Non-Operative Field Wound Care

1. Non-Operative Field Wound Care COL Cliff Cloonan, MD, FACEP Vice Chair Dept. of Military and Emergency Medicine USU

2. Field Wound Care • Objectives - At the end of this session the participant will be able to: • Describe the common wounds and wounding mechanisms likely to be incurred during combat • List the critical factors in preventing wound infection

3. Field Wound Care • Objectives - At the end of this session the participant will be able to: (cont.) • Describe how the combat environment impacts on wound care • Define an approach to wound care that takes into consideration limited resources and the austere combat/field environment

4. Field Wound Care • Four Main Teaching Points • The wound you can see on the outside may be the least severe regardless of how bad it looks. Make sure the patient is evaluated and resuscitated (control all controllable bleeding) before doing wound care. • Irrigation and lots of it! • Debridement (“unbridle” the wound) • NO Primary Closure*

5. Dulce bellum inexpertis(War is delightful to those who have no experience of it)Erasmus

6. Wounds of War

7. War Wound Distribution Chest Other 13% 9% Head & Neck Upper 17% Upper Extremities Extremities Abdomen Lower Extremities 21% 5% Abdomen Head & Neck Lower Chest Extremities Other 35%

8. No study is possible on the battlefield,one does simply what one can in order to apply what one knows. Therefore, in order to do even a little, one already has to know a great deal and know it well Marshall Ferdinand Foch

9. Two Broad Mechanisms of Combat Wounds • Penetrating/perforating wounds • Low velocity • Mostly fragments • Rarely pistol bullet wounds or “spent” bullets • High velocity • Mostly bullets from assault rifles • Some fragments

10. Impact of Distance From Center of Artillery Shell Explosion on Injury Pattern Significance – any casualty close enough to center of explosion to be sig. burned or suffer from blast injury is highly likely to be killed by fragments

11. Field Wound Care • Mechanisms of Combat Injury • Explosions/Blast • Penetrating fragment wounds • Primary, secondary, tertiary blast injury • Primary direct tissue injury from blast wave • Secondary from flying objects, ie. glass fragments • Tertiary from translational injury, ie. victim being thrown against a wall • Burns

12. Multiple small fragment wounds and superficial burns from exploding rocket propelled grenade

13. Penetrating fragment wounds and superficial burns from exploding RPG

14. Anti-Personnel Landmine Injury – Desert Storm

15. Field Wound Care • Mechanisms of Combat Injury • Bullets • High velocity – all assault rifles (>2000 feet/sec) • Low velocity – all military pistols (<1500 feet/sec)

16. 7.62 AK-47 Ammunition 7.62 Weight Magazine 30 Round Exchangeable Box Cyclic Rate 650 RPM Muzzle Velocity 2350 FPS Mechanism Gas Operated

17. The reason assault weapons are so lethal (and its NOT because they fire high velocity bullets) – HINT count the # of wounds

18. M-16 5.56 mm gun shot wound (exit)

19. Two Broad Mechanisms of Combat Wounds • Non-penetrating wounds • Burns • Blast • Blunt injury

20. Field Wound Care • Mechanisms of Combat Injury • Flame Burns • Primarily due to burning fuel or other combustable substances • Rarely due to flame weapons such as napalm or flame throwers • Occasionally due to detonating explosives

21. Field Wound Care • Mechanisms of Combat Injury • Steam Burns • Not uncommon in battle damaged ships • Chemical Burns • Usually from ubiquitous caustics such as gasoline, JP-4, exploding batteries etc… • Possible from chemical warfare agents, ie. mustard agents

22. Oklahoma City Federal Building BLAST

24. Blunt force injury in combat

25. Two Broad Mechanisms of Combat Wounds • Non-penetrating wounds • “Other” • Crush injury • Deceleration injury • Electrical injury • Chemical injury • Laser injury

26. Causes of Combat Wounds (WWI, WWII, Korea, Vietnam, Middle East)

27. “Life Is Tough... But Its Tougher When You’re Stupid!”

28. Field Wound Care • Specific Wound Management Issues • Patient Assessment • Impact of experience of health care providers • Wound Irrigation • Wound Debridement • Role of topical antiseptics • Role of prophylactic antibiotics • Role of the wound dressing

29. Field Wound Care • Issues (cont.) • Management of multiple fragmentation wounds • Management of small abdominal fragment wounds • Management of amputated digits/limbs • Pain Control • Tetanus Prophylaxis • Prevention of Hypothermia • Wound closure

30. Field Wound Care • Patient Assessment • Wound Care is NOT first priority • ABCs vs. CAB (the primacy of hemorrhage control) • Penetrating combat wounds vs. Blunt injury • Importance of initial and recurrent neurovascular assessment • REMOVE wrist watches, rings, and any other potentially constricting clothing or jewelry • The external wound is usually NOT the major concern regardless of how severe it appears

32. Large soft tissue defect in leg from exploding RPG

33. Field Wound Care • Impact of Experience of Health Care Providers On Wound Outcome

34. Field Wound Care • Impact of Level of Training on Wound Infection Rates • Medical Students: 0/60 (0%) infected • All Resident Physicians: 17/547 (3.1%) infected • Physician Assistants: 11/305 (3.6%) infected • Attending Physicians: 14/251 (5.6%) infected Level of Training, Wound Care Practices, and Infection Rates Am J of Emerg Med Vol 13, No 3, May 95

