1. BASIC MANAGEMENT OF WOUNDS IN WAR & NATURAL DISASTER Christos Giannou Advanced Course in the Management of Disaster Victims Nicosia, October 2011

2. 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

3. Basic Principles 1  Examine the patient  resuscitation: ABCDE  hypothermia  Examine the wound  grade and type  Basic patient hygiene

4. Basic Principles 2  Wound incision for drainage  Excision of devitalised tissues  Irrigation  Leave the wound open for drainage – no sutures  Large bulky dressing

5. Basic Principles 3  No unnecessary dressing changes  Delayed Primary Closure (DPC: after 4-7 days)

6. Basic Principles 4  Anti-tetanus  Antibiotics, as adjuvant  Analgesics  General condition of the patient + nutrition + hygiene  Physiotherapy + rehabilitation

7. Laboratory: essential examinations  Hb / Hct  Urine (sugar, pregnancy)  WBC total & differential  Platelets  Coagulation time, bleeding time  Fasting blood sugar  No bacteriology  No blood gases

8. Blood transfusion  No components  Whole blood, as fresh as possible  Walking blood bank: friends, family, clan  Autotransfusion  Forget recombinant Factor VIIa!

9. Wound excision - debridement  Layer by anatomic layer  Skin: incision, excision  Subcutaneous tissues  Fascia, aponeurosis: drainage  Muscles: 4 C's  Periosteum  Bone

10. 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

11. 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)

12. Principles for the Management of Weapon Wounds “Damaged tissues must be removed in time.” Qanun fi el-Tib (The Laws of Medicine) Avicenna – Ibn Sinna 980 – 1036 CE

13. Explore the wound

14. Wound opened, track debrided, large foreign body

15. Shell fragments and detached bone removed

16. Supraclavicular bullet wound

17. Multiple superficial fragments

18. Serial debridement of large wound: line of demarcation of necrotic tissue apparent

19. Excise skin wound & Extend the skin incision

20. Fasciotomy & opening up of the wound cavity After incision of fascia, protrusion of injured muscle

21. Cavity excised & clean wound left open

22. Bulky, absorbent and dry dressing

23. Mismanaged wound: primary suture

25. Primary suture of heel without debridement: infection, tetanus, patient died

26. Mismanaged wound: primary suture

27. Mismanaged wound: signs of inflammation

28. Stitches released, necrotic edges, subcutaneous oedema

29. Re-debrided, wound is now larger than original injury

30. 5 days later, wound clean

31. Partial closure with sutures

32. Closure with split-skin graft

33. Healing

34. Well-managed patient: dirty wound

35. Dirty wound debrided

36. 5 days later, removal of dressing

37. Sticky dressing peals off

38. Fully exposed wound 5 days after debridement

39. Immediate skin graft as DPC

40. Orthopaedics  No internal fixation / osteosynthesis  Plaster of Paris POP  Thomas splint  Skeletal traction  External fixation

41. Vega cast

42. Skeletal traction

43. Thomas splint

44. External fixation

45. Old lessons for new surgeons War wounds are dirty and contaminated, from the moment of injury. The rules of septic surgery apply.

46. Old lessons for new surgeons The best antibiotic is good surgery.