Front Line Surgery (eBook)

Matthew J. Martin, MD, FACS Trauma Director Madigan Army Medical Center Deployment Experience: Chief of Surgery 47th Combat Support Hospital Tikrit, Iraq 2005-2006 Chief, General Surgery and Trauma Theater Consultant for General Surgery 28th Combat Support Hospital Baghdad, Iraq 2007-2008 Alec C. Beekley, MD, FACS Staff Surgeon Madigan Army Medical Center Deployment Experience: Staff Surgeon 102nd Forward Surgical Team Kandahar Airfield, Afghanistan 2002-2003 Chief of Surgery 912th Forward Surgical Team Al Mussayib, Iraq 2004 Staff Surgeon 31st Combat Support Hospital Baghdad, Iraq 2004 Director Deployed Combat Casualty Research Team 28th Combat Support Hospital Baghdad, Iraq 2007

Chapter 1: Prehospital and Enroute Care 23
BLUF Box (Bottom Line Up Front) 23
Critical Tasks and Priorities 24
Psychology of Prehospital Care 25
Some Important Considerations for Treatment 27
Tourniquets (Fig. 1.2) 27
Thoracic Needle Decompression 28
Airway Treatment 28
IV Fluids for Resuscitation 29
Resuscitation Fluid Choice 30
En Route Considerations 31
Secure the Patient 31
Airway 31
Be Wary of the IV Drip 31
Wound Dressing 32
Chest Decompression 32
Hypothermia Prevention 32
General Considerations 33
Chest Seals 33
Hemostatic Dressings (Fig. 1.4) 33
Chest Tubes 35
Pre-hospital Antibiotics 35
Pain Control 36
Ketamine 36
Recombinant Factor VIIa 36
Prehospital Blood and Plasma 37
Summary 37
Chapter 2: Combat Triage and Mass Casualty Management 39
BLUF Box (Bottom Line Up Front) 39
Introduction 40
Resources 40
Security 40
Context 41
Trained and Ready Personnel 41
Culture 41
Supply and Transport 43
Rehearsal 43
Plan 43
Response 45
During the Event 45
Hospital Level Triage and the “Triage Officer” 47
Special Considerations: Mental, Behavioral Health and Spiritual Needs 51
Route 51
Reset 52
Ethics and Resiliency 52
Conclusion 53
Chapter 3: Initial Management Priorities: Beyond ABCDE 54
BLUF Box (Bottom Line Up Front) 54
Initial Management Priorities 56
Sick or Not Sick? 56
Hemorrhage Control Über Alles 57
Tension Pneumothorax 59
Open Pneumothorax 59
Airway 60
Massive Extremity Injuries 61
Unexploded Ordinance 62
Operating Room Priorities 63
The “Blood Vicious Cycle” Revisited 64
The Multi-System Combat Casualty: Putting It All Together 65
Chapter 4: Damage Control Resuscitation 67
BLUF Box (Bottom Line Up Front) 67
Introduction 68
Damage Control 69
Acute Coagulopathy of Trauma Shock (ACoTS) 69
Identification of Patients Requiring DCR 70
When Does DCR Start 71
Creation of DCR Protocol 71
Delivery of DCR 72
Termination of DCR 74
Fresh Whole Blood 74
Organization of Walking Blood Bank 75
Collection of Fresh Whole Blood 76
Recombinant Factor VIIa 76
The Aftermath of DCR 77
Forward Surgical Team Specifics 77
Chapter 5: To Operate or Image? (Pulling the Trigger) 79
BLUF Box (Bottom Line Up Front) 79
The Stable Patient 80
The “Rule Out” Head or Spine Injury 82
The Unstable Patient 83
The Sirens of Combat Trauma Imaging (Specific Pitfallsand How to Avoid them) 84
Final Points 86
Chapter 6: Ultrasound in Combat Trauma 87
BLUF Box (Bottom Line Up Front) 87
Why Ultrasound? 88
Advantages of US 89
Disadvantages of US (for the Average Ultrasonographer) 89
How to Perform an EFAST 90
Basic Terms and Knobology 90
Abdomen 92
RUQ (Perihepatic or Hepatorenal) View 92
LUQ (Perisplenic or Splenorenal) View 93
Pelvic View 94
Pericardial View 96
Pneumothorax Scan 97
Making Clinical Decisions with EFAST Findings 98
Other Useful Applications 99
Evaluation of Hemodynamic Status/CVP Measurement 99
Triage 100
Procedural 100
Foreign Body/Soft Tissue/Musculoskeletal Application 100
Other 100
Chapter 7: The Bowel: Contamination, Colostomies, and Combat Surgery 102
BLUF Box (Bottom Line Up Front) 102
Does the Patient Have a GI Tract Injury? 103
What to Do Once in the Operating Room? 104
