Emergency War Surgery (2004)

Emergency War Surgery

Blast over-pressure CNS injuries.

ο A force transmitted by the great vessels of the chest to the

brain; associated with unconsciousness, confusion,

headache, tinnitus, dizziness, tremors, increased startle

response, and occasionally (in the most severe forms)

increased ICP. Bleeding may occur from multiple orifices

including ears, nose, and mouth.

A combination of multiple injury types are typically involved

in combat-related brain injuries. Those injuries generally involve

the face, neck, and orbit; entry wounds may be through the

upper neck, face, orbit, or temple (Fig. 15-1).

Trans-suboccipital

Transfrontal

Transorbital

Transtemporal

Transfacial/infratemporal

Fig. 15-1. Common vectors of penetrating injury.

The subocciput, occiput, and retroauricular regions are

overlooked most. Injuries to these areas can indicate underlying

injury to the posterior fossa, major venous sinus, or carotid

artery, as fragments pass through the skull base. Reconstructing

the fragment path based on combination of plain films and

15.2

Head Injuries

computed tomography (CT) can be challenging. In transorbital,

transtemple, or penetrating injuries that cross the midline, an

underlying injury to intracranial vessels should be suspected with

associated pseudoaneurysms, dissections, or venous sinus injury.

Explosion results in flying fragments, with possible vehicular-

collision-associated blunt injuries. Depending on the proximity

to the explosion, a blast over-pressure phenomenon may also

result. In a severely brain-injured patient, more deficits than

indicated by the CT scan may be due to possible underlying

injury to brachiocephalic vessels, shear injury, or the effects of

blast over-pressure with resulting cerebral vasospasm. Plain

films, more useful in penetrating than blunt trauma, may reveal

a burst fracture of the skull indicating the tremendous

perforating force of a penetrating missile. Transventricular

bihemispheric fragment tracts portend a poor prognosis.

Severe head injuries are often seen in combination with

significant chest, abdomen, and extremity injuries. Very rapid

hemorrhage control is the priority in the noncranial injuries;

utilizing damage control concepts and focusing attention on the

head injury. All efforts should be directed toward early diagnosis

and intervention of the head injury.

Traditional Classification of Head Injuries

Open injuries are the most commonly encountered brain

injuries in combat.

Closed injuries, seen more often in civilian settings, may have

a higher frequency in military operations other than war.

Scalp injuries may be closed (eg, contusion) or open (eg,

puncture, laceration, or avulsion).

ο Any scalp injury may be associated with a skull fracture

and/or underlying brain injury.

ο Open scalp injuries bleed profusely, even to the point of lethal

blood loss, but usually heal well when properly repaired.

Skull fractures may be open or closed, and are described as

linear, comminuted, or depressed.

ο Skull fractures are usually associated with some degree of

brain injury, varying from mild concussion, to devastating

diffuse brain injury, to intracranial hematomas.

15.3

Emergency War Surgery

ο Open skull fractures are prone to infection if not properly

treated.

Mechanisms of Injury

Primary injury is a function of the energy transmitted to the

brain by the offending agent.

ο Very little can be done by healthcare providers to influence

the primary injury.

ο Enforcement of personal protective measures (eg, helmet,

seatbelts) by the command is essential prevention.

Secondary injury results from disturbance of brain and

systemic physiology by the traumatic event.

Hypotension and hypoxia are the two most acute and easily

treatable mechanisms of secondary injury.

ο Other etiologies include seizures (seen in 30%-40% of patients

with penetrating brain injuries), fever, electrolyte disturbances

(specifically, hyponatremia or hyperglycemia), and infection.

ο All of the above conditions can be treated.

ο Elevations of ICP may occur early as a result of a space-

occupying hematoma, or develop gradually as a result of

brain edema or hydrocephalus.

ο Normal ICP is 5-15 mm Hg, with normal cerebral

perfusion pressure (CPP = MAP-ICP) usually around 70-

80 mm Hg.

ο Decreases in perfusion pressure as a result of systemic

hypotension or elevated ICP gradually result in alteration

of brain function

(manifested by impairment of

consciousness), and may progress to global brain ischemia

and death if not treated.

Patient Assessment and Triage

During the primary and secondary assessment, attention

should be placed on a complete examination of the scalp and

neck. Fragments that enter the cranial vault with a

transtemple, transorbital, or cross midline trajectory should

be suspected as having associated neurovascular injuries.

Wounds are typically contaminated by hair, dirt, and debris

15.4

Head Injuries

and should be copiously irrigated clean with control of scalp

hemorrhage but not at the expense of delaying definitive

neurosurgical treatment! Scalp hemorrhage can be controlled

with a head wrap, scalp clips, or surgical staples; a meticulous

plastic surgical closure is only appropriate after intracranial

injuries have been ruled out.

The most important assessment is the vital signs.

Next is the level of consciousness, best measured and

recorded by the Glasgow Coma Scale (GCS) (see below).

GLASGOW COMA SCALE

Component

Response

Score

Motor Response

Obeys verbal command

(best extremity)

Localizes pain

Flexion-withdrawal

Flexion (decortication)

Extension (decerebration)

No response (flaccid)

Subtotal

(1-6)

Eye Opening

Spontaneously

To verbal command

To pain

None

Subtotal

(1-4)

Best Verbal Response

Oriented and converses

Disoriented and converses

Inappropriate words

Incomprehensible sounds

No verbal response

Subtotal

(1-5)

Total

(3-15)

Triage decisions in the patient with craniocerebral trauma

should be made based on admission GCS score.

ο A GCS < 5 indicates a dismal prognosis despite aggressive

comprehensive treatment and the casualty should be

considered expectant.

15.5

Emergency War Surgery

ο A GCS > 8 indicates that a casualty may do well if managed

appropriately.

♦ In general, neurologically stable patients with

penetrating head injury can be managed effectively in

the ICU with airway and ventilatory support,

antibiotics, and anticonvulsants while awaiting surgery.

