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Cpe IVthoraCICtrauma



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.



120 | War SurGErY IN aFGhaNIStaN aNd Iraq: a SErIES oF CaSES, 2003–2007

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).




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.




Figure 7. Patient on post-op day 7.




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




Cpe 22: S-isse injies. In: Emergency War







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




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).


1. Wen e pien pesens wi peneing ncl

injy, pcee wi atLS pcl. I e pien

es n ve n inicin n eegency




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.




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




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









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




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.




Figure 1. The lung ater it has been mobilized and twisted around the hilum to slow the bleeding.


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.




Figure 2. Hilar clamping or “hilar twist.”

Figure 3. Illustration o pulmonary tractotomy.




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 23: Exeiy ces. In: Emergency War


dC: depen e ay, oce te SgenGenel, Ben Insie; 2004




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.




Figure 1. Intraoperative view o duodenal injury.


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.




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




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,



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.




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




Figure 1. Patient undergoing resuscitation. Note penetrating injuries to let chest.




Figure 4. Median sternotomy.

Figure 5. Exposed pericardium with blood clot rom initial pericardiotomy.




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




Figure 7. Single horizontal mattress suture using pericardium or pledgets.

Figure 8. Completed cardiac repair.




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.









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.




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).




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.




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.




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.


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.




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


depen e ay, oce te Sgen Genel,Ben Insie; 2004.



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.




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




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




e ce e pien, llwing e bl ive

ncin inepenenly e sgicl s.


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






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.




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




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.



Cesy dvi Leesn, The Dallas Morning News

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