

Continuouslyreassessthepatient’shourlyurineoutput,whichisthesinglemostreliableindicatoroftheadequacyofresuscitation.

Targetaurineoutputof30–50mL/h inadultsor1mL/kg/h inchildren. Ifurineoutput is less than the target for1–2consecutivehours, increase theLR infusion rate by about 25%; if the response is greater than the target,decreaseratebyabout25%.Avoid overresuscitation, which may lead to edema-related complications(eg,compartmentsyndromeandpulmonaryedema).Other indices of effective resuscitation include a decreasing base deficit,improved tachycardia (a heart rate of 100–130 is expected in adult burnpatients),andanimprovingornormalmentalstatus.The use of diuretics is rarely, if ever, indicated in the treatment of burnshock,exceptwhengrosspigmenturiaispresent(seebelow).Glycosuria is common following severe thermal injury and may causehypovolemiasecondarytoosmoticdiuresis.ChecktheurineforglucoseandtreathyperglycemiawithIVinsulinasneeded.

BurnResuscitation—Second24Hours

Attheendofthefirst24hourspostburn,decreaseuseofcrystalloidlactatedRinger’sandimplementuseof5%albumininnormalsaline.

Calculationof24-houralbuminvolumeisasfollows:

5%albuminvolume=(*mL)×(%TBSAburned)×(preburnweight,kg)

%TBSAburn 30–49 50–69 70+*mL 0.3 0.4 0.5

Forexample,inaburnofapproximately40%inan80-kgpatient:

Albuminvolume=(*mL)×(40%)×(80kg)=(0.3)×(3,200)=960mL/24h=40mL/h.

Burns<30%TBSAgenerallydonotrequireinfusionofcolloidsolution.Itisrarelynecessarytoadjustthecolloidinfusionrate.Ifalbumin isnotavailable, fresh frozenplasmaorsyntheticcolloidcanbe

usedat the same rateused for5%albumin. Ifnoneof theseareavailable,continueutilizingLRwhilemonitoringurineoutput.Monitor electrolytes. Burn resuscitation is usually complete by 48 hoursafterburninjury.However,evaporativewaterlossreplacementisrequired.Bewatchfulforbothhypo-orhypernatremia!Document and communicate. Accurately document all fluid volumesadministeredtothepatientandcommunicatethisinformationtoprovidersas thepatient is transferredbetween levelsof care.Utilizationof the JointTheater Trauma System (JTTS) Burn Resuscitation Flowsheet is stronglyencouragedanddemonstratedtoimproveoutcomesfollowingsevereburns.Earlycommunicationwiththeburncenterisalsoencouraged.

BurnWoundCareThe burn wound itself is not immediately life-threatening. However,adequate wound care reduces the risk of infection, which remains theprimary complication in burn casualties. Early care of the burn woundshould be performed in a clean and warm environment where adequatesedationandanalgesiaareavailable.

EarlyburnwoundcareincludesadequateIVpainmanagement,removalofforeign materials, debridement, cleansing with antibacterial soap, andapplicationofatopicalantimicrobialdressing.

Adequatewound care requires adequate pain control. Small, intermittentboluses of IV morphine or fentanyl are effective for basal pain control.Ketamine,1mg/kgIV,iseffectiveforpainfulwoundcare.Prophylactic antibiotics are generally not recommended for burnwoundsalone.However, otherwounds—such as open fractures, facial injuries, orintraabdominal injuries—may justify use of IV antibiotics and are notcontraindicatedbythepresenceoftheburninjury.Apply a topical antimicrobial agent twice daily after thorough cleansingwithasurgicaldetergentsuchaschlorhexidinegluconate(Hibiclens).Useofsilvernylondressings:

Burnsmaybedressedinpliablesilvernylondressings,whichprovideeffectiveantimicrobialcoveragebyreleasingsilverions.Theyrequirea slightly moist environment to remain effective. They should bewrappedwitha layerof sterilegauze (KERLIX)andmoistenedwithwatertomaintainadampenvironment.Avoidoversaturationleadingtopossiblehypothermia.Silvernylondressingsmaybeleftinplaceforextendedperiods(48–72hours),whichmayofferanadvantageduringtransport.

Useoftopicalantimicrobialsolutionorcreams:Aqueousmafenideacetate(Sulfamylon)5%solutionmaybepreparedand used to moisten sterile gauze and wrapped or laid on burnwounds. Sulfamylon5% solution shouldbe applied to thedressingsapproximatelyevery8hourstomaintainmoistureinthedressings.

1% silver sulfadiazine (Silvadene), and/or 11.1% mafenide acetate(Sulfamylon),burncreamsmaybeused.Theyareappliedasa thicklayer(1/16to⅛inchthick)ontheburnandwrappedwithsterilegauze.During the period of activewound exudation, it is helpful to placebulkydressingsbeneaththeburnedpartstoabsorbtheexudate.Burncreamshouldbereappliedtoopenburnsasoftenasneededtokeepthemcovered.

Burnpatientsmustbeadequatelyimmunizedagainsttetanus.

Definitiveburnsurgeryinthecombatzoneisnotadvisedforpatientswhocanbeevacuatedtoadefinitiveburncarefacility.Prevent thermal stress by keeping the environment as warm as possible(>85°F).Cornealabrasionsinburnpatientscanleadtofull-thicknessulcerationandblindness, and require aggressive treatment with antibiotic ointments,preferably gentamicin or a quinolone every 4 hours, alternating witherythromycinevery4hours.Ear burns are prone to chondritis. Avoid placing ties across the ears andapplySulfamyloncreamtoburnsinvolvingtheearbecauseitwillprovidebetterpenetration.Itiscommonforpatientstodevelopasterile,chemicalcellulitis,manifestedby an erythematous rim of normal tissue extending 1–2 cm around thewound margin. Erythema extending beyond this margin, with otherclinical evidence of infection, likely represents beta-hemolyticstreptococcal cellulitis. Consider early use of vancomycin. Treat withappropriateIVantibiotics.Invasive gram-negative burn wound infection is heralded by strikingchangesinthecoloroftheburnwoundandaclinicalcourseconsistentwithsepsis.

Antibiotic treatment with an aminoglycoside and a semisyntheticantipseudomonal penicillin is recommended. Apply SulfamyloncreamBIDandplanurgentevacuation,ifavailable.Considersubescharclysis(injectionviaaspinalneedle)withthedailydose of an antipseudomonal penicillin (ticarcillin, piperacillin) in asuitablevolumeofcrystalloidsolution(eg,500mL).Thisisdoneatthetimeofdiagnosisandthenimmediatelypriortoexcisiontofascia.

Daily inspection of the burn wound by a surgeon is essential to identifyearlyinfectioncomplications.

ExtremityCareCarefully monitor the extremities throughout the resuscitation period.Managementoftheburnedextremitycanbesummarizedasfollows:

Elevate.Exerciseburnedextremitieshourly.

Evaluatepulsesandneurologicalstatushourly.Performescharotomyasindicated.

In extremities with full thickness, circumferential burns, and edemaformationbeneaththeinelasticescharmaygraduallyconstrictthevenousoutflow and, ultimately, arterial inflow. Adequate perfusion must beassessedhourlyduringresuscitation.

Progressive diminution of audible arterial flow by Doppler is aprimaryindicationforescharotomy.Dopplerflowshouldbesoughtinthepalmararch,notthewrist.

Pulses may be difficult to palpate in edematous, burned extremities.However, intheabsenceofaDopplerflowmeter,andintheappropriateclinical setting, loss of palpable pulses may indicate a need forescharotomy.Patients requiring escharotomy often presentwith a tight and edematousextremity. They may have progressive neurological dysfunction, such asunrelentingdeeptissuepainorparesthesias,and/ordistalcyanosis.Priortoprolongedtransport,stronglyconsiderprophylacticescharotomy.Note that loss of the palmar arch Doppler signal, in the presence ofadequate radial and ulnar pulses, is an indication for dorsal handescharotomies. These are performed over the dorsal interossei. Digitalescharotomiesmaybeusefulinsomecases.Following escharotomy, document restoration of normal pulses andcontinuetomonitorthepatient.Ifoneincisionfailstorestorepulses,makeasecondincisionontheothersideofthelimb.After escharotomy, coverwounds, including the escharotomy incisions, inburncream.Thepatientmaystilldevelopatrueintramuscular,subfascialcompartmentsyndromerequiringfasciotomy.Fractures associatedwith thermal injury are ideally treatedwith externalfixation to permit exposure of the burns and their treatmentwith topicalantimicrobial agents. Plaster, if used, should be bivalved immediately topermit access for wound care and to accommodate edema of the burnedlimb.

OtherConsiderationsBurn patients manifest a hypermetabolic state, with hyperthermia,tachycardia, and hypercatabolism, which may be difficult to distinguishfromearlysepsis.Stress ulcer prophylaxis with IV medication is crucial during the earlyphasesoftreatmentfollowingsevereburns.Implement early enteral nutrition once the patient is hemodynamicallystable,generallybetween24and48hourspostburn.Respiratorycare.

About 1week after injury, patientswith subglottic inhalation injury

maydevelop casts composed of blood,mucous, anddebris. Inhaledheparin sodium, at a dose of 10,000 units, may be given bynebulizationevery4hourstopreventtheformationofcastsandhelpprevent potentially life-threatening obstruction of endotracheal ortracheostomytubes.Subglottic inhalation injury may persist longer than clinicallyevident.Extubationmustbeperformedwithcautionafteradequateairwayassessment.

Patientswithlargeburnsareatriskforabdominalcompartmentsyndrome,which is best avoided through judicious resuscitation, avoidingoverresuscitation.

ElectricalInjuryHigh-voltage electrical injury (>1,000 volts) causes muscular damage thatoftenismuchgreaterinextentthantheoverlyingcutaneousinjury.Examine the extremities for compartment syndrome and perform urgentfasciotomyasneeded.Grosspigmenturia(myoglobinuria)mayresult,andfluidresuscitationmustbemodifiedtoprotectagainstrenalinjury.

Pigmenturiaisdiagnosedbyreddish-brownishurine,withadipsticktest that is positive for blood, butwith insignificant numbers of redbloodcellsonmicroscopy.Increase the hourly LR rate until a urine output of 100 mL/h isachieved.If increasinghydration fails to result inaprogressive clearingof theurinarypigmenturiaoveraperiodof3–4hours,add12.5gmannitoltoeachliterofLRinfused.Infusionofsodiumbicarbonateinwater(150mEq/L)toalkalinizetheurinemaybeuseful.

Hyperkalemia may occur as a result of rhabdomyolysis, and must becarefullyassessedandtreatedwithcalciumgluconateinfusion,insulin,andglucose.Surgical debridement of nonviable muscle is the definitive treatment ofmyoglobinuria.

High-voltage electric injury requires consideration of deep muscleinjury, with resultant rhabdomyolysis, hyperkalemia, acute renalfailure, and compartment syndrome. Cardiac monitoring, aggressivefluid and electrolyte management, fasciotomy, and debridement areoftenrequired.

Patientswithelectricalinjuriesareatincreasedriskforspinalfractures.

ChemicalBurnsInitialtreatmentrequiresimmediateremovaloftheoffendingagent.

Brush any dry materials off the skin surface before implementing

lavagewithcopiousamountsofwater.Inthecaseofalkaliburns,lavagemayneedtobecontinuedforseveralhours.Resuscitateandmanagechemicalburns justasyouwoulda thermalburn.

WhitePhosphorusBurnsMostofthecutaneousinjuryresultingfromphosphorusburnsisduetotheignitionofclothingandistreatedasaconventionalburn.Fragmentsofthismetal,whichigniteoncontactwiththeair,maybedrivenintothesofttissues.First-aid treatment of casualties with imbedded phosphorus particlesincludes copious water irrigation and placement of a saline-soakeddressingthatmustbekeptcontinuouslywet.Profound hypocalcemia and hyperphosphatemia have been described aseffectsofwhitephosphorusinjury.TreatwithIVcalcium.Rapidsurgicalremovaloftheidentifiableparticlesshouldbeperformed;aUVlampcanbeusedtohelplocateparticles.

Adilute(1%),freshlymixedsolutionofcoppersulfatehasbeenusedtohelpidentifywhitephosphorusparticles.However,thisisnolongerrecommendedbecause,ifthesolutionisabsorbed,itcancauseseverehemolysis. If it is used, immediatelywash it offwith copious salineirrigation;donotapplyitasawetdressing.

Liberallyapplytopicalantimicrobialburncreamspostoperatively.

TriageConsiderations

Applicationofoptimalcarecurrentlyresultsinsurvivalofapproximately50%ofyoung adults whose burns involve 80% of the TBSA or greater. However,treatmentoptions inabattlefield triage situationmaybe less thanoptimal, andexpectantcaremaybeconsideredforpatientswithburnsthatexceed80%TBSAwhen resources are limited. Expectant status (comfort care) should not beimplemented based solely on the severity of injury alone, and resuscitationshouldbeimplementedforallburnpatients,providedresourcesareavailableforprogressivecare,includingevacuationtodefinitivecare.Carecanbedelayedforthosepatientswithburnsof 20%or lesswhoareotherwise thermodynamicallystable.

CareofLocalNationalBurnPatientsTreatmentoflocalnationalpatientswithburnsisfrequentlyencounteredbydeployed medical units. The basic tenants of burn care apply to anypopulation.However, decisions regarding futilitymay arise based on theresources available both at the field facility and among civilian facilitieswithin the region. The inability to evacuate patients for any furtherdefinitive care may preclude initiation of aggressive resuscitative oroperative interventions and warrant early transition to comfort care

measuresifthereisnopotentialforevacuationfordefinitivecare.REMEMBER:Definitivecareofburnpatientsisresource-intensiveandaffectspersonnel, supplies, operating room availability, and the blood bank.Carefulplanningandstagingofoperationsareessential.Graft failureenlarges theoverallwoundburden.Protectionof thehealingdonorsite(s)isalsocrucial.Likewise,itisveryimportanttoutilizealldonorsitesefficiently,includingthescalp.

SummaryBurn patients must be evaluated as trauma patients, searching for otherinjuriesthatmaybemoreimmediatelylife-threateningthantheburnitself.Patientswithburnsinvolving20%ormoreoftheTBSAgenerallyrequireaformalfluidresuscitationandclosemonitoring.The Rule of Tens provides a simplified means of estimating the initialhourlyfluidresuscitationrate.Placement of a Foley catheter and close monitoring of urine output areessentialpartsoftheresuscitationprocess.Bothunder-andoverresuscitationareassociatedwithundesiredeffectsthatmustbeavoidedtoachieveoptimaloutcomes.Inmostsituations,thekeyfactoraffectingwhetherornotapatient’sburnsaredeemedsosevereastowarrantimplementingcomfortcaremeasuresisnot the extent of burn alone, but rather the availability and access todefinitivecare,includinglong-rangeevacuationifnecessary.Early communication and consultation with staff at the burn center areencouraged;earlydiscussionofmanagementandtransportoptionsensuresoptimalcoordinationalongthecontinuumofcare.Consultationmaybeobtained24/7/365bycallingtheUSArmyInstituteofSurgical Research (USAISR) Burn Center at Fort Sam Houston, Texas, at(210)222-BURN(2876)orviaemailat:burntrauma.consult@us.army.mil.UpdatedClinicalPracticeGuidelines(CPGs)relatedtoburntraumamaybefoundattheUSAISRpublicwebsiteundertheheadingforJTTSCPGs.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter27

EnvironmentalInjuries

Introduction

Thesuccessfulpreventionandcontrolofcold,heat,andaltitudeinjuriesdependonvigorouscommandinterest,theprovisionofadequateclothing,andanumberofindividualandgroupmeasures.Themedicalofficermustensurethatheorsheunderstands how military duties impact the occurrence and severity ofenvironmentalconditions,andadvisethecommanderonpreventivemeasures.

ColdInjuries

Trench foot and frostbite together have accounted for more than 1 million UScasualtiesinWorldWarI,WorldWarII,andtheKoreanWar.Influencingfactorsincludeprevious cold injury, fatigue, concomitant injury resulting in significantbloodlossorshock,geographicorigin,nutrition,tobaccouse,activity,drugsandmedication, alcohol, duration and exposure, dehydration, environment(temperature,humidity,precipitation,andwind),andclothing.

NonfreezingColdInjuryChilblains.

Results from intermittent exposure to temperatures above freezing,usually accompanied by high humidity and moisture; 1–6 hours ofexposure.Swelling, tingling pain, and numbness,with pink-to-red flushing oftheskin(especiallythefingers).Extremitieswillbepruriticastheywarmup.Symptoms usually subside overnight; some superficial scaling mayoccur.Mildjointstiffnessmayoccuracutely,butsubsidesinafewhours.Nopermanentdamageoccurs.

Pernio.Continuumofeventsfromchilblains.Exposurefor>12hourstocoldand/orwetconditions.Tight-fittingfootwearcanshortenexposuretimeandincreaseseverityofinjury.Swellingismoresevere;painismorepersistentthanwithchilblains.Thin,partial-skinthicknessandnecroticpatches(fromthedorsumofthehandsorfeet).

Plaquesmaysloughwithoutscarring,butmaybeparticularlypainfulformonthsoryears.

Trenchfoot.Epidemiology/clinicalappearance.

Occursfromprolongedexposuretocold,wetconditions,orprolongedimmersionoffeetattemperaturesashighas17°Cfor>12hours.Shorterdurationatornear0°Cresultsinthesameinjury.

Occursinnonfreezingtemperatures0°C–12°C.

Canoccurathighertemperaturesfromprolongedwaterimmersion.

Blunttraumaofmarchingcanproducemoreseriousinjury.

Firstsymptomisoftenthefeetbecomingcold,mildlypainful,andnumb.

Tightfootwearincreasesriskoftrenchfoot.

Commonsymptomsare“coldandnumbness”or“walkingonwood.”

Footmayappearswollen,withtheskinmildlyblue,red,orblack.

Limbishotandoftenhyperhidrotic.

Onrewarming,painisexcruciatinganddoesnotrespondtopainmedication,includingmorphine.

Astimeprogresses,liquefactionnecrosisoccursdistally,butmoreproximaltissuemayalsobecompromised.

Nosharplineofdemarcationofdeadtissuefromviabletissue.

Nerve,muscle,andendothelialcellsaremostsusceptibletothislong-termcooling.

Microvascularvasospasmwithtissueischemiaistheapparentetiologyoftrenchfoot.

Postinjurysequelaeincludepain,numbness,lossofproprioception,andcoldfeet.Hyperhidrosiswithsubsequentparonychialfungalinfectionsarecommon.

Lifelong,life-changinginjury.

Treatment.

Preventfurthercoldexposure.

Donotmassage.

Dryextremity,warmtorso,andallowslowpassiverewarmingof

feet.Neverimmersefeetinwarmorhotwater.Elevatefeet.

Rehydrate.

Ifvesiclesdevelop,donotdebride.

Painmedication:Theonlyeffectiveapproachisamitriptyline50–150mgatbedtime.Otheranalgesicsareeithercompletelyineffectiveor(aswithnarcotics)donotactuallyrelievepain.

Blistersshouldbeleftintact;rupturedblistersrequiremeticulousantisepsisafterunroofing.

Systemicantibioticsandtetanusprophylaxisareindicatedwhentherearenonviabletissues,aswithanyothercontaminatedwound,orwhenthereisevidenceofinfection.

Debridementofnecrotictissuemayberequiredintrenchfoot.

Maceratedordamagedskinrequirestopicalantibacterialprecautions.

Avoidtrauma.

Earlymobilizationisvitaltopreventlong-termimmobility.

Recoveryisprotractedandmayrequireevacuationbecausetrenchfootmayleadtoweeksandmonthsofpainanddisability.

Long-termsequelaeareverycommonandincludesensitivitytothecold(secondaryRaynaud’sphenomenon),chronicpain,neurologicalimpairment,andhyperhidrosis.

Frostnip.Exposedskinappearsredorminimallyswollen.Tissueisnotactuallydamaged.Nottruefrostbite;freezingislimitedtoskinsurfaceonly.Signalsimminentlikelihoodoffrostbitedeveloping.Resolvesquicklywithwarming.

Frostbite.Results fromcrystallizationofwater in the skinandadjacent tissuesexposedtotemperaturesbelowfreezing.Depth and severity of injury are a function of temperature andduration—thelowerthetemperature,theshorterthetimerequiredtoproduceinjury.Atlowtemperatures,inthepresenceofwind,exposedskincanfreezewithinafewseconds—startsdistallyandprogressesupthefingerortoe.Freeze front (line where the ice is formed in the tissues) is whereliquefactionandnecrosisoccur.Tissuesimmediatelyproximaltothis

linemayalsodie,buttherapeuticmodalitiesaredirectedatimprovingtheirsurvival.Clinicalappearance.

Skininitiallybecomesnumbandfeelsstifforwoody.

Mottled,bluish,yellowish,“waxy,”or“frozen.”

Depthofinvolvementmaybedifficulttodetermineuntildemarcationoccurs,whichmaytakeanextendedperiod.

Frostbitegrading.

Classificationintodegreesisprimarilyaretrospectiveevaluationandhaslittletreatmentvalue.

Amoreclinicallyusefulgradingtypicallydividesinjuriesintosuperficialordeep.

Superficialfrostbite.

Involvesonlytheskinwithswelling,mildpain,andminorjointstiffness.

Noblistersform.

Nonmedicalpersonnelcanmanagesimplybyrewarming.

Deepfrostbite.

Involvesdeepertissuestoincludebone.

White-hard,anesthetic,blanched,andinflexible.

Skinwillnotmoveoverjoints.

Onrewarming,thereisgreatpainandablue-gray-to-burgundycolorchange.

Blistersformandareclear,fluid-filled,orhemorrhagic(thelatterindicatesamoresevere,deeperinjury).Theyshouldbeleftinplace;willsloughin7–10dayswithoutconsequence.

Failuretoformvesiclesinanobviouslydeep-frozenextremityisagravesign.

PostinjurysequelaeincludeRaynaud’sphenomenon;pain;paresthesias;hyperhidrosis;lossofproprioception;cold,discoloredfeet;andgaitmodification.

Fieldtreatment(first-aid).Superficial(blanchedcheeks,nose,ears,fingertips).

Warmwithpalmofhandorusewarm,wetcloth;warmfingersinarmpits.

Emollientsmayhelppreventskinfromdryingorcracking.

Donotmassage,rubwithsnow,orwarmbodypartbyanopenfireorhigh-heatsource.

Meticulousskincareisrequired.

Deepfrostbite.

Preventfurthercoolingofbodypart,aswellasthepatientasawhole.

Applydry,sterilebandageandelevateinvolvedextremity.

Protectfromrefreezingduringevacuation.

Evacuatepromptlytodefinitivemedicalcare.

Avoidthawingandrefreezing;thisleadstothegreatestdamagetotissueandthepoorestoutcome.

Medicaltreatmentfacility.Theoutcomeofafrozenextremityisnotdirectlyrelatedtolengthoftimefrozen,butmoreimportantlytothemethodofrewarmingandanysubsequentrefreezing.

Ifthesoldierwillagainbeatriskforrefreezing,noattemptatrewarmingshouldbeinitiated;thesoldiershouldambulateonthefrozenextremitiesuntilheorshereachesdefinitivecare.

Fortransport,thepatient’sextremityshouldbesplinted,paddedwithdrydressings,andprotectedfromheatsourcesthatwouldslowlyrewarmtheextremity.

Rapid rewarming (without the possibility of refreezing) is thetreatmentofchoice.

Immerseingentlycirculatingwater(whirlpoolbath)at40°C(104°F)foratleast30minuteslongerthanwouldbeneededtodefrostallaffectedtissues.Ifdeepfreezingofthelegorarmhastakenplace,thoroughsurgicalfasciotomyismandatorypriortorewarmingtopreventcompartmentsyndromesubsequenttothereperfusionofthawingtissue.Extremitiesarerewarmeduntilpliableanderythematousatthemostdistalareas.

Twicedailywhirlpoolbathsat40°Cwithtopicalantibacterialaddedtothewater,togetherwithoralethanol.Thealcoholreducestheneedforanalgesiaandmayimproveoutcome.Otherdrugregimensremainunproven.

Afterrewarming,edemawillappearwithinafewhoursandvesiclesformwithinthenext6–24hours.

Intensivemobilizationisessentialtoavoidlong-termimmobility.

Vesicles.

Frostbitevesiclesaretypicallyleftintact.

Debridementisnotrecommended.Earlysurgeryisonlyindicatedinseverelyinfectedcases.Normally,surgeryshouldbedelayedforatleast6months.

Generalconsiderations.

IbuprofenorKetorolacshouldbegivenassystemicthromboxane/prostaglandininhibitors.

Systemicantibioticsandtetanusprophylaxisareindicatedwhentherearedeadtissues,aswithanyothercontaminatedwound,orwhenthereisevidenceofinfection.

Dry,loosedressingsmaybeapplied.

Cigarettesmokingand/ornicotineusearecontraindicatedduringtreatmentduetotheireffectonthemicrovasculature.

Dailyhydrotherapyisrecommended.Paincontrolwithnonsteroidalantiinflammatorydrugsandnarcoticswillbeneeded.

Sequelaeincludecontractures,coldsensitivity,chroniculceration,arthritis,andhyperhidrosis.

Frostbitecaseswillrequireprolongedhospitalcare(9daysonaverage);therefore,allbutthosewiththemosttrivialinjuriesshouldbeevacuatedtomoredefinitivecareassoonaspossible.

Earlysurgeryisindicatedonlyinthemostseverefreeze-thaw-refreezecases,wheremassivetissuedestructionhastakenplace,andinsomemoreseverelyinfectedcases.Normally,surgeryshouldbedelayedforatleast6months(“freezeinJanuary,operateinJuly”).

Due to the inability to reliably predict the outcome in thepostthawperiod, there isno role fordebridement/amputationofnecrotic or potentially necrotic tissue in the initial treatment offrostbite.

Hypothermia

Hypothermiaisclassicallydefinedaswhole-bodycoolingbelow35°C.Thedegreeofhypothermia is furtherdefinedaccording to thebody’score temperatureandtheclinicaleffectsseeninagiventemperaturerange.

Causativefactorsandprevention.Waterimmersion.

Rainandwind.Prolongedexposuretosevereweatherwithoutadequateclothing.Theinsulation effect of clothing is markedly decreased with wetness,whichincreasestheconductiveheatloss.Staydryandavoidwindyexposure.Shiveringcanprovide5timesthenormalmetabolicheatproduction.Exhaustion and glycogen depletion decrease the time of shivering.Compromise of shivering due to inadequate food intake (skippingmeals), exhaustion, heavy exercise, alcohol, and drugs increases thethreatofhypothermia.

Mildhypothermia:>33°C(>91°F).Shivering,hyperreflexia.Amnesia,dysarthria,poorjudgment,ataxia,apathy.Colddiuresis.

Moderatehypothermia:28°C–33°C(82°F–91°F).Standard hospital thermometers, mercury as well as digital, cannotmeasuretemperaturesbelow34°C(93°F).Stupor,lossofshivering.Onsetofatrialfibrillationandotherarrhythmias.Progressive decrease in level of consciousness, respiration, andpupillaryreaction;eventualpupildilation.

Severehypothermia:<28°C(<82°F).Increased incidence of ventricular fibrillation, which often occursspontaneously.Lossofmotionandreflexes,areflexicatapproximately23°C(72°F).Markedhypotension/bradycardia.

Profoundhypothermia:<20°C(<68°F).Asystole.Lowestknownadult survival fromaccidentalhypothermia is 13.7°C(56°F).

TreatmentPrehospital(field)treatment.

Awakepatients.

Removewetclothing;dryandinsulatethepatient.

Giveoralsugarsolutionstohydrate.

Walkoutortransporttomedicaltreatmentfacility.(Thisshouldbeattemptedifitistheonlyalternativebecauseitislikelytoworsenthecondition.)

Althoughwalkingmaydeepenhypothermiaduetothereturnofperipheralcolderbloodtothecore,adequateprehydrationdecreasesthepostexposurecooling.

Comatosepatients.

Patientshouldremainhorizontalandbehandledgentlytoavoidinducingarrhythmias;donotmassage.

IVfluids,warmedto40°C–42°C,ifpossible.

DonotuselactatedRinger’ssolutionbecausethecoldlivercannotmetabolizelactate;warm(40°C–42°C[104°F–107.5°F])D5NSisthefluidofchoice.

Removewetclothes,dry,insulate,andaddanoutervaporbarrier.Wrappatientinmultiplelayersofinsulation.

Limitactiverewarmingprincipallytothebody’scenter/coreonly.

Heated(40°C–45°C),humidifiedair/oxygenisthemethodofchoice.

Norwegianpersonalheaterpack(charcoalheater),withwarmingtubeplacedintoinsulationwrap.

Forcedair(BairHugger)withrigidchestframe.

Hotwaterbottlesingroin/axilla.

Intubationandheatedventilationmaybeperformed.

Ifapneicandasystolic,considerCPR,becausethebrainmaysurvivelonger.

REMEMBER:Thepatientisnotdeaduntilhe/sheiswarmanddead.Continueresuscitation,ifpossible,untilpatienthasbeenrewarmed.

Medicaltreatment.Ventilate;applyCPRifasystolicorinventricularfibrillation.As the body cools, the peripheral vasculature constricts, causingpoolingofcoldacidoticblood.Rewarmingtheperipheryof thebodyrather thanthecorecausesaninrushof this coldacidoticblood into thecore, furtherdropping thecoretemperature(afterdrop)andworseningcardiacinstability.Core rewarming—peritoneal dialysis, thoracic lavage, heated andhumidified oxygen, external warm blankets, and warm water torsoimmersion.Forventricularfibrillation.

Bretyliumtosylate,10mg/kg.Bretyliumistheonlyknowneffectiveantidefibrillationdrugforhypothermia.Itremainsfunctionalinacoldheart.Othermedicationshavenotproveneffective.

WarmedIV(lactateandpotassium-free).

Monitorcoretemperatureviaesophageal(preferred)orrectalprobes.

Carefulcorrectionofacid–basebalance.

Rewarmcoreto32°C(90°F)andattemptcardioversion(360J).Continuerewarmingandrepeat.Defibrillateafterevery1°Criseintemperature.

Monitorpotassium,glucose,temperature,andpH.

Majorcausesoffailuretoresuscitateincludeelevatingcentralvenouspressuretoofastortooearly,attemptingdefibrillationwhencoretemperatureisbelow32°C,orcontinuingtorewarmpast33°CwhenpotassiumlevelsarehighandpHislow.Ifserumpotassiumlevelsarehigh,considertheuseofintravenousglucoseandinsulin.

Avoidotherantiarrhythmicsandothermedications.

Patientswithcoretemperature(rectal)above30°Ccangenerallyberewarmedexternallyinavarietyofmethods,includingwarmblanketsandwarmwatertorsoimmersion.Patientsbelow30°Crectalshouldbeconsideredmorefragileandwilloftenrequireinternalmethodsofrewarming(ie,warmgastric,colonic,and/orbladderlavage;warmperitoneallavagedialysis;warmthoraciclavage;andextracorporealbloodrewarming).Lavagefluidsshouldbewarmedto40°C–42°C(104°F–107.5°F).

Coretemperaturewillcontinuetodropafterthepatientisremovedfromcoldexposure.Continuedtemperaturedropcanhavegraveprognosticimplicationandincreasesthelikelihoodoffibrillation.Post-rewarmingcollapseofanapparentlyfunctionalheartoftenleadstoanonresuscitableheartanddeath.

Cardiopulmonaryresuscitation.Ifthecardiacmonitorshowsanyelectricalcomplexes,checkcarefullyfor apical and carotid pulses before initiating CPR. If any pulse—howeverthready—ispresent,DONOTINITIATECPR.

Traumapatientsshouldbeconsideredtohavehypothermiamoreprofound than the core temperature indicates and be warmedmoreaggressively.

Treatmentofmildstablehypothermia.Insulation.Heatlamps.WarmedIVfluids.Warmedforcedair (BairHugger).Hairdryershavebeen jury-riggedforthispurpose.Considerarteriovenousanastomoseswarming.

Immersehand,forearms,feet,andcalvesinwaterheatedto44°C–

45°C(111°F–113°F).

Opensarteriovenousanastomosesinthedigitscausingincreasedflowofwarmedvenousbloodtotheheartanddecreasesafterdrop.

Treatmentofseverehypothermiawithhemodynamicinstability.Cardiopulmonarybypasswithrewarming,whenavailable,istheidealtechnique in this circumstance because it provides core rewarmingwhileensuringcirculatorystability.

HeatInjury

In themilitary setting, heat illness occurs in otherwise healthy individuals andranges from mild (heat cramps) to life-threatening (heatstroke). Individualstypicallypresentwithexertionalheatillnessandarehotandsweaty,nothotanddry,asseeninclassicheatstroke.

Lackofsweatingisnotacriterionforheatstroke.Somemilitarycasualtiesofheatstrokehaveprofusesweating,especiallywithrapidonsetofheatstroke.

Minorheatillnessesincludeheatcrampsandheatexhaustion.Majorheatinjuriesinclude exertional heat injury, exertional rhabdomyolysis, and heatstroke. Thediagnostic categories of heat exhaustion, exertional heat injury, and heatstrokehaveoverlapping features,andshouldbe thoughtofasdifferent regionson thecontinuumratherthandiscretedisorders,eachwithitsowndistinctpathogenesis.

Heatinjuryprevention.Easiertopreventthantreat.Occursmostcommonlyinunacclimatizedindividuals.

Acclimatizationtoheatrequires7–10days.

Predeploymenttraininginartificiallywarmenvironmentsdoesaidheatacclimatization.

Onehourofprogressivelymoredifficultexercisesufficienttoinducemoderatesweatingeachdaywillmaximizeacclimatization.(Regularstrenuousexercisesufficienttostimulatesweatingandincreasebodytemperaturewillresultinasignificantdegreeofheatacclimation.)Aerobicfitnessprovidescardiovascularreservetomaintaintheextracardiacoutputrequiredtosustainthermoregulation,muscularwork,andvitalorgansinthefaceofheatstress.

Utilizepublishedwork–restcycleguides(eg,FM21-10/MCRP4-11.1Dor Field Hygiene and Sanitation) or work–rest cycles tailored to theindividual’sphysicalcapacitybydirectmedicaloversight.Water restriction/discipline leads to increased heat injury and iscontraindicated.Acclimatizationdoesnotreduce,andmayactuallyincrease,water

requirements.

Servicememberswill,onaverage,notfeelthirstyuntil1.5L(1%–2%)dehydrated.

Fluidintakeshouldbemonitoredtoensureurineappearsdilute.Additionally,soldiersshouldbemonitoredforbodyweightchangesandorthostaticbloodpressurechangesduetohydration.

Thegastrointestinaltractcanabsorbonly1–1.5L/h.