♦ An exception to this would be a deteriorating patient

with a large hematoma seen on CT—this should be

considered a surgical emergency.

ο Casualties with GCS 6-8 can be the most reversible, with

forward neurosurgical management involving control of

ICP and preservation of CBF.

Another important assessment is pupillary reactivity.

A single dilated or nonreactive pupil adds urgency and

implies the presence of a unilateral space-occupying lesion

with secondary brain shift. Immediate surgery is indicated.

ο The presence of bilateral dilated or nonreactive pupils is a

dismal prognostic sign in the setting of profound alteration

of consciousness.

Radiographic evaluation.

ο Deployable CT scanners in standard ISO shelters are

increasingly available in the field environment. To keep

the scanner operational, a qualified maintenance chief

should be married to the scanner (“crew-chief” concept).

♦ CT is the definitive radiographic study in the evaluation

of head injury, and should be employed liberally as it

greatly improves diagnostic accuracy and facilitates

management.

ο Skull radiographs still have a place in the evaluation of

head injury (especially penetrating trauma).

♦ In the absence of CT capability, AP and lateral skull

radiographs help to localize foreign bodies in cases of

penetrating injuries and can also demonstrate skull

fractures.

♦ This can help direct otherwise “blind” surgical

intervention initially to the side of the head where the

fracture is identified.

15.6

Head Injuries

ο Cervical spine injury is uncommon in the setting of

penetrating head injury.

♦ Closed head injury is commonly associated with injury

of the cervical spine.

♦ Assume the presence of cervical spine injury and keep

the cervical spine immobilized with a rigid collar until

standard AP, lateral, and open-mouth radiographs can

be obtained to exclude injury.

♦ CT once again is useful in evaluating casualties with a

high suspicion for spinal injury.

Management

Medical.

Primary tenets are basic but vital; clear the airway,

ensure adequate ventilation, and assess and treat for

shock (excessive fluid administration should be

avoided).

In general, patients with a GCS < 12 should be managed

in the ICU.

ICU management should be directed at the avoidance

and treatment of secondary brain injury.

♦ PaO₂should be kept at a minimum of 100 mm Hg.

♦ PCO₂ maintained between 35 and 40 mm Hg.

♦ The head should be elevated approximately 30°.

♦ Sedate patient and/or pharmacologically paralyze to

avoid “bucking” the ventilator and causing ICP

spikes.

♦ Broad-spectrum antibiotics should be administered

to patients with penetrating injuries (a third-

generation cephalosporin, vancomycin or Ancef,

Unasyn or meropenen if acinetobacter suspected).

♦ Anaerobic coverage with metronidazole should be

considered for grossly contaminated wounds or those

whose treatment has been delayed more than 18 hours.

♦ Phenytoin should be administered in a 17-mg/kg

load, which may be placed in a normal saline

piggyback and given over 20-30 minutes (no more

than 50 mg/min, because rapid infusion may cause

cardiac conduction disturbances).

15.7

Emergency War Surgery

◊ A maintenance dose of 300-400 mg/d, either in

divided doses or once before bedtime, should be

adequate to maintain a serum level of 10-20 µg/L.

♦ Measure serum chemistries daily to monitor for

hyponatremia.

♦ Monitor and treat coagulopathy aggressively.

♦ Monitoring of ICP is recommended for patients with

GCS< 8 (in essence, it is a substitute for a neurologic

examination).

◊

A simple fluid-path monitor usually works well and

allows CSF drainage. It may then be coupled to a

manometer or to a multifunction cardiac monitor

similar to a central venous catheter or arterial line.

Administer prophylactic antibiotic.

Make an incision just at or anterior to the coronal

suture, approximately 2.5-3 cm lateral to the

midline (Fig. 15-2a,b).

A twist drill craniostomy is performed, the

underlying dura is nicked, and a ventricular

catheter placed into the frontal horn of the

lateral ventricle (encountered at a depth of 5 to

6 cm) (see Fig. 15-2b,c). Catheter should be directed

toward the medial epicanthis on the coronal plane,

and the tragus in the sagittal plane.

Even small ventricles can be easily cannulated

by aiming the tip of the catheter toward the

nasion in the coronal plane.

Ventricular catheters are highly preferable;

acceptable substitutes are an 8 F Robinson

catheter or pediatric feeding tube.

A key feature of this technique is to tunnel the

drain out through a separate incision 2-3 cm

from the primary one, thus reducing the risk of

infection.

◊

The goal of management is to maintain a CPP of 60-

90 mm Hg.

◊

A sustained ICP > 20 mm Hg should be treated (Fig. 15-3).

15.8

Emergency War Surgery

Levels of Intervention

Pentobarbital

or Thiopental Load

Hemicraniectomy/Duraplasty

Mild Hypothermia (34°-36°C) should be

considered in isolated head

injury but should be avoided in multi-trauma

Mannitol/Lasix (possible 3.0% Hypertonic Saline)

CSF Drainage via Ventriculostomy

Moderate Head-Up Posture (30°)

Adequate Sedation/Analgesia (Versed, Fentanyl, Morphine, Propofol)

Fig. 15-3. Levels of intervention to reduce ICP.

Sedation, head elevation, and paralysis.

CSF drainage if a ventricular catheter is in place.

Hyperventilation to a PCO₂of 30 to 35 mm Hg only

until other measures take effect. (Prolonged

levels below this are deleterious as a result of small

vessel constriction and ischemia.)

Refractory intracranial hypertension should be

managed with an initial bolus of 1g/kg of

mannitol and intermittent dosing of 0.25-0.5 g/

kg q4h as needed.

Aggressive treatment with mannitol should be

accompanied by placement of a CVP line or even

a PA catheter because hypovolemia may ensue.

Any patient who develops intracranial hypertension

or deteriorates clinically should undergo prompt

repeat CT.

◊ Mild hypothermia may be considered in isolated

head injury, but avoid in the multitrauma patient.

