Emergency War Surgery (2004)

Abdominal Injuries

ο Even if ductal injury is not identified, it should be

presumed and drained.

ο Resect clearly nonviable pancreatic body/tail tissue.

Transection or near-transection of the pancreatic duct can be

treated by

ο Distal end of proximal pancreas segment oversewn/stapled.

ο Proximal end of distal segment oversewn/stapled and

entire distal segment left in-situ.

ο Distal segment resection (typically requires splenectomy).

ο Distal segment drainage by Roux-en-Y anastomosis to

small bowel.

Major injuries to the head of the pancreas may require

pancreaticoduodenectomy, which SHOULD NEVER BE

ATTEMPTED in an austere environment but instead

treated by the principles of damage control surgery—

DRAIN, DRAIN, DRAIN.

Liver Injuries

Most liver injuries can be successfully treated with direct

pressure and packing followed by aggressive resuscitation

and correction of coagulopathy.

Generous exposure is required and should be gained early

and aggressively.

ο Mobilize triangular and coronary ligaments for full exposure

ο Use extension into right chest if needed.

ο Place several laparotomy pads above the dome of the liver

to displace it down into the field of view.

Short duration clamping of hepatic artery and portal vein (Pringle

maneuver) may be required to slow bleeding while gaining other

control. If bleeding continues despite Pringle maneuver, especially

from behind the liver, this indicates a retrohepatic venous injury

or retrohepatic vena caval injury. The injuries should be

approached in only the most advanced settings with extraordinary

amounts of resources. On table retriage or aggressive packing

and intensive care unit (ICU) resuscitation should be employed.

Use finger fracture of liver parenchyma to expose deep

bleeding vessels.

17.11

Emergency War Surgery

Large exposed injuries of the liver parenchyma can be

controlled in a number of ways:

ο Exposed large vessels and ducts should be suture-ligated.

ο Overlapping mattress sutures of No. 0-Chromic on a blunt liver

needle is fast and effective for controlling raw surface bleeding.

ο Placement of Surgicel on the raw surface and high-power

electrocautery to “weld” it in place is also effective.

Bleeding tracts through the liver can be controlled by tying

off the end of a Penrose drain, placing it through the tract,

and “inflating” it with saline to tamponade the tract.

Urgent surgical resection is strongly discouraged:

ο Indicated only when packing/pressure fails.

ο Follows functional or injury pattern, not anatomic lines.

Use a pedicle of omentum in a large defect to reduce dead space.

Avoidance of coagulopathy, hypothermia and acidosis is

essential in successful management of major liver injuries.

APPLY DAMAGE CONTROL TECHNIQUES EARLY.

Retrohepatic vena cava and

hepatic vein injuries require a

tremendous amount of resources

(blood products, OR time,

equipment) typically unavailable

in a forward surgery setting (on-

table triage in mass casualty).

ο Packing is most successful

option.

ο If packing fails, consider an atrio-

caval shunt. (see Figure 17-8).

Provide generous closed suction

drainage around major liver injuries.

Biliary Tract Injuries

Injuries to the gall bladder are

treated by cholecystectomy.

Repair common bile duct injuries

over a T-tube.

Fig. 17-8. Atrio-caval shunt.

17.12

Abdominal Injuries

ο A No. 4-0 or smaller absorbable suture is used on the biliary tree.

Extensive segmental loss requires choledochoenterostomy or tube

choledochostomy (depending on time and patient physiology).

Drain widely.

Splenic Injuries

Splenic salvage has no place in combat surgery.

Drains should not be routinely placed postsplenectomy if the

pancreas is uninvolved.

Splenic injury should prompt exploration for associated

diaphragm, stomach, pancreatic, and renal injuries.

Immunize post-op with pneumococcal, haemophilus, and

meningococcal vaccines (may defer until Level 3/CONUS

MTF, but must not be forgotten).

Small-Bowel Injuries

Debride wound edges to freshly bleeding tissue.

Close enterotomies in one or two layers (skin stapler is a rapid

alternative).

With multiple enterotomies to one segment of less than 50%

of small-bowel length, perform single resection with primary

anastomosis. Avoid multiple resections.

Colon Injury

Simple, isolated colon injuries are uncommon. In indigenous

populations and enemy combatants (eg, patients who cannot

be readily evacuated), diversion with colostomy should be

the procedure of choice, especially at Level 2. The often poor

nutritional status of these populations does not support

primary repair. The presence of any of the complicating

factors listed below mandates colostomy.

Simple, isolated colon injuries should be repaired primarily.

ο Debride wound edges to normal, noncontused tissue.

ο Perform two-layer closure or anastomosis.

For complex injuries, strongly consider colostomy/diversion,

especially when associated with:

ο Massive blood transfusion requirement.

ο On-going hypotension.

ο Hypoxia (severe pulmonary injury).

17.13

Emergency War Surgery

ο Reperfusion injury (vascular injury).

ο Multiple other injuries.

ο High-velocity injuries.

ο Extensive local tissue damage.

Potential breakdown of a repair or anastomosis is highest in

the setting of concomitant pancreatic injury.

Damage control technique: control contamination with

ligation/stapling of bowel, delay creation of the stoma to the

definitive reconstruction.

Clearly document treatment for optimal follow-up

throughout Levels of Care.

At the time of formation, a colostomy should be matured.

Rectal Injuries

Rectal injuries can be difficult to diagnose unless very

dramatic. Any question of an injury raised by proximity of

another injury, rectal examination, or plain abdominal film

radiography MANDATES proctoscopy. Gentle distal washout

with dilute Betadine solution is usually required to be able

to perform rigid proctoscopy. Findings can be dramatic

disruptions of the rectal wall but more commonly are subtle

punctuate hemorrhages of the mucosa. All abnormal findings

should prompt corrective intervention.

Consider the traditional 4 “Ds” of rectal injury: Diversion,

Debridement, Distal washout, and Drainage.

ο Of these, diversion is the most important.

♦ Transabdominal sigmoid colostomy is easiest.

♦ If the injury has not violated the peritoneum,

exploration of the extraperitoneal rectum should NOT

be done at laparotomy unless indicated for an associated

nonbowel injury. This avoids contaminating the

abdominal cavity with stool.

ο Debridement and closure of small- to medium-sized

wounds is unnecessary in patients who have been

diverted and drained. In any but the lowest of wounds,

debridement and closure are difficult and troublesome.

ο Distal washout is usually necessary to assess the injury. Use

gentle pressure when irrigating to minimize contamination

of the perirectal space.

