war surgery afghanistan & iraq atlas_chap4
TRANSCRIPT
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Cpe IVthoraCICtrauma
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thoraCIC trauma | 119
IV.1Peneing toco-
abdoinl tu, I
CASE PRESENTATION
tis 20-ye-l s nin le ws iing is nkey n g
cg in bge. he pesene wi ypensin
n liple gen eny wns is ces n ben
(Fig. 1). a FaSt ex evele peicil esin (Fig. 2). a
lpy, lge live lcein ws iscvee (Fig. 3). tis
ws pily pcke cnl bleeing. a ein seny wspee. a peneing injy ne e ig il ppenge, in e
gve e ig cny ey, ws ienie (Fig. 4). tis ws
epie sing 3-0 Plene se wi pleges sine e
pien’s peici. a iznl ess se ws se vi
ccling e ig cny ey (Fig. 5 [ls see Fig. 8]). Cnine
bleeing e ig ces necessie ig cy
wee sevel lng lceins wee cnlle. Fe binl
explin evele sevel sll bwel lceins wee epie.
a epy binl clse ws pee (Fig. 6). ae 36 s,
e pien ws ene e peing eexplin. te
live lcein ws n bleeing, n bwel ee eslve. te
pien’s ben ws clse, n is ecvey ws nevenl (Fig. 7).
TEACHING POINTS
1. tis cse enses e elively cn cb sceni in wic
pien pesens wi liple ncl wns n ypensin, psing
e ile wic by cviy pen s. In is cse, lg
e FaSt ex evele peicil esin, e pien’s elive
sbiliy llwe exply lpy wi cnl bleeing pi
seny.
2. I is ipn be we e cny eies wen epiing
cic injies. In is cse, iznl ess se ws se
vi cclsin e cny ey.
3. I is ciicl e sgen ce wi liply wne pien ppc ec injy syseiclly. te ipnce well-ine
e ble keep e pien sble n w ing is pcess
cnn be vese. onging essciin n pien wing e
nenl.
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Figure 1. (tp, pge 120) Patient on admission to
the CSH. Note penetrating wounds o the chest and
abdomen.
Figure 2. (B, pge 120) Ultrasound (FAST) shows
pericardial eusion (w).
Figure 3. (tp, pge 121) Laparotomy revealing large
liver laceration.
Figure 4. (B, pge 121) Median sternotomy
exposure. Note right atrial penetrating wound (w).
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Figure 5. The cardiac injury has been repaired.
Figure 6. Temporary abdominal closure.
CLINICAL IMPLICATIONS
1. Isle pnces e e sl be expse
by pening e peici n ccling e injy
wi nge pesse. oe es incle e se
Fley cee skin sples.
2. use plegee iznl ess ses (2-0 3-0
Plene) n pee neele eniive epi. Ce
s be ken vi injy e cny ey
n scle (Fig. 8). Siple ge--eig se
epi y be se i ee is n isk cny
ey cclsin.
3. ail epis y incle siple lige, sple
epi, nning se clse.
DAMAGE CONTROL
tis cse epesens clssic ge cnl. Bleeing
e e, lng, n live ws cnlle. Cn-
inin ws cnlle by clsing eneies,
n e ben ws epily clse wi plnne
epein.
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thoraCIC trauma | 123
Figure 7. Patient on post-op day 7.
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Figure 8. Repair o penetrating cardiac injury.
SUMMARY
tis cse enses n pppie ppc
pien wi liple peneing injies e x
n ben. using ge cnl ecniqes n
syseic ppc wi nging pppie
essciin, e pien e ll ecvey.
SUGGESTED READINGCpe 12: dge cnl sgey. In: Emergency
War Surgery, Third United States Revision. Wsing-
n, dC: depen e ay, oce te
Sgen Genel, Ben Insie; 2004.
Cpe 16: tcic injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
Cpe 17: abinl injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
Cpe 22: S-isse injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
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thoraCIC trauma | 125
IV.2Peneing toco-
abdoinl tu, II
CASE PRESENTATION
a40-ye-l s nin le ive e Fw Sgicl
te (FSt) 30 ines e ssining liple gns
wns n aK-47. he ws cnscis. tee wee liple
eny n exi wns e le ppe exeiy, s well s w eny
wns e le x, wic enee lel e nipple e
nipple line. Vil signs swe bl pesse 100/60 hg n
e e 120 bes pe ine. a ces be ws plce in e
le eix wi en 250 cc bl. a FaSt scn ws
negive inbinl bl n negive peicil bl.
abinl exinin ws negive signs peiniis, n e
ben ws f wi isenin. an iniil ces X-y, ken e
ces be plceen, swe ee-size le ex n
eqe ces be plceen. tee wee w blle gens
wee ppenly in e lwe ipsilel x. N binl ls wee
ken, n essciin ws pee ccing avnce t
Lie Spp (atLS) pcl. te pien ws ken e peing
(or) ess e exeiy wns e iniil essciin
wi cyslli n 2 nis pcke e bl cells (PrBCs). heeqie ws e liple gns wns n pen ecin
e ce. tl ie in e or ws 90 ines. ding
is ie, ces be p ws llwe clsely. dinge e nex
ws 200 cc. he cnine eceive essciin in e or wi
cyslli, n is bl pesse eine sble. te pien ws
en nsee e inensive ce ni (ICu), wee ces be p
cnine be nie. he bece ypensive n espne
blses cyslli n pcke rBCs. Ces be p incese
300 cc e nex . a epe ces X-y swe eqe
inge e ex. abinl exinin evele is-
ene ben. repe FaSt scn ws psiive inpeinel
fi. he ws ene e or gen lpy. te pienws plce spine wi bp ne e le eix in pepin
le cy. on eneing e ben, lge n
bl ws evce ieiely. a splenic lcein (Fig. 1) n
le cln pein e splenic fexe wee encnee. tee
ws gss ecl silge e peinel cviy, wi n ppxiely
2-c ipg eec. Splenecy ws pee n ge cnl
pinciples llwe. te le eix ws inspece g e
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Figure 1. Splenic laceration.
ipgic eec (Fig. 2), n ee ws n cive
ege e le eix. Pspeively,
ee ws n e signicn ege e
ces be. te pien ws genly evce
level III eicl een ciliy, wee eniive
sgey ws pee.
