Non-Operative Field Wound Care

COL Cliff Cloonan, MD, FACEP Vice Chair Dept. of Military and Emergency Medicine USU

Field Wound Care

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

Field Wound Care

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

Field Wound Care

• Four Main Teaching Points – The wound you can see on the outside may be the least severe regardless of how bad it looks. Make sure the patient is evaluated and resuscitated (control all controllable bleeding) before doing wound care.

– – – Irrigation and lots of it!

Debridement (“unbridle” the wound) NO Primary Closure*

Dulce bellum inexpertis

(

War is delightful to those who have no experience of it)

Erasmus

Wounds of War

War Wound Distribution

Head & Neck 17% Abdomen 5% Chest 13% Other 9% Upper Extremities 21% Lower Extremities 35% Upper Extremities Lower Extremities Abdomen Head & Neck Chest Other

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

Two Broad Mechanisms of Combat Wounds

•

Penetrating/perforating wounds

– Low velocity • Mostly fragments • Rarely pistol bullet wounds or “spent” bullets – High velocity • Mostly bullets from assault rifles • Some fragments

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

Field Wound Care

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

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

Penetrating fragment wounds and superficial burns from exploding RPG

Anti-Personnel Landmine Injury – Desert Storm

Field Wound Care

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

7.62 AK-47 Ammunition Weight Magazine Cyclic Rate Muzzle Velocity Mechanism 7.62

30 Round Exchangeable Box 650 RPM 2350 FPS Gas Operated

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

M-16 5.56 mm gun shot wound (exit)

Two Broad Mechanisms of Combat Wounds

•

Non-penetrating wounds

–

Burns

–

Blast

–

Blunt injury

Field Wound Care

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

Field Wound Care

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

Oklahoma City Federal Building BLAST

Blunt force injury in combat

Two Broad Mechanisms of Combat Wounds

–

Non-penetrating wounds

• “Other” – Crush injury – Deceleration injury – Electrical injury – Chemical injury – Laser injury

Causes of Combat Wounds

Burns 6% Blast 3% Other 6% Bullets 23% Fragments 62%

(WWI, WWII, Korea, Vietnam, Middle East)

Fragments Bullets Burns Blast Other

“Life Is Tough...

But Its Tougher When You’re Stupid!”

Field Wound Care

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

Field Wound Care

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

Field Wound Care

• Patient Assessment – – Wound Care is NOT first priority ABCs vs. CAB (the primacy of hemorrhage control) • Penetrating combat wounds vs. Blunt injury – Importance of initial and recurrent neurovascular assessment •

REMOVE

wrist watches, rings, and any other potentially constricting clothing or jewelry • The external wound is usually NOT the major concern regardless of how severe it appears

Large soft tissue defect in leg from exploding RPG

Field Wound Care

• Impact of Experience of Health Care Providers On Wound Outcome

Field Wound Care

• Impact of Level of Training on Wound Infection Rates – Medical Students: 0/60 (0%) infected – All Resident Physicians: 17/547 (3.1%) infected – Physician Assistants: – Attending Physicians: 11/305 (3.6%) infected 14/251 (5.6%) infected

Level of Training, Wound Care Practices, and Infection Rates

Am J of Emerg Med Vol 13, No 3, May 95

Field Wound Care

• Impact of Level of Training on Wound Infection Rates – Junior practitioners • • • Used

high-pressure irrigation

more often Less likely to use subcuticular sutures Applied Bacitracin ointment more frequently than – More “Experienced” Physicians!

Level of Training, Wound Care Practices, and Infection Rates

Am J of Emerg Med Vol 13, No 3, May 95

Field Wound Care Wound Irrigation

Field Wound Care

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

•

Field Wound Care

Irrigation (cont.) – Zerowet( TM ) produces 5-8 psi and is very effective at preventing back splash – The irrigation stream should not be directed into puncture/narrow based deep wounds - if these wounds are to be irrigated they should be opened –

DO NOT

wounds)!

irrigate with Hydrogen Peroxide (esp. puncture – Amount of irrigation depends upon wound size and degree of contamination [100 - 500 or more cc’s] – IF unlimited resources use normal saline to irrigate BUT potable, non-sterile, well chlorinated water will suffice and is not associated with increased infection rates. Irrigation with potable water is MOST CERTAINLY better than no irrigation!

