war surgery afghanistan & iraq atlas_chap5

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Cha VABDOMINOpelVICtrAuMA



ABDOMINOpelVIC trAuMA | 159

V.1Indic effcs of

Wounding

CASE PRESENTATION

this 15-ya-od hos naion ma snd a ody

having bn sho onc wih an M-16. th wonds w

aan. A aa abdomina wond was h sscd

nanc wond (Fig. 1). two xi wonds w cad sconday

o agmnaion (Figs. 1 and 2). th ain ndwn xoaoy

aaoomy. In sgy, h was no vidnc o naion o hionm (Fig. 3). Nvhss, h was a 3-cm, -hicknss

injy o h ansvs coon (Fig. 4). this wond was iky casd

by caviaion commony associad wih high-vociy gnsho wonds.

Bcas o h ain’s aan good niiona sas and h isoad

xn o injy, h was ad wih xndd igh hmicocomy and

iocoosomy. Hos naion ains do no n h Amy vacaion

sysm and insad ncssaiy civ hi dniiv ca a a comba

so hosia (CSH). this ain’s wonds w on and

ad wih dssing changs. H covd wiho comicaions.

TEACHING POINTS

1. this is an xam o nonniom ngy ans o a high-vociyond. th widh o iss disbanc is an indicaion o h

magnid o ngy ans, which may incas aong h ajcoy

o a ojci.

2. th scic c invovd is caviaion. th hysica ois o

h ag iss dmin h dimnsions o h moay caviy. Fo

xam, h caviy may b sma in h ng, b ag in h iv.

Caviy siz can b imssiv—as mch as 20-od ga han h

diam o h b ha casd i.

3. this gnsho wond o h xaiona abdomina wa, which

casd an injy o h ndying bow, is aso an xam o indic

cs o wonding. psmd by is na o b a, h Wond Daa

and Mniions ecivnss tam (WDMet)—a daabas o Amicancasais in h Vinam Wa—cods ony v docmnd xams

o simia injy o 299 sviving casais wih inaabdomina

ama.

4. this cas aso cognizs h no ncommon scnaio in which, i oca

mdica aciiis a no avaiab o a d hosia is no sabishd

o ha so os, h CSH bcoms h highs v o mdica ca

avaiab o many aid miiay and civiians.



160 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007

Figure 1. (to)

M-16 entry and

exit wounds.

Figure 2. (Boom)

Close-up o M-16 entry

and exit wounds.




CLINICAL IMPLICATIONS

Sim, isoad coon injis a ncommon. In hos

naion casais and nmy combaans, oo niiona

sas o hs oaions may cd imay ai.

Divsion wih coosomy shod b songy considd

in a ains in h snc o any o h comicaing

acos isd bow:

1. Massiv bood anssion imn.

2. Ongoing hyonsion.

3. Hyoxia (sconday o a monay injy).

4. rsion (vasca) injy.

5. Mi oh injis.6. High-vociy injis.

7. exnsiv oca iss damag.

High-ngy angnia wonds a on o ogssiv

so-iss dviaizaion and may vov ino ncoizing

asciiis. ths wonds shod b siay dbidd and

aowd o ha by ih dayd imay cos osconday innion.

DAMAGE CONTROL

1. In h nsab ain, cono conaminaion

wih igaion/saing o h bow. esabishing

insina coniniy is no imaiv.

2. Day caion o h soma ni h ain is

sab.

3. Docmn amn o oima oow-

hogh a vs o ca.

SUMMARY this is an ncommon cas in which angnia injy

by a high-vociy ojci snd wih a aivy

bnign aaanc. An ndsanding o h indic

c o moay caviaion in high-vociy wonds

omd oma aaoomy. righ hmicocomy

wih iocoosomy was omd. In his cas,

Figure 3. Exploratory laparotomy. Note: There is no penetration o the refected peritoneal wall.




Figure 4. The transverse colon has a large wound resulting rom the indirect eects o the gunshot wound.

oongd ca was ncssay bcas h ain was

a hos naiona and cod no b vacad.

No: S discssion o hs cass on ag 201.

SUGGESTED READING

Cha 17: Abdomina injis. In: Emergency War

Surgery, Third United States Revision. Washingon,

DC: Damn o h Amy, Oc o th Sgon

Gna, Bodn Insi; 2004.

Bamy rF, Zajchk r, ds. Conventional Warare:

Ballistic, Blast, and Burn Injuries. In: Textbook o

Military Medicine. Washingon, DC: Damn o

h Amy, Oc o th Sgon Gna, Bodn

Insi; 1991.




V.2pnaing tauma o h

Somach and pancas

CASE PRESENTATION

Aca bombing occd na a comba so hosia (CSH).

A sa ad immdiay o a mass casay vn.

Iniiay, ony ains wih mino injis cam o h hosia.

Howv, sva hos a, a hos naion oicman snd wih

acia, abdomina, and xmiy injis. H was awak and a,

wih a midy nd abdomn and mi agmn wonds o h

ac ovying h aoid gand, h hoacoabdomina gion, and h

g (Fig. 1). His chs X-ay was signican o ai nd h

diahagm (Fig. 2). Ding sgy, a sing agmn was ond ha

had nd h abdomn, assd hogh h anio and osio

was o h somach, and mbddd in h ancas. th anio and

osio somach wonds w cosd in wo ays (Figs. 3–5), and a

disa ancacomy and sncomy w aso omd (Fig. 6).

th aoid injy was mino, and h ac acaion was cosd. th

g wond id ony washo, acking, and dssing changs.

TEACHING POINTS

1. this cas is an xcn xam o a ain who snd sva hosa injy bcas o h consion ny ncond oowing

an aack. A ims, h CSH was noid o ag-sca aacks and was

inomd o xc casais. Sisingy, hs ains may no aiv

o many hos.

2. In his cas, nogh im asd om h im o injy ni snaion

o h ain o aow ai o accma nd h diahagm and b

visib on h chs X-ay. pains wih naing abdomina injy and

ai nd h diahagm shod ndgo immdia aaoomy.

3. pnaing injis bow h nis, abov h symhysis bis, and

bwn h osio axiay ins ms b ad as injis o h

abdomn and manda xoaoy aaoomy.

4. Somach wonds i minima dbidmn and a cosd in woays. th agmn ha casd h injis was ond mbddd in

h disa ancas. I casd signican iss damag and ho

id disa ancacomy and sncomy.


th somach is w vascaizd and say has w wih imay cos.

Ais sying h somach a no nd ais and can b igad. th

oowing oins shod b mhasizd:




Figure 1. Abdominal entrance wound beore surgery. The acial wound overlying the let parotid gland is also apparent.

Figure 2. Chest radiograph (AP) o ree air under the diaphragm. (Objects are visible outside the body.)




Figure 4. Anterior stomach wound closed in two layers.

Figure 3. Anterior stomach wound beore closure.




1. en h ss sac o idniy osio somach and

ancaic body and ai injis. A Koch manv

shod b omd o hooghy vaa h

dodnm and had o h ancas. Aways

xamin h ancas in cass invoving naing

ama o h abdomn.

2. Dain a ancaic injis.

3. ta anscion o injy o h ancaic dc

by h oowing:

a. rscion (disa ancacomy, as in his

cas).

b. Ovswing o saing h oxima ancassgmn.

c. rox-n-Y dainag o h injy.

4. th somaosain anaog, ocoid aca (San-

dosain), adminisd sbcanosy (saing

dos, 50 mg .i.d.) can b iniiad i a ancaic

ak occs and may dcas o.

DAMAGE CONTROL

In an as nvionmn, onc hmohag is conod,

ancaic injy can b managd by dainag aon. I

h cinica siaion dicas, conoing bding wih

acking and imiing conaminaion by saing o

bow injis may b sd.

SUMMARY

this cas is an xam o a sing agmn assing

hogh h anio and osio was o h

somach and mbdding in h ancas. Managmn

o his cas was aivy saighowad, bcas hain snd wih a signican abdomina wa

injy, ndnss, and ai nd h diahagm.

this cas aso dmonsas ha a signican day

can occ bwn im o aca aack and aiva

o ains a a CSH, vn i ha hosia is wihin

cos oximiy o h aack. Mdica sa shod

Figure 5. Posterior stomach wound beore repair.