Dailyrehydrationshouldnotexceed12L/dorally.Toomuchhydrationcanalsobedangerousandleadtowaterintoxication!

Leadersmustreinforcehydrationbyplanningforallaspectsofadequatehydration—eliminationaswellasconsumption.(Soldiersmaynotdrinkatnighttoavoidawakeningandhavingtodresstourinate,orsoldiersmaynotdrinkpriortoaconvoybecausenoreststopsareplanned.)

MOPP (Mission-OrientedProtectivePosture) gearwill increase fluidlossesandtheincidenceofheatinjuries.In the first fewdays of acclimatization, sweat–salt conservationwillnotbefullydeveloped.Saltdepletionisariskifsoldiersareexposedduring this time to sufficient heat or work stress to induce highsweating rates (more than several liters/day), particularly if rationconsumptionisreduced.Saltdepletioncanbeavoidedbyprovidingasaltsupplementintheformofsaltedwater(0.05%–0.1%).Acclimationshouldeventuallyeliminatetheneedforsaltsupplementation.Salt supplements are not routinely required and are onlyrecommended in rare instances where adequate rations are notconsumed.Coincidental illnesses increase heat casualty risk through fever anddehydration. Fever reduces thermoregulatory capacity leading toincreasedrisk,evenafterclinicalevidenceofillnesshasdisappeared.Requires increased command supervision and moderate workschedule.Sunburn and other skin diseases of hot environments reduce theabilityof theskin to thermoregulate.Sunburnmustbepreventedbyadequate clothing, shade, and sunscreen. Skin diseases are bestpreventedbyadequatehygiene.Medications that affect thermoregulatory adaptations and increaserisk of heat injury include anticholinergics, antihistamines, diuretics,tricyclic antidepressants, major tranquilizers, stimulants, and beta-blockers.

Despitepreventivemeasures,servicemembersmaysufferfromheatillness.Onecaseofheat illness is awarning sign thatmanyothers are imminent.Themost

life-threatening condition is heatstroke. Severity of heat illness depends on themaximumcoretemperatureandduration.

Heatstroke.

Heatstroke is distinguished from heat exhaustion by the presence ofclinically significant tissue injury and/or altered mental status. Degree ofinjury appears to relate to both the degree of temperature elevation anddurationofexposure.

Ifheatstrokeissuspectedandtemperature iselevated,coolingshouldnot be delayed to accomplish a diagnostic evaluation. Cooling andevaluationshouldproceedsimultaneously.

Clinicalpresentation.

Heatstrokeisatrueemergency.Itinvolvescomponentsoffiveorgansystems:brain,hemostatic,liver,kidneys,andmuscles.

Encephalopathyrangesfromsyncopeandconfusiontoseizuresorcomawithdecerebraterigidity.Profoundneuropsychiatricimpairmentspresentearlyanduniversallyincasualtiesofadvancedexertionalheatstroke.

Coagulopathy:Thermaldamagetoendothelium,rhabdomyolysis,anddirectthermalplateletactivationcausesintravascularmicrothrombi.Fibrinolysisissecondarilyactivated.Hepaticdysfunctionandthermalinjurytomegakaryocytesslowtherepletionofclottingfactors.Hepaticinjuryiscommon.Transaminaseenzymeelevation(values100ormoretimestheuppernormallimit),clottingfactordeficiencies,andjaundice(within24–36hoursofonset)arealsopresent.Transaminaselevelsmaybetransientandreversible;but,iftheypersistfor48hours,itisindicativeofmoresevereinjury.Hypoglycemiaisafrequentcomplicationofexertionalheatstroke.

Renalfailure:Myoglobinuriafromrhabdomyolysisinexertionalheatstroke,acutetubularnecrosisduetohypoperfusion,glomerulopathyduetodisseminatedintravascularcoagulation,directthermalinjury,andhyperuricemia.

Musclesareoftenrigidandcontracted:Rhabdomyolysisisafrequentacutecomplicationofexertionalheatstroke.Acutemuscularnecrosisreleaseslargequantitiesofpotassium,myoglobin,phosphate,uricacid,andcreatine,andsequesterscalciuminexposedcontractileproteins.

The patient with heatstroke requires immediate evacuation tomedical facilitieswith intensivecare capabilities.Active coolingshouldbestartedimmediatelyandcontinuedduringevacuation.

Prodromalsymptomsincludeheadache,dizziness(lightheadedness),restlessness,weakness,ataxia,confusion,disorientation,drowsiness,irrationaloraggressivebehavior,syncope,seizures,orcoma.

Collapseisauniversalfeatureofheatstroke.

Anindividualwithacoretemperatureof≥40ºC(104°F)andCNSdysfunctionthatresultsindelirium,convulsions,orcomahasheatstroke.

Casualtieswhoareunconsciousandhaveacoretemperatureof≥39°C(102.2°F)haveheatstroke.

Coretemperatureisoftenloweronarrivalatatreatmentarea.

Seizures:

Occurfrequently(>50%ofcases)withheatstroke.

Hindercoolingefforts.

Treatwithdiazepam5–10mg.

Treatment.

Rapidcoolingcanreduceheatstrokemortalityanywherefrom50%downto5%.Coolingbysprayingcoolwateroverthebodyandvigorousfanningcanbeeffective,althoughnotaseffectiveasicewaterimmersion.Anyeffectivemeansofcoolingisacceptable.

Avarietyoftechniqueshavebeenused.Althoughevaporativecoolingislesseffective,theiceimmersionmethodmaypreventsafecardiacmonitoringorrapidresuscitation.

Coolwaterimmersion(20°C)withskinmassageistheclassictechnique.Itprovidesrapidcooling.Closelymonitorpatientfor,andprevent,shivering.

Coolingwithcoolwater-soakedsheetsoricechipsandvigorousfanningishighlyeffective.

Donotusealcoholinthecoolingsolutionbecausefreezingoftheskincanoccur.

The goal of treatment is to effect a rapid lowering of the coretemperatureto38°C(101°F),withoutinducingshivering.

Rectaltemperatureshouldbecloselymonitoredduringcooling.Discontinuecoolingeffortswhencoretemperaturereaches38.3°C(101°F)toavoidhypothermia.

AspirinandacetaminophenshouldNOTbegiventocasualtiesofheatstroke.

Aggressivefluidresuscitationisnotrequired.Fluidrequirementsof1Linthefirst30minutes,withanadditional2Lormoreinthenext2hoursmaybesufficient.Becauseheatstrokepatientsarefrequentlyhypoglycemic,theinitialfluidshouldincludedextrose(chilledIVfluidisoflimitedbenefit).

Basefurtherhydrationonfluidstatus/urinaryoutput(Foleyrequired).

Overhydrationcanleadtocongestiveheartfailure,cerebraledema,andpulmonaryedemaintheheat-stressedlung.

Ifshiveringdevelops,treatwithdiazepam(5–10mgIV)orchlorpromazine(50mgIV).

Patientsarefrequentlyagitated,combative,orseizing.Diazepamiseffectiveforcontrolandcanbeadministeredintravenously,endotracheally,orrectally,butshouldbeusedwithcaution.

Airwaycontrolisessential.Vomitingiscommon,andendotrachealintubationshouldbeusedinanypatientwithareducedlevelofconsciousnessorotherwiseunabletoprotecttheairway.Supplementaloxygenshouldbeprovidedwhenavailable.

Hypotensivepatientswhodonotrespondtosalineshouldreceiveinotropicsupport.Carefultitrateduseofdopamineordobutamineisreasonableandhasthepotentialaddedadvantageofimprovingrenalperfusion.

Pulmonaryarterywedgepressuremonitoringshouldbeusedinpatientswithpersistenthemodynamicinstability.

Managementofencephalopathyissupportiveinnatureandisdirectedatminimizingcerebraledemabyavoidingfluidoverreplacementandbyensuringhemodynamic,thermal,andmetabolicstability.IVmannitolhasbeenusedtotreatlife-threateningcerebraledema,butisquestionableunlessrenalfunctionisadequateandthepatientisfullyhydrated.Theefficacyofdexamethasonefortreatingheatstroke-inducedcerebraledemaisnotknown.

Complications.

Rhabdomyolysisandsecondaryrenalfailureduetomyoglobinuriaandhyperuricemia;hyperkalemia;hypocalcemia;andcompartmentsyndromesduetomuscleswelling.

Elevatedcreatinephosphokinase(inthethousands).

AdministerIVfluidandpossiblyfurosemidetomaintainurinaryoutput>50cc/h.(Assuranceofadequaterenalperfusion

andurineflowwillmoderatethenephrotoxiceffectsofmyoglobinanduricacid.)

HyperkalemiacanbemanagedbyK++/Na+ionexchangeresin(Kayexalate)givenorallyorrectallyasanenema.Ifavailable,dialysismayoccasionallybeindicated.

Hypocalcemiadoesnotusuallyrequiretreatment.

Increasingtendernessortensioninamusclecompartmentmayrepresentincreasingintracompartmentalpressures.Directmeasurementofintramuscularpressureorfasciotomyshouldbeconsidered.Painandparesthesiafromacompartmentsyndromemaynotbepresentuntilafterpermanentdamagehasoccurred.

AlkalinizeurinewithsodiumbicarbonateIV(2ampsNaHCO3/LD5W).Managementofacuterenalfailurerequiresexquisiteattentiontofluidandelectrolytebalance.Uremicmetabolicacidosisandhyperkalemiarequiredialysisforcontrol.

Coagulopathyduetohepaticinjury.

Hepaticinjuryiscommon,resultingintransaminaseenzymeelevation,clottingfactordeficiencies,andjaundice.Transaminaselevelsmaybetransientandreversible.But,iftheypersistfor48hours,thenitisindicativeofmoresevereinjury.

Worstprothrombintimeoccursat48–72hourspostinjury.

Thrombocytopeniaanddisseminatedintravascularcoagulationpeakat18–36hourspostinjury.

Bewareofthecoagulopathytimeframewhenplanningevacuation.

Subclinicalcoagulopathydoesnotrequireactivemanagement.Clinicallysignificantbleedingisanominoussign.Treatmentisdirectedatreducingtherateofcoagulationandreplacementofdepletedclottingfactors.Intravascularcoagulationcanbeslowedbycautiousheparininfusion(5–7units/kg/h),followedin2–3hoursbyfreshfrozenplasmaandplatelets.Successfulmanagementleadstoadeclineintheindicesoffibrinolysis(eg,fibrinsplitproducts).Heparinistaperedgraduallyover2–3daysasdirectedbylaboratoryevidenceofcontrol.

Monitorforhypoglycemiaorhyperglycemia.

Prognosisisworseinpatientswithmoreseveredegreesofencephalopathy.Permanentneurologicalsequelaecandevelopafterheatstroke,includingcerebellarataxia,paresis,seizuredisorder,andcognitivedysfunction.

Neurologicaldeteriorationafterinitialrecoverymayrepresentintracranialhemorrhagerelatedtodiffuseintravascularcoagulationorhematomarelatedtotraumaunrecognizedatthetimeofinitialpresentation.

Othercomplicationsincludegastrointestinalbleeding,jaundice,aspirationpneumonia,noncardiogenicpulmonaryedema,andmyocardialinfarction.Immuneincompetenceandinfectionarelatecomplications,particularlyinpatientswithsevererenalfailure.

Hyperkalemiaisthemostlife-threateningearlyclinicalproblem.Measurementofserumpotassiumisanearlypriority.

Heatcramps.Clinicalpresentation.

Brief,intermittent,recurring,andoftenexcruciatingtonicmusclecontractionsthatlast2–3minutes.Precededbypalpableorvisiblefasciculations.

Typicallyinvolvemusclesoftheabdomen,legs,andarms(voluntarymusclesofthetrunkandextremities).Smoothmuscle,cardiacmuscle,thediaphragm,andbulbarmusclesarenotinvolved.

Occuroftenwithheatexhaustion.(Despitethesaltdepletionassociatedwithheatcramps,franksignsandsymptomsofheatexhaustionareunusual.)

Therearenosystemicmanifestations,exceptthoseattributabletopain.

Occurinhealthyindividualswhoexerciseforprolongedperiodsinwarmenvironments.

Occurinsalt-depletedpatients,generallyduringaperiodofrecoveryafteraperiodofworkintheheat.

Differentialdiagnosis:tetanyduetoalkalosis(hyperventilation,severegastroenteritis,cholera),hypocalcemia,strychninepoisoning,blackwidowspiderenvenomation,andabdominalcolic.

Treatment.

Mildcasescanbetreatedwithoral0.1%–0.2%saltsolutions.Salttabletsshouldnotusedasanoralsaltsource.

Most“sportsdrinks”(diluted1:1withwater)effectiveformildcases.

IVnormalsaline(NS)providesrapidreliefinmoreseverecases.

Patientswithheatcrampsusuallyhavesubstantialsaltdeficits(15–30gover2–3days,usualdietaryintake).Theseindividualsshouldbeallowed2–3daystoreplenishsaltandwaterdeficitsbeforereturningtoworkintheheat.

Heatexhaustion.Clinicalpresentation.

Thirst,headache,dyspnea,lightheadedness(orthostaticdizziness),profoundphysicalfatigue,anorexia,confusion,anxiety,agitation,moodchange,chills,piloerection,nausea,andvomiting.Thereisnocombinationofpresentingsymptomsandsignsthatispathognomonic.

Oftenaccompaniedbyheatcramps.

Oliguria,clinicaldehydration,ataxia,tachycardia,andtachypnearesultinginsymptomatichyperventilationwithacroparesthesiaandcarpopedalspasm.

Syncopemayoccur.

Coretemperatureis<39°C(102.2°F),evenattimeofcollapse.

Treatment.

Oralrehydration(ifpatientisnotvomiting).

Parenteralfluidsproducemorerapidrecovery:nomorethan250mLNSboluswithoutlaboratorysurveillance;after2.5Lofplainsaline,adddextroseasasourceofenergy(D2.5½NaCl);subsequentfluidreplacementshouldbeD5½NSorD5¼NS.Individualswithsignificantsaltdepletionhavecoincidentpotassiumdepletion,oftenamountingto300–400mEqofKCl.Tobeginrestorationofpotassiumdeficit,inclusionofpotassiuminparenteralfluidsaftervolumeresuscitationisappropriateifthereisnoevidenceofrenalinsufficiencyorrhabdomyolysis.

Doesnotrequireactivecooling;however,becausesymptomsaredifficulttodistinguishfromheatstroke,thesafestcourseistoprovideactivecoolingforallcasualtieswhoareatriskforheatstroke.

Removalfromhotenvironment.

Stopexercising,moveoutofthesun.

Minorheatillnesses.Miliariarubra,miliariaprofunda,andanhidroticheatexhaustion.

Subacute(miliariarubra)pruriticinflamedpapulovesicularskineruptionthatappearsinactivelysweatingskinexposedtohigh

humidity.Becomesgeneralizedandprolonged(miliariaprofunda);lesionsaretruncal,noninflamedpapular,withlessevidenceofvesiculationthanthelesionsofmiliariarubra.

Eachmiliarialpapulovesiclerepresentsaneccrinesweatglandwhoseductisoccludedattheleveloftheepidermalstratumgranulosumbyinspissatedorganicdebris.

Eccrinesecretionsaccumulateintheglandularportionoftheglandandinfiltrateintothesurroundingdermis.

Pruritusisincreasedwithincreasedsweating.

Miliarialskincannotfullyparticipateinthermoregulatorysweating;therefore,theriskofheatillnessincreasesinproportiontotheamountofskinsurfaceinvolved.Sweatdoesnotappearonthesurfaceofaffectedskin.

Sleeplessnessduetopruritusandsecondaryinfectionofoccludedglandshassystemiceffectsthatfurtherdegradeoptimalthermoregulation.

Miliariaistreatedbycoolinganddryingaffectedskin,avoidingconditionsthatinducesweating,controllinginfection,andrelievingpruritus.Eccrineglandfunctionrecoverswithdesquamationoftheaffectedepidermis,whichtakes7–10days.

Miliariaprofundacausesanuncommon,butdisabling,disorder:anhidroticheatexhaustion(ortropicalanhidroticasthenia).Miliariaprofundacausesamarkedinhibitionofthermoregulatorysweatingandheatintolerancesimilartothatofectodermaldysplasia.Thatindividualismoreatriskforheatexhaustionandathighriskofheatstrokeinconditionstoleratedbyothers.

Evacuationtoacoolerenvironmentuntilrestorationofnormaleccrineglandfunction.

Heat-inducedsyncope.

Duetoareducedeffectivebloodvolume.(Thermalstressincreasestheriskofclassicneurallymediated[vasovagal]syncopebyaggravatingperipheralpoolingofbloodindilatedcutaneousvessels.)

Symptomsrangefromlight-headednesstolossofconsciousness.

Typicallysomeonestandinginahotenvironment.

Greatestriskonfirstdayofheatexposure;subsequentriskdecreasesdaily.

Riskalmost0after1weekofheatexposure;however,syncope

occurringduringorafterworkintheheat,oraftermorethan5daysofheatexposure,shouldbeconsideredevidenceofheatexhaustion.

Coretemperatureisnotelevatedoronlyveryminimallyso.

Patientregainsconsciousnessimmediatelyaftersyncope.

Clinicalevaluationandmanagementshouldbedirectedtowardthesyncopalepisode,notpotentialheatillness.Treatmentisoralhydrationandcontinuedacclimatization.

Heatedema.

Seenearlyinheatexposure.

Plasmavolumeexpandingtocompensatefortheincreasedneedforthermoregulatorybloodflow.

Intheabsenceofotherdisease,conditionisofnoclinicalsignificance.

Willresolvespontaneously.

Diuretictherapyisnotappropriateandmayincreaseriskofheatillness.

Sunburn.

Reducesthermoregulatorycapacityofskin.

Systemiceffect:hyperthermia.

Preventable.

Affectedsoldiersshouldbekeptfromsignificantheatstrainuntiltheburnhashealed.

Heattetany.

Rare;occursinindividualsacutelyexposedtooverwhelmingheatstress.

Extremelysevereheatstressinduceshyperventilation.

Manifestationsincluderespiratoryalkalosis,carpopedalspasm,andsyncope.

Treatment:removalfromheatsourceandcontrolofhyperventilation(rebreathingintopaperbagtoreverserespiratoryalkalosis).

Dehydrationandsaltdepletionarenotprominentfeatures.

AltitudeIllness

Exposureoftroopstothehypobarichypoxiaofaltituderesultsinadecrementof

performance, as well as the possible development of altitude illness. Altitudeillnessspansaspectrumfromhigh-altitudebronchitis,toacutemountainsickness(AMS),todeathfromhigh-altitudepulmonaryedema(HAPE),andhigh-altitudecerebraledema(HACE).

Altitudebasics.

The occurrence of altitude illness is based on altitude and rapidity ofascent. Contributory factors include level of exertion, physiologicalsusceptibility,age,andcoexistingmedicalconditions.

Physiologicalchangesduetoaltitudebegintooccuratjustover1,500m(4,900ft).Thesechangesarethebody’sattempttoacclimatizetoaltitude.Symptomsoccurringbelow2,250m(7,400ft)arerarelyduetoaltitudeillness.

Rapidascenttohighaltitudesresultsinahighincidenceofaltitudeillness.

ClimbingMt.Rainierbringsonefromsealevelto14,500ft(4,400m)in36hoursandresultsina70%incidenceofaltitudeillness.Anascenttoasimilarheightoverthecourseof5dayswouldonlyresultina5%incidenceofaltitudeillness.

10%–20%ofsoldierswhoascendrapidly(<24hours)toaltitudesbetween1,800to2,500m(6,000–8,000ft)experiencesomemildsymptoms.

Rapidascenttoelevationsof3,600to4,300m(12,000–14,000ft)resultsinmoderatesymptomsinmorethan50%ofthesoldiers,and12%–18%mayhaveseveresymptoms.

Rapidascentto5,300m(17,500ft)causessevere,incapacitatingsymptomsinalmostallindividuals.

Descentbasics.Almosteverythingimproveswithpromptdescent.Forillnessrequiringdescent,oneshouldtrytodescendatleast1,000m(3,300ft)ifnotmore.AGamowbag(USA;aportablefabrichyperbaricchamber)orCertecSAbag (Europe)can temporizeapatient ifevacuation/descent isnotpossible.Symptoms typicallyresolvequicklywithdescent,butmay linger forseveraldays.VictimsofHACEandHAPEshouldnotreascenduntil72hoursaftersymptoms abate, and then they must ascend much slower thanpreviously.VictimsofHACEorHAPEshoulddescendattheearliestsign,before

theybecomemoribundandincapableofaidingintheirowndescent.There are no reliable predictors of susceptibility to AMS, exceptpriorexperienceataltitude.

Incidenceandseverityofsymptomsvarywithinitialaltitude,rateofascent,levelofexertion,andindividualsusceptibility.

Vigorous physical activity during ascent or within 24 hours afterascentwillincreaseboththeincidenceandseverityofsymptoms.

Ifasoldierbecameillpreviouslyatagivenaltitude,heorshewilllikelybecomeillatthesamealtitudeunlesstheascentisslowertoallowforbetteracclimatization.

Physicalfitnesslevelhasnoeffectonsusceptibilitytoaltitudeillness.

OralSildenafil(Viagra)50mgqdincreasesexercisetoleranceinhealthyvolunteersataltitude(5,200m[17,000ft]),althoughithasnotbeenapprovedforthispurpose.Theroleofthisdruginthetreatmentand/orprophylaxisofAMSandHAPEhasnotbeenestablished.

Ifarapidascenttoaltitudemustbemade,useprophylaxisagainstAMS.

Acutemountainsickness.AMSisthemostcommonformofaltitudeillness.Onsetisshortlyafterarrivalathighaltitude.Onsetoccurs3–24hoursafterascent.Symptomsreachpeakseverityin24–72hoursandusuallysubsideoverthecourseof3–7days.Further ascent without an acclimation period usually exacerbatessymptomsandcanresultinincreasedincidenceofHAPEandHACE.Themajority ofAMS casesdonotprogress tomore serious altitudeillnesswithoutcontinuedascent.Symptoms.

Headache:Symmetric,globalinlocation,andthrobbingincharacter.Mostintenseduringnightandshortlyafterarisinginthemorning,attributedtoincreasedhypoxemiacausedbyaltitude-inducedsleepapnea.

Anorexia.

Nausea.

Fatigue(weakness).

Generalmalaise.

Decreasedcoordination.

Dizzinessorlight-headedness.

Oliguria.

Emesis(vomiting).

Lassitude.

Insomnia:Sleepdisturbanceswithperiodicbreathingwithrecurrentapneicperiodsduringsleepareusuallypresent,butarenotnecessarilyacomponentofAMS.

Diagnosis.

Occurrenceofaheadacheandatleastoneothersign/symptominanindividualwhoascendedfromlow(1,524mor<5,000ft)altitudetohighaltitude,orfromhighaltitudetohigheraltitudeintheprevious24–48hours.

Differentialdiagnosisincludesviralgastroenteritis,hangover,exhaustion,dehydration,carbonmonoxidepoisoning,andHACE.

Presenceofneurologicalsymptoms—suchasincoordination,ataxia,andexcessivelethargyorcognitivedysfunction—isindicativeofprogressiontoHACE,whichrequiresimmediatetherapeuticintervention.

ProphylaxisforAMS.

Gradualacclimation.

Stagedascent:Soldiersascendtointermediatealtitudesandremainthereforthreeormoredaysbeforeascendingfurther.

Gradedascent:Limitsdailyaltitudegaintoallowpartialacclimation.Sleepaltitudeismostimportant.Havesoldiersspendtwonightsat2,743m(9,000ft)andlimitthesleepingaltitudetonomorethan305m(1,000ft)perdayabovethepreviousnight’ssleepaltitude.

Combinedstagedandgradedascent:Thisisthesafestandmosteffectivepreventionmethod.

Diet:Highcarbohydratediet(<70%oftotalenergyintakeascarbohydrates);stimulationofventilationthroughincreasedcarbondioxideproducedfromthemetabolismofcarbohydrates.

Acetazolamide(250mgqidor500mgbidpo),starting48hoursbeforeascentandcontinuingfor48hoursafterascent.Sideeffectsincludeperipheralparesthesias,fatigue,increasedurination(polyuria),andalteredtasteimpartedtocarbonatedbeverages.ItpreventsAMSin50%–75%ofsoldiersandreducessymptomsinmostothers.Short-termusewhenchangingaltitudesignificantly

(400m).Contraindicatedinsulfaallergy.

Dexamethasone(4mgqidpo)istheprophylaxisofchoiceinsulfa-allergicindividuals.Dexamethasonedoesnotaidacclimatization,andeffectsaregonewhenitisstopped.Dexamethasone±acetazolamideisalsotheprophylaxisofchoiceformissionsofarapid,high(morethan4,000m[13,000ft]),short-durationprofile(raids,rescues).

Cyanosis:Oxygen2–6L/min.Donotdelaydescent.

Treatment.

AMSalonedoesNOTmandatedescent.

Remainatthesameelevation;donotascenduntilsymptomsabate.

Acetazolamide(250mgbidto500mgtidpo)—donotuseinpatientswithsulfaallergies.(Ifalreadyreceivingapreventivedoseofacetazolamide[1,000mg/d]andstillsymptomatic,500mgcanbeaddedwithcaution.)DiureticeffectmayexacerbateAMS.

Dexamethasoneindosesof2–4mgq6h(hasthesamepotentiallyserioussideeffectsaswhenusedasaprophylaxis).Symptomsmayrecurwhenmedicationstopped.

Oxygenbynasalcannula2–6L/min(severeheadache).

DoNOTadvancesleepingaltitude.

Symptomatictreatmentwithacetylsalicylateacid(oraspirin);acetaminophen;prochlorperazinefornauseaandvomiting5–10mgtid–qid,po,orIM;or25mgbidPRNalsostimulatesrespiration;ibuprofenforheadache.

Minimizeutilizationofsleepingagentsataltitude;theycanworsenillness.Acetazolamideforsleepdisorders,250mgqidortidpo.Temazepamforinsomnia,30mgqhspo;triazolamforinsomnia,0.125–0.25mgqhspo.Short-termuseonly.Possibleshort-termmemoryloss.

High-altitudepharyngitisandbronchitis.Commonconditionoccurringafter2–3weeksataltitude.Commonataltitudesover5,486m(18,000ft).Sorethroat,chroniccough,andseverecoughspasms(severeenoughtocauseribfractures).Environmental,frombreathingcolddryair.Altitude-inducedtachypneaaggravatestheproblem.Cold-inducedvasomotorrhinitis,especiallyatnight,stimulatesmouthbreathingandalsoaggravatesproblem.Usuallynotcausedbyinfection,althoughinfectioncanoccur.

Patientwillnothavedyspneaatrest.Symptomatic treatmentwith lozenges,mild cough suppressant, anddecongestant nasal sprays. Personnel can use a mask or a porous,breathable silk balaclava as a mouth covering to reduce respiratoryheatandmoistureloss.Maintainhydration.

High-altitudeperipheraledema.Altitude-relatededemaofthehandsandface.Hypoxia-inducedretentionofsodiumandwater.NotconsideredrelatedtoAMS/HACEedemaspectrumorHAPE.Decreasedurineoutputandweightgainof2.7–5.4kg(6–12lbs)overseveraldays;mostevidentonawakening.Diagnosisbasedonassociationofcharacteristicperipheraledemawithascent tohighaltitude; recurs consistentlywith repeatascents;morecommoninfemales.Differential diagnosis includes cardiogenic edema, allergic reactions,andedemaoftheupperextremitiescausedbypackstrapsorbindingbytightclothes.Prophylaxisincludessaltrestriction.TheacetazolamideregimenusedtopreventAMSisoftensuccessfulinpreventingperipheraledema.Treatmentwithdiuretics(one20-to40-mgdoseoffurosemideor250mgofacetazolamideevery8hfor3doses)andsaltrestriction.

High-altituderetinalhemorrhage.Bleeding from retinal vessels during altitude exposure. One of themanifestationsofhypoxia-inducedretinopathy.Causedbybloodpressure“surges”withinthedistendedvessels.Usually asymptomatic; normally does not adversely affect militaryoperations;however,canaffectanindividualsoldier’svision.Hemorrhagesareself-limitingandresolvein1–2weeksafterdescent.

Thromboembolicevents.Increased possibility of thromboembolic event with ascent to highaltitude: thrombophlebitis, deep venous thrombosis, pulmonaryembolus,transientischemicattacks,andstroke.Probably result from hypoxia-induced polycythemia and clottingabnormalities, but alsomay result from environmental andmissionfactors—such as dehydration, cold, and venous stasis caused byprolonged periods of inactivity during inclement weather or byconstrictionoftight-fittingclothingandequipment.Unusualbelow4,267m(14,000ft).Atveryhighandextremealtitudes(>4,200 m [13,700 ft]), these events are not uncommon; andthrombophlebitisappearstoberelativelycommon.Clinical manifestations are similar to manifestations ofthromboemboliceventsatlowaltitude,exceptfortheiroccurrenceinyoungandotherwisehealthypersonnel.

Preventionreliesonreducingtheriskfactorsbymaintainingadequatehydrationandwarmth,andbyavoidingconditions thatmightcausevenousstasis.Evacuation to loweraltitude is required.Treatment follows standardtreatment guidelines, including appropriate anticoagulation. In thefield setting, fractionated heparin (1 dose of 250 IU/d) can be usedpriortoandduringevacuation.

Subacutemountainsickness.Prolongeddeployment(weekstomonths)toelevationsabove3,658m(12,000ft).Commonmanifestationsincludesleepdisturbances,anorexia,weightloss,fatigue,daytimesomnolence,andsubnormalmentation.Causedbyfailuretoacclimatizeadequately.Some relief of symptoms obtained from low-flow oxygen andacetazolamide.Evacuatetoloweraltitudeassoonaspractical.Somedegreeofimmunesuppressionandpoorwoundhealingoccursin personnel at very high and extreme altitudes. Injuries resultingfromburns,ballistics,andphysicaltraumashouldbeconsideredmoreclinicallysignificantathighaltitude.

High-altitudepulmonaryedema.Potentiallyfatal,noncardiogenicpulmonaryedema.Occursin<10%ofpersonnelascendingabove3,700m(12,000ft).Onset 2–4 days after rapid ascent to altitudes greater than 2,438 m(8,000ft).Repeated ascents and descents above 3,700 m (12,000 ft) increasesusceptibility.Riskfactors.

Moderate-to-severeexertion.

Coldexposure.

Anxiety.

Youngage.

Malesex.

Obesity(possibly).

Earlysymptoms(pulmonaryedema).

Nonproductivecough.

Rales(few).

Dyspneaonexertion.

Fatigue.

Weaknesswithdecreasedtoleranceforphysicalactivityandincreasedtimeforrecoveryafterphysicalexertion.

Restingtachycardiaandtachypneagreaterthaninducedbyaltitudealone.

Oncesymptomsappear,HAPEcanprogressveryrapidly(<12hours)tocomaanddeath.

Nailbedsandlipsmaybemorecyanoticthanotherunitmembers.

Progressingpulmonaryedema.

Productivecoughoffrothyandsometimespinkorbloodstainedsputum.

Ralesmorenumerousandwidespread.

Wheezingmaydevelop.

Lungsoundsbecomeaudibleevenwithoutastethoscope,especiallywhentheindividualissupine.

Orthopneamayoccur(<20%).

Progressivehypoxemiacausesdyspneaandcyanosis.

Arterialbloodgas(ifavailable)documentshypoxemia,hypocapnia,andaslightincreaseinpH.

Mentalstatusdeteriorateswithprogressiveconfusionandsometimesvividhallucinations.

Obtundation,coma,anddeathoccurwithouttreatment.

Subfebriletemperature<38°C(100.5°F)andamildincreaseinwhitebloodcellcountmaybepresent.

Dyspneaatrest.

Markedhypoxiabyoximetry.

DyspneaatrestandcoughshouldbeconsideredtobetheonsetofHAPE.

Delay in the TREATMENT of progressive pulmonary edema ataltitudeusuallyresultsinDEATH.

Treatment.

Dependsonseverity.

Immediatedescentismandatory!Descentofevenafewhundredmeters(300–1,000m)canbehelpfulorevenlifesavinginseverecases.

Mortalitycanapproach50%ifdescentcannotbeaccomplished

rapidly.

Oxygenbycannula2–6L/min(mild)orbymask4–6L/min(moderateandsevere).DONOTDELAYDESCENT!

Portablefabrichyperbaricchambermaybelifesaving—Gamowbag/CertecSAbag.

Nifedipine,10mgchew+10mgswallowimmediately,then10mgpoq4h.Ifthepatientiscomatose,piercethenifedipinecapsuleandsquirttheliquidintothepatient’smouth.

Nifedipine shouldnot beused in lieu of descent, supplementaloxygen, or treatment in a hyperbaric bag. It may be used inconjunctionwithothertherapies.

Immediatedescenttolowerelevation;ifsymptomsresolve,waitatleast72hoursbeforeattemptedreturntopreviouselevation.

Neither furosemidenormorphine sulfate shouldbeused in thetreatment of HAPE (high-altitude pulmonary edema), unlessother,moreeffective,treatmentoptionsarenotavailable.

Treatmentafterdescent,atamedicaltreatmentfacility,isdirectedtowardensuringadequateoxygenationandreducingpulmonaryarterypressure;includesbedrest,supplementaloxygen,andnifedipine.

Invasivediagnosticprocedures,suchasbronchoscopyorpulmonaryarterycatheterization,areNOTindicatedunlessclinicalcoursedeterioratesandthediagnosisisindoubt.Endotrachealintubationisseldomnecessary.

HAPEprophylaxis.

Nifedipine,20mgtidpo,24hoursbeforeascent,continuing72hoursafterascent.

High-altitudecerebraledema.OnsetfollowingascentishighlyvariableandoccurslaterthaneitherAMSorHAPE.Meanduration of 5-day onset,with a range of 1–13days.IncidencelowerthanAMSorHAPE(<1%ofindividualsmakingrapidascent).Potentiallyfatal,uncommon(<2%above3,700m).Canoccuraslowas2,430 m (8,000 ft), but vast majority of cases occur above 3,600 m(12,000 ft).UntreatedHACE canprogress todeath over 1–3days orbecomemorefulminantwithdeathoccurringin<2hours.Exacerbationofunresolved,severeAMS.MostoftenoccursinpeoplewhohaveAMSsymptomsandcontinuetoascend.

Signsandsymptoms.

Mostsignsandsymptomsareamanifestationofprogressivecerebraledema.

EarlysignsresembleAMS.(Thesesymptomsarenotinvariablypresent.)

Severeheadache.

Nausea.

Vomiting.

Extremelassitude.

Progressingsigns.

Mentalstatuschanges:Confusion,disorientation,drowsiness,andimpairedmentation.

Truncalataxia(swayingofupperbody,especiallywhenwalking).Astheedemaprogresses,soldiermayalsoexhibitanataxicgaitinadditiontothetruncalataxia.