TEACHING POINTS
1. tcbinl injies, especilly e level
e nipple line belw, cy ig incience
inpeinel injy. as ense in is cse,
ig inex sspicin s ccpny sc injies
n ieie lpy cnsiee, even wi
eniive evience inpeinel injy.
2. ae plcing e ces be n e ece sie, is
pien’s cniin sbilize, llwing e sies
lly evle is injy. Lcking sensiiviy, FaSt
scn pee ely e peneing y be
negive. I plin X-ys (ces X-ys, KuB [kineys,
ees, n ble]) wi ipqe kes
e eny n exi wns evel e jecy
e gen likely psse g e peinel
cviy, en lpy sl be pee.
3. Wen i is ncle e sgen wic by cviy
is likely e sce bleeing, psiin e pien
spine wi e ece eix “bpe p”
30- 45-egee ngle. tis will llw ccess
b e ben n e ces. By ing e
or ble p 30 egees, e ces will essenilly
be in e lel ecbis psiin, esily llwing
cy incisin be e (Fig. 3).
CLINICAL IMPLICATIONS
1. Wen e pien pesens wi peneing ncl
injy, pcee wi atLS pcl. I e pien
es n ve n inicin n eegency
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thoraCIC trauma | 127
be p y ne ieie cy.
Speciclly, i gee n 1,500 cc bl e
ecvee ieiely, en ieie cy
is inice. Wi lesse ns iniil ces be
p (less n 1,500 cc), gen pein y
be necessy bse n e ie elpse e injy,
e pien’s clinicl cniin, e sgen’s
jgen.
3. te pills n liie sensiiviy ces X-y,
FaSt scn, ces be p, n ignsic pei-
nel lvge (dPL) e ny n well knwn.1–5
Nneeless, iniil evlin sble pien wi
gns wn e ces sl incle ces
X-y wi eny n exi kes, s well s FaSt
scn. te FaSt scn cn be elpl in eeining
piiies. I pien wi gns wn e
ces is ypensive n n iniil ces X-y evels
n signicn ex pnex, neg-
epen (Ed) cy (ie, lss vil signs
ecy ypensin wi peneing cic
wn), en pcee wi plin ces X-y n
binl ls. mk e eny n exi wns
wi ipqe ke. tis cn elp eeine
e jecy e issile (ie, es i css e
ipg?; Fig. 4). obvis signs—sc s ee i
ne e ipg epnex—
will elp gie e sgen e nex sep. If the
patient loses vital signs in the ED, he will require an
immediate thoracotomy for resuscitation.
2. Piens ypensive wi peneing ces injies
sl neg ieie be csy wi
iwy cnl. rpi evlin wi ces X-y
n FaSt scn will elp gie e sgen s
wic by cviy sl be enee s, b neie
sy sl vele clinicl jgen. Sl
e pien ein nsble, e n ces
Figure 2. Small diaphragmatic injury.
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ive FaSt scn peicil bl will gie e
sgen w peing lpy s einiil pcee. te ces wn cn be nge
wi siple be csy.
4. hweve, i e pien s signicn ex
n e ces be is plce s, is y n
clly efec n incic injy. Even i sc
n injy is pesen, nscic inbinl
Figure 3. Bent table.
injy cnn be excle. I ee is ipgic
injy, e ces be p y clly efecinbinl bleeing. In is siin, dPL
cl be elpl, sing 15,000 rBCs/3 s e
esl psiive esl. Wi negive dPL,
e iniil pcee sl be cy.
5. a Ct ige e ces n ben y ls
pvie cles s e lcin e injy. a Ct
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thoraCIC trauma | 129
T4T4
Figure 4.
Penetrating
thoracic injuries
below the T4 level
(nipple line) havea high probability
o involving
abdominal
structures.
e bes es ignsis, e wng cviy is enee
b 23% 44% e ie.4,5 te bes cse
cin is inin inpeive fexibiliy n be
pepe cnge cse pily n ene ne
by cviy. te bes psiin ese cses is spine,
s exene, wi bp ne e elevn x.
Pep e pien wiely, neck knees. a Fley
cee sl be in plce. tis psiining llws esgen pe lpy, cy,
ein seny wi e nee epsiin e
pien.
REFERENCES
1. my Ja, Bene J, asensi Ja. Peneing -
cbinl . Emerg Med Clin North Am.
1998;16(1):107–128.
2. Blnge Br, Keney Pa, e l. te ine se
sngpy in peneing s injy is benecil.
J Trauma. 2001;51(2):320–325.
3. tl E, my ra, Beesinge d. Peinel lvge. Isnelibiliy in gns wns e lwe ces
n ben. Arch Surg . 1980;115(4):430–433.
4. asensi Ja, ay h J, e l. Peneing -
cbinl injies: onging ile—Wic
cviy n wen? World J Surg . 2002; 26(5):539–
543.
5. hisbeg a, Wll mJ J, e l. dble jepy:
tcbinl injies eqiing sgicl ine-
venin in b ces n ben. J Trauma. 1995;
39(2):225–229.
SUGGESTED READING
Cpe 16: tcic injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
Cpe 17: abinl injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
meli GJ, dilln BC, e l. Peinel lvge in
peneing cbinl . J Trauma.1988;28(1):17–23.
ige is e sensiive n specic igns-
ing inbinl n incic ege.
In e el envinen, Ct iging y n be
vilble. Wi n nsble pien, Ct iging is
n n pin.
