Emergency War Surgery (2004)

Damage Control Surgery

occurs before the site can be identified; the liver is packed

again; the patient is resuscitated again; and the entire cycle

is repeated.

ο Definitive therapeutic packing is based on three basic

principles.

♦ Pressure stops bleeding.

♦ Pressure vectors should recreate tissue planes (attempt

to recreate the pressure vectors created by the capsule

of a solid organ or fill the space of that organ, not

random pack placement).

♦ Tissue viability must be preserved.

ο 6-12 laparotomy pads are the best commonly available

packing material.

ο An intervening layer, such as a bowel bag, sterile drape,

absorbable mesh, or omentum, can be placed between

packs and the tissue to aid in easy pack removal at

relaparotomy.

Abdominal Closure.

Leave the fascia open.

Vacuum pack (preferred technique — easy, keeps patient

dry, allows for expansion).

♦ With fascia open, place fully plastic-covered (bowel bag,

X-ray cassette bag, Ioban drape) sterile operating room

(OR) towel circumferentially under the fascia to cover

the viscera. Place a small number of central perforations

to allow fluid to egress to the drains.

♦ Place closed-suction drains (Jackson-Pratt, modified

Foley, small chest tube) above the plastic at the level of

the subcutaneous tissue brought out through separate

stab wounds or the inferior portion of the wound.

♦ Place lap sponges to fill in the wound.

♦ Cover the entire wound with a large Ioban drape.

♦ Place drains on low suction and secure to the skin.

A silastic sheet or 3-liter IV bag, sewn to the skin or fascia,

can accomplish abdominal closure in virtually every

instance.

Skin closure is not recommended, but may be quickly

accomplished with skin staples, towel clips (reliably

stronger), or running monofilament suture.

12.5

Emergency War Surgery

Skin closure may lead to abdominal compartment

syndrome.

Thoracic injuries

The goal of abbreviated thoracotomy is to stop the bleeding

and restore a survivable physiology; contamination is

usually not a problem.

In the exsanguinating patient, formal lung resection gives

way to using large staplers in a nonanatomic wedge resection

to rapidly achieve hemostasis and control of air leaks.

In pulmonary tractotomy, the lung bridging the wound tract

is opened between long clamps or with a linear stapler. The

tract can thus be directly inspected, bleeding points selectively

ligated, and air leaks controlled.

Vascular injuries can be treated with intraluminal shunts or

Fogarty balloons to achieve distal control in inaccessible areas.

Tracheal injury can be treated with airway control placed

through the site of injury.

Extensive bronchial repairs are not feasible in the patient in

extremis; therefore, rapid resection of the affected lobe or lung

would be best.

When dealing with esophageal injury, diversion, and wide

drainage, not definitive repair, is the best course of action.

A single en masse suture closure of the chest wall is best

because wound closure of skin with towel clips may result in

significant blood loss from the musculature.

Phase 2: Critical Care Considerations

Physiologic support in the post-op TASC patient is

paramount to survival.

ο Core rewarming: warmed resuscitative fluids, blankets,

ventilator air, and environment, or commercially available

products such as Bair Hugger, Chill Buster.

ο Reversal of acidosis: appropriate/aggressive resuscitation

with crystalloid, colloid, and blood products.

ο Reversal of coagulopathy: at many locations, only ultra-

fresh whole blood is available to correct coagulopathy.

Abdominal compartment syndrome.

12.6

Damage Control Surgery

Abdominal compartment syndrome is a condition in which

increased intra-abdominal pressure adversely affects the

circulation and threatens the function and viability of

the viscera.

Measurement is performed using urinary bladder pressure

(normal = zero).

♦ Several methods are available for performing bladder

pressure.

◊ Place 100-150 cc of sterile saline in the bladder and

clamp the foley.

◊ Access the needle port on the catheter and attach to a

pressure monitor (central venous pressure transducer).

◊ Access the needle port and create a column of water

via plain IV tubing held vertically or use of the

pressure gauge from a lumbar puncture kit.

◊ If there is no needle port, clamp the foley proximal

and the distal end of regular IV tubing in the usual

drainage end of the catheter until firmly in place.

♦ Measurement of bladder pressure is a good variable to

test and follow; however, intervention for abdominal

compartment syndrome (ACS) should occur when

suspected or clinically indicated.

Occurs in abdominal trauma accompanied by visceral

swelling, hematoma, or abdominal pack use.

Physiology of abdominal compartment syndrome.

♦ Cardiac output and venous return are decreased.

♦ Reduction in blood flow to liver, intestines, and kidneys

can result in anuria.

♦ The two hemidiaphragms push upward, decreasing

thoracic volume, and compliance leading to elevated

peak airway pressures.

♦ Central venous, pulmonary capillary wedge, and right

atrial pressures increase with intra-abdominal pressure

(can lead to false PA catheter pressures).

♦ PO₂ is decreased due to increases in airway pressures

and ventilation/perfusion abnormalities that worsen

with positive end-expiratory pressure (PEEP).

12.7

Emergency War Surgery

Abdominal Pressure Degree of Elevation Clinical Effect

10-20 mm Hg

Mild

Insignificant

20-40 mm Hg

Moderate

Oliguria and organ dysfunction

>40 mm Hg

Severe

Requires immediate attention

Phase 3: Planned Reoperation

Packs should be left in place until the patient’s hemodynamics

are stable and all major sites of hemorrhage have had time to

clot.

Reoperation should be scheduled when the probability of

achieving definitive organ repair and complete fascial closure

are highest.

Timing must coincide with reversal of hypotension, acidosis,

hypothermia, and coagulopathy. Typically occurs 24-48 hours

following the primary insult when brisk diuresis, negative

fluid balance, diminishing abdominal girth, and decreasing

peripheral edema indicate reduction in visceral and parietal

edema.

This surgery may occur at the next echelon of care.

ο Stratevac should be weighed carefully because transit

operative care is minimal. Surgical expertise is generally not

available and transit times are often greater than 24 hours.

Timing can, however, be dictated by other pressing clinical

concerns such as abdominal compartment syndrome, limb

ischemia, and suboptimal control of spillage at primary

operation.

In cases of a packed and drained duodenum, pancreas, kidney

or bladder, or liver injuries with gross bowel contamination,

packs should be retrieved within 36-48 hours.

It is sometimes necessary to perform this type of operation

at the bedside, as the patient’s cardiopulmonary status does

not allow a trip to the OR.

Conduct of Relaparotomy

It is to be presumed that injuries were missed.

A complete laparotomy must be performed in search of

missed injury.

12.8

Damage Control Surgery

The surgeon must exercise caution and sound judgment

before performing full reconstruction of the GI tract because

the patient is typically still critically ill and catabolic, making

the patient less likely to heal anastomoses and even less likely

to tolerate a leak or uncontrolled fistula.

Feeding tube placement, either transabdominal or naso-

enteric, should be placed at this time.

Repacking may be re-employed if other measures fail to

control hemorrhage.

