the british military surgery pocket book

AC 12552

The BritishMilitary Surgery

Pocket Book

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The British Military Surgery Pocket Book

"War is Delightful to the Inexperienced"

Inscription on the tomb of Henry III in Westminster Abbey

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© Crown Copyright 2004

This publication supersedesThe Field Surgery Pocket Book 1981(AC No 12552)

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Editor: Colonel P Roberts CBE MS FRCS Emeritus Professor of Military SurgeryRoyal College of Surgeons of England

Department of Military Surgery,Army Medical Directorate,Former Army Staff College,Slim Road,Camberley, Surrey GU15 4NP, [email protected]

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Foreword

The Field Surgery Pocket Book first appeared in1944 and the last edition, edited by Major GeneralNorman Kirby OBE QHS FRCS and Mr GuyBlackburn MBE MA MChir FRCS, was published in 1981. This new edition has been retitled to reflectthe relevance of its content to military practitionersserving in the Royal Naval, Army and Royal Air ForceMedical Services irrespective of the arena of combat.

Weapons systems are becoming more 'sophisticated'and are generating different patterns of injury some of which will require new treatment protocols.However, battle trauma remains primarily a surgically-focussed specialty.

Surgical capability and professional education have changed enormously since the earlier editionand the increasing emphasis on specialisation andsubspecialisation is conspiring to limit the surgeon'srepertoire to a single system if not a single organ.

Clearly, this creates a substantial challenge for thesurgeon who specialises in military surgery who,of necessity, has to be capable of entering most, if not all, body cavities and deal competently with a variety of trauma-related emergencies invariablywithout access to the modern diagnostic toolsavailable in peacetime hospital practice.

This book is produced primarily for the DefenceMedical Services, not only for surgeons but for other doctors, nurses and military medical respondersIt is also of relevance to our civilian colleagues who increasingly have to manage injuries in thecommunity which were previously confined to the battle-field.

Foreword

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The book has been completely revised in both format and content to make it clinically relevant,easily understandable and always accessible. It has been skillfully edited from a vast source of contributors to whom I am personally very grateful.

Ian Jenkins CVO QHS FRCSSurgeon Vice AdmiralSurgeon General

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The British Military Surgery Pocket Book

Foreword

Contents list

List of Contributors

Preface and Acknowledgments

Introduction

Abbreviations

Chapter 1 Patterns of Injury in Military Operations

Chapter 2 Pathophysiology of Ballistic,Blast and NBC Injury

Chapter 3 Battlefield Advanced Trauma Life Support

Chapter 4 Damage Control Surgery

Chapter 5 Principles of Wound Management

Chapter 6 Triage

Chapter 7 Analgesia in Forward Areas

Chapter 8 Infections, Antibiotics and Biological Weapons

Chapter 9 Limb Injuries

Chapter 10 Vascular Injury

Chapter 11 Amputation

Chapter 12 Abdominal Injuries

Contents

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Chapter 13 Pelvic Injury

Chapter 14 Urological Trauma

Chapter 15 Thoracic Injury

Chapter 16 Head Injury

Chapter 17 Ophthalmic Injury

Chapter 18 Maxillofacial Injuries

Chapter 19 Injuries of the Ear, Nose and Throat (ENT)

Chapter 20 Spinal Injuries

Chapter 21 Peripheral Nerve Injuries

Chapter 22 Burns

Chapter 23 Principles of Plasticand Reconstructive Surgery

Chapter 24 Tropical Diseases

Chapter 25 Field Anaesthesia and Intensive Care

Chapter 26 Heat, Cold and Immersion Injury

Chapter 27 Military Psychiatry

Chapter 28 Major Incident Medical Management

Chapter 29 The Incident Response Team and Aeromedical Evacuation

Chapter 30 Practical Procedures

Index

Normal values

Contents

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Contributors

A Allsopp PhD,Head, Applied Physiology, Institute of Naval Medicine, Gosport.

N Buxton FRCS (Neurosurg) DMCC RAMC (V),Lieutenant Colonel, Consultant Neurosurgeon,The Walton Centre, Liverpool.

L C Cancio MD FACS,Lieutenant Colonel, Medical Corps US Army.

J C Clasper DPhil FRCS(Orth), Lieutenant Colonel, Consultant Orthopaedic Surgeon,MDHU Frimley Park Hospital, Camberley.

G J Cooper OBE PhD,Team Leader (Trauma),Biomedical Sciences, Dstl Porton.

T C S Cubison FRCS,Major, Specialist Registrar in Burns and Plastics,Queen Victoria Hospital, East Grinstead.

A Gibbons FDA FRCS RAF (V),Wing Commander, Specialist Registrar in Oral andMaxillofacial Surgery,Craniofacial Unit, Birmingham Children's Hospital.

A D Green MRCPath DTM&M,Wing Commander, Defence Consultant Advisor in Medical Microbiology,Army Medical Directorate, Camberley.

M F P Griffiths FRCOphth,Colonel, Defence Consultant Advisor in Ophthalmology,MDHU, Frimley Park Hospital, Camberley.

R J Guy MD FRCS, Surgeon Commander, Consultant General Surgeon,MDHU, Peterborough District General Hospital. ix

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A Hosni FRCS (ORL),Colonel, Consultant Advisor in Otolaryngology,MDHU, Frimley Park Hospital, Camberley,

G D Housam CD FRCA,Consultant Anaesthetist, Defence Nuclear, Biological and Chemical Centre, Winterborne Gunner.

J B Hull MD FRCS (Orth),Consultant Orthopaedic Surgeon,Frimley Park Hospital, Camberley.

B C Jenner Dip IMC RCSEd QARANC,Major. Resuscitation Officer,West Kent Health Trust, Pembury.

A S Jacks OstJ FRCOphth,Lieutenant Colonel, Army Consultant Advisor in Ophthalmology,Royal Centre for Defence Medicine, Birmingham.

A R Kay FRCS FRCS (Plast)Lieutenant Colonel, Consultant Plastic Surgeon,Director, Burns Unit, Frenchay Hospital, Bristol.

A W Kent FRCS,Lieutenant Colonel, Consultant Orthopaedic Surgeon,Royal Hospital Haslar, Gosport.

L Lundberg MD PhD, Assistant Professor, Surgeon General's Department, Stockholm.

P F Mahoney FRCA,Major, Consultant Anaesthetist,16 Close Support Medical Regiment, Colchester.

A D Malyon FRCS (Plast),Lieutenant Colonel, Consultant Plastics Surgeon,Royal Hospital Haslar, Gosport.

J Martin MD,Colonel, Medical Corps, US Army.

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N McGuire FRCA,Wing Commander, Consultant Anaesthetist and Intensivist,John Radcliffe Hospital, Oxford.

S G Mellor MS FRCS,Colonel, Defence Consultant Adviser and ConsultantGeneral Surgeon,MDHU, Frimley Park Hospital, Camberley.

EHM Oakley MB BCh,Head of Survival and Thermal Medicine, Institute of Naval Medicine, Gosport.

I Palmer MRCPsych,Lieutenant Colonel, Professor of Military Psychiatry.Royal Centre for Defence Medicine. Birmingham.

A N Pandya FRCS (Plast),Squadron Leader, Consultant Plastic Surgeon,Royal Hospital Haslar, Gosport.

P J Parker FIMC FRCSEd (Orth),Lieutenant Colonel, Consultant Orthopaedic Surgeon,MDHU, Friarage Hospital, Northallerton.

C Pipkin FRCPath,Surgeon Commander, Consultant Advisor in Medical Microbiology,Royal Hospital Haslar, Gosport.

L Pitkin MRCS MSc,Specialist Registrar in Otolaryngology, St George's Hospital, London.

P Revington TD, FDS FRCS RAMC (V),Lieutenant Colonel, Consultant Oral and Maxillofacial Surgeon,Frenchay Hospital, Bristol.

M J Roberts MA FRCA,Consultant in Anaesthesia and Intensive Care,University of Colorado Health Sciences Centre, USA.

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P Roberts CBE QHS MS FRCS L/RAMCColonel, Professor of Military Surgery, DGAMSAdviser in Surgery,Army Medical Directorate, Camberley.

P J Sadler FRCA,Consultant in Critical Care and Anaesthesia,Queen Alexandra Hospital, Portsmouth.

G V Scerri FRCS, FRCS (Plast),Wing Commander, Consultant Plastic and Hand Surgeon,Royal Hospital Haslar, Gosport.

R A H Scott FRCS, FRCS (Ophth),Wing Commander, RAF Consultant Advisor in Ophthalmology,Royal Centre for Defence Medicine, Birmingham.

C L Shieff FRCS RAMC (V),Lieutenant Colonel, Consultant Neurosurgeon,Royal Free Hospital, London.

M F Smith TD ChM FRCS L/RAMC (V)Colonel, Consultant Urologist,Forth Valley Acute Hospitals NHS Trust.

P A Stanworth MA FRCS RAMC (V),Lieutenant Colonel, Consultant Neurosurgeon,Walsgrave Hospital, Coventry.

M J Tipton PhD,Professor, Head Environmental Medicine Unit,Institute of Naval Medicine, Gosport.

D J Vassallo FRCS,Lieutenant Colonel, Consultant General Surgeon,Royal Hospital Haslar, Gosport.

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This book has been produced to replace the current edition of Field Surgery Pocket Book (FSPB) - the British Military Medical Services'standard pocket guide to military surgery in the fieldsince WWII and last revised in 1982. The FSPB waswritten for military surgeons and, to lesser extentcivilian surgeons, called upon to carry out warsurgery. It was regarded as both a directive on and doctrine for, surgery in the field in time of war.

To this end, the FSPB has always been about themost appropriate management for war wounds, from time of wounding, through surgery torehabilitation. Succeeding editions of FSPB havecontinued to reflect changes and improvements incasualty care but, at the same time, placed emphasison the tried and trusted methods of war woundmanagement learnt in past conflicts.

Although this current book has been completelyrewritten and has a new title, its aims are basicallyunchanged from those aspired to by the FSPB. Not least, The British Military Surgery Pocket Bookcontinues the directive and doctrinal approach of its predecessor in terms of emphasising thebasics. For surgeons to be unaware of the basics of war surgery or worse still forget them will, at best,condemn some casualties in their care to suboptimaltreatment and, at worst, others to an unnecessarydeath. During high-intensity conflict with manycasualties, the basic tenet is 'do the most for themost'. The surgical corollary of this may seemperverse. It is not about doing complex, definitivesurgery for all; it is about doing the minimumnecessary to save life and limb. This approach alone will benefit the majority of those injuredduring war-fighting.xiv


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Why was it felt necessary to change to the new titleand completely revise the book's content? Since 1982, British military personnel have beenincreasingly involved in Operations Other Then War,(OOTW). These are low-intensity military operationsproviding Humanitarian aid, peace-keeping dutiesand peace-enforcement. Nevertheless, they incur the risk of injuries occurring to UK military personnel.

They also carry the added burden of dealing withother nation's military and civilian casualties, albeit,usually small in number. Not infrequently, the localmedical infrastructure in areas where OOTW areundertaken has been destroyed or is inadequate. The onus then falls on deployed military medicalpersonnel to deal with the whole spectrum of trauma(and non-trauma) cases presenting to them.Because the environment is stable (non-hostile),casualties few in number and time-lines for casualtytransferto surgery short, surgeons are faced withmajor injuries requiring more than 'field' surgery.

The basic management principles still apply but,because casualty numbers and time allow, morecomplex surgery can be considered. In the samevein, follow-on surgery not normally done in anaustere setting may need to be undertaken,particularly on civilians. This is one reason I haveincluded in this book complex management andsurgical procedures, not normally associated with war surgery. There are other reasons.

Bomb and bullet terrorism worldwide is on theincrease. Civilian surgeons in the main, deal with the victims injured by 'military' weapons but, do so in a peace-time setting with the full range of supportservices available to them. Further, military medicinein the field is becoming more sophisticated. Fieldintensive care is now the norm and relativelysophisticated modes of investigation are available,CT scanning being one example. I have attempted in this book, to reflect the needs of my civilian xv


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colleagues when, for some, they deal with unfamiliarinjuries. Equally, I have also attempted for my militarymedical colleagues in all three Services, toencompass the more sophisticated approachto Operational medical care, we all aspire to.

The title also reflects the tri-service approach to theprovision of medical care during military operations. It is not just about the Army providing care in thefield, it is about all three services’ medical services,deployed separately or on combined operations,providing care in whatever military environment they find themselves.

This book is primarily for surgeons. Nevertheless,experience with the FSPB tells us that General Dutiesmedical officers and others working alone for example,at sea and, surgeons with little experience, will lookto this new PB for guidance. As editor, I haveunashamedly included some very basic surgicalprocedures and techniques, diagnostic guidelinesand first principles - for example - BATLS, in the text.

This is a multi-author book. Like most British militarytexts, it is not author-attributed for individual chaptersor parts of chapters. To all contributors who haveacted as subject matter experts, including my sub-editorial colleague, I extend my sincere thanks.Without their expertise and effort, this book would nothave been published.

I am also indebted to the HQ Adjutant GeneralDesign Studio, who illustrated and designed thelayout of this book, I extend my thanks.

P RobertsArmy Medical DirectorateCamberleyJuly 2003

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Introduction

Recognition of the value of an easily portable vademecum for those tasked with the care of the injuredon the battlefield long predates the Field SurgeryPocket Book, first published in 1944. Indeed ,theclassic surgical textbooks of Ambroise Pare andPeter Low written in the 16th century dealt primarilywith injuries sustained in war. Noel Chavasse, thefirst world war RAMC surgeon who won the VC andbar for undertaking surgery on the battlefield, wroteto his mentor, the famous orthopaedic surgeon Sir Robert Jones describing how he carried Jones'textbook in his knapsack.

It is well recognised that the lessons of militarysurgery are easily and rapidly forgotten after conflictceases. Ever since its initial publication, the FieldSurgery Pocket Book has served to remind thoseconfronted by the need to manage war injuries of the different techniques and priorities that may be required. My own much treasured 1962 editionreminded me of these principles when I was facedwith management of the Old Bailey and Tower ofLondon terrorist bomb explosions a decade later.

This new edition, renamed The British MilitarySurgery Pocket Book, retains the principle, evoked inprevious editions, of concentrating on practical adviceand keeping theoretical information to an essentialminimum whilst at the same time filling a gap in the current surgical literature. It re-emphasisesthose lessons that have stood the test of time suchas excision and delayed primary suture of penetratingwounds. It also introduces newer concepts such as damage control surgery, tried and tested in theUnited States in the management of the epidemic of firearm injuries in their major cities. The chapterson intensive care and the management of psychiatric

Introduction

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and psychological problems reflect the increasingsophistication of care on the battlefield.

This handbook will also be of value to civiliansurgeons who sadly, because of a world wideincrease in terrorism and violence, will need tomanage bomb, bullet and bioterrorism injuries without warning, everywhere from large cities to idyllic tropical holiday resorts. Such surgeons with few exceptions will not have had experience in dealing with the wide spectrum of injury thatfollows such assaults. This book will be an essentialcompanion to them in such times of need.

The editor and contributors deserve congratulationsin distilling the vast amount of knowledge that hasgrown exponentially since the last edition just overtwenty years ago, down to an easily comprehensibleand manageable level that reflects all that was bestin the previous editions of the Field Surgery PocketBook. It will be welcomed by military surgeonsworldwide and also deserves disseminationthroughout the emergency departments, acute wards and operating theatres of civilian hospitals.

British surgical textbooks have always had a highreputation. The British Military Surgical Pocket Book is a significant addition to this body of literature.

Sir Miles Irving

DSc (Hon) MD. ChM. FRCS. FACS (Hon). FRCS Canada (Hon). FmedSci.Emeritus Professor of Surgery, University of Manchester; Civilian Consultant in Surgery to the Army; Honorary Colonel 201(Northern) Field Hospital; Chairman, Newcastle upon Tyne Hospitals NHS Trust.

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Introduction

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Abbreviations

A&E Accident and Emergency DepartmentAP Anterior-PosteriorARDS Adult Respiratory Distress SyndromeAPPT Activated Partial Thromboplastin TimeAXR Abdominal X-Ray

BP Blood PressureBVM Bag-Valve-Mask

CRT Capillary Refill TimeC&S Culture and SensitivityCSF Cerebrospinal FluidCT Computer-aided TomographyCXR Chest X-Ray

DIC Disseminated Intravascular CoagulopathyDNA Deoxyribonucleic AcidDPL Diagnostic Peritoneal LavageDVT Deep Vein Thrombosis

ERCP Endoscopic Retrograde Cholangio-Pancreatography

FAST Focused Abdominal Sonography for TraumaFBC Full Blood CountFFP Fresh Frozen Plasma

GA General AnaesthesiaGIT Gastro-Intestinal Tract

HDU High Dependency Unit

i.m. IntramuscularITU Intensive Therapy Uniti.v. Intravenous

LA Local Anaesthesia

MO Medical Officer

NATO North Atlantic Treaty OrganisationNBC Nuclear Biological and Chemical

Abbreviations

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NBM Nil By MouthNG Naso-GastricPA Posterior-Anterior

OGD Oesophago-Gastro-Duodenoscopy

PE Pulmonary EmbolismPRE Per Rectal ExaminationPRV Per Vaginal ExaminationPT Prothrombin Time

RAF Royal Air ForceRBC Red Blood Cell (count)RN Royal NavyRTA Road Traffic Accident

s.c. Subcutaneous

U&Es Urea and ElectrolytesUSS Ultra Sound Scan

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Abbreviations

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Chapter 1

Patterns of Injury in Military Operations

Introduction

0101 The Armed Services exist to conduct operations on behalf of the Nation. This covers a spectrum of operational scenarios from thoseinvolving no combat to large scale war fighting. In between, are smaller scale, lower intensity operations which, nevertheless, carry the risk of incurring casualties.

Patterns of injury and the 'casualty template' can vary,depending upon the nature of the military operationbeing undertaken. A typical 'casualty template',derived from a meta analysis of major conflicts since WWI, is shown in Table 0101.

In the Falklands campaign of 1982, half (51%) ofBritish casualties sustained during land battles, werecaused by rifle and machine gun bullets: most of the engagements were infantry versus infantry. In contradistinction, during the Gulf War of 1991,

A military operationis anything theNation (Parliament)directs the military to carry out.

The patterns of injurycaused by fragmentsand bullets aregenerally different.

1: Patterns of Injury in Military Operations

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Table 0101 The average distribution of wounds (%) in conventional warfare - the “casualty template”.

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armour and artillery were extensively used, resulting in a higher proportion of casualties injuredby fragments (80%), as opposed to bullets.

The different spread of regional injuries seen in thesetwo disparate military operations and others since WWI, is illustrated in Table 0102. In the future, theuse of so called "novel weapons" designed to causethermal injury and/or primary blast injury (fuel-air andthermobaric weapons), is likely to produce new patterns of trauma, which may have implications for the provision of medical support. For example, an increased need for ventilatory support for blastand thermal lung injury, as well as intensive care inthe field.

In order to appreciate the unique nature of battlefieldinjuries, it is necessary to understand something ofthe aetiology of injury, the complexity and lethality of some of the wounds and the impact of time delayon outcome.

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* Buttock and back wounds, all multiple fragment injuries, as a separate figure. † Multiple wounds.** 80% caused by fragments; range of hits 1-45, mean of 9.

Table 0102 Anatomical distribution of penetrating wounds as a percentage, for varioius conflicts.

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Aetiology of Injury

0102 The causes of trauma fall into four maingroups:

• Penetrating.

• Blunt.

• Blast.

• Thermal.

In peace, or during transition to war (TTW), themajority of injuries are caused by blunt trauma (e.g., RTAs and training injuries). In war, penetratinginjuries predominate, the average figure being 90%for all conflicts since WWI. Blunt trauma, includingthe effects of blast, together account for 8% of battlefield injuries.

Penetrating injury

0103 The magnitude and lethality of injuries sustained in war is related to:

• The mechanism of injury.

• The type of missile.

• The distribution of the injuries.

• Wound location i.e., which internal organs are injured.

Between 60 to 90% of penetrating injuries in war are due to primary or secondary fragments fromexploding munitions; the remainder are caused bybullets. These may occur in combination with othercauses of trauma e.g., blast and burns. Limb injuriespredominate, with twice as many lower limb to upperlimb wounds.

0104 Most modern explosive munitions are"improved" fragmentation devices, that deliver hundreds to thousands of preformed fragments

Missile Injury: see Chapter 2

Penetrating injuriesare occasionallyencountered during TTW whenlive ammunition is used in training.

Penetrating injuriesare caused by fragments, bullets or both. Fragmentsmay be primary or secondary.


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contained within the munition, or submunition such asbomblets. Older devices produced random fragmentsderived from the weapon casing. The lethality forfragmentation weapons and bullets is shown in Table 0103.

The mortality caused by preformed fragmentationweapons has fallen but, the hit rate has risen. This was well illustrated during the Gulf War of 1991where, in one British Field Hospital, 81% of thereceived casualties had sustained fragment wounds.In this series, wound numbers per casualty rangedfrom 1-47 with an average of 9. This is exactly whatimproved fragmentation weapons are designed to do:increase surviving casualty numbers and place anadditional burden on the casualty transfer chain.

0105 Fragments (and bullets) do not respectanatomical boundaries. At least 40% of casualties in conventional war will have multiple, penetratinginjuries involving limbs and body cavities. This may significantly change the casualty profile with, for example, many more penetrating eye injuries (in the absence of eye protection) and more peripheralnerve and vascular injuries (approximately 2-4% of alllimb wounds).

Fragment injuries involving several body systems can present a diagnostic problem: which wound orcombination of wounds is likely to be causing clinicaldeterioration? Similarly, the multiplicity of traumaimplies that, in the absence of specialist teams, military anaesthetists and surgeons must be capable

Most fragmentwounds are lowenergy-transfer

injuries and superficial in nature.

On average, it takesfour people to look

after each casualty!1: Patterns of Injury in M

ilitary Operations

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Table 0103 The lethality of penetrating missiles.

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of operating on all the body cavities, as well as treating vascular injuries, soft tissue and bone injury.

0106 The lethality of military rifle and machinegun bullets has remained unchanged for the last 100 years, with a 33% chance of being killed if hit(Table 0103). Figures derived from the “hostile actioncasualty system” (HACS) database, show theoutcome for soldiers injured in Northern Ireland by a single rifle bullet during the period 1969 to 1979(Table 0104).

These figures also confirm the lethality of these bullets when they strike the 'critical area', (i.e. brain,mediastinum and abdomen), as opposed to the limbs.

0107 Missiles can produce wounds that vary froma simple laceration to one causing massive tissuedestruction and disruption. Often, because of shockwave and temporary cavitation effect, there is nerveand vessel damage lateral to the primary missiletrack (0206). This means wounds vary enormously in their complexity but, as will be seen in subsequentChapters, this does not imply they require complexprocedures for their initial management.

Following multiplefragment injury, in approximately one third of casualties one bodyarea is involved, in another third, two body areas and in the remainingthird three or moreareas are affected.

It only requires a single fragmentwith sufficient energyto lacerate a majorartery or vein, or injure the brainstem, to produce a lethal injury!


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Table 0104 Outcome following injury by a single rifle bullet.

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Blunt injury

0108 The spectrum of blunt trauma is similar to that encountered in peacetime e.g., RTAs, falls,blows to the head, torso and limbs.

Blast injury

0109 Primary blast injury alone is an infrequentcause of survivable injury on the battlefield (0221).For a casualty to sustain mainly primary blast injury,e.g., bowel damage, they must be close to the pointof detonation. This close proximity means the likelihood of mutilation, or fatal injury caused by fragments, is high. The effects of a blast may becompounded if it occurs in water or a confined space,resulting in a larger number of casualties or moreserious injuries (0221).

Those who survive a blast injury are at risk ofdeveloping blast lung. Many will require ventilationand all that that implies in terms of medical andnursing care. The more rapid the onset of respiratorysymptoms, the worse the prognosis, making for amore complex and demanding clinical problem.

Thermal injury

0110 Thermal injury is common in certain militaryenvironments, e.g., on board ship and in armouredfighting vehicles. During the Israeli - PLO war in theLebanon, the incidences of burns amongst tankcrews was 20%. During WWII burns have beencalculated as affecting 40% of American tank crews(includes all grades of severity). The figures forBritish tank crews ranged from 17-37%. What ispertinent is that 50% are complicated by penetratinginjury. Because burning in armoured fighting vehiclesoccurs in confined spaces, the incidence of inhalationinjury is high. Many of these casualties, if they are tosurvive, will require ventilation and management inan HDU or ITU environment.

Blast Injury: see Chapter 2

Following a blast in the open,

the effectivenessof the shock wave

to cause injurydecays rapidlywith distance.

Traumatic amputations due toblast are relatively

common and have a unique causation.

Because penetrating injury

predominates, thermal and blast

injury tend to be forgotten.


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Lethality of War Injury

0111 The anatomical distribution of penetratingwounds for various conflicts, is shown in Table 0102.What these figures do not illustrate is the complexityof many, and the lethality of some wounds.

During a high intensity engagement, 17-25% of thoseinjured will be Killed in Action (KIA) and die beforereaching a surgical facility; 3-8% will subsequentlyDie Of Wounds (DOW).

0112 During war fighting, 90% of deaths (KIA)occur on the battlefield, the majority within 30 minutesof wounding. In these cases, injury is generally tocritical areas. Further, 70% of the fatally woundeddie within 5 minutes. The majority of these immediate deaths are due to through - and - throughpenetrating brain or brain stem injury, or damage tomajor vessel(s), with subsequent exsanguination(Table 0105).

It does not matterwhether the cause of injury is a highvelocity rifle bullet, or a low velocityfragment, what isimportant is theamount of energyconverted to actual damagein the tissues.

British figures forDOW's after theNormandy landingsshow 50% diedwithin 24 hours, 80% within 3 daysand 95% at 7 days.


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*Definitions in this group vary, the majority relate to casualties who die after reachinga hospital (surgical) facility; others do not.

Table 0105 Battlefield deaths: major groupings by cause (limb injuriesvary from a single major vessel bleed to traumatic amputation of three limbs).

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Surgery has no part in the management of through-and-through brain injury: death is virtuallyinstantaneous. Both immediate care and early surgery,have a significant part to play in reducing the incidenceof death from exsanguination. The majority of bleedingfrom the extremities (compressible haemorrhage) iscontrollable by simple measures (0330 - 0331); torsotrauma (non-compressible) haemorrhage that doesnot result in immediate death, requires early surgeryif there is to be a favourable outcome.

Improving Outcome

0113 Can the figure for those killed in action be reduced? Assessment based on post mortemfindings, suggest 15-20% of KIAs can be salvagedby appropriate, immediate aid including surgery.Others have suggested that 10% of battlefield fatalitiesresulted from errors in pre-hospital management, with 11% of these errors caused by faulty first aid.What matters is that the casualties receive timely and appropriate management. In war, time is notalways on the casualty's side.

0114 Table 0106 shows the predicted outcome for 1000 untreated casualties over time. These figuresare based on data derived from WWII, Vietnam andNorthern Ireland. The overall mortality at 24 hours isestimated to be 36%. Given the lowest figure alreadyquoted of 17% KIAs, versus a predicted mortality of36% without treatment, current management protocols

Unlike peacetimepractice, treatment at

the point of injury is subject to

many constraints,not least,

the tactical situation:continued enemyaction may deny

access to thecasualties!


8

Head (160) 80 13 25 25+

Thorax (190) 34 8 12 12

Abdominal (100) 28 16 16 30+

Limbs (650) 26 195

Site <1 hour 1-6 hours 6 - 24 hours >24 hours

Table 0106 Predicted Mortality for 1000 untreated casualties.

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for the spectrum of battlefield injuries save the livesof half of the casualties with potentially fatal injuries.

0115 If the principle of trying to provide peacetime standards of care for the spectrum of war injuries, is applied, the above mortatility figuresare totally unacceptable. How can more lives besaved? Potential areas for improvement include:

• Better combat body armour (CBA) and helmet.Their effectiveness tends to be limited by weight:heavier protective clothing reduces mobility andbecomes unacceptable to the fighting soldier.Undoubtedly, CBA has reduced mortality fromchest wounds and better helmets have reducedfatal brain injury caused by fragments. Furtherimprovements in head protection can save evenmore lives. (see Table 0105).

• Improved haemorrhage control at point ofwounding. Better ways of achieving wound compression, haemostatic self-applied dressingsand the use of clotting adjunct factors are examples (0330). The aim must be to reducedeaths due to exsanguination (Table 0105).

• Improving casualty extraction and transfer.Removing a casualty from the battlefield or a ship is often dangerous and can involve longlines of evacuation. Irrespective of increasinglysophisticated care, if a seriously injured casualtycannot get to the surgical team or the team tothe casualty, time will decide the outcome.

• Triage: in war, casualties tend to occur in peaksand troughs dictated by the intensity of thefighting. In terms of numbers, this would equateto a major civilian disaster happening severaltimes in 24-48 hours. Appropriate triage at eachechelon of care will maximise survival (0603).

• Trained and experienced personne: a knowledgeof the principles of resuscitation, including

Haemorrhage Control: see Chapter 3


9

Chapter_1.qxd 28/09/2004 16:03 Page 9

hypovolaemic resuscitation for non-compressiblehaemorrhage (0333) and “damage controlsurgery” are essential. In the management oftorso and complex limb injuries, attempts at timeconsuming, complicated procedures, are often tothe detriment of the wounded, (and those waitingin the queue for surgery). There is no place forfutile care!

Damage Control Surgery: see Chapter 4

It is worthremembering that,

even if all of theabove are improved,

the nature of manybattlefield injurieswill still dictate an

unfavourableoutcome.


10

Chapter_1.qxd 28/09/2004 16:03 Page 10

Chapter 2

Pathophysiology of Ballistic,Blast and NBC Injury

Introduction

0201 Projectiles that strike the body are classed as:

• Non-penetrating (blunt): projectiles transferenergy to the body wall without causingperforation. The magnitude of the body walldeflection and its peak velocity, determine how energy is transferred to internal organs.Some impacts (e.g., RTAs) produce low speed,gross deflections, resulting in injury largely dueto crushing and stretching of tissues (e.g., rib fractures, liver laceration). Others produce small,high speed wall deflections (e.g., baton rounds,trauma behind body armour struck by bullets),which generate stress (pressure) waves. Thesepropagate through tissues causing additionalinjuries such as pulmonary and bowel contusions.Non-penetrating impacts may also result inacceleration of a part of the body. The rapidacceleration and rotation of the head, for example,may produce serious brain injury.

• Penetrating: missiles pass through the body walland interact directly with tissues. The work doneby the projectile on tissues results in contusion,laceration, bone fracture and the displacement of organs. In addition to the laceration produceddirectly by its passage, the projectile may alsotransfer energy laterally, centrifugal to its path, producing indirect trauma.

Terminal ballistics is a foundation, not a dictat for clinicalmanagement:treat the wound notthe weapon.

2: Ballistic, Blast and NBC Injury

11

chapter_2_ballistics.qxd 28/09/2004 15:54 Page 11

Definition of Penetrating Interactions and Wounds

0202 Penetrating projectiles are classified according to their available energy and the amount ofenergy transferred when causing mechanical damage.

• The available energy (Joules) of a projectile is 0.5 x mass (kg) x velocity2 (m/s). Typical rifle bullets have available energies of 800-1500 Joules.

• The energy transferred is the difference betweenthe energy at entry and the energy at exit. If theprojectile is retained in the body, all the availableenergy is converted into mechanical damage. If the projectile (or parts of it) passes through the body and emerges, it will have retainedsome of its pre-impact energy.

0203 Wounds may be

• Low energy-transfer: mechanical damage isconfined principally to the path of the projectile(direct injuries). The projectile simply cutsthrough tissues (e.g., knives, low energy anti-personnel fragments and many pistol bullets),with the depth of penetration dependent upon a number of factors (tissue density, projectileshape etc.). In practice, many of the projectileswill be retained in the body (Figure 0201).Functional consequences vary according to thetraversed tissues.

• High energy transfer: these are due to high energy missiles transferring much of theirenergy to the tissues (Figure 0202). They arecharacterised by mechanical injury lateral to thepath of the projectile (indirect injuries). An exampleis a rifle bullet hitting the femur and stoppingdead (Figure 0203). The bone shatters producing

Projectiles are classified by

available energy, notvelocity. The energy transferred does the

damage, not theincoming energy.

High energyprojectiles can cause

low energy-transferwounds e.g.,

a stable rifle bulletpassing through themuscle of the thigh,

missing bone andvital structures

and carrying on for afurther 600 metres.


12


secondary fragments and extensive soft tissuedamage. Indirect injury may be severe, bothmechanically and functionally. Whether the projectile is retained in the body depends onits shape, which tissues it encounters andwhether it breaks up into pieces. In practice,wounds will span these classifications.

0204 Historically, there were two classes ofweapons - pistols and rifles - with loosely distinctvelocities (low hundreds and high hundreds of metresper second, respectively). Consequently, wounds


13

� � ��

Fig 0201 Low energy wound: The permanent track caused by themissile is narrow. Necrotic tissue is generally confined to within 2-3cmof the line of travel. Any outlet wound is small.

��

��

� � ��

Fig 0202 High energy wound: In addition to the permanent track, the large energy-transfer by the bullet causes a bigger temporary cavityand frequently a wider exit wound. Maximum energy-transfer occurswhen the bullet is at 90 degrees of yaw.


were described in terms of the projectile's pre-impactvelocity - i.e., low or high. This classification is nolonger appropriate e.g., an anti-personnel fragmentmay have a velocity greater than a rifle bullet but,because of its small mass (< 1g) and consequentlylimited energy, is unlikely to cause the same degreeof mechanical damage, (tens of Joules compared tothousands of Joules).

0205 Injury can be classified as mechanical and functional:

High velocityweapons e.g.,

rifle bullets, do notalways cause severewounds. Conversely,low velocity weaponse.g., hand guns and

fragments can be fatal.


14

Fig 0203 The effect of a missile hitting the femur. Bone fragmentscause secondary injury. Shock waves may damage tissue remote fromthe path of the missile.


• Mechanical: the damage done to tissues,expressed solely in terms of gross and microscopic disruption.

• Functional: the physiological and clinical consequences of the mechanical damage.

A small hole in bowel caused by an anti-personnelfragment may be classed as minor mechanical damage, but with serious functional consequences(peritonitis). Conversely, a large superficial soft tissue injury may be gross mechanical trauma, but will (generally) not be classed as a serious, life-threatening functional injury. Always consider the likely direction of travel of the missile and thepossible organs involved (Figure 0204), but, do notuse this as an absolute predictor for organ damage.

Transfer of Energy to the Body

0206 Missile injury may be direct and indirect.Mechanisms producing indirect damage away fromthe track are:

• Stress (pressure) waves: The passage of a bullet

Limb Injury: see Chapter 9

Do not confusemechanical andfunctional injury;small holes in thewrong place mayproduce seriousfunctional injury.


15

Fig 0204 Missiles can cause multiple injuries along their course.


through tissue will generate a pressure wave(it is not a true shock wave), which, dependingon the density and the characteristics of thetissue, can cause mechanical damage. It is aninfrequent cause of significant injury but may beimplicated in, for example, a long bone fracture.

• Break-up of the projectile leading to multiplewounds tracks and damage away from the bodyof the projectile.

• Temporary cavitation.

The temporary cavity

0207 Temporary cavitation is a transient, low pressure cavity formed around the track of theprojectile, which stretches the surrounding tissues(Figure 0202). It is (arguably) the principal cause ofindirect injury from penetrating projectiles. Transfer of energy from the projectile causes acceleration ofthe tissues away from the track. This leads to the formation of a temporary cavity, with a peak volumeoccurring about 3 milliseconds after passage of theprojectile i.e., many high energy-transfer bullets willhave exited the body before the peak cavity volumeis attained.

0208 The key features of a temporary cavity are:

• Size.

• Shape.

• Contamination.

• Clinical consequences.

Size:

0209 The magnitude of the cavity is largelydependent upon the energy transferred. Temporarycavitation is not an "all or none" phenomenon. Low energy-transfer projectiles (e.g., anti-personnel

Long bones can be broken by

high energy-transferprojectiles passing

close to them. Directimpact of compact

bone will lead tocomminution, breakup of the projectile

and motion of secondary

bone fragments.

It must not beassumed that all

tissue affected by the cavity is damaged by it.


16


fragments) will produce a small cavity that has littlemechanical or clinical significance. If energy transferis increased, cavity volume will increase and may be capable of causing gross tissue injury, or lessobvious neurovascular and cellular damage.

Shape:

0210 Projectiles do not distribute energyuniformly along the wound track, therefore, thetemporary cavity is not a uniform, longitudinal shape.There are differences between temporary cavitiescaused by fragments and bullets arising from theiravailable energy and shape.

• Fragments: modern anti-personnel fragmentstend to be uniform in shape (some are spheres)i.e., yawing may occur but usually has little effecton the missile's presented area and hence retardation. Because retardation is greatestwhen the velocity is high, namely at the point of entry, fragments tend to deposit most energy(Joules/cm) in the proximal part of the track, followed by a fairly steady decline as they penetrate. The temporary cavity matches theenergy transfer i.e., is largest close to the entrypoint. Because most fragments tend to beretained in the body, the nature of the wounddepends on the available energy . Low energy-transfer fragments tend to producesmall entry points, travel a short distance (typicallya few centimetres), produce limited cavitationand cause limited damage (Figure 0201).

By comparison, a high-energy fragment (e.g.,a large piece of weapon casing or bomb splinter)may result in a gaping wound.

• Bullets: are long and pointed; they are designedto be stable in air but not in tissues. On enteringthe body nose-on a bullet tends to rotate around a transverse pivot (yawing) through their centre,markedly changing the presented area.

Most small anti-personnel fragments producelow energy-transferwounds with injuryprincipally confinedto the wound track;they are usuallyretained in the body.

High energy fragments tend todeposit most energyin the proximal partof the wound track;bullets deposit mostenergy when theyyaw (tumble), and this may besome distance intothe track.


17


This rotation increases the retarding forcesslowing the projectile down and, in doing so,transfers energy. When it has reached 90degrees of rotation, retardation, energy transferand cavity diameter, are at a maximum. Energytransfer declines as the bullet continues 180degrees and, if the wound track is long enough,270 degrees. Thus, if plotted in Joules/cm alongthe wound track, initially the energy transfer islow, increases to maximum at 90 degrees, thendeclines as the presented area of the bullet andits available energy decline (Figure 0205).

The shape of the temporary cavity matches theenergy transfer. With high energy bullets, moreenergy is deposited deep within the wound track,than close to the entry point. Typically, the entrysite is a small hole (Figure 0202); the exit woundis usually (but not always) much larger, in between, are likely to lie severely damagedinternal organs.

Contamination

0211 All military wounds are contaminated. Ingeneral, fragment wounds are more severely contaminated than bullet wounds.

• Bullets: the formation of a temporary, sub-atmospheric pressure cavity following a high

Wound Excision: see 0503

High available energy projectiles

(such as rifle bullets)usually produce

high-energy transfer wounds with injury also

present away fromthe wound track; this

is frequently thecase if the wound

track is long.


18

��

��

��

��

��

��

� ��

��

��

Fig 0205 Typical energy transfer of a 5.56mm bullet in gelatine.


energy-transfer wound, sucks contaminants intothe track and fascial planes, principally (but notexclusively) from the exit wound. Large piecesof clothing may be thrust down tissue planesduring the cavitation process and retained whenthe cavity collapses. Because the bullet is pointed,very little material is cut and transferred fromthe entry site. Low energy-transfer bullets thatproduce small cavities and may be retained inthe body (i.e. no exit wound) generally result inlimited contamination

• Fragments: fragments contaminate wounds by cutting clothing and skin at the entry pointand transferring the material along the track.With small anti-personnel fragments, plaques of clothing may be found associated with thefragment and fibres may be strewn along thetrack. Large low energy fragments may cutpieces of clothing the same size as the fragment; material is frequently found wrappedaround the missile. High energy fragments(which are inevitably also large) tend to shredlarge pieces of clothing and skin into smallpieces and scatter these throughout thetemporary cavity and along the track. These are severely contaminated wounds.

Clinical consequences of the cavity

0212 This depends on the mechanical propertiesand function of the affected tissue. The cavity stretchestissue rapidly; it may also cause laceration if itselastic properties are exceeded.

• Friable: in the brain or organs enclosed within a capsule the cavity may disrupt the coveringleading to gross disruption of the friable interior, e.g.,

• Head: high energy-transfer to the craniumwill result in a temporary cavity and intense

Penetrating Head Injury: see 1619

All wounds are contaminated.Contaminants fromanti-personnel fragments are confined to the track; with high energy-transferwounds, the contaminants are widely distributedwithin the wound andin fascial planes.Fragment woundsare usually more severely contaminated than bullet wounds.

It is in skeletal muscle wounds that the axiom "treat the wound notthe weapon" is themost appropriate. It is in this tissue that inappropriatewound excision (too much, too little) typically occurs.


19


stress waves that will shatter the vault andgrossly disrupt the brain. The probability ofdeath is very high.

• Liver and other dense, friable organs:the cavity will lead to severe disruption and haemorrhage with a high probability of death.

• Elastic: in tissues that are capable of withstandingsome degree of stretch by the cavity (principally,skeletal muscle), damage may be minimal.The discrimination of viable and non-viable tissue (0503) around the wound track may be difficult.

• Indirect: the formation of a large temporarycavity near a long bone may result in fracturewithout direct interaction. The mechanism is likely to result from a combination of the bendingstrain on the bone by the cavity, and straininduced by the transfer of a stress wave into thebone. High energy-transfer projectiles passingclose to the spine may also affect the spinalcord. Similarly, intimal damage to arteries canoccur without external damage being evident(1005).

Compounding factors

0213 Changes in presented area: in a bullet thismay be due to yawing or splaying of the nose oncontact with tissues. Splaying is usually achieved by removing the jacket from the front of the bullet,to expose the lead/steel core. These unjacketedbullets are prohibited for military use, but they could be employed by police forces or by civilianmalevolents. The high retardation forces on such a bullet will lead to high energy-transfer (and henceserious tissue damage) in the more superficial partsof the body. Penetration is limited. The aim is totransfer the total available energy of the bullet intothe target.

Abdominal Injury: see Chapter 12


20


0214 High yaw: this may occur from:

• Prior impact or interaction with materials (e.g., twigs may induce a bullet to tumble in flight).

• Assault at close range: a rifle bullet does notbecome stable until about 50 m from the barrel.At short range, the bullet may strike with "high"yaw (only a few degrees, but sufficient toescalate the energy transfer). When the bullet enters tissue, it begins its yaw cycle immediatelyand deposits high energy early in the woundtrack - there is no "neck".

0215 Tissue properties: the tissues of the bodyhave different densities and mechanical properties e.g.,

• Compact bone is stiff and relatively brittle. A small, low energy fragment may produce asimple fracture in a long bone. As the availableenergy is increased, a projectile may suffersevere retardation leading to:

• High energy-transfer with severe comminution of the bone, a large bonydefect and damage by the resultant cavity to the surrounding soft tissues. (Figure 0203).

• Acceleration of bone fragments to becomesecondary missiles leading to laceration ofsoft tissues e.g., blood vessels.

• Disruption of the jacket of the bullet leadingto break-up or extrusion of components,higher energy-transfer and generation ofmetallic, secondary fragments.

• Lung has low density and is elastic. The retardation forces on projectiles are low.Small, low energy fragments, penetrate easilyand damage is confined exclusively to the trackof the fragment. High available energy projectilesare similarly, poorly retarded and may transfer

Lung Injury: see Chapter 15

Within a short distance in tissueyawing will increase.This "neck" variesbetween bullet calibres - the neckfor a 7.62 mm bulletis longer than that of a 5.56 mm.

Bullet wounds to the thorax involving lungparenchyma alone,do very well.


21


little energy, leading to low energy-transferwounds. Even when the energy produces a cavity,the elastic nature of the lung parenchyma limitsits effect.

0216 Fragmentation. In military bullets, this mayoccur due to:

• Inappropriate design: the rear of the bullet may be vulnerable to distortion of the jacket and extrusion of lead.

• Wounds at short range: high forces on the bullet during the early yaw may lead to distortion, lead extrusion or even break-up.

• Interaction with dense bone.

• Prior impact with materials: this may erode ordisrupt the nose, thereby removing or weakeningthe jacket causing splaying on impact.

0217 Wound track length. Energy transfer isdependent on track length. Stable, intact high available energy projectiles striking tissue require a considerable track length to deposit all their energy(Figure 0205). Wound tracks in the human body canrange from 1-2 cm to >40-50 cm in length. Thus:

• In short wounds (e.g., hand, foot, arm): the projectile will not have sufficient track length toenter its yaw cycle; energy transfer is sometimeslimited. Bone may complicate the issue, particularly in the upper arm. The relatively "soft", mobile bones of the foot and hand, maynot exert a notable effect on energy transfer.

• In medium wounds (e.g., soft tissue of thigh)a bullet with a track length of 20 cm will be wellinto its yaw cycle and is likely to exit the tissueswith high yaw, causing high energy-transfer, a big cavity and a large exit wound. Interactionwith bone will accentuate this.


22


• In long wounds (e.g., abdomen) a lengthy woundtrack may enable the bullet to undergo yawthrough 90, 180 and 270 degrees, thereby losing a large proportion of its available energy.The exit (if there is one) may be a small hole, an example being a low energy-transfer defect in the abdominal wall from a nearly "spent" projectile (masking significant intra-abdominalcarnage!). It is also worth noting that with longtrack lengths, the motion of the bullet around its longitudinal axis and interaction with differenttissue planes, may lead to a swerving of the bullet away from the projected wound track(Figure 0206).

Blast

Classification0218 Blast injury may be classified as in Table 0201:

1. Primary blast injury (PBI): caused by a sudden overpressure (shock wave) generated

The small entry andsmall exit woundmay suggest that alow energy-transferwound has occurred,whereas, in fact,substantial internaldamage existsbetween thesepoints.


23

Fig 0206 Passage of a missile through tissue may alter course e.g., hitting bone. The position of the casualty at the time of woundingmay be very different when examined from that on a stretcher.


!�" #��

$��%��&'��#��

��''�� '�(�� )��


24

Fig 0207 Effects of blast.

��

*��+(�''�� %��%��, ��-��' ��%��- '%��-��' ��

.��- �� '��)�� +�� %��-�� '��

.�� " ��/%�-'��) (��%��- ��%��%��0 $�� !��' ��%� ��- ��'� �� '��

1%��- �"��

��

$�� !��%�� ( ��%��!�" #��

�� '�� )��!� )'��

�!��' ��'��( �!� )�� )� �!�)'�� #��

2��''��%� �3�%��((�� ' �)'�� 0�0- �%��- (�� !� ��

��

�452647

�89:$647

��4�5647

;<64��4:647

Table 0201 Classification of blast injuries and principal organs affected.


by the explosion (Figure 0207). Gas containingstructures are predominantly affected, particularlythe ear (e.g., ruptured eardrum), paranasalsinuses, lungs (e.g., contusion) and gastrointestinal tract (e.g., haemorrhage, rupture).

2. Secondary blast injury: due to primary and secondary fragments (e.g., glass, masonry) causing penetrating and non-penetrating trauma (Figure 0207). Energised fragments are the mostfrequent cause of injury after a blast. Collapse ofbuildings may produce additional trauma.

3. Tertiary blast injury: due to victimdisplacement by the movement of air (blast wave or wind) and collision with nearby objectsproducing blunt and/or penetrating trauma(Figure 0207). This mechanism accounts for the high incidence of head and neck injuries and fractures, seen following most bombexplosions. The force may be sufficient to cause limb amputation.

4. Quaternary (miscellaneous) blast injury:due to flash burns, burns from combustion of the surroundings, inhalation of noxious gases (especially carbon monoxide) and psychological effects.

Mechanisms of primary blast injury0219 The blast shock wave. When an explosivedetonates in air, an intense, rapidly expanding shockwave is generated, producing an almost instantaneousincrease in air pressure. The incident pressure is thepressure perpendicular to the direction of travel ofthe shock wave; its magnitude is inversely related to the cube of the distance from the source. In theopen, the effectiveness of the shock wave to causeinjury, decays rapidly. Simple blast waves are characterised by a pressure rise to a maximum peak overpressure (A in Figure 0208). Pressure then

Inhalational Injury: see Chapter 22


25


Underwater, reflections occur

from the under-surface

and seabed. Because there is

slower blast wavedecay and more

efficient propagationof shock waves,

injury may be enhanced, particularly to the intestines.


26

=��

=��

=��

=��

� +��

� �� >� �� ?��

6

&

8

@��

Fig 0208 Simple blast wave in air showing A) peak overpressure, B) decay and C) sub-atmospheric pressure.

declines exponentially (B in Figure 0208) to a negative sub-atmospheric pressure (suction wave) (C in Figure 0208) lasting up to ten times longer thanthe positive phase. Sub-atmospheric pressure effectsare seen when glass splinters from windows areaccelerated backwards towards the blast source.

Injurious effects of the shock wave depend predominantly upon peak overpressure and durationof the positive phase. Blast waves are capable offlowing over and around obstructions and may affectmilitary personnel sheltering behind defences, particularly if there is reflection of the wave (e.g., a sheltered gun emplacement). In confined areas or under water, complex blastwaves occur characterised by multiple overpressurepeaks e.g., a person standing near a wall or in a confined space facing an explosion will be exposedto both incident and reflected pressures, resulting ina very significant increase in overpressure.

0220 Acoustic coupling. The initiating mechanism of primary damage by the blast wave is the rapid inward motion (acceleration) of the bodywall. Energy is then propagated through tissues by:

• Stress waves - longitudinal pressure waves.Multiple, air-tissue interfaces in lungs and gut,extract energy from the stress wave. This energy


disrupts the delicate interface between alveoliand blood vessels, leading to haemorrhage.

• Shear waves - transverse waves of low velocityproducing gross distortion of tissues and organs.These account for mesenteric injuries, aortic rupture, some solid organ injuries and possibly,disruption between layers of the bowel wall.

Patterns of injury0221 Many casualties suffer a combination of the effects summarised in Table 0201. Total body disruption normally only occurs if they are carryingthe explosive device or are in very close proximity.Traumatic amputations are relatively common (e.g., standing on a land mine) and have a uniquecause: a stress wave coupled into the limbs fracturesa long bone (frequently the tibia), the blast wave thencarries the limb away. Contamination is forced up thetissue planes. Those who survive primary blast injuryare at risk of developing blast lung and many willrequire intermittent positive pressure ventilation.

The immediate environment in which an explosionoccurs influences the pattern of injuries. This mayallow prediction of the consequences. For example, a bomb detonated in a bus will tend to inflict a highproportion of primary blast injuries on the occupants;detonation in a building will tend to produce moresecondary and tertiary effects. In addition, fuel-airexplosives are designed to disable troops by pure primary blast effects on a massive scale.

Blast protection 0222 Conventional textile armours do not preventinjury from primary blast effects. Employing a foamlayer which reduces energy transfer faced with adense material such as resin-bonded aramid, canprovide protection.

Fuel-air and thermobaricweapons are likely to increase the number of casualtieswith combined blastand burn injuries.


27


Nuclear Injury

Nuclear reaction0223 Nuclear explosions result from

• The break up of large, unstable nuclei into multiplesmaller and more stable nuclei (e.g,. isotopes ofplutonium and uranium). Once initiated, the energyproduced causes adjacent, unstable isotopes todecay (chain reaction). This fission reaction wasused in the original nuclear weapons and isemployed in peace for power generation.

• In fusion weapons, isotopes of hydrogen arefused to form heavier helium, a process thatrequires intense heat. Once initiated (e.g., detonation of a fission weapon withinfusion material), the energy produced is greaterthan that of a fission reaction.

Effects of nuclear explosion0224 A nuclear explosion causes injury by threemechanisms: radiation, blast and thermal burns.Their relative energies in a standard nuclear weaponare shown in Figure 0210. Radiation enhancednuclear devices, designed to deliver a fatal radiationdose to fighting troops, but less damage to property,may be used as tactical weapons.

• Radiation exposure. This is usually due to neutron and gamma radiation. In the earlystages, primary radiation injury is confined to a distance of 1-2km from the epicentre of theexplosion and can kill. The rising fire ball causesan updraft of radioactive debris (mushroomcloud), which is subsequently deposited over a large area. The greatest risk is from largenuclear particles, which fall to earth within thefirst 48 hours close to the epicentre of the blast. (Figure 0209)

The effects of anuclear explosion

depend on the energy of the

weapon and thedistance from

its epicentre (Figure 0209).

Sensitivity to radiation exposure

varies greatly, making prediction

of outcome difficult.


28


• Blast. The effects are similar to conventionalexposure but more intense (0218).

• Thermal burns. The intense thermal energy initially causes damage over a much wider area than blast and radiation (Figure 0209)and accounts for the majority of early injuriesand death after a nuclear explosion. The lightflash associated with a nuclear detonation, can result in blindness. This is usually temporary,lasting from seconds to 30 minutes. Personnelmay suffer damage confined to exposed areas.Combustion of clothing and adjacent materialcan cause deep burns.

Triage of Nuclear Casualties: see Chapter 6


29

.�� )'��

<��(� ( �� )��

.�� '�� (�'' (��

1��!�� '�� ' (%�!�

&'��

� 2�

�� @�

�� @�

�@�

5��'4��

�0� "�

�0? "�

� "�

�0? "�

&'�� 5�/%�

�0� "�

� "�

� "�

�0� "�

&%��

�� "�

� "�

� "�

�0� "�

Fig 0209 Rings of nuclear destruction. For the given distance, eachof the three causes of injury carry a 50% mortality.


Clinical features0225 Most casualties will have a combination of injuries:

• Burns. Because of its short duration and the skin's resistance to thermal injury, burnsamongst survivors often appear serious butare, in reality, confined to the epidermis andsuperficial dermis and heal well (treatment2212). Rarely, severe local burns developwithin hours of a casualty being in contact with gamma radiation emmitting material.

• Blunt (0201) and blast trauma (0218).

• Radiation. Ionizing radiation affects cell structure, in particular DNA. Rapidly dividing cells(e.g., bone marrow, bowel, skin), are affectedbefore the cardiovascular and nervous systems.Symptoms range from nausea, anorexia andmalaise, through to vomiting, diarrhoea, skin erythema, confusion and collapse. Significantexposure is suggested by earlier onset of clinical features.

Treatment is supportive (resuscitation, antibiotics, etc,). If the casualty survives, theremay be cycles of recovery and deterioration as

Management of Burns: see Chapter 22


30

&'��

�!��' ��A�''%�

5��' ��

0210 Typical energy associated with a nuclear explosion.


With appropriateequipment and training, it is possibleto both survive andprovide medical carein a chemicalenvironment.


31

the body attempts to repair itself. Depending onthe dose received, these phases of radiationsickness can last several days/weeks, or be as short as a few hours. A longterm complicationoccuring in a small, unpredictable proportion ofcasualties, is an increased risk of cancer.

Biological Agents

0226 Likely biological agents and their management are discussed in Paragraphs 0838through to 0841.

Chemical Agents

Introduction0227 Chemical agents come in the form of solids, liquids and gases. They are relatively easy to manufacture and deliver using, for example, shells,rockets, bombs and sprays. In addition to physicalincapacity and death, effects also include physiological disturbances which place increaseddemands on medical resources. There are four maingroups of chemical agent in common use:

1. Nerve agents

2. Cyanide

3. Blister agents

4. Oedemagens

Nerve agents and cyanide are the most dangerousand can cause death within minutes. Correct identification ('Quick Look' Figure 0301) and treatment, are essential. Useful information includes:

• To determine possible exposure: is there evidence of aircraft or artillery bombardment;spray, droplets, smoke or unusual smells? Was the casualty wearing individual protection


equipment (IPE 0228)? Were others affected?Did detection equipment respond positively?

• To identify the agent(s): symptoms, speed ofonset and effect of donning a respirator and useof Combopens (0235)?

• To assess degree of exposure: was the casualty under cover or exposed, exercising or at rest? Time lapse between exposure anddecontamination?

Protection0228 Everyday clothing provides little protection;rubber and polythene are more resistant. Charcoal-embedded, liquid repellent NBC suits,gloves and respirator (IPE), provide complete protection against liquid and vapour agents for atleast six hours. Suits and gloves should be changedtowards the end of this period (NB: following cyanidepoisoning, change the respirator cannister after 20minutes). Leather boots will be slowly penetrated;this can be prevented by the use of overboots. IPE isunpleasant to work in, is hot, bulky and impairs visionand hearing; prolonged use can cause heat illness.

Detection0229 Chemical weapons can be detected byreagents that induce a colour change and by

Biological Weapons: see Chapter 8

Military personnelwho suddenly

become a casualtywithout being

wounded, or who are suffering agreater degree

of incapacitationthan is compatiblewith their wounds,

should be considered a

possible chemicalcasualty. Single

chemical casualtiesare unlikely on the

battlefield.

Webbing and surrounding

materials may present a hazard

from 'off-gassing'.


32 Table 0202 Chemical agents and methods used for their detection.


Management of Heat Illness: see Chapter 26

Man PortableChemical AgentDetector (MCAD): this is due to replaceNAIAD in the nearfuture. It can detectnerve, blister andchoking agents,cyanides and sometoxic industrialchemicals.


33

methods that detect the in vitro inhibition of theenzyme cholinesterase or, the presence of ionizedagents. In liquid form, agents react with:

• One Colour Detector Paper (turns blue in thepresence of all liquid nerve and blister agents).

• Three Colour Detector Paper (Table 0202).

Vapour may be detected by

• Nerve Agent Inhibited Enzyme and AlarmDetector (NAIAD) system.

• Chemical Agent Monitor (CAM). In 'G' mode,CAM picks up and quantifies nerve agents; in 'H' mode, it detects mustard vapour (NB: it will not function at low temperatures). The main disadvantage of CAM is that it takesapproximately 6 minutes to monitor a singlecasualty and confirm no exposure.

• Residual Vapour Detector (RVD).

Decontamination0230 Start decontamination under shelter. Unless the casualty's condition is life-threatening,decontamination should take place before treatment.Carers must wear full IPE.

• Removal of the casualties clothing will eliminate up to 90% of contamination (NB: deposit clothing in gas proof bags).

• Scrub exposed skin, respirator and cuffs ofgloves with 0.5% hypochlorite solution combinedwith a wetting agent (e.g., household detergent).Dabbing or rubbing with large quantities ofFuller's earth to absorb adherent liquid agents,can result in poisonous 'snowdrift'.

• Irrigate eyes with normal saline.

• Iif you have nothing else available, brush offadherent liquid (e.g., using a tree branch) and


irrigate with copious amounts of water (nerveagents are not water soluble).

• If casualty protection equipment (CPE) is available, remove the caualty's respirator andplace the decontaminated victim within the bag.CPE consists of a sleeping bag with a clearpatch over the face; it is supplied by pump-filtered air.

• If buildings or equipment are contaminated,it is safer to use IPE, rather than attempt largescale decontamination.

Management of contaminated wounds 0231 This is discussed in 0503. Drop potentiallycontaminated fragments and wound debris intobleach to prevent “off-gassing”.

Nerve agents

Pathophysiology0232 Most nerve agents are liquid organophosphorous esters which appear colourlessor pale yellow. They are usually known by code letters e.g., GA (Tabun), GB (Sarin), GD (Soman)and VX. Depending on formulation, they can be

persistent liquids (especially V agents) or rapidlyvapourising gases. Nerve agents quickly penetratemucous membranes and, in vapour form, areabsorbed by the respiratory tract and cornea. Both liquid and vapour forms can enter via the skin(NB: symptoms may take several hours to develop).Once absorbed, nerve agents inhibit the enzymeacetylcholinesterase, resulting in an accumulation of acetylcholine at neural junctions and unabatedstimulation of cholinergic receptors triggering acholinergic crisis.

With small doses,typical symptoms

are: pinpoint pupils,runny nose andchest tightness.

With larger doses,irregular and

shallow breathing, bradycardia,

convulsions anddeath follow these

symptoms.


34


It can be difficult sometimes to differentiatebetween chemicalweapon injury andmental incapacitation- see Chapter 27.

During the Gulf Warof 1990-91, approximately 1% of military personnelhad to stop takingNAPS tablets due toside effects.


35

Clinical features 0233 Features of cholinergic crisis include (Figure 0301):

• Pupils: pinpoint.

• Respiration: bronchoconstriction, wheezing, rapid shallow breathing.

• Secretions: excessive bronchial secretions,excessive salivation.

• Skin: sweaty, cyanosed, underlying muscle fasciculation.

• Brain: anxiety, depression of cerebral function,convulsions, loss of consciousness.

• Heart rate: bradycardia or tachycardia.

• Gut: vomiting, abdominal colic, involuntarydefaecation and micturition.

Death can occur in minutes and is usually fromasphyxia secondary to bronchoconstriction, excessive secretions in the lungs, paralysis of respiratory musclesand failure of the respiratory centre in the brain.

Protection from the effects of nerve agentpoisoning0234 Pretreatment with oral pyridostigmine, 30mg eight hourly (Nerve Agent Pre-treatment Set - NAPS tablets), protects a proportion of peripheralnerve cholinesterase. Start before any likely attack.Side effects can include abdominal colic and urinary frequency.

0235 If symptoms of nerve agent poisoning are experienced, inject a Combopen (atropine 2mg, pralidoxime 500mg, avizafone 10mg) through clothinginto the lateral thigh. Avizafone converts to the equivalent of diazepam 5mg. Injections can berepeated every 15 minutes up to three times.


Treatment0236 The CAM in 'G' mode is used to detect the presence of nerve agent on casualties. Start decontamination once under shelter (0230).

• Suck out secretions or allow postural drainage;give oxygen. Depending on casualty numbers,ventilation (BVM or intubation) may be appropriate. Bronchospasm and excessivesecretions can make this difficult. NB: avoidmouth to mouth contact!

• Give i.v.

• Atropine 2mg every 3-5 minutes (up to200mg) until there is evidence of effect(pulse >90, drying of secretions, improvedease of ventilation). NB: do not use pupilsize to monitor response.

• Pralidoxime 500mg slowly (maximum,including Combopens, 3.5 g in 24 hours).

• Diazepam 5mg as needed for convulsions.

• Continue treatment e.g., atropine i.v., post-operatve respiratory support.

The function of the respiratory centre and musclepower can return within 3-4 hours. Complete clinicalrecovery from acute effects may take several days.

0237 Atropine poisoning. This usually arrisesfrom misuse of Combopens. Features include:

• Mental changes: confusion, euphoria, hallucination, anxiety, restlessness, excitementand delirium, coma and depression of respiration.

• Tachycardia.

• Dry mouth.

• Pyrexia.

• Dilated pupils.


36


Tolerance to nerve agent poisoning does not develop.


37

• Failure to sweat (can result in heat illness).

• Urinary retention.

Treatment is sedation with bolus doses of diazepam 2mg i.v., titrated against response (or use physostigmine).

Potential interactions 0238 Casualties who have suffered nerve agent poisoning and also need surgery, may havebeen given a cocktail of drugs before operation (e.g., pyridostigmine/nerve agent/musclerelaxants/atropine). This is usually of little consequence and should not prevent or delay surgery. The main problem is likely to be delayed reversal of anaesthesia requiring prolonged ventilation. NB: make sure the casualty continues to be wellatropinised (0236).

Cyanide

Pathophysiology0239 Hydrogen cyanide (prussic acid) is a gas at room temperature, making lethal concentrationsdifficult to obtain in the field (i.e., it is a non-persistantagent). It is colourless, smells of bitter almonds andcan be experienced at sublethal levels. Detection ofattack concentrations is by using NAIAD (0229).Cyanogen chloride and cyanogen bromide are thepreferred forms, because they are heavy vapours.Once absorbed through the lung, they are both converted to hydrogen cyanide. The cyanide ionforms a reversible complex with the respiratorycytochrome oxidase enzyme system, resulting inimpairment of cellular oxygen ultilisation.

Detoxicification in the body is by conversion to harmless thiocyanate, a reaction catalysed by


intracellular trans-sulphurase enzymes, one of which requires thiosulphate as a substrate.

Clinical features0240 The respiratory centre is particularly susceptible to cyanide, this leads to respiratory failure. A few breaths of concentrated hydrogencyanide initially cause respiratory stimulation (the victim may be forced to take a breath whilst donning a respirator), followed by slow, deep breathingand convulsions. Cessation of respiration may occurwithin one minute. Nevertheless, blood remains welloxygenated and the skin is often pink (Figure 0301).

With lesser exposure, there may be weakness,headache, nausea, dizziness, convulsions and comalasting several hours. In addition, cyanogen chlorideand bromide cause irritation of the eyes and upperairway, with tightness of the chest, coughing, chokingand dyspnoea.

Treatment0241 The treatment team is usually safe once thecasualty is stripped.

• Administer oxygen. Depending on casualty numbers, ventilation (BVM or intubation), may be appropriate (NB: avoid mouth to mouth contact).

• Give slow injections i.v. of sodium nitrite 300mgand sodium thiosulphate 12.5g. This treatmentmay be repeated once only after 30 minutes.

• Post-treatment metabolic acidosis may causevomitting; if this happens, delay surgery andtransfer where possible.

Management of Heat Illness: see Chapter 26


38


Depression of bone marrow is a late effect, unlikely to be seen in the field. Thisresults in anaemia, neutropenia, thrombocytopeniaand increased susceptibility to infection.


39

Blister (vesicant) agents

Pathophysiology0242 Blister agents are powerful alkylatingagents, varying in colour from clear to brown. Theiroily nature and absorption by surrounding material(e.g., wood, leather, rubber, paint), pose a persistanthazard. Both liquid and vapour damage eyes andskin (especially moist areas). Following exposure,irreversible tissue binding takes place within 3-5 minutes. Blister agents are primarily intended to produce casualties and reduce fighting efficiency,rather than kill. In the longer term they produce cytostatic, mutagenic and cytotoxic effects.Haemopoietic and gastrointestinal cells are particularly affected. The two main agent groups are:

• Sulphur and nitogen mustards. Sulphur mustard smells of garlic and nitogen mustardhas a fishy odour.

• Arsenical blister agents (e.g., Lewisite).Lewisite smells of geraniums. Arsenical blisteragents are often mixed with sulphur and nitrogen mustards.

The chief difference between these groups is thatsulphur and nitrogen mustards have an insidiousonset over several hours and a cumulative effect.Conversely, skin and eye discomfort is instantaneousfollowing exposure to arsenical blister agents.Systemic arsenical poisoning may follow exposure toLewisite. Both classes of agent can be picked upusing detection paper and RVD (Table 0202).

Clinical features and management0243 Liquid and vapour readily penetrate theskin and mucous membranes causing dermal injuryand damage to the eyes. Inhalation results in pulmonary irritation and, if swallowed, there isdelayed nausea, vomiting, diarrhoea and risk ofgastro intestinal perforation.


0244 Skin:

Hot, humid conditions accelerate onset and worsenthe depth of injury. Moist areas are particularly affected (perineum, axillae, face and neck). With the exception of arsenical blister agents whichhave an immediate dermal affect, there are four clinical stages after all but the most trivial exposure:

1. Latent period lasting several hours.

2. Skin irritation, smarting, erythema.

3. Vesicle formation.

4. Necrosis. Damaged tissue is susceptible to secondary infection, ulceration and fibrosis. Healing is delayed and cutaneous scarring common.

Detection is by using CAM in 'H' mode.Decontaminate the skin (0230) and treat burns conventionally. Because mustards and Lewisite may be mixed, treat with systemic and/or local dimercaprol (British Anti-Lewisite BAL). NB: becauseBAL cream chelates silver, it is not compatible withFlamazine use. Following systemic absorption,administer dimercaprol 5% (2.5mg/kg i.m.) four hourlyfor the first 16 hours, followed by a twice daily dosedetermined by the casualty's condition (NB: BALinjections are very painful). At Role 3 or 4, healingmay be promoted by dermabrasion.

0245 Eyes

Onset of symptoms occur approximately one hour after exposure. Features include: excessivelachrymation, burning, blepharospasm preventing eyeopening, pain, severe conjunctivitis and lid swelling.There is a risk of secondary infection and temporaryadherence of the eyelids. Treatment is immediate irrigation with normal saline. Administer topical antibiotics, mydriatics (dilates the pupil and paralysesthe ciliary muscle -Table 1702) and apply vaseline

Burns: see Chapter 22

NB Blister fluid from Lewisite is

hazardous - double glove and

change immediatelyif contaminated

(2245).2: Ballistic, Blast and NBC Injury

40


Management of Ophthalmic Injury: see Chapter 17

Carers are at risk of the cumulativerespiratory effects of small doses e.g., bronchitis,pulmonary fibrosis.


41

(prevents adhesions). Use BAL drops after Lewisiteinjury. Give systemic analgesia (topical analgesiadelays healing). Reassure the casualty and coverboth eyes with an eye shield (1713) and refer to an ophthalmologist. NB: avoid pressure on the globe. Convalescence is often prolonged due to photophobia,lachrymation and blepharospasm, but recovery isusually complete.

0246 Respiratory effects

Inhaled vapour causes inflammation followed bynecrosis affecting the mucous membranes of thewhole respiratory tract. There is a triphasic response:

• Sterile phase: several hours after exposure thecasualty experiences a runny nose, sneezing, adry burning sensation in the throat, hoarse voiceand a harsh, dry cough proceeding to bronchitis.The more rapid the onset of these symptoms,the worse the prognosis.

• Secondary infection phase: results in expectoration of mucopurulent sputum. Deathmay occur secondary to bronchopneumonia.

• Late phase: due to bone marrow depression andleucopenia (seen at Role 3 or 4).

Management is nebulised oxygen, physiotherapy,sputum C&S and appropriate antibiotics. Late complications include: chronic obstructive airways disease, malignancy and sensitivityto further exposure.

Oedemagens0247 The most important examples are phosgeneand chlorine. During WWI, phosgene accounted for85% of all chemical agent deaths. Phosgene andchlorine are rapidly vapourising liquids and consequently, do not generally pose a persistentthreat (NB: pockets of gas can persist in clothing -wear IPE). Phosgene smells of new-mown hay


(there is no device available for detecting this agent),and chlorine of swimming pools.

Oedemagens cause increased permeability of thealveolar capillaries leading to massive pulmonaryoedema. After a latent period there is coughing,choking and increasing repiratory distress with copious expectoration of frothy fluid. Treatment isrest, humidified oxygen and cough suppression(codeine phosphate 30-60mg).

High dose steriods and diuretics are often tried as a last resort. Casualties frequently require assistedventilation (0329).

Oedemagens may be of military

or civil origin e.g., toxic oxides

of nitrogen are contained in smoke

from burning buildings, ships, aircraft or tanks.


42


Chapter 3

Battlefield Advanced Trauma Life Support

Introduction

0301 Managing trauma on the battlefield, isstressful. It may be dark, dangerous, noisy, wet andcold. You are likely to be tired, hungry and frightened.Acquiring a drill will allow you to respond to casualtieswith life-threatening injuries with a minimum of mental effort, regardless of the environment and your own stress.

What follows in this chapter is not about casualtymanagement under fire, or other, equally dangeroussituations. Casualty care in the face of enemy actionmay be best achieved by winning the firefight, in whichyou may be a participant! Then, deal with the injured.Under these circumstances, simple, life-saving firstaid may be the reality. Attempting more sophisticatedcare may be achievable but, at the expense of yourlife and the lives of others. Nevertheless, in a relativelysafe environment, even an austere one with limitedequipment, diagnostic aids and assistance, it is possible to carry out advanced trauma life support techniques.

It is incumbent upon those who provide medical careto the victims of war to have a thorough knowledge of the basic techniques that will save lives. Fieldmedical personnel must learn to assess casualties - and the situation - using the five senses, temperedby the sixth sense - commonsense! That is what thischapter is about.

Mechanism of Injury: see Chapter 2

Do not become acasualty yourself.Make sure the sceneis safe before you oryour team approachthe injured.

3: Battlefield Advanced Trauma Life Support

43

Chapter_3.qxd 28/09/2004 15:54 Page 43

The first rule: prevent further injury to yourself andthe casualties! Reassure casualties that help is athand. Get a quick history (Mechanism of injury,Injuries sustained, Signs and symptoms, Treatmentgiven - MIST). Then, consider immediate casualtymanagement in four phases:

• Primary survey Identifies life-threatening problems.

• Resuscitation Deals with these problems.

• Secondary survey Top-to-toe examination.

• Definitive care Specific management.

The last two are likely to be carried out at a rearward echelon.

Primary Survey

0302. The primary survey is the most importantphase; it is easily remembered as

A B C D E

Airway with (when indicated) cervical spine control.

Breathing and ventilation.

Circulation with haemorrhage control.

Disability (Displaced brain) or neurological status.

Exposure depending on environment or Evacuation.

A consistent, systematic approach

is essential.

For every casualty consider

the following:• Is the airway

patent? • Is the casualty

breathing?• Is there

life-threatening blood loss?


44

Chapter_3.qxd 28/09/2004 15:54 Page 44

Airway with cervical spine control.

Airway

0303 Do not be distracted by other injuries; airway obstruction can quickly result in cerebralhypoxia (3 minutes) and death (10 minutes).

Talk to the casualty! A 'normal' reply indicates thatthe airway is patent, breathing is normal and brainperfusion adequate (NB: this can rapidly change).Failure to respond implies an altered level of consciousness with potential, or actual, airway compromise. Inappropriate or incomprehensiblespeech suggest onset of airway and/or breathing difficulties with reduced cerebral oxygenation.

Look. Is the casualty agitated (hypoxia?), drowsy(hypercarbia?) or cyanosed? Look for evidence offacial fracture (1805) or neck injury (0307). Check theback of the mouth for blood, vomit or foreign bodies.Is there evidence of nerve agent or cyanide poisoning(Figure 0301)? Remember:

• The absence of cyanosis does not mean thecasualty is adequately oxygenated.

• A casualty who refuses to lie quietly may be trying to sit up in an attempt to keep their airwayopen and/or breathing adequate. Similarly, theabusive casualty may be hypoxic rather thaninsubordinate or intoxicated.

Listen for abnormal sounds. Snoring, stridor and gurgling are associated with partial airwayobstruction. Remember:

• Hoarseness implies laryngeal injury.

• Total obstruction equals total silence!

Feel for air movement on expiration.

Maxillofacial Injury: see Chapter 18

Airway problemsmay be: immediate,delayed (minutes orhours) or insidious(deteriorates withtime and is easilyoverlooked).


45

Chapter_3.qxd 28/09/2004 15:54 Page 45

0304 Early preventable deaths from airway problems are frequently due to:

• Failure to recognise the urgent need for intervention.

• Limited experience in clearing the airway.

• Selecting an inappropriate airway manoeuvre.

• Failure to secure the airway prior to casualty transfer.

• Becoming distracted by less urgent problems.

0305 Battlefield injuries associated with airwaycompromise include:

• Head injury with decreased level of consciousness allowing the tongue to fall backand block the hypopharynx.

• Other causes of reduced consciousness (e.g., poisoning, alcohol, reduced atmosphericO2, carbon monoxide).

• Maxillofacial injuries:

• Displaced mid-face fractures obstructing the airway.


46

��

��

��

��

��

��

�� !��!��"#��

��

Fig 0301 Chemical weapons: nerve agent and cyanide poisoning is likely to be most immediately fatal. Comparison of features identified at “quick look”.

Chapter_3.qxd 28/09/2004 15:54 Page 46

• Unstable mandibular fractures causing tongue instability.

• Blood, debris or mucus blocking the airway.

• Injuries to the neck:

• Direct trauma to the larynx and supporting structures.

• Bleeding inside the neck compressing the hypopharynx and/or the trachea.

• Burns to the face, neck and airways.

0306 A cleared airway may obstruct again if:

• The casualty's level of consciousness deteriorates.

• There is further bleeding or vomiting.

• There is increasing swelling in or around the upper airway.

Cervical spine injury

0307 Cervical trauma is less of an issue on thebattlefield; the management of life-threatening ABCinjuries take priority. Nevertheless, the integrity of the cervical spine must be considered. Cervical spine injury is suspected:

• In falls >5m.

• Significant blunt injury above the clavicle.

• Following high-energy trauma e.g.,RTA, pedestrian injury, explosion.

• In the unconscious casualty unable to give a history following blunt trauma.

• In the casualty complaining of neck pain or loss of sensation and/or motor function in one or more limbs.

Airway burns: see Chapter 22

Cervical spine injuryoccurs after ~ 4% of penetrating headinjuries. In civilianpractice, cervicalspine injury is reported to occur in 7-15% of casualties after blunt head injury.


47

Chapter_3.qxd 28/09/2004 15:54 Page 47

0308 Penetrating neck wounds involving the bonycervical spine or spinal cord, carry a 95% mortality. In survivors, these wounds can be ignored in terms of cervical spine protection. A combination of bluntand penetrating neck injuries should be managed as for blunt injury.

0309 Whilst moving from Airway to assessing thechest (Breathing), quickly examine the neck. An aidememoire is Twelve. Look for

• Tracheal displacement. Feel with two fingerseither side of the trachea in the suprasternalnotch. In an advanced tension pneumothorax,the trachea is pushed away from the affected side.

• Wounds.

• Surgical Emphysema. This may affect the neck,face and trunk. Feel for the characteristic subcutaneous crepitus. Causes include: tensionpneumothorax, tracheobronchial damage,oesophageal rupture, fractured larynx (rare), or a dislodged chest drain (commonest cause).

• Laryngeal injury.

• Venous distension. Consider tension pneumothorax or cardiac tamponade (NB: maybe absent in hypovolaemic casualties).

• Examine the neck everywhere, every time!

Breathing and ventilation0310 Examine the following:

• General: Repiratory rate, cyanosis, respiratorydistress, wheezing, tachypnoea and haemoptysis.Rapid, shallow respiration is usually due to chestwall trauma, pain, air hunger or anxiety. Considernerve agent or cyanide poisoning (Figure 0301).

• Inspect: the anterior and lateral sides of thechest, run your hands down the back feeling for

25% of casualtieswith chest injuriesdie unnecessarilyand 85% of thesecan be saved by

simple care!


48

Chapter_3.qxd 28/09/2004 15:54 Page 48

wounds, look for the presence of blood on yourhands. Inspection of the back, unless urgentlyindicated e.g., detection of an open pneuthorax,can wait until the secondary survey. Look forwounds, bruising and asymmetrical movement.Signs of respiratory distress include: sitting forward with use of accessory muscles of respiration, intercostal recession, see-saw respiration and supraclavicular and epigastricindrawing. Paradoxical movement associatedwith flail segments may not be obvious in a muscular serviceman.

• Feel: Rib fractures are suspected if there is localtenderness, pain on springing the chest, chestwall deformity or surgical emphysema (0309).Use the hands to check for wounds and symmetrical chest movement, especially if lighting is poor.

• Percuss: Hyper-resonance suggests a pneumothorax and dullness a haemothorax or lung contusion (Figure 0302). NB: All threeconditions (pneumothorax, haemothorax andlung contusion) commonly coexist following major chest injuries.

• Auscultate: breath sounds are absent or reducedwith a pneumothorax or haemothorax. Heartsounds may be muffled in cardiac tamponade.NB: auscultation may be severely impeded byexternal noise!

0311 Identify or exclude the six crisis injuries(aide memoire: ATOMIC):

• Airway obstruction.

• Tension pneumothorax.

• Open pneumothorax.

• Massive haemothorax.

Chest Injury: see Chapter 15

Wounds to the chestmay be associatedwith abdominal andspinal injuries. Do not forget theabdominal cavityextends up as highas the level of nipples and tips ofscapulae.

Meaningful chestexamination isimpossible in themidst of battle, during tactical casevac by air or in a moving vehicle!


49

Chapter_3.qxd 28/09/2004 15:54 Page 49

• Indented (Flail) chest.

• Cardiac tamponade.

Circulation with haemorrhage control 0312 Shock is the general response of the bodyto inadequate tissue perfusion and oxygenation. On the battlefield, this is usually due to bleeding orburns. Approximate volumes of blood lost in commoninjuries are shown in Figure 0303. In the young andfit, classical signs of shock do not usually appearuntil >30% of circulating volume is lost (Table 0301).

0313 Assess:

• External bleeding. Do not forget the back; run your hands down the postero-lateral aspectsof the head, trunk and limbs looking for bloodand wounds.

• Possible internal haemorrhage. Look for suspicious features in the:

1. Chest (0310).

2. Abdomen (1206) e.g., bruising, distension,open wounds, tenderness, guarding andrebound. NB: the abdomen is a silent reservoir for blood loss! Absence of signsdoes not equal absence of an intra-abdominal catastrophe!

3. Pelvis/retroperitoneum (1310) e.g., severepain, buttock wounds, abdominal wallhaematoma, deformity, pain with one pelviccompression (Figure 1302), crepitus, scrotalhaematoma, meatal bleeding and bleedingPVE and/or PRE.

4. Long bones (0903) e.g., pain, swelling,wounds, deformity, loss of function, visiblebone, absent pulses.

• Mental state. See Table 0301

Aide memoire for sources of

major blood loss:Blood on the floor(external loss) and

four more: • Chest.

• Abdomen/Pelvis.• Retroperitoneum.

• Long bones.


50

Chapter_3.qxd 28/09/2004 15:54 Page 50

Abdominal assessment: see Chapter 12

NB: In fit military personnel with a low resting pulse,any increase in ratedue to haemorrhagemay not initially,appear significant.


51

$��

��

Fig 0302 Severe chest injury commonly causes a haemo-pneumothorax and lung compression/contusion. The percussion note is typically resonant over air and dull over blood.A chest drain should be placed so as to evacuate both.

Heart rate

Systolic BP

Pulse pressure

Capillaryrefill

Respiratoryrate

Urine output

Cerebralfunction

<100/min

Normal

Normal

Normal

14-20/min

>30 ml/hr

Normal/slightly anxious

>100/min

Normal

Narrowed

Prolonged

20-30/min

20-30 ml/hr

Anxious/frightened/hostile

120-140/min

Decreased

Narrowed

Prolonged

>30/min

5-20 ml/hr

Anxious/confused

Class ofshock

Blood loss

I

Up to 750ml

<15% lost

II

750-1500 ml

15-30% lost

III

1500-2000ml

30-40% lost

IV

>2000 ml

>40% lost

>140/min

Decreased/unrecordable

Very narrow/absent

Prolonged/absent

>35/min

Negligible

Confused/unresponsive

Table 0301 Classes of shock and associated clinical features.

Chapter_3.qxd 28/09/2004 15:54 Page 51

• Colour. Hypovolaemic casualties are typicallypale, cold, sweaty and cyanosed.

• Presence of pulses. In the absence of a sphygmomanometer, minimum systolic BP can


52

%��!��#��&''�

&''��

(�)��!��*�+,

-.&,

-,

*&'�

$�� *.&,

&''��!�**

Fig 0303 Typical blood loss associated with common injuries.

Chapter_3.qxd 28/09/2004 15:54 Page 52

be estimated from the presence or absence ofpalpable peripheral pulses: Radial = 90mmHg;Femoral = 80mmHg; Carotid = 70mmHg. Absentradial pulses (check both sides), is significant.

• Pulse rate. A rate over 120 indicates significanthaemorrhage until proven otherwise.

• Capillary refill time (CRT). Press the finger pulp for five seconds, normal colour shouldreturn within two seconds. Delay indicatesimpaired peripheral perfusion (NB: unreliablein cold and dark!).

Disability or neurological status 0314 This is a simple AVPU assessment of thecasualty's level of consciousness and pupils (1610,1612). Are they:

Alert.

Voice responsive.

Pain responsive.

Unresponsive?

0315 What is the approximate pupil size, are they equal and do they react to light? An abnormalitysuggests brain Displacement due to blood clot.Record the findings so that any change can beappreciated later.

Exposure 0316 This should be sufficient to allow assessment and treatment of life-threatening injuries.NB: total exposure may not be possible in austeresurroundings; this may have to wait for a more stableenvironment but, do not miss life-threatening injuries.

Head Injury: see Chapter 16

Level of consciousness not only reflects neurological status, it can be influencedby hypovolaemiawith cerebral hypoperfusion.


53

Chapter_3.qxd 28/09/2004 15:54 Page 53


54

Fig 0304 Safe helmet removal requires two rescuers. The head andneck are initially supported from above. The second rescuer then supportsfrom the front. The first rescuer removes the helmet and then takes controlfrom above.

Chapter_3.qxd 28/09/2004 15:54 Page 54

Resuscitation

0317 The resuscitation phase is carried out simultaneously with the primary survey. Life-threateningconditions are identified and managed as they arefound. Administer oxygen to all serious casualtieswith maximum flow rates (10-15 l/min) through atight-fitting mask and reservoir. Keep casualties aswarm as conditions allow. Management of nerveagent and cyanide casualties is discussed in 0236and 0241 respectively.

Airway and cervical spine

Cervical spine

0318 In a casualty with suspected cervical spineinjury (0307), inline immobilisation and airway management are carried out together. Avoid extendingthe neck (e.g., during chin lift). The head and neckare controlled bimanually at all times by an assistant.Remove any head gear (Figure 0304). Do not releasehead and neck control until injury has been excluded,or three point fixation is applied (semirigid collar,sandbags/blocks, head tape). Measuring for andapplying a cervical collar, are illustrated in Figure 0305.

Cervical spine control may initially have to be ignored(e.g., on the battlefield or a rescuer attempting tomanage an airway single-handedly). In the combativecasualty, trying to immobilise the spine may causemore harm than good; compromise by using acervical collar only.

Airway management

0319 This comprises clearing, maintaining andprotecting the airway at risk and may need to be supplemented by ventilatory support.

If the casualty's neck is bent and there are problemsmaintaining the airway, gently move the head into the

Chemical Casualties: see Chapter 2

Priority is CLEAR THEAIRWAYbut stay safe


55

Chapter_3.qxd 28/09/2004 15:54 Page 55


56

Fig 0305 (A) the cervical collar is sized from the tip of the chin to thetop of trapezius. The head must be immobilised during application inthe vertical (B) and horizontal positions (C).

(A)

(B)

(C)

Chapter_3.qxd 28/09/2004 15:54 Page 56

neutral position. Stop if there is resistance, or thecasualty complains of pain. Immobilisation may haveto be in a suboptimal position.

0320 Clearing the airway

• In a casualty with an altered level of consciousness, the tongue falls back andobstructs the hypopharynx. This can be correctedby a chin-lift (Figure 0306) or jaw thrust (Figure0307) manoeuvre. Jaw thrust is preferred becauseit is will successfully open an obstructed airwayin 95% of casualties (chin lift 70-80%) and is lesslikely to destabilise a cervical spine fracture.

• Blood and vomit should be aspirated under direct vision i.e., use a torch or laryngoscope.Alternatively, perform a finger sweep using agauze swab wrapped around the fingers. Solidmaterial may be removed with the aid of Magillforceps. Do not inadvertently push foreign bodiesfurther down the airway.

• Where airway obstruction is due to a fracturedmaxilla, attempt to reduce it as in Figure 1805. A mandibular fracture may destabilise thetongue; treatment is to pull the mandible and tongue forward until the airway can be maintained by other means.

Try simple airwaymanoeuvres first. If the casualty gagsor coughs, stop anduse another method.

Ventilation is generally beneficialafter severe headinjury. Attempting to intubate the semiconscious casualty mayincrease intracranialpressure and worsen the situation.


57

Fig 0306 Chin lift: in the unconscious casualty, this may be aided byplacing the thumb in the mouth. Avoid extending the neck .

Chapter_3.qxd 28/09/2004 15:54 Page 57

0321 Maintaining the airway

Clearing the airway may result in an improvement inlevel of consciousness and the casualty being able tobreath unaided and protect their own airway. It maythen be safe to turn them into the three-quartersprone position (Figure 0308). NB: consider cervicalspine injury. If they cannot maintain their own airway,continue with jaw thrust or chin lift; alternatively, use an oropharyngeal (OPA) or nasopharyngeal airway (NPA).

An OPA (e.g., Guedel, Figure 0309) is simple andquick to insert. A NPA (Figure 0310) can be usedwhen there is oral injury, a fractured mandible ormasseter spasm. It is better tolerated than an OPAand is less likely to be dislodged during transfer.

Insertion of OPA: see 3002 Insertion of NPA: see 3003

OPA and NPAdevices maintain

the airway but do not protect from aspiration. This can

only be prevented bya secure (definitive)airway i.e., a cuffed

tube placed in thetrachea by the surgical route

or by endotracheal intubation.


58

Fig 0307 Jaw thrust: fingers are positioned behind the angle of the mandible. Place palms on cheekbones for counter traction.

Fig 0308 Three-quarters prone position.

Chapter_3.qxd 28/09/2004 15:54 Page 58

Airway Manoeuvres: see Chapter 30


59

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0��!��#�

/*

Fig 0309 Insertion of an OPA. Place a mask and reservoir bag overmouth and nose.

A suspected fractured base of skull is a relative contraindication for its use: if it is needed to maintain an airway, use it!

0322 Protecting the airway at risk

This requires advanced airway techniques: a surgicalairway (cricothyroidotomy 3005 rarely, tracheostomy3007), or endotracheal intubation (3009). Insertion ofan appropriate tube into the trachea maintains a clearpassage and the cuff provides a protective seal

Chapter_3.qxd 28/09/2004 15:54 Page 59

Aeromedical Evacuation: see Chapter 29

In casualties being evacuatedby air, inflate thecuff with saline;

air expands withincreasing altitude.

It is not lack of intubation that kills,it is lack of oxygen!


60

against aspiration. Indications include:

• Real or anticipated difficulty clearing and maintaining an airway:

• Maxillofacial and neck injuries.

• Face and airway burns.

• Obstruction due to swelling or aspiration.

• Continued loss of consciousness.

• To allow accurate control of oxygenation andventilation (e.g., general anaesthesia, treatmentof head injury).

• Management of some chest injuries.

• Safe transfer of “at risk” casualties.

Fig 0310 Insertion of NPA. Lubricate well and stay close to the floorof the nose.

Chapter_3.qxd 28/09/2004 15:54 Page 60

Unless an anaesthetist is available, or you are experienced and have access to anaesthetic drugsfor those too awake to intubate without their use (i.e., GCS >4), a surgical airway is recommended.Endotracheal intubation without drugs, has very little,if any, part to play in airway management in trauma.A laryngoscope and endotracheal tube in the wronghands, can deprive casualties of oxygen!

A cricothyroidotomy can be performed under LA andis easier than a tracheostomy in the field. Commercialsets are available for rapid access using a Seldingerguide wire technique. There are limited indications forneedle cricothyroidotomy (3004). Both the laryngealmask airway (LMA) and Combitubes have been usedin civilian practice to manage the trauma casualty'sairway. Their role in military trauma has still to be evaluated.

Breathing and ventilation0323 Thoracic trauma can be penetrating and/orblunt (includes blast injury). Occasionally, injury isoccult e.g., a missile tracking across the diaphragmfrom the abdomen. Pulmonary function is affected bythe degree of lung tissue damage and the presenceof blood and air in the pleural cavity. This may or maynot be accompanied by rib fractures and an openwound; both can compound the problem.

Having assessed the casualty, you must decidewhether they:

• Require resuscitation thoracotomy as part of theprimary survery (rarely indicated) (1529).

• Require urgent thoracotomy (1530).

• Have thoracic pathology requiring non-surgicaltreatment e.g., insertion of a chest drain (3013).

• Do not have significant thoracic injury.

Thoracotomy: see Chapter 15

Do not use themouth-to-mouth or mouth-to-masktechnique if there is a chemical agentvapour hazardeither in the environment or on the casualty.

Tracheal deviationand cyanosis are late signs of a tension pneumothorax. You must perform a needlethoracocentesis.


61

Chapter_3.qxd 28/09/2004 15:54 Page 61

Tension pneumothorax

0324 Features suggestive of a tension pneumothorax are illustrated in Figure 0311. If yoususpect the diagnosis, perform an immediate needlethoracocentesis (3012) on the most likely side. NB:can be bilateral.

Open pneumothorax (“sucking chest wound” 1508)

0325 For wounds <12 cms in diameter (size ofclosed fist), apply an Ashermann seal (3011), orocclusive dressing; follow this by insertion of a chestdrain remote from the defect (3013). Cover any exitwounds with an occlusive dressing.

Wounds >12 cms in diameter are managed by applying the external cover of a field dressing (clean side against the wound) taped to the skin onall sides. Insert a chest drain remote from the wound.If the defect overlies the normal site of insertion, thedrain may be laid in the wound before the applicationof occlusive dressings. In a dire emergency, the chestdrain can be inserted through the defect, irrespectiveof its location.

Small chest wall defects (<1cm) are more likely to result in a tension pneumothorax than a suckingwound. If there is respiratory distress, perform animmediate needle thoracocentesis (3012), apply anocclusive dressing followed by insertion of a chestdrain (3013).

Massive haemothorax

0326 This is usually due to a penetrating wounddisrupting the systemic or pulmonary vessels. Each hemithorax can hold up to 2·5 litres of blood.Clinical signs are of hypovolaemic shock and respiratory distress, with absent breath sounds and dullness to percussion on the affected side(Figure 0302).

Performing a needle

thoracocentesis in acasualty who doesnot have a tension

pneumothorax mayproduce a

pneumothorax or lung damage in

10 to 20%.

On the battlefield, it is safer to

follow needle thoracocentesis by

insertion of a chest drain.

If respiratory distress supervenes

following the application of

occlusive dressingsand before the

insertion of a chestdrain, assume the

development of a tension

pneumothorax and perform needle

thoracocentesis.

On an erect chest X-ray, at least 500 ml

of blood can be hidden behind the

shadow of thediaphragm.

A massive haemothorax is

defined as >1500ml.


62

Chapter_3.qxd 28/09/2004 15:54 Page 62

Treatment is i.v. fluid resuscitation followed by insertion of a chest drain if there is respiratory distress (3013). Most cases will stop bleeding spontaneously. In the absence of respiratory distress(RR < 30), consider delaying chest drainage untilthere are facilities for immediate thoracotomy: inserting the drain can lead to circulatory collapse as the tamponading effect of blood in the chest cavity,is released.

Flail chest

0327 This occurs when a complete segment ofchest wall loses bony continuity with the rest of thethoracic cage (Figure 1502). Associated features are haemothorax and underlying lung contusion,the latter being the main problem. Field managementinvolves inserting a chest drain and appropriate painrelief (Figure 0701). Use of intercostal nerve blocks(0736) can reduce pain and aid respiration.Subsequently, a period of positive pressure ventilationmay be required.

Nerve blocks: see Chapter 7

The injured lung is sensitive to over hydration aswell as hypovolaemicshock - give i.v. fluids carefully.


63

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Fig 0311 Features of a tension pneumothorax

Chapter_3.qxd 28/09/2004 15:54 Page 63

Cardiac tamponade

0328 Leakage from the heart or great vessels intothe pericardial sac is commonly due to a penetratinginjury. Unless small, it is usually immediately fatal- the most likely outcome on the battlefield. Considerthe diagnosis in casualties with a penetrating chestinjury who do not rapidly respond to resuscitation.Classical signs are hypotension, muffled heartsounds and distended neck veins (Beck's triad). An open subcostal pericardiocentesis is preferred(1542). Needle pericardiocentesis even withmonitoring, is rarely effective (3015). A subsequentthoracotomy is required for direct repair of thecardiac injury.

Ventilatory support

0329 The aim is to improve gaseous exchange inthe lungs and to breathe for the casualty if spontaneousventilation has stopped, or is inadequate. Indicationsfor assisted ventilation include:

• Head injury.

• Chest injury, usually lung contusion.

• Respiratory depression (e.g., nerve agents and opiates).

Assisted ventilation can be achieved by the followingtechniques:

• Mouth to mouth (NB: pinch nostrils) or mouth to nose. Use a face shield where available.

• Mouth to mask (Figure 0312)

• Bag-valve-mask (Figure 0313)

• Bag-valve surgical airway (3005)or intubation (3009).

• Automatic ventilation.

The aim is to achieve obvious chest movement at arate of approximately 12-15 breaths per minute (one

Intensive care: see Chapter 25

Unconscious casualties without a definitive airway

must not be transferred lying

on their backs.

A face mask without a reservoir

bag can deliver 35-60% oxygen.

With a reservoir thisincreases to 85%.

A correctly fittingbag-valve-mask with a reservoir, will deliver up to

100% oxygen.


64

Chapter_3.qxd 28/09/2004 15:54 Page 64

breath, release for three to four seconds). An oxygensource and reservoir should be attached. If there isno oxygen inlet, place the oxygen tubing under theside of the mask.

Circulation with haemorrhage control

0330 The treatment of shock is to restore cellularand organ perfusion with oxygenated blood. Think ofhaemorrhage as either compressible: you can dealwith this, or, non-compressible: a surgeon deals withthis. External haemorrhage must be arrested. This ismore important than establishing i.v. lines. Remember,blood on the floor is forever lost to the casualty!

Crystalloids arecheap and safe but, only remain inthe circulation for 30minutes.

Three volumes arerequired to replaceone volume of bloodlost. Colloids remainin circulation forlonger and replacelost volume on aone-to-one basis.They become viscous below 10°C.


65

Fig 0312 Mouth to face mask ventilation. NB: Combined with Jaw thrust.

Fig 0313 Bag-valve-mask (BVM) ventilation. NB: Combined with Jaw thrust.

Chapter_3.qxd 28/09/2004 15:54 Page 65

Options for haemorrhage control include local pressure (digital, pressure dressing), elevation, compression over the brachial or femoral arteries and application of a tourniquet.

• One or more sterile field dressings are packedinto the wound and held in place with a firmlyapplied crepe bandage (0502). It they becomesaturated with blood cover with fresh dressings.Removal of the original dressing risks dislodgingany clot that has already formed.

• It may be possible to reduce bleeding from apuncture wound in the root of the neck or groinby inserting a urinary catheter, inflating it with50-60ml of water and pressing over the balloon.A technique for safely applying pressure to aneck wound is to place a rolled-up dressing overthe defect and an i.v. fluid bag on the oppositeside and to firmly bandage around both.

• Tourniquets should only be used to control life-threatening haemorrhage when all othermeasures have failed. The ideal tourniquet is

Attempts to control bleeding by

the blind insertion ofa clamp or artery

forceps into thedepths of a wound

are unlikely to besuccessful and

may cause further damage.


66

Fig 0314 Use of a tourniquet.

Chapter_3.qxd 28/09/2004 15:54 Page 66

broad and can be applied single-handedly by the casualty. It should be positioned as distallyas possible to preserve limb length should amputation become necessary. Place a padover the artery to be compressed. Tighten untilbleeding stops (Figure 0314). Record the timeand draw the letter 'T' on the casualty's forehead;release it hourly. Often, on first release, you willfind that bleeding has ceased or local pressurewill suffice!

• Clotting adjuncts are currently under trial. Thesetake the form of impregnated sponges, dry fibrinsealant dressings, water absorbent granuleswhich concentrate clotting factors or sytemicallyadministered clotting factors (e.g., recombinantFactor VIIa).

0331 Splint and immobilise fractures and extensive soft tissue wounds by any means available(Figures 0315, 0316). Elevate the part if possible(Figure 0317). Malleable (e.g., SAM splint Fig 0318),inflatable or vacuum splints, provide good emergencysupport. Where available, use a traction splint for afractured femur (e.g., Sagar splint Fig 0319) or apply

Management of Limb Injury: see Chapter 9

Unless released for 2-5 minutes every hour, a tourniquet is likely to cause irreversiblesoft tissue damageafter 6-8 hoursnecessitating amputation.

You are sacrificingthe limb to save thecasualty's life.


67Fig 0315 Immobilisation of upper limb injuries in the field.

Chapter_3.qxd 28/09/2004 15:54 Page 67

a Thomas splint with a Crookham halter. (Figure 0320). In addition to holding the fracture,traction has the effect of converting the initial spherical wound haematoma into a smaller volumeellipse, thereby reducing blood and tissue fluid loss(Figure 0321).

In anteroposterior compression pelvic fractures (openbook - 1305), some control of bleeding may be achieved by pelvic splinting (Figure 0322).

0332 Non-compressible haemorrhage requires“hypotensive” resuscitation and urgent surgical control. Occasionally, an immediate thoracotomy or laparotomy is necessary, as part of the primary survey in casualties with major bleeding.

0333 Restore circulation to an acceptable level.

Establish two large calibre intravenous lines (i.e., size 12 or 14) in both antecubital fossae. Wherethis is not possible, perform a cut down (3017) or afemoral vein cannulation (3019). Intra-osseous fluidinfusion is an option when intravenous access isdifficult or impractical.



68

Fig 0316 Immobilisation of lower limb injury in the field.

Chapter_3.qxd 28/09/2004 15:54 Page 68


69

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Fig 0317 Supporting the injured arm.

Chapter_3.qxd 28/09/2004 15:54 Page 69

Infuse warmed crystalloids or colloids. Where available, use blood in Class III or IV haemorrhageas an adjunct to surgery. In the shocked casualty,give fluid at a rate that will quickly restore the radialpulse. Thereafter, infuse according to response. The aim is to obtain a blood pressure sufficient tomaintain tissue perfusion to vital organs (~ 90mmHg),that is, a just palpable radial pulse. Over enthusiasticresuscitation causes rebleeding by inducing transitoryrebound hypertension, hypothermia (unless the fluidis at 37o C) and dilutional coagulopathy. In fit soldiers,a systolic pressure of 75-80 mmHg, is acceptable.

If it is possible to urgently transfer a casualty withnon-compressible haemorrhage to a surgeon, do notdelay by attempting to gain i.v. access and starting

Civilian data suggest that, where urgent

transfer is possible,“scoop and scoot”

is better than“stay and play”


70

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Fig 0318 Uses of the (Splint Aluminuim Maleable) SAM splint.

Chapter_3.qxd 28/09/2004 15:54 Page 70

Management of Limb Injury: see Chapter 9


71

Fig 0319 Application of the Sagar traction splint for femoral fracture.

Chapter_3.qxd 28/09/2004 15:54 Page 71

resuscitation. Follow the algorithm in Table 0302.Hypertonic saline dextran (HSD) is used in someunits for emergency fluid restoration (1ml replaces10ml lost). Give casualties suffering from non-compressible haemorrhagic 100ml HSD i.v. over 5 minutes. Further aliquots should be administered as required to maintain a radial pulse.Where transfer time is prolonged, a total of 5 x 100mlaliquots may be administered before conventionalfluid therapy is started.


72

Fig 0320 Immobilisation of a fractured femur using a Thomas splitand Crookham halter.

�� !��

2��#�� 2��"��

2��#�� 2��"�.!.��

��#�� 7 ��

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Table 0302 Summary of battlefield fluid resuscitation.

Chapter_3.qxd 28/09/2004 15:54 Page 72

Assess effects of resuscitation 0334 Monitor:

• Alertness (AVPU, GCS 1611).

• Respiration (rate, expansion and symmetry).

• Pulse rate and rhythm.. • Capillary refill time.

• Blood pressure.

• Urinary output (ideal: adults 50ml/hr - children 1-2ml/kg/hr).

• Pulse oximetry/ECG (if available).

• Arterial blood gases (if available).


73

Fig 0321 Traction reduces the volume of the fracture haematoma.

Chapter_3.qxd 28/09/2004 15:54 Page 73

Secondary Survey and Packaging

0335 Carry out a secondary survey when andonly when the casualty is stable. Remember: all of us have backs, sides tops and bottoms, as well as lots of holes, both natural and as a result of injury,all should be examined! Perform a log roll wherespinal injury is a possibility (Figure 0323).

Spinal Injury: see Chapter 20

Remember every orifice merits

a finger, a light or a tube.


74

Figure 0322 Immobilisation of a fractured pelvis in the field. Placepadding between pressure points.

Fig 0323 Performing a four-man log roll.

Chapter_3.qxd 28/09/2004 15:54 Page 74

Examine systematically:

• Scalp and vault of skull (1618).

• Face and skull base (1805).