6. a elpl neve wen peing lpyis lk signicn ege g
e ipg in e eix. I ee is
ipgic eec wi gss ecl silge, i is
ls pen lvge g e eec
ece e isk pspeive epye. Enlge
e eec s necessy n clse wi nning
Plene se. In iin, e bes cles will ce
e nesesilgis. Eleve pek iwy
pesses, pesisen ypensin, ypxi
sgges ee is pble in e x e
n in e ben.
DAMAGE CONTROL
Wi ssive inpeinel n cic injies, e
piiy is ege cnl. tis y be ccplise
wi pcking e ben e bleeing s been
cnlle. te cic cviy cn ls be pcke nce
ege cnl s been cieve. tepy clse
b cviies cn be se n e pien ene e
ICu e essciin n wing pi en
e or eniive epi.
SUMMARY
mnging cbinl injies eqies iginex sspicin injies in b e x n
ben. In e nsble pien, be csy n
X-ys wi ipqe kes will ssis e sgen
in eeining wee inevene. ajncive sies
incle e FaSt scn n Ct iging y pve
elpl in e pppie clinicl siin. despie ll
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IV.3tocooy fo
mssive heoox
CASE PRESENTATION
tis 27-ye-l le pesene b 90 ines e ssining
peneing injies e ig ces n le ig. te pien
ws ypensive. Ieie ig be csy esle
in 1,700 cc bl p. he ws ypeic, wi epee
93.9°F n ph 7.09. te ineninl nlize i ws
1.7. a wle bl ive ws iniie. tnssin in cbininwi ecbinn Fc VII cece is cglpy. rig
nelel cy ws pee. te ig inenl y
ey ws nsece n lige ieiely. te inei plny
ligen ws ivie, n e enie lng ws bilize. te blle
c ws in e viciniy e plny il. te plny
il ws issece eng llw vscl cnl. te blle c
incle ll ee lbes, n bleeing is wn ws evy. te
lng ws cnseqenly wise n e il, esling in se
ege cnl n llwe ssessen e wns (Fig. 1).
Injies e inei n ile lbes wee e peipel n wee
sple css wi gsinesinl nssis (GIa) sple sing
ew els. tis cnlle e bleeing. Injy e ppe lbews e cenl n bleeing cnine. a cy wi GIa
sple ws pee, wi vesewing e bleees n i lek
pce excellen esls. te eix ws wse , e
lng ws ene is cec nicl psiin, n e ces ws
clse wi w lge csy bes in plce. te e ce
n wn wee esse wi ws n exenl xin s e
pien ws we n esscie e en e cy.
TEACHING POINTS
1. Piens pesening in ypvleic sck wi e i ypei,
cglpy, n cisis ve liy e s ig s 90%.1 tey
s be we n esscie pily. te pien in is cse wsgiven wle bl, pcke e bl cells, ecbinn Fc VII,
n es zen pls, in iin cyslli. miliy eicl
pesnnel s be expe in e se ll ese pcs sve
piens in exeis.
2. tcy is inice ssive ex slly ene s
1,500 cc p wi iniil be csy 200 cc p
pe 4 s.
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thoraCIC trauma | 131
Figure 1. The lung ater it has been mobilized and twisted around the hilum to slow the bleeding.
CLINICAL IMPLICATIONS
1. tbe csy lne is eqe een s siple lng pencyl injies.
2. Lge i leks n espning csy will
eqie pen epi.
3. Siple bleeing sl be cnlle wi bsbble
ses n pee neele wi sples (eg, ta-90
sples).
4. Bleeing cs sl be pene wi GIa sple,
n bleeing pins sl be lige. t vi n i
eblis pce by psiive pesse venilin,
siple clse e ennce n exi wns
e lng pency is cninice. reebe:
te e cenl e injy, e ige e isk i
eblis.
5. resecin e bleeing e e lng y be
necessy. avi nicl esecin in v
siple wege esecin.
6. uncnlle pencyl il bleeing,
cplex il injies wi ssive i leks, sl
be cnlle wi il clping ( “il wis”;
Fig. 2) n epe epi. Pnenecy
sl be pee s ls es becse i issscie wi 90% liy e.1
DAMAGE CONTROL
In piens wi exsngining ege
cic injy, e gl is sp e bleeing n
ese sble pysilgicl ss. te llwing
pinciples pply:
1. Lge lng sples sl be se pe
nnnicl wege esecins cieve e-
ssis n cnl i leks pily.
2. In plny cy (Fig. 3), e lng biginge wn c is pene beween lng clps
wi sple, e wn is inspece, bleeing
pins e lige, n i leks e cnlle.
3. I e pien cnines blee espie e bve
eses, pcking n epy ces clse
y be necessy llw e essciin.
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Figure 2. Hilar clamping or “hilar twist.”
Figure 3. Illustration o pulmonary tractotomy.
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thoraCIC trauma | 133
SUMMARY
tis cse enses sccessl ppc ssive
ex in ypensive, cglpic, n cl
pien. te cbinin expe essciin wi
ge cnl cy esle in is pien’s
svivl.
REFERENCE1. deb S, Fnsec P. respiy isess llwing
pnenecy. Chest . 1999;116:1461–1463.
SUGGESTED READING
Cpe 16: tcic injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
Cpe 17: abinl injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
Cpe 23: Exeiy ces. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te SgenGenel, Ben Insie; 2004
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134 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007
IV.4Spinl Injuy Wi Peneing
tocobdoinl Injuies
CASE PRESENTATION
a25-ye-l le pesene wi single gns wn
enee g e bck n vese e icic spine.
te pien ws pplegic wi n sensin ncin
belw icic level (t5). he cpline il binl pin.
te iniil ces igp ws nekble, s ws e FaSt ex. te
pien ws ken e peing (or) binl explin.Sly e inbin, e evelpe syps cnsisen wi ensin
pnex, n ig ces be ws plce wi eslin
syps. Inpeively, e pien ws n ve lge injy
e nei en exene e s pin e
en e by e sc n slle psei injy
e secn pin e en (Fig. 1). te nei en
ws epie sing heineke-miklicz epi, pening i iznlly n
clsing i veiclly ense e len ws n nwe. a ig
eil viscel in ws pee ense ee ws n injy
e inei ven cv. Injy e pnces, pll, p epiis,
n ipg wee speciclly le , s well s sll bwel n cln
injies. a sll injy e live ws pcke. Bwel ee pecleclse e ben, n seile bg ws sewn e skin (Fig. 2).
