General Considerations Provide care with available resources based on echelon and location of care Stabilize the patient for transfer to a higher level of care and definitive management Provide treatment within the Golden hour: One hour time frame in which treatment of life threatening injuries is vital, with increased mortality outside of this window Echelons of Care Role 1 point of injury care self aid buddy aid combat lifesaver (An intermediate level of training for non-medical service members) corpsman and medic advanced life-saving skills tactical combat casualty care (TCCC) Role 2 can be permanent structure versus mobile limited surgical capabilities with a focus on stabilization of emergent life-threatening injuries damage control resuscitation damage control surgery damage control orthopaedics Role 3 permanent or semi-permanent combat zone hospital with more resources and capabilities generally have CT scanner, lab, ward/ICU able to do some definitive care if needed Role 4/5 Large permanent hospitals located within the continental United States or overseas perform definitive care access to post-operative rehabilitation Tactical Combat Casualty Care (TCCC) Phase 1: Care Under Fire return fire and take cover direct casualty to remain engaged as combatant direct casualty to move to cover and provide self-aid apply tourniquets as needed Phase 2: Tactical Field Care (MARCH) massive hemorrhage airway respiration circulation hypothermia/head injury Phase 3: Tactical Evacuation (TACEVAC) prepare patient for transfer re-assess all treatments transfer patient to next level of care Vascular Trauma Hard Signs pulsatile bleeding visible expanding hematoma absent distal pulse or cold, pale limb palpable thrill audible bruit near the artery Soft Signs history of hemorrhage at the scene proximity of wound to major artery peripheral nerve deficit abnormal flow velocity waveform on Doppler ultrasound Initial Management immediate control direct pressure tourniquets place proximal to zone of injury but as distal as possible to minimize iatrogenic injury in event of prolonged tourniquet time. tighten until vascular occlusion occurs in the event bleeding continues, consider adding a second tourniquet proximal to the first mark time of tourniquet application. volume resuscitation low titer O whole blood (LTOWB) is gold standard when available if LTOWB is not available, then goal is 1:1:1 (platelets:plasma:pRBC) consider walking blood bank for fresh whole blood Surgical Management emergent surgical vascular approaches may be needed for adequate control of bleeding. vascular reconstruction or restoration of flow with shunting within 3 hours of injury is generally accepted to have the best outcome subclavian artery access incision over the anterior clavicle. use a perforating towel clamp to grasp the clavicular head and a Gigli saw to divide the clavicle from its mid portion. free the sternal head of the clavicle free of soft tissue. identify the anterior scalene and the overlying phrenic nerve. divide the anterior scalene and dissect to expose the subclavian vasculature. axillary artery access incision from inferior border of deltopectoral groove to mid clavicle. split pectoralis major in line with its fibers. divide the pectoralis minor to expose the axillary artery and vein. brachial artery access incision in medial arm between the triceps and biceps. median nerve lies over the brachial artery and is superior to the basilica vein seen with the medial antebrachial cutaneous nerve. continue dissection deeper to identify the brachial artery. can extend the incision obliquely across the antecubital fossa to identify the bifurcation into the radial and ulnar arteries. must divide the bicipital aponeurosis to expose the bifurcation, which is just distal to the antecubital fossa femoral artery access incision to expose the common femoral artery is made 2cm lateral to the pubic tubercle from a point 1-2cm above the inguinal ligament extending caudally along the medial border of the sartorius. the femoral triangle is formed by the medial border of sartorius, medial border of adductor longus, and inguinal ligament. dissect deeper within the femoral triangle to isolate the common femoral artery and its bifurcations. profunda femoris is largest branch and is usually 4 to 6 cm below the inguinal ligament following a posterolateral course. the danger is the lateral femoral circumflex vein (“Vein of woe”) that crosses the origin of the profunda femoris and should be avoided or divided. place a vessel loop around the profunda femoris to isolate it. the SFA is a continuation of the common femoral artery that dives into Hunter’s canal distally. popliteal artery access to expose it proximal to the knee, make an incision along the medial aspect of the thigh. careful not to injure the saphenous vein and nerve, dissect deeper to find Hunter’s canal, and take the dissection distal to identify the popliteal artery for exposure distal to the knee, make an incision one thumb breadth posterior to the medial border of the tibia. detach soleus fibers