Abdominal War Wounds—Experiences from Red Cross Field Hospitals
ABSTRACT The traditional approach to abdominal war wounds consists of triage, eche-loned care, and mandatory laparotomy for penetrating abdominal injuries, and it remains valid in modern conventional wars with well-organized evacuation and surgical services. Expectant management of abdominal casualties can be considered under difficult circumstances with a high influx of patients exhausting the available resources. This can occur in regional conflicts associated with mass movements of people and with collapsed infrastructure. While always combined with adequate fluid resuscitation, antibiotic treatment, and other supportive care, the expectant approach in patients with penetrating abdominal injuries could be indicated for asymptomatic patients with multiple fragment wounds or for patients presenting several days post-injury in good condition. The focus of surgical resources and competence should be on the majority of patients with intestinal perforation only, who need surgery to save life--but not necessarily on an urgent basis--and who have a good chance of survival. The limited availability of blood products to correct blood loss and coagulation factor deficiencies, and the lack of sophisticated monitoring of hemodynamic variables that call into question the value of a damage-control approach for the most severely injured. Even if the bleeding could be temporarily controlled, the subsequent need for adequate resuscitation before returning the patient to the operating room could be difficult to achieve and would result in incompletely resuscitated patients being reoperated while acidotic, coagulopathic, and even hypothermic. Perhaps, in mass casualty situations these patients should be recognized during triage or at least early during operation, and aggressive surgery should be replaced with adequate expectant management with sedation and analgesics.
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ABSTRACT: Historically, military surgical doctrine has mandated exploratory laparotomy for all penetrating fragmentation wounds. We hypothesized that stable patients with abdominal fragmentation injuries whose computerized tomography (CT) scans for intraperitoneal or retroperitoneal penetration disclosed nothing abnormal, can be safely observed without therapeutic laparotomy. We retrospectively studied all hemodynamically stable patients with penetrating fragmentation wounds to the back, flank, lower chest, abdomen, and pelvis evaluated by abdominal physical examination (PE), CT, or ultrasound treated during a 6-month period at one combat support hospital. Sensitivity, specificity, and positive and negative predictive values were calculated comparing each positive test to laparotomy and each negative test to successful nonoperative management. One hundred forty-five patients met study criteria. Based on CT scans, 85 (59%) patients were managed nonoperatively; 60 (41%) underwent laparotomy. Forty-five of 60 (75%) of laparotomies were therapeutic. CT scan for intraperitoneal or retroperitoneal penetration that disclosed nothing abnormal was 99% predictive of successful nonoperative management. In detecting intra-abdominal injury requiring laparotomy, sensitivity for each method was 30.2% (PE), 11.7% (ultrasound), and 97.8% (CT) (p < 0.05). Specificity was 94.8% (PE), 100% (ultrasound), and 84.8% (CT). The areas under the receiver operating characteristic (ROC) curves were 0.565 (PE), 0.543 (ultrasound), and 0.929 (CT) (p < 0.0001). All patients with a positive ultrasound (n = 4) underwent therapeutic laparotomy. PE alone was unreliable in stable patients with abdominal fragmentation injuries. The clinical value of ultrasound results was limited, likely because the majority of these stable patients did not have injuries associated with the large accumulation of peritoneal fluid. CT scan safely and effectively analyzed nonoperative management of penetrating abdominal fragmentation injuries and should be the diagnostic study of choice in all stable patients without peritonitis with abdominal, flank, back, or pelvic combat fragmentation wounds.The Journal of trauma 03/2008; 64(2 Suppl):S108-16; discussion S116-7. DOI:10.1097/TA.0b013e31816093d0 · 2.96 Impact Factor
Article: Combat damage control surgery.[Show abstract] [Hide abstract]
ABSTRACT: Although the use of damage control surgery for blunt and penetrating injury has been widely reported and defined, the use of damage control surgery on the battlefield (combat damage control surgery) has not been well detailed. Damage control surgery is now well established as the standard of care for severely injured civilian patients requiring emergent laparotomy in the United States. The civilian damage control paradigm is based on a "damage control trilogy." This trilogy comprises an abbreviated operation, intensive care unit resuscitation, and a return to the operating room for the definitive operation. The goal of damage control surgery and the triology is avoidance of irreversible physiological insult termed the lethal triad. The lethal triad comprises the vicious cycle of hypothermia, acidosis, and coagulopathy. Although the damage control model involves the damage control trilogy, abbreviated operation, intensive care unit resuscitation, and definitive operation, all in the same surgical facility, the combat damage control paradigm must incorporate global evacuation through several military surgical facilities and involves up to ten stages to allow for battlefield evacuation, surgical operations, multiple resuscitations, and transcontinental transport. Combat damage control surgery represents many unique challenges for those who care for the severely injured patients in a combat zone.Critical care medicine 08/2008; 36(7 Suppl):S304-10. DOI:10.1097/CCM.0b013e31817e2854 · 6.15 Impact Factor
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ABSTRACT: The abdominal viscera are among the most vulnerable organs of the body to penetrating trauma. Proper management of such trauma in war victims at the first-line hospital where these victims are first seen is of paramount importance. We reviewed medical records of war victims suffering small bowel and colorectal injuries treated at first, second and third-line hospitals during the Iraq-Iran War (1980-88) to assess surgical outcomes. The medical records of 496 Iranian war victims suffering penetrating gastrointestinal (GI) injuries treated at first, second and third-line (tertiary) hospitals, a total of 19 centres, were reviewed. Laparotomy had been performed at the 1st line hospitals for all patients who had an acute abdomen, whose wounds violated the peritoneum or whose abdominal radiographs showed air or shrapnel in the abdominal cavity. Stable patients were transferred from first-line to second-line or from second line to tertiary hospitals postoperatively. The treatments, complications and patient outcomes were documented and analyzed. There were 496 patients; 145, 220 and 131 victims underwent laparotomy for GI injuries at first, second and third-line hospitals respectively. The small intestine and colon respectively were the most prevalent abdominal organs damaged. Those first treated for GI injuries at front-line hospitals (145 victims) had more serious conditions and could not be transferred prior to surgery and presented a higher prevalence of complications and mortality. Overall mortality from GI surgery was 3.6% (18 patients). Eleven patients (7.5%) whose first GI operation was performed at frontline hospitals and 7 patients (3.2%) who underwent their first surgical operation at second-line hospitals died. The most common reason for these deaths was complications relating to the gastrointestinal operation such as anastomotic leak. Six missed injuries were seen at the frontline and one at second line hospitals. There were no deaths at the 3rd line hospitals. Penetrating abdominal injuries were common in Iranian victims of war often causing multiple organ injuries. The colon and small intestine were the more commonly injured organs and carried the most postoperative complications. Mortality at 1st line hospitals was more than double that of 2nd line hospitals; the complication rate was also greater as was the number of missed injuries. Adherence to the standard surgical protocols, prompt evaluation, proper triage and management are factors which may lower patient morbidity and complications.Journal of the Royal Army Medical Corps 03/2010; 156(1):25-7. DOI:10.1136/jramc-156-01-05 · 0.81 Impact Factor