TEACHING POINTS
tis cse enses e escive pwe ig-velciy issile
eneing e bck n vesing e ben n ces wi injy
liple gns. te llwing pins eseve epsis:
1. Peneing injies e bck—especilly gns wns—sl
neg exply lpy, piclly wen Ct iging is
n vilble.
2. denl epis sl be libelly ine.
3. t peven binl cpen syne, e ben sln be clse ne ensin.
4. Wen cic injy is sspece, be csy sl be
pee, especilly i e pien cnn be bseve cninsly.
5. Spine ibilizin sl be inine in piens wi spinl
c injy nil ey ve been evle by nesgen, i ne
is vilble.
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thoraCIC trauma | 135
Figure 1. Intraoperative view o duodenal injury.
CLINICAL IMPLICATIONS
1. Psei ncl peneing injies e ip
e scpl e sc (Figs. 3 n 4) y
ve cse epeinel n inbinl
injies. a lw esl exply lp-
y is wne in ese piens.
2. Injies e en e eqenly sscie
wi injy e gns. dge cnl
ecniqes sl be cnsiee ely. d n
clse e binl sci ne ensin. Leve
e skin pen.
3. min injies e en cn be epie
piily, n lge injies sl be epie
i e len will n be nwe by e n
50%.1 I e len will be nwe by e
n 50%, cnsie e llwing pins:
Figure 2. Temporary abdominal closure with sterile bag.
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136 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007
Figure 3. (tp) Trajectory
o missiles may include
both chest and abdomen.
Figure 4. (B Le)
Penetrating thoracic
injuries below the T4level (nipple line) have
a high probability o
involving abdominal
structures.
Figure 5. (B rig)
(a) Duodenal injury.
(B) Gastrojejunostomy.
(C) Ligation o the
pylorus. Alternate
method o closing the
pylorus is stapling across
it with a TA stapler.
C
B
A
T4T4
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thoraCIC trauma | 137
SUMMARY
Peneing spine injies sscie wi llw
viscs injies sl neg pppie een
e viscs wi exensive ebieen
e spinl injy, llwe by pppie b-
spec nibiics. tis pien pesene wi
peneing bck injy n pplegi. Exply
lpy evele injies liple gns. tepien’s ben ws epily clse peven
binl cpen syne, s is en nec-
essy wi ese ypes injies.
REFERENCE
1. Cpe 17: abinl injies. In: Emergency
War Surgery, Third United States Revision.
Wsingn, dC: depen e ay, oce
te Sgen Genel, Ben Insie; 2004.
SUGGESTED READING
Cpe 16: tcic injies. In: Emergency WarSurgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
Cpe 20: Wns n injies e spinl cln
n c. In: Emergency War Surgery, Third United
States Revision. Wsingn, dC: depen
e ay, oce te Sgen Genel, Ben
Insie; 2004.
. F j injies, clse e pyls ep-
ily n ive e gsic se wi
gsjejnsy (Fig. 5).
b. use heineke-miklicz epi (s in is
cse) e s pin e en
exening e sc.
c. Cee n nssis beween e injy n
rx-en-Y lib.. Cnsie ining e inje e n ns-
eing e pien ciliy eqippe
lge pcees, i pnceicenecy
is eqie.
e. Clse e injy n be ensy
sing 2-0 VICrYL se wi mlec
cee, i vilble.
DAMAGE CONTROL
Injies e en e eqenly sscie
wi injies e gn syses n ege.
Wen epi enl injies cnn be peesing elively siple ecniqes, ge cnl
sl be cnsiee, speciclly:
1. Cnl ege n cninin.
2. Pck n clse e pien epily.
3. resscie e pien nl pysilgy.
4. Pln e epein n eniive epi.
5. Ne eegen spine sgey peneing
injies e spinl c is inice nly in e
pesence nelgicl eeiin.
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138 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007
IV.5tuic Peicdil
tponde
CASE PRESENTATION
a40-ye-l civilin cnc ws wne wen
sck in e viciniy is sleep ile. te pien ws
bg e Eegency meicl teen (Emt) secin
e cb spp spil (CSh) wee e ws le, iene,
n cplining lile pin in e ig gin n le ces. his
vil signs n ivl wee e e 110 bes pe ine n
bl pesse 80/60 hg. te iniil svey evele specil
wn belw e le nipple, peneing wn e ig gin,
n w ppee be peneing wn e ces bve e le
nipple (Fig. 1). his ben ws s wi eneness. a le ces
be ws plce wi inil ecvey incic bl. FaSt
exinin ws negive inpeinel n peicil fis. a
ces X-y (CXr) evele ellic gen in e le ces (Fig. 2).
despie fi essciin n n bvis bleeing sce, e pien’s
bl pesse eine belw 100 hg syslic. a Ct scn e
ces evele peicil bl (Fig. 3), n e pien ws ken
e peing wee e newen n gen ein seny
(Fig. 4). te peici ws pen wi ieie exsin clebl (Fig. 5). te pien’s vil signs nlize e peicil
pne ws elieve. te peici ws lly pene, n
peneing injy e pex e e ws n (Fig. 6). tis
ws epie wi single iznl ess se sing peici
pleges (Figs. 7 n 8). te pien’s ces ws clse, n e
ws evce ee e llwing y. he n nevenl
ecvey.