• Neck and cervical spine.

• Chest (0310).

• Abdomen (1206).

• Pelvis (1310).

• Limbs (0903).

• Spine and neurological examination (2006).

0336 Following polytrauma, take X-rays of the lateral cervical spine, pelvis and chest. In penetratingchest injuries, perform an additional abdominal X-ray.Look for:

• Foreign bodies.

• Position of fractures (NB: fractures of the transverse processes and first and second ribs indicate severe force).

• Position of any tubes.

• Soft tissue injury, evidence of lung contusion, pneumothorax and/or haemothorax.

0337 Methods used to aid the diagnosis ofintraperitoneal bleeding following blunt traumainclude:

• Focused Abdominal Sonography for Trauma (FAST-1213).

• Diagnostic Peritoneal Lavage (DPL 1212).

• CT scanning (1214).

Penetrating abdominal injury invariably requires a laparotomy.


75

Chapter_3.qxd 28/09/2004 15:54 Page 75

Packaging prior to transfer0338 Consider the following:

• Is the airway secure?

• Is in-transit (escort) care adequate?

• Explain and reassure.

• Analgesia (Figure 0701).

• Antibiotics (0813-0822) and tetanus toxoid (0828).

• Insertion of a urinary/suprapubic catheter (Figure1409), nasogastric tube or chest drain (3013).

• Stabilisation of fractures and soft tissue injuries.

• Where indicated, fix to a spinal board or vacuummattress (Figure 0324)

• Record events.

Whenever possible and if the situation does notdemand a 'scoop and scoot' approach, the casualtymust be adequately packaged before transfer.

Once in an evacuation vehicle, especially a helicopter,dealing with a deteriorating casualty is virtuallyimpossible. Even simple monitoring procedures canbe difficult.

Definitive Care

0339 Definitive care generally takes place in rearareas and is discussed in the relevant Chapters.

It is equally important to remember that if you do notget the primary survey and resuscitation phases correct, definitive care may be in the hands of theWar Graves Commission!


Whenever possibleand if the situationdoes not demand

a “scoop and scoot”approach, the

casualty must beadequately packaged

before transfer.


76

Chapter_3.qxd 28/09/2004 15:54 Page 76


77

Fig 0324 Immobilisation on a spinal board with three-point cervicalspine fixation.

Chapter_3.qxd 28/09/2004 15:54 Page 77


78

Chapter_3.qxd 28/09/2004 15:54 Page 78

Chapter 4

Damage Control Surgery

Introduction

0401 The traditional role of surgery in the management of torso trauma is to control bleedingand, within the abdomen, deal with enteric, biliaryand pancreatic spillage. This is usually attempted bydefinitive repair or removal, of damaged structures. It has been demonstrated that this approach can beassociated with an unacceptably high mortality in theseverely injured.

The recognition that outcomes are determined by the physiological limits of the seriously injured casualty, rather than by the efforts of the surgeon torestore disrupted anatomy, has led to the acceptanceof “damage control” being the optimal surgicalapproach for selected victims of major trauma. In other words, the approach that is most likely tosave life. Descriptive terms applied to this processinclude: abbreviated laparotomy, bail-out surgery and temporary abdominal closure. These terms implydamage control is only applicable to abdominal trauma; this is not the case.

For this reason, the term “damage control surgery”(DCS) is preferred, especially in the context of military trauma.

Put simply, DCS techniques are applied when themagnitude of tissue and organ damage are such that,prolonged surgery is likely to exceed the casualty'sphysiological limits. The concept is that only the minimum is done to deal with life-threatening problems. Examples include: methods for rapid control of bleeding, control of enteric spillage without restoration of gut continuity, tractotomy for

Mechanisms of Injury: see Chapter 2

4: Damage Control Surgery

79

Chapter_4.qxd 28/09/2004 15:54 Page 79

penetrating lung injury, rapid amputation of a mangled limb in the presence of other equally serious injuries and temporary restoration of bloodflow to a limb using vascular shunts. Further surgeryis then delayed until various physiological parametershave been restored to as near normality as possible.

Why Perform DCS?

0402 The commonest cause of death on the battlefield is shock due to blood loss. Hypovolaemicshock leads to the onset of three inter-related variables: metabolic acidosis, profound hypothermiaand overt coagulopathy (Figure 0401). Each of thesefactors reinforces the others and contributes to thedeath of the casualty, usually by exsanguination.Metabolic acidosis occurs as a result of reduced tissue perfusion and oxygenation triggering the onsetof anaerobic metabolism. Hypothermia is induced or compounded by: reduced heat production due to shock, a low ambient temperature, exposed bodycavities (operative or traumatic), anaesthetic agentsand infusion of cold fluids. A core temperature below35oC, significantly affects coagulation despite normallevels of clotting factors. Mortality in casualties with a core temperature below 32oC, approaches 100%.

By comparison, aggressive re-warming is associated with a reduction in mortality, blood loss,fluid requirement, organ failure and in subsequentlength of time to recovery.

When to Perform DCS?

0403 The majority of battlefield casualties requiretraditional surgical management (0401). DCS shouldbe limited to the minority who are critically unstable.These will usually have multi-visceral injuries andexsanguinating haemorrhage; DCS is an integral partof resuscitation for this group. In one large civilian

Amputation: see Chapter 11 Hypothermia: see Chapter 26

NB: laboratory measurements for

standard laboratoryvalues are obtained

on specimenswarmed to 37°C,

hence in-vitro clotting times may

be normal in the face of in-vivo coagulopathy

due to hypothermia.

The onset of diffusebleeding in a cold

casualty implies thephysiological limit

for that casualty has already

been passed.


80

Chapter_4.qxd 28/09/2004 15:54 Page 80

series, DCS was only necessary in 5% of casualtiesrequiring laparotomy for trauma. This figure is likelyto be higher in military practice, where surgical facilities can be exposed to simultaneous multiplecasualties - when operative procedures should be asshort as possible - and where the surgeon may lackthe skills or equipment for complex reconstruction. In the latter case, simple, short procedures will oftenproduce the best results.

The decision to adopt a DCS approach to casualtymanagement should be taken in the early stages of surgery or, better still, before surgery is started.The longer the decision is delayed, the more futilethe process becomes because the outcome is likelyto be unfavourable. Some of the factors that indicatethe need for a damage control approach, are inTables 0401 and 0402.

0404 Disadvantages of DCS include: an increasedconsumption of resources (e.g., transfusion, staplingdevices, ITU facilities etc., all of which may be

ITU Support: see Chapter 25


81

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Fig 0401 Consequences of major trauma.

Chapter_4.qxd 28/09/2004 15:54 Page 81

severely limited) and the potential build up of post-operative DCS casualties requiring time consuming and complex second-look surgery in the next 24 to 48 hours. In such circumstances,techniques such as intraoperative autotransfusion of blood and a “minimal transfusion” approach, are helpful in reducing the need for blood products.

To ensure that resources are not "wasted" on theunsalvageable casualty (DCS is not synonymous with futile care!), triage protocols driving casualtyselection for DCS, must be rigorously enforced.

1 Haemodynamic instability

2 Multiple torso penetrating injuries

3 Survivors of class IV haemorrhage

4 Pre-operative core temperature <35°C

5 Arterial pH < 7.3

6 Serum lactate > 5mmol/l

7 Established coagulopathy:

PT or PTT > 50% normal

8 Multiregional injuries,

e.g., quick laparotomy before neurosurgery

Table 0401 Pre-operative casualty selection for DCS.

1 Resuscitation and operative time exceeding 90 minutes

2 Core temperature 34°C or less

(further surgery is probably futile)

3 Worsening non-mechanical diffuse bleeding

4 Massive transfusion, > 10 units packed cells

(unlikely in a war setting)

Table 0402 Per-operative indications for DCS.


82

Chapter_4.qxd 28/09/2004 15:54 Page 82

DCS Techniques

Initial operation

Incision:

0405 Always make generous incisions. For abdominal injury, perform a full midline incision(Figure 0402), with the casualty draped to allowextension into a thoracotomy, median sternotomy or to gain vascular access at the groin.

Laparotomy

0406 Evacuate the haemoperitoneum and packthe four abdominal quadrants and pelvis. Carefullyremoving each one in turn should allow identificationof the sources of bleeding (Figure 0403). Perform a systematic laparotomy looking for organ damage and other sources of blood loss (Figure 0404).

Abdominal Surgery: see Chapter 12


83

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Fig 0402 Standard abdominal midline incision for trauma. Drape thecasualty so as to allow extension into the chest and vascular access.

Chapter_4.qxd 28/09/2004 15:54 Page 83

A peacetime manoeuvre for controlling torrentialabdominal haemorrhage is to clamp the thoracic aortathrough a left anterolateral thoracotomy (Figure 0405).Visualisation may be easier than controlling theabdominal aorta above the coeliac axis (Figure0406). Both techniques are unlikely to be applicablein the field (1276).

Controlling the Aorta: see 1276


84

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)

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+,

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Fig 0403 The classical sites for blood to collect in the abdomen. Initially control by packing.

Fig 0404 Perform a systematic laparotomy NB: examine both leavesof the small bowel mesentery. Consider opening the lesser sac, mobilising the colon/rectum and “Kocherising” the duodenum.

Chapter_4.qxd 28/09/2004 15:54 Page 84

Control of haemorrhage

0407 This is achieved by direct means usingsutures, ligatures, clips and diathermy, or indirectly,by packing or various tamponade techniques. Packsshould be so placed as to re-approximate disruptedtissue planes. Unless packing is effective at the timeof laparotomy, the hope that time, tamponade andhaemostatic mechanisms will control bleeding,especially if arterial in origin, is futile. In this case,repack or use other means. Conversely, overpackingwithin the abdomen risks compressing the inferiorvena cava thereby increasing intra-abdominalpressure and reducing venous return (1258). Packing may also be used to control pelvic andretroperitoneal bleeding. Clotting adjuncts, such asrecombinant factor VIIa (rVIIa), are currently underinvestigation (0330). Preliminary results suggesttimely administration of rVIIa will help control severe haemorrhage.

Liver Injury

0408 Compression is the quickest and mosteffective method of controlling bleeding from a disrupted liver; it is even applicable following retrohepatic caval injury (Figure 0407). The injuredlobe is mobilised and compressed by packs placedabove, below and lateral, or in front and behind

Approach to the Liver: see 1257


85

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Fig 0405 Clamping the thoracic aorta to temporarily control torrentialabdominal haemorrhage.

Chapter_4.qxd 28/09/2004 15:54 Page 85

(Figure 0408). The key is to pack the liver so as tore-approximate its shape and not to force packs into disrupted liver substance. A non-crushing clampplaced across the structures in the free edge of thelesser omentum (Pringle’s manoeuvre), will reduceblood flow to the liver via the portal vein (70% ofhepatic blood flow) and hepatic artery (Figure 0407).Continued bleeding following liver packing andrelease of the clamp, indicates bleeding from theretro-hepatic vena cava. Balloon tamponade can beused to control deep or through-and-through hepaticwounds. A Penrose drain tied at one open end thenpassed over a rubber tube and tied around the innertube at the other end, then inflated via the tube, givesgood tamponade along a lengthy wound track (thesame principle as a Sengstaken tube compressing


86

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Fig 0406 Clamping the abdominal aorta above the coelic axis.

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Fig 0407 Manually compression and Pringle’s manoeuvre to controlhepatic bleeding.

Chapter_4.qxd 28/09/2004 15:54 Page 86

oesophageal varices). Vena caval tamponade using a Foley catheter inserted via a small venotomy, canbe used as a last resort (Figure 0409). Splenic injuryon the battlefield necessitates splenectomy (1251).

Abdominal visceral injury.

0409 Spillage following damage to thegastrointestinal tract may be controlled by tying withtapes, simple runnning sutures or the use of staplingdevices, including skin staples (Figure 1204). The closed-off loops of bowel are returned into the abdominal cavity. Large bowel perforations maybe exteriorised in the manner of a loop colostomy(Figure 1213); small perforations can be closedquickly using skin staples. Biliary (Figure 0410),pancreatic (Figure 0411) and urinary leaks (1408,1417, 1421), should be controlled by external tubedrainage. All reconstruction is deferred until relaparotomy

Chest wounds

0410 Thoracic injuries do not lend themselves to packing as a means of controlling blood loss.Cross clamping the hilum (Figure 1549) or rotatingthe lung through 180 degrees after dividing theinferior pulmonary ligament, will control major lunghaemorrhage and/or air leak. Other useful DCStechniques include: non-anatomical lung resection

Managing Urinary Leaks: see Chapter 14


87

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Fig 0408 Placing packs to compress the liver.

Chapter_4.qxd 28/09/2004 15:54 Page 87

using staples (Figure 1550) and tractotomy (Figure1514). The latter is achieved by passing two longarterial clamps down the length of a penetratingwound, the tissue between the clamps is then dividedThis allows the wound to be inspected, vascularcontrol obtained and an airtight seal effected byoversewing the tissue in the clamps (1550). The

Surgical Handicraft: see Chapter 30


88

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Fig 0409 Massive liver bleeding: isolating the vascular supply usingPringle's manoeuvre and controlling the IVC with a balloon catheterand sloop.

Fig 0410 Draining the biliary tree: cholecystostomy tube and 'T' tubein the bile duct.

Chapter_4.qxd 28/09/2004 15:54 Page 88

same procedure can be done more quickly employinglinear staplers in place of clamps.

Vascular injuries

0411 Simple repair is the preferred treatment following vascular trauma. It can usually be completedquickly and will control haemorrhage and restore circulation. Other options include: ligation, placementof a temporary vascular shunt or insertion of a synthetic graft:

• The risk of critical limb ischaemia (CLI) necessitating limb amputation following ligationof a supplying vessel, is shown in Figure 0412.CLI is more likely if there is extensive soft tissuetrauma causing damage to collateral vessels andin elderly casualties with pre-existing vasculardisease. When necessary, all leg veins and theinferior vena cava can be ligated (1277). This islikely to result in varying degrees of limb oedema.The individual jugular veins can be tied off without major sequelae. In extremis, the portalvein can be ligated; this is likely to result in massive ascites (1280).

• A Shunt can be used to temporarily restore distalblood flow (Figure 0413), allowing time for returnof normal physiology, transfer to a vascular surgeon, or whilst first attending to higher priorityinjuries. Examples include: bridging a defect inthe common femoral artery or carotid artery andre-establishing venous return following majorvein injury. Shunts may be purpose made (e.g., heparin-bonded silastic, Javid shunt) and held in place by ring clamps or snuggingdevices, or extempore shunts. A length of sterileplastic tubing (e.g., cut from a giving set),inserted into both ends of the damaged arteryand held in place with double ties, will suffice.Complications include: shunt displacement,thrombosis and intimal damage. Alternatively,

Vascular Techniques: see Chapter 12

Shunts may become dislodgede.g., during transfer,leading to suddenunrecognised haemorrhage. They should only beused where trainedpersonnel are available to monitorand treat this complication.


89

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consider inserting a synthetic graft (GoreTex™is preferred) - this is almost as quick in the righthands, as shunting.

• Where available, angiographic embolisation may complement other methods of haemostasis.

Temporary abdominal closure

0412 Formal abdominal closure is unnecessary inthe interval before relaparotomy. Techniques include:closure of the skin only using clips or a running


90

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1�� #�

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Fig 0411 Placing balloon catheters and drains to control a major tearof the head of the pancreas and duodenum.

Chapter_4.qxd 28/09/2004 15:55 Page 90

suture or, suturing a piece of plastic (e.g., infusionbag) to the wound edges (“Bogota Bag”). A suturelesstechnique that reduces the likelihood of abdominalcompartment syndrome and prevents soiling of theward bed, is the “Opsite sandwich”. An abdominalpack is opened out and covered by the adherentsurface of a sheet of Opsite™ (1290). This sandwichis tucked under the edges of the wound (rectusmuscle) and two suction drains placed over it. The entire wound is then occluded with a largeOpsite sheet and the drains attached to continuous,low-pressure suction (Figure 0414).

Abdominal Compartment Syndrome: See 1290


91

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Fig 0412 The likelihood of emergency arterial ligation leading to limbamputation in a young fit casualty.

Chapter_4.qxd 28/09/2004 15:55 Page 91

Restoring Normal Physiology0413 Interventions include:

• Mechanical ventilation to improve oxygenationand removal of CO2.

• Enhancing oxygen delivery. Therapeutic optionsinclude: improving cardiac output with volumeinfusion and inotropic drugs and increasing oxygen-carrying capacity by blood transfusion.

• Rewarming can be achieved by increasing the ambient temperature to the thermoneutralzone (28-30oC), employing external warmingdevices and warming all intravenous fluids andventilator circuits.

• Restoration of normal coagulation using freshfrozen plasma and platelets

Re-operation

Timing

0414 Timing of further surgery depends on thecasualty's condition and the type of trauma e.g., an injury requiring revascularisation calls for earlier,definitive repair than reanastomosing stapled bowel.Ideally the casualty should be normothermic with a normal coagulation profile. Conversely, delaying

Intensive Care: see Chapter 25

Laboratory tests of coagulation

and haematocrit lag behind real-time

blood-loss andempirical transfusion

is recommended.

Placement of a pulmonary artery

catheter will allowmeasurement of oxygen transport

parameters.


92

Fig 0413 Insertion of a temporary arterial shunt.

Chapter_4.qxd 28/09/2004 15:55 Page 92

surgery beyond 72 hours may lead to sepsis, ARDS and organ failure. The majority of casualtiesare returned to the operating theatre between 6 to 48hours post-DCS. In a military setting, the tactical situation may need to be considered when decidingtimings for re-operation. If the surgery has been carried out in a forward mobile unit, the casualtyshould be transferred rearward as soon as possible,ideally using “helevac”. The most suitable time islikely to be soon after surgery when there isphysiological improvement. Delay beyond this maysee the onset of deterioration demanding surgicalintervention beyond the capability and capacity ofa small, mobile unit. The unit's mobility may also becompromised. Re-operation should ideally, be carriedout in a well equipped, well resourced field hospital.

Other onsiderations

0415 Relaparotomy provides an opportunity tosearch for the 10% of intra-abdominal injuries missedat initial operation. They are a potent cause of morbidity and mortality. Classic markers that mayalert to this possibility include: a discontinuous missile trajectory, or an odd number of gastrointestinal perforations.

0416 Packs are sequentially removed and repairs inspected, vascular reconstruction may then



93

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Fig 0414 Temporary abdominal closure: the Opsite™ sandwich.

Chapter_4.qxd 28/09/2004 15:55 Page 93

be undertaken and urological and gastrointestinalcontinuity restored. If possible, 'critical' packs should be left undisturbed until the last momentas unpacking may lead to recurrent bleeding andthe need for repacking.

0416 Trauma victims have increased nutritionalneeds and early enteral feeding has been shown toreduce postoperative septic morbidity after trauma. It may be possible to manipulate a fine-bore feedingtube beyond the pylorus, if not, consider a feedingjejunostomy. Intestinal anastomoses are not acontraindication to enteral feeding.

0417 It may not be possible to close theabdominal wall due to distension. Alternatively it maybe considered undesirable to do so because ofconcerns over the development of the abdominalcompartment syndrome, or possible need for afurther laparotomy. Definitive closure may have towait until visceral oedema has completely subsided(0412).


94

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Chapter 5

Principles of Wound Management

Comparison of Civilian and Military Wounds

0501 There are important differences; militarywounds are usually:

• Caused by penetrating trauma. Involvement ofmore than one body compartment or area, iscommon e.g., thigh and pelvic wounds can becomplicated by spillage of abdominal contents.By comparison, civilian wounds are usually dueto blunt trauma and tend to be associated withsolid organ damage.

• More heavily contaminated than civilian wounds, notably with Clostridia species andGram-negative bacteria (0808).

• Infected because of delays in transferring thecasualty to a surgeon.

• Treated in less than ideal circumstances withlimited resources. The presence of large numbersof casualties may influence management.

General Casualty Management

Overview0502

1. Apply Battlefield Advanced Trauma Life Support(BATLS) measures, as soon as the tactical situation permits.

2. Apply a sterile field dressing, or dressings, firmlyover the wound. If this becomes saturated, putfurther dressings on top. Do not remove or loosen

BATLS: See Chapter 3

Delays in transferaveraged 10 hoursbetween woundingand starting appropriate surgeryduring the 1990-91Gulf war.

5: Principles of Wound M

anagement

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dressings unless there is evidence of distal limbcirculatory compromise, until the casualty hasreached a surgeon.

3. Give systemic antibiotics (0816) and tetanus toxoid (0828) as soon after wounding as possible.Antibiotics should be self-administered or, givenby buddy aid within one hour of wounding; they delay the speed of onset of wound infection (0804).

4. Where the missile has penetrated a body cavity,explore via a standard incision (e.g., abdominalmidline, anterior thoracotomy) and not throughthe wound.

5. Initial wound excision followed by delayed primary closure, is the norm for military wounds.The wound is lightly packed and the skin leftopen to avoid tension and aid drainage. Ideally,excision should be within six hours of wounding.For many soft tissue-only wounds, this timeframe can be stretched, providing appropriateantibiotics have been administered. Injuries of the face, scalp and scrotum are discussed in 0504.

6. Many superficial fragment wounds can be successfully managed by scrubbing them clean,followed by application of a dressing andantibiotics (0816).

7. Major limb wounds require fasciotomy (0908).Splint fractured limbs and extensive soft tissueinjuries. Elevate the injured part.

8. Delayed primary closure is usually performedfour to five days after wound excision. Heavilycontaminated wounds and limbs that may requireamputation, are reassessed at 48 hours.

9. Exposed joint surfaces should be covered at theinitial operation to reduce the risk of infectioncover vascular suture lines.

Haemorrhage control: see - 0407

Sterile dressingsapplied at point ofwounding and leftundisturbed until

surgery, reduce therisk of established

pre-operative sepsisfrom 20% to 5%.

Provided there is nourgency to control

haemorrhage, dealwith any wounds on

the back first.

.Antibiotics must not be regarded

as a substitute for surgery or

a reason forinadequate surgery.


anagement

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Chapter_5.qxd 28/09/2004 15:55 Page 96

10. Consider DVT/PE prophylaxis (0980).

Wound excision0503 Once the casualty has reached a surgicalfacility, the vast majority of military wounds requireexploration and wound excision or cleansing, underGA or LA. The principle is to remove all foreign andnon-viable tissue and to leave the wound open:

• Following wounding in a chemical environment,remove hazardous material e.g., clothing, with a no-touch technique. Irrigate the track withdilute Milton or 0.5% hypochlorite solution for 2 minutes. Wash body cavities with saline only.Place foreign bodies and fragments into bleachto prevent "off-gassing" (0230).

• All wounds should be thoroughly irrigated at thebeginning, during and at the end of the procedure.

• Start by excising the skin (Figure 0501). Removeonly that which is obviously beyond survival, or grossly contused. In a penetrating missilewound, it is usually only necessary to excise 1-2mm of the skin edge. Degloving injuries may necessitate more radical excision.

• Superficial fragment or low energy-transfer bulletwounds, can usually be managed by scrubbingthe wound, applying dressings and administeringsystemic antibiotics.

• If extension of skin wounds is required, incisionshould be in the long axis of the limb andobliquely or transversely across joints to preventlate contracture (Figure 0502). If for example,the track between entry and exit wounds crossesa joint, do not simply expose the damaged areabetween these two points; an "S"- shaped incisionis appropriate. A tourniquet is often helpful forforearm, hand and foot wounds. In the face,make incisions parallel to skin creases (askingthe casualty to screw their face up will aid

Abdominal Injury: see Chapter 12. Thoracic Injury: see Chapter 15

Neither antibioticsnor the method of splintage are a substitute for adequate woundexcision.

Traumatic flaps,once cleaned andrepositioned, oftenrecover to provideuseful skin cover.

Avoid opening upintact tissue planesand spreading contamination.


anagement

97

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anagement

98

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Fig 0501 A) Trimming the skin edge, B) Removing damaged deep fascia, C) Excising necrotic muscle, D) Loosely dressing wound with fluffed up, plain gauze.

Chapter_5.qxd 28/09/2004 15:55 Page 98

identification if surgery is being done under local anaesthesia).

• Damaged subcutaneous fat should be removed,but additional areas of degloving must not becreated by over generous excision.

• Deep fascia should be incised to give adequateaccess to underlying muscles. Do not incisedeep fascia unnecessarily unless it needs to be converted into a fasciotomy.

• Adequate excision of all non-viable muscle is essential. Irrigate with warm saline beforestarting to excise muscle; its colour may change,especially if the wound is very dirty. Excise withcare until viable tissue is apparent. Do not gougeout large divots of muscle, this may sacrifice living tissue. But, if in doubt, remove it.


When using a tourniquet, a broad,pneumatic device is preferred. Aim for a pressure of ~250 mmHg.

Do not inflate forlonger than 90 minutes.

Home made or non-pneumaticdevices will causelocal tissue damage.


anagement

99

��

Fig 0502 Perform wound extension in the long axis of the wound and obliquely or transversely across joints. In the face, make incisionsparallel to skin creases.

Chapter_5.qxd 28/09/2004 15:55 Page 99

Look for the "four C's" that indicate viability:

• Capillary bleeding when cut.

• Contracts when pinched.

• Colour of red meat.

• Consistency firm and not looking like 'stew'.

• Do not worry about exposing bone and tendons,leaving dead muscle will not provide protectionfor underlying bone.

• Many deep limb wounds, crush injuries, openand closed fractures, major vein ligation and re-vascularised limbs, require fasciotomy (0908),splinting (0331) and elevation.

• Primary amputation may be necessary as part of the operative management i.e., “radical”wound excision. Below knee amputation iscommonly required after anti-personnel minetrauma (0221).

• Nerves, patent blood vessels and tendons in continuity with muscle, are not excised. Dividednerve ends and tendons should be marked witha non-absorbable, monofilament suture for subsequent repair (tendons 3027, nerves 2119).Exposed bone or tendon does not have to becovered at the initial operation, but considerationshould be given to early closure of these woundsto prevent desiccation. Bone or tendon leftuncovered for long periods will usually requirefurther excision despite appearing viable at initialsurgery. All vascular repairs, including grafts,should be covered by muscle: do not applydressings directly to vascular suture lines (1028); the vessel or graft is likely to thrombose.

• All dead and contaminated bone must beremoved. The aim is to create a clean and non-infected wound in which later reconstructioncan take place. Viability of bony fragments can

Compartment syndrome: see 0906

The inexperiencedsurgeon may be surprised by the

extensive damagecaused by a

standard 5.56mmround and will

frequently underestimate the

amount of tissuerequiring excision.

Avoid antisepticsoaked dressings. If wound excision

has been adequate,antiseptics are

unnecessary and are toxic to bone

forming cells.


anagement

100

Chapter_5.qxd 28/09/2004 15:55 Page 100

be difficult to determine. Bone regenerationdepends on leaving as much periosteum as possible. Pieces of bone with no, or only minimal,soft tissue attachments, should be removed.Dirty bone ends are cleaned by scraping or useof bone nibblers back to bleeding healthy bone.The same applies to necrotic bone when operatingon neglected wounds.

Wounds of the face, scalp and scrotum0504 Because of their excellent blood supply,wounds in these areas can be closed primarily. Onlyminimal excision is usually required. Extensive facialwounds usually benefit from a deep layer ofabsorbable sutures. Try and match up landmarkse.g., edge of lip (Figure 0503). Use closely spaced,6/0 interrupted nylon sutures for the skin (remove at4-5 days and apply Steristrips™). Trimming the skinedge may produce a better cosmetic result,especially if the skin is contused. Where there is significant loss of skin and mucosa, tack them together, as in Figure 0503; this can be reconstructedlater employing a plastic procedure. Repair of injuriesto cartilaginous structures see 1903.

Open joint wounds0505 Penetrating joint injuries require explorationthrough the wound or a separate incision, removal ofunattached bone or cartilage and foreign bodies, followed by irrigation. Preserve as much synoviumand osteochondral fragments as possible. Insert asuction drain. The joint must be covered at the initialoperation to reduce the risk of infection. This can beachieved by closure of the synovium using anabsorbable suture, or covering the defect withadjacent capsule, muscle or skin. The remainingwound is left open for delayed primary closure.Immobilise the joint and elevate the limb. Repair of the capsule and ligaments is performed at the second operation.

Indications for Amputation: see 1106


anagement

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Chapter_5.qxd 28/09/2004 15:55 Page 101

Retained foreign bodies0506 The majority of foreign bodies are removedat the time of initial wound excision:

• Fragments - Do not open healthy tissue purelyto locate fragments. Retained, radio-opaque foreign bodies, are often found on subsequentradiography. Most can be left, with only a small


anagement

102

Fig 0503 Facial wounds: only minimal excision of facial wounds isusually required. Closure may necessitate a layer of deep absorbablesutures. Try and match up landmarks. Where there is significant loss of skin and mucosa, approximate using sutures.

Chapter_5.qxd 28/09/2004 15:55 Page 102

risk of complications. If wound sepsis occurs,secondary surgery will be required to removethe fragment.

• Bullets - If lying subcutaneously, these may be removed. Bullets retained in soft tissues and bone, can be treated conservatively. By comparison, those lodging in joints, bursae or spinal meninges, are preferably retrieved dueto the risk of lead arthropathy and toxicity. Thiscan be delayed until after casualty transfer andmay be facilitated by arthroscopic techniques.

Irrigation

0507 All wounds should be irrigated with copious amounts of fluid. In the case of openfractures, the bone ends must be washed. Wheresupplies are restricted, potable water can be usedwith a final washout of 1l of sterile saline. Following ahigh energy-transfer wound, tissue planes should bethoroughly irrigated "the solution to pollution is dilution".

Dressings

0508 Wounds should be dressed with large quantities of fluffed up, plain gauze, then coveredwith cotton wool or Gamgee and the skin left open.Do not pack wounds tightly; this prevents drainageand oxygen diffusion. Bandages and tape used tosecure the dressing must not tightly encircle and constrict the limb.

Repeated postoperative examination is unnecessary,painful and contributes to the spread of infection; the wound should not be disturbed unless specificindications arise:

• Evidence of systemic infection e.g., unexplained pyrexia, tachycardia or toxicity.

• Presence of spreading local erythema, oedema or crepitus.

Optimising Wound Healing: see 2303 and 3021

It has beenrecommended that5-10l of sterile fluidbe used for fractureirrigation.


anagement

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Chapter_5.qxd 28/09/2004 15:55 Page 103

• signs of distal vascular insufficiency, NB: remove all restricting bandages and casts (0908).

Immobilisation0509 Splint extensive soft tissue wounds (0331).Sometimes, a bulky dressing is sufficient. Elevatelimbs where possible. Fixation of bony injuries is discussed in Chapter 9. NB: walking wounded shouldnot be turned into stretcher cases by inappropriateimmobilisation, particularly if mass casualties are present.

Delayed primary closure0510 Following adequate excision, the wound is generally left undisturbed for four to five days.Heavily contaminated wounds and limbs that mayrequire amputation, are reassessed at 48 hours - earlier, if indicated by the presence of fulminating sepsis.

Inspection of large wounds should be performed intheatre under GA. If there is tension, infection or

Plastic Procedures: see Chapter 23

Offensive odouralone is not an

indication to takedown the dressing.


anagement

104

��

Fig 0504 Undermining of the wound edges to facilitate closure.

Chapter_5.qxd 28/09/2004 15:55 Page 104

necrotic tissue, closure is inappropriate. Perform a further wound excision. Deep exploration of thewound is not routinely performed. If necrotic tissueremains, the tissue planes will fall apart to reveal it.

Where appropriate, close the wound in layers. Thismay require some undermining of the wound edges(Figure 0504). A suction drain is advisable for deepcavities. This may be an appropriate time to performtendon (3027) or nerve repair (2119). Use staples ormonofilament nylon for the skin. Small wounds oftenclose themselves after repeated dressings. Surgicaltape, rather than sutures, should be used.

A panoply of plastic procedures are available to close wounds too large for complete delayed primarysuture (2310). Not infrequently, a combination of skinsuture and split skin grafts, are necessary to achievewound cover.

Suture and Knotting Techniques: see Chapter 30


anagement

105

Chapter_5.qxd 28/09/2004 15:55 Page 105


anagement

106

Chapter_5.qxd 28/09/2004 15:55 Page 106

Chapter 6

Triage

Introduction

0601 The management of a single, seriouslyinjured casualty in peacetime, is frequently difficult.On the battlefield, problems are compounded byenvironment, difficult terrain and tactical constraints.The situation is even more difficult when faced withlarge numbers of casualties. If a system for prioritisation of care of the injured is not in place,many salvageable casualties may die unnecessarily.Triage (from the French verb trier, to sieve or to sort),has evolved through military conflicts dating from theNapoleonic Wars and American Civil War, to recentcivilian disasters. It may be defined as:

Sorting casualties and the assignment of treatment and transfer priorities to wounded at each echelon of medical care.

0602 The principles of military triage are:

• Do the most for the most.

• Use available resources as efficiently as possible.

• Transfer rearwards those casualties requiring further treatment who can withstand the journey.

• Return personnel to duty as soon as possible.

Triage Priorities

0603 The T (Treatment) System of triage is widelyemployed. Triage priorities in a compensatedsituation - when the medical facilities can cope - are:

6: Triage

107

Chapter_6.qxd 28/09/2004 15:55 Page 107

T1 - casualties needing immediate life-saving resuscitation and/or surgery.

T2 - stabilised casualties needing early surgery but, delay is acceptable.

T3 - casualties requiring treatment but, a longer delay is acceptable.

Dead.

0604 In a mass casualty setting, when medicalfacilities are overwhelmed, the situation becomesuncompensated and triage priorities must change in order to save the maximum number of lives.Priorities become:

T1 - Immediate Treatment. Casualties needingemergency, life-saving resuscitation and/or surgery.Procedures should not be time consuming andconcern only those with a high chance of goodquality survival. Examples are: remedial airwayobstruction, accessible haemorrhage and emergency amputations.

T2 - Delayed Treatment. Those requiring majorsurgery (after initial treatment such as i.v. fluids,antibiotics and fracture splinting), or medicaltreatment, but where conditions permit some delay without endangering life. Examples are: open fractures of long bones, large joint dislocations and burns covering 10-30% BSA.

T3 - Minimal Treatment. Casualties with relativelyminor injuries, where a longer delay before treatmentis acceptable. T3 casualties can effectively take care of themselves or be helped by untrainedpersonnel. Examples are: minor lacerations and uncomplicated fractures.

T4 - Expectant Treatment. Multiply-injuredcasualties needing extensive time-consumingtreatment, or with a poor chance of survival. Theyshould receive appropriate supportive treatment

Severe Head Injury: see 1607 Severe Spinal Injury: see Figure 2001

Examples of a mass casualty

situation include a single MO with

limited equipmentdealing

simultaneously with6 major casualties,

or a field hospitalsuddenly receiving

100 chemicalcasualties.

Some ambulatorycasualties

categorised as T3,may have injuries ofsufficient magnitude

to cause clinicaldeterioration

requiring a change in priority.

6: Triage

108

Chapter_6.qxd 28/09/2004 15:55 Page 108

compatible with resources, e.g., analgesia. Examplesare: severe head and spinal injuries, extensive burnsand large doses of radiation. Once casualties in theother categories have been treated, medicalpersonnel can then turn their attention to survivorsin the T4 group.

Dead

0605 Categorisation and the level of careprovided, depends on resources and casualtynumbers. During a mass casualty situation, life-saving treatment may initially be confined to openingairways and stopping compressible haemorrhage.

Triage for treatment0606 A widely accepted physiological method oftriage for treatment is the Triage Sieve. This involvesan assessment of the casualty's mobility, followed byairway, breathing and circulation (Figure 0601).

Severe Burns: see Chapter 22 Radiation Injury: see 0224

6: Triage

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0607 Triage is only a 'snapshot' of how thecasualty is at the time of assessment. In order toidentify changes, the triage sieve must be repeatedat each link of the casualty evacuation chain and thepriority adjusted to reflect deterioration or improvementin the casualty's clinical condition. It is importantinitially not to try to predict how a casualty maydeteriorate, this will lead to over-triage (a higher thannecessary triage category) and can overwhelm thesystem with T1 and T2 casualties.

Triage for transfer0608 Following performance of the triage sieveand initial treatment, casualties should be morestable with, for some, a significant change in theirinitial triage category. The next consideration is whoshould be transferred rearwards first and theoptimum facility they should go to. Determiningpriority for transfer can be accomplished with the aid of the Triage Sort. Triage sort uses therespiratory rate, systolic blood pressure and GlasgowComa Scale, to numerically score the casualty from 0 to 12 and give an indication of priority for transferand/or the need for further intervention (Figure 0602). This score has a proven direct relationship tooutcome from severe injury.

0609 After coding each of the three parameters,add them together to give a score ranging from 0(dead) to 12 (physiologically normal). Priorities fortransfer are assigned as follows:

• T1 1-10

• T2 11

• T3 12

• T4 1-3

• Dead 0

Triage sort for Head injuries: see Figure 1602

Assessing CRTis unreliable in the

cold or dark.

In a casualty with arespiratory rate inthe normal range,

absence of a radialpulse will put them

in the Priority 1category for

treatment.

6: Triage

110

Chapter_6.qxd 28/09/2004 15:55 Page 110

The overlap in scores for T1 and T4 (expectant)allows for the seriously injured to be placed in eithercategory, depending on number of casualties andavailable resources. Similarly, where the prioritydetermined by physiology does not match theanatomical severity of injuries, the priority can beupgraded. An example is the soldier with severehaemorrhage from a leg wound. Because of theCirculation problem, he is triaged for treatment usingthe triage sieve as T1. Following application of atourniquet and fluid resuscitation the triage sort scoreis 12 i.e., low priority for transfer. Because herequires urgent surgery, this is changed to T2.

Triage sort for Burn injuries: see 2217, 2231 and 2246

6: Triage

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0610 Medical cases are categorised in exactly thesame way in relation to their need for resuscitationand timely intervention by a physician.

0611 Psychiatric cases generally fit into the T3bracket. Treating them as far forward as possibleresults in the maximum number being rendered fitenough to be returned to duty.

Casualty Transfer Chain

0612 During military operations, casualties areusually transferred rearwards through Echelons ofMedical Care. These correspond with the levels ofoperational deployment:

• First Line at unit level.

• Second Line at brigade or divisional level.

• Third Line between the divisional rear boundaryand point of entry.

• Fourth Line at the base.

0613 Echelons should not be confused with Rolesof Medical Support which is the term used throughoutNATO to define levels of medical capability.

Role 1 Treatment to restore and stabilise vitalfunctions. (Regimental Aid Post - Unit Aid Post -Medical Section).

Role 2 Resuscitation and stabilising treatment. If A&E, surgical and intensive care teams areattached, thereby enhancing capability at this level,this is described as Role 2+.

Role 3 Field Hospital. All hospital facilities andsupport staff.

Role 4 Time consuming, specialist and long termtreatment, usually back in the home country.

Military Psychiatry: see Chapter 27

6: Triage

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0614 Early surgery is generally carried out atRole 3 (i.e., Field Hospital; Primary CasualtyReceiving Ship - PCRS), with subsequent care takingplace at a Role 4 hospital There will be occasionswhen surgery, through a field surgical team beingattached, is available forward of field hospitals. This will be the norm in airborne, airmobile andamphibious operations and when surgical teams areattached to Squadrons of Close Support MedicalRegiments (previously Field Ambulance). Specialist teams, such as burns, neurosurgery and maxillofacial, are allocated to selected fieldhospitals. All of these considerations will influencethe transfer of casualties.

Major Incident Medical Management: see Chapter 28Incident Response Team and Aeromedical Evacuation: see Chapter 29

6: Triage

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6: Triage

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Chapter 7

Analgesia in Forward Areas

Introduction

0701 The priority for most casualties after injury is rapid and effective pain relief. Pain is a complexphenomenon, the perception of which can be affectedby psychological, emotional and physiologicalprocesses. Effective management requires you todeal with all of these aspects simultaneously by:

• Repeated explanation and reassurance. Thisdecreases both physiological and emotionalfactors and is helped by keeping the casualtywarm, treating them in quiet and familiarsurroundings and early transfer.

• Reducing the pain stimulus e.g., by splintingfractures and cooling burns.

• Reducing pain sensation by giving analgesicsusing the battlefield protocol (Figure 0701).

Effects of Inadequate Pain Control

0702 Pain exaggerates clinical shock, There is evidence to show that pain relief reduces thepotential for serious complications following majorinjury. Inadequate pain relief is associated with:

• Reduced ability to cope psychologically with the effects of injury and surgery.

• An uncooperative casualty who is difficult to assess.

• Reduced casualty mobility resulting in:

• Poor lung expansion and expectoration

Physiologicalresponse to pain:

• Increasedsympathetic activitycausing release of“stress” chemicals(catecholamines).• Nausea andvomiting.• Hyperventilation.• Tachycardia.• Peripheral vasoconstrictioncausing reducedtissue O2 delivery. • Increased O2

consumption.• Increasedintracranial pressure.• Hypoxia,hypercarbia andhypovolaemia lowerthe pain threshold.

7: Analgesia in Forward Areas

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leading to hypoxia.

• Increased risk of DVT (0979).

• Delayed recovery from surgery.

• Painful casualty transfer.

0703 Pain relief after injury or surgery isfrequently inadequate for a variety of reasons:

• Not viewed as a priority by rescuers or medical staff.

• Inadequate assessment and reassessment.

• Analgesia inappropriately withheld e.g., fear of side effects.

• Inappropriate method of analgesia, choice of drug and route of administration.

• Inadequate dosage.

• Inadequate frequency.

• Poor operator technique e.g., nerve block.

Analgesia

0704 Careful assessment and reassessment of the casualty's degree of pain and a logical approachto the choice of analgesic technique or drug, arerequired to achieve the best results. Initialassessment of pain immediately follows the primarysurvey and should be hourly thereafter. Improvementor deterioration can be monitored using a numerical(for example 0 - 10) or visual analogue scale (Figure 0701). An increasing pain score despitetreatment, can be the first indication that the casualtyis developing complications and should cause you tore-examine them.

Spinal damage may prevent the

casualty feeling painbelow the level

of the injury. Thiscan result in injuries

being missed orworsened.


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Considerations0705 Use of pain relieving drugs will depend ona number of factors:

Logistic

• What drugs are available?

• Stocks of necessary equipment e.g., syringes and needles.

• The number of casualties requiring treatment.

• Tactical situation.

Casualty

• Contraindications to a drug's use e.g., allergy.

• The clinical condition of the casualty, in particular, the presence of shock orrespiratory distress.

This analgesicprotocol summarisesthe principles ofacute painmanagement in thefield. Unlesscontraindicated: Entonox can be used at any stage for rapid, short-termpain relief.i.v. morphine worksrapidly and may begiven by trainedpersonnel titeratingdose against effect.

Most i.m. and oralpreparations take=10-30 minutes to work.

Adding ibuprofenenhances theanalgesic effect and may reducemorphinerequirement.


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Chapter_7.qxd 28/09/2004 15:55 Page 117

• Whether the casualty is about to undergogeneral anaesthesia and surgery.

Personnel

• The level of care and monitoring available.

• The skill, experience and training of the person administering the drug.

• The legal entitlement of the medical ornursing personnel to use a particular drug.

Severe pain

Morphine sulphate

0706 Morphine Sulphate is the gold standardanalgesic for moderate to severe pain in the field.Acting on opiate receptors, morphine influences paintransmission within the spinal cord and perception ofpain in the brain. This results in analgesia, anxiolysis,mood elevation and a degree of sedation.

0707 Morphine can be administered at the pointof wounding using the Medimech Auto Injectordevice. It contains 10mg of the drug and is designedfor injection through the casualty's clothing deep intomuscle. The preferred site is the upper outerquadrant of the buttock on the uninjured side.

This can be done by the casualty, a buddy or a medicadministering first aid. An 'M' should be drawn on thecasualty's forehead along with the time the drug wasgiven. It usually starts to work after 10-30 minutes,but the peak effect is later. A further dose may needto be given after 30 minutes. Subsequently, no moremorphine should be administered until the casualtyhas been reviewed by a medical officer. A medic isallowed to give further 10mg injections every twohours, providing that certain physiological criteria are met (Figure 0701). This approach is equallyapplicable at Role 1 or Role 4.

The most feared side effects from the

use of morphine in the field

are respiratorydepression and

vasodilation in theunder-resuscitated

casualty, resulting inworsening

hypotension.

Injecting into thelateral thigh risks

damaging the lateralcutaneous nerve.


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0708 Intramuscular morphine has the advantagesof not requiring qualified staff and a more sustained,if less predictable effect, than i.v. morphine. In thecold or shocked casualty, morphine can linger inpoorly perfused muscle until warming andresuscitation allows absorption into the blood. If several doses have been given and aresimultaneously washed out of the muscle,this can lead to a relative overdose.

0709 Morphine is available in ampoules of 10 or 15mg which may be given i.m. or i.v. Intravenousmorphine has the advantage of a rapid response.Dilute 10mg with 0.9% saline to give a volume of10ml (1mg morphine = 1ml). In the resuscitated adultgive an initial slow i.v. injection of 5 mg of morphinefollowed by boluses of 1 to 2 mg according to paincontrol, heart rate and BP. Continuous i.v. infusionsof morphine and Patient Controlled Analgesia (PCA)devices, are available at Role 3.

0710 Antiemetics

These will frequently be necessary where morphinehas been used, particularly when the casualty isbeing transported, as the incidence of vomitingduring transfer is significant. The phenothiazines(e.g., prochloperazine 12.5mg i.m.) andmetoclopramide (10mg i.v./i.m.), are effective intreating nausea and vomiting caused by drugs but,ineffective in motion sickness. Prior to transfer,motion sickness can be prevented with hyoscine(400mcg s.c./i.m.), cyclizine (50mg i.v./i.m.) orondansetron (4mg i.v/i.m.).

0711 Naloxone

Naloxone antagonises the effects of morphine.Available as a 400 mcg/ml i.v. injection, initial dosesare 100-200 mcg, with increments of 100 microgramsevery two minutes. Its action is specific but short


Age is a goodpredictor of total morphinerequirement duringthe first 24-48 hourperiod. Casualties>20 years of ageusually need 100 mgper 24 hours minustheir age in years.

For example, theapproximate dose fora 20 year old soldierwould be 100 mgminus 20 = 80 mg ofmorphine in divideddoses.


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lived and the reappearance of respiratory depressionafter 1 hour is a possibility. The duration of action of naloxone can be prolonged by giving additionaldoses i.m. Side effects include: nausea, tachycardiaand hypotension. Analgesia will also usually be reversed.

0712 Side effects of morphine

These include:

• Drowsiness.

• Nausea and vomiting (common).

• Hypotension (due to histamine release and vasodilation).

• Respiratory depression (rare when pain is still present).

• Constriction of pupils.

• Constipation.

0713 Contraindications

Morphine should not be given to:

• An unconscious casualty.

• Respiratory depression i.e., respiratory rate <8-10/minute.

• Hypotension (systolic BP <90mmHg).

Ketamine hydrochloride

0714 In sub-anaesthetic doses (adults 0.5mg/kg), ketamine can be used to provide analgesia for potentially painful procedures.Examples include: redressing burns, manipulation offractures or the extrication of a trapped casualty.Advantages are:

• Powerful dissociative analgesia.

• Sedation.

Do not withholdmorphine because

of fears of addiction:

Casualties do notdevelop dependence

when morphine is used to treat

acute pain.


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• A wider margin of safety than other anaesthetic agents.

• Possible to titrate dose against response.

• Short acting (5-10 minutes).

• Laryngo-pharyngeal reflexes tend to be preservedand the airway maintained better than with otheranaesthetic agents (NB: not guaranteed).

• Stimulates the cardiovascular system resulting inmaintenance of cardiac output and BP (althoughboth may fall in the shocked casualty).

0715 Side effects of ketamine

• Transient psychosis/hallucinations. Thesesymptoms occur in the recovery phase and are more common with high doses or repeatedadministration. They can usually be prevented by small doses of a benzodiazepine (e.g., midazolam 1-2mg i.v.).

• Nausea and vomiting.

• Salivation (may need suction).

• Respiratory depression (more likely to occur if morphine or othersedative drugs have been given).

• Increased intracranial pressure following headinjury. In ventilated casualties, where blood CO2 levels can be controlled, this is less of a problem.

• Increased intraocular pressure.

Entonox™

0716 This is a safe and effective analgesic gaswhich, when inhaled, enters the circulation, crossesthe blood/brain barrier and produces a central effect. It is composed of 50% nitrous oxide (weak anaesthetic agent) and 50% oxygen.

Ketamine for Anaesthesia: see 2523

NB: Use ofbenzodiazepinesincreases the risk of airwaycompromise and cardiovascularsuppression.


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0717 Entonox is primarily used for pain relief atthe scene of an incident and when manipulating andsplinting fractures. Give Entonox for at least twominutes before attempting treatment (NB: it takes on average two to five minutes to take effect, butmay be as long as 10 minutes).

0718 Explain the purpose of the gas mixture to the casualty and how to use the mask. Suitablecandidates must be fully conscious, capable ofunderstanding what is being offered and not haveany airway or breathing problems. The very young or very old may have difficulty in correct mask fittingand require assistance. Reassure the casualty aboutthe possibility of nausea or drowsiness.

0719 Because the mixture will separate below 6oC with oxygen on the top and nitrous oxide below,cylinders should be stored above 10oC. Alternatively,rewarm by immersing the cylinder in water at 37oC forfive minutes then invert several times to mix thegases. Size D cylinders allow 20 - 30 minutescontinuous use.

0720 Special features include:

• Self-administered on demand by the casualtyinhaling deeply through a hand-held maskconnected via a demand valve to the gas cylinder.

• Inhalation of excess Entonox is prevented by the casualty becoming drowsy and releasingthe mask.

• Minimal side effects.

• Analgesic effect rapidly reverses.

0721 Cautions

The use of Entonox requires care in:


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• Head injuries (see 0737)

• Chest injuries (see 0738)

• Intoxication - Entonox increases the depressanteffects of alcohol, morphine and/or illicit drugs.

• Mental Illness or psychiatric disturbances - The casualty may not understand instructionsor become distressed or violent.

0722 Contraindications

In casualties from diving injuries nitrous oxide willincrease the size of the nitrogen bubbles that comeout of solution in large joints (‘the bends’), in thespinal cord (‘the staggers’), in the lungs (‘the chokes’)and in the skin (‘the creeps’).

Mild to moderate pain

Codeine phosphate

0723 Codeine is a weak opioid analgesicavailable for oral or i.m. use (15 mg every 2 hour, or 30mg every 4 hours to a maximum of 240mg). It is useful in the management of mild to moderatepain, particularly after head injuries or neurosurgery.

Compound analgesic preparations

0724 Oral preparations combining paracetamoland one of the weaker opioid analgesics such ascodeine, dihydrocodeine and dextropropoxyphene,are available for the treatment of moderate pain.These may be useful in postoperative casualties or in those with minor fractures or soft tissue injuries.

Non-steroidal anti-inflammatory drugs (NSAIDs)

0725 NSAIDs act on the pain chemicals releasedat the site of injury. Ibuprofen (400mgs 4-6hourly;max 2.4g daily), diclofenac and ketorolac, areavailable in oral, rectal and injectable preparations.

Oral analgesia is of limited value inbattlefield injuries. Its effectivenessdepends, in part, on gut motility andabsorption; both canbe delayed by injuryand shock.

Compoundpreparations havelittle advantage overparacetamol aloneand can produce thefull range of opiateside effects,including nausea,vomiting, drowsinessand respiratorydepression.


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They have a place in the management of soft tissueinjuries, minor fractures and postoperative pain,either in isolation or in combination “balanced analgesia”.

0726 Contraindications to the use of NSAIDsinclude:

• Severe asthma, especially if sensitive to aspirin.

• Where there is a threat of reduced renalperfusion, as in shock or dehydration.

• Active haemorrhage, in the anticoagulatedcasualty or a history of peptic ulceration/ cerebral bleeding.

A new class of selective NSAIDs (COX-2 inhibitors)are available which may have fewer side effects.

Paracetamol

0727 This is a simple analgesic and antipyretic. Side effects are rare. The usual dose in adults is 2 tablets (1g) 4-6hourly. Because of the risk of liverdamage, the casualty should ideally not receive morethan eight tablets per day (4g/day).

Local analgesia0728 The infiltration of local anaesthetics around a wound or the use of nerve blocks, can significantlyreduce pain in the pre- or post-operative periods anddecrease the casualty's requirement for morphine.Local anaesthetic blocks can provide safe andeffective analgesia in acute trauma.

The most commonly used agents are lignocaine andbupivicaine. There are a number of limitations in field conditions:

• Wounds do not respect anatomical boundariesand may be multiple; the chance of treating thecasualty's pain by the exclusive use of localanaesthetics is slim.

Adding ibuprofen can reduce the need

for morphine by 20-50% and improve

the quality of analgesia.

The antiplateleteffect of ibuprofenresults in a small

increase in woundbleeding which is

rarely of clinicalimportance.

Using several types of analgesiatogether, such as

morphine, ibuprofenand a local nerve

block, can producesuperior pain control.This is referred to as"balanced analgesia".


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• Personnel with appropriate anatomicalknowledge and training may not be available.

• Preparation of both casualty and materials is usually less than ideal in respect of casualtyaccess and positioning, fluid resuscitation and sterility.

• There may be insufficient time to perform and wait for the technique to work.

• Inadvertent toxic problems, although rare, will be difficult to manage on scene.

0729 Lignocaine (Lidocaine)

Lignocaine is a rapidly acting local anaestheticavailable in 0.5, 1.0, or 2.0% concentrations, with or without adrenaline. It usually starts to work withintwo to five minutes and persists for up to 90 minutes.The maximum safe dose (MSD) is 4 mg/kg bodyweight without, and 6 mg/kg of body weight with,adrenaline. 1% solutions are suitable for mostinfiltration and nerve block techniques. Because of the risk of complications, the use of solutionscontaining adrenaline are best avoided in the field.

0730 Bupivicaine

Available concentrations are 0.25% (2.5mg/mL) or 0.5% (5mg/mL). Bupivicaine takes five to 30minutes to work, but lasts up to 12 hours. The MSD of bupivicaine is 2mg/kg (up to 60ml of 0.25%, or 30mL of 0.5%).

0731 Safety

This is maximised by

• Inserting an i.v. cannula to allow rapid fluidresuscitation and treatment of allergic and toxic reactions.

• Always draw back on the syringe before injectingto avoid accidental i.v. injection.

In clinical practice,lignocaine andbupivicaine are often mixed togetherin equal proportionsin the same syringeso as to achieverapid action andprolonged duration(NB: beware of MSD).


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• do not exceed the MSD relevant for nerve blockand infiltration techniques.

0732 Regional techniques such as spinal andepidural analgesia may be used at Role 3 or Role 4(see 2524 - 2525)

0733 Topical analgesia is useful in eye injuries(Table 1702) and for urethral catheterisation.

Specific blocks0734 Femoral nerve block

Inject 10 to 15 ml of a mixture of 1% lignocaine and0.5% bupivicaine just below the inguinal ligament ata site 1.5 cm lateral to the femoral artery (Figure0702). Aspirate the syringe before injecting to checkthe artery has not been punctured. The block willonset in 5 to 15 minutes and last up to 12 hour.It provides good analgesia for femoral shaft fractures, allowing them to be reduced and splinted.If necessary, this block can be used in combinationwith morphine or ketamine.

0735 Haematoma block for reduction of closedwrist fractures

This is useful when dealing with a large number ofcasualties. Attention to sterile technique is importantto avoid infecting the haematoma. Adrenalinecontaining solutions should not be used. Inject 15 mlof a mixture of 1% lignocaine and 0.5% bupivicaineinto the haematoma at the fracture site. The blockwill take effect in about 5 minutes and last about 12 hours.

0736 Intercostal nerve blocks and pleuralanaesthesia

Intercostal blocks are used to treat the pain fromfractured ribs. They are also useful when placing

Rib Fractures: see 1503


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chest drains in alert casualties. The practical dangeris the risk of pneumothorax. Using short, small gaugeneedles will reduce the risk. Palpate the rib to beblocked in the posterior axillary line. If the ribcannot be palpated - do not attempt the block.Insert the needle through the skin until it hits boneclose to the lower margin of the rib (Figure 0703).

When the needle contacts bone, slowly move itdownwards until it just slips under the lower marginof the rib. Aspirate the syringe checking for absenceof air and blood. Inject 5ml of a mixture of 1%lignocaine and 0.5% bupivicaine. Good analgesiawill usually require additional blocks at one or twolevels above and below the fracture(s).

Following thoracic trauma, pain is often due to injuryto the sensitive pleura. If a chest drain has beeninserted this can be used to introduce 15mL of 0.5%bupivicaine into the pleural space. Afterwards, clampthe drain for 5 minutes to allow the drug to takeeffect. Observe the casualty during this period.

Pneumothorax: see 1505


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Chapter_7.qxd 28/09/2004 15:55 Page 127

Clinical Problems

Analgesia in head injury0737 Untreated pain may cause a rise inintracranial pressure which, in turn, can worsen a developing brain injury. Excess use of morphinewill cause respiratory depression (with hypoxia andhypercapnia) and make pupillary assessmentunreliable (1612). Pain management in the headinjured military casualty is a balance between treating pain and masking an injury requiringneurosurgical intervention.

• The casualty in coma after resuscitation is assumed not to be feeling pain.

• Headache in the casualty with minor/moderatehead injury is treated with either paracetamol,NSAIDs or codeine phosphate.

• Pain due to other injuries is treated with a combination of nerve blocks, paracetamol andNSAIDs. Ideally, morphine, if needed, is given as incremental i.v. doses (0709). Level ofconsciousness and cardiorespiratory state need careful monitoring.

Management of Head Injuries: see Chapter 16

Severe headacheassociated with

vomiting orneurological

deterioration, may indicate

an intracranialhaematoma (1625).


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Fig 0703 Performing intercostal nerve blocks.

Chapter_7.qxd 28/09/2004 15:55 Page 128

• In a casualty with a fractured skull, the nitrousoxide in Entonox coming out of solution (see0739) could increase the size of an intracranialair collection (pneumocephalus). This may causedeteriorating CNS signs. Practically, casualtieswith a serious head injury are unlikely to be ableto self administer Entonox. In those with mildconcussion and pain from other injuries, Entonoxshould be safe, particularly as the gas is onlylikely to be given over a short period of time.

Analgesia for casualties with chest injury0738 Fractured ribs and other chest injuries arevery painful. The act of breathing moves the brokenribs making the pain worse. The casualty is reluctantto take effective breaths and to cough. This results in retained secretions, atelectasis, poor oxygenationand carbon dioxide retention. Infection andrespiratory failure may follow. Treat chest injurieswith a combination of intercostal blocks, paracetamolor NSAIDs and incremental i.v. morphine, dependingon effect and the changing clinical picture. At Role 3or 4, management may include physiotherapy andepidural or intrapleural blocks. The casualtypresenting in respiratory failure needs ventilatorysupport and management in a field ITU.

Entonox and chest injury0739 Nitrous oxide is 35 times more soluble thannitrogen. It readily diffuses into air-filled spaces fasterthan nitrogen can be removed, causing increases in pressure and volume. In a casualty with a pneumothorax, the nitrous oxide in Entonoxincreases the size of the air collection and may evencause it to tension. A functioning chest drain must bein place before Entonox is used.

Mass casualties

0740 The provision of effective analgesia for

Chest Injuries: see Chaper 15


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mass casualties needs to be simple in its scopeand application, supporting the principle of providingthe greatest good for the greatest number. Followingtriage and resuscitation, administration ofintramuscular analgesics is likely to be the mostpractical approach, particularly if personnel lack i.v.injection and cannulation skills and resources arelimited. Large numbers of casualties with minorinjuries can be given oral analgesia. The monitoringof such casualties may need to rely on minimally trained personnel using simple clinical parameters.


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Chapter 8

Infections, Antibiotics and Biological Weapons

Introduction

0801 Despite the best efforts of man, battle injuryhas never been the greatest cause of death andinjury during warfare. That distinction falls toinfectious disease, accounting for up to 10 times the number of trauma casualties. An example is the American Civil War, which remains the singlegreatest loss of life by American Forces in combat - infectious disease accounted for three quarters ofcasualties and two thirds of deaths.

0802 Most infectious diseases of militarysignificance are transmitted by direct person-to-personcontact, faecal-oral spread, or by arthropod vectors.The importance of secondary infections of both battletrauma and subsequent surgical wounds, has longbeen recognised.

One of Florence Nightingale's observations at Scutariwas the apparent futility of military medical care:injured soldiers would be saved by heroic surgery in the field, only to succumb several days later towound infections acquired in the squalid hospitals.Around the same time, Ignaz Semmelweissdemonstrated the importance of hand washing on post-operative infection rates.

Changes in management brought about by suchobservations, formed the basics of infection controland present-day surgical techniques.

0803 The history of using biological agents toachieve military advantage ranges from the simple

8: Infections, Antibiotics and Biological Weapons.

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smearing of spears with faeces in order to inducewound infection, to the use of toxins such as ricinapplied to modern munitions.

Back to Basics - War surgery and infection

0804 The fundamental principles of much battlesurgery are based on reducing the risk of subsequentwound infection. These include:

• Primary surgery to remove foreign bodies - that may act as foci for infection - and deadand dying tissue that provide a bacterial growth medium.

• Prophylactic antibiotics to reduce rates ofbacteria multiplication in compromised tissues.

• Aseptic technique reduces further bacterialcontamination of wounds. NB: this may notalways be important in wounds heavilycontaminated by extraneous material and the casualty's own microflora, and not always practicable.

• Infection control to reduce post-operativecontamination of wounds by bacteria fromelsewhere on the casualty, other casualties or medical attendants.

Battle Trauma and Infection

0805 In elective surgical wounds, infection ratesfor many procedures can be reduced to <5%. Incontrast, battlefield injuries are prone to developinfections, either de novo or following surgery.Contributing factors include:

• Breach of skin and exposure of underlyingtissues to microorganisms.


Antibiotics do noteliminate bacteria

from contaminatedwounds, but merely

delay the speed of onset of

clinical infection.

Their use in the fieldis complimentary to

immediate anddefinitive surgery.

The single, most important

means of reducingpost-operative

rates of infection ishand hygiene, even

on the battlefield.


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• Implanted foreign matter.

• Tissue necrosis due to penetrating and blunttrauma, impaired blood supply, burns or chemicals.

• Penetration of hollow viscera releasing largenumbers of microorganisms into previouslysterile areas.

• Delays in primary or definitive surgical intervention.

• Deliberate contamination by an aggressor (0803).

Microbiology of War Wounds

0806 One of the few joys that a microbiologist has is the taunting of surgeons, either by discoveringnew bacteria or by changing the names of existingones. In reality, there are few pathogens of importanceto be aware of, and even these vary in their degreeof significance.

A rule of thumb in assessing surgical infections is to treat the casualty rather than the microbiologyresults! Clinical judgement will usually determine if a wound is clinically infected. Bacteria are said tocolonise sites from which they were previouslyabsent - infection, by definition, implies a diseaseprocess. It follows that there is little to be gained by"routine" sampling of normal wounds - treatmentwould only be indicated if infection was present.

The main reason for knowing something about themicrobiology of war wounds is to allow the clinician to make an informed and rational selection ofantibiotic treatment when infection occurs. In practice, pathogens are grouped according tothe site and nature of the injury; this can be used

to determine therapy.

Infection control is an integral part of good surgicalpractice.


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0807 Simple skin penetration or laceration,with or without environmental contamination

Likely organisms:

• Conventional pathogens.

• Aerobic organisms (grow well in the presence of oxygen).

• From the casualty's skin Staphylococcus aureus, less commonly Streptococcus pyogenes.

• environmental origin - Bacillus cereus.

0808 Wounds with necrotic tissue or poorperfusion, with or without environmentalcontamination

Likely organisms:

• conventional pathogens.

• anaerobic organisms (grow well in the absence of oxygen).

• Originating from the casualty's skin anaerobic cocci (Peptococcus species,Peptostreptococcus species).

• Environmental origin Clostridium species (such as Cl. tetani, Cl. perfringens, Cl. septicum).

• Often mixed infections with simple aerobic organisms.

0809 Wounds involving perforation of a viscus(usually gut)

Likely organisms:

• Conventional pathogens.

• Usually mixed aerobic and anaerobic organisms.


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• Gut origin.

• Aerobic Gram-negative bacilli (Escherichiacoli, Klebsiella species, Proteus species).

• Anaerobic gut bacilli (Bacteroides fragilis).

0810 Post-operative infection

Likely organisms

• Often hospital-associated infection. Contributoryfactors include:

• Infected and highly susceptible casualties concentrated together.

• Most casualties will be taking or have taken antibiotics.

• Sub-optimal control of infection practices in field conditions.

• Types of organism encountered are varied andsometimes unexpected.

Utility of Laboratory Support

0811 Basic microbiology investigations are notessential in forward locations, since the range andsensitivity patterns of organisms involved is largelylimited. In addition, casualties are likely to betransferred before any culture results are available(usually at 24 - 48 hours post-sampling). In a morestatic location, the laboratory will provide:

• Organism identification.

• Organism sensitivity patterns.

0812 In a large, static facility, microbiologicallaboratory studies will allow:

• Identification of infections due to sensitiveorganisms. This allows tailoring of treatment toa specific antibiotic or to investigate possible


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surgical reasons for persistence of an infection(e.g., a foreign body, abscess),

• Identification of infections due to resistantorganisms, allowing change to an appropriate antibiotic,

• Identification of clusters of infection in parts of the hospital due to similar organisms. Also,identification of organisms causing infections in staff (e.g., Streptococcus pyogenes),

· monitoring of antibiotic resistance patterns (such as multi-drug resistant Klebsiella species,methicillin-resistant Staphylococcus aureus-MRSA).

Antibiotic Use

Principles of treatment0813 The basics of antibiotic use are the same regardless of clinical situation or location. Any antibiotic should be given:

• Only when indicated and not when unnecessary.

• Ideally target the organismi.e., have a narrow spectrum of action.

• By the appropriate routei.e., in serious infection this is i.v.

• In a large enough dose; underdosing is common.

• To reach the target area. Some antibiotics do notpass into urine, bile or CSF.

• For long enough. i.e., until the clinical condition resolves.

• Then: be stopped when extended use is of no value.

Antibiotics following Maxillofacial Injury: see 1819

The appearance of drug resistance is important even

in field conditions. In some

circumstances, a facility may be

forced to close tonew admissions, to

stop or delaysurgery, or be unable

to transfer infectedcasualties.


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Battlefield considerations0814 These include:

• Antibiotics buy time to surgery but are not an alternative.

• Injectable drugs are more reliably absorbed.

• Antibiotics may need to be given by non-Medical Officers.

• Simple regimens are easier to pre-position in forward locations.

• Narrow spectrum drugs will cover most commonpathogens and make subsequent choices ofantibiotics in hospital easier.

Choice of antibiotics0815 Knowledge of the basic microbiology ofbattle trauma allows a rational choice of antibiotics to be made according to a clinical assessment of a wound:

0816 Limb, soft tissue and muscle injuries(pre-surgery). Likely organisms are Staphylococcusspecies, Streptococcus species or simple anaerobicorganisms. Most are sensitive to penicillin.

Give: benzyl penicillin 1.2 g as a single i.m. dose(ideally, within 1 hour of wounding).

0817 Perforating wound of gut or other hollowviscus. Organisms are likely to be mixed aerobes and anaerobes of gut origin. Most will be penicillin resistant.

Suitable antibiotics: co-amoxyclav (Augmentin™) 1gas a single i.v. dose or ceftriaxone (Rocephin™) 1gas a single i.v. dose plus metronidazole (Flagyl™)500 mg as a single i.v. dose. Ceftriaxone can begiven by non-medical staff by deep i.m. injection.

Severe Peritoneal Contamination: see 1225


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0818 Open head injury. Organisms are likely tobe aerobes. Consider anaerobes (and possiblesubsequent brain abscess) if there is a breach ofthe air sinuses or the middle ear. Antibiotics mustpenetrate the blood-brain barrier.

Suitable choices are: ceftriaxone (Rocephin™) 1 g as a single i.v. dose or, if there is sinus/middle earinvolvement: ceftriaxone (Rocephin™) 1 g plusmetronidazole (Flagyl™) 500 mg as a single i.v. dose.

0819 Hospital-acquired infection. Because ofthe wide range of organisms and likelihood of drugresistance, seek microbiology guidance

0820 Urinary tract infection. Uncomplicatedinfection is commonly due to Escherichia coli andsimilar organisms.

A suitable antibiotic is: trimethoprim 200mg twicedaily orally for 7 days. Complicated infection may bedue to any organism (including drug resistantspecies). A suitable antibiotic is: ciprofloxacin(Ciproxin™) 250mg twice daily orally for 7 days (i.v. if evidence of systemic disease).

0821 Lower respiratory tract infection.Uncomplicated infection is commonly due toStreptococcus pneumoniae.

A suitable antibiotic is: co-amoxyclav (Augmentin™)500mg orally three times daily for 7 days.Complicated infection may be due to any organism(including drug resistant species). A suitableantibiotic is ceftriaxone (Rocephin™) 1g i.v. oncedaily until resolved. Consider adding clarithromycin(Klaricid™) 500mg i.v. twice daily.

0822 Wound infection. This is usually due toStaphylococcus aureus, less commonlyStreptococcus pyogenes. In civilian hospitals,Staphylococcus aureus is usually resistant to

Infection and Antibiotics in burns: see 2238


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penicillin. Resistance is less of a problem in fieldhospitals where the operating theatres, at leastinitially, are unlikely to be colonised by penicillinresistant bacteria.

A suitable antibiotic for penicillin resistance is:flucloxacillin 500mg orally four times daily for sevendays (i.v. if there is evidence of severe disease).

Penicillin allergy0823 True penicillin allergy (anaphylaxis) is rare.(0.05%) Most reactions are minor ones, e.g. transientrashes, nausea and gastrointestinal upset. In life-threatening infections, such events should notbe a contraindication to treatment. Of thoseindividuals with true anaphylactic reactions, onlyabout 15% have cross-reaction to cephalosporins.

For severe illness where a penicillin-type drug isrequired give: cefuroxime (Zinacef™) 750 mg i.v.three times daily. For less severe illness, a differentclass of antibiotic could be used e.g. ciprofloxacin(Ciproxin™) 250mg twice daily orally for 7 daysor clarithromycin (Klaricid™) 250mg orally twice dailyfor 7 days.

Specific Conditions Related to the Battlefield

0824 A number of infective complications are traditionally associated with battlefield injuries.Accurate microbiology in recent years has enabledthe underlying pathogens to be identified. With fewexceptions, the clinical diagnoses are characteristic.

Whilst antibiotics may reduce some of the localeffects and delay systemic spread of infection,definitive treatment is usually surgery.

Antibiotics following ENT Injury: see Chapter 19


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Tetanus0825 Pathophysiology

The cause is Clostridium tetani, a widely distributedspore-forming organism, present in greatest numberswhere human or animal faeces are to be found.Sporulation requires an anaerobic environment.

Once inoculated into tissues, the incubation periodis up to 7 days. Local and systemic effects are due

to release of toxin.

0826 Clinical features

These include:

• Muscle stiffness e.g., masseter muscles (trismusor “lockjaw”), facial muscles (risus sardonicus),limbs and thorax.

• Muscle spasm, often painful and typicallytriggered by mild stimuli.

• Death associated with respiratory impairment or unstable cardiovascular system.

0827 Treatment

Principles of treatment are based on the diseasepathogenesis and include:

• Medical management (ventilatory support,stabilisation of cardiovascular system,antispasmodics).

• Elimination of circulating toxin by human tetanusimmunoglobulin (5,000-10,000 units i.v.).

• Removal of the source of toxin (usually surgicalwith a secondary role for antibiotics),prevention of recurrence (0828).

0828 Prevention

Prevention is easier than cure.

Opthalmic Preparations: see Table 1702

Because the toxin is non-immunogenic,

clinical infectiondoes not provide

natural immunity tore-infection:

immunisation with altered toxin

("toxoid") is required(0828).


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• Immunise with tetanus vaccine (0.5ml i.m.)followed by further doses at 4 and 8 weeks. Give a booster dose every 10 years (NB: all UKmilitary personnel should be covered).

• Non-immunised battlefield casualties: performwound excision; start immunisation (see above),give human tetanus immunoglobulin (250-500units i.m.) and antibiotics (0816).

"Gas gangrene"0829 Pathophysiology

Caused by spore-forming organisms related toClostridium tetani (0825), of which Clostridiumperfringens is the commonest. Once inoculated intoanaerobic tissues, the incubation period is usually 48 hours or less. Wounds prone to Clostridiumperfringens infection tend to be deep, necrotic,avascular and often associated with the presence of foreign bodies. Clinical features are caused by a variety of toxins, producing both severe localreactions (myonecrosis and gas production intissues) and systemic effects.


Local: severe pain, intramuscular and subcutaneousgas, extensive tissue necrosis.

Systemic: cardiovascular collapse, renal failure,intravascular haemolysis.

0831 Treatment

This is based on first principles:

• Medical management - resuscitation, antibiotics(limited role).

• Surgery - excision of all necrotic tissue.

• Adjuncts - hyperbaric oxygen therapy can be of benefit but, is not practical for the battlefield.

Wound Excision: see 0503


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Antitoxin is available in limited supplies but is of minor importance.

Human vaccine is unavailable. Disease prevention isby appropriate wound management (0503).

Necrotizing fasciitis0832 Pathophysiology

Necrotizing fasciitis comprises two distinctmicrobiological aetiologies which produce identicalclinical features:

• Streptococcus pyogenes alone

• A mixture of anaerobic cocci, with or withoutaerobic organisms (usually Gram-negativebacilli). This is the most common form.

The aetiology is important - Streptococcus pyogenesis highly transmissible to both other casualties andstaff whereas, the mixed infection, is not.

Initial trauma may be trivial. The incubation period is variable. This is followed by a rapidly spreadinginfection involving subcutaneous tissues. Trackinginto muscle is a late event.


Signs and symptoms develop rapidly. These include:

• Pain and tenderness; erythema with a poorlydemarcated edge. Loss of sensation in theaffected area is a late, characteristiccomplication. Gas in tissues commonly occurs with the mixed infection group.

• Systemic toxaemia is common and out ofproportion to local symptoms.

0834 Treatment

• Medical management - resuscitation. Antibioticsare of minor importance (0816). In the absence


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of microbiology, choice of antibiotics should cover both aerobic and anaerobic organisms.

• Surgery - perform early and extensive surgicalexcision beyond the advancing edge of infection.Amputation is not usually necessary, it is usuallysufficient to excise an affected musclecompartment. Delayed surgery or sub-totalresection, is associated with a poor outcome.

• Adjuncts - hyperbaric oxygen therapy can be ofbenefit, but is not practical for the battlefield.

Infection Control on the Battlefield

0835 When operating under field conditions, it can be tempting to dismiss infection controlpractices as being of limited benefit. On the contrary,the subject is of greater importance than in aseptic,civilian environments, since the consequences ofinfection are more serious. Measures to preventspread of infection from the environment, andbetween casualties and carers, include:

• Staff hand hygiene (reduces post-operative cross-infection).

• Skin cleansing.

• Source isolation.

• Occlusive dressings (disturb them only when really necessary).

• Use of gloves and operator masks (the latter are of limited value).

• Air filtration (unlikely to be of benefit in the field).

• Clinical waste management, sharps policy(important to prevent blood-borne virus infections).

Principles of Wound Management: see Chapter 5

The efforts of heroicsurgery must not becompromised bysloppy infectioncontrol practice.

The mostappropriateapproach will bedictated by individualcircumstances andwill always be acompromise betweenthe "gold standard"and what is safe.The aim is todevelop localpractices that arepractical and ofmaximum benefit.


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Biological Warfare

Introduction0836 The term "biological weapon" is applied to any organism or material of biological origin, usedwith the intention of causing death or disease in atarget. A "biological agent" refers to either a micro-organism or a toxin of biological origin (e.g., ricin).

For practical purposes, agents are grouped according to their effects - lethal or non-lethal andbehaviour in the target population-transmissible or non-transmissible.

0837 Following its initial dissemination bywhatever means, the agent behaves in exactly thesame manner as naturally-occurring disease. In other words, the management of casualties outsidethe immediate area of attack, with an illness causedby a specific agent, is no different from that of the"normal" infectious disease.

Likely or possible agents

0838 Anthrax

Bacillus anthracis is a Gram positive, spore-formingrod. The disease normally has an incubation periodof 1-6 days. There are three forms:

Cutaneous: originates from infected livestock.Pustules, which progress to fluid filled vesicles,develop on the hands and forearms. Eventually,these dry to form a black scab. Approximately 25% oflocal infections progress to a fatal, systemic infection.

Gastrointestinal: is rare and is secondary to eatinginfected meat; it carries a 100% mortality.

Inhalational (Woolsorter's disease): is due toinhalation of spores. Initial symptoms are: fever,malaise, fatigue, cough and chest discomfort,progressing to severe respiratory distress and shock. Death generally occurs within 24-36 hours.


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The organism can be detected by Gram-staining ofblood and by blood cultures. Treatment, includingsupportive measures and high dose antibiotics(penicillin, ciprofloxacin or doxycycline), is of limitedeffectiveness. Prophylaxis is by anthrax vaccinationand administration of ciprofloxacin or doxycycline tothose who may have been exposed. Mortality inestablished disease is close to 100%.

0839 Plague

The causative organism is Yersinia pestis, a transmissible, Gram-negative organism. Threeforms occur in man.

1. Bubonic plague: is spread by fleas frominfected rodents. After an incubation period of 2-10 days, the casualty develops a high fever,malaise, abdominal pain and painfullymphadenopathy. Because the fleas tendto bite the lower limbs, nodes in the groin areparticularly affected (buboes). There may behepato-splenomegaly Approximately 25%progress to the septicaemic form.

2. Septicaemic form: features are similar to otherGram-negative septicaemias and may progressto shock, thrombosis and DIC.

3. Pneumonic plague: is an infection of the lungs,either due to inhalation - primary (incubationperiod 1-6 days) or, rarely secondary tosepticaemia. In biological warfare, the organismis likely to be disseminated as an aerosol.

Clinical features include: acute onset of pyrexia,malaise and respiratory distress, classicallyaccompanied by haemoptysis. Gastrointestinalsymptoms are often present. Death is due torespiratory failure, circulatory collapse anda bleeding diathesis.

Tropical Diseases: see Chapter 24


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Suspect the diagnosis if a group of previously healthy service personnel or casualties developGram-negative pneumonia. The diagnosis can beconfirmed from Gram-stain of sputum, CSF or lymphnode aspirate and by blood culture. Earlyadministration of ciprofloxacin, doxycycline orgentamicin is essential; delay is invariably fatal.Prophylaxis for those at risk is with doxycycline. No effective vaccine is currently available.

0840 Botulinum toxin

Botulism is caused by a group of neurotoxinsproduced by the spore-forming bacillus Clostridiumbotulinum. These neurotoxins are the most potentknown to man (weight for weight 15,000 times morelethal than VX; 100,000 times more lethal thanSarin), even at small doses. Deaths continue to occurdue to ingestion of contaminated food. The toxin canbe dried and is most likely to be administered by anaerosol attack.

Symptoms usually begin 12-36 hours after exposure,with paralysis of the cranial nerves (ptosis, blurredvision, diplopia, dry mouth, dysphagia and dysphonia).This is followed by symmetrical, descending flaccidparalysis with generalised weakness and progressionto respiratory failure. Diagnosis is clinical. Treatmentis supportive. An antitoxin is available.

0841 Smallpox

The causative organism is an orthopox virus (variola major and minor). It is an attractive biological weapon because:

• It is relatively easy to manufacture.

• Can be administered by an aerosol.

• Is transmissible.

• Immunity across the population is now relatively low.

Chemical Weapons: see Chapter 2


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• There is no effective chemotherapy.

After an incubation period of 7-19 days, there is acute onset of malaise, fever, rigors, vomiting,headache and backache. Approximately 2-3 dayslater, macules appear on the face, hands and arms; these progress to papules and eventually to distinctive vesicles. Diagnosis is clinical andtreatment supportive. Smallpox can be prevented by vaccination. Mortality in unvaccinated casualties is 30%.

Battlefield considerations0842 What is the target?

• Military personnel: may be protected by IPE (0228), vaccines and antibiotics.

• Civilians: are usually easier targets than military personnel.

• Animals and plants: with the aim of compromisingthe food supply and logistic infrastructure.

• Environment: employing organisms currentlyavailable which can degrade organic materials(such as crude oil and hydraulic fluids).

0843 What is the strategy?

• Death or incapacitation? The latter may be more effective.

• Individual or tactical targeting e.g., assassinationor targeting of small, mission-essential groupson the battlefield.

• Operational e.g., attack against one functionalsector of an operational theatre, or a logistic"choke point", such as a key airfield.

• Strategic e.g., to affect an entire operationaltheatre or, the use of a non-deniable organism,such as smallpox.

Greater resourcesare required to nursethe sick than burythe dead!


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• Terror i.e., psychological warfare ("PSYOPS")..• Bluff i.e., take advantage of disease control

measures likely to be employed by an opponent, such as quarantine and cessation of offensive operations.

0844 What is the impact on Field Surgery?

• All members of the surgical team need to beindividually protected against likely agents(vaccination, antibiotics, IPE).

• Forward surgical teams may need to operate inareas of collective protection This can beproblematic, in terms of its efficacy, whenbiological agents have been used. It can alsoseverely reduce casualty throughput.

• Casualties require decontamination beforemedical treatment (NB, chemical agents mayalso have been used).

• All infectious diseases (natural or unnatural)have an incubation period - any casualtyoperated on could subsequently developsymptoms up to 3 weeks after exposure.

• Because of their contact with casualties, it is likely that the first indications of a covertbiological attack will be seen in medical units.Concentration of casualties and medicalpersonnel will allow rapid spread of transmissible agents, unless infection control practices are enforced.

• The critical nature of medical support unitsmeans that they become an attractive target foran aggressor - loss of such a unit will cause adisproportionate impact on offensive operations.

Decontamination: see 0230


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0845 What actions can be taken?

• Rapid communication of medical suspicions tothe command chain.

• Application of infection control precautions at alltimes, with "source isolation" when suspectedcases are identified.

• Sample collection. Samples are required for:

• Clinical diagnosis - "quick and dirty" to allow effective treatment to be given.

• Forensic - "slow time" with a detailed chain of custody, for use in later legal and political actions.

Technology changes rapidly and advice oncurrent procedures should be sought through the medical command chain.

• Restriction of movement will limit the spread of a transmissible disease. This will be a commanddecision since there are significant implicationsfor force effectiveness.

From a medical perspective, this will mean bothsuspension of resupply, and cessation of allmedical evacuation.

The effect ofdeliberately releasingbiological agents onfield surgical unitscan be reduced byhigh standards ofclinical practice.


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Chapter 9

Limb Injuries

Introduction

0901 Limb trauma accounts for 50-70% of all warinjuries. The lower limb is more frequently affectedthan the upper limb, in a ratio of 2:1. Life-threateninginjuries include: complete or incomplete traumaticamputation, multiple long bone fractures and majorpelvic injuries. Other wounds can be sufficientlyserious to threaten limb viability. These include:vascular damage, crush injury, compartmentsyndrome and bone and soft tissue sepsis.The majority of casualties will have relatively minorsoft tissue injuries and may be able to walk to findaid or, apply self-aid. Between 35% and 50% of limbwounds have bone involvement. Fracture types areillustrated in Figure 0901. In addition to war wounds,deployed service personnel may experience thesame range of orthopaedic trauma seen in civilianpractice. The management of these injuries isdescribed in the second half of this Chapter.

0902 Differences between military and civilianwounds are discussed in 0501. Features of limbwounds in war include:

• Damaged bone is more likely to communicatewith the skin surface resulting in open(compound) fractures (Figure 0902).

• They are generally triaged as T3, consequently,delays in transfer mean that the majority ofwounds will be infected by the time the casualtyreaches a surgical facility.

Amputation: see Chapter 11

Ten percent ofbattlefield casualtieswith limb woundsbleed to deathunnecessarily. Do not allow this to happen. Limb bleeding iscompressible orcontrollable by useof a tourniquet. To a lesser extent,haemorrhage frompelvic fractures isalso compressible.

Delays in managinglimb wounds are notusually life-threatening, somost casualties aretriaged as T3.

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• Thigh and pelvic wounds may be complicated byspillage of abdominal contents.

• Initial treatment is often under field conditionsand may take place in the absence of equipmentand an orthopaedic surgeon.

Management

Management in the field

0903 Initial management includes:

• ABC, with emphasis on arrest of compressiblehaemorrhage as part of the resuscitation phaseof BATLS (0330).

• Analgesia.

Battlefield Advanced Trauma Life Support: see Chapter 3

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� � � � �

�� !��

!

Fig 0901 Fracture types. Fractures can be open or closed dependingon whether they communicate with a skin wound.

chapter_9.qxd 28/09/2004 15:55 Page 152

• Look for long-bone fractures, covert vascularinjury (the six ‘Ps’ 1010) and neurological deficit(2114 - 2117). Note deformity, CRT, skin colourand temperature, the presence of peripheralpulses, cutaneous sensation and active andpassive limb movement.

• Correct deformity by manual traction (Fig 0902).

Analgesia: see Chapter 7

Be suspicious ofopen wounds inclose proximity to a major artery.

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Fig 0902 Manual reduction of an open lower leg fracture. The penetrating fragment is repositioned by local pressure.

chapter_9.qxd 28/09/2004 15:55 Page 153

This relieves pain and protects the circulation. A bone fragment poking through the woundshould be repositioned by direct pressure.

• Clean and, where feasible, irrigate wounds;dress wounds with firm, sterile dressings (0502).

• Splint and elevate fractures and extensive softtissue wounds (0331). If possible, use a tractionsplint for a fractured femur (Figure 0319) orapply a Thomas splint with a Crookham halteraround the boot (Figure 0320).

• Give parenteral antibiotics, preferably within onehour of wounding (0816). Consider DVTprophylaxis (0980).

• Transfer to a surgical facility.

Management at Role 2 or 30904 The principles are:

• Restoration of circulation.

• Wound excision, for subsequent delayed primaryclosure.

• Fasciotomy if appropriate.

• Stabilisation of fractures and major soft tissueinjuries. Reduction of dislocations.

• Obtaining skin cover.

Restoration of circulation

0905 Following major arterial injury,revascularisation should be achieved within six hoursto optimise limb survival.

Compartment syndrome

0906 A rise in pressure in an enclosed bodycompartment (e.g., a limb, the abdomen), such as tointerfere with tissue perfusion, is a ‘compartmentsyndrome’. Causes include:

Management of Vascular Injury: see Chapter 10

Peripheral pulses arepalpable in 30% of

injured limbs despitemajor arterial

trauma..

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• Tight bandages or plaster cast.

• Trauma and surgery.

• Arterial injury.

• Crushing.

• Burns.

• Strenuous exercise.

In the limb, accumulation of blood and tissue oedemawithin a muscle compartment surrounded by inelasticfascia, interferes with capillary flow, leading to localmuscle ischaemia and tissue necrosis.

0907 The limb is typically swollen, tense andtender (NB: if late in onset - consider DVT 0979).Peripheral pulses and capillary filling are usuallynormal distal to the affected compartment(s). Pain isoften out of proportion to the injury and may beuncontrollable with morphine. Increasing discomforton gently dorsiflexing the toes or fingers of anaffected limb, can be an early sign. Where pressuremonitoring is available, insertion of a pressure probebelow the deep fascia, will aid diagnosis.

0908 When a compartment syndrome issuspected, initial treatment is to split any plastercylinder or circumferential dressing down to skinlevel, then open them widely along their completelength. If this does not improve symptoms, rapidlyperform a fasciotomy (see under Specific Management).The whole length of the compartment(s) must bedecompressed. After fasciotomy, the wound is leftopen, dressed with a bulky dressing, splinted and thelimb elevated to reduce swelling. Unless obviouslynecrotic, excision of non-viable muscle is usuallydeferred until the casualty is reviewed in theoperating theatre 2-5 days later. By then, tissueoedema will have partially subsided and the woundcan usually be approximated. Any remaining defect

Abdominal Compartment Syndrome: see 1290

Limb fasciotomy: thecommonest causesof failure areoperative delay andthe use of a closedtechnique ; this isinsufficient to fullyrelease all affectedtissues.

If transfer is delayed,consider whether 'atrisk' wounds requirefasciotomy in thefield. Perform understerile conditions(GA or LA). Avoidusing a tourniquet.

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may require application of a split skin graft 7-10 daysafter fasciotomy.

Wound excision

0909 The majority of military limb wounds requireexploration and wound excision under GA or LA (0503).

Principles of stabilisation of fractures andmajor soft tissue wounds0910 Radiographs are useful to assess the natureof a limb fracture and plan stabilisation, but are notessential for initial management. Taking radiographsmust not delay treatment or transfer.

0911 The majority of fractures and deep orextensive soft tissue wounds, should be splinted.Where there is significant deformity or jointdislocation, reduce under GA, i.v. ketamine (0714),Entonox (0716), or nerve block (0734 - 0736).

Reduction and stabilisation:

• Provides pain relief.

• Reduces haemorrhage.

• Prevents further soft tissue injury.

• Reduces the incidence of fat embolism.

• Allow some casualties to care for themselves.

0912 The optimal method of splinting a fracturedepends on which bone is injured, the wound and thenature of any bone defect. In general, the initialtreatment of choice for long bone fractures isapplication of a plaster of Paris (POP) splint. Because of the direction of pull of attached muscles,femoral fractures tend to result in overriding of thebone ends, an extensive haematoma and limbshortening. Place the limb in a Thomas splint andimmobilise it by applying either fixed skeletal (0935)


Followingpenetrating, highenergy fractures,

the extent ofcontamination canbe estimated fromthe position of the

fragments on X-ray.

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or skin traction (0936). Stabilisation during transfercan be improved by conversion to a Tobruk splint(0937).

0913 At Role 3 or 4, a back slab may beconverted to a full POP cylinder or another method of immobilisation (e.g., external fixation). Similarly, itmay be decided to nurse the casualty with a fracturedfemur in a Thomas splint with balanced traction or,use intramedullary nailing.

Joint dislocation

0914 Dislocation may complicate a fracture andinterfere with reduction. Ideally, obtain a radiographbefore treatment. All dislocations should be reducedat the earliest opportunity (for techniques: see‘Civilian Limb Injury’); Check the circulation andneurological function before and after manipulation.The joint should subsequently be immobilised.

Methods of stabilisationPlaster of Paris (POP)

0915 This is rapid and easy to apply with minimalequipment. It is suitable for most limb soft tissuewounds and fractures. With the exception of thefemur, it is the treatment of choice in the initialmanagement of long bone fractures. It can becombined with other external splints.

• Apply stockinet (not Tubigrip™) to preventplaster sticking to the skin and cover this with alayer of wool padding, particularly over bonyprominences. Cut a suitable length of full-thickness plaster and apply this as a backslab(Figure 0903A). For major arm and tibialfractures, the backslab must incorporate the jointabove and below the defect and, wherenecessary supplemented with lateral slabs(Figure 0903B). Wet the POP thoroughly then

Analgesia: see Chapter 7 Anaesthesia: see Chapter 25

Plaster was originallydeveloped for use onthe battlefield.Encasing the woundin plaster andallowing it to healwas employedextensively duringthe Spanish CivilWar with goodresults (Truetatechnique).

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squeeze out excess water before application.Mould plaster slabs to the limb until set and holdthem in place using a crepe bandage. Ensurethe edges and ends of the plaster are smoothand do not dig in. Check the circulation andelevate the limb. In the acute situation, or afterinitial wound excision, plaster must not beallowed to encircle the limb.

• At the second operation, manipulation of the fracture may be required to obtain optimumalignment. By now, swelling should havesubsided and the backslab can be convertedto a complete cylinder. Mould the POP cast toprevent limb rotation. In civilian practice,lightweight synthetic plaster substitutes arecommonly employed. To reduce the risk ofdeveloping a compartment syndrome, cylindersmay be split down to skin along their completelength (Figure 0904) and the two halves bandagedto the limb. Bi-valve of a POP cylinder is essentialprior to lengthy casualty transfer by air.


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Fig 0903 A) POP back slab for: ankle injury (stockinet and paddingomitted for clarity). B) POP back slab for lower leg injury.

A

B

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• Limited wound access can be achieved bycreating a plaster window (Figure 0904), but thismay compromise fracture reduction byweakening the plaster.

• If the casualty develops numbness ordisproportionate pain, consider a compartmentsyndrome (0906).

Traction

0916 Traction is a simple method of maintaining asatisfactory reduction, especially where orthopaedicexperience and resources are limited. It has theadvantages of safety and of not interfering withsubsequent methods of bone fixation but, mayrequire prolonged bed rest.

External fixation

0917 Indications for external fixation rather thanplaster include:

• Unstable fractures with extensive bone loss.

• Large soft tissue wounds e.g., after fasciotomy.

• Vascular injuries requiring repair.

• Fractures associated with burns.

• Polytrauma.

• To facilitate casualty transfer.

0918 External fixators allow wound access,early mobilisation and discharge but, are technicallydifficult to apply well in the field. Commomcomplications include pin site infection and loosening.Fixators must only be used by those with previousexperience. Technical points for their use include:

• Stab incisions in the skin should be at least 1cm in length.

• Ideally, pins are inserted into the subcutaneous

Symptoms of tootight a plaster arepain and numbness.Check for swelling,pulses, CRT andcyanosis.

If the casualty has along bone fractureand requires afasciotomy, thefracture must bestabilised by amethod which allowsaccess to thefasciotomy woundi.e., application of anexternal fixator orThomas splint.

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surface of a bone. Where there is a risk ofdamaging adjacent structures, use an opentechnique (e.g., distal humerus, distal radius).

• Insert 2-3 pins to hold the main bone ends aboveand below the fracture (Figure 0905). Additionalpins may be required to immobilise majorfragments.

• Because of the risk of infection and propagatingcracks, avoid inserting pins within 2-3 cm of afracture.

• Ensure bicortical pin placement; the pin mustpass through the cortex, medullary canal andpenetrate the far cortex (Figure 0905). In hardbone, pre-drilling with a 3.2mm drill bit will be necessary with the older type of Britishmilitary-pattern external fixators. The newerHoffmann II™ pattern pins are self- drilling and self-tapping.

• Ideally, all pins should be connected to the samebar. This can be achieved by inserting the mostproximal and distal pins first. These are thenconnected to a single bar and the fracturereduced as accurately as possible. Further pinscan than be inserted by fixing pin-to-barconnectors to the bar and using these as guides.

Pelvic External Fixator: see 1319

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Fig 0904 Completed full leg POP cylinder split on both sides. A 'window' allows wound access.

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Generally, a second bar should be used toincrease the stability of the frame.

• Following fracture reduction, pin wounds shouldbe checked and any tenting of the skin released.The pin wounds are regularly cleaned to preventcrusting and are left exposed to drain.

Internal fixation

0919 This requires appropriate equipment andimplants. Internal fixation is technically demanding. It is not available at forward surgical facilities, whereits use is inappropriate. It may be required forsubsequent, definitive surgery. Disadvantages include an increased risk of infection.

9: Limb Injuries

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chapter_9.qxd 28/09/2004 15:55 Page 161

Obtaining skin cover0920 Delayed primary closure of military woundsis the norm (0503). If the wound is clean, it is closedby sutures, split skin grafts or soft tissue flaps. Small defects can be left to heal by formationof granulation tissue.

Fractures are often manipulated at this stage toobtain a better position and a decision made as tothe optimum method of stabilisation during healing.

Crush injuries0921 Crushing causes tissue ischaemia and maynecessitate limb amputation. Depending on theamount of tissue damaged and the duration ofentrapment, return of circulation after release can beassociated with:

• Acidosis and release of intracellular potassium,leading to fatal cardiac arrhythmias.

• Severe tissue oedema causing hypovolaemicshock.

• Release of mediators of the systemicinflammatory response syndrome (SIRS)resulting in vasodilatation and shock.

• Breakdown of muscle tissue and release ofmyoglobin. The presence of this large moleculein the circulation may cause acute renal failure.

0922 Following a significant crush injury (e.g.,whole leg entrapment for >3hours):

• Administer high flow oxygen, analgesia and setup an i.v. infusion prior to release.

• Be prepared to administer 2 to 3l of crystalloidquickly to control shock and maintain a urineoutput of >100ml/hour.

• Give 500ml of 10% Mannitol to promotea diuresis.


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• Perform a fasciotomy. Dress the wounds, splintthe limb and elevate.

• Ideally, the casualty should be connected to acardiac monitor and observed for arrhythmias inan ITU.

• It may be appropriate to manage a severelyinjured (mangled) limb by application of atourniquet at scene, followed by amputation after release (1106).

Specific Management of Military Limb Trauma

Upper limbHumerus

0923 Following wound excision, fractures andextensive soft-tissue wounds are initially splinted.

• Use a POP back slab extending from theshoulder to the forearm (Figure 0906). Gravitywill help pull displaced fractures of the neck and shaft of the humerus into alignment.

• A SAM or improvised splint can be similarlyeffective (Figure 0318).

• Provide support using a lesser arm sling, orcollar and cuff with the elbow at 90 degrees.Hold the arm in place by bandaging it to chestwall under the casualty’s clothing.

• Nurse the casualty sitting up; encourage them to exercise their fingers and wrist.

0924 If the radial pulse is absent, gently movingthe elbow may relieve pressure from a bone fragmenton the brachial artery and restore flow. Immobilisethe limb in this successful position. If the elbowcannot be readily flexed, lay the casualty on astretcher and strap the arm to their side (Figure

Principles of Plastics and Reconstruction: see Chapter 23

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0315). Continue to monitor neurovascular function.Transfer to a surgical facility as priority T1.

0925 External fixation of the upper arm is avoidedunless there are specific indications (e.g., bone loss,vascular repair, multiple injuries). If external fixationis considered necessary:

• Do not insert pins into the proximal humerusbecause of poor hold and the risk ofneurovascular damage (Figure 0907).

• Insert pins through the lateral aspect of the shaftavoiding the anteromedial neurovascular bundle.

• Insert distal pins laterally using an openapproach to prevent damage to the radial nerve.

• A bridging fixator, with pins inserted into thedistal humerus and the shaft of the ulnar, can beused to treat fractures or severe soft tissueinjuries around the elbow joint.

0926 Decompression: The upper arm consists oftwo compartments: the flexor, containing the biceps

9: Limb Injuries

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Fig 0906 Hanging back slab and lesser arm sling used to treat afractured humerus.

chapter_9.qxd 28/09/2004 15:55 Page 164

and related muscles and extensor, containing thetriceps (Fig 0907). Decompression is rarely required.When considered necessary, perform this through asingle, lateral incision.

0927 After transfer to Role 4, treatment usingPOP or splinting is usually continued. This may beconverted to internal or external fixation.

9: Limb Injuries

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Forearm

0928 The forearm can be divided into flexor andextensor compartments (Figure 0908). The closelyapplied neurovascular bundles are easily damagedduring wound excision.

• Both soft tissue and bony injuries, are treated byapplication of a POP backslab and elevation in asling. Once tissue swelling has subsided, thiscan be converted to a cylinder that includes thewrist. For proximal injuries, the elbow should beincorporated in the plaster.

• Unless viability is a problem, vascular injuries in the forearm are unlikely to be repaired at aforward surgical facility (1043).

• In casualties with severe soft tissue and boneinjuries, primary amputation may be necessary(1120). This usually follows anti-personnel mineinjuries, where the device has been handled.

0929 External fixation is rarely required. Where

Vascular Injury: see Chapter 10

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indicated, pins are inserted through the subcutaneousborder of the ulna. If it is essential to place a pin intothe radius, use only the distal part of the bone andemploy an open technique. Internal fixation withplates may be considered at Role 4, together with abone graft to replace extensive bone loss.

0930 Decompression:

• The superficial and deep flexor compartmentsare approached through a single anterior skinincision beginning proximal to the antecubitalfossa and extending to mid-palm (Fig 0909).

• Skin flaps are raised and the dissectioncontinued in the interval between flexor carpiulnaris and flexor digitorum superficialis, so as to expose the median and ulnar nerves and theflexor digitorum profundus (Figure 0908). This allows division of the superficial and deepfascia, as well as release of the carpal tunnel byincision of the transverse carpal ligament.

• Where necessary, the approach to the extensorcompartment is through a posterior incision inthe pronated forearm, beginning 2cm medial and

Indications for Amputation and Technique: see Chapter 11

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167

Fig 0909 Decompression of forearm flexor compartment: 'lazy-S'skin incision and division of deep fascia.

chapter_9.qxd 28/09/2004 15:55 Page 167

2cm distal to the lateral epicondyle (Fig 0910).The incision extends towards the wrist. Skinflaps are raised and the dorsal fascia dividedthroughout the length of the forearm. Dissectionis between extensor carpi radialis brevis andextensor digitorum communis (Figure 0908). In the forearm, incise the fascia over individual muscles.

Hand

0931 Extensive wound excision is not necessaryand removal of skin is kept to a minimum.

• Skin flaps should be preserved for subsequentclosure, even if they appear degloved.

• Tendon (Figure 3032) or nerve repair (Figure2110) is usually inappropriate in the field.

• All injuries should be splinted using POP; theoptimal position is with the wrist slightly bentback, the metacarpo-phalangeal joints at 90 degrees and the interphalangeal joints extended(Figure 0911).

• The hand is elevated in a high sling (Figure0317) to reduce swelling and the tips of thefingers left exposed for inspection.

0932 To optimise functional recovery, earlytransfer to a hand surgeon is indicated. Definitive

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Fig 0910 Skin incision for decompression of forearm extensorcompartment.

chapter_9.qxd 28/09/2004 15:55 Page 168

management may involve the use of K wires, platesand mini external fixators.

0933 Crush injuries can produce carpal tunnelcompression and/or a compartment syndromeaffecting the interossei, thenar or hypothenarmuscles. Treatment is division of the transversecarpal ligament (0930) together with dorsal incisionsover the affected muscles (Figure 0912).

Lower limbPelvic injury See 1304-1309

Femur

0934 Blood loss following a femoral fracture isapproximately 1.5-2l (Figure 0303). This may beincreased by the presence of extensive, open thighwounds. Though such casualties may appear stable,there is a risk of sudden deterioration. They requireresuscitation, traction splintage and early transfer to

Resuscitation: see 0333

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Fig 0911 Immobilisation position following hand injury.

chapter_9.qxd 28/09/2004 15:55 Page 169

a surgical facility. Open traction splints (Figure 0319),are ideal for first aid management and initial transferSkeletal or skin traction in a Thomas splint can beused to provide both immediate and definitivemanagement of thigh injuries (Figure 0320). It requiresexperience and several personnel to apply a Thomassplint quickly and effectively.

0935 Skeletal traction:

• Under general, ketamine (0714) or localanaesthesia (0728), short medial and lateralincisions are made 1-2cm distal and 1-2cmposterior to the tibial tubercle (Figure 0913A).The muscles deep to the lateral wound areopened with forceps. Prior to inserting a pin,align the great toe and patella in the samevertical plain. A 4mm Steinman or Denham pin isinserted using a ‘T’ handle, there is no need topredrill the bone.

• Stout cord is fixed under tension to both ends ofthe pin and hence to the end of the Thomas splint. Tightening is achieved using a windlass(Figure 0913B).

• The pin site should be cleaned daily with salineand left exposed. Inspect for inflammation,tenderness and pin loosening.

Pelvic Injury: see Chapter 13

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Fig 0912 Hand injury: incisions for interosseus muscledecompression.

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0936 In skin traction, wide Elastoplast™ tape anda bandage are applied to the lower leg which is thenfixed under tension by stout cord to the end of thesplint (Figure 0914).