35. Field Wound Care • Impact of Level of Training on Wound Infection Rates • Junior practitioners • Used high-pressure irrigationmore often • Less likely to use subcuticular sutures • Applied Bacitracin ointment more frequently than - • More “Experienced” Physicians! Level of Training, Wound Care Practices, and Infection Rates Am J of Emerg Med Vol 13, No 3, May 95

36. Field Wound Care Wound Irrigation

37. Field Wound Care • Irrigation • “The Solution To Pollution Is Dilution!” • The SINGLE most effective method of reducing bacterial counts on wound surfaces • High pressure streams (5-7 psi) clearly superior to low pressure streams (bulb syringe) • 35 ml syringe with 19-gauge cath generates 7-8 psi • Pulsatile lavage is very effective at lowering bacterial counts and wound infection rates

38. Field Wound Care • Irrigation (cont.) • Zerowet(TM) produces 5-8 psi and is very effective at preventing back splash • The irrigation stream should not be directed into puncture/narrow-based deep wounds - if these wounds are to be irrigated they should be opened • DO NOT irrigate with Hydrogen Peroxide (esp. puncture wounds)! • Amount of irrigation depends upon wound size and degree of contamination [100 - 500 or more cc’s] • IF unlimited resources use normal saline to irrigate BUT potable, non-sterile, well chlorinated water will suffice and is not associated with increased infection rates. Irrigation with potable water is MOST CERTAINLY better than no irrigation!

39. Field Wound Care • Irrigation (cont.) • Pulsatile jet lavage, i.e. SurgiLav Plus (Stryker Instruments) delivers 1400 ml/min with variable pressure and pulse frequency • “Pulse lavage may be a means of significantly helping patients withstand lengthy delays in treatment while minimizing the morbidity and mortality caused by infection.” - Keblish Mil Med 163, 12:844, 1998 • Gravity fed “jet lavage” by placing chlorinated water storage tank on elevated platform and running hose into OR - a low tech solution

40. Field Wound Care • Debridement

41. “If there bee any strange bodies…he must take them away, for otherwise there is no union to be expected…All strange and external bodies must bee taken away…if there be danger in delay, it will bee fit the Cirurgion fall to worke quickely…[that] he may pull out the strange bodies…” Ambroise Pare (1510-1590)

42. The first intention, with regard to wounds made by a musket…is, if possible, to extract the ball, or any other extraneous bodies lodged in the wounded part. The next object…is the hemorrhage, which must be restrained…[A]dvise as little search with the probe or forceps as possible, as all irritation…increases the subsequent pain and inflammation…we ought not to attempt the extraction of anything which lies beyond the reach of the finger…” John Jones, M.D. Plain Concise, Practical Remarks on the Treatment of Wounds and Fractures (1775)

43. “. . . balls and foreign bodies were extracted, bleeding vessels secured, and splinters of bone removed ... In determining the extent of injury it was not unusual to enlarge thewound caused by the missile, especially in cases where . . .swelling caused difficulty or uncertainty of touch, or where. . . necessary to remove splinters or foreign bodies.” Civil War The Medical and Surgical History of the Rebellion Vol II

44. WWI Belgian Surgeon Antoine Depage Re-introduced the discarded French practice of wound incision and exploration and combined it with excision of devitalized tissue

45. Field Wound Care “…there is a tendency for suppuration, especially when careless and hurried interventions are carried out on the field. Poorly equipped, moving daily (even by the hour), surgeons who are called to intervene on the battlefield must repress the desire to operate, and often only bandage wounds temporarily… Preventing the immediate or delayed infection of wounds as much as possible must be one of the main priorities... COL Antoine Depage MD

46. Field Wound Care Debridement - From the French Word debrider meaning to “unbridle or release”

47. Field Wound Care • Debridement • ALL wounds incurred during combat should be considered to be contaminated because they are usually: • Old (> 6 hours) • Highly Contaminated • “Jagged” / crushed tissue

48. Field Wound Care • Debridement (cont.) • Original concept of debridement was more to facilitate wound drainage by “unbridling” the wound than to remove all devitalized tissue • Today debridement has come to mean the removal of ALL apparently devitalized tissue • Problem is that it is often difficult, within the first few hours after injury, to accurately identify devitalized tissue • Bone and lose muscle fragments and most foreign bodies must be removed • Remove as little skin as possible

49. Field Wound Care • Single most important therapy - • Complete debridement and removal of foreign bodies, thorough and copious irrigation, and good wound drainage/decompression of tissues as required • Small glass and metallic fragments and intact bullets rarely cause problems if left in wounds - extended efforts to find and remove them are unnecessary and dangerous • Foreign materials such as mud, clothing, and unattached bone fragments MUST be removed. • Mud/dirt in an explosive wound must be excised

50. Field Wound Care • Single most important therapy (cont.) - • Tap water (clean, chlorinated, potable water) is adequate/appropriate for irrigating most wounds • In most circumstances NS/water is the appropriate irrigating solution - Betadine and other anti-bacterial soaps/solutions are cytotoxic