war surgery afghanistan & iraq atlas_chap1

7/29/2019 War Surgery Afghanistan & Iraq Atlas_chap1

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Chpr IaCuteResusCItatIonand

CRItICal CaRe



aCute ResusCItatIon and CRItICal CaRe | 19

I.1Forwr Ruciiv surgry

an Inroucion o Polyrum

CASE PRESENTATION

tw ir wr ig gr wh hy i mip

gh w by kw i. Bh iivi wr

r i h by mic rpr Frwr

srgic tm (Fst) ciiy i mic vhic. th w ir

wr brgh i by hir i. emi r high. thir i h b

i, vr mmbr m h ir rriv h Fst.th r ir r ig, high-vciy w h h. o

qick ipci, h h g brhig h b ib.

H w ib, h rig h h b pc r hi h

w rmv. H hi crim w miig, wih prri

mcr bri mr ( bviy mr ijry). th c ir

i mip w, icig pri rmic mpi

hi h. High-vciy w ( ibr pg 23) wr pr

wih ri xi bh high crm. Rpi m

hi c ir rv h h w wk, r, wrig

qi pprpriy. H mii hi w irwy mv ir

ry. H h ppr ch r bmi w. triq wr

pc j bv hi h high h ppr pri bhhigh. Irv (IV) cc w rpiy bih, wih rg-br

IV i bh ppr xrmii. Iii vi ig rv mi chycri

yic b prr r 100 mm Hg. thi ir i hv

m zig hrgh rig h h b pc vr hi bir

high w. Fi rcii w iii whi cry rvy

w cmp. n ii ppr by ijri wr ii. Hi

pvi ppr b. Hi righ ppr xrmiy w wih ijry;

h h pri rmic mpi j bv hi wri. lwr

xrmii xmii rv rc xi w bh ppr

high r, wih ppr bir mr rcr. H h p

crm wih xp ic. Hi ph ppr ic. I hi wr

xrmii, h pi h ig ijry bw h high. Hwvr,h h pr pri bh wr xrmii. Ch X-ry (CXR)

rv pmhrc. th Fast (Fc abmi sgrphy

r trm) xm w giv r r fi i h bm. th pvi

m rv pvic rcr r rig bi. ahgh h pi

rmi hmymicy b, h bcm prgrivy cmbiv.

th rg jg h h pi w h vrg hmymic

cp. Cqy, whi rcivig fi b rcii,



20 | WaR suRGeRY In aFGHanIstan and IRaq: a seRIes oF Cases, 2003–2007

TO OPERATE OR TO TRANSPORT? thi ir w vry w wh vhic-br imprvi xpiv vic (Ied) xp r

vhic whr h w ig. th wr xrmiy w ry mp by h xpi. th

righ wr xrmiy w

vry ijr wih mip

rgm, rcr,

ppi rry ijry. th

ir w r wih

riq bv h k,

pi, immiy

rpr rby

Fst, rrivig wihi 10

mi h ijry. a

h Fst, h w wr

. sigic b

hypi r-

qir immi r-

i PRBC i.th pi w biiz.

a 45-mi hicpr

rpr CsH w

immiy vib. th

ir rg c

pr h pi

h Fst. Vcr rpir w

mp, xiv

xr xr w pc.

th pri pprx-

imy 4 hr, h

b vib h Fstw xh rig h

prcr. th pi w

h rpr vi MedeVaC hicpr h CsH. e r (pprximy 20 mi i h

figh), h pi h cric rr. dpi mp rcii, h i.

TEACHING POINTS

1. I i iky h hi pi ccmb rm h h ri hyphrmi, cii, cg-

phy.

2. th rgic mii Fst i xrmy ic, ic imi. ahgh h cpbiiy

qipm cry prrm wi vriy rciiv iiv rgic prcr

r vib h Fst, h m pricip miiry rgry mk i impriv h

pi wh c r rpr h x v cr r biiz mv xpiiy mr rb rgic ciii.

3. th jgm h ir rg c b vry . Pi h y rg xiv

rgic prcr h Fst i, i h jgm h ir rg, h pi wi rviv

rpr h x v cr. ev wh ch ir circmc prvi, h g i biizi

ch h h pi c r rpr h x v cr.




h w k rgy h prig rm (oR)

r rhr vi xpri hi mip

xrmiy w. th “wkig b bk” w

mbiiz bc h icip r wh

b. I h oR, pmic riq w pcbv h rig cmpi mpi

h h w rpiy prrm. th pmic

riq w r wih vic gig

big rm h xrmiy. th high h i

zig bw h riq, pmic

riq c b pc prximy. thrr,

h w w xpr wih h riq i

pc. th riq w gry r,

h mjr rc big wr ii. th

prci mr vi (sFV) h b rc,

w ig bh iy prximy. th

prci mr rry (sFa) w iiiy i pm,b bg b pry c h riq w

r. th rc wr ii,

argy h w rpiy pc (Fig. 1). dppr

ig wr bi i h ri pi

prir ibi rri. ai w h irc

h righ wr xrmiy. th sFa ppr

ic, b h sFV w rc. th v w

ig big cr. expri bh

wr xrmiy w k pprximy 1 hr

cmp, rig which im h pi rciv

6 i pck r b c (PRBC) 4i wh b. Prpri r rpr w

iii. exr xr wr pc bh wr

xrmii cimi prrm (Fig. 2). th

vcr h w r r i h

bcm ig rig h prviy crib

prcr. Whi wiig rpr, h pi’

ic wr prc by pcig hm ii h

ijr crm y pprximig h cr

g. a rp Fast xm w prrm, which

w giv. Bc h vriy h pi’

ijri h r gig rcii,

h Fst rg ccmpi h pi i-figh h cmb ppr hpi (CsH). th c

rg c h rcivig rg ry

irmi b h r h ijri,

h pi, priv prcr prrm.

tr xpcy, h r cy ccmb

hi w.

Figure 1. Extensive loss o tissue associated with a high-velocity wound. A shunt is in place in the SFA.




Figure 2. Compartment release o lateral leg has been perormed. External fxation o the let emur is in place.

TEACHING POINTS

1. thi ircry c prvi iigh i h

ymic h rpi, r, qi

pprch rqir i h c mgm

cmpx b rm. Fc wih crwmrgcy r h mi ch h

mm, h rg h wk hrgh

prc : rpi iii m, rig,

rm wih i h aBC, xpr,

IV pcm, ry c r wkig b bk,

cry rvy, pi m h ch wr

xrmii, h Fast xm, h mv h oR,

i ppr xrmiy mpi, i h

wr xrmii, cr v rri

big ic pcm rri h,

crmi i fw, ri, xr

xr pcm, prphycic wr xrmiycimi, rm rp Fast xm,

rpr, cmmici.

2. spcicy: Cr h mrgcy r -

mic pr, icig cmmr. d

w mic pr—icig h wh

r ijr, hir bi, r hir cmmr—

bcm ivv wih mic rig.

3. th Fst h i w b ck, b i ci

y PRBC. nihr h Fst r CsH rmy h

cc rh rz pm r p. Whvr

i i rmi h m my bcm cg-

phic, wh b i rw.4. th Fst i riiy qipp wih X-ry

cpbiiy. I Fst wih X-ry, xr x-

r r pc b kw mrk. thi

prcr rqir ki xpric. Gr

rg h b cpb prrmig hi

prcr.

5. I cmb ii, pib v cmm-

icig pri i irmi m

b mp wh rprig pi h

x v cr. thi my ic wriig h

pi /r h bg ( Fig. 5, pg 175),

irmig ccmpyig rpr pr,ricmmici, -mi, wri rcr, r

v ccmpyig h pi wh xcpi

circmc prmi.

