Acute Wounds: Lacerations, GSW’s and Blasts

Better Acute Wound Care Better Patient Outcomes

Better Collaborations• John P. Kirby, MD, FACS• Director Wound Healing

Programs• Coursemaster, Surgical

Clerkships, ATLS• Washington University School

of Medicine

We stand on the shoulders of giants….Increasing ISSDecreasing CFR : WW2 19% Vietnam 16% and now….8%US Army ISRJ of Trauma Vol 75, 2, August Suppl 2013

LT Stuart Hitchcock, MSHS BSN, RN-BC, PhDcDivision Officer, Complex Wound & Limb CenterNational Naval Medical Center, Bethesda

Disclosures

• K30 Program• BJH and WUSM Foundations• Merck, Inc----research funding for intra-abdominal infections• Neumedicines, Inc---research for novel immunomodulation in

injury states• Musculoskeletal Transplant Foundation—research in AWR• Ethicon, Inc—research in topical hemostasis• Cook, Inc—developing wound infomatics analyses• Wendi Gordon Shelist Foundation—NF, Surg Infections & WH• None of these disclosures represent conflicts of interests for

this presentation

For Governmental Compliance

• The information provided is as accurate as possible as of the date indicated.

• Numbers have been rounded• Treatment modalities and preferences vary

among surgical services• No commercial interests• Informational purposes only, not meant to be

official recommendations of any government or private entity

Important Disclosure to considerAcute & Critical Care Surgery

• A new practice model…we have learned from military surgical services….

• 10 BC ACCS Surgeons • 24 X 7 X 365 in house attending coverage for the ED

and inpatients …3/day 1/night “MOD”• 36 Bed SICU covered in partnership with Anesthesia

with in house attending coverage • Multi-Specialty Outpatient Clinic 5 days a week• Full teaching service: Students, Residents, Fellows and

Nurses: Post Grad Training in CC, ACS, WC• Complemented by APN’s, Clin RN Specialists, PA’s

Barnes-Jewish WUSM• Acute & Critical Care

Surgery• Level I Trauma Center• Affiliated with St Louis

VA (shared with SLU)• Wound Care in our

group practice• >2,000 traumas/yr• 24 bed ICU now 36 Bed • Allows us to care for a

wide variety of wounds

What have we learned?Better Acute Care means Better Outcomes• Better acute wound care mitigates later chronic

wound problems• Shared Goal: Treat the WHOLE patient not just

the HOLE in patient• Paradigms for better acute wound care– Lacerations– Gun Shot Wounds– Burn Wounds

• Summary—Blast Injuries

Acute Management

• Military has its own and accompanying manuals

• Multiple society based course offerings– ATLS, TEAMS, ABLS, FCCS,

FDM• Today, wound care is one

way to stimulate your thoughts and appetite for the care improvements they represent

Primary and Secondary Surveys

• ABCDEFF: Airway—Breathing—Circulation—Deficits—Exposure—Fluids—Strip’em—Flip’em and Cover’em Up!

• Secondary Survey: Head to Toe physical exam with tubes and fingers in every orifice

• Follow up Exams—This is where Wound Care might come in a crucial role: double check to be sure all lacerations, GSW’s and injuries are accounted for

Keep focused on the Primary Survey

• Airway has been 1st for more than 20 years…• But military experience is moving Bleeding

up…• Stopping exsanguinating hemorrhage may be

promoted up the primary survey• Whole blood based resuscitation currently

only possible in the military• 1:1:1 ratio’d massive transfusion in civillian

Acute Wounds: Lacerations

• Lacerations– Assume contaminated, may not be recommended

to be closed v. approximated– Tetanus Prophylaxis: Host and Injury• Host: prior history of immunization• Injury: quantity of Clostridium tetanii innoculation

– Rusty Nail vs Soil contamination

• Recommendations

– Tetanus treatment

Double Check on Tetanus1

• Rare, but if missed carries 13% mortality in US care, and 30 – 50% mortality world wide

• Complications usually in those not previously immunized, those who do not receive a timely booster or who have an overwhelmingly large innoculum

1. Centers for Disease Control and Prevention tetanus surveillance UnitedStates, 2001Y2008. MMWR Morb Mortal Wkly Rep 2011;60:365Y369.

Tetanus Treatment2-4

• Consider HTIG in suspected tetanus; tetanus-prone wounds;• those with an incomplete primary vaccination series, or

unknown• vaccination status. A single intramuscular dose of 500• IU suffices.• & A protective serum antitoxin antibody level, commonly

accepted• as 0.01 IU/mL (in vivo) or 0.15 IU/mL (in vitro), makes• the diagnosis of tetanus less likely, but not impossible.

2. Biological products. Bacterial vaccines and toxoids; implementation of efficacy review; proposed rule. Fed Regist 1985;50:51002Y51117.

3. Simonsen O, Bentzon M, Heron I. ELISA for the routine determination of antitoxic immunity to tetanus. J Biol Stand 1986;14:231Y239.

4. Borrow R, Balmer P, Roper MH. Tetanus update 2006. In: Immunization,Vaccines and Biologicals (Immunological Basis for Immunization Series; Module 3). Geneva: World Health Organization; 2006: 1Y35.