TEACHING POINTS
1. Piens pesening wi peneing ces n ypensin
eqie pi evlin n een ei injies. Ieie
neele ces ecpessin pi insein ces be n eece sie will eie e le ensin pnex
ssive incic bleeing s e cse ypensin. FaSt
scn sl ls le ssive inpeinel bl, s well
s peicil bl pne. oe sces signicn
bl lss (epeinel, pelvic lng bne ces,
exenl bleeing lge, s isse sclp wns) sl
be sg explin ypensin. a ig inex sspicin
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thoraCIC trauma | 139
Figure 1. Patient undergoing resuscitation. Note penetrating injuries to let chest.
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thoraCIC trauma | 141
Figure 4. Median sternotomy.
Figure 5. Exposed pericardium with blood clot rom initial pericardiotomy.
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142 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007
Figure 6. Penetrating injury to the apex o the heart (w).
peicil pne sl be inine piens wi peneing ces injies n
n e sce bl lss. tis pien’s
lge size y ve ecese e sensiiviy
FaSt exinin. Wi Ct vilble,
ces scn eily evele peicil bl.
I Ct is nvilble n e FaSt is negive,
sbxipi peicil winw is inice
wi peneing ces n nging
ypensin wi n bvis sce bleeing.
a il peicicenesis y be ignsic (s
well s epeic), b spiin y be lsely
negive in e pesence n gnize cl.2. Wen sing cic injies, peici
e pleges is eily vilble n n excellen
cice. alg ge--eig ses y
be se, vi cpessing cpising
cny vessels by sing iznl ess
ses i e vessel will be csse by e epiing
se (Fig. 9).
CLINICAL IMPLICATIONS1. Piens pesening wi peneing ces
n w e ypensive eqie pi evlin.
ae ensing e pien s n eqe iwy
n is being, ypensin nes pi
ces ecpessin (neele ces be) le
ensin pnex. I iscvee by neele
ecpessin (s evience by s i
ipveen e pien’s eynics),
ces be sl be ieiely insee. tee
is n ie wi CXr cn e
ignsis ensin pnex.
2. Wi nging ypensin, espie ces ec-pessin, ssive ex sl be evele
by ces be plceen CXr. I lge
n bl is ine ieiely ces
be insein, gen cy sl qickly
llw. alg avnce t Lie Spp
(atLS) gielines sgges 1,500 cc bl s e
iniil n ine nes ieie
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thoraCIC trauma | 143
Figure 7. Single horizontal mattress suture using pericardium or pledgets.
Figure 8. Completed cardiac repair.
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144 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007
Figure 9. Repair o penetrating cardiac injury.
cy, is nbe sl be iige by
e ype injy (lge peneing gen), e
pien’s clinicl cniin, s well s e leng
ie injy ces be insein. Piens
y pesen e CSh nly ines e injy.
a pien in sck wi 500 cc bl in e
ces wiin ew ines wning w
eins ypensive espie iniil essciive
es y nee gen cy.
DAMAGE CONTROL
alg inseing pecnes peicil cee
y epily llevie pne peneing
e injies, eniive epi cnn be elye
wi pibiive isk epne n cic
es. Lge cic injies cn be epily
cnlle e seny wi e insein
Fley Fgy cee (epening n e size e
injy) n infing e blln cnl bleeing.
Skin sples y ls be se clse cic injy
pily.
SUMMARY
Piens wi peneing ces injies w pesen in
sck eqie expeiis evlin n ngeen
lce e cse n qickly nge i. tensin
pnex, ssive ex, n peicil
pne sl be pily invesige n ee.
Wi nging ypensin n e sces sck
eliine, ig inex sspicin peicilpne—espie negive FaSt—sl be
inine n sbxipi peicil winw
pee eniively le is injy.
SUGGESTED READING
asensi Ja, ay h J, e l. Peneing -
cbinl injies: onging ile—Wic
cviy n wen? World J Surg . 2002;26(5):539–543.
Blnge Br, Keney Pa, e l. te ine se
sngpy in peneing s injy is benecil.
J Trauma. 2001;51(2):320–325.
Cpe 16: tcic injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
Cpe 17: abinl injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
hisbeg a, Wll mJ J, e l. dble jepy:tcbinl injies eqiing sgicl ine-
venin in b ces n ben. J Trauma. 1995;
39(2):225–229.
meli GJ, dilln BC, e l. Peinel lvge in
peneing cbinl . J Trauma.
1988;28(1):17–23.
my Ja, Bene J, asensi Ja. Peneing -
cbinl . Emerg Med Clin North Am.
1998;16(1):107–128.
tl E, my ra, Beesinge d. Peinel lvge. Is
nelibiliy in gns wns e lwe ces
n ben. Arch Surg . 1980;115(4):430–433.
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thoraCIC trauma | 145
IV.6Peneing rig
Ces Injuy
CASE PRESENTATION
tis le slie ssine peneing ig ces injy
n. he ws ieiely nspe e cb
spp spil (CSh). on ivl in e Eegency meicl
teen (Emt) e, e ws illy cycic n ypensive.
ding e pien’s essciin, ig ces be ws plce yieling
e ieie en 800 cc bl wi cnine p. hews pily ve e peing (or) n n gen ig
pselel cy pee (Fig. 1). hil bleeing n i
lek wee ppen, n line sple ws se pen e gen
c. In cnjncin wi e injy, is neve essenilly esle
in ig ppe lbecy. once e ig ppe lbe ws eve,
cnine bleeing ws ne e il e ile lbe.
te pien cplee ile lbe sse, n line sple
ws plce e ile lbe il n e, cpleing ile
lbecy (Figs. 2 n 3). tis cpleely cnlle e bleeing (Fig.
4). te ces ws gly iige wi w sline, e ennce
wn ebie, n e ces clse wi ig ngle n picl ces
bes in plce. te pien ws evce in sble cniin levelIV eicl een ciliy e llwing y.