Figure 6. Distal pancreatectomy and splenectomy. Fragment is visible (aow) within the parenchyma o the pancreas.




consid his whn aniciaing a mass casay vn.

A ama sysm shod b in ac o ns ha

s cycs a mainaind and ha sonn do no

xhas hmsvs waiing o ains o aiv.

No: S discssion o his cas on ag 201.

SUGGESTED READINGCha 13: Fac and nck injis. In: Emergency War




Cha 16: thoacic injis. In: Emergency War






DC: Damn o h Sgon Gna, Bodn

Insi; 2004.




V.3Blun Abdominal

tauma

CASE PRESENTATION

this ma ain was invovd in a moo vhic cash. H

was ansd o a comba so hosia (CSH) a an

iniia vaaion a a hos naion mdica aciiy. tyica o

hs ys o accidns, dais w no avaiab whn h ain

aivd a h hosia. On admission, h was hmodynamicay and

noogicay ncomomisd. H had a nd abdomn. Imagingcaabiiy was imid o a cvica sin sis, a oab chs X-ay,

and a vis adiogah (a noma). A dcision was mad o xo

h ain’s abdomn. On ning h abdomn, vgab ma was

nod hogho h iona caviy, as w as 500 ml o bood. th

abdomn was hooghy xod, and a injis w imid o h

abdomn. th mos aan injis w o h somach and

dodnm. th somach was amos comy anscd bwn h

body and anm, and ony 1 cm o somach maind inac aong

h ss cva (Fig. 1). th dodnm was comy disd

bwn h scond and hid oions. th sio msnic vin

(SMV) was aso injd js cada o h ancas, and h ibay

vins had bn on fsh wih h SMV. Bding om h SMV wasmanagd wih n pon ss a h sis o h avsd banchs.

th bding nds o h ibais w managd wih igaion, and

h SMV maind an a h ai. On visa inscion, h

ancas was injy-. No oh abdomina injis w idnid.

Damag cono aaoomy was omd. No o was mad

o imay ai o h gasoinsina ac. th on nd o h

oxima somach was sad cosd. th on nd o h disa

somach was aso sad. In addiion, h wo anscd nds o h

dodnm w sad. this anaomica congaion h ain

wih a bind och consising o h disa somach and h oxima

dodnm. tmoay abdomina cos was omd, and h

ain was ssciad in h innsiv ca ni. A ssciaion,h was akn back o h oaing oom. Immdia soaion o his

gasoinsina anaomy was no omd. th oxima somach

was managd wih b gasosomy, and h disa somach and

oxima dodna och w managd wih b dainag. A 24-

Fnch Maco cah was acd hogh a s-sing sich in h

anio wa o h disa somach, and h cah advancd hogh

h yos ino h dodnm. th disa somach was bogh

o h igh adan o h abdomina wa and scd o h




Figure 1. With the patient’s head to the let, the Babcock on the patient’s right (A) is on the distal stomach

remnant. The two Babcock clamps on the let side o the patient are on the proximal gastric remnant (B). The

duodenal injury is not shown.

aia ionm. Ahogh h ancas had no

bn injd, wo dains w acd adjacn o h

ancas, and h abdomina wa ascia was on.

A wo mo days, h ain ndwn a hid

oaion. th SMV maind an. Nonhss,

bow dma vnd abdomina wa cos.

Abdomina ingiy was sod wih VICrYl msh.

Vacm dssing was aid o omo ganaion.

two days a, a achosomy was omd o assis

in waning h ain om h vniao. th ain

was ansd o a hos naion mdica aciiy. H

had good siaoy ncion, jjnosomy dings a

goa, and no vidnc o ssis a h im o ans.

TEACHING POINTS

1. Bn injis o h dodnm may b associad

wih massiv abdomina ama, as in his

cas. eay ding h iniia oaion, considaion

shod b givn o sagd damag cono sgy.

2. Whn odcd by bn oc, gasic s a

on ag wih coios inaiona soiing.3. Wih massiv oxima insina injy a iniia

oaion, ony bow ha is nsionaby

dvascaizd o ncoic shod b scd.

Ahogh bow o sionab viabiiy can b

assssd inaoaivy (Do fow, foscin), a

scond-ook oaion in 24 hos is commndd.




REFERENCE

1. 86h Comba So Hosia. exinc o h

86h Comba So Hosia. Oaion Iai

Fdom-1. Janay 2003 hogh Jn 2003.

unbishd daa.

SUGGESTED READING

Cha 1: Waons cs and aach injis. In:Emergency War Surgery, Third United States Revision.

Washingon, DC: Damn o h Amy, Oc o

th Sgon Gna, Bodn Insi; 2004.

Cha 11: Ciica ca. In: Emergency War Surgery,

Third United States Revision. Washingon, DC:

Damn o h Amy, Oc o th Sgon




DC: Damn o h Amy, Oc o th SgonGna, Bodn Insi; 2004.

Cha 34: Ca o nmy isons o wa/inns.

In: Emergency War Surgery, Third United States

Revision. Washingon, DC: Damn o h Amy,

Oc o th Sgon Gna, Bodn Insi;

2004.

uS Amy Cn o Hah pomoion and pvniv

Mdicin. Clinical Practice Guidelines. Abdn

poving Gond, MD: uSACHppM; Mach 2005.

44h Mdica Command.


1. evn hogh Amy mdica asss can b gad

owad comba ama in a comba zon, noncomba

ama si occs. Aoximay 40% o sgis

omd by on CSH ding comba doymn

w noncomba ad.1

2. Amy mdica sonn doyd in h comba zon

a socd o ovid ca o comba casais.Howv, many ama ains wi b hos naionas

dnding on h mdica s o ngagmn and

socs avaiab. Whn socs a avaiab and

sciy mass in ac, oviding ca o h oca

oaion may b ossib.

DAMAGE CONTROL

1. this cas is yica o h y o damag cono

sgy ha is id in comba hosias.

2. Cinica acic gidins sggsing damag

cono aaoomy incd h oowing:

a. Mi i-haning injis.

b. Acidosis (H < 7.2).

c. Hyohmia (ma < 36°C).

d. Hyonsion and shock.

. Combind hoow viscs and vasca injy.

. Coagoahy.

SUMMARY

this ain had a combind hoow viscs and a

majo vasca injy. H id 8 nis o ackd

d bood cs. His ioaiv sas incdd

hyonsion, and h snd a iad o hyohmia(34.6°C), acidosis (H 7.27), and coagoahy

(aia homboasin im, 54 sconds). th

ain’s Injy Sviy Sco (ISS) was 16. H

was ad wih damag cono aaoomy, and

damag cono chnis sd ay in his amn

sd in a sccss ocom. tams aing o

doymn nd o anicia oviding ca o h

oca oaion and o noncomba ama ains.

No: S discssion o his cas on ags 201–202.




V.4Missd Duodnal

Injuy

CASE PRESENTATION

this 20-ya-od main was ansd—a aaoomy and

ai o naing gasic injy—om a v II Fowad Sgica

tam (FSt) o a v III comba so hosia (CSH) mdica

amn aciiy. Whi awaiing aomdica vacaion, h xhibid

achycadia and hyonsion, wih a sma amon o biios dainag

om h osio xi wond (ow back). th ain’s abdomn wasxod io o aomdica vacaion. A aaoomy, bi saining

was nod a h si o gasic ai. A Koch manv was omd.

A missd hogh-and-hogh dodna injy was aso discovd (Fig.

1). In addiion, a sio o acaion o h igh kidny was ond

(Fig. 2). th dodna injy was aid wih a wo-ay cos

anioy and osioy (Figs. 3 and 4). th na injy was dbidd,

and bding was conod wih cocay. Boh injis w

xnay daind. th ain imovd cinicay and was a vacad.

TEACHING POINTS

1. lv II sgy nis (g, FSts) oa in as and soc-

consaind nvionmns. On, hy om isaving oaions invy dic condiions. I is ciicay imoan ha mdica sonn

om a hoogh xoaion (i im mis) whn oaing on

naing abdomina ama.

