BASIC MANAGEMENTOF WOUNDS
IN WAR & NATURAL DISASTER
Christos Giannou
Advanced Course in the Management of Disaster Victims
Nicosia, October 2011
Outcome depends on:
Injury: severity of the wound & structures injured General condition of patient
Pre-hospital care: evacuation time Pre-hospital care: triage Pre-hospital care: first aid
Resuscitation & hospital triage & hygiene Surgery Post-operative nursing care
Physiotherapy & Rehabilitation
Basic Principles 1
Examine the patient
resuscitation: ABCDE hypothermia
Examine the wound grade and type
Basic patient hygiene
Basic Principles 2
Wound incision for drainage
Excision of devitalised tissues
Irrigation
Leave the wound open for drainage – no sutures
Large bulky dressing
Basic Principles 4
Anti-tetanus
Antibiotics, as adjuvant
Analgesics
General condition of the patient + nutrition + hygiene
Physiotherapy + rehabilitation
Laboratory: essential examinations
Hb / Hct Urine (sugar, pregnancy)
WBC total & differential Platelets Coagulation time, bleeding time Fasting blood sugar No bacteriology No blood gases
Blood transfusion
No components
Whole blood, as fresh as possible
Walking blood bank: friends, family, clan
Autotransfusion
Forget recombinant Factor VIIa!
Wound excision - debridement
Layer by anatomic layer
Skin: incision, excision
Subcutaneous tissues
Fascia, aponeurosis: drainage
Muscles: 4 C's
Periosteum
Bone
Exceptions
Face, neck, scalp and genitals – PC after DBR
Soft tissue of the chest wall – muscles to close open pneumothorax
Head – brain injury by dura : closure should be effected if possible
Abdominal wall (open abdomen)
Joints – synovial membranes should be closed
Blood vessels, tendons, nerves – muscle cover
Metallic foreign bodies
Should be left alone unless
Jeopardy to organ, major vessels and nerves
Inside of joints
Anterior chamber of eye
Superficial subcutaneous (painful movement)
Infection around FB (abscess)
Principles for the Managementof Weapon Wounds
“Damaged tissues must be removed in time.”
Qanun fi el-Tib
(The Laws of Medicine)
Avicenna – Ibn Sinna
980 – 1036 CE
Orthopaedics
No internal fixation / osteosynthesis
Plaster of Paris POP
Thomas splint
Skeletal traction
External fixation
Old lessons for new surgeons
War wounds are dirty and contaminated, from the moment of injury.
The rules of septic surgery apply.