TEACHING POINTS
1. alg avnce t Lie Spp (atLS) gielines ecen
gen cy wen eie 1,500 cc bl is ecvee
ieiely n plcing ces be e e ces be p is
gee n 200 cc/ 4 s, se clinicl cicsnces eqie
e ggessive een. In is cse, e clse pxiiy e
wne slie e essciin sie esle in ces be being
plce wiin ines e peneing injy. te ieie ecvey
800 cc bl, wi nging bleeing, inice e likeli
sgicl bleeing. te pien ls pesene in sck. tken gee,gen cy ws e pppie cse cin.
2. mssive ces bleeing y ke pinpining e specic injy icl.
In is cse, plping e lng evele e gen c, wic llwe
pi expse e wn c wi line sple. once e c is
pene, lcing e specic sie bleeing beces pssible (see Cse
IV.3, Fig. 3).
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146 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007
BEHIND ARMOR BLUNT TRAUMA (BABT)
all ypes by n eles
e esigne peven issiles eneing e p e by pece
by e , n, e se ie,
issipe e kineic enegy cee
by e issile. hweve well e
pes, se kineic enegy
is sill nsee e inivil.
I penein is pevene, e
ecnis injy is cnvee
“bein bln ”
(BaBt).1 te seveiy e injy
e pien epens n:
• missilevelocity• energy transfer produced by the
eee issile
• energydissipatedbythearmor
• areaofthebodythatabsorbsthe
eining enegy. Figure1. Let-lateral chest wall injury rom BABT.
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thoraCIC trauma | 147
Enegy nse wi esling by wll ein n viscel cncin cn pce signicn injy
n e. BaBt is cn ecnis bleel bln . Injies pce by is ecnis
incle:
• fractures
• pneumothorax
• pulmonarycontusion• cardiaccontusionand/orarrhythmia(commotiocordis)
• liverandspleenlacerations
• bowelinjury
• traumaticbraininjuries.
Invibly, skin bsins n es e evien e pin ipc (Figs. 1 n 2). Cnlel
cnes injies y ls be pesen. Vicis bln ecniss in cb s be syseiclly
evle ccing atLS (avnce t Lie Spp) pcls. In e cse cic injies,
ces Ct is sensiive n spei sn ces X-y in vislizing lng cnsin, pnex, n
ex.2
1. Cnnn L. Bein bln —an eeging pble. J R Army Med Corps. 2001;147(1):87–96.
2. tpk a, Wys C, e l. Vle cic cpe gpy in e s ssessen seveely inje
piens wi bln ces : resls pspecive sy. J Trauma. 1997;43(3):405–412.
Figure 2. Soldier struck by a
ragment rom a close proximity
explosion. The ragment did not
penetrate his Kevlar helmet. Notethe scalp laceration as well as the
underlying let occipital contusion
injury. No skull racture occurred
and the soldier recovered.
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148 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007
3. Peseving vible lng isse is ceinly n ipn
spec eegen cy bleeing. un-nely, eqe expse n cnl ssive
bleeing y eqie esecin ewise nl
lng. Nneeless, evey e peseve nge
lng sl be e.
CLINICAL IMPLICATIONS
1. hig-velciy peneing lng injies cy ig
penil lie-eening incic injies
(ces wll, lng, e, n ge vessels), s well
s e pssibiliy peinel penein. I e
pien’s clinicl cniin llws, ilgicl
sies wi ipqe kes e ennce nexi wns—lng wi FaSt scn evle
peicil inpeinel bl—sl be
pee.
2. I pien pesens wi binble vil
signs wi ecen signs lie, pceeing wi n
eegen (in e Emt e) cy in e
cb zne sl be cnsiee nly ne e
s vble cicsnces (inil sscieinjies, sll peneing ces injy, ew
n e gen piens, bnn esces,
sgens, n or vilbiliy, ne js ew
cnsieins). In genel, sc pien sl
be ige s expecn.
3. Piens pesening in sck sl be pily
nspe e or gen cy.
Silnes essciin wile lcing n
cnlling e sce bleeing sl cc.
DAMAGE CONTROL
1. on eneing e ces, i ssive ege i lek es n llw pi vislizin
n cnl e specic injy, ieiely
eeing e inei plny ligen (y
be ccplise blnly) n wising e lng
n e il y cieve epy cnl.
ding is ie, e sgen cn cc p n
Figure 1. (tp Le)
Patient in OR preoperatively.
Figure 2. (tp rig)
Separately resected lobes.
Figure 3. (B rig)
Reconstructing the hilar injury
with the lobes together.
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thoraCIC trauma | 149
esscie e pien wi fi, bl, n
e pppie pcs. tis y ls llw
eqe expse e sgen bincnl e il wi lge vscl clp,
liely peiing expse e injy n
pppie epi.
2. Pnenecy lng injy (speciclly lge
il injy) sl be se nly i il sces e
iepbly ge s pcee ls es,
given e ig liy is pein.
3. I sgicl bleeing is cnlle, b e pien
s liple sies zing n is slipping w
e lel i (ypei, cglpy, n
cisis), pcking e ces n epy clse
(siil e epy binl clse) slbe se nil e pien cn be eqely esscie
llw en e or eniive epis.
SUMMARY
hig-velciy issiles (blles n gens)
pene e ces ve ig penil incic
injy y eqie gen cy n/
lpy. rpi evlin n ssessen ese
injies e essenil s piens will eceive epppie iniil een (cy, lpy,
n ces be), esling in e bes pssible ce.
SUGGESTED READING
Cpe 6: hege cnl. In: Emergency War
Surgery, Third United States Revision. Wsingn, dC:
depen e ay, oce te Sgen Genel,
Ben Insie; 2004.
Cpe 12: dge cnl sgey. In: Emergency War
Surgery, Third United States Revision. Wsingn, dC:
depen e ay, oce te Sgen Genel,Ben Insie; 2004.
Cpe 16: tcic injies. In: Emergency War
Surgery, Third United States Revision. Wsingn, dC:
depen e ay, oce te Sgen Genel,
Ben Insie; 2004.
Figure 4. Open right chest with intact lower lobe and stapled upper and middle lobe vessels.