An abdominal film should be obtained to insure all packs

have been removed from the abdomen. Sponge counts should

be considered unreliable in this situation.

Unplanned Reexploration.

ο Emergent, unplanned reexploration should be performed

in any:

♦ Normothermic patient with unabated bleeding (> 2

units of PRBCs/h).

♦ Patient who develops severe intra-abdominal compart-

ment syndrome.

♦ Patient requiring postoperative transfusion of > 10 units

of PRBCs.

♦ Patient with persistent lactic acidosis.

Austere Field and Military Surgical Considerations

Due to severe physiological insult, the typical civilian damage

control patient requires 2 surgeons and 1 nurse, at a minimum,

at the bedside for the first 6 hours. An example of the magni-

tude of the ICU problem that may be encountered is a casualty

who requires a pulmonary artery catheter, 3 operations, 33

units of PRBCs, and an ICU stay of 23 days. In mass casualty

scenarios, this patient would likely be triaged as expectant.

Tactical Abbreviated Surgical Control philosophy allows

the surgeon to apply damage control techniques when the

limitations of reserve exist outside the patient, in the

tactical environment, not just to patients about to exhaust

their physiological reserve (classic damage control

scenario).

12.9

Emergency War Surgery

Summary Points

Damage control is not a procedure of last resort. The

consideration of damage control techniques should be made

at the initiation of operative intervention in any multitrauma

casualty and reconsidered during any case where extensive

injuries are involved.

Consider damage control in patients with severe liver injury,

combined vascular and hollow viscus injuries, multiple sites

of hemorrhage, diminished physiological reserve, and com-

binations of severe injury involving multiple organ systems

(eg, CNS, orthopedic, vascular, or thoracoabdominal).

Consider damage control early, ISS > 35, pH < 7.2, temp-

erature < 34°C, shock, or coagulopathy.

Avoid: hypothermia, ‘pack and peek’, tight abdominal

closure, abdominal compartment syndrome, delayed

relaparotomy for surgical bleeding, and getting stuck in a

conventional thinking mode.

Think: vascular shunts/fasciotomy, abdominal packing,

external fixators, angiographic embolization (when avail-

able), temporary closure, nonanatomic resections, and missed

injury.

Plan sequence of operation in stable patients to allow for use

of damage control if instability develops.

12.10

Chapter 13

Face and Neck Injuries

Introduction

Immediate recognition and appropriate management of

airway compromise is critical to survival.

Face and neck injuries can be the most difficult-to-manage

wounds encountered by health care providers in the combat

zone. Focusing on ABC priorities is vital.

During airway control, maintain cervical spine

immobilization in bluntly injured patients. (Unstable C-spine

injury is very rare in neurologically intact penetrating face

and neck wounds.)

Bleeding should be initially controlled with direct pressure.

If bleeding cannot be controlled, immediate operative

intervention is necessary.

Complete assessment of remaining injuries (fractures,

lacerations, esophageal injury, ocular injuries).

Immediate Management of Facial Injuries

Airway.

ο Airway distress due to upper airway obstruction above

the vocal cords is generally marked by inspiratory stridor:

♦ Blood or edema resulting from the injury.

♦ Tongue may obstruct the airway in a patient with a

mandible fracture.

♦ A fractured, free-floating maxilla can fall back,

obstructing the airway.

♦ Displaced tooth fragments may also become foreign

bodies.

ο Maneuvers to relieve upper airway obstruction:

13.1

Emergency War Surgery

♦ Remove foreign bodies (strong suction, Magill forceps,

among others).

♦ Anterior jaw-thrust maneuver.

♦ Place adjunctive airway device (nasal trumpet or

oropharyngeal airway).

♦ Endotracheal intubation and assisted ventilation.

♦ Cricothyroidotomy or emergent tracheotomy may

become necessary.

Cervical spine.

ο Up to 10% of patients with significant blunt facial injuries

will also have a C-spine injury.

♦ In awake patients, the C-spine can be cleared clinically

by palpating for point tenderness.

♦ Obtunded patients with blunt facial trauma should be

treated with C-spine immobilization.

Vascular Injury.

ο Injuries to the face are often accompanied by significant

bleeding.

ο Control of facial vascular injuries should progress from

simple wound compression for mild bleeding to vessel

ligation for significant bleeding.

Vessel ligation should only be performed under direct

visualization after careful identification of the bleeding

vessel. Blind clamping of bleeding areas should be

avoided, because critical structures such as the facial nerve

and parotid duct are susceptible to injury.

♦ Foley catheter inserted blindly into a wound may

rapidly staunch bleeding.

ο Intraoral bleeding must be controlled to ensure a patent

and safe airway.

♦ Do not pack the oropharynx in an awake patient due to

risk of airway compromise: first secure the airway with

an endotracheal tube.

♦ Copious irrigation and antibiotics with gram-positive

coverage should be used liberally for penetrating

injuries of the face.

13.2

Face and Neck Injuries

Evaluation.

Once the casualty is stabilized, cleanse dried blood and

foreign bodies gently from wound sites in order to evaluate

the depth and extent of injury.

The bony orbits, maxilla, forehead, and mandible should

be palpated for stepoffs or mobile segments suggestive of

a fracture.

A complete intraoral examination includes inspection and

palpation of all mucosal surfaces for lacerations, ecchymosis,

stepoffs, and malocclusion as well as dental integrity.

In the awake patient, abnormal dental occlusion

indicates probable fracture.

Perform a cranial nerve examination to assess vision, gross

hearing, facial sensation, facial muscle movement, tongue

mobility, extraocular movements, and to rule out

entrapment of the globe.

Consult an ophthalmologist for decreased vision on gross

visual field testing, diplopia, or decreased ocular mobility.

If the intercanthal distance measures

> 40 mm

(approximately the width of the patient’s eye), the patient

should be evaluated and treated for a possible naso-orbito-

ethmoid (NOE) fracture.

If a NOE fracture is present, do not instrument the nose if

possible. There may be a tear in the dura, and instrumentation

may contaminate the CSF via the cribiform.

Facial Bone Fracture Management

The goals of fracture repair are realignment and fixation of

fragments in correct anatomic position with dental wire (inferior,

but easier) or plates and screws.

With the exception of fractures that significantly alter

normal dental occlusion or compromise the airway (eg,

mandible fractures), repair of facial fractures may be

delayed for two weeks.

Fractures of the mandible.

ο Second most commonly fractured bone of the face.

ο Most often fractured in the subcondylar region.

13.3

Emergency War Surgery

Multiple mandible fracture sites present in 50% of cases.

Patients present with limited jaw mobility or malocclusion.

Dental Panorex is the single best plain film (but is

unavailable in the field environment); mandible serves as

a less reliable but satisfactory study (might overlook

subcondylar fractures).

Fine cut (1-3 mm) CT scan will delineate mandibular

fractures.

Treatment is determined by the location and severity of

the fracture and condition of existing dentition.

♦ Remove only teeth that are severely loose or fractured

with exposed pulp.