2. I h cinica siaion o condiion o h ain dos no mi his

xaminaion, i is ssnia ha h v II mdica amn aciiy

commnica in som way (vn i i invovs wiing on h abdomina

dssing; Fig. 5) wih h civing v III aciiy o mak s ha

h nx v o ca sonn ndsand ha xoaion io o

h vacaion is mandaoy.

3. I is ciica ha v III mdica amn aciiis cay vaa

ains civd and consid ay oaion whn ains main

nsab o dioa a aiva. Sia xaminaions and anivobsvaion o osoaiv ains a mandaoy hogho h

MeDeVAC sysm.


Injis o h dodnm a on associad wih massiv abdomina

ama. Damag cono chnis shod b considd ay.




Figure 1. Through-and-through injury to the duodenum ater Kocher maneuver. Note bile staining o

surrounding tissue.

1. Missd injis o h dodnm hav dvasaing

mobidiy and a associad wih high moaiy.

2. Bi saining o hmaoma in h idodna

isss mandas xoaion o h dodnm.

3. Mino injis can b aid imaiy.

4. Majo injis shod b aid i h mn

wi no b naowd by mo han 50%.1

5. Consid h oowing o injis invoving mo

han 50% o h mn1:

a. Dain h injy hogh a rox-n-Y jjnaimb.

b. Avoid ancaicododncomy.

c. Div h gasic sam wih a gasosomy

and cos h yos. Do no divid h yos.

d. Widy dain a injis wih cosd-scion

dains.Figure 2. Injury to the kidney.




Figure 3. Duodenal injury in the process o being closed.

. Cos h dodnm aond a Maco cah

sing 2-0 VICrYl (b dodnosomy).

DAMAGE CONTROL

1. pnaing na injis can b managd by dbidmn

and dainag. th shod b a ow hshod o

nhcomy in h nsab ain.

2. Dodna injis shod b cosd imaiy i asib

and naowing o h mn ss han 50% can b

obaind. A dodna injis shod b daind.

SUMMARY

In his cas, dsi h ack o commnicaion ny

ncond in comba nvionmns, sgons cocy

dmind ha his ain id xoaion. this

acion vnd h wosning o his condiion, sciay

a h os o oongd vacaion.


THE KOCHER MANEUVER

Namd o Nob piz-winning

sgon D emi thodo Koch

(1841–1917), h Koch manv

(o Koch’s manv) is a sgica

ocd o xos scs in

h oionm bhind h

dodnm and ancas. In his

manv, h had o h ancas

is mobiizd and accssd ding

an oaion. to b y cad aKoch manv, h who scond

a o h dodnm has o b

mobiizd wih h oionm

ba o inscion a h way o h

aoa.




REFERENCE

1. Cha 17: Abdomina injis. In: Emergency War



Gna, Bodn Insi; 2004: . 17-9.

SUGGESTED READING

Cha 2: lvs o mdica ca. In: Emergency War




Cha 4: Aomdica vacaion. In: EmergencyWar Surgery, Third United States Revision. Washing-

on, DC: Damn o h Amy, Oc o th

Sgon Gna, Bodn Insi; 2004.Figure 5. Communication involving writing on

abdominal dressing rom level II to level III medical

treatment acility.

Figure 4. View o closed duodenum.




V.5taumaic eviscaion

CASE PRESENTATION

A30-ya-od hos naion ma ssaind a bas injy o his

fank. I ook 12 hos o ach h Fowad Sgica tam

(FSt) oaing bas. A d dssing had bn acd ov

h wond, b no oh ssciaiv os w iniiad. Whn h

ain aivd, h was a and oind, wih noma via signs and

no achycadia. A sconday svy vad a signican abdomina

wa injy wih viscad sma bow (Fig. 1). H had mi

noomis in h viscad sgmns o h sma bow. th

was an isod o biios msis, and a nasogasic b was acd o

dcomss h somach. th ain was sad on inavnos fids

and givn a scond-gnaion chaosoin inavnosy. H was

hn akn o sgy. th abdomn was xod hogh a midin

incision, and no goss ca conaminaion o h ionm was ond.

th w no oh visca o vasca injis nod. th viscad

sma bow was addssd by s cosing h noomis moaiy

wih sik ss osid o h abdomn and hn dcing h bow

ino h abdomina caviy. th bow was assssd o ischmia, and

gossy ischmic-aaing bow and nonviab bow w scd(Fig. 2). Bow coniniy was sabishd ding sgy wih

imay anasomoss. th abdomn was washd o wih 6 is o

noma sain and hn cosd. H was xbad and ansd o h

innsiv ca ni (ICu). th ain had an nvn osoaiv

cos; was sad on a ga di on osoaiv day 4; and had no

sho-m, osoaiv comicaions.

TEACHING POINTS

1. phosia managmn shod b imid o coving viscad

abdomina conns wih moisnd gaz o oh si dssings

and hn scing h conns wih a o vn h

viscaion. Mdics shod no am dcion o conns,bcas his can s in dcion o gangnos o oad

bow ino h iona caviy.

2. Whn h ain aivs wih viscaion o abdomina conns,

h hysician shod no b disacd by h obvios injy and

shod ocd wih Advancd tama li So (AtlS)

ooco. Ony a hoogh imay and sconday svys is h

amaic viscaion addssd.

Cosy David lson, The Dallas Morning News




Figure 1. Wound showing evisceration o the small intestine.


Onc h dcision is mad o ak h ain o h

oaing oom, managmn o a sim viscaion is

saighowad.

1. th ain can b d widy, and h viscad

bow can b d wih badin a hoogh

iigaion.

2. Any oh immdiay i-haning abdomina

injis shod b addssd s—hn dc h

bow and assss viabiiy.

3. th ocd shod bgin wih a midin incision.

4. th viscad bow can b xamind osido h abdomina caviy. I h a noomis,

cono conaminaion by cosing h dcs wih

a sim s bo dcing h bow back

ino h abdomn.

5. rmmb, as in an incacad hnia, sim

dcion o h insins may b a ha is

ndd o n bood fow o ischmic aas.

6. A anky ncoic bow is movd, and a i-

may anasomosis o an osomy may b omd.

Choic o imay anasomosis vss osomy and

dayd imay ai dnds on many acos

(g, h snc o associad injis, hyonsion,

and dg o inaabdomina conaminaion). pi-

may ai in yong, hahy ains who a

hmodynamicay sab is accab. An osomy

and dayd ai a svd o nsab ains

o sv, goss ca conaminaion, as in a coon

o ca injy.

DAMAGE CONTROL1. Cono aiway and hmohag s in hmo-

dynamicay nsab ains.

2. Cono goss conaminaion by cosing no-

omis wih sim ss o sas.

3. rsc dad and ischmic bow and day anaso-

mosis o caion o an osomy ni ains a

hmodynamicay sab.




Figure 2. Removal o necrotic and ischemic bowel.

SUMMARY

In h comba sing, h managmn o viscad

abdomina conns is said ino wo cagois:

(1) ay mandaoy aaoomy and (2) nongn

aaoomy. unik in h civiian sing, nonoaiv

amn o hs ains is no aoia.


SUGGESTED READING

Aikan S, Kocaksak A, a. A osciv comaison o

h sciv obsvaion and oin xoaion mhods

o naing abdomina sab wonds wih ogan o

omnm viscaion. J Trauma. 2005;58(3):526–532.

Bnissa N, Zobidi M, a. Abdomina sab wond injy

wih omnm viscaion. Ann Chir. 2003;128(10):

710–713.

Cha 3: tiag. In: Emergency War Surgery, Third

United States Revision. Washingon, DC: Damn

o h Amy, Oc o th Sgon Gna, Bodn

Insi; 2004.








V.6pnaing rcal

Injuy

CASE PRESENTATION

this 35-ya-od ma ain was iding in a miiay vhic whn

an imovisd xosiv dvic (IeD) was donad. H was

ad by mdics in h d and hn bogh o h comba

so hosia (CSH) by MeDeVAC hico. H aivd awak

and comaining o ain in his g. A hoogh xaminaion vad

an obvios m ac wih a aa nanc wond and a

mdia xi wond. th ain’s ss w noma, wih no vidnc

o aia injy. Fh xaminaion vad a scond naing

wond ha nd h bock, cad a ag sbcanos ac

wih aab cis, and xid hogh a ag wond in h igh

bock. examinaion o h inm showd no bising, and no

oh injis w nod. th ain id xna xaion o h

m ac and xoaion o h saca wond. I was ca ha h

ocd wod ak som im o om. A bood div was iniiad

o 8 nis o who bood. Bcas h was minima bding om

h saca wond, xna xaion o h m ac was omd

o minimiz bood oss om ha wond. thn h ain was acd

in h on osiion. th saca wond was addssd by oning hwond ac bwn h nanc and xi wonds. th ojcis

(ocks) had assd hogh h sacm a h S2 v and comy

dividd h bony sacm (Fig. 1). th msca bding was ackd.

