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Learning to treat terrorist attack victims
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An instructional session organized by the Combined Services Orthopaedic Society at the 2007 British Orthopaedic Association Annual Meeting in Manchester provided a valuable update on the cause and management of extremity war injuries.
In a special Round Table discussion, Orthopaedics Today International explores how these military experiences can translate to treating victims of terrorist attacks.
Participants include Col. Michael P.M. Stewart, QHS, FRCSGlas (Tr&Orth), L/RAMC, of Middlesbrough, England, and colleagues Lt. Col. Jon Clasper, DPhil, DM, FRCSEd (Tr&Orth), RAMC, and Lt. Col. Peter Hill, MChir, FRCS (Tr&Orth), RAMC, of Surrey, England.
The presentations were based on their experiences as members of the British Armed Forces Medical Services, who recently served in Iraq and Afghanistan.
David L. Hamblen, PhD, FRCS
Moderator
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David L. Hamblen, PhD, FRCS
Col. Michael P.M. Stewart, QHS, FRCSGlas (Tr&Orth), L/RAMC
Lt. Col. Jon Clasper, DPhil, DM, FRCSEd (Tr&Orth), RAMC
Lt. Col. Peter Hill, MChir, FRCS (Tr&Orth), RAMCDavid L. Hamblen, PhD, FRCS: Can we learn anything from the military experience that might help the civilian services improve their plans for dealing with possible future terrorist attacks in our towns and cities?
Col. Michael P.M. Stewart, QHS, FRCSGlas (Tr&Orth), L/RAMC: Yes, these will inevitably involve explosion or blast-type injuries producing devastating, high-energy transfer limb wounds with severe bone fragmentation, as well as damage to nerves, tendons, muscles, vessels and soft tissue. These wounds are extremely challenging to treat, and following standard resuscitation protocols, a decision will have to be made between limb salvage and amputation. Nonviable limbs will usually be amputated immediately. For viable limbs, the contamination and soft tissue injuries caused by the blast effect will require meticulous surgical excision of all devitalized tissue, wound irrigation, leaving wounds open, early fasciotomy, fracture stabilization, broad spectrum antibiotics, and rapid evacuation to more capable levels of care.
Hamblen: What are the types and patterns of injury we should expect, and how might these differ from more conventional low-velocity hand gun injuries?
Lt. Col. Peter Hill, MChir, FRCS (Tr&Orth), RAMC: Explosive devices cause a blast wave due to rapidly expanding gases that accelerate projectiles away from the center of detonation. Projectiles are packed around the device to increase lethality, but often secondary projectiles are formed by the interaction of the explosive with the environment. There will be multiple laceration injuries caused by the cutting and tearing effect of projectiles and amputation of body parts due to blast. The blast wave can damage gas-filled viscii such as the bowel, the lungs and the ear. Victims close to the detonation will suffer burns, deafness and difficulty in breathing. Fractures will occur due to the direct impact of projectiles, but also from the secondary effects of blast. The injury potential of the explosive device is magnified if detonation occurs in a confined space such as a room or vehicle.
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| Figure 1A shows the entry wound from a bullet. Figure 1B shows the exit wound. Modern bullets are designed to maximize soft tissue and bone damage upon exits. | |
Hamblen: Can you explain what is meant by an “improvised explosive device,” and might we expect to encounter this type of weapon in the civilian setting?
Stewart: Improvised explosive devices (IEDs) are munitions that have been doctored from established or manufactured munitions, often termed “homemade.” The types of munitions used vary from small arms rounds to artillery shells, and are usually seen in multiple forms. The net effect of such homemade IEDs is usually to create larger munitions or a novel weapon system for a specific task. The delivery or detonation is usually via command wires or a mobile phone signal. While many of the IEDs seen in the operational theatres of Iraq and Afghanistan fall into the category of “roadside” bombs, the bombing of civilian targets in Madrid and London used IEDs. Equally, the Sarin attack in the Tokyo subway consisted of an improvised delivery method, which could also be termed an IED.
Hamblen: Why is there such a high incidence of extremity injuries in the military?
Stewart: In Iraq and Afghanistan, improvements in body armor offer significant protection to the thorax and abdomen from high-energy rounds. This also provides significant blast and fragmentation protection to the axilla and inguinal regions. As a result, we are treating patients with multiple and severely mangled limbs that were seen infrequently in survivors of previous conflicts.