17.14

Abdominal Injuries

ο Fecal contamination of the

perirectal space mandates

presacral drainage. Presacral

drains should be placed any

time the patient will leave

your immediate care.

♦ Drains are placed

through the perineum

into the retrorectal space

(Fig. 17-9).

Peritonealized rectal injuries are

easily accessed transabdominally

and should be repaired and

protected with diversion.

Hematoma in the perirectal space

should be drained either

transluminally by leaving the

injury open or by placing

presacral and/or intraabdominal

Fig. 17-9. Presacral drain.

drains.

Retroperitoneal Injuries

Left medial visceral rotation moves the colon, pancreas,

and small bowel to expose the aorta rapidly. Proximal

aortic control can be rapidly obtained with compression

or a clamp on the aorta at the hiatus, or through the left

chest.

Right medial visceral rotation (colon plus Kocher maneuver to

elevate duodenum) exposes the subhepatic vena cava.

Three zones of the retroperitoneum (Fig. 17-10).

ο I-Central, supracolic: explore for all injuries.

ο II-Central, infracolic: penetrating trauma, explore; blunt

trauma, explore for expanding hematoma.

ο III-Lateral: blunt trauma, avoid exploration if possible

because exploration increases the likelihood of opening a

stable hematoma and, thus, precipitating nephrectomy.

Explore for penetrating trauma.

Gain proximal vascular control before entering the

hematoma.

17.15

Emergency War Surgery

Fig. 17-10. Three zones of the retroperitoreum.

Abdominal Closure

Close fascia if possible.

ο Massive swelling associated with large amounts of blood

loss and resuscitation and large injuries may necessitate

temporary closures (see Chapter 12, Damage Control

Surgery). Otherwise, closure is usually possible.

A few penetrating battlefield wounds are isolated, small, and

without visceral contamination, and it is perhaps safe to close

the skin. Most are not, and these patients will be passed

quickly from one surgeon to the next, so the risk of missed

and catastrophic infection is increased; the skin should not

be closed.

Retention sutures are strongly recommended for the same

reasons.

17.16

Chapter 18

Genitourinary Tract Injuries

Introduction

Genitourinary (GU) injuries constitute approximately 5% of the

total injuries encountered in combat. Their treatment adheres

to established surgical principles of hemostasis, debridement,

and drainage. Proper radiographic evaluation prior to surgery

may replace extensive retroperitoneal exploration at the time

of laparotomy in the diagnosis of serious GU injuries.

GU wounds, aside from injuries of the external genitalia,

are typically associated with serious visceral injury.

Renal Injuries

Most renal injuries, except for those of the renal pedicle, are

not acutely life threatening. Undiagnosed or improperly

treated injuries, however, may cause significant morbidity.

While the vast majority of blunt renal injuries will heal

uneventfully with observation and conservative therapy, a

significant number of renal injuries in combat will come from

penetrating wounds and require exploration.

The evaluation of a suspected renal injury is based on

the type of injury, physical examination, and urinalysis.

Hematuria is usually present in patients with renal trauma,

and gross hematuria in the adult patient is concerning for a

significant injury. The absence of hematuria, however, does

not exclude renal trauma. Renal injury must be suspected in

patients who have sustained significant concurrent injuries

such as multiple rib fractures, vertebral body or transverse

process fractures, crushing injuries of the chest or thorax, or

penetrating injury to the flank, chest, or upper abdomen.

18.1

Emergency War Surgery

Adult patients who present with gross hematuria, micro-

scopic hematuria with shock at any time following the injury,

and significant concurrent injury require further evaluation

of their kidneys. Computed tomography (CT) provides

excellent staging of renal injuries and aids in the decision

whether or not to explore the injured kidney.

In the combat setting, many patients require rapid exploration

before definitive radiographic staging can be completed. An

intraoperative single-shot intravenous pyelogram (IVP) is

useful in their evaluation.

ο Procedure for one-shot IVP:

♦ 2 cc/kg of high-dose contrast is injected in either the

ED or OR setting.

♦ A single standard KUB radiograph is obtained 10

minutes following the contrast injection.

ο While high-osmolality contrast (Renografin, Hypaque, or

Conray) is adequate, low-osmolality contrast (Omnipaque,

Isovue, Optiray) is less likely to generate a reaction and is

less toxic to the kidney.

Major renal injuries usually appear as obscured renal

shadows on IVP.

ο Detailed anatomic information regarding the degree of

renal injury or presence of urinary extravasation should

not be expected on the trauma IVP. Delayed films, however,

may improve detection of urinary extravasation.

ο The study should confirm the presence and function of

the contralateral kidney and may demonstrate congenital

anomalies such as renal ectopia or fusion. Understanding

the function of the contralateral kidney is imperative to

sound intraoperative decision making during exploration

and possible salvage of the injured kidney.

Renal trauma is categorized by the extent of damage to the

kidney.

ο Minor injuries.

♦ Consist of renal contusions or shallow cortical lacerations.

♦ Most common after blunt trauma and usually resolve

safely without renal exploration.

♦ Hydration, antibiotics, and bed rest are the cornerstones

of successful nonoperative management.

18.2

Genitourinary Tract Injuries

ο Major injuries.

♦ Consist of deep cortical lacerations (with or without

urinary extravasation), shattered kidneys, renal vascular

pedicle injuries, or total avulsion of the renal pelvis.

♦ There is an 80% incidence of associated visceral injuries

with major renal trauma. Most cases will require a

laparotomy for evaluation and repair of concurrent

intraperitoneal injuries.

♦ Operative intervention includes debridement of

nonviable renal tissue (partial nephrectomy), closure of

the collecting system, and drainage of the retroperitoneal

area.

♦ Kidney preservation should be considered if at all

possible, although total nephrectomy may be required

for the severely damaged kidney or the unstable patient.

Vascular control of the renal pedicle can be obtained prior

to opening the perirenal fascia when control of

hemorrhage from the kidney requires exploration of the

retroperitoneum.

Operative Technique.

ο Obtain vascular control from a periaortic approach to the

renal vascular pedicle.

♦ The small intestine is retracted laterally and superiorly,

and the posterior peritoneum is incised over the aorta.

♦ The left renal vein, crossing anterior to the aorta, must

be mobilized to gain control of either renal artery.

♦ Atraumatic vascular clamps are used to occlude the

appropriate artery.

ο While vascular control in this fashion may provide the

safest approach against renal hemorrhage and reduce the

likelihood of nephrectomy, it is not a commonly performed

maneuver by either urologists or general surgeons. Direct

reflection of the colon to expose the kidney is feasible (Fig.