Soldierappearswithdrawn,andbehaviorismistakenlyattributedtofatigueoranxiety.

Cyanosisandgeneralpallorarecommon.

SymptomsofHAPE.

UntreatedHACE.

Varietyoffocalandgeneralizedneurologicalabnormalitiesmaydevelop:visualchanges,anesthesias,paresthesias,clonus,pathologicalreflexes,hyperreflexia,bladderandboweldysfunction,hallucinations,andseizures.

Papilledemamaybepresentinupto50%ofthesoldiers,butisNOTuniversal.

Coma.

AtaxiaataltitudeisHACE(orhigh-altitudecerebraledema).

Prophylaxis.

No definitive evidence; however, due to similarity with AMS,prophylactic measures for HACE include use of staged or gradedascent,highcarbohydratediet,anduseofacetazolamide.

Treatment.

Immediatedescentismandatory.DefinitivetreatmentofHACEisimmediatedescent.Ingeneral,thegreaterthedescent,thebetter

theoutcome.Descent>300m(1,000ft)mayberequiredforclinicalimprovement,anddescentstoaltitudesof<2,500m(8,000ft)areoptimal.

Ifdescentisdelayed,treatmentwithaportableclothhyperbaricchambermaybelifesaving.Mayrequireatleast6hoursofpressurizationinchamber.

Oxygenbymaskorcannula2–6L/m;shouldnotbeusedasasubstitutefordescent.

Dexamethasone,4–8mginitially;then,4mgqid,po,IV,orIM.DONOTDELAYDESCENT!Fewsideeffectsifusedonly3–4days.

High-altitude cerebral edema (HACE) and high-altitudepulmonaryedema(HAPE)oftencoexist. IndividualswithHACEwilloftenhaveHAPE;however,mostindividualswithHAPEdonothaveconcomitantHACE.

Loopdiureticsandosmoticdiureticagents—suchasmannitol,urea,andglycerol—havebeensuggested,butthereislittleexperiencewiththeminthisrole.Carefulattentionisrequiredbeforediureticsareused.Individualmayhavealtitude-induceddecreaseinintravascularvolumeconcomitantwithcerebraledema.

Hospitalmanagementconsistsofsupplementaloxygen(ifneededtomaintainarterialoxygenlevels),supportivecare,andpossiblydiuretics.Comatosepatientsmayrequireintubationandbladdercatheterization.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter28

RadiologicalInjuries

The reader is strongly advised to supplementmaterial in this chapterwiththefollowingtworeferences:

1. Armed ForcesRadiobiologyResearch Institute.MedicalManagement ofRadiologicalCasualties.3rded.Bethesda,MD:AFRRI;2009.

2. WaselenkoJK,MacVittieTH,BlakelyWF,etal.Medicalmanagementofthe acute radiation syndrome: recommendations of the StrategicNational Stockpile Radiation Working Group. Ann Intern Med. 2004;140:1037–1051.

Introduction

Radiological casualties on the battlefield may occur with improvised orconventional nuclear devices or radiological dispersal devices (“dirty bombs”)(Table28-1).

Conventionalnuclearweapons.The relative casualty-causing potential depends primarily on fourfactors:

Yieldoftheweapon.

Heightofburst.

Environmentalconditionsinwhichthedetonationoccurs.

Distributionandshieldingoftroopsinthetargetarea.

A nuclear detonation generally causes injuries with the followingdistribution:

Blastinjury:50%.

Thermalinjury:35%.

Ionizingradiationinjury.

Initial:5%.Residual:10%.

Aradiologicaldispersaldevice(RDD)isanydevice—includinganyweaponorequipment—otherthananuclearexplosivedevice,specificallydesignedtospreadradiation.

RDDs contaminate conventional casualties with radionuclides,complicatingmedicalevacuation.RDDsareidealweaponsforterrorism,andareusedtointimidateanddenyaccesstoanareabyspreadingradioactivematerial.

Table28-1.RadiologicalCasualties

WeaponEffectWeaponYield(kt)/Distance(m)

1kt 10kt 100kt 1,000kt

Blast(50%casualties)

140m 360m 860m 3,100m

Thermalradiation(50%deepburns)

370m 1,100m 3,190m 8,020m

Ionizingradiation(50%immediatetransientineffectiveness)

600m 950m 1,400m 2,900m

Ionizingradiation(50%lethality)

800m 1,100m 1,600m 3,200m

kt:kiloton;m:meter.

TriageTriage should be conducted on traditional surgical and medicalconsiderations,thenmodifiedbyradiationinjurylevel.

Radiation interacts deleteriouslywith trauma. Patientswithmedicalor traumatic injurywhoalsohavewhole-bodyor significantpartial-bodyirradiationhaveasubstantiallyworseprognosisandwillrequireahighertriagepriority.Makeapreliminarydiagnosisofradiation injuryonly for thosewithexposuresymptoms,suchasnausea,vomiting,diarrhea,fever,ataxia,seizures,prostration,andhypotension.Radiationpatienttriageclassifications.

Immediate:Thoserequiringimmediatelifesavingintervention.Pureradiationinjuryisnotacutelylife-threateningunlesstheirradiationismassive.Ifamassivedosehasbeenreceived,thepatientisclassifiedasexpectant.

Delayed:Casualtieswithonlyradiationinjury,withoutgrossneurologicalsymptoms(ataxia,seizures,andimpairedcognition).Fortraumacombinedwithradiationinjury,allsurgicalproceduresmustbecompletedwithin36–48hoursofradiationexposure,ordelayeduntilatleast2monthsaftertheinjury.

Minimal:Buddycareisparticularlyusefulhere.Casualtieswithradiologicalinjuryshouldhaveallwoundsandlacerationsmeticulouslycleanedandthenclosed.

Expectant:Receiveappropriatesupportivetreatmentcompatiblewithresources;largedosesofanalgesicsasneeded.

Table28-2providesmedicalaspectsofradiationinjuries.

Table28-2.MedicalAspectsofRadiationInjuries

Thelethaldose(LD)ofradiation,whichwillkill50%ofapopulationwithin60daysofexposure,iscalledLD50/60.TheLD50/60 isapproximately3–4Gyforapopulationwithradiationinjuryaloneandwithnosignificantmedicalcare.TheLD50/60 forapopulationwithradiation injuryaloneandthebestavailable medical care (including antiemetics, antivirals, antibiotics,hematopoieticcytokines,andtransfusion)maybe6Gyormore.Combinedinjurieswith radiation and trauma and/or burnswillmarkedly lower theLD50.Significant medical care may be required at 3–5 weeks for 10%–50% ofpersonnel.Anticipatedproblems should include infection, bleeding, fever,vomiting, and diarrhea. Wounding or burns will markedly increasemorbidityandmortality.Treatment.

Fluidandelectrolytesforgastrointestinallosses.Cytokines for immunocompromised patients (follow granulocytecounts).Restricted duty. No further radiation exposure, elective surgery, orwounding. May require delayed evacuation from theater duringnuclearwarinaccordancewithcommandguidance.If therearemore than1.7×109 lymphocytesper liter, 48hoursafterexposure,itisunlikelythatanindividualhasreceivedafataldose.Patientswithlow(300–500)ordecreasinglymphocytecounts,or lowgranulocyte counts, should be considered for cytokine therapy andbiologicaldosimetryusingmetaphaseanalysiswhereavailable.

Asymptomaticpatientswithlethalradiationdosemayperformusualdutiesuntilsymptomatic.

PotentialInjuries

Thermal/flashburnsorthermalpulseburnsarecauseddirectlybyinfraredradiation. Close to the fireball, the thermal output is often so great thateverything is incinerated, andevenatgreatdistances, thermal/flashburnswilloccur(seeChapter26,Burns,formanagement).

Burn mortality rates associated with radiation exposure aresignificantlyhigherduetobonemarrowsuppressionandinfection(a50%totalbodysurfaceareaburnassociatedwith radiationexposurehasamortalityof90%).

Blastinjuriesassociatedwithanucleardetonationinclude:Direct blast wave overpressure forces measured in terms ofatmosphereoverpressure.Indirect blastwinddrag forces,measured in termsofwindvelocity,whichmaydisplacelargeobjects(eg,vehiclesorcausethecollapseofbuildings).

Radiationinjuriesareduetoionizingradiationreleasedbothatthetimeofthenucleardetonationandforaconsiderabletimeafterward.Thetwotypesofradiationreleasedareelectromagnetic(gamma)radiationandparticulate(alpha,beta,andneutron)radiation.

Alphaparticlescanbeshieldedagainstbyclothing.Betaparticlesshieldingrequiressolidmaterials,likeawall.Gamma and neutron radiation are the most biologically active andrequireleadequivalentshieldingforprotection.Fission products are themajor radiation hazard in fallout because alarge number emit penetrating gamma radiation. This can result ininjuries,evenatgreatdistances.Falloutcauseswhole-bodyirradiationfromgamma-emittingisotopesbecause they do not actually have to be on a person’s skin to causedamage.

Flash blindness may occur as the result of a sudden peripheral visualobservation of a brilliant flash of intense light energy.Retinal burnsmayalsooccur,andresultinscarringandpermanentalteredvisualacuity.

TreatmentofCombinedInjuriesFollowing the detonation of a nuclear device, the majority of resultingcasualties will have sustained a combination of blast, thermal, andradiologicalinjuries.Theusualmethodsoftreatmentforblastinjuriesmustbemodifiedinthosecasualtiessimultaneouslyexposedtoionizingradiation.

Traditionally,combatwoundsareleftopen.However,woundsleftopentohealbysecondaryintentionintheirradiatedpatientwillserveasanidus of infection. Wounds exposed to ionizing radiation should bedebridedandclosedatasecond-lookoperationwithin36–48hours.

Hypotensionshouldalwaysbeassumedtobehypovolemiaandnotduetoradiologicalinjury.

Hyperthermiaiscommon.Radiologicalinjuriesincreasethemorbidityandmortalityofinjuriesduetocompromiseofthenormalhematopoieticandimmuneresponsestoinjury.Surgical procedures may need to be delayed during bone marrowsuppression,ifatallpossible.Potassium iodide may be used for prevention of thyroid uptake ofradioisotopesafternuclearreactoraccidents.Chelating agents may be used to eliminate metals from the bloodstreambeforetheyreachtargetorgans.Mobilizing agents are used to increase the excretion of internalcontaminants.Prussian blue is used to remove radionuclides from the capillary bedsurrounding the intestine and prevents their reabsorption. Delay untilpatientisstable.TreatABCsfirst.

DecontaminationThere are no reports of healthcare provider injury with radiation whileperformingABCsonaradiationvictim.Removal of the casualty’s clothing can eliminate as much as 90% of theradiologicalcontamination.The first priority of surface decontamination should be to open wounds,thenotherareas.

To prevent rapid incorporation of radioactive particles, woundsshouldbecopiouslyirrigatedwithnormalsalineforseveralminutes.The eyes, ears, nose, mouth, and areas adjacent to uncontaminatedwounds,hair,andremainingskinsurfaceshouldbedecontaminatedwithsoapandwater.Personnel providing decontaminationmust protect themselves fromionizingradiationexposurewith:

Protectiveouterclothing.

Aprons,gloves,andmasks.

Amputation should be seriously considered when the contaminationburdenisgreatandsevereradionecrosisislikely.

LogisticsofCasualtyManagementIf nuclear weapons are employed within theater, the entire medicalevacuation and treatment system will be severely overburdened, andsomesystemofclassificationandsortingofcasualtiesmustbeaddedtothenormalproceduresofevacuationandhospitalization.Patients entering a medical treatment facility should be routinelydecontaminatedifmonitoringforradiationisnotavailable.Thesetworequirements—thesortingofcasualtiesandtheholdingofexcessnumbers—must be planned for and drilled as part of the normalorganizationandoperationofthehealthservicesupportsysteminatheater

ofoperationswhereradiationexposurepotentialishigh.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter29

BiologicalWarfareAgents

The reader is strongly advised to supplementmaterial in this chapterwiththefollowingreference:

US Army Medical Research Institute of Infectious Diseases (USAMRIID).MedicalManagementofBiologicalCasualtiesHandbook.6thed.FortDetrick,MD:USAMRIID;2005.

Introduction

Biologicalwarfare (BW) agents infect the bodyvia the sameportals of entry asinfectious organisms that occur naturally. These include inhalation into therespiratorytract;ingestionintothegastrointestinaltract;andabsorptionthroughmucousmembranes,eyes,skin,orwounds.MostBWagentswillenterthebodythroughinhalation.Usually,thediseaseproducedbyaBWagentwillmimicthenaturally occurring disease, but the clinical presentation can be different ifdeliveryofanagentoccursthroughaportalthatdiffersfromthenaturalportal.

DetectionCompressedepidemiologywithrecordnumbersofsickanddyinginashorttime.Highattackrates(60%–90%).Highincidenceofpulmonaryinvolvementwhenusualformofinfectionisnot(eg,anthrax).Incidenceofaparticulardiseaseinanunlikelylocation.Increaseddeathsofanimalsofallspecies.Nearsimultaneousoutbreaksofseveraldifferentepidemicsatthesamesite.Biological Identification Detection System or standoff BW detectorsalarming.Direct evidence of an attack, such as contaminated or unexplodedmunitions.

Diagnosis

The first indication of an attack may be when large numbers of patientspresentwiththesameconstellationofsignsandsymptoms,especiallyforadiseasethatisnotendemictotheareaofoperations.

Rapiddiagnostictestsmaybeavailableinforwardareastoassistcliniciansinearlydiagnosis:

Isolationoftheetiologicalagentcanoccurwithin1–2daysforsomeagents.Enzyme-linkedimmunosorbentassays(ELISAs).Genomedetectionbypolymerasechainreaction.Antibodydetection.

PreventionandProtectionImmunizations:Anthraxand,inspecificscenarios,smallpoxandplague.

Pre- or postexposure chemoprophylaxis—anthrax, plague, Q fever,and tularemia.Chemoprophylaxis for anthrax is presently approvedbytheFoodandDrugAdministrationforpostexposureonly.

InvestigationalnewdrugsexistforthetreatmentofArgentinehemorrhagicfever,botulinumtoxin,Qfever,RiftValleyfever,Venezuelanequineencephalitis,andtularemia.

Protectiveclothingandmask.

Decontamination—Personnel,Equipment,andClothingMechanical decontamination removes, butnotnecessarilyneutralizes, theBWagent.

BrushingtoensurelooseningoftheBWagentfromthesurface.Filtrationandchlorinationofdrinkingwatertoremoveorganisms.

ChemicaldecontaminationrendersBWagentsharmlessthroughtheuseofdisinfectants.

Soap and water followed with copious rinsing with water is oftensufficient.For patients requiring urgent decontamination, biological agents areneutralized within 5 minutes when contaminated areas are washedwith a 0.5 % hypochlorite solution (1 part household bleachmixedwith9partswater).Donotusehypochloriteintheeyes,abdominalcavity,oronnervetissue.A 5% hypochlorite solution (ie, household bleach) may be used todecontaminateclothingorequipment.

Physicaldecontamination,suchasheatandsolarultravioletradiation.Dryheatfor2hoursat160°C.Autoclavingat120°Cunder1atmofoverpressurefor20minutes.Ultravioletradiationdifficulttostandardize.

Drybiologicalagentscanbeahazardthroughsecondaryaerosolization,butadequateliquiddecontaminationwillpreventthishazard.Thereisnovaporhazard,andspecialprotectivemasksaregenerallynotrequiredforsurgicalpersonnel.

InfectionControl

Infection control procedures should be reinforced for situations involving BWagents.StandardprecautionsareappropriateforBWagentsoncetheyhavebeenidentified.ForanundifferentiatedfebrileillnessfollowingaBWagentattack:

Placepatients together in an isolated setting, such as adesignated tent orotherstructure.Surgicalmasksmaybeplacedonpatientswhenisolationisnotpossible.Employ respiratory droplet precautions along with standard precautionsuntildiseasestransmissiblebydroplet(eg,plagueandsmallpox)havebeenexcluded.

MedicalEvacuationIfplague,smallpox,andhemorrhagicfeverscanbeexcluded,patientsmaybe evacuated using standard precautions and the disease-specificprecautions.

Plagueandsmallpoxareinternationallyquarantinablediseases.Donotevacuatepatientacross internationalbordersunlessauthorizedbythetheatersurgeon.

Isolationprecautionsshouldbeaddedtostandardprecautions.Immediatelyupondiagnosingpatientswithsmallpox,thelineandmedicalchainofcommandmustbenotified.Observestrictquarantine.

Standardandrespiratorydropletisolationprecautions.

Standardprecautions.

Handwashingafterpatientcontact.

Useofgloveswhentouchingblood,bodyfluids,secretions,excretions,andcontaminateditems.

Useofmask,eyeprotection,andgownduringprocedureslikelytogeneratespraysofblood,bodyfluids,secretions,orexcretions.

Handlecontaminatedpatient-careequipmentandlineninamannerthatprecludestransferofmicroorganismstoindividualsorequipment.

Practicecarewhenhandlingsharpsandusepocketmaskorotherventilationdevicewhenventilatingthepatient.

Placepatientinprivateroomwhenpossible.Limitthemovementortransferofpatient.

Dropletprecautions.Standardprecautionsplus:

Placepatientinprivateroomorwithsomeonewiththesameinfection.Ifnotfeasible,maintainatleast1mdistancebetweenpatients.

Useamaskwhenworkingwithin1mofpatient.

Maskthepatientifhe/sheneedstobemoved.

All contacts should be vaccinated within 7 days of exposure andquarantined together for at least 17 days following themost recentexposure.

HemorrhagicFevers—Hanta,Ebola,Lassa,RiftValley,andHemorrhagicFeverWithRenalSyndrome

Except foryellow fever,quarantine isnotmandatory;however,person-to-person transmission is possible. Therefore, universal precautions arerecommended.Medicalevacuationmayresult in increasedmorbidityandmortality; thus,treatmentatlocalmedicaltreatmentfacilitesispreferred.Whennecessary,patientsmaybeevacuatedusinguniversalandrespiratorydropletisolationprecautions.

BiologicalAgents

Thefourtoxinsmostlikelytobeusedasbiologicalagentsarebotulinumtoxins,ricin,staphylococcalenteroxinB,andT-2mycotoxins(Table29-1).

Table29-1.SymptomsandMedicalManagementofBiologicalToxinsBiologicalToxin Signs/Symptoms MedicalManagement

Botulinum Cranialnervepalsies Antitoxin/supportivecare

Paralysis

Respiratoryfailure

Ricin Fever,cough,shortnessofbreath

Arthralgias,pulmonaryedema Nonspecific/supportivecare

SEB Nausea,vomiting,diarrhea Nonspecific/supportivecare

Fever,chills,headache

T-2mycotoxin Skinpain,redness,blistering Nonspecific/supportivecareNasalitching,epistaxis,rhinorrheaDyspnea,wheezing,cough

SEB:staphylococcalenteroxinB.

BacterialAgents

ThebacteriaorrickettsiamostoftenconsideredtobepotentialBWthreatagentsinclude Bacillus anthracis (anthrax), Brucella sp. (brucellosis), Vibrio cholerae(cholera), Burkholderia mallei (glanders), Yersinia pestis (plague), Francisellatularensis(tularemia),andCoxiellaburnetii(Qfever)(Table29-2).

Table29-2.SymptomsandMedicalManagementofBacterialAgentsBacterialAgent Signs/Symptoms MedicalManagement

Anthrax Fever,malaise,cough,shortnessofbreath,cyanosis Ciprofloxacin

Plague Highfever,chills,headache,cough,shortnessofbreath,cyanosis Streptomycin

Brucellosis Fever,headache,myalgias,sweats,chills Doxycycline

Cholera Massivewaterydiarrhea Fluidtherapyandantibiotics(tetracycline,doxycycline,orciprofloxacin)

Tularemia Localulcer,lymphadenop-,athyfever,chills,headache,andmalaise Streptomycin

Qfever Fever,cough,andpleuriticchestpain Tetracycline

ViralAgents

AnumberofvirusesareBWagents,includingsmallpox,viralhemorrhagicfevers,andthealphavirusthatcausesVenezuelanequineencephalitis(Table29-3).

Table29-3.SymptomsandMedicalManagementofViralAgentsViralAgent Signs/Symptoms MedicalManagement

VEE Feverandencephalitis Nonspecific/supportivecare

Smallpox Malaise,fever,rigors,vomiting,headachefollowedbypustularvesiclesAntiviralunderinvestigation/supportivecare

VHF Flushingoftheface,petechiae,bleeding,fever,myalgias,vomiting,anddiarrhea Nonspecific/supportivecare

VEE:Venezuelanequineencephalitis;VHF:viralhemorrhagicfever.

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Chapter30

ChemicalInjuries

The reader is strongly advised to supplementmaterial in this chapterwiththefollowingreference:

US Army Medical Research Institute of Chemical Defense (USAMRICD),Chemical Casualty Care Division.Medical Management of Chemical CasualtiesHandbook.5thed.AberdeenProvingGround,MD:USAMRICD;2013.

Introduction

The use of chemical agents in modern history includes the use of riot controlagents, pulmonary agents (chlorine and phosgene), and vesicants (mustard)duringWorldWarIthroughtheuseofvesicants(mustard)andnerveagentsbyIraqonIraninthe1980s.Thechemicalagentsmostlikelytobeusedtodayonthebattlefieldincludenerveagentsandmustard.However,withtheimplementationof various types of medical defenses, chemical casualties can be saved andreturnedtoduty,andmortalitycanbeminimized.

PersonalProtectionPrevention!

Avoidbecomingacasualty.Protectyourselfandinstructyourpersonneltodothesame.

Prevent further injuryof thecasualtyby instructinghim/her toputon theprotectivemaskandMOPP(Mission-OrientedProtectivePosture)ensemble,and administer self-aid. If contaminated, tell the individual to removeclothinganddecontaminatepotentiallyexposedbodysurfaces.Providebuddyaidbymaskingtheindividual,administeringantidotes,andspotdecontaminatingexposedbodyareas.Ensurecompletenessof thedecontaminationprocess to thegreatestextentpossibleattheco-locatedpatientdecontaminationstation.

Potential for vapor exposure from an off-gassing residual agent orinadvertent contact with undetected liquid is a hazard for medicalpersonnel.Avoidcontaminationofthemedicaltreatmentfacility.

InitialTreatmentPrioritiesThereisnosingle“best”waytoprioritizeemergencytreatmentforchemicalormixedcasualties,althoughrespiratoryinsufficiencyandcirculatoryshockshouldbetreatedfirst.Oneworkablesequenceisshownbelow.

1. Treatrespiratoryinsufficiency(airwaymanagement)andcontrolmassivehemorrhage.

2. Administerchemicalagentantidotes.3. Decontaminatetheface(andprotectivemaskifdonned).4. Remove contaminated clothing and decontaminate potentiallycontaminatedskin.

5. Renderemergencycareforshock,wounds,andopenfractures.6. Administersupportivemedicalcareasresourcespermit.7. Transport the stabilized patient to a contamination-free (ie,clean)area.

SpecificChemicalWarfareAgentsandTreatmentConsiderations

NerveAgentsTabun (GA), sarin (GB), soman (GD), cyclosarin or cyclohexyl sarin (GF),andmethylphosphonothioicacid(VX).General: Nerve agents are among the most toxic of the known chemicalagents.Theyposeahazard inbothvaporandliquidstates,andcancausedeathinminutesbyrespiratoryobstructionandcardiacfailure.Mechanismofaction:Nerve agents are organophosphates that bindwithavailable acetylcholinesterase, permitting a paralyzing accumulation ofacetylcholineatthemyoneuraljunction.Signs/symptoms: Miosis, rhinorrhea, difficulty breathing, loss ofconsciousness,apnea,seizures,paralysis,andcopioussecretions.Treatment: Each deployed US service member has three AntidoteTreatmentNerveAgentAutoinjectors(ATNAAs)forIMself-injectioninapocket of the protectivemask carrier. Each kit delivers 2-mg injections ofatropine sulfate and 600 mg pralidoxime chloride (2-PAMC). Each USservice member also carries a 10-mg diazepam autoinjector to beadministeredbyabuddy.

ImmediateIMorIVinjectionwith:

Atropinetoblockmuscariniccholinergicreceptors(mayrequiremultipledosesinmuchgreateramountsthanrecommendedbyAdvancedCardiacLifeSupportdoses).

2-PAMC(ifgivensoonafterexposure)toreactivatecholinesterase.

Pretreatment:Militarypersonnelmayhavealsoreceivedpretreatmentpriorto nerve agent exposure. In the late 1990s, the US military fieldedpyridostigminebromidetabletsasapretreatmentfornerveagentexposure(this reversibly binds to the enzyme acetylcholinesterase, enhancing theefficacyofatropineagainstsoman).

VesicantsSulfur mustard (HD or H), nitrogen mustard (HN), Lewisitec (L), andphosgeneoxime(CX).General:Thevesicants (blisteragents)arecytotoxicalkylatingcompounds

exemplifiedbythemixtureofcompoundscollectivelyknownas“mustard.”Mechanismofaction:MustardisanalkylatingagentthatdenaturesDNA,producingaradiomimeticeffect;andproduces liquefactionnecrosisof theepidermis, severe conjunctivitis, and, if inhaled, injures the laryngeal andtracheobronchialmucosa.Signs/symptoms: Skin blisters, moderate-to-severe airway injury(presentationcanbedelayed),conjunctivitisofvaryingseveritythatcausesthe casualty to believe he/she has been blinded, and mucus membraneburns.NodelaywithLewisite;immediateburningoftheskinandeyes.Treatment: Preventive and supportive. Immediate decontamination of thecasualty has top priority. Agent droplets should be removed asexpeditiously as possible by blottingwith Reactive SkinDecontaminationLotion (RSDL) or flushing with water or 0.5% hypochlorite. RSDL isextremelyeffectiveatinactivatingmustard.

Mostmilitary forces carry a decontamination powder or liquid thatshouldbeusedimmediatelytoremovethevesicant.Becausemustard tends tobeanoily solution,watermay spread theagent. Dimercaprol is used by some nations in the treatment ofLewisite. Dimercaprol must be usedwith caution because the drugitselfmaybetoxic.

Lung-Damaging(Choking)AgentsPhosgene(CG),diphosgene(DP),chloropicrin(PS),andchlorine.General:Lung-damagingorchokingagentsproducepronouncedirritationoftheupperandthelowerrespiratorytracts.CGsmellslikefreshlymowedhayorgrass.Mechanism of action: CG is absorbed almost exclusively by inhalation.Mostoftheagentisnotsystemicallydistributed,butratherisconsumedbyreactionsoccurringatthealveolar–capillarymembrane.Signs/symptoms: CG exposure results in pulmonary edema following aclinicallylatentperiodthatvaries,dependingontheintensityofexposure.Immediate eye, nose, and throat irritations may be the first symptomsevident after exposure (choking, coughing, tightness in the chest, andlacrimation). Over the next 2–24 hours, the patient may developnoncardiogenicfatalpulmonaryedema.Treatment:

Terminate exposure, force rest, manage airway secretions, oxygen;considersteroids.Triage considerations for patients seen within 12 hours afterexposure:

ImmediatecareinICU,ifavailableforpatientsinpulmonaryedema.

Delayed:dyspneawithoutobjectivesignsofpulmonaryedema;reassesshourly.

Minimal:asymptomaticpatientwithknownexposure.

Expectant:patientpresentswithcyanosis,pulmonaryedema,andhypotension.Patientspresentingwiththesesymptomswithin6hoursofexposurewillnotlikelysurvive.

TheCyanogensBloodagents:hydrogencyanide(AC)andcyanogenchloride(CK).General:ACandCKformhighlystablecomplexeswithmetalloporphyrins,suchascytochromeoxidase.Theterm“bloodagent”isanantiquatedtermused at a timewhen it was not understood that the effect occursmostlyoutsideofthebloodstream.Mechanismofaction:Cyanideactsbycombiningwithcytochromeoxidase,blocking the electron transport system. As a result, aerobic cellularmetabolismcomestoahalt.Signs/symptoms:Seizures,cardiacarrest,andrespiratoryarrest.Treatment:

Immediate removal of casualties from the contaminated atmospherepreventsfurtherinhalation.100%oxygen.If cyanide was ingested, perform gastrointestinal lavage andadministeractivatedcharcoal.Specific antidotal therapy:Administer sodiumnitrite (10mL of 3%solution IV) over a 3-minute period, followedby sodium thiosulfate(50mL of 25% solution IV) over a 10-minute period. Sodiumnitriteproducesmethemoglobinthatattractsthecyanide;sodiumthiosulfatesolution combines with the cyanide to form thiocyanate, which isexcreted.

IncapacitationAgentsBZ(3-quinuclidinylbenzilate)andindoles.General: Heterogeneous group of chemical agents related to atropine,scopolamine, and hyoscyamine that produces temporary disablingconditionswithpotentCNS effects that seriously impair normal function,butthatdonotendangerlifeorcausepermanenttissuedamage.Signs/symptoms: Mydriasis, dry mouth, dry skin, increased reflexes,hallucinations,andimpairedmemory.Treatment:

Immediateremovaloffirearmsandotherweaponstoensuresafety.Closeobservation.Physostigmine, 2–3mg IM every 15minutes to 1 houruntil desiredlevelisattained;maintainwith2–4mgIVevery1–2hoursforseverecases.

ThickenedAgentsThickened agents are chemical agents that have beenmixedwith another

substancetoincreasetheirpersistency(persistentagentsmayremainintheenvironmentmorethan24hours).Casualtieswiththickenednerveagentsinwoundsareunlikelytosurvivetoreachsurgery.Thickened mustard has delayed systemic toxicity and can persist inwounds,evenwhenlargefragmentsofclothhavebeenremoved.

SurgicalTreatmentofChemicalCasualtiesWounddecontamination—Initialmanagement of a casualty contaminatedbychemicalagentswillrequireremovalofMOPPgear,aswellasinitialskinand wound decontamination with available decontaminant beforetreatment.

Bandagesareremoved,woundsareflushed,andbandagesreplaced.Tourniquets are replaced with clean tourniquets afterdecontamination.Splintsarethoroughlydecontaminated.

Vesicants and nerve agents are potential wound contamination hazards.Cyanogens are so volatile that it is extremely unlikely theywould remain in awound.

Off-GassingTheriskofvaporoff-gassingfromchemicallycontaminatedfragmentsandclothinwoundsisverylowandinsignificant.

Off-gassingfromawoundduringsurgicalexplorationwillbenegligible.

UseofRSDL

RSDL inactivates nerve agents andmustard, and can remove an agent that hasalready begun to penetrate the skin. It is the preferred spot decontaminant forchemicalcasualties,butisnotcurrentlyapprovedforuseineyesorwounds.

WARNING:Concomitantusewithbleachmayresultinanexothermicreactioncapableofgeneratingsufficientheattodamagetissue.

UseofHypochloriteSolutionHouseholdbleachis5%sodiumhypochlorite;hence,mix1partbleachwith9partswatertocreatea~0.5%solution.Dilute hypochlorite (0.5%) is an effective skin decontaminant, but thesolutioniscontraindicatedforuseinoronanumberofanatomicalareas:

Eye:maycausecornealinjuries.Brainandspinalcordinjuries.Peritonealcavity:Mayleadtoadhesions.Thoraciccavity:Hazardisstillunknown,althoughitmaybelessofaproblem.

Full strength 5% hypochlorite is used to decontaminate instruments,clothing,sheets,andotherinanimateobjects.

WoundExplorationandDebridement

Surgeons and assistants should wear well-fitting, thin, butyl rubber gloves ordoublelatexsurgicalgloves.Glovesshouldbechangedoftenwhileascertainingthattherearenoforeignbodiesorthickenedagentsremaininginthewound.

Wound excision and debridement should be conducted using a no-touchtechnique.Removedfragmentsoftissueshouldbedumpedintoacontainerof5%hypochloritesolution.Superficialwoundsshouldbewipedthoroughlywith0.5%hypochloriteandthenirrigatedwithcopiousamountsofnormalsaline.

FollowingtheSurgicalProcedureSurgical and other instruments that come into contact with possiblecontaminationshouldbeplacedin5%hypochloritefor10minutespriortonormalcleansingandsterilization.Reusable linen should be checked with the chemical agent monitor, M8paper, or M9 tape for contamination. Soak contaminated linen in 5%hypochlorite.

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Chapter31

PediatricCare

Introduction

The military surgeon needs to be familiar with the unique challenges thatpediatric population patients present, not only in war, but also in noncombatmilitaryoperationsotherthanwarscenarios.ForUSArmymilitarymedicalunits,thehumanitarianaugmentationmedicalequipmentset,requestedbythehospitalcommander through command channels, provides medical supplies andequipmentforapopulationof10,000people.

Table31-1.HourlyFluidRequirementsforChildrenWeight(kg) HourlyVolume FluidUpto10kg 10mL/kg D5¼NS+20mEqKCl/L11–20kg 40mL+2mL/kgover10kg D5½NS+20mEqKCl/L>20kg 60mL+1mL/kgover20kg D5½NS+20mEqKCl/L

AnatomicalandPhysiologicalConsiderationsFluid,electrolyte,andnutrition.

Normal fluid requirements in children are estimated via a weight-basednomogram(Table31-1)ora length-basedmethod(Table 31-1),suchastheBroselowPediatricEmergencyTape.Fluid resuscitation is bestperformedwith isotonic fluids at 20 cc/kgboluses.(SeeEvaluationandDiagnosis.)Totalfluidrequirementshouldbeadjustedforagoalurineoutputof1–2cc/kg/h.Daily caloric andprotein requirements are estimated byweight andage(Table31-2).

Table31-2.DailyCaloricandProteinRequirementsforChildren

Age(yrs) BodyWeight(kcal/kg) Protein(g/kgBodyWeight)

0–1 90–120 2.0–3.5

1–7 75–90 2.0–2.5

7–12 60–75 2.0

12–18 30–60 1.5

>18 25–30 1.0

Breast milk is always the first choice when initiating oral intake ininfants.Alternatively,infantformulascontain20kcal/oz.Anestimateoftheamountofformulaneededtoprovide120kcal/kg/dis:

Infant’sweight(kg)×22-30=Amount(incc)offormulaneededq4h.

Pulmonary.Inallchildren,itisimportanttorecallthatthemostcommoncauseofcardiacarrestisrespiratoryarrest.Hypoxemiacanleadtobradycardiawithhypoperfusionandthencardiacarrestinrapidsuccession.Newborns tend to be obligate nasal breathers; thus, nasal airwaysshouldbeavoidedifpossible.The child’s larynx ispositionedmoreanterior in theneck,making itmoredifficulttovisualizeduringintubationandnecessitatingamoreforwardpositionofthehead.The acceptable range of PaO2 (60–90 mm Hg) correlates to oxygensaturationsof92%–97%.Apremature infant’soxygenationsaturationshouldneverexceed94%toavoidretinopathyofthepremature.Infants breathe mostly with their diaphragm; thus, increases inintraabdominal pressure or other problems that limit diaphragmaticmovementcansignificantlyinhibitrespiration.