♦ Even teeth in the line of a fracture, if stable, and not

impeding the occlusion, should be maintained.

Nondisplaced subcondylar fractures in patients with

normal occlusion may be treated simply with a soft diet

and limited wear of Kevlar helmet and protective mask.

Immediate reduction of the mandibular fracture and

improvement of occlusion can be accomplished with a

bridle wire (24 or 25 gauge) placed around at least 2 teeth

on either side of the fracture.

More severe fractures with malocclusion will require

immobilization with maxillary-mandibular fixation

(MMF) for 6-7 weeks.

Place commercially made arch bars onto the facial aspect

of the maxillary and mandibular teeth.

♦ The arch-bars are then fixed to the teeth with simple

circumdental (24 or 25 gauge) wires (Fig. 13-1).

♦ After proper occlusion is established, the maxillary arch

bar is fixed to the mandibular arch bar with either wire

or elastics.

♦ If the patient’s jaws are wired together, it is imperative

that wire cutters be with the patient at all times.

♦ If portions of the mandible have been avulsed or the mandib-

ular fragments are extremely contaminated, an external

biphase splint should be placed to maintain alignment.

13.4

Face and Neck Injuries

Fig. 13-1. Arch bar applications.

ο Open reduction and internal fixation with a mandibular

plate across fracture sites may obviate the need for MMF.

Nasal fractures.

ο Most common fracture.

♦ Control of epistaxis: anterior pack-gauze/balloon/

tamponade.

ο Diagnosed clinically by the appearance and mobility of

the nasal bones.

The patient’s septum should be evaluated for the presence

of a septal hematoma, which if present, must be

immediately drained by incision, followed by packing.

ο Treat by closed reduction of the fractured bones and/or

septum into their correct anatomic positions up to 7 days

after fracture.

13.5

Emergency War Surgery

♦ Place a blunt elevator (Sayer) into the nasal cavity in

order to elevate the depressed bony segment while

simultaneously repositioning the bone with the

surgeon’s thumb placed externally.

ο The nose may then be fixed with tape or a splint in order

to maintain the reduction (Fig. 13-2).

Fig. 13-2. (a) Anterior and (b) posterior packing of the nose.

Maxillofacial Trauma.

ο Life-threatening due to loss of airway, hemorrhage, or

spinal injury.

ο Fragment wound of maxillary sinus is commonly seen and

requires surgical removal of retained fragments (can delay

until specialist is available).

Bleeding.

ο Common from epistaxis, oral hemorrhage or combination

bleeding.

ο Nasal fracture—most common fracture.

♦ Control Epistaxis with Anterior Pack (gauze/balloon/

tampon).

ο Mandibular fracture fixation (wires/archbars, with wire

cutters at bedside).

ο Facial and scalp lacerations.

ο Mid-face fracture (Le Fort)—The most difficult bleeding

to control.

13.6

Face and Neck Injuries

♦ Requires “significant” trauma.

♦ Be aware of associated CNS and orbital injury.

♦ Significant hemorrhage due to laceration of IMA and

branches.

◊ Is difficult to control.

◊ May be life-threatening.

◊ Treat by controlling airway, reducing fracture, and

placing a pressure dressing such as packing or

balloon.

♦ Edema may cause loss of airway, which may be

immediate or delayed.

♦ Can be difficult to diagnose. Criteria:

◊ Mobile hard palate and mid-face while stabilizing the skull.

◊ Penetrating injury may not follow classic Le Fort

patterns but may have a significant soft tissue injury

component (base of tongue, soft palate).

Treatment.

ο ABCs.

ο Check CNS and vision.

ο Can immobilize maxilla by using the mandible as a splint

(wires/archbars, with wire cutters at bedside).

ο Control hemorrhage by tamponade.

♦ Nasopharynx, nasal cavity.

♦ Oropharynx.

Surgical Repair.

ο Not an emergency once hemorrhage is controlled.

ο Requires ENT, oral, plastic, and ophthalmology surgical

expertise.

ο Time consuming.

ο Open and closed reductions with hardware that is usually

unavailable in the field.

Fractures of Facial Bones.

ο Potentially life-threatening due to loss of airway,

hemorrhage, or spinal injury.

ο Fragment wound of maxillary sinus is commonly seen,

and requires surgical removal of retained fragments (can

delay until specialist available).

ο Mid-face fracture (Le Fort)—The most difficult bleeding to

control.

♦ Requires “significant” trauma.

13.7

Emergency War Surgery

♦ Be aware of associated CNS and orbital injury.

♦ Significant hemorrhage due to laceration of IMA and

branches.

◊ Is difficult to control.

◊ May be life threatening.

◊ Treat by controlling the airway, reducing fractures,

and placing pressure dressings such as packing or

balloon tamponade.

♦ Edema may cause loss of airway, which may be

immediate or delayed.

♦ Can be difficult to diagnose.

◊ Mobilize the hard palate and mid-face while stabilizing

the skull. Place thumb and forefinger of one hand on

nasal bridge to stabilize, then with the other hand,

determine mobility of maxilla by placing the thumb on

alveolus and forefinger on the palate and attempting

gentle distraction in an anterior-posterior direction.

◊ Penetrating injury may not follow classic Le Fort

patterns but may have a significant soft tissue injury

component (base of tongue, soft palate).

◊ Apply principles of systemic palpation and

inspection, looking for crepitus, tenderness, internal

and external ecchymosis, and subconjunctival

hemorrhage that might suggest fractures.

Classification by Le Fort (Fig. 13-3).

III

Fig. 13-3. Le Fort facial fracture classifications.

13.8

Face and Neck Injuries

♦ I-Fracture separates the entire alveolar process from

maxilla.

♦ II-Separation of mid-face, including the nasal bone,

from the orbit (pyramidal).

♦ III-Detachment of the face from the skull (craniofacial

disarticulation).

Treatment.

♦ ABCs.

♦ If nasal intubation is used, extremely careful placement

is mandatory to avoid cribriform plate or anterior

cranial fossa penetration.

♦ Classification by Le Fort.

♦ Check CNS and vision.

♦ Can immobilize maxilla by using the mandible as a splint

(wires/arch bars, with wire cutters at bedside). It is much

easier to place patient into maxillomandibular fixation if

either a nasal airway or tracheostomy is employed.

♦ Control hemorrhage by tamponade as previously

described.

◊ Nasopharynx, nasal cavity.

◊ Oropharynx.

Definitive Surgical Repair.

♦ Not an emergency once hemorrhage is controlled.

♦ Requires expertise in ENT, oral and maxillofacial,

plastic, and ophthalmology surgery.

♦ Time consuming.

♦ Open and closed reductions require hardware usually

unavailable in the field.

Soft Tissue Injuries

General principles.

ο Avoid injury to surrounding structures such as the facial

nerve or parotid duct.

ο Wounds should be gently cleansed with saline and light

scrub solutions; foreign bodies should be meticulously

cleaned from wounds prior to closure.