18-1). A kidney pedicle clamp should be readily available

for this approach.

18.3

Emergency War Surgery

Fig. 18-1. Exposure of left renal hilum.

ο Damaged renal parenchyma can be locally debrided (Fig.

18-2), excised in a partial nephrectomy (Fig. 18-3), or

removed in a total nephrectomy depending on the degree

of injury and the condition of the patient.

Nephrectomy may be the best solution for major renal

injuries when associated life-threatening injuries are

present.

ο Watertight closure of the collecting system with absorbable

suture prevents the development of a urine leak.

♦ Urinary diversion is typically unnecessary if formal

renal reconstruction is accomplished.

18.4

Genitourinary Tract Injuries

Fig. 18-2. Steps in renal debridement.

◊ For the sake of expedience or in the presence of

associated injuries of the duodenum, pancreas, or

large bowel, diversion may be required.

◊ Tube nephrostomy, ureteral stent, or ureterostomy

may be utilized.

ο The reconstructed kidney should be covered by perirenal

fat, omentum, or fibrin sealant.

ο A closed suction drain should be left in place.

Fig. 18-3. Steps in partial nephrectomy.

18.5

Emergency War Surgery

Ureteral Injuries

Ureteral injuries are rare but are frequently overlooked

when not appropriately considered. They are more likely

in cases of retroperitoneal hematoma and injuries of the

fixed portions of the colon, duodenum, and spleen.

Isolated ureteral injuries are rare and usually occur in

conjunction with other significant injuries. They can represent

a difficult diagnostic challenge in both the preoperative and

intraoperative settings.

ο Ureteral injuries are not reliably diagnosed by the

preoperative IVP.

ο Hematuria is frequently absent.

ο Blast injury to the urethra may produce significant delayed

complications even when the IVP is normal and the ureter

appears visibly intact. Placement of an indwelling stent is

reasonable when a high-velocity or blast injury occurs in

proximity to the ureter.

ο If a ureteral injury is initially missed and presents in a

delayed fashion, urinary diversion with a nephrostomy

tube and delayed repair at 3-6 months is a safe approach.

Operative Technique.

ο Intraoperative localization of the ureteral injury is

facilitated by IV injection of indigo carmine or direct

injection into the collecting system under pressure.

ο Basic principles of repair.

♦ Minimal debridement.

♦ Primary tension free, 1 cm spatulated anastomosis using

an interrupted single-layer absorbable suture (4-0 or

5-0) closure technique.

♦ Internal (double J ureteral stent) and external drainage.

♦ Lengthening maneuvers.

◊ Ureteral mobilization.

◊ Kidney mobilization.

◊ Psoas hitch (Fig. 18-4).

◊ Boare flap.

18.6

Emergency War Surgery

♦ Isolate repairs with omentum or posterior peritoneum.

The type of repair is based on the following:

♦ Anatomical segment of the traumatized ureter (upper,

middle, and lower third).

♦ Extent of segmental loss.

♦ Other associated injuries.

♦ Clinical stability of the patient.

Upper or Middle ureteral injuries:

♦ Short segment loss/transection: Perform a primary

ureteroureterostomy (Fig. 18-5).

♦ Long segment loss: May require a temporizing tube/

cutaneous ureterostomy with stent placement or

ureteral ligation with tube nephrostomy.

Lower ureteral injuries.

♦ When the injury occurs near the bladder, an ureteroneo-

cystostomy should be performed (Fig. 18-6). This is

typically completed by fixing the bladder to the fascial

covering of the psoas muscle using permanent suture

such as 2.0 or 3.0 Prolene. A transverse cystotomy assists

in elongating the bladder to that location and facilitates

the development of a submucosal tunnel for the

reimplanted ureter.

♦ When a distal ureteral injury is associated with a rectal

injury, ureteral reimplantation is not recommended;

temporary diversion should be performed.

Fig. 18-6. Ureteroneocystostomy.

18.8

Genitourinary Tract Injuries

Ureteral injuries in the combat setting may be best

managed with temporary tube drainage with a small

feeding tube or ureteral stent followed by delayed

reconstruction.

Bladder Injuries

Bladder wounds should be considered in patients with

lower abdominal gunshot wounds, pelvic fractures with

gross hematuria, or those patients unable to void

following abdominal or pelvic trauma.

Bladder disruptions can occur on the intraperitoneal or

extraperitoneal surface of the bladder. The location may

change the symptoms, complications, and management of

this injury.

After ensuring urethral integrity in appropriate cases (see

Urethral Injuries, below), evaluation of the bladder is

performed radiographically with a cystogram.

ο Cystography is performed using a 3-film technique: (1)

scout or plain film KUB concentrating on the pelvis, (2)

full-bladder radiograph after retrograde filling of the

bladder with contrast, and (3) a postdrainage radiograph.

ο Technique: Fill the bladder by gravity with a urethral

catheter using radiopaque contrast medium elevated 20-

30 cm above the level of the abdomen. At least 300 cc (5-7

cc/kg in children) are required for an adequate study. Take

a full-bladder radiograph.

ο Drain the bladder using the catheter and take a postdrainage

radiograph. Small extraperitoneal areas of extravasation

may be apparent only on the postevacuation film.

Operative Technique.

ο Intraperitoneal Injuries.

♦ Cystography reveals contrast medium interspersed

between loops of bowel.

♦ Management consists of immediate exploration,

multilayer repair of the injury with absorbable suture,

suprapubic tube cystostomy, and drainage of the

18.9

Emergency War Surgery

perivesical extraperitoneal space.

Extraperitoneal injuries.

♦ Bladder laceration is most often the result of laceration

by bony fragments from a pelvic fracture.

♦ Cystography reveals a dense, flame-like extravasation

of contrast medium in the pelvis on the postevacuation

film.

♦ The bladder usually heals with 10-14 days of Foley

catheter drainage without the need for primary repair.

If the urine is clear, catheter drainage alone is preferred

for treatment of most extraperitoneal ruptures.

♦ In cases of abdominal exploration for other injuries,

primary repair and drainage are necessary if the extra-

peritoneal space is entered. Repair can be completed

from inside the bladder through a cystotomy to avoid

disturbing any pelvic hematoma. Patients with

concurrent rectal injuries should be managed more

aggressively and may benefit from hematoma evacuation

and primary bladder repair.

Urethral Injuries

A urethral injury should be suspected in patients with a

scrotal hematoma, blood at the meatus, or a floating/high-

riding prostate. Catheterization is contraindicated until

urethral integrity is confirmed by retrograde urethro-

graphy.