A -hicknss, 50% cicmnia osio ca injy—wih

goss ca conaminaion—was idnid. th was bding om h

ain’s sid bwn h cm and aa vic wa. th

svd nds o h hyogasic ay w idnid wih dicy

and igad. th saca vnos xs o h and ow saca

agmns was comssd wih acks. Wih hmohag conod,

h ain’s hysioogica sas was assssd. His ma was

34°C, and h was cinicay coagoahic and acidoic. th dcision

was mad ho o ocd wih damag cono by aidy cosingh ca wond wih VICrYl s, aying qikCo hmosaic

agn, and acking h wond. th skin was cosd ov h acks o

ay ss (Fig. 2), and h ain was hn akn o h innsiv

ca ni (ICu) o ssciaion and waming (Fig. 3). A ha im,

h CSH did no hav aciv waming dvics (g, Bai Hggs), so

inavnos cah bags had in a micowav ovn and acivad

Mre (Ma, rady-o-ea) has wad in ows w sd o wam




Figure 1. Pelvic radiograph. Note numerous oreign

bodies. The sacrum is transected at S2.

h ain. H was givn who bood anssions

ni his a v was abov 50,000 s/ml. Wih

ssciaion, h ain’s ma and via signs

nomaizd and acidosis imovd. Howv, h ain’s

abdomn bcam incasingy disndd, and sia

asond xaminaions vad incasing amons

o inaiona fid. Onc sabiizd, h ain was

nd o h oaing oom (Or) o aaoomy

o o inaabdomina hmohag and o om

a diving coosomy o a h cosaca wond.

No inaabdomina wond was idnid, and an nd

dscnding coosomy was omd (Fig. 4). th disa

coon was cosd, oowd by cos o h abdomn.

th oowing moning, 24 hos a iniia injy, h

ain was hmosaic. evacaion was annd, b h

iming o ha vacaion is ndicab; ho,

h ain was akn back o h Or o washo and

dbidmn o h ca wond. th saca acks wmovd (Fig. 5). th aw sacs w hmosaic, wih

h sandik mnans o h qikCo in ac. Coios

iigaion was sd o mov h aics and ncoic

iss. Maniaion o h saca body vad a

cbosina fid ak, and inaoaiv consaion

wih a nosgon was obaind. Dniiv amn

o ha injy was dd o v V. tho, h

wond was cosd ov cosd-scion dains. la ha

vning, h ain was vacad o a v IV mdica

amn aciiy wih his sgon anding and wih

CCAtt (Ciica Ca Ai tanso tam) assisanc.

TEACHING POINTS

1. Comba-injd ains on sn wih mi

comx wonds. A vaiabs ms b considd

whn caing o hs ains. I can b agd

ha h saca injy shod hav bn addssd

s. Howv, i was ca ha, whn his ain

snd, h wod i sagd ocds and

damag cono chnis.

2. th nd o who bood and oh bood odc

anssions ms b idnid ay.

3. th nd o damag cono sgy ms b mad

bo ivsib acidosis and coagoahy dvo.us a o yo socs—hysicians, nss, and

anshiss—o sscia and sabiiz h ain.

4. ligaion o inna iiac ais may b civ in

managing ohwis nconoab vic hmo-

hag. I can b omd hogh h osio

wond in som siaions. Biaia igaion o h

inna iiac ais is o b avoidd, i ossib.

5. In h comba sing, om h as amon

o sgy ossib. In his cas, h cbosina

fid ak was conod, and dniiv ai was

dd o a v V mdica amn aciiy. I

ossib, am imay cos o h hca sac.

In many cass, his canno b don bcas dic

accss may b dic, o bcas h da nds o

b diahanos and ams a siching can nag

h a. Insad, consid a da sbsi (g,

DaGn). Foow wih a bin saan.

Figure 2. Damage control. Skin temporarily closed

over packing.




6. CSHs a dsignd o a comba ama. p-

doymn and acim aining ms incd

ain ca wihin h d amn aciiis. In his

cas, imn as ndamna as ain wams

w no incdd in his hosia’s invnoy. Amy

sgons ms disciin hmsvs o aicia in

doymn aining and h ocss ha dvos

d hosias and h imn s.


Whn caing o ains wih mi comx wonds,

mmb h basics:

1. Cono h aiway, obain ada inavnos

accss, and sscia h ain wih wam fids,

incding who bood whn aoia.

2. Idniy socs o hmohag and cono

hmohag by h sims mans avaiab.

this may incd sabiizing xmiy and vic

acs. Hmosaic agns (g, chiosan) may bs. Fsh ozn asma and combinan aco

VII may b avaiab. tama sgons nd o

ndsand h aaion and s o a avaiab

bood odcs.

3. Cono goss conaminaion and ibay d

dniiv ai o bow injis ni h ain is

sab. A moay cos wih acks and dains

in ac is on h. Whn h ain is sab,

annd oaion is s.

4. rca wonds can b dic o diagnos. Injy

shod b sscd i ama has occd in

oximiy o h cm, i h is an abnoma caxaminaion, o i a adiogah sggss injy. th

oowing incis ay:

a. A ca injis shod hav oxima

divsion. Sigmoid nd coosomy is say

ada. I h injy has no vioad h

ionm, xoaion o h xaiona

cm shod no b don a aaoomy nss

indicad o an associad nonbow injy.

this avoids conaminaing h iona caviy

wih soo.

b. A ca wonds shod b daind. psaca

dains shod b sd o xaiona ca

injis. Fca conaminaion o h ica

sac mandas saca dainag.

c. Disa washo o h cm is say ncs-

say o assss h injy. Gn ss whn

iigaing wi minimiz conaminaion o h

ica sac.

d. Dbidmn and cos a no ncssay insma- o mdim-sizd wonds ha hav bn

divd and daind.

. Hmaoma in h ica sac shod b

daind ih ansminay by aving h

injd cm on o by acing dains ans-

abdominay o hogh saca dains.

. pionaizd ca injis a asiy accssd

ansabdominay and shod b aid and

ocd wih divsion.

DAMAGE CONTROL

this cas ay isas h incis o damag

cono. Damag cono is dnd as h aid iniia

cono o hmohag and conaminaion, moay

cos, ssciaion o noma hysioogy in h ICu,

and sbsn xoaion and dniiv ai.

Concning h cbosina fid ak: sw in a ach

ga o ay on down and saa i wih ascia and a.

Figure 3. Rewarming and stabilization o the patient

in ICU.




Figure 4. Surgery; exploratory laparotomy and diverting colostomy.




Div cbosina fid wih a mba dain. pack h

wond. K h ain fa.

SUMMARY

In his cas, a ain wih sv injis svivd

hos wonds by civ s o damag cono

chnis, incding ay aggssiv ssciaion

wih who bood and cono o hmohag and

goss conaminaion. Whn sab, h ain was

nd o h Or o h id sgy and hn

vacad. pom Ct/myogahy a v V o

o sdomningoco.

No: S discssion o his cas on ags 202–203.

SUGGESTED READING

Cha 4: Aomdica vacaion. In: Emergency War




Cha 6: Hmohag cono. In: Emergency War

Surgery, Third United States Revision. Washingon,DC: Damn o h Amy, Oc o th Sgon


Cha 12: Damag cono sgy. In: Emergency

War Surgery, Third United States Revision. Washingon,



Figure 5. Third surgery; sacral packs are removed.








Cha 22: So-iss injis. In: Emergency War


THREE PHASES OF DAMAGE CONTROL

th goa o damag cono is o so noma hysioogy ah han noma anaomy. I is sd o

h miy injd ain, wih combinaions o abdomina, vasca, gnioinay, noogica,

ohoadic, and/o hoacic injy in h saa and disinc hass.