Hamblen: How should the poly-traumatized patients be managed at the site of the incident, and how would this differ from the military situation?
Hill: The basic principles of treatment are the same for both civilian and military casualties. Triage needs to be carried out in the mass casualty situation to identify those patients in most need of help, and to which limited medical resources can be applied most effectively.
Advanced Trauma Life Support principles should be followed to clear the airway, encourage adequate breathing and maintain circulating volume. Fractures will be splinted. Rapid evacuation to a medical facility is the goal. In the civilian setting, medical know-how may not be available immediately but greater resources can be sent to the site of the emergency.
Hamblen: What type of splintage should be used on severely traumatized limbs with penetrating injuries?
Lt. Col. Jon Clasper, DPhil, DM, FRCSEd (Tr&Orth), RAMC: The first point to appreciate is that the initial debridement is far more important that the method of stabilization. Second, we must accept that the initial method of stabilization may not be the definitive method, but can compromise the definitive method if complications such as infection occur. Third, absolute stability is not essential in the management of open fractures.
The specific type of splintage used depends on available resources and what transport or evacuation is required. With limited resources, plaster can be used for open tibial fractures, particularly with an intact fibula. Open femoral shaft fractures will heal with traction, and humeral fractures can be managed in a sling. These are the methods most commonly used by the U.K. forces when evacuation is not possible.
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Hamblen: In previous wars, we were taught that these large wounds should be thoroughly debrided, but never closed primarily. Does the advice still apply?
Clasper: For the majority of extremity injuries, yes.
Hamblen: What do you mean by “treat – not just respect soft tissues?”
Clasper: Military fractures are highly contaminated injuries and are the equivalent of civilian sewage or agricultural injuries. This is due to the effect of the weapons, the environment the casualty was in at the time of wounding, and delays in initiating treatment. They are not the same as the hand gun injuries seen in the United States, or increasingly commonly in the United Kingdom.
New civilian plating techniques emphasize disturbing the fracture site as little as possible, using percutaneous techniques. In contrast, ballistic fractures should be exposed and washed out, as all fracture fragments will be contaminated, and those without soft tissue attachments should be removed.
Hamblen: Why do you state that “management of fractures in war is the treatment of infection,” and does this principle apply in this potential civilian situation?
Clasper: This is because significant ballistic fractures of the long bones have a 30% to 50% wound infection rate, an approximately 10% risk of osteomyelitis, and some will require amputation for uncontrollable infection. While this is similar to severe Gustilo IIIB and IIIC injuries seen in civilian practice, these are uncommon injuries in most hospitals. However, in war, these will be one of the most common injuries seen.
Hamblen: Is there a place for primary definitive amputation when the extent of the soft tissue injury is uncertain, or should we conserve as much bone and soft tissue as possible?
Stewart: We believe that the site of amputation should be at the lowest level possible. However viable tissue must not be excised to perform the amputation at an optimal site – this is performed at the time of delayed primary closure. At initial debridement, all viable tissue should be preserved, even if bone length appears excessive or excess soft tissue is present. When the foot remains viable, debridement of the wound, rather than amputation should be performed. Amputation, if appropriate, can be carried out following evacuation to a base hospital.
Hamblen: Now that so few of our young surgeons have the opportunity to serve with the armed forces, could they benefit from cross-training from military surgeons to equip them in dealing with future terrorist attacks?
Stewart: Given the current threat of terrorist attacks in our towns and cities and the likelihood of encountering similar injuries to those we experience on a daily basis in Iraq and Afghanistan, I believe that there is a strong case for cross-training of our civilian colleagues. This would facilitate the translation of the principles of war surgery and advances in military trauma care into civilian trauma practice.
For more information:
- Col. Michael P.M. Stewart, QHS, FRCSGlas (Tr&Orth), L/RAMC, is a defense medical services consultant adviser in trauma and orthopaedics. He can be reached in the Department of Orthopaedic Surgery, James Cook University Hospital, Middlesbrough, England TS4 3BW; +44-1642-282-788; e-mail: stewartmpm@clara.net.
- Lt. Col. Jon Clasper, DPhil, DM, FRCSEd (Tr&Orth), RAMC, and Lt. Col. Peter Hill, MChir, FRCS (Tr&Orth), RAMC, can be reached at the Department of Orthopaedic Surgery, Frimley Park Hospital, Portsmouth Road, Frimley, Surrey, England GU16 7UJ; +44-1276-526-447.