Cardiovascular.Vitalsignsbyagegroup(Table31-3).

Table31-3.NormalVitalSignsforAgeAge Weight(kg) RespirationRate Pulse BP(Systolic)Premie <3 40–60 130–150 42±10Term 3 40 120–140 60±101–5years ~10–20 20–30 100–130 95±306–10years 20–32 12–25 75–100 100±15Adolescent 50 12–18 70 120±20

Cardiac stroke volume in children is relatively fixed. Therefore,bradycardiaorrelativebradycardiacansignificantlydecreasecardiacoutput.Stimulationandoxygentherapyarecorrectiveformorethan90%ofsignificantbradycardiasininfants.

LimitperipheralIVaccessattemptsto2within90secondsforthechild in shock, then immediately proceed to saphenous veincutdown or intraosseous infusion. (See Chapter 7, Shock,

Resuscitation,andVascularAccess.)Burns.

Aninfantorchild’sheadtendstoencompassmoreofthebodysurfacearea,withthelowerextremitiesbeingasmallerpercentage.Theareaof the hand represented by the palm and fingers can be used toestimate1%oftotalbodysurfaceareaforburncalculations(Fig.31-1).

Fig.31-1.Bodysurfaceareapercentagesforinfantsandchildren.

Gastrointestinal.Reflux is a common finding, especially in the newborn period. Thispredisposes some children to difficultywith digestion and frequentemesis.Children are predisposed to hypoglycemia due to the low glycogenstorage capacity of their liver. Full-term infants will tolerate NPOstatus for approximately 5 days (with an appropriateD10 solution).Prematureinfantswilltolerateonly3daysofNPOstatuspriortotheinitiationoftotalparenteralnutrition.Achild’sGItractisverysensitivetomostinsults,includingelectrolyteabnormalities and systemic illnesses. This can result in an ileus,manifest as feeding intolerance, and may precipitate necrotizingenterocolitis.Gastroenteritis with diarrhea, often associated with fevers, is also averycommoncauseofseveredehydration.

Hematologyandbloodvolume.Infantshaveaphysiologicalanemiaduringthefirst3–5months,withahematocritof30%–33%.Estimatesofbloodvolumeareasfollows:

AgeEstimate Volume(cc/kg)

Newborn 90

Infant 80

School-agechild 70

Renal.Infantsandyoungchildrenhavealimitedabilitytoconcentrateurine(maximum: 400–600mOsm/L) and a fixed ability to excrete sodium,thus causing an inability to handle excess sodium and resulting inhypernatremiaiftheyreceivetoomuchsodium.

Thermoregulation.Infants and young children are predisposed to heat loss, and theycompensate poorly for wide fluctuations in ambient temperatures.Children have a higher ratio of body surface area to mass, andtherefore are likely to become dehydrated earlier than adults whenfebrile.Reduceexposureandkeepinfantsandchildreninaregulatedwarmenvironment.

Immunesystem.Premature infants have incomplete development of their immunesystem,causinga60-foldincreasedriskofsepsis.Allelectivesurgeryin infants under 30 days of age requires 48 hours of prophylacticantibiotics (with anaerobic coverage added when appropriate) afterthefirstweekoflife.Early signs of sepsis can include lethargy, intolerance to feedings,fever,hypothermia,tachycardia,andirritabilitybeforeariseinwhitebloodcellcount.

EvaluationandDiagnosisPediatriccervicalspineclearancecanbeperformedwithaphysicalexaminchildrenwhoareawakeandwhohavenoneurologicaldeficits.Ifthereisnomidlinetendernessandnopainwithactivemotion,thespinecanbecleared.Obtunded children, thosewith focal neurological deficits, and thosewithtendernessshouldhavefurtherimaging,whichwillbedictatedbywhatisavailableinyourfacility.CTimagingcanbeavaluabletoolinpediatrictrauma.Trytolimitthedoseof radiation with the CT protocol, if possible. In children under 10 kg,contrastshouldbeinjectedbyhand.BasicATLS guidelines should direct the initial assessment and evaluationforallchildreninvolvedintraumas.Itisessentialtokeepthepatientwarmbecausechildrenaremuchmorepronetoheatlossthanadults.

ModifiedGlasgowComaScalescoresforchildren<4yearsold:

VerbalResponse VerbalScore

Appropriatewords/social 5

smile/fixes/follows

Cries,butconsolable 4

Persistentlyirritable 3

Restless,agitated 2

None 1

TreatmentThetreatmentalgorithmshownhereprovidesthepropersequencefor therapid sequence intubation of the pediatric patient (Fig. 31-2).

Fig.31-2.Rapidsequenceintubationforthepediatricpatient.

EquipmentandSuppliesAccessorypediatricmedical/surgicalequipmentarrangedaccordingtoageandweight(Table31-4).Surgicalinstruments.

If a pediatric surgical set is not immediately available, a peripheral

vascular set will usually contain instruments delicate enough toaccomplishmosttasksinnewborns.

Table31-4.PediatricResuscitationEquipmentandSupplies

CommonlyUsedDrugsandDosages

AlldosesareIVorIM.

Phenobarbital: 10–20 mg/kg IV at a rate not to exceed 1 mg/kg/min(maximumdose:40mg/kg).Diazepam:0.04–0.3mg/kg/dose.Midazolam:0.1mg/kgIV(maximum:5mg).Atropine:0.02mg/kgIV.Phenytoin:15–20mg/kgIV;administeredat0.5–1.5mL/kg/minasaloadingdose,then4–7mg/kg/dIVformaintenance.Mannitol:0.25–1.0g/kgIV.Succinylcholinechloride:2mg/kgIVfor<10kgand1mg/kgIVfor>10kg.Ampicillin:25–50mg/kgIVq6h;100–200mg/kg/ddividedq6h.Gentamicin:4.5–7.5mg/kgIVqd[oncedailydosing(ODD)];keepdosesinmanualforq8hdosing.Metronidazole:7.5mg/kgIVq6h.Acetaminophen:15mg/kgPOq4h.Cefazolin:25–100mg/kg/ddividedq6h–q8h.Clindamycin:15–40mg/kg/ddividedq6h–q8h.Hypertonicsaline(3%):5–10mL/kg.Morphine:0.1–0.2mg/kgq2h–q4hPRN.Ketamine:0.5–1.5mg/kgIVover1minute>3months;2–4mg/kgIM.

SurgicalManagementBasics.

Asageneralguideline,transverseincisionsshouldbeusedininfants.This minimizes the risk of postoperative dehiscence, while still

allowingadequateexposure.Absorbablesutures,suchasVICRYLorPDS(2-0),shouldbeusedtoclosetherectusfascia,regardlessoftheincision.Theskincanthenbeclosed using staples or absorbable monofilament suture (eg,MONOCRYL4-0).

References

Fuenfer MM, Creamer KM, eds. Pediatric Surgery and Medicine for HostileEnvironments.Washington,DC:Departmentof theArmy,OfficeofTheSurgeonGeneral,BordenInstitute;2010.

TschudyMM,ArcaraKM,eds.TheHarrietLaneHandbook:AManual forPediatricHouseOfficers.19thed.Philadelphia,PA:ElsevierMosby;2012.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter32

CareofEnemyPrisonersofWar/Internees

Introduction

Healthcare personnel of the armed forces of the United States have aresponsibility to protect and treat, in the context of a professional treatmentrelationship and universal principles of medical ethics, all detainees in thecustody of the armed forces. This includes enemy prisoners of war (EPWs),retained personnel, civilian internees, and other detainees. For the purposes ofthischapter,allsuchpersonnelarereferredtoasinternees.

DepartmentofDefense (DoD)healthcarepersonnel shouldmakeeveryeffort tocomply with “Principles of Medical Ethics Relevant to the Role of HealthPersonnel, Particularly Physicians, in the Protection of Prisoners andDetaineesAgainst Torture and Other Cruel, Inhuman, or Degrading Treatment orPunishment”—adopted by the United Nations General Assembly Resolution37/194,December18,1982(seeAppendix1inthisbook)—andallapplicableDoDpolicies.

TheGenevaConventionsDefinemedicalpersonnelas those individuals“exclusivelyengaged in thesearchfor,orthecollection,transport,ortreatmentofthewoundedorsick,or in the prevention of disease; and staff exclusively engaged in theadministrationofmedicalunits and establishments” (GenevaConventionfor theAmelioration of theWounded and Sick inArmed Forces in theField[GWS]).Medical personnel of enemy forces are not considered internees, but areclassified as “retained” in order to treat other EPWs. Internees are alsoentitled to the protections afforded under the provisions of theGenevaConvention Relative to the Treatment of Prisoners of War (GPW).Detained persons who are not protected under GWS and GPW, may beprotectedunder theprovisionsof theGenevaConventionRelative to theProtectionofCivilianPersonsinTimeofWar.

TheGenevaConventionfortheAmeliorationoftheWoundedandSickinArmedForces in theField states thatbelligerentsmust care for the sickand wounded without any adverse distinction founded on sex, race,nationality,religion,politicalopinions,oranyothersimilarcriteria.Onlymedicalurgencycanjustifypriorityintheorderoftreatment.

Workload

Thenumberof internees and retained/detainedpersonnel requiringmedical in-processingand/ormedicalcarecanbestaggering.Coalitionforcescapturedover62,000interneesduringOperationDesertStorm.Duringthe1-weekgroundwar,untiltheendofMarch1991,8,979interneesweretreated.

Themost common interneemedical condition reported duringOperationDesert Storm was dental disease (24%). Other common medical illnesseswereunexplainedfever,nephrolithiasis,pepticulcerdisease,andmalaria.

Wounds in interneesmaybedifferent than thoseseen in friendly forcesdue to differences in personal protective gear, preexisting diseases,malnutrition,andneglect.

MedicalCareofInterneesHealthcare providers have a responsibility to report information thatconstitutesaclearandimminentthreattothelivesandwelfareofothers.Whenever possible, internees should receive medical care equal to thatgiventoourowntroops.

Providers should report any suspected abuse ormaltreatment of aninternee.Providers should inform the theater internment facility chain ofcommandof interneephysical limitations.Medicalrecommendationsconcerning internee activities are nonbinding. Decisions concerninginterneeactivitiesaremadebythechainofcommand.

Healthcare providers charged with the care of internees should not beactively involved in interrogation, advise interrogators how to conductinterrogations,orinterpretindividualmedicalrecords/medicaldataforthepurposesofinterrogationorintelligencegathering.Healthcarepersonnelorderedtoperformdutiestheydeemunethicalshouldrequesttoberecusedthroughhisorherchainofcommand.Ifthesituationis not resolved satisfactorily, healthcare providers may contact theirCommandSurgeonortheInspectorGeneral.Requirements for internee care are provided in AR 190-8/OPNAVINST3461.6/AFJI31-304/MCO3461.1.Interneesmusthaveanexaminationuponarrivalatthedetentionfacility,aswellasachestradiograph(tuberculinskintest forchildrenup toage14years).Sickcallmustbeavailabledaily,andeach internee must be weighed at least once per month. Sanitation andhygienemustbemaintainedatalltimes(AR190-8).Medicalrecords.

Internee medical records are the property of the US Government.Interneesareentitledtoacopyoftheirmedicalrecordsuponrelease.Originalrecordsareretained.The Health Insurance Portability and Accountability Act (HIPAA)does not apply to themedical records of internees (DoD Instruction

6025.18andDoD6025.18R).However, thehandling,disposition,andrelease of all types of medical records are governed by regulation.Commandersandotherswhohaveanofficialneedtoknowcanaccessinformation contained in internee medical records by following theproceduresgiveninAR40-66,usingDAForm4254.Patientconsentisnotrequired.Themedical treatmentfacilitycommanderordesignee,usually the patient administrator, determines what information isappropriateforrelease.Onlyspecificmedicalinformationrequiredtosatisfy the termsofa requestwillbedisclosed.Healthcareprovidersshould expect that releasedmedical informationwill beusedby thechainofcommand,toincludeinterrogators.

Medicalinformation.Releasable medical information includes that which is necessary tosupervise the general state of health and cleanliness of internees, todetectcontagiousdiseases,andtoprovideforthesafetyandsecurityofthefacility.

Setup/PlanningDevelopplansforprisonersonahungerstrikeorwhorefusetreatment.Enemy forces may have preexisting medical conditions requiringmedication.Ensurethatanyinternee/retained/detainedpersonevacuatedtothemedicaltreatmentfacilityfortreatmentisescortedbyanarmedguard,asdesignatedbythenonmedical(echelon)commander.Theguardmustremainwiththepatientwhileinthemedicalevacuationandtreatmentchain.Whenpossible,keepinterneessegregatedfromfriendlyforcespatients.Internees requiring evacuation will receive an internee identificationnumberuponentry into thedetainee reportingsystem.Medicalpersonneldonotsearch,guard,orinterrogateinternees.

It is critical thatmedical personnel not enter the general EPW holdingarea,buthavepatientsbroughtouttothemforsickcallandanymedicaltreatment.

NATOSTANAG2131,MultinationalPhraseBookforUsebytheNATOMedicalServices—AMedP-5,providesbasicmedicalquestionsinanumberofNATOlanguages.Use other retained persons/internees (especially medical personnel) astranslators.Detaineesmayfeignmentalillnesstoavoidinterrogation.

ScreeningGuardsshouldensureinterneesarescreenedforhiddenweaponsandotherpotentiallydangerousmaterials.Medicalpersonnel,however,mustremainvigilantof thesethreatsandmentallypreparedshoulda threatorattackoccur.

During transfer, release, and/or repatriation, anothermedical examinationshould be performed. Final documentation of any ongoing medical,surgical,orwoundcareproblemiscompletedandforwardedtothegainingfacilityortotheappropriatemedicalrecordsrepository.

SupplyTheinternmentfacilitymustenforcefieldhygieneandsanitationprinciples.Plan for personal hygiene requirements and protective measures (insectnetting,insectrepellent,sunscreen).Coordinate with the supporting medical headquarters for additionalpreventive medicine support (pest management, potable water, diningfacilitysanitation,andwastedisposal)andVeterinaryServicessupport forfoodsafetyasrequired.

MedicalStaffingThe facility should be staffed to ensure that detainees receive the samestandardofcareasUSforces.RetainedmedicalpersonnelshouldbeutilizedforcareoftheircompatriotsinconformitywiththeGenevaConventions.

LegalWhen possible, signed permission should be obtained for all surgical orinvasiveprocedures.The patient’s identity should be absolutely clear in each photograph.Photographsareinvaluableshouldtherebeaclaimofunnecessarysurgeryoramputation.Ahigh-qualitycameraisimportant.

Anypatientwhorequiresamputationormajordebridementoftissueshouldbephotographed(faceaswellaswoundimages).

InterneeAdvocateThemilitaryphysicianisoftenthecommander’sadvisorformedicalethics.Thephysicianshouldbealertforpotentialandactualethicalconflicts,andmakeeffortstoresolvethem.Theymustalsostrivetomaintaina“moraldistance”fromparticipatinginanyproceedingpotentiallyadversetothepatient’sinterest.

Personal safety should never be taken for granted by the medical team,regardlessoffamiliaritywithinterneesandsurroundings.

SecurityThere is always an element of danger to the medical staff in treatinginternees.Physicalsecuritywillbeprovidedbynonmedicalpersonneldesignatedbytheappropriateleadership.It is the capturing line unit’s responsibility to provide security forEPWs/detaineesuntilarrivalataninternmentfacility.

Security personnelmust accompany all internees whenever they are in atreatmentorholdingarea.Inforwardareas,itmaynotbepossibletohaveseparate and secure medical treatment/holding areas for internees.Whenpossible, internees should be segregated from allied, coalition, and USforces.Whenpossible,avoidtakingmedicalequipmentintothepatientwardsforsecurityreasons(ie,bringthepatienttotheequipment).Following treatment, the provider should alert internment medicalpersonnelofanyspecialneedstheinterneemayhave.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter33

BattlefieldTransfusions

Introduction

About75%ofalltraumacasualtiesrequiringevacuationdonotrequireanybloodproduct transfusion,and, for theremaining25%,mostonlyrequire1–4unitsofblood. However, exsanguinating hemorrhage is the leading cause ofpreventabledeathsduringwar.Between5%–8%ofevacuatedcasualtieswillloselargevolumesofbloodduringinitialcareandrequire“massivetransfusion”(10ormoreunitsof redbloodcells [RBCs] in24hours),which isassociatedwithahigh mortality. Such deaths occur early, generally within the first 6–12 hoursfollowing injury. In cases of massive blood loss, there is no substitute for thetransfusionofblood.Itiscriticaltorecognizesuchcasualtiesbecausetransfusionsupport formassively transfusedpatientsmustbemanageddifferently than forothercasualties.

Thischapterwillbrieflyaddressearlycontrolofhemorrhage,bloodproductsandtheir availability by role, ABO Rh matching of blood products, massivetransfusion and its specific complications/management, emergency freshwholebloodcollection,andtransfusionreactions/managementrelevanttothefield.

EarlyControlofHemorrhagePatientswhodonot lose largeamountsofblood following injurywillnotlikely need blood products. Although this is an obvious statement, ithighlights thepoint thateveryattempttocontrolexternalbleedingshouldbemadeduringinitialcare.Tourniquetsshouldbeappliedimmediatelytoextremitieswithpotentialforlife-threatening blood loss, such as with traumatic amputation,active/ongoingbleeding,orsuspectedvascularinjury(ie,pulsatilebleedingorexpandinghematomaformation).Advanced bandages or topical hemostatic agents approved for use intheatershouldbeusedtohelpcontrolsitesofexternalbleeding.Proximal extremity bleeding (eg, in the groin, axilla, and neck) is notamenable to tourniquet application; therefore, direct manual pressureshouldbeappliedasbestaspossibleduringevacuation.Control of severe bleeding at “noncompressible” sites in the thorax,abdomen, and pelvis can only be accomplished with surgery. Therefore,patients with suspected bleeding from injuries to the thorax, abdomen,and/or pelvis must be evacuated quickly to medical units with surgical

capability.

Early control of extremity and external hemorrhage with tourniquets,bandages,anddirectmanualpressureisessential.

Patientswithsuspected thoracic,abdominal,orpelvicbleedingmustbeevacuatedquicklytomedicalunitswithsurgicalcapability.

BloodProductsAvailablebyRoleBloodproducttransfusionisanessentialcomponentforthemanagementofexsanguinating hemorrhage, but is insufficientwithout definitive surgicalcontrolofbleeding.Damagecontrolresuscitationinitiatedintheprehospitalphaseofcaremayincludetheuseofbloodproducts.BecausenosurgicalassetsareavailableatRole1,bloodproductsmaynotbeavailable.Blood products fielded with forward surgical units are predominantlygroup O-stored RBCs and AB plasma (fresh frozen plasma [FFP] that isthawedandstoredat1°–6°Cforupto5daysasthawedplasma).Combat Support Hospitals have a much larger inventory of ABO type-specific blood products that also includes apheresis platelets (aPLTs) andcryoprecipitate.Availability,storage,andshelf-lifeoftheseproductsareoutlinedinTable33-1.

Table33-1.BloodProductsbyRoleofCare

ABOMatchingofBloodProductsOncetheABOtypingofthecasualtyisknown,type-specificbloodproductsshouldbeusedifavailable.

Until the ABO type of the casualty is known, type O RBCs are safe foremergencytransfusion.Only AB plasma (which contains neither anti-A nor anti-B antibodies) isconsideredsafeforemergencytransfusion.However,ABplasmaisascarceresource because only 4% of the population has this blood type, so ABplasmaisfrequentlyunavailable.ReactionsagainsttheAantigentendtobemoresevere;therefore,Aplasma(whichdoesnotcontainanti-Aantibodies)isthenextsafestalternativeforemergencytransfusion(Table33-2).At Role 2 surgical units, platelets are generally not available, and plasmaproductsmaybeinshortsupply.Insuchcases,ifsuchproductsareneeded(as in massive transfusion), emergency collection of type-specific freshwholebloodisnecessary.

Table33-2.ABOMatchingforTransfusedBloodProducts*RecipientGroup Unknown O A B AB

RBCs

1stchoice O O A B A,B,orAB

2ndchoice O O O

Freshfrozenplasma

1stchoice AB O A B AB

2ndchoice A† A AB AB A†

3rdchoice B† B B† A† B†

Wholeblood‡ Type-specific O A B AB

RBCs:redbloodcells.*Plateletsandcryoprecipitatedonotneedtobetype-specific.†Onlysuitableforemergencyusewhenotherplasmatypesareunavailable.‡FreshwholebloodMUSTbetype-specific.

Giventhetimethatittakestocollectfreshwholebloodfromthetimeit isrequested (30–45 minutes at best), it would be a very uncommoncircumstancethattheABOtypeofthecasualtywouldbeunknown.IfABOtypingisunavailable,typeOfreshwholebloodisnotsafeandcanonlybeconsideredinextremecircumstancesafteratleast10UoftypeORBCshavebeen transfused (ie, after the native blood of the patient has been largelyreplacedwithtransfusedtypeORBCs).

TypeORBCissafeforemergencytransfusion.

AB plasma (or A plasma as the next safest alternative) is used for

emergencytransfusion.

Iffreshwholebloodisrequired,itMUSTbeABOtype-specific.

RhBloodMatchingforFemaleCasualtiesWomen, military and civilian, are becoming more frequent victims ofconflict.SeriousconsequencestoRhincompatiblebloodarerareinmenwhohavenoprevioushistoryoftransfusions.Rh–womentransfusedwithRh+bloodareverylikely(approximately80%)to produce anti-D (Rh+) antibodies. This seroconversion can jeopardize asubsequent pregnancy when this Rh– mother, now sensitized by Rh+transfusion, conceives an Rh+ fetus. Chronic hemolytic disease of thenewbornmayresult,whichcanbefatal tothefetusin50%ofpregnancieswithout modern treatments (which have reduced the mortality down to16%).When the supply of group O blood permits, group O Rh– blood foremergency release should be reserved for women of child-bearingpotential(age<50)untiltheirABOandRhtypesareknown.IfRh–bloodisnot available, Rh+ blood should NOT be withheld (saving a life takesprecedenceoverriskofRhimmunization).Although there is a risk ofRh seroconversionwith aPLTs (due to a smallamount of RBCs in the unit), Rh incompatibility should not influencetransfusion.IfRh+platelets are transfused to aRh–woman, this canbemitigated by use of Rh immunoglobulin (RhoGAM)within 72 hours ofplatelettransfusion.RhseroconversionfromFFPandcryoprecipitateisrare,andtheseproductsarenotgenerallyRhmatched.

Under no circumstances should a lifesaving transfusion be withheldbecauseofRhincompatibility.Savinga life takesprecedenceoverRhimmunization.

MassiveTransfusionMassive transfusion has been defined in various ways, but the mostcommondefinitionistheneedfor≥10Uofbloodin24hours.(Thisisbasedon the estimate of 1 blood volume for an average adult male. Smallindividualsandpediatricpatientshavealowerbloodvolumethatshouldbeconsideredwhendeemingapatientasneedingamassivetransfusion.)Survival inmassively transfused combat casualties ishigher inpatientswhoaretransfusedwithincreasedamountsofplasmaandplatelets.Basedon these observations, prior to definitive surgical control of bleeding,massively bleeding patients should be transfused in fixed ratios of bloodproducts aiming at a ratio of 6 RBCs:6 FFPs:1 aPLT. It is reasonable toconsidertransfusing10Uofcryoprecipitatealongwiththisratio.Earlyrecognition(onadmission)ofneedformassivetransfusion.

Systolicbloodpressure<110mmHg.

Heartrate>105beatsperminute.Hematocrit<32%.pH<7.25.Patientswiththreeoftheabovefourriskfactorshaveapproximatelya70%riskofmassivetransfusion.Patientswith all four of the above risk factors have an 85% risk ofmassivetransfusion.

Laboratory-directedtransfusionthresholdsshouldnotbeusedinmassivelybleeding patients until the patient has been stabilized (because of thesignificanttimelagbetweendrawinglabsandreceivingtheirresults).Therateandvolumeofbloodproducts totransfuseshouldbedeterminedclinically, until surgical correction of hemorrhage has been established.Goalsincludeclinicalfactorssupportingadequateperfusion,restorationofhemodynamic physiology, mentation, skin color, and urine output > 0.5mL/kg/h.Massive transfusion protocols (Fig. 33-1) and good communicationsbetweenprovidersintheER,OR,ICU,andbloodbankareessential.If platelets or plasma are unavailable, type-specific fresh whole blood(which provides all the blood components in a fixed ratio) should becollectedandtransfusedtoprovidethesecriticalcomponents.

Survival inmassively transfused combat casualties is higher inpatients who are transfused with increased amounts of plasmaandplatelets.

Crystalloiduseshouldbeminimizedtoavoiddilution.

Goal blood pressure is systolic blood pressure ~90 mm Hg (inpatients without central nervous system injury) until surgicalcontrolofbleedingisestablished.

Bloodproductsshouldbetransfusedwithagoalratioof6RBCs:6FFPs:1aPLT.

If plasma or platelets are unavailable, type-specific freshwholebloodshouldbecollected/transfused.

ManagementofComplicationsDuringMassiveTransfusionHypothermia in trauma patients develops from conductive, convective,evaporative, and radiative losses due to environmental and surgicalexposure.

Because RBCs are stored at 4°C, hypothermia can develop quicklyduringmassivetransfusion.Hypothermia contributes to coagulopathy (impaired clotting factorsandplatelets)andincreasedriskofcardiacdysrhythmias.Fluid warmers are absolutely essential for preventing or limiting

hypothermia,alongwithothermeasureslistedinTable33-3.Currently, the goal during resuscitation is normalization of bodytemperature, 37°C.

Fig.33-1.Combatsurgicalhospitalexampleofmassivetransfusionprotocol.aPLT:apheresisplatelet;cryo:cryoprecipitate;CSH:combatsupporthospital;DCCS:DeputyCommanderforClinicalServices;FFP:freshfrozenplasma;FWB:freshwholeblood;pRBCs:packedredbloodcells;RBCs:redbloodcells;RTD:returntoduty.

Acidosis inmassively transfusedpatients is largelydue tohypoperfusion,but can be exacerbated by crystalloids and stored RBCs. (RBCs becomeprogressivelymoreacidicduringstorageduetocellularmetabolism.)

Acidemia contributes to coagulopathy and can cause dysrhythmia,hypotension,anddecreasedresponsivenesstocatecholamines.Reversalofacidosis isprimarilyaccomplishedthroughrestorationofadequatetissueperfusion.Bicarbonate or tromethamine (THAM) can be used as necessary toachieveanarterialbloodgaspH>7.2.

Hyperkalemia is a common complication due to extracellular potassium

thatincreasesovertimeinstoredRBCs.During massive transfusion, blood can be administered rapidlythroughcentrallineswithoutsufficienttimeormixturetopreventthisextracellular potassium from reaching the right heart and result inventriculararrhythmiaandcardiacstandstill.Limit effects by transfusing blood from lines farther away from therightatrium.Hyperkalemia canalsobe limitedwith theuseof fresherblood (<14days).Vigilance for this complication is necessary (with labs and EKGmonitoring).ManagementofhyperkalemiaislistedinTable33-3.

Hypocalcemia occurs in massive transfusion due to the citrate(anticoagulant) in plasma and platelet products. Under normalphysiological conditions, citrate is rapidly metabolized by the liver.Metabolism can also be overwhelmed by rapid infusion of plasma-containing components (>100mL/min). It is alsodramatically impaired inhypoperfusedpatientsorthosewithadvancedliverdisease.

Hypocalcemic/citrate toxicity manifests by decreased myocardialcontractility and increased susceptibility to arrhythmia fromcoexistinghyperkalemia.Monitor for/anticipate hypocalcemia based on the pace of plasmatransfusion,electrocardiographicchanges,orionizedcalciumlevels.Treatwithintravenouscalciumchloride.If labs are not immediately available, 1 amp of calcium chlorideshouldbeadministeredwithevery8unitsofplasma.

Table33-3.Management/PreventionofComplicationsofMassiveTransfusionHypothermia

Prehospitalactive/resistivewarmingwithhotpacks/heatingblankets

High-capacityfluidwarmers

Warmedtraumasuites/operatingrooms

Forced-airwarmingblankets

Warmed/humidifiedoxygen

Limitsurgicalexposure(eg,damagecontroltechniques)

Acidosis

Restorationofadequatetissueperfusion

Sodiumbicarbonate

Hyperkalemia

Transfusefresherblood(<14days)

Transfusebloodfromlinesfartherawayfromtherightatrium

Calciumchloride(1amp)tostabilizethemyocardium

Shiftextracellularpotassiumintotheintracellularspace

Correctionofacidemia/alkalinizingsolutions

Regularinsulin10unitswith1amp(50mL)50%dextrose

Inhaledbeta-agonists

Hypocalcemia

Calciumchloride(1amp)basedonmeasurementofserumionizedcalciumlevelsorwithevery8unitsofplasma

Coagulopathy/MicrovascularBleeding

Goaltemperature>37°C

GoalpH>7.2

Goalratiooftransfusedbloodproductsof6RBCs:6FFPs:1aPLT.

Type-specificfreshwholebloodshouldbeusedifsomeorallofthesebloodproductsareunavailable

rFVIIa7.2mgIVifpersistentmicrovascularbleeding,despiteothermeasures

aPLT:apheresisplatelet;FFPs:freshfrozenplasmas;RBCs:redbloodcells;rFVIIa:recombinantfactorVIIa.

Coagulopathy(trauma-inducedanddilutional).Trauma-induced coagulopathy is frequentlypresentonadmission inseverelyinjuredpatients,anditiscorrelatedwiththeneedformassivetransfusion,aswellasincreasedmortality.Dilutional coagulopathy develops in massive transfusion as aconsequenceofthereplacementofshedwholebloodwithfactorandplatelet-poorfluidslikecrystalloids,colloids,andstoredRBCs.Dilutional coagulopathy may be inevitable in patients requiring amassiveresuscitationduetotheadditionofpreservativesolutionstostored blood products following collection. Transfusion of storedRBCs, plasma, and platelets—even in a 1:1:1 ratio—results in asolutionwithahematocritof30%, coagulation factor levelsofabout60%,andplateletsof80×109/L.Limitcrystalloidsorcolloids;theygreatlyintensifydilutionaleffects.

Primarilyusedonlyasacarrierformedications.

Additionaladministrationofcrystalloidstorestorevolumeshouldbeavoidedinpreferencetobloodproducts.

Ifbloodproductsarenotavailable,volumereplacementwith6%Hetastarch(Hextend)500–1,000mLcanbeconsideredtoachievegoalsystolicbloodpressure~90mmHg.

Recombinant factor VIIa (rFVIIa) can reduce blood loss in blunttrauma,although itsbenefit is less clear forpenetrating trauma.Theoff-label use of rFVIIa (100 µg/kg or 7.2 mg) is still consideredcontroversial,andshouldonlybeusedwithsoundclinical judgmentand after optimal management of hyperthermia, acidosis, anddilutionalcoagulopathy.If rFVIIa is used, adequate platelet counts and fibrinogen levels arenecessary(managedwithtransfusion)priortorFVIIaadministration;otherwise,itwillbemuchlesseffective.

In stabilized patients, standard transfusion thresholds should be adoptedforpatients.

RBCtransfusion.

Hemoglobin<7.0g/dL.

Hemoglobin<9.0g/dLwithanticipatedbloodlossesfromplannedsurgery.

Hemoglobin<10.0g/dLforpatientswithmyocardialischemia.

Plasmatransfusion.

Nobleedingorplannedinvasiveprocedures:Nospecifictransfusiontrigger.

Activebleedingorplannedinvasiveprocedure:Transfuseforprothrombin>18.0orInternationalNormalizedRatio>1.5.

Platelettransfusion.

Plateletcount<50withactivebleedingorforinvasiveprocedures:Higherforneurosurgicalinjuriesasdirectedbythesurgeon.

Plateletcount<30forpatientsrequiringtherapeuticanticoagulation(withheparinorCoumadin).

Plateletcount<20forfebrileor“ill”patients.

Plateletcount<10.

EmergencyCollectionofFreshWholeBloodintheField(“WalkingBloodBank”)

Freshwholebloodcollectionshouldbe reserved forwhenstandardbloodproducts are exhaustedorunavailable (eg,whenaPLTsareunavailable tosupportamassivetransfusionatRole2).Current Clinical Practice Guidelines and Department of Defense (HealthAffairs)policyfortheuseoffreshwholebloodintheateralsoincludethatfreshwholebloodcanbe requestedonclinicalgroundswhenotherblood

products are unable to be delivered at an acceptable rate to sustain theresuscitationofanactivelybleedingpatient,orwhenstoredcomponentsarenotadequatelyresuscitatingapatientwithanimmediatelylife-threateninginjury.Emergency collection and transfusion of freshwhole blood should not beperformedatRole1.ForRoles2and3,freshwholebloodcollectionshouldnot be performed in lieu of securing blood products through normalchannels.Risks: Even with soldiers who are immunized against hepatitis B virus(HBV) and screened for human immunodeficiency virus (HIV)predeployment, there is a real risk for transmission of hepatitis C virus(HCV), HIV, syphilis, human T-cell leukemia virus I/II, and endemicdiseases (eg, malaria, dengue, and leishmaniasis). Additionally, cases oftransfusion-associated graft-versus-host disease (a fatal, although rarecomplication)haveoccurredfollowingfreshwholebloodtransfusion.Despitethesepotentialrisks,freshwholebloodisaLIFESAVINGproductthat should not be withheld when standard blood components areunavailable.FreshwholebloodmustbeABOtype-specifictothepatient.

Trying to collect blood at a time of extreme emergency,with little time, is verydifficultandstressful.Itcannotbemasteredforthefirsttimeonactualcasualties.Emergencyfreshwholebloodcollectionatbesttakes30–45minutesfromrequestto itsavailabilityatbedside. Itrequirescoordinationbetweenclinicians,nursingstaff, and the blood bank. Variations will exist depending on blood productinventory, frequency of resupply, availability of donors, size and capability ofmedicalunit, numberofpersonnel (in clinical areas, aswell as in the lab/bloodbank), casualty flow, and mass casualty situations. Planning and hands-ontraining are critical. The medical unit should practice with realistic trainingexercises,includingmasscasualtysituations,towalkthrough/simulatetheentireprocess.Theboxedinformationthatfollowsbelowandonthenextfewpagesisatemplatetoorganizeanemergencyfreshwholebloodcollectionprogramthatwillneedtobeindividualizedtothespecifictacticalsituationandenvironment:479

1. ClinicalDeterminationoftheNeedforFreshWholeBloodWhenwillweuseit?

Only to provide platelets during massive transfusionbecauseaPLTsareunavailable?(atRole2)Only for mass casualty situations because of smallinventory?(atRole2or3)Only tomanage low inventory of typeObloodbecause oftheneedtoreserveforemergencyrelease?(Role2or3)Willprovidersbeabletorequestiftheyclinicallydeterminethat standard blood products are not adequate forresuscitation?