1. pimay Oaion and Hmohag Cono—sgica cono o hmohag and mova o

conaminaion; aaoomy minad, abdomn ackd, and moay cos; dniiv

ai is dd.a. Cono o hmohag.

b. exoaion o dmin xn o injy.

c. Cono o conaminaion.

d. thaic acking.

. Abdomina cos.

2. Ciica Ca Considaions—noma hysioogy sod in h ICu by co waming, coc-

ion o coagoahy, and hmodynamic nomaizaion.

a. Co waming.

b. rvsa o acidosis.

c. rvsa o coagoahy.

3. pannd roaion—xoaion o com h dniiv sgica managmn o vacaion.



Cha 23: exmiy acs. In: Emergency War







V.7rnal tauma

CASE PRESENTATION

A23-ya-od hos naion ma snd wih a sing gnsho

wond oowing a sni incidn. th ain was a

and sonding aoiay o sions. Iniia via signs

vad h oowing: bood ss, 90/60 mm Hg; ha a,

115 bas min; and ma, 36ºC. pimay and sconday

svys vad dis abdomina ndnss and bond, and a sing

nanc wond in h osio axiay in on h js bow h

12h ib. th ain wn dicy o sgy, wiho imaging, basd

on h cinica xaminaion. exoaoy aaoomy was ngaiv, o

incd no obvios oiona hmaoma. th ain civd 2

nis o ackd d bood cs inaoaivy. posoaivy, his via

signs sabiizd. Aoximay 10 hos osoaivy, h ain’s

via signs bcam nsab, wih bood ss o 80/60 mm Hg and

a ha a o 130 bas min. ra aboaoy vaaion

vad h oowing: hmogobin, 7.5 g/dl; innaiona nomaizd

aio (INr), 3.1; and aia homboasin im (ptt), 68 sconds.

A Ct scan was obaind (Fig. 1) and vad a gad III igh na

injy (tab 1) wih no inay xavasaion and inac vsss. thb is shown. Bcas o h cn ons o hmodynamic insabiiy

and coagoahy, a ia o nonoaiv managmn was cd.

th ain was givn 2 addiiona nis o ackd d bood cs,

4 nis o sh ozn asma, and 7,500 µg o acivad Faco VII.

Fid ssciaion conind. Ov h nx sva hos, in o

incasd and via signs sabiizd. th coagaion aams aso

nomaizd. th ain was dischagd hom on osoaiv day 5.

TEACHING POINTS

1. Signican oiona injis can b missd a xoaoy

aaoomy. Consid ay imaging wih ngaiv ndings a

xoaion.2. th majoiy o gad III na injis do no i oaion.

Coagoahy was a comicaing aco in his cas.

3. In ains wih gad III o IV na injis—wih no oh indicaion

o oaiv xoaion—a ia o aggssiv ssciaion wih

cysaoid and bood odcs is h s in o invnion. Oaiv

xoaion o h oionm is svd o nonsonds.




4. th s o acivad Faco VII is conovsia; in

his cas, i may hav bn ogan-saing.


1. Managmn o bn and naing na ama

is dicd by h gad o injy. Gads I o III

invov vaying dgs o acaion and hmaoma

wih no dision o h majo vsss o cocing

sysm. Gad V sns avsion o h dic

and is amos aways managd oaivy. Gad IV

invovs vaying dgs o cocing sysm and/o

vasca injy. Managmn o gad IV injis

can invov ih immdia oaiv xoaion

o a ia o aggssiv ssciaion wih cysaoid

and bood odcs, dnding on h avaiabiiy

o socs and h v o xis o avaiab

sgons.2. rna ama ains shod hav a Foy cah

in ac and shod main on bd s ni goss

hmaia cas.

DAMAGE CONTROL

In h absnc o a Ct scann, a FASt xaminaion

o h oionm may dc a oiona

hmaoma. I no imaging is avaiab, a high indx

o ssicion o oiona injy ms b

mainaind basd on h ocaion o nanc and xi

wonds. I h ain sonds o fid and bood

odc ssciaion, immdia vacaion o h

nx v o ca shod b iniiad. I hmodynamics

mains nsab, mgn oaiv invnion is

id, wih ca anion o assssmn o h

oionm. Nhcomy may b h bs soion

o majo na injis whn oh i-haning

injis a sn. Dmining h ncion o h

conaaa kidny (conmd by conas sdy) is

dsiab io o nhcomy.

SUMMARY

th kidnys and oh oiona scs aa isk wih bn and naing abdomina, back,

and fank ama. I oaiv managmn is no

immdiay indicad, h imaging modaiy o choic

is a h-has Ct scan o h abdomn and vis.

Basd on Ct scan ndings, na ama can b gadd

on a sca o I o V. Gads I o III and many gad IV

grade Type oF injury descripTion

Minor

I Consion Micoscoic o goss hmaia; oogica sdis noma

Hmaoma Sbcasa, nonxanding wiho anchyma acaion

II Hmaoma Nonxanding ina hmaoma connd o na oionm

lacaion <1.0-cm anchyma dh o na cox wiho inay xavasaion

Major

III lacaion >1.0-cm anchyma dh o na cox wiho cocing

sysm o inay xavasaion

IV lacaion panchyma acaion xnding hogh na cox, mda,

and cocing sysmVasca Main na ay o vin injy wih conaind hmohag

V lacaion Comy shad kidny

Vasca Avsion o na him ha dvascaizs kidny

Table 1. Renal Injury Scale




Figure 1. Abdominal CT images obtained postoperatively. A large perinephric fuid collection and air lucencies

(l) , as well as bullet ragment (righ) are evident.

injis can b managd nonoaivy wih aggssiv

fid and bood odc ssciaion.

SUGGESTED READING





Cha 18: Gnioinay ac injis. In: Emergency







V.8pnaing plvic

tauma

CASE PRESENTATION

A27-ya-od ma ssaind injis a xos o a bas om

an imovisd xosiv dvic (IeD). H was h on-sa

assng in a vhic, and h bas occd a h igh on

i. On aiva, h was a and answing sions aoiay.

Via signs w sab. pimay and sconday svys vad a igh

ank bas injy and naing wonds o h osio igh

high (Figs. 1 and 2) and mdia high. Abdomn, gnioinay,

and ca xaminaions, as w as h maind o h hysica

xaminaion, w noma. A ain m was obaind o h igh oo

and ank and h igh high. An anoosio vis adiogah

was odd. two ag shan agmns w idnid ovying

h vis (Fig. 3). Wih his inomaion, a Ct scan was hn obaind

o h abdomn and vis. th Ct scan showd wo agmns: on

agmn was adjacn o h bas o h badd on h igh, and h

oh agmn was adjacn o h inio bic ams and osio

asc o h igh cos cavnosm (Fig. 4). th ocaion o h

agmns aisd concn o h ingiy o boh h inay ac

and ow gasoinsina (GI) ac. H was bogh o h oaingoom o washo o h igh ank and h invsigaion o h

ow inay and GI acs. pocoscoy was ngaiv. Cysoscoy and

ogad conas sdis vad no injy in h ha, badd,

o disa igh . H was obsvd ovnigh and vacad in 24

hos o h nx high v o ca.

TEACHING POINTS

1. IeD agmns may hav a signican disanc o xcsion om

h nanc wond. Consny, ain ms shod b obaind

ibay in h ama bay.

2. Whn vic agmns a idnid, h ingiy o h inayand ow GI acs ms b considd. Fh diagnosic sing

shod b annd basd on adiogahic and hysica xaminaion

ndings.


pnaing injis o h vis a on associad wih abdomino-

vic ogan injy. Diagnosis o associad injis may i




Figure 1. Penetrating blast injury, right ankle.

Figure 2. Penetrating wounds, right posterior thigh.




Figure 3. AP pelvis radiograph. Note the two ragments.

Figure 4. Pelvic CT image. Note ragment (with associated scatter eect) at right posterior corpus cavernosum.




xoaoy aaoomy. Cahizaion is conain-

dicad ni ha ingiy is conmd by o-

gad hogahy.