6. Cmbiv my b impig ig hyp-

vmic hck hmymic cmpi.

I i miirpr q c-h

ijry, which m, i vr, i h c.




7. Gr rg hv rpibiiy r h vr

mgm pyrm pi h Fst.

airwy mgm rcii r criic

pririi i cjci wih cr hmrrhg.

8. oc big i cr, xr xi

rcr my b pprpri. Frcr igm

biiz wih xr xr my imprv i

pri. diiv vcr rpir my b yby pcig mprry vcr h. I rpr

im h x v cr r hr (1 hr r

) h pi c b biiz, mprizig

wih h riq pi rpi

rpr h x v cr h b rgy

cir ( ibr pg 20).

CLINICAL IMPLICATIONS

o, cmb w wi pr h rg i

highy chic miy chrg virm.

a mr i hi c, hrc

pricip miiry rgry—icig rig, r-cii, mg cr rgry, vci wih

cci cmmici h x v cr—i

criic chivig cc cm.

DAMAGE CONTROL

thi c i rpriv h yp mg c-

r rgry prrm by Fst. I hi c, r

pprpri rig, rcii w r, hmrrhg

w cr, vci ccmpih. Pcm

xr xr wr xrmiy cimi

w wihi h cp h Fst. diiv vcr

rpir w prrm r h CsH.

SUMMARY

thi c mr w hw qicky m rgic

m c bcm gg i i--h rgg

v w ir. I hi c, h Fst w

cc bc hy r h ig impig

crivcr cp, i prvi r

rm r virm, impm prc

iq wr rm. thi c cpr h ci

ch m m m vrcm i cmb.

SUGGESTED READINGChpr 3: trig. I: Emergency War Surgery, Third United

States Revision. Whig, dC: dprm h army,

oc th srg Gr, Br Ii; 2004.

Chpr 12: dmg cr rgry. I: Emergency War

Surgery, Third United States Revision. Whig, dC:

dprm h army, oc th srg Gr,

Br Ii; 2004.

DR JANICE MENDELSON AND THE

BALLISTICS OF WOUNDING

I hi bk whr, rm rg

rqy h phr “high-vciy w.”

I, mr mii i xrriry

vcii. B br r h m-

chic wig, h rr h hiki rm “high-rgy rr.” I i h

vciy, b h kiic rgy h prjci,

rrr h i, h prc i

irpi. High-vciy rif b h

rvr i rm i b

rjcry my rr y m rci

(< 20%) hir kiic rgy, whr b

h brk p whi rvrig i ( b

rgm) rr cirby mr hir

kiic rgy (> 40%), h rig i

rgr w. ergy rr y i

irmy irib g h w rc.

thi i bc h prjci my yw, ricch,

rgm, /r rm i ri. I ii,

h cy pr hmg i

(grm, ki, , mc, rg vryig

ii, b) wih ir vicic

prpri. I i qi pib prc

miv w wih (rivy) w hvy

mii h h b rjcry.

thi rig rgy rr rhr

h vciy pr h rmi hx w w rgy crib by

cii h us army’ Biic Rrch

lbrry egw ar i abr,

Mry. o h ivigr rpib

r hi wrk w C Jic a. M.

sh rv Chi h trm Ivigi

Brch (Biphyic divii) egw

rm 1958 1966. dr M w

h r m rg i h army Mic

Crp. sh w ivigr r mbr

i ccrig h ciic cr

miiry ijri—i which r grrrig y c b rib. drig

h Vim Wr, h py rg

(1970–1971) wrk i Vim br

i whr h mr h rmrkb

ccy pic mi hyrchri

(smy).




I.2emrgncy surgicl airwy

Mngmn

CASE PRESENTATION

thi h i m w ijr by imprvi xpiv

vic (Ied) brgh h cmb ppr hpi (CsH).

H i xiv ci ijri (Fig. 1 2), icig

mxiry rcr, cmmi mibr rcr, g

-i ijri. thr wr rgm w i hi bm

fk. th pi c y brh iig p w b

mii hi xyg ri bv 90%. H ri r pc

him i h pi pii. Cqy, h higi c

ry ib h pi. th cii w m prrm

crichyrimy. Whi i iig pii, h pi’ ck w

prpr wih bi i. H w giv prp, pc i h

pi pii, immi crichyrimy prrm. th

prcr k h 1 mi. drig hi im, h pi’ xyg

ri rpp 45%, b qicky rr rm c hi

rch w ib (Fig. 3 4). Wih h irwy cr, h pi

rw xprry prmy h rv irbmi

ijri. a grmy b w pc, ci rcrci w

prrm. Wihi 48 hr, h crichyrimy w cvr rchmy, h pi rcvr w pprivy wih

cmpici.

TEACHING POINTS

1. thi c prvi xmp pi wh rqir mrgcy

rgic irwy. th pi w b mii q xyg

ri i rriv v III ( Prg) mic rm

ciiy h h xpric rgic . I hi pi h b

cci, i i iky h rgic irwy migh hv b

h i ijry.

2. Crichyrimy i imp prcr h i ypicy prrm

i r virm. th prcr i gh rgwrkig v I r v II mic rm ciiy ( ibr

pg 25).

3. trchmy h b vi i hi cri bc i i

mip prcr h ic iviig rp mc

iviig r vig h hyri ihm. th pi, wh c

b prxyg, migh rviv h ii im

prrm rchmy.

Cry dvi l, The Dallas Morning News




Figure 1. Patient transported to the CSH in a

sitting position. This position allowed the patient to

maintain his own airway until experienced trauma

personnel could secure his airway.

4. t prc b ci pr

wih mxici rm. ahgh bihig

mrgcy rgic irwy i w wihi h

cpbiii gr rg, cmpx mxi-ci rcrci i . thi c mr

h r r mxici rg r

qiv h v III mic rm ciiy.

5. thi c hw h irq r

iiv rcrciv rgic prcr b

prrm h CsH.


Crichyrimy i h prcr chic r

mrg rgic irwy mgm. Iici

r crichyrimy ic h wig:

1. Mxici rm h prc ibi.

2. Ibiiy cr h irwy r y r i

hypxic pi.

a phryg irwy (nPa) my b riv

rgry i h mrg mgm r

mxici ijri.

STEPS OF SURGICAL CRICOTHYROIDOTOMY 1. Iiy crichryri

mmbr bw

crici crig (r

crici rig)

hyri crig (a).2. Prp ki wiy.

3. Grp h

rch, biizig

h irwy.

4. Mk vric

ki icii w

h crichyri

mmbr ( .

10 r . 11 b).

5. By ic h i xp h mmbr.

6. Mk hriz mmbr icii (B).

7. op h mmbr wih rcp r h cp h.8. Ir m, c rch b (6.0–7.0 ir imr) j bv h b (C).

9. Crm rch ibi.

10. sr h rch b i pc cr i wih i h p r h ck.




Figure 2. Radiograph o a comminuted mandible racture. Note cricothyroidotomy.




Figure 3. Patient immediately ater cricothyroidotomy.

Figure 4. Patient immediately post-op. The cricothy-

roidotomy was converted to a tracheostomy within

48 hours.

Contraindications to an NPA:

Cgphy, mic rm, bir

k rcr, pc v

ircri prr.

DAMAGE CONTROL

Crichyrimy i i mg cr

chiq cr irwy h c b

ry ib. a rch b (6.0–7.0 ir

imr) r rchmy b (. 4 r . 6 shiy

rchmy b) c b .

