SLIDE 1 1 BASIC PRINCIPLES in the MANAGEMENT OF WAR WOUNDS
Hat Yai July 2012
Outcome depends on:
Injury: severity of the wound & structures injured General condition of patient Pre-hospital care: evacuation time Pre-hospital care: triage Pre-hospital care: first aid Resuscitation & hospital triage & hygiene Surgery Post-operative nursing care Physiotherapy & Rehabilitation
Basic Principles 1
Examine the patient
resuscitation: ABCDE hypothermia
Examine the wound
grade and type
Basic Principles 2
Wound incision for drainage Excision of devitalised tissues Irrigation Leave the wound open for drainage – no sutures Large bulky dressing
Bulky, absorbent and dry dressing Basic Principles 3
No unnecessary dressing changes Delayed Primary Closure (DPC: after 4-7 days)
SLIDE 2 2
Basic Principles 4
Anti-tetanus Antibiotics, as adjuvant Analgesics General condition of the patient + nutrition + hygiene Physiotherapy + rehabilitation
Wound excision - debridement
Layer by anatomic layer Skin: incision, excision Subcutaneous tissues Fascia, aponeurosis: drainage Muscles: 4 C's Periosteum Bone
Exceptions to DPC
Face, neck, scalp and genitals – PC after DBR Soft tissue of the chest wall – muscles to close open pneumothorax Head – brain injury by dura : closure should be effected if possible Abdominal wall? Joints – synovial membranes should be closed Blood vessels – muscle cover if repaired primarily; tendons, nerves
Metallic Foreign Bodies Should be left unless
Jeopardy to organ, major vessels and nerves Inside of joints Anterior chamber of eye Superficial subcutaneous (painful movement) Infection around FB (abscess) Principles for the Management of Weapon Wounds “Damaged tissues must be removed in time.”
Qanun fi el-Tib (The Laws of Medicine) Avicenna – Ibn Sinna
980 – 1036 CE
Explore the wound
SLIDE 3
3
Wound opened, track debrided, large foreign body Shell fragments and detached bone removed A: Debridement medial aspect A: Debridement lateral aspect A: Loose bone fragments removed B: Gunshot wound femur
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4
B: X-ray pre-debridement B: Entry wound B: Entry wound exploration B: Exit wound B: Exit wound debridement B: Bone fragments removed
SLIDE 5
5
C: Excise skin wound & Extend the skin incision C: Fasciotomy & opening up of the wound cavity After incision of fascia, protrusion of injured muscle C: Cavity excised & clean wound left open Mismanaged wound: primary suture Mismanaged wound: primary suture Primary suture of heel without debridement: infection, tetanus, patient died
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6
D: Mismanaged wound: primary suture D: Mismanaged wound: signs of inflammation D: Stitches released, necrotic edges, subcutaneous oedema D: Re-debrided, wound is now larger than original injury D: 5 days later, wound clean D: Partial closure with sutures
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D: Closure with split-skin graft D: Healing E: Well-managed patient: dirty wound E: Well-managed patient: dirty wound Debrided E: 5 days later, removal of dressing E: Sticky dressing peals off
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E: Fully exposed wound 5 days after debridement E: Immediate skin graft as DPC Supraclavicular bullet wound Multiple superficial fragments Serial debridement of large wound: line of demarcation of necrotic tissue apparent
Old lessons for new surgeons War wounds are dirty and contaminated, from the moment of injury. The rules of septic surgery apply.
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Surgical infections 1
Primary infection due to initial inoculation at time of injury: culture medium in wound dead tissue devitalised tissue, compromised circulation haematoma and serum foreign bodies, soiling
Surgical infections 2 Septic complication:
inadequate surgery or inadequate sterile technique
Surgical infections 3 Nosocomial infection:
inadequate hygiene and nursing techniques
Prophylaxis of surgical infections
- 1. Primary infection: surgery + adjuvant antibiotics
- 2. Septic complication: surgery + sterilisation
(treatment with antibiotics if systemic signs & symptoms; no longer prophylaxis but treatment of invasive infection) biofilm (esp. in chronic bone infection) requires surgery + irrigation (physical disruption of biofilm)
- 3. Nosocomial: good hygiene and nursing
Old lessons for new surgeons
The best antibiotic is good surgery. Antibiotic prophylaxis can only be assured for Clostridia species and β-haemolytic Streptococcus. Penicillin! Anti-tetanus prophylaxis: toxoid + serum
