Soft Tissue Extremity Injuries EWSC 1 · 2020-04-17 · 2020, v1.0 2 23 year old infantry stepped...

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Emergency War Surgery CourseJoint Trauma System

Soft Tissue and Extremity Injuries

Joint Trauma System Battlefield Trauma Educational Program

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23 year old infantry stepped on a mine and has a traumatic amputation of the left lower extremity near the hip with severe soft tissue injuries to the right leg and perineum.

1. What are initial priorities in management?

2. What are some of the principles of management of war wounds?

EWS Soft Tissue, Extremity Injuries

Scenario

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Understand principles of debridement and management of soft tissue injuries.

Recognize the clinical pattern of crush injuries.

Understand the principles of amputation.


Objectives

14 December 2011 Pre‐decisional FOUO

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Soft Tissue Injury Goals Prevent exsanguination

Prevent infection

Preserve function


Soft Tissue


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Combat Wounds


Wound exploration & debridementNO primary closure

Antibiotics/tetanus coverage

Contaminated at best, dirty the norm Extensive tissue destruction

Combat Wounds

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∎ Evaluate bone, soft tissues, vascular supply and neurologic function.

∎ Evaluate wounds completely with limited longitudinal incisions to facilitate full exploration.

War wounds will evolve over the period of several days.

Skin and fascia damage may be minimal compared to the damage underneath and should be opened to expose entire zone of injury.

EWS Soft Tissue, Extremity InjuriesExtremity Wound Assessment

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∎ Evaluate muscle using 4Cs (color, contraction, consistency,and circulation).

∎ These signs may be unreliable individually and should be used together to determine viability.

Consistency may be the best predictor.

Viable muscle will rebound to its original shape when grasped by forceps.

EWS Soft Tissue, Extremity InjuriesExtremity Wound Assessment

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∎ Realign bone and stabilize. Preserve bone fragments with vascularized soft tissue

attachments and large free articular fragments.

∎ Conservatively excise skin edges with 1‐2 mm resection distance.

∎ Excise devitalized tissue.

∎ Intravenous Antibiotic Prophylaxis

Soft tissue: Cefazolin 2 gm IV q6 hrs for up to 3 days

EWS Soft Tissue, Extremity InjuriesExtremity Wound Management

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∎ Temporize or repair vascular injuries. Artery: Shunt is damage control.

Vein:

Repair if easy and quick

Otherwise ligate (some exceptions exist)

∎ Tag or ligate nerve stumps.

∎ Irrigate and debride soft tissue.

EWS Soft Tissue, Extremity InjuriesExtremity Wound Management

Steps to washing out soft tissue injuries

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∎ Irrigation and debridement Low flow irrigation with sterile physiological fluid (6 – 12 Liters) Cystoscopy tubing helpful Bulb syringe

Potable water if sterile saline not available

∎ Sterile, bulky, loose, dry dressings are best for transport through and out of the battlefield.

∎ Plan return to OR for second debridement at 24‐48 hours. Repeat debridements in 24 to 48 hours until a clean wound achieved. 48 to 72 hours if negative pressure wound treatment (NPWT) device

used and all nonviable tissue has been removed.

EWS Soft Tissue, Extremity InjuriesExtremity Wound Treatment

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Treatment

BEFORE AFTER

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Management after initial operation

∎ Between procedures, there may be better demarcation of devitalized tissue and development of local infection.

∎ Soft tissue war wounds heal well through secondary intention.

Early soft‐tissue coverage desirable within 3‐5 days when wound is clean. Clean wound can be closed with undue tension. Clean wounds difficult to achieve in war wounds.

Skin grafts and muscle flaps should not be done in theater if evacuation possible.


Post Operation

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∎ Dressings can be gently packed with gauze to serve as wick for fluid egress. Loosely apply circumferential bandages in anticipation of swelling.

Negative pressure wound therapy may be an effective adjunct.

Consider antibiotic beads.


Post Operation

Antibiotic beads

Management after initial operation

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∎ Avoid Swiss cheese surgery; do not connect multiple small wounds.

∎ Superficial penetrating injuries do not usually require surgical exploration.

∎ NPWT device failure (i.e. loss of suction) can create environment with high rate of infection.

∎ Makeshift and improvised NPWT perform unpredictably and should not be used in combat theater or during aeromedical transport.