ο Sharply debride devascularized wound edges minimally.

ο Facial lacerations should be closed in layers within 24 hours.

♦ Use 4-0 or 5-0 absorbable suture for subcutaneous/

dermal layers.

13.9

Emergency War Surgery

♦ Use 5-0 or 6-0 nonabsorbable sutures on the skin of the face.

♦ Remove sutures in 5-7 days.

Facial nerve injuries.

ο Carefully examine for facial nerve function in all five

branches (Fig. 13-4).

Temporal Branches

Zygomatic Branches

Buccal Branches

Marginal

Mandibular Branch

Cervical Branch

Fig. 13-4. Branches of the facial nerve parotid duct injury.

Facial nerve branches that are lacerated at a site anterior to

a vertical line drawn down from the lateral canthus of the

eye do not need to be surgically reapproximated because

these branches are very small and will spontaneously

regenerate with good return of facial function.

ο The severed ends of the nerve may be located in the wound

with a nerve stimulator, for up to 3 days.

ο Cut nerve ends should be reapproximated primarily with three

or four fine (9-0) nylon sutures placed through the epineurium.

ο If a gap exists between severed ends of the facial nerve due

to tissue loss, an interposition graft may be placed using a

section of the great auricular nerve to bridge the gap.

13.10

Face and Neck Injuries

ο If the wound is heavily contaminated and cannot be closed

primarily, the severed ends of the nerve should be located

and tagged for identification and repair at the time of

wound closure.

Parotid duct injuries.

ο Evaluate penetrating wounds of the parotid/buccal

regions of the face for salivary leakage due to a lacerated

parotid duct (see Fig 13-5).

♦ The wound may be manually compressed and inspected

for salivary leakage.

♦ If the parotid duct is injured by a facial laceration, the

distal end of the duct may be identified by placing a

lacrimal probe through the intraoral opening of the duct

located near the maxillary second molar (see Fig. 13-4).

♦ The proximal end may be identified by compressing

the wound and identifying any areas of salivary

leakage.

ο Repair with absorbable (6-0) sutures (Fig. 13-5).

Fig. 13-5. Repair of parotid duct.

ο A stent may be placed into the duct to facilitate the closure

and prevent stenosis.

♦ Possible stents include lacrimal stents, large (size 0)

polypropylene sutures, or long angiocaths.

♦ Stents may be sutured to the buccal mucosa and

removed after seven days.

13.11

Emergency War Surgery

Penetrating Neck Trauma

Introduction.

ο Vascular injuries occur in 20% and aerodigestive tract in

10% of cases.

ο Mortality is primarily due to exsanguinating hemorrhage.

ο Esophageal injury, which results in mediastinitis and

intractable sepsis, may also be fatal.

Anatomy.

The neck is divided into three zones to aid decision making for

diagnostic tests and surgical strategy. In each zone, the primary

structures at risk of injury are different (Fig. 13-6).

Zone 3

Zone 2

Zone 1

Fig. 13-6. Zones of the neck.

ο Zone 1 (clavicle to cricoid membrane): The structures of

concern include large vessels of the thoracic outlet

(subclavian artery and vein, common carotid artery), the

lung, and the brachial plexus.

ο Zone 2 (cricoid membrane to angle of mandible): Structures

of concern include the common carotid artery, internal

jugular vein, esophagus, and trachea.

ο Zone 3 (angle of mandible to base of skull): The structure

of concern is primarily the internal carotid artery.

13.12

Face and Neck Injuries

Immediate management.

ο Initially, same as above.

ο Obtain chest and soft tissue neck radiographs.

ο Address tetanus and antibiotic prophylaxis.

Operative strategy.

ο If no platysma violation, surgical intervention is not

indicated.

ο Zone 2 injuries that penetrate the platysma should undergo

routine exploration to rule out life threatening vascular,

esophageal or tracheal injuries via an incision along the anterior

border of the sternocleidomastoid muscle (Fig. 13-7).

Fig. 13-7. Neck exposure of zone 2.

ο Zone 1 and 3 injuries require selective management, based

on clinical signs and chest radiograph findings, making

an incision dependent on the vascular structure most

probably injured.

♦ Zone 1 and 3 penetrations without clinical signs of

injury (see below) may be evacuated without operative

intervention.

ο The most important clinical signs pointing to probable

injuries (pertinent to all 3 zones):

13.13

Emergency War Surgery

♦ Signs of vascular injury.

◊ Current or history of significant bleeding.

◊ Expanding hematoma.

◊ Bruit or thrill in the neck.

◊ Hypotension.

◊ Dyspnea, hoarseness, or stridor.

◊ Absent or decreased pulses in neck or arm.

◊ Focal neurologic deficit or mental status change.

◊ Chest radiograph findings of hemothorax or

mediastinal widening.

♦ Signs of aerodigestive injury (esophagus, trachea,

larynx).

◊ Crepitus or subcutaneous emphysema.

◊ Dyspnea or stridor.

◊ Air bubbling from wound.

◊ Tenderness or pain over trachea; odynophagia.

◊ Hoarse or abnormal voice.

◊ Hematemesis or hemoptysis.

Surgical Principles

The groin and upper thigh should be surgically prepped for

greater saphenous vein interposition graft or patch angioplasty.

Exsanguinating hemorrhage from injured vessels at the base

of the skull (Zone 3) can often be controlled with inflation of

a directed catheter (Fogarty, Foley), left in place and inflated

for 48-72 hours, then deflated in the OR under controlled

visualization for rebleeding.

Repair esophageal injuries in a single-layer and place closed

suction drains. The drain tip should not be placed near a

concomitantly repaired carotid artery. A muscle flap should

be interposed between repaired esophageal and tracheal

injuries to prevent fistula. Obtain an oral contrast swallow

radiograph seven days after repair before feeding.

Repair laryngotracheal injuries with single-layer

monofilament absorbable suture. Must search for

concomitant esophageal injuries.

Unreconstructable (significant segmental loss, or > 50%

diameter loss) tracheal injuries should be managed with an

endotracheal tube placed through the defect.

13.14

Face and Neck Injuries

Vertebral artery injury.

ο Suspect if bleeding continues from a posterolateral neck

wound despite pressure on the carotid artery.

ο Preoperative angiography localizes site of injury and estab-

lishes the existence of a patent contralateral vertebral artery,

aplasia of which is most commonly located on the left side.

ο Exposure of vertebral artery may be difficult. When

contralateral vertebral artery is intact, ligation proximal

and distal to the injury will likely be necessary.

ο Bone wax or a Foley catheter may be useful for control of bleeding.

Intraoral injuries

ο Penetrating injuries to the oral cavity LATERAL to the

tonsillar fossa are at a significant risk of causing occult

internal carotid injury. Neurologic testing/monitoring is

critical and CT scanning and/or angiography should be

considered. If after a penetrating lateral oral injury the

patient bleeds a small amount only to stop, this may signify

a “sentinel” bleed. A carotid blowout may follow.

Internal carotid artery injury.