♦ Treat hypovolemia with albumin, normal saline,

hypertonic saline, or other volume expanders to create

a euvolemic, hyperosmolar patient (290-315 mOsm/L).

♦ Blast over-pressure CNS injuries.

15.10

Head Injuries

◊ Supportive medical therapy is usually sufficient.

Only in rare cases is an ICP monitor, ventriculostomy,

or cranial decompression necessary. In the absence

of hematomas the use of magnesium has been

beneficial. Structures particularly sensitive include

optic apparatus, hippocampus, and basal ganglia.

Delayed intracranial hemorrhages have been

reported. Additionally, these patients have a higher

susceptibility to subsequent injury and should be

evaluated at a level 4/5 facility. Repetitive injury and

exposure to blast over-pressure may result in

irreversible cognitive deficits.

Surgical

Goals: prevent infection and relieve/prevent intracranial

hypertension.

Indications for emergent exploration.

♦ Space-occupying lesions with neurological changes (eg,

acute subdural/epidural hematoma, abscess).

♦ Intracranial hematoma producing a > 5 mm midline

shift or similar depression of cortex.

♦ Compound depressed fracture with neurological changes.

♦ Penetrating injuries with neurological deterioration.

Relief of ICP with hemicraniectomy/duraplasty/

ventriculostomy.

♦ A large trauma flap should be planned for the

evacuation of a mass lesion with significant underlying

edema in the supratentorial space.

♦ The flap should extend a minimum of 4 cm posterior to

the external auditory canal and 3-4 cm off midline.

Exposing the frontal, temporal, and parietal lobes allows

for adequate cerebral swelling and avoids brain

herniation at the craniotomy edge.

♦ A capacious duraplasty should be constructed with

a subdural ICP/ventricular catheter in place,

allowing monitoring and drainage from the injured

hemisphere.

Shave hair widely and scrub and paint the scalp with

betadine.

General anesthesia for major cases.

15.11

Emergency War Surgery

ο Administer empiric antibiotics

(third-generation

cephalosporin).

ο Positioning can be adequately managed with the head in

a doughnut or horseshoe-type head holder. For unusual

positioning of the head, such as to gain access to the

subocciput, use a standard three-point Mayfield fixation

device.

ο Make a generous scalp incision to create an adequate flap.

♦ The flap should have an adequate pedicle to avoid

ischemia.

♦ Retraction of the scalp flap over a rolled laparotomy

sponge will avoid kinking the flap, which also may lead

to ischemia.

ο The skull should be entered through a series of burr holes

(Fig. 15-4) that are then joined to create a craniotomy flap

(Fig. 15-5a).

2 cm

4–5 cm

5-6 cm

zygoma

Fig. 15-4. Cranial landmarks and location of standard burr holes.

15.12

Emergency War Surgery

♦ The bone work may be done with a Hudson brace

and Gigli’s saw, though a power craniotome is certainly

preferable if available (see Fig. 15-5a).

A dural opening, using the entire expanse of the cranial

opening (with enough edge left to close the dura at the

end of the case), should be created.

♦ The base of the dural opening should be on the side near

any neighboring major venous sinus to avoid injury to

large draining veins and aggravation of cerebral edema.

The hematoma should then be gently evacuated with a

combination of suction, irrigation, and mechanical removal

(see Fig. 15-5b).

Meticulous hemostasis should be achieved and the dura

closed.

Approach to penetrating injury with neurologic changes

is aimed at removal of devitalized brain and easily

accessible foreign bodies.

♦ Perform copious irrigation with an antibiotic solution

(such as bacitracin) and a concerted attempt made to

achieve watertight dural closure (again, using

pericranium, among others, as needed).

♦ Tension-free scalp closure is also essential, but

replacement of multiple skull fragments in an attempt

to reconstruct the skull defect is not appropriate in the

battlefield setting.

◊ Excellent results can be achieved with cranioplasty

after evacuation out of the theater and a sufficient

delay to minimize risk of infection.

If a duraplasty is required, pericranium, temporalis fascia,

or tensor fascia lata may be used.

Tack-up sutures should be placed around the periphery

and in the center of the dural exposure to close the dead

space and discourage post-operative epidural hematoma

formation.

Replace bone flap and secure with wire or heavy suture.

♦ If severe brain swelling precludes replacement of the

bone flap it can be discarded or preserved in an

abdominal-wall pocket.

15.14

Head Injuries

ο The galea of the scalp should generally be closed separately

with an absorbable suture, and with staples used to close

the skin.

♦ A single layer closure with heavy monofilament nylon

is acceptable but should definitely include the galea,

with the sutures remaining in place at least 10 days.

♦ A subgaleal or epidural drain may be used at the

discretion of the surgeon.

ο Apply a snug dressing using roller bandages around the

entire head.

Evacuation of the Severely Head-Injured Patient

The trip is always longer than advertised. Transport only

patients who can be expected to survive 12-24 hour movements,

due to unexpected delays, route changes, or diversion in the

tactical situation. A post-operative, craniotomy patient should

first be observed for 12-24 hours prior to transport. Evacuating

immediately may lead to the inability to treat delayed post-

operative hematomas that may occur.

All patients with GCS < 12 are ventilated.

Patients with GCS < 8T require ICP monitoring.

Ventriculostomies should be placed, position confirmed,

secured, and working prior to departure.

The critical care evacuation team must be confident in the

ability to medically treat increased ICP and troubleshoot

the ventriculostomy.

Medical management of ICP in flight is limited to the use

of head-of-bed elevation (30°-60°), increased sedation,

thiopental, ventricular drainage, and mild

hyperventilation. Loading a patient head-of-bed first limits

the effect of takeoff on ICP.

The escort of a severely head-injured patient must be able

to manage the airway, ventilator, IV pumps, IV medicines,

suction, in addition to ICP and CBF.