from the posterior border of the tibia to identify the neurovascular bundle. dissection can be continued to dissect out the trifurcation Shunting Tips prior to placing shunt, distal vessel should be allowed to back bleed a Fogarty catheter can be used to clear clot largest intraluminal shunt should be used shunt should be 4cm longer than defect in vessel, allowing 2cm of shunt to be placed into each end of the artery papaverine can be applied to transected ends to assist with dilation of the lumen place silk tie in middle of shunt to aid in manipulation and orientation of shunt position once placed occlude with hemostat insert shunt into proximal lumen first and secure with a silk tie 5mm from end of vessel release hemostat to confirm pulsatile flow then clamp again insert shunt into distal lumen and place another silk tie 5mm from end of vessel tie proximal and distal silk ties to each end of the midline silk tie to secure shunt in place Shunt Options commercially available vascular shunts pediatric feeding tube IV tubing chest tube Compartment Syndrome Diagnosis compartment syndrome remains a clinical diagnosis poorly controlled pain, tense compartments, pain with passive stretch of the involved compartment, paresthesias, pulselessness, paralysis, pallor needle manometry pressure within 30mmHg of diastolic pressure techniques conventional needle device arterial line attach arterial line and tubing to monitor. attach stopcock to the tubing with a needle/syringe to the stopcock. flush the system with normal saline and zero the monitor. insert the needle into the suspected compartment. inject 0.1cc of saline using the stopcock and then flip the stopcock to the monitor. record the pressure. Forearm compartments: volar, dorsal, and mobile wad Gluteal compartments: tensor fascia lata, medius/minimus, and maximus Thigh compartments: anterior, posterior, and medial Lower Leg compartments: anterior, lateral, superficial posterior, deep posterior External Fixation Indications damage control orthopaedics resource-limited environment Principles to Increase Construct Strength increased pin diameter (most influential) increased pin spread increased number of pins decreased distance from pin to fracture increased number of bars pins/bars in different planes (e.g. multiplanar is stronger than uniplanar) Pin Diameters pelvis/femur/tibia/humerus: 5mm forearm: 4mm hand/foot: 3mm Wound Debridement Indications contaminated wounds and open fractures should be treated initially with debridement and irrigation Wound Debridement Principles extend wound edges longitudinally sharply excise devitilized skin remove contaminated/non-viable tissue sharply excise damaged muscle and subcutaneous tissue evaluate bone ends in open fractures for debridement of the intramedullary canal and fracture ends solution used should be sterile water/saline; however, potable water can be used in austere environments if sterile solution is not available irrigation can be delivered via any means available (gravity flow, pulse lavage, etc.) Burns Background eschar can compromise chest wall excursion and peak airway pressure escharotomy allows the cutaneous envelope to increase in compliance, allowing the soft tissue to expand Escharotomy Indications circumferential eschar with: impending extremity vascular compromise impending respiratory compromise impending abdominal compartment syndrome Escharotomy Prinicples place incisions such that a subsequent fasciotomy can be performed using the same incision incision into the eschar should cause a split of the involved tissue with bulging of the subcutaneous tissues divide the eschar completely and extend escharotomy beyond the edges of the eschar to ensure tissue is decompressed Amputations Background in the austere or resource-limited environment, consideration should be given to preserving length when possible during the initial debridement, allowing for the definitive amputation and closure to be performed after the wounds are clean and tissues confirmed to be viable General Principles minimize risk of infection with thorough and aggressive debridement preserve length by maintaining all viable bone and soft tissue this includes nerves, do not perform traction neurectomy do not close the wound at initial surgery, leave the field open for subsequent debridements stabilize bony injuries to maximize length and function of limb Trans-humeral Trans-forearm preserve as much length as possible to allow for forearm rotation/strength, but any length of forearm is better than an above elbow amputation Trans-femoral Trans-tibial Military Specific Complications Infection increased risk of open fracture, blast injury, amputation, and blood transfusion pathogens: Acenitobacter baumenii 40% of DCO-associated intramedullary nails osteomyelitis: 2-15% of extremity injuries primary: Acenitobacter, Klebsiella, Pseudomonas recurrent: MRSA, MSSA Heterotopic Ossification increased risk with blast injury and amputation Disability osteoarthritis and back pain are most common causes of separation from military during peacetime and war