Retrograde urethrography is performed to evaluate the

anatomy of the urethra.

ο Take oblique radiographs of the pelvis to avoid “end-on”

imaging that obscures the bulbar urethra.

ο Insert the end of a sterile catheter tip syringe (60 cc) into

the urethral meatus while grasping the glans to prevent

leakage. Alternately, insert an unlubricated Foley catheter

into the fossa navicularis (approximately 3 cm) and inflate

the balloon with 3 cc of water.

ο Gently instill 15-20 cc of water-soluble contrast. The

radiograph is taken during injection.

18.10

Genitourinary Tract Injuries

ο Contrast must be seen flowing into the bladder to clear

the proximal urethra of injury. Posterior urethral injuries

seen in pelvic fractures may be missed otherwise.

ο If no injury is identified, carefully place a Foley catheter.

If any difficulty in passing the catheter is encountered,

the urethra should not be instrumented and a suprapubic

tube cystostomy is performed.

Operative Technique.

The urethra is divided into anterior and posterior

(prostatic) segments by the urogenital diaphragm.

♦ Anterior urethral injuries may result from blunt trauma,

such as results from falls when astride an object

(straddle) or from penetrating injuries.

◊

Blunt trauma resulting in minor nondisruptive

urethral injuries may be managed by gentle insertion

of a 16 French Foley catheter for 7-10 days.

◊

Penetrating wounds should be managed by explora-

tion and judicious debridement.

Small, clean lacerations may be repaired primarily

by reapproximation of the urethral edges using

interrupted 4-0 chromic suture.

Do not mobilize the entire urethra for a primary

anastomosis, because the shortened urethral

length in the pendulous urethra may produce

ventral chordee and an anastomosis under tension.

Instead, marsupialize the injured urethral segment

by suturing the skin edges to the cut edges of the

urethra. Marsupialization should be performed until

healthy urethra is encountered both proximally

and distally. Closure of the marsupialized urethra

is subsequently performed at 6 months to

reestablish urethral continuity.

♦ Posterior urethral disruption commonly occurs

following pelvic fracture injuries.

◊ Rectal examination reveals the prostate to have been

avulsed at the apex.

18.11

Emergency War Surgery

◊ Improved continence and potency rates are attained

when suprapubic tube cystostomy is used as the

initial management.

◊ Suprapubic urinary diversion is maintained for 10-14

days and urethral integrity is confirmed radiograph-

ically prior to removal of the suprapubic tube.

◊ With expectant observation, virtually all these

injuries will heal with an obliterative prostatomem-

branous urethral stricture, which can be repaired

secondarily in 3-6 months after reabsorption of the

pelvic hematoma.

◊ Initial exploration of the pelvic hematoma is strictly

reserved for patients with concomitant bladder neck

or rectal injury.

External Genitalia Injuries

The management of wounds to the penis, scrotum, testes,

or spermatic cord should be as conservative as possible

and consists of hemorrhage control, debridement, and

early repair to prevent deformity.

Injuries to the penis that disrupt Buck’s fascia should be

sutured to prevent further bleeding and avoid future penile

curvature with erection. When extensive penile skin is lost,

the penis may be placed in a scrotal tunnel until a plastic

repair can be performed.

The scrotum is highly vascularized, and extensive debridement

is usually not necessary for scrotal wounds.

ο Most penetrating scrotal injuries should be explored to

evaluate the testicle for injury and reduce the risk of

hematoma formation.

ο Most partial scrotal avulsions are best treated by primary

closure with absorbable 3-0 sutures in two layers.

ο Primary closure is selected for patients without associated

life-threatening injuries who sustained injury less than 8

hours prior. A Penrose drain or small closed drain can be

placed to reduce hematoma formation. The testes can be

18.12

Genitourinary Tract Injuries

placed in protective pockets in the medial thigh for

complete scrotal avulsion.

It is essential, when dealing with testicular wounds, to

conserve as much tissue as possible.

ο Herniated parenchymal tissues should be debrided, and

the tunica albuginea closed by mattress sutures.

ο The testicle is placed in the scrotum or in a protective

pocket in the medial thigh.

ο A testicle should never be resected unless it is hopelessly

damaged and its blood supply destroyed.

18.13

Chapter 19

Gynecologic Trauma and Emergencies

Introduction

The current active duty population consists of 14% women,

many of whom are subject to the same risks of combat injury as

their male colleagues. This chapter deals with OB/GYN

emergencies that may present to a deployed medical treatment

facility (MTF), particularly in military operations other than war

(MOOTW).

Gynecologic Trauma

Vulva

Vulvar injuries include lacerations and hematomas.

ο Lacerations that are superficial, clean, and less than 6 hours

old can be primarily closed with absorbable suture.

Debridement of obviously devitalized tissue is

recommended.

♦ Deep lacerations should be examined and explored to

rule out urethral, anal, rectal mucosa, or periclitoral

injuries.

♦ Placing a urethral catheter will assist in determining

injury. If found, single-layer closure with fine (4-0 or

smaller), absorbable suture, leaving the catheter in place,

is recommended. Rectal and periclitoral injuries are

closed in a similar fashion.

♦ Anal lacerations should be repaired by approximating

the cut ends of the anal sphincter with size 0 or 1

absorbable suture.

♦ Antibiotics (2nd generation cephalosporin) are

recommended with contaminated wounds.

19.1

Emergency War Surgery

Vulvar trauma may cause infrafascial (below the pelvic

diaphragm) hematoma.

ο Because the deeper layer of subcutaneous vulvar fascia is

not attached anteriorly to the pubic rami, hematoma can

spread freely into the anterior abdominal wall.

ο Most vulvar hematomas are treated conservatively.

ο External compression and ice packs should be applied

until hemostasis is ensured by serial examination of the

vulva, vagina, and rectum.

ο Signs of shock in association with a decreasing

hematocrit should prompt consideration of extraperi-

toneal expansion. Ultrasound or computed tomography

is useful for detecting expansion not diagnosed by clinical

exam.

A vulvar hematoma continuing to expand despite

external pressure, or presenting acutely with a size

greater than 10 cm, should be incised and evacuated, with

ligation of bleeding vessels and packing placed to secure

hemostasis.

Vagina

Trauma to the vagina can cause lacerations, and less

commonly, suprafascial (above the pelvic diaphragm)

hematoma.

Vaginal trauma has been reported in approximately 3.5% of

women with traumatic pelvic fractures. Concomitant

urologic trauma, most often involving the bladder and/or

urethra, has been described in about 30% of patients with

vaginal trauma.