Patients with possible intracranial pathology who may

deteriorate inflight should be neurosurgically maximized

on the ground prior to departure (eg, placement of a

ventriculostomy or evacuation of a hematoma).

15.15

Emergency War Surgery

If a head-injured patient (GCS > 12) deteriorates in flight

and is not already intubated, intubation should be

performed and planned. Ensure rapid sequence intubation

medicines, IV access, and airway equipment (especially

Ambu bag, ventilator) are working and available.

The most difficult part of an evacuation is from the CSH

to the CASF/MASF. Typically, battery life of the ventilator

and monitors, and supplies of oxygen can be depleted

before the exchange of the patient to the CASF/MASF.

Although electric power is available on Black Hawks and

FLA (ground ambulance), it is rarely used.

Prior to departure from the CSH the following precautions

must be taken by the escort:

♦ Ensure knowledge of patient injuries and clinical course.

(Have narrative summary and pertinent radiographs

in hand.)

♦ Ensure adequate medicines for minimum of 3 days.

♦ Ensure monitors, ventilators, and suction and IV pumps

all have adequate battery life.

♦ Ensure adequate oxygen supplies, and that the escort

has the familiarity with and the ability to switch oxygen

tanks.

♦ Have an alternate battery-operated, tactical light source

to read monitors during transport.

♦ Assemble patients on the stretcher to avoid iatrogenic

injuries to limbs, organizing tubes, lines, electrical leads,

and wires so as not to become snared during

movements. (When available, a SMEAD shelf attached

to the stretcher allows monitors to be secured and

elevated off the patient’s body.)

♦ Ensure that limbs (toes and fingers) and torso are

covered and insulated during the trip to prevent

hypothermia.

♦ During movements ensure central lines, a-lines, and

ventricular catheters do not become dislodged. Ensure

lines and tubes are sutured or otherwise secured.

♦ Ensure the ventriculostomy does not develop an air-

lock. Venting the tublet can be performed with a 21-

gauge needle.

15.16

Chapter 16

Thoracic Injuries

Introduction

About 15% of war injuries involve the chest. Of those, 10% are

superficial (soft tissue only) requiring only basic wound

treatment. The remaining 90% of chest injuries are almost all

penetrating.

Those injuries involving the central column of the chest (heart,

great vessels, pulmonary hilum) are generally fatal on the

battlefield. Injuries of the lung parenchyma (the vast majority)

can be managed by the insertion of a chest tube and basic wound

treatment. Although penetrating injuries are most common,

blunt chest trauma may occur and can result in disruption of the

contents of the thorax as well as injury to the chest wall itself.

Blast injuries can result in the rupture of air-filled structures

(the lung) as well as penetrating injuries from fragments.

The immediate recognition and treatment of tension

pneumothorax is the single most important and life-

saving intervention in the treatment of chest injuries in

combat. Distended neck veins, tracheal shift, decreased

breath sounds, and hyperresonance in the affected

hemithorax, and hypotension are the cardinal signs.

None or all may be present. Immediate decompression

is lifesaving.

With the advent of body armor, it is hoped that the majority of

thoracic injuries seen in past conflicts will be avoided.

Unfortunately, there will be individuals who will not have such

protection, as well as others who will sustain chest injuries

despite protection.

16.1

Emergency War Surgery

Anatomic Considerations

Superior border is at the level of the clavicles anteriorly and

the junction of the C7-T1 vertebral bodies posteriorly. The

thoracic inlet at that level contains major arteries (common

carotids, vertebrals), veins (anterior and internal jugulars),

trachea, esophagus, and spinal cord.

Within or traversing the container of the chest itself are found

the heart and coronary vessels, great vessels including arteries

(aorta, arch, inominate, right subclavian, common carotid,

left subclavian, and descending aorta), veins (superior and

inferior vena cava, azygous vein, brachiocephalic vein),

pulmonary arteries and veins, distal trachea and main stem

bronchi, lungs, and esophagus.

The inferior border is described by the diaphragm, attached

anteriorly at the T6 level and gradually sloping posteriorly

to the T12 level.

Penetrating thoracic injuries below the T4 level (nipple

line) have a high probability of involving abdominal

structures (Fig. 16-1).

Evaluation and Diagnosis

Knowledge of the mechanism of

injury (eg, blast, fragment, among

others) may increase the index of

suspicion for a particular injury. A

complete and accurate diagnosis is

usually not possible because of the

limited diagnostic tools available in

the setting of combat trauma. None-

theless, because injuries to the chest

can profoundly affect breathing and

circulation (and on rare occasion, the

Fig. 16-1. Thoracic incision

airway), a complete and rapid assess-

of abdominal contents.

ment of each injury is mandatory.

If the casualty is able to talk, there is reasonable assurance

that the airway is intact.

16.2

Thoracic Injuries

Life-Threatening Injuries

Injuries not immediately obvious, yet requiring urgent

attention, include tension pneumothorax, massive

hemothorax, and cardiac tamponade.

Tension Pneumothorax.

ο A patient with a known chest injury presenting with an

open airway and difficulty breathing has a tension

pneumothorax until proven otherwise and requires rapid

decompression and the insertion of a chest tube.

Massive Hemothorax.

ο The return of blood may indicate a significant intrathoracic

injury. Generally, the immediate return of 1,500 cc of blood

mandates thoracotomy (especially if the wound was

sustained within the past hour). With less blood initially,

but a continued loss of 200 cc/hour for over 4 hours,

thoracotomy is indicated.

ο Casualties with massive thoracic hemorrhage require

damage control techniques (see Chapter 12, Damage

Control Surgery).

Cardiac Tamponade.

ο Distended neck veins (may be absent with significant

blood loss) in the presence of clear breath sounds and

hypotension indicate the possibility of life-threatening

cardiac tamponade.

ο Fluid resuscitation may temporarily stabilize a patient in

tamponade.

ο Perform an ultrasound (US) with a stable patient.