Should be repaired primarily unless there is profound

hemiplegia with deep coma Glasgow Coma Scale (GCS <

8). All other carotid branches can be ligated.

The use of carotid shunts during repair has no proven benefit.

In small perforations, debride minimally, and close with

6-0 polypropylene.

With loss of vascular tissue, vein angioplasty is required.

If there is extensive destruction, segmental resection and

restitution of flow is established by:

♦ End-to-end anastomosis (if the vessel is sufficiently

elastic to permit).

♦ Interposition vein graft.

♦ External carotid swing-over and interposition.

♦ Temporary (24-48 h) shunt as part of damage control

maneuver.

The mortality is high in patients with severe neurologic deficit;

carotid ligation is justifiable in complete occlusion of the entire

carotid system and depending on the triage situation.

Distal clot may be removed by extremely gentle use of a

balloon catheter prior to shunt insertion or repair.

13.15

Emergency War Surgery

Internal jugular vein injury.

Preferably repaired by lateral suture.

Ligation OK, if the contralateral internal jugular is patent.

Larynx.

After immediate control of the airway has been achieved

by intubation or tracheotomy (not through the wound in

the larynx!), a complete airway evaluation by direct

laryngoscopy and bronchoscopy must be performed.

Debridement of laryngotracheal injuries must be careful

and conservative. A fragmented larynx or trachea should

be reapproximated and sutured with extraluminal,

absorbable sutures for tracheal injuries and nonabsorbable

sutures or micro-plates used for laryngeal fractures.

The management of laryngeal trauma includes accurate

reduction and stabilization of fractures, mucosa-to-mucosa

closure of lacerations, and use of a soft stent if there is

extensive cartilaginous damage and structural support is

decreased or the anterior commissure is involved. The stent

may need to be temporarily placed for 4-6 weeks to

maintain correct anatomic architecture and requires a

complementary tracheotomy.

The excessive removal of cartilage and mucosa must be

avoided to prevent tracheal or laryngeal stenosis.

Laryngotracheal injuries.

ο If laryngotracheal separation is suspected (massive crepitis

over the larynx/trachea) in an otherwise “stable” airway,

endotracheal intubation should not be undertaken as this

may cause a partial separation to become a complete

separation and/or blind passage of the endotracheal tube

may occur with resulting impending airway emergency.

ο It is best to perform an awake tracheotomy/

cricothyroidotomy under local anesthesia without

paralysis. Good anesthesia can be achieved with a 4%

(40mg/cc) lidocaine nebulizer, 2cc in 3cc of saline, and

direct administration of 4% lidocaine into the trachea for

an awake tracheotomy (in addition to local anesthetic

infiltration into the skin and subcutaneous tissues). When

instilling anesthesia into the airway, aspirate and ensure

air enters the syringe before injecting.

13.16

Face and Neck Injuries

Tracheal injury and reconstruction.

ο Small anterior wounds can have tracheostomy tube placed

through them after debridement.

ο Repair simple lacerations with absorbable monofilament

suture.

ο Up to 5 cm can be resected with proximal and distal

mobilization.

ο Mobilize anteriorly and posteriorly to preserve lateral

blood supply.

ο Remove endotracheal tube as soon as possible post-op.

ο May need to suture chin to chest for 10 days to avoid

extension injury.

Esophageal injury and repair.

ο Difficult to diagnose.

ο 25% may be asymptomatic.

ο Missed injury is a major source of late morbidity/mortality.

ο Insufflation with air may aid in identification during

exploration.

ο Debride devitalized tissue.

ο Wound closure in two layers with absorbable sutures.

ο Viable muscle flap to protect repairs from leak.

ο Drainage with closed suction drain.

ο Barium swallow 7 days post-op, prior to oral intake.

ο Oral intake prior to drain removal.

ο Extensive injuries may require lateral cervical

esophagostomy.

ο Cervical esophagostomy is preferred to closure under

tension.

Combined injuries.

ο All esophageal injuries combined with airway or vascular

injury require separation with healthy tissue. Strap muscles

are ideal, but can use pedicle of sternocleidomastoid if

straps are devitalized.

Esophageal fistula.

ο 10%-30% incidence.

ο Due to inadequate debridement, devascularization of

remaining esophageal wall, closure under tension, or

infection.

ο Treatment.

13.17

Emergency War Surgery

♦ Maintain nutrition.

♦ Assure control with drains.

♦ Weekly barium swallow to assess closure.

♦ Oral intake prior to removing drain.

Skull Base, Temporal Bone and Otologic Injury

Ensure that the facial nerve is assessed and documented on

an awake patient and at the earliest convenience in a patient

who has regained consciousness. Delineation between

delayed onset and acute facial paralysis is critical for

management and outcome of facial nerve injuries. Also critical

is delineation between a distal and proximal nerve injury. If

a distal injury is present, one or more branches may be

affected.

ο Be as concise as possible in describing facial motion even

if not technically accurate; be complete in the description.

A more proximal injury (proximal to the Pes Anserinus)

will most likely result in all branches being equally

affected. Accurate documentation may spare the patient

from unwarranted surgical intervention to explore the

entire length of the facial nerve. It is desirable to accurately

describe the motion of EACH branch of the facial nerve.

Eyelid movement does not ensure that the facial nerve is

intact since the levator palpebrae is innervated by the

occulomotor nerve and will remain intact despite facial

nerve injury.

ο If there is no contraindication for systemic steroids, they

should be administered for suspected facial nerve

paralysis. Crush injuries to the facial nerve may present

with delayed onset paralysis and the severity and course

of the paresis may be improved with systemic

administration of steroids.

Skull base fractures are often occult. Assess the patient for

evidence of basilar skull fractures (Battle’s sign, raccoon eyes).

Ensure that the external auditory canal is examined. Do not

instrument the external auditory canal, however. If a temporal

bone fracture is present and the dura is not intact,

instrumentation may introduce bacteria and/or a foreign

body into the CSF.

13.18

Face and Neck Injuries

The external auditory canal should be inspected for a tear of

the lining of the canal. A tear of the lining of the canal suggests

a temporal bone fracture.

ο If a temporal bone fracture is suspected, it is critical that

the facial nerve be assessed.

Tympanic membrane perforations can be managed

expectantly. The vast majority of them will heal

spontaneously, but the patient should be followed for

evidence of cholesteatoma formation from traumatic

implantation of the squamous epithelium. This may occur

months to years after the injury. Acutely, application of otic

antibiotic drops will prevent the perforation from desiccating,

but this is not required. The patient should be instructed to

keep the ears dry (avoid water contamination).

Hemotympanum may be seen with acoustic & temporal bone

trauma. These patients will have hearing loss. If available,

perform a gross audiological evaluation with tuning forks.

Hemotympanum with hearing loss (conductive) should

resolve in about 6 weeks.

ο Examination for hearing in the field can be accomplished

with a single 512 tuning fork.

♦ With the tuning fork placed on the mastoid tip and then

alternately in front of the external canal (Rinne).