Howoftendoweanticipatetheneedtocollectfreshwholeblood?HowearlydoIneedtoinitiateafreshwholeblooddrive?

Howlongwill it taketoget freshwholeblood?45minutesorseveralhours?Do Ihaveaprocess inplace to facilitateordering from theER,aswellasfromtheORandICU?

2. Request/NotificationforEmergencyCollectionofType-SpecificFreshWholeBlood

Whoisauthorizedtoinitiateawholeblooddrive?Surgeon?Deputy Commander for Clinical Services (DCCS) and/orHospitalCommander?BloodBankDirector?

Who must be contacted to initiate the process (to mobilizeresources)?

NursingSupervisorand/orDeputyCommanderofNursing(DCN)?BloodBankDirector/LabDirector?Hospital S-3 to announce the blood drive outside thehospital?

3. ABOTypingoftheCasualtyWhowillperformABORhtyping,andhowlongwillittaketogetaresult?

Dogtagsareonlyalastresortbecausetheycannotbereliedon.Dogtagshavea3%errorrateineitherABOorRh,andciviliancasualtieswillnothaveknownABORh.

4. IdentificationofPotentialDonorsWhowillbeavailabletodonate?

MedicalPersonnel—usuallyonlytostarttheprocess/providethefirstcoupleofdonorunits.Soldiersawaitingreturntoduty—ifholdingareaforhealthytroopsawaitingreturntodutyisavailable.Local troops—if US soldiers are reasonably close by to becalledontoprovidedonors.

Howwillwenotify/requestdonors?Overheadannouncementinthehospital?Runner to go to the “return-to-duty” area to ask forvolunteers?Tacticalcommunicationstolocalmilitaryunits?

5. ScreeningofDonorsWillweonlyhaveblood type screeningwithdog tags (3%errorrateineitherABOorRh)?Canweestablish inadvanceformalABORhtypingandadonorroster?

Dowehavedonorscreeningquestionnairesreadilyavailable?Wherewillwe screenwithdonor questionnaires? (History of IVdruguse,historyofhepatitis,historyofhigh-risksexualbehavior,recent febrile illness, use of aspirin or NSAIDs [nonsteroidalantiinflammatorydrugs]withinthelast72hours.)Willweneed tomodifydonor screening to account for endemicdiseases(eg,malaria,dengue,orleishmaniasis)?Dowehaveorcanweget“pedigree”donorswithrecent testingfortransfusiontransmittedviruses?Ifdonorrosteriscreated,whowillkeepthisrosterup-to-datewithchangesinpersonnelandwhentheylastdonated(canonlydonateonceevery8weeks)?

6. CollectionofFreshWholeBloodDowehavethecurrent/standardSOPonEmergencyWholeBloodCollectionfromthetheaterBloodProgramOfficer?Dowehavethenecessaryequipment,suchas theCDPA-1bloodcollectionbags(equipmentlistedinSOP)?Aretherelimitstotheamountofbloodcollectedbecauseofhighaltitudes?Wherewillwephysicallycollectblood?Beds?Cots?Chairs?Howmanydonorscanwecollectatatime?Wherewilldonorsrestafterdonation?Repeat donors should receive iron supplementation. Who willorderitforthem?Aretherelimitstothenumberofsoldiersfromasingleunitwhocan donate? (Performance may be impaired by donation. Largenumberscanleadtoincreasedunitineffectiveness.)

7. ProcessingoftheCollectedUnitABOconfirmation.Unitlabeling.Rapidscreeningforinfections(pretransfusion):CurrentlyforHIV1/2,HBV,andHCV.Writetheexpirationoftheunit,whichis24hoursfromcollection.Keep the product at room temperature (20°–24°C) becauseplateletsbecomeinactiveinwholebloodstoredcold.Recordingofdatainthebloodinventoryanddispositionrecords.(If units are not transfused, input donor information anddispositionas“Destroyed/Expired.”)ManagementofunitswithpositiverapidscreeningforHIV,HBV,orHCV.

Destroyunitandplacedonorondeferrallist.InformCommunityHealthNurseofpositivescreeningandconfirmatorydonorinfectiousdiseaseresults.Inform the Blood Program Officer of any donors with a

confirmed positive infectious disease marker where thepatientreceivedthedonor’sblood.Notifydonortoseekfollow-upwithhealthcareprovideronpositive test results and not to donate blood or bloodproducts.

Process inplace tosendsegments toCONUSforposttransfusioninfectiousdiseasetesting.

8. ReleaseofFreshWholeBloodtoBedsideAdditional runnersandnursing staffwillbeneeded.Wherewilltheycomefrom?WhowillrunthefreshwholebloodtotheER/OR/ICU?Will additional standard blood components, such as RBCs andFFP, also be issued if they are available? Will only fresh wholebloodbeusedonceawholeblooddrivehasbeeninitiated?

9.MonitoringofOngoingRequirementsforFreshWholeBloodWho will coordinate with the clinicians to communicate to thebloodbankandcollectionareahowmanyandhowfastadditionalunitsareneeded?

10. CessationofFreshWholeBloodCollectionWhowill determine that freshwhole blood is no longer needed(ie,thepatienthasstabilizedorongoingresuscitationisfutile)?

________________________aPLTs:apheresisplatelets;CONUS:continentalUnitedStates;CPDA-1:citrate-phosphate-dextrose-adenine;HBV:hepatitisBvirus;HCV:hepatitisCvirus;HIV:humanimmunodeficiencyvirus;SOP:standardoperatingprocedure.

TransfusionReactionsintheFieldTransfusionreactionsmaybedifficult to recognize inseverelyormultiplyinjured casualties. Regardless, clinicians should be aware of the potentialcomplications of transfusion and their management in the deployedenvironment.

TreatmentPlanforTransfusionReaction

STOPthetransfusion.Assess thepatient: reviewvitalsandauscultate lungs. Ifpatient isconscious,askaboutsubjectivecomplaints.Iffeverandunexplainedhypotension,considerABOmismatchandbacterialcontamination/sepsis.If unexplained hypoxia, consider volume overload and TRALI(transfusion-relatedacutelunginjury).If unexplained hypotension/shock without fever, consider severeallergicreaction/anaphylaxis.Ifbronchospasmorangioedema,considerallergicreaction.Ifonlyurticaria,likelyurticarialreaction.

If only fever in stable patient, consider febrile reaction, but stillsend unit to blood bank to rule out ABO mismatch or bacterialcontamination.

AcuteHemolyticTransfusionReaction(ABOIncompatibility)Generally develops rapidly (minutes to a fewhours) after initiation of anABOincompatibleRBCtransfusion.Mortalitycanbe>15%andincreaseswiththeamountofincompatiblebloodthatisinfused.Themostcommoncauseofhemolytictransfusionreactionsisclericalerrorthatoccursoutsideofthebloodbank.Feveristhemostcommonearlysign;thus,ahemolytictransfusionshouldbeconsideredanytimeafebrilereactionfollowsatransfusion.Inunconscious/sedatedpatients,theonlysignsmaybe:

Fever.Inappropriatehypotension.Tachycardia.Darkurine(reflectinghemoglobinuria).Renalfailure.Development of generalized/coagulopathic bleeding due toassociateddiffuseintravascularcoagulation(DIC).

Frequently, suchpatients aregiven additionalunits of incompatiblebloodbefore medical personnel realize that a hemolytic transfusion reaction isoccurring.Consciouspatientscanalsoreportchills,severelowbackpain(reflectingrenal involvement), dyspnea, apprehension, chest pain, nausea, andvomiting.To prevent renal failure, administer 0.9% normal saline and intravenousfurosemide as needed tomaintain urinary output (goal: 100mL/h or 1–2mL/kg/hforsmallpatients)untilresolutionofhemoglobinuria.The coagulation system and platelet count must be monitored for thedevelopmentofDIC.FFP and platelet transfusions may be needed if coagulopathic bleedingdevelops.

Acutehemolytictransfusionreactiongenerallydevelopsrapidly(fromminutesto a few hours) after initiation of an ABO incompatible red blood celltransfusion.

AcuteHemolyticTransfusionReactionTreatment

Stoptransfusionandclearlymarkthesuspectedunit.

Maintain blood pressure and urinary output with 0.9% saline ±intravenous furosemide as needed (goal urine output: 100 mL/h untilresolutionofhemoglobinuria).

Observe for coagulopathic bleeding from diffuse intravascularcoagulation and monitor coagulation tests/platelet counts. Treat asnecessarywithfreshfrozenplasmaand/orplatelets.

Recheckidentificationofpatientandunitforclericalerrors.

Annotate field medical card or patient record with description of thesuspectedreactionandtreatments.

Sendalltransfusedunitsatthebedsidetothebloodbank(ortothenextechelonofcare).

BacteremiaandSepsisFromContaminatedBloodProductsLiquidstoredbloodproducts(aPLTsandRBCs)areafertileculturemedia,andsmallamountsofcontaminatingbacteriamaygrowinbloodproductsduringtheirstorage.Thesebacteriacancausefeversandbacteremiaduringorsoonafteratransfusion.Ifthebacterialloadissufficientlyhighorgram-negative organisms are present, frank sepsis (hypotension/shock) candevelop.Plateletscarrythehighestriskforbacteremia/sepsisbecausetheyarestoredatroomtemperatureforupto5days.If fever and hypotension develop during or immediately following atransfusion of platelets, then broad-spectum antibiotics should beadministered.BecausefeverandhypotensionarealsosignsofABOmismatch,sepsisoftencannot be immediatelydistinguished froman acute hemolytic transfusionreaction at bedside. The blood bank can clarify/rule out ABOincompatibility.OnceABOmismatchhasbeenexcludedbythebloodbank,broad-spectumantibioticsshouldbeconsidered.

FebrileNonhemolyticTransfusionReactionApproximately 1% of all transfusions are accompanied by a temperatureelevation (defined as an increase of 1°C above normal within 1 hour oftransfusion),whichcanbewithorwithoutchills.Preventedbyuseof leuko-reducedbloodproductsorwithacetaminophenprior to transfusion (unlikely to mask fevers from hemolytic reactions orbacterialcontamination).There is no definitive test withwhich tomake the diagnosis of a benignfebrilereaction,whichmayalsobethefirstsignofahemolyticreactionortheinfusionofaunitcontaminatedwithbacteria.Forthisreason,ifafeveroccurs,managementinvolves:

Immediatecessationofthetransfusion.Evaluation/considerationforABOmismatchorbacteremia.

Transfusion-RelatedAcuteLungInjuryTransfusion-relatedacutelunginjury(TRALI)ismanifestedbyrapidonset

of “noncardiogenic” pulmonary edema with dyspnea, hypoxemia, andpulmonaryinfiltrateswithin6hoursaftertransfusion.Whole blood, platelets, packed RBCs, and FFP are most commonlyimplicated.TheestimatedmortalityrateforrecognizedTRALIis5%–8%,althoughmostpatientsrecovercompletelywithappropriatesupportivecare.Recognition.

TRALI in trauma patients can be challenging to distinguish fromconcomitant pulmonary contusions, blood aspiration, fatembolization, and/or inhalational injury (particular mechanism ofinjuryisanimportantconsideration).Chest radiography is similar to acute respiratorydistress syndrome,with bilateral patchy alveolar infiltrates, typically with a normalcardiacsilhouetteandwithouteffusions.Patientswhorequireintubationhaveelevatedpeakairwaypressuresandfrothypinkairwaysecretions.AkeyfeatureofTRALIisthatnoncardiogenicpulmonaryedemamustbedifferentiatedfromvolumeoverloadorheartfailure.

AtRole2,evaluationisguidedbyclinicalevaluation,exam,andtransducedcentralvenouspressure.

AtRole3,bedsideECHOmayfurtherassistinevaluationofvolumestatus.

Ifvolumestatusofthepatientcannotbedetermined,administrationoffurosemidecanbeconsidered.Iftheclinicalstatusofthepatientdoesnotimprovewithdieresis,thenTRALIismorelikely.

ManagementofTRALI:Supportive.Milder cases may only require supplemental oxygen as required tomaintainoxygensaturation.Intubationwithmechanicalventilationisoftenrequired.Ventilation ispreferablywith“lungprotective”modes (eg, low tidalvolumesandplateaupressures).Unlikeadultrespiratorydistresssyndrome,resolutionoccursrapidly.Mostpatientscanbeextubatedwithin48hours,andchestradiographsgenerallyreturntonormalwithin4–7days.

UrticarialTransfusionReactionsUrticaria(hives/itching)istheonlytransfusionreactioninwhichthebloodproductcanbecontinued.Thought to occur from an allergenic substance in the plasma of donatedbloodproducts.Does NOT have wheezing/bronchospasm or inappropriate hypotension

(whichareallergicreactions).Managementofurticarialreactions:

Holdtransfusion.Treatwithdiphenhydramine25–50mgIVorPO.Ifurticariawanesandneitherdyspneanorhypotensionareapparent,thetransfusionmayberesumed.

AllergicTransfusionReactionsMild allergic reactions involve dyspnea, bronchospasm/wheezing, and/orabdominalpain(intestinaledema).More severe allergic reactions can include rapid onset of stridor,angioedema,andrespiratoryfailure.Trueanaphylacticreactions(markedbyhypotensionandshock)arerare.Doesnotcausefevers.Managementofallergicreactions:

Immediatecessationofthetransfusion.Ifonlybronchospasm (without stridor, angioedema,orhypotension)isevident:

Bronchodilators(albuterol).

Diphenhydramine25–50mgIV.

Considergivingranitidine50mgIV.

Oxygen6–8L/minviafacemasktomaintainoxygensaturations>93%.

If stridororangioedema is evident, include themeasuresaboveandalso:

Intubation.

Epinephrine,0.3mLofa1:1,000solutionintramuscularly(adultdose),repeatedevery3–5minutesasneeded.

Ifinappropriatehypotensionorshockareevident:

Fluidresuscitationandvasopressors(eg,dopamine)asneededtomaintainbloodpressure.

Considergivingmethylprednisolone125mgIV.ForClinicalPracticeGuidelines,goto

http://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter34

CompartmentSyndrome

Introduction

(SeeChapter25,VascularInjuries.)

Compartment syndrome may occur with an injury to any fascialcompartment.Thefascialdefectcausedbytheinjurymaynotbeadequatetofullydecompressthecompartment,andcompartmentsyndromemaystilloccur.Mechanismsofinjuriesassociatedwithcompartmentsyndrome.

Openfractures.Closedfractures.Penetratingwounds.Crushinjuries.Vascularinjuries.Reperfusionfollowingvascularrepairs.

Earlyclinicaldiagnosisofcompartmentsyndrome.Painoutofproportion.Painwithpassivestretch.Tense,swollencompartment.

Lateclinicaldiagnosis.Paresthesia.Pulselessnessandpallor.Paralysis.

Measurement of compartment pressures:Not recommended, just do thefasciotomy.

Diagnosisofcompartmentsyndromeismadeonclinicalgrounds.Measurement of compartment pressures is not recommended in thecombatzone.

Considerprophylacticfasciotomyfor:Vascularrepair/shuntand/orligationindependentofischemiatime.High index of suspicion injuries and limited capacity for serialexamination.

Intubated,comatose,sedated.

Traumaticbraininjury.

Prolongedtransport.

FasciotomyTechniqueUpperextremity.

Arm: The arm has two compartments: the anterior flexors (biceps,brachialis)andtheposteriorextensors(triceps).

Lateralskinincisionfromthedeltoidinsertiontothelateralepicondyle.

Sparethelargercutaneousnerves.

Atthefasciallevel,theintermuscularseptumbetweentheanteriorandposteriorcompartmentsisidentified,andthefasciaoverlyingeachcompartmentisreleasedwithlongitudinalincisions.

Protecttheradialnerveasitpassesthroughtheintermuscularseptumfromtheposteriorcompartmenttotheanteriorcompartmentjustbelowthefascia.

CompartmentsyndromeinthehandisdiscussedinChapter24,InjuriestotheHandsandFeet.

Forearm: The forearm has three compartments: the mobile wadproximally,thevolarcompartment,andthedorsalcompartment(Fig.34-1).

Apalmarincisionismadebetweenthethenarandhypothenarmusculatureinthepalm,releasingthecarpaltunnelasneeded.

Thisincisionisextendedobliquelyacrossthewristflexioncreasetotheulnarsideofthewristandthenarchedacrossthevolarforearmproximallytotheulnarsideattheelbow.

Attheelbow,justradialtothemedialepicondyle,theincisioniscurvedobliquelyacrosstheelbowflexioncrease.Thedeepfasciaisthenreleased.

Attheantecubitalfossa,thefibrousbandofthelacertusfibrosusoverlyingthebrachialarteryandmediannerveiscarefullyreleased.

Fig.34-1.(a)Fasciotomyincisionforvolarcompartment.(b)Forearmcompartments.R:radius;U:ulnar.

Thisincisionallowsforsoft-tissuecoverageoftheneurovascularstructuresatthewristandelbows,andpreventssoft-tissuecontracturesfromdevelopingattheflexioncreases.

Asecondstraightdorsalincisioncanbemadefromthedorsalwristtothelateralepicondyletoreleasethedorsalcompartment,reachingproximallytoreleasethemobilewad,ifnecessary.

Lowerextremity.Thigh:Thethighhasthreecompartments: theanterior compartment(quadriceps),themedialcompartment(adductors),andtheposteriorcompartment(hamstrings).

Alateralincisionismadefromthegreatertrochantertothelateralcondyleofthefemur.

Then,theiliotibialbandisincised,andthevastuslateralisisreflectedofftheintermuscularseptumbluntly,releasingtheanteriorcompartment.

Theintermuscularseptumisthenincisedthelengthoftheincision,releasingtheposteriorcompartment.

Thisreleaseoftheintermuscularseptumshouldnotbemadeclosetothefemur,becausethereareaseriesofperforatingbranchesoftheprofundafemorisarterypassingthroughtheseptumfromposteriortoanteriornearthebone.

Themedialadductorcompartmentisreleasedthroughaseparateanteromedialincisionstartingslightlydistaltotheadductororiginonthepubisandextendingtothedistalmedialthigh.

Calf: The calf has four compartments: the lateral compartment,containingtheperonealbrevisandlongus;theanteriorcompartment,containing the extensor hallucis longus, the extensor digitorumcommunis, the tibialis anterior, and the peroneus tertius; thesuperficialposteriorcompartment,containingthegastrocnemiusandsoleus; and the deep posterior compartment, containing the flexorhallucislongus,theflexordigitorumlongus,andthetibialisposterior(Fig. 34-2).

Fig.34-2.Calfcompartments.

Cmpt.:compartment;EDL:extensordigitorumlongus;EHL:extensorhallucislongus;FHL:flexorhallucislongus;G.:greater;M.:muscle;V.:vein.

Fig.34-3.Anteromedialincisionofthecalf.

Two-incisiontechnique.(CAVEAT:Theone-incisiontechniqueISNOTAPPROPRIATEforcompartmentsyndromedecompressionincombattheater.)

Incisionsmustextendtheentirelengthofthecalftoreleaseallofthecompressingfasciaandskin(Fig.34-3).

Alateralincisionismadecenteredbetweenthefibulaandanteriortibialcrest.

Thelateralintermuscularseptumandsuperficialperonealnerveareidentified,andtheanteriorcompartmentisreleasedinlinewiththetibialisanteriormuscle,proximallytowardthetibialtubercleanddistallytowardtheanteriorankle.

Thelateralcompartmentisthenreleasedthroughthisincisioninlinewiththefibularshaft,proximallytowardthefibularhead,anddistallytowardthelateralmalleolus.

Asecondincisionismademediallyatleast2cmmedialtotheposteromedialandpalpableedgeofthetibia.

Amedialincisionoverornearthesubcutaneoussurfaceofthetibiaisavoided,preventingexposureofthetibiawhenthetissuesretract.

Thesaphenousveinandnerveareretractedanteriorly.

Thesuperficialcompartmentisreleasedthroughitslength,andthenthedeepposteriorcompartmentovertheflexordigitorumlongusisreleased.Thenidentifythetibialisposteriorandreleaseitsfascia.

Foot.

SeeChapter24,InjuriestotheHandsandFeet.

Compartmentreleaseofthefootisrarelyindicatedandnotroutinelyrecommendedincombatsurgery.

Fasciotomywoundmanagement.As with all war wounds, the fasciotomy is initially left open andcoveredwithsteriledressings.Following fasciotomy, the wound should be treated with delayedprimarysurgicalclosureandstandardwoundmanagement,removingdebridementofalldevitalizedtissue.

The vacuum wound closure system is an important adjunct to moderncombatwoundcareandmaybeconsideredathigherechelonsofcare.

Onlyonedeviceiscurrentlyapprovedforthisapplication:thewoundVacuum-AssistedClosure(VAC)TherapySystem.Field-expedient, vacuum-assisted wound closure is an alternative.Field-expedient vacuum dressings are easily created with standardissueitems,includingthefollowing:

Laparotomysponges.

Jackson-Pratt(JP)drains.

Ioban.

Benzoin.

Adaptec(nonadherentgauze,forskingrafts).

SterileperforatedIVbags.

Forwoundsofthesofttissueandextremities,layerlaparotomyspongeswithJPdrainssandwichedbetweenthespongesandcoveredwithIoban.ApplyBenzointotheskinedgestopreventleaks.

AttachtheJPdrainstothestandardvacuumpumpadjustedto125mmHgsuction.Thisdressingeliminatestheneedforskintractioninamputations.

Forskingrafts,staplethegrafttotheedgesofthewound.Applynonadheringgauzeandapplytofield-expedientvacuumdressing.Donotremovefor3days.GraftscanbedressedwithSilvadenewhenthefield-expedientvacuumdressingisremoved.

Foropenabdominalwounds,placesterileperforatedIVbagsonthebowelandsewtheIVbagtothefascia,orunderlaythefasciawiththeIVbag.PlacelaparotomyspongesontheIVbagsandlayerwithJPdrains.ApplyBenzointotheskinedgeandcoverwithIoban.Attachthedrainstosuction.Thisdressingpreventsleakingofabdominalfluidsduringtransport.

Manysurgeonsconsider thisan importantpartofwoundmanagementbecausethe use of vacuum systems may improve and accelerate wound healing in avarietyofconditions,including:

pressureulcers,partialthicknessburns,orthopaedicwoundswithlargesoft-tissuedefects,openabdominalwounds,andskingraftviability.

Treatment of soft-tissue injury is the most common denominator in themanagementofwarwounds.

Pitfalls

Delay in diagnosis and treatment of suspected or impendingcompartmentsyndrome.Inadequatefascialincisionlength.Failuretoopendeepposteriorandanteriorcompartments.Failuretolocatelaterallegintermuscularseptumandperformbothlateralandanteriorrelease.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter35

BattlefieldTraumaSystems

Introduction

Atraumasystemisanorganized,coordinatedeffortinadefinedgeographicareathatdeliversthefullrangeofcaretoallinjuredpatientsandisintegratedwiththelocal public health system. The true value of a trauma system is the ability toprovide the appropriate level of care to injured patients, integrating existingresourcestoachieveimprovedpatientoutcomes.

MilitaryTraumaSystems

In the battlefield setting, the region is frequently represented as theCombatantCommand(COCOM),whichhasprincipalresponsibilityformilitaryoperations,includingmedical support. Regionsmay be further subdivided into Theater ofOperations (TO) and areas of responsibility, or by specific operations (eg,OperationEnduringFreedom[OEF]andOperationIraqiFreedom[OIF]).ForUSforces injuredoutside thecontinentalUnitedStates (CONUS), thecontinuumofcare includesall levelsofcarewithin theTO(Roles1–3), caredeliveredoutsidetheTO(Role4),caredeliveredwithinCONUS(Roles4and4a),andallphasesofpatientmovement(enroutecare)frompointofinjurytodefinitivecare.Thegoalofabattlefieldtraumasystemistoensurethateverycasualtygetstherightcare,at the right time, in the right place, and that overall survival and chance formaximalfunctionrecoveryaremaintainedthroughoutthecontinuumofcare.

BattlefieldTraumaSystemModel

The currentmodel of the deployedmilitary trauma system is the Joint TheaterTrauma System (JTTS). Currently being codified in Services and Joint doctrine,thedevelopment,implementation,andmaturationoftheJTTSaremajorfactorsinthelowdiedofwounds(DOW)rateandintheimprovedfunctionalrecoveryseeninbattlefieldcasualtiesinOEF/OIF.

The COCOM JTTS team is assigned to and works directly within the TO andreportsdirectlytotheCOCOMSurgeonGeneral(SG).AdedicatedtriserviceJTTSteamundergoes specialized training inCONUS justprior todeployment to theTO.Theteamconsistsof:1TheaterMedicalDirectororTraumaMedicalDirector(TMD) who is either a trauma-trained/critical care surgeon or a combatexperiencedgeneral surgeon, 1 critical carenursewho is theProgramManager(PM), sufficient numbers of critical care nurseswho function as TraumaNurseCoordinators(TNCs)attachedtoRole3medicaltreatmentfacilities(MTFs)within

theater, sufficient numbers of enlisted personnel to support the team and itstaskings,andadditionalnursesandenlistedpersonneltosupportspecialprojectsasdirectedbytheDepartmentofDefense(DoD)ortheCOCOMSG.

TheTMDistheseniorconsultanttotheCOCOMSGonallmattersrelatedtothecareofthetraumapatient.TheTMDworkscloselywithalltraumacareproviderswithin theTOandwithin theboundsof theoperationalenvironment.Also, theTMD makes frequent site visits to fixed MTFs and evacuation platforms. TheTMDistheprimaryadvocateforthetheater-wideperformanceimprovement(PI)program.Theprincipaldutiesof theTMDare to advise theCOCOMSGonallmatters related to trauma; conduct system-wide patient care conferences on aregular basis; update, revise, educate, and oversee compliance with theaterClinicalPracticeGuidelines(CPGs);andproduceamonthlytheaterupdatereportbasedondatafromtheDoDTraumaRegistry(DoDTR).

TheprimaryresponsibilitiesofthePMaretosupporttheTMDinalleffortsandtaskings, manage the entire team of nurses and enlisted personnel, ensure arobust theater-wide PI programwith the TNCs, communicatewith theater andthe CONUS Joint Trauma System (JTS) team on a regular basis, and ensurequalitydataabstractionintotheDoDTRbytheTNCs.

TNCsarecritical to thesuccessof the JTTS.Theirprimaryduty is to facilitatearobustPIprogramwithintheirrespectiveMTFsworkingdirectlywiththeChiefofTrauma.Additionally,theyperformnearreal-timeextractionofdatafromthecasualty’s medical record into the DoDTR to support ongoing PI initiatives.Enlisted personnel provide critical administrative and technical support to theteam,aswellasfunctionalexpertiseintheirprimarydutydesignation.

PurposeoftheJTTS

TheJTTSisasystematicandintegratedapproachtocoordinatebattlefieldcaretominimize morbidity and mortality, and optimize essential casualty care. Theprimary focus of JTTS is to improve battlefield trauma care to ensure that therightpatientgetstotherightplaceattherighttimetoreceivetherightcare.

TheJTTSwasmodeledaftertheciviliantraumasystemprinciplesoutlinedintheAmericanCollegeofSurgeons–CommitteeonTraumaResourcesforOptimalCareofthe Injured Patient, 2006. This document identifies trauma care resources andpracticesforoptimizationofstandardsofcare,policies,procedures,andprotocolsfor both prehospital and hospital personnel. Additionally, it identifies andintegratesprocesses andprocedures to record traumapatient-relateddata at alllevelsofcareforcontinualprocessimprovement.

Thereis jointserviceparticipationintheJTTSandDoDTR.AJTTStraumaTMDand theater TNCs are rotated from each service and integrated into the TO tofacilitate improvements in care. The DoDTR, the repository for all significanttrauma-related data, is utilized to facilitate PI, utilization of resources, andprovide command-level information to the battlefield commanders and DoD

decisionmakers.

JTTSGoalsEstablish and maintain a trauma registry to capture data and provideinformation on the care and outcomes of military and civilian traumapatients.

Provide the services with full and complete access to data in thetraumaregistry.Provide a database that can generate reports for authorizedgovernmentagencies.ProvideadatabasethatcanbequeriedforInstitutionalReviewBoard-approvedresearchstudies.Provideelectroniccollectionanddisseminationoftraumapatientdataavailableforalllevelsofcaresupportingalongitudinalhealthrecord.Establish andmaintain a trauma outcomes database to analyze andevaluate clinicaldecision-makingandmeasure subsequentoutcomesforimprovingtreatmentmodalities.

Provide theDoD and other authorized interestswith timely and relevantinformationaboutcareandoutcomes.Create a research strategy that supports reduction of morbidity andmortality.Standardize trauma practices across the continuum of care with thedevelopmentandimplementationofevidence-basedCPGs.Improvemedicalrecorddocumentationquality.Improvecommunicationacrossthecontinuumofcasualtycare.

JointTraumaSystem

The JTS is the CONUS-based enduring organization in theDoD that promotesimproved traumacare toourwoundedwarriorsandotherDoD-eligible traumavictims.Italsoexistsasthechieforganizationforconsultationinthecareoftheinjured for the services, COCOMs, and the entire DoD, to include its seniorleadership. It is designed to meet the needs of the President, the Secretary ofDefense,andCOCOMswithregardtoallaspectsoftraumacarewithintheDoD.Tofulfillthismission,thereisacorecadreoftrainedindividualsledbyaseniorsurgeon with prior deployment experience as the JTTS TMD and adequateresourcesand funding to sustainall the componentsof the traumasystem.Theultimate size of the organization is dictated by events and contingencies—ie, alarger,more robustorganizationduring timesof extremeconflict anda smallerbutstillfullycapableorganizationduringtimesofrelativelowoperationstempoandkineticoperations.JTSworksproactivelywithCOCOMstofacilitatetheearlyimplementation of JTTS in support of future kinetic operations or othercontingencies. The JTS is the primary steward and maintainer of the DoDTR.ComponentsoftheJTS(Fig.35-1)include:

Prevention.

Integratedprehospital,enroute,andRoles1–4care.

Fig.35-1.JTScomponentsacrossthecontinuumofcare.

DoD:DepartmentofDefense;JTS:JointTraumaSystem;MTFs:medicaltreatmentfacilities;MOAs:memorandumofagreements;PI:performanceimprovement.CourtesyofJointTraumaSystem,USArmyInstituteofSurgicalResearch.

Educationandadvocacy.Leadershipandcommunication.ContinuousPI.Research.Informationsystems(eg,DoDTRLevelIIDatabase,MassiveTransfusionsDatabase,etc).

Summary

ImplementationoftheJTSandtheJTTShasbeenamajoradvanceincasualtycareduringOEF/OIF.Lessonslearnedhavebeencodifiedinmultiplewaystoincludedoctrinal and policy changes, manning, CPGs, and patient treatment and

managementtechniques.Everyindividualinvolvedincasualtycareisamemberof the system, including providers, MEDEVAC personnel, medical logisticians,etc.AsystemsapproachtocasualtycarecontributedtodecreasedmorbidityandmortalityinOEF/OIF.

Reference

American College of Surgeons.Resources for Optimal Care of the Injured Patient,2006.Chicago,IL:ACS;2007.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

Chapter36

EmergencyWholeBloodCollection

Introduction

Thischapterdescribesthestepsforemergencywholebloodcollection.

MATERIALSANDEQUIPMENT

MiscellaneousSharpscontainersBiohazardbagsTrashbagsLeak-resistantchucksAmmoniainhalantsColdpacksTesttuberacks

DonorScreeningEmergencyDonorListModifiedDDForm572Clipboards

VitalsSphygmomanometerStethoscopeLancetsAlcoholpads2×2gauze

BagIssueEmergencyWholeBloodCollectionLogISBT(InternationalSocietyofBloodTransfusion)labels(ifavailable)ABO/Rhstickers(ifavailable)

PhlebotomyandSuppliesDonorchestDonorchairBloodbagscales(HemoFlow)BloodbagstandTerumosinglebloodbagsFrepp/Seppkit

GlovesSurgicaltape4×4gauzeHandstripper,sealer,cutterHandsealerclipsScissorsHemostatsVENOJECTLuerAdapterLuerAdapterhubCollectiontubes

3EDTAplasmatubes(purpletop)3serumseparatortubes(marbletop)

Cobanself-adherentwrapRapidMalariaScreeningTestRapidHCVScreeningTestRapidHIVScreeningTestRapidHBsAgScreeningTestRapidRPRTestforsyphilisAntiserumforABO/Rhtesting

________________________DDForm572:BloodDonationRecord;EDTA:ethylenediaminetetraaceticacid;HBsAg:hepatitisBsurfaceantigen;HCV:hepatitisCvirus;HIV:humanimmunodeficiencyvirus;RPR:RapidPlasmaReagin;Sharps:referstosharpobjects(needles,scalpelblades,disposablescissors,stylets,trocars,glass,etc).

Activation/DonorScreeningAnorder toactivate thewalkingbloodbankmust come fromthemedicalproviderscaringfortheintendedrecipientoffreshwholeblood.Once the proper order is obtained in the laboratory from the appropriatemedicalstaff,therecipientbloodtypemustbeobtained.OncetherecipientABO/Rhbloodtypeisknown,thewalkingbloodbankisactivated.LaboratorypersonnelwilltheninterviewdonorsforsuitabilitytodonateandreviewthemodifiedDDForm572,anddetermineifthedonorisaGOorNOGOfordonatingwholeblood.If the donor is accepted, record donor temperature, heart rate, and bloodpressure on themodifiedDDForm 572 to ensure adequacy for donation:temperature<99.6F,heartrate<100beatsperminute,andbloodpressure≤180/100mmHg.

BagIssueFordonorsfoundtobesuitablefordonation:

VerifydonorwithDDForm572.Labelthedonorbagsegmentnumberfromthecollectionline.Theunitnumbershouldbelinkedtothedonorcard(DD572)andbeuniquetothat individual donation. Unit can get donor unit numbers from itssupportingblooddetachment.

ProperlyfillouttheEmergencyBloodBankDonorLog.Annotatebaglotnumber,manufacturer,expirationdate,andanticoagulantusedonthedonor’smodifiedDDForm572.

PerformingPhlebotomyConfirmwithdonorhis/herfullname,thelast4digitsoftheSocialSecurityNumber(SSN),dateofbirth,andcheckagainstDDForm572.Also,checktomakesureallofthedonor’sinformationiscorrectlyrecordedonthedonorbloodbag.Place blood pressure cuff on the donor’s arm. Pump cuff up to 40–60mm/Hg and inspect arm for appropriate vein. Palpate vein. Releasepressure.