0937 Plaster on its own is unsuitable for femoralfractures. It can be used to support the leg in aThomas splint by encasing both leg and splint in POP(Tobruk splint Figure 0915).

0938 External fixation is generally avoided whenstabilising femoral fractures. When indicated, theremust be sufficient proximal and distal bone to takethree good pins into each segment, with at least 2-4bars used to connect them. Insertion is through theanterior, lateral or postero-lateral surface of thefemur. The safe area for pin insertion is shown inFigure 0916.

0939 At Role 4, intramedullary nailing may becarried out for definitive treatment. Alternatively,the casualty can be managed by Thomas splint

and balanced traction (Figure 0917) until the fractureis healed.

0940 Decompression: The thigh contains threecompartments: anterior (quadriceps), extensor(hamstrings) and medial adductor (Fig 0918). In civilian practice, release of anterior and posterior

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Fig 0913A Position for Steinman pin insertion through tibia.

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compartments through a single lateral incision, is usually sufficient. The superficial fascia is dividedlongitudinally over both compartments. Penetratinginjuries to the thigh may require release of the medialcompartment through a separate incision.

Failure todecompress the

deep posteriorcompartment is the

commonest errorwhen performing

lower limbfasciotomy.

This usually occurswhen, in freeing upthe soleus muscle,

the surgeonmistakenly believes

that he has releasedthe compartment.

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172

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Fig 0913B Skeletal traction in a Thomas splint. Tightening is bymeans of a windlass.

chapter_9.qxd 28/09/2004 15:55 Page 172

Knee

0941 Injuries around the knee can be immobilisedwith a Thomas splint, or using a full-length POPbackslab, with side supports at the knee and ankle.Extensive injuries can be effectively immobilised byexternal fixation with pins inserted in the femur(Figure 0916) and proximal tibia.

0942 The popliteal artery (0971) and peronealnerve (0972) are at risk from posterior dislocation ofthe tibia.

Lower leg

0943 The prognosis for open fractures of the tibiais worse than that of other long bones. Consequently,

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0914 Use of skin traction to immobilise a fractured femur in a Thomas splint.

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they require appropriate, early wound excision,fasciotomy and immobilisation.

0944 Decompression: There are fourcompartments (Figure 0919):

• Anterior.

• Lateral.

• Superficial posterior.

• Deep posterior.

The posterior tibial artery is located between the twoposterior compartments and is used as a landmarkduring surgery (Figure 0919). With the casualty in thesupine position, a two longitudinal incision technique

Wound Excision: see Chapter 5

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0915 Tobruk splint: the injured limb, Thomas splint and all attachmentsare encased in plaster.

chapter_9.qxd 28/09/2004 15:55 Page 174

is recommended, leaving an adequate bridge of anterior skin (Figure 0919). To ensure completedecompression, incisions should extend from levelwith the head of the fibula to the malleoli.

0945 The anterior and lateral compartments aredecompressed through a longitudinal skin incisionbetween the lateral border of the tibia and the fibula(Figure 0920).

9: Limb Injuries

175

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Fig 0916 External fixation of the femur: safe area for insertion of pins.

Fig 0917 Ballanced traction to treat a fractured femur.

chapter_9.qxd 28/09/2004 15:55 Page 175

• The skin edges are undermined. The exposedfascia is first incised transversely to help identifythe lateral intermuscular septum.

• Separately incise the fascia over eachcompartment in the line of the skin incision.

• Avoid the superficial peroneal nerve, which liesin the lateral compartment just posterior to theseptum.

0946 The posterior compartments aredecompressed through an incision 2cm posterior tothe medial border of the tibia (Figure 0921).

• The skin edges are undermined and thesaphenous vein and nerve retracted anteriorly.

• A transverse incision is made in the fascia inorder to identify the septum between superficialand deep posterior compartments.

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• The superficial posterior compartment, containingthe gastrocnemius and soleus muscles, isdecompressed by a longitudinal fasciotomy.

• The deep posterior compartment is released bydividing the fascia overlying flexor digitorumlongus and tibialis posterior muscles distally,then proximally under the soleus bridge. In orderto adequately free the posterior compartment,the soleus may require mobilisation from the tibia.

0947 An above knee plaster backslab with sidesupports provides sufficient initial stabilisation formost fractures and soft tissue injuries Mould to theleg so that the ankle is held at 90 degrees and theknee is flexed to 30 degrees. A below knee POP issufficient for ankle injuries (Figure 0903).

0948 External fixation is increasingly used (0918).Pins are inserted into the subcutaneous surface of

9: Limb Injuries

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chapter_9.qxd 28/09/2004 15:55 Page 177

the bone (Figure 0905). Remember, the tibia istriangular in cross section: make sure there is bi-cortical pin placement.

0949 Tibial traction is occasionally employed. A Steinman pin is inserted through the calcaneum,2.5cm below the malleoli then, traction ofapproximately 0.5kg per 10kg body weight, is applied(Figure 0922).

There is no place forso-called 'blind'

fasciotomy via smallskin incisions.

9: Limb Injuries

178

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Fig 0920 Decompression of the anterior and lateral compartments: ashort transverse incision is used to identify the anterior intermuscularseptum. Separate fascial incisions are made over both compartments.

chapter_9.qxd 28/09/2004 15:55 Page 178

Foot injuries

0950 Foot injuries are not life-threatening, but cancause late morbidity and impairment of function.Management principles are the same as listed above.Stabilisation of severe foot injuries can be difficult.Plaster is inadequate, except in the short term.External or wire fixation are preferred methods. The fracture can be stabilised by means of anexternal triangulation frame with pins inserted intothe tibial shaft, the great toe metacarpal and a

9: Limb Injuries

179

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Fig 0921 Decompression of the superficial and deep posteriorcompartments. A short transverse incision is used to identify theintermuscular septum. Separate fascial incisions are made over bothcompartments. Retract the saphenous vein and nerve posteriorly.

chapter_9.qxd 28/09/2004 15:55 Page 179

transfixion pin through the calcaneus. By maintainingthe foot at 90 degrees, the risk of developing anequinus deformity is reduced.

0951 At Role 4, management of severe footinjuries may include flap coverage, bone grafting,local bone fusion or partial amputations.

Civilian Limb Injuries0952 Military limb trauma will predominate duringarmed conflict. On low-intensity military operations,civilian-type injuries are more common. Militarysurgeons require a basic knowledge of theemergency management of these injuries. Becausemost civilian fractures are closed injuries without therisk of wound contamination, there is less urgency forsurgical intervention. The majority of these injuriescan be simply managed by analgesia, splintage andtransfer to a Role 3 facility or, local civilian hospital.Joint dislocations do require early reduction.

Upper limb

Clavicle fracture

0953 Fractures of the clavicle are common. They may be caused by direct trauma or indirectlye.g., falling on the outstretched hand. Most claviclefractures are closed, occur in the midshaft of the

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180

Fig 0922 Calcaneal traction used to treat a fractured tibia.

chapter_9.qxd 28/09/2004 15:55 Page 180

bone and are associated with overlap of thefragments.

• Treatment is to rest in a broad arm sling (Figure0317), followed by mobilisation as comfort allows.Internal fixation is occasionally performed.

Acromioclavicular joint injuries

0954 Disruption of the acromioclavicular joint isrelatively common. It is typically a sports injury seenin young males. There is superior subluxation ordislocation of the lateral end of the clavicle; this isusually obvious on clinical examination.

• Most injuries are treated conservatively with abroad arm sling (Figure 0317).

Fractures of the scapula

0955 Fractures of the scapula are uncommoninjuries usually caused by direct trauma.Management of any associated chest injury takes priority.

• Management is an arm sling with early activemovement of the shoulder joint (Figure 0317).

Dislocation of the glenohumeral joint

0956 This is the commonest site of major jointdislocations in adults. In the majority, the humeralhead is displaced anteriorly as a result of forcedabduction/external rotation, often sport related.Less than 5% of dislocations are posterior. A dislocated glenohumeral joint should be reduced asearly as possible; this can usually be accomplishedunder sedation. Ideally, a radiograph is obtained toconfirm the diagnosis and exclude a fracture. If thereis delay in obtaining a radiograph or, a history ofprevious dislocation, attempted relocation is justified.There are three common methods. Once relocated,the arm is rested in a sling.

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0957 Hippocratic method: The casualty liessupine on a bed or the ground. Traction is applied to the arm with the elbow extended. The arm is thenflexed and abducted at the shoulder. As tractioncontinues to be applied, the humeral head is easedback into the joint, classically, by the surgeon'sstockinged foot (Figure 0923).

0958 Kocher’s method: Traction is applied to thearm with the elbow flexed to 90 degrees.The arm isslowly externally rotated, then internally rotated andflexed across the body. Kocher’s method may bemodified by abducting as well as externally rotatingthe arm (Figure 0924). A collar and cuff bandage inthe axilla, can be used to provide counter-tractionover the humeral head. Those who are not familiarwith Kocher’s method, should use a different technique.

0959 Hanging-arm method: The advantage ofthis method is that it may be attempted by theinexperienced without sedation. The casualty isplaced face down on a bed, or bent over a chair. The arm is allowed to hang free under gravity withthe elbow extended; a fluid bag can be tied to thearm to provide traction.

Manoeuvres toreduce a dislocationof the glenohumeral

joint should becarried out gradually

as spiral fractures of the humerus,

and brachial plexusinjuries have

been reported.9: Lim

b Injuries

182

Fig 0923 Hippocratic method for reduction of anterior dislocation ofthe shoulder joint.

chapter_9.qxd 28/09/2004 15:55 Page 182

0960 Posterior dislocation: The humeral headappears ‘light bulb’ shaped on antero-posteriorradiographs, an appearance that is best seen on a lateral or axillary view. Reduction is by applyingtraction to the abducted arm, followed by gentleexternal rotation.

Humeral shaft fracture

0961 Humeral shaft fractures commonly occur asa result of RTAs; there may be an associated radialnerve palsy causing wrist drop. Nerve exploration willbe required.

• Closed fractures are splinted with a plaster U-slab (Figure 0906).

• Because of the risk of neurovascular damage,external fixation of this bone should only beattempted by an experienced surgeon (0925).

Elbow dislocation

0962 Axial loading on a slightly flexed elbow cancause it to dislocate posteriorly. There may beassociated fractures of the distal humerus, radialhead and coronoid. The elbow should be reduced assoon as possible; this is generally accomplished byclosed means under GA.

• Traction is applied with the arm slightly flexed.The olecranon can usually be pushed into placeover the distal humerus, reducing with anaudible ‘clunk’.

• Post-operatively, the arm is immobilised in acollar and cuff.

Forearm fractures

0963 The majority of forearm fractures aredisplaced; definitive treatment is open reduction and internal fixation with plates.

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.

9: Limb Injuries

184Fig 0924 Kocher's manoeuvre for reduction of anterior dislocation ofthe shoulder joint.

chapter_9.qxd 28/09/2004 15:55 Page 184

9: Limb Injuries

185

• In the field, the arm should be splinted until thecasualty reaches a hospital.

• Use an above elbow POP splint with applicationof gentle traction to facilitate some reduction ofthe fracture. Ensure adequate immobilisation ofthe elbow.

• External fixation is inappropriate except forselected cases.

• Variants of this injury e.g., a fracture of one boneplus a dislocation of the other, are uncommon; they should not be diagnosed without anadequate radiograph.

Wrist fractures

0964 The majority of wrist fractures are closedinjuries and should be managed by a POP splint untilradiographs are available (Figure 0925). Openfractures are dealt with as in 0965.

Hand injuries

0965 Trauma to the hands is common; damage

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Fig 0925 Wrist fracture: application of a back slab.

chapter_9.qxd 28/09/2004 15:55 Page 185

may include crushing and tendon lacerations.

• Open wounds should be excised (0503), irrigatedand the hand immobilised in a high sling (Figure0317). Conserve as much tissue as possible.

• Decompression may be necessary (0933).

• In general, tendon (3027) or nerve repairs (2119)should not be attempted at a forward location.Transfer the casualty to a hand surgeon.

Lower limbPelvic injury See 1315-1317

Hip dislocation

0966 This usually occurs during high energyvehicular trauma; There are two types.

• Ninety percent of dislocations are posterior.Clinically, the limb is shortened and internallyrotated. Sciatic nerve palsy occurs in 10% ofcases (diagnosis 2115). There may be damageto the posterior acetabular wall (1308).

• An anterior dislocation may cause femoral nervepalsy and rarely, damage to the femoral vessels.The limb is shortened and externally rotated.

0967 Treatment is early relocation under GA(generally, this is not possible with sedation alone). In the dislocated position, the blood supply of thefemoral head is compromised. Delay may causeosteonecrosis and permanent sciatic nerve damage.The casualty is placed on the floor or table.

• In order to reduce a posterior dislocation, thepelvis is fixed by an assistant (Figure 0926). The operator takes control of the limb with theknee and hip each flexed at 90 degrees. Firmupward traction is applied. Slight adduction ofthe thigh may aid reduction. The femoral headshould palpably ‘clunk’ back into place. In


Following hipdislocation, exclude

associated injuries tothe head, chest and

abdomen.

Beware - limbshortening and

internal rotationoccur with femoral

neck fractures.

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chapter_9.qxd 28/09/2004 15:55 Page 186

extreme cases, the knee may be placed over thekneeling operator’s shoulder from behind as theyface the casualty’s feet, allowing greaterapplication of force.

• In anterior dislocations, the knee is flexed to 90degrees and the hip to 60 degrees. The proximalthigh is pulled laterally by an assistant: The thighis adducted to 30 -40 degrees and the lower legrotated away from the body (internal rotation ofthe hip). Firm downward pressure on thekneecap causes the hip to relocate.

• Following relocation of either type of injury, a distal femoral or proximal tibial traction pin(0935) is used to apply 10kg of skeletal tractionfor 6 weeks, followed by a further 6 weeks ofpartial or toe-touch weight bearing on crutches.

Femoral neck (hip) fractures

0968 A high energy injury is required to fracturethe femoral neck in young casualties. If the fractureis displaced, there is a significant risk of avascularosteonecrosis of the femoral head. Optimal care inyoung casualties is reduction and internal fixationwithin 6 hours.

• Initial treatment in the field is to apply a tractionsplint or, other form of traction to the affected limb.

• For older casualties or when specialised

Approximately 5% ofall femoral shaftfractures will have anipsilateral femoralneck fracture.

The use of externalfixators on closedfemoral shaftfractures is notrecommended.

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187

Fig 0926 Reduction of a posterior dislocation of the hip.

chapter_9.qxd 28/09/2004 15:55 Page 187

operative intervention is unavailable, bed rest inskeletal traction for 6 weeks may be the onlyalternative; the complication rate is high.

Femoral shaft fractures

0969 If transfer to hospital is likely within two tothree days, apply skin traction. Further managementis described in 0939. If intramedullary nailing isunavailable within the theatre of operations, applyskeletal traction (trans-tibial or trans-femoral condylarDenham pin) for 6 weeks, followed by a hip spica orcast brace for 6 weeks.

Knee dislocation

0970 Dislocations of the knee are either anterioror posterior and are usually clinically obvious. If thecause was a vehicle accident, there may be a historyof the kneecap striking the vehicle's dashboard.

0971 Between 20-35% of knee dislocations areassociated with popliteal artery damage. An intimalflap tear is the most frequent finding (1005). This isimportant because the circulation may initially beintact. Later, as the flap extends, the circulation fails;this may be missed in a sedated casualty undergoingtransfer. If appropriate, vascular repair is undertakenwithin 6 hours: even then, the amputation rate is11%. Ideally, arteriography should be undertaken in all cases of knee dislocation (Figure 1004). Where arterial repair is delayed beyond 8 hours,the amputation rate is >85%.

0972 Peripheral nerve damage after kneedislocation occurs in 30-40% of casualties,particularly affecting the lateral peroneal nerve,leading to foot drop. Recovery may be limited and isnot generally helped by nerve exploration. Excessivedimpling of the skin over the medial part of joint,combined with a knee that is irreducible, implies that

Vascular Injury: see Chapter 10

.

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the medial collateral ligament or joint capsule isentrapped within the joint. This requires surgery.

0973 Treatment is to relocate the knee as earlyas possible under GA. In the field, the limb isstabilised with a long leg POP back slab.(Figure 0903 B) Rapid assessment of the popliteal circulationby Doppler ultrasound or arteriography, is thenundertaken. If neither is available and intimal damageis suspected, the artery is exposed and, if necessaryrepaired with a reversed saphenous vein graft(1030, 1048).

Patellar dislocation

0974 This is a separate entity from complete jointdislocation. The patella dislocates laterally after alow-energy blow to the medial side of the knee. The knee is held in flexion.

• Simple extension of the knee allowsspontaneous relocation. Vascular damage doesnot occur.

• Subsequent treatment consists of 6 weeks in apadded POP cylinder with the knee in 5 degreesof flexion.

Tibial fractures

0975 Treatment:

• Simple transverse or short oblique fractures(Figure 0901) can be managed to union in aPOP cast for 8-12 weeks.

• Open fractures are managed as in 0943.

• Long, unstable spiral fractures, may benefit fromthe informed use of an external fixator to holdthe bones in anatomical alignment (0948).

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Ankle dislocations

0976 Ankle dislocation typically occurs after fallsor parachuting injuries. The deformity is obvious. Not infrequently, the skin is tented over the displacedtalus and shows signs of vascular compromise.

• Emergency reduction under analgesia isnecessary. Longitudinal traction and correction of the deformity will allow the talus to relocate.

• A well moulded, padded plaster is then applied.Check X-rays are taken to ensure adequatereduction.

• Some dislocations will not reduce. This impliesthat a tendon, usually the tibialis posterior, hasbecome displaced into the joint. This requires an open, medial approach, to free it and relocatethe joint.

Ankle fractures

0977 Ankle injuries are common in all theatres of operations:

• Isolated lateral malleolar fractures without anymedial tenderness or injury, may be treated withice, compressive elastic bandages, elevation andphysiotherapy.

• Where there is medial injury, either in the form of ligament damage or a medial malleolarfracture, a well-moulded below knee plaster isused as the definitive treatment (Figure 0903).

• Most injuries involving service personnel arebest managed by transfer to a Role 4 facilityfor internal fixation.

• For local civilians in a Theatre of Operations,closed reduction and a below-knee POP, may bethe only, or better, option to open reduction andinternal fixation.

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Ankle ligament sprains

0978 The majority of ankle sprains can bemanaged within the area of Operations and therebyavoid casualties unnecessarily clogging the transferchain.

• Treatment includes immediate physiotherapy,ice, compression, elevation, analgesia, supportwith stirrup taping or bracing and controlledmobilisation beginning 24 hours after injury.Avoid POP immobilisation.

Deep vein thrombosis (DVT) and pulmonaryembolism (PE)

0979 Casualties suffering major limb, hip or pelvictrauma are at risk of developing a DVT and PE.Onset of symptoms is classically 3-7 after injury.Features of a DVT include:

• Limb swelling.

• Pain.

• Redness.

• Dilated superficial veins.

• Calf tenderness.

• Low-grade pyrexia.

Up to 75% of DVTs are silent. Where thrombosisaffects the veins above the knee, there may beembolisation to the lungs resulting in chest pain,dyspnoea and haemoptysis. Three percent of hospitaldeaths are due to PE. Confirmation of DVT is byvenography or Duplex scanning (1016).

0980 The value of prophylaxis for these conditionsin the field, is unclear. However, prophylaxis shouldgenerally be started as soon as haemorrhage iscontrolled.

• Traditional therapy is with s.c. heparin 5000 units


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12 hourly until ambulant. APTT monitoring is not required.

• Prevention of dehydration, limb elevation,graduated compression hosiery and earlymobilisation, may be of benefit.

• Using a low molecular weight heparin isconvenient (single daily dose) and will be more effective.

0981 Treatment of a confirmed case is by:

• Continuous i.v. infusion of 25,000 -40,000 unitsof heparin per 24 hours.

• Start oral warfarin. An initial regime is 9 mg ofwarfarin on Days 1 and 2 followed by 6mg onDays 3 and 4. Monitor by daily measurement ofprothrombin time (PT). Once PT is twice or threetimes the control value, heparin can be stopped.Adjust the daily dose to keep PT in this range.

Fat embolism

0982 This complication typically occurs 3-10 daysafter major long bone fractures. Lipid globules lodgingin the brain, lung, skin and kidneys may cause:

• Drowsiness, confusion, coma and death.

• Pyrexia and tachycardia.

• Petechial rash over the upper trunk.

• Dyspnoea, cyanosis and reduced PO2.

• Renal failure.

Diagnosis is confirmed by the finding of lipid globules in sputum or urine. The appearance of the lung on CXR is similar to that seen in ARDS.Treatment is supportive. Ventilation and dialysis maybe necessary.

Loss of Consciousness: see Chapter 16

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Chapter 10

Vascular injury

Introduction

1001 Major vascular injury in survivingcasualties is uncommon. Nevertheless, these injuries require timely intervention, with rapid control of haemorrhage at point of wounding or early recognition that bleeding is non-compressible.This should be followed by urgent transfer to asurgical facility. It should not be forgotten thathaemorrhage is the commonest cause of death on the battlefield - 10 to 20% of these deathsoccurring in those with limb injuries. Casualties with compressible haemorrhage are salvageable.Those with non-compressible haemorrhage are likelyto die unless they undergo emergency surgery.Damage control techniques may be necessary(0407).

The incidence of major vascular injury is between 1 and 4%, the vast majority involving the limbs. This figure has risen from 1% in WW II in parallelwith the increasing use of pre-formed fragmentationweapons causing multiple wounds. Approximately60% occur in the lower limb, 30% in the upper limb,5% in the neck and the remaining few in the torso.Arterial injury alone is uncommon; 40% areassociated with injury to a major vein and/or nerve.This is especially so in injuries around the axilla and popliteal fossa. Vascular injury is frequentlyaccompanied by significant soft tissue damage and one third are associated with injury to bone.

Limb Injury: see Chapter 9

The challenges ofvascular trauma are:• Making the diagnosis. • Planning theappropriateprocedure.• Exposing andcontrolling damagedvessels. • Performing difficultsurgery in adversecircumstances.

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Pathophysiology

Mechanisms of combat vascular trauma 1002 These include:

• Penetrating injury: low energy-transfer missileinjuries and stabbings typically cause vessellaceration or transection. Occasionally, distalflow is maintained by the surroundinghaematoma, leading to diagnostic difficulties.High energy-transfer missiles can result inmassive vascular disruption. In these cases,injury can occur remote from the missile trackdue to stress wave and cavitation effects or, be caused by secondary bone fragments (0206).

• Blunt trauma: vessel disruption can be direct(e.g., crushing) or indirect (e.g., traction orshearing). Examples of indirect trauma includedamage to the brachial artery secondary to a supracondylar fracture of the humerus, orinjury to the popliteal artery following dislocationof the knee joint. Blunt trauma, including theeffects of blast, can result in intimal disruptionand thrombosis.

• Blast: see 0218.

• Iatrogenic injury: examples include arterialdisruption during cannulation, accidental ligationor a neglected tourniquet. Occasionally, a majorvessel is deliberately tied off in an attempt tocontrol life-threatening haemorrhage e.g., theinternal iliac arteries after pelvic fracture (1282).

Consequences of vascular trauma 1003 Haemorrhage: bleeding may be externaland obvious “blood on the floor”, or internal andhidden “and four more” - examine the four classical sites. Contained haemorrhage leadsto haematoma formation.

Penetrating, Blunt and Blast Injury: see Chapter 2

Prior to definitivevascular repair,

fractures anddislocations should

be reduced and fixed.

Blood loss in trauma may be

into five sites:• External.

• Chest.• Abdomen.

• Pelvis/retroperitoneum.

• Around longbones (especially

the femur).

“Blood on the floorand four more”.

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1004 Ischaemia: may be acute, due to suddeninterruption of the arterial supply, or delayed. Causes of delayed ischaemia include: developmentof a compartment syndrome (0906) and extension of an intimal flap with slow build-up of thrombus.Irreversible tissue damage and necrosis rapidly follow (brain: 3 minutes, muscle 6-8 hours).

1005 Intimal flap and thrombosis: all forms of vascular trauma can cause part of the intima andmedia to become detached, leading to obstructionof the lumen. The distal circulation may initially beintact. The exposed thrombogenic surface can lead to thrombosis (Figure 1001). At operation, the outsideof the artery often appears normal. The diagnosis isconfirmed by pre-operative or on-table arteriographyor, exploration.

1006 Arterial spasm: the ends of transectedarteries tend to go into spasm and thrombose.Bleeding from lacerated vessels is more profusebecause the partially intact wall prevents retraction.Arterial occlusion due to spasm alone is rare andshould only be diagnosed after angiography orexploration, has excluded other causes.

1007 Arteriovenous fistula (AVF): an AVFoccurs when an adjacent artery and vein are injured,

If bleeding iscompletely controlledwith direct pressure,dressings or carefulapplication of a clipor tourniquet, thisshould bemaintained until theprimary andsecondary surveysare completed.

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Fig 1001 Intimal flap and thrombus formation causing arterial obstruction.

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usually by penetrating trauma (e.g., radial artery andvein following a wound to the forearm). Arterial bloodpreferentially finds its way directly into the lowerpressure venous circulation (Figure 1002). Most acquired AVFs present late, by which time theassociated veins have become dilated and tortuous.Effects may include: a bruit, an increase in pulserate, pulse pressure and cardiac output; distalischaemia and, eventually, cardiac failure.

1008 False aneurysm: partial disruption of anarterial wall can lead to a walled-off, pulsatinghaematoma (Figure 1003). The contents of this falseaneurysm remain in continuity with the lumen of theartery. Distal flow is often maintained makingdiagnosis difficult. Presentation is usually delayed.

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Fig 1002 Arteriovenous fistula.

Fig 1003 False aneurysm communicating with lumen of artery.

ARTERY

VEIN

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Management of Vascular Injury

Examination1009 Assessment of circulation and haemorrhagecontrol is performed during the 'C' part of the primarysurvey (0313).

1010 Clinical assessment of acute limb ischaemiais undertaken during the secondary survey. Look forthe classical features (the six 'P's):

• Pain.

• Pallor.

• Pulseless.

• Paraesthesia.

• Paralysis.

• 'Perishing' with cold.

The most important are paraesthesia and paralysis -nerves are very sensitive to anoxia. The absence of neurological signs implies no immediate risk ofgangrene. Conversely, if they are present, circulationneeds to be restored within 4 to 6 hours, assumingno pre-existing arterial disease.

An expansile haematoma may be palpable. Examinefor the presence of a palpable arterial thrill or audiblebruit. Compare CRT in both limbs.

1011 Penetrating or blunt trauma to the commonor internal carotid arteries can cause cerebralischaemia. Neurological signs, especially in theyoung, are sometimes subtle. Early investigation byDuplex scanning or arteriography may be necessary.

Neck Injury: see Chaper 19

NB: collateralcirculation may mean that pulses are occasionallypresent at the ankleor wrist despitecomplete disruptionof the brachial orfemoral artery.

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Investigation

Role 1 & 2

1012 Pulse oximetry: a digital probe is a simple method of monitoring extremity tissue oxygensaturation; always compare with the uninjured limb.NB: saturation is affected by the haemoglobinconcentration.

1013 Doppler: a hand-held Doppler probe maybe available to detect blood flow at the ankle or wrist.Apply conducting jelly, position the probe at 45degrees to the direction of flow and listen for thecharacteristic 'whoosh'.

1014 Ankle brachial pressure index (ABPI):using the Doppler probe and a sphygnomanometer,measure the systolic pressure over either theposterior tibial or dorsalis pedis arteries and thecasualty's brachial artery. Dividing the ankle pressureby the brachial pressure should give an ABPI of > I.0.A value of 0.7 or less indicates significant ischaemia.Serial measurements of the ABPI may be useful fordetecting deterioration in blood supply.

The presence of palpable distalpulses, a normal

CRT or a Dopplersignal do not

absolutely excludevascular injury.

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Fig 1004 On-table arteriogram. Position X-ray plate under steriledrapes. Place opaque marker adjacent to site of injury. Inject contrastvia proximal needle and syringe.

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1015 On-table arteriography; this relativelysimple investigation should be available at most Role 2+ or 3 facilities to confirm arterial damage and demonstrate its location. In the operating theatrean X-ray plate is placed under the drapes oppositethe site of trauma (Figure 1004). Between 20 and50mls of radio-opaque contrast is rapidly injected into the exposed artery proximal to the injury.Approximately 10 seconds later the plate is exposed (allow a one second delay for eachcentimetre of travel).

Role 3 & 4

1016 Doppler ultrasound (Duplex): this is acombination of Doppler and b-mode continuous waveultrasound. It is quick, non-invasive and has, incertain areas, replaced arteriography. Duplexscanning can detect arterial and venous disruption or occlusion, intimal flaps, haematomas, falseaneurysms and arteriovenous fistulae.

1017 Digital subtraction angiography (DSA).This will only be available at a Role 4 facility.

1018 Computerised tomography (CT):contrast-enhanced CT scanning can be used todiagnose vascular injury in the neck, chest andabdomen. In civilian practice, early whole-body CTscanning, is favoured by many for the assessmentof casualties with multiple trauma.

Immediate treatment 1019 This may summarised as follows:

• Compressible haemorrhage is controlled by acombination of direct pressure, elevation, splintingor a tourniquet (0330). Fibrin-impregnated fielddressings and other topically applied adjuncts for haemorrhage control are available.

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Arteriography is anunnecessary andtime wasting pre-operativeprocedure when thediagnosis is obvious!

The CT scanner is a dangerous placefor an unstablecasualty; access is restricted andsudden deteriorationmay go unnoticed.

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• Casualties with non-compressible haemorrhagerequire hypotensive resuscitation (0333) andurgent transfer to a surgeon for operativecontrol. Occasionally, a resuscitative laparotomyand/or thoracotomy are necessary as part of theprimary survey.

• Where facilities are available and the casualtyremains stable, consider interventional radiologyto control haemorrhage.

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Fig 1005 a) Embolectomy/thrombectomy using a balloon catheter. b) Installation of heparinised saline.

a) b)

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Definitive Vascular Surgery Techniques

Simple vascular repair

Artery

1020 Exposure and control: expose the arteryproximal and distal to the injury. Control smallvessels by passing a silastic sling or fine ligaturetwice around the vessel and apply gentle traction.Ideally, larger vessels require application of vascularclamps. Reduce intimal damage by closing theclamp's ratchet just enough to achieve occlusion.Vessels can also be controlled by 'snugging-down'encircling slings. In difficult circumstances, considerinserting proximal and distal intraluminal ballooncatheters; they are less traumatic than a vascularclamp hurriedly misapplied.

1021 Inadequate back bleeding and inflow:this is probably due to thrombus formation and canbe cleared by the passage of a balloon catheter upand down the lumen (Figure 1005):

• Choose an appropriate size e.g., size 5 Fogarty above and size 3 below, the common femoral artery.

• Remove the stylet. Check the balloon by inflatingit with a syringe containing the recommendedvolume of saline.

• Gently pass the catheter into the artery, ensuringit lies within the lumen. Ideally, prior angiographywill have excluded an intimal tear; this can beworsened by blind instrumentation. The distancetravelled is indicated by marks on the outside ofthe catheter.

• Inflate and vary the pressure using the syringe,so that the balloon just makes contact with thearterial wall during its slow withdrawal. Continue

If bleedingcontinues, look formissed injury tocollateral vessels.

Standard vasculartechniques are:• Non-crushingclamps.• Fine Prolenesutures.• Balloonthrombectomy.• Spatulation for small anastomoses.• Completionangiogram.

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passing the balloon until no further thrombus is extracted.

• Flush the proximal and distal lumen with severalsyringes of heparinised saline (5,000iu heparinper 500ml saline).

1022 Intimal flap: inspect the lumen of the artery for intimal flaps. Anchor these down using a double-ended 5/0 Prolene suture. Pass eachneedle through the flap from inside to outside thevessel (Figure 1006). Tie on the outside. Defects on the back wall require rotation of the artery.

Where simple repairsignificantly narrowsthe lumen i.e., >25%

perform a patchangioplasty. If in

doubt patch it.

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Fig 1006 Fixing an intimal flap.

Fig 1007 Trimming the lacerated vessel prior to repair.

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1023 Repair: trim the edges of a raggedlaceration taking minimal tissue (Figure 1007). Effectclosure with a lateral repair providing this does narrowthe lumen. Use a double-ended Prolene suture:

• 3/0 for the aorta.

• 4/0 for the iliac arteries.

• 5/0 for the femoral arteries.

Pass each needle from inside to out at the comer of the arterial wound (Figure 1008). Repeat with a second suture at the other end of the wound. Tie and attach a clip to the shorter end to use as a stay suture. Using the longer end, suture in thedirection of flow using a simple over-and-overtechnique. Take care to pick up all layers of thevessel wall. Each bite should be 2mm apart and a similar distance from the wound edge. Handle theartery gently. To prevent intimal damage, avoidgrasping the full thickness of the vessel with forceps.Insert 2-3 bites using the long end of the distal sutureworking proximally.

1024 Restoration of flow: before completing theanastomosis, ensure that back bleeding and infloware satisfactory (1021). Carefully release the distal


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��

��

Fig 1008 Simple arterial repair of a major vessel: a) use two double ended Prolene sutures. b) Place sutures 2 mm from edge and 2 mm apart.

a)

b)

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clamp, sling or balloon, instil heparinised saline andre-occlude to prevent embolus passing distally whenproximal control is released. Then release proximalcontrol to assess forward flow. Complete the vascularrepair. Before tying the final suture, temporarilyrelease the proximal occlusion to flush out any clot or debris. Balloon catheters are deflated andremoved at this stage. Leave the suture ends longto prevent unravelling.

1025 Anastomotic bleeding: this can normallybe controlled by gentle pressure without occludingthe vessel. If there is a major coagulopathy,transfusion of clotting factors may be necessary. Use 'rescue' sutures sparingly. They should beplaced parallel to the line of the anastomosis, taking a small bite through the adventitia of the artery (or vein patch) on either side of the leak.Tie with tension just sufficient to control haemorrhage.

1026 Completion angiography: following repairof a small-calibre vessel, perform an angiogram toensure a satisfactory run-off (1015). Bleeding fromthe puncture site can be controlled with directpressure or the placement of a small adventitial'Z'-stitch.

1027 Fasciotomy: consider whether the limb is at risk of developing a compartment syndrome(0906). A fasciotomy is often beneficial followingvascular repair (0908).

1028 Drainage and cover: use closed suctiondrainage for all limb vascular repairs unless they liewithin the primary wound. Drains should be removedwhen they cease to drain. If a repair is sited within a primary wound which is to be left open forsubsequent delayed closure, do not apply dressingsdirectly to the repaired vessel. (0503), it is likely tothrombose or rupture. Cover the repair by swingingacross a local muscle flap:

Technique of Fasciotomy: see Chapter 9

The anastomosiscan easily be ruined

by a poorly-placedsuture which narrows

the lumen.

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• Sartorius and gastrocnemius in the thigh andlower leg.

• The scalene muscles or trapezius for the carotids.

• Latissimus dorsi for the axillary vessels.

Failing this, tack together viable local soft tissuesover the involved vessels. Then apply dressings.Obtaining cover for large wounds may necessitatethe use of relieving skin incisions or local fascio-cutaneous flaps: seek the advice of a plastic surgeon.

Vein

1029 With concomitant injuries to major veins and arteries repair the vein first. This will reducetroublesome venous bleeding during arterial repair. If other injuries in the limb require attention e.g.,external fixation of a fracture, consider placingtemporary shunts in both the vein and artery (0411). Venous bleeding is initially managed by applyingpressure either side of the defect, e.g., using swabson sticks. This is safer than trying to dissect out,sling and clamp the vessel. Small vessels may beligated. Large veins should, when feasible, berepaired with 5/0 Prolene sutures (1030), especiallyif there is extensive soft tissue injury that may havecompromised other venous channels. Complex grafts,for example spiral and panel grafts, constructed tobridge defects in large veins, are technicallydemanding and time-consuming in practise.

Nevertheless, every effort should be made to restorecontinuity of large veins, even if only temporarily.This may involve the use of PTFE grafts in selectedcases. Ligation of the vein should be the last resort.

Advanced vascular repair The following require time, technical skill and judgement. They are best performed onstabilised casualties.

Tissue Flaps: see Chapter 23

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End-to-end anastomosis

1030 This technique is suitable for arterial and venous repairs where the vessel ends can be approximated without tension.

• Check that the inflow and backflow aresatisfactory (1021). Mobilise and control thevessel above and below the defect (1020),(Figure 1009 a)

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Fig 1009 a) Excise the damaged arterial segment at an angle. b) Place two stay sutures. c) Technique of end-to-end anastomosis. Use the stay

sutures to rotate the artery.

a)

b)

c)

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• Divide the ends at an angle to reduceanastomotic stenosis (Figure 1009 b). Insert two stay sutures. Alternatively, insert and tie a double-ended Prolene (1023).

• Suture between the stays using a continuoussuture for vessels >6mm diameter (e.g., commonfemoral artery) or, interrupted for smallervessels. Pass the needle from outside-inproximally and inside-out distally. Use the staysto rotate the vessel, (Figure 1009 c).

• Restoration of flow - see 1024.

Interposition graft

1031 An interposition graft is used to bridge a damaged vessel where the ends cannot beapproximated without tension.

• The best graft material is autologous vein, thelong saphenous vein (LSV) is ideal. Vein is thepreferred material if the graft crosses a joint. The LSV is usually harvested from the groin ofan uninjured leg. The calibre of the vein at thissite is sufficient to replace vessels up to thediameter of the superficial femoral artery.

• Tributaries of the LSV are ligated using fine,non-absorbable ties. To prevent the valvesinterfering with flow, the vein must be reversed.Mark one end of the vein to avoid confusion!Irrigate with heparinised saline.

• Divide the ends at an angle to reduce narrowingand insert stay sutures (Figure 1010). Performan end-to-end anastomosis as in 1030. If thegraft is being inserted end-to-side, vein to artery,suture the heel of the vein first using a'parachute' technique. Cut the graft to therequired length after completing the firstanastomosis.

Restoration of flow: see 1024.

Where there is doubt aboutexcessive tension it is wiser to insertan interposition graft.

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• If suitable vein is not available or a shortenedoperating time essential, consider using asynthetic graft, PTFE is preferred. It is no longeranathema to use synthetic grafts in war wounds,providing the graft is covered (1028), suitableantibiotics are administered and the casualty can be observed for secondary haemorrhage.Even if the graft becomes infected or occluded,subsequent extra-anatomical by-pass withexcision of the first graft, may save the limb.

Antibiotics: see Chapter 8

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�

�

a)

b)

c)

Fig 1010 Reconstruction using an interposition graft: a) If the graft is narrower, incise as shown. b) Place stay sutures. c) After completing the first anastomosis, trim to length.

Use the stay sutures to rotate the artery.

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Patch angioplasty

1032 This is the preferred method of closinglacerations affecting small vessels (<6mm) so as toprevent stenosis.

• Usually there will be a suitable segment of veinavailable at the site of injury, if not, harvest partof the proximal long saphenous vein.

• Control the vessel and trim the jagged edge of the defect.

• Cut the vein patch to the required size and roundthe ends in order to reduce apical narrowing.

• Fix in place using a double-ended Prolenesuture. The apical sutures should be laid in such a way as to resemble the outspreadfingers; this prevents narrowing of the lumen.Aim to tie the Prolene along one side of thepatch, not at the apex, (Figure 1011).

Restoration of flow: see 1024.

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Fig 1011 Patch angioplasty.

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Fig 1012 Extra-anatomical bypass grafts: a) Axillo-femoral. b) Femoro-femoral crossover. c) Technique of performing an end-to-side anastomosis - first place sutures in the 'heal' and parachute down before working round the 'toe'.

a)

b)

c)

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Bypass procedures

1033 Extra-anatomical bypass procedures areoccasionally required but, rarely indicated in the field,even if feasible. Indications include:

• Following ligation/obstruction of major arteries.

• Where there is wound contamination.

• Because of extensive soft tissue loss.

Examples are: an axillo-femoral graft or a femoro-femoral crossover (Figure 1012). A synthetic graft is anastomosed end to side to the respectivearteries after being tunnelled subcutaneouslybetween them. This can be performed under LAin the high risk casualty.

Repair of arteriovenous fistulae

1034 The artery and vein should be controlledproximally and distally and the fistula disconnected.Each defect is repaired with Prolene. Interposition of a muscle pedicle will reduce recurrence.

Post-operative management1035 This includes:

• Monitor pulse, BP, respiratory rate, temperatureand urine output.

• Elevate the limb and keep the digits exposed.

• Observe the six 'P's and CRT (1010).Assessing circulation with pulse oximetry (1012)and Doppler (1013), may give an early clue to deterioration.

• Consider the need for DVT/PE prophylaxis (0980)

• Drains can usually be removed at 48 hours.

• Regular wound examination is harmful unless thereis an indication to do so (0508). A serous orlymphatic leak generally resolves spontaneously.

Wound Management: see Chapter 5

Deteriorating limbcirculation may bean indication forangiography,radiologicalintervention, re-exploration or amputation.

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• Sutures can usually be removed at 7-10 days.

Vascular Exposure

Following vascular trauma, rapid and adequateaccess to involved vessels is essential.

Vessels at the root of the neck 1036 Damage to the subclavian, carotid andvertebral arteries is usually caused by penetratingtrauma and can lead to massive haemorrhage intothe neck and chest. The common carotid artery ismore likely to be affected than its branches, as thebifurcation is high in the neck and protected by theangle of the jaw. Avulsion injuries generally occur atthe origin of the main arteries on the arch of the aorta.

Carotid, brachiocephalic and proximal subclavian vessels

1037 Injuries below the cricoid cartilage:

• Approach is via a median sternotomy incision(1538). This gives good access to the proximalleft common carotid artery (LCCA),brachiocephalic artery (BCA), proximal rightsubclavian artery (RSA) and origin of the rightcommon carotid artery (RCCA). The LCCA andBCA are initially intrapericardial.

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Fig 1013 Incision along anterior border of sternomastoid muscle.

Chapter_10.qxd 28/09/2004 15:55 Page 212

• Median sternotomy is often combined with anextension into the neck along the medial borderof the sternomastoid muscle (Figure 1013).

• It may be possible to obtain sufficient exposureof the proximal left subclavian artery (LSA) via amedian sternotomy; other options are: a leftanterior thoracotomy (1534) or trapdoor incision(1540).

1038 Injuries above the cricoid cartilage:

• Approach via a longitudinal incision along theanterior border of the sternomastoid (Figure 1013)from 2cm below the mandible to the suprasternalnotch. Turn the head to the opposite side andsupport with the neck slightly extended.

• Divide the platysma and the deep fascia in the line of the skin incision. Retract the musclelaterally to reveal the carotid sheath. Incise anddissect along the anterior border of the internaljugular vein (IJV) to expose the common carotidartery (CCA) (Figure 1014). Tributaries of the IJV (e.g., common facial vein, middle thyroidvein) and the omohyoid muscle, usually require division.


Have an arterialclamp to hand in the event of majorhaemorrhage.

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Fig 1014 Exposing the carotid sheath.

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• Retract the IJV laterally. Pass a sling around theCCA. Avoid the vagus nerve which lies behindand the ansa hypoglossi and hypoglossal nerve,which lie in front of the artery (Figure 1015).Continue the dissection cephelad.

• If required, access can be improved by division of the posterior belly of the digastricmuscle and the sternomastoid muscle near itsinsertion. NB: avoid the glossopharangeal andaccessory nerves.

• Above the carotid bulb, pass slings around the internal (ICA) and external carotid arteries(ECA). The ECA lies anterior to the ICA andgives off branches in the neck; it can be safely ligated.

• Because of the risk of stroke, the CCA and ICAshould be repaired. Allow free back bleeding toavoid embolisation of air, thombus or debrisbefore releasing the proximal clamp. Occlusionfor more than four minutes requires insertion of a temporary shunt (0411).

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Fig 1015 Common carotid artery, internal and external carotidarteries and associated nerves.

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Vertebral arteries 1039 Injuries to the origin of the vertebral arteryare accessible via an incision along the anteriorborder of sternomastoid (Figure 1013). Thesternomastoid is divided and swung laterally. The carotid artery and the jugular vein are mobilisedand retracted medially to reveal the vertebral artery.Once the artery has entered the bony canal, bleedingcan only be stopped with difficulty and attempts arelikely to be futile.

Upper limb

Distal subclavian artery

1040 Exposure is via a supraclavicular approach.This can be difficult to perform quickly. Considertemporary control by pressure applied to an inflatedballoon catheter inserted through the wound (0330).

• Make a horizontal incision 1cm above the medial two-thirds of the clavicle and divide the fat and platysma (Figure 1016). Access canbe improved by excising the clavicle medial tothe coraco clavicular ligament (Figure 1017).

• Ligate and divide the external jugular vein.

• Mobilise the scalene fat pad to expose thescalenus anterior muscle. Identify and preserve

Classiffication of Neck Injury According to Zones: see 1924

Casualties withpenetrating injuriesof the cervical spine have a 95% mortality.

Upper limb vesselsare more delicatethan lower limb and requirecareful handling.

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Fig 1016 Incision used to expose the distal subclavian artery.

Chapter_10.qxd 28/09/2004 15:55 Page 215

the phrenic nerve as it crosses the muscle fromlateral above to medial below. Beware the cordsof the brachial plexus. Divide scalenus anteriornear its insertion on the first rib, this will exposethe subclavian artery.

Axillary artery

1041 The axillary artery commences opposite thelateral border of the first rib and becomes thebrachial artery at the lateral edge of teres major. It isdivided into three parts, the mid portion lying behindpectoralis minor (Figure 1018).

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• Make an incision 2cm below the lateral half ofthe clavicle extending onto the upper arm(Figure 1018). Split the fibres of pectoralis majorand insert a self-retaining retractor. For greaterexposure divide the clavicular and humeralheads of pectoralis major (Figure 1019). Preserve the medial and lateral pectoral nerves.

• Pass a finger around pectoralis minor and dividethe muscle near its insertion into the coracoidprocess of the scapula (1018).

• Dissect the axillary artery away from the axillaryvein and control with slings.

Brachial artery

1042 The brachial artery passes down the medialaspect of the arm beneath the deep fascia. It iscrossed by the median nerve, which comes to liemedially in the antecubital fossa (Figure 1020). Here the artery divides into radial and ulnar branches.

• Abduct the arm. Make a longitudinal incisionalong the medial border of biceps.

• Divide the deep fascia and dissect the arteryfrom the nerve.

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Fig 1019 Exposure of the axillary artery (NB: avoid damage to thebrachial plexus and pectoral nerves).

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Radial and ulnar arteries

1043 The origin of both arteries lies superficiallyin the antecubital fossa. Exposure and repair is rarelynecessary. As long as one of the arteries remainspatent, the other can be ligated.

• Place the arm abducted on a board with thepalm facing upwards.

• To expose the radial artery make a longitudinalincision along the antero-lateral aspect of theforearm (Figure 1021). Divide the deep fascia

Injury to the Heart, Thoracic Aorta and Hilar vessels: see Chapter 15

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and dissect in the interval betweenbrachioradialis and the long flexors muscles(Figure 1022).

• To expose the ulnar artery, make a longitudinalincision along the antero-medial aspect of theforearm (Figure 1021). Dissect between the longflexor muscles and flexor carpi ulnaris (Figure 1022).

Lower limb

Common iliac (CIA) and internal iliac arteries (IIA)

1044 Following penetrating trauma, the iliacarteries are approached via a standard midlinelaparotomy incision (1282).

External iliac artery (EIA)

1045 In casualties with a groin injury, it may benecessary to expose the EIA in order to obtainproximal control. Extend the vertical groin incisionupwards and laterally (Figure 1023). Divide theinguinal ligament and abdominal wall muscles in

Abdominal vessels, Aorta and Inferior Vena Cava: see Chapter 12

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the line of the incision passing lateral to the deepinguinal ring. Push the peritoneum forwards off theiliac vessels. Avoid entering the abdominal cavity. For large wounds in the femoral triangle, obtain rapidproximal control by clamping the aorta. Do not wastetime delving blindly into the wound.

Femoral artery and vein

1046 Femoral arteries

• Make a vertical incision over the femoral arterystarting just below the mid point of the inguinalligament (Figure 1023). Continue for 10-15cm, or until sufficiently distal to the injury.

• Incise through fat and fascia and develop aplane along the length of the artery (Figure1024). Pass slings around the common femoral(CFA) and superficial femoral arteries (SFA).Control side branches using heavy, untiedligatures passed twice around the vessel.

• At a variable distance in the wound, the CFAdivides into the SFA and profunda femorisarteries (PFA). The CFA may be seen to narrowat this point. Traction on the proximal and distalslings will reveal the deeper-lying PFA, usuallyon the lateral side of the SFA. Pass a sling

Renal vessels: see Chapter 14

Treat arteries with respect. Roughhandling can lead tointimal damage and

tear the adjacentvein. Pass each

rubber sling twicearound iliac or

femoral arteries fromthe medial side using

curved forceps.

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around the PFA taking care to avoid theprofunda femoris vein (PFV).

• Where necessary, the SFA can easily befollowed distally; there are no branches ofsignificance in the thigh. Tracing the PFA is more difficult; it has multiple side brancheswhich must be controlled using heavy ties.

1047 Femoral veins

The need for venous repair is discussed in 1029.

• The common femoral (CFV) and superficialfemoral veins (SFV) lie medial to their respectivearteries; together with the PFV, they arecontrolled with slings.

• The long saphenous vein lies in thesubcutaneous tissues of the medial thigh. It passes through a window in the deep fascia to join the CFV in the groin. The LSV mayrequire ligation or control with a sling.

Where possible,preserve the longsaphenous veinwhich may berequired for asubsequentreconstruction.

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Popliteal vessels 1048 The popliteal artery extends a hand'sbreadth above and below the line of the knee joint.Depending on the site of injury, the artery is usuallyexposed via a medial incision above the knee whichcan be extended distally as necessary. If there isextensive bleeding, it is safer to obtain proximalcontrol in healthy tissue prior to opening the haematoma.

• Position the leg as in Figure 1025.

• The above knee popliteal artery is first exposedvia a 15cm long incision placed 2cm behind theposterior border of the distal femur on its medial aspect.

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Fig 1026 Exposure of the popliteal vessels above the knee.

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• The subcutaneous fat and deep fascia areincised and the dissection continued deep to theanterior border of sartorius (Figure 1026). Sweepaside the popliteal fat pad to expose the artery. It is usually surrounded by two venaecommitantes. Control with slings and occludeside branches with heavy ties.

• Expose the below knee popliteal artery asnecessary (Figure 1025). To improve access itmay be necessary to divide the tendons ofsartorius, gracilis, semimembranosus andsemitendinosus along with the medial head ofgastrocnemius (Figure 1027). The artery and itsaccompanying venae commitantes will be foundlying close to the posterior surface of the tibia.The tibial nerve lies posteriorly. Control theartery with slings.

• If there is an isolated popliteal artery injurybetween the femoral condyles, a posteriorapproach using a lazy-S incision, should beconsidered. This avoids dividing the musclesand tendons on the medial aspect of the knee.

Peroneal and Posterior Nerve Injury: see 2116 and 2117

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Crural vessels

1049 The main branches of the infrageniculatepopliteal artery are the anterior tibial, posterior tibial and peroneal arteries. Because only one of these is required to maintain foot viability, repair is rarely necessary.

1050 Anterior tibial artery

The artery arises from the lateral border of thepopliteal artery near the soleal arch. It may beexposed via a 15cm longitudinal incision just anteriorto the tibia (Figure 1028). Divide the fascia anddissect in the plane between tibialis anterior mediallyand extensor digitorum longus and extensor hallucislongus laterally (Figure 1029). The anterior tibialartery and veins lies deep to these muscles on theinterosseous membrane.

1051 Posterior tibial artery

Expose via a 20cm longitudinal incision down themedial side of the leg, just behind the posteriorborder of the tibia (Figure 1028). Incise the deepfascia and separate the soleus from its attachment to the tibia (Figure 1030). In the proximal calf, the

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Fig 1028 Approaches to the crural vessels.

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posterior tibial artery lies deep to soleus on flexordigitorum longus. Exposure of the artery is easier inthe distal half of the calf where it lies more superficial.

1052 Peroneal artery

The artery can either be exposed by a deepening ofthe incision used to expose the posterior tibial artery(Figure 1028), or via a longitudinal incision directlyover the fibula. In the latter, muscle attachments arestripped off the fibula and a segment excised using aGigli saw (Figure 1031). The peroneal artery liesimmediately deep to the fibula.

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Chapter 11

Amputation

Introduction

1101 Traumatic amputation is one of the mostdevastating consequences of armed conflict and isfrequently due to blast or antipersonnel mine injury(Figure 1101). Unless the blast is focused, death isthe usual outcome. Victims of antipersonnel minesgenerally survive despite a significant amputationrate. In modern conflict surgery, traumatic lower limb amputation account for 5-10% of all injuries, with non-combatants and children frequently affected.The wounds are usually complex, with multilevelinjury to skin, muscle, neurovascular structures andbone. Re-implantation is not possible.

1102 In a military setting, an unsalvageablelimb is usually obvious and the decision to operatestraightforward: the surgeon simply completes theamputation. Management of lesser wounds can bedifficult, especially when dealing with bilateral limbinjuries or severe crush injury. Where possible,obtain a second opinion. Perform wound excision,fasciotomy and lavage. Take a photograph andobserve the limb for 24-48 hour. During high intensity warfare with limited facilities, masscasualties and transfer delays, amputation may be indicated for injuries that might be salvageable in a civilian environment.

General Principles

1103 Amputation is disabling, distressing andirreversible. Despite the emotive nature of the injury,

Fasciotomy: see Chapter 9

Surgical amputationis a form of radicalwound excision.Inadequate initialtreatment can resultin gas gangrene,increased morbidityor death.

It is better to lose a limb than the lifeof the casualty.

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Fig 1101 Effect of a mine blast on the lower limb.

Chapter_11.qxd 28/09/2004 15:55 Page 228

particularly when dealing with children, initialmanagement priority remains ABC. Unless thereis major haemorrhage, management of the limbwound is not addressed until the casualty has been resuscitated.

1104 In the military environment, acceptedpractice is an emergency amputation, preserving asmuch viable skin, soft tissue and bone as possible.Because of the degree of likely contamination, asecond-look wound excision is undertaken 48 hourslater. If clean, a delayed primary closure of thewound is performed within 3-5 days, ideallyemploying a myoplastic repair. By then, the casualtyshould be at a Role 3 or 4 facility. After the woundhas healed, definitive amputation may still berequired weeks or months later.

1105 Administer antibiotics (0816) and tetanustoxoid (0825).

Emergency Amputations

1106 Indications

Arterial injury: amputation is performed if there islimb ischaemia ('6 P's' 1010) with significant softtissue damage. If the injury is mainly arterial, withonly moderate distal soft-tissue damage and minimaldelay in revascularisation, consider vascular repair or insertion of a temporary arterial shunt (1023, 0411).

Severity of damage (mangled limb): In the lowerlimb, amputation is indicated for significant skin, soft tissue, nerve or bone defects, especially incombination. Various scoring systems have beendevised to aid decision-making including the'Mangled Extremity Severity Score’(MESS - Table 1101) Amputation (in the absence of life-threatening damage) is justified in the upper

ABC: see Chapter 3

If the wound remainscontaminated or stillcontains necrotictissue whenexamined at 48hours, furtherexcision is requiredand closure delayedfor subsequentwound inspection.

Delayed primaryclosure should be performed before skin andmuscle retract and become fixed.

Amputation is usuallyindicated because ofsoft tissue ratherthan skeletaldamage. Loss ofbone without nerveand vascular injurymay not justifyamputation.

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limb only if the magnitude of injury precludesrecovery of any degree of function in the hand,fingers or thumb.

Overwhelming infection: delays in treatmentcommonly result in grossly infected wounds andsepticaemia. In gas gangrene (0829), it is importantto amputate one level higher than the superficialtissue changes would suggest i.e., if infection isconfined to the lower leg, perform an above kneeamputation. In necrotizing fasciitis, it is usuallysufficient to excise the affected muscle compartment (0832).

Entrapment: In casualties trapped for >6 hours witha pulseless leg, release can cause fatal cardiacarrest due to K+ ion and lactic acid release (0921).


Rapid amputationmay be the only

way to resuscitate the casualty.

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Skeletal/soft-tissue injuryLow energy (stab, simple fracture, pistol gunshot wound) 1Medium energy (open or multiple fractures, dislocation) 2High energy (high speed RTA or rifle GSW) 3Very high energy (high speed trauma + gross contamination) 4

Limb ischaemia*Pulse reduced or absent, but perfusion normal 1Pulseless; paraesthesia, diminished capillary refill 2Cool, paralysed, insensitive, numb 3

ShockSystolic BP always >90mmHg 0Transient hypotension 1Persistent hypotension 2

Age (years)<30 030-50 1>50 2

If score above 7 - Amputate.If score below 6 - Try to save.

* If the warm ischaemia time is over 6 hours, this score is doubled.

Table 1101 Mangled Extremity Severity Score (MESS).

Chapter_11.qxd 28/09/2004 15:55 Page 230

This also applies to casualties with a field patternmilitary tourniquet left unreleased for several hours. It may be preferable to perform primary amputation at the scene as a life saving measure.

The seriously ill casualty with multiple injuries:In selected cases, amputation may be the simplestand fastest means of removing damaged, necroticlife-threatening tissue.

Level of amputation1107 The following should be considered:

• The injury dictates the level of bone division.Initially, it should be performed as distally aspossible and at a level where the tissues appearviable (Figure 1102). This may be suboptimal forfunction and require subsequent revision.

• Attempt to retain the knee joint in order toachieve a more functional stump. The medialhead of gastrocnemius is often sufficientlypreserved to provide soft tissue cover for abelow knee amputation. Where this cannot be


The level ofamputation mayneed revision.

This can beperformed at thetime of delayedprimary closure orweeks or monthslater when aprosthesis is being considered.

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achieved, it is better in an emergency to amputate through the joint rather than through the lower femur.

• To release a trapped casualty, perform aguillotine amputation as distally as possible.

• To prevent infection, remove all deadtissue/foreign material. Remember that each limb has a number of separate longitudinalcompartments. Blast injury typically drivesfragments of boot, dirt and clothing far up these fascial planes.

Operative technique in emergency amputation

1108 Essential points are:

• Resuscitation should continue during surgery to ensure adequate urinary output.

• A well-padded, proximal thigh tourniquet should be applied, but not necessarily inflated, during removal of field dressings and subsequent surgery.

• Perform under GA; Ketamine (0714) can be usedin the field.

• Identify and control the main vessels using arteryforceps. Once the level of the amputation hasbeen determined, the arteries and veins areindividually doubly ligated with Prolene anddivided. If uncontrollable bleeding is encountered,inflate the tourniquet and secure the vessel.

• The skin incision is often dictated by the wound.Retain as much viable skin as possible. Unequalflaps are often constructed so that the final scarwill avoid the end of the stump.

• Incise the deep fascia at the same level as theskin and reflect it up as a single layer. Do not

Anaesthesia: see Chapter 23

The three aims ofprimary amputation

are to:

1.Save life.

2.Excise all dead, contused and

contaminated tissue.

3.Facilitate delayedprimary closure.

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dissect unnecessarily between skin and deepfascia. Leave viable muscle for at least 5-10cmdistal to the proposed level of bone section.Nerves should be cut with a sharp blade undergentle traction at the level of amputation so thatthey retract proximally away from the stump.

• Excise all dead tissue, remove foreign materialand copiously irrigate the wound, (0503).

• Divide the bone with an amputation or Gigli saw.Avoid damage to soft tissues by using a guard orswab wrapped around the wound. File any sharpbone edges. It is not necessary to reflect aperiosteal cuff.

• If a tourniquet has been used, it should now be released and all bleeding points secured.

• Perform further irrigation.

• Loosely pack the wound with fluffed, dry gauzeto encourage free drainage and absorb exudate.Flaps should be allowed to fall into place withoutkinking: do not suture. Avoid soaking thedressings in antiseptic solution. Cover the stump with two thick layers of cotton wool placed crosswise and secure with a crepebandage (Figure 1103). Below knee amputationsshould be splinted with the knee in extension so as to prevent flexion contracture.

Preventing retraction1109 In order to prevent skin and muscleretraction where the amputation flaps are scanty orclosure is delayed, apply gentle skin traction. Attachsterile adhesive tape to the skin above the amputationlevel. Fix by means of a stockinet cuff to a Kramerwire cage incorporated in a plaster of Paris cast over the stump.


Preserve as muchviable skin, muscleand bone length asyou can withoutendangering thecasualty's life.

Never perform a primary stumpclosure followingamputation in the field.

Following a blastinjury, the other limbfrequently requiressurgical treatment.

Muscle retractionresults in a conicalstump withinadequate cover of the bone, makingprosthetic fittingdifficult and revision amputation a possibility.

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Casualty Transfer

1110 Once the casualty's condition has beenstabilised following emergency amputation, transfer.Splint the limb and provide adequate analgesia.If transfer is prolonged, immobilise the stump ina well-padded plaster of Paris back slab or cast. This must be split, easy to remove and not interfere with wound drainage. Important details of the procedure can be written on the cast as wellas in the notes. Use splints to prevent ankle and wrist contractures.


The dressing oftenbecomes offensive in the time before

delayed primaryclosure. This alone

is not a reason tosuspect stump

infection or re-explore.

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1111 Redressing during transfer is only indicatedif the casualty develops severe wound pain orsignificant pyrexia. Ideally, this should be carried out in theatre under sedation or anaesthesia. The usual causes are stump swelling within tightdressings or infection.

1112 Where the casualty is a civilian, furthertreatment may have to be delegated to local orcharitable facilities. Bear in mind the quality of on-going local care available to civilians, whenplanning an amputation.

Delayed Primary Closure

1113 At around 5 days after amputation, the stump is re-examined in theatre under GAor Ketamine. By this stage, granulation tissue willnormally have started to appear. Lack of tissue cover or prosthetic considerations may necessitatean amputation at a higher level. As long as thewound looks clean and healthy, delayed primaryclosure can be safely performed. If in doubt, re-examine 48 hours later.

1114 Where it has been possible to leave enoughmuscle at the primary operation, a myoplastic closureis performed:

• Opposing muscle groups are sutured to the boneend using a strong, braided absorbable suture(e.g., No 1 Vicryl). The aim is to providecoverage, strengthen the stump and optimisefunction (Figure 1104).

• Drain the wound using a closed suction system;this can usually be removed 24 to 48hrs later.

• The deep fascia is approximated with Vicryl andthe skin with interrupted nylon mattress suturesor clips.


If nothing else isavailable, the side of a sterile glove can be used as animprovised Penrose-type drain.

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• Apply a firm stump bandage.

• The wound is inspected 7-10 days later, bywhich time sutures can usually be removed.

1115 The use of split skin grafts to cover thewound may permit a lower level of amputation. If employed on weight-bearing areas, these willsubsequently require replacement (1117).Alternatively, if there is insufficient skin to cover a myoplastic closure, leave it exposed. Once theswelling subsides, the defect usually closes rapidly.

Principles of the Final Amputation

1116 Following emergency amputation, furthersurgery may be required. Ideally, this is deferred untilthe wound is healed and the casualty is beingassessed for prosthetic fitting.

1117 Damaged areas of the stump which areessential for weight bearing may need to be coveredby full thickness, rotation, advancement, transpositionor pedicle flaps (2310). In non weight-bearing areas,split skin grafting may suffice. Few modern

Plastic Reconstructive Surgery: see Chapter 23

The aim of the final amputation is

to produce a well-formed

and controlledamputation stumpthat is suitable for

limb fitting.

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Fig 1104 Myoplastic recontruction.

Chapter_11.qxd 28/09/2004 15:55 Page 236

prostheses are now end bearing, most rely oncircumferential support.

1118 Specialised bone transport techniques areavailable at Role 4 to lengthen an inadequate stump.

Specific Regions

Upper limb 1119 In the upper limb there is no optimum levelof amputation, the bone being divided as low aspossible. Preserve as much of the hand as you areable, particularly the thumb. Even a short thumbstump can act as a grip post. Surplus dorsal skinmay be used to provide cover.

1120 Above the wrist, the bones are cut cleanlyand the edges filed smooth. Opposing muscle groupsand tendons are sutured over the bone ends. Ideally,cover with equal anterior and posterior skin flaps(Figure 1105).

In the arm conserveevery centimetre oflength, in the leg doa standardamputation.

Complications areless common afterupper than lowerlimb amputation.

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Lower limb

Above knee amputation (AKA)

1121 Technique:

• Divide the femur 12-15 cm above the knee;bevel the bone end.

• Construct semi-circular shaped anterior andposterior flaps with their longest point just abovethe knee (Figure 1106). The aim is to have a flaplength such as to offset the final scar away fromthe point of the stump.

• Divide the quadriceps tendon above the patellaand the hamstrings at their insertions.

• The muscle groups are fixed to the end of thefemur using Vicryl sutures passed through drillholes 1 cm from the bone end.

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Fig 1106 Above knee amputation.

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• The skin is closed over a drain.

• Do not worry about the bulky stump, this willresolve with the application of a stump dressingand subsequent muscle atrophy.

Knee disarticulation

1122 This is rarely performed other than as an emergency:

• Construct anterior and posterior skin flaps; theanterior should end 10cm below the knee andthe posterior 5cm (Figure 1107).

• Free the patella tendon from the tibial tubercleand dissect upwards to reveal the knee joint.

• Cut the cruciate ligaments level with the tibialplateau and the muscles at their insertion.

• Suture the hamstring tendons and the patellatendon to the stumps of the cruciate ligamentsand nearby tissues.

• Most knee disarticulations are later converted toabove knee amputations.


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Below knee amputations (BKA)

1123 Technique:

• The tibia is ideally divided 15cm below the kneeand the fibula 2cm more proximal (Figure 1108).

• Cut the anterior part of the tibia at an angle toavoid a sharp edge.

• Leave a long, posterior musculo-cutaneous flapextending 15cm beyond the divided tibia.

• Anteromedial and anterolateral drill holes aremade in the distal 1 cm of the tibia and themuscles sutured to these using Vicryl.

• Some filleting of the soleus and gastrocnemiusmuscle bulk may be necessary.

• The skin and deep fascia are divided so that thewound comes to lie over the front of the bone.

The safest elective technique

for a below kneeamputation in the

field is to use a15cm tibial stump

and add 15cm to thisfor the posterior flap.

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Ankle

1124 The Syme operation is recommended forankle amputations (Figure 1109):

• Divide the malleoli level with the articular surfaceof the tibia.

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Fig 1109 Syme amputation.

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• Fillet the heel pad off the calcaneus, pull this forwards to cover the bone ends andsuture anteriorly.

Foot

1125 Satisfactory function is possible withamputations as proximal as the bases of themetatarsals:

• Try to salvage the medial or lateral borders of the foot.

• Avoid sectioning through the hindfoot or tarsus;muscle imbalance will result in a tilted stump.

Rehabilitation and Revision

1126 A below knee stump should be held inextension to avoid flexion contractures during theearly healing phase. Adjuncts include passivestretching and the use of sandbags. Start quadricepsand hamstring exercises with knee flexion as soon aspossible. The casualty should start mobilising with atraining prosthesis or pylon within the first two weeks.

1127 Revision of the stump may be requiredmonths or years later. Indications include:

• To facilitate fitting of a prosthesis.

• Neuroma.

• A painful scar tethered to bone.

• Chronic sinus from non-absorbable sutures.

• Sequestrum formation.

• Sharp or protruding bone end.

• Growing bone in children.

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Chapter 12

Abdominal Injuries

Introduction

1201 Abdominal wounds are challenging; theychallenge the life of the victim and the skill of themedical team. In contrast to UK civilian practice,where 90% of abdominal injury is due to blunt trauma,penetrating injuries predominate on the battlefield.They account for approximately 10% of all woundsand can be associated with mortality as high as 40%.Fragments are the most common cause of injury butbullet wounds are the most lethal.

Haemorrhage, often occult and always non-compressible, is the usual cause of death duringthe first 24 hours. Subsequent mortality occurs as a result of missed or delayed bowel perforation,development of sepsis, secondary haemorrhage andmulti-organ failure. The majority of abdominal woundsrequire surgery. (UK data from WWII suggest, in 10%of laparotomies for penetrating ballistic trauma, theperitoneum was not breached). Recognising thepossibility of intra-abdominal injury followed bycareful resuscitation, early transfer, appropriatesurgery including damage control surgery and skillednursing, are prerequisites for a successful outcomefollowing these injuries.

Pathophysiology of Abdominal Injury

1202 High available-energy missiles entering the abdomen are associated with long wound tracks,yawing, fragmentation and serious visceral injury(0203). They often travel an unpredictable route fromtheir point of entry particularly, if they strike bone.

Wound Ballistics: see Chapter 2

The frequency ofabdominal visceraldamage as a resultof penetrating chest,flank or back injuryranges from 10-50%depending on theavailable energy of the missile.

12: Abdominal Injuries

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Where cavitation has occurred in solid organs,mortality is significant (0207). Anti-personnelfragments and handgun bullets typically, but notalways, cause low energy-transfer injury confined tothe wound track (0203).

Casualties who have experienced significantdeceleration or deformation forces are likely to havesustained visceral disruption (0201). Blast injurytypically causes multiple haematomas and tears inthe wall of hollow viscera (0218). These haematomascan cause obstruction, notably to the duodenum, andmay rupture up to 14 days later. Crushing is likely todamage fixed organs, whilst shearing causesmesenteric tears and disruption or avulsion of major blood vessels.

1203 Patterns of blunt injury are typicallyrecognised: steering wheel and seat belt traumaresults in damage to the myocardium and greatvessels, the liver and spleen. Similarly, a fall from a height of >5m may fracture the pelvis leading to urethral and bladder injury, avulsion of the renalpedicles and diaphragmatic rupture.

Initial Management in the Field

1204 Principles include:

• ABC: Abdominal injury is mainly a 'C' problem.

• Assessment of circulation: this is performedduring the 'C' phase of the primary survey. The history and a quick examination (0313)may provide clues indicating probable abdominal injury.

• Abdominal trauma is likely to cause non-compressible haemorrhage. Organise urgenttransfer to a surgeon. Start hypotensiveresuscitation (0333).

Pelvic injury: see Chapter 13 Urological injury: see Chapter 14


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• Perform a full physical examination during thesecondary survey to include: the back, lowerchest, pelvis, perineum and rectal and vaginalexaminations, (PRE and PVE). An absence of physical signs does not mean an absence of intra-abdominal injury (1205). The abdomen is a silent reservoir for blood loss.


• Antibiotics (0817)

• Casualty packaging for transfer:

• Wound dressings: in bleeding wounds, a degree of tamponade may be achieved by packing two or more field dressings intothe wound. If they become heavily soiled,additional dressings can be applied on top(NB: record the number of dressings used).Secure dressings around the trunk in a waythat does not embarrass respiratory function.

• Eviscerated bowel: should be irrigated with sterile fluid and gently returned to the abdomen before application of fielddressings. If this is not possible, cover with a moist field dressing to prevent drying.Where there is leakage of bowel contents,the damaged segment should be isolatedoutside the abdomen by wrapping it in afield dressing, polythene bag or similar.

• Fluid restriction: keep casualties 'nil bymouth' (NBM). Sips of water <30mls/hourare permitted to moisten the mouth.If transfer is delayed and i.v. infusionunavailable, give oral or nasogastric fluids(up to 500ml/hour). Absorption from theproximal small bowel is usually maintainedduring the early stages after trauma.

• Position: casualties with abdominal woundsmay be more comfortable nursed in a 'W'

ATLS: see Chapter 3. Analgesia: see Chapter 7. Antibiotics: see Chapter 8.

Where non-compressibleabdominalhaemorrhage is suspected, puttingup drips, completingthe secondarysurvey etc., shouldnot delay casualtytransfer to a surgeon.Research suggeststhat delay caused by initial attempts at management in the field increases mortality.


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position i.e., lying with knees drawn up and shoulders raised; or on their side in the foetal position. This reduces tension on the anterior abdominal wall and mayprevent evisceration.

• Documentation: 'MIST' (0301).

• Decompression: If conditions permit, passa nasogastric tube and bladder catheter.

• Monitor and prevent hypothermia.

Management at a Surgical Facility(Roles 2+ and 3)

1205 On arrival, casualties must undergo furthertriage. A surgeon should be involved early in anydecision-making process - laparotomy may be thenext step in resuscitation.

Assessment of abdominal injuriesHistory

• Time of wounding.

• MIST (0301).

• Path of missile: knowing the casualty's positionwhen hit and the direction of travel may providean indication as to the internal path of themissile. But, this can be notoriously misleading!Multiple hits mean multiple possibilities!

• Pain: is it localised, generalised or referred?Shoulder tip pain may be referred from asubdiaphragmatic haematoma or abscess.

• Blunt trauma: knowing the vectors of the forcesinvolved and their direction ('reading thewreckage') can help predict organ damage(patterns of blunt injury - see 1203).

Prevent Hypothermia: see Chapter 26

The exsanguinatingcasualty who is not

responding to i.v.fluids and has no

evidence ofextremity, chest

or pelvic bleeding,requires animmediate

laparotomy duringthe primary survey

to stop the bleeding.

Where the cause of shock is unclear,

examine the casualtyin general and

the abdomen inparticular and do

it repeatedly.


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• Features of blast injury may include abdominalpain, vomiting, haematemesis, rectal bleeding - fresh blood or melaena - and tenesmus.Absence of blast injury to the eardrums does not equal absence of blast injury elsewhere.

Examination

1206 Routine examination includes:

• Inspect the abdomen, lower chest, back,buttocks, perineum and thighs for penetratingwounds, bruising (e.g., tyre or seat belt marks)and swelling. This may point to which organs areaffected. Restricted abdominal wall movementwith respiration suggests abdominal wall injury,peritonitis or spinal trauma.

• Palpate. The presence of tenderness, reboundand guarding are diagnostic of peritonitis. NB:tenderness is often minimal or absent during the initial stages of intraperitoneal haemorrhage.Check the perineum, genitalia and perform a PREand PVE. This may draw attention to a fracturedpelvis (1312) or ruptured urethra (1423).

• Percuss. Suprapubic dullness suggests an enlarged bladder: is the urethra injured?Dullness in the flanks can be a sign of blood in some quantity in the paracolic gutters.

• Auscultate. Minimal or absent bowel soundssuggest abdominal trauma or ileus from othercauses e.g., spinal cord injury andretroperitoneal haemorrhage.

• Associated injury. Examine the chest, vertebralcolumn, spinal nerves, pelvis and lower limbvessels. A reduced pulse volume over onefemoral artery suggests iliac artery damage.

Investigations

1207 The presence in the field of a variety of


Abdominalexamination is oftenunreliable, especiallyfollowing blunttrauma. A negativeexamination doesnot excludesignificant injury.Early transfer on suspicion ofabdominal traumaalone is appropriate.Delay until signsbecome obvious will result in mortalityrates over 90%.

Abdominaldistension aloneis a poor indicator of intra-abdominalpathology.


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investigative tools should not become an excuse fordelaying surgery, especially when surgery is definitelyindicated on clinical grounds alone. The uniqueconditions under which military surgeons are required to work, mean they must learn to placerobust reliance on their own clinical judgement.This particularly applies to the assessment ofabdominal injury, where delay in surgery for some,can be fatal. Delay should not be compounded byunnecessary investigations.

1208 If the diagnosis or magnitude of intra-abdominal injury are in doubt and the casualty isstable, investigations at Roles 2+ and 3, may aidmanagement. But, if laparotomy is indicated, that isthe only investigation necessary!

1209 X-rays: are routinely performed in the initialassessment of polytrauma (0336). Significant findingsinclude: the presence of intra-abdominal foreignbodies on two views (a single view will not excludeforeign bodies in the abdominal wall), or free gasunder the diaphragm. Injuries that cause fractures of the lower ribs, lumbar spine and pelvis, indicatethe likelihood of intra-abdominal injury.

1210 Sigmoidoscopy: is used to assess rectalinjury where PRE demonstrates bleeding.

1211 Contrast studies: a swallow/meal orenema, are simple and rapid methods of detectingvisceral leakage: use a water-soluble contrast medium.

1212 Diagnostic peritoneal lavage (DPL): maybe employed to detect blood or visceral perforation.Points to note:

• Following blunt abdominal trauma, DPL has asensitivity of 95% and specificity of 99%.

• A positive result is indicated by the presence

The results of DPLafter major pelvic

fracture can beconfusing. Blood

tends to track extra-peritoneally

up the anteriorabdominal wall.

Under suchcircumstances,

a supraumbilicalapproach is

recommended.

Deaths due to sepsis may occur

as a result of missedretroperitonealinjuries to the

duodenum, colon,pancreas, urinarytract and rectum.

Peritoneal lavage:- Catheterise.

- Clean and infiltratewith 1% Lignocaine

in the midline 2.5 cmbelow the umbilicus.

- Have a smallincision down to

peritoneum.- Insert a peritoneal

dialysis catheter.- Infuse 500 ml of

warm saline- Tilt casualty to

distribute fluid.- Lower the infusionback to allow fluid to

drain back.


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of macroscopic blood, bile or bowel contents; or a laboratory analysis of aspirated fluid thatshows one of the following: >100,000 rbc/mm3,>500wbc/mm3, an amylase of >175iu and thepresence of vegetable fibres.

• Relative contraindications to DPL includeprevious abdominal surgery, obesity, pregnancy,cirrhosis and coagulopathy.

• DPL has little diagnostic value in assessingpenetrating trauma and is generally inappropriate:the majority of casualties require laparotomy.

1213 Focused abdominal sonography fortrauma (FAST): is used to detect free fluid in theperitoneal cavity and pericardium.

• It is quick, non-invasive and now widely used in place of DPL. It is the immediate investigationof choice in unstable casualties with suspectedor actual blunt abdominal trauma.

• When performed by trained personnel a sensitiveof 88% and specificity of 90-99% has beenreported following blunt trauma.

• It is usually only possible to detect bloodvolumes >100ml.

• Where positive, the casualty will requirelaparotomy. By comparison, a negative resultdoes not exclude intra-abdominal injury, it shouldbe repeated or the findings confirmed by DPLor CT.

1214 Computerised tomography (CT): in civilianpractice, this is regarded by many as the investigationof choice in stable casualties following major blunttrauma. Although scanners are now robust and canbe moved relatively easily, their use in the field todate is limited.

• Modern scanners are quick and have a

Imaging difficultiesfor FAST may be dueto rib shadowing,obesity, intestinal gasand subcutaneousemphysema.


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sensitivity of 88% and specificity of 98%. Theyare accurate for assessment of solid organ andretroperitoneal injury. Features of intestinal injuryseen on scanning include: free gas, largecollections of peritoneal fluid and thickening of bowel wall and mesentery.

• Scanning is undertaken from the dome of thediaphragm to the symphysis pubis.

• When performed after administration of a contrast enema, it can be used to exclude a retroperitoneal colonic injury in a casualty with a posterior abdominal wound.

1215 Laparoscopy has been used at Role 3 todetect bleeding, organ damage (e.g., diaphragmatictears) and identify bowel perforation. Combinations oflaparoscopy and ultrasound scanning (USS) arebeing used to effect control of bleeding from solidorgans. USS can be modified to both, detect andcontrol, sources of haemorrhage.

Surgical decision-makingWhen assessing casualties with suspected abdominalinjuries, the surgeon must answer five questions:

1. Does the injury involve the peritoneal cavity?

1216 Suspicious or absolute features include:

• Penetrating wounds in the vicinity of theabdominal cavity - nipple to perineum - or, in the case of gunshot wounds, nipple to knees.

• Protrusion of bowel or omentum.

• A heavily bleeding wound or one dischargingintestinal contents, bile, pancreatic juice or urine.

• Peritonitis.

• Unexplained hypovolaemic shock especially withfailure to respond to resuscitation; unaccountable

Bowel sounds maybe present despite

intestinal perforation.


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vomiting or a casualty whose condition isproportionately worse than the wound would suggest.

• Absent bowel sounds.

• Positive investigations (1207).

1217 Decision-making can be difficult in:

• The unconscious or confused casualty.

• Retroperitoneal perforation: in the absence ofleakage into the peritoneal cavity, clinical signsmay initially be absent.

• Spinal cord injury.

• Superficial wounds confined to the abdominalwall. Diagnostic features may include minimalshock, improvement with observation andcontinued presence of bowel sounds.

• Thoracic trauma: abdominal rigidity may occur following thoracic injury. It can usually be differentiated from that due to peritonitis byits variability during respiratory movement.

2. What structures are likely to be injured?

1218 This can be guessed at from the history(1205) and examination (1206). If the casualty isstable, consider appropriate investigations (1208).

3. Does the casualty need an operation?

1219 The majority of casualties in whom apenetrating injury of the abdominal cavity is provenor inferred, will require a laparotomy. Circumstanceswhere surgery may be delayed include:

• No clear evidence of damage to intra-abdominalviscera. Such cases should be observed,repeatedly examined and have appropriateinvestigations (1208).

Probing the wound is an unreliablemethod of detectinga breach in theperitoneum and isnot an alternative to laparotomy.Similarly, becausethe relationship ofthe layers of theabdominal wall to the underlyingviscera is likely to be different at thetime of wounding,probing can notreliably tell you the direction of the wound track.

Unrecognisedabdominal injury is a common cause ofpreventable death. In up to 50% ofcasualties withsignificantintraperitonealhaemorrhage, seenat Role 1, physicalsigns will be few or absent.

Laparotomy in thepresence of lung or cardiac injurycarries a highmorbidity andmortality.


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• Where injuries are so severe that recovery isunlikely. Triage category is then T4 until all othercasualties have been treated.

• Casualties who have remained stable for morethan 18 hours. Those who have survived so longwithout medical aid have usually succeeded inlocalising their injuries and conservativetreatment may be appropriate.

4. Who to operate on first?

1220 Generally, casualties with abdominal injuriesrequire surgery as soon as possible. The optimumshould be aimed at restoration of a normal circulatingvolume and surgery proceeding in parallel. Unstablecasualties, who need urgent laparotomy as part ofthe primary survey and, given other injuries, have a good chance of survival, take precedence. The surgeon has to decide priority. Cases wherehaemorrhage is the main problem take precedenceover intestinal perforation.

5. Which injury to operate on first?

1221 In a casualty with multiple injuries it cansometimes be difficult to prioritise the approach.

• Thoracic injury and controlling exsanguinatingperipheral haemorrhage take precedence overabdominal trauma.

• Management of the abdomen takes precedenceover head, spinal, pelvic and non-exsanguinatinglimb trauma.

• When it is necessary to undertake surgery on both the front and the back, the latter should generally be performed first. Experiencehas shown that turning a casualty face downafter a laparotomy can cause profoundhypovolaemic shock due to pooling of blood in the splanchnic circulation.

Moribund casesshould be madecomfortable and

treated expectantly.Included in this

group may be somecasualties with

multiple injuries,established

peritonitis, endotoxicshock and failing

peripheral circulation.They may be

mentally alert but arefrequently in pain

and restless.


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• Where major wounds co-exist with abdominaltrauma, for instance, a limb requiring amputation,a second surgeon should operate simultaneously.

• Antibiotics given within the first hour after injuryusually allow excision of soft tissue wounds to be delayed. These injuries presenting incombination with an abdominal wound, can wait until the casualty is stable.

Local factors affecting surgical prioritisation.

1222 A Unit may become overwhelmed by morecasualties than it can deal with in a reasonable timespan. Also, there may be staff fatigue and lack of re-supply of equipment. Options then include:

• Avoiding protracted surgery in favour of simpler and quicker operations.

• Sending those who are in the best state to withstand a journey to another Unit.

• Conservative treatment. In civilian practice,approximately 8% of casualties with perforationsof the small, or even the large bowel, recoveredspontaneously on supportive treatment. Theproblem with this approach in a field setting isthe ability to observe casualties closely enoughfor long enough.

Operative Considerations

Resuscitation prior to abdominal surgery 1223 The aim of resuscitation is to get thecasualty into the operating theatre in a conditionthat will allow the surgeon time to find and control

bleeding. Experience has shown that a limit of 2hours should be set upon resuscitation; it must beactively supervised.

Shock in an abdominal casualty is due to:

Resuscitation: see 0333

In 20% to 40% of laparotomiesperformed forpresumed intra-abdominalbleeding,haemorrhage is found to have stoppedspontaneously: but,better a negativelaparotomy than a dead casualty.

Laparotomy forexsanguinatinghaemorrhage is futileif the casualty hasalready suffered acardiac arrest.


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• Loss of blood.

• Dehydration from sweating and diminished fluidintake during fighting.

• Loss of plasma from other wounds and into the peritoneum.

• Sequestration of fluid in the small intestine.

• Toxaemia from early infection.

A casualty with abdominal wounds who is severelyshocked is nearly always suffering from ongoingblood loss. This is likely to continue until the bleeding is controlled. Such casualties requireimmediate operation for resuscitation rather thanresuscitation for operation.

Blood transfusion should be available wheneverabdominal surgery is contemplated. In Grade III or IVshock (Table 0301), type-specific blood is used untilcross-matched units become available. The rate oftransfusion prior to operation depends on the initialresponse to resuscitation. Where there has been aresponse, blood should be infused at such a rate that the systolic pressure is maintained at ~90mmHg.Where the casualty remains unresponsive, theyshould be rapidly transferred to the operating theatre.

Damage control surgery1224 Visceral damage following high-energypenetrating or blunt abdominal injury is typicallyextensive. Damage control surgery to controlbleeding and prevent peritoneal soiling may beappropriate (0403).

General plan for emergency abdominal surgery1225 Stages include:

• Position the casualty supine on the operatingtable. Apply warming devices to the extremitiesand upper body, including the head. Pass a

Damage Control Surgery: see Chapter 4.


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bladder catheter and nasogastric tube. Administerantibiotic prophylaxis i.v. at the start of surgery(0817); start DVT prophylaxis (0980). Generalanaesthesia with muscle relaxation is needed foroptimum operating conditions (2501). Clean andprepare the skin. Drape the torso so that theincision can be extended into the chest andgroins (Figure 0402). Have two working suckers,large packs and vascular clamps available.

• In most cases, gain rapid entry through a full-length, midline incision. Skirt around or excise skin wounds.

• Situation permitting, carry out toilet of theabdominal cavity.

• Carry out a systematic identification and arrest of haemorrhage.

• Do a systematic search for intra- and retroperitoneal organ damage.

• Repair: where appropriate, confine youroperation to damage control surgery (0403).

• Perform a final peritoneal lavage.

• Use drains only when indicated.

• Mass closure: close the rectus sheath with a continuous, non-absorbable suture. There isno need for separate closure of the peritoneum.Perform a temporary closure following damagecontrol surgery where re-laparotomy is requiredor, if there is risk of the casualty developing anabdominal compartment syndrome. (1290).

• Monitor temperature, pulse, BP and fluidinput/output. Continue i.v. fluids. Restrict oralfluids for the first 36-48 hours (30mls per hour)then gradually increase them unless contra-indicated by the presence of ileus.Pressure area care and physiotherapy are noless important in a military setting than a civilian one.

Antibiotics: Chapter 8.


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• Where there has been major faecalcontamination after colorectal surgery, give 2-3 doses of co-amoxiclav 1g i.v. (0817) every 8 hours for the first 24 hours. Continue for 2-5days if there is a significantly increased risk of infection.

Incision

1226 A midline incision from xiphisternum to pubisis the standard approach to the abdomen in militarysurgery. It is rapid, relatively bloodless and givesgood exposure. Catheterise the bladder beforemaking the incision.

• The wound can be extended laterally orcontinued into either hemithorax by curving theincision across the costal margin into the 5th or 6th intercostal space. Divide the diaphragmcircumferentially 3cm from its attachment withthe chest wall to avoid damaging the phrenicnerve. This incision can also be extended as a sternotomy.

• A right thoraco-abdominal incision gives accessto the subdiaphragmatic surface of the liver and the Inferior Vena Cava (IVC), on the leftit gains an approach to the thoracic aorta anddistal oesophagus.

• In a small number of cases it will be sufficient to extend the primary wound but, always beprepared to enlarge the incision.

Systematic identification and arrest of bleeding

1227 Following blunt trauma, the site(s) ofbleeding can be obvious and amenable to rapidcontrol. This is far from true for penetrating injury,where damage to several viscera and/or vessels, isthe norm. In this case, it is necessary to insert largepacks to isolate the abdominal compartments where

Damage Control Surgery: see Chaper 4

Remember, theremay be more thanone bleeding site.

Once bleeding iscontrolled, allow thetransfusion to begin

catching up withblood loss before

continuing with the operation.


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blood collects (Figure 0403). Do not waste time trying unsuccessfully to deal with one bleeding pointwhen the abdomen is full of blood; there is likely tobe more than one source of bleeding. Pack theabdomen systematically:

• Pack the right upper quadrant above the rightlobe of the liver, then retract the hepatic flexureof the colon downwards, the liver upwards andexplore and pack the space under the righthepatic lobe lateral to the duodenum.

• To pack the left upper quadrant and over thespleen: retract the stomach medially and thesplenic flexure of the colon downwards toexpose the area under the left lobe of the liver and around the spleen.

• Right and left infra-colic compartments: lift thetransverse colon, omentum and small bowel.Explore and pack the spaces medial to the rightand left sides of the colon along each leaf of thesmall bowel mesentery.

• To pack the rectovesical pouch: Tilt the tablehead down and retract the small bowel upwards.

Careful removal of each pack in turn will enable thesource of the bleeding to be traced and controlled. Where the abdominal cavity is full of blood, the mostlikely sources are:

• Multiple vessels in the small bowel mesentery.

• Liver.

• Spleen.

• Kidneys.

• Pancreas.

• Retroperitoneal vessels.

1228 Emergency control of haemorrhage is byfinger pressure, packing with swabs, a carefullyplaced vascular clamp or balloon catheters (0407).

Identifying the source of Abdominal Bleeding: see 0406

Occlusion of the thoracic orabdominal aorta for5-10 minutes may besufficient to allow BPto be restored andthe bleeding site tobe identified andcontrolled.


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Occasionally, aortic cross clamping is required(1276). Bleeding points should be ligated or underrun with a stitch. Essential blood vessels e.g.,the superior mesenteric artery, require repair or insertion of a temporary shunt (0411). Always check the circulation to the gut following control of mesenteric bleeding; absent arterial pulsation andcyanosis are indications for gut resection or majorvessel exploration.

Retroperitoneal haematomas are generally managedby packing (1274).

Systematic search for organ damage

1229 Perform a systematic examination of theintra- and retroperitoneal organs (Figure 0404). The following is one suggested method:

1. Small bowel and mesentery: examine from theileocaecal valve to the ligament of Treitz. Look atone side on the way up and the other on the waydown (assessment of bowel viability - see 1232).

2. Colon and rectum: start with the caecum andwork distally. Where you suspect retroperitonealdamage, divide the peritoneum along the lateralreflection and lift the colon forward for inspection.Mobilisation of the rectum requires incision ofthe pelvic peritoneum.

3. Spleen, left diaphragm, stomach and gastro-oesophageal junction: where indicated,divide the gastro-colic omentum to inspect theposterior wall of the stomach (1255).

4. Liver, right diaphragm and biliary tree.

5. Duodenum: inspect the four parts. Whereindicated, Kocherise the second part of theduodenum (1262) to inspect its posterior surface.

6. Pancreas. Anterior and posterior surfaces of thehead of the pancreas are exposed as forduodenal examination. The body and tail of the

During thesystematic search

temporarily close anybowel perforations

using Babcock'sforceps, swabs

or tapes to reduceleakage. Delay repairor resection until the

extent of the damageis known.

In the field, avoid exploring a

non-expanding retro-peritoneal

haematoma - mostare managed

by packing.


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pancreas are inspected through a window made in the gastro-colic omentum (1255). The posterior wall is approached by mobilisingthe spleen, tail and body of the pancreas to the right.

7. Retroperitoneum and pelvis: Bleeding frompelvic fractures can track in a cranial directionthrough the layers of the anterior and posteriorabdominal walls.

Drainage

1230 A drain may reduce peritoneal soiling. Only use them when there is likely to be somethingto drain!

• Position drains close to the operative field or atknown sites of fluid collection - paracolic gutters,subdiaphragmatic and subhepatic areas andrecto-vesical pouch.

• Use a closed system: a silastic suction drain or tube drain connected to a bag.

• Place the openings so that drainage undergravity is facilitated. Bring the drain out througha separate incision.

• Drains should be removed when they are no longer draining.

Wound closure

1231 Steps include:

• Excise penetrating wounds that lie in the line of the incision.

• Wash the peritoneal cavity thoroughly with 4-6l of warm saline. Remove any gross fibrinousexudate using swabs.

• A secure, rapid method of closing the deeplayers of the incision is using a mass closuretechnique employing continuous No 1 looped



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monofilament nylon or PDS (3027).• The skin edges can be brought together using

staples or a continuous monofilament suture(3027).

• If severe contamination of the operative field has occurred, as in heavy and prolonged faecalsoiling following delayed surgery for a largebowel perforation, close the deeper layers butleave the skin open for delayed primary suturefive days later.

• When re-laparotomy is planned, or it is necessaryto leave the abdomen open as a laparostomy,carry out temporary closure as described in0412. This will reduce heat and fluid loss fromthe open wound. It also aids nursing care.

• Where the defect is too big to close, variousplastic and other procedures are availableincluding flap repair (2310), insertion of nylonmesh or allowing the wound to granulate. Theseshould be carried out in a plastic surgery unit atRole 4 hospital.

Regional Injuries

Small bowel Introduction

1232 The small intestine and mesentery are the most frequently injured part of the gut, damagedin >30% of penetrating abdominal wounds. Themajority of wounds are multiple. For this reason,resection is often safer and quicker than individualwound repair. Perforations are often small,impalpable and easily missed.

Bleeding is usually from the mesentery rather thanthe gut and often stops spontaneously. Small bowelcontusions of <15mm diameter and non-expandinghaematomas in the mesentery, can be left



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undisturbed. A mesenteric haematoma extending tothe bowel wall may be the only sign of a perforation,they should be explored. The presence of ahaematoma may also indicate compromise to theblood supply of the gut adjacent to the haematoma.Check gut viability again before closing the wound. If in doubt, release the haematoma, control anybleeding and check the viability again. If there is still doubt, resect the small bowel.

Multiple small bowel resections may criticallycompromise small bowel length and function. Facedwith this problem, an alternative is to leave possiblyischaemic gut and check its viability at a 'secondlook' procedure 24 hours later.

Assessment of bowel viability includes:

• Colour.

• Sheen.

• Peristalsis.

• Mesenteric pulsation.

• Free bleeding from transected ends.

Single perforation

1233 These usually require minimal woundexcision (Figure 1201).

• Place stay sutures.

• Close transversely using a single layer ofinterrupted or continuous sero-submucosal(extramucosal), inverting sutures placed 5mmapart (1202 D). Use 3/0 absorbable sutures on a round-bodied needle or 3.5mm skin staples.The technique for the latter is exactly the sameas for sutures. The stay sutures, when pulledapart, help to invert the defect allowing for aserosa-to-serosa closure.

• Contused areas >15mm in diameter should beinvaginated and oversewn, or excised and the

Using 3.5mm skinstaples to repairdefects oranastomose bowel is rapid and effective.


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262

�

�

�

�

Fig 1201 Simple repair of small laceration: A) minimal woundexcision. B) insertion of stay sutures. C) transverse repair usinginterrupted, serosubmucosal inverting sutures. D) completed repair.

Chapter_12.qxd 28/09/2004 15:55 Page 262

bowel closed transversely.• Normal small bowel has an excellent

blood supply and most wounds heal without complications.

Indications for resection

1234 These include:

• If simple suture is mechanically unsatisfactory;this applies when a group of perforations are soclose that individual repairs would overlap.

• When excision and re-anastomosis saves time.

• There is injury to the mesenteric border.

• When the gut is ischaemic.

Standard end-to-end anastomosis

1235 Steps are (Figure 1202):

• Select a healthy segment of bowel either side of the damaged area. Occlude the lumen usingpairs of inner (crushing) and outer (non-crushing)bowel clamps.

• Ensure a wide lumen by dividing the bowel at an angle away from the mesenteric border of the retained gut. If the bowel ends do not look pink or fail to bleed when transected,resect more widely.

• Ligate and divide the mesenteric vessels. Place two stay sutures on the mesenteric and antimesenteric borders.

• Perform an end to end anastomosis using a single layer of interrupted sero-submucosal(extramucosal) inverting sutures placed 5mmapart. Choose a 3/0 absorbable suture on around-bodied needle. Alternatively, use skinstaples or a continuous, inverting Connell stitch.First anastomose one side then turn the bowelover and anastomose the other.


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264

��

��

��

��

Fig 1202 Resection and small bowel anastomosis: A) Division of small bowel between crushing and non-crushing clamps(NB: divide at an angle). B) Place stay sutures. C) Repair front wallfirst then rotate. D) Use interrupted, serosubmucosal sutures. E) completed repair.

A

B C

D

E

Chapter_12.qxd 28/09/2004 15:55 Page 264

• If skin staples are used, triangulate the ends of the gut with 3 stay sutures inserted over theclamps. Remove the crushing clamps but leavethe crushed ends to maintain haemostasis.Invert each limb of the triangle by pulling apartadjacent stays, then insert 4 to 5 staples perlimb and tie the stay sutures.

• Finally, to ensure the lumen is patent, gentlyinvaginate the walls of the bowel between fingerand thumb. Close the defect in the mesenteryusing sutures or clips without damaging theblood supply.

1236 Anastomosing bowel of unequal diameter.Where there is disparity in size, use the techniqueillustrated in Figure 1203. Incise the smaller diameter


265

Fig 1203 Technique of anastomosing bowel ends of disproportionate size.

Chapter_12.qxd 28/09/2004 15:55 Page 265

bowel along its antimesenteric border until it matchesthe larger diameter, then cut the edges of the bowelwall straight before doing the anastomosis.


266

Fig 1204 Stapled anastomosis: A) The bowel is closed and divided.B) The bowel ends are approximated using a stay suture; a smallincision is made in each limb. C) The limbs of the stapler areintroduced, clipped together and the device fired. D) The remainingdefect is closed using a second stapler.

A

B

C

D

Chapter_12.qxd 28/09/2004 15:55 Page 266

Alternatively, perform a side to side (Figure 1204) or


267

Fig 1205 End-to-side anastomosis: A) Close-off the distal limb. Milkthe bowel contents away from the closed end and clamp. Make alongitudinal incision over a taenia coli equal to the diameter of thesmall bowel. Insert stay sutures. B) Anastomose the back wall usingvertical mattress sutures. C) Anastomose the front wall usinginterrupted sero-submucosal sutures.

A

B

C

Chapter_12.qxd 28/09/2004 15:55 Page 267


268

Fig 1206 Constructing a loop ileostomy: incise so as to construct aproximal spout and suture in place.

Chapter_12.qxd 28/09/2004 15:55 Page 268

end to side anastomosis (Figure 1205).Stapled anastomosis

1237 The use of stapling devices provides aconvenient method of small bowel resection andanastomosis (Figure 1204).

• Resect and close the bowel using a linearstapler (e.g., Autosuture™ GIA 60).

• Approximate the two bowel segments side-to-side. Hold with a stay suture.

• Make a small incision in the antimesentericborder of both bowel segments. Introduce a limb of the stapler through each hole and clip the halves of the device together. "Fire the gun".

• Place stay sutures and close the remainingdefect (e.g., using a Autosuture™ TA 55).

Loop ileostomy

1238 This may occasionally be required to protecta right-sided colonic repair (Figure 1206).

• Lift up a distal loop of small bowel to aconvenient site on the anterior abdominal wall,usually the right iliac fossa midway betweenumbilicus and anterior superior iliac spine. This may be facilitated by passing a rubber sling through the mesentery adjacent to thebowel. Ensure that the orientation is correct and that there is no tension.

• Excise a disc of skin. Make a cruciate incision in the underlying fascia, rectus muscle andperitoneum.

• Pull the small bowel through the defect and holdthis temporarily in place with a colostomy bar.

• Open the small bowel transversely as shown inFigure 1206. In order to reduce skin irritation,evert the proximal limb so as to construct aspout. Fix in place using interrupted 3/0


269

Chapter_12.qxd 28/09/2004 15:55 Page 269

absorbable sutures on a round-bodied needle.• Cover with a suitable sized stoma bag. Remove

the bar after one week.

End ileostomy

1239 This may be required in combination with amucous fistula following a right hemicolectomy whenanastomosis is contra-indicated, (1244).

• The divided bowel end is brought to the surfacevia a skin trephine, as in 1238.

• Pull the bowel back on itself using Babcockforceps in order to create a 5-7 cm spout (Figure 1207).

• Fix in place using interrupted 3/0 absorbable sutures.


270

Fig 1207 End ileostomy: constructing a spout.

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ColonIntroduction

1240 Wounds to the colon occur almost asfrequently as those of the small intestine. Thoughrarely multiple, they tend to be more serious thansmall bowel injury because:

• The walls of the colon are thin and more vulnerable to vascular injury andsubsequent ischaemia.

• Colonic injuries are frequently extensive.

• Damage is easily missed, particularlyretroperitoneal injuries and wounds along the mesenteric aspects of the transverse and sigmoid colon.

• The contents usually escape earlier and ingreater quantities than small bowel perforations,leading to gross faecal contamination.

• Leakage of anaerobic organisms intosurrounding tissues can lead to fatalretroperitoneal cellulitis.

In civilian practise, many injuries of the colon, both ascending and descending, are dealt with by primary closure or resection and anastomosis,without a covering stoma. There is no reason whythis approach could not apply on the battlefieldsubject to the caveats in 1244. There is one furthercaveat: continuity of postoperative care. Militarycasualties tend to be transferred early in the postoperative period. Close observation by the operatingsurgeon may be impossible. Anastomotic leaks and clinical deterioration can go unnoticed until it is too late. This is just one of many unique features of battlefield surgery that can influence decision making.

Rectal wounds have a highmorbidity andmortality. They areoften complicated by pelvic fractures,small bowelperforations,urological damage,nerve injuries andhaemorrhage fromiliac vessels.


271

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Features of colonic perforation

1241 These are present or, should be suspected,if there is:

• A defect, haematoma, contusion ordiscolouration of the colon.

• Retroperitoneal haemorrhage.

• Emphysema (colonic gas) in the region of theascending or descending colon.

• An adjacent wound track especially penetratingback, flank or low, posterior chest wounds.

• A faeculent smell or faecal contamination of theperitoneal cavity.

Mobilisation and inspection

1242 Where access to the posterior surfaceof the ascending and descending colon and


272

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Fig 1208 Incising the peritoneum to mobilise the ascending colon,descending colon and rectum

Chapter_12.qxd 28/09/2004 15:55 Page 272

rectum is indicated: • Divide the lateral parietal peritoneum and

mobilise the bowel medially (Figure 1208).

• Take care not to damage the ureters. These canbe identified as they cross each common iliacartery close to the bifurcation.

• The posterior surface of the transverse colon isinspected by lifting the greater omentum out ofthe wound and dissecting in the avascular planebetween it and the bowel.


273

��

��

��

��

��

��

��

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Fig 1209 A) Vascular supply to the bowel. B) Standard methods of large bowel resection.

A

B

Right hemicolectomy

Left hemicolectomy

Transverse hemicolectomy

Sigmoid hemicolectomy

Chapter_12.qxd 28/09/2004 15:55 Page 273

• The rectum is visualised by incising the pelvicperitoneal reflection. The arterial supply of thelarge bowel is shown in Figure 1209.

Simple colonic repair

1243 Following injury by low velocity missiles or stab wounds:

• Most colonic wounds can be safely closedprimarily without the need for a covering stoma(Figure 1210). Use the techniques described in1233. If resection of the right colon is necessary,an ileo-colic anastomosis is safe for the majority.(see 1244).