DAMAGE CONTROL

Fo cass o sscd ha ama (bood a h

mas, scoa hmaoma, high-iding osa), a

ogad hogam shod b omd ioo insion o a Foy cah. I a ha injy is

discovd, a sabic cah is commndd.

SUMMARY

IeD bass a h mos common mchanism o

injy in Oaion Iai Fdom. thy may s

in mi sis o ama o a givn ain. th

ocaion o h nanc wond oms vaying vs

o concn o adjacn scs basd on ocaion.

I ms b mhasizd ha agmns may com o

s a signican disanc om hi nanc wonds.

liba s o ain adiogahy and coss-scionaimaging shod b iizd wih his mchanism o

injy.

SUGGESTED READING

Cha 18: Gnioinay ac injis. In: Emer-

gency War Surgery, Third United States Revision.



Cha 21: pvic injis. In: Emergency War

Surgery, Third United States Revision. Washingon,DC: Damn o h Amy, Oc o th Sgon






Cha 26: Injis o h hands and . In: Emer-







V.9pnaing Scoal

tauma

CASE PRESENTATION

A23-ya-od hos naion ma snd as a o a mass

casay vn a a sicid bomb aack. th ain was

a and comaind o igh hand, igh goin, and igh high

ain. His injis incdd a igh-hand ac and an avsion o

skin and sbcanos iss in h oxima/mdia igh high wih

a oign body vidn on xaminaion (Fig. 1). th ni and scoa

xaminaions vad dis dma and cchymosis. th sic

was aab and nmakab. th igh sic was nonaab.

A adiogah o h vis/ow xmiis vad a oign body

simosd on h inio bic ams on h igh (Fig. 2). A Ct

scan o h abdomn and vis vad an abnoma aaanc o

h igh sic, ai in h scom, and h oign body osio o

h scom (Fig. 3). th ain was bogh o h oaing oom

o sabiizaion o h igh hand, washo o h igh high wond,

and—basd on adiogahic ndings and hysica xaminaion—

scoa xoaion. On xoaion, h oign body was movd and

was consisn wih a hman ib agmn wih aachd incosa

msca (Fig. 4). th scom was xod hogh a midinincision a h mdian ah. th ain had a d igh sic.

An ochicomy was omd. H covd w and was dischagd

on osoaiv day 2.

TEACHING POINTS

1. pains injd in sicid bomb aacks a a isk o boh

mchanica injy om bas cs and agmns. thy a aso

a bioogica isk om “missi-izd” body as.

2. th absnc o a aab sic a bn naing ama

shod om scoa xoaion.


1. In many cass o scoa ama, as in his cas, h a associad

injis oming Ct scan. Ct scan and asond o h scom

a insnsiiv o sica and oh scoa ahoogy. A

high indx o ssicion basd on mchanism o injy and hysica

xaminaion ndings shod om scoa xoaion.

2. tsica savag a is ossib. Dmining acos a

h dg o maining vasca sy o h b mass and




Figure 1. Scrotum refected to show proximal medial thigh wound. Note oreign body in wound (aow).

Figure 2. Coned pelvic radiograph demonstrates oreign body overlying the right pubic ramus (aow).




Figure 3. Pelvic CT image demonstrates air in right scrotum with the oreign body located posteriorly. Right

testicle is abnormal.

Figure 4. Fragment o human rib removed rom right

scrotum.

Figure 5. Avulsed right testicle.




h avaiabiiy o maining nica abgina o

consc h sic. In his cas, h was

amos com avsion o h b mass

(Fig. 5); ho, ochicomy was omd.

Howv, as soon as h nica abgina (o

ididymis o vas dns) is vioad, h is a

bach o h bood–sis bai, and h xiss

onia o h omaion o anism anibodisgadss o h disosiion o h sic (savag

o mova). this dos no gaan iniiy,

b cas h isk o sbiiy. I iiy

bcoms a cinica obm o hs ains in

h , ay a o an iniiy sciais

is indicad.

3. In ms o sica ncion, h maining

noma sic odcs nogh soson o

noma ma hysioogica ncion.

DAMAGE CONTROL

In as condiions, scoa injis a no mgnas ong as hmosasis is achivd. I sica savag

is o b naind, h ain shod b sn by a

sgon wihin 3 o 4 hos o injy. I h mission

cds immdia a o a sgon, i cod b

managd consvaivy indniy ni oogica

vaaion is ossib.

SUMMARY

pains injd in sicid bomb aacks a a isk

o boh mchanica and bioogica injis. th

xamining ovid ms dvo an indx o ssicion

o sica injy basd on mchanism and hysica

xaminaion ndings. Ct scan and asond a

on nsaisying in diagnosing sica injy.

tsica savag shod b h goa, i mission aows,and h ain shod b vacad o h nas

oogis wihin 3 o 4 hos o injy. I immdia

a is no ossib, and oaiv aciiis a no

immdiay avaiab, scoa injis can b managd

consvaivy indniy ni a is ossib.

SUGGESTED READING





Cha 18: Gnioinay ac injis. In: Emer-







V.10Gnial Sof-tissu

tauma

CASE PRESENTATION

Whi on ao, a 29-ya-od ma sodi ssaind mi

bas injis whn his vhic was sck by an imovisd

xosiv dvic (IeD). H was ssciad a h Fowad

Sgica tam (FSt) aciiy and ansd o a v IV mdica aciiy.

In addiion o damaic so-iss injis o h nis and scom, h

sd had, ac, igh hand, and biaa ow xmiy injis.

th ain ndwn wond dbidmn and gnia conscion

ha incdd a ochicomy, ai o h d igh sic,

ha conscion ov a 12-gag Fnch ha cah, ni

gans conscion, and skin cos (Fig. 1). H was vacad o

h unid Sas on h h day oowing his injy. th ni and

ha conscions aid wih ogssion o nonviab iss, and

h ais w akn down o addiiona dbidmn (Fig. 2). Dayd

conscion was sad 2 wks a h injy by acmn o a

si-hicknss skin ga o h wond bd (Fig. 3).

TEACHING POINTS

1. High-ngy injy o h so iss o h gniaia can cas dayd

iss ncosis.

2. eay conscion has a ga isk o ai.

3. Cos o h cos cavnosm is advisab o sma injis.

4. tnsion- aoximaion o h ha and cos songiosm

wih absobab s is commndd.

5. Gnia skin shod b aoximad oosy a is anaomica si.

6. Gnos s o dains is commndd.


1. Gnia wond dbidmn can b don icky ding damag

cono sgy. this is accomishd hogh jdicios mova o

nonviab iss wih coios iigaion o ss avag o hwond. tiss dviaizaion om high-vociy ojcis is no

aways aan a iniia vaaion. Dayd ncosis can joadiz

ay consciv os. Dniiv wond cos shod,

ho, no b amd in his ay iod. Fina cosmic and

nciona ss, howv, a nhancd i oos aoximaion o

h iss is accomishd wih sva widy saad nyon ss

ha can b movd a h nx sgy o h dbidmn. th




Figure 1. (to l)

Intraoperative appearance

o genital trauma rom

blast. The let testicle

has been removed and

the right one repaired.

The glans penis is

traumatically divided with hal partially

attached by a skin bridge.

The transected corpus

cavernosum is visible

below a small intact

segment o glans. The

proximal urethral

opening is visible at

the base o the shat

near the penoscrotal

junction. (to righ) An

aggressive, early attempt at reconstruction. Little

o the reconstructed

tissue would survive.

Figure 2. (Boom)

Subsequent intra-

operative appearance

o the injury ater all

nonviable removed.

The scrotum is nearly

reapproximated in

this image.




oosy aoximad wond shod b daind

comy wih pnos dains, sma scion

dains, o a wond vacm.

2. Injy o h cos cavnosm and ha

is mo daid anion a h im o injy.

th ingiy o h ha can b dmind by

ogad hogahy o hoscoy. Cavno-

sa injis shod b sscd whn a ag ni

hmaoma is sn. exoaion and ai o h

nica abgina can imov na ncion. this

ai can b comd hogh h ni wond,

by ni skin dgoving, o by a vica incision inh nis a h si o cooa injy. I is imoan

o mmb ha h novasca bnd o h

gans ns aong h dosm o h nis. A vna

aoach o h nica abgina can dc injy

o hs scs.