SUMMARY

thi pi rqir mrg rgic irwy.

Mic pr py cmb virm

m b ri prrm rgic irwy h i

ijry. Crichyrimy i h rgic prcr

chic.

SUGGESTED READING

Chpr 5: airwy/brhig. I: Emergency War

Surgery, Third United States Revision. Whig,dC: dprm h army, oc th srg

Gr, Br Ii; 2004.

Chpr 13: Fc ck ijri. I: Emergency War

Surgery, Third United States Revision. Whig,

dC: dprm h army, oc th srg

Gr, Br Ii; 2004.

Chpr 22: s-i ijri. I: Emergency War



Gr, Br Ii; 2004.




I.3dving Burn, Bl,

n Pnring Injury

CASE PRESENTATION

o mii, hi m pi pr wih br cvrig

pprximy 60% hi by rc (Fig. 1). th

mchim ijry w cr. H rciv iii cr

(icig ibi bc c ck br) w vc

v III mic rm ciiy (cmb ppr hpi [CsH])

h h b bih i r virm. Hi xygi rmi pr pi ibi ppm xyg. th

pi w chycric hypiv. Ch w chrmi

wr prrm bc cr ch w cmpic. aggriv

fi rcii w iii. n gr xrmiy rmiy w

. Hwvr, cr ipci hi prr ch

rv rgm w. dpi fi b ii, h pi

bcm mr hypiv i p wr . I h prc

prig ch ijry wi vi ig, rciiv

hrcmy w iic prrm. op cric mg w

prrm, rcii w cc. thrcmy rv h

h iphrgm h b rvr by h rgm. Cqy,

h pi rw prmy i which pic, gric, hpicijri wr . expii pcmy cr mch

w wr prrm. th pi rqir 14 i b. H h

mch hi by h h cmbi c br, fi

rcii, hrcmy, prmy. dpi civ rwrmig

hr ggriv, ivig r, h pi i.

TEACHING POINTS

1. Cmb rm pi my i y cmbii

prig, b, hrm ijri r b rm

xpiv mii. Ijri p h prximiy h

iivi h i.

2. expiv mii hv hr mchim ijry (Fig. 2); mchim wr pr i hi pi bc h w i c

prximiy h picr h xpi:

. a br cvrig pprximy 60% hi by rc.

b. evic primry b ijry h g ( brv

rig rciiv hrcmy).

c. a hrcbmi rgm ijry (vic biic ijry).





Iiyig wp c i y. Cir hwig pi:

1. thrm ijry i y iy ii, b b

ijry i bvi prci xmii.

2. th r, g, grii rc r

gr rik r b c.

3. a mjr hrm ijry c bcr prig

w.

4. thrgh cry rvy i mry

vi miig i-hrig ijri rig

rm xpiv mii.

5. trm pi wih br ijri, wh rp fi rcii, m b r

r mi ijri.

DAMAGE CONTROL

th rciiv hrcmy i h cmb

z h b imi pi i xrmi wih

prig hrcic ijri h y r h

Figure 1. Patient ater resuscitative thoracotomy (but beore laparotomy) or thoracoabdominal ragment injury.

m vrb circmc (g, m pr-

ig ijry, miim ci ijri, brrc, hr rg pi). ev i h

circmc, pi vg i rr. I hi c,

i which prmy w rqir r cr

gig big, h b miim irvi

(pckig, bw pig, igi big v)

i i.

SUMMARY

thi c mr cmm irc bw

cmb rm civii rm. Civii rm

i ypicy chrcriz prig r b

ijry. Cmb-ijr pi pr wihcmbii prig, b, hrm

ijri. a i civii rm, cmb-ijr pi

rqir hrgh cry rvy r h

i-hrig ijri r ii ry i h

rcii ph. dcii rg r rk

bic, ggriv rciiv r, i hi c,

r wy ic ic ciri




rig, rrc vibiiy, r h ijri,

iivi xpri.

SUGGESTED READING

Chpr 3: trig. I: Emergency War Surgery, Third

United States Revision. Whig, dC: dprm

h army, oc th srg Gr, Br

Ii; 2004.

Chpr 16: thrcic ijri. I: Emergency War



Gr, Br Ii; 2004.

Chpr 28: Br. I: Emergency War Surgery, Third

United States Revision. Whig, dC: dprm

h army, oc th srg Gr, Br

Ii; 2004.

Figure 2. Combat blast injuries

oten depend on the proximity o

the individual to the detonation.

In the case examined here, the patient was in close proximity to

the epicenter o the explosion.

INDICATIONS FOR

EMERGENCY THORACOTOMY

• Penetrating thoracic trauma.

— trmic rr wih prviywi cric civiy (pr-

hpi r i-hpi).

— urpiv hypi (b

prr < 70 mm Hg).

• Blunt thoracic injury.

— urpiv hypi (b

prr < 70 mm Hg).

— Rpi xgii rm ch

b (> 1,500 ml).

• Suspected systemic air embolism.

CONTRAINDICATIONS FOR EMERGENCY THORACOTOMY

• Blunt thoracic injuries with no witnessed

cric civiy.

• Multiple blunt trauma.

• svr h ijry.

• Severe multisystem trauma.




I.4to shun, Rpir, or

ampu . . . ?

CASE PRESENTATION

a 23-yr- m i mip b ijri whi riig i

b wh imprvi xpiv vic (Ied) w .

th pi rriv h emrgcy Mic trm

(eMt) ci cmb ppr hpi (CsH) i pprximy

65 mi r h ck. H w ichr hypiv

rriv, wih mprr 97.2ºC hr r 120 b

pr mi. Hi ijri ic p righ mibr rcr,

p righ r mcrp rcr, p w,

rg hrgh--hrgh mi high w wih rg -

i c rri big. n riq w pr,

w hig irc prr h w. n vic

mr rcr w pr, miim big w rm h

h, , ci w.

PREOPERATIVE ISSUES

1. obvi rri ijry (iky prci mr rry [sFa]).

2. Hypi/hypvmi.

3. aci xrmiy ijri.

ar iii rcii vi rg-br IV, h pi w k h

prig rm (oR). a righ ir jgr cri w ir. Bh

xrmii wr prpp whi prr w mii h high

pi hmrrhg. Hi iii hmcri w 24%. expri h

w rv r rci h sFa rci h mr

vi. armic cmp wr ppi gi prxim i cr

h sFa, h vi w ig. Big w civy pp

wig h mr.

DECISION POINT

Repair vascular injury vs shunt vascular injury

vs primary amputation

Giv h pi’ hmymic biiy wih gig rcii

h ci igic big, rri rpir wih irpii

rvr mr vi w prrm. th hi m miir 4

i pck r b c rig h rpir, h brry prpr




4 i rh rz pm (FFP). Ppb p wr

pr, b irpriv rrigrm rv

fw h . ar r h cmp, h pi

mr ciic vic cgphy by i

big, hi b prr rpp. thi cii

w r wih ii wrm cryi 2

i wh b; hrg FFP ici

hwig h vib pm prc ri ccr cr. th pi’ cgphy

cii wr, r ch rgic

big rm rc mc w g wr

cc. Hi by mprr 34ºC,

cii hypi i rp rcii.

a mg cr pprch w k: r h

big wr br, w wr pck,

pmi rip w iii, h pi w k

h iiv cr i (ICu). Bc r civ

wrmig vic wr vib, imprvi hr

rmbig Bir Hggr w crc ig bihzr

bg pc hr. th pi rciv iiwrm wh b FFP; im bicrb

w miir. Hypi wr

piphri rip w r. Hi b prr c

b mii pi ii prr, h

bcm yic rwr. Frhr vc

cric i ppr mr wr cc; ,

pi ggriv rciiv r, h pi i.

