Chapter 24: Surgery: Trauma

PRIORITIZING PATIENTS FOR THE OPERATING ROOM

As with all medical care under austere circumstances, priority for the operating room (OR) should be given to patients with the best chance of benefiting. For example, when prioritizing multiple patients with penetrating abdominal injuries, keep these statistics in mind¹:

• If operating <3 hours after the injury, there is a 10% mortality rate.

• If operating >10 hours after the injury, there is a 50% mortality rate.

• Stable patients with abdominal wounds should be prepared for surgery, but can wait up to 4 hours post-injury for surgery.

For patients in shock, assume that these unstable patients have ongoing abdominal bleeding. A laparotomy is the only effective basic life support. Control external bleeding, administer volume and transfuse (type O or type-specific), and perform a laparotomy without further examination.

Patients who arrive >10 hours after injury have a high risk of complications from surgery, which does not increase much with a further delay. Provide basic fluid and airway support; give broad-spectrum antibiotics, if available; and, at surgery, concentrate on establishing a diversion stoma and effective drainage.

RAKING AND SWEEPING FOR UNDETECTED WOUNDS

Combat medics and many prehospital providers use the “rake and sweep” method to detect injuries when they cannot remove clothing due to combat, extreme cold, constricted or dangerous environments, etc. Form the hand into a rake/claw and firmly pass it over the patient, beneath as many layers of clothing as possible. The fingers may catch in and identify penetrating injuries. Using clean gloves (or hands), again pass the open hand over the body and as close to the skin as possible to identify blood. Use a combination for best effect.

NECK

Penetrating neck injuries are commonly treated using an ever-changing set of rules that often depend on the resources available. In austere circumstances, with limited evaluation and monitoring resources, exploration may often be the safest treatment, especially for Zone 2 injuries (Fig. 24-1), if any doubt exists regarding injury to deep structures.

When faced with severe hemorrhage from neck or facial injuries that cannot be stopped any other way, Dr Husum and colleagues advise that “the internal jugular vein or the carotid artery on one side may be ligated for lifesaving reasons: The brain is well drained through the other side. Some neurological problems may follow ligature of a bleeding carotid artery, but in most cases the blood supply from one carotid artery is sufficient.”²

The US military medical community has found that inserting Foley catheters to tamponade arterial or venous bleeding for wounds in any zone of the neck or in the maxillofacial area buys sufficient time to get patients to a ...