♦ If positive, proceed to the OR (pericardial window,

sternotomy, thoracotomy). Any pericardial blood

mandates median sternotomy/thoracotomy.

♦ A negative US requires either repeat US or pericardial

window, depending on level of clinical suspicion.

ο Pericardiocentesis is only a stopgap measure on the way

to definitive surgical repair.

16.3

Emergency War Surgery

Open pneumothorax (hole in chest wall) is treated by placing

a chest tube and sealing the hole. Alternatives include one-

way valve chest dressings or a square piece of plastic dressing

taped to the chest on three sides.

Flail chest (entire segment of the chest wall floating due to

fractures of a block of ribs, with two fractures on each rib)

will require treatment (either airway intubation or obser-

vation) based on the severity of the underlying lung injury.

In cases where intubation is not required, repeated intercostal

nerve blocks with a long-acting local anesthetic such as

Marcaine may be very helpful in relieving pain and limiting

atelectasis and other pulmonary complications.

Surgical Management

Most penetrating chest injuries reaching medical

attention are adequately treated with tube thoracostomy

(chest tube) alone.

Tube thoracostomy (chest tube).

Indications.

ο Known or suspected tension pneumothorax.

ο Pneumothorax (including open).

ο Hemothorax.

ο Any penetrating chest injury requiring transport (manda-

tory in case of aeromedical evacuation).

Procedure (Fig. 16-2).

ο In cases of tension pneumothorax, immediate decom-

pression with a large bore needle is lifesaving. An IV

catheter (14/16/18 gauge at least 2-3 inches in length) is

inserted in the midclavicular line in the second interspace

(approximately 2 fingerbreadths below the clavicle on the

adult male). Entry is confirmed by the sound of air passing

through the catheter. This must be rapidly followed by

the insertion of a chest tube.

ο In a contaminated environment, a single gram of IV

cefazolin (Ancef) is recommended.

ο If time allows, prep the anterior and lateral chest on the

affected side with povidone-iodine.

16.4

Thoracic Injuries

ο Identify the incision site along the anterior axillary line,

intersecting the 5^th or 6^th rib.

ο Inject a local anesthetic in the awake patient, if conditions

allow.

ο Make a transverse incision, 3-4 cm in length, along and

centered over the rib, carrying it down to the bone.

6th Rib Site

Axillary Line

Lungs

Heimlich valve

Suction/ Open

Chest tube

Fig. 16-2. Procedure for tube thoracostomy.

16.5

Emergency War Surgery

Insert a curved clamp in the incision, directed over the

top of the rib, and push into the chest through the pleura.

A distinct pop is encountered when entering the chest and

a moderate amount of force is necessary to achieve this

entry. A rush of air out of the chest will confirm a tension

pneumothorax. Insertion depth of the tip of the clamp

should be limited by the surgeon’s hand to only 3 or 4 cm

to make sure that the clamp does not travel deeper into

the chest, resulting in damage to underlying structures.

Spread the clamp gently and remove. The operator’s finger

is then inserted to confirm entry.

Insert a chest tube (24 to 36 French) into the hole. All chest

tube side-holes must be in the chest. If no chest tubes are

available, an adult endotracheal tube may be used.

Attach a chest tube to a Heimlich valve, sealed pleurovac,

or bottles. In a resource constrained environment, a cut-

off glove or Penrose drain may be attached to the end of

the chest tube.

Secure the tube with suture, if possible, and dress to

prevent contamination.

Resuscitative Thoracotomy

ï Only indicated in penetrating chest injury in extremis

or with recent loss of vital signs.

ï These patients are generally unsalvageable, even with

unlimited resources and no other significant casualties.

ï If performed, a rapid assessment of injuries should be

made, and in the case of unsalvageable injuries, the

procedure should be immediately terminated.

Procedure

With the patient supine, make an incision in the left

inframammary fold starting at the lateral border of the

sternum extending to the midaxillary line (Fig. 16-3).

The procedure should be abandoned upon the discovery of

devastating injuries to the heart and great vessels.

16.6

Thoracic Injuries

If no injury is found in left

chest, rapidly extend the

incision across the midline,

crossing through the sternum

with a Lebsche sternum knife,

performing a mirror-image

thoracotomy (clamshell,

Fig. 16-4). When doing this

procedure you will cut across

both internal mammary

arteries, which will be a sig-

Fig. 16-3. Incision for resuscitative

nificant source of bleeding.

thoracotomy.

Elevating the anterior chest

wall will expose virtually all mediastinal structures.

Open the pericardium and assess the heart.

Priorities are to stop bleeding and restore central perfusion.

ο Holes in the heart and/or great vessels should be

temporarily occluded.

♦ Temporary occlusion can be achieved with fingers, side-

biting clamps or Foley catheters with 30 cc balloons.

Any other sterile device of opportunity is acceptable.

ο Major pulmonary hilar injuries should be cross-clamped

en masse.

ο Descending aorta located, cross-clamped, and cardiac

function restored via defibrillation or massage. (Make sure

to open the mediastinal pleura over the aorta to securely

apply the vascular clamp.)

ο If unable to restore cardiac function rapidly, abandon the

operation.

With successful restoration of cardiac function, injuries should

be more definitively repaired.

Subxiphoid Pericardial Window

Subxiphoid pericardial window should not be attempted

in an unstable patient. Unstable patients with penetrating

injuries suspicious for cardiac injury should undergo

immediate median sternotomy/thoracotomy.

16.7

Thoracic Injuries

Place two stay sutures into the membrane and sharply incise

between them, with care to avoid the heart, opening the

pericardial sac and exposing the underlying beating heart.

Median Sternotomy

Indications.

ο Suspected cardiac injury in an unstable patient.

ο Positive pericardiocentesis/subxiphoid pericardial

window.

ο Suspected injury to the great vessels in the chest.

ο Suspected distal tracheal injury.

Procedure.

ο In the supine position, make a midline skin incision from

the sternal notch to just below the xiphoid.