LEARNING POINTS

1. Br rkig vcr rcrci, pc

h pi’ (hmymic, cgi

prmr, ri p, cr by mprr)h b v rmi i rpir c/h

prc h im. n h wr r wi

b imy vib. oc vcr rpir

h bg, i bcm ic brk h priv

fw cir ii irmi (crr

cr mprr, r i cgi prmr,

rp gig rcii). I bcm

pychgicy ic p rpir c i h

b iii. thrr, i i criic cmmic

civy wih h hi ccry

h pi’ cii br mkig h

cii rpir, h, r mp.

2. Hyphrmi c b iii b y, c

crib cgphy cii. I hi

c, h oR hr w iprb g r h

c h r. Imprvi civ hr, fi

wrmr, hr jc (IV bg wrm

i micrwv pc gi h by,

c) h b wh r qipm i

vib.

3. th r cmp r vcr rpir c

vry impc pi wh w prviy b.

Cmmici wih h hi wrhm h impig rr fw (wih pim,

mbic ci, ifmmry mir) c

hp hm prpr r h hmymic q

cmp r. d m h h hi

pr r wr h rg’ ci r

ii.

SUMMARY/DAMAGE CONTROL

I rrpc, hi pi’ chc rviv w

hv b igicy imprv i h sFa h b

h r ig mg cr h b

impm by pckig h -i w mvig h pi h ICu r rcii

wrmig.

SUGGESTED READING

Chpr 13: Fc ck ijri. I: Emergency War



Gr, Br Ii; 2004.



dC: dprm h army, oc th srgGr, Br Ii; 2004.

Chpr 23: exrmiy rcr. I: Emergency War



Gr, Br Ii; 2004.

Chpr 26: Ijri h h . I:

Emergency War Surgery, Third United States Revision.

Whig, dC: dprm h army, oc

th srg Gr, Br Ii; 2004.

Chpr 27: Vcr ijri. I: Emergency WarSurgery, Third United States Revision. Whig,


Gr, Br Ii; 2004.




I.5exrmiy trum

Wih Profoun shock

CASE PRESENTATION

a us rvicm cr cmp w wihi 10

h impc pi rg mrr r r vr

ijri. H rmi cci h q irwy

pi vr big h c b cmpy cr h

c wih irc prr. H w rpr immiy cmb

ppr hpi (CsH) h w h mi wy. I h rcii

r, prr h w ppi h wig c w mii

by mic pr pi miim big. H h i vr

xrmiy -i w, icig rmic mpi

h righ h, rm ri rry ijry wih -i ijry

h h, r mpi h g, vr ijri

h righ g (Fig. 1). th pi rw rpi rcii by h

mb rm m, which ic mrgcy rm criic

cr phyici, r, mic, rg, hi prvir. H

w ib, righ bcvi cr i w ir, 4 i

pck r b c (PRBC) wr rpiy r. th wkig

b bk w civ immiy h rh wh b w

b vib wihi 45 mi. th pi w rpr immiy h prig rm (oR), whr hi rcii ci (Fig. 2).

a mr rry rri i w pc bc hr i

wr immiy vib. Hi iii rri i prr w 80/40

mm Hg. th r mpi h g w cmp, rqirig

hip irici. Bc h xiv i, b, rv,

vcr mg h righ g— w h pi’ criic

cii— rmr mpi w prrm qicky. a rpi

prmy w p cmy hi. th righ rm

mp w bri, w h -i ijry h hr

mic. th ri rry, which w bg b pry,

w ig r i w cr h h h w qy pr by

h r circi. W wr r by pg h i pcby pig xpb mh rig h ki (Fig. 3). th pi’

irpriv hmcri (r h iii 4 i PRBC) w 15,

h w r wih ii i rh wh b h

wr vib. H w k h iiv cr i (ICu) whr

wrmig rhr rcii wr ci. oc b, h

pi w vc by by Criic Cr air trpr tm

h v IV mic rm ciiy i lh, Grmy. ar




bri pvr, h w vc v V mic

ciiy i h ui s, whr h rriv j 36

hr r vig h CsH (Fig. 4). ar mip

rgic prcr xiv rhbiii (Fig.

5 6), h w micy rir i crry

y mpy (Fig. 7).


1. Bc h riv yh m cmb

ci, h iii vi ig (hr r, b

prr) gig big my r h

rcii m h gr hypvmichck iii pri. Immi rcgii

pr hck i vr cmb ijri,

pricry h cr by rg xpi

(imprvi xpiv vic [Ied] mrr/

riry mii), i criic pi rviv.

2. Pi wh rriv wih miv ijri (rmic

mpi; p bmi r ch ijri;

rg, -i w mip xrmii)

r i pr hck viry h mm

wig rqir ggriv, immi

rcii ( --chpr Cmmry).

TEACHING POINTS

1. svry w pi wih mip r

ijry b rm m pprch rm

cr. Frm h iii c wig hrgh

rcii, rgry, biizi, criic cr i

h ICu, hrgh cii criic cr rig

vci iiv cr rhbiii, xpric m hhcr prvir r h

gr chc rviv ci cm

r h wh r rm wr w. tm

ch v cr, w h ir m

h miiry hhcr ym xig rm h

b i mic cr, r criic

pi rviv cm.

Figure 1. Patient at arrival to the Emergency Medical Treatment (EMT) area. Note direct pressure applied to the

transected ends o both emoral arteries.




Figure 2. Patient in OR.




Figure 3. Immediately post-op.

Figure 4. Patient at Walter Reed Army Medical Center during initial examination.




2. I h py ig, h oR i h bci rci pi wih vr w,

wig xc 360-gr pi cc

mip prvir, prir irwy cr (h-

i pr), mirig, mprr cr,

pi cr. ev i rgic prcr i

, r rr bc mg cr

ciri, h pi c b qicky

rcii iii i hi ci.

DAMAGE CONTROL

1. I h c vr hmrrhg xiv i

ijry, hyphrmi, cgphy, cii rvr-pr hr pi rviv. a ry

cii r mg cr—ig bbrvi

rgry wih h g crig hmrrhg,

ppig cmii, rmvig vib

i— prv b criic vrb

cm.

2. oc h pi chiv phyigic biiy ih ICu, rr h oR r rhr iiv

rgry c b cir. I ii, pi

my b rpr highr v cr c

biiz, i hi c.

SUMMARY

exiv cmb w r i pr

hck, rqirig immi m, rcgii,

rcii. Hvig xpric rm m

mb prpr i criic pi rviv.

Rcii i h oR r my vg r

criicy ijr pi vr h vib i crw rcii r. a ry cii

mg cr chiq, b h pi’

phyigic cii, i h m impr

ik viig h y ri hyphrmi,

cgphy, cii. th “chi cy”

r h w pi—rm h pi wig

Figure 5. Several months ater wounding during

rehabilitation.

Figure 6. Further rehabilitation.




h b, hrgh rcii, iii r-

gry, rhr rcii, criic cr rpr

iiv cr, rhbiii—rqir gb m r prvi by h us miiry.

SUGGESTED READING

Chpr 7: shck rcii. I:Emergency War



Gr, Br Ii; 2004.

Chpr 11: Criic cr. I: Emergency War Surgery,

Third United States Revision. Whig, dC:

dprm h army, oc th srg

Gr, Br Ii; 2004.