•

Field Wound Care

Irrigation (cont.) – Pulsatile jet lavage, i.e. SurgiLav Plus (Stryker Instruments) delivers 1400 ml/min with variable pressure and pulse frequency – “Pulse lavage may be a means of significantly helping patients withstand lengthy delays in treatment while minimizing the morbidity and mortality caused by infection.” - Keblish

Mil Med 163, 12:844, 1998

– Gravity fed “jet lavage” by placing chlorinated water storage tank on elevated platform and running hose into OR - a low tech solution

Field Wound Care

•

Debridement

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

Ambroise Pare (1510-1590)

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

John Jones, M.D.

Plain Concise, Practical Remarks on the Treatment of Wounds and Fractures

(1775)

Civil War

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

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

Field Wound Care

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

COL Antoine Depage MD

Debridement -

Field Wound Care

From the French Word debrider meaning

to “unbridle or release”

Field Wound Care

• Debridement – ALL wounds incurred during combat should be considered to be contaminated because they are usually: • • •

Old (> 6 hours) Highly Contaminated “Jagged” / crushed tissue

Field Wound Care

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

Field Wound Care

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

• Mud/dirt in an explosive wound must be excised

Field Wound Care

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

Field Wound Care

• • • No Primary Closure of Combat Wounds!!!* – Delayed Primary Closure (DPC) at 4-5 days post-wounding when wound has no further exudate • If pus or evidence of dead tissue excise and leave open for later closure Splint large soft tissue wounds If dressing is applied in a clean environment and kept relatively clean do NOT do daily dressing changes unless obvious wound infection is present *Except those involving the head/neck/face and groin

Field Wound Care

• Topical Antiseptic Solutions

Field Wound Care

• Antiseptics in Wound Care (use in wounds) – Little to no demonstrated benefits in preventing infection or enhancing healing of open wounds – – Toxic to neutrophils Increased inflammation, tissue necrosis and endothelial cell damage – – Retard wound contraction and epithelialization Hydrogen peroxide, in particular, has little antimicrobial potency and relatively significant toxicity

Field Wound Care

• Prophylactic Antibiotics in wound management

Field Wound Care

• Use of Prophylactic Antibiotics – Cummings & Del Beccaro:

Antibiotics to Prevent Infection of Simple Wounds: A Meta-Analysis of Randomized Studies,

Am J of Emerg Med, Vol 13, No. 4, July 95 – No evidence that prophylactic antibiotics offer protection against infection of nonbite wounds in patients treated in emergency departments – No benefit even among patients treated with penicillinase-resistant antibiotics

Field Wound Care

• Antibiotics have a limited role – Must be given within 30-60 minutes of wounding to be effective for prophylaxis and must have good tissue penetration ability – Clearly not effective to PREVENT infection if given more than 4-6 hours after wounding • Ceftriaxone 1 gm IV or IM for isolated penetrating extremity wounds • Cefoxitin 2 gm IV or IM ASAP after wounding for abdominal wounds

Field Wound Care

• Topical Antibiotics – Some demonstrated benefit particularly Bactroban BUT – Not a substitute for good irrigation, thorough debridement, and a good dressing

Field Wound Care

• Dressing and Splinting

Field Wound Care

• Wound Dressing – Most important is the dressing applied by the “surgeon” at end of wound debridement – Dressing • Absorbs blood and serum and by stabilizing the wound reduces pain and helps prevent recurrent bleeding • • • • Prevents desiccation of wound Protects wound from mechanical injury Protects wound from environment Provides thermal protection for wound

Field Wound Care

• Dressing (cont.) – Is held in place by a firm but not constrictive bandage – Is left undisturbed until delayed closure in 4-5 days – Is applied by the “surgeon”

Field Wound Care

• Dressing (cont.) – If available bio-occlusive or semipermeable dressings can, if properly selected and used, significantly decrease healing times, reduce infection, and improve patient comfort • • • Wound Contact Layer Biobrane Others – The presence of a purulent appearing drainage under the dressing in the absence of tissue signs of infection does not represent infection

Field Wound Care

• Splinting / Bulky Dressing – Splint all large soft tissue injuries • • Reduces pain Improves healing – When in doubt splint • • Check pulses before and after Elevate extremities

Field Wound Care

• Fragment Wound Management

Exploding 20mm cannon shell at moment of detonation

Fragments from an unimproved conventional munition

Multiple small penetrating fragments from a rocket propelled grenade

FRAG WOUND MANAGEMENT

• Management of multiple fragmentation injuries – ABC’s – Primary concern is underlying injury – Local wound care (Debridement the “French” way) – DO NOT PROBE WOUND BLINDLY!