• Where there are doubts about a repair, coverwith a loop ileostomy (Figure 1210) or colostomy(Figure 1211).

Management of extensive or contaminatedcolonic injury


274

��

��

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Fig 1210 Closing a simple perforation of the right colon. Whereconsidered necessary, this can be protected by a loop ileostomy.

Chapter_12.qxd 28/09/2004 15:55 Page 274

1244 Casualties included in this category are: • High energy- transfer wounds.

• Multiple colo-rectal injuries.

• Delay before surgery of >6hours.

• Prolonged hypovolaemic shock before surgery.

• Gross faecal contamination.

• Rectal injury, those below the peritonealreflection mandate faecal diversion.

Five of the above 6 factors are not dictats mandating that surgery must include diversion of the faecal stream. They are pointers to greaterrisks of leakage from repairs or anastomoses. In thepresence of any one of these factors, particularlyinjury to the rectum below the peritoneal reflection,faecal diversion is wise. But, each case and thecircumstances - clinical and 'military' - surrounding it,must be weighed-up on its merits.

1245 Treatment options are:

• Mobilise and exteriorise the damaged segment.

• Resect, anastomose and cover with a loop

Post-operativedeterioration oronset of peritonitisare indications forrelaparotomy.

A common mistakewhen operating onthe left colon isfailure to mobilisethe splenic flexureadequately.


275

��

��

Fig 1211 Covering a colonic or proximal rectal repair with a loop colostomy.

Chapter_12.qxd 28/09/2004 15:55 Page 275

ileostomy or colostomy (NB: not appropriatewhere there are multiple casualties or whenconducting damage control surgery).

• Resection with construction of an end colostomy


276

Fig 1212 Loop colostomy: A) A suitable skin incision is made toexteriorise the transverse or sigmoid colon. B) A loop of colon ismobilised and brought through the incision avoiding any tension. C) The loop is held in place using a colostomy bridge. The bowel isopened longitudinally. D) fix the bowel in place using interrupted sutures.

A

B

C

D

Chapter_12.qxd 28/09/2004 15:55 Page 276

and mucous fistula or double-barrelled colostomy.• Following rectal injury, construct an end

colostomy and close off the distal rectum(Hartmann's procedure).

• Excluding the rectum, resection and primary anastomosis.

Loop colostomy or exteriorisation

1246 The transverse and sigmoid colons arerelatively mobile and can be freed up to form a loopcolostomy (Figure 1212) or a damaged segmentexteriorised (Figure 1213).

• Mobilise a suitable segment of colon, sufficientto reach the anterior abdominal wall withouttension. Pass a rubber sling through themesentery adjacent to the bowel to aid traction.

• Make a 10 cm skin incision. This should ideallybe midway between the umbilicus and the costalmargin, or the umbilicus and anterior superioriliac spine. Divide the deep fascia, muscle and


277

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Fig 1213 Managing a colonic laceration by exteriorisation orresection and a double-barrelled stoma.

Chapter_12.qxd 28/09/2004 15:55 Page 277

peritoneum in the line of the incision.• Pull the bowel through the defect in the anterior

abdominal wall and hold it in place with acolostomy bridge. Suture the bridge to the skin.

• Open the bowel longitudinally along one of the taenia coli. Attach the edges to the skinusing absorbable sutures on a cutting needle or skin clips.

• Attach a suitable stoma bag. Remove the bridge after one week.

Resection

1247 Where there is extensive damage orcontamination, resect the affected segment.

• Mobilise the involved bowel as in 1242.

• It may be sufficient just to resect severalcentimetres of colon. More usually, the line of


278

��

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Fig 1214 Managing an extensive laceration of the right colon bya right hemicolectomy and ileostomy plus mucous fistula, or ileo-transverse anastomosis (+ or - loop ileostomy).

Chapter_12.qxd 28/09/2004 15:55 Page 278

bowel division is governed by the remainingblood supply unaffected by injury (Figure 1209).This usually means performing a righthemicolectomy, transverse colectomy, left hemicolectomy or sigmoid colectomy.

• Divide the bowel between crushing and non-crushing clamps (1235).

• Incise the mesentery and ligate the supplyingvessels as close to the bowel as injury allows.Where anastomosis is planned, make sure thebowel ends look healthy and bleed when cut.

Ileo-colic anastomosis

1248 Perform an end-to-end anastomosis as in 1235. If there is discrepancy in size between theterminal ileum and colon, use the technique depictedin Figure 1203 to achieve parity. Alternatively,a side-to-side stapled anastomosis (Figure 1204), or an end-to-side sutured anastomosis, can beemployed, (Figure 1214).

End-to-side anastomosis:

• Mobilise the colon above and below the injury so as to approximate the ends without tension

• The colon is closed off by a continuous layer of3/0 absorbable suture on a round-bodied needle


279

��

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Fig 1215 Management of a rectosigmoid injury: where there issufficient length, both ends may be mobilised to the surface as an endcolostomy plus mucous fistula or, perform a Hartmann's procedure.

Chapter_12.qxd 28/09/2004 15:55 Page 279

passed over and over a non-crushing bowelclamp. This can be pulled tight once the clamp is released. Then bury the closure with a secondlayer of sutures.

• Milk the adjacent colon to empty it of faeces.Apply a non-crushing bowel clamp. Incise thecolon along one of the tenae coli to a distanceequal to the diameter of the ileum. Insert staysutures (Figure 1205).

• Anastomose the back wall first using interruptedvertical mattress sutures. The front wall isattached using sero-submucosal sutures.Approximate the mesentery to prevent internal herniation.

• Alternatively, perform a stapled anastomosisas in Figure 1204.

End colostomy and mucous fistula or double-barrelled stoma

1249 Following resection, it often quicker andmore appropriate to bring the proximal bowel out asan end colostomy and the distal bowel as a mucousfistula (Figure 1215). Using separate incisions maybe more convenient and avoids faecal contaminationof the distal limb. The disadvantage is the need toperform a further laparotomy to re-establish bowelcontinuity. The latter can be avoided by bringing outthe ends adjacent to each other as a double-barrelledstoma. NB: if one limb is small bowel, constructa spout (Figure 1214).

• Select an appropriate point on the anteriorabdominal wall to place the end colostomy. This is usually in the left or right iliac fossae,midway between the umbilicus and anteriorsuperior iliac spine.

• Lift up and excise a disc of skin (Figure 1216).Make a cruciate incision in the rectus sheath,muscle and peritoneum.


280

Chapter_12.qxd 28/09/2004 15:55 Page 280


281

Fig 1216 Construction of an end stoma: A) Excise a disc of skin. B)Make a cruciate incision in the abdominal wall. C) Bring the bowel endthrough the abdominal wall. D) Fix to skin using interrupted sutures. E)Close the lateral space. F) Completed stoma.

A

B

C

D

E

F

Chapter_12.qxd 28/09/2004 15:55 Page 281

• Bring the bowel end through the wound usingBabcock's forceps. Ensure that the bowel is nottwisted and that there is no tension.

• Attach the colon to the rectus sheath usingabsorbable sutures on a round-bodied needle.Fixing bowel to skin can be achieved usinginterrupted, absorbable sutures on a cuttingneedle or clips. Because large bowel content areunlikely to cause skin irritation, there is no needto form a spout.

• To prevent internal herniation, close the lateral space.

• Cover with a stoma bag.

• The mucous fistula is constructed in a similarmanner. Positioning is less crucial. The fistulacan usually be covered by a pad.

• In a double-barrelled stoma, bring both endsthrough the same defect. Attach the two limbs toskin and abdominal wall, as well as to each other.

Hartmann's procedure

1250 This is useful for rectal injuries.

• An end colostomy is brought out as in 1249.

• The distal end is closed off using two layers of inverting sutures and dropped back into thepelvis (Figure 1215). Alternatively, close it with a stapling gun (e.g., an Autosuture TA 55). If the rectal stump is low in the pelvis, it can be left open.

• Where the rectum has been closed off, consider irrigating the stump to reduce soiling of perineal injuries.

• If the rectal wound is intraperitoneal, drain therecto-vesical pouch. Where injury has occurredbelow the peritoneal reflection, drain thepresacral space. If a buttock wound is already

A defunctioningcolostomy to prevent

faecal soiling is advised for the

initial managementof extensive wounds

of the perineum orbuttock which may

involve the analcanal or require

plasticreconstruction.


282

Chapter_12.qxd 28/09/2004 15:55 Page 282

present, this could be used to introduce thedrain. Alternatively, the drain is brought outthrough an incision placed in the median raphebetween coccyx and anus, guided by a hand inthe abdomen.

Spleen 1251 The friability and vascularity of the spleenmake it susceptible to blows, crush and blast injury.Treatment is by splenectomy (Figure 1217).

• Lift the left costal margin and retract the stomachmedially and the splenic flexure downwards. A lateral wound extension may improve access.

• Gently lift the spleen forward (NB: the alreadytorn capsule is easily further torn). This willreveal the posterior layer of the lienorenalligament; divided this up to the diaphragm using scissors. The spleen can now be rotatedmedially and a pack inserted posteriorly.

• Divide the short gastric vessels in thegastrosplenic ligament and any omentalattachments to the spleen.

• The splenic artery and vein are individuallyligated close to the hilum; take care not todamage the tail of the pancreas. Drain thesubphrenic space.

Post-splenectomy septicaemia

1252 After splenectomy give triple vaccine(S.pneumoniae, N.meningitidis, H.influenzae/B.microti[HIB]) and penicillin prophylaxis to reduce the risk ofopportunistic, post-splenectomy infection (OPSI risk0.1-0.5%; mortality 50%). In endemic areas, providemalarial prophylaxis (2406).

Diaphragm1253 Injury can occur following blunt or


There is no place for conservativetreatment of splenicinjury in militarypractice.


283

Chapter_12.qxd 28/09/2004 15:55 Page 283


284

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Fig 1217 Splenectomy: A) Emergency haemorrhage control.B) Division of the lienorenal ligament. C) Lifting the spleen forwards. D) Division of lienogastric ligament. E) Ligation of the splenic vesselsat the hilum.

A

B

C

D

E

Chapter_12.qxd 28/09/2004 15:55 Page 284

penetrating trauma. The left side is more commonlyaffected. Defects allow herniation of abdominalcontents into the thoracic cavity. This can result incardio-respiratory embarrassment or strangulation of the herniated viscera. Small wounds may graduallyenlarge causing delayed symptoms (1519).

• Repair is using a strong absorbable suture (e.g.No1 PDS) taking care not to injure branches ofthe phrenic nerve.

Oesophagus This is discussed at 1553

Stomach Introduction

1254 The stomach is injured in 10 to 15% of all abdominal trauma. Associated injuries to thetransverse colon, jejunum, liver, spleen, pancreasand left kidney are common. Occasionally, a posteriorperforation is the only defect and when missed, isusually fatal. Wounds range from small to largeperforations, linear tears to complete transections.The gastric wall has a good blood supply and, ifappropriately repaired, will heal well. Because thearteries supplying the stomach are not end-arteries,they can be ligated without fear of necrosis.

Procedures

1255 Major stomach resections are rarelyindicated:

• Inspect both anterior and posterior surfaces ofthe stomach. The posterior wall is exposed bymaking a window in the gastrocolic omentum(Fig 1218).

• Tears of the fundus and the body should beexcised - remove only devitalised tissue - andclosed by an inverting technique. Place stay

Oesophageal Injury: see Chapter 15

Blood on naso-gastricaspiration suggestsstomach and/orduodenal injury.


285

Chapter_12.qxd 28/09/2004 15:55 Page 285

sutures at either end of the defect and closeusing an all layers continuous absorbable suture(e.g., 3/0 PDS). In order to ensure haemostasis,include the mucosa (Figure 1219).

• Gastric repair can be reinforced by serosalsutures or clips. A strand of omentum may be fixed over the defect

• Wounds near the pylorus should be closedtransversely to avoid narrowing the lumen.Addition of a gastro-jejunostomy is occasionallyrequired if there are concerns regarding gastricoutlet obstruction.

• Leave a nasogastric tube in place on freedrainage with regular aspiration for 3-5 days.


286

Fig 1218 Division of the gastrocolic omentum to expose the anteriorsurface of the pancreas and the posterior surface of the stomach.

Chapter_12.qxd 28/09/2004 15:55 Page 286

Liver Introduction

1256 The liver is damaged in approximately 20per cent of abdominal wounds, with a ratio of right to left lobe of 5:1. It is particularly vulnerable in right-sided thoraco-abdominal wounds. The hepaticcirculation is 1500mls of blood/minute. Consequently,casualties with serious liver trauma frequently diewithin minutes of injury. By the time those whosurvive receive medical attention, most liver injurieshave stopped bleeding. Major tears can heal withoutintervention. Liver trauma is broadly divided intothree grades of severity:


287

Fig 1219 Stomach repair: minimal wound excision is required. Insertstay sutures. Close defects and control haemorrhage with all-layerscontinuous suture. This may be reinforced by a serosal suture layer.Wounds near the pylorus are closed transversely.

Chapter_12.qxd 28/09/2004 15:55 Page 287

1. Low energy-transfer penetrating injury result in an oozing, cored-out track, which usually heals spontaneously.

2. Blunt or penetrating trauma that disrupts the liver parenchyma causing moderate tosevere haemorrhage.

3. High energy-transfer penetrating injury producingcavitational effects resulting in extensivedisruption of the liver parenchyma with damageto the hepatic veins and inferior vena cava.

Approach

1257 Ideally, have adequate surgical access, able assistance, adequate light, two working suckers,good venous lines, blood for transfusion and clottingadjuncts - FFP, platelets and rVIIa. A midline incisioncombined with a lateral extension may be sufficientaccess (Figure 0402). An inverted 'T', 'Mercedes star'

Injury to the venacava may initially be

tamponaded by anintact posterior

parietal peritoneum;sudden massive

haemorrhage fromthis site may catch

the unwary surgeonoff guard.

Extensive woundexcision or

resections are notappropriate in the

emergency treatmentof liver injury.


288

Fig 1220 Liver suture using large, atraumatic needles; re-enforce with an omental patch. Wound drainage.

Chapter_12.qxd 28/09/2004 15:55 Page 288

or roof top incision parallel to both costal margins,gives excellent exposure to the liver and spleen. A right thoraco-abdominal incision (1534) or sternalsplit (1538) are rarely necessary. Avoid prolongedsurgery (0402).

Control of bleeding

1258 At laparotomy, if haemorrhage from tears in the liver has ceased, do not disturb the wound oradherent haematoma. Insert suction drains aboveand below the liver.

• Minor bleeds can be controlled with diathermy,haemostatic agents or sutures on a largeatraumatic needle (Figure 1220).

• Most major liver bleeding can be controlled bypacking (0408). Effective placement of packs is aided by division of the suspensory ligaments(Figure 1221). These packs are removed atlaparotomy 24-72 hours later. In the majority of casualties, haemorrhage will have ceased.

• The risks of tight packing include: liverischaemia, diaphragmatic splinting andcompression of the IVC. These considerationsare secondary to haemorrhage control.


Placing packs orribbon gauze in theliver wound shouldbe avoided.


289

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Fig 1221 The venous anatomy of the liver. Position of suspensoryligaments - these require division when mobilising the liver.

Chapter_12.qxd 28/09/2004 15:55 Page 289

• Control of bleeding from a large defect may beaided by packing it with a vascularised pedicle of omentum held in place with sutures (Figure 1220).

• Severe bleeding can be reduced by Pringle'smanoeuvre (0408). Each period of occlusionshould last no more than 15-30 minutes. Allow 5 minutes for recovery. If Pringle's manoeuvrealone is ineffective, occlude the IVC above andbelow the liver using vascular clamps, directcompression, tapes or intraluminal balloontamponade (Figure 0409). By dividing thecoronary and right triangular ligaments (Figure 1221), it may be possible to place the upper clamp just below the diaphragm. An easier alternative is to perform a rightthoraco-abdominal incision (1538) and clamp the IVC above the diaphragm.


290

�

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Fig 1222 Dividing damaged liver by finger fracture. This enablessafe exposure of vessels and biliary canaliculi.

Chapter_12.qxd 28/09/2004 15:55 Page 290

Liver resection

1259 Once haemorrhage has been controlled,devitalised liver tissue may be removed usingfracture techniques:

• The area to be resected is marked out byincising Glissen's capsule using diathermy.

• The parenchyma is pinched between finger andthumb, or gently crushed using an artery forcep(Figure 1222). This will reveal bile ducts andhepatic vessels which can then be safelycontrolled. Do not excise deep into the liver.

• Insert at least two suction drains through the posterior aspect of the right flank.

Complications of liver trauma

1260 These include:

• Bleeding: A subcapsular or intrahepatichaematoma usually resolves spontaneously.Secondary haemorrhage typically occurs 4-8days after injury and is caused by infection or an increased bleeding tendency. There may bedelayed rupture leading to traumatic haemobilia.

• Suppuration. Contributory factors include failureto excise necrotic or devitalised liver tissue,strangulation by injudicious use of deep sutures,inadequate drainage and contamination by bowelcontents. Abscesses can be subphrenic,subhepatic or intrahepatic; they are oftenmultiple. Treatment is by drainage. This can be open, or percutaneous under ultrasoundguidance with antibiotic cover.

• Biliary fistula. Bile is frequently seen in thedrain after liver surgery; this usually resolves.Collections can be drained percutaneously underultrasound guidance. Development of bileperitonitis necessitates laparotomy. A persistent

Antibiotic Prophylaxis: see Chapter 8

A formal hepaticlobectomy in a fieldsurgery setting is not indicated.


291

Chapter_12.qxd 28/09/2004 15:56 Page 291

biliary fistula is often managed by endoscopicretrograde cholangio-pancreatography (ERCP)and interventional radiology.

DuodenumIntroduction

1261 Wounds of the duodenum, biliary tree andpancreas are rarely encountered on the battlefielddue to the high mortality from combination wounds to organs in close proximity, or coincidental trauma to the aorta or IVC. Operative findings suggestingduodenal injury include:

• Adjacent haematoma.

• Retroperitoneal gas.

• Tissue discoloration due to bile leakage.

Retroperitonealinjuries of the

duodenum are oftenmissed and

frequently fatal.


292

Fig 1223 "Kocherising" the duodenum to expose its posteriorsurface and the posterior surface of the head of the pancreas.

Chapter_12.qxd 28/09/2004 15:56 Page 292

Following blunt injury, a water soluble contrast mealmay confirm a duodenal leak; (use CT if available).Problems with healing, especially following injuries ofthe second part, are caused by tension at the site ofrepair. This is due to the large, combined output ofthe stomach, pancreas and biliary tree. Duodenalwall haematomas usually resolve spontaneously butcan perforate. When causing obstruction, they can be managed by incision of the serosa and evacuationof the haematoma, or by nasogastric aspiration.


293

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Fig 1224 Simple duodenal lacerations can be closed transversely.Cover with an omental patch and decompress. Options fordecompression are a nasoduodenal tube or a duodenostomy tubeproximal to the repair.

Chapter_12.qxd 28/09/2004 15:56 Page 293

Approach

1262 Where indicated, inspect the anterior andposterior surfaces of the four parts of the duodenum.

• Mobilise the hepatic flexure of the colon and free sufficient greater omentum from thetransverse colon.

• The posterior surface of the duodenum and head


294

Fig 1225 The duodenal repair may be protected by temporarilyclosing off the pylorus from within using an absorbable purse-stringsuture plus either, continued nasogastric aspiration or, a gastro-jejunostomy.

Chapter_12.qxd 28/09/2004 15:56 Page 294

of the pancreas can be visualised by carrying outKocher's manoeuvre, (Figure 1223).

• Dissection is continued medially to expose theinferior vena cava and aorta.

• The third and fourth parts of the duodenum areexposed by mobilisation of the ligament of Treitz.

Simple wounds

1263 Minor wounds can be treated by minimalwound excision and transverse closure, providing thisdoes not significantly narrow the lumen (Figure 1224)

• Use one or two layers of absorbable sutures(e.g., 3/0 PDS). This may be reinforced by anomental patch.

• After repair, the duodenum must bedecompressed with a naso-duodenal tube, or balloon catheter inserted as a tubeduodenostomy. Where a tube duodenostomy is being used to protect a repair, it is insertedthrough a separate proximal incision (Figure1224). The site of the anastomosis and the retro-duodenal area should be drained usingsuction drains.

• Short segment loss affecting the 1st, 3rd and 4th parts of the duodenum can be treated byexcision and re-anastomosis, providing this can be achieved without tension.

• Healing of a duodenal repair may be aidedby temporarily closing off the pylorus. This isperforming via a short gastrotomy. A continuousabsorbable suture is inserted around the pylorus.This is combined with a gastro-jejunostomy orregular nasogastric aspiration, (Figure 1225).In approximately 90% of cases, the pylorusreopens within three week, by which time therepair should have healed.

In the severely illcasualty with aduodenal injury, youmay be forced to dono more than packthe area at the initialoperation. If youdecide thatexploration of aretroperitonealhaematoma isessential, beprepared to deal withmajor bleeding.


295

Chapter_12.qxd 28/09/2004 15:56 Page 295

Major injury

1264 Damage control surgery for significantduodenal injury is to:

• Insert one or more wide-bore, balloon cathetersthrough the defect so as to form a 'controlledfistula' (Figure 0411).

• Each balloon is inflated with 3-5mls of water and the catheter left on free drainage.

• Where possible, the defect in the wall is closedaround the catheter using absorbable sutures.Fix a strand of omentum over the duodenum.

A duodenostomy is a useful technique

in inexperiencedhands, particularly

where surgery isdifficult or delayed. It

will protect a repairconsidered at risk of

dehiscence.


296

Fig 1226 A jejunal serosal patch used to repair a duodenal laceration.

Chapter_12.qxd 28/09/2004 15:56 Page 296

• Adjuncts to the above include: nasogastricaspiration, parentral feeding and pharmaceuticalreduction of gastric secretion (e.g., proton pumpinhibitors e.g., octreotide.

• After 14 days, a track will have formed and thecatheter can be gradually withdrawn.

Where repair of major defects is indicated, thetraditional approach is to construct a jejunal serosalpatch (Figure 1226). Place the sutures well clear of the edges of the defect. Though simple, thistechnique may leak. Other options are illustrated in Figure 1227.


297

Fig 1227 Other methods for repair or drainage of a duodenal laceration.

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Gallbladder and biliary tree Introduction

1265 Tears in the gallbladder are common after blast injury. Injuries to the bile ducts areassociated with major vascular injuries and are often fatal. Injuries to the gallbladder are treated bycholecystectomy or insertion of a cholecystostomytube. Injuries to the duct system are dealt with bydirect repair around a T-tube using absorbablesutures (Figure 0410).

Approach

1266 Exposure is by upward retraction on the liver, medial retraction on the duodenum anddownward traction on the hepatic flexure of the colon.Exploration of the distal common bile duct requiresincision of the overlying peritoneum and"Kocherisation" of the duodenum (1262)in order to inspect the pancreatic portion.

Cholecystectomy

1267 Identify and ligate the cystic artery in Calot's Triangle. Free up the cystic duct and doubleligate or transfix it with absorbable ties or sutures.Free the gallbladder from the liver bed. Following allforms of biliary surgery for trauma, insert an adjacentsuction drain.

Cholecystostomy

1268 A quick and easier alternative tocholecystectomy is to resect the damaged portionand close the remaining gallbladder around acholecystostomy tube (Figure 0410). Introduce a large rubber balloon catheter through the adjacentanterior abdominal wall into the defect in thegallbladder. Inject 5mls of fluid in the balloon. Close the wall around the tube using an absorbable,purse string suture. Suture the catheter to theabdominal wall.


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Approximately 10- 14 days after cholecystostomy orinsertion of a T-tube, a track will have formed. Injectcontrast into the tube and X-ray in order to checkbiliary flow. If satisfactory, remove the tube. Anyleakage of bile will dry up.

Pancreas Introduction

1269 Pancreatic trauma is often associated withmajor vascular damage, diagnostic delay particularly,after blunt injury and a fatal outcome.

The only reliable method of excluding a suspectedpancreatic duct injury is to inject contrast through theSphincter of Oddi via an intra-operativeduodenostomy or, preoperative ERCP. Delayedpancreatic surgery is often unsuccessful.

Approach

1270 Anterior and posterior surfaces of the headof the pancreas are exposed as for duodenalexamination (1262). The body and tail of thepancreas are inspected through a window made inthe gastro-colic omentum (Figure 1218). To inspectthe posterior aspect, mobilise the spleen and thepancreas to the right (Figure 1228).


299

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Fig 1228 Mobilisation of the distal pancreas and spleen prior todistal pancreatectomy.

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Major injury

1271 Damage control surgery for haemorrhage isto pack the wound. Insert two or more drains. Do notexplore a retroperitoneal haematoma unless it isclearly expanding (1274). Where there is extensiveinjury to the head of the pancreas and duodenum,drain as in Figure 0411.

Transection through the pancreatic neck or tail in astable casualty may be treated by resection of thedistal pancreatic remnant.

• Mobilise as in Figure 1228. Because of theproximity of the splenic vessels, pancreaticresection is usually accompanied bysplenectomy (1251).

• Swing the mobilised pancreas and spleenforwards to release any posterior attachments(Figure 1229).

• Divide the neck of the pancreas over the aorta(Figure 1230). Oversew the proximal end of the


300

Fig 1229 The pancreas can be swung forward to ligate the splenicvein. Note exposure of the coelic axis, portal vein and inferiormesenteric vein.

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divided pancreatic duct. Close the thinpancreatic capsule over the remaining tissuesusing interrupted sutures (e.g., 3/0 Prolene) and cover with omentum.

• Resection of the head of the pancreas andreconstruction should only be contemplated atRole 4 (Figure 1231).

Minor injury

1272 Where there is minimal contusion or a laceration not involving a major duct, treat bysuction drainage.

Where a fresh defect in the pancreatic duct can beidentified:

• Effect repair using interrupted, monofilamentnon-absorbable sutures (e.g., 5/0 Prolene).

• Close pancreatic tissue and capsule over theinjury using lightly tied sutures (e.g., 3/0Prolene) and cover with a pedicle of omentum.


301

Fig 1230 Distal pancreatectomy: the pancreatic duct is transfixedand the fish-tailed pancreas approximated.

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• Place suction drains anterior and posterior tothe pancreas.

Complications

1273 These include:

• Haemorrhage: occurs as a result of infection orerosion of adjacent blood vessels secondary toleakage of pancreatic juice. This requires anemergency laparotomy.


302

Fig 1231 A method of reconstruction after pancreatico-duodenectomy.

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• Pancreatic fistula and pseudocyst formation:loss of pancreatic juice via the drain is commonand rarely serious. Drainage should be into abag to prevent skin damage. Small leaks resolveon conservative treatment. Damage to a majorduct may require a pancreatectomy, or Roux-en-Y diversion. Investigate by ERCP.Pseudocysts can be drained percutaneouslyunder ultrasound control.

• Abscess formation: usually due to a missedpancreatic injury or leakage of pancreatic juice.Treatment is by drainage.

• Pancreatitis: usually responds to conservative treatment.

• Protracted recovery: Maintain nutrition byparenteral or enteral feeding.

Urological Trauma

This is discussed in Chapter 14

Management of retroperitoneal haemorrhage1274 Most retroperitoneal haematomas aremanaged by packing. Before exploring you mustobtain proximal and distal control of potentiallyinvolved vessels. The retroperitoneum can be dividedinto four zones:

• Central: haematomas should be explored toexclude injuries to the aorta, IVC, pancreas and duodenum.

• Left and right lateral: haematomas can be leftundisturbed unless they are expanding or thecasualty remains hypotensive and, in theabsence of other injuries, unstable. Routineexploration of lateral haematomas results in an unnecessarily high nephrectomy rate.

Urological Injury: see Chapter 14

Always examine thepancreas in cases ofupper abdominaltrauma.

If a retroperitonealhaematoma is notexpanding, otherabdominal injuriestake precedence.


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• Pelvis: if the haematoma is not expanding, leaveit alone. If it is rapidly enlarging, the pelvic cavityshould be packed and, if not done already,external fixation or other methods of compression,applied to the pelvis. In the right setting, performarteriography with a view to embolisation (0411).This will only control bleeding that is arterial inorigin. Surgical exploration of pelvic haematomasis rarely helpful and often leads to uncontrollableblood loss.

Retroperitoneal exposure

1275 The two main manoeuvres for the exposureof the major vessels in the abdomen are:

1. Medial visceral rotation from the right

• The avascular peritoneum lateral to the caecum,ascending colon and hepatic flexure is incisedand the bowel and mesentery mobilised towardsthe midline (Figure 1208).

• Stay in front of the right kidney and ureter.

• The duodenum and head of pancreas aremobilised by Kocher's manoeuvre to expose therenal vessels, infrahepatic inferior vena cava andaorta (Figure 1223).

2. Medial visceral rotation from the left

• The peritoneum lateral to the sigmoid colon,descending colon and splenic flexure is incisedand the bowel and mesentery mobilised towardsthe midline (Figure 1208).

• The spleen and tail of pancreas can bemobilised with the colon (Figure 1228).

• Continue dissection until the full length of theabdominal aorta is exposed, as well as thecoeliac axis, superior mesenteric artery, leftrenal artery and inferior mesenteric artery(Figure 1229).

Major vasculardamage is more

common afterpenetrating than

blunt trauma, butwhen it does occur

it tends to becomplex and oftenfatal. Shearing andtraction forces can

cause avulsion,intimal tears,

thrombosis and distal ischaemia.

Presentation may be delayed.


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Individual exposure of major vessels and their management

1276 Aorta

• In the severely hypotensive casualty, the aortamay be clamped via a thoracotomy or laparotomyincision. NB: this unlikely to be applicable underfield conditions.

• Perform a left anterior thoracotomy through the5th intercostal space (1534). This may befacilitated by deflating the left lung. Freeattachments of the inferior surface of the lungand retract anteriorly and superiorly. Incise themediastinal pleura over the thoracic aorta andseparate the latter from the oesophagus.Occlude the aorta with a vascular clamp placedjust above the crura (Figure 0405).

• The supra-coeliac aorta can be clamped bymaking a window in the lesser omentum. Lift the oesophagus and lesser curve of the stomachforward and identify the aorta at thediaphragmatic hiatus (Figure 0406). Clamp theaorta above the coeliac artery (NB: avoid thepancreas). An alternative is to compress theaorta at the same site.

• The infrarenal aorta is exposed by retractingsmall bowel to the casualty's right anddescending colon to the left (Figure 1232). Incise the peritoneum at the duodenojejunalflexure (ligament of Treitz) and mobilise it to theright. The incision is continued down as far asthe common iliac arteries and the posteriorperitoneum reflected off the aorta. Exposure can be improved by dividing the left renal vein as it crosses the aorta - this is unlikely to causecomplications in the young and fit.

1277 Inferior vena cava (IVC)

• The infrahepatic IVC is exposed by medial

Wounds of the aortaand intra-abdominalvena cava areusually fatal. Thosethat survive to reacha surgical centre will require urgentsurgery.


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displacement of the viscera from the right(1275). Haemorrhage is controlled by localpressure (1029) or use of balloon catheters(Figure 0409), in preference to clamping. Tearsin the IVC are closed with continuous 5/0Prolene. Posterior lacerations are best repairedtranscavally by enlarging the defect in the

Opening the chesthelps to prevent air

emboli by equalisingintrathoracic and

abdominalpressures.


306

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��

��

�� +��

��

��

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Fig 1232 Incising the posterior peritoneum to expose the infrarenalaorta and vena cava. The colon is retracted to the left and the smallbowel to the right.

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anterior wall, rather than attempting to rotate the vessel. In extremis, the infrarenal IVC canbe ligated; this will result in varying degrees ofleg oedema.

• Injuries of the suprarenal IVC are best treated by reconstruction with an externally supportedPTFE graft and systemic anticoagulation.

• Control of bleeding from the liver andretrohepatic IVC is discussed in 0408.Subsequent repair of the cava may necessitatewound extension into a right anterior thoracotomyor median sternotomy. Occasionally, it may bepossible to control the defect using a Satinskyclamp applied to the side of the vessel, therebyonly partially occluding the IVC. At Role 4, use of an atria-caval shunt will preserve venousreturn whilst the retrohepatic IVC is repaired.

1278 Coelic axis and its branches

• The coelic axis is exposed by medial visceralrotation from the left (1275). Because it isdifficult to repair, ligate the damage vesselproximal to the main branches; if the superiormesenteric artery is intact, the risk of visceralischaemia is approximately 10%.

• The left gastric artery can be ligated with impunity.

• The splenic artery is best tied rather thanrepaired. Perform a splenectomy (1251).

• The origin of the common hepatic artery canbe exposed by medial visceral rotation from theleft (1275). Alternatively, make a window in thelesser omentum adjacent to the distal lessercurve of the stomach and retract the duodenuminferiorly. The hepatic artery lies in the freeedge of the lesser omentum medial to thecommon bile duct and anterior to the portal vein


Compression of theIVC while trying toeffect repair maycause cardiac arrest.Exposure of thedefect in the IVCmay result in airembolism.

Do not attemptcomplex interpositiongrafts when repairinginjuries of thecoeliac, SMA, IMA ortheir branches.

To preventgallbladder necrosisafter ligation of thehepatic or righthepatic arteries,perform acholecystectomy.


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(NB: identify and avoid these structures). Thecommon hepatic artery can be ligated safelyproximal to the gastroduodenal artery; occlusiondistal to the gastroduodenal artery infrequentlycauses hepatic necrosis.

1279 Superior mesenteric artery (SMA)

• The origin of the SMA is exposed by medialvisceral rotation from the left (1275). Moredistally, the artery can be found in the base of the small bowel mesentery.

• The proximal SMA must be repaired or bypassedusing saphenous vein or a synthetic graft (NB:avoid graft kinking). Administer 5,000 unit of i.v.heparin systemically prior to clamping the artery.Check inflow and backflow; flush beforecompleting the final anastomosis (1024).

• The distal SMA may be ligated; this usuallynecessitates resection of a segment ofdevascularised small bowel (1235).

1280 Portal vein (PV)

• The PV is formed by the confluence of thesplenic and superior mesenteric veins behind the pancreas.

• The origin may be exposed by Kocher'smanoeuvre (1262) from the right, or medialvisceral rotation from the left (1275). It may benecessary to divide the neck of the pancreas togain adequate access (1271).

• The PV in the free edge of the lesser omentumis mobilised by dividing the peritoneum andretracting the common bile duct to the left.

• Injuries to the PV are closed with 5/0 continuous Prolene.

• In extremis, the PV can be ligated.

Rarely it may benecessary to divide

the neck of thepancreas to improve

exposure to the SMA.

Where there aredoubts concerning

bowel viability aftervascular repair,

perform a secondlook laparotomy

24-48 hours later.


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1281 Inferior mesenteric artery (IMA)

• The origin of the IMA can be identified whenexposing the infrarenal aorta (1276).

• Unless there is damage to the SMA and internaliliac arteries, it can be safely ligated (1% risk ofcolonic ischaemia). NB: check colonic viabilityprior to abdominal closure.

1282 Iliac arteries

• Exposure of the common iliac arteries (CIAs)and external iliac arteries (EIAs) is through astandard midline laparotomy incision. On theright, mobilisation of the caecum may benecessary, on the left, freeing-up of the sigmoidcolon. Identify the ureters as they cross the iliacbifurcation on both sides. Passing slings aroundthe iliac arteries may damage the adherent iliacveins. It is safer to control the artery by pinching,applying a Fogarty clamp or use of occlusivecatheters passed upwards from the groin.

• The distal external iliac artery is difficult toapproach from the abdomen and maynecessitate separate groin incisions (1045).

• Ligating the CIAs and EIAs risks lower limbischaemia (Figure 0412); they should berepaired or replaced with a syntheticinterposition graft (1031). If close to the aorticbifurcation, this may require a trouser graft.Where a unilateral injury cannot satisfactorily be repaired, ligate the vessel and perform anextra-anatomical bypass (Figure 1012).

• Injuries to the internal iliac arteries are managedby packing (1274). Exposure of the artery isdifficult and because of pelvic cross-filling,ligation of one artery is often not effective at controlling haemorrhage.

Pelvic Fracture: see Chapter 13


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Complications of abdominal surgery Conditions that may require re-operation include:

1283 Wound dehiscence: contributory factorsinclude infection, poor nutrition, prolonged abdominaldistension and inadequate wound closure techniques.

1284 Missed intra-abdominal injury: commonlyoverlooked injuries are those involving retroperitonealstructures, fixed portions of the colon and the viscerabordering the lesser sac.

1285 Intestinal obstruction: a prolonged ileus is common after abdominal trauma or major surgery.It usually resolves with a regimen of "drip and suck"and correction of predisposing factors (e.g.,electrolyte imbalance). Mechanical obstruction is due to the development of adhesions or abscessformation between loops of bowel. Early operationmay correct the obstruction more successfully thanconservative treatment.

1286 Secondary haemorrhage: is due to infection causing erosion of a blood vessel.Haemorrhage is generally profuse necessitatingemergency surgery. This is particularly likely tohappen when a haematoma, resulting from an injuryto a retroperitoneal vessel, is not explored at theoriginal operation.

1287 Intra-abdominal abscesses: classicalfeatures are a toxic casualty with a swinging pyrexia.The usual locations are the four abdominal quadrantsplus the pelvis. It may be possible to drain anabscess under ultrasound control.

1288 Anastomotic dehiscence: classicallyoccurs 5-10 days after bowel surgery. Providing thereis no distal obstruction and the casualty remains well,90% heal on conservative treatment. Management

Wound Healing: see 3020


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includes radiology to define the fistula (fistulogram,small bowel meal/enema), enteral or parenteralnutrition and skin protection. Surgery to close thefistula is occasionally required at Role 4.

1289 Stomal problems: include necrosis,retraction or stenosis. The commonest causes are inadequate mobilisation or poor blood supply.Though a local procedure may be possible, majorstomal problems usually require revision at a second laparotomy.

1290 Abdominal compartment syndrome(ACS): a persistent increase in abdominal pressurecan compromise intra-abdominal organs, the lungsand abdominal wall. Features include:

• Reduced glomerular filtration rate leading tooliguria and renal failure.

• Diminished blood flow to the splanchniccirculation allowing increased absorption of toxins, translocation of gut bacteria and septicaemia.

• Hypoperfusion of the abdominal wall increasingthe risk of wound infection and breakdown.

• IVC compression leading to reduced cardiacoutput and heart failure.

• Decreased pulmonary compliance leading to an increase in peak inspiratory pressure (e.g.,>40cm water), a deterioration in the PaO2/FiO2ratio and respiratory failure.

The syndrome is usually suspected when thecasualty develops oliguria and becomes increasinglydifficult to ventilate. It is typically seen in casualtieswho have suffered:

• Severe trauma requiring large volume blood transfusion.

Compartment Syndrome: see 0906


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• Tight abdominal closure over packs or dilated bowel.

• Prolonged hypotension.

• Burns >20%.

The diagnosis is confirmed by bladder pressuremonitoring at Role 4. This is believed to accuratelyreflect intra-abdominal pressure. A value >25mmHgfor four hours is diagnostic.

Initial treatment may include

• Diuretics, increased sedation and nasogastrictube aspiration.

• Failure to respond to these measures over the next two hours is an indication for urgentlaparotomy, decompression and partialabdominal closure (0412).

• Where ACS is considered a likely complication, it may be preferable to leave the wound openafter the initial operation.


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Chapter 13

Pelvic Injury

Introduction

1301 The mortality from pelvic fractures is highdue to exsanguinating retroperitoneal haemorrhageor associated injuries. Surgical intervention is oftenrequired to arrest haemorrhage after major injury.Managing such casualties in an austere environmentis challenging.

Pathoanatomy

1302 The pelvis is a complete ring of three bones(two innominate and the sacrum) and three joints(two sacroiliac and the symphysis pubis). Thesejoints rely completely on ligamentous reinforcementfor their integrity. The broad anterior and posteriorsacroiliac ligaments are the strongest in the body.

The internal iliac and superior gluteal arteries arebound to the bones of the posterior pelvis. All pelvicviscera lie upon a thin-walled, venous plexus thatdrains directly into the internal iliac veins or portalvenous systems. Following sacroiliac joint damage,there may be disruption of these vessels and damageto the sacral nerves. Typically, there is retroperitonealhaemorrhage from the major vessels, bleeding fromexposed raw bone surfaces and from the thin-walledvenous plexi.

The majority of pelvic fractures are closed. Openpelvic fractures represent the most severe form ofthis injury and half of those affected will die.

Massive force isrequired to disruptthe pelvic ring.

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Major Pelvic Fractures

1303 Major pelvic fracture is usually the result of blunt trauma e.g., vehicular accidents, falls andcrushing. Penetrating injury may also occur. Highenergy-transfer wounds involving the bony pelvis,blood vessels and viscera, carry a high mortality.There are three main fracture patterns.

Lateral compression fracture (LC)1304 This "implosion" injury is the commonestpelvic fracture type (66-75%) and is typically seenafter side impact vehicular accidents. Major vasculardisruption is uncommon and, if present, is usuallydue to vessel penetration by a bone fragment. Lessthan 10% of casualties with this fracture pattern arehypotensive. Morbidity and mortality are usually dueto associated abdominal, thoracic or head injury onthe side of impact. Application of a pelvic externalfixator is rarely necessary. There are three sub-types:

• Lateral compression type 1 (LC1): moderatedirect lateral force to the posterior pelvis causestransversely orientated ramus and sacralcompression fractures. Distortion of the ovalsacral foramina is seen on AP pelvicradiography. This is a stable fracture.

• Lateral compression type 2 (LC2): moderatedirect lateral force to the anterior pelvis causestransversely orientated ramus and cresentric iliac wing fractures (Figure 1301 A). Asymmetry is seen on the pelvic radiograph.

• Lateral compression type 3 (LC3): majorcompression force is applied to both halves ofthe pelvis. Firstly, the ipsilateral iliac wing isrotated inwards and either fractures or disruptsthe posterior sacroiliac ligaments. As the forcecontinues across the pelvis, the contralateraliliac wing is rotated outwards. The result is

Penetrating Injury: see Chapter 2

The direction and magnitude of

the force applied tothe pelvis, will define

the fracture type.

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sometimes referred to as a "windswept pelvis".LC3 injuries occur after vehicular rollover orsevere crushing and are often accompanied by major degloving of pelvic skin.

Anteroposterior compression (APC) fracture

1305 APC fractures are due to major forcesapplied to either the front or back of the pelvic ring.This injury is characterised by pubic symphysisdiastasis and/or vertical pubic rami fracture. Incontrast to vertical shear injury (1306), there is nomarked upward shift of the pelvis. APC fracturesoften occur in motorcyclists after frontal, high-speedimpact. The anterior pelvis is forced against the fueltank and splayed open. There are three sub-types:

• Anteroposterior compression type 1 (APC1):This is typically a sporting injury. There is minorseparation of the symphysis pubis (<2.5cm), withintact posterior structures and no fractures. This is a stable injury.

• Anteroposterior compression type 2 (APC2,"open book” injury). This is the most frequentsub-type. The anterior sacroiliac ligaments aredisrupted, whilst the posterior ligament complexis undamaged. This broad posterior ligament hasbeen likened to the binding of a book. The bookopens at the front but is held together at theback (Figure 1301 B). Symphyseal separation is >2.5 cm in the unreduced state. Verticalfractures of the rami may be seen in this and theAPC3 subtype. A radiological clue to an APC2injury is the presence of an avulsion fracture ofthe transverse process of L5 secondary totraction on the iliolumbar ligament. Thesacrotuberous and sacrospinous ligaments arealso torn. There is likely to be associated pelvicvisceral and soft tissue damage. One third ofthese casualties will be hypotensive on arrival ata field surgical facility.

Direct frontalaccidents of any type have thehighest mortality.

APC2 and APC3pelvic fractures arepotentially fatal."Closing the book"by emergencysplintage andapplication of anexternal fixator, may be life saving.

Ejectees are twenty-five timesmore likely to beseriously injuredwhen compared to belted, restrainedvehicle occupants.Following a fatalRTA, expectsurvivors to haveserious injuries.

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.

13: Pelvic Injury

316

�

�

�

Fig 1301 A. Lateral compression type 2 injury: fracture of the transversepubic rami plus either, a sacral compression or, a cresentic iliac wingfracture. The pelvic ligaments are intact.

B. Anteroposterior compression type 2 injury: wide symphysealdiastasis and disruption of the anterior and posterior sacroiliacligaments. The sacrotuberous and sacroiliac ligaments are also torn.

C. Vertical shear injury.

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• Anteroposterior compression type 3 (APC3):This massive injury consists of a completeseparation of one hemipelvis from the rest of thepelvic ring and, by definition, the rest of the body("complete traumatic hemipelvectomy").The anterior and posterior sacroiliac ligamentsare torn. APC3 injuries are associated withsevere pelvic visceral and vascular disruption.Two-thirds of these casualties will behypotensive on admission with an average GCS of 9. There is little or no vasculartamponade because the complete ligamentousdisruption permits unrestricted expansion of thehaematoma into the retroperitoneal space and pelvis. On average, 15 units of blood arerequired during initial resuscitation and surgery.

Vertical shear injury (VS)1306 VS injury typically results from a fall of >5 metres. The key feature is upward and posteriordisplacement of the hemipelvis (Figure 1301C). Theposterior injury is usually through the sacroiliac joint,but can be via a sacral or iliac wing fracture.Anteriorly, there may be symphyseal diastasis, or avertical fracture of the rami. The diagnosis should besuspected from the history or, the finding of unequalleg length in the absence of an obvious femoral shaftfracture or hip dislocation. Hypotension on admissionis present in approximately 12% of casualties.

Minor Pelvic Fractures

1307 Isolated fractures of the iliac wing andsingle fractures through a pubic or ischial ramus, do occur. As the pelvic ring remains intact, these are of limited clinical importance. Managementconsists of 2-3 days bed rest, analgesia andprogressive mobilisation. Isolated low energypenetrating fragment injuries of the iliac wing, in the


"Read the injury".Check all casualtieswith pelvic fracturesfor associatedinjuries: femoralshaft fracture, closed head injury,haemothorax, liver orsplenic trauma,urological and rectal damage.

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absence of other injury, require wound excision(0503) and minor nibbling of the bone edges.

Acetabular fractures1308 Fractures of the acetabulum are caused byforces applied through the femur and femoral headfollowing falls or vehicular accidents They areuncommon and not life threatening. Often, thefemoral head dislocates posteriorly and can injure the sciatic nerve (0966). Reduce as in 0967 andapply traction. Open reduction and internal fixation of the acetabulum may be necessary at Role 4.

Soft tissue trauma1309 All fracture types may be open orassociated with soft tissue trauma. Deep buttockwounds are at risk of gas (Clostridial) gangrene(0808). Injuries involving the perineum - especially ofthe "splitting type" - which run from the lower anteriorabdominal wall, through the perineum, to theposterior surface of the sacrum, must be assumed to involve the rectum.

Assessment and Management

Role 1 and 21310 Suspect a pelvic fracture in all those who have suffered major blunt trauma. Knowing thehistory (e.g., fall >5m = vertical shear injury?) and"reading the wreckage" (e.g., inwards deformation at door level = lateral compression injury?), providesa clue as to the likely pattern of injuries.

1311 Assess and resuscitate according to BATLSprinciples. Casualties with APC and some VSinjuries, are often profoundly hypotensive.

Battlefield Advanced Trauma Life Support: see Chapter 3

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1312 Look

• Deformation of the pelvis, unequal leg lengthand excessive external rotation of one orboth feet.

• Open wounds: perineal splitting wounds point to an "open book" injury. Following missile injury,look for entry and exit wounds.

• Soft tissue injury: shearing skin wounds suggestvehicular roll-over or crush injury. Examine forbruising and tenderness of the groin, perineum,pubic area and posteriorly over the sacroiliacjoints. Look for tyre marks on the skin or clothing.

• Scrotal haematoma and blood at the externalurethral meatus are the classical signs ofurethral disruption but, may not alwaysaccompany this injury (1423).

• In the secondary survey, test for altered legsensation and/or foot drop (2115). If either ispresent, it suggests sciatic nerve compression or damage.

• Abdominal distension may be due to intra-abdominal injury.

1313 Feel

• Pubic diastasis. The pelvis may be examined bytaking hold of the iliac blades behind the anteriorsuperior iliac spines. A single attempt is made topull the blades apart followed by squeezing themtogether (Figure 1302). This manoeuvre shouldbe performed carefully, slowly and once only (if at all), as a life saving clot can be dislodgedby repetition. Movement, crepitus or severe pain,indicate a pelvic fracture. It may be possible tofeel a gap at the pubic symphysis.

• Following a vertical shear injury, abnormalcephalad/caudad movement of the disrupted

If the casualty has an injury above and below the pelvis, assumethat the pelvis is also affected .

A retroperitonealhaematoma maycause paralytic ileus.

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pelvis can be tested for by performing a single,gentle push-pull manoeuvre of the limb on the affected side. Get an assistant to steady the pelvis.

• When circumstances allow, perform a rectaland/or vaginal examination. Look for featuressuggestive of a rupture of the membranousurethra (1423). Blood in the vagina or rectum isusually due to penetration by a fracture fragmentand typically occurs following LC injuries (NB:this is by definition, an open pelvic fracture).

1314 Investigations

• Perform standard primary survey radiographs (C-spine, chest and pelvis).

• FAST (1213).


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320

Fig 1302 Testing for an anteroposterior compression “open book”pelvic fracture.

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1315 Initial treatment

• Apply a pressure dressing to open wounds.

• Immobilise "open book" pelvic fractures using a strap, belt or sheet wrapped firmly around thepelvis at the level of the greater trochanters(Figure 1303). The legs should be tied togetherin internal rotation with a series of bandages(feet, calves and thighs). Prevent pressure soresby placing padding between knees and ankles(Figure 0322). Alternatively, use a well-mouldedvacuum splint.

• Following a VS injury, splint the affected leg toits neighbour in as near to the correct length aspossible. Immobilise the pelvis as above.


• Give antibiotics for open or potentiallycontaminated wounds (0816 and 0817).

• Urgently transfer to a Role 3 or 4 facility.

Role 3 and 41316 Investigations

Consider:

• Ultrasound scan, CT (1214) or supra-umbilicalDPL (1212) looking for bleeding.

• Proctoscopy, sigmoidoscopy and vaginalspeculum examination.

• Ascending urethrogram, cystogram or IVU (1407).

1317 Treatment

• Most LC1 and LC2 injuries are managed by 2-3 days of bed rest and analgesia, followed bymobilisation, starting with partial weight bearingon crutches. LC3 and some LC2 injuries needspecialist reconstruction at Role 4.

Infection and Antibiotics: see Chapter 8

Do not attempt tomanipulate and splintbroken legs together- check for other limbinjuries first!

The use of MilitaryAnti-Shock Trousers/Pneumatic Anti-Shock Garmentsis no longerrecommended. Their removal during examinationcan result in fatalhypovolaemic shock.

13: Pelvic Injury

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• APC2 and APC3 injuries require emergencyapplication of a pelvic external fixator (1320), an effective pelvic binder or C-clamp. "Closingthe book" will tamponade retroperitonealbleeding and may save the casualty's life. This should be achieved before laparotomy. An external fixator applied to the pelvis can bearranged such that it will not interfere with a full,mid-line laparotomy. Binders are now availablethat will also allow laparotomy after they havebeen applied.

• An external fixator can be used as definitivetreatment, but often loosens. At Role 4, considerinternal fixation.

• Where transfer is not possible, bed-rest and traction may be the only safe alternative to surgery.

• VS injuries are reduced by applying 10kg of tibialtraction to the affected leg (0935) for 6 weeks.The traction is adjusted to bring the hemipelvisinto the correct position.

• Therapeutic options if bleeding continues, aresummarised in Figure 1304. At Role 4, considerangiographic embolisation.

• Approximately 85% of casualties who havesustained a transpelvic gunshot wound, require laparotomy.

Laparotomy: see Chapter 12

Infraumbilical DPLmay produce a falsepositive result from a

anteriorly trackingretroperitoneal

haematoma - use asupraumbilical

approach.

13: Pelvic Injury

322

Fig 1303 Emergency immobilisation of an anteroposteriorcompression “open book” pelvic fracture with a broad Velcro™ strapapplied firmly over the greater trochanters.

Chapter_13.qxd 28/09/2004 15:56 Page 322

• Deep, soft tissue and open fractures, requirewound excision (0503).

• Following major perineal injury, perform acolostomy and wash out the distal segment(1249). Faecal matter must not be allowed toenter the distal loop and contaminate the wound.The colostomy may be closed once the perinealinjury has healed.

• Prophylaxis against deep vein thrombosis (DVT)and pulmonary embolism (PE) - see 0980.

Complications of Pelvic Injury

1318 Early

• Continued bleeding, rebleeding or haematoma.

• Paralytic ileus.

• Retention of urine.

• Infection and abscess formation.

• DVT/PE (0979).

• Fat embolism (0982).


13: Pelvic Injury

323

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Fig 1304 Management of a hypotensive casualty with a fracturedpelvis. (APC - anteroposterior compression; VS - vertical shear; LC - lateral compression; DPL - diagnostic peritoneal lavage; USS - ultrasound scan).

both

Chapter_13.qxd 28/09/2004 15:56 Page 323

Late

• Abnormal gait.

• Osteoarthritis.

Application of a Pelvic External Fixator

1319 Technique:

1. Use two Centrafix™ or Hoffmann II™ UK MilitaryPattern External Fixator packs. Stand facing thecasualty's feet with your pelvis adjacent to theirlateral chest wall. Identify the anterior superior iliacspines (ASIS). Follow the iliac crest two fingerbreadths back from the ASIS. Make a 4 cm longincision centred over this point, perpendicular to theiliac crest.

2. The aim is to insert three pins in both iliac bones(Figure 1305). In order to obtain maximum purchase,each pin must lie between the inner and outer tablesof bone. To help you judge the required angle ofinsertion and bone thickness, probe the position of the inner and outer tables of the iliac wing usingthe pin mounted on the chuck. Alternatively, use ahand-placed K-wire left in-situ to act as a guide to the correct angle.

Management of Urological Injury: see Chapter 14

13: Pelvic Injury

324

Fig 1305 Insertion of three pins in the ilium

Chapter_13.qxd 28/09/2004 15:56 Page 324

3. Steady the first pin on the bone. The point of boneentry should be at the junction of the outer 2/3 andinner 1/3 of the pelvic brim - i.e., stay closer to theinner table (Figure 1306). The pins are self-drilling;let the pin find its own way between the inner andouter tables. The aiming point is the thickest area ofsupra-acetabular bone. The pin should be inserteduntil all of the thread is buried in the bone.

4. Place a second and then a third pin, each spacedsome 2-3cm behind the other. Separate incisions areneeded for each pin. The pins should be generallyconvergent, (Figure 1305). Attach a short bar tothese pins with the pin-to-bar clamps.

5. Reduce the pelvis by internal rotation of the legs.Ask an assistant to compress the posterior halves ofthe iliac wings together (i.e., do not lever on the pinsto aid reduction - only to hold). Add a bar-to-barclamp to each cluster of pins (Figure 1307). Attach along bar to each bar-to-bar clamp and angle them sothat they meet between the umbilicus and pubis.Clamp the two long bars together as an inverted V with a third bar-to-bar clamp.

6. Make any final adjustments and securely tightenall clamps. Reinforce the anterior long bars with asecond V- Frame mounted behind the first.

Skeletal Traction: see 0935

13: Pelvic Injury

325

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Fig 1306 Distraction at the sacroiliac joint in an “open book” pelvic injury: anteroposterior position of pins inserted in the ilium prior to reduction.

Chapter_13.qxd 28/09/2004 15:56 Page 325

1320 Pin care

Release any tight or tented skin from around the pinswith a blade. Lengthy incisions may be partly closed.Spray each wound with Povidone™ iodine. Cut 2cmstrips of dry gauze and loosely wrap them around the base of each pin. These dressings should bechanged daily, any crusts removed, the skin cleanedwith saline and Povidone iodine reapplied.

Pin tract infection is managed by saline wound toilet,bacteriological culture and appropriate oral antibiotics.


13: Pelvic Injury

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1307 Final assembly of the external fixator prior to reducing the pelvis.

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Chapter 14

Urological Trauma

Introduction

1401 Injury to the urogenital system occurs inapproximately 3% of casualties. The kidneys, ureters,bladder and posterior urethra are retroperitoneal orpelvic structures. Because they are protected by thespine, lower ribs, pelvis and muscle, considerableblunt force is required to produce injury. Adjacentorgans are frequently injured obscuring the urologicaldamage. The management of the associated injuriesfrequently takes precedence. It follows that themajority of casualties who have suffered significanturological trauma need urgent surgical intervention. If in doubt, get them to a surgeon who can controltheir non-compressible haemorrhage.

Renal Trauma

Aetiology

1402 Renal injury may be:

Blunt: This accounts for 90% of civilian renal injuriesin the UK. Forty percent have serious, associatedinjuries. Trauma may be direct or indirect. Examplesof direct injury include: a blow beneath the ribs or acrush between the 12th rib and lumbar spine. Rapiddeceleration may injure the kidney indirectly byavulsing the renal vessels, rupturing the ureter at the pelvi-ureteric junction (PUJ), or by causing anintimal tear of the renal artery. Damage is more likelyif the kidney is abnormal, or in children, who havelimited perinephric fat and less protection fromsurrounding tissues.

Compressible and Non-Compressible Haemorrhage: see Chapter 3

Always considerurological trauma in casualties withpenetrating woundsof the back, loin,buttock and thosewith pelvic fractures.

Absence ofhaematuria does notexclude urologicaltrauma. There maybe few signs.

14: Urological Trauma

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Penetrating: The majority are missile injuries; a feware stab injuries. The kidney is involved in 4 to 8% of penetrating abdominal and thoraco-abdominalwounds. Approximately two-thirds have associatedinjuries (in descending order: colon, liver, lung,spleen, small bowel, stomach, pancreas, duodenumand diaphragm). In the majority, the associatedinjuries are the cause of the reported relatively highmortality (30%), rather than the renal injury itself.High available-energy missiles with their potential for shock-wave and temporary cavity effects, arecapable of causing massive disruption of the renalsubstance and avulsion of the renal vascular pedicleand ureters.

Clinical features

1403 Renal injury is suggested by:

• History - the mechanism of injury.

• The site of entry and exit wounds, abrasion,contusion, haematoma or bruising affecting theupper abdomen, loin or lower chest.

• Macroscopic haematuria (90% of cases).

• Loin pain and tenderness. Passage of clots may cause ureteric colic.

• Loss of loin contour or a mass due tohaematoma, urinoma or both.

• Associated fractures of the lower ribs and/or lumbar transverse processes.

Not uncommonly, the diagnosis is made atlaparotomy and, less commonly, at thoracotomy.

1404 Based on an intravenous urogram (IVU),ultrasound and/or CT scanning, injuries can beclassified into three functional groups. Figure 1401illustrates some examples. The approximatefrequency of these injuries in peacetime is givenin brackets:


An APC fracture ofthe pelvis (1305),points to possible

bladder or urethraldamage (or both).

Isolated renal traumais an uncommoncause of shock.

If present, theprobability of

associated injuries is high.


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1. Minor (85%): Contusions and superficiallacerations of the renal parenchyma not involvingthe pelvicalyceal system and with an intact renal capsule.

2. Major (10%): Deep lacerations affectingparenchyma and capsule. There may beextension into the collecting system.

3. Life-threatening (5%): Renal fragmentationand pedicle injury (vascular avulsion, rupture of PUJ).

Laparotomy: see Chapter 2


329

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Fig 1401 Types of renal injury: Minor: A contusion and superficial laceration.Major: B. deep laceration. C. Penetrating injury.Life-threatening: D. Pedicle avulsion. E. Renal fragmentation.

Chapter_14.qxd 28/09/2004 15:56 Page 329

• The perirenal (Gerota's) fascia usually preventsblood and urine escaping from around thekidney. A large retroperitoneal urinoma and/orhaematoma may cause an ileus.

• After a penetrating injury, blood and urine track in all directions and may enter theperitoneal cavity. This can result in abdominalrigidity and ileus.

• The renal outflow may become obstructed byblood clot in the renal pelvis or ureter. Cessationof haematuria may suggest improvement when,in fact, the casualty is losing renal function.

Management of blunt renal injury

1405 With the exception of parenchymalfragmentation and pedicle injury, 90-95% of bluntrenal trauma can be treated conservatively.

Minor renal trauma

1406 In the field, investigate all those with slighthaematuria or blood on microscopy or urine Dipstixtesting (see below). Casualties should remain on bedrest and antibiotic treatment until the haematuria hasresolved. They may return to duties if clinically andhaemodynamically stable. Warn of the small risk ofsecondary haemorrhage or severe haematuriaoccurring up to three weeks after injury.

Major or life-threatening renal trauma

1407 Casualties with definite haematuria ± shock:

• Resuscitate: this may involve urgent laparotomyin the unstable casualty.


• Regular monitoring: pulse, BP, inspection of theabdomen (e.g., increasing loin mass) and serialobservation of the urine. A change in colour from

Resuscitation: see Chapter 3

Slight haematuria or blood found on

microscopy orDipstix, usuallyindicates minor

urological traumawhich will resolve

spontaneously.


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red to brown usually indicates that haematuria is settling.

• Bed rest until haematuria has settled.

• High fluid intake to avoid clot colic.

• Prophylactic antibiotics (0820).

• Stage the renal injury by IVU, ultrasound and/orspiral CT (if available). Perform an early IVU with100ml of contrast (not diagnostic if the systolicBP <90mmHg). Take two films within 5 minutesand a third at 15 minutes. Unilateral absence offunction suggests serious disruption of thekidney or its blood supply and the need for earlylaparotomy (NB: a solitary kidney occurs in1:1200, almost invariably with compensatoryhypertrophy of the single kidney). In 85% ofcasualties the IVU will be normal. This does notmean that the kidney is uninjured. Ultrasound orCT may reveal a renal tear, haematoma orperirenal collection. Serial scans are used tomonitor resolution.

Surgery following renal trauma

1408 Exposure of the kidney through a mass ofblood clot is not easy.

• The decision to operate depends on thecasualty's clinical condition and, if time allows,the results of IVU, ultrasound and CT. Indications include:

• Penetrating renal injury.

• Haemodynamic instability.

• Uncontrollable haemorrhage or enlarging haematoma.

• A shattered kidneyor damage to the renal pedicle.


What to look for on the control filmand IVU:Is there a functioningcontralateral kidney?Adjacent fractures.Loss of psoasshadow/renal outline.Bowel displacement.Distortion of calyces.Extravasation ofcontrast.Non-visualisation ordelay in appearanceof nephrogram orpelvi-calycealsystem.

If you are forced toexplore the kidney,the priority is to stopbleeding. This maymean damagecontrol surgery by packing. Woundexcision, repair of ureteric injuries or nephrectomy canbe delayed until a second look.


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• Significant haematuria causing a continuingfall in haemoglobin.

• Because the likelihood of other intra-abdominalinjuries is high, approach through a full-lengthmidline incision (1225). Do not open a large,pulsatile perirenal haematoma without firstcontrolling the renal pedicle(s).

• Eviscerate the small bowel on its mesenteryto the right and cephelad. Incise the posteriorperitoneum from the caecum to the ligament of Treitz (Figure 1232). This gains access to theaorta, inferior vena cava and origins of the renalvessels. Control the renal pedicle vessels on the affected side(s). This permits Gerota's fasciato be opened without the threat of torrentialhaemorrhage. With small, non-pulsatilehaematomas, the kidney can be approacheddirectly, (Figure 1402). Options now are:

• Suture the laceration(s).

• Carry out a partial nephrectomy.

• If 1 and 2 are not possible, ligate the renalvessels and carry out a nephrectomy.

1409 Ideally, renal lacerations should be excisedand closed with deep absorbable sutures on a bluntneedle (Figure 1403). Do not tie too tight or usemattress sutures, they tend to cut out. Aids tohaemostasis and closure include: tying over perirenalfat, muscle or omentum. The perinephric spaceshould be drained through a separate loin incision.

1410 If the pedicle has not been controlled andthere is heavy renal bleeding, apply pressure withpacks over the kidney without opening Gerota'sfascia. Re-explore 24-48 hours later once thecasualty is stable. By this stage, bleeding will usuallyhave stopped and it may be possible to repair thekidney. Failing that, carry out a nephrectomy.



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Management of Retroperitoneal Haemorrhage: see 1274


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Fig 1402 Exposure of the renal pedicle and kidneys:Right kidney: A. The hepatic flexure is mobilised and the duodenum"Kocherised". B. The colon and duodenum are retracted to expose thekidney and renal vessels. Left kidney: C. The splenic flexure ismobilised. D. The bowel is retracted inferiorly. E. The most commonrelationships of the renal vessels, aorta and IVC.

A)

B)

C)

D)

E)

Chapter_14.qxd 28/09/2004 15:56 Page 333

1411 When performing a nephrectomy, transfix or double ligate the artery and vein separately. Tie off the distal end of the ureter using anabsorbable ligature. Drain the renal bed through a separate stab incision.

1412 The only absolute indication for a partialnephrectomy (Figure 1404), is a solitary functioningkidney. This requires time and expertise and canresult in greater blood loss than a nephrectomy. If it can be identified ligate, and divide the artery tothe damaged segment. Remove non-viable tissue by finger fracture or a wedge or guillotine incision.Drain the renal pelvis via a nephrostomy tube (e.g., Foley catheter) gently introduced through the renal substance using forceps. Repair the pelvi-calyceal system using fine absorbable sutures.Close the kidney with deep absorbable sutures tiedover crushed muscle or omentum.


Absence of renalperfusion for >30-60minutes may cause

permanent loss of function.


334

Fig 1403 Repair of a renal laceration. The wound is excised. Closewith interrupted deep sutures on an atraumatic needle. The defect canbe covered by omentum. Drain

Chapter_14.qxd 28/09/2004 15:56 Page 334

If flaps of the renal capsule are available, use theseto cover the defect. Drain the perinephric spacethrough a separate incision.

Drainage: see 2030 and 3028


335

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Fig 1404 Technique of partial nephrectomy. A. The segmentalvessels are ligated and divided. The kidney is divided using fingerfracture. B&C. The collecting system and capsule are closed separately.Reinforce with crushed muscle or omentum. D. the renal pelvis isdrained with a nephrostomy.

A)

B)

C)

D)

Chapter_14.qxd 28/09/2004 15:56 Page 335

1413 Repair of renal vessels depends on time and experience. Nephrectomy is usually more appropriate.

1414 If an unexpected perinephric haematomais encountered during the course of a laparotomy,

observe for several minutes and, in a stable casualty,perform an on-table IVU. If the haematoma remainsstatic and the X-ray does not show serious injury, it should be left undisturbed. The intact peritoneumand perinephric fat will usually tamponade thebleeding and prevent contamination. Unwiselyincising the peritoneum may cause catastrophichaemorrhage and circulatory collapse (1274).


336

Fig 1405 Ureteric repair: Spatulate and insert stay sutures.Repair using 4-8 interrupted absorbable sutures.

Chapter_14.qxd 28/09/2004 15:56 Page 336

1415 Complications of renal trauma

Early: secondary haemorrhage due to infection - may require surgery or, if available, selectivearterial embolisation; urine leak (generally settles)and abscess formation (drain).

Late: (>6 weeks) hypertension, arteriovenous fistula, hydronephrosis, pseudocyst formation,calculus formation, chronic pyelonephritis and loss of renal function.

Ureteric Injury

1416 Ureteric trauma is uncommon. Clinical signsare often absent in the early stages and may onlybecome apparent when the casualty presents withloin pain, abdominal swelling or a urinary fistulaseveral days later. The torn ureter may becomeobstructed by adjacent haematoma or urinecollection. A missed diagnosis usually results in loss of the kidney. Iatrogenic injury typically occurs if the surgeon has failed to identify the ureters duringcolonic mobilisation or pelvic surgery.

Management

1417 The diagnosis can usually be confirmed by IVU (but not always).

Consider, depending on the extent of trauma andpresence of multiple wounds, whether the wholelength of the ureter needs to be examined.

If detected at the time of injury, mobilise both ends of the ureters to avoid carrying out an anastomosisunder tension. Trim and spatulate and hold with twostay sutures (Figure 1405). A straight end-to-endanastomosis is liable to stenose. Pass a Double- Jureteric stent across the defect to reach the renalpelvis and the bladder (Figure 1406). Anastomoseusing a single layer of interrupted fine absorbablesutures (e.g., 5/0 PDS). NB: 4-8 should be sufficient.

The ureters canusually be identifiedas narrow tubeswhere they passover each of thecommon iliacarteries. They canthen be followedproximally anddistally. Typically,peristalsis is seenwhen they arepinched.

Principles of uretericrepair:- No tension.- Spatulate ends.- Stent across repair.- Take Care


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Leave a tube drain (not a suction drain) close to the injury. The ureteric stent can be removed 10-14days later.

1418 Depending on the level of ureteric injury,limited loss of ureteric length can be compensated for by mobilisation of the kidney and, at the distalend, relieving tension by a psoas hitch-stitch or Boariflap procedure (Figure 1407). Options if the defect istoo wide include:

• Bring the end of the ureter out to the skin as a temporary measure and suture it with a stentor tube in place to aid drainage (Figure 1407).Subsequent repair should be carried out by a urologist.


338

Fig 1406 Place a Double-J stent across the ureteric repair.

Chapter_14.qxd 28/09/2004 15:56 Page 338


339

Fig 1407 A. Boari flap operation. B. Cutaneous ureterostomy. C. Uretero-ureterostomy.

A)

B)

C)

Chapter_14.qxd 28/09/2004 15:56 Page 339

• Anastomosis to the opposite ureter (Figure 1407).

• Interposition of small bowel or appendix tobridge the gap.

The first of the above options is quickly carried out.The other two are specialised, time-consumingprocedures best done by a urologist at a subsequentoperation. In an unstable casualty:

• Nephrectomy may be the best course if the otherkidney is normal.

Bladder Injury

Aetiology

1419 The bladder may be damaged by a bonyfragment following a pelvic fracture, a penetratinginjury, by rapid deceleration and by a direct blow tothe lower abdomen. It is more vulnerable when full.The condition may initially be missed in theunconscious casualty.

Clinical features

1420 Rupture of the bladder can be intra orextraperitoneal, or a combination of both (Figure1408). Following a pelvic fracture, the leak is usuallyextraperitoneal (NB: there may also be damage tothe urethra). A direct blow typically causes anintraperitoneal rupture of the dome or posteriorsurface. Common findings are:

• Acute abdominal pain and shock.

• Lower abdominal tenderness. Followingextraperitoneal rupture tenderness is suprapubic;after intraperitoneal rupture it is more generalisedand develops into peritonitis within 24 hours.

• Bleeding per urethram. Haematuria can be due to bladder contusion or injury to the ureterand kidney.


Injury of the bladdermay co-exist with

injuries to the smallbowel, rectum,

vagina and uterus.

Even if the bladder is perforated, there

may still be somedrainage of urine on

catheterisation.Beware of clumsy

attempts atcatheterisation

with failure of thecatheter to enter the

bladder.


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Chapter_14.qxd 28/09/2004 15:56 Page 340

• Swelling of the abdominal wall.

• Inability to pass urine, failure of bladderdistension or absence of urine on bladdercatheterisation.

• An AXR may show a pelvic fracture or thepresence of a missile.

• If a rupture is missed, blood and urine becomeinfected. Pus may track to the buttock and thigh.

Management of bladder injuries

1421 Steps include:

• Resuscitation (0333).

• Pass a urethral catheter (NB: consider urethral injury - see 1423).

• The diagnosis is confirmed by a cystogram (NB: use water soluble contrast) or IVU,demonstrating extravasation. FAST maydemonstrate fluid in the pelvis (1213). Bladder injury is easily missed at laparotomy.

• Start antibiotics (0820).

• Perform a laparotomy. Washout the peritonealcavity with saline. Tears in the bladder wall



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Fig 1408 Intra and extraperitoneal rupture of the bladder. Commonsites for injury to the urethra are illustrated.

Chapter_14.qxd 28/09/2004 15:56 Page 341

require minimal wound excision. Repair is done in two layers with a continuous absorbablesuture (NB: avoid the ureters). If you cannot findthe defect, open the bladder and feel frominside; tears may be multiple. Carry out a second lavage.

• Insert a suprapubic catheter - a large Foley isideal. This may be introduced through a separatestab incision, the balloon inflated and thebladder closed snugly around the catheter. Aurethral catheter is also inserted (Figure 1409).

• Drain the retropubic space.

• Leave both catheters in place for 10 days.Remove the urethral catheter first, check that the casualty can pass urine by clamping thesuprapubic catheter. Once spontaneousmicturition has been established, the suprapubiccatheter can be removed.

• If the casualty has an extraperitoneal ruptureand no other injures, this can be managed bycatheterisation for 10 days and antibiotics(0820). The defect will heal itself and any urine be absorbed. If circumstances allow,confirmation of closure by a cystogram shouldfirst be obtained.

Management of life-threatening

injuries takeprecedence.

Depending oncircumstances,

treatment of lowerurinary tract injuriesmay be delayed by

up to 24 hours. Theurine is initially

sterile. 14: Urological Traum

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342

Fig 1409 Site of insertion of a suprapubic catheter. The casualty alsohas a urethral catheter in place.

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Urethral Injury

Aetiology

1422 Causes include:

• A blow to the perineum for example, 'fall-astride'may injure the anterior urethra (Figure 1408).

• 10% of pelvic fractures result in rupture of theposterior urethra.

• Missile injury, e.g., mine fragments.

Clinical features

1423 These may include:

• Blood at the external meatus.

• Pelvic fracture on AXR (typically types II and IIIanteroposterior compression fractures 1305).

• Difficulty or failure to pass urine causing bladder distension.

• Bruising of the lower abdominal wall, scrotum or perineum. Later there may be extravasation of urine into these sites.

• Blood in the rectum on rectal examination or the presence of palpable pelvic bone fragments.

• A high-riding prostate on rectal examination, thatis, a complete tear of the posterior urethra whichallows the prostate to be pulled up in a cepheladdirection. This sign can be difficult to elicit and aboggy swelling due to blood and urine where theprostate should be, is more likely.

• Most tears are partial and usually heal withconservative treatment.

• Long term complications include strictures and impotence.

Because it is short,the female urethra is rarely injured.


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Management of urethral injury

1424 Steps include:

• Ask a conscious casualty to try to pass urinewithout straining. If it is blood free, they areunlikely to have damaged their lower urinary tract.

• The safest option is to insert a suprapubiccatheter into a distended bladder and giveantibiotics. The injury can then be assessedback at Role 4 by urethrography or endoscopy.Any pelvic fracture is likely to require fixation(1317).

• The experienced clinician is permitted to makeone gentle attempt at passing a narrow urethralcatheter (size 14F) under antibiotic prophylaxis(0817). If the rupture is incomplete, it may bepossible to negotiate the tip across the defectand into the bladder. The risks in doing this areconverting the injury into a complete tear andintroducing infection. This is not a procedure for the unskilled; in their hands, a suprapubiccatheter is safer!

• Formal urethral repair should be carried out by askilled urologist.

Technique of suprapubic catheter insertion

1425 Steps include:

• Only perform a percutaneous insertion when thebladder is distended or under ultrasound control.

• With the casualty supine, clean and drape thesuprapubic abdominal skin.

• The site of insertion is 2-3 finger-breadths abovethe symphysis pubis in the midline. Infiltrate theskin and deeper layers with 1% lignocaine.Advance the needle until aspiration of urineconfirms that you are in the right place.

Insertion of a suprapubic

catheter may not be easy in an obeseor restless casualty,

or when the bladder is empty.

An ultrasound may help.


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• Make a 1cm stab incision in the skin andabdominal wall. Push the catheter and trochargently into the bladder. When urine isencountered, remove the trochar, advance thecatheter and secure it as appropriate. Connect tothe catheter bag.

• If the bladder is impalpable or ultrasoundunavailable, perform an open cystotomy. This may require a GA. Make a lower midlineskin incision. Incise the linea alba. Identify thebladder and insert two stay sutures. Make asmall incision and introduce a Foley catheter.Close the bladder with an absorbable pursestring suture.

Penile Injury

1426 The penis is seldom involved in war injuries.Laceration and partial amputation is encounteredfollowing land mine trauma. The urethra should becatheterised and wound excision carried out withclosure of any defects in the corpora. Full thicknessskin grafts may be necessary to provide cover ifprimary suture is not possible. Alternatively, the mobilescrotal skin can be used to cover penile defects.

Injury to the Testis

1427 The testes may be injured by a direct blowor by missiles - especially land mine fragments.Clinical features include pain, swelling and bruisingof the scrotum.

• Most blunt injuries will settle with analgesia,scrotal support and rest. Examine regularly.

• Penetrating injuries require exploration.

• A large and expanding scrotal swelling is due toa haematoma; it should be evacuated urgently.

LA and GA: see Chapter 25


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Administer prophylactic antibiotics (0820).Depending on the severity of injury, eitherundertake an orchidectomy or suture the tunicaalbuginea (e.g., 3/0 PDS).

• If the scrotal skin is extensively damaged, carryout a wound excision and primary skin closure(0504). This can be aided by a split skin graft.



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Chapter 15

Thoracic Injury

Introduction

1501 Thoracic injury accounts for 30% of civilian10% of battlefield injuries. It is responsible forapproximately 25% of all trauma fatalities and maycontribute to death in a further 25%. Some casualtiesare unsalvageable and die shortly after injury. Otherscan be saved by prompt recognition of the presenceof a life-threatening injury, followed by simpleinterventions such as application of an Ashermannseal, needle thoracocentesis or insertion of a chesttube. Only 10-15% of chest injuries require surgeryfor severe bleeding, or a significant air leak.

Pathophysiology

1502 Battlefield chest trauma is generally causedby penetrating or blast injury. The spectrum of blunttrauma mirrors that seen in civilian practice.Considerations include:

• Injury is usually obvious, with signs in the chest wall or thoracic cavity. Occasionally,trauma is occult, exemplified by a bullet thatenters the neck or abdomen and continues on into the chest. Similarly, a missile may cross the mediastinum to involve thecontralateral hemithorax.

• The dome of the diaphragm reaches as high as the nipples and tips of scapulae duringexpiration. Twenty-five percent of chest woundsinvolve the abdomen. Remember also, the apexof the lung lies in the root of the neck behind themedial third of the clavicle.

Spectrum of Battlefield Injuries: see Chapter 1

The chest cavity is one of the fourclassic sites ofhidden blood loss.A massivehaemothorax isdefined as a volume >1500.

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• Missiles hitting the ribs or spine may changedirection, or release secondary fragments(Figure 1501).

• Following crush or blast injuries, there may be extensive visceral damage withoutexternal wounding.

• Because symptoms may take several hours to develop, all chest wounds and inhalationalinjuries (2204-2206) should be regarded aspotentially serious.

Chest Injury: General Overview

Rib fractures1503 Significant thoracic trauma commonlycauses fracture of one or more ribs. The resultantpain may interfere with breathing and expectoration.Retention of secretions can lead to bronchialobstruction and pulmonary collapse. Multiplefractures are usually associated with underlying

Insertion of a chestdrain will allow the

lung to expandagainst the chestwall. This is often

successful incompressing any

sources of bleedingor air leaks.

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Fig 1501 Bullet wound of the chest with secondary bone fragmentation.

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lung damage; this is the major cause of morbidity andmortality following chest injury.

Treatment: analgesia (Figure 0701) with or withoutsupport with a field dressing and/or strapping; neithermust limit respiratory excursions. Intercostal nerveblocks may be of value (0736).

Flail chest1504 This is discussed in 0327. Damage to the underlying lung is the principal cause ofhypoxia in flail chest. The effects are compounded by paradoxical movements of the detached segmentand splinting of the chest wall due to pain (Figure 1502).

Treatment: see 1503. Insert a chest drain (3013).Administer oxygen (0317). Subsequently, a period of positive pressure ventilation may be required(2542). Contused lung is very sensitive to over-hydration as well as hypovolaemic shock- give i.v. fluids carefully.

Pneumothorax 1505 Air in the pleural space can accumulateafter penetrating or blunt trauma (NB: can bebilateral). It signifies chest wall, lung parenchyma,tracheo-bronchial or oesophageal injury. Thediminution in lung volume and vital capacity isproportional to the size of the pneumothorax. There are three types:

1. Simple pneumothorax

1506 The volume of air within the pneumothoraxremains unchanged. A small pneumothorax may beasymptomatic and is usually absorbed over a fewdays. A significant pneumothorax may be associatedwith chest pain and non-progressive respiratorydistress. Clinically, there may be hyper-resonance on

Examining the Chest: see 0310

Chest wall defects1cm in diameter are more likely toresult in a tensionpneumothorax than asucking wound. If thecasualty hasrepiratory distressperform a needlethoracocentesisfollowed by a chest drain.

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percussion and reduced breath sounds on theaffected side. The diagnosis is confirmed by CXR.

Treatment: in the field, insert a chest drain whateverthe size of the pneumothorax (3013). This avoids the risks of expansion during unsupervised holdingand transfer.

Analgesia for Chest Injury: see 9738

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Fig 1502 Flail chest: A) A section of ribs has become detached fromthe rest of the thorax. B) This causes paradoxical movement of thechest wall on expiration-inspiration.

A

B

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2. Tension pneumothorax

1507 A unidirectional valve-like laceration in the chest wall or lung can result in a tensionpneumothorax. This is a life-threatening condition.With each inspiration, air is drawn through the defectinto the pleural space from which it cannot escape.Progressive accumulation of air causes collapse of the ipsilateral lung, shift of the mediastinum to the opposite side and hypoxaemia. The combinationof high intrathoracic pressure and mediastinal shift,leads to a reduction in venous return, cardiac fillingand a fall in cardiac output. Clinical features areshown in Figure 0311:

Treatment: immediate needle thoracocentesis (3012)and closure of any external wounds (e.g., Ashermannseal (3011), suture), followed by insertion of a chestdrain (3013).

3. Open pneumothorax ("sucking chest wound")

1508 A wound between the pleural cavity andexternal environment, allowing air to enter and leaveduring respiration, is termed an open pneumothorax(Figure 1503). Air follows the path of least resistance.If the chest wall defect is greater than two-thirds thediameter of the trachea (approximate 1.5-2cm), air will preferentially flow through the wound rather

Practical Procedures: see Chapter 30

Absent breathsounds and hyper-resonance can be difficult todetect in the field.Distended neckveins depend on thepresence of a normalcirculating volume.

Open wounds of thechest must be closedor sealed.Insert chest drainsimmediately in allpenetrating injuriesand serious bluntinjuries (NB obtaini.v. access first).Early chest draininsertion isparticularly importantin children and theelderly.

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Fig 1503 Open ('sucking') chest wound causing a pneumothorax; it can cause mediastinal displacement.

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than the tracheobronchial tree. This causes collapseand underventilation of the lung on the affectedside(s). Pressure on the mediastinum cancompromise the contralateral lung and interfere with venous return to the heart and cardiac output.

Clinically, there is (usually) a sucking sound and respiratory distress.

Treatment is discussed in 0325: Definitive surgeryinvolves extending the defect into a smallthoracotomy, excising the wound edges and partialclosure (1516).

1509 Surgical emphysema

Air escaping into the tissues causes subcutaneouscrepitus and swelling. The usual cause is a pleuralinjury or a dislodged chest drain. A tensionpneumothorax may result in dramatic inflation of thetrunk, neck and face. Swelling, starting in the neck,suggests air passing up the mediastinum from a wound of the tracheobronchial tree or oesophagus.Surgical emphysema is not dangerous; once thecause is treated, the air rapidly absorbs.

Haemothorax 1510 Blood in the pleural space may originatefrom the lung or vessels in the chest wall ormediastinum. A traumatic haemothorax is usuallysecondary to bleeding from intercostal or internalmammary vessels. Bleeding generally occurs slowlyand has stopped spontaneously by the time oftreatment. Less commonly, life-threatening bleedingmay be due to laceration of the lung, injury to thepulmonary hilum, aortic disruption or cardiac wounds.The total fluid volume in the chest is increased by anassociated pleural effusion. Initially, this prevents thehaemothorax from clotting. Clinical features aredescribed in 0326.

As the pleural space fills, there is progressive

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interference with lung expansion, inhibition of venousreturn and mediastinal displacement. Hypovolaemicshock and dyspnoea indicate major bleeding. A CXRwill show hazy oppacification but, 500mls of bloodcan be easily missed, hidden behind the shadow of the diaphragm.

1511 Treatment:

• The majority of casualties are successfullytreated by chest drainage alone (0326).

• A resuscitation thoracotomy to clamp the hilum,may be necessary as part of the primary surveyin casualties with life-threatening haemorrhage(1541).

• If, after insertion of the chest drain, there ismajor blood loss (i.e., >1.5 litre), or evidence of continuous bleeding (>200ml/hour for 2-4hours), urgent thoracotomy is required (1534).

• Complications include pneumonia, ARDS,abscess formation and multi-organ failure. A haemothorax persisting for more than one week will clot and become organised,preventing lung expansion. Treatment is by early thoracotomy and decortication. Similarly,abscesses which fail to respond to tube drainagerequire a thoracotomy and wound toilet.

Lung injury1512 Penetrating or blunt injury may cause pulmonary contusion, lung laceration or disruption of the larynx, trachea and distalbronchial tree. Haemoptysis is a frequent symptom;it is rarely profuse.

Pulmonary contusion

1513 The lung is "bruised". This is a commonfinding after serious blunt chest trauma and is

Without a CXR, it can be difficult totell the differencebetween ahaemothorax andsignificant lungcontusion. A chestdrain is appropriatefor both conditions.

Ensure that there is i.v. access andthat you have startedfluid resuscitationfirst, as suddencollapse can occurwhen the tamponadeeffect of the closedhemithorax isremoved.

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potentially fatal. Pathological effects includeinterstitial and alveolar haemorrhage and oedema.These result in

• A progressive reduction in alveolar membrane diffusion.

• Increased pulmonary vascular resistance.

• Decreased pulmonary vascular flow.

• Reduced lung compliance.

• Shunting of blood through a non-ventilated lung causing a ventilation-perfusion mismatch.

All of the above cause hypoxaemia. The symptoms of contusion and blast lung are similar (1514).Subsequent problems include pneumonia and ARDS.

Treatment: see 1504. Complications may beprevented or attenuated by physiotherapy andantibiotics (0821).

Blast lung

1514 Casualties who survive blast injury (0218) gradually develop over time, features similar to pulmonary contusion (1513):

• Dyspnoea, chest pain, cyanosis and tachycardia.

• Rib fractures and chest wall bruising may be absent.

• Those severely affected often sit up and holdonto fixed points to aid use of their accessorymuscles of respiration.

• Ineffective expectoration of frothy, often bloodstained mucus is common; some casualties areliterally drowning in their own blood.

The radiological appearance of haziness and lungmottling is usually an early feature, but can take 24hours to become apparent. This can be confused with a haemothorax (the two frequently coexist).

Blast Injury: Chapter 2

Following blastinjury, respiratory

compromiseincreases with time.

Few who developsevere symptoms inthe first two to three

hours survive.

In pulmonarycontusion, anxietyand restlessness

may lead to diagnostic

confusion withhypovolaemic shock.

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Treatment is as for lung contusion (1513).

Penetrating injury

1515 Because of the elasticity and excellent blood supply of the lung, most penetrating injuriescan be successfully managed by tube drainagealone. The presence of a defect in the chest wall and dirt and bone fragments in the lung parenchyma,risks the development of wound infection, pneumoniaand lung abscess.

1516 Treatment: definitive surgery involvesextending the defect into a small thoracotomy and excising the wound edges. Then:

• Obtain haemostasis.

• Inspect the underlying lung. If there iscontamination, foreign bodies, bone fragments or necrotic parenchyma, explore, excise andwashout through a formal thoracotomy incision(1534). Insert one or more chest drains: bothapical and basal drains may be required.

• Approximate the ribs in the vicinity of thepenetrating wound using interrupted sutures(e.g., No 1 Vicryl). Attempt to cover the defect by closing the muscles of the chest wall in layers(e.g., continuous 2/0 Vicryl). Leave the skin openfor secondary suture (0510). Occasionally, flapclosure or skin grafting is required to close thedefect (2305).

Laryngeal injury

1517 These are rare. Clinical features andmanagement are discussed in 1926. Prevention of airway obstruction necessitates a tracheostomy(3007) rather than a cricothyroidotomy.

Tracheobronchial injuries

1518 On the battlefield, tracheal injuries are

Plastic and Reconstructive Surgery: see Chapter 23

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mainly due to penetrating injury and are oftenassociated with concomitant injury to the oesophagusand aorta. Most casualties die before reaching Role 1.Features amongst survivors include:

• Laboured respiration.

• Haemoptysis.

• Tension pneumothorax.

• Surgical emphysema in the neck.

• Mediastinal air on CXR.

• A classical sign is a pneumothorax thatcontinues to leak significant amounts of air after chest tube insertion.

Treatment: surviving casualties require surgicalrepair (1552).

Diaphragmatic disruption1519 The left hemidiaphragm is more commonlyaffected. The usual cause is a compressiveabdominal injury resulting in a radial, diaphragmatictear. This allows abdominal contents to herniatethrough the diaphragm into the chest, where they risk strangulation. Smaller diaphragmatic tears oftenpresent late. Clinically there may be:

• Chest pain, absent breath sounds, thoracicbowel sounds and cardiac embarrassment.

• A CXR may demonstrate an altereddiaphragmatic contour.

• Introducing a nasogastric tube and repeating the CXR may aid diagnosis (the tube is seen in the chest) and, to a certain extent, relieverespiratory distress. When feasible, a contrastswallow may confirm the diagnosis.

Treatment: is emergency surgery to reduce the abdominal contents and repair the diaphragm.

Abdominal Surgery: see Chapter 12

The degree of airleak following

tracheobronchialinjury may require

insertion of a secondchest drain to

prevent developmentof a tension

pneumothorax.

The radiologicalappearances

of stomach andbowel in the chest

can be confused witha haemothorax or

pleural effusion,leading to the

potentially disastrousinsertion of a

chest drain.

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The approach can be through the abdomen or chestdepending on clinical circumstances (1253).

Injury to the heart and great vessels 1520 Aortic transection, great vessel rupture, hilar injury or cardiac laceration, usually result inexsanguinating haemorrhage, profound hypovolaemicshock and early death. Immediate survivors are atrisk of low cardiac output, cardiogenic shock andmyocardial failure.

Aortic tears

1521 The descending part of the arch is most commonly affected. Approximately 80% dieimmediately. If the haematoma is contained bysurrounding tissue, a third of the remainder livebeyond 5 days. The casualty may be asymptomatic.Suspicious features on CXR are:

• Widened mediastinum.

• Fractures of the first and second ribs.

• Blurring of the aortic arch and hilum of the lung.

• Tracheal or oesophageal deviation (e.g., a displaced nasogastric tube).

• Oppacification over the apex of the lung.

Assessment requires CT scanning with contrast, or arteriography.

Treatment: surgical repair in a cardiothoracic unit.

Myocardial contusion

1522 Significant contusion results in arrhythmias(20%), decreased ventricular contractility and/orcompliance and conduction defects. Casualties are at risk of sudden ventricular fibrillation. An ECG and elevated cardiac enzymes may suggest infarction.

Examining a C+R: see 1531

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Treatment is rest, oxygen (0317), analgesia (Figure0701) and care on a HDU. Casualties may needantiarrhythmics (e.g., digoxin), diuretics to relievepulmonary oedema or defibrillation.

Coronary artery injury and occlusion

1523 Interference with myocardial blood supplycan lead to tissue necrosis and infarction. Treatmentis as for myocardial contusion (1522). Ischaemia mayalso occur as a result of reduced coronary perfusionsecondary to hypovolaemia and hypoxaemia.

Treatment: Give aspirin. Transfer to a unit able to provide thrombolysis.

Valvular disruption

1524 This can result in regurgitation, acutecongestive cardiac failure and death. Some valvularlesions are only diagnosed months or years after the event.

Treatment: surgical repair in a cardiothoracic unit.

Cardiac tamponade

1525 Blood in the intact, inelastic pericardium canobstruct venous return and interfere with normal atrialfilling (0328). Beck's triad may be difficult to detect.Differential diagnosis is from a tension pneumothorax.Where the casualty's condition allows, confirm byFAST (1213).

Treatment: is described in 0328.

Oesophageal disruption1526 This uncommon injury is usually caused bydirect penetration. It is occasionally due to increasedpressure at the gastro-oesophageal junctionsecondary to blunt abdominal injury, or as a result of forceful retching. Features include:

The removal of as little as 15-20ml

of blood from thepericardial sac candramatically benefit

the circulation.

When performingpericardiocentesis, itcan be difficult to tellif the aspirated blood

is from thetamponade or the

ventricle. Aspirationmay be unsuccessful

if the haematoma isorganised.

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• Severe chest and/or epigastric pain, often out of proportion to the apparent injury.

• A CXR may show a left-sided pneumothorax orhaemothorax without any associated rib fracture.There may be air in the mediastinum.

• Mortality is high. A lethal mediastinitis can develop within hours.

Treatment: the level and side of the perforation is identified by a contrast swallow or endoscopy.Urgent surgical repair is most likely to produce a livecasualty. Where surgical expertise is unavailable,treat casualties medically (0000).

Management of Thoracic Injury

Overview1527 The priority is to manage ABC, especially at Roles 1 and 2 and to get those casualties mostlikely to need operative treatment to a surgeon. Early transfer on suspicion of serious chest traumaalone is justified.

Get a History ("MIST" 0301), perform a primarysurvey (ABC 0302) and start life-saving treatment(0317).

Remember: most lives are saved by simpleinterventions - application of an Ashermann seal,needle thoracocentesis or insertion of a chest tube.If facilities allow, a resuscitation thoracotomy (1541)may be indicated for major bleeding or air leak. NB: most suspected thoraco-abdominal injuries are initially managed by laparotomy plus insertion of a chest tube.

Where appropriate:

(1) Apply a field dressing or Ashermann seal to thechest wound(s) (3011).

Management of ABCD: Chapter 3.

Casualties with smallpenetrating woundsof the heart cansurvive followingpericardiocentesiswithout the need for an immediatethoracotomy.

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(2) Perform needle thoracocentesis (3012).

(3) Perform pericardiocentesis -rarely required in the field and probably ineffectual in mostcases (3015).

(4) Undertake a full secondary survey, including the casualty's back and sides.

(5) Insert one or more chest drains (3013). NB: there may be bilateral injury.

(6) If the situation allows, package the casualtybefore transfer. This may require all of theabove, plus analgesia (Figure 0701) andantibiotics (0821).

(7) Keep NBM in case of surgery. Sips of water<30mls/hour to moisten the mouth are permitted.

(8) Organise transfer to a surgical facility; If possible, discuss casualties with a member of the surgical team. Record findings and management.

Decision making: this will be influenced by the Role (level or echelon) at which the casualty is beingmanaged and the operational scenario. For example,in a war-fighting situation, an immediate thoracotomyat Role 1 is not tenable. Equally, casualties in thiscategory are unlikely to survive transfer to a surgicalfacility. Conversely, in a mature military operationwhere casualty transfer can be rapid, immediatethoracotomy may need to be part of the decisionmaking algorithm. The following should be read with this in mind.

1528 Having assessed the casualty, you mustdecide whether they:

• Require immediate thoracotomy as part of the primary survey.

• Require emergency thoracotomy.


Wounds to the chestmay have caused

abdominal and spinal injuries.

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• Have thoracic injuries requiring non-surgical treatment.

• Do not have significant thoracic injury.

1529 Indications for immediate thoracotomy(1541) are:

• Cardiac arrest following an isolated penetratingchest injury. The casualty must have displayedsigns of life in the last five minutes, otherwisesurgery is futile.

• Life-threatening haemorrhage into the chestwhich appears uncontrollable by means otherthen hilar clamping.

Blunt thoracic trauma is a relative contraindication to immediate surgery. In the majority of cases whoare in extremis, the injuries will not be repairable and the continued blood loss from laceratedpulmonary and intercostal veins enormous. Control of large volume haemorrhage undersuboptimal conditions is usually impossible.

1530 Indications for emergency thoracotomy are:

• Major blood loss following chest drain insertion(>1.5 litres).

• Continued bleeding from the chest drain (200ml per hour for 2-4 hours).

• Massive air leak or obvious airway injury.

• Oesophageal perforation.

• Foreign body transfixion.

• Cardiac tamponade following penetrating or blunt trauma.

• Aortic disruption.

Attempts to deal with the first six can legitimately be made in a field setting. Ideally, the last requiresconfirmatory arteriography and facilities for partial or

Compressible and Non-Compressible Haemorrhage: see Chapter 3

After resuscitativethoracotomy, closethe chest usinga single layer

technique; themajority of survivorswill be formally re-explored in theatre.

Few casualties who undergo a resuscitationthoracotomy outsideof the operatingtheatre survive. Also there is ahigher incidence of complications.

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complete cardiopulmonary by-pass. Hypotensivetreatment and rapid transfer are the best that can be offered in an austere environment. As a lastresort, cross-clamping of the aorta and synthetic graftinsertion ('cut and stitch') may be tried (1546). Thereis significant risk of brain and spinal cord ischaemia.This approach probably amounts to futile care.

Investigations1531 If the casualty's condition allows or there isdiagnostic doubt, consider:

CXR: ideally, an erect PA not AP view, (plus lateraland oblique views). Examine:

• Bones: look at ribs, clavicles, vertebrae and scapulae.

• Soft tissues: pleura, diaphragm, lungparenchyma, heart and mediastinum. Look for absent vascular markings and a visiblelung edge (pneumothorax). Hazy oppacificationsuggests a haemothorax or lung contusion.

• Mediastinum: widening may signify aortic injury.NB: false positives and negatives are common.The mediastinum appears wider on supine or sitting CXRs, compared to erect films.

• Make sure tubes - nasogastric, endotracheal,chest drain and central line - are in the rightplace. Look for foreign bodies.

AXR: particularly following penetrating injury.

ECG: Assess myocardial damage and look for arrhythmias.

FAST: can be used to detect cardiac tamponade(1213).

1532 Reassess ABCDE at each Role of care andperform a full secondary survey. At Role 3 (and 4),consider the need for specialist investigations:

Major or continuousthoracic bleeding is

due to injury to: Heart

Great vessels Descending aorta

HilumLung parenchymaIntercostal/internalmammary vessels

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• CT: may be of value in the stable casualty to detect parenchymal, pleural and mediastinal injuries.

• Cardiac enzyme assays; an increase mayindicate myocardial contusion or infarction.

• Aortography to exclude injury to the aortic arch and great vessels.

• Contrast swallow for oesophageal leak and todetect herniation through a ruptured diaphragm.

• Endoscopy: bronchoscopy; OGD to identify an oesophageal perforation.

Principles of thoracotomy for trauma Approach and instrumentation

1533 The casualty should be anaesthetised andintubated. A double lumen tube allows the lung on theaffected side to be collapsed. Alternatively, a singlelumen endotracheal tube is advanced down the mainbronchus on the healthy side. If necessary, ketamineanaesthesia may be used, providing one lung isuninjured. (2520)

Prepare and drape the skin as appropriate. Haveready a scalpel, dissecting forceps, haemostats, self-retaining rib retractor (e.g. Finochietto), lungretractors and large straight and side-swipingvascular clamps to control the hilum or aorta.Performing a median sternotomy requires a sternalsaw, Gigli saw or Lebsche knife. Important adjunctsare good assistance, lighting and diathermy. An anterolateral thoracotomy through the fifthintercostal space is the usual approach for chesttrauma. The incision can be:

• Performed on the supine casualty without theneed for a sternal saw.

• Enlarged posteriorly for access to the posteriormediastinum.

Anaesthetic Techniques: Chapter 25

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• Converted into a bilateral anterior thoracotomy('clam shell') so as to expose the pericardiumand contralateral hemithorax.

• Extended across the costal margin to expose theabdomen, (thoraco-abdominal incision see 1226and 1553).

• Combined with a separate abdominal incision.

A median sternotomy is used by cardiac surgeons to expose the heart and great vessels (1538). A subclavicular ‘trapdoor’ incision may be used to access the origins of the subclavian vessels,especially on the left (1540).

Left anterolateral thoracotomy

1534 Steps include

• Place wedges, sandbags or fluid bags under theipsilateral shoulder and buttock so as to rotatethe casualty by 30 degrees (Figure 1504).

• Incise over the fifth intercostal space (ICS) in the inframammary crease using a blade ordiathermy. Start at the left edge of the sternumanteriorly and continue to the mid-axillary linelaterally (Figure 1504); if necessary, this can beextended posteriorly to just below the tip of thescapula. Follow the contour of the upper borderof the rib.

• Divide fibres of serratus anterior and latissimusdorsi in the line of the wound. Incise theintercostal muscles down onto the periosteum of the upper border of the sixth rib.

• Pass the periosteal elevator (Rougine) anteriorly and posteriorly to free the ligamentousattachments at either end of the wound. Theinternal mammary artery (IMA) runs parallel tothe costal margin and usually requires ligation.

• Carefully incise the parietal pleura to expose

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the lung, which will fall away from the chest wall.Insert the rib retractor and open it fully,Iatrogenic rib fracture is common at this stage.

• On the left, the lung can be retractedposterolaterally to expose the pericardial sacand heart. Improved access is obtained bydividing the sternum (1537).

Right and left posterolateral thoracotomy

1535 The position and incision on the right is illustrated in Figure 1505.

Thoracotomy closure

1536 Steps include

• Check for haemostasis and perform saline lavage.

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��

��

��

Fig 1504 Anteriolateral thoracotomy: position on the operating tableand site of incision.

Chapter_15.qxd 28/09/2004 15:56 Page 365

• Insert a large bore chest drain (e.g., 36 French).If significant bleeding is encountered, or lungresection or repair (tractotomy) have beenundertaken, use two drains. One directedapically ('apical and anterior for air - AAA') and one directed basally ('basal at the backfor blood - BBB'). The drains should be insertedanterior to the mid-axillary line for ease of nursingcare and casualty comfort, preferably threespaces below the incision. Fix them to the skinas shown in Figure 1506 and Figure 3022. Pullon latissimus dorsi with a clip so as to maintainits normal position during drain placement.

Chest Drain Insertion: see Chapter 30

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��

��

��

Fig 1505 Posterolateral thoracotomy: position on the operating tableand site of incision. The muscle layers requiring division are shown.

Chapter_15.qxd 28/09/2004 15:56 Page 366

• Approximate the ribs using three strongabsorbable sutures (e.g., No 5 Ethibond) passedaround the ribs above and below (Figure 1506).Re-inflate the lung. Close trapezius, latissimusdorsi and serratus anterior muscles separately.This will reduce pain and maintain shoulderfunction. The skin is approximated with a runningblanket stich or skin staples. If speed is required,perform a mass closure of the skin and deeplayers using mattress sutures.

• Perform a CXR at the end to check for fluidcollections, pneumothoraces and the drainpositions. Casualties often continue to beventilated during transfer; functioning drains are essential in this case.

Bilateral anterolateral thoracotomy(submammary/ clamshell/ suitcase handleincision), (Figure 1507).

1537 Steps include:

• Place the casualty in the supine position and position sandbags so as to arch the back.

• The incision follows the line of the fifth ICS from


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Fig 1506 Thoracotomy closure: The ribs are approximated. Three strong absorbable sutures are placed around the ribs. Close the muscle layers individually. Secure the drain by suture to awoven adhesive 'flag' around the tube, using the 'double-knot' technique.

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the left to the right anterior axillary lines. Steps in opening up each hemithorax are as for an anterolateral thoracotomy (1534).

• Divide the sternum using a Gigli saw, boneshears or heavy scissors. Both internalmammary arteries will require ligation.

• Open the wound using two self-retaining rib retractors.