Chpr 17: abmi ijri. I: Emergency War



Gr, Br Ii; 2004.

COAGULOPATHY

Ciic vic cgphy my b

“micrvcr big,” i big

rm rgicy c r rmicy mg

i rc, big rm mc

rc r irvcr chr.

lbrry vic cgphy i i b v prhrmbi im (Pt) r

pri hrmbpi im (Ptt), wih

pciyig hw mch vi. Pbih

gii gg ig c 1.5 im

rm (mirg Pt rrc r ppr

Ptt). th gg rh rz

pm crrc cgphy i 10 15 ml/

kg pi by wigh, y 4 6 i

rh rz pm r h vrg .

th h iri rmiz ri

(InR) i vc. th InR w vp

vi wih rpc icgi

wih cmi. I y v, h Pt v

i rbirry. I h b rcgiz h h

Pt v i cr vi cmpx

hmic ym.

Figure 7. Approximately 2 years ater wounding.



dC: dprm h army, oc th srgGr, Br Ii; 2004.

Chpr 24: op ji ijri. I: Emergency War



Gr, Br Ii; 2004.

Chpr 27: Vcr ijri. I: Emergency War



Gr, Br Ii; 2004.




I.6Miv Bloo trnfuion in

Pin Wih Hmoprionum

CASE PRESENTATION

aFrwr srgic tm (Fst) i rm aghi w i

pprximy 30 mi prir h rriv 24-yr-

us ir wih mip aK-47 gh w. th pi

w rpr b chycric, hypiv, i vr ir. a

wh b riv w iii immiy, 4 i rh rz

pm (FFP) wr hw i prpri r icip rqirm

r miv ri. o rriv, h pi w hv b

h hrgh h righ ch, h righ wr xrmii.

H rriv chycric wih hr r 150 b pr mi

b prr 90 yic wih bviy i bm. H

h 14-gg hrcmy i h c irc pc

h righ ch. Rcii wih pck r b c (PRBC)

FFP w iii immiy, ch b w pc i h righ

ch wih i rr b. a righ bcvi cri w pc,

h pi w k h prig rm (oR) r xprry

prmy. Prir ici wih gr hi, Fy chr

w pc, h w prpp wih bi i rm h ck

h k. th rg i wr gw, h piw rp i icipi pr rp i b prr r

ici. th pi’ b prr rpp 70 yic

ici. th bm w rpiy p hrgh mii icii,

miv hmprim w cr. a r qr

wr immiy pck. th hmprim w h r

vr ijri h ivr, m, mch, c, gm

mric rri. Pi big rm h mric rri w

rpiy cr by igi. th pck wr h rmv rm h

ivr. a rg, gr 4, cri c b cr by

pckig. thrr, Prig mvr w prrm, h rg,

gm hpic vi wr ii vy cr wih

igi ig r rgic cip. drig hi pri hpri, b w igic. th pi imy rciv

12 i rh wh b (FWB), 12 i PRBC, 13 i

FFP, 5 i cryprcipi, 7.2 mg rcmbi Fcr VII.

Wih h ivr big cr, h ivr w pck h pi’

hr r m immiy cr. Hi b prr rmiz.

lbrry v h im h pi’ m pr hck wr

igic r b ci 14. th mch ijri




PLASMA Pm r ri i bi rm vr hm r by cci i bg wih icg

prrviv mixr. th pm, r cr pri h b, i y pr by crigi

wh b i, b c b pr by r r crigi ig m vic. th

prcr, kw phri, c cc my 3 im h vm pm h bi rm

ig i wh b, whi imy rrig h cr cmp h r.

Pm h b r h cmb-

ijr ic Wr Wr II. Hiricy, h

iii i w i ci r vm

rpcm. Hwvr, i rpc

cgi cr i big pi wih

cr cicy h b vc i ri

civii prcic r rm rm

cii. thr i i ciic vic

pprig h prcic r gg h b

prcic. Hwvr, i m ri h, i

pi wih brry r ciic vic cgphy ci wih big,

rpcm wih pm my crrc h

cr cicy rc big.

Pm i pr rm h cr pri b rz (rh rz pm) wihi 8 hr

cci. Bc h mim g ic bw rgiz b riv h x ciii

wih qipm r pri rzig, h 8-hr rqirm c wy b m. I hi c,

pri h pm i ccr wihi 8 hr, b rzig my ccr p 24 hr r cci.

eihr vriy, c hw br ri, h iy h m ccri ky pm pri.

th w vrii r imir iqi pm vr rz. thr i vry m crm i Fcr V

ccri rgr crm i Fcr VIII wh r iqi vr im. Rrigri w

h gri pm pri, cgi cr rmi i chg r g 5 y.

thrr, y h yp pm, kp iqi rrigr p 5 y, c b r h m

iici. (th xcpi i h r pm r Fcr V rpcm. thi i rv r

rig h cgphy rm pi.)

th i cci, prcig, rg my ir, b h ir vrii prc i

igic ciic vrii vr. ech i pm h mch h m ccri pm pri

rm pm, h vrii rm i i i h rm hm vrii. Kpig i mi

i--i vrii, pm ig i rh rz pm h h wig qii:

• Overall volume: 190–220 mL (includes about 25 mL of anticoagulant preservative).

• Coagulation factors, including anticoagulants and brinolytic activity in normal concentrations.• Plasma proteins, including antibodies, notably the red cell major group (ABO) isohemaglutinins, an

iby h i y pricby pr b h r’ b yp:

typ a r pm: i-B.

typ B r pm: i-a.

typ aB r pm: i-aBo.

typ o r pm: i-a, i-B, i-aB.




Consideration of ABO Type

Pm rm aB r h i-a r i-B, h c irc icmpibiiy wih h

r c y b yp. typ o r pm h bh i-a i-B, h i icmpib

wih h mjriy pi h hr yp (a, B, aB). thrr, wh h r mrgcy

pm ri i irq, h chic pm r prhwig mrgcy ri h

b aB. Hwvr, wh pm i rqy r pi wih kw aBo yp, h aB pm wi qicky p h ivry, aB rcipi wh mr pm wi hv

y vib.

Wh rg mbr pm i r r, h b chic yp h bc rrc wih

rik rcipi i plasma of type A donors. Fr h ii, yp a pm h b ch r h

prhw mrg ri. typ a pm i cmpib wih o a rcipi. Icmpib

rcipi (B aB) mk p miriy h gr ppi. Bc h B ig h wkr

iby iy i pr i wr mbr r c h a, h i-B i a pm i iky

c prbm i icmpib rcipi. Frhr miigig immi icmpibiiy

r i-B, pm ci h B (r a) ig pr’ b yp. th B ig i

rcipi’ pm prvi rizig bc h rc iby vibiiy bi r c.

th vm icmpib pm h b imi, bc ci ri icmpib

pm wi vy c r c c c hmyi. typ-pcic pm h b giv

pib, y h iii 2 i r h b giv yp a, prhw.

Rc rrpciv y ri

pr ciic cm i h

opri Irqi Frm opr-

i erig Frm (aghi)

cfic gg pprch, r

gi, ig rh rz pm i

big pi wih cgphy. I

rrpciv cmpri r c

pm ri pr mriy,

pck r c pm i ri

1–2:1 w ci wih h w

mriy. (s ibr pg 44–45.)

B hi brvi xiig

gii, h wig rcmmi i rb: Fr pi wih brry ciic

vic cgphy, h ry pm r big my ri pck r

c pm 1–2:1. Hwvr, h hi ri h b ppi r pi, r

y big pi wih cgphy. sch rri prcic w crib

pi rrc wih xpc b— rrc h h b rrv r hcgphic pi wih cr hmrrhg.