Documentation as A>B (air > bone) or B>A is sufficient

- do not report as “positive” or “negative”:

◊ Air conduction greater than bone conduction with a

512 tuning fork is normal.

◊ Bone conduction greater than air is suggestive of a

conductive hearing loss.

♦ With the 512 tuning fork on the frontal bone/ nasal

dorsum/ or central incisors (best) (Weber):

◊ If the Rinne test suggests a conductive hearing loss -

the 512 should lateralize to the side with the

conductive loss.

◊ If the Rinne is NORMAL (A>B) - the 512 should

lateralize to the ear with a sensorineural loss

Any otologic blast injury or injury to the temporal bone may

result in tinnitus. Management is expectant and it may resolve

13.19

Emergency War Surgery

spontaneously. Accurate documentation is critical for future

management of these patients, however.

If sensorineural hearing loss is suspected and documented

after a blast injury or noise trauma, steroids are indicated.

1mg/kg of prednisone is appropriate. If after five days there

is no improvement, the patient can be taken off of the steroids.

If improvement is noted, a taper over 3-4 weeks is indicated.

Be mindful that steroids may affect a patient’s affect and

impair judgment.

Dizziness and vertigo may result from acoustic trauma. If

true vertigo exists after an otologic injury (observed

nystagmus), the patient may have a perilymphatic fistula

from depression of the stapes into the oval window or

rupture of the round window. These patients may have

tinnitus and hearing loss with vertigo. If a perilymphatic

fistula is suspected, this patient should be seen by an

Otolaryngologist as soon as possible to prevent further

damage to the inner ear.

13.20

Chapter 14

Ocular Injuries

Introduction

The preservation of the eyes and eyesight of service personnel

is an extremely important goal. Despite comprising as little as

0.1% of the total body surface area, injuries to the eye are found

in 5-10% of all combat casualties. In the Vietnam War almost

50% of casualties with penetrating eye wounds eventually lost

vision in the injured eye. Improvements in ophthalmic care in

the last 30 years offer hope that blindness in combat casualties

will be less common in future wars.

Triage of Patients With Eye Injuries

ABCs (airway, breathing, and circulation) and life-threatening

injuries have priority, then treat eyesight and limbs.

Soldiers with mild eye injuries may be treated and returned

to duty by nonspecialized personnel.

Soldiers with more severe injuries should be evacuated to

save vision.

Distinguishing major ocular injuries from minor ones may

be difficult.

At the FST level, due to time and equipment restraints,

surgeons will likely ‘patch and evacuate’.

Identifying Severe Eye Injuries

Associated injuries.

ο Shrapnel wounds of the face — think intraocular foreign

body (IOFB).

ο Lid laceration — check for underlying globe laceration.

Vision.

14.1

Emergency War Surgery

ο Use book print, medication labels, finger counting, and

the like, to evaluate vision.

ο Compare sight in the injured eye to the uninjured eye.

ο Severe vision loss is a strong indicator of serious injury.

Eyeball structure.

ο Obvious corneal or scleral lacerations.

ο Subconjunctival hemorrhage — may overlay an open

globe.

ο Dark uveal tissue presenting on the surface of the eye

indicates an open globe.

ο Foreign body — did it penetrate the eye?

ο Blood in the anterior chamber (hyphema) indicates severe

blunt trauma or penetrating trauma.

Proptosis — may indicate a retrobulbar hemorrhage.

Pupils.

ο Pupillary distortion — may be associated with an open

globe.

Motility.

ο Decreased motility on one side may be caused by an open

globe.

ο Other causes include muscle injury, orbital fracture, and

orbital hemorrhage.

Open Globe

May result from penetrating or blunt eye trauma.

May cause loss of vision from either disruption of ocular

structures or secondary infection (endophthalmitis).

Biplanar radiographs or a CT (computed tomagraphy) scan

of the head may help to identify a metallic intraocular

fragment in a casualty with severe vision loss, a traumatic

hyphema, a large subconjunctival hemorrhage, or other signs

suspicious for an open globe with an IOFB.

Immediate Treatment of an Open Globe

Tape a rigid eye shield (NOT a pressure patch) over the eye.

Do not apply pressure on or manipulate the eye.

Do not apply any topical medications.

Start quinolone antibiotic PO or IV (eg, ciprofloxacin 500 mg bid).

14.2

Ocular Injuries

Schedule an urgent (within 24-48 h) referral to an ophthal-

mologist.

Administer tetanus toxoid if indicated.

Prevent emesis (Phenergan 50 mg or Compazine 10 mg IM/IV).

Treatment of Other Anterior Segment Injuries

Subconjunctival Hemorrhage

Small subconjunctival hemorrhages (SCH) may occur

spontaneously or in association with blunt trauma. These

lesions require no treatment.

SCH may also occur in association with a rupture of the

underlying sclera.

Warning signs for an open globe include a large SCH with

chemosis (conjunctiva bulging away from globe) in the setting

of blunt trauma, or any SCH in the setting of penetrating

injury. Casualties with blast injury and normal vision do not

require special care.

Suspected open globe patients should be treated as described

above.

Treatment of Chemical Injuries of the Cornea

Immediate copious irrigation (for 30 minutes) with normal

saline (NS), lactated Ringer’s (LR), or balanced salt solution.

Nonsterile water may be used if it is the only liquid available.

Use topical anesthesia before irrigating, if available.

Measure the pH of tears to ensure that if there is either acid

or alkali in the eye, the irrigation continues until the pH

returns to normal. Do not use alkaline solutions to neutralize

acidity or vice versa.

Remove any retained particles.

Using fluorescein test, look for epithelial defect.

ο If none, then mild chemical injuries or foreign bodies may

be treated with artificial tears.

ο If an epithelial defect is present, use a broad-spectrum

antibiotic ophthalmic ointment (Polysporin, erythromycin,

or bacitracin) 4 times per day.

Noncaustic chemical injuries usually resolve without

sequelae.

14.3

Emergency War Surgery

More severe chemical injuries may also require treatment with

prednisolone 1% drops 4-9 times per day and scopolamine

0.25% drops 2-4 times per day.

Pressure patch between drops or ointment if a large epithelial

defect is present.

Monitor (daily topical fluorescein evaluation) for a corneal

ulcer until epithelial healing is complete.

Severe acid or alkali injuries of the eye (recognized by

pronounced chemosis, limbal blanching, and/or corneal

opacification) can lead to infection of the cornea, glaucoma,

and possible loss of the eye. Refer to an ophthalmologist

within 24-48 hours.

Treat mustard eye injuries with ophthalmic ointments, such

as 5% boric acid ointment, to provide lubrication and minimal

antibacterial effects. Apply sterile petrolatum jelly between

the eyelids to provide additional lubrication and prevent

sealing of the eyelids.

Treat nerve agent ocular symptoms with 1% atropine sulfate

ophthalmic ointment, repeat as needed at intervals of several

hours for 1-3 days.

Corneal Abrasions

Diagnosis.