ο Through blunt/sharp dissection, develop a plane for

several centimeters both superiorly and inferiorly beneath

the sternum.

ο Divide the sternum with a sternal saw or Lebsche knife.

Keep the foot of the knife/saw tilted up toward the

undersurface of the sternum to avoid cardiac injury. Bone

wax can be used to decrease bleeding on the cut edges of

the sternum.

ο Separate the halves of the sternum using a chest retractor.

ο Carefully divide the pericardium superiorly, avoiding the

innominate vein, exposing the heart and base of the great

vessels.

In general, exposure to the heart and great vessels is best

achieved through a median sternotomy. For proximal left

subclavian artery injuries, additional exposure (trap

door) may be necessary.

ο Close with wire suture directly through the halves of the

sternum, approximately 2 cm from the edge, or around

the sternum through the costal interspaces using wire

sutures.

ο Place one or two mediastinal tubes for drainage, exiting

through a midline stab wound inferior to the mediastinal

skin incision.

16.9

Thoracic Injuries

♦ Perform supraclavicular approach as above.

♦ Perform a partial median sternotomy to the fourth

intercostal space.

♦ At the fourth intercostal interspace, incise the skin

laterally in the submammary fold to the anterior axillary

line.

♦ Divide the sternum laterally and continue in the 4^th

intercostal space (ICS) to the anterior axillary line. The

internal mammary artery will be divided and must be

controlled.

♦ It may be necessary to either fracture or remove a section

of clavicle to gain adequate exposure of the proximal

left subclavian artery.

♦ Approach distal left subclavian artery injuries through

a supraclavicular incision.

Thoracoabdominal.

ο Indication.

♦ Combined thoracic and abdominal injuries.

ο Procedure.

♦ The resuscitative thoracotomy can be continued

medially and inferiorly across the costal margin into

the abdominal midline to complete a thoracoabdominal

incision.

♦ Alternatively, a separate abdominal incision can be

made.

♦ With right-sided lower chest injuries, the liver and

retrohepatic vena cava can be exposed well using a right

thoracoabdominal approach.

Specific Injuries

Vascular.

ο Initially, holes in vessels should be digitally occluded.

Stopgap measures include placing Fogarty or Foley

catheters, side-biting clamps, or in the case of venous

injuries, sponge sticks.

ο Total occlusion or clamping may temporarily be necessary

to allow resuscitation to continue and restore cardiac

function.

16.11

Emergency War Surgery

ο If cardiac function cannot be restored within 5 to 10

minutes, the procedure should be abandoned (on-the-table

triage).

ο Repair of vessels should follow the principles detailed in

vascular repair: attempting primary repair if possible, with

the use of prosthetics if primary repair is not feasible.

Consider shunting as an alternative.

Heart.

The usual result of high-velocity injuries to the heart is

irreparable destruction of the muscle.

ο Isolated punctures of the heart should be exposed (opening

the pericardium) and occluded by finger pressure. Other

methods include the use of a Foley catheter or skin staples.

ο Use pledgeted horizontal mattress sutures (2-0 prolene)

on a tapered needle for definitive repair. Care must be

taken to avoid additional injury to coronary vessels.

Extreme care must be taken to avoid tearing the cardiac

muscle.

ο Atrial repairs may include simple ligature, stapled repair,

or running closures (Fig. 16-6).

ο Temporary inflow occlusion may prove helpful in repair.

ο More complex repairs are impractical without cardiac

bypass.

Lung.

ο Tube thoracostomy alone is adequate treatment for most

simple lung parenchymal injuries.

ο Large air leaks not responding to chest tubes or that do

not allow adequate ventilation will require open repair (see

tracheobronchial tree below).

ο Posterolateral thoracotomy is preferred for isolated lung

injuries. Anterior thoracotomy may also be used.

ο Control simple bleeding with absorbable suture on a

tapered needle. Alternatively, staples (TA-90) may be used

for bleeding lung tears.

16.12

Thoracic Injuries

ο Tractotomy: Open any bleeding tracts (through and

through lung penetrations) with a GIA stapler and ligate

bleeding points.

Do not simply close the entrance and exit points of

penetrating tracts in the lung. With positive pressure

ventilation, the risk is air embolism. The more central

the injury, the higher the risk.

ο Resection for bleeding may be indicated with severe

parenchymal injury. Anatomic resections are not indicated

and simple stapled wedge excisions recommended.

ο Uncontrolled parenchymal/hilar bleeding, or complex

hilar injuries with massive air leak should be controlled with

hilar clamping and repair attempted. Pneumonectomy is

performed as a last resort (90% mortality).

Fig. 16-6. Repair of penetrating cardiac injury.

16.13

Emergency War Surgery

Tracheobronchial tree.

ο Suspect the diagnosis with massive air leak, frothy

hemoptysis, and pneumomediastinum.

ο Confirm by bronchoscopy.

ο Airway control is paramount.

ο Median sternotomy is best approach.

ο Repair over endotracheal tube with absorbable suture --

may require segmental resection. Bolster with pleural or

intercostal muscle flap.

ο Temporizing measures include:

♦ Single lung ventilation.

♦ Control the airway through the defect.

Esophagus.

ο Isolated thoracic esophageal injuries are exceedingly rare.

They will usually be diagnosed incidentally associated

with other intrathoracic injuries.

ο Diagnostic clues include pain, fever, leucocytosis, cervical

emphysema, Hamman’s sign, chest X-ray (CXR) evidence

of pneumothorax, mediastinal air, and pleural effusion.

Contrast swallow may confirm the diagnosis.

ο Start IV antibiotics as soon as the diagnosis is suspected,

and continue post-op until fever and leucocytosis resolve.

This is an adjunctive measure only. Surgery is the

definitive treatment.

ο For stable patients in a forward location, chest tube

drainage and a nasogastric tube placed above the level of

injury is a temporizing measure. Ideally, primary repair is

performed within 6-12 hours of injury. Beyond 12 hours,

isolation of the injured segment may be necessary.

