BASIC MANAGEMENTOF WOUNDS

IN WAR & NATURAL DISASTER

Christos Giannou

Advanced Course in the Management of Disaster Victims

Nicosia, October 2011

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 patient hygiene

Basic Principles 2

Wound incision for drainage

Excision of devitalised tissues

Irrigation

Leave the wound open for drainage – no sutures

Large bulky dressing

Basic Principles 3

No unnecessary dressing changes

Delayed Primary Closure (DPC: after 4-7 days)

Basic Principles 4

Anti-tetanus

Antibiotics, as adjuvant

Analgesics

General condition of the patient + nutrition + hygiene

Physiotherapy + rehabilitation

Laboratory: essential examinations

Hb / Hct Urine (sugar, pregnancy)

WBC total & differential Platelets Coagulation time, bleeding time Fasting blood sugar No bacteriology No blood gases

Blood transfusion

No components

Whole blood, as fresh as possible

Walking blood bank: friends, family, clan

Autotransfusion

Forget recombinant Factor VIIa!

Wound excision - debridement

Layer by anatomic layer

Skin: incision, excision

Subcutaneous tissues

Fascia, aponeurosis: drainage

Muscles: 4 C's

Periosteum

Bone

Exceptions

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 (open abdomen)

Joints – synovial membranes should be closed

Blood vessels, tendons, nerves – muscle cover

Metallic foreign bodies

Should be left alone 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 Managementof 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

Wound opened, track debrided,large foreign body

Shell fragments and detached bone removed

Supraclavicular bullet wound

Multiple superficial fragments

Serial debridement of large wound:line of demarcation of necrotic tissue apparent

Excise skin wound & Extend the skin incision

Fasciotomy & opening up of the wound cavity

After incision of fascia, protrusion of injured muscle

Cavity excised & clean wound left open

Bulky, absorbent and dry dressing

Mismanaged wound: primary suture

Mismanaged wound: primary suture

Primary suture of heel without debridement:infection, tetanus, patient died

Mismanaged wound: primary suture

Mismanaged wound: signs of inflammation

Stitches released,necrotic edges, subcutaneous oedema

Re-debrided, wound is now larger than original injury

5 days later, wound clean

Partial closure with sutures

Closure with split-skin graft

Healing

Well-managed patient: dirty wound

Dirty wound debrided

5 days later, removal of dressing

Sticky dressing peals off

Fully exposed wound 5 days after debridement

Immediate skin graft as DPC

Orthopaedics

No internal fixation / osteosynthesis

Plaster of Paris POP

Thomas splint

Skeletal traction

External fixation

Vega cast

Skeletal traction

Thomas splint

External fixation

Old lessons for new surgeons

War wounds are dirty and contaminated, from the moment of injury.

The rules of septic surgery apply.

Old lessons for new surgeons

The best antibiotic is good surgery.