Injuries to the Stomach 105
Injuries to the Small Intestine 106
Injuries to the Colon 110
Injuries to the Rectum 113
Timing of Reconstruction After Damage Control 115
“Used” Trauma 116
Tractotomies/Treatment of Entrance and Exit Wounds 116
Final Points 117
Chapter 8: Liver and Spleen Injury Management in Combat (Old School) 118
BLUF Box (Bottom Line Up Front) 118
Introduction 119
Basic Concepts 119
Diagnosis 120
Exposure 121
Are You a “Packer” or a “Sucker”? 122
Spleen 124
Liver 126
Postop Pearls 131
Chapter 9: Pancreatic and Duodenal Injuries (Sleep When You Can…) 133
BLUF Box (Bottom Line Up Front) 133
Making the Diagnosis 134
Anatomy: The Key to the Battle Plan 135
The Body and Tail of the Pancreas 138
Injury to the Head of the Pancreas 140
The Pancreatic Duct 140
Duodenal Injuries 141
The Trauma Whipple 145
Chapter 10: Operative Management of Renal Injuries 147
BLUF Box (Bottom Line Up Front) 147
Introduction 148
Indications for Operation and Renal Exploration 148
Exposure and Injury Evaluation 150
Repair and Resection 154
Parenchymal Injuries 154
Vascular Injuries 156
Nephrectomy 157
Complications 157
Chapter 11: Major Abdominal Vascular Trauma 159
BLUF Box (Bottom Line Up Front) 159
Introduction 159
The Basics in the ER 160
In the OR: Getting Started 161
In the OR: Injuries Encountered 161
In the OR: Operative Technique 163
Zone 1 Supramesocolic Injuries 163
Specific Zone I Supramesocolic Vascular Injuries 164
Zone 1 Inframesocolic Injuries 165
Specific Zone I Inframesocolic Vascular Injuries 165
Zone 2 Vascular Injuries 167
Zone 3 Vascular Injuries 168
Damage Control in Abdominal Vascular Trauma 171
The Massive Pelvic Disruption 171
Tips and Tricks 172
Final Thoughts 172
Chapter 12: To Close or Not to Close: Managing the Open Abdomen 173
BLUF Box (Bottom Line Up Front) 173
Why Leave the Abdomen Open? 174
How to Temporarily Close the Open Abdomen 177
Serial Abdominal Closure 179
Complex Abdominal Wall Reconstruction: Component Separation 182
Specific Pitfalls and How to Avoid them 184
Final Points 185
Chapter 13: Choice of Thoracic Incision 188
BLUF Box (Bottom Line Up Front) 188
Why This Chapter Matters to You 189
Rules of Engagement 189
One Way In and Only One Way Out 195
Variation on BLUF #6: The Costal Margin is Just Cartilage 196
Bottom Line 198
Chapter 14: Lung Injuries in Combat 199
BLUF Box (Bottom Line Up Front) 199
Surgical Approach (“You Can’t Get There from Here”) 200
Damage Control Principles in the Chest (This Ain’t The Abdomen) 201
Pneumothorax and Hemothorax 202
Lung Parenchymal Injuries 203
The Pulmonary Hilum: Tread Lightly 206
Pulmonary Hilar Control 209
Pneumonectomy (It Is Not a Dirty Word) 210
Air Embolism 212
Evacuation 213
Final Points 214
Chapter 15: Diagnosis and Management of Penetrating Cardiac Injury 215
BLUF Box (Bottom Line Up Front) 215
Introduction 216
Diagnosis of Penetrating Cardiac Injury 216
Important Techniques in the Diagnosis and Management of PCI 219
Pericardial Window 219
Median Sternotomy 220
Pericardial Well 221
Identifying Penetrating Cardiac Injury 222
Repairing Penetrating Cardiac Injury 223
Intra-cardiac Injury 227
Summary 228
Chapter 16: Thoracic Vascular Injuries: Operative Management in “Enemy” Territory 229
BLUF Box (Bottom Line Up Front) 229
Introduction 230
Wounding Patterns and Physiology on the Modern Battlefield 230
Pre-operative Management 231
Patient Preparation 232
What Incision Do I Make? 233
Principles of Repair for Specific Injuries 233
Use of Heparin 237
Shunts 238
Surgical Technique 239
Conduits 239
Closure of Incisions 240
Endovascular Procedures 240
Required Equipment 244
Summary 244
Chapter 17: Chest Wall and Diaphragm Injury 245
BLUF Box (Bottom Line Up Front) 245
Chest Wall Injuries 246
Flail Chest 249
Diaphragmatic Injuries 250
Diagnosis 250
Treatment 250
Final Points 253