ο Be alert for the possibility of an associated open globe.

ο The eye is usually very symptomatic with pain, tearing,

and photophobia.

ο Vision may be diminished from the abrasion itself or from

the profuse tearing.

ο Diagnose with topical fluorescein and cobalt blue light

(Wood’s lamp).

ο A topical anesthetic may be used for diagnosis, but should

NOT be used as an ongoing analgesic agent — this delays

healing and may cause other complications.

Treatment.

ο Apply broad spectrum antibiotic ointment (Polysporin,

erythromycin, or bacitracin) qid.

ο Options for pain relief.

♦ Pressure patch (usually sufficient for most abrasions).

♦ Diclofenac 0.1% drops qid.

14.4

Ocular Injuries

♦ Larger abrasions may require a mild cycloplegic agent

(1% Mydriacyl or Cyclogyl) and a pressure patch.

♦ More severe discomfort can be treated with 0.25%

scopolamine one drop bid, but this will result in pupil

dilation and blurred vision for 5-6 days.

ο Small abrasions usually heal well without patching.

ο If the eye is not patched

♦ Antibiotic drops (fluoroquinolone or aminoglycoside)

may be used qid in lieu of ointment.

♦ Sunglasses are helpful in reducing photophobia.

ο Casualties who wear contact lenses should have the lens

removed and should not be treated with a patch because

of the higher risk of developing a bacterial corneal ulcer.

ο Abrasions will normally heal in 1-4 days.

ο Initial treatment of thermal burns of the cornea is similar

to that for corneal abrasions.

All corneal abrasions need to be checked once a day until

healing is complete to ensure that the abrasion has not

been complicated by secondary infection (corneal ulcer,

bacterial keratitis).

Corneal Ulcer and Bacterial Keratitis

Diagnosis.

ο Corneal ulcer and bacteria keratitis are serious conditions

that may cause loss of vision or even loss of the eye!

ο A history of corneal abrasion or contact lens wear.

ο Increasing pain and redness.

ο Decreasing vision.

ο Persistent or increasing epithelial defect (positive

fluorescein test).

ο White or gray spot on the cornea seen on examination with

penlight or direct ophthalmoscope.

Treatment.

ο Quinolone drops (eg, Ocuflox), 1 drop every 5 minutes

for 5 doses initially, then 1 drop every 30 minutes for 6

hours, then 1 drop hourly around the clock thereafter.

ο Scopolamine 0.25%, one drop bid may help relieve

discomfort caused by ciliary spasm.

14.5

Emergency War Surgery

ο Patching and use of topical anesthetics for pain control

are contraindicated (see pain control measures above).

ο Expedited referral to an ophthalmologist within 3-5 days

unless patient is not improving within 48 hours. Infection

may worsen, leading to permanent injury.

Conjunctival and Corneal Foreign Bodies

Diagnosis.

ο Abrupt onset of discomfort and/or history of suspected

foreign body.

ο If an open globe is suspect, treat as discussed above.

ο Definitive diagnosis requires visualization of the offending

object, which may sometimes be quite difficult.

♦ A hand-held magnifying lens or pair of reading glasses

will provide magnification to aid in the visualization

of the foreign body.

♦ Stain the eye with fluorescein to check for a corneal

abrasion.

ο The casualty may be able to help with localization if asked

to indicate the perceived location of the foreign body prior

to instillation of topical anesthesia.

ο Eyelid eversion with a cotton-tipped applicator helps the

examiner identify foreign bodies located on the upper

tarsal plate.

Treatment.

ο Superficial conjunctival or corneal foreign bodies may be

irrigated away or removed with a moistened sterile swab

under topical anesthesia.

ο Objects adherent to the cornea may be removed with a

spud or a sterile 22-gauge hypodermic needle mounted

on a tuberculin syringe (hold the needle tangential to the

eye).

ο If no foreign body is visualized, but the index of suspicion

is high, vigorous irrigation with artificial tears or sweeps

of the conjunctival fornices with a moistened cotton-tipped

applicator after topical anesthesia may be successful in

removing the foreign body.

ο If an epithelial defect is present after removal of the foreign

body, treat as discussed above for a corneal abrasion.

14.6

Ocular Injuries

Hyphema: Blood in the Anterior Chamber

Treatment (to prevent vision loss from increased intraocular

pressure).

Be alert for a possible open globe and treat for that

condition if suspected.

Avoidance of rebleeds is a major goal of management.

♦ Avoid aspirin or nonsteroidal antiinflammatory drugs

(NSAID).

♦ No strenuous activity (bedrest) for 14 days.

♦ No reading for 7 days.

Prednisolone 1% drops 4 times a day.

Scopolamine 0.25% drops twice a day.

Cover eye with protective shield.

Elevate head of bed to promote settling of red blood cells

(RBC) in anterior chamber.

Provide a 24-48 hour referral to an ophthalmologist to

monitor for increased intraocular pressure (which may

cause permanent injury to the optic nerve) and to evaluate

for an associated open globe.

If evaluation by an ophthalmologist is delayed (> 24 hrs),

treat with a topical B-blocker (timolol or levobunolol) bid

to help prevent intraocular pressure elevation.

If intraocular pressure is found to be markedly elevated

(above 30 mm Hg) with a tonopen or other portable

tonometry device, other options for lowering intraocular

pressure include acetazolamide 500 mg PO or IV and

mannitol 1-2 g/kg IV over 45 minutes.

Retrobulbar (Orbital) Hemorrhage

Keys to recognition: Severe eye pain, proptosis, vision loss,

decreased eye movement.

ο Marked lid edema may make the proptosis difficult to

appreciate.

ο Failure to recognize may result in blindness from increased

ocular pressure.

Perform an immediate lateral canthotomy.

Provide an urgent referral to an ophthalmologist, within 24-

48 hours.

14.7

Emergency War Surgery

If evaluation by an ophthalmologist is delayed (>24 hrs), treat

with a topical B-blocker (timolol) bid to help lower intraocular

pressure elevation.

If intraocular pressure is found to be elevated (>30 mm Hg),

treat as discussed above.

Lateral Canthotomy/Cantholysis

Do not perform such procedures if the eyeball structure has been

violated. If the eye is sliced open, apply a Fox shield for

protection and seek immediate ophthalmic surgical support.

Inject 2% lidocaine with 1:100,000 epinephrine into the lateral

canthus (Fig. 14-1a).

Crush the lateral canthus with a straight hemostat, advancing

the jaws to the lateral fornix (Fig. 14-1b).

Using straight scissors make a 1-cm long horizontal incision

of the later canthal tendon, in the middle of the crush mark

(Fig. 14-1c).

Grasp the lower eyelid with large toothed forceps pulling

the eyelid away from the face. This pulls the inferior crus

(band of the lateral canthal tendon) tight so it can be easily

cut loose from the orbital rim (Fig.14-1d).

Use blunt tipped scissors to cut the inferior crus.

Keep the scissors parallel (flat) to the face with the tips

pointing toward the chin.