—Francis M. chiricosta, MD, Ltc, Mc, us army




Figure 1. Patient immediately ater stabilization surgery. The abdomen is open, and the extremity ractures have

been splinted, deerring additional surgery until the patient is stable.




wr cr wih p, c bw

ijri wr rc wih cri m.

th bm w c wih Bg bg r

big wh wih i. th pi’ xrmiy

w wr h rpiy . Big rm h

p w w cr wih chi rig

pckig, hi rcr wr pi (Fig. 1).

H w k h p-p rcvry r. lb rwi h immi p-p pri wr igic r

b ci 3, wih hmcri 32%. th

pi’ hr r w ciy h 100,

hi yic b prr w ciy bv 120

mm Hg. Wihi 1 hr rgry, h pi w

rrr v III miiry mic rm

ciiy r gig cr.

TEACHING POINTS

I pi wih miv hmprim hck, pr-

hypi h im hi ici

rgic pig m b icip. Mici i wi w h rgic m rp

hi pricb v.

1. Prpr (riy) rp h pi prir

ici hi. th ymphic

rig ici wi r i c rp i h

pi’ b prr. opig h bm

rig h pri mp wi xcrb

h hypi. th rqirm r b prc

wi iky icr rig hi im i h rc

hmrrhg i cr.

2. ebih civ irv cc. tw rg-br irv chr my b iq,

pcm cri cr chr h b

rgy cir.

3. Bgi h ri b prc prir

rgry, i pib. thw FFP, c r FWB r

p ry pib. Wrm fi 40°C

miimiz cryi ii. u rcmbi

Fcr VII wih h iii ri.

4. trr h pi h oR pib.

thi cii rpi ry i h ch r bm

i h v c cmpi. Rcii

h hck rm cy h b cir

rg oR v h b y

by mrgcy rm vi rciiv

vr.

5. Cr irbmi hmrrhg iiiy wih

igh pckig qr. th, r big

i qr im.

6. Pc pg (wh pckig h ivr) i ch wy

pprxim h rcr b h ivr

cmpr big i. thi rqy rqir

prir pckig my rqir mbiizi

h ivr vryig gr. a Prig mvr myb hp.

7. n: Wh big i rr, rpiy cr

y rc pri cmii rm bw

ijry. d mp cr y mi,

m cri i wi. Pck h bm

v h bmi ci p. Pc Bg

bg r w VaC p vc r rr

h oR wh h pi h biiz.


ucr hmrrhg rmi h ig c

piy prvb h i h pr cfic ishw ai. Miv ri i miir

pprximy 7% 8% cmb ci. Cmb

rg m b miir wih h b prc

rrc vib hm, hy m b xpr

i h miiri b prc kw h

iici r hir . I r virm, b

prc r vib i vryig m; b, ri

b bk chici my b vib, h

vig h phyici cmpy rpib r h

miiri hi ivig rrc. Wh cmb-

w pi rqir ri, h wig

gii ppy:

1. Bgi rcii wih PRBC. I r r mr

i PRBC r rqir, r FFP ri

(PRBC:FFP) 1:1 r 2:1. Miimiz rcii

wih cryi, which c c ii c-

gphy.1

2. I miv ri ( 10 i r mr

PRBC) i icip, h p h b

miir. I p r vib, h FWB

h b giv.2

3. FWB i b h h b rcy rw. I pr-

vi r b c, pm, cig cr, p. o i FWB i h qiv 1 i

PRBC 1 i FFP. I ci h qiv

20,000 30,000 p/cc.3 FWB i iic r

i r virm whr cmp




PLATELETS vs FRESH WHOLE BLOOD IN MASSIVE TRANSFUSION

I h rm cgphy big i rm pi, h pm c wy

b civ. Prgriv hrmbcypi i ci wih ci big ri. P

ri c b hp.

Civii rm cr i h ui shv vib vriy b cmp

r big. Cmmy mg

h cmp r p. Cvry,

hgh rh wh b (FWB) i

imi i h ui s, h miiry

riy iiz FWB i h ig miv

ri (Mt) bh rc p

hr cr wh rg qii

b r rqir.

srg hv cy rpr rpi

crrci micrvcr big r ii FWB. Hwvr, hr r rwbck gr FWB ri h c b vi r by h pr p.

a mrgcy wh b riv (“wkig b bk”) rqir h cmmim my hhcr

wrkr r, kig hm wy rm hr i h prci im high m r rm.

P, h hr h, c b prcc ch im h p ccr’ r’

chig. Frhy cc wh b c

b qy r ri-rmi

i. Wih p cci, r c

b h im c hw b

-giv, ig r c wic

wk, prviig my r rm vr

h cr 2 mh. a r wh b

c y y 1 i i h im, i

i pr. th aBo yp wh b

m b yp-cmpib wih h rcipi. s

prcic (ypig h r, rig h i

i b wih h yp, ypig h rcipi,

rig h h crrcy yp i g

h crrcy yp rcipi) i my-

p prc wih high ikih rrr i

r mrgcy r m cy ig.

th yp cmpibiiy p i c b

bi cry b-chck i hqi bw mrgci. aBo-icmpib

p ri i mch iky c

hmyic rci h icmpib

wh b ri.

I y ri pr cm i opri Irqi Frm/opri erig Frm

(prrm by MaJ Jrmy Prki), h wh b r h phri p (Plt; cc

48-Hour Survival 30-Day Survival

100%

80%

60%

40%

20%

0%

p < 0.001

p = 0.04

PlateletsNo platelets

Figure 1. 48-hour and 30-day survival by platelet vs

no platelet groups. Groups compared using chi-square.

Forty-eight-hour survival: platelet group—218/266, 82

± 2%; no platelet group—90/137, 66 ± 3%; p < 0.001.

Thirty-day survival: platelet group—121/196, 62 ± 4%;

no platelet group—53/107, 50 ± 5%; p = 0.04.




i hr) i mivy r pi r

i mriy h i pi wih h

ihr. th cm w imir whhr

wh b r p wr (i ii

pck r c pm). Bc p

i mii y y i rr h 5 y, giv h g im i

k rpr ppi rm h ui s

py miiry mic rm ciiy

i hr, i p wr b r i Irq

aghi by us mic rm ciii,

hy w hv b cc i hr.

I nvmbr 2004, h cmb ppr hpi

(CsH) i Bgh, Irq, cqir h cpbiiy

cc (by phri) prvi p

(Plt) i. thi r iq ppriy

cmpr y cm pimg wih wih p, b

cmpr cm r pi wh rciv

FWB cmpr wih h rcivig Plt.

Rcr r rm mii h CsH i

Bgh bw Jry 2004 dcmbr 2006 wh rqir Mt wr rviw. Mt,

ri 10 i pck r b c /r FWB i 24 hr, w miir 708/8,618

(8.2%) rm mii. o h 708 rqirig Mt, rcr wr vib r 535 pi. o h,

hr 101 pi wr xc bc hy wr mg Frwr srgic tm (Fst) ciii

r i rciv ri i h r 24 hr. o h rmiig 434 pi, 285 rciv p

ihr FWB r Plt, 149 pi rciv p (ihr FWB r Plt). Fry-igh-hr

(82% v 66%, p < 0.001) 30-y (62% v 50%, p = 0.04) rviv wr highr i pi rcivig

p, cmpr wih h wh i rciv p (Fig. 1). ayi FWB Plt bgrp

hw irc r 48-hr (80% v 82%, p = 0.7) r 30-y (60% v 62%, p = 0.9) rviv (Fig. 2).