Median sternotomy

1538 Steps include

• Incise skin and subcutaneous tissues from thesuprasternal notch to below the xiphoid process,(Figure 1508 A).

• Identify the decussation of the pectoral muscles.Mark the sternal periosteum in the midline.

• Incise the upper 5cm of the linea alba and dividethe xiphisternum. Develop a plane between theposterior aspect of the sternum and pericardiumusing blunt, finger dissection.

• Divide the sternum longitudinally using anelectric sternal saw. Other options include:

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Fig 1507 Bilateral anterolateral thoracotomy.

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a Gigli saw (Figure 1508 B) or Lebsche knife.Protect underlying structures. In young children,the cartilaginous sternum can be divided withheavy scissors.

• Divide the thymus (NB: this can be sizeable in children). Avoid damaging the brachiocephalic vein.

• Open the chest using a self-retaining retractor.Sweep away fatty tissue using a swab to expose

Application of bonewax to the sternaledges will aidhaemostasis.

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!�� "��

��

Fig 1508 A) Median sternotomy and possible extensions. B) Dividing the sternum using a Gigli saw.

A

B

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the pericardium and left and right pleurae. The pericardium and pleura can safely beopened after first picking up the membranebetween clips.

• Options for extending the median sternotomyincision are shown in Figure 1508 A.

Sternotomy closure

1539 Steps include

• Check for haemostasis and perform saline lavage.

• Insert a mediastinal tube drain anterior, and apericardial drain posterior to the heart (24-28F).These are brought out through the skin eitherside of the midline below the xiphoid process.Where indicated, drain the pleural cavity(s). The pericardium is left open to avoid tamponade.

• Approximate the sternum using 6-8 horizontalwires or No 5 Ethibond sutures. Close thesubcutaneous tissues in two separate layers with absorbable sutures. Repair the linea alba.and close the skin with a blanket stitch orstaples. For speed, use mattress sutures toclose the skin and deep layers.

Subclavicular ’trapdoor’ incision

1540 Exposure of the arch of the aorta and originof the great vessels is via a median sternotomy. The distal subclavian vessels can be exposed by asupraclavicular approach (1040). Access to the originof the left subclavian artery and vein is sometimesachieved by a 'trap-door' incision (Figure 1508):

• Perform a left supraclavicular incision (Figure 1016). Divide the sternocleidomastoid,strap muscles and scalenus anterior muscle(1040). Either dislocate the sternoclavicular joint, or resect the medial half of the clavicle(Figure 1017).

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• Perform a left anterior third space thoracotomy.

• Divide the manubrium and upper sternum.

• Retract the three ribs laterally.

Resuscitative thoracotomy

1541 Steps include:

• Perform a left anterolateral thoracotomy (1534).

• Insert a hand and feel for the pericardium. Incise it using scissors. This will release anycardiac tamponade. Palpate through the openpericardium for a laceration in the heart andocclude it digitally until it can be repaired.Transfer to the operating theatre for definitive surgery.

• If cardiac contractions are absent, performinternal cardiac massage. This is more effectiveinside the pericardium. Using your fingers,squeeze the ventricles gently at a rate of60/minute. Alternatively, place your hand behindthe heart and compress it against the sternum,or perform bimanual massage.

• Torrential pulmonary bleeding can be controlledby hilar clamping (1549).

Definitive Thoracic Procedures for Trauma

Cardiac tamponade1542 Emergency treatment can be attempted by needle pericardiocentesis (3015). ECG monitoring is required. Many now prefer to go directly to an opendrainage approach. The two open approaches are:

Subxiphoid

Under local or ketamine anaesthesisia, make a short

Cardiac Tamponade: see Chapter 3

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midline epigastric incision inferior to the xiphoid(Figure 3023). Incise the linea alba and by a combination of scissors and finger dissection workup towards the pericardium. Stay close to the back of the sternum. The bulging pericardial sac is incisedto release the tamponade. Transfer to the operatingtheatre for a definitive thoracotomy.

Transthoracic

Perform a left anterolateral thoracotomy (1534) or a median sternotomy (1538). Identify and protect theleft phrenic nerve posterior to the pericardial fat pad.Make a vertical pericardial incision, parallel to but

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Fig 1509 Emergency control of cardiac haemorrhage using thesurgical finger or a balloon catheter. An alternative for the low pressureatrium is to use a clamp. The atrium is repaired in two layers.

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at a safe distance from, the phrenic nerve. Extendthe incision superiorly and inferiorly and enlarge thewindow by a transverse extension (inverted 'T'). Suckout all the pericardial blood and clots and irrigate withnormal saline.

Cardiac laceration1543 Temporary control may be obtained bydigital occlusion (Figure 1509). Alternatively, insert a balloon catheter (e.g., Foley catheter) through thedefect into the ventricular or atrial cavity, inflate theballoon and apply gentle traction (Figure 1509). This may allow enough time for transfer to theoperating theatre.

Atrium

1544 The atrium is a low pressure compartment;control bleeding with a vascular clamp (Figure 1509).Suture the laceration in two layers with 3/0 Prolene,using an over-and-over technique. Because theatrium is thin walled and sutures tend to cut out,insert and tighten them carefully.

Ventricle

1545 Clamping is not applicable to the highpressure ventricles.

• Oversew using a Z-stitch or inverted mattresssutures. Move the occluding finger to expose a small portion of the wound (Figure 1510).Insert 3/0 double-ended Prolene suturesreinforced with Teflon™ pledgets or smallsquares of pericardium on either side of thedefect. Take sufficient bites through theventricular muscle to prevent 'cutting through'.Repeat until the defect is closed.

• Suturing wounds close to the coronary arteriesrisks inclusion or injury. A safe technique is toplace horizontal mattress sutures reinforced with

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pledgets deep to but not across the vessels(Figure 1511).

Injury to the aorta and great vessels Thoracic aorta

1546 Repair is a specialist cardiothoracicprocedure usually requiring cardiac bypass. The essential steps are:

• An extended left anterolateral thoracotomy.

• Because disruption generally affects the

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Fig 1510 Closing a cardiac defect: digital pressure reduceshaemorrhage. The finger is gradually moved along the wound as the sutures are tied.

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descending aorta, proximal control is usuallyobtained by placing a sling or clamp between the left common carotid and left subclavianarteries. Sling or clamp the aorta distal to thehaematoma. Repair the aorta end-to-end with3/0 Prolene or by inserting a woven Dacrongraft. Aortic sutures should be re-inforced with pledgets.

1547 Controlling severe abdominal bleeding

Aortic clamping via a left anterolateral thoracotomymay be appropriate in a minority of casualties (1276).

Injury to the origin of the great vessels

1548 The safest option is to obtain proximalcontrol via a median sternotomy (1038). Possibleextensions include (Figure 1508):

• Along the sternocleidomastoid muscle toapproach the carotid and jugular vessels (1038).

• Above the right clavicle to expose the right subclavian artery and vein (1040).

Techniques of Vascular Repair: see Chapter 10

There is a 10% riskof paraplegia duringaortic cross clampingand repair.

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Fig 1511 Technique of suturing close to coronary vessels.

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• Above the left clavicle to access the leftsubclavian. An alternative is a trapdoor incision (1540).

In wounds of the neck affecting Zones 2 and 3(Figure 1906), it may be appropriate to explore theneck first (1038).

Lung injuryHilar clamping

1549 This is used to control life-threateningbleeding and air leaks. Hilar clamping is a routine,first step prior to major lung surgery.

Perform an anterolateral thoracotomy (1534). Dividethe inferior pulmonary ligament and free the lungfrom any adhesions. Encircle the pulmonary artery,pulmonary veins and main-stem bronchus using yourfinger and thumb. Control the hilum with a vascularclamp or sling (Figure 1512).

Following hilarclamping, early

definitive surgery isrequired before the

onset of lungischaemia.

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1512 Emergency clamping of the hilum following severe lung injury

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Repair of lacerations

1550 Insertion of a chest drain will allow the lung to expand against the chest wall. This is usuallysuccessful in compressing most sources of bleedingor air leaks. Where necessary, lacerations areapproached by an extended anterolateral (1534)or posterolateral (1535) incision.

After lung injury,every attempt shouldbe made to preservelung parynchyma.

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Fig 1513 A) Using stapling devices to perform a non-anatomicalperipheral lung resection. B) Clamping and excising damaged lung. The line of resection is closed using two layers of sutures.

A

B

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Superficial lung lacerations can be repaired withinterrupted Z-mattress sutures using 2/0 Prolene. Non-viable peripheral lung parenchyma may require a non-anatomical wedge resection. Use a linearstapler (Figure 1513). Alternatively, apply a crushingclamp, reset and oversew the edge continuously in two layers.

Simple closure of deep penetrating injuries risks thedevelopment of an air embolism. Treatment is toincise the lung over the wound track in order toexpose and control the damaged vessels andbronchioles - pulmonary tractotomy - (Figure 1514).The hilum is first controlled (1549). Insert one bladeof a linear stapler along the tract and attach it to the

For major andongoing

haemorrhage fromthe centre of the

lung or unrepairablebronchial disruption

the safest optionmay be lobectomy or

pneumonectomy.

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Fig 1514 Performing a tractotomy following a penetrating lung injury.This can be performed using a linear stapler or two clamps. This allowsaccess to vessels and bronchioles along the wound track. If clamps areemployed, oversew the lung in two layers.

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second blade on the pleural surface. Close anddivide the overlying lung. Alternatively, use two linear clamps and oversew the divided edges.

Lobectomy and pneumonectomy

1551 The usual indication is massivehaemorrhage from multiple sites or widespreaddestruction of lung parenchyma.

• In an emergency, perform a pneumonectomy by stapling the hilum en masse and dividingdistal to the stapler.

• Alternatively, ligate, oversaw or staple and divide the hilar structures individually, startingwith the superior and inferior pulmonary veins(Figure 1515).

• For security, doubly ligate the pulmonary arteryand close/divide the bronchus flush with thecarina (Figure 1516).


Large areas of non-viable tissueremaining in thechest risks thedevelopment ofinfection.

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Fig 1515 Individual ligation and division of structures at the hilum.

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Tracheobronchial injury 1552 The priority is adequate lung ventilation.Surgery should be performed by a specialist thoracic surgeon.

• Introduce an endotracheal or tracheostomy tubebeyond the injury and inflate the cuff. This isbest performed over a flexible bronchoscope.Alternatively, intubate the uninjured bronchus.

• Improve lung expansion by inserting one or more chest drains to drain air and blood (3013)

• Administer antibiotics (0821).

• Assess the location and extent of the injuryusing a flexible bronchoscope.


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Fig 1516 Technique of flush closure of a main bronchus.

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• A collar incision in the neck gives the best initial exposure to the trachea in the emergencysituation. Combining it with a median sternotomyallows visualisation of the entire trachea (1538).If there is a disruption of one of the main stem or lobar bronchi, perform a posterolateralthoracotomy (1535).

• Excise devitalised tissue. Repair using a one-layer technique (Figure 1517). Where there is tissue loss, perform an end-to-end anastomosis.

Oesophageal Injury1553 Treatment: this is preferably by urgentsurgical repair and drainage. Where expertise isunavailable or the casualty too ill to undergo surgery,the last resort is medical treatment.

Exposure of the Neck: see Chapter 10

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Fig 1517 Technique of bronchiol repair.

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Medical treatment

1554 This includes:

• Chest drainage.

• Continued high dose antibiotics (0817).

• Keep NBM; administer parentral nutrition.

• Regular nasogastric aspiration.

• Acid suppression (e.g., i,v. ranitidine 50mg three times daily).

• Nurse sitting up. Chest physiotherapy.

Surgery

1555 Incision

The approach depends on the location of the injuryand damage to other organs.

• A left thoraco-abdominal incision gives good exposure to the lower oesophagus andgastro-oesophageal junction. Place wedgesunder the left shoulder and buttock so as torotate the casualty by 30 degrees. Start theincision from the midline 5cm above theumbilicus to just anterior to the tip of the scapula through the 6th ICS.

• A right or left posterolateral thoracotomy (1535)through the 5th ICS is used to expose the midand upper thoracic oesophagus.

• The cervical oesophagus is approached via an incision along the anterior border of eithersternocleidomastoid muscle (Figure 1013). NB: there is a risk of damaging the thoracic ducton the left and the recurrent laryngeal nerve onthe right. Divide the middle thyroid vessels andomo-hyoid muscle (Figure 1014). Retract thestrap muscles and thyroid gland medially and the internal jugular vein and carotid sheath


The presence of a nasogastric tube

aids identification ofthe collapsedoesophagus.15: Thoracic Injury

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laterally to expose the cervical oesophagusbehind the trachea.

1556 Procedures

Where possible, lacerations should beclosed primarily.

• Administer antibiotics. Use interrupted, all coatsabsorbable sutures (e.g., 3/0 PDS). Repairs canbe reinforced using a flap of parietal pleural .Perform copious lavage. Place a drain close tothe repair. Keep NBM. Leave a nasogastric tubein place on free drainage combined with regularaspiration until a water soluble contrastexamination 5-7 days later demonstrates nofurther leakage. Start parentral nutrition.

• If the repair is ragged or delayed, considerclosure around a 'T' tube (i.e., a ‘controlledfistula’). This can start to be withdrawn 10-14days later.

Thoraco-Abdominal Incision: see Chapter 12

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Fig 1518 Cervical oesophagostomy, isolation of the damagedoesophagus and drainage.

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• If repair is likely to narrow the lumen, defectsin the lower third can be closed by mobilising thegastric fundus and using this to patch theoesophagus (Nissan-Thal operation).

• If it is not possible to perform a repair, drain the site of injury, close and divide theoesophagus in the neck and bring out an endcervical oesophagostomy (Figure 1518).Close the distal oesophagus and perform a gastrostomy for decompression and feeding.Reconstruction using stomach, colon or smallbowel may be performed three months later.

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Chapter 16

Head Injury

Introduction

1601 Head trauma is a common injury on the battlefield and is often combined with traumaelsewhere. Helmets provide some protection;continuing improvements in their design will furtherthis protection. In combat, penetrating injury faroutweighs that seen in UK civilian practice. Highavailable-energy missiles cause severe disruptionand are associated with a 50% mortality. Severehead injury is the most common cause of mortalityfollowing terrorist bombing incidents. Injury is usuallycaused by falling masonry.

The outcome amongst head injury survivors is notpredictable. Some casualties with extensive woundsand visible brain tissue may make a full recovery.The initial aims of head injury care are to:

• Prevent secondary brain damage by maintaining ABC.

• Identify those casualties who may benefit fromearly surgery.

Anatomy

1602 The skull contains brain, cerebrospinal fluid (CSF) and vessels carrying circulating blood.The brain is supplied by the internal carotid andvertebral arteries and drained via the internal jugularveins. Surrounding the brain are two membranes:dura mater in contact with the skull and a thin, innerarachnoid mater (Figure 1601). The venous sinusesrun in a dural sheath closely attached to the skull,

The commonestmistake after headinjury is to donothing. Deaths mayoccur because of theseverity of injury or because surgerywas too late.

"No head injury is so severe as to bedespaired of, nor sotrivial as to be lightlyignored" -Hippocrates.

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with the sagittal sinus in the midline. CSF circulatesin the space between the arachnoid and brain.Haemorrhage within the skull is described in relation to these layers namely, extradural, subdural, subarachnoid or intracerebral.

Types of Brain Injury

Primary 1603 This occurs at the moment of trauma;noxious biochemical changes continue for severalhours afterwards. Primary injury can be:

Penetrating. The weapon or missile breachesthe scalp, skull and dura and enters the brain. A high energy-transfer wound typically resultsin cavitation and extensive brain disruption. By comparison, following a low energy-transferwound, damage is usually confined to the woundtrack. The track often contains bone fragmentsand foreign bodies.

Blunt. Rapid acceleration, deceleration orrotation incurred during blunt injury, results indiffuse or focal brain damage (1624). There maybe pathological changes beneath the impact site(coup injury) or on the opposite side of the brain


Loss of oxygenatedblood flow for morethan three minutescauses irreversible

brain damage.

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(contre-coup injury). This is especially likely ifthe mobile brain hits unyielding bone, such asthe sphenoid ridge or the edge of the tentorium.

Secondary 1604 Secondary brain injury occurs as a result of complications following the primary event. This can usually be avoided by prompt recognitionand appropriate treatment.

Causes of secondary brain injury

1605 These include

1. Hypoxia.

2. Hypotension causing reduced cerebralperfusion. NB: the effects of hypoxia andhypotension are cumulative.

3. Raised intracranial pressure. Intracranialpressure (ICP) - typically 10 mmHg - is thepressure inside the skull. Tissue oxygenationdepends on the cerebral perfusion pressure(CPP), which, in turn, is a product of meanarterial pressure (MAP - normally 70 to 90mmHg) minus the ICP (CPP = MAP - ICP).If ICP rises, a higher blood pressure is neededto perfuse the brain. If CPP falls to <50 mmHg,cerebral hypoxia can follow.

Anything that causes an increase in brainvolume, such as haematoma or vasodilation, will lead to a rise in ICP. Hypoxia and raised CO2 levels cause cerebral blood vessels todilate. This also happens following interferencewith venous return (e.g., neck wound, tensionpneumothorax).

Swelling of the brain may lead to it beingdisplaced through the only available openings,termed herniation or 'coning'. Compression

Preventing a rise in ICP or a fall incerebral perfusion is essential topreventingsecondary injury i.e., correctmanagement of ABC.

Injuries to the brainand spinal cordfollowing blast areusually caused bysecondary andtertiary effects(0218). Cerebral airemboli may produceneurological deficits.

Alteredconsciousness is the hallmark of braininjury. Drowsiness isoften the first sign of raised ICP.Pupillary dilation is a late feature.

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of the mid-brain at the tentorium causesdrowsiness and unilateral limb weakness. It may also produce a third cranial nerve palsymanifested as pupillary dilatation - initially on the affected side. Damage to the motor orsensory cortex, or tracts leading from them, will result in a motor or sensory deficit on theopposite side to the injury. At the foramenmagnum, compression of the medulla causes the pulse rate to fall, the blood pressure to riseand the respiratory rate to fall (the reverse ofhypovolaemic shock). These features are knownas Cushing's Response; they precede deathand are an indication for immediate surgery.

4. Convulsions. These may be general e.g., a grand mal seizure, or focal. Convulsions can cause hypoxia, raised ICP and loss ofconsciousness. Prompt treatment is essential to prevent further brain damage. Penetratingbrain injury is often associated with post-traumatic epilepsy (1640).

5. Infection. A dural tear causes leakage of CSFand enables ingress of organisms. Constantcirculation of CSF aids spread of infectionthroughout the nervous system. Post-traumaticmeningitis, abscess formation and osteomyelitis,carry a high morbidity and possible mortality.

6. Hyperthermia. Pyrexia, which is oftenfluctuating, may be due to primary or secondaryinjury to the heat regulating centre in thehypothalamus. The presence of local or systemicinfection must be ruled out before making thisdiagnosis. Treatment is to cool the casualtywhilst monitoring core temperature (2604).

Hyperthermia: see Chapter 26

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General Management of Head Injuries

Role 1 1606 Steps include:

• Obtain a history (MIST see 0301). The mechanism of injury will provide a clue as to the degree of energy transfer. What wasbrain function like immediately after injury forexample, was the casualty talking, was there a lucid interval?

• Primary survey. Assess and manage ABC(0302). Other life threatening injuries takeprecedence over head trauma. Give oxygen(0317) and maintain a normal BP. NB: this posesa dilemma in casualties requiring hypotensiveresuscitation for non-compressible haemorrhageelsewhere (0333).

• Assess AVPU (1610), and pupil size and reaction to light (1612). During the secondarysurvey, measure GCS (1614) and look forlocalising signs (1613).

• If there is a reduced level of consciousness,clear the mouth and pharynx, insert an airwayand place the casualty into the three-quarterprone position. Where there is likelihood of a cervical spine injury and circumstances allow, immobilise the C-spine combined with the additional security of a spinal board (0318).

• Dress scalp wounds. Bleeding can usually be controlled by a pad or by under-running with sutures.

• Record details and arrange casualty transfer(1639).

Managing ABC: see Chapter 3

Assume a cervicalspine injury incasualties who havesuffered a significantblunt head injury; itis uncommon afterpenetrating headinjury (4%).

Hypovolaemic shock in head injurycasualties is usuallydue to blood lossfrom other organs.Scalp trauma rarelyresults in lifethreatening bleeding.

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Triage of head injury casualties

1607 In ideal circumstances

a. Severe head injuries need neurosurgical referral:

• Coma score =8.

• Open or depressed skull fracture.

• A skull fracture with neurological signs.

• Deteriorating GCS: a score that falls by 2, or more.

• Development of localising signs.

• (Significant intracranial haematoma on CT).

b. Moderate head injuries (GCS 9-13) should be admitted for observation and CT scanning (if available):

• Simple skull fracture.

• Neurological signs, including confusion.

• Casualties who are difficult to assess e.g., those affected by drugs or alcohol.

c. Minor head injuries (GCS 14-15) following loss of consciousness need 24 hours (or until fully recovered) observation undertakenby designated personnel. These casualties are:

• Fully orientated.

• Have no skull fracture.

• Have no neurological signs.

1608 In the less than ideal circumstances of the battlefield, the task is to identify those casualtieswho will benefit from transfer to a neurosurgical unit,versus those whose outlook is so poor they shouldnot be put into the evacuation chain ahead of prioritycasualties. The head injury triage scheme (Figure1602) is not foolproof but will act as a guide.

Head Injury Triage: see Chapter 6

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Role 2, 3 and 41609 Steps include:

• Re-triage and reasses ABCD.

• Look for:

• A reduction in GCS of 2 or more (1614),alteration in pupil size (1612), localisingsigns (1613) or an increase in BPassociated with a fall in pulse or respiratoryrate (1605). Such casualties require urgentassessment by a neurosurgeon. Continue to monitor regularly for 24-48 hours.

• External signs - look for scalp swelling,abrasions, lacerations, fractures, exposed

Fluid resuscitation:following head injury:cerebral perfusionshould bemaintained with asystolic BP>120. The dilemma in a casualty with co-existing non-compressiblehaemorrhage is thatyou want to minimisebleeding by keepingthe BP around90mmHg. Do thebest you can!

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brain and foreign bodies. Adequateexamination necessitates a head shave(1618). NB: it easy to miss a small,penetrating wound.

• Features of a basal skull fracture (1636).

• Epilepsy - describe the appearance of a seizure.

• Radiological assessment:

• If the history and examination suggest a penetrating injury or fracture, perform AP and lateral skull radiographs (NB: less important than regularobservations). Look for fractures,intracranial air, foreign bodies, midline shift of a calcified pineal or fluid in the airsinuses - this may be blood and/or CSF.

• Where available, a CT scan is the goldstandard investigation. It is used to diagnosebrain injury and guide the need for surgery.Look for intracranial bleeding, air or brainswelling. NB: to protect the airway duringscanning, it may be safest to anaesthetise,intubate and ventilate the casualty.

• Analgesia. Oral analgesia - codeine phosphate30-60mg (0723) - may be sufficient. Do notwithhold morphine if there is severe pain (0706)but remember, pinpoint pupils interfere withneurological examination. Give small doses toavoid an increase in ICP by depressingrespiratory drive.

• Prophylactic antibiotics. These should beadministered to all casualties with a suspectedopen skull fracture or penetrating injury (0818).

• Anticonvulsants. Seizures should be stoppedimmediately using lorazepam 5mgs i.v. stat.;diazepam is said to be less effective. Monitor the airway and breathing during drug


Look for a cause forthe casualty's

convulsions e.g.• Hypovolaemic

shock.• Anoxia.

• Hypercarbia. • Haematoma.

• Depressed skull fracture.

• Infection.

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administration. If lorazepam is ineffective, give i.v. phenytoin, 1.5g over 30 minutesaccompanied by ECG monitoring. Continuedseizures are managed by mechanical ventilationand i.v. barbiturates. Prophylactic treatment is essential in 'at risk' casualties (1640); give phenytoin 300mgs orally at night.

• Ventilate those with an airway or breathingproblem and potentially survivable casualtieswith a GCS of =8 (coma). This may require a surgical airway in the absence of anaesthetist.Maintaining a normal PaO2 (typically 10KPa)and preventing a rise in PaCO2 (typically 4-5KPa), will reduce the likelihood of cerebraloedema. Hyperventilation is no longerrecommended, but normocapnia is!

• Nursing care. Unconscious casualties requirebladder catheterisation, nasogastric tube suctionto prevent aspiration (consider an orogastrictube following a basal skull fracture), fluids,maintenance of nutrition, physiotherapy,prevention of faecal impaction and two-hourly turning to prevent pressure sores.

• Operative treatment. If a casualty requiresneurosurgery, they should be transferred to an appropriate unit (1639). If facilities are notavailable and the casualty is deteriorating, it maybe necessary to undertake life saving surgery. If there are other, more serious injuries, it isusually safe to delay treatment of open headwounds for up to 12 hours providing antibioticcover is given. Avoid exploratory surgery without a clear indication.

• Post head injury instructions. See 1638

Mini-neurological examination

1610 During the primary survey, neurologicaldeficit is rapidly assessed using AVPU and pupil

100ml of 10%mannitol i.v. over30minutes mayreduce cerebraloedema and buytime. Steroids are of no value. Lumbar punctureis generally

contraindicatedfollowing head injury.

With progressivebrain compression,first one pupil dilatesthen the other.

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examination (1612). AVPU, is the casualty:

• Alert?

• Responding to Voice?

• Only responding to Pain?

• Unresponsive?

1611 In the secondary survey, the mini-neurological examination is carried out to:

• Identify neurological injuries.

• Establish an anatomical diagnosis.

• Determine severity.

• Identify casualties needing early surgery.

The mini-neurological examination assesses:

• Pupil function.

• Presence of localising signs.

• Level of consciousness by the Glasgow Coma Scale.

When applied repeatedly, the mini-neurologicalassessment can be used to objectively monitorneurological deterioration.

1612 Pupils. Are they equal and do they respondto light? A difference in diameter of >1 mm isabnormal Beware: this may be caused by local eyeinjury (1705). A bright light shone into the eye shouldcause rapid constriction of the pupil and aconsensual response (1706). A sluggish responsesuggests brain injury; but, enlargement of the pupil,is a more important sign than failure to react to light.A dilated pupil on the side of the injury usuallyindicates ipsilateral brain compression.

1613 Localising signs. Obvious limb weaknessor loss of sensation localised to one side, suggests

Eye Injury: see Chapter 17

Other causes ofcoma include:

• Diabetes. • Epilepsy.

• Drugs/alcohol.• Stroke.

• Meningitis.• Liver failure.

• Heat/cold illness.• Malaria.

• Trypanosomiasis

Changes in thecasualty's

neurologicalcondition can only be

detected if the mini-neurological

examination isregularly repeated

and documented. Ifyou detect a

deterioration, actupon it.

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intracranial injury causing contralateral braincompression.

1614 Glasgow Coma Scale (GCS): This providesa quantitative and descriptive assessment of theconscious level. It is the sum of scores awarded for three types of response. (NB: These parametersare different in children).

Scoring the GCS:

• Eye opening (E). Document if the eyes cannot be examined due to injury and swelling.The standard painful stimulus is pressure overthe supraorbital nerve.

Spontaneous, i.e., open with normal blinking. 4 points

Eye opening on request. 3 points

Eye opening only to painful stimuli. 2 points

No eye opening despite pain stimulation. 1 point

• Verbal response (V). Document if scoring is not possible because the casualty cannot speak(e.g., endotracheal intubation, neck injury).

Orientated, spontaneous speech; knows name, age etc. 5 points

Confused conversation but answers questions. 4 points

Inappropriate words, i.e., garbled speech, but with recognisable words. 3 points

Incomprehensible sounds or grunts. 2 points

No verbal response. 1 point

• Motor response (M). The best responseobtained for either arm is recorded, even thougha worse response may be present in the legs. If the casualty is not able to move their limbs

GCS: do not simplygive a total score,record individualfindings descriptivelye.g.., 'eyes open topain'.

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because of trauma or spinal injury, ask them to blink or stick their tongue out.

Obeys commands and moves limbs when requested. 6 points

Localises pain i.e, moves upper limb in response to supraorbital compression. 5 points

Withdraws limb from painful stimulus. 4 points

Abnormal flexion - decorticate posture. 3 points

Extensor response - decerebrate posture. 2 points

No movement to any stimulus. 1 point

1615 A decrease in GCS of two points or moreindicates deterioration. If this happens, exclude aproblem with ABC, only then assume that changesare due to rising ICP. A fall of three points or moreis a bad prognostic sign and requires immediateintervention. Dramatic changes in the Glasgow Coma Scale are often preceded by more subtle signs such as:

• Onset or increase in severity of a headache.

• Vomiting.

• Fits.

• Double or blurred vision.

• Giddiness, mental confusion or drowsiness.

1616 Coma can be defined as that state in which:

• There is no eye opening despite stimulus.

• The casualty does not follow commands.

• There is no verbalisation.

Consequently, a GCS that equates to coma is 8 orless. The scale gives some indication of the severity

To correctly localisesupraorbital

pressure, the handmust rise above the

level of the chin,otherwise this is aflexion response.

The unconsciouscasualty who has

been drinking or taking drugs has

a head injury untilproven otherwise.

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of brain injury as follows:

Score 8 or less Severe

Score 9 to 12 Moderate

Score 13 to 15 Minor

1617 Common clinical situations after serioushead injury are:

• Brief loss of consciousness with rapid recovery.

• Unconsciousness, followed by gradual recovery.

• Deeply unconscious with fixed, dilated pupils and no response to stimuli.

These casualties do not require immediateneurosurgical intervention; the first two groupsrecover, the third group die. By comparison, the following relatively uncommon situations may require intervention:

• Unconscious, followed by improvement or a lucid interval, followed by furtherdeterioration of consciousness.

• Unconscious with a deteriorating GCS or localising signs.

• Conscious immediately after injury followed by deterioration.

Specific Head Injuries

Scalp lacerations1618 The scalp tends to bleed profusely. Unless lacerations are treated properly they can lead to infection and skin defects.

• Management is to clean and shave the scalp and remove hairs with adhesive tape.

• Use local anaesthetic (0728). Keep wound

Following long bone fractures orextensive soft tissueinjury, fat embolismcan cause loss ofconsciousness.There may be otherclinical signs (0982).Features of coningare absent.

All casualties in a militaryenvironment with a scalp woundshould beconsidered to havea penetrating braininjury until provenotherwise. Suchinjuries are easilymissed - it is safestto perform a wide orcomplete headshave in all thosewith blood in theirhair. This will alsoreducecontamination, but takes time.

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excision to a minimum otherwise closure may be difficult (Figure 1603). Because of theexcellent blood supply, primary wound closure is allowed, unless this is prevented by tissueloss (0504).

• Pressure applied on either side the wound willusually control bleeding.


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Fig 1603 Managing a scalp wound. A) Minimal wound excision.Pressure on either side of the wound aids haemostasis. B) Where necessary, elevate the pericranium to inspect the skull. C) Close with deep mattress sutures to include the galea aponeuroticaor suture in two layers.

A

B

C

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• Suture the scalp using deep mattress sutures to include the galea (Figure 1603). Do not leavebare bone exposed.

• Extensive skin loss may be treated with a splitskin graft as long as underlying pericranium ispresent. Alternatively, denuded bone may requirea skin flap (Figure 1604).


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Fig 1604 Closure of large scalp defects. A) Making an 'S'-shapedincision reduces tension and may permit closure. B) Rotation flap. C) Transposition flap.

A

B

C

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Penetrating brain injuriesClinical features

1619 These include:

• The diagnosis may be obvious in a casualty with a single or multiple scalp lacerations.Conversely, a fragment entering the eye, orbit or roof of mouth and going on to penetrate thebrain, is often missed during initial assessment.

• Casualties who are in deep coma (GCS 3-5)have a near 100% mortality rate (Table 1601).

• Through-and-through wounds and injuries to the brain stem are nearly always fatal. By comparison, an open brain injury in a conscious casualty carries a good prognosis if surgery is not delayed.

Management

1620 X-rays in two planes will show metallicfragments, a skull defect and bone fragments withinthe intracranial cavity. A CT scan will demonstrate the missile track and the fragments.

In general, missile injuries merit formal surgicalexploration. But, the nature of the injury and thecasualty's condition may mean they are a low priorityfor transfer and only supportive measures areappropriate (1607).

1621 Operative treatment.

• The best operating conditions are achieved by

Probing wounds to diagnose a

penetrating injury orfracture is

contentious! Do notuse an instrument;

it may cause furtherinjury. If necessary,use a gloved fingergently but, better tomiss a fracture than

make it worse!

If the casualtycontinues to have

a GCS of = 5 afterresuscitation for apenetrating headinjury, treatment

is futile.

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Table 1601 Mortality rates following penetrating head injuries.

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having an anaesthetised, paralysed andventilated casualty. Control of arterial CO2

and O2 and prevention of coughing and straining,optimises operating conditions and minimisesbleeding. Local infiltration with lignocaine plusadrenaline will aid haemostasis and, becausethere are no pain receptors in the brain, may be sufficient for simple procedures.

• Perform a complete head shave to allow formore than one incision to be made. Tilt theoperating table so that the head is 20 to 30degrees above the heart (NB: too high risks air embolism). Stabilise the head with the site of injury uppermost. Where possible, positionwith the vault projecting over the end of theoperating table to allow access to all areas(Figure 1605). Clean the skin and apply sterile drapes.

• The minimum instruments required are illustrated in Figure 1606. Extend the scalpdefect, preferably in a vertical direction but, do not turn a soft-tissue flap. Scalp bleeding is controlled by firm pressure near the skinedge followed by application of forceps to thegaleal edge at 1cm intervals (Figure 1607).Insert a self-retaining retractor.

Anaesthesia: see Chapter 25

Excision of thewound track isdifficult. Havingexposed the defect in the dura, a decision has to be made whether to proceed. If indoubt, close thewound and refer to a neurosurgical unit.

Dead tissue andcontamination maylead to abscessformation. Metallicfragments do notgenerally cause lateproblems and shouldonly be retrieved ifeasily accessible.Pieces of bone aremore likely to causeinfection and shouldideally, be removed.

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Fig 1605 Positioning and draping the head prior to neurosurgery.

Chapter_16.qxd 28/09/2004 15:57 Page 401

• Strip the periosteum back for 2cm around the defect. Perform a small craniectomy(approximately 4cm diameter) using bonenibblers with the missile hole as a starting point.Strip off underlying dura as the opening enlarges.

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• Keep the wound moist with normal saline.Explore the direction of the track with a sterileprobe. Aspirate the missile-track using lowpressure suction (Figure 1608). Dead brainsucks easily. Remove all non-viable tissue, bone fragments and foreign bodies. Do notprobe with your finger, this will push foreignmaterial more deeply into the wound. Irrigate the resultant cylindrical hole with normal saline.Essential aids to exploration are a headlamp and a narrow, malleable retractor.

• Haemorrhage may be severe, especially from a dural venous sinus and cannot be managed by pressure. Control arterial bleeding withdiathermy - bipolar set on low power ispreferred, a fine suture passed under the vessel or Ligaclips™. Every bleeding point must be controlled. Several minutes of lightpressure using a wet pattie over a piece ofgelatine sponge, Oxycel™ or crushed muscle(e.g., temporalis), should stem most venous

Applying haemostatsor attempting tosuture a bleedingvenous sinus usually makesmatters worse.

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Fig 1607 Controlling haemorrhage using artery forceps applied to the galea aponeurotica. Enlarging a penetrating head injury using nibblers.

Chapter_16.qxd 28/09/2004 15:57 Page 403

bleeding. Use bone wax to control bleeding fromthe edge of the skull.

• Uncontrollable bleeding is probably from thesagittal sinus or from deep inside the brain andhas a poor prognosis. It may be impossible tolocate or control. Gently insert a moist, ribbongauze tampon for 10-15 minutes. If bleedingcontinues after stepwise removal of the tampon,leave it in place for 24 hours.

• Expose and excise the dural defect. If it cannotbe closed, trim the edges and patch the defectwith an adjacent piece of pericranium (Figure 1609A). Options for larger defectsinclude use of temporalis fascia or fascia latafrom the thigh. Ensure there is no CSF leakage.

• Replace clean skull fragments (Figure 1609B).Large bone defects can always be repaired later.If there is continued extradural bleeding, insert a suction drain. Close the skin in two layers.Sutures are removed at 5-7 days.

• Apply a light dressing. Keep the head elevated by nursing the casualty on severalpillows. Continue antibiotics, anticonvulsants and mobilise the casualty.

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Fig 1608 Aspiration of a penetrating brain injury.

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Protruding foreign bodies

1622 Ideally, all objects protruding from the skullshould be left in place, immobilised and the casualtytransferred to a neurosurgical unit for angiographyand surgery. Removal may lead to torrential anduncontrollable haemorrhage. This has to be balancedwith the risk of further injury from leaving the objectin-situ during a difficult and prolonged transfer.

Blunt head injuries1623 Casualties who have suffered blunt head injury are usually asymptomatic or have mildconcussion. With increasing severity of injury, there

16: Head Injury

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Fig 1609 A) Patching a defect in the dura. B) Replacing clean bone fragments.

A

B

Chapter_16.qxd 28/09/2004 15:57 Page 405

may be diffuse or focal structural changesin the brain, producing altered consciousness and localising signs.

1. Diffuse brain injury

1624 Shearing forces caused by rapid headmotion (1603) can cause widespread damage withinthe brain substance. Such injuries form a spectrumfrom mild concussion - no structural changes - todiffuse axonal injury:

• Concussion. Clinically, there is brief loss of consciousness and temporary confusion oramnesia. The severity and duration of symptomsare proportional to the magnitude of the injury.Associated features include: headache, dizzinessor nausea. Localising signs are absent.

• Diffuse axonal injuries. Prolonged coma ispresent in 44% of cases. The overall mortalityrate ranges from 30 to 50%. Treatment involvescontrolled ventilation. Because the mortality is so high, these casualties have a low priorityfor treatment resources and transfer.

• Traumatic subarachnoid haemorrhage may accompany severe, diffuse brain injury. The irritant effect of the bloody cerebrospinalfluid in the subarachnoid space causesheadache, photophobia and neck stiffness. On its own, subarachnoid haemorrhage is not serious, but prognosis is poor if associated with brain injury.

2. Focal brain injuries

1625 Haemorrhage may arise from meningealvessels or from vessels within the brain substance.Correct diagnosis and rapid transfer for surgery,reduces morbidity and mortality. The spectrum of focal brain injury ranges from:

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• Contusion. This may be coup or contre-coup(1603). If the contusion occurs near the sensoryor motor areas of the brain, casualties presentwith varying degrees of neurological deficit.Coma is more likely to be due to contusion thanclot. Precise diagnosis requires CT scanning.

• Extradural haematoma (1627).

• Subdural haematoma (1630).

• Subarachnoid haemorrhage (1624).

• Intracerebral laceration. Intracerebral clots cause raised intracranial pressure. The majority resolve spontaneously. Large ones require neurosurgical evacuation if there is clinical deterioration.

Management of blunt head injury

1626 Most blunt head injuries do not requiresurgery and are managed as in 1609. The majoritymake a good recovery. Operative treatment may berequired to relieve pressure from an extradural orsubdural haematoma, elevate a depressed skullfracture or seal a CSF leak.

Extradural haematoma (EDH) Clinical features

1627 These include:

• They are uncommon, accounting for <1% of trauma-related coma.

• EDH classically follows a fracture of the temporalbone, damage to the middle meningeal arteryand arterial bleeding into the space between the skull and the dura (Figure 1610). As thehaematoma expands, it strips the dura from the inside of the skull. This in turn, leads to braincompression and, if not rapidly treated, death of the casualty.

If you operate and fail to find a blood clot, you are unlikely to havedone any harm.

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• On examination, there may be boggy swelling in front of the ear. This is due to blood forcing its way through the fracture line to form a temporalis haematoma.

• Following injury, in a classic case, there is loss of consciousness followed by someimprovement, or a lucid interval lasting severalhours, (it can be up to a week). With increasingbrain compression, there is secondary loss ofconsciousness, contralateral limb weakness andipsilateral dilatation of the pupil. NB: the lucidinterval may be absent.

Investigation

1628 Skull radiographs usually demonstrate a fracture. On CT scan, there is a localised, welldefined opacity. By comparison, a subduralhaematoma is more diffuse.

Operative treatment

1629 If the casualty with suspected EDH isdeteriorating (1609), perform an urgent burr hole and craniectomy, even if sophisticated investigationsare available.

It is usually difficultto differentiate

between an extra- and a subdural

haematoma onsymptoms alone.

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Fig 1610 Extradural haematoma causing oculomotor (third) nervecompression and ipsilateral dilatation of the pupil. Note the morelocalised nature of the haematoma compared to SDH (Fig 1613).

Chapter_16.qxd 28/09/2004 15:57 Page 408

• Prepare the casualty as in 1621.

• Position burr holes over the site of injury on the same side as the dilated pupil (Figure 1611).This will be correct in 85% of extradural andmany subdural haematomas. If both pupils are dilated, start on the side where dilation was first noticed. Avoid making burr holes within 2cm of a dural sinus or over loose or depressed bone fragments.

• Make a 4-5cm vertical incision down to bone(Figure 1612). For the temporal burr hole, makean incision 1cm in front of the ear, centred 2cmabove the zygoma. (NB: a common mistake is to make it too high). Incise the temporalis fasciaand split the temporal muscle.

• Perform a burr hole in the centre of the incision,first using the brace and sharp perforator. When you start to see dura, widen the hole with increasing sizes of burr. Applying too muchpressure will easily result in laceration of thecortex. Do not open the dura, but gently push it away with an elevator. Nibble the skull towiden the defect. A common error is not tomake the craniectomy large enough.

If you suspect a subdural orextraduralhaematoma in a casualty whoserespiratory rate isslowing, do not waitfor investigations,proceed to burr holeand craniectomy.This is rapid, simpleand life saving.

Performing burrholes in a casualtywith a respiratoryrate < 6 is likely to be futile.

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Fig 1611 Site of burr holes. These can be joined to perform a craniotomy.

Chapter_16.qxd 28/09/2004 15:57 Page 409

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Fig 1612 Technique of performing a temporal burr hole. A) Incision.B) The temporalis muscle is divided to expose bone. Use artery forcepsand a self-retaining retractor to improve exposure and control bleeding.C) Make the burr hole first with a perforator, then a conical burr. D) Separating dura from skull. E) Enlarging the burr hole usingnibblers. F) Controlling bleeding by placing a ligature under the vessel.

A

B

C

D

E

F

Chapter_16.qxd 28/09/2004 15:57 Page 410

• Aspirate as much haematoma as possible.Identify and control the bleeding point (1621).Leave the burr hole and craniectomy open and close the scalp in layers over a vacuumdrain. Leave the drain for at least 24 hours. Start anticonvulsants (1609) and mobilise the casualty. Most make a good recovery.

• If haemostasis is difficult and you haveneurosurgical experience, perform a craniotomy("trauma flap"). Make additional burr holes as in Figure 1611 and divide between them using a Gigli saw. Alternatively, simply leave theoriginal burr hole open with a vacuum drain,close the scalp in layers and transfer thecasualty to a neurosurgical unit.

• If the first exploration is "dry":

1 Gently probe between the skull and dura in all directions.

2 If the dura is blue and bulging, suspect a subdural haematoma and incise the dura.

3 Make additional burr holes at the positionsindicated in Figure 1611.

4 Make burr holes on the opposite side.

Subdural haematoma (SDH)Clinical features

1630 These include:

• They occur in up to 30% of serious head injuriesand can be bilateral.

• A blow to the head, particularly to the fronto-temporal region opposite the sphenoid ridge,results in cortical laceration and tearing of thebridging veins between the cortex and the dura.Bleeding occurs in the subdural space andspreads slowly over the whole of the affectedhemisphere (Figure 1613). SDH are typically

If, on making thetemporal burr holethere is brisk arterialbleeding, there isprobably iatrogenicinjury to the middlemeningeal artery.Locate and controlwith diathermy.

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seen after road traffic accidents and falls. The casualty frequently presents in a coma and deteriorates over the next 6-12 hours. There may be accompanying focal signs.

• Because of associated injury to the underlyingbrain tissue, mortality is as high as 60%

Investigation

1631 CT scan shows a diffuse, subdural clot,often extending over the whole hemisphere (Figure 1613).

Operative treatment

1632 Optimum treatment involves an extensivecraniectomy starting in the temporal region andopening the dura widely (1629). This requiresneurosurgical experience.

• In an emergency, the inexperienced surgeonmay do some good by performing burr holesstarting in the temporal region (Figure 1611).

• Open the dura sufficiently to allow evacuation of some clot and insertion of a suction drain.

16: Head Injury

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Fig 1613 Subdural haematoma. Note the spread of the haematomaover the hemisphere and the underlying cerebral laceration. There is acontrecoup injury and early coning.

Chapter_16.qxd 28/09/2004 15:57 Page 412

This may enable transfer to a neurosurgical unit for further care. In military casualties, startantibiotics and anticonvulsant treatment (1609).

Skull fractureClosed skull fracture

1633 This is common and usually uncomplicated.The significance of a skull fracture is that it identifiesa casualty with a higher probability of having ordeveloping an intracranial haematoma. Forexample, the presence of a skull fracture, togetherwith a period of loss of consciousness, carries a 1:4risk of intracranial bleeding. All casualties with skullfractures should be detained for observation.

Open linear skull fracture

1634 Most of these can be left alone.

• Remove dirt and contaminated periosteum.

• If there is leakage of CSF, this can usually becontrolled by plugging with a piece of crushedtemporalis muscle or careful, layered closure of the scalp wound.

• Where the fracture crosses the line of intracranialvessels e.g., middle meningeal artery (1627), be aware of possible haematoma formation.

Open depressed skull fracture

1635 By definition, there is a tear in the duraallowing communication with the brain. Because ofthe energy required to shatter the adult skull, mostopen skull fractures are associated with depressedbone fragments. The diagnosis may be obvious.Alternatively, skull radiographs, including tangentialviews, or a CT scan, may be necessary. In order toreduce infection and late complications (1640),treatment is to explore, preferably under generalanaesthetic (1621).

Brain injuryfrequently occurs in the absence of a skull fracture.Similarly, most skullfractures are notassociated withsevere brain injury.

Be wary of fracturesoverlying duralvenous sinuses.Haemorrhage can be torrential and lifethreatening.

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• Administer antibiotics (0818).

• Extend the skin laceration using a vertical curvedincision in line with the scalp arteries. Scrape offthe periosteum. Enlarge the fracture site usingbone nibblers (Figure 1607).

• If the dura appears intact, it is generally safer to leave the depressed fragments alone andtransfer the casualty. The bone fragments maybe jammed together; careless manipulation ofthem can cause serious bleeding. Otherwise,remove the fragments and repair or patch thetorn dura (1621).

• If the fracture is close to a venous sinus, it is wisest to leave it alone and refer to a neurosurgeon.

• Replace uncontaminated bone fragments; suturelarge fragments to the pericranium. Close theskin in two layers with a vacuum drain. Prescribeanticonvulsants if the dura has been torn.

Basal skull fractures

1636 The base of the skull runs diagonallybackwards and downwards; fractures produce signs anywhere along this line (Figure 1614). Points to note:

• A subconjunctival haematoma may occurfollowing a fracture of the roof of the orbit as well as a base of skull fracture. Whenexamined, there is no posterior limit to thehaematoma whatever the eye position. Lesserdegrees of this finding are likely to be due tolocal eye trauma.

• Bilateral periorbital haematomas (racoon eyes)are associated with fractures through thecribriform plate.

• Bruising over the mastoid process (Battle's sign)usually takes 12-36 hours to develop.


Only replacefragments if these

are uncontaminated.Skull defects

can readily bereplaced in aneurosurgical

unit.

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• Basal skull fractures are difficult to diagnose onplain radiographs. Look for the presence ofintracranial air or blood in adjacent air sinuses.Confirmation requires a CT scan.

The importance of a base of skull fracture is that itcan be associated with intra-cranial injury and longterm morbidity.

CSF leak1637 Leakage of CSF occurs in casualties with an open, depressed skull fracture or penetratingbrain injury. CSF leaking from the nose (rhinorrhoea)or ears (otorrhoea) is diagnostic of a tear in the thindura at these sites. These are features of a basalskull fracture (1636).

• When CSF is mixed with blood it may be difficultto detect. A simple test is to place a drop ofsuspect blood onto a white gauze swab and lookfor the appearance of a pink halo (ring sign).

Orbital Fractures: see Chapters 17 and 18

16: Head Injury

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• Because close observation is not possible under field conditions, give prophylacticantibiotics (0818).

• Leakage, especially from the ear, usually stopswithin a few days. Occasionally, leakage fromthe nose persists; warn casualties not to blowtheir nose. Seek neurosurgical advice.

Further Management

1638 Good nursing is more likely to save livesand prevent complications than neurosurgery.

• Following recovery from a severe head injury,the casualty is returned to the UK for furthertreatment and rehabilitation in a specialist unit.

• After lesser degrees of head injury, they shouldnot be allowed to fight or operate machinery untilthey have made a full recovery.

• Warn them to seek medical advice if they developheadaches or other neurological symptoms.

Transfer of head injuries

1639 Most casualties transferred following headinjury will be sent to a neurosurgical unit. Casualtiestravel well, even if ventilated, provided they are fullyresuscitated and stabilised. One risk of airtransportation is expansion of intracranial air at altitude (2919).

• Casualties should be carried at a low altitude or the cabin pressurised to that of sea level.

• Transfer should be in a head-up position (20-30 degrees) to improve venous drainage andreduce ICP. This is important to remember whenmoving casualties by helicopter - most of themfly in a nose-down attitude.

Aeromed-transfer: see Chapter 29

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Long term complications

1640 Specific complications include:

• Epilepsy. Injuries carrying a high incidence include:

• Secondary brain abscess (50%).

• Penetrating missile wounds of the brain (40%).

• Acute extradural and subdural haematomas (30%).

• Early epilepsy - fits occurring in the first week (30%).

• Open, depressed skull fracture with a dural tear (25%).

• Brain abscess.

• Persistent CSF leak.

• Hydrocephalus.

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Chapter 17

Ophthalmic Injury

Introduction

1701 Approximately 10% of all battle casualtiessustain eye trauma. Fifty percent of these arepenetrating wounds of the globe; 15% are bilateralinjuries. Corneal abrasions, corneal foreign bodiesand conjunctival lacerations are common andincapacitating. If the casualty has multiple injuries or is unconscious, ophthalmic injuries are easilymissed and may result in blindness. In 15% of eyeinjuries there are associated injuries to the craniumand brain.

Anatomy

1702 See Figures 1701 and 1702.

History

Previous ophthalmic history1703 Points include:

• Acuity. Did the affected eye see normallybefore the injury?

• Amblyopia. Is the injured (or uninjured) eyeamblyopic (lazy)?

• Allergies. For example, any antibiotic sensitivity?

• Aid. What first aid has the casualty received?

• Admissions. Any previous eye operations or injuries?

Only 25% of eyeinjuries can return to active duty,compared with 85% of all survivingwounded.

Consider occult eye or brain injuryin all casualties.Always examine theeyes during thesecondary survey.

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Details of injury1704 Find out about:

• Activity and circumstances of injury e.g.,hammering, munition blast, laser strike?

• Blunt or sharp trauma?

• Chemical injury: was it acid, alkali or a chemicalagent attack (nerve agent - pinpoint pupils 0232;blister agent -irritation 0243)?

• Eye drops. Is the casualty on eye medication orhave they received miotics (constrict the pupil)or mydriatics (dilate the pupil and paralyse theciliary muscle)?

• Eyewear at the time of injury e.g., glasses,protective eyewear or contact lenses?

• Foreign body? Examine a sample if available.

Examination and Treatment

1705 Check visual acuity and perform asystematic examination of the eye:

1. Acuity should be recorded as the best correctedvision. This is measured by asking the casualtyto read a standard reading chart (Snellen’s chart)

Take a detailedhistory of the

mechanism of injury.

Always record thevisual acuity. Initialacuity is the single

most importantpredictor of finalvisual outcome.


420

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at 6 metres. The acuity is recorded as a fraction,the casualty's distance from the chart is thenumerator and the line achieved on the chart inthe denominator (e.g., can see the fifth line downbut not the sixth = 6/5). A Pin hole occluder cancorrect most refractive errors if the casualty'sglasses are not available.

The eyes are tested one at a time with the other eye carefully occluded. If a Snellen's chart is unavailable, acuity should be recordedas follows:

• Able to read normal text or only headlines.

• Count fingers.

• Hand movements.

• Perception of light or no perception of light.

2. Systematic examination of the eye and orbit:

1. Check for a relative afferent pupil defect.

2. Assess for facial and lid injury.

3. Examine the anterior and posteriorsegments of the globe.

These will now be discussed in more detail.


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Fig 1702 Muscular attachments of the eye.

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1. Check for a relative afferent pupil defect(RAPD) The swinging torch test

1706 This assesses the direct and consensualreflexes of each pupil and hence, their relativesensitivity to light. Shine a bright light into the firstpupil for 2 seconds and then the other pupil for a

The swinging torchtest is the most

important objectivetest in ophthalmology.

If a bright light isused, this test can

be carried out evenwhen one lid

is closed.


422

Fig 1703 A) Fracture of the orbital floor causing enopthalmos andmuscle entrapment. B) Zygomatic fracture causing deformity of theorbital rim and reduced jaw movement.

A

B

Chapter_17.qxd 28/09/2004 15:57 Page 422

similar period, taking 1 second to swing across. This cycle is repeated several times. Both pupilsshould be the same size and constrict equally tolight. If there is dilation, then that eye has damagedretinal or optic nerve function and a poor visualprognosis i.e., it has a RAPD. NB: Drugs used in the field can affect pupil size and reactivity e.g., the Combopen contains atropine - overdoseagecauses dilation of the pupil (0237).

2. Assess for facial and lid injuryOrbits.

1707 Examination:

• Look for mal-occlusion or limitation of jawmovement (Figure 1703), swelling, asymmetry or flattening of the cheeks (malar fracture?).

• Horizontal alignment. Assess this using astraight edge or ruler. Each pupil should be anequal horizontal distance from the bridge of thenose and horizontally aligned with the canthi. An inferiorly displaced lateral canthus indicates a zygomatic fracture (Figure 1704).

• Enophthalmos - a depressed eye, suggests anorbital blow out fracture, (Figure 1703) whileproptosis - bulging eye, suggests a haematoma.Gently palpate over the upper lid. A tense orbitwith reduced visual acuity indicates a severeorbital haemorrhage. This is a sight-threatening

Facial Fractures: see Chapter 18

Injury to the opticnerve is common in head and orbittrauma. In certaincases, high dosesteroids are ofbenefit if given early (1822).


423

Fig 1704 An inferiorly displaced right lateral canthus and displacedpupil indicates a zygomatic fracture.

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problem requiring immediate surgicaldecompression (1822).

• Diplopia (double vision) and restriction of eyemovements indicates injury to cranial nerves ormuscle entrapment, (Figure 1703).

• Infraorbital hypoaesthesia indicates involvementof the infra-orbital nerve in a blow-out fracture ofthe orbital floor, (Figure 1702).

• Palpate the orbital rim for steps and crepitus,that indicate fracture of the orbital rim or damageto an air sinus.

1708 Intra-orbital foreign bodies.

In the field these are best left undisturbed.

• General measures for dealing with eye injuriesare summarised in Table 1701.

• Large, protruding foreign bodies should be stabilised. Further investigations that will be needed include: facial radiographs andultrasound or CT scanning. Administerprophylactic antibiotics (Table 1702) and transfer the casualty as a stretcher case to an ophthalmic unit.

Orbital Fractures: see Chapter 18


424

• Systemic antibiotics and antitetanus.

• Treat as a stretcher case.

• Analgesics and antiemetics.

• Topical antibiotics. Administer every 1-2 hrs with

an initial loading dose (one drop every minute for

5 minutes). Because ointment may enter the globe

through even small wounds, use drops if there is any

possibility of perforation.

• Shield not pad. Padding the eye may extrude ocular

contents or promote infection. It is better to leave the

eye open and protect it with a shield (1713).

Table 1701 General measures (STATS) for dealing with eye injuries.

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• Orbital haemorrhage and infection pose a threatto vision from pressure effects; drain the formerand give i.v. antibiotics (Table 1702) for the latter.

1709 Orbital fractures.

Management is not urgent.

• Where suspected, give systemic antibiotics(Table 1702) and instruct the casualty not toblow their nose. Transfer.

• Investigate with plain facial radiographs and CT scanning.

When faced with a lid injury, alwaysconsider penetrationof underlyingstructures:• Eye• Sinus • Brain


425

Table 1702 Useful ophthalmic preparations.

G Amethocaine, G Benoxinate topical anaesthetic as required

G Fluorescein dye to highlight corneal abrasions

Oc Lacri-Lube lubricant as required (Oc chloramphenicol commonly used in field)

G Cyclopentolate or dilates the pupil and paralysesG homatropine the ciliary muscle(act for 2 days), G atropine (acts for 2 wks)

G or Oc chloramphenicol, topical antibiotics (see Table 1701)Ofloxacin

G Maxidex topical steroid preparation 4-6 hourly

Ciprofloxacin (oral 0820), antibiotics that enter the eyeazithromycin (500mg once daily orally)

Co-amoxyclav (i.v. 0817; antibiotics for sinus fracturesoral 0821), ceftriaxone + metronidazole (0818)

G Timolol (twice daily) Treatment of glaucomaor acetazolamide (oral four times daily)

Oc = ointmentG = drops

Topical preparations contain preservatives which are toxic ifthey enter the eye - avoid if you suspect a penetrating injury.

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• Injuries may require reduction and fixation(1823-1824).

Lids

1710 Examine the lid contours

Asymmetry can be caused by ruptured canthaltendons; these attach the medial and lateral ends ofthe lids to the orbit. A flattened upper lid may meanthe globe is perforated.

1711 Search for foreign bodies

Evert the upper lid (Figure 1705). NB: do not do thisif globe penetration is suspected. Consider doing a plain radiograph - a small wound can hide a largeforeign body.

1712 Lid wounds

Assess:

• Depth of injury - full or partial thickness.

• Tissue loss. This may lead to corneal exposure.

• Site. Lacerations medial to the puncta mayinvolve the lachrymal drainage apparatus

• Contamination. Clean dirty wounds and explorethem to exclude a foreign body.

• Levator function. Ptosis and inability to open theeye, suggest levator muscle involvement.

1713 Management of lid lacerations:

• The lids have an excellent blood supply, soextensive wound excision should be avoided.

• Superficial lacerations not involving lid marginsand with good levator function, may be repairedwith 6/0 Prolene.

• Full thickness injuries and those involving thelevator muscle, may require complex alignment

Conjunctival swellingis common in lid

injuries, and mayhide a penetratinginjury of the globe.


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and should ideally be repaired by anophthalmologist.

• Stop active bleeding. If necessary, use severaltacking sutures to hold wound edges together.Avoid pressure on the globe in case there is anundetected perforation.



427

Fig 1705 Technique of everting the upper eye lid and foreign body removal.

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• Before transfer, instil ocular lubricants (Table1702, NB: avoid them if there is a suspicion ofglobe perforation) and protect the eye with aperforated Cartella shield. Alternatively, a shieldcan be improvised from the base of a polystyrenecup or gallipot. If there is lid avulsion, 'cling film'held in place by the shield can be used toprevent corneal desiccation.

1714 Lid burns

Approximately 5 to 10% of all burn casualties sufferdamage to their eye lids. Principles of managementare the same as for burns elsewhere. Lubricantsshould be used liberally. Topical antibiotics (Table 1702) are given for corneal epithelial defectsor conjunctivitis. Initially, lid tissue swelling mayprotect the globe, but subsequent sloughing andcontracture can lead to corneal exposure. Immediatecare of the eye - prevent exposure - and ophthalmicintervention 2 or 3 days later - desloughing orexcision of eschar - can improve visual outcome.



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3. Examine the anterior and posteriorsegments of the globeGeneral

1715 Globe injury

Serious signs are:

• Prolapse or expulsion of lens, iris, vitreous, choroid or retina.

• Associated hyphaema (Figure 1706).

1716 Occult signs of globe rupture following bluntor penetrating injury include:

• Soft eye.

• Total hyphaema.

• Abnormally deep anterior chamber.

• Restriction of eye movement.

• Chemosis (swelling of the conjunctiva).

• Subconjunctival haemorrhage (1636).

1717 Management of globe rupture orpenetrating injury

This is an emergency:

• Do not apply topical medication.

• Cover with a protective eye shield (1713). Do not use an eye pad as any pressure cancause ocular contents to extrude.

• Nurse the casualty sitting up.

• Give systemic antibiotics, an anti-emetic, pain relief and a tetanus booster.

• The casualty requires urgent transfer to anophthalmologist for surgical repair within 48hours. If transferred by air, keep the cabin

Aeromedical Transfer: see Chapter 29

To examine theglobe, the lids should be held openby pressure againstthe orbital margins.Do not press on apossibly penetratedglobe. Be verygentle.

All injuries should beassumed to have aretained intra-ocularor orbital foreignbody. Alwaysconsider a plainradiograph, CTscan or ultrasound.

Do not manipulateany instrumentsinside the globe. Do not suture the iris.


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pressure to that at sea level. The inexperiencedsurgeon is likely to do more harm than good.The use of 'super glue' tends to interfere withsubsequent repair- 'bio-glue' may soon beavailable.

• At Role 3 or 4, protruding tissue from inside theeye is cut level with the cornea or sclera. Thecornea and sclera are closed using interrupted,non-absorbable monofilament 9/0 sutures.Sutures must not be too superficial or they willtear out, yet should not cross the inner layer (the cornea is only 1-2mm thick). Largeconjunctival lacerations require closure with 6/0 absorbable suture.

Anterior chamber

1718 Assess chamber depth by Illuminating fromthe side with a focusing torch.

1719 Hyphaema.

The presence of blood in the anterior chamber isusually associated with blunt trauma (Figure 1706).Even a small hyphaema may rebleed. The rebleed is usually more serious than the primary bleed,leading to high intra-ocular pressure and cornealblood-staining (NB: exclude a ruptured globe, 1716).The casualty is often drowsy or restless and may feelnauseous. Serious signs are:

• Total hyphaema filling the anterior chamber,especially if this is black, implying anoxia due tohigh pressure and stagnant aqueous circulation.

• Deteriorating vision or complete loss of vision.

• Afferent pupil defect (RAPD), indicating opticnerve or retinal damage (1706).

• A rebleed.

• Increasing pain.


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1720 Treatment of hyphaema

• Bed rest for 4 or 5 days with the head slightlyraised to allow blood to settle out of the visual axis.

• Analgesics and antiemetics; avoid aspirinbecause of its antiplatelet action.

• Dilate the pupil with homatropine or atropine(Table 1702).

• Treat any associated corneal abrasion (1726). If there is no abrasion, then do not pad the eye.

• Instil topical steroid drops (Table 1702).

• If intraocular pressure is raised, use oral and/or topical glaucoma medication; NB: notpilocarpine - constricts the pupil and increasesiris vessel leakage.

Pupil

1721 Assess shape, symmetry and reactionsdirectly and against the red reflex (1723) The irisshould be flat and the pupil central and round. Ifeither is distorted, this suggests one or more of the following:

• Anterior segment trauma.

• Iris plugging a hole in the cornea.

• Vitreous prolapsed into the anterior chamber.

The presence of a hyphaema indicates significantinjury and the need for urgent transfer to anophthalmologist. Transillumination defects in the irisare due to tears or passage of a foreign body. Alsolook for dialysis (disinsertion of the iris root) andnotching of the pupil margin.

Lens

1722 Examine this using a direct ophthalmoscope


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with a +10 or +15D lens dialled up. Look for:

• Partial or total dislocation into the anteriorcompartment or vitreous.

• A tract made by the passage of a small foreignbody (seen against the red reflex).

• Traumatic anterior or posterior subcapsularcataract may be seen at an early stage- after 3-4 days.

• If the len's capsule is ruptured, flocculent lensmatter may be visualised in the anterior chamberor vitreous.

Red reflex

1723 Dim the room illumination. Using anophthalmoscope with a 0 power lens, examine thecasualty's eye from a distance of 50cm. The redreflex is a bright reflection from the casualty's retina,similar to the red eye on a photograph taken with aflash. Any reduction in intensity indicates somethingbetween the examiner and the casualty's retina.

Cornea.Examination

1724 The cornea should be transparent andsmooth, giving an even and bright reflection of theilluminating light. Check for abrasions, lacerationsand foreign bodies. Instill topical anaesthetic if thereis lid spasm due to pain (Table 1702). Symptoms andsigns include:

• Foreign body sensation.

• Pain.

• Photophobia.

• Redness (injection) or chemosis (swelling).

• Decreased vision.

Do a red reflex teston every casualty.


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A white corneal infiltrate usually indicates a cornealabscess. The anterior chamber can fill with pus(hypopyon). Treatment is with systemic and topicalantibiotics (Table 1702).

1725 Management of corneal or subtarsalforeign bodies

• Removal of even superficial corneal foreignbodies is difficult without high, binocularmagnification and good illumination.

• Corneal foreign bodies can be buried in thecorneal stroma or protrude into the anteriorchamber. Deep corneal foreign bodies are often well tolerated and can be left; more severe damage and scarring may be caused byattempts to remove them. Further managementis as for penetrating injury (1717).

• Loose foreign bodies can be irrigated from theeye. If not, instil topical anaesthetic (Table 1702)and removed with a needle using a tangentialapproach whilst steadying the casualty's head. A cotton bud is useful to wipe away looseepithelium or superficial foreign bodies (Figure1705). Further management is as for cornealabrasion (1726).

1726 Management of corneal abrasions

Abrasions are due to trauma; ulcers are caused byinfection.

• Abrasions are best visualised after staining with fluorescein.

• If pain relief is required other than forexamination, use oral analgesics. Topicalanaesthetics slow epithelial healing.

• Instill medium-acting mydriatics to rest the eye- use cyclopentolate or homatropine - and topicalantibiotics (Table 1702). Apply a firm, double eye

Beware of infectiveconditions simulatingcorneal abrasion(e.g. herpetic orbacterial ulcers).

Corneal abrasionsand foreign bodiesare incapacitatingbut, with appropriatetreatment, most healwithin 24 hours.


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pad ensuring that the upper lid is closed underthe covering.

• After 24 hrs, if an abrasion has healed, stopmydriatics and continue antibiotic drops for afurther week.

• Repeat above if not healed.

• After 48 hrs, leave the eye open, even if it isunhealed and use copious ocular lubricants(Table 1702). Over-padding leads to cornealanoxia, oedema and reduced epithelial healing.

• Consider referral to an ophthalmologist.

1727 Corneal infection (infectious keratitis).

This requires immediate transfer to an ophthalmologist.If this is not feasible, start treatment with intensive,topical antibiotic drops for example, chloramphenicolevery 30 minutes - (Table 1702) and transfer as soonas possible. Infectious keratitis may be associatedwith contact lens wear.

Conjunctiva

1728 Management of lacerations and foreign bodies:

• Consider an underlying scleral laceration orintra-ocular foreign body. Evaluate for perforation(1716).

• Irrigate with saline.

• Pick out foreign bodies with forceps or wipethem away with cotton buds (Figure 1705).

• Large lacerations require closure with 6/0absorbable suture.

• Use topical antibiotic drops (Table 1702).

• Do not pad the eye(s).

• Consider transfer to an ophthalmologist.


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1729 Chemical injuries.

In the field, acid burns are usually due to explodingvehicle batteries. Alkali burns are more serious thanacid burns and are often due to caustic soda used inchemical latrines. Alkali can cross the cornea into aneye in 5 seconds, whereas acids coagulate tissue toform a barrier.

The severity of the injury depends on the extent of:

• Sloughing of corneal epithelium.

• Corneal haze, obscuring iris details.

• Corneal folds (corneal oedema due to loss ofendothelial cells).

• Conjunctival and scleral ischaemia, seen asblanched, avascular areas. Extensive limbalischaemia is a particularly poor prognostic sign:it is seen as blanched, avascular areas at the limbus.

• Raised intra-ocular pressure.

• Progressive opacification of the cornea.

• Cataract formation

1730 A chemical injury to the eye is an emergency:

• If it is suspected, irrigate the casualty's face andeyes with sterile eyewash or saline. Continue for20 minutes.

• Evert the eyelids (Figure 1705), remove anyparticles and direct irrigating fluid under them.

• Consider chemical injury elsewhere, particularlyto the airway.

• Early and vigorous treatment with ascorbic andcitric acid - topical Topveal four times daily - hasgreatly improved the outcome in alkali injuries.

Chemical Weapons Injury: see Chapter 2

The Morganirrigating contactlens is useful for dealing withbilateral or multiplechemical injuries.


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• All chemical burns should be urgently referred toan ophthalmologist.

Vitreous

1731 Opacification may cause loss of the redreflex and obscure the fundus. Causes include:

• Haemorrhage.

• Inflammatory or infective reactions, usually due to a retained foreign body.

Management is generally as for hyphaema (1720).

Fundus and retina.

1732 Examine both using direct ophthalmoscopy.Look for:

• Retinal oedema and infarction (comotio), theretina appears white and cloudy, obscuring thechoroidal pattern.

• Haemorrhages look as if they have been "air-brushed" onto the retina. In more severeinjury, haemorrhages are "blot-like" and themacula may show up as a "cherry red spot"against the infarcted retina.

• There may be a darker mass of sub-retinal or choroidal haemorrhage sometimes overlying a crescentic, choroidal rupture concentric to the disc.

• Retinal detachment looks like a waving netcurtain. Only 12% of traumatic detachmentsoccur immediately. Acuity may be normal if themacula is not involved and the media are clear.

• Foreign body.

Management is generally as for hyphaemia (1720).

Ultrasound can be used to examine

the retina andvitreous in the

presence ofintraocular

haemorrhage.

Always carefullyrecord the position

of any intraocularforeign bodies.These may be

obscured later byfurther bleeding or

inflammation.


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Laser injury 1733 Damage depends on the intensity of theburn. High energy injuries can cause corneal or lensopacity (cataract). Usually, the laser light will passthrough the transparent media of the eye and causea retinal burn. Effects can range from greydiscolouration of the retina, a retinal hole, sub-retinalbleeding to an eye full of blood. In the field, manageas for hyphaema (1720).

At Role 3 and 4, treatment options extend fromconservative therapy through to surgical rotation ofthe retina.

Sympathetic Ophthalmia 1734 This occurs when one globe has beenseverely disrupted. It is rare if satisfactory, primaryrepair is carried out within 10 days of injury. Sight inthe injured eye may ultimately be better than that inthe sympathising eye.

Removal of the globe may be indicated in the case of an infected or painful eye with no perception oflight. This is not a field procedure. Evisceration(contents scooped out of sclera) is performed inpreference to enucleation (whole eyeball removed).


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Chapter 18

Maxillofacial Injuries

Introduction

1801 On the battlefield, 10-15% of casualties who reach Role 1 have maxillofacial injuries.Penetrating trauma, usually caused by fragmentinjury, is commoner than in civilian practice. The principles of initial management are:

• Maintain the airway. Following maxillofacialinjuries the airway is at risk from the tonguefalling back, fragments of bone or teeth,continued haemorrhage and soft tissue swelling. Clear and maintain the airway (0319). A definitive surgical airway may be necessary.

• Diagnosis of associated head, ophthalmic orENT trauma (15% have associated injuries).

• Preparing the casualty for transfer to specialistcare (1835). Provide simple splintage andanalgesia (Figure 0701) for mandibular fractures.

• If transfer is delayed or the injuries unstable,initiate treatment. Subtle injuries are unlikely to be life threatening. Most closed injuries maybe left without surgical intervention for up to 10 days. Consider antibiotic prophylaxis(0816-0818).

Mechanism of Injury

1802 Penetrating trauma produces soft tissueinjury and fractures at the site of impact. The bonesof the face and head are illustrated in Figure 1801.High velocity missiles that strike teeth or dense bone

ABC: Chapter 3

Definitive treatmentof maxillofacialinjuries is neitherrapid nor easy, and may involve a multidisciplinary

approach.

Do not let thecasualty die for want of an airway.Most casualties aretransferred in thethree-quarter proneposition withsupervision..

Unless severe,maxillofacial injuriesare rarely a causeof shock. Look for

causes elsewhere.

18: Maxillofacial Injuries

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cause high energy-transfer with comminution of bone,multiple fractures, tissue loss and contaminationalong the missile track. Low velocity missiles lead to local laceration and crushing.

1803 Blunt trauma results in predictable fracturepatterns of the mid-face (Figure 1802) and at thecondylar, angle and parasymphyseal regions of themandible (Figure 1803). Approximately 50% of jawinjuries are blunt.

Management

General examinationExternal

1804 Inspect all surfaces of the head, face andneck. Look for

• Asymmetry, depression or deformity of bonylandmarks and difference in eyeball level (1707).Assessment is easiest immediately after injury.

• Lacerations, bruising, haematomas or tissue swelling.

• Evidence of a basal skull fracture (1636).

• Facial muscle weakness suggests damage to the facial nerve.

1805 Palpate all bony surfaces and margins,comparing both sides, to detect breaks in continuity of:

• Cranium.

• Orbital rims.

• Nose.

• Zygomas and zygomatic arches.

• Condyles.

Mechanism of Injury: see Chapter 2

Remember that the unconsciouscasualty may haveinhaled any missingteeth A chest X-raymay be indicated toexclude this.

Look for evidence of airway obstructiondue to tissueoedema; it typicallystarts 60-90 minutesafter injury.


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• Posterior border of the ramus and the lowerborder of the mandible.

1806 Examine for sensory loss, especially over the cheek and lower lip; tenderness and surgical emphysema.

Pressing firmly inwards at both angles of themandible simultaneously will flex the mandible and cause discomfort and movement at a fracturesite if present.

Pulling on the upper teeth with the head stabilised,will produce palpable movement intra-orally:

• In the buccal sulcus in Le Fort 1 fractures.

• Externally at the infra-orbital margin in Le Fort 2 fractures.

• At the zygomatico-frontal suture at the lateralorbital margin in Le Fort 3 fractures.

A gloved finger gently passed into an open woundmay reveal a fracture or foreign body.

Mouth

1807 Inspect for:

• Broken, missing or displaced teeth.

• Alteration in alignment of the teeth.

• Malocclusion - failure of the teeth to meet correctly.

• Limitation of mandibular movement and/or asymmetrical opening.

• Bleeding, haematomas and tears of the mucousmembranes of the cheeks, gums, floor of themouth, hard palate and tongue.

Palpate the teeth, dental arches, palate and maxillato detect abnormal mobility.

Examination of the Eye: see Chapter 17

Take care when inserting

a naso-pharangealairway in thepresence of

a suspected basalskull fracture (0321).There is a small risk

of it ending up in the brain!


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Eyes

1808 Examination points include:

• Check pupillary size and response to light (1706).

• Look for enophthalmus or proptosis (1707).

• Check for subconjunctival haemorrhage (1636)or hyphaema (1719).

• If conscious, check visual acuity (1705), eye movement and diplopia.

• Pooling of tears and epiphora indicate lachrymal damage.

Ears

1809 Examine for:

• Otorrhoea.

• Ruptured eardrums.

• Haemotympanum (1905).

• Hearing deficit.

Pathophysiology and examination of facial fracturesUpper third

1810 Fractures of the skull vault are suspecteddeep to penetrating wounds, under areas ofdepression or when bone edges are encountered by the examining finger.

Middle third

1811 Fractured zygoma

After nasal fracture (1913), this is the second mostcommon bony, middle third facial injury. It usuallyfollows blunt trauma and is suggested by one ormore of the following signs:

Examination of the Ear: see Chapter 19 Head injury: see Chapter 16

Step deformity of the inferior orbitalrim indicates afracture, of either the orbital rim itself,zygoma, or middlethird of the facialskeleton.


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1. Step deformity of the inferior orbital rim (Figure 1703).

2. Diplopia.

3. Infraorbital paraesthesia or numbness indicating damage to the infraorbital nerve.

4. Subconjunctival haemorrhage.

5. Limited mouth opening (Figure 1703).

6. Flattening of the malar eminence.

Injuries of the Orbit: see Chapter 17


444

Fig 1802. Classification of mid facial fractures according to Le Fort.

Le Fort 1

Le Fort 2

Le Fort 3

Chapter_18.qxd 28/09/2004 15:57 Page 444

1812 Orbital blow out fractures.

In addition to the first four of the features associatedwith a fractured zygoma, the casualty may also have:

• Abnormal eye movements and displaced lateralcanthus (Figure 1704). Typically, there is loss ofupward and outward gaze due to inferior rectusmuscle tethering (Figure 1703A).

• Enopthalmos (1707).

• The maxillary antrum will appear opaque on X-ray due to the presence of blood. It may alsodemonstrate the 'hanging drop' sign anddisruption of the posterior wall of the antrum.

1813. Maxillary fractures

Such fractures indicate the casualty has sufferedsignificant violence. Classification is according to Le Fort (Figure 1802):

• Le Fort 1: the palate and tooth-bearing parts of the maxilla are separated from the mid face.

• Le Fort 2: the pyramidal fracture is at a higher level than Le Fort 1 and includes the naso-ethmoidal complex but not thezygomatic complexes.

• Le Fort 3: the whole of the facial skeleton is separated from the base of the skull including the zygomatic complexes at thezygomatico-fontal suture and zygomatic arch.

In addition to many of the features of a fracturedzygoma and orbital blow out fracture, there may also be:

• Lengthening of the face and dished-in deformity.

• Disruption of dental occlusion.

• CSF rhinorrhoea.

• 'Cracked cup' note on percussion of the upper teeth.

Examining the Eye: see Chapter 17

Any combination ofLe Fort 1,2 and 3 onone side of the facemay be combinedwith Le Fort 1,2 or 3on the other.


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• Bleeding, especially from the nose, may beprofuse. Haematomas may result in severe softtissue swelling.

Fractures may be visible on radiographs along thelateral wall of the maxillary sinuses and the inferiormargin of the bony orbit.

The lower third. 1814 A blow to the chin may cause uni- orbilateral fractures of the condyles, or fracture the centre of the body of the mandible near thesymphysis menti ('guardsman's fracture'). A blow tothe side of the jaw will fracture it at the site of impact.There may be associated fractures of the mandiblenear the canine tooth or contralateral condylar neck.Common mandibular fractures are illustrated inFigure 1803. Displacement depends on the pull of the muscles attached to the fragments.

Unstable, anterior mandibular fractures, mayprejudice the airway by allowing the tongue to fall backwards. Respiratory embarrassment can be caused by gross swelling of tissues around theupper airway. Diagnosis of mandibular fractures isstraightforward if the casualty is conscious and thefracture displaced. Look for:

• Irregularity of the teeth, abnormal dentalocclusion or deviation of the jaw to one side.

• Pain and mobility about the fracture site.

• Paraesthesia over the lower lip signifyingdamage to the inferior dental nerve.

• Swelling and tears of the mucous membranes of the cheeks, gum and floor of the mouth.

• Fractures of the mandibular condyle arecharacterised by disordered occlusion withoutnerve signs. They are accompanied bypronounced stiffness on mouth opening and

Mandibular FractureClearing the airway: see 0320 Maintaining the airway: see 0321

Always suspectmultiple fractures in

the mandible.


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tenderness over the condyle when compressionis applied to the chin. A 'gagging' or open bite is usually due to a fracture of the ramus orfracture-dislocation of the condyle, but may alsobe associated with posterior displacement ofmid-facial fractures.

Management of facial fracturesRadiological investigation

1815 Views are taken at right angles to minimise superimposition of the facial structures on the skull base.

• Suspected vault fractures are diagnosed by AP and lateral radiographs.

• Fractures of the zygoma, orbit and middle thirdare usually investigated by 10 and 30-degreeoccipito-mental radiographs, lateral facial andsubmento-vertical views.

• Fractures of the body of the mandible are bestseen on panoral tomography (OPG/OPT), lateraloblique, PA or PA oblique views. The PA oblique,or rotated PA is useful for throwing themandibular symphysis clear of superimpositionof the cervical spine. If not otherwise imaged, a reverse Towne's view provides reliable detail ofthe mandibular condyles.

Experience hasshown that it ispreferable for thecasualty to arrive at a special unit 48 hours afterwounding, ratherthan be operated on earlier by a non-specialist and possibly bemismanaged.


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Fig 1803 Common mandibular fractures.

Chapter_18.qxd 28/09/2004 15:57 Page 447

• Complex injuries of the face are confirmed by CTscan, ideally with 3-D reconstruction.

General management

1816 Control of bleeding

External bleeding from the head and neck canusually be controlled by applying a pressure dressingand sitting the casualty upright. NB: taking care thatthis does not interfere with the airway or put pressureon the globe. A useful technique in the neck is to use a fluid bag (0330). Alternatively, ligate thebleeding vessel with the aid of a good light, retractionand suction.

Bleeding from the mid-face may require packing, e.g.,a penetrating wound of the maxillary antrum. In thecase of severe bleeding from the nose, insert ananterior nasal pack (1916). An alternative emergencymeasure is to introduce two balloon catheters (1917).If the palate has a midline split, the maxilla will beunstable and nasal packing will not tamponadebleeding. If expertise and equipment are available, fix a miniplate over the midline of the palate, drillingthrough the mucosa, to stabilise the maxilla beforepacking the nose.

1817 Pain relief

Severe pain is not usually a feature of maxillofacialinjuries. Swallowing and talking can be uncomfortable.Give analgesia (Figure 0701), but take care to avoidrespiratory depression.

1818 Fracture treatment

For most facial injuries, no immediate splinting isrequired. Mobile, painful fractures can be supportedwith a bandage (Figure 1804).

Treatment of facial fractures should be carried out assoon as practicable. Most can be left untreated for upto ten days without adversely affecting the outcome.


Ligation of theexternal carotid is

rarely needed tocontrol facial

bleeding.

Nasal packing iscontra-indicated in

the presence of CSFrhinorrhoea.


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Because of the regional blood supply, healing is oftenuncomplicated and rapid. Fracture union usuallyoccurs in 3-4 weeks in the maxilla and 6-8 weeks in the mandible. Open reduction and internal fixationusing titanium plates, is favoured by many civiliansurgeons in preference to external fixation, evenwhen treating comminuted fractures. This allowsaccurate alignment, does not interfere with the airway and the casualty can soon eat a semi-soliddiet. Existing lacerations may be used for directaccess to fractures.

Where such equipment or expertise is unavailable,treatment should be aimed at preserving as muchviable bone and soft tissue as possible andpreventing infection.

1819 Antibiotics

Fractures involving the teeth and/or sinuses areregarded as compound and the casualty treated with peroperative antibiotics (0817, 0818). Longercourses should be given if wounds are contaminatedor treatment is delayed. Give tetanus toxoid wherenecessary (0828).

1820 Further management

With significant tissue loss, long term problems oftenoccur due to scarring and wound contracture. Tissues

Antibiotics: see Chapt 8


449

Fig 1804 Support of the injured jaw.

Chapter_18.qxd 28/09/2004 15:57 Page 449

should be maintained in their anatomical positionsand defects packed or dressed. Definitivereconstruction is best carried out early bymultidisciplinary teams once local infection is cleared and the casualty's general condition permits.

Fractures of the upper third

1821 Depressed or comminuted fractures of theskull vault often require treatment in conjunction witha neurosurgeon (1635). Isolated fractures of thesupra-orbital rim or frontal bone without a dural tear, may require reduction and fixation because of pressure on the orbital contents. These can bereadily treated under general anaesthesia via abicoronal flap. In the field, the wound should beexcised and dressed. Give antibiotics (0817, 0818)and refer for urgent repair.

Fractures of the middle third

1822 Zygoma

Displaced fractures are reduced via a temporal (in the hairline), or oral incision, using an elevatorto reposition the zygoma. Unless eye signs or limitedmouth opening are present, failure to reposition thefracture results in no more than a cosmetic defect.Reduced fractures are generally stable and do notrequire miniplate fixation. The risk of retrobulbarhaemorrhage is small, but is increased in fracturestreated late. After surgery, visual acuity should beregularly assessed. Orbital decompression isindicated if the casualty develops:

• Proptosis.

• Increasing pain.

• Diminished visual acuity.

In an austere environment, medical treatment with Acetozolamide 500mg i.v. (or 200ml of 20%mannitol plus 8mg Dexamethasone), may reduce

Management of Nasal Fractures: see Chapter 19

Definitive sinussurgery should only

be undertaken by anexperienced

surgeon. There is a risk of stenosis of

the frontal sinus.


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globe pressure and delay ischaemic changes in theoptic nerve.

1823 Orbital blow out fractures

Treatment involves replacing orbital structures which have herniated into the maxillary antrum andreleasing muscles trapped in the fracture line (Figure1703). This commonly requires insertion of a silasticor titanium mesh via a subciliary incision. Alternativegraft materials include: cartilage, bone andlyophilised pig dermis. Casualties should not blow their nose for 3 weeks; this may force antralcontents into the orbit, causing surgical emphysemaand infection.

1824 Maxillary fractures

The fracture is reduced so as to obtain a normaldental occlusion. If there are no associatedpenetrating injuries, this may be achieved by closedmanipulation. Open reduction allows precise fixationof fractures in their correct anatomical position.Methods of fixation include: internal wiring orsuspension wiring and intermaxillary fixation, internal miniplate fixation and external fixation. Mid face injuries may bleed heavily. Occasionally, a displaced mid face fracture may occlude the upperairway. This can be reduced bimanually and held in place by pulling on the nose (Figure 1805).

Alternatively, insert Foley catheters into eachposterior nasal space, inflate the balloons and apply forward traction (Figure 1905).

Mandibular fractures

1825 These are managed by open reduction and fixation using miniplates, or by eyelet wiring.Dental occlusion should be the guide to the correctrepositioning of the fragments, rather than theradiographic appearance of the bone ends.

Control of Epistaxis: see 1915 - 1917


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1826 Fractures of the mandibular condyles, even if displaced, are commonly not subjected to the difficult procedure of open reduction and fixation.Instead, a soft diet is prescribed. If the casualty canachieve their normal dental occlusion, surgery is notrequired (NB: eating will be painful in the first fewdays after injury). If the occlusion is still derangedafter one week, the fracture is treated by fixing eyelet wires or arch bars on the teeth and placingintermaxillary elastics to restore the correct occlusion.

1827 Only teeth which are loose should beremoved. Firmly embedded teeth near fracture linesare best left alone. Even damaged teeth can be used for fracture immobilisation. If the casualty wears a denture, this may be used for fracture stabilisation by inter-denture wiring or fixing it across the fracture site.

1828 Fixation techniques

• The simplest form of intermaxillary fixation is byinterdental eyelet wiring. In conjunction withcircum-zygomatic wires, it can provide a degreeof craniomaxillary fixation. Eyelet wires are mostcommonly made from soft, stainless steel wire of

Almost any soft wire can be used for intermaxillary

fixation, even fusewire. Failing this,

elastic bandswrapped around

the cleats of archbars will produce

stable fixation.18: M

axillofacial Injuries

452

Fig 1805 Bimanual reduction of a Le Fort 3 fracture which isobstructing the airway.

Chapter_18.qxd 28/09/2004 15:57 Page 452

0.5, 0.4 or 0.35 mm diameter, pre-stretched by10% (Figure 1806).

• An arch bar is used where multiple teeth aremissing. This is fixed to the existing teeth usingwire (Figure 1807). Once in place, the cleats on the bar can be used to stabilise and hold thefragments and to apply intermaxillary fixation.

• An alternative to miniplate fixation for anunstable mandibular angle fracture, is to drill two holes, either via the intra-oral route or asubmandibular incision and fix the fragments


453

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!

Fig 1806 Techniques of interdental wiring.

Chapter_18.qxd 28/09/2004 15:57 Page 453

together using stainless steel wire (Figure 1808).This is followed by intermaxillary fixation.

• For avulsion injuries causing continuity defectsof the mandible, the remaining teeth are placedin intermaxillary fixation and external pin fixationis applied to stabilise the bone fragments.(Figure 1809). The intermaxillary fixation is bestleft on but can be released for casualty transfer.Distraction osteogenesis may be a useful adjunctfor the reconstruction of larger bony defects.

Anitbiotics for Soft Tissue Wounds: Chapter 8


454

Fig 1807 Using an arch bar: several methods of fixation illustrated.

Chapter_18.qxd 28/09/2004 15:57 Page 454

Soft tissue injuriesExcision and closure

1829 Wound excision and closure are describedin 0504. Additional points include:

Ideally, dental or fracture fixation is carried out first. If there is delay, lacerations overlying a bony injuryare closed.

Contaminated wounds should be excised (LA or GA)to avoid infection and skin tattooing (0503, 0504).Particles can be removed with forceps, a blade or a sterile scrubbing brush using hydrogen peroxide.Such wounds need antibiotic treatment (0816, 0817).

Preserve as much viable soft tissue and bone aspossible. If contused or ragged, trim 1-2mm off the skin edge using ophthalmic scissors and a No 15 blade so as to achieve non-contaminated, non-bevelled edges. If bone fragments are attached

Plastics and Reconstruction: see Chapter 23

Always coverexposed bone with soft tissues.


455

Fig 1808 Fixing a mandibular fracture using wire (usually combinedwith intermaxillary fixation).

Chapter_18.qxd 28/09/2004 15:57 Page 455

to periosteum or soft tissues, leave the bone in situ.Small areas of borderline viability often survive. Use absorbable sutures within the oral cavity such as3/0, undyed polyglactin (Vicryl rapide™).

Close deep facial wounds in layers. A watertightclosure over a fracture is desirable. Avoid deadspace. Undermining of the edges may be required to reduce tension (Figure 0504). Drains are rarelynecessary. Remove skin sutures after 4-5 days.Steristrips can be used for superficial wounds, or to support wounds after suture removal.

1830 Facial nerve

If severed branches are encountered they should be tagged with a non-resorbable suture for lateranastomosis and the wound closed (1910).

1831 Soft tissue loss

If there has been extensive soft tissue loss so thatclosure without tension is impossible, the underlyingbone can be covered by suturing skin to mucosa(Figure 0503). This can be revised later.

Large areas of tissue loss can be reconstructed usinglocal or distant flaps. Such areas may be covered inBetadine soaked swabs until the casualty istransferred for definitive treatment.



456

Fig 1809 External fixation of a mandibular fracture where there isbone loss.

Chapter_18.qxd 28/09/2004 15:57 Page 456

Indications for a surgical airway in maxillofacial casualties1832 These include:

• Where there is doubt about the continuedpatency of the airway without supervision,especially during transfer.

• Wounds of the jaw associated with laryngeal and some pharyngeal injuries.

• Intermaxillary fixation with any degree of respiratory obstruction.

• Gross tissue loss which is associated withsevere swelling.

Nursing of maxillofacial casualties 1833 Essentials are:

• Pain control.

• Oral hygiene. Brush teeth daily and regularlyirrigate the mouth with 0.9% saline or a weakchlorhexidine mouthwash. Intermaxillary fixationmay dry and traumatise the lips. Apply petroleumjelly frequently.

• An appropriate soft diet for the period of fixation.In the case of intermaxillary fixation, the casualtyrequires a per oral, liquid diet. Alternativeapproaches are via a fine bore nasogastric tube or percutaneous gastrostomy.

Wisdom Teeth1834 In recent conflicts, a significant cause of sickness amongst UK troops has been impactedwisdom teeth. The affected tooth (usually the lower)is partly erupted, allowing food and debris to becometrapped around and beneath the gum. If the soldier is unable to clean the area, it becomes inflamed,infected and painful.

Analgesia: see Chapter 7 Technique of Surgical Airway: see Chapter 30


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• Cure is by removing the tooth. Alternatively, it isoften helpful to extract the opposing tooth fromthe upper jaw.

• Until dental treatment is available, prescribewarm saline mouth baths and antibiotics e.g., penicillin V, 500 mg four times daily, ormetronidazole, 400 mg three times daily (0816,0817).

Transfer1835. Considerations are:

• Casualties without a definitive airway should be transferred in the three-quarter prone position(Figure 0308). They must be carefully supervised.

• A suture through the tongue does not produceadequate control of the airway. If in doubt,perform a surgical airway (1832).

• Attendants must be instructed in the dangersand management of respiratory obstruction.

• For casualties transferred in intermaxillaryfixation, especially by air or sea, it is mandatorythat wire cutters are available. If the casualtydevelops respiratory obstruction anyintermaxillary fixation must be releasedimmediately. Anti-emetics may be prescribedbefore transfer but, are not a substitute forcareful supervision.

• The priorities for transfer of maxillofacialcasualties are:

• T1 Airway problems.

• T2 Multiple facial injuries without airway compromise.

• T3 Uncomplicated maxillofacial injuries.

Triage: see Chapter 6


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Chapter 19

Injuries of the Ear, Nose and Throat (ENT)

Introduction

1901 Missile and blast weapons affecting thehead and neck can cause injury in areas served byone or more of the following specialities: neurosurgery(Chapter 16), ophthalmology (Chapter 17),maxillofacial surgery (Chapter 18), and ENT. Early management of ENT injuries is generallystraightforward. The immediate risk is airwayobstruction due to disruption of the pharynx andlarynx, a facial fracture or bleeding and swellingaround the upper airway. Because endotrachealintubation is likely to be difficult and requireanaesthetic expertise, securing the airway may need a cricothyroidotomy or tracheostomy (0322).

1. Ear

1902 Rupture of the tympanic membrane,disruption of the ossicles and damage to the innerear, can all affect hearing. Balance may be disturbedby injury to the vestibular apparatus. The grossanatomy of the ear is illustrated in Figure 1901.

External earInjuries to the pinna

1903 These include haematoma, simplelaceration and partial or complete avulsion:

• A haematoma requires prompt treatment to avoid cartilaginous necrosis and development of a "cauliflower ear". If liquefied, aspirate using

Causes of Injury: see Chapter 2

Following blast injury deafness may impaircommunication with the casualty.

Incorrect treatmentof injuries to theexternal ear canresult in cosmeticdeformity.

19: Injuries of the Ear, Nose and Throat (ENT)

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a syringe and large bore needle. If a solid ororganised clot is present, incise and evacuatethis under aseptic conditions. Afterwards, apply a pressure dressing.

• For a simple laceration, excise damagedauricular skin and close with interrupted, non-absorbable sutures (e.g., 4/0 Prolene).

• Following partial avulsion of the auricle, excise nonviable tissue and re-approximate as illustrated in Figure 1902A. Do not suturecartilage; this may cause infection(perichondritis) leading to necrosis.

• If a portion of the auricle is lost, suture theremaining anterior and posterior skin layers overthe exposed cartilaginous edge (Figure 1902B).A plastic surgical repair can be undertaken later.



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A

B

Chapter_19.qxd 28/09/2004 15:57 Page 460

Injuries to the ear canal

1904 Treatment is generally to suture and pack:

• Repair lacerations of the external auditorymeatus using absorbable sutures (e.g., 4/0Vicryl). If this is difficult, approximate the edgesas best you can.


461

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Fig 1902 A) Suturing a simple laceration of the external ear. B)Repair after tissue loss.

Chapter_19.qxd 28/09/2004 15:57 Page 461

• Pack the lumen with bismuth iodoform paraffinpaste (BIPP) ribbon gauze to keep the meatuspatent and prevent stenosis. The pack should be left in until formal assessment by an ENT surgeon.

• If there is otorrhoea, place a cotton wooldressing in the entrance of the ear canal.

Middle ear1905 Damage to the tympanic membrane (TM) is common and often associated with more seriousinjuries elsewhere. Causes include direct penetration,base of skull fracture involving the tympanic ring andblast injury. Haemorrhage into the TM may also occurwithout rupture (haemotympanum), causingimmediate deafness. When damage is suspected,examine the ear carefully using an otoscope with a sterile tip. Do not syringe.

• If the tympanic membrane is ruptured, avoid interference.

• Protect from further injury:

• Ideally, the casualty should wear eardefenders - there may be tactical constraints!

• Keep it dry - place cotton wool in the entrance of the ear canal.

• Nose blowing is contraindicated until the rupture has healed, (approximately 6 weeks).

• Seek an early review by an ENT Surgeon. The tympanic membrane usually healsspontaneously. If not, it can be repaired later.

• Antibiotics are not routinely required. If suppuration develops, treat with topical and systemic antibiotics:

• Sofradex™ or Gentisone HC™ 2 drops

The most importantdelayed complication

of middle ear injuryis infection.


462

Chapter_19.qxd 28/09/2004 15:57 Page 462

three times daily for at least 5 days or untilotorrhoea has stopped.

• Amoxicillin (500mg) or co-amoxiclav (375 to 625mg) three times daily for 7 days.

• Because of the risk of meningitis, administerantibiotics in the presence of CSF otorrhoea in a battlefield situation (0818). Leakage usuallyceases spontaneously (1637).

Inner ear1906 Causes of inner ear damage include:

• Continuous loud noise.

• Blast injury.

• Otitic barotrauma.

• Head injury.

Blast injury

1907 The tympanic membrane (TM) is particularlysusceptible to overpressure (0219) and ruptures atabout 35kPa. The shock wave and high intensitynoise, may cause sensorineural hearing loss(damage to the function of the cochlear nerve).Hearing usually improves rapidly, but high frequencylosses can persist. When possible, the casualtyshould avoid exposure to further acoustic trauma by wearing ear defenders.

Small overpressures in a confined space can causedislocation of the ossicles by direct displacement or,distortion of the TM at the attachment of the malleus.Deafness may result.

Otitic barotrauma

1908 Damage may occur due to changes in external pressure e.g., during flying and diving,and where the Eustachian tube fails to adequately



463

Chapter_19.qxd 28/09/2004 15:57 Page 463

equalise pressure in the middle ear. Negativepressure causes medial displacement of the tympanic membrane resulting in hyperaemia,oedema and ecchymosis of the middle ear mucosa.

The tympanic membrane may rupture. In extremecases, a perilymph fistula develops secondary torupture of the membrane of the round window. The casualty presents with profound vertiginoussymptoms, nystagmus and sudden sensorineuralhearing loss:

• Keep the ear dry.

• Otalgia and aural fullness are reduced bydecongestant nasal drops e.g., xylometazolinehydrochloride 2 drops three time daily for 7 daysfor a maximum of 2 weeks.

• Dizziness usually slowly improves. Treat vertigowith prochlorperazine, 5mg three time daily(maximum 2 weeks).

• Seek urgent ENT advice.

Head injury

1909 Labyrinthine concussion - mild unsteadinesswith change of head position - generally only occursafter major head injury. The casualty may also havenystagmus and a mild, high frequency sensorineuraldeafness. As the effects of the concussion resolve,so do the signs and symptoms.

A blow sufficient to cause a transverse fracture of thetemporal bone may produce a high frequencysensorineural deafness.

• Treat vertigo with prochlorperazine, 5mg threetime daily (maximum two weeks).

Facial nerve1910 Facial nerve paralysis - partial or complete -can occur following fracture of the skull base.

Symptoms of inner ear damageinclude deafness,

high-pitched tinnitusand, in severecases, vertigo.


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Chapter_19.qxd 28/09/2004 15:57 Page 464

Approximately 80% of temporal bone fractures arelongitudinal; the inner ear is generally not involvedand facial nerve damage is unusual. If there isparalysis, it tends to be late and occur as a result of swelling. Prognosis is generally good.

The inner ear is often in the line of a transversefracture, resulting in total sensorineural hearing loss, horizontal nystagmus and giddiness due todestruction of the vestibular labyrinth. Approximately50% of these casualties will suffer a facial paralysis.

• In general, early facial nerve palsies requireurgent repair by an experienced ENT surgeonvia a middle ear and mastoid exploration.

2. Nose

1911 Injuries of the upper third of the face tend to involve the frontal sinuses and can be associatedwith dural tears and CSF leakage. Fractures of themiddle third of the face may be confined to the noseor involve the maxilla and the zygomatic arch (Figure 1802).

Septal haematoma1912 This follows a direct blow to the nose. A septal haematoma may occur in combination withfracture of the nasal bones. The casualty complainsof nasal obstruction. On examination, the septumbulges and resembles a cherry tomato. Treatment is prompt incision and drainage.

• Under aseptic conditions, incise the anterior and dependent portion of the haematoma andevacuate the contents.

• Insert bilateral intranasal packs; leave them in-situ overnight to prevent re-accumulation of the haematoma.

Skull Fracture: see Chapter 16


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• Give co-amoxiclav (625mg three times daily) for 7 days.

• Neglecting a septal haematoma leads toinfection, abscess formation, cartilaginousnecrosis and nasal deformity.

Nasal fracturesSimple fractures

1913 Management of an obviously displaced fracture:

• If seen immediately after injury, attemptreduction (without anaesthetic).

• If presentation is delayed, reduce the fracturebetween 7 and 14 days post-injury. This can be done under local or general anaesthesia. To obtain local anaesthesia, spray inside thenose with lignocaine or cophenylcaine and inject approximately 2ml of 2% lignocaine with1:80,000 adrenaline, at various points around the bony nasal skeleton using a dental needle.


466

Fig 1903 Insertion of a nasal tampon.

Chapter_19.qxd 28/09/2004 15:57 Page 466

Open fractures

1914 Treatment is wound excision and earlyreduction under GA.

• If the wound is clean, close the defectimmediately using fine, non-absorbable sutures.

• If the wound is contaminated, excise andperform delayed primary closure (0503).

· Give co-amoxiclav (625mg three times daily) for 7 days.

Epistaxis

1915 Bony injury to the nose, maxillary antrum orethmoid cavities, can cause significant haemorrhage(1816). This is controlled by packing.

1916 Anterior nasal packing

• The easiest method is to insert a nasal tampon - application is aided by applying aqueouslubricating jelly to the tampon (Figure 1903).

• For more specific control, a BIPP ribbon gauzepack is inserted in layers (Figure 1904).


Haemorrhage from one side can manifest itselfequally from bothnostrils.


467

Fig 1904 Insertion of a BIPP ribbon gauze pack.

Chapter_19.qxd 28/09/2004 15:57 Page 467

• Management of epistaxis in the presence of a midline split in the palate - see 1816.

1917 Posterior nasal packing

This may be required if anterior packing fails tocontrol the epistaxis.

• Insert a 12 or 14G Foley catheter with a 20mlballoon into the nose until the tip of the catheteris just visible behind the soft palate.

• Inflate the balloon with air or water to three-quarters capacity and pull the catheterback until the balloon occludes against thechoana at the back of the nose (Figure 1905).

• Tape the catheter to the side of the face.

3. Injury to the Face and Para-Nasal Air Sinuses

1918 Management of fractures are discussed inparagraph 1818. Skin wounds can usually be closedprimarily after minimum excision (0504).

Management of Facial Fractures and Soft Tissue Wounds: see Chapter 18

When insertingballoon catheters to

control epistaxis,ensure that the nasalrim is protected with

gauze to preventpressure necrosis.


468

Fig 1905 Insertion of balloon catheter to control epistaxis

Chapter_19.qxd 28/09/2004 15:57 Page 468

4. Pharynx and Larynx

Cervical spine1919 Blunt trauma is discussed in paragraph0307 and penetrating injury in 0308.Ensure that neck radiographs include the mostcommonly injured vertebrae - C6 and C7. Where afracture or dislocation is suspected, perform odontoidpeg and AP views in addition to a lateral radiograph.CT scanning may allow a more confident diagnosis.

Blunt trauma to the anterior neck1920 The classic cause is impact with thesteering wheel or motorcycle handlebars in a roadtraffic accident. The mechanism of injury is any directblow from whatever cause. The aide memoire'TWELVE' is useful during the primary survey (0309).Signs and symptoms of anterior neck trauma aresometimes subtle. During the secondary survey look for:

• Hoarseness or change in voice quality.

• Dysphagia.

• Odynophagia.

• Pain and tenderness on palpation.

• Surgical emphysema.

• Ecchymosis.