Thorough inspection and palpation of the vagina and

rectovaginal exam are necessary for detection of vaginal

trauma and to determine the need for further urologic

evaluation/imaging. Due to pelvic instability (in fracture

cases) or pain, examination under sedation or anesthesia

may be necessary.

Patients with vaginal lacerations typically present with

bleeding, sometimes profusely, from the well-vascularized

vagina.

19.2

Gynecologic Trauma and Emergencies

Lacerations are repaired using the guidelines given above

for vulvar lacerations.

Vaginal hematoma is usually accompanied by severe rectal

pressure and is diagnosed by palpation of a firm, tender mass

bulging into the lateral vagina. Vaginal hematoma should

be treated by incision, evacuation, ligation, and packing.

Unrecognized vaginal trauma can result in dyspareunia,

pelvic abscess, and fistula formation.

Uterus/Cervix

Trauma to the uterus and cervix is most commonly found in

association with pregnancy, but may be seen as a result of

penetrating vaginal or abdominal trauma.

Noninfected simple cervical lacerations should be repaired

to optimize restoration of normal anatomy (and possibly

decrease the risk of cervical incompetence or stenosis with

dysmenorrhea from poor healing). Absorbable 0 grade suture

can be used.

Acute penetrating trauma involving the uterine fundus

usually causes little bleeding and can be managed expectantly

without repair. Damage to the uterine wall with bleeding can

be repaired with size 0 absorbable suture.

Trauma involving the lateral wall of the uterus may cause

significant bleeding, but can usually be controlled by

successive ligation of the ascending and descending branches

of the uterine artery as described below in the obstetrical

section “uterine atony.”

Hemorrhage not responding to ligation, or extensive

mutilating damage to the cervix or uterus, is best treated

by hysterectomy.

Prophylactic antibiotics should be given. Adnexa should be

retained unless there is an indication for removal (see next

page).

19.3

Emergency War Surgery

Basic steps for performing an emergent total

abdominal hysterectomy.

Ligate/cauterize round ligaments (Fig. 19-1).

Incise anterior leaves of broad ligaments bilaterally, then

continue across midline to incise vesicouterine fold.

Mobilize bladder downward by blunt dissection (and

sharp dissection if necessary) from lower uterine

segment and cervix.*

To retain adnexa, clamp/cut/ligate utero-ovarian

ligaments and fallopian tubes near their connections to

uterine fundus (Fig. 19-2).

To remove adnexa with uterus, clamp/cut/ligate

infundibulopelvic ligaments after making windows in

posterior leaves of broad ligaments above ureters.

Incise posterior peritoneum to mobilize adnexa either

away from (if being retained) or toward (if being

removed) uterus.

Incise peritoneum overlying rectovaginal space, then

mobilize rectum downward and away from posterior

vagina by blunt dissection (Fig. 19-3).*

Clamp/cut/ligate uterine arteries along lateral surface

of uterus at uterocervical junction, staying within 1 cm

of uterus to avoid damaging ureters.

Clamp/cut/ ligate remainder of cardinal ligaments,

paracervical tissue, and uterosacral ligaments by taking

successive inferior bites until cervicovaginal junction

is reached; each bite should be placed medial to previous

bite to avoid injuring ureter and bladder.

Crossclamp vagina below cervix.

Transect vagina, removing uterus (and attached adnexa,

if applicable).

Suture vaginal cuff closed, ensuring bladder is not

incorporated.

^*In case of dense adhesions between cervix and bladder or rectum in

emergent setting, or ongoing hemorrhage with poor visualization,

supracervical hysterectomy can be performed. After mobilizing bladder

and rectum from uterus and ligating uterine arteries, uterine fundus is

transected from cervix with a knife. Cervix is then oversewn with a baseball

stitch, staying medial to ligated uterine arteries.

19.4

Gynecologic Trauma and Emergencies

Anterior View

Fallopian Tube

Utero-Ovarian

Ovary

Ligament

Round Ligament

Broad Ligament

Bladder

X: Location to Incise

Peritoneum and Enter Vesicocervical

Uterine Space

Fig. 19-1. Abdominal hysterectomy anterior view.

Adnexa

Fallopian Tubes.

ο Damage to the wall of the fallopian tube by ruptured

ectopic pregnancy or penetrating abdominal trauma

should be treated by salpingectomy if there is significant

damage to the tube, due to the risk of subsequent or recur-

rent ectopic pregnancy if left in situ. If the damage is

Adnexal View

Location for Ligation if Adnexum Retained

Ovary

Fallopian Tube

Utero-Ovarian Ligament

Round

Ligament,

Location for Ligation

Ligated

if Adnexum

Removed

Infundibulopelvic

Ligament

Ureter

Window in Posterior Leaf of Broad Ligament

Fig. 19-2. Abdominal hysterectomy adnexal view.

19.5

Emergency War Surgery

Posterior View

Uterus

Cardinal Ligament

Infundibulopelvic

Ligament

Ureter

Uterosacral Ligament

X: Location to Incise Peritoneum

and Enter Rectovaginal Space

Rectosigmoid Colon

Fig. 19-3. Abdominal hysterectomy posterior view.

equivalent to a linear salpingotomy (see below), achieve

hemostasis, then allow healing by secondary intention.

ο The mesosalpinx is ligated or cauterized, then the tube

ligated and cut at its connection with the uterine fundus.

ο Unruptured ampullary/isthmic ectopic pregnancy can be

treated by linear salpingotomy, with extraction of the

ectopic gestation. The tubal incision is left open to heal by

secondary intention.

ο An unruptured or ruptured corneal/interstitial ectopic

pregnancy requires wedge resection of the uterine

cornuum with salpingectomy.

ο An ectopic pregnancy spontaneously aborted into the

abdominal cavity through the end of the tube should be

removed, but the tube may be left in situ if hemostasis is

attained.

Ovaries.

ο A ruptured ovarian cyst should be treated via cystectomy

by shelling the cyst wall out of the ovary, then cauterizing

or ligating any bleeding vessels, usually at the base of the

cyst.

19.6

Gynecologic Trauma and Emergencies

ο Torsion of an ovarian mass is first treated by assessing

the ovary. Untwist the ovary and or fallopian tube. If it

appears healthy with some continuing blood supply, it can

be left in situ. If the ovary contains a large (> 4 cm) simple

appearing cyst, the cyst can be drained and the cyst wall

removed. Interrupted sutures using a fine monofilament

or electrocautery can be used to obtain hemostasis. If the

ovary appears dark and dusky after untwisting, perform

a salpingo-oophorectomy by ligating the infundib-

ulopelvic ligament first (after identifying the ureter), then

the utero-ovarian ligament and fallopian tube.