NOTE:Youmayusearubbertourniquet.

Askthedonorifhe/shehasanallergytoiodine,Betadine,shellfish,orlatex.If no allergies exist, use the Frepp/Sepp kit to prepare the donor arm forphlebotomy.

First take the scrubbing pad (Frepp) out of the wrapper withouttouching the pad. Break the ampule and scrub a 3-inch site for 30seconds.Then, take the ampule (Sepp), break it, and place it directly in themiddleoftheintendedphlebotomysite.Startinginthemiddleofthephlebotomy site and moving in concentric circles, swab an area 3inchesindiameterwithoutoverlapping.EnsurethattheentireareaiscoveredwithiodineSepp.Place4×4gauzeoverthesiteandallowtoairdry.If an allergy to iodine, Betadine, or shellfish exists, an alcoholalternativeorchlorhexidineproductmaybeused.

Labelallsixbloodcollectiontubes(3red/marbletoptubesand3 lavendertoptubes)withdonordemographics:

Fullname.SSN.Date/timeofcollection.

Properlylabelthebloodcollectionbag.Ensurethat thedateofcollection iswrittenon theunit in the spaceprovided and document the time the phlebotomy was initiatedunderneaththecollectiondate.Documenttheexpirationdateandtimeinthespaceidentifiedontheright-hand side of the blood collection bag. Expiration date is 24hoursafterthedateandtimeofcollection.Donotwrite thedonor’s blood typeuntil the bloodhas been typedandtested.Afterall labelingof thebloodcollectionbaghasbeenaccomplished,applyhemostatsapproximately6inchesabovetheneedle.

Donorbloodunitandsampletubecollection.

Pump blood pressure cuff up between 20–60 mm Hg. A rubberconstricting band or tourniquet may be used instead of a bloodpressurecuff.Verifyveinagain,butdonotrepalpate.Advisethedonortomakeafistandsqueezeseveraltimes.Thensqueezeandhold.Twist off the needle cover and inspect the needle for barbs or otherdefects.Pull the skin taut below the venipuncture site. This helps preventsuddenmovementofthearmandanchorsthevein.Withthebevelup,holdtheneedleatthehub.Atapproximatelya30°–45°angle,piercetheskinattheselectedpointofentry.Whenthebevelis completely under the skin, lower the angle of the needle toapproximately10°orless.Withasteadypush,advancetheneedletopenetrate the vein wall. Thread the needle approximately ½ inchinsidetheveintomaintainasecurepositionandtolessenthechanceofaclotforming.Releasethehemostatclamponthecollectionbagtubingandobservethebloodflowthroughthetubingandintothecollectionbag.Ifthereisnobloodflow,tryadjustingtheneedlewithouthurtingthedonor, and seek assistance from another phlebotomist beforediscontinuingtheprocedure.

NOTE: A second venipuncture may be performed if there was anunsuccessfulcollection(nobloodenteredthecollectionbag),ifdonoragrees to a secondvenipuncture, andanacceptablevein is availableontheoppositearm.Thesecondcollectionrequiresanewbloodbagtopreventcontaminationoftheunit!

Fill sample tubes using the tube adapter. After filling pilot tubes,verify once again that donor identification information on the tubescorrespond to the donor identification information on the collectionbag.Instruct the donor to relax his/her grip and to squeeze rhythmicallyevery3–5seconds.Securetheneedletothedonor’sarmwithtapeacrossthehuband/oron the tubing near the hub of the needle. The tape optimizes thepositioningoftheneedleandpreventsrotationoftheneedlewhileinthevein.Partially reduce the pressure by loosening the tourniquet or bloodpressurecufftoapproximately20–40mmHg.Cover thephlebotomy sitewith a 4 × 4 gauzedressing, keeping thesite clean and the needle out of view. Lift the gauze occasionally tomonitorforevidenceofahematoma.AnnotateontheDDForm572thetimephlebotomywasstartedinthe“start” block and supply the initials of the laboratory technician

performing the phlebotomy. Ensure that the start time is annotatedbeneaththecollectiondateonthecollectionbag.Monitor the donor for signs of discomfort or the onset of a donorreaction,suchasdizzinessorfainting.Manually mix the blood and anticoagulant every 90 seconds topreventclottinginthelineandbag.Watch for the scale to read an optimal volume of 450 mL (digitalscale). For trip scales, the scale will drop, indicating the desiredweight.AnnotatethetimetheunithasreachedthedesiredvolumeontheDDForm 572 in stop time block.Acceptable units can have a volumebetween405–495mL.Clampthetubing1to2inchesbelowthe“Y”segmentoftubingusingthemetalsealclipsandthehandcrimper.Strip a segment below the first clamp (away from the needle) andplaceanotherclampinthislocationusingametalsealclipandahandcrimper.Then,cuttheseggingjustbelowthefirstclampclosesttotheneedle,butbetweenthetwometalclamps.Connect the multisample Luer adapter to the tube holder. RemovecoversandconnectthemultisampleLueradaptertothefemaleLuerattheendofthedonorsamplingtubing.Breaktheampuleinthedonorsampling tubing to open the blood pathway and insert the bloodcollectiontubefirmlyintothetubeholder.Removesampletubewhenfull.Repeattocollectadditionalsamples(3EDTAtubesand3redtoptubes).Removebloodpressurecuff.Placefingersof1handgentlyoverthe4×4gauze.DONOTapplypressureovertheneedle.Withtheotherhand,smoothlyandquicklywithdrawtheneedle.Applyfirmpressuretothephlebotomysiteandinstructthedonortomaintain pressure on the phlebotomy site and extend the armvertically. Instruct the donorNOT to bend the arm at the elbow toreduce/preventthechanceofahematoma.On completion of venipuncture, shout “Sharps” and discard into abiohazardcontainer.Usingahandstripper/crimper,stripallbloodfromthetubingintotheprimarycollectionbagandinvertbagaminimumof3times.

PostdonorCareApply pressure with fresh gauze on the collection site and wrap withCoban,ensuringastableclothasformed.When the donor is ready to stand, have him/her walk to the designatedrecoveryroomandremainintheareaunderclosesupervision.Observeforsignsofareactionandaskdonorhowhe/shefeels.Instruct the donor on fluid replacement and light postdonation activities.Provideextraresttimefordonorswhohaveexperiencedadonorreaction:

eitherdizzinessorfainting.Ensure theability torehydrateorallyandwalkwithasteadygaitwithoutdizzinesspriortodischargefromtherecoveryroom.

PerformingRapidTestingWHENAVAILABLE:ABO/Rhbloodtyping,andrapidtestingforHIV(humanimmunodeficiency virus), HCV (hepatitis C virus), HBsAg (hepatitis Bsurface antigen), and malaria will be performed with documentedappropriate results prior to the release of fresh whole blood from thelaboratory.Rapid testing for syphiliswillbeperformedoneachdonor’sblood during the walking blood bank. However, given the duration oftime required to centrifuge theblood sample for this test and thebatchednature of the test, results will be obtained prior to the conclusion of thewalking blood bank, but not prior to release of the donor unit from thewalking blood bank. Follow appropriate testing standard operatingprocedures for each rapid test performed: ABO/Rh, HIV, HCV, HBV(hepatitisBvirus),malaria,andRPR(RapidPlasmaReagin)forsyphilis.Document test results of ABO/Rh and all infectious screening on the DDForm572,intheWalkingBloodBankDonorLogBook,andonthedonor’sbloodbag.Thelaboratorytechnicianperformingeachtestwillplacehis/herinitialsonthedonor’sbloodbag.

ReleasingWholeBloodLabelfreshwholebloodbagsasVERIFIED.

ABO/Rhresult.ResultsfromrapidscreeningtestsforHIV,HCV,malaria,andHBsAg.Theinitialsofthelaboratorytechnicianwhoperformedeachtest(1=technician performing ABO/Rh typing; 2 = technician performinginfectioustesting).Initialsof thelaboratorytechnicianwhohasverifiedeachresult(3=technicianperformingbloodbagstripping).Thepatientnumberoftherecipientpatient.Donor’sfullname.Last4digitsofthedonor’sSSN.Dateofunitcollection.

Onlyafter all of theabove labelingandcross-checkswill thedonorbloodunitbereleasedfromthelaboratoryfortransfusion.Properbloodtypingandinfectiousscreeningrequiretime.Thisisattimesat odds with the deterioration of the recipient patient’s clinical status. Insuch circumstances, if the licensed clinical providers caring for therecipientpatientdeemitnecessarytoobtainfreshwholebloodata fasterrate,theymayauthorize theemergencyreleaseof freshwholebloodfromthewalkingbloodbankafteronlyABO/Rhtypingwithout thecompletionofall infectious screening tests.This is tobemeticulouslydocumentedby

laboratorypersonnel, and theymust obtainwrittendocumentationof thisdirective from the licensedprovider(s) on the standard freshwholebloodrelease form. All freshwhole blood units released in this fashionwill bedocumentedassuchintheWalkingBloodBankLog.

NOTE:Freshwholebloodmaybekeptstoredatroomtemperatureforupto8hours.However,itishighlyrecommendedthatunitsoffreshwholebloodbe stored immediately following collectionat 1°–6°C forup to24hours.

PosttransfusionVerificationAllresultsfromRPRrapidtestingforsyphiliswillbereviewedpriortothecompletionofthewalkingbloodbank.AnypositiveresultswillberelayedtotheLabOfficer,withmedicalfollow-uptobedirectedbytheLabOfficerinconjunctionwiththeUnitChiefofProfessionalServices(CPS).After completion of the walking blood bank, all donor blood units—ordonorunitbloodbagsposttransfusion—willbereturnedtothelaboratory.Laboratory personnel will verify the disposition ofALL donor units anddocumentthisintheWalkingBloodBankLogas:

Transfused.ReturnedNOTtransfused.HeldinlaboratoryandNOTreleasedandwhy.Sentwithrecipientpatientintransporttoanotherfacility.

All donor blood units transfusedwill be documented on the daily BloodReport.RegularcontactwillbemaintainedwiththeBloodSupportDetachmenttoobtainfollow-upresultsonconfirmatorytestingofdonorbloodsamples.

SpecimenProcessingDuringwholebloodcollection,6 tubesofbloodwillbedrawn for furthertesting.

3redtoptubes.3EDTAtubes.

Tubeswillbespundowntoseparateserum/plasmafromredbloodcells.Serum will be collected and stored in appropriate blood tubes with thecorrelatingdonormodifiedDDForm572withproperrefrigeration.AphotographiccopyofallmodifiedDDForm572’swillbemadeprior toshipment and maintained in electronic storage with a backup CD copymadeaftereverywalkingbloodbank.SpecimenswillbeshippedtotheBloodSupportDetachmentforshipmentforFDA(USFoodandDrugAdministration)-licensedconfirmatorytesting.

OnsiteSpecimenProcessingSpindowntubesfor10minutesat3,000rpm’s.Usingatransferpipette,transferserumfromthespun-downspecimenintoa transfer tube. Label the transfer tube with the donor’s demographics.

Securethecaponthetransfertube.Ship all specimens in a shipping container with cold packs as soon aspossible to the Blood Support Detachment for further processing. Ensurethatacopyofthedonor’sDDForm572,rapidtestingresultsheets,andtherecipientinformationsheetaresentwiththespecimens.

BloodDonorCriteria

Appropriatedonorcriteria.Donorweight:≥110lbs.Bloodpressure:≥180/100mmHg.Pulse:50–100beatsperminute(maybe<50ifdonorisathletic).Temperature:<99.6F.

Medications.Do not collect from donors currently on antibiotics, to excludeantimalarialprophylaxis.Donorstakingmedicationsthatcompetentmedicalauthoritydeemsmaycauseharmtotherecipientmustbedeferredfromdonating.BEADVISED: If thepurposeof thewholeblooddrive is toderiveasourceofplateletsandclotting factors fora recipient, thendonorswhohavetakenaspirininthelast72hoursshouldbedeferred.

Recentdonation.Asingleunitofwholebloodorabloodcomponentmaybedrawnfromasingledonornomoreoftenthanevery60days.

References

American Association of Blood Banks.AABB Standards. 4th ed. Bethesda, MD:AABB;2012.

AmericanAssociationofBloodBanks.TechnicalManual. 17thed.Bethesda,MD:AABB;2011.

National Committee for Clinical Laboratory Standards. Clinical LaboratoryTechnical Procedures Manual: Approved Guideline, GP02-A5. 5th ed. Wayne, PA:NCCLS;2002.

ForClinicalPracticeGuidelines,gotohttp://usaisr.amedd.army.mil/clinical_practice_guidelines.html

EnvoiIwould say that two contrary laws seem to bewrestlingwith eachothernowadays:Theone,a lawofbloodanddeath,ever imaginingnewmeansofdestructionandforcingnationstobeconstantlyreadyfor the battlefield—the other a law of peace,work, and health everevolvingnewmeansofdeliveringmanfromthescourgeswhichbesethim. Which of these two laws will ultimately prevail God aloneknows.

—LouisPasteur

Appendix1

PrinciplesofMedicalEthics

RelevanttotheRoleofHealthPersonnel,ParticularlyPhysicians,intheProtectionofPrisonersandDetaineesAgainstTortureandOtherCruel,Inhuman,orDegradingTreatmentorPunishment

AdoptedbytheUnitedNationsGeneralAssembly,Resolution37/194,December18,1982

Principle1

Health personnel, particularly physicians, charged with the medical care ofprisoners and detainees have a duty to provide them with protection of theirphysical and mental health and treatment of disease of the same quality andstandardasisaffordedtothosewhoarenotimprisonedordetained.

Principle2

Itisagrosscontraventionofmedicalethics,aswellasanoffenceunderapplicableinternationalinstruments,forhealthpersonnel,particularlyphysicians,toengage,actively or passively, in acts which constitute participation in, complicity in,incitement to, or attempts to commit torture or other cruel, inhuman, ordegradingtreatmentorpunishment.

Principle3

It is a contravention of medical ethics for health personnel, particularlyphysicians, to be involved in any professional relationship with prisoners ordetainees,thepurposeofwhichisnotsolelytoevaluate,protect,orimprovetheirphysicalandmentalhealth.

Principle4

It is a contravention of medical ethics for health personnel, particularlyphysicians:

(a) toapply theirknowledgeand skills inorder toassist in the interrogationofprisoners and detainees in amanner thatmay adversely affect the physical ormental health or condition of such prisoners or detainees and which is not inaccordancewiththerelevantinternationalinstruments;and

(b) to certify, or to participate in the certification of, the fitness of prisoners ordetaineesforanyformoftreatmentorpunishmentthatmayadverselyaffecttheirphysical or mental health and which is not in accordance with the relevantinternationalinstruments,ortoparticipateinanywayintheinflictionofanysuch

treatmentorpunishmentthatisnotinaccordancewiththerelevantinternationalinstruments.

Principle5

It is a contravention of medical ethics for health personnel, particularlyphysicians,toparticipateinanyprocedureforrestrainingaprisonerordetaineeunlesssuchaprocedureisdeterminedinaccordancewithpurelymedicalcriteriaasbeingnecessaryfortheprotectionofthephysicalormentalhealthorthesafetyoftheprisonerordetaineehimself,ofhisfellowprisonersordetainees,orofhisguardians, and presents no hazard to the physical or mental health of theprisoner/detainee.

Principle6

There may be no derogation from the foregoing principles on any groundwhatsoever,includingpublicemergency.

Declaration on the Protection ofAll Persons FromBeing Subjected to TortureandOtherCruel,Inhuman,orDegradingTreatmentorPunishmentfollowsonpage517.

DeclarationontheProtectionofAllPersonsFromBeingSubjectedtoTortureandOtherCruel,Inhuman,orDegradingTreatmentorPunishmentAdoptedbytheUnitedNationsGeneralAssembly,Resolution3452(XXX),December9,1975

Article1

(a)ForthepurposeofthisDeclaration,torturemeansanyactbywhichseverepainorsuffering,whetherphysicalormental,isintentionallyinflictedbyoratthe instigationofapublicofficialonaperson for suchpurposesasobtainingfromhimorathirdpersoninformationorconfession,punishinghimforanacthehascommittedorissuspectedofhavingcommitted,orintimidatinghimorotherpersons.Itdoesnotincludepainorsufferingarisingonlyfrom,inherentinorincidentalto, lawfulsanctionstotheextentconsistentwiththeStandardMinimumRulesfortheTreatmentofPrisoners.

(b)Tortureconstitutesanaggravatedanddeliberateformofcruel,inhuman,ordegradingtreatmentorpunishment.

Article7

EachStateshallensurethatallactsoftortureasdefinedinArticle1areoffencesunderitscriminallaw.Thesameshallapplyinregardtoactswhichconstituteparticipationin,complicityin,incitementto,oranattempttocommittorture.

_____________

The information contained herein is adapted from the Office of the UnitedNationsHighCommissionerforHumanRights(Geneva,Switzerland).

Appendix2

GlasgowComaScale

Component Response Score

Motorresponse Obeysverbalcommand 6

Localizespain 5

Flexion-withdrawal 4

Flexion(decortication) 3

Extension(decerebration) 2

Noresponse(flaccid) 1

Subtotal (1–6)

Eyeopening Spontaneously 4

Toverbalcommand 3

Topain 2

None 1

Subtotal (1–4)

Bestverbalresponse Orientedandconverses 5

Disorientedandconverses 4

Inappropriatewords 3

Incomprehensiblesounds 2

Noverbalresponse 1

Subtotal (1–5)

TOTAL (3–15)

Datasource:TeasdaleG,JennettB.Assessmentofcomaandimpairedconsciousness.TheLancet.1974;304(7872,July):81–84.

Appendix3

DepartmentofDefenseTraumaRegistry

General

Evidence-basedmedicineallowsforidentificationofbestpracticesandthetimelyformulationofclinicalpracticeguidelines.Unfortunately,becauseoftherealitiesofcombattrauma,timelyandaccuratedatacollectionandinterpretationofresultsare difficult. Quality information on casualties for combatant commanders isessential because it facilitates optimal placement, utilization, and resupply ofscarce medical resources, and rapid identification of new trends in wounding,prevention, and treatment. Timely, accurate, aggregated theater information isnecessarytoshortenqualityimprovementcyclesandimproveoutcomes.

Furthermore,aggregation,evaluation,andreportingof thesedataproviderapidfeedbackforprovidersacrosstheentirechainofcareandevacuationintheJointTraumaSystem(JTS).Applicationoftheseprinciplestothebattlefield,usingasetof jointly approved data elements as ameans to drive concurrent performanceimprovementwithintheJTS,hasbeenamajoradvancementoftherecentconflictsinAfghanistanandIraq.Thisefforthasleadtotheadaptionoftechnologyandthetraining of specialists to serve themission of timely and accurate collection ofcombat injury data. The trauma documentation tool that facilitates this processshould be used as the trauma medical record (for both battle and nonbattleinjuries) and should accompany the casualty throughout the chain of care andevacuation.

SituationalAwareness

Therevolutioninwarfightingthathasdigitizedthebattlefieldtodisplayfriendlypositions, intelligence, and engagements electronically has not been equallyappliedtothecasualtycaresideoftheequation.Thisplacesdemandsonmedicalorganizations to provide online and continuously updated status and locationinformation on killed, wounded, ill, and psychologically impaired combatantsandnoncombatants,includingboththecasualtylosstotheunitandthereturn-to-dutypatient.Thisneedwillonlyescalateasmedicalsituationalawarenessplaysan increasing role in the tactical risk assessment process. At a minimum,commanders should be able to assess the case fatality rate (CFR; fraction of anexposedgroup—all thosewounded inaction [WIA]whodie—ameasureof thelethalityofthebattlefield;thecalculationincludesthoseWIAindividualswhoarereturned to duty [RTD]) percentage killed in action (KIA; died before reachingmedical care/forcewounded) andpercentagediedofwounds (DOW;diedafter

reachingmedical care/forcewounded) in order tomeasure risk associatedwithoperationsandthecapabilityofthemedicalforcetocontrolmortality.

whereMTF is defined asmedical treatment facility or any fixed facilitywith amedicalprovider.

Categorizationof casualties by type anddistributionof injurywithin themajorbody regions (ie, face, head and neck, chest, abdomen and pelvis, upper andlowerextremities,andskin)enablesanalysisofinjurypatternsandassessmentofinjury severity that can be utilized to design prevention applications and careinterventions,thusdecreasingtheburdenofinjury,morbidity,andmortality.

OtherUses

Dataontypesofwounds,theircauses,andappropriateprocedureshavepotentialvalue in constructing predictive models for medical force development andplacement, logistical delivery systems, and research on improved medical andsurgical interventionsandprevention.Thehistoryof improvements inmedicineand surgery are grounded on the battlefield, and dissemination should not belimitedtotheisolatedinnovatorwithapersonalspreadsheetfordocumentation.Individualprovidersatindividualmedicaltreatmentfacilitieshavelongrecordedclinical data and observations. This Department of Defense Trauma Registry(DoDTR) is an organized and coordinated effort to facilitate documentation ofinformationthatisaggregatedintotheregistrythatprovidesthemeanstobetterunderstandtheeffectivenessofpreventionmeasuresandcasualtycare,aswellastheburdenofinjury,morbidity,andmortalityinapopulation.

MinimumEssentialData

Inadditiontorecordingthestandardcontentsofthepostprocedurenote(ie,whodidwhat,onwhom,why,andaplan),thestandarddatacomponentsofatraumaregistryareespeciallyhelpful(eg,demographics,circumstanceandmechanismofinjury, injuryseverity,prehospitalmonitoringandcare,hospitalmonitoringandcare,outcome,participants,directassessmentagainststandards).FigureA3-1isasampleoftheformthatservesasboththetraumamedicalrecordandasasourcefordatacapture.Theminimumessentialelementspresentonthisformhavebeenagreed upon by the US Army, the US Air Force, and the US Navy; officialDepartment of Defense (DoD) forms are pending. Data are collated into theregistry,evaluated,andreportedbytheJTS.

RecommendedMethodsandTechnology

The process to document emergency trauma care can be used on either theimmature ormature battlefield. Thiswould entail utilizing paper or computer-assistedelectronic technology,respectively. Inthe idealenvironment, thiswouldbeasingle-stepprocess.Realityismuchdifferent.Itisimportanttorecognizethatdocumentation should occur across the chain of care and evacuation, whereasaggregationofdata shouldoccurat the first levelof care that can support suchactivity.Ataminimum,paperdocumentationshouldbeused foreachcasualty,and the chart should accompany the patient to the rear as evacuation occurs.Wheneffectiveelectronicrecordsareavailable,thisprocesswillbeexpeditedandsimplified.

Fig.A3-1.Sampleresuscitationrecord.

AbbreviationsandAcronymsA

ABC:airway,breathing,circulation

ABCA:America,Britain,Canada,Australia

Abd:abdomen

ABD:autologousblooddonation

ABG:arterialbloodgas

A/C:assist/control

AC:hydrogencyanide

ACE:angiotensin-convertingenzyme

ACLS:AdvancedCardiacLifeSupport

ACS:abdominalcompartmentsyndrome

ADH:antidiuretichormone

ADMIN:administrativepersonnel

AE:aeromedicalevacuation

AELT:AeromedicalEvacuationLiaisonTeam

AF:USAirForce

AFB:AirForceBase

AFI:AirForceInstruction

AFJI:AirForceJointInstruction

AFP:DepartmentoftheAirForcepamphlet

AFRICOM:AfricaCommand

AIREVAC:airevacuation

ALI:acutelunginjury

amps:ampules

AMS:acutemountainsickness

AOR:areaofresponsibility

AP:anteroposterior

aPLTs:apheresisplatelets

AR:ArmyRegulation

ARDS:acuterespiratorydistresssyndrome

ARDSNet: Acute Respiratory Distress Syndrome Network ARF: acute renalfailure

ARG:AmphibiousReadyGroup

ASAP:assoonaspossible

ASF:AeromedicalStagingFacility

ATLS:AdvancedTraumaLifeSupport

ATN:acutetubularnecrosis

ATNAA:AntidoteTreatmentNerveAgentAutoinjector

B

BICEPS:Brief-Immediate-Central-Expectant-Proximal-Simple

bid/BID:twiceadayB.I.G.:BoneInjectionGun

BL:bladder

BP:bloodpressurebpm:beatsperminute;breathsperminute

BUN:bloodureanitrogen

BURP:BackwardUpwardRightwardPressure

BW:biologicalwarfare

BZ:benzodiazepine;3-quinuclidinylbenzilate

C

Cal:caliber

CAR:cabinaltituderestriction

CASEVAC:casualtyevacuation

Cath:catheter

CBF:cerebralbloodflow

CCATT:CriticalCareAirTransportation(orTransport)Team

CENTCOM:USCentralCommand

CFR:casefatalityrate

CG:phosgene

CHF:congestiveheartfailure

CK:creatininephosphokinase;cyanogenchloride

CKT:creatininekinase

CNS:centralnervoussystem

C.O.:cardiacoutput

CO2:carbondioxide

COCOM:CombatantCommand

CONUS:continentalUnitedStates

COPD:chronicobstructivepulmonarydisease

CPAP:continuouspositiveairwaypressure

CPDA-1:citrate-phosphate-dextrose-adenine

CPG:ClinicalPracticeGuideline(s)

CPK:creatininephosphokinase

CPP:cerebralperfusionpressure

CPR:cardiopulmonaryresuscitation

CPS:ChiefofProfessionalServices

CrCl:creatinineclearance

Cre/Cr:creatinine

CRNA:CertifiedRegisteredNurseAnesthetist

CRTS:CasualtyReceivingandTreatmentShip

CRVAP:combat-relatedventilator-associatedpneumonia

CSF:cerebrospinalfluid

CSH:CombatSupportHospital

C-spine:cervicalspine

CSW:cerebralsaltwasting

CT:computedtomography

CTA:computedtomographyangiography/angiogram

CVA:cerebrovascularaccident

CVN:thisisaship’shullclassificationsymbol;C=aircraftcarrier,V=fixedwing,N=nuclearpowered

CX:phosgeneoxide

CXR:chestX-ray

D

D5:5%dextrose

D5NS:5%dextroseinnormalsaline

D5W:5%dextroseinwater

D5½NS:5%dextrosein½normalsalinesolution

DA:DepartmentoftheArmy

DAPAM:DepartmentoftheArmypamphlet

Dbili:directbilirubin

DBP:diastolicbloodpressure

DCCS:DeputyCommanderforClinicalServices

DCN:DeputyCommanderofNursing

DCS:damagecontrolsurgery

DDForm:DepartmentofDefenseForm

DDForm572:BloodDonationRecord

DDAVP:1-deamino-8-D-argininevasopressin(orDesmopressin)

Ddx:differentialdiagnosis

DECON:decontamination

DIC:diffuse/disseminatedintravascularcoagulation

DKA:diabeticketoacidosis

DO2:oxygendelivery

DOB:dateofbirth

DoD:DepartmentofDefense

DoDTR:DepartmentofDefenseTraumaRegistry

DOW:diedofwounds

DP:diphosgene

DPA:diagnosticperitonealaspiration

DSN:DefenseSwitchedNetwork

DVA:DepartmentofVeteransAffairs

DVT:deepvenousthrombosis

E

EAC:EchelonAboveCorps(orechelonofcare)

ECFV:extracellularfluidvolume

ECG:electroencephalogram

ECHO:echocardiogram

ED:EmergencyDepartment

EDTA:ethylenediaminetetraaceticacid

EKG:electrocardiogram

ELISA:enzyme-linkedimmunosorbentassay

EMEDS:ExpeditionaryMedicalSupport

EMT:EmergencyMedicalTechnician

ENT:ear-nose-throat

EOD:explosiveordnancedisposal

ePTFE:expandedpolytetrafluoroethylene

EPW:enemyprisonerofwar

ER:emergencyroom

ERC:enroutecare

ERG:ExpeditionaryReadyGroup

ET:endotracheal

ETT:endotrachealtube

EUCOM:EuropeanCommand

F

FAST:FocusedAbdominalSonographyforTrauma

FDA:USFoodandDrugAdministration

FeNa:fractionalexcretionofsodium

FFP:freshfrozenplasma

FiO2:fractionofinspiredoxygen;inspiredoxygen

FM:fieldmanual

FMC:fullmetalcase

Fr:Frenchgauge

FS:FlightSurgeon

FST:ForwardSurgicalTeam

FWB:freshwholeblood

G

GA:tabun

GB:sarin

GCS:GlasgowComaScale

GD:soman

GF:cyclosarinorcyclohexylsarin

GI:gastrointestinal

GOS:GlasgowOutcomesScore

GPW:GenevaConventionRelativetotheTreatmentofPrisonersofWar

gr:grains

GSW:gunshotwound

gtt:drops(fromtheLatinguttae)

GWS: Geneva Convention for the Amelioration of the Wounded and Sick inArmedForcesintheField

H

H2O:water

HACE:high-altitudecerebraledema

HAPE:high-altitudepulmonaryedema

HBsAg:hepatitisBsurfaceantigen

HBV:hepatitisBvirus

HCV:hepatitisCvirus

HD/H:sulfurmustard

HEAT:highexplosiveantitank

Hgb:hemoglobin

H/H:hematocrit/hemoglobin

HHS:hyperglycemichyperosmolarsyndrome

HIDA:hepatobiliaryiminodiaceticacid

HIPAA:HealthInsurancePortabilityandAccountabilityAct

HIT:heparin-inducedthrombocytopenia

HIV:humanimmunodeficiencyvirus

HN:nitrogenmustard

HR:heartrate

HTS:hypertonicsaline

HUB:HospitalUnit–Base

HUS:HospitalUnit–Surgical

I

iCa:hypocalcemia

ICFV:intracellularfluidvolume

ICP:intracranialpressure

ICU:intensivecareunit

ICW:intermediatecareward

I:E:inspiration:expiration

IED:improvisedexplosivedevice

IM:intramuscularIMA:inferiormaxillaryartery

IMV:intermittentmandatoryventilation

INR:InternationalNormalizedRatio

IO:intraosseous

I&O:intakeandoutput

ISBT:InternationalSocietyofBloodTransfusion

IV:intravenous

IVC:inferiorvenacava

IVV:intravascularvolume

J

JP:Jackson-Pratt

JTS:JointTraumaSystem

JTTR:JointTheaterTraumaRegistry

JTTS:JointTheaterTraumaSystem

K

K:clottime;potassium

KCl:potassiumchloride

KIA:killedinaction

KUB:kidneys,ureters,bladder(afrontalsupineradiograph)

K-wires:Kirschnerwires

L

L:Lewisite

LA:leftatrium

LAT:lateral

LD:lethaldose

LHA:labelforaTarawaclassship

LHD:landinghelicopterdeck

LMA:laryngealmaskairway

LR:lactatedRinger’s

LUQ:leftupperquadrant

LV:leftventricleLZ:landingzone

M

MA:maximalamplitude

MAC:minimalalveolarconcentration

MAP:meanarterialpressure

MCO:MarineCorpsOrder

meds:medicine

MEDEVAC:medicalevacuation

MEF:MarineExpeditionaryForce

MESS:MangledExtremitySeverityScore

MF2K:MedicalForce2000

MFST:MobileFieldSurgicalTeam

MMF:maxillary-mandibularfixation

MOPP:Mission-OrientedProtectivePosture

MRI:magneticresonanceimaging

MRSA:methicillin-resistantStaphylococcusaureus

MTF:medicaltreatmentfacility

MVA:motorvehicleaccident

MvO2:mixedvenousoxygendelivery

N

N2O:nitrousoxide

N/A:notapplicable

Na:sodium

NaCl:sodiumchloride

NaHCO3:sodiumbicarbonate

NATO:NorthAtlanticTreatyOrganization

NAVMEDP:DepartmentoftheNavypublication

NBC:nuclear,biological,andchemical

NCO:noncommissionedofficer

NG:nasogastric

NHLBI:NationalHeart,Lung,andBloodInstitute

NIH:NationalInstitutesofHealth

NIPR:NonsecureInternetProtocolRouter

NOE:naso-orbital-ethmoid

NP:neuropsychiatric

NPO:nothingbymouth

NPWT:negativepressurewoundtherapy

NS:normalsaline

NSAIDs:nonsteroidalantiinflammatorydrugs

NSTEMI:non-STelevationmyocardialinfarction

O

O2:oxygen

OB/GYN:obstetrics/gynecology

OCONUS:outsidethecontiguousUnitedStates

ODD:oncedailydosing

OEF:OperationEnduringFreedom

OET:oxygeneconomizertube

OIF:OperationIraqiFreedom

OPNAVINST:OfficeoftheChiefofNavalOperationsInstruction

OR:operatingroom

P

PA:Physician’sAssistant;pulmonaryartery;posteroanterior

PaCO2:partialarterialgaspressure(tension)ofcarbondioxide

PACOM:PacificCommand

2-PAMC:pralidoximechloride

PaO2:partialpressureofoxygeninthebloodorinarterialblood

PBW:predictedbodyweight

PCWP:pulmonarycapillarywedgepressure

pCXR:portablechestX-ray

PE:pulmonaryembolism

PEEP:positiveend-expiratorypressure

PHTLS:Pre-HospitalTraumaLifeSupport

PI:performanceimprovement

PM:preventivemedicine;ProgramManager

PMMA:poly(methylmethacrylate)

PMRC:PatientMovementRequirementsCenter

PNT:penetratingnecktrauma

po/PO:peros(bymouth)

post-op:postoperative

Pplat:plateaupressure

PRBCs:packedredbloodcells

PRinterval:measuredfromthebeginningofthePwavetothebeginningoftheQRScomplex

PRN:asneeded

PS:pressuresupport;chloropicrin

PSI:poundspersquareinch

PvO2:mixedvenousoxygentension

Q

q4h:every4hours

q6h:every6hours

q8h:every8hours

q12h:every12hours

qd:everyday

qhs:atbedtime

qid/QID:4timesaday

QRScomplex:combinationofthreegraphicaldeflectionsonanelectocardiogram;representsventriculardepolarization

QTinterval:measureoftimebetweenstartofQwaveandendofTwave

R

R:reactiontime;radius/radial

R4:rightpatient,rightplace,righttime,rightcare

RA:regionalanesthesia;rightatrium

RBC:redbloodcell

RDD:radiologicaldispersaldeviceResus:resuscitation

rFVIIa:recombinantfactorVIIa

RN:RegisteredNurse

RPG:rocket-propelledgrenade

rpm:revolutionsperminute

RPR:RapidPlasmaReagin

RR:respiratoryrate

RSDL:ReactiveSkinDecontaminationLotion

RSI:RapidSequenceIntubation

RTD:returntoduty

RUQ:rightupperquadrant

RV:rightventricle

S

SaO2:percentageofoxygensaturationofhemoglobin

SBP:systolicbloodpressure

SCH:subconjunctivalhemorrhage

SCre:serumcreatinine

ScvO2:centralvenousoxygensaturation

SEAL:SEa,Air,Land

SG:SurgeonGeneral

Sharps:referstosharpobjects,suchasneedles,scalpelblades,disposablescissors,stylets,trocars,brokentesttubes,glass,etc.