Management

1921 When available, perform laryngoscopy toevaluate the mobility of the vocal cords and patencyof the airway.

1922 Minor neck injury

• In the absence of hoarseness or change in voicequality, dysphagia, surgical emphysema and

Any history of blunttrauma to the neckshould always raisethe question oflaryngeal injury.

Failed attempts tointubate a casualtywith a significantneck injury, may riskcompletely losing analready marginalairway. This is a taskfor an experiencedanaesthetist.


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abnormal laryngoscopy findings, the injury can be managed conservatively. Observe thecasualty for a minimum of 24 hours to excludedelayed airway compromise. Give 3 doses of 4 - 8mg dexamethasone i.v.

1923 Major neck injury

• All casualties who have suffered significant blunttrauma to the neck require a secure airway. In an emergency, perform a cricothyroidotomyunder LA (3005). Where time, experience andcircumstances allow, undertake a tracheostomy(3007).

• Adjunctive medical treatment includes:

• 4-8mg of dexamethasone i.v. three times daily for 1-3 days.

• Humidified oxygen.

• Gastric acid inhibition - ranitidine 50mgtwice daily i.v.

• If the mucosa has been disrupted, give antibiotics (0817).

• Oral feeding due to pain and swelling willinitially be difficult. Nasogastric feedingshould be started as soon as possible.

• Transfer the casualty to a specialist unit for CTimaging and formal direct larygopharyngoscopy,oesophagoscopy and bronchoscopy. This willallow the extent of the injury to be ascertainedand formal repair planned and executed.

Penetrating neck injury1924 The neck is divided into 3 zones (Figure1906) based on patterns of vascular injury:

• Zone 1: contains the vessels at the root of theneck: the brachiocephalic trunk, subclavian and

Performing a Surgical Airway: see Chapter 30


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Chapter_19.qxd 28/09/2004 15:57 Page 470

common carotid arteries and their correspondingveins. The other main structures are the thoracicduct, thyroid gland, trachea, oesophagus andspinal cord.

• Zone 2: contains the internal and externalcarotid arteries, internal jugular veins, vertebralarteries, larynx and hypophayrnx, spinal cordand cranial nerves X, XI and XII (Figure 1015).

• Zone 3: contains internal and external carotid


471

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Fig 1906 Penetrating neck injury - classification according to zones.

Chapter_19.qxd 28/09/2004 15:57 Page 471

arteries, vertebral arteries, internal jugular veins,cranial nerves V and VII to XII and the spinal cord.

The most common site of injury is Zone 2 followed by Zones 1 and 3. Identifying the zone of injury hasimplications for the surgical approach (1036-1039).

1925 Penetrating injuries are life threatening due to

• Disruption of the trachea.

• Bleeding - exsanguination is the commonestcause of death following neck injury. Haematomamay also cause tracheal compression.

• Surgical emphysema and subsequent infectionwithin the tissue planes.

Signs and symptoms of penetrating neck injury

1926 These include:

• Vascular injury: shock, profuse bleeding,evolving stroke, expanding haematoma,haemoptysis, haematemesis and the presence of a bruit or thrill over the wound.

• Laryngotracheal injury: subcutaneousemphysema, hoarseness, respiratory distressand stridor.

• Oesophageal injury: limited signs andsymptoms may make early diagnosis difficult.Clinical features can include: neck pain, blood in saliva or nasogastric aspirate and thepresence of surgical emphysema in the neck.

· Spinal cord injury: there may be a mixture ofneurological signs including hemi orquadriparesis, with or without spinal shocksyndrome - hypotension without a tachycardia.

Perform a surgicalairway whenever

there is doubt aboutthe continuing

adequacy of theairway, especially

when supervision islikely to be poorduring transfer.

"The time to do atracheostomy is

when you first thinkabout it" - Mosler


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Treatment

1927 Measures include:

• Where the airway is at risk, perform acricothyroidotomy (3005) or tracheostomy (3007).

• Control haemorrhage (0330) and resuscitate(0331).

• In the field, the absence of angiography andinterventional radiology mean that all injurieswhere the platysma has been penetrated, must be explored, even in asymptomaticcasualties. Exposure and treatment arediscussed in 1037-1039.

Vascular Exposure in the Neck: see Chapter 10

Neck explorationmust be undertakenby an experiencedsurgeon.


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Chapter 20

Spinal Injuries

Introduction

2001 The spine is a bony, articulated structurethat extends from the base of skull to the pelvis; it protects the spinal cord and supports the frame. The centrally located cord divides at L1 into thecauda equina comprising multiple nerve roots.Spinal trauma is uncommon during militaryoperations and usually occurs in combination withother injuries. Damage to the bones can causeinstability, whilst injury to the spinal cord may resultin neurological deficit. Outcome following cord injuryis dependent upon:

• Level of injury.

• Early recognition.

• Prevention of secondary insult, both mechanical and physiological.

• Prevention of complications: respiratory,gastrointestinal, urological and pressure sores.

Spinal casualties require specialist care at Role 4 tooptimise recovery.

Aetiology

2002 Spinal damage can be caused by blunt injury, including blast, penetrating injury or combinations of both. Penetrating neck woundsinvolving the bony cervical spine and spinal cord,carry a 95% mortality (0308). The military surgeonis far more likely to be called upon to deal with bluntrather than penetrating trauma.

Cervical Spine Protection: see Chapter 3

When a fracture is seen in one part of the spine, a second, non-contiguousfracture is present in~10% of casualties- this must be

looked for.

20: Spinal Injuries

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Blunt

2003 Fractures and dislocations of the spine in military personnel are typically seen after RTAs,tactical parachute drops, falls, sports injury andbodily displacement secondary to blast. The cervicalspine and thoraco-lumbar junction are particularly at risk. There may be disruption to the bone or softtissues, resulting in an unstable injury. At this stage,the casualty may or may not have spinal cord injuryproducing neurological deficit.

Penetrating

2004 High energy-transfer wounds are often fataldue to associated injuries. Fragments or bullets candamage the spinal cord directly and affect a variablenumber of adjacent levels. Alternatively, the shockwave of the missile passing close to or striking thevertebrae, can produce indirect injury (0206).

Management

History2005 Features suspicious of spinal trauma aredescribed in 0307 and 0308. Neurological deficit maybe readily apparent in a co-operative casualty. It isfrequently missed in the unconscious or those withmultiple injuries. Symptoms may include localisedspinal pain or regional discomfort.

Examination2006 A neurological examination is undertakenduring the secondary survey.

• Inspection of the back requires a four man log roll (Figure 0323).

• Look for wounds, swelling or palpable deformity.

• Examine for associated injuries, including

High Energy Transfer Wounds: see Chapter 2

The frequency of gunshot woundsin civilian practice

affecting the spinalcord varies between<1% in Croatia to up

to 25% in the USA.

During primary and secondary

surveys, spinal cordinjury can maskcoexisting intra-

thoracic orabdominal injuriese.g., guarding and

tenderness may be absent.

20: Spinal Injuries

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calcaneal fractures, lumbar burst fractures and multi-level spinal cord damage.

• The level of cord damage can be estimated fromassessing sensory disturbance (Figure 2001).and motor weakness (Table 2001). Look forsacral sparing i.e., the presence of peri-analsensation and anal muscle tone and contraction,this indicates incomplete spinal cord damage.

• Respiratory difficulties are a sign of cervicaltrauma (Figure 2001). Diaphragmatic breathingand paradoxical chest wall movement arefeatures of lower cervical injury. In high cervicalinjuries, there is loss of diaphragmatic innervation(C3,4 and 5).

• Loss of sympathetic tone results in bradycardiaand hypotension. The male casualty may havean erection.

Findings should be carefully documented. Attentionto detail is vital; the initial neurological examination is often the most important and is a guide to theultimate prognosis.

Investigation2007 As long as the casualty is appropriatelyimmobilised, plain radiographs can wait until Role 3.CT scanning is undertaken at Role 3 or 4 to clarifyvertebral and cord damage.

Treatment at Role 1 and 22008 If there is any doubt regarding the presenceof a neurological deficit or stability of the spine, thenthe casualty should be assumed to have an unstablespine, until proven otherwise at Role 3. If this isdone, radiographic clearance of the spine can besafely deferred.

• Management of ABC. This will minimisesecondary physiological insult to the traumatised

Management of ABC: see Chapter 3

Casualties withspinal injury shouldalso be consideredto have head injuriesuntil provenotherwise and viceversa, in particular,those who areunconscious.

20: Spinal Injuries

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spinal cord. Give i.v. fluids to counteract the lossof vaso-motor tone but, avoid over transfusion.Atropine and vasopressors can be of benefit inneurogenic shock.

• Apply three point, cervical spine immobilisation

20: Spinal Injuries

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(0318) and fix the casualty to a spinal board(Figure 0324). NB: pressure sores start todevelop after 30 minutes. Pad well, remove thecontents of back pockets and move the casualtyoff the board as soon as possible.

• Ventilatory support, if appropriate may berequired in those with high cervical cord injuries.

• Because of the risk of aspiration, pass anasogastric tube; leave it on free drainage and aspirate the tube regularly.

• Catheterise the bladder and monitor fluid balance.

• Consider prophylactic antibiotics (open injuries - 0818; associated penetratingabdominal injury - 0817), antacid treatment (e.g., ranitidine) to prevent stress ulcers andDVT prophylaxis (0980).


• Sedation for agitation, but, first exclude a medical cause .

Transfer2009 Move fixed to a spinal board or using a fullsize vacuum mattress. Casualties should be


Do not dismisshypotension as being secondaryto the spinal cordinjury until allpotential sources of bleeding havebeen excluded.

Steroids are notconsidered of valuein acute spinalmanagement.

20: Spinal Injuries

479

C-5 Deltoid (biceps jerk C5, 6)

C-6 Wrist extensors (extensor carpi radialis longus/brevis)

C-7 Elbow/extensors/triceps jerk (triceps)

C-8 Finger flexors to middle finger (flexor digitorum profundus)

T-1 Little finger abductors (abductor digiti minimi)

L-2 Hip flexors (iliopsoas)

L-4 Knee extensors (quadriceps; knee jerk L3,4)

L-5 Ankle dorsi flectors (tibialis anterior)

S-1 Ankle planter flexors(gastrocnemius, soleus; ankle jerk S1,2)

S-5 Anal reflex

Table 2001 Key muscle(s) and their spinal nerve segment.

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appropriately marked e.g.;

"Unable to move please alter position 2 hourly"

Where resources and experience are available,immobilise the cervical spine using skull tractionfor example, Gardner-Wells' callipers and transport

the casualty on a turning frame - Stryker or Poveyframe. Facilities and medical experience must beavailable to deal with potential complications en-route. Comprehensive documentation mustaccompany the casualty.

Treatment at Role 3 and 4Nursing

2010 Appropriate care by a multi-disciplinaryteam will prevent complications and optimiseoutcome after cord damage. Considerations include:

• Respiratory

Regular chest physiotherapy and, when indicated, ventilatory support.

• Gastrointestinal

Nasogastric intubation to combat ileus.Maintenance of nutrition (high protein diet).Prevention of faecal impaction i.e., suppositories,enemas, manual evacuation.

• Genitourinary

Catheter care. Consider a supra-pubic catheter.

• Locomotor

Early mobilisation of paralysed joints to prevent contracture.

• Skin

Avoid soiling with faeces or urine.Two hourly turning. Assessment for pressure sores.

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Surgery

2011 Penetrating injuries involving the spinal cord

With the exception of wound excision and delayedprimary closure, operative treatment of these casesshould not be undertaken in anything other than a fixed specialist facility. The role of surgicalmanagement remains controversial. Possibleindications include:

Spinal instability.

Progressive neurological deficit.

Persistent CSF leak.

Decompression of partial cord injuries.

Prevention and treatment of infectious complications.

Retention of a foreign body in or around the spinalcord rarely causes problems. Indications for removal include:

• Infection.

• Foreign body reaction.

• Copper or lead foreign body in a join or disc space.

• Radicular pain where the foreign body isdemonstrated to be compromising the root.

2012 Non-penetrating injuries

Surgical stabilisation should be delayed pending appropriate radiological investigations.


Early fixation can help with themobilisation andtransfer of complex,unstable spinalinjuries but requiresexpertise.

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Chapter 21

Peripheral Nerve Injuries

Introduction

2101 Peripheral nerve damage occurs as a resultof penetrating or blunt trauma. It is frequent in warfighting and can have a major effect on functionaloutcome. Partial loss of nerve function is common.Nerve injury is rarely isolated and commonlyassociated with vessel, bone and soft tissue damage. Careful, early management optimisesrecovery. Where necessary, nerve repair should becarried out at a Role 3 or 4 facility but, only underideal conditions, which are:

• Following excision of all devitalised tissue.

• An absence of infection.

• A well vascularised wound environment.

• A skilled surgeon with appropriate equipment.

Pathophysiology

Anatomy2102 The structure of a peripheral nerve isillustrated in Figure 2101.

Classification of nerve injuries2103 This is based on the degree of anatomicaldamage and the potential for regeneration.

2104 Neurapraxia (First degree injury).Stretching or distortion of the nerve due to blunt,blast or high energy-transfer injury results in a

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physiological paralysis. The neurilemma sheath(Schwann cell layer) and the central axon remain in-continuity and degeneration does not occur.Recovery time varies between several hours up to twelve weeks and is usually complete.

2105 Axonotmesis (Second - Fourth degreeinjury). The axon is severed, but the structure of thenerve is maintained by the intact neurilemmal sheath,perineurium or epineurium. A typical example ofaxonotmesis is radial nerve palsy after fracture of the humerus. Initially, there is degeneration of theaxon distal to the division (Wallerian degeneration),followed by regeneration. A spray of processes grows from the proximal end of the axon. When one of these finds its way into the distal neurilemmalsheath, the others regress. The process grows downthe tube at a rate of 1-2mm per day. Eventually, thereis regeneration of the end organ.


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The damage to the supporting connective tissuelayers and the degree of intraneural fibrosis, dictatethe extent of axonal regrowth and eventual recovery:

• Second-degree injury: no intraneural fibrosis.Recovery may be near complete.

• Third-degree: moderate fibrosis.

• Fourth-degree injury: dense fibrosis blocking any axonal fibre regrowth. Regeneration is onlypossible if the affected segment is excised andthe nerve repaired or grafted.

2106 Neurotmesis (Fifth-degree injury). Thenerve is completely divided. The ends tend to retractcausing a variable gap. Degeneration occurs distal tothe injury. The nerve must be repaired if any recoveryis to take place; results are better if this is carried outearly. Even after the most skillful repair, recovery isaffected by incorrect rewiring i.e., regeneratingsensory and motor nerve fibres make connectionswith organs which they did not previously innervate.

Management

Recognition of injury2107 Find out the mechanism of injury and, in the case of penetrating injury, factors that mayindicate the path of the missile. Certain long bonefractures (e.g., humerus+radial nerve, femur+sciaticnerve) and fracture-dislocations (e.g., elbow+ulnanerve, knee+common peroneal or posterior tibialnerve) are associated with nerve damage. Besuspicious when dealing with penetrating injuries and high energy-transfer wounds in the vicinity ofimportant nerves. Because the major arteries andperipheral nerves usually accompany one another,injury to one suggests damage to the other.

Test and recordfunction of the major peripheralnerves beforeanaesthesia ortransfer. This takesonly seconds to do.Nerve injury is easily missed in the unconsciouscasualty.


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Compare findings in both limbs. Look for:

• Loss of sensation - for pure sensory or mixednerves. Test with a pin. Two-point discriminationis useful in assessing significant nerve injury and monitoring recovery of digital nerve injuries.All that is required is a bent paper clip. In thefinger pulp, normality is approximately 4mm.

• Loss of sweating - sensory nerve only: this is demonstrated in hand injuries by assessingadherence:

The plastic pen test. A plastic pen is gentlystroked along the skin on each side of the finger.There is normally slight adherence. Followingnerve damage, if there is no sweating there is no adherence.

• Loss of motor activity - pure motor or mixed nerve.

Following neurapraxia, there is typically paralysis of the muscle groups innervated by the nerve; a degree of sensation and autonomic function is preserved. After axonotmesis and neurotmesis, all power, sensation and autonomic function are lost.Diagnosis of nerve injury can be difficult and majordefects are frequently missed. When in doubt, re-examine with 48 hours of injury.

At Role 4, MRI can be used to determine thecontinuity of a peripheral nerve. Nerve conductionstudies and electromyography are used to determinethe functional status of a segment of nerve.Myelography may be helpful in assessing avulsionfrom the cord following brachial plexus injury (2130).

Specific nervesBrachial plexus

2108 Injuries are due to violent traction orpenetrating trauma. Nerve roots may be avulsed from the spinal cord. All parts of the plexus canundergo any of the injury types described in 2103.

When carrying out the plastic pentest, always try an

uninjured finger firstso as to get a feel

for the normalamount of

adherence.


486

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The classic sites for damage are at the C5-C6 (Erb's Palsy) and C8-D1 roots (Klumpke's Palsy - rare). In the former, there is loss of abduction and external rotation at the shoulder, elbow flexionand forearm supination: the arm adopts the 'waiter'stip' position.


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The effects of injury may range from paralysis ofmuscle groups and areas of anaesthesia, through toa useless, flail limb. The affected parts of the brachialplexus can be diagnosed by assessing dermatomesand motor and sensory loss in the peripheral nervesof the upper arm (Table 2001, Figure 2102). Look forswelling in the posterior triangle of the neck, a Horner's syndrome (indicates preganglionic injury)and fractures of the clavicle, ribs and vertebrae.

Axillary nerve

2109 The axillary nerve winds round the neck of the humerus and is injured following shoulderdislocation. Feel for contraction in the deltoid muscleon abducting the arm. Test pinprick sensation in theouter shoulder - the skin overlying the lower deltoid.The majority of cases recover spontaneously.

Musculocutaneous nerve

2110 Assess for absence of elbow flexion andloss of sensation along the lateral forearm.


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Chapter_21.qxd 28/09/2004 15:57 Page 488

Median nerve

2111 In the upper arm, the median nerve isassociated with the brachial artery (Figure 1020);damage to one is likely to affect the other. The nerveis classically injured at the elbow or wrist. Assessmotor function by asking the casualty to touch the tipof the little finger with their thumb (Figure 2103). Test the power of finger flexion in the index andmiddle finger. Can the casualty feel a pinprick at the tip of this index finger (Figure 2104)?

Ulnar nerve

2112 The ulnar nerve passes behind the medialepicondyle at the elbow and continues distally in the forearm with the ulnar artery (Figure 1022).It is vulnerable at both sites. Assess motor functionby asking the casualty to spread their fingers againstresistance (Figure 2105) or to grip a piece of paperbetween them. Test sensation in the tip of the littlefinger with a pin (Figure 2104).

Radial nerve

2113 The radial nerve passes in a grove behindthe mid humerus and is at risk following missileinjuries. If motor function in the hand is affected


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(wrist drop), the injury is above the elbow. If onlysensation is lost then injury is below the elbow. Ask the casualty to extend their wrist and fingers(Figure 2106). Because of overlap, test pinpricksensation over the first dorsal web space (Figure2104). Recovery is usually good, either afterconservative management or repair.

Femoral nerve

2114 The femoral nerve passes under theinguinal ligament lateral to the femoral artery (Figure 0702), beyond which it divides into multiple,superficial branches. Damage results in paralysis ofthe quadriceps muscles, loss of knee extension andanaesthesia of the anteromedial thigh.

Sciatic nerve

2115 The sciatic nerve may be damage along itscourse by a pelvic fracture, posterior dislocation ofthe hip, femoral fracture or a compartment syndromeof the thigh (Figure 2107). Assessment is as for theperoneal and posterior tibial nerves. Prognosis ispoor, especially for proximal lesions.

Peroneal nerve

2116 The peroneal nerve is at risk from lateralblows to the knee, badly applied POP and traction


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Fig 2105 Ulnar nerve: testing motor function.

Chapter_21.qxd 28/09/2004 15:57 Page 490

splints, or a lower leg compartment syndrome (0906).Paralysis causes foot drop. Test the casualty's abilityto dorsiflex their ankle against resistance (Figure 2108) or instruct them to walk on their heals.Sensation is lost in the area indicated in Figure 2109.

Posterior tibial nerve

2117 Test the casualty's ability to plantar flex theirankle against resistance (Figure 2108) or instruct

Compartment Syndrome: see Chapter 9


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them to stand on tiptoe. Sensation is lost in the areaindicated in Figure 2109.

Initial management of penetrating wounds 2118 General wound management is described inChapter 5. Nerve repair in the field is generallydelayed until a 'second look' procedure (0510).

• During wound excision, identify the nerve ends.Tack them with a fine nylon suture to aidsubsequent identification.

• Prevent retraction of the nerve ends witha loose, intervening suture, or fix them toadjacent tissues.

• Often, the nerve will be swollen and discolouredbut in continuity. Open the sheath longitudinallywithout damaging the local blood supply. Trimobviously damaged fascicles, but leave partiallydamaged tissue alone. Mark the site of injury.

• Keep the wound moist with saline or Povidoneiodine soaks during surgery. At all stages, coverthe exposed nerve with soft tissue, otherwise it will dry out. This may require mobilisation of a flap.


• Keep injured limbs elevated. Immobilise using


Management of nerve injuries begins

with appropriatecasualty and wound

management.Management of ABC

takes priority.

The effects of nerve damage

can sometimes behelped by tendon

transfer or jointarthrodesis.

Keep manipulationto a minimum so as

to reduce scarringand subsequent

surgical difficulties.


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Chapter_21.qxd 28/09/2004 15:57 Page 492

a Plaster of Paris slab in a position of function.Examples include: a cock-up splint to preventwrist drop and a right-angle splint in casualtieswith foot drop. This minimises muscle and jointcontractures and reduces pain.

• Document which nerve(s) are injured, thepresence and width of any gaps found atsurgery, details of tacking sutures andassociated injuries.

• Whenever feasible, the joints of the injured limbshould be mobilised through their entire range(arcs) of movement. This keeps the musclesfrom shortening and the joints supple.

Nerve repair2119 The aim is to restore the continuity of motorand sensory fascicles in the proximal segment withthe corresponding fascicles in the distal segment.

Timing of surgery

2120 Early primary repair provides the bestresults. It may sometimes be justified in the fieldfollowing sharp, penetrating trauma that is less than6 hours old, with minimal contamination and a stable

Limb Immobilisation: see Chapter 9


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casualty. Repair should be carried out by a trainedsurgeon, in a bloodless field and with magnificationto ensure precise suture placement.

Combat casualties are often unstable and haveconsiderable soft tissue trauma. Nerve surgery isdelayed until they are fully resuscitated, inflammationhas abated and the surrounding soft tissues havehealed. This can range from 2 weeks to 6 months.Another consideration is that there can be nervedamage both proximal and distal to the site oftrauma; this may not be immediately apparent.

Consequences of delayed repair

2121 These include:

• Adherence of nerve ends to surrounding tissues.

• Proximal neuroma formation.

• Epineureal thickening, (its presence aids suture placement).

• The need for further nerve excision back tohealthy fascicles, thus increasing the likelihoodof nerve grafting.

• Poorer outcome compared to immediate repair.

Principles of repair

2122 These are:

• Mobilisation of the nerve ends from surroundingtissues. This is likely to require a tourniquet.Look for and preserve any undamaged branches.

• Unless cleanly divided without neuromaformation, cut the nerve ends back until healthy tissue is encountered (Figure 2110).

• Under magnification, align the ends usingsurface vessels, angle of division or fasciculararrangement, as a guide.

Remember, too much dissection

of the nerve candeprive it of itsvascularity and

reduce its capacityto regenerate.


494

Chapter_21.qxd 28/09/2004 15:57 Page 494

• Approximation of the nerve ends with minimaltension using fine monofilament sutures placedin the epineurium (6/0 for the sciatic nerve, 8/0for median, ulnar and radial nerves and 9/0 fordigital nerves), using an atraumatic needle.Leave two ends long to act as stay sutures.Usually, 4-6 sutures placed equidistant aroundthe circumference are sufficient (Figure 2110).NB: the epineurium does not readily hold suturesin the early stages after injury.

• Reduce tension by flexing proximal and distaljoints. It is seldom possible to gain significantextra nerve length by extensive mobilisation.


Secondary nerverepair takes time.Frequently, there issevere scarring anddistortion of anatomymaking identificationand dissectiondifficult. Attempts at reconstructionmay make mattersworse. Sometimes,amputation is abetter option.


495

Fig 2110 Preparing the nerve ends for repair. End to end repair.

Chapter_21.qxd 28/09/2004 15:57 Page 495

If in doubt, perform nerve transposition forexample, the ulnar nerve from behind the elbow,or grafting (2123). Occasionally, bone shorteningmay be justified.

• Provide soft tissue cover.

• Postoperative splinting with appropriate flexion for 3-6 weeks. The angle can be reduced as healing progresses. Provide regular passive exercising.

2123 Nerve grafts

A graft is required when the ends cannot beapproximated to allow a tension-free repair despitemobilisation and/or transposition. Common sourcesare expendable nerves, such as the sural nervelateral to the Achilles tendon - mobilised throughsmall, transverse incisions - and the medial andlateral cutaneous nerves of the forearm.

• The graft is cut 15% longer than the gap in thenerve to allow for subsequent shortening.

• Cable grafts are used for larger nerves. Several lengths of nerve are laid alongside each other, to make up the thickness required for a larger nerve (Figure 2111). The drawback is that the cables are in contact with each otherrather than with a vascular bed.

Monitoring recovery2124 Nerve regeneration usually begins around four to six weeks after repair and progressesat a rate of 1-2mm per day.

Ruptured tendonscan be differentiated

from nerves by traction, this

will reveal their distalattachment. Look forthe fascicle bundles

in the cut nerve.

A nerve graft musthave a suitable graftbed. Free grafts in asuitable bed acquireexcellent circulation

within a few days.


496

Fig 2111 Cable graft.

Chapter_21.qxd 28/09/2004 15:57 Page 496

• Motor recovery is first seen in muscle groupsnearest the site of injury or repair.

• Sensory recovery is initially manifest bysweating, followed by crude touch, a useful, two-point discrimination distance (2107) andlastly, fine touch.

2125 Tinel's sign

Commence firm digital percussion in a distal-to-proximal direction over the nerve towards the site of repair. An electric shocksensation in the territory of the nerve is a positiveTinel's sign. Regularly monitor distal progression.

Factors influencing recovery2126 Preoperative

• Age: younger casualties do better.

• Type of nerve: pure sensory or motor do betterthan mixed nerves. Some nerves recover morequickly than others: digital > radial > median > ulnar.

• Type of injury (e.g. neurapraxia). Sharp cuts give better results than crush or avulsion.The presence of a gap impairs recovery.Proximal lesions do worse than distal ones.

• Timing of repair: the earlier the repair, the betterthe prognosis.

• Presence of infection and associated injuries.

2127 Operative

• Meticulous haemostasis.

• Tension free repair.

• Gentle handling.

• Precise suture placement.

Warn the casualty:lack of sensationduring recovery risksinjury from extremesof temperature,pressure and sharpobjects. Because ofthe lack of sweatingregularly applymoisturising cream.


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2128 Postoperative

• Splinting.

• Physiotherapy.

• A motivated casualty.

Management of closed nerve injuries2129 Closed nerve injury may occur at the time of wounding (primary) or during treatment (secondarye.g., fracture reduction). Because the severity ofinjury may not be clear, they can pose managementdifficulties:

• In primary, closed nerve injuries, whereoperative management is unnecessary forfracture treatment, early exploration of the nerveis rarely indicated. Monitor regularly for signs of impaired nerve function. Spontaneous nerverecovery following isolated nerve injuriesassociated with closed fractures occurs in 85% (open fracture 65-70%). If there are no signs of regeneration after 2-3 months, the lesion is likely to be degenerative. Exploration should be considered.

• If surgery is required for internal fixation, fracturereduction or vascular repair, take the opportunityof exploring adjacent nerves.

• In difficult cases, MRI scans can be used todetermine the continuity of a peripheral nerve. If the Compound Nerve Action Potential (CNAP)is absent when performing Nerve ConductionStudies in the early months after a closed nerveinjury, resection and repair of the nerve isrequired. Where CNAP is present but altered,consider neurolysis of the whole nerve, or splitrepair of damaged fascicles.

• In secondary, closed nerve injuries, nerveexploration is mandatory.

Persistent pain or paraesthesia

in the distribution of a nerve is likely

to be due tocompression

(e.g., scar tissue,callus) and isan indication

for explorationfollowing

closed injury.21: Peripheral Nerve Injuries

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Chapter_21.qxd 28/09/2004 15:57 Page 498

Management of brachial plexus injury

2130 Transfer to a specialist unit assess usingMRI (2107). Early exploration may be beneficial. The overall outlook is often poor.


499

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Chapter 22

Burns

Introduction

2201 Burns are distressing and challenginginjuries. Lack of familiarity and the unpleasant nature of the injury, often distract the carer fromfollowing BATLS principles. Accurate assessment,appropriate resuscitation and timely transfer alloptimise recovery.

Modem burn care is based on large, specialisedcentres staffed by multidisciplinary teams. Theresources required to deliver this specialist care are substantial and are not appropriate furtherforward than role 4. The civilian standard is to deliver the burn victim to such a facility within sixhours. Current military practice is to stabilise thecasualty then transfer to definitive care as soon aspossible. In most operational deployments, there willbe a requirement for non-specialists to provide burncare with fewer resources, than those available ina UK-based burn unit. They are also unlikely to

achieve casualty transfer to a specialist unit within6 hours. In all environments, treating a severe

burn draws heavily on resources: a small number of casualties can overwhelm a facility. In thissituation, clinical management may involvedifficult triage decisions.

Epidemology

2202 On military exercises or during transition to war, the majority of burns encountered amongstpersonnel will be accidental, often due to incorrect

Patterns of Injury in Military Operations: see Chapter 1

Use of BATLSprinciples offers the best chance of survival from burn injury.

Up to 50% ofbattlefield burncasualties will have other non-burn injuries.

In the 1982Falklands conflict,34% of those injuredon HM ships,sustained burns,compared to 14% of the total UKcasualties. Burnswere seen in 10% of injured troops inthe 1973 Yom Kippurwar, but in up to 70%of Israeli tank crewcasualties.

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use of equipment and ignoring safety procedures.The variety of injuries will be similar to those seen in civilian practice.

In war fighting, burn injury rates vary with the type of conflict. Traditional anti-personnel munitions tendnot to cause significant burns in survivors. Certainweapons are designed to inflict burns, Napalm,weaponised phosphorus and flame-throwers, aresome examples. Munitions used to destroy buildings,vehicles, aircraft and ships may cause burns, often due to secondary ignitions. Thermonucleardetonations will result in large numbers of burncasualties (0224). Newer blast weapons, such as thermobaric explosives, produce significantlyhigher amounts of heat, but their impact has yet to be encountered (0221).

Pathophysiology

Systemic injury2203 Direct thermal injury causes progressive celldeath as temperatures rise above 45°C. Cell deathis almost instantaneous above 60°C. Heat is alsoconducted into surrounding tissues, causing sub-lethal inflammatory injury. Features includeincreased capillary permeability and loss of fluid from the intravascular space. The clinical impact of the inflammation evolves over several hours and is related to the total volume of tissue injured. This is best expressed as the percentage of totalbody surface area burned (%TBSAB):

• Superficial burns produce erythema with noeffect on capillary leakage; they should not be considered when calculating the %TBSAB.

• Injuries over 15% TBSAB (10% in children) cause sufficient loss of intravascular fluid forcompensatory mechanisms to be overwhelmed.Additional fluids need to be administered toprevent shock developing.

Blast and Nuclear Weapons: see Chapter 2

Although not fire proof, standardUK combat clothing

offers protectionagainst burning and

does not readilyignite. The main area

of risk continues tobe flash burns to

exposed skin,namely face and

hands. Futurestrategies to protect

exposed skin mayinclude lightweightgarments, goggles

and thermal barrier creams.

Early cooling of a burn wound

can reduce themagnitude of the

local inflammatoryinjury.

22: Burns

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• Injuries above 25-30% TBSAB cause massiveactivation of inflammatory mediators, resulting in development of a Systemic InflammatoryResponse Syndrome (SIRS). This is aprogressive process that continues to developfor several hours after the burn. The clinicalsigns of SIRS can be delayed. Toxins releasedfrom the burn wound further stimulate the SIRS.In the healthy, excessive i.v. fluid administrationcan be compensated for by an increased urineoutput. In the burn victim, too much fluid resultsin excessive oedema.

Inhalation injuryInhalation injury is not a single entity, it consists of avariable combination of:

1. Airway burn

2204 This is caused by inhalation of hot gasesfrom flame, smoke and steam. The injury is usuallyconfined to the upper airways. There is intensemucosal congestion, followed by severe oedema with the risk of obstruction. The swelling developsover several hours and is maximal between 12 and36 hours. The laryngeal mucosa eventually becomesulcerated and breaks down leading to secondaryinfection and perichondritis.

2. Lung injury

2205 If the products of combustion are inhaledinto the lower airways, they dissolve into the fluidlining the bronchial tree and alveoli. This leads to achemical injury to the lungs which produces varyingdegrees of pulmonary failure, often delayed by hoursor even days.

3. Systemic toxicity

2206 Absorption of the products of combustioninto the circulation through the alveoli leads to

Over 25% TBSABcan cause a lifethreatening systemicinflammatoryresponse.

There is no wayto quantify the

severity of aninhalation injury, its presencesignificantly worsens theprognosis following a burn.

Note that in thepresence of carboxy-haemoglobin, pulseoximeter readingsare unreliableindicators of oxygensaturation (%Sa02).

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systemic toxicity. The most important agents arecarbon monoxide and cyanides. This is the mostcommon cause of death due to fires in enclosedspaces. Carbon monoxide competes with oxygen for binding to haemoglobin, with 240 times theaffinity. It displaces oxygen, effectively causinghypoxaemia. It also binds to the intracellularcytochrome system, causing abnormal cellular function:

• A low level of carboxyhaemoglobin (<10%)causes no symptoms and can be found in heavy smokers.

• Above 20%, the casualty experiences fatigue,nausea and impairment of higher mental functions.

• Levels above 40% lead to progressive loss of neurological function.

• Death occurs with levels over 60%.

Cutaneous injuryClassification of the burn wound is purely descriptiveand indicates the depth involved (Figure 2201).

Epidermal burns

2207 Cause erythema alone, the most commonbeing sunburn. Healing is rapid and spontaneous.Erythema is not included when calculating %TBSAB.

Partial thickness burns

2208 The superficial dermis is affected, it becomes wet and blistered. There is markederythema which blanches on pressure; capillary refill remains intact. Deeper skin adnexal structuressurvive. If managed correctly, a partial thickness burnshould heal in less than 2 weeks.

Deep dermal burns

2209 The skin is darker red and does not blanch.

Pain levels are not a reliable indicator

of burn depth.

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This 'fixed staining' is caused by damage to deeperblood vessels. Deep dermal burns rarely heal withinin two weeks and often require skin grafting.

Full thickness burns

2210 There is total destruction of the dermisleaving a firm, leathery necrotic layer known aseschar. The appearance can be 'waxy white' or'lobster red'. Soot or charred tissue may mask thetrue appearance. Surgery is required except whenthe area of burn is small. Deep dermal and fullthickness burns can constrict deeper structures,particularly if the burn is circumferential. Around thetorso, this can restrict respiratory movement. In thelimbs, a similar picture to compartment syndromemay develop. Surgical release of the constriction(2235) is indicated.

2211 Burn wounds are dynamic and theinflammatory process can cause progression of

Burn wounds are not homogenous and a mixed patternmay be seen.

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��

��

��

��

��

��

��

Fig 2201 Cross section of skin to illustrate the structures affected byincreasing depth of burn.

Chapter_22.qxd 28/09/2004 15:57 Page 505

depth. Burn depth has little bearing on resuscitation,but will dictate later wound management. Attempts to accurately define burn depth in the first few hoursare unnecessary.

Management

First aidImmediate priorities

2212 These are:

• Stop the burning process. This is best achievedby dousing the effected area in cold water andremoving smouldering clothes and those soakedin scalding fluids.

• Manage ABC.

• Remove all potentially constricting items such as finger jewellery and wrist watches.

• Loosen boots and belts.

• If chemical burns are suspected, decontaminate(0230). Chemical powder is best removed priorto irrigation.

Cooling

2213 Further cooling of the burn wound for at least twenty minutes after injury, is beneficial. This can moderate local inflammation and has an analgesic effect. Cool water should be used,preferably flowing. Very cold water and ice causelocal vasoconstriction and may worsen the injury.Protracted cooling may lead to systemic hypothermia.

Dressings

2214 If available, Clingfilm™ should be laid on tothe burn wound as soon as possible (be cautious inchemical burns - see below). Do not wrap it around

Effective first aid can significantly

improve outcome.Stop the burning

process. Continue tocool the burn, but

warm the casualty.

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a burn, this can cause constriction; apply it inlongitudinal, overlapping strips. Other options areclean linen or clothing. Soaks can then be placedover the initial dressing and the casualty kept warm.

Additional measures

2215 Burns are painful and the casualties areoften terrified. Reassure them, give opiate analgesia(0706), oxygen (0317) and obtain i.v. access (0333).

Estimate the size of the burn

2216 Use the process of serial halving:

• Over half the body surface area burnt.

• Between half and a quarter burnt.

• Between a quarter and an eighth burnt.

• Less than an eighth burnt.

Transfer to Role 2 or 3

2217 Priorities are:

• Any suggestion of inhalation injury = T1

• Burns over a quarter of the body = T1

• Burns between a quarter and an eighth = T2

• Burns less than an eighth = T3

Management at Role 1 and Role 2 Use standard BATLS principles.

Airway

2218 Airway obstruction may not be evident whenthe casualty is first seen. It is important to anticipatethose at risk:

• A history of exposure to fire and smoke in an enclosed space.

BATLS: see Chapter 3

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• Exposure to blast.

• Collapse, confusion or restlessness at any time.

• Hoarseness or any change in voice.

• Harsh cough.

• Stridor.

• Flame or steam burns to the face.

• Singed nasal hairs.

• Soot in saliva or sputum.

• An inflamed oropharynx.

2219 Treatment

• Administer oxygen (0317).

• If any degree of upper airway obstruction is present, a secure airway is mandatory ( NB: swelling is likely to deteriorate). The majority of cases will be conscious andendotracheal intubation will not be possiblewithout anaesthetic assistance. Where this isunavailable in forward areas, perform a surgicalairway under LA (0305).

• If it is considered safe to transfer the casualtyunintubated, they should be nursed sitting up.Note: i.v. dexamethasone is not considered ofvalue in this situation and is certainly not asubstitute for a secure airway!

Breathing

2220 The pulmonary manifestations of burn injuryrarely occur early. Compromise of respiration occurringsoon after injury may be due to restriction of chestexcursion by a deep circumferential torso burn- perform an emergency escharotomy (2235).

Securing the airway: see Chapter 3

A high index of suspicion is thekey to diagnosing

inhalation injury.

Deep circumferentialtorso burns require

emergencyescharotomy.

A terrified casualtygasping for air

may have a blastlung injury.

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Circulation

2221 Hypovolaemic shock secondary to a burntakes some time to produce measurable physicalsigns. If the burn victim is shocked early, othercauses should be excluded.

• Start fluid resuscitation with crystalloidindependent of the severity of burn (0333). It is possible to cannulate through burnt skin but this is generally avoided.

• If necessary, use venous cut-downs (3017),intraosseous or, as a last resort, central routesfor fluid administration (2547).

Disability

2222 A reduced level of consciousness, confusion and restlessness, normally indicatehypoxia secondary to an inhalation injury. Do notoverlook the possibility of other injuries or drugand/or alcohol ingestion contributing to the casualty's reduced mental state.

Exposure / Environment

2223 The entire body surface area should beinspected for burns and other injuries. Unwrap onelimb at a time to avoid excessive loss of heat. It maybe possible to assess the burn without removingpreviously applied Clingfilm™. Ensure no constrictingitems of clothing remain, including boots and belts. If possible, keep the ambient temperature high.

Other interventions

2224 These include:


• If available, measure FBC, U&Es and blood gases.

• In uncomplicated civilian-type burns, there is no

Peripheral Venous Cutdown: see Chapter 30

If hypovolaemicshock is evidentearly after burning,exclude otherinjuries. A history of a blast, vehiclecollision or a fallwhilst escaping the fire, should raise suspicion of other injuries.

Hypothermia is asignificant risk duringthe management of burns.

Burns are initiallysterile and infectionis uncommon for the first few days.

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requirement for antibiotic prophylaxis. On thebattlefield, assume there is wound contaminationand administer antibiotics (0816).

• Insertion of a nasogastric tube and urinarycatheter will be required for burns >20% TBSAB.

• Reassess the casualty's ABCD and perform a fullsecondary survey.

Initial specific burn managementAssessment

2225 Regularly reassess casualties withsuspected inhalation injury.

Estimate the size of the burn

2226 Accurate assessment is impractical at Role1 and Role 2. Aids to estimating the %TBSAB are

• Serial halving (2216).

• 'Rule of Nines' (Figure 2202).

• In very large burns, it is often easier to work outhow much is not burnt.

• The palmar surface of the casualty's hand,including the fingers, equates to approximately1% TBSAB and can be used to estimate smallareas of burn.

At this stage it is not necessary to evaluate burndepth, apart from identifying circumferential burnsand considering the need for emergencyescharotomies (2235).

Calculate the fluid requirements

2227 Administer i.v. fluids above normalrequirements to prevent burn shock in injuries greaterthan 15% TBSAB (10% in children). An estimate ofthe likely volume of crystalloid needed in the first 24hours is made using the formula:

Beyond keeping a patent airway

and delivering themaximally

achievable oxygenconcentration, there

is little that can bedone for those with

inhalational burnswithout critical care

facilities.

Accuratelycalculating %TBSAB

is difficult at Role 1and 2. Make an

estimate. Do notworry about

accurately assessingburn depth.

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"

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Fig 2202 Rule of nines in children and.adults.

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• Volume needed in first 24 hours (mls) = 2 x Weight (kg) x %TBSAB

• In children = 3 x Weight (kg) x %TBSAB

The need for fluids starts at the time of injury. Halfthis volume is given in the first eight hours from injurythen the second half in the following 16 hours. Other fluid requirements are not accounted for in this regimen. Administer additional fluids whereindicated for losses due to other injuries and normaldaily maintenance.

Hartmann's or Ringer's lactate solution isrecommended. Normal saline can be used ifnecessary, but will cause more disturbance toelectrolyte balance.

2228 Example:

A 75 kg Chef spills boiling water over his combattrousers at 0600. He arrives at Role 1 at 0630 and isfound to have mixed depth burns to both his legs witherythema of his buttocks and perineum. The TBSAburn is estimated as 36%. By the time he has beenassessed, it is 0700.

• Volume required: 2 x 75kg x 36% = 5,400 mls in 24 hours.

• Half required in first 8 hours after injury = 2,700mls by 1400.Time now 07.00 = 385 mls/hr ofHartmann's until 1400.

• Second half required in subsequent 16 hours = 170 mls/hr of Hartmann's from 1400 until 0600 tomorrow.

Monitoring fluid balance

2229 The calculated volume is an initial guideonly. It is essential to monitor the individual'sresponse. Keep an accurate fluid balance record.

• The simplest guide to adequacy of fluid

The formula is a guide only.

Monitor theindividual's response

and adjust asnecessary.

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administration is urine output. Aim to keep theurine output between 0.5 - 1 ml/kg bodyweight/hour. This should be doubled for children.

• Do not be afraid to adjust the fluid input to keepthe urine output within these limits. Large, fullthickness burns and those with an inhalationinjury, often require very large volumes of fluid. It is equally as important to reduce fluidadministration when indicated.

• Use pulse oximetry to monitor %Sa02 and pulserate. Carbon monoxide poisoning can giveanomalously high %Sa02 readings.

Dressings

2230 Ensure burnt areas are covered withClingfilm™, laid on, not wrapped. Hands can beplaced in plastic bags. Moistened linen with holes cut for the eyes and mouth can be used to cover the face. Keep the casualty warm.

Transfer to Role 3

2231 Priorities are:

• Inhalation injury = Tl A

• Burns >25% TBSAB =. Tl C

• Burns <25% receiving i.v. fluids = T2

• Burns of face, hands, across major joints and perineum = T2

• Chemical or electrical burns = T2

• Other burns = T3

Role 32232 At Role 3, the following interventions takeplace in addition to all of the above:

• Continued resuscitation.


At Role 3, reassessABCDE and repeatthe secondarysurvey.

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• Thorough burn wound cleaning.

• Accurate burn area assessment.

• Appropriate surgery if indicated.

• Dressings.

• On-going care.

• Casualty transfer.

• Burn injured casualties need to be kept warm. In advance of their arrival, aim to get theambient temperature to 28°C, with a highrelative humidity This is uncomfortable to work in, but good for the casualty! If this is not possible, warm the casualty directly with an active, warm-air blanket.

• Measure FBC, U&Es, glucose and blood gases.For deep burns greater than 20% TBSAB, havecross-matched blood available.

• In cases of potential inhalation injury, obtain a baseline chest radiograph and measurecarboxyhaemaglobin.

• Evaluate the adequacy of fluid administration.Key indicators of under-resuscitation are: lowurine output, raised haematocrit and an increasingbase deficit. Adjust infusion rates accordingly.

Inhalation injury

2233 Look for features of inhalational injury (2218).

• Actual upper airway oedema is an indication for endotracheal intubation or surgical airway.Those without signs of airway compromiseshould be nursed sitting up in a HDU equippedfor endotracheal intubation. Administer oxygen to keep the PaO2 above 10 kPa.

• Fibreoptic bronchoscopy is the investigation ofchoice. The later manifestations of pulmonaryinjury can be anticipated if damage to the


Assess and manageinhalational burns inconjunction with an

experiencedanaesthetist.

Even in severeinhalation injury

initial blood gas andchest X-ray results

may be normal.

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trachea and larger bronchi is seen. Be preparedto instigate pressure support ventilation at theearliest sign of pulmonary failure (2541). Thenormal clinical picture is of deterioration up to several days following injury.

• Chest physiotherapy should be started early in all cases. The use of pulmonary lavage andnovel ventilation strategies will depend on theexperience of clinicians and equipment available.

· Systemic intoxication is treated with generalsupportive measures and administration of 100% inspired oxygen until signs resolve orcarboxyhaemoglobin levels fall below 15%.

· Current practice suggests there is no role forprophylactic antibiotics (but, see 2224), steroidsor hyperbaric oxygen.

Accurate burn assessment

2234 Points include:

• Full assessment can be painful. Give adequateanalgesia (0704).

• Assess large burns in a warmed operatingtheatre (~30°C) under GA (2232).

• Remove first aid dressings and thoroughly clean all involved areas with copious volumes of warm, aqueous-based antiseptic solution. Allblister roofs, loose skin, debris and soot shouldbe removed. This has to be a vigorous physicalprocess; gentle dabbing of the burn is ineffectual.

• Accurately assess the burn once it has beencleaned. Draw the burn areas on a Lund &Browder chart (Figure 2203) and calculate the%TBSAB. Do not include simple erythema.Adjust the fluid requirements accordingly, takinginto account the physiological response to fluidsalready administered.

• Do not worry too much about defining precise

Respiratory Support: see Chapter 25

The presence of an inhalation injuryincreases thevolumes of fluidneeded to preventburn shock.

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burn depth but identify deep areas that maycause circumferential constriction. If not alreadydone, this is the time to perform escharotomies(2235).

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Surgery

2235 Complicated wound interventions are notappropriate until definitive care at Role 4. Early burnwound excision is common practice in the civiliansetting but is time and resource consuming. In thefield, the only burn-specific procedure required is escharotomy.

The necrotic layer of deeply burnt skin is known aseschar and is firm and unyielding. As oedema formsin the deeper tissues, the eschar resists swelling andtissue pressure rises. When circumferential, this cancompromise perfusion and, in the torso, restrictventilation. Urgent surgical division of the eschar is then indicated:

• Escharotomy is rarely required within the first 2 hours.

• Unless there is interference with respiration, it is best to perform the procedure under GAin an operating theatre.

• Use cutting diathermy to carefully incise thewound until the constriction is released.Continue this along the full length just intounburnt tissue. Slashing down into unburnt fat is unnecessary. The lines of election forescharotomies are shown in Figure 2204.

• Take care to avoid the ulnar nerve at the elbowand peroneal nerve around the fibular head.

• Dorsal hand and mid-lateral finger releases may be needed.

• Because of the need to extend them into healthytissue, escharotomy is painful. As with releasinga tourniquet, a period of local hyperperfusionfollows escharotomy and significant bleeding canoccur. Be patient in ensuring good haemostasis.

• In cases of high voltage electrical burns andwhen there has been prolonged delay in

Skin Grafting: see Chapter 23

Perform limbescharotomies under controlledconditions in theoperating theatre.

As most normalventilation isdiaphragmatic, it is important toensure the horizontaltorso release is overthe upper abdomenfollowingcircumferential torso burns.

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performing escharotomies, compartmentsyndrome may be encountered (0906). This is an indication for fasciotomies (0908).

Dressings

2236 The burn wound needs to be dressed forcomfort and to help prevent infection during transfer.

• Apply a 0.5cm layer of cerium in silversulphadiazine cream (Flammacerium™) directlyon to the burn. Cover with a thick layer of bulky,absorbent gauze and hold this in place withbandages or net dressings. An alternative issilver sulphadiazine cream (Flammazine™); this is no longer the treatment of choice.

Compartment Syndrome: see Chapter 9

Bags for hands areonly useful in the

alert casualty.

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Fig 2304 Escharotomy incisions - dotted lines, avoid crossing joints.

Chapter_22.qxd 28/09/2004 15:57 Page 518

• If neither of these creams is available, apply a layer of paraffin gauze and cover withBetadine™ or chlorhexidine soaked gauze.Again, cover with a thick absorbent dressing.

• Topical creams are suitable for covering theneck, scalp and ears but should not be used forthe face. Keep the face moist with plain aqueouscream reapplied regularly.

• In the fully alert and co-operative casualty, burnt hands can be placed in plastic bags.A small amount of Flammacerium is applied. For the first couple of days, exudate rapidlycollects in the bags and reduces the advantageof the casualty being able to participate in theirown care.

• In the HDU/ITU, hands are best dressed withFlammacerium and gauze. Palmar splints shouldbe used to keep the wrist extended at 45 degrees,metacarpo-phalangeal joints flexed at 45 degreesand the interphalangeal joints straight.

On-going care


• Record hourly fluid balance and adjust fluid input as indicated. A low urine output suggestshypovolaemia.

• Measure FBC and U&E at least twice in the first24 hours.

• Severe, deep burns result in loss of red bloodcells. Transfuse blood if indicated by the Hb andhaematocrit levels.

• Breakdown products of destroyed red cells areexcreted in the urine and increase the risk ofacute tubular necrosis. If dark red pigmentationof the urine is seen, increase fluid input toachieve a urine output of 1.5 - 2mls/kg/hr. Do not use diuretics.

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• Start nasogastric feeding, ideally, immediately on admission. This helps maintain gut function,lowers the risk of peptic ulceration and may bebeneficial in reducing bacterial translocation fromthe gut. If it is not possible to start nasogastricfeeding, give either an H2 antagonist or, protonpump inhibitor to prevent peptic ulceration.

• Nurse casualties partially sitting up with armselevated on pillows to help reduce oedema.Physiotherapy should start early, with the aim of maintaining normal ranges of joint movements.

• Once burns have been dressed and the casualtyplaced in bed, analgesia requirements decrease.Nevertheless, high levels of anxiety remain andgood psychological support is important.Anxiolytics can help, along with a balancedanalgesia regimen (Figure 0701). NSAIDs should be avoided in the first 24 hours.

• Additional fluid requirements extend beyond the first 24 hours. With nasogastric feeding, a standard regimen will provide for the majorityof cases. Give 500ml boluses of colloid (10 ml/kgin children) if hypovolaemia becomes apparent.Again, the casualty's physiological response is the main indicator of fluid requirement.

• Burn wounds produce a large volume of exudate. The dressings need to be changedwhen soaked through, or at least daily. Use the same dressing technique.

Infections in burns

2238 Burn wounds are initially sterile but becomeprogressively contaminated, increasing the risk ofinvasive infection.

• Streptococcal and Staphylococcal infectionspredominate in the first five days (0816), withGram negative organisms becoming evidentbeyond this time.


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• The normal systemic response to burn injuryincludes a tachycardia, pyrexia up to 38.5 °Cand a leucocytosis. In large burns there ismarked immunosupression, making thediagnosis of systemic infection difficult. Positive surface wound cultures do notnecessarily indicate invasive infection.

• There is no evidence that prophylactic antibiotics are beneficial in civilian pattern burns.By comparison, battlefield injuries should receivesystemic antibiotics (0816). The antimicrobialactivity of topical agents is the main strategy for reducing burn wound infection in the field.

• If infection is apparent, antibiotics should begiven according to microbiological culture andsensitivity results. In cases that are in-extremis,blind therapy should be:

• First five days: benzylpenicillin (1.2g i.m./i.v. four times daily) and flucloxacillin (oral/i.m. - 0822; alternatively 0.5-2g i.v. four times daily).

• Beyond five days: a third generationcephalosporin e.g., ceftriaxone (1g daily)and gentamicin (2-5mg/kg daily in divideddoses every 8 hours).

Special BurnsElectrical burns

2239 Passage of electricity through the bodyproduces heat which can cause burns. The type ofinjury seen depends on voltage and two groups aregenerally recognised:

2240 Low voltage - under 1,000 volts

This includes the normal domestic mains of 240volts, voltage from field generators and the commonindustrial supply of 415 volts. Electrocution leads to

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cutaneous contact burns at the sites of entry and exit of the current. The tissue damage extendsthrough the full thickness of the skin; deep structuresimmediately under the wounds can also be damaged.

2241 High voltage - over 1,000 volts

Entry and exit wounds have a blast component withmassive local damage. There may be multiple entryand exit wounds as the current can arc across joints.As current flows through the tissues, extensive, deepdamage occurs. Entire muscle compartments can bedestroyed, sometimes without involving the overlyingskin. There is a high incidence of compartmentsyndrome (0906) due to muscle damage; thelimbs should be regularly monitored for signs of neurovascular compromise.

2242 Management

• In both high and low voltage electrocution,the cutaneous burn is an under-representation of the true extent of the injury. Reliance on thenormal formula for calculating fluid requirements,may lead to under-resuscitation; monitor urineoutput carefully.

• Urinary excretion of the breakdown products ofhaemoglobin and myoglobin is common followingextensive electrical burns. This produces a riskof renal failure. Prevention is by administeringadditional i.v. fluids, aiming for a urinary outputof 2mls/kg/hour.

• Electrocution is frequently associated with other injuries e.g., falls and violent, tetanicmuscle spasms.

• Cardiac dysrhythmias can occur followingpassage of current across the thorax. Cardio-respiratory arrest is often reversible andprolonged efforts at resuscitation are justified. In all cases of electrocution, a 12 lead ECG

Fasciotomy: see Chapter 9

Following electricalburns, the threshold

for both escharotomyand fasciotomyshould be low.

The obviouscutaneous wound

of an electrical burnwill be an

understatement of the true injury.

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should be performed; if normal, there is nobenefit in continued cardiac monitoring.

Chemical burns

2243 Contamination and injury to others areserious risks when dealing with chemical burns.

• All those involved should wear appropriateprotective equipment (0228). Decontamination is discussed in 0230. If powder or lumps of theproduct are visible, these should be removedfirst. Any clothes or materials from the victim,together with used irrigation fluid, must betreated as contaminated.

• Acids produce coagulative necrosis and theeschar helps reduce penetration. Alkalis causeliquefaction and penetration into deeper tissuesis more significant. Irrigation for alkali burnsshould continue longer than for acid burns, at least one hour. (NB: there is increased risk of hypothermia with prolonged irrigation). Oncethe chemical burning process has been halted,management is the same as for other burns.

• Covering chemical burns with Clingfilm™ willkeep any residual chemical on the skin, where it will continue to injure. It is vital to ensure alltraces of the chemical agent have been removedprior to applying Clingfilm™.

• Chemical burns of the eye require prolongedirrigation. Seek ophthalmic advice (1730).

· Petrol, kerosene and diesel, produce a chemicalburn which initially appears superficial but, mayprogress to full thickness injury. Systemic toxiceffects can occur. Treatment is the same as forother chemical injuries.

Phosphorus burns

2244 These are almost exclusively a military

Decontamination: see Chapter 2

Be cautious whenusing cling film overchemical burns.

The use of neutralising agents can causeexothermic reactionsand worsen the burn.Their use is notgenerallyrecommended.Where possible,obtain an expertopinion on theproperties of thechemical.

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phenomenon. The element spontaneously ignites inair and is prevented from doing so by immersion in water. The majority of phosphorus burns arecaused by secondary ignition of clothing and aretreated as normal:

• To prevent further ignition of phosphorusimbedded in wounds, visible lumps should be removed and the area irrigated with water.Soaking dressings are then applied and kept wet until arrival at a surgical facility.

• To help identify further particles during wound excision, an ultraviolet lamp will highlight phosphorescence.

• Irrigation of the wound with 1% copper sulphatesolution will coat fragments with a layer of blackcupric phosphide. This reduces the chance ofignition and makes them easier to see. Coppersulphate is toxic and should be thoroughlywashed from the wound. It must never be usedas part of a dressing.

Vesicant burns

2245 Various chemical warfare agents causecutaneous burns and are discussed in 0242.

• Full decontamination procedures must be carriedout before admission to any medical facility.Thorough cleaning, with removal of all blisters is performed (0244). There is usually no activeagent in blister fluid. The exception is Lewisite,but this is easily neutralised by using a weakhypochlorite solution.

• Dressings and fluid resuscitation are then the same as for thermal burns.

• The loss of fluid can be delayed in vesicantburns and the need for replacement starts when blisters appear, as opposed to themoment of exposure.

Blister (Vesicant) Agents: see Chapter 2

Removedphosphorus particlesmust be immersed in

water to preventignition in the

operating theatre.

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• Wound healing is significantly slower than with a comparable thermal injury (0244).

Transfer to Role 42246 All but the most minor of injuriesnecessitates transfer. A high priority is appropriatebecause there are clear benefits of early surgery.Also, complications of inhalation injury, SIRS andinfection become extremely difficult to manage afterabout five days. Experience has shown that burnvictims can tolerate long distance transfer within the first five days. Transfer priorities to Role 4:

Inhalation injury = T1

Clinical evidence of SIRS = T1

Burns over 25% = T1

Those having had escharotomies = T1

Deep burns over 5% = T2

Burns of face, hands, perineum = T2

The rest = T3

Burns in Mass Casualty Scenarios

2247 With optimal care, survival with good qualityof life is common even in massive burn injury. It is nolonger appropriate to arbitrarily choose a certain %TBSAB above which it is assumed care is futile.Nevertheless, the high demand of burn carenecessitates careful use of triage when resources are stretched. The factors that significantly reducesurvival rates are:

• Inhalation injury except for isolatedoropharyngeal swelling.

• Deep burns over 80% TBSA.

• Age > 60 years.


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• Significant concomitant illness or injury.

Two or more of the above, should be the first criteriaused for allocating a T4 (expectant) triage category(0604).

To help reduce use of resources, it is possible to useonly oral fluid therapy for burns at least up to 20%TBSA and possibly higher. Moyer's solution orproprietary oral rehydration formulae may beemployed. A normal diet, with extra water to drink,is probably as efficacious.

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Chapter 23

Principles of Plastic andReconstructive Surgery

Introduction

2301 Injuries sustained during military operations frequently require the involvement of a plastic surgeon. This chapter focuses onreconstructive techniques of soft tissue wounds that may be applicable in the field. Treatment oftrauma to the hand (Chapter 9), peripheral nerveinjuries (Chapter 21) and burns (Chapter 22) arecovered elsewhere.

The aim of reconstructive surgery is to restore formand function. The objectives are:

Short term: achieve wound healing.

Longer term: achieve functional and aesthetic recovery.

Considerations when attempting to achieve woundhealing include:

• Management of ABC to maintain tissue perfusion and minimises further tissue loss.

• Prevention of infection by wound excision(0503), antibiotics (0816) and repair of visceralinjury. The use of appropriate techniques ofwound closure.

Methods of Wound Closure

2302 Options are summarised Figure 2301.

• In a military environment, delayed primaryclosure is the norm (0503). Primary suture is restricted to areas with an excellent blood

Hand Injury: see Chapter 9Peripheral Nerve: see Chapter 21 Burns: see Chapter 22

Prevent further injuryby handling tissuesgently, especiallynerves and vessels.Place sutureswithout tension. Ligate vessels withminimal loss oflength -they may be used for futureanastomoses.Maintain nerve length.

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supply for example, the face, scalp and scrotum(0504).

• Some hand wounds are closed primarilyto avoid exposure of underlying structures.

• Skin grafting and the use of flaps to importtissue are usually reserved for use at Role 3 and Role 4. These techniques risk complicationsand all result in donor site morbidity. Their application other than at Role 4, should be limited to situations where transfer to a plastic surgeon is delayed or impossible.

2303 The following optimise wound healing:

• Hydration.

• Nutrition.

• Warmth.

• Rest.

• Elevation.

• Stopping smoking.

Primary Closure and Delayed Primary Closure: see Chapter 5


528

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Fig 2301 The reconstructive ladder. Start at the bottom with simpletechniques. Methods near the top are retained for more complex cases.

Chapter_23.qxd 28/09/2004 16:05 Page 528

Management of Wounds Not Closeableby Delayed Primary Suture

Overview2304 Points include:

• Attempt to cover vital structures such as nerve,tendon, vessel anastomosis and bone, by closingpart of the defect. Keep the remaining exposedtissues moist with appropriate dressings. Avoidrelieving incisions as these may jeopardise theuse of local flaps for later reconstruction.

• Split skin graft can be used as a definitivemethod of wound closure or, as a temporarysolution prior to complex reconstruction. It isvery effective at preventing desiccation and, insome parts, may 'take'. This will allow healing of the surrounding areas and buy time beforedefinite cover can be arranged. Disadvantagesare that it requires technical skill to harvest thegraft and results in a painful donor site.

• Consider using a flap.

Skin grafts2305 Skin grafts are the 'grass seeds' of skinreplacement and flaps are the 'turf'. A skin graftrequires a suitable bed of viable tissue to 'take' by a process of revascularisation. It must be immobilisedduring the first five days to prevent shearing of thenew growth of blood vessels.

For optimum graft take the wound must be

• Clean.

• Free from significant infection.

• Well vascularised.

An ideal bed is healthy muscle or fascia. Grafts will take on paratenon, periosteum, nerve, vessel and


Paratenon andperiosteum are keptmoist during woundexcision as dryingwill jeopardise anyfuture graft take.


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deeper tissues, such as dura and omentum. Even ifthere is exposed bone, a split skin graft can still beused as temporary cover.

Split skin grafts2306 Different depths of graft can be taken using a dermatome or hand knife, (Figure 2302). The superficial layers of the skin are most commonlyharvested (split skin graft) leaving a donor site thatheals by re-epithelialisation from deeper adnexalelements, such as hair follicles.

Harvesting the graft

2307 Steps include

• Adjust the dermatome to a setting of 10-12.When using a hand knife (e.g., Humby knife),adjustment is usually done by eye and requiresexperience. A simple aid is to insert a size 15scalpel blade between the skin graft knife andthe base of the instrument. When correctlyadjusted, the gap will allow three quarters of the bevel of the scalpel blade to be admitted.

The quality of harvested skin isdependent on both

the surgeon and theassistant. Do not

start until you havegood 'stretch'.

Remove any iodineskin preparation to

avoid sticking.


530

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Fig 2302 The thickness of various types of skin graft.

Chapter_23.qxd 28/09/2004 16:05 Page 530

• Donor sites are illustrated in Figure 2303.The most common site is the anterolateral thigh.

• Stretch the skin while immobilising the softtissue of the knee and thigh.

• The donor area and knife are lubricated using liquid paraffin or aqueous jelly. The skin is separated by a forward and backward cuttingmotion, rather than trying to advance the knifedown the thigh. A hand or graft board is movedin front of the advancing knife to flatten the skin(Figure 2304). The donor skin is separated byeither, an upsweep of the graft knife or, by theuse of scissors.

Managing the donor site

2308 Points to note:

• The donor site should now be covered with finepinprick bleeding areas. More active bleeding orvisible fat indicates that the harvested graft is


531

Fig 2303 Donor sites for harvesting split skin grafts.

Chapter_23.qxd 28/09/2004 16:05 Page 531

too thick. Replace the donor skin and perform a second harvest after adjusting the knife setting.

• Dress the donor site using an alginate, paraffin gauze, wool and a crepe bandage.Secure this well, movements of the dressingagainst the raw donor site can be a source ofsignificant discomfort.

• The donor site dressing is left intact for fourteen days. If wound exudate seeps throughthe dressing, this should be over-wrapped toprevent ingress of bacteria. Change the dressingif there is suspicion of infection.

Applying the graft

2309 Prepare, apply, fix and immobilise:


532

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Fig 2304 Adjust the knife or dermatome. Stretch the skin andlubricate using liquid paraffin. The skin is harvested by a forwards andbackwards cutting motion. A hand or graft board is moved in front ofthe advancing knife to flatten the skin.

Chapter_23.qxd 28/09/2004 16:05 Page 532

• The graft should be fenestrated with a scalpel(Figure 2305) or passed through a mesher. The resultant defects prevent exudate collecting

Methods of Suturing: see Chapter 30


533

Fig 2305 A) Technique of meshing a split skin graft. B) fixing it to the wound.C) tying the sutures over foam or cotton wool to hold thegraft in place.

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Fig 2306 Random and axial pattern flaps.

Chapter_23.qxd 28/09/2004 16:05 Page 533

beneath the graft and enable a larger area to be covered.

• The split skin is secured to the wound usingsutures, glue or staples. Apply an overdressingof paraffin gauze and foam (or cotton woolballs). This can be fixed in place by tying thelong ends of the sutures over the top to preventshearing (Figure 2305). The area is then coveredwith dressing gauze, wool and a crepe bandage.A plaster of Paris splint is used to immobilisejoints (0915), where movement might interferewith healing.

• Elevate affected limbs to minimise swelling.

• The dressing is removed 5 days later. By this stage, the graft should be adherent to the wound when lightly touched and have a pale pink colour.

Limb Immobilisation: see Chapter 9


534

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Fig 2307 Advancement flap.

Chapter_23.qxd 28/09/2004 16:05 Page 534

Skin flaps 2310 Flaps have an integral blood supply, which is either based on a random or axial pattern(Figure 2306).

Random pattern flaps

2311 These rely on basic geometrical principlesand must have an adequate breadth to length ratioto ensure good vascularity, (Figure 2307). Usually,

these flaps are small and simply redistribute localexcess tissue. Common applications are the hands,face and scalp (Figure 1604).

Examples are: advancement (Figure 2307), rotation(Figure 2308) and transposition flaps (Figure 2309).

Skin Flaps on the Scalp: see Chapter 16


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Fig 2308 Rotation flap. A backcut or triangle can be used to reduce tension.

Chapter_23.qxd 28/09/2004 16:05 Page 535


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Fig 2310 Rhomboid flap.

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Others include rhomboid (Figure 2310), hatchet or V-Y advancement flaps (Figure 2311). In most cases,the donor site is closed primarily. Some will result ina defect that requires grafting.

Axial flaps

2312 Axial flaps are based on a known blood supply, usually by a single, large and constantvessel. These flaps can be used locally on a pedicleor at distant sites using free tissue transfertechniques with microvascular anastomses (Figure 2312).


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Fig 2311 V-Y advancement flap.

Chapter_23.qxd 28/09/2004 16:05 Page 537


538

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Fig 2312 Axial and Free flaps.

Chapter_23.qxd 28/09/2004 16:05 Page 538

Chapter 24

Tropical Diseases

Introduction

2401 Provision of medical care in the tropicspresents a number of challenges. Many diseases areunique to specific geographical regions; other, moreubiquitous diseases may display a broader clinicalspectrum in the tropics. Lack of infrastructure andmedical sophistication may exacerbate epidemics(e.g., water borne illness, AIDS). Inadequateimmunisation programs can result in development of tetanus in trivial wounds (0825). RTAs oftenprovide a major part of the surgical workload. Clinical manifestations of disease are distorted bymultiple disease processes that are at play in theindigenous population.

Surgical methods sometimes require modification in the tropics. Humidity and ambient temperature, for example are important considerations whentreating burns and during postoperative care.Clinicians must obtain information concerningendemic diseases, medical facilities andcircumstances that may influence the care they provide.

In general:

• Air conditioning helps reduce post-operative complications.

• Elective surgery should be avoided in severe hot weather.

• Post-operative heatstroke/hyperpyrexia can occur rapidly and be fatal.

Heat Illness: see Chapter 26

24: Tropical Diseases

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• Dehydration must be corrected, even before trivial surgery.

• Maintain scrupulous fluid balance charts andallow for large volumes of loss from sweatingand insensible loss.

• Over-sweating is worsened by bulky dressings;use minimal wound coverage.

• Tropical diseases are not confined to the tropics!Service personnel can develop symptoms afterreturning home.

Fever

2402 Fever constitutes a diagnostic challengein the tropics. Significant causes are shown in Table 2401. There are four important aetiologies:


540

Common

• Malaria.

• Invasive diarrhoeal infections.

• Influenza and other respiratory infections.

Less common

• Leptospirosis.

• Typhoid fever.

• Pyogenic bacterial infections.

• Rickettsial infections (to include typhus).

• Trypanosomiasis.

• Acute schistosomiasis.

• Acute retroviral syndrome (HIV).

• Viral haemorrhagic fevers.

• Viral encephalitis.

Table 2401: Potential causes of pyrexia in military populations in the tropics.

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1. MalariaPathophysiology

2403 Malaria is caused by the plasmodiumprotozoa.

• Sporozoites are transmitted to humans by female anopheline mosquitoes.

• Once injected through the skin, they invadehepatocytes to mature as tissue schizonts.Subsequently, these rupture to releasemerozoites into to the bloodstream where theyinvade and multiply in RBCs causing haemolysisand the further release of merozoites. These continue the cycle of RBC invasion and haemolysis.

• Concomitant with this process is the release oftumor necrosis factor and other cytokines whichcause fever and systemic symptoms.

• There are four species of malaria that infecthumans. P. falciparum is the most malignant andhas the highest complication rate.

Clinical features

2404 Malarial may mimic many other conditions.Features include:

• Rigors, high fever (up to 41°C), and marked sweating.

• Fatigue, headache, dizziness, myalgia,arthralgia, backache, and dry cough.

• Typical gastrointestinal symptoms are anorexia,nausea, diarrhoea, vomiting, and crampingabdominal pain.

• Textbook malaria fever patterns show periodicityof 48-72 hrs between attacks. In practice, thesefever patterns are variable and not usually usefulin diagnosis.


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Diagnosis is made by microscopy of thick and thinperipheral blood smears. Because of periodicity of parasitaemia, multiple examinations may berequired to exclude the diagnosis. A dipstick antigen-capture assay is available for field diagnosisof P. falciparum and P.vivax malaria (sensitivity andspecificity 75 - 95 %).

Complications of P. falciparum malaria:

2405 These include:

• Cerebral malaria.

• Hyperpyrexia.

• Haemolytic anaemia.

• Non-cardiogenic pulmonary oedema.

• Acute renal failure.

• Jaundice without liver failure.

• Hypoglycaemia.

• Adrenal insufficiency-like syndrome.

• Cardiac dysrhythmias.

• Gastrointestinal syndromes.

• Fluid and electrolyte imbalance.

• Concurrent bacterial pneumonia.

Prophylaxis

2406 Drugs useful in prophylaxis of malaria are shown in Table 2402: Prophylaxis should bestarted one week before travel (preferably 2-3 weeksin the case of mefloquine; Malarone™ 2 days) andshould be continued for 4 weeks after leaving(Malarone 1 week).

Due to emergence of drug resistant falciparumstrains, both prophylaxis and treatment regimenshave become complicated. Appropriate prophylaxis


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requires local knowledge of the species prevalenceand resistance patterns. Since prophylaxis is never100% effective, it must be included with other controlmeasures, such as use of window screens, mosquitonetting impregnated with permethrin, vector populationcontrol, frequently applied insect repellant andprotective clothing. Long sleeves and trousers afterdark should be a Standard Operating Procedure!

Treatment

2407 The following are examples of commontreatment regimens. You must obtain expert adviceearly in all casualties.

1. Treatment of P. vivax, P. ovaleand P. malariae malaria

Oral treatment:

600mg chloroquine base, then 300mgchloroquine base at 6-8 hours, then300mg chloroquine base daily for 2 days.Chloroquine is adequate for P. malariae, but in the case of P. vivax, and P. ovale, a radicalcure to destroy liver parasites is required. Thisis achieved by with primaquine (15mg daily for

14-21 days given after chloroquine).

2. Treatment of P. falciparum malaria

In most parts of the world P.falciparum is


543

• Chloroquine 300mg once weekly.

• Proguanil hydrochloride 200mg once daily.

• Mefloquine 250mg once weekly.

• Doxycycline 100mg once daily.

• Atovaquone/proguanil (Malarone™) 1 tablet daily.

Table 2402 Drugs useful in malaria prophylaxis (choice of regime depends on local risk and resistance). May be required singularly or in combination.

Chapter_24.qxd 28/09/2004 15:57 Page 543

resistant to chloroquine, which should not now be given for treatment. Where the casualtycan swallow and retain tablets and there are no serious manifestations (e.g., impairedconsciousness), in adults give oral:

• Quinine (salt) 600mg three times daily for 7 days and (if quinine resistance known or suspected):

Fansidar (3 tablet single dose) or,Doxycycline 200mg daily for 7 days.

Alternatives to quinine:

• Mefloquine (20-25mg/kg oral single dose or preferably 2-3 divided doses over 24 hours) or,

• Malarone (4 tablets once daily for 3 days).

Parenteral regimen:

In the ill casualty or those unable to swallow, givequinine dihydrochloride, 20mg/kg (salt) in 500 ml of 5% glucose solution i.v. slowly over 4 hours.

Thereafter, administer 10mg/kg (salt) three timesdaily until oral therapy is possible (maximum dose: 1.4g/day).

2. Enteric feverPathophysiology

2408 This is caused by a range of differentorganisms, the commonest of which is Salmonella typhi.

• Infection occurs after ingestion of contaminatedfood or water.

• There is an incubation period of 5-14 daysduring which time the intracellular Salmonellapathogens breach the mucosal barrier andreplicate in the reticuloendothelial tissues


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of Peyer's patches, mesenteric lymph nodes and the spleen.

• Infected tissues become inflamed and ulcerate,resulting in bacteraemic spread of infection.

Diagnosis is made by blood cultures. These remainpositive for up to three weeks in those who have notreceived antibiotic therapy. Where this fails to identifythe organism, bone marrow cultures are sometimespositive. Serological tests are of little value in thediagnosis of enteric fevers.

Clinical features

2409 Typhoid fever is a systemic illnesscharacterized by:

• Malaise, sustained fever and bacteraemia (2-4 weeks).

• Rose spots: 2-4 mm maculopapules occurring predominantly on the anterior chestand abdomen (pink; blanch under pressure).

• Bradycardia.

• Abdominal pain, tenderness and distention. Splenomegaly.

• Haemorrhage and perforation. There may besudden hypotension and tachycardia, with orwith out passage of blood per rectum. Smallbowel perforation can be difficult to detect in the presence of an already tender and distendedabdomen. Look for free fluid in the abdomen or air under the diaphragm on AXR.

• Mental confusion.

• Hypovolaemic and/or septic shock.

• Bacteraemic spread may cause osteomyelitis,septic arthritis, mycotic aneurysm and meningitis.

• Relapse occurs in 10-20% of those treated with antibiotics (1-6 weeks after completion of


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therapy). This is probably due to sequestration of intracellular organisms.

• Death and severe complications typically occurduring the third week of illness.

Treatment:


• Oral ciprofloxacin 500 mg twice daily for 10days, or ceftriaxone 2gm i.v. daily for 14 days. If shock or mental confusion are present, givedexamethasone 3mg/kg i.v. just prior to initiatingantibiotic therapy followed by 1 mg/kg i.v. every6 hours for 8 doses.

• Haemorrhage may necessitate blood transfusion.

• Surgery is indicated for intestinal perforation.

Drug resistance is now widespread and every attemptshould be made to confirm the diagnosis by bacterialculture and sensitivity testing.

3. Pyogenic infectionsPyomyositis

2411 A soft tissue infection, common in thetropics, which is characterized by pyogenic infectionof muscles. Pyomyositis is rare in temperateclimates. The resultant woody induration issometimes misdiagnosed as a malignant mass.Infection is usually confined to muscle, but canoccasionally cause septicaemia with metastaticspread to other organs. Staphylococcus aureusis the pathogen in 90% of cases.

• Aspirate purulent material for Gram-stain and culture prior to starting therapy.

• Treatment is excision of necrotic muscle,drainage of purulent material and antibiotics(0822).


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Toxic shock syndrome

2412 Super-antigen phenomena result fromspecific toxin production in some Staphylococcusaureus and Lancefield Group A streptococcalinfections (Streptococcus pyogenes). Typically, the casualty is more toxic than the infection appearsto warrant. There is rapid progression to shock, acute respiratory distress syndrome and renal failure.Unless the infectious source of toxin is eliminated(surgery, antibiotics), deterioration and death is likely.Staphylococcal infections in toxic shock syndrometend to remain localized. By comparison,streptococcal infections are highly invasive withbacteraemia occurring in the majority of cases.Mortality rates have been reported as high as 80%.

• Treatment is surgical drainage and woundexcision. Administer high dose penicillin 1.2gi.v./i.m. 4 hourly +/- clindamycin 600 mg i.v. fourtimes daily (clindamycin inhibits toxin production).

4. SchistosomiasisPathophysiology

2413 Schistosomiasis is a visceral, trematodalparasitic infection caused by one of five schistosomalspecies that infect humans. The source of infection isfresh water containing snails that allow for thedevelopment of the infective cercariae. Innoculationoccurs through exposed skin, usually of the lower limb.

Clinical features

Illness may be acute or chronic:

2414 Acute:

A previously unexposed individual may develop an acute febrile illness (Katayama fever) 4-6 weeksafter transmission; this coincides with onset of eggproduction by maturing schistosomes. The usualcause is Schistosoma japonicum, less commonly


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Schistosoma mansoni. Commonest early symptoms are:

• Dysentery (S.mansoni, S. japonicum).

• Haematuria (S. haematobium).

Later clinical consequences include:

• Abdominal pain, weight loss, headache, malaise,chills, fever, myalgia, diarrhoea, dysentery, dry cough, hepatomegaly and eosinophilia.

• Acute myelitis has been reported.

• Infection may result in death from toxaemia and myocarditis. This is thought to be due tohigh levels of circulating immune complex.

Diagnosis is suggested on history and clinical course. Eosinophilia is common and serologicalinvestigations are usually positive.

2415 Chronic:

Eggs are produced by adult worms living in veinsthroughout the body. Ova migrate through bloodvessel walls, generating intense inflammatoryresponses. Clinical features reflect the site of theadult worms (and ova), and are related initially tosevere inflammation. Chronic infection results intissue damage, scarring and carcinomatous change.Clinical consequences include:

• Urological system: S. haemotobium and S. intercalatum cause obstructive uropathy,haematuria and bladder carcinoma.

• Liver: hepatosplenomegaly, hepatic granulomand periportal fibrosis, leading to portalhypertension and portocaval shunting.

• Lung: granulomatous pulmonary arteritis and cor pulmonale.

• Gut: intestinal fibrotic pseudotumors andpolyposis. The clinical features depend on


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the pattern of egg deposition and tissueinflammatory reaction. Responsible organismsare S. mansoni, S. japonicum, and S. mekongi.

• Others: myelopathy and cerebral schistosomal infection.

Diagnosis is made by microscopic observation of eggs in faeces or urine.

Treatment

2416 Praziquantel is effective against all humanschistosomes. Give 40 mg/kg in 2 divided doses at 4-6 hour intervals. This may be combined withcorticosteroids for the acute febrile syndrome. ForS.japonicum, 60mg/kg is required in 3 divided doses.

Diarrhoea

2417 Diarrhoeal diseases are a significant causeof morbidity (and for infants, mortality) in the tropics.Common protozoan, bacterial, and viral pathogensare listed in Table 2403. Epidemics frequently occurin the field. Spread of infections can be prevented by:

• Avoidance of suspect food and water sources.

• Isolation of infected subjects.

• Maintenance of adequate toilet facilities.

• Scrupulous and frequent hand washing.

Amoebic dysenteryPathophysiology

2418 Although Entamoeba histolytica occursworld wide, it causes infection more frequently in thetropics. On sigmoidoscopy, single or multiple ulcersindicative of invasive disease, can be seen in therectum or lower colon. Diagnosis:

• Identification of motile trophozoites in the stools,


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scrapings of the exudates or biopsy of the ulcermargins (presence of phagocytized RBCsconfirms pathogenicity). NB: the presence of cysts is suggestive of infection but does not confirm active disease.

• Serologic tests may be helpful in confirming the presence of extra-intestinal invasive disease.

• Differential diagnosis includes: bacillarydysentery (Shigella and entero-invasive E. coli),schistosomiasis, ulcerative colitis, Crohn'sdisease and carcinoma of the colon or rectum.

Clinical features

2419 Presentation is usually with diarrhoea.Amoebic dysentery typically presents as a subacuteillness, in contrast to the sudden onset of severeillness with bacillary dysentery. Complications ofamoebiasis include:

• Perforation and peritonitis usually respond toconservative management with metronidazole..

• Amoeboma granulomas may cause masses,usually in the caecum, which can result in intussusception.


550

• Vibrio cholera, V. parahaemolyticus.

• Escherichia coli (toxigenic and entero-invasive).

• Protozoa: (Entomoeba histolytica, Balantidium coli Cryptosporidium species).

• Giardia lamblia.

• Viruses (noroviruses, rotaviruses).

• Shigella species (sonnei, flexneri, boydii, dysenter).

• Bacterial agents of food poisoning (Clostridium, Bacillus cereus, Staphylococcus aureus).

• Salmonella typhi, S. enteritidis, S perfrigens.

• Campylobacter jejuni.

• Schistosomiasis.

Table 2403: Infectious causes of diarrhoea.

Chapter_24.qxd 28/09/2004 15:57 Page 550

• Haemorrhage invasive disease with erosion of a bowel vessel may result in massive bleeding.

• Hepatic amoebic abscess will usually respond to treatment with metronidazole; occasionallythey require needle aspiration.

Treatment

2420 Metronidazole 800 mg orally three timesdaily for 5 days (or tinidazole 2g daily for 2-3 days).Followed by a 10 course of diloxanide furoate, 500mgthree times daily.

Emergency Abdominal Surgery: see Chapter 12


551

Nematodes

• Strongyloides stercoralis, S.fülleborni.

• Ascaris lumbricoides.

• Visceral larva migrans - Ascaris suum.

• Trichinella spiralis, T.nativa, T.pseudospiralis,

T.nelsoni, T.britovi.

• Anisakaisis anisakis, A.pseudoterranova.

• Capillaria philippinensis.

• Angiostrongylus parastrongylus, A. cantonesis.

Trematodes

• Schistosoma mansoni, A. haematobium, S japonicum.

• Fasciola hepatica, F.gigantica.

• Fasciolopsis buski.

• Clonorchis sinensis.

• Opisthorcus felineus, O viverrini.

Cestodes

• Echinococcus granulosus.

Protozoa

• Isospora belli.

• Dientamoeba fragilis.

Table 2404: Tropical causes of abdominal pain-associated with eosinophilia.

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Abdominal Pain

2421 Medical causes of abdominal pain in thetropics are listed in Tables 2404 and 2405. These are considered with and without the presence ofeosinophilia. When confronted with an acuteabdomen suggestive of appendicitis, consider theconditions listed in these tables and do not forgetacute sickle cell crisis.


552

• Typhoid fever -Salmonella typhi.

• Amoebiasis - Entamoeba histolytica.

• Salmonella typhumirium, S enteritidis.

• Enterohaemorrhagic and enteroinvasive Eschericha coli.

• Halophilic Vibrio infections - V. parahaemolyticus, V.alginolyticus, Vvulnificus.

• Campylobacter jejuni.

• Shigella dysenteriae, S boydii, S. flexneri, S.sonnei.

Table 2405: Tropical causes of abdominal pain without eosinophilia.

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Chapter 25

Field Anaesthesia and Intensive Care

Introduction

2501 Anaesthesia has two main aims:

1. To control physiology e.g., pain, BP, muscle activity and intracranial pressure.

2. To provide suitable conditions for surgery e.g., sleep, amnesia and muscle relaxation.

2502 The type of anaesthesia that the militaryanaesthetist can provide will depend on:

• Their training and skill level.

• Available resources, including anaestheticequipment, drugs, fluids, syringes, needles. This may appear trivial but, in a field situation,even simple equipment may be in short supply.

• Supporting personnel to provide care for thecasualty before, during and after surgery.

• Tactical situation.

• Mobility of the surgical facility.

Environment2503 Safe anaesthesia requires a safeenvironment. This means:

• Adequate shelter, clean water and lighting.Spacious, pre-fabricated units e.g., a ModularTransportable Surgical Facility (MTSF) or buildings are preferable.

• An appropriate environment for staff, exposed

Anaesthesia inforward areas is not for theinexperienced. It ischallenging andneeds to beapproached with a cool head andcommon sense. A cavalier attitudeor cutting corners

will lead to a drop in clinical standards.

25: Field Anaesthesia and Intensive Care

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casualties and sensitive equipment. A hightemperature predisposes to adverse outcomefollowing head injury, whilst a low temperatureleads to hypothermia, especially in unconsciouscasualties with disordered thermoregulation andlimited physiological reserves. Tented structuresare usually more difficult to thermoregulate andkeep clean.

• A reliable power supply with at least one back up system and a large number of electricalsockets in the operating theatre and intensivecare unit (ITU).

• Correct maintenance of anaesthetic equipment,generators and climate control systems.

Roles2504 You may find yourself in one of the following situations:

• At a fully equipped Role 3 Field Hospital. Here it may be possible to provide a standard of anaesthesia and post-operative care similar to that in the UK. Personnel working within a host nation hospital may encounter markeddifferences in staff, medicines and equipment.

• As part of a Field Surgical Team (FST) forwardat Role 2. Here, compromises in medical carewill be necessary.

• A member of an Incident Response Team (IRT),often working alone in difficult and dangerouscircumstances at the scene of an incident. Here, the emphasis will be on speed of actionand rapid casualty transfer.

Types of Injuries: see Chapter 2

Cleanliness andasepsis are

problems in forwardunits where clean

water is in shortsupply. Take care tominimise the risk of

infection whenperforming centralvenous or arterial

cannulation. Once transferred,

it may be safer to change all thecasualty's lines.

Wherever you are, the aim must

be to treat thecasualty as safelyand humanely aspossible with the

constraints of the situation.


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Casualties

Introduction2505 Military casualties are usually fit youngsoldiers from a medically screened population. Be prepared to treat local civilians, refugees,children, pregnant women and the elderly; all of whom may have pre-existing medicalconditions. Complicating factors may include: delays in treatment, sepsis, dehydration, malnutritionand emotional or psychiatric problems. Casualties willhave received variable pain relief and resuscitation.

2506 Injuries may be battle or non-battle in origin.Often, such casualties require several operationsto produce healing e.g., contaminated wounds and burns; anaesthetic techniques need to beadapted accordingly.

Preoperative assessment2507 A careful preoperative assessment is as important in the field as in a peacetime, civilian hospital:

• Follow the principles outlined in BattlefieldAdvanced Trauma Life Support (BATLS) to ensure that no potentially serious injuries are been missed.

• Ask about past medical history, medications,allergies and previous anaesthetics.

• Look for any Medic Alert tags.

A number of anaesthetic concerns are emphasised:

Airway

2508 Considerations include:

• Because of the risks of vomiting and aspiration,all trauma and emergency casualties should be

BATLS: see Chapter 3


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assumed to have a full stomach and usuallyneed endotracheal intubation for anaesthesiaand surgery. The time of the casualty's lastmeal is a poor guide to gastric contents. Trauma and opiate administration both delaygastric emptying. The risk of aspiration can be reduced by:

• Emptying the stomach with a nasogatrictube and suction in non-urgent cases.

• Being prepared to perform immediatesuction and head down tilt.

• Applying cricoid pressure during rapidsequence induction (3009).

• Premedication with an anti-emetic e.g.,metoclopramide 10mg i.v. and an antacid,H2 blocker or proton pump inhibitor.

• During endotracheal intubation, casualties in C-spine immobilisation should have their collaropened or removed and substituted by manualin-line stabilisation.

• Casualties with penetrating neck injuriesinvolving the larynx and trachea will need asurgical airway rather than intubation. Considercricothyroidotomy (3005) for injuries above thecricothyroid membrane and tracheostomy (3007)for those below.

Breathing

2509 Make sure the casualty does not have a pneumothorax prior to intermittent positive pressure ventilation (IPPV). IPPV can convert a simple pneumothorax to a tension pneumothorax. If in doubt, insert unilateral or bilateral chest drainsbefore starting IPPV.

Chemical Weapons: see Chapter 2

Nerve Agent Pre-treatment System

(NAPS) tablets -Pyridostigime, have

no clinicallyimportant effect on

the action of musclerelaxants at theneuromuscular

junction or theirreversal withneostigmine.


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Circulation

2510 With the exception of the casualty sufferingfrom non-compressible haemorrhage who requiresimmediate surgery, fluid resuscitation should beunderway before induction of anaesthesia. Personnel on military operations are likely to bedehydrated and exhausted prior to injury, especiallyin hot climates. This will compound the degree of shock resulting from haemorrhage. For example, in Class III shock, give 1-2L of warm crystalloid(Hartmann's, 0.9% Saline) or colloid (Haemaccel, Gelofusin), at induction. Unless adequatelyresuscitated at induction, decompensation can result in profound hypotension.

Analgesia and premedication

2511 Find out the dose and timing of opiateanalgesia given during the evacuation chain. This may still be effective and avoid the need forpremedication. Remember, shock and cold can delay absorption of i.m. morphine (0706). Thiscaution should not prevent a casualty from receivingadequate analgesia, titrated to effect, as soon aspossible (Figure 0701). Equally, opiates should notbe withheld on the grounds that the casualty isscheduled to receive an anaesthetic. Where timepermits, opiate or benzodiazepine premedication will reduce anxiety.

Anaesthetic Technique

Introduction2512 There are many anaesthetic techniques andthe following is intended only to be a guide. The mostcommonly used method in British military practice isthe balanced technique with intermittent positivepressure ventilation using the Tri-Service AnaestheticApparatus. Balanced anaesthesia comprises sleep,

Morphine and Respiratory Depression: see 0711


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analgesia and muscle relaxation. If you have limitedequipment or are inexperienced, Total IntravenousAnaesthesia (TIVA) using Ketamine, is the safestoption (2521).

Overview of balanced anaesthesiaSleep

2513 Casualties are put to sleep using i.v. orinhaled anaesthetic agents. Sleep is then maintainedusing intermittent i.v. injections, a continuous infusionor by inhalation through an anaesthetic breathingsystem. Intravenous drugs for this purpose include:thiopentone, propofol, midazolam and ketamine.Isoflurane is the preferred inhalational agent.Anaesthetic drugs can cause hypotension due to vasodilation and cardiac depression. A degree of muscle relaxation and analgesia is also produced.

Analgesia

2514 This is usually achieved using i.v. or i.m.opiates or local anaesthesia. Commonly used opiatesinclude: morphine (0706), fentanyl and alfentanil.Ketamine has both anaesthetic and analgesic actions(0714). Lignocaine or bupivacaine may be infiltratedlocally or used for regional plexus blockade (0728).Plexus blockade will also produce a degreeof muscle relaxation.

Muscle relaxation

2515 This assists anaesthetic access to theairway for endotracheal intubation and surgicalaccess during major procedures. Commonly usedneuromuscular blocking agents include:suxamethonium, vecuronium or pancuronium. These produce temporary muscle paralysis, but do not provide sleep or analgesia.

Ketamine: see 0714

Methods forcontinuous infusion

include a syringepump or, adding the

drug to a bag of intravenous fluid

(if drug and fluid are compatible).

Oxygen andanaesthetic agents

may be in shortsupply. Consider

using local orregional anaesthesia

and ketamine.


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A suggested balanced anaesthetictechnique for emergency cases Induction of anaesthesia

2516 Steps include:

• Shocked or dehydrated casualties should beresuscitated prior to anaesthesia. The timing of this to coincide with the start time of surgeryis critical, in terms of rebound hypertensioncausing an increase in bleeding. Use appropriatecombinations of crystalloid, colloid and blood.This should be continued during induction.

• Preoxygenate as soon as the casualty has been transferred to theatre. The time required foreffective preoxygenation will depend on the flowof oxygen available and the breathing system inuse; two minutes preoxygenation at 15l/min isusually adequate.

• Induction of anaesthesia takes place on the operating table using a rapid sequencetechnique with application of cricoid pressureuntil the position of the endotracheal tube hasbeen checked and the cuff inflated. A workingsucker should be immediately available in caseof regurgitation.

• Give i.v. morphine 5-10mg for analgesia if required. Alternatively, use a short-actingopioid such as fentanyl (1-1.5mcg/kg) oralfentanil 10-15mcg/kg. These two drugs havethe advantage of reducing the hypertensiveresponse to intubation.

• The choice of induction agent depends onavailability, familiarity and the clinical scenario.Ketamine and etomidate produce lesscardiovascular depression than thiopentone and propofol, especially in the shocked casualty.Adult doses by slow i.v. injection are:

Endotracheal tube insertion: see 3009 Ketamine in head and eye injuries: see 0715


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Chapter_25.qxd 28/09/2004 15:58 Page 559

• Ketamine 1-2mg/kg

• Etomidate 0.2-0.6mg/kg

• Thiopentone 3-5mg/kg

• Propofol 1.5-2.5mg/kg (less in those >55years)

NB: reduce the above doses in shocked casualties.

• Suxamethonium chloride, 1mg/kg is a depolarising muscle relaxant. It acts within one minute and usually lasts less than 5minutes; it facilitates rapid tracheal intubation.Depolarisation usually causes the casualty totwitch. Wait for this to stop prior to passing theendotracheal tube.

• Once intubated, the endotracheal tube isconnected to the anaesthetic breathing systemand the casualty is ventilated, initially by handwith the self-inflating bag and then, with the bag removed, by the ventilator. Make sure theendotracheal tube is secure prior to proceeding.

Maintenance

2517 Steps include:

• The casualty is ventilated with air supplementary oxygen and isoflurane 1-2%,depending on clinical condition and what otherdrugs have been administered. Nitrous oxide,with its analgesic and anaesthetic actions, iswidely used in UK civilian practice as a carriergas. Logistical reasons mean it is not usuallyavailable in the field. Anaesthetists used togiving nitrous oxide will have to modify theirtechnique, substituting larger doses of opiate or isoflurane instead.

·• Once the suxamethonium has worn off, paralysiscan be maintained with vecuronium. The initialadult dose is 80-100mcg/kg i.v., followed by

Ventilators: see 2534-2535


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Chapter_25.qxd 28/09/2004 15:58 Page 560

20-30mcg/kg every 20-30 minutes accordingto response.

• Further intermittent doses of i.v. opiates,morphine (1-2mg), fentanyl (25-50mcg) andalfentanil (250-500mcg) are used to providethe analgesic component of anaesthesia.Peroperative opiate requirements vary widelydepending on the type of surgery and previous analgesia.

• During the maintenance phase of anaesthesia,oxygen flow can be reduced to 1litre/minute if stocks are limited. Monitor the oxygensaturation, aiming for 94% or greater.

Reversal

2518 At the end of the procedure:

• Isoflurane is turned off, the flow of oxygenincreased and residual paralysis reversed withneostigmine 2.5mg and atropine 0.6mg i.v. over1 minute or, neostigmine 2.5mg andglycopyrolate 0.5mg i.v.

• Casualties should be extubated awake, on their side and with head down tilt.

• Postoperative analgesia can be achieved with continuous i.v. infusion of morphine or by intermittent i.m. injections, according to thebattlefield analgesia algorithm (Figure 0701).Patient controlled analgesia (PCA) may beavailable at Role 3.

• Critically ill casualties are best transferredventilated from the operating theatre to theintensive care unit (ITU) for further resuscitationand warming prior to extubation. If an ITU bed isunavailable, continuing ventilating the casualtyand transfer them as soon as practicable to arear hospital. Repatriation by a specialistaeromedical transfer team may be appropriate.

Aeromedical Evacuation: see 2908Post-operative morphine: see 0707

In adequatelyventilated andpreviously fitcasualties,acceptable levels of arterial oxygensaturation can bemaintained with no oxygensupplementation.


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Balanced anaesthesia for non-emergency cases2519 Semi-elective cases such as delayedprimary suture, change of burn dressings or drainageof abscesses, can be appropriately starved beforesurgery. Because there is less risk of vomiting andaspiration, they can be anaesthetised using aspontaneously breathing technique. This involves an oropharangeal or nasopharyngeal airway andmask, or insertion of a laryngeal mask airway.Oxygen supplementation should be providedthroughout the procedure.

Total intravenous anaesthesia (TIVA)2520 TIVA is relatively simple and avoids pollutionby anaesthetic vapours. Three proven techniques are described.

1. Ketamine as the sole anaesthetic agent

2521 Ketamine has features which make itsuitable for use in trauma e.g., the extrication of a casualty from the scene of a RTA where access isdifficult. It is the drug of choice where an anaestheticis to be administered by the inexperienced.:

• The usual induction doses are 2mg/kg i.v. or10mg/kg i.m. Smaller doses are used to provideanalgesia in a conscious casualty (0714).

• Anaesthesia is induced 45 seconds after i.v.administration and lasts 5-15 minutes, with a longer period of amnesia.

• Following i.m. injection, anaesthesia is inducedafter 5-10 minutes and the effect is significantlylonger and more variable.

• A technique suitable for longer procedures using ketamine alone involves an i.v. inductiondose, followed immediately by an i.m. dose (200-500mg in the adult) with i.v. supplements of

Advantages and complications of Ketamine: see 0714

Waiting times for semi-elective

cases can beunpredictable.

Avoid dehydration by giving i.v. fluids.


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Chapter_25.qxd 28/09/2004 15:58 Page 562

100mg, as required to suppress reflex responsesto stimulation.

• Hallucinations are reduced by recovering thecasualty in a quiet and darkened area.

2. Ketamine and midazolam

2522 A TIVA technique combining ketamine andmidazolam has been developed for use in the field.This has been shown to produce satisfactoryanaesthesia with minimal hallucinations, even when casualties are not nursed in a quiet, dark area.Blood pressure and pulse rate tend to be maintained.

• After opiate premedication, induction is achieved with midazolam 0.07mg/kg andketamine 1mg/kg. Anaesthesia is maintainedwith an infusion of a mixture of the two drugs.The mixture is obtained by combining midazolam5mg, ketamine 200mg and normal saline to atotal volume of 50mls. The rate of administrationis calculated as:

Casualty's body weight in kg = mls/hr

2

• This gives rates of midazolam of 50mcg/kg/hrand ketamine 2mg/kg/hr. The mixture can bemade up in advance with a shelf life of 72 hours.

• Suxamethonium and rapid sequence inductionare employed where indicated. Paralysis can bemaintained by adding vecuronium 12mg to theinfusion mixture or by administering the drug asdescribed in 2517.

3. Propofol and alfentanil

2523 Propofol and alfentanil are commonly usedin civilian practice to provide TIVA. Both drugs areshort-acting, resulting in a rapid, clear-headedrecovery, with a low incidence of nausea and


563

Chapter_25.qxd 28/09/2004 15:58 Page 563

delirium, allowing safer onward casualty transfer.These attributes allow rapid movement from thetheatre and recovery area to a lower dependencyward or, early inter-hospital transfer, if required. The cardiovascular depressant effects of propofolmake this drug unsuitable in casualties who arenot fully resuscitated.

• After an induction dose of propofol of 1.5-2.5mg/kg (less in those >55years) andalfentanil 10-15mcg/kg and muscle relaxation,anaesthesia is maintained in the ventilatedcasualty with a mixture of 1.5mg of alfentaniladded to 500mg of propofol in a 50ml syringe.The infusion rate is initially 10mg/kg/hr for thefirst 10 minutes, then altered according to clinical signs - pulse rate, BP, respiration, pupilresponse and absence of sweating, aiming fora final infusion rate of 5mg/kg/hr.

Regional AnaesthesiaSpinal anaesthesia

2524 Spinal block is contraindicated in theshocked casualty, due to the potentially catastrophicloss of sympathetic tone and consequent profoundhypotension. Spinal anaesthesia in the field carries a significant risk of infection. It may be a practicalchoice, for those medical staff unable to administergeneral anaesthesia, for surgery on the lowerabdomen and legs.

Epidural

2525 The administration of local anaestheticdrugs via the epidural route, although more easily titrated than the spinal route, has similardisadvantages. Its use for postoperative analgesiamay be considered in rear hospitals, where asepsiscan be more readily achieved.


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Chapter_25.qxd 28/09/2004 15:58 Page 564

Local block

2526. Wound infiltration with local anaesthetic andnerve blocks, can be usefully employed as an adjunctto general anaesthesia and analgesia (0728). Nerveblocks alone are unlikely to be sufficient for surgery,as wounds rarely respect anatomical boundaries.

EquipmentGeneral

2527 Anaesthetic and monitoring equipment used in forward, mobile areas, should be compact,lightweight and robust, yet sophisticated enough tocomply with peacetime standards. They should beof a type familiar to military anaesthetists throughpeacetime employment. Electrical equipment shouldhave battery back up, especially items used in thetransfer of casualties, such as ventilators andmonitors. Avoid items which require frequent resupply for example, a ventilator driven only bycompressed gas is inappropriate in forward units with a limited number oxygen cylinders and noguaranteed resupply.

Oxygen

2528 A critically ill casualty may require 10 litres/min of oxygen (14400 litres/day). A commonapproach to supplying oxygen in the field is the useof portable, oxygen concentrators, with cylinder backup for emergencies. Five litres/minute of 92% oxygenis the maximum output of the commonly used, floorstanding oxygen concentrator.

Refrigeration

2529. Refrigeration is another potential problem."Thermopols" are used to store blood andtemperature sensitive drugs. Their performanceshould be regularly monitored. The "cold chain", from supplier to user, must be reliable. Where

Nerve blocks: see 0728


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Chapter_25.qxd 28/09/2004 15:58 Page 565

possible, drugs that are not temperature sensitiveshould be used, as refrigeration space is likely to be limited.

Monitoring equipment

2530 Equipment used in the field includes thePropaq series and the Datex-Engstrom Compact and Datex-Engstrom Lite.

Anaesthetic apparatus and ventilator

2531 The Tri-Service Anaesthetic Apparatus (TSAA)continues to be the main anaesthetic system used byBritish Forces in the field. It was developed for theadministration of halothane and trilene. It is nowroutinely used with isoflurane alone. It consists ofa Laerdal Resusci bag (self-inflating), a one-waypatient valve, an Oxford Miniature Vaporiser (OMV),a Sanders Oxygen 'T' and a length of reservoirtubing. In the configuration shown in Figure 2501, the TSAA is used for spontaneous ventilation ormanual positive pressure ventilation with the self-inflating bag.

2532 The TSAA can be used in conjunction with the CompPAC ventilator (PneuPAC, Luton UK)(Figure 2502). This is a flow generating, time cycled

The OMV Tri-ServiceVaporiser is not fully

temperaturecompensated.

Consequently, theoutput will fall with

rising temperature asa result of agent

vaporisation. Thisshould not be a

problem at ambienttemperatures

suitable for surgery.


566

Fig 2501 The Tri-Service Anaesthetic Apparatus (TSAA).