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150 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007
IV.7tnsedisinl Gunso
Wound
CASE PRESENTATION
a27-ye-l le slie n ine pl encnee
sll s e. all ebes is pl wee weing s
bllisic pecin. te slie ssine iec i e
s, eneing e le ces lng e nei xilly line js bve
e nipple n evenlly exiing e s g e ig ixilly
line e nipple. te 7.62- n ws ecvee by e eing
eic e i exie e ig ces. I ws n ee (Fig. 1). Neele
ces ecpessin ws pee in e el. rpi nsp
e pin injy e Fw Sgicl te (FSt) ws ccplise
wiin 15 ines. on ivl, e pien ws ypensive, ypxic,
n ypeic. Bilel be csies wee pee, n
lge epnex (1,500 cc) ws evce e le ces.
recy ypensin cnine. a le cy ws pee
g e inecsl spce eveling lge lcein e le
ppe lbe wi cive ege segenl plny vessels
wee cnlle wi cy n ligin. te blle vese
e nei eisin. an ppe nei eisinl e ws
ne, n exensin e le cy css e sen wspee wi e inen expling e e j vscl
injy (Fig. 2). a pxil injy e le inenl y ey/
vein n ce e ppe sen wee encnee e
n. te le inenl y vessels wee lige n e sen
ce pcke. te pien ws cglpic, n e eisin
ws genly pcke n e ces cvee wi Ibn (niicbil incise
pes). a wle bl ive ws insie by e c-lce blin
i sin pesnnel, s pevisly eese. Bl ws nsse
n e cglpy qickly evese. te pien ws nsee
level III inensive ce ni, n e essciin ws cnine. he
ws eexple e llwing ning, n e ces ws eniively
clse (Fig. 3). te pien eine eyniclly sble n wsevce cb spp spil (CSh) n evenlly Wle
ree ay meicl Cene.
TEACHING POINTS
1. Cnepy ngeen nseisinl gns wns
eins cnvesil. mny piens ie j vscl
cic injies s esl issiles. tse inivils w
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thoraCIC trauma | 151
Figure 1. A 7.62-mm round that caused the injury in
this case.
svive eniive sgicl ce in e civilin
wl n ein eyniclly sble y
neg less invsive wkp evle
ese injies, wi eniive ce plnne bse
n e nings. tse piens w peseneyniclly nsble eqie pp s-
gicl explin. Injies e eisin
cn be exple eie vi ein seny
“clsell” cy. Ec pcee s
is vnges n isvnges, n is lise in
tble 1. regless e e explin,
g evlin ll eisinl sces
(cic, vscl, plny il, cel,
n espgel) is pen, becse ny injy
le niscvee y esl in e.
2. deile e uS depen deense
sies line e bsics wn bllisics.
Specic inin eging e picl
issile s signicn ipc n e penil
exen e injy. missiles wi less ein
yw in isse will cceisiclly pce less
cviin n slle wn cviies inepenen
e isse encnee, b wi gee isse
penein. hweve, specic isses e e
pne e nse kineic enegy (eg, e e
n ge vessels) elive isses less pne (eg,
lng). In is cse, e wn cviy ws elively
sll n eqie plny cy cnl ege, b e esling nsgessin
css e eisin p e e n ge
vessels signicn isk b e piy n
secny bllisic cviies pce. Explin
ws wne le injy espie e
pjece p e blle.
3. In is cse, ilizin wle bl ws ciicl
in pily cecing e pien’s cglpy.
Pi inscin n eesl by e c-
lce blin i sin pesnnel llwe
sgicl pesnnel eice eselves wlly
exposure AdvAntAges disAdvAntAges
Median Excellen expse e Psei eisin icl expse
sternotomy Excellen expse ge vessels my eqie sepe cy
Excellen expse plny il epi cel espgel injies
“Clamshell” Excellen expse e Expse e n ge vessels ineithoracotomy Excellen expse ge vessels ein seny
Wie expse plny il, Incisinl isc/biiy
lng, n psei eisin
in b cic cviies
tAble 1. Approaches to the Chest
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thoraCIC trauma | 153
e ce e pien, llwing e bl ive
ncin inepenenly e sgicl s.
CLINICAL IMPLICATIONS
1. tnscic issile injies e en cspic.
ace inevenin n ngeen peneing
cic eqie e sgen nicipe
spec injies incles e llwing:
. tcic vscl injies.
b. Plny cy n cnl
plny ege.
c. Plny il injies.
. tcic eigesive injies.
e. Peneing cic injies.
2. Expse ese injies necessily ees
sgen peeence, b sl incpe se
knwlege e bllisics, s well s e penil
injies cse by ese issiles.
DAMAGE CONTROL
dge cnl pcees e less well lee in
e cic cviy becse esicins n plny
n vscl ynics. Ces wll bleeing cn be
nge wi pcking n expece eexplin,
b cel weness e eecs pcking n
eynics, plny cplince, n venilin
s be weige celly.
SUMMARY
Svivl nseisinl bllisic injies sgicl
ciliy is e, n svivl llwing explin s
ig liy n ig biiy es. Bleel
envinens n llw cplex ignsic wkpspi explin. In is cse, e pien newen
ce ggessive inevenin wi sccessl ce.
SUGGESTED READING
Cpe 8: Vscl ccess. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te Sgen
Genel, Ben Insie; 2004.
Cpe 16: tcic injies. In: Emergency War
Surgery, Third United States Revision. Wsingn,
dC: depen e ay, oce te SgenGenel, Ben Insie; 2004.
Belly rF, Zjck r, es. Conventional Warare:
Ballistic, Blast, and Burn Injuries. In: Textbook o
Military Medicine. Wsingn, dC: depen e
ay, oce te Sgen Genel, Ben Insie;
1991.