The preferred approach for intrathoracic esophageal

injuries is posterolateral thoracotomy; right for upper

esophagus and left for lower esophagus.

ο Locate the injury by mobilizing the esophagus. Primarily

repair with a single layer of 3-0 absorbable suture and cover

with pleural or intercostal muscle flap.

16.14

Thoracic Injuries

Drainage with chest tubes (one apical, one posterior) is

recommended.

If unable to primarily repair (as with a large segmental

loss or severely contaminated/old injury), staple above

and below the injury, place a nasogastric (NG) tube into

the upper pouch and place a gastrostomy tube into the

stomach. Drain the chest as indicated above. Complex

exclusion procedures are not indicated in a forward

operative setting.

An alternative when the esophageal injury is too old for

primary repair is to close the injury over a large T-tube,

which converts the injury to a controlled fistula. The

mediastinum is then widely drained using chest tubes or

closed suction catheters placed nearby. After a mature

fistula tract is established, slowly advance the T-tube and

later the mediastinal drains can be slowly advanced.

Diaphragm.

ο All injuries of the diaphragm should be closed.

♦ Simple small lacerations (< 2 cm) should be reapprox-

imated with interrupted nonabsorbable 0 or 1-0

horizontal mattress sutures.

♦ Lacerations larger than 2 cm should be approximated

as above, then reinforced with a running suture to assure

an airtight closure.

♦ Care should be exercised in the central tendon area to

avoid inadvertent cardiac injury during the repair.

ο If there is significant contamination of the pleural space

by associated enteral injuries, anterior thoracotomy and

plueral irrigation and drainage with two well-placed chest

tubes should strongly be considered.

♦ Inadequate irrigation and drainage leads to a high

incidence of empyema, especially of the fungal variety.

16.15

Chapter 17

Abdominal Injuries

Introduction

Changing patterns of warfare together with improvements in

protective body armor combine synergistically to minimize

truncal trauma incidence, severity, and mortality, despite

increasingly lethal weapons systems. Despite these advances,

penetrating abdominal trauma still occurs and treatment of these

injuries will always be an important component of war surgery.

Trauma to the abdomen, both blunt and penetrating, can lead

to occult injury that can be devastating or fatal if not treated. In

the unstable patient with abdominal injury, the decision to

operate is usually straight forward and should be acted on as

soon as it is made. In a few rapidly hemorrhaging patients with

thoracoabdominal injuries, a rapid decision must be made as to

which cavity to enter first. This chapter addresses some of these

issues.

Penetrating injuries below the nipples, above the

symphysis pubis, and between the posterior axillary lines

must be treated as injuries to the abdomen and mandate

exploratory laparotomy.

Posterior truncal penetrating injuries from the tip of the

scapula to the sacrum may also have caused retroperitoneal

and intra-abdominal injuries. A low threshold for exploratory

laparotomy in these patients is warranted when there are not

other diagnostic modalities available.

Diagnosis of Abdominal Injury

Document a focused history to include time of injury,

mechanism of injury, previous treatments employed, and any

drugs administered.

17.1

Emergency War Surgery

Inspection of the chest and abdomen will be the most reliable

part of the physical examination, especially regarding

penetrating injuries.

Determine if the patient requires laparotomy, not the specific

diagnosis.

Indications for Laparotomy - Who, When, and Where

First imperative is to determine who needs surgery.

Patients who have

ο Penetrating abdominal wounds as described in box above.

ο Other penetrating truncal injuries with potential for

peritoneal penetration and clinical signs/symptoms of

intraperitoneal injury.

ο Blunt abdominal injuries presenting in shock.

When and Where.

ο When aeromedical evacuation is uncertain and will involve

substantial distance, unstable patients with life or limb

threatening circumstances should undergo laparotomy at

the nearest forward surgical team (FST).

ο Stable patients who can tolerate transport and delay of 6

hours or so, should undergo initial controlled resuscitation,

presurgical care (including antibiotics), and be transported

to the next level of care for surgery.

When the tactical situation is static, aeromedical evacuation

effective, and the distance between FST and combat support

hospital (CSH) or higher level hospitals is short, all casualties,

including those who are unstable, should bypass the FST and

be taken directly to a higher level hospital.

Diagnostic Adjuncts

Minimally invasive adjuncts to diagnosis—computed

tomography (CT) scan, diagnostic peritoneal lavage (DPL), and

ultrasound (US)—have been used to decrease the number of

negative laparotomies in stable, blunt abdominal trauma

patients in peace-time settings with good follow-up of patients.

Some have been used in lieu of laparotomy to evaluate those

with penetrating injuries, when the suspicion is high that no

intra-abdominal injury has occurred. This practice has the

17.2

Abdominal Injuries

potential of missing injuries. These diagnostic screening

procedures are primarily used in stable patients with a

mechanism of injury suggesting abdominal injury, but without

an obvious operative indication. They should be relied on only

when good follow up is possible. US and, to a limited extent,

DPL have some use in the unstable patient to indicate which

cavity should be entered first. US and DPL may also serve as

triage tools in the mass casualty situation.

Abdominal Ultrasound

Advantages: Noninvasive, may repeat frequently, quick, easy,

identifies fluid in the abdomen reliably.

Disadvantages: Operator dependant, may miss small

amounts of fluid associated with hollow-viscus injuries.

Sonography (focused abdominal sonography for trauma

[FAST]) has become an extension of the physical examination

of the abdomen and should be performed whenever available

and when abdominal injury is suspected.

ο 3.5 to 5 MHz curved probe is optimal.

ο The abdomen is examined through four standard

sonographic windows.

A FAST examination assists the surgeon to determine the need

for laparotomy in blunt-injured patients but does NOT

identify specific injuries.

ο A FAST examination does not identify or stage solid organ

or hollow-viscous injury, but reliably identifies free

intraperitoneal fluid.