Chapter_25.qxd 28/09/2004 15:58 Page 566

ventilator. As the unit incorporates an air compressor,it can be driven electrically or by compressed gas.The electricity source can be from an internal battery(Lithium or rechargeable NiCad), an external AC source, via a transformer, or a 24-28v AC supply.When driven by compressed oxygen, the output canbe set at either 45 or 100%. When driven electrically,ambient air is drawn in through a NATO standardNBC filter and compressed. Supplementary oxygencan be added either at the back of the unit at 0.5-4 litres per minute, or at the Sanders 'T' when in use with the TSAA.

The CompPAC is used with the OMV Tri-Servicevaporiser in push over mode, driving the oxygen oroxygen-enriched air through the vaporiser and intothe casualty via the one-way patient valve.


567

�

�

��

��

��

�� !"�#$#�� %��"�� !"�#��"��&�" �� &��$

��

Fig 2502 Ventilation using the ComPAC ventilator in either 1) oxygen-driven or 2) compressor driven mode.

Chapter_25.qxd 28/09/2004 15:58 Page 567

Intensive Care in the Field

Introduction2533 Intensive Care (IC) is the provision ofsupport to two or more vital organ systems or a highlevel of respiratory support in isolation, to a criticallyill casualty.

2534 High Dependency Care (HDC) is the support of one vital organ system, excludingrespiratory support.

2535 IC/HDC in an operational environment has become necessary due to improved earlyresuscitation, reduced time to surgery in battlefieldcasualties and as a vital adjunct to damage controlsurgery. Ideally, such support should be available as far forward as the Role 2 Field Surgical Team(Role 2+). In most situations, care will be required for a maximum of 48 hours.

Indications for IC support2536 These include:

1. To stabilise the ill casualty prior to transfer.

2. To manage casualties in acute organ failure or, at high risk of developing organ failure, whoare likely to benefit from continuous high levelmonitoring and support.

3. Where the situation and environment prohibitmovement of the severely ill casualty. Examplesare: poor weather preventing helicopter transfer,movement by road is too prolonged and whenevacuation facilities are overwhelmed.

Warning signs of a casualty requiring IC support2537 These include:



568

Chapter_25.qxd 28/09/2004 15:58 Page 568

• Altered conscious level post resuscitation or persisting beyond expected recovery timefrom anaesthesia.

• Respiratory failure or distress (PaO2 < 10kPa on >40% oxygen, PaCO2 > 6.5kPa, and RR <10 or >30 breathes per minute).

• Persistent hypotension or tachycardia (>120 beats/minute) despite adequate fluid resuscitation.

• Low urine output (<30 mls/hr for >2 hoursdespite vigorous fluid resuscitation).

• The casualty has received a massive bloodtransfusion (circulating volume replaced in < 24 hours).

• Specific injuries e.g., major thoraco-abdominaltrauma, severe head injury, burn > 20% BSA,burns complicated by anatomical site orinhalation and combined chemical andconventional injury.

Assets required.

2538 IC in the field is a major drain on manpowerand logistic resources. Each casualty requires morespace, staff, drugs dressings, equipment and powerthan other casualties.

Staff

2539 Improvements in ICU care are largely due to the increased ratio of staff to casualties. Thefollowing is the minimum requirement:

1. Intensive care-trained medical staff, including a consultant available 24 hours a day.

2. Intensive care-trained nurses at a ratio of one per casualty, 24 hours a day.

3. Other support staff, e.g., physiotherapists.

If you think thecasualty may needITU support thenthey probably do.If in doubt, discuss

early with senior ITU staff.


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Chapter_25.qxd 28/09/2004 15:58 Page 569

Environment and logistical support

2540 Requirements are similar to those in theoperating theatre (see 2503).

Equipment

2541 This must meet peacetime standards, be sturdy, portable, reliable, easy to repair andflexible in the supplies it requires to function.Packaging should be robust and re-usable. The main items required are:

1. Bed with suitable mattress so as to protectpressure areas and allow optimal positioning of the casualty - sitting up, head up or headdown tilt.

2. Ventilator with oxygen supply which is able tofunction without compressed gas (2532).

3. Suction.

4. Back up oxygen supply with self-inflating bag and non-rebreathing valve in case ofventilator failure.

5. Casualty monitor with ECG, oxygen saturationprobe, non-invasive blood pressure,temperature, at least two invasive pressurechannels and capnography (e.g., PROPAQ106EL, DATEX Lite).

6. Six syringe drivers and two volumetric infusionsystems per bed, allowing a number of drugsand fluids to be given simultaneously.

7. Defibrillator.

8. Extensive pharmacy including: sedatives,analgesics, inotropes and other cardioactivedrugs, antibiotics, bronchodilators,anticoagulants, diuretics, antacid preparations,anticonvulsants, insulin and i.v. fluids.Refrigeration will usually be necessary.


570

Chapter_25.qxd 28/09/2004 15:58 Page 570

9. Laboratory support including haematology,biochemistry, blood bank, blood gas analysis and microbiology.

10. Radiology.

11. Flexible bronchoscope.

Organ support.Prolonged endotracheal intubation andrespiratory support

2542 Indications are listed in Table 2501

• Respiratory failure can become part of any majorillness or injury. Chest trauma, prolonged lifesaving surgery, massive blood transfusion andsepsis, are some of the common causesencountered in the field.

• For efficient positive pressure ventilation, the airway needs to be secured with a correctlypositioned endotracheal tube. This will alsodecrease the risk of aspiration.

• The casualty will require sedation in order to tolerate the endotracheal tube and positivepressure ventilation. If sedation and analgesiaare adequate, they do not usually need to be paralysed. Suitable agents include a combination of midazolam (1-10mg/hr) or propofol (50-200mg/hr), with alfentanil (1-5mg/hr) or morphine (1-10mg/hr). Propofoland alfentanil together has the advantage of a shorter recovery time when sedation isterminated. Ketamine can also be used and maybe advantageous in the hypotensive casualty.

• The tidal volume and respiratory rate vary withsize, age, and clinical situation. A starting pointin a 70kg adult is to set the ventilator to deliver a tidal volume of 700 ml, at a rate of 12-14breaths per minute.

Intubation: see 3009

Over-ventilation ofhead injuries is nowconsidered harmful- see 1609

In persistent shock despiteresuscitation,consider non-haemorrhagiccauses, especiallyif this follows

a therapeuticprocedure. For example, IPPVin a casualty withmultiple rib fracturesmay precipitate a tensionpneumothorax if achest drain has notbeen inserted.


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Chapter_25.qxd 28/09/2004 15:58 Page 571

• Using the arterial blood gas results as a guide,tidal volume and respiratory rate can be adjustedto achieve a PaCO2 of 4.5 - 5.5 kPa. Following a head injury, the target PaCO2 should be 4 - 4.5 kPa.

• The PaO2 is mainly controlled by adjusting theinhaled oxygen concentration to maintain a valuegreater than 10kPa.

Cardiovascular support

2543 Hypovolaemia is the main cause of shock in both the trauma victim and a casualty who hasrecently undergone surgery. Further bleeding or thirdspace losses into the abdomen, pelvis or tissuecompartments can occur, especially in majorabdominal trauma and burns casualties. The following standard of cardiovascular monitoring can be offered in a field ICU:

• ECG.

• Pulse oximetry.

• Core and peripheral temperature gradient.

• Urine output - as a measure of end organ perfusion.

• Invasive arterial monitoring.

• Central venous pressure monitoring.

• Pulmonary artery pressure monitoring and cardiac output measurement (not usually available in forward ITUs).

2544 Indications for an arterial line are:

• Anticipated haemodynamic instability requiring beat to beat monitoring.

• Guidance of inotropic or vasodilator therapy.

• Repeated blood sampling, especially for arterialblood gas measurement.


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Chapter_25.qxd 28/09/2004 15:58 Page 572

2545 Technique of arterial line insertion

The usual site is the radial artery at the wrist. Palpateto check the presence of both the radial and ulnararteries. After cleaning the skin, insert a 20G cannulawithout an injection port, at 45 degrees and advancein a cranial direction when you see the flash back.Monitoring of pressure is then through a specifictransducer set with a sampling port, which slowlyinfuses 0.9% Saline to prevent occlusion.

2546 Indications for insertion of a centralvenous line:

1. Monitoring of central venous pressure as an extra guide to fluid resuscitation.

2. Administration of i.v. drugs, e.g., inotropes and antibiotics.

2547 Technique of central venous line insertion

• The commonest site used is the right internal jugular vein. Landmarks used for insertion arejust lateral to the carotid pulse at the mid-pointof a line drawn between the suprasternal notchand the mastoid process (Figure 2503). Thecasualty should be positioned supine, slightlyhead down and with the head turned away fromthe side of insertion (Figure 2504). Anaesthetisethe skin with a wheal of 1% lignocaine. Attach an ECG monitor (NB: if the casualty developsarrhythmias, withdraw slightly).

• Using an aseptic Seldinger technique, the needleis inserted at 45 degrees to the skin, directedtowards the ipsilateral nipple until venous bloodis aspirated. A guide wire is inserted and theneedle removed. A dilator is passed over thewire and then removed. The catheter is nowinserted over the guide wire. It should passwithout resistance. The tip of catheter should be in the superior vena cava just above the right


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Chapter_25.qxd 28/09/2004 15:58 Page 573

atrium. Estimate the length required from thepuncture site prior to insertion.

• An alternative is to cannulate the subclavianvein. Identify the junction of the lateral third ofthe clavicle with its medial two-thirds. Inject awheal of local anaesthetic just below the bone.Insert the needle horizontally through the skinand underneath the clavicle (Figure 2505). Aim towards the contralateral mid-clavicularpoint. Aspirate as you advance.

• Most catheters have three or four lumens toallow for simultaneous monitoring (Figure 2506)


574

' �� "(%�%"��

)�� "��%��"�

�"��"�

)%*�"��

)%*�"�� +��*

Fig 2503 Land marks for the internal jugular and subclavian veins.

Fig 2504 Casualty position and approach to the internal jugular vein.

Chapter_25.qxd 28/09/2004 15:58 Page 574

and administration of multiple drugs. These should be aspirated and flushed withheparinised 0.9% Saline to check patency andthen capped off. The line is sutured in place. A chest radiograph is performed to check correctpositioning of the catheter tip in the superiorvena cava and to exclude a pneumothorax.

2548 Inotropic drugs

These may be required for shocked casualties in whom reversible causes have been excluded; e.g., tension pneumothorax and cardiac tamponadeand who fail to respond to resuscitation. Inotropescan be divided into two main groups: inodilatorsand inoconstrictors.


575

�

�

Fig 2505 Cannulating the subclavian vein. A) The skin is puncturedat the junction of middle and outer thirds of the clavicle. The needle isadvanced under the bone aiming for the contralateral mid-clavicularpoint. Once blood is aspirated a guide wire is advanced. B) The catheter is passed over the guide wire and fixed in place.

Chapter_25.qxd 28/09/2004 15:58 Page 575

• Inodilators cause increased cardiac contractilityand vasodilation. This results in a rise in cardiacoutput but little affect on blood pressure.Examples include dopexamine (0.5-2 mg/kg/min)and dobutamine (2.5-20mg/kg/min).

• Inoconstrictors cause increased cardiaccontractility and vasoconstriction. The result is a rise in blood pressure above that which onewould expect from the increase in cardiac outputalone. Commonly used drugs are noradrenaline(0.05-1mg/kg/min) or high dose adrenaline (0.1-2mg/kg/min).

Nutrition

2549 Early nutrition following major illness orinjury is beneficial, especially using the enteral route- nasogastric tube or gastrostomy. Total parenteralnutrition is reserved for casualties in whom theenteral route is not possible, or for those with special circumstances.

Unresponsivenessto inotropes should

prompt further re-assessment to

ensure a treatablecause has not been

missed.


576

&��

��

�

,��-� �� "��"#��%�

.� ��-�� /�0$

Fig 2506 Measuring central venous pressure using a manometer.Prime the system with saline. The casualty is positioned at 45 degrees.The zero mark on the manometer should be level with the right atrium.Turn the three-way tap to connect the manometer and central line andread off pressure.

Chapter_25.qxd 28/09/2004 15:58 Page 576

Renal Support

2550 Haemodialysis or haemofiltration is unlikelybe available in forward areas. Renal support is notnecessary during the first 48 hours after injury. If acute renal failure does develop during this time,its effects can be controlled by careful fluid balanceand control of serum potassium and acid-basebalance by pharmacological means, (e.g., insulin anddextrose, sodium bicarbonate), until casualty transfer.

The best treatmentfor renal failure is toavoid it by early,aggressiveresuscitation andcontinued support.


577

Chapter_25.qxd 28/09/2004 15:58 Page 577

1. Unable to maintain secure airway

• Decreased level of consciousness.

• Absent gag reflex.

• Severe facial injuries.

• Inhalation burns.

• Risk of aspiration.

• Direct airway injury or oedema.

2. Failure to maintain adequate gas exchange despite supplemental oxygen (PaO2 <10kPa, PaCO2 > 6.5kPa)

• Respiratory depression e.g., head injury, morphine overdose.

• Spinal cord injury.

• Chest wall injury, e.g., flail chest with pulmonary contusion.

• Inadequate analgesia ("it hurts to breathe").

• Inhalational or aspiration injury.

3. Severe head injury

• Glasgow Coma Score < 10 or decrease of 2

• Signs of raised intracranial pressure

• Irregular respiratory pattern

4. Risk of the above occurring during transfer of the casualty


578 Table 2501 Indications for prolonged respiratory support.

Chapter_25.qxd 28/09/2004 15:58 Page 578

Chapter 26

Heat, Cold and Immersion Injury

1. Heat Illness

2601 Heat illness is an acute syndrome causedby an excessive rise in core temperature. This occursas a result of overloading, or failure of, thethermoregulatory system during exposure to heatstress (heat stroke), exercise (exertional heat injury),or both. Certain organs, particularly the brain, areintolerant of temperature change: an increase to 43oC will cause death.

In hot climates, several days acclimatisation arenecessary to allow the sweat glands to beginsecreting the large quantities of sweat needed fortemperature regulation during strenuous activity.Military personnel are at greater risk in a jungle(continuously hot and wet), as opposed to a desertenvironment (hot and dry, cold at night). They areparticularly vulnerable whilst wearing IPE (0228).


• These include: thirst, headache, nausea orvomiting, weakness, fatigue, agitation,staggering and loss of coordination, cramps,hyperventilation, disturbed vision, dizziness,impaired judgement, confusion, collapse,seizures, loss of consciousness and death.Sweating eventually ceases and the skinbecomes flushed and dry. Prodromal featuresoccur in 20-25% of cases.

• Diagnosis is supported by a high (>40°C) coretemperature (NB: unless measured at an early

Heat illness must beexcluded as a causeof collapse duringexercise. A singlecase may be awarning that otherpersonnel are at risk.

Exertional heat injurycan result from shortduration exercise,typically occurringwithin one hour or5km of the start of a run.

26: Heat, Cold and Imm

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stage - this may not reflect the peak temperature attained).

• Prognosis depends on the length of time thebody temperature remains elevated.

2603 A note on core temperature measurement

• The rectum (15 cm beyond sphincter) is the preferred site, especially in suspectedhypothermia. Alternatively, measure intra-aural (requires care and experience) or oesophageal temperature.

• Regularly calibrated electronic thermometers are the most accurate.

• Oral and tympanic membrane (infrared)thermometers (as opposed to intra-aural) areunreliable and unsuitable for regular monitoring.

Management

Treatment in the field

2604 The extent of treatment will depend on the circumstances:

• Check ABCD (0302). Administer oxygen (0317).

• Move casualties to the shade or away fromradiant heat. Keep them recumbent and stopfurther physical activity.

• Undress casualties and cool them by soakingwith tepid water.

• Fan to assist evaporative cooling and continue to cool and fan until fully recovered.

• Measure rectal temperature (where possible).

• Administer oral fluids and glucose to consciouscasualties, otherwise give 1-2 litres of normalsaline by intravenous infusion in the first hour.

ABCD and Resuscitation: see Chapter 3

Prevent heat illness by:

• Adequate water and salt intake.

• Acclimatisation.• Physical fitness.

• Reduced activity.• Appropriate

clothing.• Avoiding alcohol.

Treatment ofhyperthermia is

rapid cooling: • Strip.• Soak.

• Fan.• Fluids.

Do not use ice orvery cold liquids.


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• Monitor:

• Pulse.

• Respiratory rate.

• Consciousness level - AVPU and GCS(1610, 1614).

• Temperature.

• Transfer casualties to a Role 2 or 3 facilityif there is a rectal temperature >40°C, a reduced level consciousness or failure to respond to cooling.

Continued treatment at Roles 2 and 3

2605 This includes:

• Continue cooling and fluid administration.Perform a more detailed examination.

• Monitor rectal temperature, ECG, blood glucose and urine output regularly.

• Treat convulsions (1609).

• Consider transfer to HDU or ITU if response to treatment is poor.

HDU/ITU care


• Continue to cool.

• Consider intubation and ventilation - severelyhyperthermic casualties are often hypoxic.

• Monitor:

• Rectal temperature.

• Blood gases.

• Accurate fluid balance (assessing output via urinary catheter).

Management of Seizures: see Chapter 16

Be aware of the riskof vomiting duringrecovery. Place theunconsciouscasualty in the ¾prone position. Because of theincreased metabolicrate, hyperthermiccasualties are oftenhypoglycaemic.

Convulsionsgenerate more heat - treat promptly.

A casualty who has sustained heatillness may be moresusceptible to theeffects of heat in thefuture. They shouldbe referred to a heatillness specialist forassessment.

Continue to cool until rectaltemperature is<38.5°C. Oncestable, monitor for a further 48 hours.


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• CVP (NB: risk of fluid overload and pulmonary oedema).

• Clotting, liver function, creatinine kinase and myoglobin clearance; this helpsassessment of the degree of DIC, liver and muscle damage.

• Treat oligura with mannitol once fluid volume has been replaced. Aim for 100ml urine outputper hour, especially if there is evidence ofrhabdomyolysis (look for blood or protein in the urine).

• There may be some benefit in treating cerebraloedema with dexamethasone.

Compounding factors

2607 These include:

• Dehydrated personnel due to high sweat loss,inadequate fluid intake, diarrhoea or vomiting,are at increased risk.

• Anticholinergic agents (e.g., atropine) inhibitsweating (0237).

• A febrile illness, (e.g., septicaemia, malaria) can cause hyperpyrexia leading to misdiagnosis(NB: avoid aspirin).

• Heat illness in those suffering other injuries, willworsen shock and increase the risk of renal andother organ failure.

2. Cold Injury

2608 Cold injuries are common in warfare. During WWI, 115,000 British soldiers were affected.This was a major problem during the Falklandscampaign. Cold injuries can be systemic(hypothermia) or local.

Malaria: see Chapter 24

In casualties withother injuries, you

will need to increasefluid replacement.

Be careful not toover-infuse and

generate pulmonaryoedema.


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Hypothermia2609 Hypothermia is defined as a coretemperature (rectal, aural, oesophageal) of 35°C or less. It ranges from mild to severe:

• Mild 35-32°C.

• Moderate 32-28°C.

• Severe <28°C.

Military causes include:

• Reduced heat production due to immobilisatione.g., fatigue, an injured casualty.

• Disturbed thermoregulation due to hypovolaemicshock following trauma.

• Increased heat loss due to an unfavourableenvironment and insufficient protection. Wetclothing or immersion in water increases heatloss by a factor of 25, compared to air. Heat istransferred to the surroundings e.g., an injuredcasualty lying on the ground as opposed to astretcher. Increasing wind speed worsens heatloss by removing the warm air surrounding thebody. At altitude, atmospheric pressure, oxygentension and temperature (a fall of 6°C per1000m rise above sea level), are all reduced,predisposing to hypothermia and local cold injury.

Clinical features

2610 These can include:

• A history of exposure e.g., immersion, avalanche.

• Early and non-specific symptoms include hunger,fatigue, altered mood or confusion. As bodytemperature falls there is apathy, hallucinationsand psychotic behaviour. Most casualtiesbecome unconscious between 30-26°C.

Helevacuation and Hypothermia: see Chapter 29

Hypothermia canoccur in <30 minutesin Arctic waters andwithin 1-2 hourfollowing immersionat 20°C. Cold injurytakes >20minutes in Arctic.

Assessment of ABCin moderate orsevere hypothermiacan be difficult.Misdiagnosis ofcardiac arrest andcommencement of external cardiacmassage may causeventricular fibrillationand death.


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• Cold initially causes a tachycardia, constrictionof peripheral circulation, shivering and anincreased respiratory rate. With decreasing bodytemperature, there is progressive bradycardia,hypotension and loss of shivering. This maycomplicate and mask hypovolaemia due to otherinjuries. Arrhythmias occur below 32°C and maybe initiated by external stimuli (2612). Breathingbecomes slower and shallower.

• Hypothermia interferes with coagulation anddelays anaesthetic recovery. Post-operativecomplications are more likely.

• Once unconscious, casualties die fromventricular fibrillation or asystole. Alternatively,they may survive for several hours in a shutdown state ("metabolic icebox"). In this state, the maxim is:"no one is dead until warm anddead", even if the casualty is cold, stiff, cyanotic with fixed and dilated pupils and no palpable pulses.

First aid

2611 Seek shelter. If one member of a group ishypothermic, others are likely to be similarly affected.In shelter, remove wet clothing and dry the casualty.Re-warm them by body heat from a colleague in asleeping bag. If this is not possible, keep wet clotheson and insulate them until shelter is reached. Avoidactive re-warming in the field. Provide consciouscasualties with hot, sweet drinks.

2612 Casualties with severe hypothermia shouldbe triaged T1 for transfer to a Role 3 or 4 facility(0608). Physical movement of these casualtiesshould be done with care and with their legselevated. Because the hypothermic myocardium has altered electrical excitability, rough handling or cardiac massage may tip those with a very slowheartbeat and low, but survivable, cardiac output intoventricular fibrillation.

In severehypothermia, survival

following circulatoryarrest for 30 minutesor more, is possiblewithout neurological

sequelae.


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Resuscitation


• Check ABCD (0302). Administer oxygen (0317).

• Start CPR if the casualty is apnoeic andpulseless (NB: slower ventilation rate due to the theoretical risk of respiratory alkalosispredisposing to ventricular fibrillation). Cardiacmassage should only be commenced if it can be maintained sufficiently long for re-warming to take place. In remote locations requiring long transfer times, it may be preferable to rely on the limited cardiac output likely to be present naturally. Never start cardiacmassage and abandon it before re-warming has been performed.

• Re-warm.

• Uncontrolled re-warming of a chronicallyhypothermic casualty may result in deathdue to hypovolaemic shock, acidosis,hyperkalaemia and release of toxins. A useful rule of thumb is not to re-warm a casualty faster than they became cold(i.e., rapid onset hypothermia - rapid re-warming; chronic hypothermia - re-warmover several hours).

• For mild hypothermia (conscious, otherwise well)a hot (40°C) bath with limbs immersed producesrapid recovery.

• Do not allow a casualty to stand in a hot shower,or sit in hot air. Keep them recumbent for at least30 minutes during rewarming to avoid risks ofcircum-rescue/re-warming collapse.

• Casualties with moderate or severe hypothermiashould be managed on an HDU/ITU, when theyare available. Insulate them, including the head.Unless the airway is secure, nurse them in therecovery position in a warm but, not hot

ABCD, Resuscitation: see Chapter 3

Heated air/oxygensystems and spaceblankets are of littlevalue in re-warming.Invasive techniquesthat may be ofbenefit includeperitoneal dialysis,haemodialysis andextra-corporal heatexchange on by-pass.

Alcohol is avasodilator. Its usetemporarily delaysthe cooling ofextremities butincreases the risk ofhypothermia. It mayhave a role in thetreatment of localcold injury.


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environment. Tilt the bed a little head down.Monitor fluid balance, serum electrolytes, pH and blood gases.

• If casualties are hypovolaemic, carefully infusefluids at 37-40°C (NB: i.v. cannulation can bedifficult!). They may require sodium bicarbonateto combat metabolic acidosis.

Local cold Injury2614 Neurological (and neurovascular)abnormalities occur during and after local coldexposure of a periphery. There are two clinicalentities:

1. Non-freezing cold injuries.

2. Freezing cold injuries.

Non-freezing cold injuries

2615 Non-freezing cold injuries are caused by any combination of: a low temperature (>0°C),moisture (wet footwear due to sweating or immersion),immobilisation and a long exposure time.

Pathological changes include arteriolar spasm,microvascular endothelial damage, vascular stasis,hypoxia and deficient cell nutrition. Appearances can be similar to those caused by freezing but, tissueloss is minimal. The lower legs and feet are mostcommonly affected ("trench foot", "immersion foot").Features include:

• Early (pre-hyperaemic phase; 6-24 hours): the peripheries are cold, swollen, and painful. Pulses may be lost. The skin is white, cyanosedor mottled-red in colour. Numbness and jointstiffness in the feet, make walking difficult.

• Intermediate (hyperaemic phase; lasting up totwo months): this includes burning pain, redflushing of the skin, bounding pulses, limbswelling, blistering and ulceration.

Low-readingthermometers should

be available duringmilitary operations in

cold climates.


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• Late (post-hyperaemic): includes cold sensitivity,pain and paraesthesia (may prevent walking and wearing of boots), hyperhydrosis and poorskin quality.

Chilblain (pernio) is commonly seen in militarypersonnel at high altitudes following exposure to drytemperatures just above freezing. The fingers andnose are usually affected. Skin redness andhypersensitivity are typical and may proceed toblistering and ulceration.

Treatment of non-freezing cold injuries is to removewet boots and socks, followed by bed rest, limbelevation and slow re-warming. Leave blisters intact.Keep affected areas clean and dry - use loosedressings or a plastic bag. Give antibiotics (0816),anti-tetanus (0828) and analgesia (Figure 0701).Transfer as a stretcher casualty. At role 3 or 4 thefeet can be washed in warm water (2617).

Because treatment is difficult, prevention isimportant. This means dry socks and footwear,insulated insoles, avoidance of constriction aroundlimbs and extra care when working in wetenvironments.

Freezing cold injuries


• Freezing cold injuries occur at temperaturesbelow 0°C. Initially, there is vascular spasm and stasis, progressing to the formation ofextracellular and intracellular ice crystals. Clues include: a history of cold exposure and thepresence of ice on the skin and in clothing e.g.,the casualty's socks. Freezing cold injuries areoften seen in association with hypothermia,immobilisation or peripheral vascularcompromise due to injury and dehydration.Commonly affected sites are the hands, feet,cheeks, nose and ears. Three subdivisionsare recognised:

Suspect local coldinjury in thoseinjured andimmobilised in the cold. Treat life-threateninghypothermia as ahigher priority thanlocal cold injury.

Local freezing injurycan result fromcontact with coldmetal e.g., thecasualty's weapon.

Where the injury is both freezing and non-freezing,treat as for thedominant type;where neitherdominates, treat asfor a freezing injury.Continue re-warming.Immobilise andprotect the affected part.


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• Frostnip: is incipient freezing injury which recovers fully within 30 minutes of re-warming. The typical appearance is thatof a white spot. The importance ofdifferentiating frostnip from frostbite is thatthe former should be re-warmed slowlyusing the skin-to-skin method (place thecasualty's hand in their groin or axilla or, for a foot, seek buddy-aid!). Do not rub theaffected areas - friction can damage theskin. Immobilisation is not required.

• Superficial frostbite: this is limited to theskin. Affected tissue is pale/waxy-white and numb.

• Deep frostbite: the skin turns white andmarble-like, feels hard and adheres toadjacent tissues. Deeper layers are wooden(NB: estimating depth is difficult).

• Severe freezing injury results in varying degreesof necrosis (skin, muscle, bone) and loss offunction. In the first 24 to 36 hours, there istissue oedema and blistering. If uninfected, the blisters blacken and dry and eventuallyslough-off leaving pinkish-red thin skin. Where the entire digit is affected, mummificationand auto-amputation may occur. Do not hastenamputation until the line of demarcation is clear.

• Late complications of freezing injury includeprolonged disabling cold sensitivity, paraesthesiaand chronic neuropathic pain.

2617 Management of freezing injuries

• Remove casualties from the scene (a sense of urgency should prevail). Extremities must onlybe re-warmed once the casualty has reached a safe, warm environment: maintain body heatand minimise heat loss. Make sure the sequence'freeze-thaw-refreeze' does not take place.

Technique of Fasciotomy: see Chapter 9

Defrost frostbiterapidly. Re-warm

non-freezing injuries slowly.


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• Management of frost nip - see 2616.

• In true freezing injuries, resuscitate with warmi.v. crystalloids and re-warm rapidly. Immerse theaffected extremities fully in stirred watermaintained at 41°C (38-42°C). Add a topicalanti-bacterial agent (e.g., aqueous chlorhexidine)to the water bath to reduce skin contamination.

• Keep limbs immersed for at least 30 minutes. It takes longer than you think to bring thetemperature of the affected parts up to aminimum of 30°C. The affected limb should be dried carefully, immobilised and protectedfrom trauma (e.g., cotton wool pledgets between toes). Leave blisters undisturbed. If possible, nurse exposed on sterile sheets and protect with a bed cradle.

• If freezing is deep, circumferential and involvesthe lower leg or forearm, perform a fasciotomyprior to thawing (0908). This will prevent a rise in compartmental pressure and further tissuenecrosis, as ice crystals expand (NB: fasciotomies may bleed profusely following rewarming).

• Thawing is often painful. Paracetamol is usuallysufficient analgesia but morphine may berequired (Figure 0701). Oral alcohol (double ortreble measures of spirits) reduces the need foranalgesics and may improve outcome byincreasing peripheral blood flow. Epidurals using0.25% bupivacaine will cause peripheralvasodilation and relieve pain but, may beimpractical in the field.

• Where there is likely to be significant tissuenecrosis, administer antibiotics (0816) andtetanus prophylaxis (0828).

• If available, hyperbaric oxygen improvesoutcome where tissue viability is compromised.Vasodilators are of no proven benefit.


If essential tosurvival, the casualtymay walk on theirfrozen feet, but notafter thawing or re-freezing: thereis an increased riskof tissue loss andinfection.


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Casualty transfer and subsequent care2618

• Insulate and protect extremities before transfer.

• Freezing injuries need twice daily 'whirlpool'baths (41°C, 30 minutes, add topicalantibacterial) and protection from infection (e.g., antiseptic-soaked dressings between the toes).

• Do not aspirate or deroof blisters (contents aresterile). Trim blisters only if sepsis supervenes.Keep casualties exposed on sterile sheets andprotect from bedclothes. Rest, good nutrition and physiotherapy are important.

• Because of the compromised vascular supply,avoid surgery to the injured part for at least 5 months. Exceptions include: infected wounds,freeze-thaw-refreeze trauma, or where there arecomplications secondary to other injuries. Delayamputation until demarcation is complete (>10-12 weeks). Limitation of joint movementmay require an escharotomy.

• Pain relief, particularly for nocturnal pain, canbest be achieved with an oral night time dose of amitriptyline (start with 50 mg increasing to150 mg as necessary -unlicensed indication).Other analgesics are generally ineffective.

• Follow-up by a cold injury clinician is essential to minimise the risk of disabling sequelae.

3. Near Drowning

2619 Near drowning is asphyxia due to inhalationof water. It commonly occurs in those who becomemildly hypothermic. Typically, immersion was brief,the water rough, and no lifejacket was worn.


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4. Secondary Drowning

2620 Secondary drowning is an uncommon adult respiratory distress syndrome resulting frominhalation of water. Onset may be delayed; it is oftenrapidly fatal. Features include:

• Sudden or rapid onset of dyspnoea, cough, haemoptysis and respiratory distress.

• Occurs up to 72 hours after (usually uneventful)immersion. NB: warn casualties who may haveaspirated water to watch for features ofsecondary drowning.

Management is administration of oxygen and urgenttransfer to an ITU. Early ventilatory support can be lifesaving.

Ventilatory Support: see Chapter 25

Aspiration of water(especially ifcontaminated e.g., harbours),commonly results in pneumonia.

Suspect secondarydrowning incasualties whodevelop respiratorydistress followingrecent immersion.


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Chapter 27

Military Psychiatry

Acute Psychological Reactions to Combat

Acute stress reactions (ASR) 2701 ASR's are uncommon, reversible,psychological reactions to extreme stress; they interfere with an individual's ability to function.Removal from events will allow recovery. If respite isimpossible, symptoms will diminish after approximately72 hours.The incidence of ASRs occurs in 10-30% ofpersonnel involved in a land campaign. ASR are mostlikely when things are going wrong e.g., whereavoidance (or action) is impossible and largenumbers of casualties are being taken.

Acute psychiatric disorders (APD) 2702 This group of clinical psychiatric disordersmay or may not be reversible. APDs include:

• Psychotic breakdown (2715).

• Dissociative (hysterical) disorders (2718).

• Somatisation (2719).

• Malingering and factitious illness (2720).

In combat psychiatry, whilst there is no need for a psychiatric diagnosis, an attempt should be madeto exclude an organic cause (2714) and to assessthe casualty's danger to themselves (2716) andothers (2704). An APD in forward areas will becomeapparent when the condition does not respond to simple rest and respite.

It must beremembered thatmost individuals do not develop eitheracute or post combatstress reactions or disorders.

27: Military Psychiatry

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Symptoms

2703 Psychic distress in combat manifests itself by changes or incongruities in behaviour. The clinical picture is usually mixed and confusing.Symptoms include:

• Fear and anxiety.

• Irritability, agitation.

• Hyper-vigilance.

• Anger and rage.

• Grief, guilt, self doubt.

• Somatic complaints.

• Carelessness, poor concentration and memory.

• Insomnia.

• Emotional volatility.

• Fugue states (amnesia and wandering).

• Illusions and hallucinations.

Violence

2704 Gross behavioural dysfunction requiresimmediate attention: violence is rare in ASRs, but common in organic (e.g., exposure to chemicalweapons, treatment with atropine) and personalitydisorders.

• Remove the casualty's weapons.

• Look for an organic cause.

• Restraint may be either physical or chemical.

• Physical restraint requires five people andshould be accompanied by reassurance and reorientation.

• Drugs may be required to defuse thesituation. The choice will be between either:

Combat is adangerous place

to lose 'self-control'and like courage fearis 'contagious' within

a unit. Thereforeindividuals must be

managed quickly,professionally

and firmly.


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• a neuroleptic which tranquillises without impairing consciousness (e.g.,chlorpromazine, flupenthixol, haloperidol).

and/or

• short acting anxiolytic (diazepam, lorazepam).

Evacuation syndromes

2705 Transferring the casualty with ASRsymptoms too soon, or too far back in the chain,potentially risks long term mental ill health. The aimmust be to keep individuals close to their comrades,yet out of direct fire.

ASRs diminish force levels and casualty removal putsa strain on those left behind and potentially increasesthe risks they face, it is therefore important for theunit to receive their men back as soon as possible. It is equally important for the individual to return totheir comrades and their job to avoid feelings ofshame and guilt.

Mental State Examination and Triage

General2706 Mental state examination in the field is an attempt to try to fit the behaviour (verbal and non-verbal) to the symptoms. The aim is to assesswhether the individual is manageable close to thefront with their comrades, or will have to betransferred. This may be limited to:

Is the individual a danger to themselves or others?

• Ask directly.

• Remove weapons.

Is this organic?

• Is there alteration in conscious level?

• Visual and olfactory hallucinations?


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• Seizures?

• Evidence of exposure to chemical weapons?

Is this psychotic?

• Are their actions (behaviours) understandableand congruent with their thoughts (as revealed in speech)?

• Is there disorder in the form (linkage) of thought?

• Is there disorder in the content, and if so, does this disturb them e.g., delusions?

• Are there perceptual disturbances, and if so are they disturbing e.g., hallucinations?

Is this malingering?

• Difficult! What are the gains and losses this individual will experience?

• Do the symptoms match the story and mental state?

Credibility 2707 Military psychiatrists must have expertise in excluding physical causes for psychologicalsymptoms. A physical examination is mandatorywhen an individual requires holding or referral. It is axiomatic that non-psychiatrists should alsodevelop an understanding of how to take a simplemental state examination. Credibility will also beenhanced if psychiatrists do not force those they are dealing with to accept a psychological, ratherthan physical, cause for their suffering.

Management of ASR

In the field2708 This is summarised by two simple acronyms:


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1. PIES

• Proximity.

• Immediacy.

• Expectancy.

• Simplicity.

2. The 7 Rs

• Recognition.

• Respite.

• Rest.

• Recall.

• Reassurance.

• Rehabilitation.

• Return.


Assessment: exclude organic and seriouspsychiatric disorder.

Reassure: explain to the individual that theiremotional and psychological feelings are normal,temporary and reversible.

Medication: drugs are best avoided as they willconfuse the clinical picture and interfere with memoryand concentration. Drugs risk the development of state dependent learning and potential wastage of time and resources. Short acting hypnotics areoccasionally indicated. Psychotic individuals willrequire neuroleptics.

Transfer: Manage with the expectancy that theindividual will return to some form of duty. Extremelydisturbed individuals may have to be sent rearward.They should spend no more than 48 hours at eachholding area throughout the chain of evacuation.

Treatment of ASRshould beundertaken as close to the front as possible; asquickly as possiblewith the expectancythat the individual isnot suffering from amental illness andwill return to duty.


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Avoid admission to medical wards as this mayincrease the risk of long-term mental illness.

PreventionPrimary

2710 The psychosocial health of the Unit is the bastion against mental breakdown in combat.Every effort must be given to the development andmaintenance of esprit de corps built on tough realistictraining, trust in comrades, the chain of command,equipment and attention to welfare issues. There is,however, no sure way of knowing how individuals willact on the day.

Secondary

2711 The early recognition of ASRs and theinstitution of management strategies as rapidly and as far forward as possible, in order to returnindividuals to duty as soon as possible, whilstmaintaining their social role. Rapid segregation and psychological management of dramatic casesand disciplinary management of mailngeres, must be instituted to prevent 'Contagion' and detersecondary gain.

Tertiary

2712 This is the management and treatment of established mental disorders and is not a front line activity.

Physical Injury and Psychiatry


• The initial 'euphoria' of having survived an injurymay give way to guilt and shame if comradeshave died, or remain behind under great threat.


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• As the consequences of disability becomeapparent the individual may become irascible,irritable and withdrawn and uncommunicative.

• Injuries which are likely to cause psychological problems include blindness,amputations, disfigurement, genital wounds,burns and paralysis.

• There is likely to be a degree of distress or anxiety at the prospect of returning to dutyfor those individuals who have had less majorinjuries and are now fit for service.

Organic Causes of Symptoms

2714 These include:

Infectious disease

Thermal and metabolic injury

The first signs of heat and cold injury may involvechanges in behaviour (2602, 2610). Atropine canlead to thermal injury (0237) and is particularlydangerous in hot climates, when sleep deprived,physically exhausted and at increased doses.

Central nervous system

• Head Injury: Acute head injuries can mimic psychiatric disorders and the level ofconsciousness of a casualty must be assessedover time. Many head injury sequelae can leadto psychological difficulties. Military psychiatristsshould be adept at managing and advising onthese conditions.

• Paralysis: Hysteria or malingering may mimicparalysis or paresis.

• Seizures: One of the commonest causes ofseizures is alcohol withdrawal and/or head injury.Pseudoseizures may be seen in malingering and

Heat and Cold injury: see Chapter 26

Military psychiatristsshould be familiarwith assessing GCS.


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dissociative disorders (hysteria), interestinglythey are more common in individuals who have epilepsy.

• Delirium. Delirium may prove fatal ifmisdiagnosed and treated as a psychiatriccondition. Always look for a physical cause.Delirium should be considered when there isfluctuation in conscious level, sleep disturbance,agitation and hallucinations.

Intoxications

• Substance misuse: consider in any differential diagnosis of altered behaviour.

• Atropine: CNS effects occur at high doses e.g., hallucinations and disorientation (0237).

• Chemical agents: chemical weapons can cause miosis and eye pain (0233). This can be prevented by pyridostigmine priorto exposure (0234). Miosis is also seen in opiate misuse. Chemical weapons may alter the epileptic threshold.

Abdominal trauma

Peritonism may lead to individuals assuming a foetal position and immobility. This may mimicuncooperativeness or malingering.

Aural trauma

Deafness is common following explosions. Similarly, deafness may be mimicked in malingering and dissociative disorders.

Occular trauma

Laser eye injuries can lead to (painless) blindness.This may also be encountered in dissociativedisorders and malingering. Blindness is particularlyterrifying in a combat situation.

Head injury: see Chapter 16


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Psychological Disorders

1. AcutePsychotic disorders

2715 These are no more common in combat thanin peacetime:

• The diagnosis is usually straightforward as behaviour is grossly disturbed and usually congruent with the underlying psychiatric disorder.

• Attempts at feigning a serious mental illness may be encountered.

• Numerous cases may raise the suspicion of chemical agent.

Suicidality

2716 It is vital to assess an individuals risk of suicide:

• Worries and problems at home and in theatre can lead to mental distress andinappropriate behaviour.

• One of the psychological hooks which keepsmilitary personnel going through difficult times is a belief, whether realistic or not, that there will be something worthwhile at home to return to.

• Bereavement in combat can be a potent causeof survivor guilt. Depression should always besought and suicidality raised when biologicalsymptoms are present.

• Sleep deprivation is a common cause of lowered mood, and so a therapeutic trial of rest,sleep and respite may see a restoration of moodand diminution in suicidal thoughts.

The key to psychoticillness is its 'non-understandibility' and incongruity.


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Personality disorders

2717 Diagnosis can be difficult.

• It is generally made on evidence of previousbehaviours; these individuals seem unable to profit from experience.

• Individuals with personality disorders causedistress for both themselves and those withwhom they work (e.g., annoyance, irritation,frank disbelief). They can disrupt a unit bysetting comrades against each other. They may also be masters at avoiding blame, or the responsibility for their actions.

• If individuals misbehave, they should be dealtwith through the disciplinary, not medical chain.

Dissociative disorders (hysteria)

2718 These conditions are occasionallyencountered:

• Presentation may include blindness, deafness, altered sensation and paresis.

• Search for an organic cause.

• Any stay in hospital should be as brief aspossible, if individuals are not to 'pick up' further medical conditions, or fail to improve.

Somatisation

2719 The presentation of physical symptoms as a manifestation of psychological symptoms is very common in time of conflict, and not a fullyconscious process. Excessive focus on the physical,unnecessary investigations and inappropriate transfermay lead to long term mental ill health anddisordered illness behaviour.

If behaviour hasrecently changed,

then an organiccause should be

sought.


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Malingering and feigned illness

2720 A high index of suspicion is required as itsmanagement is disciplinary not medical.

2. Post combat or traumatic2721 Post traumatic mental reactions are the norm, but a few will lead to post traumaticmental disorders.

• Post traumatic stress disorder (PTSD) is one of these disorders and may occur in up to 30%.The pillars of the post traumatic reaction andPTSD are re-experiencing, avoidance andarousal. Associated behaviours such as risktaking, misuse of alcohol, relationship problemsalso occur.

• Other long term complications includedepression, anxiety, substance abuse, phobias,personality change and medically unexplainedsymptoms (MUS) with associated abnormalillness behaviour.

2722 The aetiology of non-psychotic mentalillness is multifactorial and is the product of aninteraction between the:

• Individual's personality and experience.

• Traumatic stressor.

• Environment in which the event was experienced.

• Environment afterwards.

• Culture from which the individual comes and to which he returns.

2723 As in ASRs and APDs, only a minority of individuals develop a problem.

• Many are treatable with existing therapies and medication. Early referral is recommended.


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• At present, there is no evidence thatinterventions soon after the event, such asPsychological Debriefing, work; indeed there is asuggestion they may do harm.

• MUSs are therapeutically challenging anddifficult to manage.


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Chapter 28

Major Incident Medical Management

Definition

2801 A major incident for the medical services is:

Any incident where the number, severity, type or location of live casualties requiresextraordinary resources.

A major incident for a multinational deployed force is one where:

A single nation's medical assets are unable to cope with the casualty load. The "extraordinary resources" in thesecircumstances are another nation's assets.

The three phases of a major incident are:

1. Preparation.

2. Response.

3. Recovery.

1. Preparation for a Major Incident

Preparation requires planning, equipment and training.

Planning 2802 Advance formulation of a major incidentplan is essential to a successful outcome.

A generic "all hazards" plan has been designed for a multinational NATO Force deployed on apeacekeeping operation (Hodgetts TJ. KFOR Generic

"If one fails to plan,then one is planningto fail".

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Major Incident Planning Guidance, Kosovo 1999).This provides a useful template for major incidentplanning by clinicians on operational deployment. A series of NATO Medical STANAGS (standingagreements) provides the framework for componentsof the military major incident response.

Equipment2803 This includes appropriate safety clothingand advanced life support equipment as supplied by incident response teams (Table 2802).

Training 2804 Training encompasses both education and exercise:

• Educational courses should address scene management of multiple casualties (e.g., Major Incident Medical Management and Support MIMMS) and treatment (e.g., Advanced Trauma Life Support ®; BATLS).

• Medical units should regularly exercise triage,clinical co-ordination, communications, treatmentof various injuries in different settings, traumadocumentation, and interservice workingarrangements. Exercises may be:

• Paper.

• Table-top.

• Practical with or without simulated live casualties.

• Interservice.

Battlefield Advanced Training Life Support: see Chapter 3


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2a. Major Incident Response at the Scene

2805 The following seven priorities applyto all emergency services, whether civilian or militaryanywhere in the world:

• Command and control.

• Safety.

• Communication.

• Assessment.

• Triage.

• Treatment.

• Transport.

The aim is to impose order on a chaotic major incident.

Command and control2806 This involves:

• Command is exerted vertically within theemergency services. Each service at the scenewill have a commander, referred to as the IncidentOfficer (e.g., Medical Incident Officer MIO).

• Tiers of command. Control at the scene isfacilitated by the use of inner and outer cordons,commonly marked by tape. These cordonsidentify levels of command at the scene.

• Bronze. This is the immediate area of theincident, marked by an inner cordon. Theremay be several "Bronze" areas. A forwardcommander may be appointed to workwithin each.

• Silver. The outer cordon marks the area ofresponsibility of the Incident Commanders(who form the "Silver" level of command).

Incident Response Teams: see Chapter 29

Major incidentsinvolving chemicalspillage, radioactivecontamination orbiological agentsneed specialist input.


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• Gold. Strategic command (e.g., at BrigadeHQ) is designated "Gold" command.

• Control of a major incident is exerted horizontallyacross the emergency services. Overall there will be one individual (or service) in control. In the UK this is usually the job of the Police.Where there is fire, chemical or other hazardsthis role will be assumed by the Fire Servicewithin the immediate area of the incident. On military operations abroad, the ExplosivesOrdnance Disposal (EOD) may take local controlin areas where mines or other unexplodedordnance are a threat, with the battle groupbeing in overall charge.

Safety 2807 The priorities are Self, Scene, and Survivors ("1-2-3 of Safety"). Get out and stay out of the contaminated area. Personal should useappropriate protective equipment. Safety of the sceneis enhanced by effective control of the cordons. Inform the Incident Commander (2806) about any of the following:

• Difficult assess: approach may be required by rotary wing, specialist vehicle or on foot.

• Unsafe vehicles: ensure the ignition is turned off,the battery disconnected and the fuel supplyisolated. Help may be needed from theengineers to secure an unstable vehicle.

• Trapped casualty: this may require cuttingequipment and assistance from the Fire Service.

• Possible hyper- (2604) or hypothermia (2611)amongst staff and casualties.

• Hazards: high tension cables, flooding, fire,chemicals (NB: you may need to wear IPE0228),unexploded munitions, weapons at scene

Protection and Decontamination: see Chapter 2

The Fire Service is responsible

for safety followingchemical spillage.

Medical and rescuepersonnel are at risk

of secondary devicesin terrorist incidents.


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(e.g., casualty's personal weapon) andsuspected booby traps.

• Ambush or hostile local population.

Communication2808 Communications have consistently been identified as the main failing in major incidents.This applies both vertically and horizontally within thechain of communications. Incident commanders mustensure they communicate frequently with theircounterparts in other services, as well as with theirforward teams. The MIO should be in contact with thehospital clinical co-ordinator via the appropriate chainof command.

Assessment2809 The first message from the scene shouldfollow the METHANE format to ensure that essentialinformation is passed on:

M My call sign; Major incident "Standby" or "Declared"

E Exact location Grid reference

T Type of incident

H Hazards Present and potential

A Access Roads, landing areas

N Number of casualties Including severity and type

E Emergency services Present and required

Triage

2810 The aim of triage in a major incident is tosort casualties according to medical priority, so thatlimited medical resources can be directed to thosemost in need of treatment (0603). Triage is a dynamicprocess that needs to be repeated several times

Triage; see Chapter 6

All Role 1 and Role 2 operationalunits and IncidentResponse Teamsshould be equippedwith sufficient DMS-approved triage cards.


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during the stages of care. A more refined "triage sort"(0608) can be used at the casualty clearing station toprioritise transfer.

Treatment

2811 The aim of treatment at the scene is toallow the casualty to reach hospital safely. It may be preferable to "scoop and run" rather than "stay and play".

Life saving first aid is provided in the immediatevicinity of the incident. Advanced life supportmeasures are carried out at the Casualty ClearingStation. Setting the latter up at a safe distance fromthe scene of the incident is the responsibility of theAmbulance Incident Officer.

Transport

2812 Transfer following a major incident aims to "get the right casualty to the right place in the right time". Do not simply move the major incidentfrom the scene to the hospital. Casualties should bedispersed to different hospitals depending on theircapacity, the specialist care available and thelogistics of transportation.

The dead

2813 Dead casualties should be clearly labelled during the triage sieve. A major incident isoften regarded as a crime scene. The dead shouldnot be moved except to gain access to the living or to prevent destruction of a body by fire or chemical.Death should be officially pronounced by a medicalpractitioner and witnessed by a police officer.

The police are responsible for identifying the dead, informing relatives and removing bodies from the scene.



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2b. The Hospital Response to a Major Incident

Planning2814 A major incident plan must be formulatedand regularly exercised and updated. This mayrequire planning and liaison between co-locatedmedical units of different nationalities and betweencivilian and military facilities. In war fighting, a fieldhospital will permanently be in a heightened stateof readiness.

Incident activation

2815 In the UK the following messages to the hospital have been standardised:

• Major incident - standby.This alerts the hospital that a major incident is possibly imminent or is unconfirmed. Key personnel are to be informed.

• Major incident declared - activate plan.The incident has occurred and a full response is required.

• Major incident - Stand down.Return to normal activities.

Command and control

2816 During a major incident there is a need forcentral clinical command and administrative control. If available, an emergency physician would takecommand of the clinical response, with the hospitalcommander exerting overall control.

Communications

2817 The clinical co-ordinator at the hospital requires timely and accurate information from thescene. They need to know the approximate numberand nature of casualties, their probable time of arrival

.


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and when no more are to be expected. This allows reasoned decisions to be made on theusage of key resources.

Triage

2818 The triage sieve should be used to directcasualties to the most appropriate areas (0603).

Treatment of non-critical casualties 2819 There are two distinct stages of hospital management:

Stage 1 This occurs as the incident is evolving,casualties are arriving, and the scale of theincident is unknown. The priority is conservationof key resources for an unknown number ofcritically injured casualties, whilst at the sametime providing minimal acceptable care for all others.

Stage 2 Occurs after all casualties have arrived, their injuries have been defined and hospital resources are fully mobilised.Definitive care can now be provided to allaccording to triage priorities.

Treatment of critical casualties 2820 Damage control surgery aims to provideminimal intervention to save the lives of the mostcritically injured casualties (0402). Treatment isdirected at treating airway and breathingcompromise, staunching haemorrhage and temporarycontrol of hollow visceral injuries. Definitive care isdelayed for 24-48 hours until the casualty is morestable and fresh resources are available (0403).

A note on blood transfusion 2821 Experience in war and disaster scenarioshas shown that most injuries do not need transfusion(the major exception being amputations), and that the



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transfusion trigger can safely be lowered to a haematocrit of 21% (Hb 7-8g/dl). Because a field hospital has a limited blood bank and nofacilities for platelet infusion, clinicians should have a higher threshold for initiating transfusion during a major incident.

Freshly donated warm blood, with its full complementof platelets, can be life saving for casualties withsevere wounds who have entered "the bloody viciouscycle" of profound hypothermia, coagulopathy andmetabolic acidosis (Figure 0401). An emergencyblood donor panel should be set up at the start of operational deployment.

A note on investigations2822 Radiographic triage is often necessaryduring receipt of mass casualties. X-rays are routinefollowing polytrauma (0336). More specialisedinvestigations may be necessary (0337).

Transfer

2823 Following a major incident it is necessary to:

• Restore the ability of the medical unit to accept further casualties.

• Transfer casualties for definitive care.

Experience from major incidents involving Britishmilitary medical units in the Balkans and SierraLeone has shown that it takes between 28 and 30hours from the time of the incident to when the lastcasualty is transferred from the facility. This is knownas the "30 hour/next-day rule".

A major incident does not cease on transfer ofcasualties to definitive care. Specialised care well go on for weeks or months and considerably impacton the normal workload of the Role 4 hospitals.


The logistic problems associatedwith replenishingstocks of oxygen and blood usedduring a masscasualty incident on overseasdeployments should not beunderestimated.


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Chapter 29

The Incident Response Teamand Aeromedical Evacuation

1. Incident Response Team

Introduction2901 During operations in areas whereinfrastructure is limited, immediate BATLS care andevacuation (transfer) may be provided by IncidentResponse Teams (IRT). Essential features include:

• Trained personnel and appropriate resources on constant standby.

• Rapid communication from incident to deploying authorities, vehicles and IRT.

• Rapid, safe access to the incident withappropriate incident control (2806).

Requirements2902 Considerations include:

• The configuration of the IRT depends on the population at risk (PAR), likely threat local factors.

• Trained personnel with the skills necessary to care for critically injured casualties in the pre-hospital environment (Table 2901).At a major incident one of these would act asMedical Commander (Medical Incident Officer2806). When responding to small incidents, only one medical officer may be dispatched e.g., an anaesthetist. Relevant equipment is listed in Table 2902.

Command and Control: see Chapter 28

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• In order to provide a secure environment,additional staff such as Explosive OrdnanceDisposal (EOD), military police and Defence FireService are required. Training with these andother team members will ensure a coherentapproach to casualty care and mission safety.

• Where IRT is to be conducted using rotary wing aircraft, all personnel must know aboutaircraft safety (2923) and have had experiencein winching.

• In hostile environments (e.g., continued enemyactivity), specific training such as IsolationPreparation (ISOPREP) may be necessary.

Scene Safety: see Chapter 28

Medical personnelrequire advanced

airway managementskills, including use

of induction andmaintenance drugs.

Isolated ability toperform rapid

sequence inductionto allow intubation isinsufficient, as this is

only a small portionof overall airway

management.


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Medical Consultant Anaesthetist

Consultant Intensivist

Consultant in Accident and Emergency Medicine

Nursing Intensive Care

Accident and Emergency

Professions Allied to Medicine Operating Department Practitioner

Paramedic

Medical Assistant

Support Administration

Signals

Fire Service

Explosive Ordnance Disposal

Logistic Drivers

Aircrew

Security Police

Ground Forces

Table 2901. Optimum composition of an IRT.

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Monitoring Equipment and Ventilators: see Chapter 25

Electrical and gaspowered equipmentcan be dangerousand must be clearedfor use on militaryaircraft. Likewiseaircraft systems may affect medicalequipment.

During the Israelicampaign in SouthLebanon, there were 1.7 injuries per casualty. Prior to evacuationinterventionsincluded: applying a dressing (26%),establishing an i.v. line (28%) andventilation (21%).The average onscene time foraeromedicalevacuation was 3 minutes.


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617

Generic Specific

Medical Airway support Masks, OPA, NPA, ET, cricothyroid puncture kit.

Suction High performance, battery powered.

Oxygen Regulators with high and low pressure connectors for all types of delivery.

Cervical spine Collars, blocks, tape.immobilization

Vacuum mattress/spinal board

Tube thoracostomy Military pattern, without trocar.

i.v. access Large bore cannulae.

Fluids Crystalloid, colloid, blood.

Drugs Resuscitation, maintenance.

Multifunction monitors ECG, SpO2, NBP, temperature as a minimum(2530)

Defibrillator

External pacing

Warming Heated overblanket with battery power.

Ventilator Adjustable for tidal volumeand frequency, with pressure monitoring as a minimum (see 2531).

Personal Clothing suitable for location and task

Combat body armour

Combat helmet/flying helmet

Immediate survival Water, rations, e.g. following forced locator beacon,landing secure communications

Weapon e.g. pistol

Communications At least at level of vehicle to Operational control.

Vehicles Wheeled, tracked, rotary wing

Table 2802 Equipment for IRT.

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IRT in action

Callout

2903 Inadequate information and poor co-ordination may resulting in over reaction to a situation, or failure to initiate callout in medicallysignificant incidents. UK Forces use the "METHANE"system (2809) to ensure that essential information ispassed on from the scene.

Incident safety

2904 Considerations are discussed in 2807

Intervention and packaging

2905 Patterns of injuries likely to be encounteredare discussed in 0101 and 0102. The level of initialintervention is the minimum that will stabilise thecasualty for safe transfer (2811). This is often a compromise between "scoop and run" and "stayand play". The essential factor is the speedy andsafe transfer to better facilities. Types of intervention are described in 0317-0338. If you think one or more of these are essential, they are best carried out on the ground before transfer. Trying to obtain i.v. access or insert a chest drain in a movingairframe is difficult!

Preparing the casualty for flight is essentially thesame as the "packaging" of any casualty formovement (0338):

• Monitoring must be established and maintained.

• The casualty must be secured to the stretcher,and the stretcher secured to the aircraft. Whereeffective immobilisation is required, a vacuummattress is less likely to cause pressure soresduring prolonged transfer than a spinal board; it may be easier to load and unload.

• All ventilated casualties should have a naso-or

Packaging: see Chapter 3

Attendance at major incidents

can be distressingfor the careers. Look

out for acutepsychological

reactions. Symptomsare listed in 2703.

These can often beprevented by

effective teamsupport.


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orogastric tube to decompress the stomach. This will help reduce the effect of gas expansionduring flying and the likelihood of reflux.

Record keeping and handover

2906 Despite the urgency of the situation, it is essential that adequate records are kept. The minimum information required is summerised bythe acronym 'MIST' (0301). This can be convenientlyrecorded on plastic triage labels, 'T'cards or FMed826. Details of MIST must be passed on followingarrival at the medical facility.

After handover the IRT team should clean theirequipment and replenish consumables. If the incidentrequires more than one trip for the team, pre-packedselections of the most commonly used items are useful to speed the re-supply and preparation process.

2 Aeromedical Evacuation

Tactical and strategic aeromedical evacuation2907 The movement of casualties, other thanimmediately following injury, falls into the category of secondary transfer. This is should be a process of "seamless" delivery of care. By this stage mostcasualties will have undergone resuscitation +/-damage control surgery. Transfer times are likely to be prolonged.

2908 Casualties are categories according to Table 2903. Transfer is undertaken by AeromedicalEvacuation Squadrons using dedicated aircraft andmedical teams. Evacuation of those in Category 3and 4 is reasonably straightforward. Casualties inCategories 1 and 2, require active delivery of care bystaff with high dependency and intensive care skills.


Current medicalemployment of air transport in theforward area isbased on NATOStandardisationAgreement(STANAG) No 2087. This agreementdefines who, how,when and wherecasualties can beevacuated from thebattlefield.


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At tactical level, transfer between Role 2 and Role 3would involve RAF Critical Care Air Support Teams(CCAST). Co-ordination of this system is via Air Evacuation Co-ordination Officers (AECO) and Air Evacuation Liaison Officers (AELO - attached to each Field Hospital). These personnel should be deployed early in the initial stages of all UKoperations and form the forward elements of the air evacuation chain.

2909 Strategic aeromedical evacuation ispotentially most demanding. In a hot extractionsituation, where there is danger to the aircraft andpersonnel, adopt a 'scoot and run' approach.Typically, there will be limited opportunity for clinicalintervention, other than clearing and maintaining theairway. Casualties are often loaded without the aid of a stretcher and may need to be fixed to the floor of the aircraft.

Onward travel to the UK is by fixed wing aircraft.Evacuation may require full intensive care to beprovided for up to 24 hours and in various modes of transport. . Potential in-flight problems2910 These include

• Dislodgement of endotracheal tubes, i.v. lines and monitoring equipment..

• Altitude and the effects on oxygen tension and gas expansion.

• Temperature.

• Acceleration and deceleration.

• Vibration.

• Noise.

• Motion sickness.

British forces in Malaya in the late

1940's were amongstthe first to utilise

helicopters forcasualty evacuation.

During the Koreanconflict over 20,000

wounded wereevacuated strapped

to stretchers outsidethe cockpit.29: The Incident Response Team

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Altitude

2911 Atmospheric pressure falls with increasingaltitude; this relationship is not linear. Ambientatmospheric pressure halves at 18,000ft (~6,000m)and halves again at 33,000ft (~10,000m). This meansthat the higher the ascent, the less oxygen there isavailable and a given amount of gas expands to fill a larger volume.

Current fixed wing aircraft used for evacuation fly at an altitude between 26,000-35,000ft (~9,000-12,000m). To save fuel and reduce flight times, cabinpressure is generally maintained at levels equivalentto an altitude of 6,000-9,000ft (~2,000-3,000m); thisrarely causes symptoms. By comparison, reducedoxygen tension may be critical in a shocked casualtyor one with lung trauma. Similarly, expansion of air in body cavities (e.g., skull, chest or bowel) may have disastrous consequences (see below).

Altitude is less of an issue in helicopter flights wheremost evacuation is carried out between 1,000-6,000ft(300-2,000m) and flying times are usually shorter.

Temperature

2912 The internal temperature can be controlled during most flights by fixed wing aircraft;hypo/hyperthermia is not generally an issue. This isnot usually possible during helicopter transfer, wherewind chill means that external temperatures canreach - 40°C. Medical personnel need to be sensitiveto likely changes in the casualty's body temperatureand vary the number of blankets accordingly. This is

Hypothermia: see Chapter 26

Dedicated helicoptersquadrons were firstintroduced by the US military. Themore than 400,000casualties airliftedduring the VietnamWar demonstratedthe value of rapidextraction and early delivery to a surgeon.

Following injury,one of the most

dangerous times forthe casualty is duringtransfer. The airwaymay becomeobstructed andtubes/lines kinked,disconnected or fallout. Movement ofwounds andfractures results inpain and increasedbleeding.


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Category

1 Intensive care, requiring ventilation

2 High dependency care, intensive monitoring

3 Requiring infusions, catheters, drains

4 Essentially "walking wounded"

Table 2903 NATO categorisation of Aeromed casualties.

Chapter_29.qxd 28/09/2004 15:58 Page 621

especially important in the already hypothermiccasualty, or following burns and spinal trauma.

Acceleration/Deceleration

2913 Two types of acceleration are experiencedin a helicopter, linear and radial, both of which mayaffect cardiovascular function.

• Linear acceleration: results from an increase or decrease in the rate of movement along astraight line. A stretcher casualty, lying parallel to the long axis of the airframe will experience a shift of blood fluid volume towards the lowerextremities, stimulating baroreceptors andresulting in transient tachycardia.

• Radial acceleration: occurs due to a change indirection of motion. A banking helicopter causesa uniform increase in gravitational force actingoutwards from the centre of the turn (measuredin Gs). This will increase hydrostatic pressure in vessels below the level of the heart, impairingvenous return and thus dropping cardiac output(Starling's Law). The physiological responsesthat follow mimic those seen in hypovolaemicshock. This could have serious consequences in a casualty who is already hypovolaemic.

Vibration

3914 Vibration is an inevitable feature of helicopter flight and can have a number of pathophysiological effects:

• Prolonged exposure to low frequencies can result in blurred vision, shortness of breath, chest/abdominal pain, motion sicknessand fatigue.

• interference with the body's ability tothermoregulate, e.g., by causing vasoconstrictionand decreased ability to sweat. Consequently,


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helicopter transfer may impair coolingmechanisms in a hyperthermic casualty.

• Increased wound pain, fracture movement and bleeding leading to increased requirementsfor analgesia and fluid resuscitation.

Vibration can interfere with medical equipment andelectrical activity sensing pacemakers. It hindersmedical personnel undertaking fine procedures (e.g., cannulation, intubation )and simple clinicalassessment (e.g., feeling a pulse).

Noise

2915 Prolonged exposure can cause:

• Headaches, ear discomfort, fatigue, nausea,visual disturbances and vertigo. When travellingin helicopters, casualties and their escort shoulduse earplugs or defenders.

• Medical personnel may notice deterioration in their performance of simple tasks.

Difficulties in communication can be avoided by the use of headsets or specifically designed flyinghelmets (NB: equipment alarms may be missed). High levels of noise prevent the use of a stethoscopeand hence conventional methods of monitoringcardiorespiratory function. During the flight, thecasualty's BP can be estimated by palpating for the presence of a radial, femoral or carotid pulse and assessing CRT (0313). Similarly, respiratory rate,chest expansion and level of consciousness continueto be assessable. Where available, approved, non-invasive ECG, blood pressure and pulseoximetry monitoring, may be used.

Motion sickness

2916 Symptoms tends to occur when visualsignals are in conflict with the vestibular evidence of motion, or when signals from the semicircular

The effects of vibration in a helicopter can be minimised by securing thecasualty with energy absorbingpadding/mattresses,whilst avoidingdirect contact

with the airframe.


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canals do not conform to expected patterns. Eventolerant individuals will eventually succumb if themotion is intense and of sufficient duration. A numberof factors are known to worsen or precipitate motionsickness including:

• Anxiety, unexpected movement, low frequencyvibration, sight or smell of food, presence of nasogastric tube or the vomiting of other casualties.

• Clinical factors include: paralytic ileus, pre-existing nausea and gastric distension.

Features are general malaise, nausea, vomiting,retching, headache, fatigue and apathy. Casualtiesare pale, cool to touch and experience excessivesweating (diaphoresis).

Clinical considerations2917 There are no absolute medicalcontraindications to evacuation by air. Considerationshould be given to what effect the flight may have on the casualty and how these can be minimised.This section gives some broad guidance for thetransportation of the more common battlefieldinjuries, particularly relevant to evacuation by fixed-wing aircraft, but need to be considered during helevacuation.

Abdomen and chest

2918 Gastrointestinal dilatation occurs due to gas expansion at altitude; following abdominal injury,make sure there is a nasogastric tube in place.

Ideally, delay emplaning for 10 days after laparotomyor thoracotomy. Following chest injury, insert a chestdrain and ensure free drainage (NB: underwater sealis unsafe). Bilateral injury is common and maynecessitate a chest drain on the opposite side.

Hyoscine(scoplamine) is themost effective drug

used to combatmotion sickness.

It causesdrowsiness, even

when taken bytransdermal route.


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During early transfer, request that the casualty isflown at sea level cabin pressure. Casualties whohave suffered significant thoracic trauma are oftentransferred whilst sedated, intubated and ventilated.

Head

2919 The casualty should be stable prior to evacuation:

• Safeguard the airway, maintain a normal BPand administer high flow oxygen. Casualties who have suffered a significant head injury are often transferred whilst sedated, intubatedand ventilated.

• Where there is a possibility of spinal injury, the casualty must be fixed to a long spinal boardor vacuum mattress.

• Significant intracranial haematomas should be evacuated prior to flying.

• Transfer requires a medical escort with access to resuscitation equipment. If thecasualty deteriorates in flight, do not assumethat it is due to the head injury.

• Transfer should be direct to a pre-arrangedneurosurgical centre.

• The casualty should be flown in a head-up position.

• Helicopters should ideally remain below 1,000ft(~300m) or, in the case of a fixed wing aircraft flywith a cabin pressure equivalent to sea level.

Musculoskeletal

2920 Fractures require immobilisation priorto transfer. Flying may increase limb swelling leadingto a compartment syndrome (0906). This is mostlikely in the first 10 days after injury/surgery andwhen a back slab has been converted to a complete

Immobilisation of Fractures: see Chapter 9


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cylinder. Plaster cylinders <3 days old or syntheticcasts <10 days old should be bi-valved (0908) priorto departure. Elevate the limb. Though older casts do not generally need to be divided, plaster shearsshould be available during transfer.

Maxillofacial trauma

2921 The airway is at risk from bleeding, swellingor obstruction. Casualties must have a secure airwayprior to transfer (0322). Motion sickness may causethe casualty to vomit in-flight leading to obstructionand aspiration. Transfer requires a trained medicalescort with access to resuscitation equipment. Where the jaw is held by intermaxillary fixation(1828), means of releasing the device (e.g., wire cutters) must be at hand.

Ophthalmic trauma

2922 Casualties are managed as in Table 1701.Transfer in a sitting position; no altitude restrictionsare required.

Following surgery to the eye, the casualty should betransferred in a sitting position and the cabin altitudepressure restricted to 2000ft (~700m).

Working with Aeromed helicopters2923 Here are some general guidelines:

• The "approach" position for a Puma or Sea Kingis at 2-3 o'clock (nose =12 o'clock), 30m (100ft)away from the helicopter. On receipt of a clearsignal from the aircrew (a "thumbs up" by day,one flash of a torch by night), approach thestarboard door ("emplaning"). In the case of the Chinook, the approach position is 50m away,between 4-5 o'clock and 7-8 o'clock, travellingtowards the rear ramp.

• Keep personal belongings and kit to a minimum.

Maxillofacial injury: see Chapter 18

It is difficult to assess limb

circulation and dividea cylinder in flight.

especially if it madeof synthetic material.When in doubt, do it

before departure.


edical Evacuation

626

Chapter_29.qxd 28/09/2004 15:58 Page 626

• When not involved in loading or unloading, stay well clear in a position where the crew can see you.

• Casualties are loaded feet first and are securedwith their heads forward (NB: those with a headinjury travelling in Puma or Sea King helicopterare secured feet forward).

• If casualties are emplaned whilst the rotor bladesare still turning, all loose items must be securedbefore approaching the aircraft.

• Care should be taken when working on slopingor uneven ground. Remember, on an uphill slopethe rotor blades will be closer to the ground.

• Discuss with the AELO any flying restrictionsimposed by the casualty's clinical condition prior to flight

• Avoid moving about inside the aircraft and do nottouch any controls, especially those painted withblack and yellow stripes.

• Obey all orders given by the aircrew. Do not leave the aircraft until told to do so.

Opthalmic injury: see Chapter 17


edical Evacuation

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Chapter_29.qxd 28/09/2004 15:58 Page 627


edical Evacuation

628

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Chapter 30

Practical Procedures

General

3001 This Chapter is intended to 'hold the hand'of the less experienced reader. Other, more specificprocedures are presented in the relevant section.There is no substitute for experience. If you areabout to do something to a casualty that you havenever done before, get someone senior to help. In extremis, consider whether the intervention is really necessary, or if there are safer options.

Explain to the casualty what you are about to do and why. If appropriate, obtain informed consent.Wear personal protective clothing - gloves, apron, face mask and eye protection. Make sure all equipment is to hand and is working correctly. Good light, correct positioning, a co-operative casualty and able assistance will make your life much easier.

Airway Manoeuvres

Oropharyngeal airway (OPA)3002 An OPA (Figure 0309) is sized from themiddle of the upper incisor teeth to the angle of thejaw. If it is too large, it may cause gagging; too smalland it will be ineffective. A size 2 or 3 Guedel airway(green or yellow) is commonly used in adults:

• Inserted concave side uppermost.

• On reaching the soft palate, turn the OPAthrough 180 degrees and slip it into place overthe tongue (NB: do not push the tongue back).

Cleaning the airway: see Chapter 3

30: Practical Procedures

629

Chapter_30.qxd 28/09/2004 15:58 Page 629

Nasopharyngeal airway (NPA)3003 Select the appropriate width: in the adultmale the usual size is an 8 and in females a 7. This approximates to the diameter of the casualty'slittle finger. Check the length; ideally, the tip shouldbe just visible in the oropharynx. This approximatesto the distance from the right nostril to the tragus of the right ear. A NPA can be trimmed to length with scissors.

• Insert a safety pin through the flange to preventinward displacement (Figure 0310).

• Lubricate the NPA well.

• Most NPAs are designed for insertion throughthe right nostril. Look for possible sources ofobstruction (e.g., fracture, polyp). Stay close to the floor of the nose. Use a gentle rotatingmotion and aim posteriorly and towards theipsilateral ear lobe.

• If there is resistance, try the other nostril or a smaller-sized NPA.

Needle cricothyroidotomy3004 This intervention has very limited application on the battlefield. Because they have

Securing the airway: see Chapter 3


630

��

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��

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Fig 3001 Location of cricothyroid membrane. Position of incision for cricothyroidotomy.

Chapter_30.qxd 28/09/2004 15:58 Page 630

a more elastic chest wall, needle cricothyroidotomymay be of greater benefit in children.

Equipment

• 12 or 14 gauge i.v. cannula.

• Oxygen tubing with Y-connector or side hole.

• Full oxygen cylinders with flow meter.

• 5 ml Syringe.

Procedure

• Place the casualty supine with the neck in theneutral position. Where indicated, have anassistant immobilise the head and neck. Remove any cervical collar.

• Position yourself at the head end of the casualty.Identify the cricothyroid membrane (Figure 3001).This can be felt just below the thyroid cartilage(Figure 3002). Unless contraindicated, identifyingthe landmarks is facilitated by extending theneck, or by backwards traction on the skin lateral to membrane. This will demonstrate a small depression at the site of the cricothyroid membrane.

• Select a 12 or 14 gauge over-a-needle cannula.Attach to a syringe containing a little air. Insertthrough the skin and cricothyroid membrane intothe trachea at 90 degrees with the bevel facing


631

��

Fig 3002 Palpating the cricothyroid 'window'.

Chapter_30.qxd 28/09/2004 15:58 Page 631

cephelad (Figure 3003). After perforating themembrane, angle at 45 degrees and advancethe cannula at the same time as removing the needle.

• Oxygen is insufflated into the lungs underpressure (insufflators are available in operatingtheatre/ITU). There is a risk of barotrauma (e.g., lung rupture, tension pneumothorax, Figure 0311).

• This technique can be performed without aninsufflator by attaching the cannula to oxygenrunning at 15 litres per minute. A Y-connector


632

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Fig 3003 Performing a needle cricothyroidotomy.

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Fig 3004 Needle insufflation. The side hole in the oxygen tubing isintermittently occluded.

Chapter_30.qxd 28/09/2004 15:58 Page 632

or side hole is incorporated into the tubing.Occluding the open end of the Y- connectoror side hole one second in every five, forces a stream of oxygen into the trachea (Figure3004). Without an insufflator, this technique will be effective for a maximum of 30-40 minutesin those with normal pulmonary function (i.e., no significant chest injury). A casualty with little or no ventilatory effort will not beadequately oxygenated.

Surgical cricothyroidotomy3005 Cricothyroidotomy is easy to perform as the cricothyroid membrane lies superficial in the neckand is relatively avascular. Extension of the neck isnot essential, this is a "safe" procedure for those with suspected cervical spine injury.

Equipment(The British military pre-packed and sterile set contains everything apart from LA, needle and syringe).

• Good operating light.

• Lignocaine 1% (20 ml).

• Cleaning solution.

Maintaining the Airway: see Chapter 3

In general,cricothyroidotomy is avoided if there is direct laryngealtrauma as this willcause furtherdisruption. Perform a tracheostomyinstead


633

Fig 3005 Incising over the cricothyroid membrane.

Chapter_30.qxd 28/09/2004 15:58 Page 633

• Bag-valve-mask device.


• Scalpel size 10.

• Small artery forceps.

• Cuffed tracheostomy tubes size 6·0mm with connector.

• Syringes and needles.

• Scissors.

• Swabs.

• Open weave cotton bandage

Procedure

• Position and identify the cricothyroid membrane(3003). If not contraindicated, extend the neckand place a sand bag under the shoulders tobring the landmarks into prominence.

• Clean the skin. In the conscious casualty,infiltrate with local anaesthetic on either side of the trachea, but not directly over thecricothyroid membrane.


634

Fig 3006 Using the blade handle to open up the incision in thecricothyroid membrane.

Chapter_30.qxd 28/09/2004 15:58 Page 634

• If you are right-handed, approach from thecasualty's right side. Stabilise the thyroidcartilage with your left hand.

• Make a 2.0-3.0cm transverse skin incisionthrough skin and platysma. Hold the bladeperpendicular (Figure 3005). Carefully divide themembrane horizontally. Insert the scalpel handleinto the incision and rotate it 90 degrees to openthe airway (Figure 3006). A disposable scalpelshaft can be broken in half before making theincision; this removes the risk of self-injury on the blade. Alternatively, use artery forceps or tracheal dilating tongs to open the airway.

• Insert a 6 mm cuffed tracheostomy tube (if unavailable, use the smallest availableendotracheal tube). Direct the tube distally into the trachea (Figure 3007). Inflate the cuff.The tube should be sutured in position with 2/0Prolene and/or fixed by tying the bandageattached to the tracheostomy tube flangessecurely round the back of the neck.

• If spontaneous breathing does not occur,ventilate the casualty.

Indications for a Surgical Airway: see Chapter 3


635

Fig 3007 Inserting a tracheostomy tube through the cricothyroid opening.

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Chapter_30.qxd 28/09/2004 15:58 Page 635

Complications of cricothyroidotomy and tracheostomy

3006 These include:

• Creation of a false passage into the tissues.

• Asphyxia.

• Laceration of the trachea.

• Laceration of the oesophagus.

• Haemorrhage or haematoma formation.

• Aspiration of blood into the lungs.

• Mediastinal emphysema.

• Subglottic stenosis/oedema.

Tracheostomy3007 This is performed either as a plannedoperation under GA with an endotracheal (ET) tubealready in place or as an emergency procedure withlocal anaesthetic infiltration.

Equipment

• Lignocaine 1% (20 ml).

• Cleaning solution.



• Scalpel size 10.

• Small artery forceps.

• Self retaining retractor.

• Tracheal dilating tongs.

• Cuffed tracheostomy tubes size 8·0 with connector.

• Syringe and needle.

• Scissors.

Major Neck Injury: see Chapter 19


636

Chapter_30.qxd 28/09/2004 15:58 Page 636

• Open weave cotton bandage.

• Swabs.

Procedure

• Position casualty as for cricothyroidotomy(3005). Palpate the cricoid cartilage andsuprasternal (jugular) notch. Make a ~3-7cmhorizontal incision midway between the two.(Figure 3008). Divide the platysma and identifythe strap muscles. The exposed anterior jugularveins can either be retracted or ligated.

• Retract the strap muscles laterally. Identify thethyroid isthmus overlying the second or thirdtracheal ring. Incise the pretracheal fascia. If necessary, mobilise, divide and transfix the thyroid isthmus (e.g., 2/0 Vicryl).


637

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Fig 3008 Tracheostomy. Site of incision.

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Fig 3009 Tracheostomy. Incision over the 2nd and 3rd tracheal rings.

Chapter_30.qxd 28/09/2004 15:58 Page 637

• Cut a circular window in the trachea (~ 1.5cm indiameter) between the second and third trachealrings (Fig 3009).

• Insert a size 8 cuffed tracheostomy tube (Figure3010). You may need to use a tracheal dilator.

• If the casualty is under GA - the anaesthetistslowly withdraws the endotracheal tube as youadvance the tracheostomy tube.

• The tube should be sutured in position with 2/0Prolene or fixed by tying the bandage securelyround the back of the neck.

Tracheostomy care.

3008 Meticulous postoperative care will reduce morbidity:

• Frequent suction, especially in the first few days.

• Prevent crusting by the administration of humidified air.

• Delay changing the tracheostomy tube for 5 daysto ensure an adequately epithelialised tract.


638

Fig 3010 Inserting the tracheostomy tube.

Chapter_30.qxd 28/09/2004 15:58 Page 638

Endotracheal intubation 3009 Endotracheal intubation is only possible in the deeply unconscious casualty (= GCS 4) orfollowing pre-intubation induction of anaesthesia withmuscle relaxation.

Equipment

• Adult endotracheal tubes (ET) size 7.0, 8.0 and 9.0.

• 10ml syringe.

• Laryngoscope.

• Stethoscope.

• Lubricant.

• Magill's forceps.

• Malleable endotracheal introducers.

• Oropharyngeal airways (OPA) size 2, 3 and 4.


• Suction (e.g., Yankauer sucker).

• Scissors.

• Open weave cotton bandage.

Procedure

• Ensure that adequate ventilation and oxygenationare in progress. Check the function of thelaryngoscope, suction and the ET tube cuffs.

• Position yourself and the casualty as in 3004.Where cervical spine injury is a possibility, avoid neck extension.

• During rapid sequence induction of anaesthesia,instruct your assistant to apply cricoid pressure(Sellick's manoeuvre).

• Hold the laryngoscope in the left hand and insertthe instrument into the right side of the casualty's

Why a Surgical Airway is preferred in the field: see Chapter 3


639

Chapter_30.qxd 28/09/2004 15:58 Page 639

mouth, displacing the tongue to the left (Figure 3011).

• Look for the epiglottis and place the tip of theblade in the vallecula. Lift the epiglottis forwardby pulling, not rotating, the handle of thelaryngoscope to visualise the vocal cords (Figure 3012).

• Gently insert the ET tube into the tracheawithout applying pressure on the teeth (Figure 3013). Connect to the bag-valve, inflate the cuff with air (water if aeromed is contemplated) to provide a gas-tight seal and commence ventilation.

• Correct positioning of the endotracheal tubeis ensured by:

• Seeing the tube pass between the vocal cords.

• Equal chest expansion.

• Air entry in lung bases (auscultate in both axillae).


640

Fig 3011 Using the laryngoscope to lift the tongue and epiglottis forward.

Chapter_30.qxd 28/09/2004 15:58 Page 640

• Absence of gurgling sounds over the stomach.

• High expiratory levels of CO2 on end-tidalmonitoring (if available).

• If you are unable to position the endotrachealtube within 30 seconds, reventilate with a bag-valve-mask device until the casualty is well oxygenated and try again. If in doubt aboutthe position of the endotracheal tube, take it outand oxygenate the casualty by another method.

• Release cricoid pressure when correct ET tubeplacement is confirmed and the cuff is inflated.Fix the tube in position by tying it around theback of the neck with an open weave cottonbandage. Reapply cervical spine immobilisation.Insert an OPA next to the endotracheal tube to act as a bite block and help stabilise thetube's position.

It is failure tooxygenate thecasualty that kills,not inability tointubate.


641

Fig 3012 Visualising the cords during endotracheal intubation.

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Chapter_30.qxd 28/09/2004 15:58 Page 641

Complications of orotracheal intubation

3010 These include:

• Hypoxia from:

• Prolonged attempts to intubate.

• Unrecognised oesophageal intubation.

• Aspiration of gastric contents.

• Damage to the cervical cord in a casualty with an unstable neck fracture.

• Pushing the tube too far down (usually into theright main bronchus). The unintubated lung doesnot get ventilated and eventually collapses.

• Leaking endotracheal tube cuff, resulting in loss of seal.

• Airway haemorrhage secondary to injury.

• Damage to the larynx.

• Dental damage caused by levering thelaryngoscope blade against the teeth. Loose teeth may be inhaled.


642

Fig 3013 Introducing the ET tube through the cords into the trachea.

Chapter_30.qxd 28/09/2004 15:58 Page 642

Breathing Manoeuvres

Application of an Ashermann chest seal3011 Apply an Ashermann seal in casualties with a penetrating chest wound <12cm in diameter. If the wound is sucking, air will be able to escapefrom the chest but be prevented from re-entering by the one-way valve during inhalation. Application of the seal must be followed by the insertion of a chest drain. If >12cm, use the opened out wrapperof a field dressing fixed on all four sides plusimmediate chest drain insertion.

Procedure

• Dry the skin using the gauze provided.

• Check that the flutter valve is functioning - if indoubt, blow through it.

• Expose the adhesive seal. Apply so that the sealcompletely covers the defect (Figure 3014).

• If there are two wounds on the same side, coverone with an impervious dressing or both with anAshermann seal.

Sucking Chest Wound: see Chapter 3


643

Fig 3014 Application of an Ashermann chest seal.

Chapter_30.qxd 28/09/2004 15:58 Page 643

Needle thoracocentesis3012 This is a potentially life-saving manoeuvre in a casualty with suspected tension pneumothorax(Figure 0311).

Procedure

• Unless contraindicated (e.g., possible spinalinjury), sit the casualty in an upright position (air rises).

• Find the second intercostal space (ICS) in themidclavicular line (Figure 3015). One method isto identify the manubriosternal junction (angle ofLouis). In most people this is a bony prominenceapproximately 5cm below the sternal notchadjacent to the second rib. The second ICS liesbetween the second and third ribs. In practice,because of the overlying muscles, the secondICS is the first easily definable space you cometo on feeling down from the clavicle.

• Attach a size 12 or 14 over-the-needle cannulato a 5 ml syringe. Fill with a little air.

Tension Pneumothorax: see Chapter 3


644

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Fig 3015 Positions on the chest wall for needle thoracocentesis andchest drain insertion.

Chapter_30.qxd 28/09/2004 15:58 Page 644

• Insert through the skin and direct the needle just over the third rib (Figure 3016). This shouldreduce the risk of haematoma and intercostalnerve damage. Use a two handed technique.Puncture the parietal pleura (this is usually <2cmfrom the surface). Aspirate air to confirm thediagnosis (the plunger may be forced out by thehigh intrapleural pressure). Occasionally, tissueobstructs the cannula and can be released byinjecting 1-2 ml of air.

• If the diagnosis is correct, advance the plasticcannula and withdraw the needle. An Ashermannseal can be placed over the cannula to stabiliseand prevent air being drawn into the chest. A second cannula may improve drainage (NB: a pneumothorax may develop on theopposite side).

• You must insert a chest drain during thesecondary survey whether or not the diagnosis isconfirmed (3013).


645

Fig 3016 Needle thoracocentesis. The over-the-needle cannula isinserted just above the 3rd rib.

Chapter_30.qxd 28/09/2004 15:58 Page 645

Chest tube insertion (thoracocentesis). (The British military pre-packed, sterile set containseverything apart from LA.)

3013 Fluid resuscitation and monitoring of vitalsigns must be in progress.

Equipment

• Surgical scrub; sterile drapes and gloves.

• 20ml syringe and needle.

• Lignocaine 1% (20ml).

• Scalpel.

• Blunt-nosed forceps.

• Chest drainage kit including chest drain (= size 28), tubing and drainage bag with one-way valve (military pattern).

Haemothorax: see Chapter 3


646

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Fig 3017 Chest drain insertion: site of local infiltration.

Fig 3018 Chest drain insertion: incision over the 5th interspace.

Chapter_30.qxd 28/09/2004 15:58 Page 646

• Suture material.(e.g. No 1 silk on a hand needle).

• Zinc oxide tape.

• Gauze swabs.

• Scissors.

• Dressing.

Procedure

• Determine the insertion site (Figure 3015). Theoptimum position is in the fifth intercostal spacejust behind the anterior axillary line (i.e., justbehind the lateral edge of pectoralis majormuscle). This is approximately in line with thenipple in the male. Alternatively, count down fromthe second interspace, or estimate position fromthe lower border of the casualty's four fingerspressed hard in the axilla.

• Position the casualty at 30 degrees. Placepillows, webbing etc. under the shoulder andpelvis. Clean and drape.

• Anaesthetise the skin, intercostal muscles andpleura (Figure 3017).

• Make a 2.5 cm incision through skin andsubcutaneous tissue onto underlying muscle(Figure 3018). Bluntly dissect apart theintercostal muscles using artery forceps (Figure3019). Work over the top of the sixth rib tominimise damage to the neurovascular bundle.

• Puncture the parietal pleura and insert a fingerinto the incision. Perform a 360 degree fingersweep to clear possible adhesions between lungand chest wall and exclude any herniatedabdominal organs (Figure 3020).

• If not using the military pattern set, select thelargest thoracostomy tube available (ideally>28F). Attach the tube to the drainage bag

When in doubt, go one space higher.


647

Chapter_30.qxd 28/09/2004 15:58 Page 647

and advance the tube into the pleural space(Figure 3021). Direct it backwards towardsthe spine and upwards to the top of the thoraciccavity. Signs that you are in the correct place are drainage and intermittent fogging of thechest tube during respiratory movements.

• Insert the chest drain to a distance of 12-13cm.All the side holes must be well within the chest.Suture the tube in place using a mattress suture and Gibbon's flag (Figure 3022). Apply a dressing and tape the tube to the chest. Check position with a CXR.

Complications of chest tube insertion

3014 These include:

• Incorrect tube positioninside or outside the chest cavity.

Sometimes the flutter valve in the

drainage bag sticks - massage

between your fingersor inject a little air

down the tubing tofree it.


648

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Fig 3019 Chest drain insertion: opening up the intercostal musclesusing blunt dissection.

Chapter_30.qxd 28/09/2004 15:58 Page 648

• Laceration or puncture of intrathoracic orabdominal organs; this can be prevented by the finger sweep before inserting the chest tube.

• Damage to the intercostal neurovascular bundle.Effects include local haematoma, haemothoraxor intercostal neuritis /neuralgia.

• Damage to the internal mammary artery if puncture site is too medial.

• Dislodgement of the chest tube or disconnectionfrom the drainage bag. Leaking drainage bag.


649

Fig 3020 Chest drain insertion: performing a 360 degree finger sweep.

Fig 3021 Inserting the chest drain, forceps illustrated; the militarychest drain set is provided with a plastic trochar to aid and direct chesttube insertion.

Chapter_30.qxd 28/09/2004 15:58 Page 649

• Chest tube kinking or becoming blocked with blood clot.

• Infection (e.g., local cellulitis, thoracic empyema).

• Persistent pneumothorax from large primarydefect; a second chest tube may be required.

• Surgical emphysema (usually at tube site).Mediastinal emphysema.

Circulation Manoeuvres

Needle pericardiocentesis 3015 Clinical features of cardiac tamponade andtechniques of drainage are discussed in 0328 and1542. Despite the diagnosis being correct, clotting of blood within the pericardium, persistent bleeding,iatrogenic myocardial damage and poor operatingconditions may all conspire to a poor outcome.Open drainage is increasingly preferred (Figure 3023).

Procedure

• Check the casualty's vital signs. Where possible,monitor central venous pressure and ECG.

• Use a 16 to 18 gauge (minimum length 16cm),over-the-needle catheter, attached to a 20 mlsyringe with a three-way stopcock.

Cardiac Tamponade: see Chapters 3 and 15

Gibbon’s Flag:When the chest

drain has stoppeddraining and can beremoved (usually at48 hours, simply cutthe loop (Fig 0322)The suture remains

in place closing the wound.


650

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Fig 3022 Closing the wound around the chest drain and fixing it inplace using a Gibbon's flag 'two knot' technique.

Chapter_30.qxd 28/09/2004 15:58 Page 650

• Puncture the skin 1-2 cm to the left of thexiphisternum (Figure 3024).

• With the needle at a 45 degree angle to the skin,advance the needle aspirating as you go. Aimtowards the tip (inferior angle) of the left scapula.

• When the needle tip enters the blood-filledpericardial sac, aspirate as much as possible.


651

Fig 3023 Subxiphoid pericadiocentesis: A) Epigastric incision. B) Aplane is developed behind the sternum starting superficial to theposterior rectus sheath. C) The bulging pericardium is picked upbetween artery forceps and incised.

A

B

C

Chapter_30.qxd 28/09/2004 15:58 Page 651

If the needle comes into contact with theventricular muscle an injury pattern will appear on the ECG monitor:

• Extreme ST or T wave changes.

• Widened and enlarged QRS complex.

• Premature ventricular contractions.

Withdraw the needle until the baseline trace reappears.

• After aspiration is completed, remove the syringeand attach a three-way stopcock leaving thestopcock closed. Suture the catheter in placeand apply a dressing. Should the cardiactamponade symptoms persist, the stopcock maybe opened and the pericardial sac re-aspirated.

• Transfer for emergency thoracotomy.

Complications of needle pericardiocentesis

3016 These include:

• Aspiration of blood from ventricle.

• Laceration of coronary vessels and myocardium.



652

Fig 3024 Position of insertion during needle pericardiocentesis.

Chapter_30.qxd 28/09/2004 15:58 Page 652

• Cardiac arrythmia.

• Pneumothorax.

• Puncture of aorta.

Peripheral venous cutdown3017 The optimal site for cutdown is over the long saphenous vein approximately 2 cm anterior and2 cm superior to the medial malleolus (Figure 3025).NB: avoid any limb with significant proximal injury. An alternative is the median basilic vein, located 2-5cm lateral to the medial epicondyle of the humerus in the antecubital fossa.

Equipment

• i.v. giving set run through with normal saline.

• 12 or 14 gauge cannula.

• Lignocaine 1% (10ml).

• Syringe and needle.

• Surgical scrub or alcohol sterets.

• Sutures (e.g., 3/0 silk on a cutting needle).

• Ties (e.g., 3/0 Vicryl).

• Scalpel (No 22 blade).


Avoid cannulating or performing acutdown on aninjured limb.


653

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Fig 3025 Ankle cutdown: position of incision 2cm above and anteriorto the medial malleolus.

Chapter_30.qxd 28/09/2004 15:58 Page 653

• Two small artry forceps.

• Two small retractors.

• Gauze swabs (4 x 4 cm). Micropore tape.

• Scissors.

Procedure

• Clean the skin. If appropriate, infiltrate with local anaesthetic.

• Make a 2.5 cm transverse incision through the skin and subcutaneous fat (Figure 3026).NB: the vein lies close to the surface. Usingblunt dissection, identify the vein and free itfrom surrounding tissues for a length of 2cm (NB: avoid adjacent saphenous nerve).

• Pass proximal and distal ties under the vessel.Ligate the distal tie. Place a clip on both tiesfor traction.


654

Fig 3026 Ankle cutdown: A) Incision. B) Pick up fascia over longsaphenous vein. C) A 2cm section of vein is mobilised. D) Place staysutures proximally and distally. Tie the distal stay. E) Make a smallvenotomy and introduce a cannula; tie the proximal stay over it.

A

D

B

E

C

Chapter_30.qxd 28/09/2004 15:58 Page 654

• Make a small transverse venotomy and gentlydilate the opening with the tip of a closedhaemostat. Introduce the plastic cannula (withouttrochar) through the venotomy and secure it inplace by tying the proximal ligature.

• Attach the giving set and commence flow. Closethe incision and apply a sterile dressing. A splintwill help secure the line and tubing.

Complication

3018 These include:

• Haemorrhage or haematoma.

• Perforation of the posterior wall of the vein.

• Nerve transection.

• Phlebitis.

• Venous thrombosis.

Femoral vein cannulation3019 The femoral vein lies medial to the femoralartery (Figure 0702). Remember the mnemonicNAVY - Nerve, Artery, Vein, Y-fronts!

Procedure

• Set up an i.v. giving set run through with normalsaline. Attach a 10 ml syringe onto a 12 or 14gauge over-a-needle i.v. cannula. Clean the skin.

• Identify the femoral artery below the mid inguinal point; the femoral vein lies 1cm medialto the pulsation.

• Insert the cannula through the skin. Advancetowards the head with the needle at 45 degrees.Apply continuous moderate suction. When thevein is punctured blood will enter the syringerapidly. Stop, and then gently advance thecannula into the vein while simultaneouslywithdrawing the needle.

Fluid infusion: see Chapter 3


655

Chapter_30.qxd 28/09/2004 15:58 Page 655

• Suture or tape the cannula into place. Attach thegiving set and commence flow. Apply a dressing.

• Alternatively, a Seldinger-technique usingcommercially available femoral vein puncture kitscan be employed.

Surgical Handicraft

Wound healingMechanisms

3020 These are:

1. Primary intention: occurs in clean wounds with direct apposition of the edges. This resultsis a small, neat scar which epithelialises rapidly.There are three stages in this process: exudation(1-5 days), proliferation (5-21 days) andremodelling (>21 days).

2. Delayed primary intention: This is routinelyemployed in military wounds where thepossibility of infection is high (0502). If afterabout 5 days the cellular exudate has done itswork and the wound looks clean, it may besutured. The processes of healing are as forprimary intention.

3. Secondary intention: An open wound which is too wide to suture will close by a process of wound contraction, granulation of its base andre-epithelialisation from its edges. The end resultis a large, distorted scar. The mechanisms arethe same as for primary healing but healing isslower with re-epithelialisation occurring at therate of 1 mm a day. It can be hastened by a partial or full-thickness skin graft.

Factors affecting wound healing

3021 These may be divided into local or



656

Chapter_30.qxd 28/09/2004 15:58 Page 656

general factors. Methods of optimising healing are listed in 2303.

1. Local

• Poor tissue oxygenation and vascularity.

• Arterial disease (e.g., atherosclerosis, diabetes, radiotherapy), venous hypertension(e.g., varicose veins), and local pressure (e.g., bedsores).

• Sepsis: interferes with granulation tissueformation.

• Increased wound tension. This leads to breakingor cutting out of sutures. Causes include: ileus,chronic cough, constipation, urinary obstruction,tumour, ascites, pregnancy and gross obesity.

• Poor apposition or movement of wound edges.

• Presence of irritants and foreign bodies.

• Poor closure technique.

2. General

• Age: healing is faster in the young.

• Weakened tissues: e.g,. wasting due to nerve damage or cachexia.

• Impaired healing: e.g., sepsis, obesity, anaemia, jaundice,malnutrition, hypoproteinaemia, malignantdisease, AIDS, steroids, chemotherapy or radiotherapy.

Complications of wound healing

3022 These include:

• Wound disruption: may be due to any of thefactors in 3021. Disruption of the deeper layersof the abdominal wall with the skin remainingintact results in an incisional hernia. If all layers are affected it is described

Skin Graft: see Chapter 23


657

Chapter_30.qxd 28/09/2004 15:58 Page 657

as a wound dehiscence ('burst abdomen'). An intestinal anastomotic leak is a serious form of wound disruption.

• Cicatrization: causes deformity and loss of function, typically seen after burns.

• Keloid scar.

• Implantation dermoid.

• Colour changes: e.g., skin tattooing due toforeign bodies and dyed suture materials.

• Wound pain: may occur due to nerve entrapment.

Principles of wound management 3023 Points include

• Wound excision and delayed primary closure see 0503.

• The incision must be sufficiently large andextendible to allow for access, but as short as possible and parallel to Langer's lines toensure optimum healing and a good cosmeticresult. Consideration should be given topreserving the local blood supply and avoidingimportant nerves. To prevent contracture,straight incisions should not be made acrossjoints (Figure 0502).

• In an elliptical wound, the length should at leastbe three times the width, Do not tie the suturestoo tight as this will cause oedema andischaemia of the wound edge.

• When closing the abdomen, disruption is lessfrequent when sufficient length (ideally, morethan four to six times that of the wound) of astrong, monofilament suture is used. Transverseincisions heal better than vertical ones. Drainsshould not be placed through wound.

• Sutures are removed when the wound is strong



658

Chapter_30.qxd 28/09/2004 15:58 Page 658

enough to support itself. On the face and neckthis is usually after 4-5 days, elsewhere after 7-10 days. Leaving sutures in longer thannecessary, can cause unsightly cross hatches.

Sutures and ties

3024 These are commonly classified according to:

• Source: either natural (e.g., silk) or synthetic (e.g., Dexon, Prolene).

• Structure: either monofilament (e.g., Maxon,Prolene) or braided (e.g., silk, Vicyl).

• Fate: either absorbable (e.g., Vicryl, PDS) or non-absorbable (e.g., Prolene).

Monofilament sutures 'run' easily and are less likelyto harbour bacteria, whereas braided sutures tiemore securely. Absorbable sutures degrade andconsequently do not require to be removed. Somelose their strength relatively quickly (e.g., Vicrylrapide), others more slowly (e.g., Maxon, PDS). They should not be used where long-termapproximation is required (e.g., vascularanastomoses). Most non-absorbable sutures retaintheir strength indefinitely (e.g., polyester, Prolene,stainless steel), a few slowly lose it (e.g., silk, polyamide).

Gauge

3025 The more '0s' on the packet, the finer the suture. Common suture sizes and their uses areshown in Table 3001. Use the smallest gauge for thejob. Popular ties (ligatures) are braided absorbablematerial (e.g., Vicryl or silk). The commonest gaugeis 2/0, though heavier or finer ties may be required,depending on the size of the vessels.

Needle

3026 Round-bodied needles are designed to


659

Chapter_30.qxd 28/09/2004 15:58 Page 659

separate tissue fibres and are used to suture hollowviscera (e.g., bowel, common bile duct, bloodvessels) and nerves. A blunt needle may sometimesbe used to close the abdominal wall (reduces risk of glove puncture) and to suture friable organs (e.g., liver). A cutting needle is used for tough ordense tissue (e.g., skin, ligaments, tendons). Needles may be straight or curved, of varying sizeand designed for instrument or hand use.When using a needle holder, the needle should beheld close to the tips of the instrument and two-thirdsof the distance from its point (Figure 3027)

Techniques of wound closure

3027 These include:

• The simplest method of closure is an all layersinterrupted suture, first picking up one side thenthe other (Figure 3028). The suture should berelatively square-on to the wound and not invertthe skin edge.

• For deeper wounds, use two layers or a verticalmattress suture (Figure 3029A). For speed,continuous sutures may be employed (Figure3029 B&C).



660

��

��

Fig 3027 Correct position of needle in needle holder.

Chapter_30.qxd 28/09/2004 15:58 Page 660

• A technique often appreciated by the casualty is to use an absorbable, subcuticular suture.Bury the knots at each end (Figure 3029D).

• Where appropriate, close deep fascia (Figure3030 A). If there is a significant fat layer, close

Abdominal Wound Closure: see Chapter 12


661

�*��

%�+

��

%��

�*��

��,��

�*��-��

Fig 3028 Simple wound closure: A) Closure in progress. B) The aimis to insert the needle at 90 degrees to the skin and reach the depthsof the wound. C) First pick up one side than the next. If skin edges areclose together, it may be possible to do this in one bite. D) tying theknot should result in a square suture. E) avoid inverting the skin andleaving dead splace.

A

D

B

E

C

Chapter_30.qxd 28/09/2004 15:58 Page 661

it with absorbable sutures and bury the knots(Figure 3030 B).

• 'Dog ears' can be managed by extending theincision (Figure 3031).

• Where appropriate, tendons can be repairedusing non-absorbable, monofilament sutures(Figure 3032). Vacular (1020), bowel (1232)and nerve repair (2119) are described elsewhere.

Vascular Repair: see Chapter 10


662

&.�#��

��

!��

/.��

��*��

�.��*��

�.��

Fig 3029 Other techniques of wound closure A) Vertical mattresssuture. A large bite closes the deeper layers and a more superficial bite the skin. B) Simple over-and-over continuous suture. C) Blanketstitch. D) Subcuticular, when using an absorbable suture, bury the knot at both ends.

Chapter_30.qxd 28/09/2004 15:58 Page 662

• Knot tying using a needle holder or forceps isillustrated in Figure 3033. For the inexperienced,this is usually quicker and safer than attemptingto hand tie.

Bowel Surgery: see Chapter 12


663

&

�

��*��

Fig 3030 A) Closing deep fascia. B) Closing fat. NB: the knots are buried.

Fig 3031 Technique for managing a 'dog ear'.

Chapter_30.qxd 28/09/2004 15:58 Page 663

• Alternative wound closure techniques areadhesive strips (e.g., Steristrips™) and woundglue. Staples are increasingly used to closeabdominal incisions and to perform bowel anastomoses.

Nerve Repair: see Chapter 21


664

Fig 3032 Technique of tendon repair.

Fig 3033 Using an instrument to tie a suture.