Chapter 18: Soft Tissue Wounds and Fasciotomies 254
BLUF Box (Bottom Line Up Front) 254
Large Soft Tissue Wounds 255
Small Multiple Wounds 261
Fasciotomies 262
Upper Extremity Fasciotomy 263
Lower Extremity Fasciotomy 265
How to Manage the Fasciotomy Wound 266
Pulley Suture: Trick of the Trade 267
Final Thoughts 270
Chapter 19: Extremity Injuries and Open Fractures 271
BLUF Box (Bottom Line Up Front) 271
Anatomy 272
Open Fractures 273
Stabilization 274
External Fixation 275
Compartment Syndrome: A Contrarian Opinion 279
Nerve and Tendon 280
Final Thoughts 281
Chapter 20: Mangled Extremities and Amputations 282
BLUF Box (Bottom Line Up Front) 282
Initial Assessment and Resuscitation 283
Amputation Vs. Limb Salvage 284
Amputation: Forward Techniques 286
Debridement 287
Skeletal Stabilization 288
Definitive Amputation Closure 289
Transtibial Amputation Technique: Long Posterior Myofascial Flap 289
Transfemoral Amputation Technique 292
Care for Local Nationals 293
Final Thoughts 294
Chapter 21: Peripheral Vascular Injuries 295
BLUF Box (Bottom Line Up Front) 295
Initial Assessment & Operative Planning: Peripheral Vascular Injury
Surgical Management: General Tips & Techniques
Specific Injuries and Approaches 302
Femoral and Popliteal Vessels 302
Upper Extremity Vessels 304
Pseudoaneurysms 306
Postoperative Care & Evacuation
Final Points 307
Chapter 22: The Neck 308
BLUF Box (Bottom Line Up Front) 308
Why Is the Neck an Important Area to Understand the Anatomy and Injury Patterns? 308
Mechanisms and Types of Injuries to the Neck 309
What Are the Life Threatening Neck Injuries? 309
What Are the Injuries that Are Easy to Miss but Can Lead to Late Morbidity or Death? 309
How Should I Evaluate a Patient with a Neck Wound? 310
Techniques of Exposure, Exploration and Repair of the Common Injuries 312
Vascular Injuries: Common, Internal, and External Carotid Arteries, Jugular Vein 312
Esophagus 318
Trachea 322
Vertebral Arteries 322
Final Thoughts 323
Chapter 23: Genitourinary Injuries (Excluding Kidney) 325
BLUF Box (Bottom Line Up Front) 325
What Genitourinary Injuries will I have to Deal with in Combat? 326
What Do I Need to Assess in a Patient with Scrotal or Penile Wound? 326
How Can I Best Diagnose a Bladder or Urethral Injury? 327
Management for the General Surgeon 328
Penis 328
Urethra 330
Scrotum and Testicles 332
Bladder 334
Ureter 335
Tips and Techniques 336
Difficult Foley Placement 336
The “Hyperlube” Technique of Foley Catheter Placement 338
Suprapubic Tube Placement 339
Open Suprapubic Tube 339
Percutaneous Placement of the Suprapubic Tube 340
Performance of the Retrograde Urethrogram 340
Performance of the Cystogram 342
Summary 342
Chapter 24: Neurosurgery for Dummies 343
BLUF Box (Bottom Line Up Front) 343
Introduction 344
The Basics 345
When Do I Need a CT Scan/What If I Don’t Have a CT Scan? 345
How Do I Know If There Is an “ICP Problem”? 346
The Isolated Severe Head Injury 346
Severe Head Injury in the Multiple Trauma Patient 347
Placement of ICP Monitor “Bolt” or EVD (Required Kits Must Be Available) 348
Preparation 348
Marking the Patient 348
Placing the Device (ICP Monitor) 349
Placing an EVD 351
Decompressive Craniectomy Tips 352
Preparation 352
Final Thoughts 359
Chapter 25: Spine Injuries 361
BLUF Box (Bottom Line Up Front) 361
Assessing Spinal Cord Injuries 362
Shocking: Spinal Shock vs. Neurogenic Shock 365
Steroids 368
Managing Closed Spine Trauma 368
Managing Open Spine Trauma 370
A Is for Airway 370
Spinal Immobilization and Spinal Stability 371
Spinal Cord Syndromes 373
No Spine Consult Needed 373
Final Comments 373
Chapter 26: Face, Eye, and Ear Injuries 376
BLUF Box (Bottom Line Up Front) 376
Getting Started 377
The Basics: Airway 378
The Basics: Hemostasis 379
The Eyes 380
Imaging 381
The Soft Tissue 382
The Bones 385
The Ears 389