Pitfalls

Patient with numerous wounds on extremity

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∎ Suspect in patients with prolonged history of being trapped

∎ Rhabdomyolysis and hyperkalemia life threatening features

∎ Physical exam findings: May appear normal after extrication. Edema develops and the extremity becomes swollen, cool and tense. Pain out of proportion with examination in tense compartments.

∎ Lab findings Creatinine phosphokinase (CPK) elevated > 100,000 IU/mL. Urine dipstick positive for blood, but no red cells secondary

to myoglobin. Hyperkalemia


Crush Injuries

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∎ Therapy

Avoid potassium and lactate containing IV solutions.

Administer IV fluids with goal urine output of 75‐100 cc/h.

May require dialysis and surgical management of compartment syndromes or even amputation.


Crush Injuries

Myoglobinuria from rhabdomyolysis

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∎ Complete or near‐complete traumatic amputation Essentially, the trauma has already done the amputation for you.

∎ Irreparable vascular injury or failed vascular repair with an ischemic limb

∎ Refractory hyperkalemia due to rhabdomyolysis Failure of medical management Failure of or inability to dialyze

∎ Life‐threatening sepsis due to severe local infection

∎ A patient in extremis with severe soft‐tissue and bony injury to the extremity precluding functional recovery


Amputation Indications

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∎ Must balance the realistic likelihood of ultimate reconstruction against risk of death.

∎ Always desirable to secure opinion of second surgeon before amputating.

∎ May require amputation of otherwise salvageable limb in certain tactical situations or a patient in extremis.

∎ If perfusion can be restored, decisions regarding amputation for nerve or bone loss can be deferred until later. Splint or externally fixate structurally

unstable limbs.


Decision to Amputate

Traumatic amputation

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∎ Lowest viable level of soft tissue Traditional anatomical amputation levels are

not considered. Excise all nonviable tissue, but leave anything

viable.

∎ Be prepared to accept atypical skin and tissue flaps. Avoid open circular/guillotine amputations in

order to preserve soft tissue for later coverage.

∎ Final level of amputation and definitive care should occur in a stable environment of a CONUS hospital, if available.


Location of Amputation

Patient post‐amputation operation in CONUSSource: Out of the Crucible, Borden Institute

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∎ Surgically prepare the entire limb to allow for evaluation of planes of injury, which may be much higher then initially suspected.

∎ Tourniquet control is mandatory.

∎ Excise nonviable tissue.

∎ Identify and securely ligate major vascular structures proximal to bone resection but as distal as possible to ensure perfusion.

∎ Transect nerves at level of muscular coverage.

∎ Do not suture flaps down or construct flaps.All wounds must be left opened for re‐evaluation and serial irrigation and debridement as the zone of injury declares itself.


Technique of Amputation

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Technique of Amputation

Gigli saw on distal lower extremity bone of mangled extremity from IED blast. Notice the preservation of other soft tissue.

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∎ Apply Skin Traction if there is a delay in transportation to definitive care to preserve tissue length. (See Emergency War Surgery Book for instructions.)

∎ Prevent contracture through splints (below knee amputation) or prone positioning or sandbags to thigh (above knee amputations).

∎ Make sure tourniquet is readily available at bedside in case of hemorrhage.

∎ Pain control is paramount for patient comfort.


Special Considerations

Skin TractionSource: Emergency War Surgery, 5th U.S. Edition

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23 year old infantry stepped on a mine and has a traumatic amputation of the left lower extremity near the hip with severe soft tissue injuries to the right leg and perineum.

1. What are initial priorities in management?

2. What are some of the principles of management of war wounds?


Exercise

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∎ Joint Trauma System (JTS) Clinical Practice Guidelineshttps://jts.amedd.army.mil/index.cfm/PI_CPGs/cpgs

JTS, Amputation: Evaluation and Treatment Clinical Practice Guideline (CPG), 01 Jul 2016.

JTS, Initial Management of War Wounds: Wound Debridement and Irrigation CPG, Apr 2020.

JTS, Infection Prevention in Combat‐Related Injuries CPG, 08 Aug 2016.

∎ The Office of The Surgeon General, Borden Institute. Emergency War Surgery, 5th U.S. Edition, 2018. Chap 9, 23.https://www.cs.amedd.army.mil/Portlet.aspx?ID=cb88853d‐5b33‐4b3f‐968c‐2cd95f7b7809


References

Photos are part of the JTS image library unless otherwise noted.

Soft Tissue Extremity Injuries EWSC 1 · 2020-04-17 · 2020, v1.0 2 23 year old infantry stepped...

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