By; Dr.Abrar Hussain Zaidi In the name of ALLAH the most beneficent the most merciful “The First” wound debridement in IED –blast injuries: The 7S’s Doctrine By; Dr.Abrar Hussain Zaidi

Prologue IED- blast injury wounds are unique First wound debridement is the key to successful management in Every wounded But it needs special emphasis In case of IED- blast injuries IED- blast injury wounds are unique Wound are Contaminated and poisoned by organic and inorganic materials Need - Thorough surgical debridement within six hours – under full anesthesia

Objectives of Presentations Young surgeons must learn to apply The “7S’s” doctrine of wound debridement routinely while treating the IED-blast wounds

Types of IED blast wounds Explosives Type -[high-order explosives (HE) or low-order explosives LE). Primary : Blast effect/ Pressure wave injuries Mutilating soft tissues , Amputations Severe Structural damage of body. Secondary : Splinter injuries/ wounds May look minor but play a havoc inside Tertiary injuries : Body displacement ,Fracture / Blunt injuries Quaternary : Body entrapment – Building falls/Crushing/ Burns Combinations of different types can be seen in one patient

Peculiar features of IED blast wounds Contamination with toxic materials & with metal objects Tissue damage much more than apparent first outlook Splinters make deep Burrows [ like rodents] Extensive local & Systemic sepsis can occur even with small wounds- if neglected Retained FBs often missed

IED’s - Composition Made from a variety of different materials : Conventional Explosives Commercial blasting materials Fertilizer, fuel oil, other household ingredients. Incorporating; Metal fragments of different nature: nails, ball bearings, screws,pieces of tin Gravel, marble, stones-----[missiles] Lubricants

Typical victims Wounds may be found in one body region/ a limb or may be extensive multi regional

Typical victims

General principles of wound debridement Wound toilet / Thorough washing and irrigation/ Remove –dirt, debris, devitalized tissue Excise dead and potentially non-viable tissue Locate and remove as many FB’s as possible Gauze pack and leave the wounds open Decide early for amputations Vascular repair attempt only when distal viability is undoubted Delay the nerve repair Delay definitive fracture repair – temp. external fixations Stabilize

Practical Application of Principles of debridement in operation theater THE – “7S’s” – Doctrine Saline Irrigation – Saline/Water jets/wound toilet Scrubbing – Use Brush and gauze Shaving -- Shaving machine / razor Searching -- Scoops & forceps For In depth FBs / gravel/ mud 5. Scissors &Scalpel -- Wound Extension Salvage OR Excise – Wound Excision /Amputation Stabilization – Dressing / Ext fixations

Team efforts

Saline irrigation Generous toilet /irrigation / removal of devitalized tissue

Scrubbing the wound Using Brush and gauze

Scrubbing the wound Using Brush and gauze

Scrubbing the wound Using Brush and gauze

Scrubbing the wound Using Brush and gauze

Shaving the wounds

Searching for FBs - Metals VS non metal Metals can be left and observed but organic materials and stones should be removed

Searching - For FBs / gravel/ mud

Scooping- In depth search and cleansing Small minor looking wounds are as dangerous as bigger ones

Scooping- In depth search and cleansing

Scissors & Scalpel Use for Wound Extension & Fasciotomies .

Scissors & Scalpel Use for Wound Extension & Fasciotomies .

Scissors & Scalpel Use for Wound Extension & Fasciotomies .

Scissors & Scalpel Use for Wound Extension & Fasciotomies .

Salvage OR Amputate - decisions Timely decision have saved many lives A few Late decisions have resulted in deaths

Salvage vs amputation- decisions

Salvage vs amputation level decisions and preservation How much can be preserved/ salvaged The level of Amputation

Stabilization and Dressings Do not apply too tight dressings Ensure proper seal and suction if vac- pack applied Remove soaked dressings – sos/ bd /tds/ Dry dressings with good padding can be left for -24- 48 hours Vac – packs - change/ reapply – 3-5 days Crammer wire / plaster Temporary fracture stabilization External fixators / K wires

Stabilization & Dressings Pre-prepared dressing pads Simple gauze dressing Cotton and Gauze pads Intermittent Suction – Guaze packed open wound Vac-pack . Selective cases (Continuous or intermittent pressures, with levels varying between −125 and −75 mmHg depending on the material used and patient tolerance- adequate wound bed preparation skin grafting).

Practical application of principles of debridement in operation theater THE – “7S’s” – Doctrine Saline Irrigation – Saline/Water jets/wound toilet Scrubbing – Use Brush and gauze Shaving -- Shaving machine / razor Searching -- Scoops & forceps For In depth FBs / gravel/ mud 5. Scissors &Scalpel -- Wound Extension Salvage OR Excise – Wound Excision /Amputation Stabilization – Dressing / Ext fixations

Added procedures Amputations / Revision amputations preserving healthy soft tissue flaps Fecal diversion – wound over Perineum / thigh Treatment of abdomino-thoracic/ spinal/ head injuries

Imaging

Relooks & Repeat debridement Ist. Re- look and repeat debridement After twenty four hour 2nd Re look – 48 hours. Check for vitality and viability of tissues Vital Decisions for limb preservation Vs Amputation Repeat debridement- as per need Subsequent dressings in ward / OT Plan for definitive care: Simple conventional wound closure Skin Graft Staged wound closure

Out come Early recovery / minimal systemic and local complications / good wound healing

Out come Early preparation of wound for definitive closure/ grafting

Wound closure Prepared for early muscle flap and skin cover

Conclusion But This is only way we can save a patient’s life. First wound debridement in IED blast injuries is pains taking & tiring But This is only way we can save a patient’s life.

The spirit of trauma care services

Thank you