Mivri giic rgri w prrm hw h bh FWB Plt wr ipy

priciv rviv. I hi rgri, highr rh rz pm/r b c ri wr ipy

priciv imprv rviv 48 hr, ci wih pbih by Brgm .1

tri p ihr i h rm Plt r FWB i ci wih imprv rviv i pi

rqirig Mt. thr ppr b rviv irc bw pi mg wih FWB,

cmpr wih Plt (i ii pck r b c pm). Bc ir cci

prc i br y pr, h p pr h ri rm cgphy

big h b prrr vr h wh b wh h rmr i vib.

a ciii whr Plt r hr b cmp r vib, FWB i ccpb riv r

h mgm cgphy i pi rqirig Mt.

—MaJ JereMy Perkins, MD, anD Francis M. chiricosta, MD

1. Brgm Ma, spi PC, . th ri b prc r c mriy i pi rcivig

miv ri cmb ppr hpi. J Trauma. 2007;63:805–813.

Figure 2. 48-hour and 30-day survival by FWB vs

aPLT groups. Groups compared using chi-square.Forty-eight-hour survival: FWB—56/70, 80 ± 5%;

aPLT group—143/174, 82 ± 3%; p = NS. Thirty-

day survival: FWB—36/60, 60 ± 6%; aPLT group—

72/117, 62 ± 5%; p = NS. NS: not signifcant.

48-Hour Survival 30-Day Survival

100%

80%

60%

40%

20%

0%

p = 0.72

p = 0.87

Fresh Whole BloodAphereis Platelets




hrpy i vib. I h crr prig

virm i shw ai, i i primriy

by v II Fst prvi p i pirqirig miv b ri. I my b

i i PRBC, FFP, cryprcipi wh

h cmp r i hr ppy r xh.

4. Prir h pr cfic i shw ai, FWB

ri w cir cri. triig

m i, ch Fst, h chiq rwig

miirig b w pi h

rq FWB i prvi cfic. spci

qipm i rqir, ch ig r cci

bg b b (Fig. 2), crig i

rqir prpr b b cc r vir

ig prir hipm.

5. th primry ccr wih h FWB i h rik

ici i rmii. us rvic mmbr

r prcr r hm immcicy vir

(HIV) r vcci r hpii B vir (HBV).

Hwvr, hy r prcr r hpii C vir

Figure 2. Whole blood donation set that has been prepared or the eventuality o the requirement or resh whole blood.

(HCV), hm t-c kmi, r yphii. thr i

h rik rmii c mic i

(g, mri). th rik rmiig icii i hgh b h 1%, whr h

rik yig rm hmrrhgic hck i grr

h 30% (pbih rm h Ji thr

trm sym Ciic Prcic Gii r Frh

Wh B). thrr, h FWB i iic

wh pr cmp hrpy i vib.

I cmb pi wh rqir miv ri,

miiri p h b hw imprv

rviv. thr i igic irc i rviv

i pi wh rciv phri p vr

h wh rciv p rm FWB ri.1

Rpi crig r vib r b yp,

HBV, HCV, yphii, HIV. th r

pprv by h us F drg amiiri,

b r i i prcrig r wh

im prmi i pr r ri i hir

. B h b rw rm r r




pri ig. a rcr i h

b kp r bh h rcipi h r i h

v h pcrig ig rv ici

i.

6. typ o PRBC r h y b yp vib

Fst. dcriy, Fst crry 20 i PRBC

hv b rrigrr rgic qipm.

FFP i criy by Fst. Hwvr, i

h crr (2007) prig virm, FFP

cryprcipi hv b m vib. thi

rqir r b rzr pm

hwig i. typ o-giv PRBC r y

rrv r m pi. thr i b

b yp mch r FWB ri. Hwvr,

bc pi h Fst m wy rciv

vr i yp o PRBC br hy rciv

FWB, y yp o FWB i r. Iy,

EMERGENCY FRESH WHOLE BLOOD COLLECTION PROCEDURE

The Walking Blood Bank

1. dvp (wh pib) rr prcr r. I c, hv h r cmp

dd Frm 572—B di Rcr. exc high-rik r. Prir b r hv b

cr prviy r rmib i. dr wih rc brry crmi byp r i, bc iici g (g g) r icrrc 2% 11% h im.

2. C h r’ rm wih pvi-ii r chrhxii i r 1 mi.

3. drw h b rm rm vi i ig r b cci bg ciig icg,

ch cir, phph, xr, i (CPda) i. drw b 450 cc b i h

bg i m .

4. drw b b r ypig crmchig (edta [hyimi rcic ci] prp

p) r ig b-br ici i (w rm prr b, r gry p).

th rm prr b h b crig r 20 mi prir hipm.

5. Irm h prig m (br rig b) h mrgcy rw rh wh b i b

b r crm b yp pri pi hiry.

6. dcm cry wh h b w rm whm i w r.

7. obi w y ii hr gii pici r h ri rh whb.

Equipment Required for Fresh Whole Blood Collection (see Fig. 2)

• Blood recipient set (collection bag), indirect Tx Y-type.

• Stopcock, IV therapy three-way, with Luer.

• Serum separator blood tubes.

• EDTA blood tubes.

• Centrifuge.

pi rcivig FWB w rciv yp-pcic

b. I c i pi i cii

rc, h pi’ b yp i kw yp

o b i .

7. I gig big i icip rcmbi

Fcr VII i iic, h i h b mii-

r ry wh h pi h pH bv 7.1

i mr iky hv q ciig

cgi cr.

8. a v II, hr i pcicy ri mic

ircr h b bk. th cmmr r rg

i iry rpib r h miiri

b prc. thr r my gii h mp

irc h rg wh h miiri

wh b i pprpri. I c, h cii

miir FWB i ciic cii h m

b m br h cgphy




xgii. awig h pi bcm

cgphic prir miirig h pprpri

b prc wi m wy r i h h

h pi. th rg m icip y

p 1 hr r h ri FWB.

DAMAGE CONTROL

FWB i h m xpii rc r c, p, cig cr i h c mgm cmb

rm. th r miv b ri m b

rmi ry, mim br h pi rriv. I

FWB i iky, c r r ry bgi hwig

FFP immiy.

SUMMARY

Hypi hck rm b rmi cmm

prbm i b rm. Rpihm b

ihr cmp r FWB i m h

cc rm h pi. a phyici

pyig wr hr m r h bicpricip ri.

REFERENCES

1. Brgm Ma, spi PC, . th ri b

prc r c mriy i pi

rcivig miv ri cmb ppr

hpi. J Trauma. 2007;63:805–813.

2. Kchm l, H JR, Hiipp s. Iici r ry

rh rz pm, cryprcipi, p

ri i rm. J Trauma. 2006;60(pp 6):s51–s58.

3. Rpi tB, Prki JG, . th rh wh b

i miv ri. J Trauma. 2006;60(pp 6):

s59–s69.