SIMV:synchronizedintermittentmandatoryventilation

SNa:serumsodium

SOD:SurgeonoftheDay

SOP:standardoperatingprocedure

SPEARR:SmallPortableExpeditionaryAeromedicalRapidResponse(team)

SpO2:noninvasivepulseoximetry

spp.:species

SSN:SocialSecurityNumber

STANAG:StandardizationAgreement

STEMI:STelevationmyocardialinfarction

STRATEVAC:strategicevacuation

STsegment:connectstheQRScomplexandtheTwave

SvO2:mixedvenousoxygensaturationofhemoglobin

T

TA:thoracoabdominal(stapler)

TBI:traumaticbraininjury

Tbili:totalbilirubin

TBSA:totalbodysurfacearea

TCCC:TacticalCombatCasualtyCare

TEG:thromboelastogram

THAM:tromethamine

tid/TID:threetimesaday

TMD:TheaterMedicalDirectororTraumaMedicalDirector

TMDS:TheaterMedicalDataStore

TNC:TraumaNurseCoordinator

TO:TheaterofOperations

TOW:tube-launched,opticallytracked,wire-guided(missile)

trachcollar:tracheostomycollar

TRALI:transfusion-relatedacutelunginjury

TTP:thromboticthrombocytopenicpurpura

U

U:ulnar/units

UCre:urinecreatinine

UNa:urinesodium

UOP:urineoutput

UPAC:UniversalPortableAnesthesiaComplete

US:UnitedStates;ultrasound

USAF:USAirForce

USAISR:USArmyInstituteofSurgicalResearchUSMC:USMarineCorps

USNS:USNavyship

USTRANSCOM:USTransportationCommand

UV:ultraviolet

UXO:unexplodedordnance

V

VAC:Vacuum-AssistedClosure

VAP:ventilator-associatedpneumonia

VCO2:carbondioxideproduction

Vd:deadspacevolume

Ve:minutevolume

VEE:Venezuelanequineencephalitis

Vel:velocity

VHF:viralhemorrhagicfever

VO2:oxygenuptake

VRE:vancomycin-resistantenterococci

VT:tidalvolume

VX:methylphosphonothioicacid

W

WDMET:WoundDataandMunitionsEffectivenessTeam

WIA:woundedinaction

Wt:weight

SignificantMilitaryMedicalTermsaeromedicalevacuation:themovementofpatientsundermedicalsupervisiontoandbetweenmedicaltreatmentfacilitiesbyairtransportation.

casualtycategory:used to specifically classifya casualty for reportingpurposesbased on the casualty type and the casualty status. Casualty categories includekilledinaction,diedofwoundsreceivedinaction,andwoundedinaction.

casualty evacuation: the unregulated movement of casualties that can includemovement both to and between medical treatment facilities. Also known asCASEVAC.

died ofwounds received in action: a casualty category applicable to a hostilecasualty,otherthanthevictimofaterroristactivity,whodiesofwoundsorotherinjuriesreceivedinactionafterhavingreachedamedicaltreatmentfacility.AlsoknownasDOW.

killedinaction:acasualtycategoryapplicabletoahostilecasualty,otherthanthevictim of a terrorist activity, who is killed outright or who dies as a result ofwoundsorotherinjuriesbeforereachingamedicaltreatmentfacility.AlsoknownasKIA.

MEDEVAC:medicalevacuation.

medical evacuees: personnel who are wounded, injured, or ill and must bemovedtoorbetweenmedicalfacilities.

medical treatment facility: a facility established for the purpose of furnishingmedicaland/ordentalcaretoeligibleindividuals.AlsoknownasMTF.

woundedinaction:acasualtycategoryapplicabletoahostilecasualty,otherthanthe victimof a terrorist activity,whohas incurred an injurydue to an externalagent or cause. The term encompasses all kinds of wounds and other injuriesincurredinaction,whetherthereisapiercingofthebody,asinapenetrationorperforated wound, or none, as in a contused wound. These include fractures,burns, and blast concussions (all effects of biological and chemical warfareagents), and the effects of an exposure to ionizing radiation or any otherdestructiveweaponoragent.Thehostilecasualty’sstatusmaybecategorizedas“veryseriouslyillorinjured,”“seriouslyillorinjured,”“incapacitatingillnessorinjury,”or“notseriouslyinjured.”AlsoknownasWIA.

ProductManufacturersAlconLaboratories,Inc,FortWorth,TX—Mydriacyl,Cyclogyl

Allergan,Inc,Irvine,CA—Ocuflox

Ambu,Cambridgeshire,UK—AmbuE-valve,Ambubag

Ambu,Inc,GlenBurnie,MD—Ambubag

AppliedScience,Inc,GrassValley,CA—HemoFlow

ArizantHealthcare,Inc,EdenPrairie,MN—BairHugger

BayerHealthCareLLC,Morristown,NJ—Neo-Synephrine

Blizzard Protection Systems Ltd, Bethesda, Gwynedd, UK— Blizzard SurvivalBlanket

BlockScientific,Inc,Bohemia,NY—i-STATBloodGasAnalyzer

BovieMedicalCorporation,Clearwater,FL—Boviecauterizer

CardinalHealth,Dublin,OH—Frepp/SeppAntisepticApplicatorKit, Jamshididisposablesternal/iliacaspirationneedle,Esmarkbandages

CareFusion,Leawood,KS—IodineSepp

CERTEC,Sourcieux-les-Mines,France—CERTECSAbag

Codman,Raynham,MA—ICPMonitoringSystem,ICPExpress

CookCriticalCare,Bloomington,IN—CookIOneedle,Sur-Fastneedle

Covidien,Mansfield,MA—KERLIX,Hi-LoTrachealTube

DraegerMedical,Inc,Telford,PA—FabiusTiroM

DRE,Inc,Louisville,KY—DragerNarkomedanesthesiamachine

E.I.duPontdeNemoursandCompany,Wilmington,DE—Kevlar

ElectraHouse,Crewe,UK—Celox

Ethicon,Inc,Somerville,NJ—Surgicel,PDSsutures,MONOCRYL,PROLENE

GEHealthcare,Laurel,MD—OhmedaUniversalPortableAnesthesiaComplete

Healthcare Services,MineralWells, TX;WaismedLtd/PerSysMedical,Houston,TX—BoneInjectionGun

Hospira,Inc,LakeForest,IL—Hextend(hetastarch)

Impact Instrumentation, Inc, West Caldwell, NJ — Impact 754 Eagle Uni-VentVentilator

Invista,Wichita,KS—Dacron

Johnson&Johnson,NewBrunswick,NJ—TYLENOL,Polysporin

Kinetic Concepts, Inc/KCI Licensing, Inc, San Antonio, TX — Wound VACTherapySystem

LMANorthAmerica,Inc,SanDiego,CA—FastrachLaryngealMask

McNeilHealthcare,Inc,Waterford,CT—Kittnersponge

MedTechSweden,Inc,Geneseo,IL—VacuumSpineBoard

MölnlyckeHealthCareUS,LLC,Norcross,GA—Hibiclens

Ortho-ClinicalDiagnostics,Inc,Rochester,NY—RhoGAM

PallCorporation,PortWashington,NY—PallHeatandMoistureExchangeFilter

PMC,Sunnyvale,CA—Adaptec

PortableHyperbarics,Inc,Ilion,NY—Garnowbag

PyngMedical,Richmond,BritishColumbia,Canada—FAST1

SonoSite,Inc,Bothell,WA—SonoSiteduplexultrasounddevice

TECHStyles,Addison,TX—TECHStylesThermo-LiteHypothermiaPreventionSystem

TechTradeLLC,NewYork,NY—Ready-Heatself-warmingmedicalblanket

Terumo Medical Products, Somerset, NJ — VENOJECT Luer Adapter, LuerAdapterHub,Terumosinglebloodbag

Thermogear, Inc, Lake Oswego, OR; Microtek Medical, Columbus, MS —ChillBuster

3MCompany,StPaul,MN—Ioban,ACEwrap,Cobanself-adherentwrap

TraumaCure,Inc,Bethesda,MD—WoundStat

Verathon,Inc,Bothell,WA—GlideScopeRanger

Vida-Care,SanAntonio,TX—EZ-IOdevice

W.L.Gore&Associates,Inc,Elkton,MD—PTFE,GORE-TEX

Z-MedicaCorporation,Wallingford,CT—QuikClotCombatGauze

IndexA

A/C.SeeAssist-controlpositive-pressureventilation

Abdominalclosure,274–275

Abdominalcompartmentsyndromeburnsand,388

Abdominalhysterectomy,294–296

Abdominalinjuries

abdominalclosure,274–275

antimicrobialagentselectionandduration,119

biliarytract,270

colon,271–272

CTscans,264

damagecontrolsurgery,178–179

diagnosisof,258

diagnosticadjuncts,259

diagnosticperitonealaspiration,263–264

duodenal,267–268

exposuretechniques,265–266

focusedabdominalsonographyfortrauma,259–263

gastricinjuries,266

indicationsforlaparotomy,258

liver,269–270

operativeplanning,265–266

pancreatic,268–269

penetrating,257

rectal,272–273

retroperitoneal,273–274

smallbowel,271

splenic,271

woundexploration,265

ABOincompatibility,484–485

ABOtyping,470–471,480

Abrasions,corneal,208–209

AC.SeeHydrogencyanide

Acalculouscholecystitis,164

Accelerationstress

aeromedicalevacuationand,50

Acclimatization,404–405

Acidosis

bloodtransfusionsand,474–476

mechanicalventilationand,145

Acinetobacter,carbapenem-resistant,123

ACSmonitoring,180–181

Acutecoronarysyndrome,155–159

Acutehemolytictransfusionreaction,484–485

Acutelunginjury,143,486–487

Acutemountainsickness,416–418

Acuterespiratorydistresssyndrome,143,146–147

Acutetubularnecrosis,165–166,168

Acutevaginalhemorrhage,297–298

Adnexalinjuries,293,295

Adrenalinsufficiency,172

AdvancedTraumaLifeSupport,455

AE.SeeAeromedicalevacuation

AELT.SeeAeromedicalEvacuationLiaisonTeam

Aeromedicalevacuation.SeealsoPatientevacuation

AirForcesystem,51–55

clearance,54

descriptionof,47

humanitariantransportrequests,58

implicationsoftheaviationenvironment,49–51

intertheatertransportchecklist,57

localflightsurgeonresponsibilities,54

medicalconsiderations,48–49

patientmovementrequirements,54

patientrequests,54–55

patientselection,55–56,58–59

patientstability,53

precedences,51–55

process,54

reportingapatient,52–53

validation,54

AeromedicalEvacuationLiaisonTeam,52–53

AeromedicalStagingFacilities,52

AirForce

aeromedicalevacuationsystem,51–55

basicprimarycare,21–22

ExpeditionaryMedicalSupport,21–22,26

theaterhospitals,26

Airsplints,50

Aircraftcarrierbattlegroups,22

Airwaymanagement

BackwardUpwardRightwardPressuremaneuver,64–65

difficultairway,66–67,94

directlaryngoscopy,64

facialinjuriesand,183–184

heatstrokeand,407

indicationsforadefinitiveairway,89–90

initial,61–62

laryngealmaskairway,68

orotrachealintubation,63–66

rapidsequenceintubation,63,90–94

secondaryairwaycompromise,90

surgicalcricothyrotomy,67–68

two-personmaskventilation,62–63

ventilation,62–63

AK-47rifles,10

Albumin,134

Albuminvolume

burncare,383–384

ALI.SeeAcutelunginjury

Alkalosis

mechanicalventilationand,145

Allergictransfusionreactions,487–488

Alliedcontractors

triageconsiderations,33

Altitudeillness

acutemountainsickness,416–418

altitudebasics,414–415

descentbasics,415–416

high-altitudebronchitis,419

high-altitudecerebraledema,423–425

high-altitudeperipheraledema,419

high-altitudepharyngitis,419

high-altitudepulmonaryedema,421–423,425

high-altituderetinalhemorrhage,419–420

subacutemountainsickness,420–421

thromboembolicevents,420

Amnestics,92

AmphibiousReadyGroup,22

Amputations

battlefieldamputations,342

dressings,345

indicationsfor,341

lengthpreservingamputations,342–343

postoperativemanagement,347

skinretractionprevention,345

skintraction,345–346

specialconsiderations,344–345

surgicaltechnique,343–344

AMS.SeeAcutemountainsickness

Anallacerations,291

Anemia,pediatric,454

Anesthesia

conclusionofgeneralanesthesia,95–96

difficultairway,94

fieldanesthesiaequipment,97–100

indicationsforadefinitiveairway,89–90

inductionagents,92

inductionofgeneralanesthesia,90

local,97

maintenanceofgeneralanesthesia,94–95

neuraxial,97

rapidsequenceintubation,90–94

regional,96–97

secondaryairwaycompromise,90

sedatives,92

Angiography

vascularinjuries,360

Anhidroticheatexhaustion,412–413

Anthrax,436,440

Antibiotics

coverage,123

dosageforinfectiontreatment,129

treatmentspectrum,129

Anticoagulation

vascularinjuriesand,374

AntidoteTreatmentNerveAgentAutoinjectors,445

Antimicrobialagents

burncare,385

durationofuse,119–122

selectionof,119–122

Antipersonnellandmines,8–9

Antitanklandmines,13–14

Anxiolytics,92

Aortainjuries,367–368

Archbars,187

ARDS.SeeAcuterespiratorydistresssyndrome

Areasupportmedicalcompany,19

ARG.SeeAmphibiousReadyGroup

Arm

compartmentsyndrome,490

vascularinjuries,361–362

Armoredvehiclecrewcasualties,11–14

Army

augmentationteams,25–26

basicprimarycare,19–20

CombatSupportHospitals,24–25

medicalevacuationprecedences,52

pointofinjurycare,18

ASFs.SeeAeromedicalStagingFacilities

Aspirationpneumonitis,152–153

Assist-controlpositive-pressureventilation,141

Ataxia,424

Atelectotrauma,142

ATLS.SeeAdvancedTraumaLifeSupport

ATN.SeeAcutetubularnecrosis

ATNAAs.SeeAntidoteTreatmentNerve

AgentAutoinjectorsAugmentationteams,25–26

Auricularinjury,193

Axillaryarteryinjuries,361–362

B

Bacillusanthracis,440

BackwardUpwardRightwardPressuremaneuver,64–65

Bacteremia

bloodtransfusionsand,485Bacterialagents,440

Bacterialkeratitis,209–210

Ballisticinjuries,6

Bandages,70,72–73

Barometricpressureaeromedicalevacuationand,49

Barotrauma,142

Battalionaidstations,18

Battlefieldtransfusions.SeeTransfusions

Battlefieldtraumasystemmodel,497–499

Biliarytractinjuries,270

Biologicalagents,439

Biologicalcontamination.SeealsoNuclear,biological,andchemicalcasualties

aeromedicalevacuationand,51

bacterialagents,440

biologicalagents,439

decontamination,436–437

detectionofbiologicalwarfareagents,435

diagnosisof,436

hemorrhagicfevers,438–439

infectioncontrol,437

medicalevacuation,437–438

preventionof,436

protectionfrom,436

symptomsof,439–441

treatmentof,439–441

triageconsiderations,32

viralagents,441

BiologicalIdentificationDetectionSystem,435

Biotrauma,142

Bladder

dysfunctionassociatedwithspinalinjuries,315

injuriesof,285–286

Blastinjuries,6,8,430

Blastmines,13

Blastwaves,5

Bleeding.SeeHemorrhage

Blindness,flash,431

Blood,freshwhole

ABOmatching,470–471

emergencycollectioninthefield,478–483,503–512

onsitespecimenprocessing,511

posttransfusionverification,510–511

rapidtestingof,509

releasing,509–510

roleofcare,469

specimenprocessing,511

Bloodagents,447

Blooddonors

appropriatecriteria,512

bagissue,505

frequencyofdonations,512

identificationof,480–481

medicationuse,512

performingphlebotomy,505–508

postdonorcare,508–509

screeningof,481,504–505

Bloodproducts

ABOmatching,470–471

Rhmatching,471–472

roleofcare,468–469

typesof,468–469

BloodSupportDetachment,511

Bloodtransfusions.SeeTransfusions

Bloodvolume,pediatric,454

Blowoutfractures,213–214

Bluntinjuries

cardiac,155

pelvic,318–319

renal,278

Bonefractures

amputationconsiderations,344

bivalvingcasts,330

burnsand,388

externalfixation,330–340

extremities,327–340

facial,186–190

hands,352

LeFortfractureclassification,189–190

mandible,186–187

maxillofacial,188–190

nasal,187–188

orbitalfloor,213–214

pelvic,292

skull,222–223

temporaryexternalfixation,327

transportationcasts,327

Botulinumtoxins,439

Boundinglandmines,8–9

Brachialarteryinjuries,362

Braininjuries

antimicrobialagentselectionandduration,120

Braininjury,traumatic.SeeTraumaticbraininjury

Breathing,unassisteddefinitionof,145–146

Breathingsupport.SeealsoAirwaymanagement

burncare,379

Brigadesupportmedicalcompany,19

Bronchitis,high-altitude,419

Brucella,440

Brucellosis,440

Burkholderiamallei,440

BurnCenter,391

BurnResuscitationFlowsheet,384

Burns.SeealsoChemicalcontaminationabdominalcompartmentsyndromeand,388

airwayinterventions,379

albuminvolume,383–384

antimicrobials,121,385

breathinginterventions,379–380

BurnResuscitationFlowsheet,384

cellulitis,386

chemical,389

circulationmanagement,380

ClinicalPracticeGuidelines,392

complications,388

cornealabrasions,386

ears,386

edemaand,387

electricalinjuries,388–389

electrolytedisturbances,384

escharotomy,387

extremitycare,387–388

fasciotomy,388

fluidresuscitation,380–382

fracturesand,388

glycosuria,383

hyperkalemiaand,389

hypothermia,378

infectioncontrol,386

inhalationinjury,378,388

localnationalburnpatients,390–391

metabolicconsiderations,388

patientevaluation,391

patientmonitoring,382

pediatric,381–382,453

point-of-injurycare,377–378

primarysurvey,378–380

radiologicalinjuries,430–431

respiratorycare,388

resuscitation,383–384

RuleofNines,381

RuleofTens,380,391

secondarysurvey,382–383

silvernylondressings,385

surgicaldebridement,389

totalbodysurfacearea,380–382,390

triageconsiderations,390

urineoutputtarget,383

USArmyInstituteofSurgicalResearchBurnCenter,391

whitephosphorus,389–390

woundcare,384–386

BURP.SeeBackwardUpwardRightwardPressuremaneuver

BZ,447–448

C

Cabinaltituderestriction

aeromedicalevacuationand,50

Calcium,139–140Calf.SeeLowerextremities

Caloricrequirements

pediatric,452

Cantholysis,212–213

CAR.SeeCabinaltituderestriction

Carbapenem-resistantAcinetobacter,123

Cardiacdisease

acutecoronarysyndrome,155–159

cardiactamponade,154–155

congestiveheartfailure,159–161

Cardiacinjuries.SeeHeartinjuries

Cardiacstrokevolume,pediatric,453

Cardiactamponade,154–155,243–244

Cardiogenicshock,78,132

Cardiopulmonaryresuscitationhypothermiaand,402

Cardiopulmonarytechnicians,56

Carotidarteryinjuries,197,369–370

Casefatalityrate,522

CASEVAC.SeeCasualtyevacuation

Casts

bivalving,330

transportation,327

Casualtyevacuation.SeealsoPatientevacuation

descriptionof,47

CasualtyReceivingandTreatmentShips,22

Casualtyrecorders,40

Caveat-Hextend,80

CCATTs.SeeCriticalCareAirTransportTeams

Cellulitis,125,386

Centralnervoussystemwoundsantimicrobialagentselectionandduration,120

Centralvenouspressure,231

Cerebraledema,high-altitude,423–425

Cerebralperfusionpressure,230–231

Cerebrovascularaccidents,161–163

Cervicalspineinjuries

considerations,184

instability,309–310

patienttransport,310

Cervicalvascularinjury,369–371

Cesareansections,emergency,300–302

CFR.SeeCasefatalityrate

CG.SeePhosgene

Chemicalcontamination.SeealsoNuclear,biological,andchemicalcasualties

aeromedicalevacuationand,51

burninjuries,389

cornealinjuries,207–208

cyanogens,447

hypochloritesolutionuse,449

incapacitationagents,447–448

initialtreatmentpriorities,444

lung-damagingagents,446–447

nerveagents,444–445

off-gassing,448

personalprotection,443–444

postsurgeryprocedures,449–450

pretreatmentof,445

ReactiveSkinDecontaminationLotionuse,446,449

surgicaltreatment,448–450

symptomsof,445–448

thickenedagents,448

treatmentof,445–448

triage,446–447

triageconsiderations,32

vesicants,445–446

wounddecontamination,448

woundexplorationanddebridement,449

Chestinjuries.SeeThoracicinjuries

Chesttubes,244–246

Chestwellcompliance,141

Chilblains,393

Childbirth,emergency

emergencycesareansection,300–302

neonatalresuscitation,304–305

precipitousvaginaldelivery,298

uterineatony,302–303

Children.SeePediatrictrauma

Chlorine,446–447

Chloropicrin,446–447

Chokingagents,446–447

Cholera,440

Cisatracurium,92

Civilianinternees.SeeInternees

CK.SeeCyanogenchloride

Clampingvessels,71

ClinicalPracticeGuidelines

burns,392

compliancewith,498

Clostridialmyonecrosis,125

Coagulopathy

bloodtransfusionsand,476–478

dilutional,476–478

heatstrokeand,406,409–410

trauma-induced,476–478

COCOM.SeeCombatantCommand

Coldinjuries

cardiopulmonaryresuscitation,402–403

chilblains,393

fieldtreatment,397,400–401

frostbite,396–397

frostnip,396

hypothermia,399–402

medicalfacilitytreatment,397–399,401–402

nonfreezing,393–397

pernio,394

rapidrewarming,398–399

trenchfoot,394–395

Coloninjuries,271–272

Combat-associatedhealthcarepneumonia,153–154,172–173

Combatlifesavers,18

Combatstress

triageconsiderations,33–34

CombatSupportHospitals

roleofmedicalcare,19,24–25

CombatantCommand,497–498

Commonfemoralarteryinjuries,363–364

Compartmentsyndrome

descriptionof,110–111,489

earlyclinicaldiagnosisof,111,489

fasciotomytechnique,111–112,490–494

fasciotomywoundmanagement,494–496

lateclinicaldiagnosisof,111,489

lowerextremities,355–356,491–496

measurementofcompartmentpressures,489

mechanismsofinjuriesassociatedwith,111,489

prophylacticfasciotomy,489–490

treatmentof,111,489

upperextremities,490–491

Compartmentsyndrome,abdominalburnsand,388

Compensatedshock,133

Computedtomographicangiographyvascularinjuries,360

Computedtomographyimagingabdominalinjuries,264

headinjuries,226–227

Congestiveheartfailure,156,159–161

Conjunctivalinjuries

foreignbodies,210–211

Consciousness

headinjuriesand,224

ContinentalUnitedStates-basedhospitals

medicalcareroles,28

militarytraumasystems,497

Contractors

triageconsiderations,33

Contrastdye-associatednephropathy,168

Controlledhypotensiveresuscitation,74,82–84

Controlledresuscitation,74

CONUS-basedhospitals.SeeContinentalUnitedStates-basedhospitals

Cornealinjuries

abrasions,208–209,386

burns,386

chemicalinjuriesof,207–208

foreignbodies,210–211

Cornealulcer,209–210

Coronarysyndrome,acute,155–159

Coxiellaburnetii,440

CPP.SeeCerebralperfusionpressure

CPR.SeeCardiopulmonaryresuscitation

Craniectomies,233–238

Cricothyrotomy,67–68

Criticalcare

acalculouscholecystitis,164

acutecoronarysyndrome,155–159

acuterespiratorydistresssyndrome,143,146–147

acutetubularnecrosis,165–166,168

adrenalinsufficiency,172

aspirationpneumonitis,152–153

bluntcardiacinjury,155

cardiacdisease,154–161

cardiactamponade,154–155

cardiogenicshock,132

cerebrovascularaccidents,161–163

combat-associatedhealthcarepneumonia,153–154

congestiveheartfailure,159–161

damagecontrolsurgery,180–181

diabeticketoacidosis,170–172

disseminatedintravascularcoagulation,168–169

distributiveshock,132

endocrinedisease,170–172

fluidmanagement,133–134

gastrointestinaldisease,163–165

glucosecontrol,173

heparin-inducedthrombocytopenia,169–170

hyperglycemichyperosmolarsyndrome,170–172

hyperkalemia,137–138

hypernatremia,135

hypocalcemia,140

hypokalemia,136–137

hypomagnesemia,139

hyponatremia,135

hypovolemicshock,131–132

iatrogeniccomplicationsoftherapy,168

ICUprophylaxis,172–174

mechanicalventilation,140–146

nephrolithiasis,167–168

neurologicaldisease,161–163

nutrition,173–174

prerenalazotemia,165–166

pulmonarycontusion,147–148

pulmonaryembolism,148–152

pulmonarymedicine,140–154

renaldisease,165–168

rhabdomyolysis,166–167

serumcalciumlevelsand,139–140

serumelectrolytemanagement,134

serummagnesiumlevelsand,138

serumpotassiumlevelsand,136

shock,131–133

stressgastritis,163–164

strokes,161–163

thromboticthrombocytopenicpurpura,168–169

traumaticbraininjury,161

uncompensatedshock,131–133

ventilator-associatedpneumonia,172–173

CriticalCareAirTransportTeams,47,55–58

Criticalcarenurses,56

CRTS.SeeCasualtyReceivingandTreatmentShips

Crushsyndrome,108–110

CT.SeeComputedtomographyimaging

CTA.SeeComputedtomographicangiography

CVA.SeeCerebrovascularaccidents

CVP.SeeCentralvenouspressure

Cyanogenchloride,447

Cyanogens,447

Cyanosis,418

Cyclohexylsarin,444

Cyclosarin,444

D

Damagecontrolsurgery

ACSmonitoring,180–181

considerations,175–176

criticalcare,180–181

definitionof,175

earlyresuscitationphase,177

generalprinciplesof,177–182

plannedreoperation,181–182

prehospitalphase,177

primaryoperation,177–179

relaparotomy,181–182

temporaryabdominalclosure,178–179

thoracicinjuries,182

unplannedreexploration,182

vacuumpacktechnique,179

Debridement

burncare,389

chemicalcontaminationinjuries,449

Decontamination

biologicalcontamination,436–437

chemicalinjuries,436–437,448

mechanical,436

physical,437

radiologicalinjuries,432

Decubitusulcers,315–316

Deepvenousthrombosis

diagnosisof,148–149

spinalinjuriesand,315

treatmentof,149

Delayedevacuation

antimicrobialagentselectionandduration,121

Deliveries.SeeChildbirth,emergency

DepartmentofDefenseTraumaRegistry

functionof,521

methods,523–525

minimumessentialdata,523

responsibilities,498

resuscitationrecords,524–528

situationalawareness,522–523

technology,523–525

usesof,523

Detainees.SeeInternees

Diabeticketoacidosis,170–172

Diagnosticperitonealaspiration,263–264

Diaphragminjuries,255

Diedofwounds,522

Dilaudid,91

Diphosgene,446–447

Dirtybombs.SeeRadiologicaldispersaldevices

Disseminatedintravascularcoagulation,168–169

Distalfemoralartery,365

Distributiveshock,78,132

DKA.SeeDiabeticketoacidosis

DOW.SeeDiedofwounds

DPA.SeeDiagnosticperitonealaspiration

Drawovervaporizer,97–100

Dressings,70,72–73

Duodenalinjuries,267–268

DVT.SeeDeepvenousthrombosis

E

Earinjuries

burns,386

Ebolafever,438–439

ECFV.SeeExtracellularfluidvolume

Ectopicpregnancies,293,295

Edema

burnsand,387

high-altitudecerebral,423–425

high-altitudeperipheral,419

high-altitudepulmonary,421–423,425

Electricalburninjuries,388–389

Electrolytemanagement,134,384,451

EMEDS.SeeExpeditionaryMedicalSupport

Emergencycesareansections,300–302

Emergencychildbirth.SeeChildbirth,emergency

Emergencywholebloodcollection,478–483,503–512

Empyema,127

Enroutecare

descriptionof,48

teams,23

Encephalopathy

heatstrokeand,406,408

Endocrinedisease

adrenalinsufficiency,172

diabeticketoacidosis,170–172

hyperglycemichyperosmolarsyndrome,170–172

Endotrachealintubation,93

Endotrachealtubes,66,94

Enemyprisonersofwar.SeealsoInterneestriageconsiderations,33

Enteralnutrition,173

Enucleation,217

Environmentalinjuries

acclimatization,404–405

acutemountainsickness,416–418

altitudeillness,414–425

anhidroticheatexhaustion,412–413

cardiopulmonaryresuscitation,402–403

chilblains,393

coldinjuries,393–403

fieldtreatment,397,400–401

frostbite,396–397

frostnip,396

heatcramps,410–411

heatedema,413–414

heatexhaustion,411–412

heat-inducedsyncope,413

heatinjury,403–414

heatstroke,405–410

heattetany,414

high-altitudebronchitis,419

high-altitudecerebraledema,423–425

high-altitudeperipheraledema,419

high-altitudepharyngitis,419

high-altitudepulmonaryedema,421–423,425

high-altituderetinalhemorrhage,419–420

hypothermia,399–402

medicaltreatmentfacility,397–399,401–402

miliariaprofunda,412–413

miliariarubra,412

minorillnesses,412–414

nonfreezingcoldinjuries,393–397

pernio,394

pruritus,412–413

rapidrewarming,398–399

subacutemountainsickness,420–421

sunburn,414

thromboembolicevents,420

trenchfoot,394–395

EPWs.SeeEnemyprisonersofwar

Escharotomy,387

Eschmannstylet,65–66

Esophagealfistulas,200

Esophagealinjuries

diagnosisof,199–200

treatmentof,200,254–255

Ethics.SeeMedicalethics

Etomidate,92

ETT.SeeEndotrachealtubes

Evacuation.SeeAeromedicalevacuation;Patientevacuation

Expeditionarymedicalfacilities,26–27

ExpeditionaryMedicalSupport,21–22,26

Explosiveordnancedisposal,16

Explosive-relatedinjuries

categoriesof,5,7

headinjuries,220–222

Extracellularfluidvolume,133,136

Extraperitonealinjuries,286

Extremityfractures

bivalvingcasts,330

externalfixation,330–340

femurdiaphysealfracturetechnique,331–334

patientevacuation,339–340

skeletaltraction,338–339

techniquetospanankle,338

techniquetospanknee,335–338

temporaryexternalfixation,327

tibiashaftfracturetechnique,334–335

transportationcasts,327

woundmanagement,328–330

Extremityinjuries

antimicrobialagentselectionandduration,119

fractures,327–340

vascular,361–367

Eyeinjuries.SeeOcularinjuries

Eyelidlacerations,214–216

F

Facialinjuries.SeealsoNeckinjuries

airwaymanagement,183–184

auricularinjury,193

bonefractures,186–190

cervicalspineinjuries,184

evaluationof,185

faciallacerations,191

facialnerveinjury,191–192

immediatemanagementof,183–185

parotidductinjury,192–193

soft-tissueinjuries,190–193

vascularinjuries,184–185

Fallopiantubeinjuries,293

Fasciotomy

arm,490

burncare,388

calf,492–494

compartmentsyndrometreatment,111

foot,494

forearm,490–491

lowerextremities,491–494

technique,111–112,490–496

thigh,491–492

upperextremities,490–491

woundmanagement,494–496

FAST.SeeFocusedabdominalsonographyfortrauma

Febrilenonhemolytictransfusionreaction,486

Femoralarteryinjuries,363–364

Fentanyl,91

Fetalheartrate,298,300

Flailchest,244

Flashblindness,431

Flashburns,430

FleetSurgicalTeams,22

Fluidtherapy

burnsand,380–382

criticalcare,133–134

pediatric,451

shock,80,83

Focusedabdominalsonographyfortrauma,259–263

Fogartythrombectomycatheters,372

Footcompartmentsyndrome,355–356,494

Footinjuries

evaluationof,353–354

externalfixation,356

hindfoot,354

initialmanagement,353–354

midfoot,354

penetrating,353

stabilization,356

toes,355

typesof,349

Forearmcompartmentsyndrome,490–491

Foreignbodies

ocular,210–211

ForwardResuscitativeSurgicalSystem,23

ForwardSurgicalTeams

aeromedicalevacuationfrom,48–49

functionof,19–20,25

Fractures.SeeBonefractures

Francisellatularensis,440

Freshfrozenplasma

ABOmatching,470–471

roleofcare,469

Freshwholeblood

ABOmatching,470–471

emergencycollectioninthefield,478–483,503–512

onsitespecimenprocessing,511

posttransfusionverification,510–511

rapidtestingof,509

releasing,509–510

roleofcare,469

specimenprocessing,511

Frostbite,396–397

Frostnip,396

FST.SeeForwardSurgicalTeams

G

Gardner-Wellstongs,312–314

Gasgangrene,125

Gastricinjuries,266

Gastritis,stress,163–164

Gastrointestinaldisease

acalculouscholecystitis,164

pediatriccare,453–454

spinalinjuriesand,315

stressgastritis,163–164

GCS.SeeGlasgowComaScale

Generalanesthesia

conclusionof,95–96

inductionof,90

maintenanceof,94–95

Geneva Convention for the Amelioration of the Wounded and Sick in ArmedForcesintheField,461–462

GenevaConventionRelativetotheTreatmentofPrisonersofWar,461–462

GenevaConventions,461–462

Genitaliainjuries,288–289

Genitourinarytractinjuries

bladder,285–286

externalgenitalia,288–289

renal,277–282

ureteral,282–285

urethral,286–288

GlasgowComaScale,219,224,228–229,455,519

GlasgowOutcomesScale,219

Glucosecontrol,173

Glycosuria,383

GOS.SeeGlasgowOutcomesScale

GPW.SeeGenevaConventionRelativetotheTreatmentofPrisonersofWar

Graftmaterial

vascularinjuries,373

Greatersaphenousveincutdowns,86–87

GumElasticBougie,65

GWS.SeeGenevaConvention for theAmeliorationof theWoundedandSick inArmedForcesintheField