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154 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007
CommENtarY
appoces o e Ces Cviyby MAJ Charles R. Mulligan, MD
te key nging ces is knwing
wen, n wen n, pee. an incec
ecisin cn le incese biiy n/
liy. unlike civilin ces , iliy ces
ens invlve e peneing injies. te
pinciples ngeen e qie siil. a ppely
plce ces be is scien e e jiy
ces wns encnee (70%–80%). Inicins
ely cy incle ces be p gee
n 1,500 cc iniil plceen, e n 200
cc/ cnsecive s, pen scking ces
wn, n eine ex. oe inicins
cy incle pscnsin inecin, epye,
n bncplel sl. Inicins eegency
cy incle peneing ces injies wi
eynic insbiliy cllpse n nncic
peneing wi winesse civscl
cllpse (essciive cy).
te iliy sgen sl be ili wi viey
ppces e ces cviy. te key sccess is sing
e incisin bes ges y qickly e pble.
aeqe expse is ciicl, n wie ens be bee
(“ig, wie, n nse”). a g knwlege
cic ny is ciicl sccess.
te qickes ccess in e ces is g n ne-
lel cy. tis cn be ccplise in
secns wi js sclpel. te le nei ppc
pvies ccess e peici, escening ,
pxil le sbclvin ey, n e le plnyil. te ig nei ppc pvies ccess e
ig plny il n e peici (n s well
s e le-sie ppc). te pill is e is
i pvies less-n-iel ppc eil-psei
pency lng injies.
a clsell incisin (bilel nei lel -
cies wi nsvese seny) ipves exp-
se e enie peici n e, s well s e
cic inle. I ls pvies qick ccess e ig
il ppenge llwing peiciy vscl
ccess i neee ing eegency essciins. I cn
be se nseisinl wns eqie bilel
ces cviy explin. te isvnge is p ccess
e espgs n psei ce.
mein seny ls pvies ccess e peici,
e, cic inle, n b lngs. In skille ns,
sing senl sw, i cn be ne pily. hweve, s
Fw Sgicl tes (FSts) n ve pwe sws,
n ein seny sing Lebsce knie is slwe.
Seny pvies liie ccess e le lwe
lbe, wic is bsce by e e. Le lwe lbe
expse cn be ipve i e seny is exene
in e le nei lel ces lng e sbycese (eiclsell sency). tis ls
ipves ccess e pxil le sbclvin ey
n e escening . aiinl vesiliy e
incisin cn be bine by exening e incisin lng
e nei be e sencleisi vi
spclvicl exensin, s pviing e expse
e sbclvin n ci vessels. te p incisin
(sency wi spclvicl exensin)
pvies excellen expse e cic inle. hweve,
i liis silnes ccess e xilly ey.
te pselel cy is e sn ccessecene nilel isle ces
eqiing sgey. I pvies e bes view e enie
lng n ces wll, s well s e incic espgs
n e cin e ig. te pien is plce in e
lel ecbis psiin wi e wn leg fexe n
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thoraCIC trauma | 155
e ppe leg exene wi pillws beween e legs. F
xi expse, ne lng venilin (lng islin)
is peee, b i is n lwys pcicl in . Lng
islin gives e sgen qiescen lng wk n;
b, e ipnly, i pecs e ninje lng
silge. te incisin sl be s lge s eqie
see e injies. Eneing e ces g e
inecsl spce cenes e sgen n e j sse,b eny cn n sl be ile e wns/
injies expece. Wiely pen e inespce pvie
pi expse. I pency bleeing is e j
isse i ee is lge cnsin, isle e il s
qickly s pssible peven silge n i ebls n
pvie ege cnl s e injy cn be
cpleely evle n esse. tis cn be ne
esily by plcing n n e il n giing
n ic css-clp lge deBkey vscl clp
n ll e sces. a il wis is n lenive
e cnl. te plny vscle is lw-
pesse syse n cn be esily cnlle wi iecpesse, wic is ne ielly wi b-bse spnge
sick wi js eng pesse sp e bleeing.
In nging pency lng injy, e gl is lii
evl vible lng n cnl bleeing. te injy
is eie bleeing n. Wiin e lng pency,
expning es n cc becse e ple
pevens expnsin wi esln cnsin. Plny
cnsins e n cely nge peively.
ms peneing lng pencyl injies cn be
nge by cy wege esecin peipelc. hweve, i e c veses e sse, e
sgen sl sspec plny ey injy, n
lb gee esecin y be eqie cnl e
ege.
once bleeing is cnlle, e sgen s nex cnl
e pspeive plel spce. Plceen b picl
sig nei n psei bes is ecene.
tis pvies e plel cvege n single picl
n bsil ig-ngle be. I ls pvies bee
pnessis. a ply cnlle plel spce les
incese biiy.
tcbinl wns pvie gee qny
e iliy sgen. Pjecile c n penil
gns inje sl ice peive incisins. miline
lpy incisin is slly siscy s ese
wns; b, i piy live n ppe binl injies
e sspece, cevn incisin y be cnsiee.
te ces cpnen s ese wns cn be
genelly ene wi well-plce bes. hweve, i
necessy, eie ese incisins cn be exene wi
seny n nelel cy, wic
pvies pi expse. d n e ging css
e cscnl jncin exening i wn ge ipg. te iliy sgen sl be ili
wi e lcin e penic neve n w e se
incisins peven is injy. te cscnl jnce
is esily epie wi n. 2 VICrYL in U-sic sin
e ipg clse.
te ppe ppc cic injy vies, epening
n e sce inje. une e bes cicsnces,
pepeive eeinin cic injies is icl.
In e cb envinen, e sgen will be eqie
en ene e ces sing clinicl jgen lne. te
sl inicin eneing e ces will be ssiveege. tee is n ckbk nswe w is e
ig incisin in is cicsnce, n e sgen sl
n esie ke secn even i incisin i
eqie expse e ge sce qickly, llwing
cnl ege. Knwlege ee-iensinl
ny e x will seve e cb sgen well
ne ese cicsnces.
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Cesy dvi Leesn, The Dallas Morning News