ο Hemorrhage from an infundibulopelvic ligament, as a

result of penetrating abdominal trauma, is best treated by

ligation with salpingo-oophorectomy.

Retroperitoneal Hematoma

Laceration of an arterial branch of the hypogastric artery

can cause a retroperitoneal hematoma.

A large amount of blood may collect in the broad ligament

with few symptoms. Dissection of the hematoma can extend

up to the level of the renal vessels. The hematoma may be

discovered during emergency surgery for trauma or during

re-operation or post pelvic surgery, or can be prompted by

signs of shock suggesting internal bleeding.

Retroperitoneal hematoma can be treated by hypogastric

artery ligation on the affected side. Bilateral hypogastric

artery ligation may be necessary for hemostasis. The uterus,

tubes and ovaries may be left in situ if viable and without

other indication for removal.

Gynecologic/Obstetric Emergencies

Acute Vaginal Hemorrhage Unrelated to Trauma.

ο Bright red vaginal bleeding filling more than one large

perineal pad per hour is considered vaginal hemorrhage.

A pregnancy test and pelvic exam direct initial therapy.

♦ If the patient is not pregnant, hormonal management

with 25 mg IV Premarin or 50 mcg estrogen-containing

oral birth control pills (OCPs) should be given every 6

hours.

19.7

Emergency War Surgery

◊ If the bleeding responds to hormonal management,

OCPs should be continued qid for 5-7 days while

more definitive diagnosis and management plans are

made.

◊ If the bleeding has not decreased significantly within

24 hours, dilatation and curettage is reasonable. If

the heavy bleeding continues, imaging studies and

possibly coagulation studies will be needed to help

direct further therapy.

♦ In the pregnant patient, heavy bleeding from the

cervical os with uterine size < 20 weeks (fundus at/or

below the level of patient’s umbilicus) suggests

spontaneous abortion. Dilatation and suction curettage

should be performed.

◊

Ectopic pregnancy uncommonly presents with acute

hemorrhage, but should be considered if the patient

has an acute abdomen or if scant tissue is obtained

on curettage.

◊

In a pregnant patient with uterine size consistent with

a third trimester gestation (> 4 cm above the

umbilicus in a singleton pregnancy), vaginal

hemorrhage is usually an indication of placental

abruption or placenta previa.

◊

Emergent cesarean section will be necessary if the

uterine hemorrhage does not spontaneously resolve

within several minutes.

◊

After delivery of the fetus and placenta, persistent

hemorrhage unresponsive to more conservative

measures may require hysterectomy (see emergent

cesarean and uterine atony below).

◊

Pregnant patients (mothers) with acute vaginal

hemorrhage who have Rh negative bloodtype, or if

their Rh status is unknown, should be given

RhoGAM 300 mcg IM.

A hemorrhaging mass in the vagina is most likely cervical

cancer. The vagina should be packed to tamponade the

bleeding after placing a urethral catheter. Placing sutures

is generally futile and may make the bleeding worse.

19.8

Gynecologic Trauma and Emergencies

Precipitous Vaginal Delivery

Preparation.

ο Supplies needed for the delivery, include povidone-iodine

sponges, a 10 cc syringe, lidocaine, 2 Kelly clamps, ring

forceps, dry towels, a bulb syringe, and scissors.

ο The mother should be placed on her left side for labor.

ο The fetal heart rate should be determined every 15 minutes

prior to pushing, and following each contraction during

the pushing phase using a vascular Doppler. Normal heart

rate is between 120-160 bpm. The heart rate often drops

with the contraction, but should recover to normal prior

to the next contraction.

If the heart rate drops below 100 and stays low for more

than 2 minutes, a cesarean section should be considered.

ο When the patient presents, the cervix should be examined

to determine dilation and fetal position. For the woman to

begin pushing, the cervix should be completely dilated

(10 cm) and no cervix should be felt on either side of the

fetal head. If the baby’s head is not presenting, move to

cesarean section immediately. If there is any question, and

ultrasound is available, it should be used to determine the

presentation.

Delivery.

ο Once the patient begins pushing, flex the hips to optimally

open the pelvis. The patient may be on her back, or tilted

slightly to the left. Assistants should support the legs

during pushing and relax them between contractions.

ο Clean the perineum with sterile Betadine solution. If this

is the patient’s first delivery, the perineum should be

anesthetized with lidocaine in case an episiotomy is

needed. There is little support for prophylactic episiotomy,

but may be necessary if the fetus is large, or tearing is

anticipated.

ο The fetal head delivers by extension. Pushing upward on

the fetal chin through the perineum can assist this process.

19.9

Emergency War Surgery

Additionally, it is extremely important to control the rate

of delivery of the head with the opposite hand.

If an episiotomy is needed, it should be cut in the posterior

midline from the vaginal opening approximately ¹/2 the

length of the perineum, and extend about 2-3 cm into the

vagina.

After delivery of the head, the mouth and nose should be

suctioned and the neck palpated for evidence of a nuchal

cord. If present, this should be reduced by looping it over

the fetal head, or by clamping twice and cutting if it will

not reduce.

Next, the operator’s hands are placed along the parietal

bones and the patient is asked to push again to allow

delivery of the anterior shoulder. Gentle downward

traction should allow the shoulder to clear the pubis, and

the fetus should be directed anteriorly to allow delivery

of the posterior shoulder. The remainder of the body will

normally follow rapidly. Wrap infant in dry towels.

Once the fetus delivers, the cord should be doubly clamped

and cut. The placenta usually delivers within 15 minutes

of delivery, but may take up to 60 minutes. Delivery of the

placenta is heralded by uterine fundal elevation,

lengthening of the cord, and a gush of blood. While

waiting, gentle pressure may be placed on the cord,

however, vigorous uterine massage and excessive traction

can lead to complications.

Following delivery of the placenta, the patient should be

started on an infusion of lactated Ringer’s with 20 units of

oxytocin (Pitocin). Oxytocin can also be given IM if there

is no IV access. If there is no oxytocin available, alternatives

are methylergonovine maleate (Methergine) 0.2 mg

intramuscular (IM) or allowing the patient to breastfeed.

The placenta should be inspected for evidence of

fragmentation that can indicate retained products of

conception.

Inspection and repair.