CoMMentaRY

dmg Conrol Ruciion by COL John B. Holcomb, MD

ahgh h v mjriy big rm

pi wh rriv i mrgcy prm

(ed) r ihr hyprcgb, r y

ighy ijr wih rm cgi prmr,

m mbr rm pi (pprximy

10%) r hypcgb (iri rmiz

ri [InR] > 1.5).1,2 thi miriy ci b

50% h wh rciv y b prc

rpr h mjriy i-hpi rm h.

dh icr hr r rcivig mr h 4

i b. Pi r cciy hyphrmic

hv cii-ic cgi cr

p yci, cmbi wih cgi cr

cmpi, cmiig i pr cgphy.

ahgh i h b g rcgiz h h h

ri hyphrmi, cii, cgphy i

ci wih igic icr i mriy,3

cgphy h b viw byprc

rcii, hmii, hyphrmi. B civii rm miiry cmb cy ,

w w kw h cgphy i, i c, pr

mii.4–6

Crr rcii prcic c primriy rpi

rvr cii prvi hyphrmi,

whr ccrr rgic irvi c

crig hmrrhg cmii wih

r pck. ery irvcr rm

cgphy h b rivy igr. sr

rcii mh r pprpri r h 90%

rm pi wh r i hck rhyprcgb r ijry.7 Hwvr, r h 10%

pi wh ci h m riy ijr,

r i hck, r cgphic (hypcgb),

pm h b ii h b rcii

fi.8,9 ury, ciici r i big gh

vr pm rcii fi.10

Rc i hv hw h wig:

• Coagulopathy of trauma is present at a very early

g r ijry.1–6

• Ringer’s lactate solution and normal saline increase

rpri ijry kcy hi.11

• Increased transfusion is associated with increased

rik.12

• Massive transfusion in military and civilian casualties

i ci wih icr rik h.13,14

tk ghr, h brvi gg h h

m vry ijr pi wi iky b rm

w rcii rgy c pim imig

mi h mbic, ifmmi,

cgi phwy.

ovr h 6 yr, h us army h gi cirb

xpric i rcii cmb ci. B

prvi civii ciic i, rcmmi iri c crc ry,

miv ri r rm,15 h cmiv

xpric xpr i h crr wr, i i pib

rpiy iiy pi high rik r cgphy

mii prmpy r hyphrmi, cii,

cgphy ( appix d). thi rgy,

kw “mg cr rcii,” r h

ir h ri immiy mii i ccr

wih ggriv hmic irvi.16 dmg

cr rcii rcr irvi bgi

immiy r rpi iii m i h ed

prgr hrgh h prig rm (oR) ih iiv cr i (ICu). Irvi irc

rmizig h InR, b ci, mprr

ic h wig:

• Repeated point-of-care testing.

• Commercial warming devices.




• Use of multiple blood products.

• US Food and Drug Administration-approved drugs

riy vib i hr (bi i w ri

m).

Cmpr wih civii mg cr rgry rci-

i rgi, py rcii r r rgy

cmp i h oR, wih i rcii rqiri h ICu. achivig hi g qicky i h oR my

imy w hi rm imi mg cr

rgry rir, ggriv rgic irvi,

icig phiic imb vg chiq

imprv cm.

dmg cr rcii ci w pr

i iii wihi mi rriv i h ed. Fir,

rcii vm i imi kp yic b

prr pprximy 90 mm Hg, prvig

rw big rm rcy c v.17–22

sc, irvcr vm rri i ccmpihby ig hw pm primry rcii

fi i 1:1 ri wih pck r b c

(PRBC).8,9,23–25 Rcmbi Fcr VII my b

g wih h vry r i r b c, hw

pm, p, i iic by h ciic ii

( Ciic Prcic Gii r dmg Cr

Rcii lv IIb III [appix d]).26 Fr

ci wh wi rqir ci rcii, h

b bk i i civ h miv ri

prc. thi prc r i h ivry 6 i

pm, 6 i PRBC, 6 pck p,

10 i cryprcipi r i iivi cr.Fr h m vry ijr wih rrcry big,

rh wrm wh b rm h wkig b bk i

rr primry rciiv fi.27,28 Cryi

i igicy imi rv miy crrir

kp i p bw h i b prc.

th vry r rm Irq cribig h iii

impmi hi pprch rv cr i

g-rm mriy, rm 65% 19%, by ig pm

i 1:1 ri wih PRBC.29

dmg cr rcii i mmriz h :

• Early diagnosis of hemorrhage/hypovolemic shock in

h ed.

• Early diagnosis and aggressive treatment in the ED of

h h ri.

• A 1:1:1 ratio (thawed plasma:red blood cells:platelets)

hrgh rcii.

• ED/OR/ICU use of recombinant Factor VIIa, as

.

• Massive transfusion protocol that delivers xed ratios

prc i pp by h rg.

• Rapid use of fresh whole blood in most critical patients

wih gig hmrrhg.

• THAM (tris-hydroxymethyl aminomethane; also

kw rmhmi) C2+ i h oR

rmiz iiz C2+ kp h pH > 7.2.30

• Minimize crystalloid.31,32

• Allow hypotension until denitive (operative) hemor-

rhg cr.

th rcmmi crib prviy r

ph “b i hr rcii prcic”

i J 2006. I i icip h h prcic wi

b imprv p w r vib. Prgr

i rm cr rqir ci imprvm i

vryy pi mgm, b g ciic

i. My r m bic rm cr pricip

r rii rhr h vic-b

b prcic. Crr rcii prcic i hicgry, y w r mrgig i h civii

rm irr cmig h ri c

ggriv cryi rcii.31,32 a i p wr,

brvi, ici, yi, rcmmi

rm xpric miiry mic, r, phyici,

cii—ghr wih r civii rm

cg—wi prvi h bi r w mic

prcic, gr i pprpri rv prciic

hm i.33,34 Ijry, prcr, cm

c i h Ji thr trm Rgiry wi

prvi hyphi-grig irmi r yr

cm. Frhr xpric, rrch, vpm, prpciv rmiz i wi gr w

irmi gig mici.

REFERENCES

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miv ri i cmb ci. J Am Coll

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ci wih h ry cgphy rm i

cmb ci. Frhcmig.

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sg prmy r h hyphrmi, cii,

cgphy yrm. Am J Surg. 1996;172:405–

410.

4. Frigr Pd, Mi RJ, . B cmp

ppmi rig miv ri as-1

r c i rm pi. J Trauma. 1993;34:481–

485.




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J Trauma. 2003;54:1127–1130.

6. Mcl JB, ly M, . ery cgphy pr-

ic mriy i rm. J Trauma. 2003;55:39–44.

7. Kiry ln, dirig Ja, . Rcii

wih rm i (ns) v. c Rigr’ (lR)

m hyprcgbiiy icr

b i cr hmrrhgic hckwi m. J Trauma. 2006;61:57–64.

8. Hirhbrg a, dg M, . Miimizig ii

cgphy i xgiig hmrrhg: a

cmpr imi. J Trauma. 2003;54:454–463.

9. H aM, di PW, . a mhmic m r

rh rz pm ri rgi rig

mjr rm rcii wih gig hmrrhg.

Can J Surg. 2005;48:470–478.

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gii r pripriv b ri

jv hrpi: a p rpr by h

amric sciy ahigi tk Frc Pripriv B tri ajv

thrpi. Anesthesiology. 2006;105:198–208.

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ymic cqc ggriv fi rcii

rgi. Shock. 2006;26:115–121.

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icr hi by vri rcii

fi. Crit Care Med. 2000;28:74–78.

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cr ciic ri ri rqirm i

criic cr. tri rqirm i criic cr

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h cr c rm. Transusion. 2004;44:809–

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rcii rig civ hmrrhg: Impc i-

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22. s Jl, Cpp VG, Hcmb JB. B prr

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rh rz pm, cryprcipi, p

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prc r c mriy i pi

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hyrxymhymimh rvrig cg-

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w fi-mgm rgi i c g ijry.

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war surgery afghanistan & iraq atlas_chap1

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