Gynecologicalemergencies.SeealsoChildbirth,emergency

acutevaginalhemorrhage,297–298

Gynecologicalinjuries.SeealsoChildbirth,emergency

abdominalhysterectomy,294–296

acutevaginalhemorrhage,297–298

adnexal,293,295

cervical,293

ovarian,295–296

retroperitonealhematoma,296–297

uterine,293

vaginal,292–293

vulvar,291–292

H

HACE.SeeHigh-altitudecerebraledema

Handcompartmentsyndrome,350–351

Handinjuries

dressing,352–353

evaluationof,350

handcompartmentsyndrome,350–351

initialmanagement,350

splinting,352–353

surgicaltechnique,351–352

tendons,349tissuemanagement,352

typesof,349

Hantafever,438–439

HAPE.SeeHigh-altitudepulmonaryedema

Headinjuries.SeealsoTraumaticbraininjury

classificationof,222–223

evacuationofhead-injuredpatients,238–239

GlasgowComaScale,219,224

intracranialpressureand,219,227–232

mechanismsofinjury,223

medicalmanagement,227–233

patientassessment,224–227

primaryinjuries,223

pupillaryreactivityand,225–226

radiographicevaluation,226–227

secondaryinjuries,223

surgicalmanagement,233–238

triage,224–227

typesofcombatheadinjuries,220–222

HealthInsurancePortabilityandAccountabilityAct,463

Healthservices.SeeRolesofmedicalcare

Heartdisease.SeeCardiacdisease

Heartinjuries

blunt,155

penetrating,252–253

treatmentof,252–253

Heartrate

fetal,298,300

infant,304–305

HEAT.SeeHighexplosiveantitankrounds

Heat-inducedsyncope,413

Heatcramps,410–411

Heatedema,413–414

Heatexhaustion,411–413

Heatinjury

acclimatization,404–405

anhidroticheatexhaustion,412–413

heatcramps,410–411

heatedema,413–414

heatexhaustion,411–412

heat-inducedsyncope,413

heatstroke,405–410

heattetany,414

miliariaprofunda,412–413

miliariarubra,412

minorillnesses,412–414

preventionof,403–405

pruritus,412–413

sunburn,414

Heatstroke

clinicalpresentation,406–407

complicationsof,409–410

coretemperatureand,407

evaluationof,405

treatmentof,407–408

Heattetany,414

Hematology

pediatriccare,454

Hematomas

headinjuriesand,236

infrafascial,292

retroperitoneal,296–297

vaginal,292

Hematuria,277–278

Hemorrhage.SeealsoTransfusions

acutevaginalhemorrhage,297–298

clampingvessels,71

controlledhypotension,74

controlof,69

dressingsandbandages,70,72–73

earlycontrolof,467–468

external,69

firstrespondertreatment,70–72

hemostaticagents,73–74

high-altituderetinalhemorrhage,419–420

internal,70,72

limbsplints,72

orbital,211–212

pressurepoints,71

scalpbleeding,72

sitesof,69–70

tourniquets,71

uterineatony,302–303

Hemorrhagicfevers,438–439,441

Hemorrhagicshock,81–82

Hemostaticagents,73–74

Hemothorax,243

Hemotympanum,202

Heparin-inducedthrombocytopenia,169–170

Hepaticarteryinjuries,368

Hetastarch,80

Hextend,80

HHS.SeeHyperglycemichyperosmolarsyndrome

High-altitudebronchitis,419

High-altitudecerebraledema,423–425

High-altitudeperipheraledema,419

High-altitudepharyngitis,419

High-altitudepulmonaryedema,421–423,425

High-altituderetinalhemorrhage,419–420

Highexplosiveantitankrounds,11–12

Hindfootinjuries,354

HIPAA.SeeHealthInsurancePortabilityandAccountabilityAct

HIT.SeeHeparin-inducedthrombocytopenia

Horizontalspraymines,9

Hospitalaugmentationteams,25

Hospitalships,27–28

HTS.SeeHypertonicsaline

Humanitariantransportrequests,58

Humidity

aeromedicalevacuationand,51

Hydrogencyanide,447

Hyperglycemichyperosmolarsyndrome,170–172

Hyperkalemia

acute,137

bloodtransfusionsand,475–476

burnsand,389

chronic,137

heatstrokeand,409

pseudohyperkalemia,137

treatmentof,137–138

Hypermetabolism

burnsand,388

Hypernatremia,135

Hypertonicsaline,80,134

Hyphema,211

Hypocalcemia,140,409

bloodtransfusionsand,475–476

Hypochloritesolution,449

Hypokalemia,136–137

Hypomagnesemia,139

Hyponatremia,135

Hypopharyngealinjuries,199–200

Hypotension

cerebrovascularaccidents,162–163

heatstrokeand,407

permissive,74,82–84

shockand,78

Hypothermia

bloodtransfusionsand,473,476

burncare,378

cardiopulmonaryresuscitation,402–403

causativefactors,399

fieldtreatment,400–401

medicalfacilitytreatment,401–402

mild,400,402

moderate,400

preventionof,399

profound,400

severe,400,403

shockand,84

Hypovolemicshock,77–82,131–132

Hysterectomy,abdominal,294–296

I

ICFV.SeeIntracellularfluidvolume

ICP.SeeIntracranialpressureIleus

spinalinjuriesand,315

Iliacarteryinjuries,369

Immunesystem,pediatric,454–455

ImpactUni-VentEagleModel754portableventilator,99–100

Improvisedexplosivedevices,6,9

Incapacitationagents,447–448

Indoles,447–448

Infantheartrate,304–305

Infants.SeePediatrictrauma

Infections

antibioticcoverage,123

antimicrobialagentselectionandduration,119–122

battlefieldenvironmentand,113

burncare,386

diagnosisof,113

intraabdominal,126

microorganismscausing,114

patternsof,114–115

preventionof,116–118

pulmonary,126–127

soft-tissueinfections,125–126

spectrumanddosageofantibioticagents,129

systemicsepsis,127–128,130

tetanus,124–125

treatmentof,115–124

Inferiorvenacavafilters,373

Infrafascialhematoma,292

Inhalationinjuries,14,378,388

Initialairwaymanagement,61–62

Initialtriageofficers,38

Intensivistphysicians,56

Internalbleeding,70,72

Internalcarotidarteryinjuries,197

Internaljugularveininjuries,197

Internaljugularvenipuncture,85–86

Internees

advocatesfor,465–466

careof,461–466

GenevaConventions,461–462

legalissues,465

medicalcareof,462–464

medicalethicsprinciples,515–517

medicalinformation,464

medicalrecords,463

medicalstaffing,465

planningfor,464

screening,464–265

security,466

setupupfor,464

supplies,465

triageconsiderations,33

workload,462

Intraabdominalinfections,126

Intracellularfluidvolume,136

Intracranialpressure

headinjuriesand,219,227–232

monitoring,229–230

Intraocularinjuries,197

Intraosseousinfusion,87–88

Intravascularresuscitationfluids,83

Intravascularvolume,131,134,168

IO.SeeIntraosseousinfusion

IVV.SeeIntravascularvolume

J

JointTheaterTraumaSystem

BurnResuscitationFlowsheet,384

“DamageControlResuscitation,”80

developmentof,1

goalsof,499–500

purposeof,497–499

triage,29

JointTraumaSystem,500–502,521

JTS.SeeJointTraumaSystem

JTTS.SeeJointTheaterTraumaSystem

Jugularveininjuries,197,370–371

Jugularvenipuncture,85–86

K

Ketamine,92

Kidneydisease.SeeRenaldisease

Kidneyinjuries.SeeRenalinjuries

Kineticenergyrounds,12–13

L

Lacerations

anal,291

cervix,293

facial,191

vaginal,292

vulvar,291

LactatedRinger’ssolution,80,133,380

Laparotomy,abdominal,258,265

Largeveininjuries,371

Laryngealinjuries,198Laryngealmaskairway,68

Laryngoscopy,64

Laryngotrachealinjuries,198

Lasereyeinjuries,216–217

Lassafever,438–439

Lateralcanthotomy,212–213

LD.SeeLethaldoseofradiation

LeFortfractureclassification,189–190

Leg.SeeLowerextremities

Lethaldoseofradiation,429

Lewisite,445

Limbsplints,72

Liverinjuries,269–270

LMA.SeeLaryngealmaskairway

Localanesthesia,97

Localnationalpatients

burns,390–391

Lowerextremities

compartmentsyndrome,491–494

vascularinjuries,362–367

Lumbarspineinjuries,310–312

Lung-damagingagents,446–447

Lunginjuries,252–253

M

M-16A1rifles,10–11

MAC.SeeMinimalalveolarconcentration

Machineguns.SeeSmallarmsinjuries

Macintoshlaryngoscopyblade,64

Magnesium,138

Mandiblefractures,186–187

MarineCorpsbasicprimarycare,23

medicalevacuationprecedences,52

pointofinjurycare,18

MarineExpeditionaryForces,23

Maskventilation,62–63

Masscasualtyevents.SeealsoTriage

responseto,29

Maxillary-mandibularfixation,186–187

Maxillofacialfractures,188–190

Maxillofacialinjuries

antimicrobialagentselectionandduration,119

Mechanicalventilation

basicsof,140

complianceofchestwall,141

initialsettings,142

positivepressureventilation,141

pressurecontrolmodes,141

protocol,144–146

setupandadjustment,144–145

unassistedbreathingdefinition,145–146

ventilator-associatedpneumonia,153–154,172–173

volumecontrolmodes,141

volumecycled,142–143

weaning,145

MEDEVAC.SeeMedicalevacuation

Mediansternotomies,248–249

Medicalcareroles.SeeRolesofmedicalcare

Medicalcompanies,19

Medicaldetachments,25

Medicalethics

principlesof,515–517

Medicalevacuation.SeealsoPatientevacuation

precedences,51–52

Medicaltreatmentfacilities

aeromedicalevacuationfrom,48–49

casefatalityrates,522

triageconsiderations,35

Mesentericarteryinjuries,369

Methylphosphonothioicacid,444

MFSTs.SeeMobileFieldSurgicalTeams

Microvascularbleeding

bloodtransfusionsand,476–478

Midazolam,92

Midfootinjuries,354

Miliariaprofunda,412–413

Miliariarubra,412

Militarytraumasystems,497

Millerlaryngoscopyblade,64–65

Minimalalveolarconcentration,95

Mission-OrientedProtectivePosturegear,404,443,448

MobileFieldSurgicalTeams,21

MOPP.SeeMission-OrientedProtectivePosturegear

Morphine,91

Mountainsickness

acute,416–418

subacute,420–421

MRSApneumonia

antibioticcoverage,123,153–154

MTFs.SeeMedicaltreatmentfacilities

Musclerelaxants,91

Mycotoxins,439

Myocardialinfarction

non-STelevation,157–159

STelevation,155–157

N

Narcotics,91

Nasalfractures,187–188

NATO.SeeNorthAtlanticTreatyOrganization

Navy

basicprimarycare,22

expeditionarymedicalfacilities,26–27

hospitalships,27–28

medicalevacuationprecedences,52

NavyExpeditionaryHealthServiceSupport,27

NBC.SeeNuclear,biological,andchemicalcasualties

Neckinjuries.Seealso Facial injuriesantimicrobialagent selectionandduration,119

esophagealfistulas,200

esophagealinjuries,199–200

hypopharyngealinjuries,199–200

immediatemanagement,194

internalcarotidarteryinjuries,197

internaljugularveininjuries,197

intraocularinjuries,197

laryngealinjuries,198

laryngotrachealinjuries,198

neckanatomy,193–194

operativestrategy,194–196

otologicalinjuries,200–203

penetratingwounds,193–196

skullbaseinjuries,200–203

surgicalprinciples,196–200

temporalboneinjuries,200–203

trachealinjuries,199

vertebralarteryinjuries,196

Necrotizinginfections,125–126

Negativepressurewoundtherapy,106

Neonatalresuscitation,304–305

Nephrectomies,280–282

Nephrolithiasis,167–168

Nerveagents,444–445,448

Nerveinjuries

facial,191–192

hand,352

Neuraxialanesthesia,97

Neurogenicshock

diagnosisof,78

spinalinjuriesand,315

treatmentof,80

Neurologicaldisease

cerebrovascularaccidents,161–163

strokes,161–163

traumaticbraininjury,161

Neurosurgicalpatients

aeromedicalevacuationand,50

Nitrogenmustard,445

Noise

aeromedicalevacuationand,50

Non-STelevationmyocardialinfarction,157–159

Noncombatantlocals

triageconsiderations,32–33

Normalsaline,133–134

NorthAtlanticTreatyOrganization

rolesofmedicalcare,20

7.62riflecartridge,11

NPWT.SeeNegativepressurewoundtherapy

NSTEMI.SeeNon-STelevationmyocardialinfarction

Nuclear, biological, and chemical casualties. See also Biological contamination;Chemicalcontamination

aeromedicalevacuationand,51

blastinjuries,430

casualtyyieldbytypeofweapon,427–428

conventionalnuclearweapons,427–428

decontamination,432

flashblindness,431

flashburns,430

lethaldoseofradiation,429

logisticsofcasualtymanagement,432–433

medicalaspectsof,429

potentialinjuries,430–431

radiationinjuries,430–431

radiologicaldispersaldevices,428

retinalburns,431

thermalburns,430

treatmentof,430

treatmentofcombinedinjuries,431–432

triage,428–429

Nutrition

criticalcare,173–174

pediatricrequirements,451–452

O

Obstetricalemergencies.SeealsoChildbirth,emergency

acutevaginalhemorrhage,297–298

Obstructiveshock,132

Ocularinjuries

anteriorsegmentinjuries,207–214

antimicrobialagentselectionandduration,120bacterialkeratitis,209–210

cantholysis,212–213

chemicalinjuriesofthecornea,207–208

cornealabrasions,208–209

cornealulcer,209–210

enucleation,217

flashblindness,431

foreignbodies,210–211

hyphema,211

identifyingsevereinjuries,205–206

lasereyeinjuries,216–217

lateralcanthotomy,212–213

lidlacerations,214–216

openglobeinjuries,206–207

orbitalfloorfractures,213–214

retrobulbarhemorrhage,211–212

subconjunctivalhemorrhage,207

triageof,205

Off-gassing,448

OhmedaUniversalPortableAnesthesiaComplete,97–100

Openglobeinjuries,206–207

Openjointinjuries,101–112

Openpneumothorax,244

OperationEnduringFreedom/OperationIraqiFreedom

casualtiesbyweapontype,2

causeofinjuries,3

Orbitalfloorfractures,213–214

Orbitalhemorrhage,211–212

Orotrachealintubation,63–66

Ostomypatients

aeromedicalevacuationand,50

Otologicalinjuries,200–203

Ovariancysts,296

Ovarianinjuries,295–296

Oxygenation,141,144

P

Pancreaticinjuries,268–269

Pancreaticoduodenectomy,268–269

Pancuronium,91

Parenteralnutrition,174

Parotidductinjuries,192–193

Partialpressureofoxygen

aeromedicalevacuationand,50

Patientevacuation

aeromedicalevacuationsystem,47–59

biologicalcontaminationand,437–438

CASEVAC,47

extremityfracturesand,339–340

headinjuries,238–239

MEDEVAC,51–52

spinalinjuries,310–312

PatientMovementRequestCenter,59

PatientMovementRequirementsCenter,49,53

Patienttransportation.SeePatientevacuation

Pediatrictrauma

anatomicconsiderations,451–452

bloodvolume,454

bodysurfacearea,453

burns,381–382,453

caloricrequirements,452

cardiovascularsystem,452–453

commonlyuseddrugsanddosages,458

diagnosisof,455

electrolytes,451

evaluationof,455

fluidrequirements,451

gastrointestinalsystem,453–454

hematology,454

immunesystem,454–455

nutrition,451–452

physiologicalconsiderations,451–452

proteinrequirements,452

pulmonarysystem,452

rapidsequenceintubation,455–456

renalsystem,454

resuscitationequipmentandsupplies,456–457

surgicalmanagement,458

thermoregulation,454

treatmentof,455–456

vascularinjuries,373

vitalsigns,453

PEEP.SeePositiveend-expiratorypressure

Pelvicinjuries

blunt,318–319

C-clampplacement,324–325

diagnosisof,317–318

externalfixation,322–323

fractures,292

penetrating,321–325

retroperitonealpacking,323–324

treatmentof,319–325

Penetratinginjuries

abdominal,257

antimicrobialagentselectionandduration,120

feet,353

head,220–221

neck,193–196

pelvic,321–325

renal,278

spinal,314

Penileinjuries,288

Peripheraledema,high-altitude,419

Permanentcavityinjuries,3–4,10–11

Permissivehypotension,74,82–84

Pernio,394

Pharyngitis,high-altitude,419

Phlebotomy,505–508

Phosgene,446–447

Phosgeneoxime,445

Pistols.SeeSmallarmsinjuries

Plague,436,437,440

Plasma

ABOmatching,470–471

roleofcare,468–469

PMs.SeeProgramManagers

PMRC.SeePatientMovementRequirementsCenter

Pneumonia

combat-associatedhealthcarepneumonia,153–154,172–173

diagnosisandtreatment,127

MRSAand,123,153–154

ventilator-associatedpneumonia,153–154,172–173

Pneumonitis,aspiration,152–153

Pneumothorax

aeromedicalevacuationand,50

open,244

positivepressureventilationand,63

Pneumothorax,tension

diagnosisof,241

positivepressureventilationand,63

treatmentof,243

Pointofinjurycare,18,121

Polymicrobialinfections,125

Poplitealarteryinjuries,364–366

Portableventilators,99–100

Portalveininjuries,368

Positiveend-expiratorypressure,141–143

Positivepressureventilation,63,141

Postoperativewoundinfections,125

Potassium,136

Precipitousvaginaldelivery,298

Pregnancy.SeealsoChildbirth,emergency

acutevaginalhemorrhage,297–298

ectopic,293,295

Prerenalazotemia,165–166

Primaryblastinjuries

descriptionof,5,7

headinjuries,220–222

Prisonersofwar.SeeEnemyprisonersofwar

Profundafemorusarteryinjuries,363–364

ProgramManagers,498

Projectileinjuries,3–4

Propofol,92

Prosthetics

vascularinjurytreatment,373

Proteinrequirements,pediatric,452

Pruritus,412–413

Pseudohyperkalemia,137

Psoashitch,282–283

Pulmonarycontusion,147–148

Pulmonaryedema,high-altitude,421–423,425

Pulmonaryembolism

deepvenousthrombosisand,148–149

diagnosisof,149–150

hemodynamicallysignificant,151–152

preventionofvenousthromboembolism,152

Pulmonaryinfections,126–127

Pulmonarymedicine

acuterespiratorydistresssyndrome,143,146–147

aspirationpneumonitis,152–153

combat-associatedhealthcarepneumonia,153–154

mechanicalventilationbasics,140–143

pediatric,452

pulmonarycontusion,147–148

pulmonaryembolism,148–152

Pupillaryreactivity

headinjuriesand,225–226

Q

Qfever,440

Quaternaryblastinjuries,5,7

R

Radialarteryinjuries,362

Radiationinjuries,430–431

Radiologicaldispersaldevices,427–428

Radiologicalinjuries.SeealsoNuclear,biological,andchemicalcasualties

blastinjuries,430

casualtyyieldbytypeofweapon,427–428

conventionalnuclearweapons,427–428

decontamination,432

flashblindness,431

flashburns,430

lethaldoseofradiation,429

logisticsofcasualtymanagement,432–433

medicalaspectsof,429

potentialinjuries,430–431

radiationinjuries,430–431

radiologicaldispersaldevices,428

retinalburns,431

thermalburns,430

treatmentof,430

treatmentofcombinedinjuries,431–432

triage,428–429

Rapidsequenceintubation,63,90–94

RDDs.SeeRadiologicaldispersaldevices

ReactiveSkinDecontaminationLotion,446,449

RecombinantfactorVIIa,477

Rectalinjuries,272–273

Redbloodcells

ABOmatching,470–471

roleofcare,468–469

Reflux,453

Regionalanesthesia,96–97

Relaparotomies,181–182

Renalarteriesinjuries,369

Renaldisease

acutetubularnecrosis,165–166,168

heatstrokeandrenalfailure,406

hemorrhagicfeverwithrenalsyndrome,438–439

iatrogeniccomplicationsoftherapy,168

nephrolithiasis,167–168

prerenalazotemia,165–166

rhabdomyolysis,166–167

Renalinjuries

blunttrauma,278

grading,278

hematuria,277–278

major,279

minor,278

nephrectomies,280–282

operativetechnique,279–282

penetrating,278

Renalsystem,pediatric,454

Respiration,141

Respiratoryrate,141

Resuscitation

burninjuries,383–384

endpoints,84

intravascularresuscitationfluids,83

neonatal,304–305

shock,79–84,131–132

Resuscitationrecords,524–528

Resuscitationstations,43

Resuscitativethoracotomies,246–247

Retainedpersonnel.SeeInternees

Retinalburns,431

Retinalhemorrhage,high-altitude,419–420

Retrobulbarhemorrhage,211–212

Retrogradeurethrography,286–287

Retroperitonealhematoma,296–297

Retroperitonealinjuries,273–274

Returnedtoduty,522

rFVIIa.SeeRecombinantfactorVIIa

Rhbloodmatching,471–472

Rhabdomyolysis

crushinjuryand,166–167

diagnosisof,166

heatstrokeand,406,409

treatmentof,166–167

Ricin,439

Rifles.SeeSmallarmsinjuries

RiftValleyfever,438–439

Ringer’ssolution,lactated,80,133,380

Rocuronium,91

Rolesofmedicalcare

basicprimarycare,19–23

CONUS-basedhospitals,28

functionof,17

medicaltreatmentfacilitycare,23–28

pointofinjurycare,18

RSDL.SeeReactiveSkinDecontaminationLotion

RTD.SeeReturnedtoduty

RuleofNines,381

RuleofTens,380,391

S

Saphenousveincutdowns,86–87

Sarin,444

Scalpbleeding,72

Scalpinjuries,222

Scopolamine,93

Scrotalinjuries,288SEB.SeeStaphylococcalenteroxinB

Secondaryblastinjuries,5,7

Sedatives,92

Seizures

heatstrokeand,407

Sepsis

antibioticcoverage,123

bloodtransfusionsand,485

systemicsepsis,127–128,130

Septicshock,78,81

Serumcalcium,139–140

Serumelectrolytemanagement,134

Serummagnesium,138

Serumpotassium,136

Shapedcharges,11–12

Shock

cardiogenic,78,132

classificationof,77–78

compensatedshock,133

controlledhypotensiveresuscitation,82–84

criticalcare,131–133

distributive,78,132

greatersaphenousveincutdowns,86–87

hemorrhagic,81–82

hypotensionand,78

hypothermiaand,84

hypovolemic,77–82,131–132

internaljugularvenipuncture,85–86

intraosseousinfusion,87–88

intravascularresuscitationfluids,83

neurogenic,78,80,315

obstructive,132

septic,78,81

subclavianveinaccess,85–86

treatmentof,79–82

uncompensatedshock,131–133

vascularaccess,84–87

Shocktraumaplatoons,18

SIMV.SeeSynchronizedintermittentmandatoryventilation

Skeletaltraction,338–339

Skullbaseinjuries,200–203

Skullflaps,235–237

Skullfractures,222–223

Smallarmsinjuries,9–11

Smallbowelinjuries,271

SmallPortableExpeditionaryAeromedicalRapidResponseteam,21

Smallpox,436,437–438,441

Sniperrifles,11

Soft-tissueinfections,125–126

Soft-tissueinjuries

compartmentsyndrome,110–111

crushsyndrome,108–110

facial,190–193

fasciotomytechnique,111–112

presurgicalcare,101

surgicalwoundmanagementpriorities,101–102

woundcare,102–107

woundmanagementafterinitialsurgery,107

Soman,444

Sonography

focusedabdominalsonographyfortrauma,259–263

SPEARR.SeeSmallPortableExpeditionaryAeromedicalRapidResponseteam

Spermaticcordinjuries,288

Spinalcolumnsupport,309

Spinalinjuries

anatomicalconsiderations,311–312

antimicrobialagentselectionandduration,120

bladderdysfunctionand,315

classificationof,307–308

decubitusulcersand,315–316

deepveinthrombosisand,315

emergentsurgery,314

Gardner-Wellstongs,312–314

gastrointestinaltractand,315

halouse,311

instability,309–310

mechanicalintegrityofthevertebralcolumn,308–310

neurogenicshock,315

pathophysiologyof,308

penetrating,314

transportconsiderations,310–312

Splenicinjuries,271

STelevationmyocardialinfarction,155–157

StaphylococcalenteroxinB,439

Staticlandmines,8

STEMI.SeeSTelevationmyocardialinfarction

Sternotomies,248–249

Stomachinjuries,266

Stressgastritis,163–164

Stressulcers

spinalinjuriesand,315

Strokes,161–163

Subclavianarteryinjuries,361

Subclavianveinaccess,85–86

Subconjunctivalhemorrhage,207

Subxiphoidpericardialwindow,248

Succinylcholine,91

Sulfurmustard,445

Sunburn,414

Superficialfemoralarteryinjuries,364

Supraclavicularthoracotomies,249–250

Surgery.SeeDamagecontrolsurgery;specificinjurytype

Surgerydebridement

burncare,389

Surgicalcompanies,23

Surgicalcricothyrotomy,67–68

Synchronizedintermittentmandatoryventilation,141–142

Syncope,heat-induced,413

Systemicsepsis,127–128,130

T

T-2mycotoxins,439

Tabun,444

Tacticalcombatcasualtycare,17

TBI.SeeTraumaticbraininjury

TBSA.SeeTotalbodysurfacearea

TCCC.SeeTacticalcombatcasualtycare

Temporalboneinjuries,200–203

Temporarycavityinjuries,3–4,10–11

Tendoninjuries,349,352

Tensionpneumothorax

diagnosisof,241

positivepressureventilationand,63

treatmentof,243

Tertiaryblastinjuries,5,7

Testicularinjuries,289

Tetanus,124–125

TheaterMedicalDirectors,498

TheaterofOperations,497

Thermalburns,430

Thermalinjuries,8

Thermalstress

aeromedicalevacuationand,50

Thermobaricinjuries,8

Thermoregulation,pediatric,454

Thickenedagents,448

Thighcompartmentsyndrome,491–492

Thirdcountrynationals

triageconsiderations,32–33

Thoracicinjuries

anatomicalconsiderations,241–242

antimicrobialagentselectionandduration,119

cardiactamponade,243–244

damagecontrolsurgery,182

diagnosisof,242

evaluationof,242

flailchest,244

massivehemothorax,243

openpneumothorax,244

surgicalmanagement,244–255

tensionpneumothorax,241,243

thoracotomies,244–255

vascular,251–252

Thoracicspineinjuries,310–312

Thoracoabdominalthoracotomies,250–251

Thoracotomies

damagecontrolsurgery,182

mediansternotomy,248–249

resuscitative,246–247

subxiphoidpericardialwindow,248

supraclavicular,249–250

thoracoabdominal,250–251

trapdoor,249–250

tubethoracotomies,244–246

Thromboembolicevents

altitude-related,420

Thromboticthrombocytopenicpurpura,168–169

Tibialarteryinjuries,366

Tidalvolume,141

TMD.SeeTheaterMedicalDirectors

TNCs.SeeTraumaNurseCoordinators

Toeinjuries,355

Torsovascularinjuries,367–369

Totalbodysurfacearea,380–382,390

Tourniquets,71,467

TOWs.SeeTube-launched,opticallytracked,wire-guidedmissiles

Trachealinjuries,199

Tracheobronchialtreeinjuries,254

Traction,skeletal,338–339

Tractotomies,253

TRALI.SeeTransfusion-relatedacutelunginjury

Transfusion-relatedacutelunginjury,486–487

Transfusions

ABOmatchingofbloodproducts,470–471,480

acidosis,474–476

acutehemolytictransfusionreaction,484–485

allergictransfusionreactions,487–488

bloodproductsavailablebyrole,468–469

coagulopathy,476–478

contaminatedbloodproducts,485

earlycontrolofhemorrhage,467–468

emergencycollectionoffreshwholebloodinthefield,478–483,503–512

febrilenonhemolytictransfusionreaction,486

hyperkalemia,475–476

hypocalcemia,475–476

hypothermia,473,476

managementofcomplications,473–478

massive,472–478

microvascularbleeding,476–478

posttransfusionverification,510–511

protocol,474

reactionsinthefield,483–488

Rhbloodmatchingforfemalecasualties,471–472

sepsis,485

transfusion-relatedacutelunginjury,486–487

treatmentplanfortransfusionreaction,483

urticarialtransfusionreactions,487

Trapdoorthoracotomies,249–250

TraumaMedicalDirectors,498

TraumaNurseCoordinators,498

TraumaRegistry,DoD

functionof,521

methods,523–525

minimumessentialdata,523

responsibilities,498

resuscitationrecords,524–528

situationalawareness,522–523

technology,523–525

usesof,523

Traumasystems.SeealsoJointTheaterTraumaSystem

battlefieldtraumasystemmodel,497–499

descriptionof,497

JointTraumaSystem,500–502

militarytraumasystems,497

Traumaticbraininjury,161.SeealsoHeadinjuries

Trenchfoot,394–395

Triage

anatomicallocationofinjuriesand,40

BICEPSmnemonic,33–34

burns,390

categories,30–31

chemicalcontaminationinjuries,446–447

decision-making,37–38

delayedcategory,30–31

emergenttreatmentarea,41–44

expectantarea,44

expectantcategory,31

externalfactors,34–35

headinjuries,224–227

immediatecategory,30

initialtriagearea,38,40–41

internalfactors,35–36

management,31–32

mechanismofinjuriesand,39

minimalcategory,31

nonemergenttreatmentarea,44

ocularinjuries,205

operationtips,44–45

principleof,29

radiologicalinjuries,428–429

resourceconstraints,34–37

resuscitationstations,43

specialconsiderations,32–34

staffing,41,43–44

typesofinjuriesand,38

TTP.SeeThromboticthrombocytopenicpurpura

Tube-launched,opticallytracked,wire-guidedmissiles,12

Tubethoracotomies,244–246

Tularemia,440

Two-personmaskventilation,62–63

U

Ulcers

corneal,209–210

decubitus,315–316

stress,315

Ulnararteryinjuries,362

Ultrasonography

focusedabdominalsonographyfortrauma,259–263

Unassistedbreathing,definitionof,145–146

Uncompensatedshock,131–133

Unexplodedordnances

injuriesfrom,15–16

triageconsiderations,32

UPAC.SeeOhmedaUniversalPortableAnesthesiaComplete

Upperextremities

compartmentsyndrome,490–491

vascularinjuries,361–362

Ureteralinjuries,282–285

Ureteroneocystostomy,284

Ureteroureterostomy,283

Urethralinjuries,286–288

Urethrography,retrograde,286–287

Urinarytractinjuries.SeeGenitourinarytractinjuries

Urticarialtransfusionreactions,487

USArmyInstituteofSurgicalResearchBurnCenter,391

USDepartmentofDefense.SeeDepartmentofDefenseTraumaRegistry

Uterineatony,302–303

Uterineinjuries,293

V

VAC.SeeVacuum-AssistedClosureTherapySystem

Vacuum-AssistedClosureTherapySystem,494

Vaginalhemorrhage,acute,297–298

Vaginalinjuries,292–293

Vaporizers,97–100

Vascularaccess

shockand,84–87

Vascularinjuries

anastomoticdisruption,374

angiography,360

anticoagulation,374

aorta,367–368

autologousveinharvestanduse,373–374

axillaryartery,361–362

brachialartery,362

carotidartery,369–370

cervicalvascularinjury,369–371

commonfemoralartery,363

diagnosisof,359–360

endovascularcapability,373

epidemiologyof,357–358

evaluationof,359–360

facialinjuriesand,184–185

Fogartythrombectomycatheters,372

hepaticartery,368

historyof,357

iliacarteries,369

inferiorvenacavafilters,373

jugularvein,370–371

largeveins,371

ligationofvessels,371–372

lowerextremities,362–367

managementof,358–359

mesentericarteries,369

pediatric,373

poplitealartery,364–366

portalvein,368

postoperativecare,374–375

profundafemorusartery,363–364

prostheticgraftmaterialuse,373

radialartery,362

renalarteries,369

rolesofcare,358–359

soft-tissuecoverage,374

subclavianartery,361

superficialfemoralartery,364

temporaryvascularshunts,372

thoracic,251–252

tibialartery,366

torso,367–369

ulnarartery,362

upperextremities,361–362

venacava,368

venousinjury,367

vertebralartery,370

Vecuronium,91

VEE.SeeVenezuelanequineencephalitis

Venacavafilters,373

Venacavainjuries,368

Venezuelanequineencephalitis,441

Venousinjuries,367,371

Venousthromboembolism,148–149,152

Ventilation,62–63,141.SeealsoMechanicalventilation

Ventilator-associatedpneumonia,153–154,172–173

Ventilators,portable,99–100

Ventricularfibrillation

hypothermiaand,401–402

Vertebralarteryinjuries,196,370

Vertebralcolumn

mechanicalintegrityof,308–310

Vesicants,445–446,448

VHF.SeeViralhemorrhagicfever

Vibriocholerae,440

VietnamWar

casualtiesbyweapontype,2

Viralagents,441

Viralhemorrhagicfever,441

Vitalsigns

headinjuriesand,224

pediatric,453

Volutrauma,142

Vulvarinjuries,291–292

W

WalkingBloodBanks,478–483,503–512Warwounds.Seealsospecifictypeofinjury

anatomicaldistributionofprimarypenetratingwounds,2

antipersonnellandmines,8–9

armoredvehiclecrewcasualties,11–14

ballisticinjuries,6

blastinjuries,6,8

epidemiologyofinjuries,1–2

explosiveinjuries,5,7

inhalationinjuries,14

mechanismofinjury,3–16

openjointinjuries,101–112

projectileinjuries,3–4

smallarmsinjuries,9–11

soft-tissueinjuries,101–112

thermalinjuries,8

thermobaricinjuries,8

unexplodedordnances,15–16

Weaponseffects

antipersonnellandmines,8–9

armoredvehiclecrewcasualties,11–14

ballisticinjuries,6,8

casualtiesbyweapontype,2

epidemiologyofinjuries,1–2

explosiveinjuries,5,7

inhalationinjuries,14

mechanismofinjury,3–16

projectileinjuries,3–4

smallarmsinjuries,9–11

thermalinjuries,8

thermobaricinjuries,8

unexplodedordnances,15–16

Whitephosphorusburns,389–390

Wholeblood,fresh

ABOmatching,470–471

emergencycollectioninthefield,478–483,503–512

posttransfusionverification,510–511

rapidtestingof,509

releasing,509–510

roleofcare,469

WIA.SeeWoundedinaction

WorldWarII

casualtiesbyweapontypeinBougainvilleCampaign,2

WoundDataandMunitionsEffectivenessTeam,1

Woundedinaction,522

Wounds.SeeWarwounds;specificinjurytype

Y

Yersiniapestis,440

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