3. Sma agmn injis o h nis may no i

xnsiv dbidmn. exinc shows ha

aggssiv xoaion o hs sma agmns

is no waand in h ac sing and can b

accomishd a i symomaic.

DAMAGE CONTROL

Gnia wonds a sn ny wih concn

wonds o h abdomn and ow xmiis. Iniia

amn on is damag cono incis.

raid mova o obvios dviaizd iss, coios

iigaion o h wond, oos aoximaion o ni

skin wih maxima wond dainag, and Foy cah

acmn—whn asib—can b accomishd swiy

in h siosy injd ain. rai o h ha

and cos cavnosm wih absobab ss may

dc bding and aid in damag cono. Daying

cos, howv, is somims ncssay whn iss

oss is sv, iss viabiiy is ncain, o h ain

is hmodynamicay nsab.

SUMMARY

So-iss injis o h gniaia a dvasaing.

eay sgica invnion shod nai jdicios

wond dbidmn ha avos obsvaion o isso ncain viabiiy ah han aggssiv mova.

Dayd conscion aas sio o ma

ams a ni and scoa skin coss. loos

aoximaion o iss wih iba s o dains

aids conscion. eay aoximaion o

ha and cos cavnosa injis may assis in

hmohag cono and imov ncion.

SUGGESTED READING

Cha 18: Gnioinay ac injis. In: Emergency


DC: Damn o h Amy, Oc o th SgonGna, Bodn Insi; 2004.





Figure 3. Final

reconstruction

ater staged

buccal and split-

thickness skin

grats are ormed

into a new

urethra.




COMMeNtArY

Damag Conol by COL George E. Peoples, MD

A hm o his cha is damag cono sgy

as i ains o h injd abdomn. usay

aid o h nsab ain, and visid

hogho his book, his aoach is a w-accd

conc among civiian and miiay ama sgons.

Is basic imn is a sagd aoach o h svy

injd ain a isk o h ha iad o hyohmia,

acidosis, and coagoahy. In gna, h a h

hass o damag cono sgy: (1) imay sgy ha

asssss h xn o injy and conos hmohag and

goss conaminaion; (2) innsiv ca ni ssciaion

o addss waming, o vs acidosis, and o coc

coagoahis; and (3) annd oaion o mo

dniiv managmn o injis. th a ss may

nd o b ad as on as ncssay o coc h

injis wiho ndy sssing h ain.

th a, howv, som noab dincs in h civiian

and miiay aicaions o h damag cono conc.th mos ominn among hs is ova managmn

o h ain. In h civiian am, a sing sgon say

manags h ni damag cono snc. H knows

shand h xn o h injis, wha was and was no

don a h s sgy, and whn bs o ak h ain

back o h oaing oom, basd on cay obsvd

and masd hysioogy. Conas ha o h comba-

wondd sodi who may hav his s ocd

omd in a n a h Fowad Sgica tam (FSt)

aciiy, is hn vacad immdiay o a Comba

So Hosia (CSH) o aggssiv ssciaion,

hn fown o a v IV mdica amn aciiy whh nx ocd is omd, and nay civs

dniiv ai a a v V hosia in h unid Sas.

Fh comond his snc by comssing i ino 4

o 5 days. Fo oima ca, h miiay snc is

cis commnicaion and coodinaion. unonay,

his chain o commnicaion is no aways asib, givn

h consicions o h acica siaion, h ncssiy

o sabishing inmdiay vs o ca, and h

ncainy o nconsd aomdica vacaion. In

h absnc o samss anss, miiay ama sgy

is dndn a is co on h ndsanding, acic,

and fxib aicaion o damag cono sgy by a

aiciaing miiay sgons.

evn wih his docin my sabishd in h miiay

am, doyd miiay sgons ms si b xa

consvaiv in hi sgica dcisions. pains ms

b hooghy assssd a ach v o vacaion.

Mos imoany, miiay sgons ms b fxib and

innovaiv in hi managmn o injd sodis.

Many o h concs ha hav bn advancd in civiian

ama cns ading o nonoaiv managmn o

cain injis (snic acaion), ianc on sciaizd

svics ik invniona adioogy (mboizaion), andai dniiv ai (coon ai vs coosomy) may

b imossib in comba-wondd sonn bcas o

h navaiab imaging o invnion chnoogis,

and/o i-advisd bcas o h inabiiy o condc

coninos cos oow-, as oind in h snc

abov. Comba wonds a aso din om hos

sn in civiian ama cns wh hs advancs in

chnoogy hav bn immnd. Comba ama

is on a s o high-ngy ojcis. Mi

comx injis a h nom. Iniia managmn on

occs in an as nvionmn wih imid socs

and oongd vacaion ims. th ain’s condiionon aiva o h miiay sgon is on no comaab

wih h civiian mgncy damn.

On o h gas changs o any vacaion sysm is

h imn o mainain h fow o van mdica

inomaion hogh ach v o ca in ac wih h




ain’s movmn. th dision o his inomaion

fow ss in missd injis, comamn syndoms,

dayd amns, and oniay nncssay oc-

ds. th vacaion sysm ms siv o imov h

convyanc o a-im amn inomaion om v

o v. Foow- inomaion sn backwads, so ha

sgons and mdica nis can assss and adjs hi

ova aiy o ca, is aso an ssnia imn.

A miiay-van agoihm o how bs o ca o any

scic injy, incding h inaabdomina injis cid

in his cha, is viay imossib bcas h a

oo many vaiabs ha a nconoab. Many o h

amn dcisions o a scic injy wi b ncssaiy

infncd by h oowing:

• patient’scondition,

• resourcesavailable(mostoftendeterminedbywhich

v o ca h sgon nds hims),

• availability of the next higher level of care (oftendicad by h has o h confic), and

• timetoevacuation(determinedbythetacticalsituation

and wah).

A sgon a a FSt who is acd wih h sam injy

as a coag a a CSH, may—by ncssiy—a i

comy diny. In h absnc o inn and

s amn agoihms, w y on incis.

th miiay vsion o damag cono sgy, as w

as h ova sgica managmn o h injd sodi,

is on h mis ha h ain shod hav ony

ha sgy ncssay o sabiiz him o sa vacaion

o h nx v o ca. this may man no sgy a an

FSt aciiy i h ain is sab. th inci giding

which injis shod b addssd and whn is ha o

scaaing invnion. Fo a vasca injy, scaaionmay man igaion i ncssay, ai i cicmsancs

mi, o byass i no aab (shn i xdinc is

id). Fo a coon injy, scaaion migh b sim

ai, xioaion, oma coosomy, ai wih

ociv osomy, scion wih osomy, o scion

wih anasomosis. this gna conc is aicab o

mos injd ogans and ais h incasing comxiy

o h ocd wih h sohisicaion o socs

avaiab, and h im id o com i. th

dcision o wha ocd o om o any givn

injy wi b dicad no ony by h sa aams

o h ain’s condiion, sviy o h scic injy,and associad injis; b aso by h v o ca,

socs avaiab, acica siaion, and avaiabiiy

o vacaion. Miiay sgons ms hav a woking

knowdg o scaaing invnions o h wid aay

o scic inaabdomina injis. thy ms mbac

h conc o damag cono sgy, ndsand h

vs o ca and h vacaion sysm, and acia

and anicia h consany changing nvionmns

in which hy may nd hmsvs whn caing o h

comba wondd.




COMMeNtArY

Abdominolvic tauma, Cass rviw by LTC Brennan J. Carmody, MD

th cass in his cha highigh h vas dincs

bwn abdomina ama ncond in

miiay and civiian sings. High-vociy o-

jcis and combinaions o bas and naing injis

can s in xnsiv iss dscion ha may no b

immdiay aan. An ndsanding o hs injy

ans and h aicaion o damag cono incis

a ccia in minimizing mobidiy and moaiy.

CASE V.1 (Indic ecs o Wonding) is an xcn

xam o h cs o combind bas-naing

injis. Dsi h absnc o iona ny, h

caviaion odcd by his high-vociy abdomina wa

injy d o a -hicknss coon injy. th nd o

o inaiona ny d o abdomina xoaion

and managmn o h coon injy. A high v o

ssicion ms b mainaind wih hs mchanisms

o injy, bcas miiay bs av in xcss o

3,000 /s. Dsi a aivy bnign-aaing wondand h absnc o objciv vidnc o inaabdomina

naion, on shod hav a ow hshod o aao-

omy. ths high-ngy angnia wonds a on

o ogssiv so-iss dviaizaion and may vov

ino ncoizing asciiis. ths wonds shod b siay

dbidd and aowd o ha by ih dayd imay

cos o sconday innion.