FAST aids in prioritization of penetrating injury patients for

the OR.

FAST aids in identifying which cavity to open first in patients

with thoracoabdominal injuries.

A FAST examination identifies pericardial fluid, and may

assist in the diagnosis of hemopneumothorax.

Ultrasound Views

A typical portable sonography device is shown in Fig. 17-1. The

standard locations for “sonographic windows” are shown in

Fig. 17-2. Examples of positive and negative sonographic

examinations are shown in Figs. 17-3 through 17-6.

17.3

Abdominal Injuries

Diagnostic Peritoneal Lavage

DPL has been a mainstay of blunt abdominal trauma diagnosis

for many years. Unfortunately, in-theatre combat medical units

from Level 1 to Level 3 are not routinely outfitted with

microscopic laboratory functions to provide cell counts or

fluid enzyme determinations. Thus, the only reliable

information obtained from DPL is the aspiration of 10 cc of gross

blood. Gross blood aspiration is the most infrequently

positive criterion of DPL, and its value is probably supplanted

by FAST.

May be useful when US or CT are not available, or as triage

tool.

Requires laboratory for most sensitivity.

ο Blunt: Aspiration of 10 cc of gross blood, RBCs > 1,000,000/

mL, WBCs > 500/mL, fecal material.

ο Penetrating: not recommended to ruling out (R/O) injury

in penetrating combat wound.

May help determine which body cavity to enter first in an

unstable patient with truncal injury.

Advantages: Sensitive to small amounts of fluid, including

hollow-visceral leaks; fairly quick.

Disadvantages: Invasive, not repeatable, slower than US.

Kits allow Seldinger technique.

ο Arrow (AK-09000).

ο Baxter Lazarus-Nelson (MLNK9001).

Field Expedient substitution: Open technique with small,

vertical infraumbilical incision and any tubing (IV, straight

or balloon catheter). Cut at least a dozen extra side holes.

CT Scan

Advantages: Defines injured anatomy in stable patients.

Disadvantages: Slow; requires contrast use and equipment

availability; may miss small hollow organ leaks; requires

transport away from emergency care area; operator/

interpreter dependant; difficult to repeat.

17.7

Emergency War Surgery

Wound Exploration

Blast injuries and improvised explosive devices (IEDs) create

many low-velocity fragments that may penetrate the skin but

not the abdominal cavity. Operative wound exploration in

the stable patient with a normal or equivocal examination

can help determine the need for formal exploratory

laparotomy.

ο When possible wound exploration should be performed

in the operating room with adequate instruments and

lighting.

ο Finding the fragment in the abdominal wall precludes

laparotomy.

ο If the tract is not adequately identified or the fragment

seen on plain film cannot be identified, formal laparotomy

should be performed.

Operative Planning and Exposure Techniques

Give broad spectrum antibiotic pre-op, continue for 24 hours.

ο Redose short half-life antibiotics intraoperatively and

consider redosing antibiotics with large amounts of blood

loss.

Perform laparotomy through a midline incision.

ο When wide exposure is needed, extend the incision

superiorly just lateral to the xiphoid process and inferior

to the symphysis pubis.

Quickly pack all 4 quadrants while looking for obvious

injuries.

Control hemorrhage.

Assess physiologic status.

ο Considering casualty physiology, create operative plan to

control contamination and complete operation.

♦ Consider damage control (see Chapter 12, Damage

Control Surgery) early and often.

♦ If stabilized/improving, proceed with definitive surgery.

Identify all organ and hollow-viscus injuries.

17.8

Abdominal Injuries

Eviscerate the small bowel to increase workspace.

Divide the ligamentous attachments of the liver to improve

exposure in the right upper quadrant or upper midline.

Fold the left lateral segment of the liver down and to the right

to improve exposure at the gastroesophageal junction.

Improve exposure to the liver by extending the incision into

the inferior sternum and across into the lower right chest

(thoracoabdominal).

Stomach Injuries

The stomach is a vascular organ and will do well after almost

any repair.

ο Always enter the lesser sac to determine posterior wall injuries.

Encircle the distal esophagus with a Penrose drain to provide

traction and improve visibility in high midline injuries.

Minimally debride and primarily close stomach defects.

Duodenum Injuries

Injuries to the Duodenum are associated with massive upper

abdominal trauma. Early consideration for damage control

surgery should be considered (see Chapter 12, Damage Control

Surgery).

Missed injuries of the duodenum have devastating morbidity.

Bile staining or hematoma in the periduodenal tissues mandates

full exploration of the duodenum (Kocher maneuver).

Minor injuries can be repaired primarily.

Major injuries should be repaired if the lumen will not be

narrowed by more than 50%. Options for closing injuries of

greater than 50%:

ο Close duodenal wall around a tube duodenostomy.

♦ Use a No. 2-0 absorbable suture (Vicryl).

♦ Use the largest malecot catheter available.

ο Bring up a Roux-en-Y jejunal limb and create an

anastamosis between the limb and the injury (Fig. 17-7).

ο The procedure of last resort is pancreaticoduodenectomy.

17.9

Emergency War Surgery

Fig. 17-7. (a) Ligation of pylorius, (b) Duodenal injury, (c) Roux-en-Y

anastomosis.

For major injuries, divert the gastric stream with a

gastrostomy and close the pylorus—two options:

ο Through a gastrotomy, ligate the pylorus with No. 0

absorbable suture.

ο Using a noncutting stapling device, staple but do not

divide the pylorus. Place a feeding jejunostomy for

nutrition at this controlled reconstruction.

Widely drain all injuries with closed-suction drains.

Any method used to close the pylorus will last only 14-21

days. The possibility of injury to the biliary and pancreatic

ducts should be considered when injuries involve the 2nd

portion of the duodenum or the pancreatic head.

Pancreas Injuries

Any injury to the pancreas/duct requires drainage.

17.10

Emergency War Surgery (2004) - page 6