ο Following delivery of the placenta, the vagina and cervix

should be inspected for lacerations. Downward digital

pressure on the posterior vagina and fundal pressure (by

19.10

Gynecologic Trauma and Emergencies

an assistant, if available) will facilitate visualization of the

cervix. A ring forceps is then used to grasp and visualize

the entire cervix.

The vagina should be inspected with special attention to

the posterior fornix. The perineum and periurethral areas

should also be inspected. Vaginal and cervical lacerations

may be repaired with 3-0 vicryl or an equivalent suture in

running or interrupted layers.

If the anal sphincter is lacerated, it should be reapprox-

imated with 2-0 absorbable interrupted single or figure-

of-eight sutures.

If the patient has torn into the rectum, the rectal-vaginal

septum should be repaired with interrupted sutures of 3-

0 vicryl. A second layer imbricating the underlying tissue

will decrease the risk of breakdown. Care should be taken

to preserve aseptic technique. If a large tear is noted, a

saddle block or spinal anesthetic may be necessary.

Patients with a periurethral tear may require urethral

catheterization. In addition to lacerations, hematoma in

the vulva, vagina, or retroperitoneum may occur. See above

gynecologic trauma for management.

Emergency Cesarean Section

Indications.

ο Fetal heart rate drops below 100 and stays down for more

than 2 minutes.

ο Acute uterine hemorrhage persisting for more than a few

minutes (suggestive of placental abruption or previa).

ο Breech or transverse fetal presentation.

The patient should be placed in the left tilt position with an

IV bag or towel displacing the uterus to the left. She should

undergo a quick prep from just below the breasts to the mid

thigh. A major abdominal equipment set should have most

of the instruments that you will need.

Basic steps to performing an emergency C-section (Fig. 19-

4 a,b,c,d).

ο Enter the abdomen through lower midline.

19.11

Emergency War Surgery

Uterine Incision

Uterus

Incision in Lower

Uterine Segment

Bladder Retracted After

Incising Vesicouterine Fold

Delivery of Fetus

Fundal Pressure

Exerted

Placenta

Operator's Hand

in Position to

Deliver Fetal Head

Delivered Infant on Abdomen

Nose and Mouth Suctioned

Umbilical Cord Doubly Clamped,

Then Cut

Uterine Fundus Exteriorized

Fig. 19-4. Emergency C-Section.

19.12

Gynecologic Trauma and Emergencies

Identify and incise the peritoneal reflection of the bladder

transversely, and create a bladder flap to retract the bladder

out of the field.

Using a scalpel, carefully incise the uterus transversely

across the lower uterine segment (where the uterine wall

thins).

Once the amniotic membranes are visible or opened,

extend the incision laterally, either bluntly or by carefully

using bandage scissors. Avoid the uterine vessels laterally.

If necessary, the incision can be extended at one or both of

its lateral margins in a J-fashion by vertical incision.

Elevate the presenting fetal part into the incision, with an

assistant providing fundal pressure.

Upon delivery of the fetus, suction the nose and mouth

and clamp and cut the cord. Hand the infant off for care

(see below).

Direct anesthetist to administer 2 grams of cefazolin

(Ancef) once the cord is clamped.

Allow the placenta to deliver by providing gentle traction

on the cord and performing uterine massage.

Begin oxytocin, if available as above.

Using a sponge, clean the inside of the uterus, and

vigorously massage the fundus to help the uterus contract.

Quickly close the incision with 0-vicryl. A single layer

(running, locking) is adequate, if hemostatic, for transverse

incisions. Take care to avoid the lateral vessels. If the

incision has a vertical extension, close it in 2 or 3 layers.

Once hemostasis is assured, close the fascia and abdomen

in the usual fashion.

In the rare case of continued uterine hemorrhage, evaluate

and treat as outlined in the section below.

Uterine Atony

The majority of postpartum hemorrhage is secondary to

uterine atony (failure of uterine contracture).

When the uterus fails to contract following delivery of

the placenta, bleeding may be torrential and fatal.

19.13

Emergency War Surgery

Initial management should include manual uterine explor-

ation for retained placenta. Without anesthesia, this procedure

is painful. An opened sponge is placed around the examiner’s

fingers. Place the opposite hand on the patient’s uterine

fundus and apply downward pressure. Gently guide your

fingers through the open cervix and palpate for retained

placenta. The inside of the uterus should feel smooth, and

retained placenta will feel like a soft mass of tissue. This may

be removed manually or by using a large curette if available.

If no tissue is encountered, use both hands to apply vigorous

uterine massage to improve the uterine tone.

Medications should also be used if available. Oxytocin may

be given by IV bolus using 40 units in 1000 cc, or up to 10

units IM, but never by IV push. Although unlikely to be

available, other medications that can be considered are

Methergine, dinoprostone (Prostin), and misoprostol

(Cytotec).

If no medication is available, the patient should be

encouraged to breast feed or do nipple stimulation to increase

endogenous oxytocin release.

If conservative measures fail to arrest the postpartum

hemorrhage, laparotomy (if the hemorrhage is occurring

post vaginal delivery), should be performed.

Intraoperative massage of the uterine fundus may be tried.

If the massage fails to improve uterine tone, the uterine

arteries should be ligated in a stepwise fashion. Begin with

the ascending branch at the junction of the upper and lower

uterine segment. Using 0 or No. 1 chromic, place a stitch

through the myometrium medial to the artery from front to

back. The stitch is then brought out through the adjacent

broad ligament and tied. If bilateral ligation of the ascending

branch does not control bleeding, the descending branch

should be ligated at the level of the uterosacral ligament. If

this fails, consider bilateral hypogastric artery ligation (see

above). If this fails, proceed to hysterectomy as outlined in

the gynecologic portion of this chapter.

19.14

Gynecologic Trauma and Emergencies

Neonatal Resuscitation

Immediately following delivery, every infant should be

assessed for need for resuscitation. Equipment that may be

needed includes warm towels, bulb syringe, stethoscope,

flow-inflating or self-inflating bag with oxygen source,

laryngoscope and blade, suction catheter, and endotracheal

tube. The two medications that may be needed are epine-

phrine 1:10,000 and naloxone (Narcan) 0.4 mg/ml.

Nearly 90% of term babies are delivered without risk factors

and with clear fluid, requiring only to be dried, suctioned

and observed. If the baby is less than 36 weeks, or if there

is meconium in the fluid at delivery, the baby will need to

be observed more closely.

In the first 30 seconds after delivery, dry and stimulate the

baby, position it in order to open the airway, and give free

flow oxygen if the color is poor.