Anoh imoan aching oin invovs h dincs

in managmn o coon injis, dnding on whh

h ain wi main in ha o n h vacaion

chain. Mos sgons wod consid i asonab oom a sgmna cocomy wih iocoosomy in

h absnc o hyonsion, signican ca soiag, and

signican associad injis in any ain who wod

main in ha nd cos svision. In ains

who wi b vacad o high chons o ca, nd

coosomy shod songy b considd, givn h

onia o oongd vacaion ims, h bak in

coniniy o ca, and h high-injy mchanisms o

ngy ny ncond.

CASE V.2 (pnaing tama o h Somach and

pancas) isas h high ikihood o associad

injis in abdomina naing ama. I is

ciica o xo a aas o h abdomn, incding

h ss sac. ros o accss his sac incd h

gasocoic and gasohaic igamns. Addiionay, a

Koch manv shod b omd oiny o assss

h osio ascs o h dodnm and ancas. In

damag cono sings, dainag o ancaic fid is

a ha shod b don. Mo dniiv invnions can

b omd whn h ain has bn aoiay

ssciad. Givn h onsiy o ancaic anaso-

moss o ak, disa ancacomy shod b considd

bo sing ancaicojjnosomy o h disa

ancaic mnan. th somaosain anaog ocoidaca (sandosain), adminisd sbcanosy (sa-

ing dos: 50 µg .i.d.), can b iniiad i ancaic ak

occs and may dcas os; h dos can b iad

o h oin o chosasis.

CASE V.3 (Bn Abdomina tama) ony

dscibs sagd managmn o a comx dodna

injy. Combind gasoinsina and vasca injis a

common, and ains who hav ssaind sch ama

on sn in shock wih vad Injy Sviy

Scos, hyonsion, coagoahy, acidosis, and hyo-

hmia. Sgons managing his cas ook h aoiainiia acions o cono hmohag and gasoinsina

soiag, and mad no os o sabish gasoinsina

coniniy. Foowing ssciaion and n o h

oaing oom, dainag o h isoad oions o

h og was sabishd, aong wih acmn o a

jjnosomy o na ds. Visca dma cdd




dniiv abdomina wa cos, and an absobab

msh was acd wih ans o sbsn skin ga and

annd vna hnia. th ain was hn ansd

o a hos naion mdica aciiy.

this cas isas sva aching oins. Fis,

dniiv gasoinsina conscions shod ony

b omd a ada ssciaion, soion o visca dma, and soaion o oin sos. this

ain’s sas sd in ans o a oca hosia

io o ming hs ciia. In ains ning h

vacaion chain, moay abdomina cos shod

b sabishd in ha wih dniiv conscion

omd a high vs o ca (wh h ain wi

b mo iky hysioogicay ady o sch comx

sgy). Dniiv conscion oions wod incd

rox-n-Y gasojjnosomy wih dodnojjnosomy

o aow o dainag o biioancaic fids.

Scond, o managmn o h on abdomnconins o vov. Whas acmn o absobab

msh wih skin gaing and annd vna hnia

main an oion, oh chnis ha avoid h

mobidiy o h annd vna hnia a bcoming

mo widy sd. Vs and coags1 od

hi xinc wih sia abdomina cos sing

oyafoohyn msh as a moay cos. In

his chni, h msh aows abdomina domain o

b sabishd, and h msh is ighnd a invas

ading o ay dniiv abdomina cos. Sch

coss invovd ih imay cos o an onay

inosiion sing oyoyn msh. No sadvod, ahogh h avag im om iniiaion o

sia abdomina cos o dniiv cos was 45 days

(ang: 15–160). A mo nov aoach invovs h s

o bioohss, sch as AoDm (an aca dma

maix ha can b sd o consc abdomina wa

dcs). this oshic sos vasca and coagn

ingowh. I is aivy sisan o incion and can b

sd o dniiv abdomina cos. Advanags incd

a onia sho inva bwn injy and dniiv

abdomina cos, and s in viosy conaminad

ds. Mo ong-m daa gading is dabiiy a

ndd. rgadss o h chni sd o abdomina

cos, ky incis incd ay s o a vacm-

assisd, nonadhn coving o h abdomn (i, h

VAC Abdomina Dssing Sysm) o a Bogoa bag ha

ocs h visca and aows accss o h ni

abdomn. Vacm and scion dssings aso imov

visca dma and aow anicaion o fid osss.

Sch ay managmn wi aow a ang o oions

o abdomina cos.

CASE V.4 (Missd Dodna Injy) ias h nd

o hoogh xoaion oowing naing

abdomina injy. th cos oximiy o gasoinsina,

vasca, and oogica scs maks concomian

injy iky. Day in diagnosis o dodna injis isassociad wih sbsania mobidiy and moaiy.

Occasionay, infammaoy changs wi cd

imay ai o an ohwis mino injy. In sch cass,

acmn o an aoiay sizd Maco dain can

conv h injy o a b dodnosomy ha aows

cono o scions. this oion shod b combind

wih a gasosomy b and wid dainag. Anaivs

incd ai wih dodna divicaizaion o yoic

xcsion. this cas aso highighs h nd o om

commnicaion bwn sgons and aciiis in cass

in which xoaion was no asib. rgadss o

h hooghnss o io ocds, a ow hshodo xo nsab o dioaing ains shod b

mainaind, givn h onia o missd o voving

injis, cn o sisn hmohag, o ndaind

cocions. this is sciay ciica in ains who wi

n h vacaion sysm wh coniniy o ca can

b comomisd.

In CASE V.5 (tamaic eviscaion), sgons

ncon and manag amaic viscaion oowing

bas injy. Ky oins incd hosia managmn

(sain gaz, no os o dc h visca), cono

o noomis io o dcion, abdominaxoaion, and scion o anky nonviab insin.

Whn viabiiy is sionab, h abdomn can b

moaiy cosd wih assssmn in 24 o 48 hos.

Occasionay, dma o h viscad bow may i

nagmn o h ascia dc (anaogos incacad

vna hnias). Managmn o h ascia dc a

h viscaion si can b obmaic, sciay in

h sing o bas injy o high-vociy ojcis.

poshss sch as VICrYl o AoDm sabish

abdomina wa ingiy and dcas h ikihood o

osoaiv viscaion hogh h nanc wond.

pogssiv dviaizaion o so iss is common, and

h wond shod b siay washd o and dbidd

as ncssay.

CASE V.6 (pnaing rca Injy) incds many

o h wa sgy ns viosy dscibd: damag

cono chnis o combind visca and vasca




injis, ay ssciaion and waming, and n o

h oaing ha o h id sgy. pom

iniiaion o a who-bood div was a ky dcision. As

simia dvasaing injis hav bcom mo common,

doyd aboaois and bood banks hav bcom

incdiby cin in aciing and aing who

bood. Acivad Faco VII is aso now widy avaiab

and has a o in simia siaions. ligaion o hinna iiac ais is civ in managing ohwis

nconoab vic hmohag and can b omd

hogh h osio wond in som siaions. I is mo

commony omd ansabdominay. rca injy

shod b sscd in nay a sings o naing

bock wonds and d o wih igid ocoscoy.

Sma xaiona ca wonds do no nd o b

aid; oxima divsion, saca dainag, and

gn disa ca washo shod sc.

this cas isas h caiviy disayd by hosia

sonn o acivy wam hi ain sing Mre

(Ma, rady-o-ea) wams. I hav aso sonay sn

sac has and hai dys sd in simia scnaios.

I is sch innovaion ha w ms consany s as w

ca o h wondd, wih incasingy sv injis, in

as nvionmns.

REFERENCE

1. Vs A, Kic D, a. eay dniiv

abdomina cos sing sia cos ch-

ni on injd sodis ning om Agha-

nisan and Ia. J Am Coll Surg. 2006;202:

762–772.



Cosy David lson, The Dallas Morning News

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