Finally 390
Chapter 27: Burn Care in the Field Hospital 391
BLUF Box (Bottom Line Up Front) 391
Immediate Care in the Field (Tactical Combat Casualty Care) 392
Acute Burn Care (In the Trauma Bay) 393
Burn Critical Care (The ICU Phase) 397
Areas of Special Interest (Face and Hands) 398
Transport of the Burn Casualty 399
Keys To Success for the Burn Casualty Who Has Nowhere Else To Go 399
Final Points 403
Chapter 28: The Pediatric Patient in Wartime 405
BLUF Box (Bottom Line Up Front) 405
Intravenous Access 407
Special Considerations in the ER 410
Special Considerations in the OR 411
Special Considerations in the ICU 413
Humanitarian and Non-trauma Care 415
Chapter 29: The Combat ICU Team 417
BLUF Box (Bottom Line Up Front) 417
Introduction 418
When Do You Need an ICU? 418
Who Should Staff the ICU? 419
How Should the ICU Work? 420
How Do You Set Up a Forward ICU and What Pieces of Equipment/Supplies Do I Need? 420
What If I Have Scarce Resources and Too Many Critical Patients? 424
Random but Practical and Important Points for the ICU 426
Final Thoughts 426
Chapter 30: Postoperative Resuscitation 428
BLUF Box (Bottom Line Up Front) 428
Introduction 429
Principles of Combat Resuscitation 429
What Fluids Should I Use? When Do I Give Blood Products? 430
How Do I Tell If I Am Winning or Losing the Battle? What Is the Best Endpoint? 431
Who Does Not Need Resuscitation? 434
When Do I Need to Go Back to the OR? 435
Final Thoughts 435
Chapter 31: Monitoring 437
BLUF Box (Bottom Line Up Front) 437
Introduction 438
Pulse Oximetry 439
Electrocardiography/Telemetry 440
Central Venous Pressure 440
Venous Oxygen Saturation 441
Pulmonary Artery Catheters 443
Arterial Lines 443
Assessing Volume Status: The Holy Grail 444
Intracranial Pressure Monitors (ICP) 445
Monitoring for Shock and Adequacy of Resuscitation 447
Correction of Coagulopathy 447
Advanced Continuous Monitors 448
Closed-Loop Systems 450
Summary 450
Chapter 32: Ventilator Management 452
BLUF Box (Bottom Line Up Front) 452
Which Combat Casualties Need Mechanical Ventilation? 453
Respiratory Failure in Combat Casualties: The Role of Blast Lung Injury 454
Initiation of Mechanical Ventilation 455
Lessons Learned from a Senior Respiratory Therapist 457
Equipment and Planning 457
Maintenance 457
Patient Care 458
Helpful References 458
Troubleshooting Common Ventilator Problems 460
Hypercapnea and Respiratory Acidosis 460
Hypoxemia and ARDS 461
Final Points 463
Chapter 33: Practical Approach to Combat-Related Infections and Antibiotics 464
BLUF Box (Bottom Line Up Front) 464
Introduction 465
Prevention of Infection 466
Care at Point of Injury (Level I) 466
Professional Medical Care Without Surgical Support (Levels I and IIa) 467
Care with Surgical Support (Levels IIb and III) 467
Care of Personnel Not Evacuated Rapidly Out of the Combat Zone 471
Final Points 472
Chapter 34: Stabilization and Transfer from the Far Forward Environment 473
BLUF Box (Bottom Line Up Front) 473
Advanced Trauma Life Support 474
Secondary Survey 475
Resuscitation 475
Forward Surgical Intervention 478
Evacuation 480
Command 484
Conclusion 488
Chapter 35: Humanitarian and Local National Care 489
BLUF Box (Bottom Line Up Front) 489
Medical Rules of Engagement Qualified 491
Medical Civic Assistance Programs 492
Local National Clinics 494
Educational Opportunities 499
Final Points 500
Chapter 36: Expectant and End of Life Care in a Combat Zone 501
BLUF Box (Bottom Line Up Front) 501
Combat Care and the “God Complex” 503
Determining Expectant Status 504
Location of Expectant Care 505
Delivery of Expectant Care 506
Aftermath of Expectant Care 508
Appendix A: Improvise, Adjust, Overcome: Field Expedient Methods in a Forward Environment 510
Appendix B: Combat Burn Flowsheet andOrder Set 517
Appendix C: Resources, References, and Readiness 521