Management of Casualties with Multiple Small Fragment Wounds

• • • Multiple wounds caused by 200-500 mg fragments (improved conventional munitions) Majority of wounds are in extremities Skin damage is very localized and muscle damage is limited along tract of projectile

Excessive removal of skin during debridement

Management of Casualties with

• • •

Multiple Small Fragment Wounds

Excision of skin should be limited Soft tissue wounds in patients without neurologic or vascular deficit can generally be managed conservatively/non-operatively Missed arterial injury can cause – – False aneurysm, A-V fistula, occlusion Superficial femoral artery is most common missed injury

Field Wound Care

• Management of Small Fragment Wounds to the Abdomen

Improperly Managed Penetrating Abdominal Wound - Fatal

Penetrating Abdominal Wounds

• Mortality depends on: – Number and Extent of Vital Organs Damaged – Extent of energy transfer – Blood Loss - Access to sufficient quantities of blood is essential to saving critically wounded – Delays in evacuation/surgery

Penetrating Abdominal Wounds

• Mortality Rate Directly Related to Energy Transfer – Low energy transfer plus competent, early, surgery associated with approx. 10% or less mortality – High energy transfer (HET) plus competent, early, surgery associated with approx. 50% mortality.

• HET abdominal wounds are present in minority of combat casualties surviving to reach medical care (approx. 20%)

• Amputations – Digits – Limbs

Field Wound Care

Amputated Digits and Amputated Limbs

Amputation of hand and wrist from exploding anti-tank missile

Field Wound Care

• Partial / Complete Amputations –

Remove all constricting clothing and jewelry from stump and amputated part

–

Do not sever tissue bridges IF any possibility of re-implantation

–

If possible avoid clamping or ligating bleeding vessels (use a proximal BP cuff @ 30 mm HG > SBP) - consider risk of re-bleeding during transport

–

Irrigate proximal (stump) and distal segments (to include amputated parts)

Field Wound Care

• Complete / Partial Amputations – Wrap amputated part in saline moistened gauze, put in sterile plastic bag, and immerse in water cooled to at least 10 o C – Splint stump (and partial amputation) – Properly treated amputations may be successfully re-implanted up to 30 hr after being severed.

Field Wound Care

• Pain Control

Not All Pain Is Gain

"

Our patients do not come to us to be cured; they come to be relieved of their pains and other symptoms and to be comforted."

Dickinson Richards (1895-?)

Field Wound Care

• Pain Control – Unrelieved pain has adverse physiologic consequences – Wide variety of pain control options that target pain pathways at different locations – Morphine IV 2-4 mg boluses for moderate to severe pain (avoid IM administration) – Ketamine for major painful procedures, i.e.. Large wound debridement, ie burn wound care

• Tetanus Prophylaxis

Field Wound Care

Field Wound Care

• Tetanus Immunization – Largest number of reported cases of tetanus occur in > 60 year olds – Also at an increased risk over the general population are: • • Those without military experience Those born/raised outside U.S.

Emerg Med Clinics of N. A. - 10:2, p. 351

Tetanus Immunization

Field Wound Care

• Hypothermia in Wounded Patients

Hypothermia in Trauma Patients

• Most hypothermia seen in trauma patients is caused by shock

not

by fluid resuscitation – 2/3 of severely injured patients are hypothermic – Traumatic hypothermia is associated with – markedly increased mortality “Traumatic Hypothermia is Related to Hypotension, Not Resuscitation” Bergstein, JM et al

Annals of Emerg Med

1996 pp 39-42

Field Wound Care

• Combat Wounds that can/should be closed primarily – Head/neck/face – Genitalia – Joint capsules – Sucking chest wounds

Field Wound Care

• Four Main Teaching Points – The wound you can see may be the least severe regardless of how bad it looks. Make sure the patient is evaluated and resuscitated before treating wound – Irrigation and lots of it!

– Debridement (“unbridle” the wound) – NO Primary Closure*

Five Most Dangerous Things In The Army

• A Private saying, “I learned this in Basic…” • A Sergeant saying, “Trust me, sir…” • A 2nd LT saying, “Based on my experience…” • A Captain saying, “I was just thinking…” • A Warrant Officer chuckling, “Watch this…”