At 30 seconds, evaluate the heart rate. If it is < 100 begin

to provide positive pressure ventilation. After 30 seconds

of ventilation, recheck the heart rate. If it is < 60, then

chest compressions should be started. After 30 seconds

of chest compressions, again re-evaluate. If the heart rate

remains < 60 you should administer epinephrine.

Epinephrine can be given either through the umbilical vein

or the endotracheal tube. The level of experience of the

team present should dictate which route should be used.

The dose is 0.1-0.3 ml/kg of the 1:10,000 solution.

If heart rate rises over 100, stop the positive pressure

ventilations, but continue to provide free flow oxygen. If

the mother has been given a dose of narcotics in the 4 hours

prior to delivery, and positive pressure ventilation has

resulted in a normal heart rate and color but poor

respiratory effort, then naloxene is indicated. Administer

naloxene by IV, IM, or endotracheal route at a dosage of

0.1 mg/kg.

If at any time during resuscitation the heart rate goes above

100, with good respiratory effort, tone and color, the baby

may be moved to an observation status.

19.15

Chapter 20

Wounds and Injuries of the Spinal

Column and Cord

Introduction

Combat injuries of the spinal column, with or without associated

spinal cord injury, differ from those encountered in civilian

practice. These injuries are often open, contaminated, and

usually associated with other organ injuries.

Following the ABCs of advanced trauma life support (ATLS),

management principles include:

Initial spine stabilization to prevent neurologic deterioration.

Diagnosis.

Definitive spinal stabilization.

Functional recovery.

In complete injuries, the likelihood of neurological

recovery is minimal and is not influenced by emergent

surgical intervention. However, incomplete injuries with

neurological deterioration may benefit from emergent

surgical decompression. Emergent, life-saving, soft

tissue exploration, and debridement may still be

required, particularly with colorectal involvement.

Classification

Four discriminators must be considered in the classification and

treatment of spinal injuries.

Is injury open or closed?

Neurologic status: complete vs incomplete vs intact.

ο Complete injury demonstrates no neurologic function

below the level of injury after the period of spinal shock

20.1

Emergency War Surgery

(usually 24-48 h, evidenced by return of the bulbocavern-

osus reflex).

Location of the injury: cervical, thoracic, lumbar, or sacral.

Degree of bony and ligamentous disruption: stable vs

unstable.

Pathophysiology of the Injury to the Spinal Cord

Injury to the spinal cord is the result of both primary and

secondary mechanisms.

ο Primary: the initial mechanical injury due to local

deformation and energy transmission.

♦ High-velocity missile wounds in the paravertebral area

can cause injuries even without direct trauma.

Stretching of the tissue around the missile’s path during

formation of the temporary cavity, or fragmentation of

the projectile and bone resulting in secondary missiles,

cause injury without any direct destruction of the spinal

column.

The destructive nature of high-velocity wounds explains

the futility of decompressive laminectomy in the

management of these wounds.

ο Secondary: the cascade of biochemical and cellular

processes initiated by the primary process that causes

cellular damage and even cell death.

The critical care of spinal cord injury patients includes

attempts to minimize secondary injury from hypoxia,

hypotension, hyperthermia, and edema.

Mechanical integrity of the vertebral column

The vertebral column is composed of three structural columns

(Table 20-1).

20.2

Wounds and Injuries of the Spinal Column and Cord

Table 20-1. Support of the Spinal Column.

Column Bony Elements

Soft-Tissue Elements

Anterior Anterior two-thirds of vertebral Anterior longitudinal ligament

body

Anterior annulus fibrosus

Middle

Posterior one-third of vertebral Posterior longitudinal ligament

body

Posterior annulus fibrosus

Pedicles

Posterior Lamina

Ligamentum flavum

Spinous processes

Interspinous ligaments

Facet joints

Injuries occur by either direct penetrating forces or a

combination of flexion, axial loading, rotation, and distraction

forces.

Loss of integrity of two of the three columns results in

instability of the spine.

Instability is common following blunt injury of the

vertebral column, but is not usually the case with gunshot

or fragment wounds of the vertebral column.

Cervical instability by lateral radiograph (must include C-

7/T-1 junction) is defined by:

ο 3.5 mm or greater sagittal displacement or translation.

ο Angulation of 11° or more on the lateral view.

ο Should questions exist regarding cervical stability, flexion

and extension lateral radiographs can be obtained in the

awake, cooperative patient.

Thoracic and lumbar spine instability:

ο 5 mm of sagittal translation.

ο 20°-30° of sagittal angulation.

ο 50% loss of vertebral body height.

ο Widened pedicles on anterior-posterior (AP) radiographs.

Computed tomography (CT) is very effective in demonstrating

spinal instability and has become available in some field

environments.

20.3

Emergency War Surgery

Instability must be presumed (and the spine stabilized) in

any patient with:

Complaints of a sense of instability (holds his head

in his hands).

Vertebral column pain.

Tenderness in the midline over the spinous

processes.

Neurologic deficit.

Altered mental status.

SUSPECTED, but NOT PROVEN injury.

Patient Transport

On the battlefield, preservation of the life of the casualty

and medic are of paramount importance. In these circum-

stances, EVACUATION TO A MORE SECURE AREA

TAKES PRECEDENCE OVER SPINE IMMOBILIZA-

TION. Data do not support the use of cervical collars and

spine boards for PENETRATING spine injuries on the

battlefield.

Extrication

Cervical spine.

ο The neck should never be hyperextended.

ο If an airway is needed.

♦ If appropriate, attempt endotracheal intubation with in-

line neck stabilization.

♦ Cricothyroidotomy is necessary if intubation fails.

ο The head should be maintained in alignment with the

body.

♦ Requires several people, including one just to stabilize

the neck.

♦ Log roll with the most experienced person stabilizing

the neck.

ο A stiff cervical collar and sandbags provide stabilization

of the neck during the transport. The head and body should

be secured to the extrication device.

Thoracic and lumbar spine.

20.4

Wounds and Injuries of the Spinal Column and Cord

ο Use log roll or two-man carry as demonstrated in Fig. 20-1.

♦ The two-man carry alone does not protect the cervical

spine.

♦ The cradle-drop drag may also be used.

ο In the absence of a spine board, makeshift litters can be

fashioned from local materials.

Fig. 20-1. (a) Log roll (b) two-man carry.

Anatomical Considerations

Cervical Spine

All potentially unstable cervical spine injuries should be immob-

ilized in a rigid collar, unless halo immobilization is required.

Indications for halo use:

20.5

Emergency War Surgery (2004) - page 7