Chapter_30.qxd 28/09/2004 15:58 Page 664

Drains

3028 Are used to drain or prevent accumulation ofbody fluids (e.g., pus, blood - see 1230). They can beclassified as open or closed, suction or non-suction.Complications of their use include introduction ofinfection (less likely with a closed system), blockageand damage to adjacent bowel or blood vessels.Rubber drains are occasionally preferred becausethey stimulate fibrosis. On removal, the surroundingfibrous tract collapses preventing further drainage(e.g., 'T' tube removal after exploration of thecommon bile duct).

Abdominal Drains: see Chapter 12


665

1 Abdominal closure

2/0 Drain attachment

3/0 Bowel anastomoses, fascial repairs

4/0 Routine skin closure

5/0 Vascular anastomoses

6/0 Facial skin closure

9/0 Microvascular anastomoses

10/0 Ophthalmic surgery

Table 3001 Common gauges of suture and their uses.

Chapter_30.qxd 28/09/2004 15:58 Page 665


666

Chapter_30.qxd 28/09/2004 15:58 Page 666

Index

Abbreviated laparotomy - see Damage Control Surgery

ABCDE 44Abdominal injury

Abdominal compartment syndrome 94, 311-312

Abscess 291, 303, 310Aeromedical evacuation

624-625Anastomotic dehiscence

310-311Antibiotics 137, 256Aorta 84, 85, 86, 305Assessment, history and

examination 50-53,244-247, 250-252

Blood supply, small bowel and colon 273

Biliary fistula 87, 291-292Biliary tree 87, 88, 90,

298-299 Casualty positioning after

injury 245-246Cholecystectomy 298,Cholecystostomy 298-299Coelic axis 307-308Colon 271-283Colostomy 277, 280-282Complications 310-312Computerised tomography

(CT) 249-250Damage control surgery

79-94, 254Decompression 246, 295Diagnostic peritoneal lavage (DPL) 248-249Diaphragm 283-285Double-barrelled stoma

280-282

Drainage 87, 259Duodenum 292-297Endoscopic Retrograde

Cholangio - Pancreatography (ERCP) 299, 303

Eviscerated bowel 245Exteriorisation of colon

277-278Fluid restriction 245Focused Abdominal

Sonography for Trauma (FAST) 249

Gallbladder 87, 298-299General plan for emergency

abdominal surgery 254-256

Haemorrhage, identification and control 83-90, 256-258

Hartmann's procedure 282-283

Hepatic artery 307-308Hypotensive resuscitation

68-72, 244, 253-254Ileo-colic anastomosis 279Ileostomy, loop, end and

double-barrelled 268-270, 280-282

Ileus 310Iliac arteries, common,

external, internal 219- 220, 309

Incision 256Inferior mesenteric artery 309Inferior vena cava 85-88, 89,

305-307Initial management in the

field 244-246

Index

667

Index.qxd 28/09/2004 15:58 Page 667

Sigmoid colectomy 273Sigmoidoscopy 248Small bowel 260-270Spleen, splenectomy and

septicaemia 283-284Splenic artery 307Stapled anastomosis 265,

266, 269Stomach 285-287Stomal problems 311Superior mesenteric artery

308Surgical decision-making

250-253 Suspicious features 50,

244-245Transverse colectomy 273Urological injury 327-345Vascular exposure 305-309Wound closure 90-91,

259-260Wound dehiscence 310Wound dressings 245

Above knee amputation (AKA) 238-239

Acceleration/deceleration, aeromedical evacuation 622

Acetabular fracture 318Acetazolamide 425Acute psychiatric disorders (APD)

593Acute psychological disorders

601-603Acute psychological reactions to

combat 593-595Acute stress reactions (ASR) 593,

596-598Acute tubular necrosis,

prevention of 519, 522Adrenaline 125, 576

Abdominal Injury (cont)Intestinal obstruction, ileus,

mechanical 310Investigations 247-250Jejunal serosal patch 296,

297Kocher's manoeuvre 292,

294-295Laparoscopy 250Left gastric artery 307Left hemicolectomy 273Liver 287-292Management at Roles

2+ and 3 246-260Mucous fistula 270, 280-282Non-compressible

haemorrhage 65-68, 243, 244, 245

Oesophagus 358-359, 381-384

Operative considerations 253-260

Organ damage, systematic search 83, 84, 258-259

Packaging for transfer 245, 246

Pancreas 299-303Pathophysiology 243-244,

253-254Portal vein 308Radiological investigations

248, 299Rectal injury 275, 282-283Resuscitative laparotomy 68,

80-87, 246Retroperitoneal haemorrhage,

management of 303-309Right hemicolectomy 273'Second look' laparotomy 261 Secondary haemorrhage 310

Index

668

Index.qxd 28/09/2004 15:58 Page 668

Adult respiratory distress syndrome 354

Advanced Trauma Life Support (ATLS) 606

Advancement flap 534, 535Aeromedical evacuation

Abdomen and chest 624-625Acceleration/deceleration 622Aeromedical Evacuation

Squadron 619Air Evacuation Co-ordination

Officer (AECO) 620Air Evacuation Liaison

Officer (AELO) 620Altitude 621Categorisation 619, 621Clinical considerations

624-626Critical Care Air Support

Teams (CCAST) 620Head injury 416, 625Maxillofacial trauma 626Motion sickness 624Musculoskeletal trauma

625-626Noise 623Ophthalmic injury 429-430,

626Potential in-flight problems

620Strategic evacuation 619Tactical evacuation 620Temperature 621-622Vibration 622-623Working with Aeromedical

helicopters 626-627Aetiology of injury - see Patterns

of Injury in Military OperationsAir Evacuation Co-ordination

Officer (AECO) 620

Air Evacuation Liaison Officer (AELO) 620

Air sinuses 448, 451Airway and cervical spine control

45-48, 55-61Airway assessment

- talk, look, listen and feel 45

Airway management 55-61, 555-556

Airway obstruction preventable deaths 46

Anaesthetic technique 557-567

Aspiration, reducing risk 556, 559

Bag-valve-mask 64Breath sounds 49Cervical collar 55, 56Cervical spine control 55Cervical spine injury

- suspicious features 47, 48

Chin lift 57Clearing the airway 57-58Combitube 61Cricothyroidotomy 59,

630-636Endotracheal intubation 59,

639-642Facial fracture, causing

airway obstruction45-47, 57

Finger sweep 57Helmet removal 54, 55Inappropriate/

incomprehensible speech 45

Inhalational injury 47, 503-504, 509-510

Index

669

Index.qxd 28/09/2004 15:58 Page 669

Alcohol, in cold injury 589Alfentanil 558, 559, 561, 563-564,

571Altered level of consciousness 45

AVPU 53, 393-394GCS 395-397Pupil assessment 53, 394

Altitude, Aeromedical evacuation 621

Amethocaine 425Amitriptyline 590Amoebic dysentery

Clinical features 550-551Diagnosis 549-550Differential diagnosis 550Diloxanide furoate 551Entamoeba histolytica 549Metronidazole 551Pathophysiology 549Tinidazole 551Treatment 551

Amputation 100Above knee amputation

(AKA) 238-239Ankle 241-242Antibiotics 137Arterial injury leading to 229Assessment for possible

amputation 96, 227Below knee amputation

(BKA) 240Casualty transfer 234-235Damage control surgery 80Definitive/final amputation

229, 236-237Delayed primary closure

104-105, 229, 235-236Entrapment leading to 230,

232Foot 242

Airway control (cont)Injuries associated with

airway obstruction 46Jaw thrust 57Laryngeal injury 48Laryngeal mask airway (LMA) 61Log roll 74Maintaining the airway 58-59Mouth to mask ventilation 64Mouth to mouth/mouth to

nose ventilation 64Nasopharyngeal airway

(NPA) 58, 630Neck examination 48Neck injury/wounds 45,47,48Needle cricothyroidotomy

61, 630-633Nerve agent poisoning

34-37,45, 46Oropharyngeal airway (OPA)

58, 59, 629Oxygen administration 55,

565Protecting the airway at risk

59-61, 555-556, 633-642Secure airway - indications

59-60Suction to clear mouth 57Surgical airway 59-61, 556,

633-638Three point cervical spine

control 55, 77Three-quarters prone

position 58Total airway obstruction 45Tracheal displacement 48, 63Tracheostomy 59, 470,

636-638Triage 107-112

Index

670

Index.qxd 28/09/2004 15:58 Page 670

Frequency of traumatic amputation 227

General principles 227-229Indications 229-231Infection leading to 230Knee disarticulation 239Knee joint, retaining the

231-232Level of amputation 231-232Mangled Extremity Severity

Score (MESS) 229-230Mine injury 227, 228Myoplastic repair 229, 235-236Multiple injuries leading to 231Operative technique in

emergency amputation 232-233

Pathophysiology 227Preventing skin/muscle

retraction 233Radical wound excision 100Rehabilitation 242Revision 242Second look wound excision

229Severity of injury leading to

229-230Skin coverage 236-237Splinting the stump 234Stump dressing/bandage

233-234, 236Syme 241Tourniquet, use leading to

231Upper limb 237Wound excision 97-101, 232,

Amoxicillin 463Anaesthesia in the field

Aims 553Airway 555-556

Alfentanil 558, 559, 561, 563-564

Anaesthetic drugs 558Anaesthetic technique

557-567Analgesia 117-119, 557,

558, 559Aspiration, reducing risk

556, 559Atropine 561Balanced anaesthesia

557-562Balanced anaesthesia,

non- emergency cases 562

Breathing 556Circulation 557CompPAC ventilator 566-567Cricoid pressure 556, 559Environment for safe

anaesthesia 553-554Epidural 126, 564Equipment 565-567Etomidate 559, 560Fentanyl 558, 559, 561Field Hospital (Role 3) 554Field Surgical Team (Role 2)

554Glycopyrolate 561Incident Response Team

(IRT) 554, 615-619Induction of anaesthesia

558, 559-560Isoflurane 558, 560, 561, 566Ketamine 558, 559, 560, 562Local analgesia 124-128,

558, 565Maintenance of anaesthesia

560-561Midazolam 558, 563

Index

671

Index.qxd 28/09/2004 15:58 Page 671

Surgical airway 556, 633-638Suxamethonium 558, 560, 563"Thermopols" 565Thiopentone 558, 559, 560Total Intravenous

Anaesthesia (TIVA)562-564

Transfer from the operating theatre 561

Tri-Service Anaesthetic Apparatus (TSAA) 557, 566

Types of anaesthesia 553, 554Types of casualty 555Vecuronium 558, 560-561, 563Ventilation 64-65, 560

Analgesia 63, 115-130, 557, 558, 559Analgesic protocol 117Antiemetics 119Approach to pain relief 116-117Assessment of pain 116-117'Balanced analgesia' 124Bupivicaine 125-126Burns 507, 509, 515, 520Catheterisation 126Chest injury 129Codeine phosphate 123Cold injury 589, 590Compound analgesic

preparations 123 Cyclizine 119Dextropropoxyphene 123Diclofenac 123-124Dihydrocodeine 123Effects of inadequate pain

control 115-116Entonox 121-123Entonox and chest injury 129Entonox and head injury 129

Anaesthesia in the field (cont)Modular Transportable

Surgical Facility (MTSF) 553

Monitoring equipment 566Morphine 557, 558, 559, 561Muscle relaxation 558NBC filter 567Neostigmine 561Nitrous oxide 560Oxford Miniature Vaporiser

(OMV) 566, 567Oxygen 565Oxygen concentrators 565Pancuronium 558Patient Controlled Analgesia

(PCA) 561Penetrating neck injuries 48,

556Premedication 118-119,

392-393, 556, 557, Preoperative assessment

555-557Preoxygenation 559Propofol 558, 559, 560,

563-564Rapid sequence induction

556, 559Refrigeration 565Regional anaesthesia

564-565Reversal of anaesthesia 561Resuscitation 557, 559Roles 554Sanders Oxygen 'T' 566, 567Sleep, induction and

maintenance 558Spinal anaesthesia 126, 564Suggested balanced

anaesthetic technique 559-562

Index

672

Index.qxd 28/09/2004 15:58 Page 672

Epidural analgesia 126, 564Eye injuries 126, 425Factors affecting choice of

analgesia 117-118Femoral nerve block 126-127Haematoma block 126Head injury 128-129, 392Hyoscine 119Ibuprofen 117, 123-124Inadequate pain relief

- possible causes 116Intercostal nerve block

126-127Ketamine hydrochloride

120-121Ketorolac 123-124Lignocaine (Lidocaine)

125-126Local analgesia 124-128,

558, 565Mass casualties 129-130Maximum safe dose (MSD)

of local analgesia 125-126Medimech Auto Injector 118Metoclopramide 119Mild to moderate pain

- management 123-124Monitoring of effect 116-117Morphine sulphate 118-120Naloxone 119-120Non-steroidal anti-inflammatory

drugs (NSAIDs) 123-124Ondansetron 119Paracetamol 124Patient Controlled Analgesia

(PCA) 119Perception of pain 115Pleural anaesthesia 127Principles of management 115Prochlorperazine 119

Severe pain - management 118-123

Spinal analgesia 126, 564Topical analgesia 126

AnastomosisColon 274-280Dehiscence, bowel 310-311Small bowel 263-269Vascular 201-211

Angiography, completion,on-table 198, 199, 204

Ankle brachial pressure index (ABPI) 198

Anteroposterior compression (APC) fracture types 1-3

315-317Anterior nasal packing 467-468Anthrax 144-145Antibiotics 132-146

Battlefield considerations 137Benzyl penicillin 137, 521Burns 510, 521Ceftriaxone (Rocephin)

137-138, 425, 521Cefuroxime (Zinacef) 139Choice of antibiotics 137-139Ciprofloxacin (Ciproxin)

138-139Clarithromycin (Klaricid)

138-139Co-amoxyclav (Augmentin)

137-138, 463, 466Doxycycline 145Ear 462-463Eye 424, 425Flucloxacillin 139, 521"Gas gangrene" 141`Gentamicin 521Gut or other hollow viscus

wounds 137Head injury - open 138, 392

Index

673

Index.qxd 28/09/2004 15:58 Page 673

Arteriography, on-table, completion 198, 199, 204

Artery - see also Vascular InjuryAnterior tibial 224, 225Aorta and great vessels 84,

85, 86, 305, 357, 374-376Axillary 216-217Brachial 217Brachiocephalic 212-213Carotid 89, 212-214Coeliac axis 307Common iliac 219, 309Crural vessels 224-226External iliac 219-220, 309Femoral 89, 220-221Hepatic 89, 307Inferior mesenteric 309Internal iliac 313, 309Left gastric 307Middle meningeal 407, 408, 413Peroneal 225-226Popliteal 222-223Posterior tibial 224, 225Profunda femoris 220-221Radial 218-219Renal 332-333Splenic 307Subclavian 212-213, 215-216Superior gluteal 313Superior mesenteric 308Ulnar 218-219Vertebral 215

Ashermann chest seal 62, 359, 643ATOMIC -life-threatening chest

injuries 49Atrium 372, 373Atropine 35-36

Anaesthesia, use in 561Heat illness 36-37, 582Ophthalmic preparation 425Poisoning 36-37

Antibiotics (cont)Hospital acquired infection

138Laboratory support to identify

sensitivity 135-136Limb injury 137Lower respiratory tract

infection 138Methicillin-resistant

Staphylococcus aureus (MRSA) 136

Metronidazole (Flagyl) 137-138

Necrotizing fasciitis 142-143Penicillin allergy 139Principles of treatment 136Prophylaxis 132Resistance - identification of

136Soft tissue and muscle injuries

137Tetanus 140Trimethoprim 138Urinary tract infection 138Wound infection 138-139

Anticonvulsants 392-393Antiemetic

Cyclizine 119Hyoscine 119Metoclopramide 119Ondansetron 119Prochlorperazine 119

Antipersonnel mine injury 100Aorta and great vessels 84, 85,

86, 305, 357, 374-376Aortography 363Arachnoid mater 385-386Arch bar 453Arsenical blister agents 39-41Arterial line, indications and

technique 572-573

Index

674

Index.qxd 28/09/2004 15:58 Page 674

Avizafone 35AVPU assessment of conscious

level 53, 389, 393-394Axial flap 537-538Axillo-femoral bypass graft 210-211Axonotmesis 484-485Azithromycin 425

Back bleeding after vascular surgery 201-202

BacteriaAerobic organisms 134 135,

138, 142Anaerobic organisms 134

135, 137, 138, 142Antibiotics 132-146Bacillus anthracis 144 Bacillus cereus 134Bacteroides fragilis 135Clostridium botulinum 146Clostridium perfringens 134,

141, 142Clostridium septicum 134Clostridium species 134Clostridium tetani 134, 140Colonisation, definition 133Escherichia coli 135, 138Gram-staining 145, 146Identification 135-136Infection, definition 133Klebsiella species 135, 136Methicillin-resistant


Multi-drug resistant Klebsiella species 136

Peptococcus species 134Peptostreptococcus species

134Proteus species 135Resistance 136, 137, 138

Sensitivity 135-136Staphylococcus aureus 134,

137, 138, 520-521, 546, 547

Streptococcus pneumoniae 138

Streptococcus pyogenes 134, 136, 137, 138, 520-521, 547

Yersinia pestis 145-146Bag-valve-mask 64Bail-out surgery - see Damage

Control Surgery'Balanced anaesthesia' 557-562'Balanced analgesia' 124Ballistic injury 11-23

Available energy 12Cavity shape 17-18Cavity size 16-17Change in presented area of

a missile 20Classification 12-15Clinical consequences 11,

19-22Compounding factors

20-23Contamination 18-19Effect of tissue properties on injury pattern 19-21Energy transfer 12, 15-23High energy-transfer wounds

12-13Low energy-transfer wounds

12Mechanical or functional

injury 15Mine injury 227Fragmentation of missile 13,

16, 21, 22Secondary fragments 13, 21Stress (pressure) wave 15-16

Index

675

Index.qxd 28/09/2004 15:58 Page 675

Breathing and ventilation - decision making 61

Breathing assessment- inspect, feel, percuss and auscultate 48-49

Capillary refill time (CRT) 53Cardiac tamponade 64, 358,

371-373, 650-651Causes of hypovolaemic

shock 50, 52Cervical collar 55, 56Cervical spine control 55, 77,

479Cervical spine injury

- suspicious features 47Chest drain (thoracocentesis)

62-63, 646-650Chest injury - suspicious

features 48-49Chin lift 57Circulation with haemorrhage

control 50-53, 65-73Clearing the airway 57-58Clotting adjuncts 67, 85, 199Colloid infusion 68Combitube 61Compressible haemorrhage 65Cricothyroidotomy 59, 630-636Crookham halter 68, 72Crystalloid infusion 70Cyanide poisoning 45Definitive care 44, 76Disability/neurological status

53Dullness to percussion 49, 51Endotracheal intubation 59,

639-642Estimating blood pressure

from pulses 53Exposure 53

Ballistic Injury (cont)Pathophysiology 11-23Temporary cavity 16-23Vascular injury 194Wound track length 22Yaw 17-18, 21, 23

Balloon catheter to control haemorrhage 66, 86- 88, 290, 306

Basal skull fracture 414-415Battlefield Advanced Trauma Life

Support (BATLS) 43-78, 95ABCDE 44Abdominal injury, suspicious features 50Abnormal breath sounds 45Airway and cervical spine

control 45-48, 55-61Airway assessment - talk,

look, listen and feel 45Airway management 55-61Airway obstruction - preventable deaths 46Altered level of consciousness

45Analgesia 63, 116-118Ashermann seal 62, 643ATOMIC 49AVPU assessment of

conscious level 53, 394Bag-valve-mask 64Balloon catheter to control

haemorrhage 66"Blood on the floor and four

more" 50Blood transfusion 70, 519,

612-613Breath sounds 49Breathing and ventilation

48-50, 61-65

Index

676

Index.qxd 28/09/2004 15:58 Page 676

Facial fracture causing airway obstruction 45-47, 57, 451, 452

Femoral vein cannulation 68, 653-655

Finger sweep 57Flail chest 63, 349, 350Fluid resuscitation algorithm 72Haemorrhage control 66,

83-90, 256-258, 376Haemothorax 62, 352-353,

646-650Helmet removal 54, 55Hoarseness 45Hyper-resonance 49, 51Hypertonic saline dextran

(HSD) 72Hypotensive resuscitation

68-72Hypovolaemic shock 50-53Immobilisation of fractures

and soft tissue injuries67-69, 156-161

Inappropriate/incomprehensible speech 45

Inhalational burns 6, 47, 503-504, 514-515

Injuries associated with airway obstruction 46

Intercostal nerve blocks 63, 126-128

Intra-osseous infusion 68Intraperitoneal haemorrhage,

methods of assessment 75, 245-250

Intravenous fluids 70-72Jaw thrust 57Laryngeal injury 48Laryngeal mask airway

(LMA) 61

Limb elevation 67-69Log roll 74Long bone fractures

- suspicious features 50Long saphenous vein cut

down 68, 653-655Lung contusion 49, 353-354Maintaining the airway 58-59Massive haemothorax 62,

352-353, 646-650Mental state in hypovolaemic

shock MIST 44Monitoring resuscitation 73Mouth to mask ventilation 64Mouth to mouth/mouth to

nose ventilation 64Nasopharyngeal airway (NPA)

58, 630Neck examination 48Neck injury/wounds 45, 47,

48, 470-473, 556Neck wound - application of

a pressure dressing 66Needle cricothyroidotomy

61, 630-633Needle pericardiocentesis

64, 650-653Needle thoracocentesis 62,

644-645Nerve agent poisoning 34-37,

45, 46 Non-compressible

haemorrhage 65Open pericardiocentesis 64,

371-373, 650-651Open pneumothorax 62,

351-352, 643Oropharyngeal airway (OPA)

58, 629Oxygen administration 55, 565Packaging 76

Index

677

Index.qxd 28/09/2004 15:58 Page 677

Tension pneumothorax 62- 63, 351, 644-646

Thomas splint 68, 72Thoracocentesis 62-63,

646-650Three point cervical spine

control 55, 77Three-quarters prone

position 58Total airway obstruction 45Tourniquet 66-67, 97, 99,

151, 195, 231, 232-233Tracheal displacement 48, 63Traction splint 67, 71Tracheostomy 59, 470,

636-638Triage 107-112TWELVE 48Venous cannulation 68,

655-656Venous cut down 68, 653-655Venous distension 48Ventilatory support 63-65,

571-572Wound dressing 66, 95X-rays after polytrauma 75

Battle's sign 414-415Below knee amputation (BKA) 240Benoxinate 425Benzyl penicillin - see PenicillinBiliary

Fistula 87, 291-292Tree 87, 88, 90, 298-299

Biological agent/warfare/weapons 144-149Actions to be taken 149Anthrax 144-145Battlefield considerations

147-149Botulism 146

BATLS (cont)Pelvic fracture 68, 74,

313-318Pelvis/retroperitoneal injury

- suspicious features 50Penetrating neck wounds

48, 470-473, 556Phases of management 44Pressure points for

haemorrhage control 66Primary survey 44Protecting the airway at risk

59-61, 633-642Pulse rate 53Pupil assessment 53, 349,

422, 431Resuscitation 44, 55Rib fractures 49, 348-349Sagar splint 67, 71Scene safety 44Secondary survey and

packaging 44, 74-76Secure airway - indications

59-60Sources of major blood loss

50Signs of respiratory distress

48-49Slings 69Splint aluminium malleable

(SAM) 67, 70Splinting fractures and soft

tissue injuries 67-69, 156-161, 163-180

Sucking chest wound 62, 351-352, 643

Suction to clear mouth 57Surgical airway 59-61, 508,

556, 633-638Surgical emphysema 48

Index

678

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Definition 144Grouping of agents 144Impact on field surgery 148Plague 145-146Ricin 132,144Smallpox 146Strategy 147Target 147

Bismuth iodoform paraffin ribbon gauze (BIPP) pack 467

Bladder injury 340-342Aetiology 340Clinical features 340-341Investigation 341Management 341-342Open cystotomy 344-345Pathophysiology 340-341Repair 341-342Suprapubic catheter insertion 344-345

Blast injury 6, 23-27Abdomen 6, 244Acoustic coupling 26-27Blast lung 6, 354-355Blast protection 27Bowel injury 6, 244Confined space 6Ear 463Mechanism of primary 25-27Mine injury 227Nuclear 29-30Patterns of injury 27Vascular injury 24, 26-27Under water 6

Blindness - see Ophthalmic InjuryBlister (vesicant) agents

Arsenical blister agents 39-40Clinical features 39-41Detection 32-33, 39-40Dimercaprol (British

Anti- Lewisite BAL) 40

Eyes, effect on 40-41, 435, 523Lewisite 39-40, 524Treatment 39-41, 524-525Nitrogen mustard 39-40Pathophysiology 39Respiratory effects 41Skin, effect on 40Sulphur mustard 39-40

"Blood on the floor and four more" 50

Blood transfusion 70, 519, 612-613Blood pressure, estimation from

peripheral pulses 53Blunt injury 3, 6, 11

Abdomen 244Head 386-387, 405-416Kidney 327Maxillofacial 441Neck 469-470Nuclear 30Spine 476, 480Vascular trauma 194

Boari flap 338, 339"Bogota bag" 91Botulism/botulinum toxin 146Brachial plexus 486-488, 499Brain injury - see Head InjuryBreath sounds 45Breathing and ventilation 48-50,

61-65Anaesthesia 556Ashermann chest seal 62, 643Assessment - inspect, feel,

percuss and auscultate 48-49

ATOMIC 49Auscultation 49Breath sounds 45Burns 47, 503-504, 507-508,

514-515

Index

679

Index.qxd 28/09/2004 15:58 Page 679

British Anti-Lewisite (BAL) 40Bupivicaine 125-126Burns

Acute tubular necrosis, prevention of 162, 519, 522

Analgesia 117-119, 507, 509, 515, 520

Antibiotics 137, 510, 521Airway 503, 507-508Benzyl penicillin 521Blood transfusion 519Carbon monoxide 504Carboxyhaemoglobin 503, 504Ceftriaxone 137, 138, 521Chemical burns 39-41, 506, 523Circulation 509, 510-513Cling film 506Combined with penetrating injury 6Compartment syndrome

154-156, 522Cooling 5061% Copper sulphate 524Cutaneous injury 504-506Cyanide 504Deep dermal burns 504-505Dexamethasone 508Dressings 506-507, 513, 518-519, 520Electrical burns 521-523Epidemiology 501-502Epidermal burns 504, 505Eschar/escharotomy 508, 516,

517-518Estimating burn size 507, 509,

510, 515-516Exposure/environment 509Fasciotomy 156Feeding 520, 526First aid 506-507Flammacerium cream 518-519

Breathing and ventilation (cont)Chest drain (thoracocentesis)

62-63, 646-650Chest injury - suspicious

features 48-49Cyanide poisoning 45,46Decision making 61Dullness to percussion 49, 51Flail chest 63, 349, 350Haemothorax 62, 352-353,

646-650Hyper-resonant percussion

note 49, 51Inhalational burns 47, 503

504, 507-508, 514-515Intercostal nerve block 63,

126-128Lung contusion 49, 353-355Massive haemothorax 62,

352-353, 646-650Needle thoracocentesis 62,

644-645Nerve agent poisoning 34-37,

45, 46Open pneumothorax 62,

351-352, 643Percussion note 49, 51Rib fracturs 49, 348-349Signs of respiratory distress

48-49Sucking chest wound 62,

351-352, 643Surgical emphysema 48, 352Tension pneumothorax 62,

63, 351, 644-646Thoracocentesis 62-63,

646-650Tracheal displacement 48, 63Triage 107-112Ventilatory support 63-65,

571-572

Index

680

Index.qxd 28/09/2004 15:58 Page 680

Flammazine 518-519Flucloxacillin 521Fluid requirement 510-513,

515, 519-520Full thickness burns 505Gentamicin 521Hand burns, management of

519Hypovolaemic shock 509,

510-513Incidence 6, 501-502Infection 520-521Inhalational injury 6 47,

503-504, 514-515Lund and Browder chart

515, 516Lung injury 503, 508Management 506-526Management at Role 1 and

Role 2 507-513Management Role 3 513-525Mass casualty scenarios 525Monitoring 512-513, 514,

519-520Moyer's solution 526Nuclear explosion 29-30Nursing 519-520Nutrition 520, 526Ophthalmic burns 39-40,

428, 435, 523 Palmar surface, to estimate

burn size 510Partial thickness burns 504Pathophysiology 6, 502-506Phosphorus burns 523-524'Rule of Nines' 510, 511Serial halving to estimate

burn size 507Staphylococcal infections

134, 137, 138, 520-521Streptococcal infection 134,

136-138, 520-521Surgery 517-518Surgical airway 59-61, 508,

556, 633-638Systemic Inflammatory

Response Syndrome (SIRS) 503, 525

Systemic injury 502-503, 504, 521

Tank crews, in 6Total body surface area

burned (%TBSAB) 502-503, 510, 511, 515-516, 525, 526

Triage for transfer 507, 513, 525Vesicant burns 39-40, 435, 524

Burr holes 408-411Bypass procedures, restoration

of blood supply 210-211

Cable graft 496Capillary refill time (CRT) 53Carbon monoxide poisoning 504Carboxyhaemoglobin 503, 504Cardiac injury 357-358, 371-375

Aorta and great vessels 357, 374-376

Atrium 372, 373Beck's triad 64Cardiac enzymes 363Cardiac laceration 373-374, 375Cardiac tamponade 64, 358,

371-373, 650-653Coronary artery injury and

occlusion 358Internal cardiac massage 371Myocardial contusion 357-358Needle pericardiocentesis

64, 650-653Open pericardiocentesis 64,

371-373, 650-651

Index

681

Index.qxd 28/09/2004 15:58 Page 681

Cerebral perfusion pressure 387Cerebrospinal fluid (CSF) 386Cervical spine - see Neck Injury

Cervical collar 55, 56Injury - suspicious features

47-48Manual stabilisation 55Radiology 469Spinal board/vacuum mattress

76-77, 478-479, 618Three point fixation 55

Chemical agents 31-42Arsenical blister agents 39-41, 506, 523Assessment of scene and

casualties 31-32Atropine 35-36Atropine poisoning 36-37Avizafone 35Blister (vesicant) agents

39-41, 506, 523Casualty Protection

Equipment (CPE) 34Chemical Agent Monitor

(CAM) 32-33Chlorine 41-42Classification 31Combopen 35Contaminated wounds 34, 97Cyanide 37-38Decontamination 33-34Detection 32-33Diazepam 35-37Eye injury 420, 435-436Formulation and delivery 31Fuller's earth 33GA (Tabun) 34GB (Sarin) 34GD (Soman) 340.5% Hyperchlorite solution 33

Cardiac injury (cont).Valvular disruption 358Ventricle 373-374

Cardiopulmonary resuscitation (CPR), cold injury 585

Cardiovascular support, indications and methods 572-576

Cartella shield 428Cartilage 101Casualty Protection Equipment

(CPE) 34Casualty template, in war fighting 1Casualty transfer chain - see

Aeromedical EvacuationAeromedical Evacuation

Squadron 619Air Evacuation Co-ordination

Officer (AECO) 620Air Evacuation Liaison

Officer (AELO) 620Close Support Medical

Regiments (113)Critical Care Air Support

Teams (CCAST) 620Echelons of Medical Care

(First -Fourth Line) 112Field Hospital 112Medical Section 112Primary Casualty Receiving

Ship (PCRS) 113Regimental Aid Post (RAP)

112Roles of Medical Care

(Roles 1-4) 112Unit Aid Post 112

Ceftriaxone (Rocephin) 137-138, 425, 521

Cefuroxime (Zinecef) 139Central venous line, indications

and technique 573-575

Index

682

Index.qxd 28/09/2004 15:58 Page 682

Individual Protection Equipment (IPE) 32

Man Portable Chemical AgentDetector (MCAD) 33

NBC suits 32Nerve Agent Inhibited

Enzyme and Alarm Detector (NAIAD) 33

Nerve Agent Pretreatment Set (NAPS) 35

Nerve agents 34-37Nitrogen mustards 39-41Oedemagens 41-42One colour detector paper

32-33Ophthalmic injury 420,

435-436Phosgene 41-42Pralidoxime 35, 36Pretreatment 35Protection 32Pyridostigmine 35'Quick look' 45-46Residual Vapour Detector

(RVD)Sulphur mustards 39-41Three colour detector paper

32-33Vesicant burns 39-41, 506,

523VX nerve agent 34Wounds in a chemical

environment 97Chemosis, eye 429Chest drain (thoracocentesis)

62-63, 360, 646-650Chest injury - see Breathing and

ventilation, Thoracic injuryChest X-ray, assessment of 362 Chilblains 587Chin lift 57

Chloramphenicol, use after eye injury 425

Chlorine poisoning 41-42Cholecystectomy 298Cholecystostomy 298-299Ciprofloxacin (Ciproxin) 138, 139,

425Circulation with haemorrhage

control 50-53, 65-73Abdominal bleeding

- identifying the source 83, 256-259

Abdominal bleeding - suspicious features

50, 247-250Abdominal visceral injury

- damage control 79, 87, 88, 254-258, 283, 289- 290

Amputation 80, 229-233Anaesthesia, maintaining

during 557Aortic clamping 84-86, 305, 373Autotransfusion 82Balloon catheter to control

haemorrhage 66, 86-88290, 306

Blood transfusion 70, 82, 519, 612-613

Capillary refill time (CRT) 53Cardiac tamponade 64, 358,

371-373, 650-651Cardiovascular support,

intensive care 572-576Causes of hypovolaemic

shock 50, 52Chest injury - suspicious

features 48-49Chest wounds - controlling

haemorrhage 87, 376-379

Index

683

Index.qxd 28/09/2004 15:58 Page 683

Liver injury 85-87, 353-356, 376-381

Long bone fracture- suspicious features 50

Long saphenous vein cut down68, 653-655

Lung injury 87, 353-356, 376-381

Lung rotation to control haemorrhage 87

Massive haemothorax 62, 352-353, 646-650

Mental state in hypovolaemic shock 51

Monitoring resuscitation 73Neck veins 48Neck wound, application of a

pressure dressing 66Needle pericardiocentesis

64, 650-653Non-compressible

haemorrhage 65Open pericardiocentesis 64,

371-373, 650-651Packing for haemorrhage

control 83, 85, 93, 289, 300, 303-304, 467-468

Pelvic fracture 68, 74, 313-326Pelvis/retroperitoneal injury

- suspicious features 50Pressure points for

haemorrhage control 66Pringle's manoeuvre 86, 290Recombinant factor VIIa

(rVIIa) 67, 85, 199, 288Retrohepatic caval bleeding

85-89, 289-299, 305-307Pulse rate 53Resuscitation 44, 55-74Sagar splint 67, 71Sources of major blood loss 50

Circulation (cont)Clotting adjuncts 67, 85, 199,

288Coagulopathy 80Colloid infusion 68Compressible haemorrhage

65Critical limb ischaemia 89Crystalloid infusion 70Embolisation 90Estimating blood pressure

from peripheral pulses 53Femoral vein cannulation 68,

653-655Fluid resuscitation algorithm

72Haemorrhage control 66-68,

83-90, 256-258, 376Haemostasis - damage

control surgery 79, 85-87 Haemothorax 62, 352-353,

646-650Hilar clamping to control

haemorrhage 87, 376Hypotensive resuscitation

68-72Hypovolaemic shock 50-53,

80Immobilisation of fractures

and soft tissue injuries 67-69, 156-161

Intra-osseus infusion 68Intraperitoneal haemorrhage

- methods of assessment75, 247-250

Intravenous fluids 70-72Ligation of arteries and veins

to control haemorrhage 89, 303-309

Limb elevation 67-69

Index

684

Index.qxd 28/09/2004 15:58 Page 684

Splenic injury 87, 283-284Splinting fractures and soft

tissue injuries 67- 72, 96, 100, 156-161

Tourniquet 66-67, 97, 99, 151, 195, 231-233

Tractotomy to control lung bleeding 79, 87, 378-379

Triage 107-112Vascular grafts and shunts

80, 89, 90, 207-208Vascular injuries 89, 193-226Venous cannulation 68,

655-656Venous cut down 68, 653-655Wound dressing 66, 95, 103,

245Clarithromycin (Klaricid) 138-139Cling film 506-507, 513, 523Close Support Medical Regiment

113Closed nerve injury, management

498-499Clostridium botulinum 146Clostridium perfringens 134, 141,

142Clostridium septicum 134Clostridium species 95Clostridium tetani 134, 140Clotting adjuncts 67, 85, 199Coagulopathy 80Co-amoxyclav (Augmentin) 137,

138, 425, 463, 466Codeine phosphate 123Coeliac axis 307-308Cold injury

Alcohol, role of 589Amitriptyline, pain relief 590Analgesia 589, 590Cardiopulmonary

resuscitation (CPR) 585

Chilblain 587 Clinical features 583-584,

586-588Epidural 126, 564, 589-590Fasciotomy 154-156, 589First aid 584-585Freezing cold injuries 587Frostbite 588-590Frostnip 588Hypothermia 80, 583-586"Immersion foot" 586-587Incidence 582Local cold injury 586-590Military causes 583Near drowning 591Non-freezing cold injuries 586Nursing care 589, 590Pathophysiology 583-584,

586-588Resuscitation 585-586Re-warming 585-586Secondary drowning 591Surgery 590Transfer 584, 590"Trench foot" 586-587Triage 584

Colloid infusion 68Colon 271-283

Blood supply 273Closing the lateral space

281, 282Comparison with small bowel

injuries 271Double-barrelled stoma

280-282End colostomy 280-282End-to-side anastomosis

279-280 Exteriorisation 87, 277-278Features of perforation 272Hartmann's procedure 282-283

Index

685

Index.qxd 28/09/2004 15:58 Page 685

Thigh 171-172Treatment 155-156Upper arm 164-165

"Complete traumatic hemipelvectomy" 317

Compound analgesic preparations 123

Compound Nerve Action Potential (CNAP) 498

Compressible / non-compressible haemorrhage 65-72, 193

Computerised tomography (CT) 199, 294-250, 363, 392, 400, 408, 412, 413, 415, 470

Concussion 406Coning 387-388Conjunctiva 434Contrast swallow 363Control of bleeding - see Circulation

and Haemorrhage ControlConvulsion/epilepsy 388, 392,

417, 5811% Copper sulphate 524Cord damage, estimating level

477, 478, 479Cordons, major incidents 607-608Core temperature measurement 580Cornea

Abrasions 433-434Examination 432-433Foreign bodies 433Infection (infectious keratitis)

434Coronary artery injury and

occlusion 358Coup and contre-coup injury

386-387, 407Craniectomy 402-403, 409-411, 412Craniotomy 409, 411Cricoid pressure 556, 559, 630-636Cricothyroidotomy 59, 470, 630-636

Colon (cont)Ileocolic anastomosis 279Left hemicolectomy 273Loop colostomy 277-278Management of extensive or

contaminated injury 274-283

Mesentery, approximating 280Mobilisation and inspection

272-274Mucous fistula 280-282Rectal injury 275, 282-283Resection 278-279Retroperitoneal injuries 271Right hemicolectomy 272Sigmoid colectomy 273Simple repair 274Stapled anastomosis 279-280Transverse colectomy 273

Colostomy 277, 280-282Coma 394, 396-397, 400, 406, 407Combat body armour (CBA) and

helmet design 9Combitube 61Combopen 35Command and control 607-608,

611Common iliac artery 219-220, 309Communication, major incident

609, 611-612ComPAC ventilator 566-567Compartment syndrome 96, 100,

154-156Abdominal 311-312Burns 522Clinical features 155Forearm 167-168Hand 169Limb 154-156Lower leg 174-177, 178, 179Pathophysiology 154-155

Index

686

Index.qxd 28/09/2004 15:58 Page 686

Critical care - see Intensive CareCritical Care Air Support Teams

(CCAST) 620Critical limb ischaemia 89Crookham halter 68, 72Crush injuries 162-163, 244Crystalloid infusion 70Cushing's Response 388Cutaneous ureterostomy 338, 339Cyanide poisoning 37-38, 45-46

Burns, inhalation 504Clinical features 38Cyanogen bromide 37Cyanogen chloride 37Detection 32-33, 37Detoxification 37Formulation 37Hydrogen cyanide 37Pathophysiology 37Sodium nitrite and sodium

thiosulphate 38Treatment 38

Cyclizine 119Cyclopentolate 425

Damage Control Surgery (DCS) 79-94, 193, 254Abdominal compartment

syndrome 94, 311-312Abdominal visceral injury 87,

88Amputation 80, 229-231Aortic clamping 84-86, 305,

375Autotransfusion 82Balloon tamponade 66,

86-88, 290, 306Chest wound 87, 361, 371Clotting adjuncts 67, 85, 199Coagulopaphy 80Control of bleeding 79, 85,

89-90, 253-259, 283-284, 287-292, 300, 303-307, 376-381, 467-468

Control of enteric spillage 79Critical limb ischaemia 89, 197Decision making 81Determinants of outcome 79Disadvantages 81Draping the wound 83Embolisation 90Feeding 94Hilar clamping 87, 376Hypothermia 80Identifying the source of

bleeding 83, 256-259Incision and extension 83Indications 82Inferior vena cava (IVC)

85-89, 289-299, 305-307 Initial operation 83Laparotomy 83, 84, 254-260Ligation of arteries and veins

89Liver injury, 85-87, 287-292Lung injury 87, 353-356Lung resection 376-381Lung rotation 87Measuring clotting times 80Metabolic acidosis 80'Minimimal transfusion'

approach 82Missed injuries 93Multi-visceral injuries 80Numbers of casualties requiring

DCS 81Packing 83, 85, 93, 289, 300,

303-304, 467-468Perforation 87Peroperative indications 82Preoperative selection 82Pringle's manoeuvre 86, 290

Index

687

Index.qxd 28/09/2004 15:58 Page 687

Diarrhoea, tropical causes 549-551Diathermy 403Diazepam 35-37, 392Diclofenac 123-124Die of Wounds (DOW) 7Diffuse axonal injury 406Diffuse brain injury 406Digital subtraction angiography

(DSA) 199Dihydrocodeine 123Dimercaprol (British Anti-Lewisite

BAL) 40Diplopia 424, 445, 451Disability/neurological status 53Dislocation 156-157 - see Fractures

Acromioclavicular joint 181Ankle 189-190Elbow 183Glenohumeral joint 181-183Hanging arm method of

shoulder reduction 182Hip 186-187Hippocratic method of

shoulder reduction 182Knee 188-189Kocher's method of shoulder reduction 182, 184Methods of stabilisation

157-161Patella 189

Dissociative disorders (hysteria) 602

Dobutamine 576Donor site, split skin graft 531-532Dopexamine 576Doppler handheld probe 198Doppler ultrasound (Duplex) 199Double-barrelled stoma 280-282Doxycycline 145Dressings 95, 103, 506-507, 513,

518-519, 520, 532, 534

DCS (cont)Re-operation 92, 93Restoring normal physiology

92, 568-577Retrohepatic vena cava

85-87, 289-299, 305-307Re-warming 80Splenic injury 87, 283-284Tactical situation 93Temporary abdominal closure

79, 90- 91Tractotomy 79, 87, 378-379Triage 107-113Vascular graft or shunt 80,

89, 90, 207-208Vascular injuries 89, 193-226

Dead casualties, major incident610Decompression, - see

Compartment SyndromeDecontamination after chemical

attack 33-34Deep vein thrombosis/pulmonary

embolismClinical features 191Prophylaxis 97, 191-192Treatment 192

Definitive care 44, 76Delayed primary closure 96, 104,

527Depressed skull fracture 413-414Dermatome, for skin grafts 530-531Dermatomes, sensory 478, 479Detector paper - one colour/three

colour 32-33Dexamethasone 470, 508Dextropropoxyphene 123Diagnostic peritoneal lavage (DPL)

248-249Diaphragm 283-285, 356-357

Index

688

Index.qxd 28/09/2004 15:58 Page 688

Duodenum 292-297Adjuncts 297Controlled fistula 296Decompression 295Drainage 90, 295Gastro-jejunostomy 294, 295Jejunal serosal patch 296, 297Kocher's manoeuvre 292, 295Major injury, management of

296-297Minor injury, management of

295Mobilisation 294-295Octreotide 297Operative findings 292-293Pathophysiology 292-293Proton pump inhibitors 297Radiology 293Temporary pyloric closure 295Tube duodenostomy 296

Dura mater 385-386Dural defects, management of

404-405

Ear injuriesAmoxicillin 463Antibiotics 462-463Aural fullness 464Avulsion injury 460Bismuth iodoform paraffin

ribbon gauze (BIPP) pack 462

Blast injury 462, 463Co-amoxyclav 463Ear canal 461-462External ear 459-461Facial nerve 456, 464-465Gentisone HC 462-463Haematoma 459-460Haemotympanum 462Head injury 464-465

Inner ear 463-465Labyrinthine concussion 464Middle ear 462-463Nystagmus 464, 465Otalgia 464Otitic barotrauma 463-464Otorrhoea 415-416, 462, 463Packing 462Perilymph fistula 464Pinna 459-461Prochlorperazine 464Protection 462, 463Repair 460-462Sensorineural deafness 463, 464, 465Sofradex 462-463Temporal bone fracture

464-465Typanic membrane 462,

463, 464Vertigo 459, 464Xylometazoline 464

Echelons of Medical Care (First - Fourth Line ) 112

Electrical burns/electrocution 521-523

Electrocardiogram (ECG), after chest injury 362

Electromyography 486End colostomy 280-282End ileostomy 270Endoscopic retrograde

cholangio-pancreatography (ERCP) 299, 303

Endoscopy 363, 470Endotracheal intubation 59,

639-642Energy transfer 11-23Enopthalmos 423Enteric fever

Ceftriaxone 546

Index

689

Index.qxd 28/09/2004 15:58 Page 689

Maxilla 451Pelvis 321-323, 324-326Pin care 326Spine 480Upper arm 164

External iliac artery 219-220, 309Extra-anatomical bypass 210-211Extradural haematoma (EDH)

407-411Eye injury, - see Ophthalmic Injury

Facial injury 96, 97, 101, 455-456Facial nerve 456, 464-465Falkland campaign 1982 1-2False aneurysm 196Fasciotomy, - see Compartment

SyndromeFat embolism 192Femoral nerve block 126-127Femoral vein cannulation 68,

653-655Femoro-femoral bypass graft

210-211Fentanyl 558, 559, 561Field Hospital 112, 554Field surgical team 554Finger sweep 57Flail chest 63, 349, 350Flammacerium cream 518-519Flammazine cream 518-519Flap, skin 529, 535-538Flucloxacillin 139, 521Fluid restriction 245Fluid resuscitation 72, 510-513Fluorescein 425Focal brain injury 406-416Focused Abdominal Sonography

for Trauma (FAST) 249Fogarty balloon catheter 201-202Foreign bodies 102, 403, 405, 481Fractures - see Dislocation

Enteric fever (cont)Ciprofloxacin 546Clinical features 545-546Diagnosis 545, 546Pathophysiology 544-545Salmomella typhi 544Treatment 546

Entonox Cautions 122-123Chest injury 129Contraindications 125Head injury 129Indications 122Method of use 122

Entrapment leading to limb amputation 230, 232

Enucleation, eye 437 Epidural analgesia 126, 564,

589-590Epistaxis, management of 448,

467-468Erb's Palsy 487Eschar/escharotomy 508, 516,

517-518Escherichia coli 135, 138Etomidate 559, 560Evacuation, - see Aeromedical

Evacuation Evacuation syndromes 595Eviscerated bowel 245Evisceration, eye 437 Exposure 53Exteriorisation of colon 277-278External fixation 159-161

Femur 171Foot 179Forearm 166-167, 185Hand 168-169Knee 173Lower leg 161, 177-178, 189Mandible 454, 456

Index

690

Index.qxd 28/09/2004 15:58 Page 690

Acetabulum 186, 318Ankle 190Classification 152Clavicle 180-181Elbow 183External fixation 159-161Femur 169-172, 173, 174,

175, 187-188Foot 179-180Forearm 166-168, 183-185Frontal bone 450'Guardsman's 446Hand 168-169, 185-186Hip 187-188Humerus 163-165, 183Immobilisation 67, 156-161Internal fixation 161Knee 173Le Fort classification 442,

444, 445Long bones 50Lower leg 173-178, 189Mandible 446-447, 451-455Maxilla 445-446, 451Nasal 466-467Open (compound) 151, 153Orbital blow out 445, 451Pelvis 68, 74, 313-326Plaster of Paris splint 156-159Radiographs 156Reduction and stabilisation

156Restoration of circulation 154Ribs 49Sagar splint 67, 71Scapula 181Skull 413-415Slings 69Spine 475-482Splint Aluminium Malleable (SAM), 67, 70

Splinting/stabilisation 67-68, 156-161, 163-180Thomas splint 67, 72, 170-173Traction 159, 480, 170-173Wrist 185Wound management 95-106, 154, 397-399, 455-456 Zygoma 443-444, 450-451

Fragments, - see Patterns of Injury in Military Operations

Fragment wounds 2-5, 96, 97, 102, 403, 405

Free tissue transfer 537-538Freezing cold injuries 587Frostbite 588-590Frostnip 588Fuel-air and thermobaric weapons

2, 27, 502Fuller's earth 33Fundus 436

GA (Tabun) 34Gallbladder 87, 298-299

Approach 298Cholecystectomy 298Cholecystostomy 298X-ray 299

Gardner-Wells' callipers 480"Gas gangrene" 141-142Gastro-jejunostomy 286, 294, 295'Guardsman's' fracture 446GB (Sarin) 34GD (Soman) 34Gentamicin 521Gentisone HC 462-463Glasgow Coma Scale (GCS) 389,

391, 395-396Globe, - see also Ophthalmic Injury

Anterior chamber 430-436Chemical injury 435-436Conjunctiva 434

Index

691

Index.qxd 28/09/2004 15:58 Page 691

Basal skull fracture 414-415Battle's sign 414-415Blunt 386-387, 405-416Brain stem injury 400Brain swelling 387-388Burr holes 408-411Classification of brain injury

386-388Cerebral perfusion pressure

387Cerebrospinal fluid (CSF) 386CSF leak 415-416, 417Coma 394, 396-397, 400,

406, 407Computerised tomography

(CT) 392, 400, 408, 412, 413, 415

Concussion 406Coning 387-388Contusion 407Convulsions/epilepsy 388,

392, 417Coup and contre-coup injury

386-387, 407Craniectomy 402-403,

409-411, 412Craniotomy 409, 411Cushing's Response 388Depressed skull fracture

413-414Diathermy 403Diazepam 392Diffuse axonal injury 406Diffuse brain injury 406"Dry" burr hole 411Dura mater 385-386Dural defects, management of 404-405Ear injury 464-465Extradural haematoma (EDH) 407-411

Globe (cont)Cornea 432-434Fundus and retina 436Hyphaema 430-431Iris 431Laser injury 437Lens 431-432Management of rupture/

penetrating injury429-430

Pupil 431Red reflex 432Signs of injury 429Sympathetic ophthalmia 437Vitreous 436

Glycopyrolate 561Gram-staining 145, 146Great vessels, injury of 374-376Gulf War 1991 1-2, 4

Haematoma block 126Haemodialysis/haemofiltration 577Haemorrhage - compressible,

non compressible 65Haemorrhage control,

haemostasis, - see Circulationwith Haemorrhage Control

Haemothorax 62-63, 352-353Haemotympanum 462Hartmann's procedure 282-283Head injury 385-417

Abscess 388, 417Aeromedical evacuation 416,

625Analgesia 128-129, 392 Anatomy 385-386Antibiotics 138, 392Anticonvulsants 392-393Arachnoid mater 385-386Assessment 389-397AVPU 389, 393-394

Index

692

Index.qxd 28/09/2004 15:58 Page 692

Focal brain injury 406-416Foreign bodies 403, 405Further management of

head injury casualties 416General management

389-397Glasgow Coma Scale (GCS)

389, 391, 395-396Haemorrhage, classification

of 386Haemorrhage, operative

control 403-404, 410, 411Head shave 392, 397, 401Hydrocephalus 417Hyperthermia 388Infection 388, 417Instruments for neurosurgery 401, 402Laceration, intracerebral 407,

411, 412Ligaclips 403Localising signs 394-395,

408, 412Long term complications 417Lorazepam 392-393"Lucid interval" 408Mannitol 393Meningitis 388Middle meningeal artery 407,

408, 413Mini-neurological

assessment 393-397Motor or sensory deficit 388Nursing care 393, 405-416Operative treatment, general

393, 400-405, 407Otorrhoea 415-416Oxycel 403Pathophysiology 385-388Penetrating 386, 400-405Phenytoin 393

Position/draping of casualty on operating table 401

Post-operative management 404

Primary brain injury 386-387Probability of intracranial

haematoma 413Pupil, assessment of 389,

391, 394Pupillary dilatation 388, 408,

412Racoon eyes 414-415Radiological assessment 392Raised intracranial pressure

387-388Rhinorrhoea 415-416Ring sign for CSF leak 415Role 1, management at

389-391Role 2-4 391-397Scalp laceration 397-399Secondary brain injury

387-388Skin flap 399Skull fracture 413-415Skull X-ray 392, 400, 408,

413, 414-415Subarchnoid haemorrhage,

traumatic 406Subconjunctival

haemorrhage 414, 429Subdural haematoma (SDH)

411-413Tentorium cerebelli 388Third cranial nerve palsy 388Through-and-through wounds

400Transfer of casualty 416, 625"Trauma flap" for head injury

411

Index

693

Index.qxd 28/09/2004 15:58 Page 693

"Hostile action casualty system (HACS) 5

Humby knife 530-531, 532Hyoscine 1190.5% Hyperchlorite solution 33Hyperthermia - see Heat Illness Hypertonic saline dextran (HSD) 72Hyphaema 428, 430-431Hypopyon 433Hypothermia - see Cold injuryHypovolaemic shock 50-53, 509,

510-513Hypotensive resuscitation 68-72,

244, 253-254

Ibuprofen 117, 123-124Ileo-colic anastomosis 279Ileostomy 268-270, 280-282Ileus 310Iliac arteries 219-220, 309"Immersion foot" 586-587Immobilisation of fractures and

soft tissue wounds 67-72, 156-161

Incident activation, at hospital 611Incident officer 607Incident response team (IRT) 554

Callout 609, 618Equipment 617Medical Incident Officer (MIO) 607, 615Packaging 618-619Record keeping and hand over

619Requirements 615-617Safety 608-609Staff 616Treatment at scene 610,

618-619Infectious keratitis 434Inoconstrictors 576

Head injury (cont)Triage of head injury

casualties 390-391Venous sinus 385-386Ventilation 393Wound closure 397-399,

404-405, 411Wound excision/aspiration

403, 404 Heart and great vessels - see

Cardiac InjuryHeat illness

Assessment 580-582Atropine 36-37, 582Clinical features 579-580Compounding factors 582Convulsions 581Core temperature

measurement 580Definition 579First aid 580-581Head injury 388Management, HDU/ITU

581-582Management Roles 2 and 3

581Pathophysiology 576Prevention 580Rhabdomyolysis 582Treatment 580-582

Helmet removal 54-55Hepatic artery 307-308High dependency care (HDC) 568Hilar clamping 376Homatropine 425Horizontal alignment, eyes 423Horner's syndrome 488Hospital acquired infection 138Hospital response to major

incident 611-613

Index

694

Index.qxd 28/09/2004 15:58 Page 694

Inodilators 576Inotropic drugs 575-576Interdental eyelet wiring 452-453Intermaxillary fixation 452-453, 454Incisions 97-99, 256Individual Protection Equipment

(IPE) 32Induction of anaesthesia 558,

559-560Infection/infectious disease

131-149 ; see also Antibiotics and BacteriaAmoebic dysentery 549-551Anthrax 144-145Antibiotics - battlefield

considerations 137Antibiotics - choice of

137-139Aseptic technique 132Bacteria 131-146Bacterial colonisation 133Biological warfare/weapons

131-132Botulism 146Burns 520-521Definition of infection 133Enteric fever 544-546Factors contributing to

infection in battlefield wounds 132-133

"Gas gangrene" 141-142Grouping of pathogens

according to site/injury 133-135

Head injury/meningitis 388, 417

Infection control 132, 143Malaria 541-544Necrotic or poorly perfused

wounds-likely pathogens 134

Necrotizing fasciitis 142-143Nightingale, Florence 131Perforated gut/viscous -

likely pathogens 134, 137Plague 145-146Postoperative infection

- likely pathogens 135Primary surgery - role of 132

Infection (cont)Principles of antibiotic

treatment 136Prophylactic antibiotics 132Proportion of battlefield

casualties 131Reducing the risk of infection

132Resistant strains 136, 138Ricin 132Schistosomiasis 547-549Scutari 131Semmelweiss, Ignaz 131Smallpox 146-147Skin laceration/penetration

- likely pathogens 134, 137

Spread/transmission 131Tetanus 140-141Utility of laboratory support 135-136

Inferior mesenteric artery 309Inferior vena cava 85-88, 89,

305-307Infraorbital nerve, damage 424Inhalational burns 6, 47, 503-504,

514-515Instruments, neurosurgery 401,

402Intensive Care (IC) in the field

Adrenaline 576Alfentanil 571

Index

695

Index.qxd 28/09/2004 15:58 Page 695

Femur 171, 188Foot 179-180Forearm 167, 183-185Hand 168, 185Hip 187Humerus 165Intramedullary nailing of

femur 171Pelvis 321, 322Spine 481

Internal iliac artery 219-220, 309Interposition vascular graft 80,

89, 90, 207-208Intestinal obstruction 310Intimal flap 195, 202Intra-osseous infusion 68Intraperitoneal haemorrhage

- methods of assessment 50, 75, 83, 247-250, 256-259

Intravenous fluids 70-72Intravenous urogram (IVU),

technique 331Iris 431Irrigation of wounds 103Isoflurane 558, 560, 561, 566

Jaw - see Maxillofacial InjuryJaw thrust 57Jejunal serosal patch 296, 297Joint dislocation - see DislocationJoint wounds 96, 101

Ketamine hydrochloride 120-121, 558, 559, 560, 562

Ketorolac 123-124Killed in Action (KIA) 7Klebsiella species 135, 136Klumpke's Palsy 487Knee disarticulation 239Kocher's manoeuvre 292, 294-295

IC in the field (cont)Arterial line, indications,

technique 572-573Assets/equipment required

569-571Cardiovascular support

572-576Central venous line,

indications, technique 573-575

Definition 568Dobutamine 576Dopexamine 576Haemodialysis/haemofiltration

577High dependency care (HDC)

568Indications 568Inoconstrictors 576Inodilators 576Inotropic drugs 575-576Midazolam 571Morphine 571Noradrenaline 576Nutrition 576-577Propofol 571Renal support 577Respiratory support,indications and technique

571-572, 578Staff 569Ventilatory settings 571-572Warning signs that casualty

requires IC support 568-569

Intercostal nerve blocks 63, 126-128, 349

Internal cardiac massage 371Internal fixation 161

Ankle 190Clavicle 180-181

Index

696

Index.qxd 28/09/2004 15:58 Page 696

Labyrinthine concussion 464Lacri-lube 425Laparoscopy 250Large bowel, see ColonLaryngeal injury, see Neck InjuryLaryngeal mask airway (LMA) 61Laryngoscopy 469-470Lateral compression (LC) fracture

of pelvis types 314-315Laser injury, eye 437Lebanon Israeli-PLO War 6Le Fort classification of maxillary

fractures 442, 444, 445Left gastric artery 307Left hemicolectomy 273Lens, eye 431-432Levels of command, at major

incident 607-608Lewisite 39-41Lids, eye

Burns 428Everting the lid 427Examination 426Foreign bodies 426Protection 428Wounds, management of

426-428Ligaclips 403Ligaments 100Lignocaine (Lidocaine) 125-126Limb injuries - see also Fractures

and DislocationsAeromedical evacuation

625-626Amputation 227-242Antibiotics 96, 97, 137Compartment syndrome

154-156Crookham halter 68, 72Crush injuries 162-163Deep vein thrombosis (DVT)/

pulmonary embolism (PE) 191-192

External fixation 159-161Fasciotomy 155-156, 164-165, 167-168, 169, 171-172, 174-177Fat embolism 192Features of war injuries 151Fracture types 152Frequency of injury 151Examination 50, 153Immobilisation 67-68, 156-161 Internal fixation 161Ischaemia 195, 197Joint dislocation 157Life-threatening injuries 151Limb-threatening injuries 151Lower limb 169-180, 186-191Management at Role 1

152-154Management at Role 2 or 3

154-156Mechanism of injury 151Mine injury 227Plaster of Paris splint 156-159Radiographs 156Reduction and stabilisation 156Restoration of circulation

154, 201-211Sagar splint 67, 71Skin cover for limb wounds

95-96, 162, 529-538Slings 69Splint Aluminium Malleable

(SAM) 67, 70Splinting/stabilisation of

fractures/soft tissue injuries 67-68, 156-161

Thomas splint 67, 72, 170-173Traction 159, 170-175, 178,180Traction splint 67-68, 71

Index

697

Index.qxd 28/09/2004 15:58 Page 697

Pleural analgesia 127Regional techniques 126, 558, 564Safety 125Spinal 126, 564

Local cold injury 586-590Localising signs, after head

injury 394-395, 408, 412Log roll 74Long bone fractures, suspicious

features 50Long saphenous vein cut down

68, 653-655Loop colostomy 277-278Loop ileostomy 268, 269Lorazepam 392-393Lower respiratory tract infection 138Lund and Browder chart 515, 516Lung injury 353-356, 376-381

Blast lung 61, 354-355Burns 503, 508Contusion 49, 353-355Flail chest 63, 349, 350Haemothorax 62-63, 352-353Hilar clamping 376Laceration 377-379Lobectomy 379Open pneumothorax

("sucking chest wound") 62, 351-352

Pneumonectomy 379-380Pneumothorax 49, 62-63,

349-352Rib fractures 49, 348-349Surgical emphysema 48, 352Tension pneumothorax 62, 63,

351Tracheobronchial injury

355-356, 380-381Tractotomy 378-379

Limb injuries (cont)Upper limb 163-169, 180-186Vascular injury 193-226Wound excision 97-101Wound management 95-106,

154Liver 85, 287-292

Abscess 291Approach 288-289Biliary fistula 87, 291-292Classification of injury

187-188Complications of injury

291-292Complications of packing 289Compression 85-87, 289-290Control of bleeding 85-87,

88, 288, 289-290Haematoma 291Haemobilia 291Packing 85-87, 289-290Pathophysiology 287-288Pringle's manoeuvre 86, 290Resection 290, 291Retrohepatic caval injury

85-89, 305-307Lobectomy, lung 379Local analgesia

Adrenaline and 125Bupivicaine 125, 558Epidural 126, 564Femoral nerve block 126Haematoma block 126Intercostal nerve block

126-127Lignocaine (Lidocaine) 125,

558Limitations in the field

124-125Maximum safe dose (MSD)

125

Index

698

Index.qxd 28/09/2004 15:58 Page 698

Major incident medical management

Blood transfusion 612-613Command and control

607-608, 611Communication 609, 611-612Cordons 607-608Dead casualties 610Definition 605Equipment 606Explosives Ordnance Disposal (EOD) 608, 616 Hospital response 611-613Incident activation, at

hospital 611Incident Officer 607Investigations 613Levels of command, bronze,

silver, gold 607-608Major Incident Medical

Management and Support (MIMMS) 606

Medical Incident Officer 607METHANE 609Planning 605-606, 611Preparation 605-606Response at scene 607-620Safety 608-609Training 606Transfer 613Transport 610, 619-626Treatment at hospital 612-613Treatment at scene 610Triage 609-610, 612

MalariaChloroquine 543, 544Clinical features 541-542Complications of P.falciparum

542Diagnosis 542

Dipstick antigen-capture assay 542

Doxycycline 543, 544Fansidar 544Fever patterns 541Malarone 542, 543, 544Mefloquine 543, 544Merozoites 541Pathophysiology 541P. falciparum 541, 543P. malariae 543P. ovale 543 P. vivax 543Primaquine 543Proguanil hydrochloride 543Prophylaxis 542-543Quinine 544Resistant strains 542-544Schizonts 541Sporozoites 541Treatment 543-544Tumour necrosis factor 541

Malingering and feigned illness 603Man Portable Chemical Agent

Detector (MCAD) 33Mandibular fractures 446-447,

451-455Mangled Extremity Severity Score

(MESS) 229-230Mannitol 393, 519, 522Mass casualty situation 108-109

Analgesia 129-130Burns 525Principles 107Priorities 107-109T (Treatment) System

107-109Triage sieve for treatment

109-110Triage sort for transfer

110-112

Index

699

Index.qxd 28/09/2004 15:58 Page 699

Malocclusion 423,442, 446, 451 Mandibular condyles,

fractures of 446-457, 452Mandibular fracture 446-447, 451-455Maxillary fractures 445-446, 451Middle third fractures

443-446, 450-451Miniplate fixation 451, 453Nursing 457Orbital blow out fractures

423-426, 445, 451Orbital decompression 450-451Pathophysiology 439-441Penetrating injury 439-441Radiological investigation

445, 447-448Respiratory embarrassment

446, 451, 452Restricted eye movements

422, 424, 429, 443, 445Retrobulbar haemorrhage 450Skull vault fractures 443, 450Soft tissue loss 456Supraorbital rim, fracture of 450Teeth, management of 452 Transfer of casualties 458Triage for transfer 458Upper third fractures 443, 450Wisdom teeth, management of

457-458Wound closure 456Wound excision 455-456Zygoma 422, 423, 443-444,

450-451Maximum safe dose (MSD) of

local anaesthetic 125-126Mechanical bowel obstruction 310Medical Incident Officer 607Medical Section 112

Mass casualty situation (cont)Medical cases 112Psychiatric cases 112

Maxidex 425Maxillary fractures 445-446, 451-452Maxillofacial injuries

Aeromedical evacuation 626Anatomy 440Antibiotics 137-138, 449Arch bar 453Bimanual reduction of a

Le Fort 3 fracture 451, 452Blunt injury 441Control of bleeding 448Diplopia 424, 443, 445Distraction osteogenesis 454Epistaxis 448Examination 441-447External fixation 451, 454Facial nerve injury 456,

464-465Frontal bone, fracture of 450'Gagging' (open bite) 447General management of

facial fractures 447-450'Guardsman's fracture' 446Horizontal alignment, loss of

423, 445 Indications for a surgical

airway 457Interdental eyelet wiring

452-453Intermaxillary fixation 454Infraorbital hypoaesthesia 424Le Fort classification of

maxillary fractures 442, 444, 445

Lower third fractures 446-447, 451-455

Index

700

Index.qxd 28/09/2004 15:58 Page 700

Medically unexplained symptoms (MUS) 603, 604

Medimech Auto Injector 118Meningitis 388Mental state

Hypercarbia 45Hypovolaemic shock 51Hypoxia 45

METHANE 609Methicillin-resistant


Metoclopramide 119Metronidazole (Flagyl) 137, 138,

425 Midazolam 558, 563, 571Military psychiatry

Acute psychiatric disorders (APD) 593Acute psychological

disorders 601-603Acute psychological

reactions to combat 593-595

Acute stress reactions (ASR) 593, 596-598

Credibility 596Dissociative disorders

(hysteria) 602Evacuation syndromes 595Examination 595-596, 597Malingering and feigned

illness 603Medically unexplained

symptoms (MUS) 603, 604

Medication 594-595, 597Organic cause of psychiatric

symptoms 599-600Personality disorder 602

Physical injury and psychiatry 598-599

Physical restraint 594Post combat or traumatic

disorders 603-604Post traumatic stress disorder

(PTSD) 603-604Prevention of acute stress

reaction 598Psychological debriefing 604Psychotic disorders 601Somatisation 602Suicidality 601Symptoms 594-595Transfer 597-598Violence 594-595

Mine injury 27, 227-228Mini-neurological assessment

393-397Miniplate fixation 451, 453MIST 44Modular Transportable Surgical

Facility (MTSF) 553Monitoring

Burns 512-513, 514, 519-520Head injury 394Resuscitation, effects of 73Vascular surgery, after 211

Morphine sulphateAnaesthesia, use in 557,

558, 559, 561, 571Antiemetic requirement 119Contraindications 120Dose 118-119Mechanism of action 118Medimech Auto Injector 118Naloxone 119-120Patient Controlled Analgesia

119Route of administration 118-119Side effects120

Index

701

Index.qxd 28/09/2004 15:58 Page 701

Dexamethasone 470Endoscopy 470Examination 48, 469Injury/wounds 45, 47, 48Laryngo-tracheal injury 48,

355 469, 472Laryngoscopy 469-470Major injury 470Minor injury 469-470Needle cricothyroidotomy

61, 630-633Oesophageal injury 358-359,

381-384, 472Penetrating neck wounds

48, 470-473, 556Pressure dressing 66Surgical airway 59-61, 556,

633-638Tracheostomy 59, 470, 636-638 TWELVE 48Vascular injury 472Venous distension 48Zones 1-3 470-472

Necrotizing fasciitis 142-143Needle thoracocentesis 62, 360,

644-645Neostigmine 561Nephrectomy 332-335Nephrostomy tube 334-335Nerve injury

Anatomy 483, 484Axillary nerve 488Axon 484Axonotmesis 484-485Brachial plexus 486-488, 499Cable graft 496Classification 483-485Closed injuries,

management 498-499Compound Nerve Action

Potential (CNAP) 498

Motion sickness 624Mouth to mask ventilation 64Mouth to mouth/mouth to nose

ventilation 64Moyer's solution 526Mucous fistula 270, 280-282Multi-drug resistant Klebsiella

species 136Muscle relaxants 558Mustards 39-41Myocardial contusion 357Myoplastic repair after amputation 229, 235-236

Naloxone 119-120Nasal injury

Air sinuses 448, 451Anterior nasal packing 467-468Bismuth iodoform paraffin

ribbon gauze (BIPP) pack 467

Co-amoxyclav 466Epistaxis 448, 467-468, Fracture 466-467Nasal tampon 466, 467Posterior nasal packing 468Septal haematoma 465-466Wound management 467, 468

Nasopharyngeal airway (NPA) 58, 630

NBC filter, use in anaesthesia 567NBC suits 32Near drowning 591Neck

Blunt trauma 469-470Cervical spine 47-48, 55, 469Computerised tomography

470Cricothyroidotomy 59-61, 70,

633-636

Index

702

Index.qxd 28/09/2004 15:58 Page 702

Delayed repair, consequences of 494

Electromyography 486Erb's Palsy 487Examination 486Facial 456, 464-465Factors influencing recovery

after repair 497-498Femoral nerve 490Horner's syndrome 488Infraorbital nerve 424Investigation 486Klumpke's Palsy 487Management 485-499Median nerve 488, 489Monitoring recovery 496Musculocutaneous nerve 488Nerve conduction studies 486Nerve grafts 496Nerve repair 100, 492-498Neurapraxia 483-484Neurilemmal sheath 484Pathophysiology 483-485Peroneal nerve 490-491, 492Penetrating wounds,

management of 492-493Plastic pen test 486Posterior tibial nerve 491-492Radial nerve 489-490, 491Recognition of injury 485-486Schwann cell layer 484Sciatic nerve 490Timing of surgery 493-494Tinel's sign 497Ulnar nerve 489, 490Wallerian degeneration 484Wound management 100,

492-493Nerve agent poisoning 34-37, 45, 46

Atropine 35-37Atropine poisoning 36-37

Avizafone 35Clinical features 35, 46Combopen 35Detection 32-33,36Diazepam 35-37Formulation 34GA (Tabun)GB (Sarin)GD (Soman)Interactions 37Nerve Agent Pretreatment

Sets (NAPS) 35Pathophysiology 34Pralidoxime 35-36Pretreatment 35Treatment 36VX nerve agent 34

Nerve Agent Inhibition Enzyme and Alarm Detector (NAIAD) 33Nerve Agent Pretreatment Sets

(NAPS) 35Neurapraxia 483-484Neurogenic shock 478Nightingale, Florence 131Nissen-Thal operation 384Nitrogen and sulphur mustards

39-91Nitrous oxide 560Noise and Aeromedical

evacuation 623Non-compressible injury 65-68,

243, 244, 245Non-freezing cold injuries 586Non-steroidal anti-inflammatory

drugs (NSAIDs)'Balanced analgesia' 124Contraindications 124COX-2 inhibitors 124Diclofenac 123-124Dose/route of administration

123

Index

703

Index.qxd 28/09/2004 15:58 Page 703

Acetazolamide 425Aeromedical evacuation

429-430, 626Amethocaine 425Anatomy 419, 420, 421Anterior chamber 430-436Antibiotics, systemic and

topical 424, 425Assessment, history and

examination 419-421Atropine 425Azithromycin 425Benoxinate 425Burns 428, 523, 524Cartella shield 428Ceftriaxone 425Chemical injury 420, 435-436Chemosis 429Chloramphenicol 425Ciprofloxacin 425Co-amoxyclav 425Conjunctiva 434Cornea 432-434Cyclopentolate 425Diplopia 424Enophthalmos 423Enucleation 437Everting the eye lid 427Evisceration 437Facial asymmetry 423Fluorescein 425Foreign bodies 424, 426, 432,

433, 434Fractures, general

management of facial fractures 447-450

Fundus and retina 436General measures 424Globe injury 429-430Homatropine 425Horizontal alignment,

NSAIDs (cont)Ibuprofen 117, 123-124Ketorolac 123-124Mechanism of action 123

Noradrenaline 576Northern Ireland bullet wounds

1969-1979 5Nose - see Nasal InjuryNuclear injury

Blast effects 29-30 Blindness 29Burns 29-30Causes of injury 28-29Fission reaction 28Fusion reaction 28Light flash 29Nuclear explosion 28Radiation effects 28, 30Radiation enhanced nuclear

device 28Treatment 30-31

Nutrition 576-577Nystagmus 464

Oedemagens Chlorine 41-42Pathophysiology 42Phosgene 41-42Treatment 42

Oesophageal disruption 48,358-359, 381-384, 472

Ofloxacin 425Ondansetron 119"Open book injury" of pelvis

315-317Open joint wounds 96, 101Open pneumothorax ("sucking

chest wound") 62, 351-352, 644-650

Ophthalmic injuryAbrasions, corneal 432, 433

Index

704

Index.qxd 28/09/2004 15:58 Page 704

assessment of 423Hyphaema 430-431Hypopyon 433Infectious keratitis 434Infraorbital hypoaesthesia,infraorbital nerve damage 424Iris 431Lacri-lube 425Laser injury 437Lens 431-432Lid wounds 426-428Limited jaw movement 422, 423Malocclusion 423Maxidex 425Maxillary fractures 445-446, 451Metron.idazole 425Ofloxacin 425Ophthalmic preparations 425Ophthalmoscope 431-432, 436Orbital decompression 450-451Orbital injury 423-426, 445, 451Pathophysiology 419, 428Proptosis 423Protecting the injured eye 428Pupil 431Raised intraocular pressure

425, 431Red reflex 432Reflexes, direct and consensual

422-423 Relative afferent pupil defect

(RAPD) 422-423Repair of ruptured globe

429-430Restricted eye movement

422, 424, 429, 443, 445Retinal detachment 436Retrobulbar haemorrhage 450Snellen Chart 420-421Subconjunctival

haemorrhage 414, 429

"Super" glue/bio-glue 430Sympathetic ophthalmia 437Timolol 425Visual acuity 420-421Vitreous 436Zygoma 443-444, 450-451

Ophthalmic preparations 425Ophthalmoscope 431-432, 436"Opsite sandwich" 91,93Orbit

Blow-out fracture 424, 445, 451Decompression 450-451Diplopia 424, 445, 451Enophthalmos 423Examination 423-424Facial asymmetry 423Foreign bodies 424Fracture 425Horizontal alignment 423Infraorbital hypoaesthesia 424Investigations 425Proptosis 423Restriction of eye movement

424, 445, 451Oropharyngeal airway (OPA) 58, 629Otalgia 464Otitic barotrauma 463-464Otorrhoea 415-416, 462, 463 Oxford Miniature Vaporiser (OMV)

566, 567Oxycel 403Oxygen administration 55, 565Oxygen concentrators 565

P's, the six 197Packaging 76, 245-246Packing 83

Abdomen 254-259Complications of 85, 93, 289Ear 462Liver 85, 289-290

Index

705

Index.qxd 28/09/2004 15:58 Page 705

Pancuronium 558Paracetamol 123-124Partial nephrectomy 334-335Patch angioplasty 209Patient controlled analgesia

(PCA) 119, 561Patterns of injury in military operations 1-10

Abdomen 243-244Ballistic injury 1-8Blast 6, 23-27, 244Blunt injury 3, 6, 11, 244Bullets 1-5Burns 6, 27Combat body armour (CBA)

and helmet 9Combination injury 3, 7Comparison of bullet and

fragment injury 2, 3Complexity of injury 5, 7Diagnostic difficulties 4Die of Wounds (DOW) 7Fragment injury 2-5Fragmentation devices

random and "improved" 3-4

Fuel-air and thermobaric weapons 2, 27, 502

Head injury 385"Hostile action casualty

system" (HACS) 5Improving outcome following

injury 8-9Injury to critical areas 5, 7Killed in Action (KIA) 7Magnitude and lethality offragments and bullets 3-5, 7Multiple penetrating injuries

4-5, 7Novel weapons 2, 27, 502Penetrating injury 1-11

Nose 467-468Pancreas 300Pelvis 85, 323Removal of packs 93, 94Retroperitoneum 85,

303-304, 331-332Pain

Analgesia 115-130Assessment of pain 116-117Effects of inadequate pain

control 115-116Inadequate pain reliefperception 115Physiological response 115Principles of management

115Pancreas 299-303

Abscess 303Approach 292, 294-295, 299Complications of injury

302-303Damage control surgery 85,

87, 90Drainage 87, 90, 300Endoscopic retrograde cholangio-pancreatography (ERCP) 303Fistula 87, 303Investigation 299Kocher's manoeuvre 292,

294-295Major injury, management

300-301Minor injury, management

301-302Packing 300Pancreatectomy 300-301, 303Pancreatitis 303Pseudocyst 303Repair 301-302Resection 300-301, 302

Index

706

Index.qxd 28/09/2004 15:58 Page 706

Predicted mortality without treatment 8

Regional injuries 1-2Surgical and anaesthetic

skills 5Thermal injury 6, 27, 501-506Vascular injury 193-196

Pedicle graft 537Penetrating injury - see Ballistic

Injury Penicillin 137, 139Penile injury 345Pelvic injury 313-326

Acetabular fractures 318Anatomy 313Anteroposterior compression(APC) fracture types 1-3

315-317Assessment, history,

examination and investigations 318-321

"Complete traumatic hemipelvectomy" 317

Complications 323-324Features suspicious of injury

50, 318-320Fractures 68, 74, 313-318Immobilisation 321Internal iliac arteries 313Investigations 320, 321Lateral compression (LC)

fracture types 1-3314-315

Major injury 314-317Management at Role 1 and 2

318-321Management at Role 3 and 4

321-323Minor pelvic fractures 317-318"Open book injury" 315-317Pathophysiology 313-318

Pelvic external fixator 321-323, 324-326

"Perineal spliting type" injury 318, 319

Pin care 326Pubic diastasis, examining

for 319Sacroiliac ligaments 313, 315Soft tissue trauma 318Superior gluteal arteries 313Traction 170-171, 322Treatment 321-326Urological injury 319, 343-345Venous drainage 313Vertical shear (VS) injury 317"Windswept pelvis" 315

Peptococcus species 134Peptostreptococcus species 134Pericardiocentesis 64-65, 360,

371-373, 650-653Perilymph fistula 464"Perineal spliting type" injury

318, 319Perinephric haematoma 332, 336Perirenal (Garota's) fascia 330,

332Personality disorders 602Pharynx - see Neck InjuryPhenytoin 393Phosgene 41-42Phosphorus burn 523-524Physical injury and psychiatry

598-599Physical restraint 594Pinna 459-461Plague 145-146Plastic and reconstructive surgery,- see Wound Management

Advancement flap 534, 535Aims 527Applying the graft 532-534

Index

707

Index.qxd 28/09/2004 15:58 Page 707

Plaster of Paris splinting 156-159Plastic pen test 486Pleural analgesiaPneumonectomy 379-380Pneumothorax 62, 63, 349-352Portal vein 308Post combat or traumatic

disorders 603-604Post traumatic stress disorder

(PTSD) 603-604Practical procedures

Airway manoeuvres 629-642Ashermann chest seal 643Bowel surgery 260-283Breathing manoeuvres

643-650Chest tube insertion

(Thoracocentesis) 646-650

Circulation manoeuvres 650-656Endotracheal intubation

639-642Femoral vein cannulation

655-656General advice on performing

procedures 629Guedel airway 58, 59, 629Knot tying 664Nasopharyngeal airway (NPA) 58, 60, 630Needle cricothyroidotomy

630-633Needle pericardiocentesis

650-653Needle thoracocentesis

644-645Nerve repair 493-498Open pericardiocentesis

371 372, 651Oropharyngeal airway (OPA)

58, 59, 629

Plastic surgery (cont)Available techniques, the

reconstruction ladder 528Axial flaps 537-538Covering vital structures 529Delayed primary closure 96,

100, 527Dermatome 530-531Donor sites for split skin

graft 531Donor site, management

531-532Dressings 95, 103, 532, 534 Facial injury 96, 97, 101Flaps 529, 535-538Free tissue transfer 537-538Graft take, optimising 529Harvesting a split skin graft

530-531Humby knife 530-531, 532Immobilisation 96, 100, 104,

534Microvascular anastomosis 537-538Nerve repair 100, 492-498Open joint wounds 96, 101Pedicle 537Primary suture 96, 527-528Random pattern flap 535-537Rhomboid flap 536, 537Rotation flap 535Scalp 96, 397-399Split skin graft 528, 529-534Tendon repair 100, 664Transposition flap 535, 536Vascular techniques 100,

201-211V-Y advancement flap 537Wound excision 96-101, 527Wound healing, optimising

528

Index

708

Index.qxd 28/09/2004 15:58 Page 708

Peripheral venous cutdown 653-655

Principles of wound management 95-105, 658-665

Surgical cricothyroidotomy 633-636

Surgical handicraft 656-665Suture removal 658-659Technique of wound closure

660-665Tendon repair 662, 664Thoracocentesis 646-650Tracheostomy 636-638Vascular repair 201-211

Predicted mortality 8Premedication, anaesthesia

118-119, 392-393, 556, 557Preoperative assessment

555-557Preoxygenation 559Pressure points for haemorrhage

control 66Primary brain injury 386-387Primary Care Casualty Receiving

Ship (PCRS) 113Primary survey 44Primary suture 96, 527-528Pringle's manoeuvre 86, 290Prochlorperazine 119, 464Propofol 558, 559, 560, 563-564,

571Proptosis 423Proteus species 135Psoas hitch 338Psychiatric symptoms, physical

causes 589-599Psychiatry see Military PsychiatryPsychological debriefing 604Psychotic disorders 601Pubic diastasis , examining for 319

Pulmonary embolism 97, 191Pulmonary contusion 353-355Pulmonary tractotomy 378-379Pulse oximetry 198Pulse rate 53, 109-110Pupil assessment 53, 388-389,

391, 394, 408, 412, 431

Raccoon eyes 414-415Radiation - see Nuclear InjuryRadiation enhanced nuclear

device 28Raised intracranial pressure

387-388Raised intraocular pressure 425,

431Random pattern flap 535-537Rapid sequence induction 556, 559Rectal injury 257, 282-283Red reflex 432Reflex, direct and consensual

422-423Refrigeration 565Regimental Aid Post (RAP) 112Regional anaesthesia 564-565Rehabilitation after amputation 242Relative afferent pupil defect

(RAPD) 422-423Renal support 577Renal trauma 327-337

Aetiology 327-328Approach, surgical exposure

331-336Blunt injury 327Classification 328-329Clinical features 328Complications 337Indications for surgery

331-332Intravenous urogram (IVU),

technique 331

Index

709

Index.qxd 28/09/2004 15:58 Page 709

Rhinorrhoea 415-416Rhomboid flap 536, 537Rib fracture 348-349Ricin 132,144Right hemicolectomy 173Ring sign for CSF leakage 415Roles of Medical Care (Roles 1-4)

112Rotation flap 535'Rule of Nines' 510, 511

Sacral sparing, spinal injury 477Sacroiliac ligaments 313, 315Sagar splint 67, 71Sanders Oxygen 'T' 566, 567Scalp laceration 96, 397-399Scene safety 44, 608-609Schistosomiasis 547-549

Acute 547-548Chronic 548-549Pathophysiology 547-549Praziquantel 549Treatment 549

Scrotum 96, 345-346Scutari 131'Second look' laparotomy 261Secondary brain injury 387-388Secondary drowning 591Secondary survey and packaging

44, 74-76Semmelweiss, Ignaz 131 Sensorineural deafness 464, 465Shunt - see Vascular ShuntSigmoid colectomy 273Sigmoidoscopy 248Skin cover 162

After amputation 236-237Scalp injury 399

Skin graft 529-538Skull fracture 413-415, 443, 450Skull traction 480

Renal trauma (cont)Investigation 328, 330-331Major injury management

330-331Minor injury, management

330Nephrectomy 332-334Nephrostomy tube 334-335Packing 332Partial nephrectomy 334-335Pathophysiology 327-330Penetrating injuury 328Perinephric haematoma 332,

336Perirenal (Gerota's) fascia

330, 332Repair of renal lacerations

332, 334Respiratory support, indications

and techniques 571-572, 578Restoration of circulation 154Restricted eye movements 422,

424, 429Restricted jaw movement 422,423Resuscitation 44, 55-74, 557, 559Resuscitative laparotomy 68,

80-87, 246Resuscitative thoracotomy 361,

371Retained bullets and fragments

102-103Retinal detachment 436Retrobulbar haemorrhage 450Retroperitoneal haemorrhage,

management 85-87, 300, 303-309, 332

Reversal of anaesthesia 561Revision of the amputation stump

242Re-warming 585-586Rhabdomyolysis 582

Index

710

Index.qxd 28/09/2004 15:58 Page 710

Skull X-ray 392, 400, 408, 413, 414-415, 464-465

Slings 69Small bowel 260-270

Anastomosing bowel of unequal diameter 265-267

Anastomotic patency, testing for 265

Assessment of viability 261End ileostomy 270End-to-end anastomosis

263-269End-to-side anastomosis 267Loop ileostomy 268-270Mesenteric injury/haematoma

260-261Pathophysiology 260-261Repair 261-262Resection, indications for 263Resection, technique

263-264'Second look' laparotomy 261Side to side anastomosis

266-267Single perforation,

management of 261-262Stapled anastomosis 265,

266, 269Small pox 146-147Snellen chart 420-421Sodium nitrite and sodium

thiosulphate 38Sofradex 462-463Somatisation 602Spinal analgesia 126, 564Spinal injury

Anatomy 475, 478Blunt injury 476, 480Complications, prevention of

480-481

Cord damage, estimating level 477, 478

Dermatomes 478, 479Examination 476-477Foreign body 481Gardner-Wells' callipers 480Immobilisation 478-479, 480Management 477-481Neurogenic shock 478Nursing 479, 480Pathophysiology 475-476Penetrating injury 476, 480Respiratory difficulties

477-479Sacral sparing 477Skull traction 480Surgery, role of 481Suspicious features, history

47-48, 476Sympathetic tone, loss of 477Transfer 479-480Turning frame, Stryker, Povey

480Ventilatory support 477, 478,

479Spleen/splenectomy 87, 283-284Splenic artery 307Splint Aluminium Malleable

(SAM) 67, 70Splinting fractures and soft

issue injuries 67-72, 96, 100, 104, 156-161

Split skin graft 528, 529-534Staphylococcus aureus 134, 137,

138, 520-521Stomach 285-287

Approach 285Pathophysiology 285Repair of injuries 285, 287

Strategic evacuation 619Streptococcus pneumoniae 138

Index

711

Index.qxd 28/09/2004 15:58 Page 711

Suture removal 658-659Sutures and ties, types of

659-665Technique of wound closure

660-665Tendon repair 662, 664Vascular repair 201-211Vertical mattress suture 660,

662Wound healing 656-658

Suxamethonium 558, 560, 563Sympathetic ophthalmia 437Sympathetic tone, loss of 477Syme amputation 242Synthetic grafts 89, 207-208Systemic Inflammatory Response

Syndrome (SIRS) 503, 525

Tactical evacuation 620Teeth, management of 452, 457-458Temperature and Aeromedical

evacuation 621-622Temporary abdominal closure 79,

90, 91,93, 259-260Temporary wound cavity 16-23

Change in presented area of missile 20

Clinical consequences 11, 19-22Compounding factors 20-23Contamination 18-19Effect of missile fragmentation

13, 16, 21, 22Effect of tissue properties 19-21Shape 17-18Size 16-17Wound track length 22-23Yaw 17-18, 21, 23

Tendon repair 100, 662, 664Tension pneumothorax 62, 63,

351, 644-650Tentorium cerebelli 388

Streptococcus pyogenes 134, 136, 137, 138, 520-521

Stomal problems 311Stump dressing/bandage, after

amputation 233-234, 236Subarachnoid haemorrhage,

traumatic 406Subconjunctival haemorrhage

414, 429Subdural haematoma (SDH)

411-413"Sucking chest wound" 62,

351-352, 643Suicidality 601 "Super glue"/bio glue 430Superficial fragment wound 96, 97Superior gluteal artery 313Superior mesenteric artery 308Suprapubic catheter, insertion

344-345Surgical airway 59-61, 508, 556,

633-638Surgical decision making,

abdominal injury 250-253Surgical emphysema 48, 352Surgical Handicraft

All layers suture 660-661Bowel surgery 260-283Continuous suture 660-661,662'Dog ends', dealing with

662-663Drains 665Gauge of suture 659, 665Knot tying 664Needle, choice of 659-660Nerve repair 493-498Principles of wound

management 95-105, 658-665

Subcuticular suture 662

Index

712

Index.qxd 28/09/2004 15:58 Page 712

Testis, injury to 345-346Tetanus 140-141

Clinical features 141Human tetanus

immunoglobulin 140, 141Pathophysiology 140Prevention 140-141Tetanus toxoid vaccine 96, 141Treatment 140

Thermal injury - see Burns"Thermopols" 565Thiopentone 558, 559, 560Third cranial nerve palsy 388Thomas splint 68, 72, 170-174Thoracic injury - see also Breathingand Ventilation

Adult respiratory distress syndrome (ARDS) 354

Aeromedical evacuation 624-625

Anterolateral thoracotomy 364-365

Aorta and great vessels 357, 374-376

Aortography 363Ashermann chest seal 359,

643Atrium 372, 373Bilateral anterolateral

thoracotomy 367-368Blast lung 27, 354-355Cardiac enzymes 363Cardiac laceration 373-374,

375Cardiac tamponade 64, 358,

371-373, 650-653Chest drain (thoracocentesis)

360, 640-650Chest X-ray, assessment of

262Computed tomography (CT) 363

Contrast swallow 363Coronary artery injury and

occlusion 358Decision making 360Diaphragmatic disruption

356-357Electrocardiogram 362Emergency thoracotomy,

indications 361-362End cervical oesophagostomy 383, 384Endoscopy 363Examination 48, 359Flail chest 63, 349, 350General overview 348-359Great vessels, injury to

375-376Haemothorax 62-63, 352-353Heart and great vessels,

injuries to 357-358Hilar clamping 376Immediate thoracotomy,

indications 361Initial management 359-363Internal cardiac massage 371Investigations 362Laryngeal injury 355Lobectomy 379Lung injury 353-356, 376-381Lung laceration, repair of

377-379Management 359-371Median sternotomy 368-370Myocardial contusion 357Needle thoracocentesis 360Nissen-Thal operation 384Oesophageal disruption

358-359, 381-384Open pneumothorax

("sucking chest wound") 62, 351-352, 643

Index

713

Index.qxd 28/09/2004 15:58 Page 713

Bilateral anterolateral thoracotomy 367-368

Closure 365-367, 370Emergency thoracotomy,

indications 361-362Median sternotomy 368-370Posterolateral thoracotomy

365, 366Resuscitative thoracotomy

361, 371Subclavicular ("trapdoor")

incision 370-371Thoracoabdominal incision 364

Thrombectomy 201-202Thrombosis 198Timolol 425Tinel's sign 497Tissue loss 101, 162, 236, 455-456, 527-538Tissue viability 100Topical analgesia

Catheterisation 126Eye 126

Torso trauma -role of surgery 79Total body surface area burned

(%TBSAB) 502-503, 510, 511, 515-516, 525, 526

Total intravenous anaesthesia (TIVA) 562-564

Tourniquet 66-67, 97, 99, 151, 195, 231, 232-233

Trachea, displacement 48, 63Tracheobronchial injury 355-356,

380-381Tracheostomy 59, 470, 636-638Traction for fractures 67-68, 71,

159Femur 169-175, 187-188Lower leg 178Pelvis 322Spine 480

Thoracic injury (cont)Pathophysiology 347-348Pericardiocentesis 64, 360,

371-373, 650-653Pneumonectomy 379-380Pneumothorax 62-63,

349-352Posterolateral thoracotomy

365, 366Pulmonary contusion

353-355Pulmonary tractotomy 76,

378-379Resuscitative thoracotomy,

361, 371Rib fractures 348-349Simple pneumothorax

349-350Subclavicular ("trapdoor")

incision 370-371"Sucking chest wound" 62,

351-352, 643Surgical emphysema 48, 352Tension pneumothorax 62, 63,

351, 644-650 Thoracoabdominal incision 364Thoracotomy, approach and

instrumentation 363-364Thoracotomy closure

365-367Tracheobronchial injuries

355-356, 380-381Tractotomy 79, 378-379Valvular disruption 358Ventricle 373-374

Thoracocentesis 62-63, 646-650Thoracotomy

Anterolateral 364-365Approach and instrumentation

363-364

Index

714

Index.qxd 28/09/2004 15:58 Page 714

Transfer - see Aeromedical evacuation

Transition to war (TTW) 3Transposition flap 535, 536Transverse colectomy 273"Trauma flap" for head injury 411Trench foot 586-587Triage 107-113

Burns 507, 513, 525Compensated/uncompensated

107-108Definition 107Head injury 390-391Major incident 609-610, 612

Trimethoprim 138Tri-Service Anaesthetic Apparatus

(TSAA) 557, 566Tropical diseases

Abdominal pain 551, 552Amoebic dysentery 549- 551Background 539Diarrhoea 549-551Enteric fever 544-546Fever 540-548Malaria 540-544Pyogenic infections 546-547Pyomyositis 546Schistosomiasis 547-549Sickle cell crisis 552Surgical considerations 539-540Toxic shock syndrome 547

Turning frame 480TWELVE 48Tympanic membrane 462, 463, 464

Unit Aid Post 112Ureteric injury 337-340

Boari flap 338, 339Cutaneous ureterostomy

Interposition, repair of ureteric defect 340

Management 337-340Pathophysiology 337Psoas hitch 338Repair 336-338Ureteric stent 337, 338Uretero-ureterostomy 339, 340

Urethral injury Aetiology 343Clinical fatures 343Management 344Suprapubic catheterisation

344-345Urinary fistula 87, 337Urinary tract infection 138Urological injury 327-346

Bladder 340-342Pathophysiology 327-330Renal trauma 327-337Suprapubic catheterisation

344-345Testis and scrotum 345-346Ureter 337-340Urethra 343-345

Valvular distruption, after cardiac injury 358

Vascular injuries 89, 193-226Advanced vascular repair

205-211Anastomosis 206-207Anastomotic bleeding,

control of 204Ankle brachial pressure

index (ABPI) 198Anterior tibial artery,

exposure 224, 225Arterial spasm 195Arteriography/angiography,

on-table 198,199, 204Arteriovenous fistula

195-196, 211

Index

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Index.qxd 28/09/2004 15:58 Page 715

End-to-side anastomosis 210Examination 50-53, 197Exposure and control 201,

212-226External iliac artery,

exposure 219-220Extra-anatomical bypass

210-211False aneurysm 196Fasciotomy - see

Compartment syndromeFemoral artery, exposure 89,

220-221Femoral vein, exposure 221 Femero-femoral graft 210-211Fogarty catheter 201-202Haemorrhage 194Haemorrhage control 65-74Hepatic artery 86Immediate treatment

65-74,199-200Incidence 193Inferior vena cava 85,88,89Internal iliac artery, exposure

219Interposition graft 207-208Intimal flap 195, 202Investigations 198-199Ischaemia 195Jugular vein 89Long saphenous vein,

exposure 221Long saphenous vein graft

207-208Lower limb 219-226Management 197-200Mechanisms of injury 194Monitoring, post-operative 211Neck 470-472Neurological signs after

carotid injury 197

Vascular injuries (cont)Associated injuries 193Axillary artery, exposure

216-217Axillo-femoral graft 210-211Back bleeding and inflow,

management 201-202Brachial artery, exposure 217Brachiocephalic artery and

vein exposure 212-213Bypass procedures 210-211Capillary refill time (CRT) 53Carotid artery, exposure 89,

212-214Clotting adjuncts 67, 199Common iliac artery,

exposure 219Completion angiography 204Compressible/

non- compressible haemorrhage 65-72, 199-200

Computerised tomography (CT) 199

Consequences of vascular trauma 194-196

Covering the vascular repair/anastomosis 204-205

Crural vessels, exposure 224-226

Definitive vascular surgery techniques 201-211

Digital subtraction angiography (DSA) 199

Doppler handheld probe 198Doppler ultrasound (Duplex )

199Drainage 204End-to-end anastomosis

206-207

Index

716

Index.qxd 28/09/2004 15:58 Page 716

P's, the six 197Patch angioplasty 209Pathophysiology 194-196Peroneal artery, exposure

225-226Popliteal artery and veins,

exposure 222-223Portal vein 89Posterior tibial artery,

exposure 224, 225Post-operative management

211-212Profunda femoris artery,

exposure 220-221Pulse oximetry 198Radial artery exposure 218-219Repair of lacerated vessel 203Restoration of flow 203-204Root of neck, vascular

exposure 212-215Subclavian artery and vein,

exposure 212-213, 215-216

Synthetic graft 89, 207-208Thrombectomy 201-202Thrombosis 195Ulnar artery, exposure

218-219Upper limb 215-219Vascular exposure 212-226Vascular repairs 100, 201-211Vascular shunts 80, 89,

207-208Veins, management of injury

205Vertebral arteries, exposure

215Vascular shunt 80,89, 207-208Vecuronium 558, 560-561, 563Veins

Femoral, exposure 221

Inferior vena cava 85, 88, 89, 305-307

Ligation 89Long saphenous vein graft

207-208Long saphenous vein,

exposure 221Management of injury to 205Jugular 89, 213-214Portal 89, 308Shunt 89

Venous cannulation 68, 655-656Venous cutdown 68, 653-655Venous sinus, head injury 385-386Ventilation - see Breathing and

VentilationVentilator settings 571-572Ventilatory support 63-65, 571-572Ventricle, injury to 373-374Vertical shear (VS) injury 317Vertigo 459, 464Vesicant agents - see Chemical

Weapons and Blister AgentsVibration, and Aeromedical

evacuation 622-623Violence, psychiatric illness

594-595Visual acuity 420-421Vitreous, injury to 436VX nerve agent 34V-Y advancement flap 537

Wallerian degeneration 484Weapons

Blast 6Bullets 1, 3-5, 11-23Fragments 2-5, 11-23Fuel air 2, 502Novel weapons 2Penetrating 3-5, 11-23Thermal 6, 502

Index

717

Index.qxd 28/09/2004 15:58 Page 717

Fasciotomy 96,100, 154-156, 164-165, 167-169, 171- 172, 174-177

Foreign bodies 102Healing 656-658Immobilisation 69, 96, 100,

104, 156-161Indications for wound

inspection 103Infection, likely bacteriology

138-139Irrigation 97, 103Langer's lines 99, 658Length 658Ligaments 100Nerves 100, 483-499Open joint wounds 96, 101Optimising healing 528,

656-657Retained bullets 103Retained fragments 102Scalp 96, 397-399Scrotum 96, 345-346Spasm, arterial 195Splint and elevate 69, 96,

100, 104, 156-161Superficial fragment wounds

96, 97Surgical handicraft 656-665

Xylometazoline 464

Yersinia pestis 145-146

Zygoma, fracture of 443-444, 450-451

Weapons (cont)Thermobaric 2, 502

"Windswept pelvis" 315Wisdom teeth, management of

457-458Working with Aeromedical

helicopters 626-627World War I 2World War II 2, 6, 193, 243Wound

Abdominal closure 259-260, 658Amputation 96, 100, 227-242Antibiotics 96, 97Antipersonnel mine injury

27, 100, 151, 227-228Bone 100,101Cartilage 101Chemical contamination

31-40, 97, 523-525Closure 90-91, 259-260,

656-665Comparison of civilian and

military wounds 95Complicating factors 95Contamination 19-19, 95, Coverage 100, 101-102,

104, 527-538Deep vein thrombosis

prophylaxis 97, 191-192Degloving injury 97, 99Dehiscence 310, 310-311,

656-658Delayed primary closure 96,

104, 658Drains 259, 658, 665Dressing 66, 95, 103, 245Excision 96-101, 658Exploration 96Extension 97Face 96, 97, 101, 455-456

Index

718

Index.qxd 28/09/2004 15:58 Page 718

Normal Values

Common Biochemical Blood Tests

Investigation Container Min. volume Adult reference(ml) required value

Acid phosphatase Plain 5 Total: <7 U/LProstatic: <4 U/L

Albumin Heparinized 5 35-51 g/L

Alkaline phosphatase Heparinized 5 30-130 U/L

Amylase Plain 5 <1000 U/L

Aspartate transaminase Heparinized 5 7-40 U/L

Bilirubin Heparinized 5 5-17 µmol/L

Calcium Heparinized 5 2.12-2.55 mmol/L

Cortisol Heparinized 5 170-600 nmol/L

Creatinine Heparinized 5 60-125 µmol/L

Creatinine kinase Heparinized 5 24-190 U/L

Lactic dehydrogenase Heparinized 5 150-450 U/L(LDH)

Sodium (Na+) Heparinized 5 135-145 mmol/L

Potassium (K+) Heparinized 5 3.5-5.0 mmol/L

Glucose Fluoride oxalate 4 3-5 mmol/L(fasting)

Gamma glutamyl Heparinized 5 Male: <50 U/Ltransferase (GGT) Female: <32 U/L

Iron Plain 10 9-29 µmol/L

Thyroxine Plain 5 50-150 nmol/L

TSH Plain 5 0.5-6.5 mU/L

Free T3 Plain 5 2.9-8.9 pmol/L

Total protein Heparinized 5 60-80 g/L

Appendix: Normal vaues

AP-I

Normal_Values.qxd 28/09/2004 15:58 Page AP-I

Arterial Blood Gases (ABGs)

Send 2.5 ml in a lightly heparinized syringe

pH 7.35-7.45

PCO2 35-45 mmHg

PO2 90-110 mmHg

Bicarbonate 22-27 mmol/l

Base excess -3 to +3 mmol/l

Haematological Values (FBC)

Send 5ml in pink EDTA tube

Erythrocyte sedimentation rate (ESR) <20

Haemoglobin (HB) Male: 13-18 g/dlFemale: 11.5-16.5 g/dl

White blood cell count (WBC) 4-11.0 x 109/l

Mean corpuscular haemoglobin (MCH) 27-32 pg/l

Mean corpuscular haemoglobin concentration (MCHC) 30-35 g/dl

Mean corpuscular volume (MCV) 78-98 ft

Packed cell volume (PCV) or haematocrit Male: 0.40-0.54

Female: 0.35-0.47

Platelets 150-400 x 109/l

Prothrombin time (PT) 11-15 s

Appendix: Normal vaues

AP-II

Normal_Values.qxd 28/09/2004 15:58 Page AP-II

FRONT_N_BACK.qxd 07/01/2005 14:28 Page 2

the british military surgery pocket book

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