Place the inner blade just anterior to the conjunctiva and

the outer blade just deep to the skin.

The eyelid should pull freely away from the face, releasing

pressure on the globe.

Cut residual lateral attachments of the lower eyelid if it

does not move freely.

Do not worry about cutting ¹/2 cm of conjunctiva or skin.

The lower eyelid is cut, relieving orbital pressure. If the

intact cornea is exposed, apply, hourly, copious

erythromycin ophthalmic ointment or ophthalmic

lubricant ointment to prevent devastating corneal

dessication and infection. Relief of orbital pressure must

be followed by lubricating protection of the cornea and

urgent ophthalmic surgical support. Do NOT apply

absorbent gauze dressings to the exposed cornea.

14.8

Ocular Injuries

Fig. 14-1. Lateral canthotomy and inferior cantholysis are indicated

for casualties presenting with serious orbital hemorrhage.

Orbital Floor (Blowout) Fractures

These fractures are usually the result of a blunt injury to the

globe or orbital rim, often associated with head and spine

injuries. Blowout fractures may be suspected on the basis of

enophthalmos, diplopia, decreased ocular motility, hypoesthesia

of the V2 branch of the trigeminal nerve, associated subcon-

junctival hemorrhage, or hyphema. Immediate treatment

includes pseudoephedrine 60 mg q 6 hours and a broad-

14.9

Emergency War Surgery

spectrum antibiotic for 7 days, ice packs, and instructing the

casualty not to blow his nose. Definitive diagnosis requires CT

scan of orbits with axial and coronal views. Indications for repair

include severe enophthalmos and diplopia in the primary or

reading gaze positions. The surgery may be performed 1-2

weeks after the injury.

Lid Lacerations

Treatment guidelines for lid lacerations not involving the

lid margin

Excellent blood supply — delayed primary closure is not

necessary.

Eyelid function (protecting the globe) is the primary

consideration.

Begin with irrigation, antisepsis (any topical solution), and a

check for retained foreign bodies.

Superficial lacerations of the eyelid, not involving the eyelid

margin, may be closed with running or interrupted 6-0 silk

(preferred) or nylon sutures.

Horizontal lacerations should include the orbicular muscle

and skin in the repair.

If skin is missing, an advancement flap may be created to fill

in the defect. For vertical or stellate lacerations, use traction

sutures in the eyelid margin for 7-10 days.

Antibiotic ointments qid.

Skin sutures may be removed in 5 days.

Treatment guidelines for lid lacerations involving the lid margin

Repair of a marginal lower-eyelid laceration with less than

25% tissue loss (Fig. 14-2).

ο The irregular laceration edges may be freshened by

creating a pentagonal wedge — remove as little tissue as

possible (Fig. 14-2b).

ο A 4-0 silk or nylon suture is placed in the eyelid margin

(through the meibomian gland orifices 2 mm from the

wound edges and 2 mm deep) and is tied in a slipknot.

Symmetric suture placement is critical to obtain post-op

eyelid margin alignment (Fig. 14-2c).

14.10

Emergency War Surgery

ο Anterior and posterior marginal sutures (6-0 silk or nylon)

are placed in the eyelid margin just in front and behind

the previously placed 4-0 suture (Fig. 14-2e).

ο The middle and posterior sutures are left long and tied

under the anterior suture. Ensure that the wound edges

are everted (Fig. 14-2f).

ο The skin is closed with 6-0 silk or nylon sutures. The lid is

placed on traction for at least 5 days. The skin sutures are

removed at 3-5 days and the marginal sutures are removed

at 10-14 days (Fig. 14-2g).

Additional Points in Lid Laceration Repair

Tissue loss greater than 25% will require a flap or graft.

If there is orbital fat in the wound or if ptosis is noted in an

upper lid laceration, damage to the orbital septum and the

levator aponeurosis should be suspected.

If the eyelid is avulsed, the missing tissue should be retrieved,

wrapped in moistened Telfa, and preserved on ice. The tissue

should be soaked in a dilute antibiotic solution prior to

reattachment. If necrosis is present, minimal debridement

should occur in order to prevent further tissue loss. The

avulsed tissue should be secured in the anatomically correct

position in the manner described for lid margin repair above.

ο Damage to the canalicular system can occur as a result of

injuries to the medial aspect of the lid margins. Suspected

canalicular injuries should be repaired by an ophthal-

mologist to prevent subsequent problems with tear

drainage. This repair can be delayed for up to 24 hours.

Laser Eye Injuries

Battlefield lasers may be designed to cause eye injuries or

may be part of other weapons or sensor systems.

Prevention is the best option! Wear eye protection designed

for the appropriate light wavelengths if there is a known laser

threat.

The type of ocular damage depends on the wavelength of

the laser — retinal injuries are most common.

14.12

Ocular Injuries

The primary symptom of laser injury is loss of vision, which

may be preceded by seeing a flash of light. Pain may not be

present.

Immediate treatment of corneal laser burns is similar to that

for corneal abrasions.

Laser retinal burns have no proven immediate treatment,

although improvement with corticosteroids has been

reported.

Routine evacuation for evaluation by an ophthalmologist is

required.

Enucleation

A general surgeon in a forward unit should not remove a

traumatized eye unless the globe is completely disorganized.

Enucleation should only be considered if the patient has a very

severe injury, no light perception using the brightest light source

available, and is not able to be evacuated to a facility with an

ophthalmologist. Sympathetic ophthalmia is a condition that

may result in loss of vision in the fellow eye if a severely

traumatized, nonseeing eye is not removed, but it rarely

develops prior to 21 days after an injury. Delaying the

enucleation until the patient can see an ophthalmologist is

thus relatively safe.

14.13

Chapter 15

Head Injuries

Introduction

The prognosis of brain injuries is good in patients who respond

to simple commands, are not deeply unconscious, and do not

deteriorate. The prognosis is grave in patients who are rendered

immediately comatose (particularly those sustaining penetrating

injury) and remain unconscious for a long period of time. Any

subsequent neurologic improvement may indicate

salvageability and should prompt reevaluation.

Neurosurgical damage control includes early intracranial

pressure (ICP) control; cerebral blood flow (CBF) preservation;

and prevention of secondary cerebral injury from hypoxia,

hypotension, and hyperthemia.

A motor examination of the most salvageable severely brain-

injured patients will demonstrate localization to central

stimulation and these patients will require expedited treatment.

Immediate intubation with adequate ventilation is the most

critical first line of treatment for a severely head-injured patient.

Evacuation to the nearest neurosurgeon, avoiding diagnostic

delays, and initiating cerebral resuscitation allow for the best

chance for ultimate functional recovery.

Combat Head Injury Types

Blunt (closed head injury).

Penetrating.

ο Penetrating with retained fragments.

ο Perforating.

ο Guttering (grooving the skull).

ο Tangential.

ο Cranial facial degloving (lateral temple, bifrontal).

15.1

Emergency War Surgery (2004) - page 5