Tetanus: A Review

• Nice review article• Ataro, Mushatt, et. Al in J. Of the Southern

Medical Association, Vol 614, 2011

Assess, Clean and Dress

• Assessment– Association with deeper structure injury• Connective tissue• Arteries• Veins• Nerves• Lymphatics• Cavities: Peritoneal, joint capsules

– Document Position, Length, Width, Depth, peri-wound: Essentially the same as a Pressure Ulcer

Assess & Clean

• I assess the wound from outside in: Evaluate and Treat the WHOLE patient not just the HOLE in the patient

• See the location of the wound and begin with the whole patient, look fore and aft– Pulses, range of motion– Allows me to think about what might be at depth

or behind or associated structures– Now you look at the wound

Basic Vascular Exam

• “Dorsalis pedis pulse was weakly/faintly palpable”

• This really means….• The doppler ultrasound was somewhere else• Everyone should be familiar with a basic Ankle

Brachial Index: ABI

Ankle Brachial Index

• Take the systolic blood pressure in each arm, select the higher of the two

• Take the systolic blood pressure above the ankle and below any injury

• Ankle value is the numerator of the two• Ration should be > 1.0, ratios less than that and

sometimes greater reflect injury or disease• This gives a value that can be tracked (like the

GCS for an extremity)

Clean

• Water, normal saline, antibiotic with saline• Simple irrigation• Pulse lavage• Combination of lavage, low energy pulse

lavage, high energy lavage-debridement• Sharp debridement• Combinations• Hard to show value in antibiotic solution(s)

Clean, debride, and stabilize

J. Of Trauma

• Infection Prevention and Control in Deployed Military Medical Treatment Facilities

• Duane R. Hospenthal, MD, PhD, FACP, FIDSA,• Andrew D. Green, MB, BS, FRCPath, FFPH, FFTravMed,

RCPS, DTM&H, Helen K. Crouch, RN, MPH, CIC,• Judith F. English, MSN, RN, CIC, Jane Pool, MS, RN, CIC,

Heather C. Yun, MD, FACP,• Clinton K. Murray, MD, FACP, FIDSA• Prevention of Combat-Related Infections Guidelines

Panel

Journal of Trauma

• Prevention of Combat-Related Infections Guidelines Panel

• All wounds and all patients should be assumed to be contaminated

• Universal Precautions• Good clinical practice guidelines• Immediate treatment for healing• Mitigating later pathogenic and resistant

bacteria

Personal Practice Habits

• NS lavage with low pressure pulse lavage, no high pressure to avoid driving debris

• Small surface areas—lavage with ultrasound• Local lidocaine gels and soaks, regional anesthetic blocks

over general• First dressing often iodine based antimicrobial—but for

hemostasis, not for antimicrobial• Tissue approximation over complete closure• OCT antibiotic ointment/xeroform early then• Collagen based/foam protective dressings• Common NPWT use

Gunshot Wounds = GSW’s

• Wound Care stresses examination of the whole person: treat the whole not the just the hole

• GSW’s are a microcosm of many wounding mechanisms

• Let’s combine acute care with wound care

GSW 101

• A gunshot wound is the hole in the surface of the body from the projectile, not the trajectory– Count the wounds and then posit on the trajectories– One gunshot yields two GSW’s or one GSW and one retained

bullet– Number of holes plus bullets should be an even number—

unless shot before (increasingly common)_• The severity of the gunshot is largely determined by the

transfer of Kinetic Energy to the body of the patient– KE = ½ MV2

– Mass v. Velocity

Elephant gun v Assault RifleStopping Power1916 Mauser

KE = ½ Mass X VELOCITY2

Contemporary M16

Large projectileHeavy Mass for “stopping power”Fewer rounds carriedSingle action

Smaller rounds, but more roundsAutomatic—every man gets a machine gun >1000 feet / secSound barrier, sonic boomPotential space behind projectile

High Velocity

• Projectile has a blast zone trailing behind it

• Injury from not only penetration of the projectile

• But from KE transferred• Larger soft tissue

injuries

50 cal to leg Traumatic Wound

Number of holes (GSW’s) plus number of bullets must be an even number

• If not…– You are missing a hole or– You are missing a bullet or – You are miss identifying a graze or a fragmentation– Or the patient has been shot before

• Note …we now leave bullets IN

• Just double checking holes plus bullets pays off• Now sometimes the holes plus bullets are

impossible to track = an exploratory laparotomy or laparoscopy

Clean, debride, and stabilize

GSW’s are usually left open

• They can be simply cleaned• They can be packed with an iodoform gauze

packing strip or normal saline wet to moist– This may keep them being observed– This may keep them open—especially for long

tracts this may be beneficial– They should be changed 1 – 2 times q 24 hours

• GSW’s can assist us with their blast effects

GSW’s v. Lacerations

• A knife will cut or puncture with very little transfer of energy—less damage to see on CT, more need for careful examination

• A GSW will have a blast effect related to its velocity– More gas in the tissues– More tissue disruption– More associated fluid/hematoma

Normal Saline Wet to….

• Conflicted as a wound care professional—but this is where some judgement comes in

• Normal Saline wet to moist often becomes wet to dry– This should be viewed as a non-specific

mechanical debriding dressing—almost anti-healing

– I say almost because most patients with acute open wounds heal with NS wet to dry dressings

GSW’s in particular

• Most of our acute GSW patients are younger—they are going to heal

• Most GSW’s have some level of contamination in the wound tract and periwound

• The mechanical debridement of the NS works well: >2,000 traumas per year—1-2 wound infections

• Calls attention if increasing pain drainage– Most of the 1-2 that get infected are either long

trajectories or have some retained material (clothing)

Enlightened NS wet to moist

• Use in setting of need for frequent dressing changes

• Utilize adjuncts: wound gels or even otc topical antibiotic ointments as lubricants when no longer needing mechanical debridement

• Topical collagen based dressings for large soft tissue areas

• Negative pressure dressings when clean

Case Presentation

• 24 year old male shot through the calf

• Right through and through

• What is notable about these wounds?

• Is this a high velocity bullet?

• Compartment syndromes

Compartment Syndromes

• Increased energy transfer will lead to compartment syndromes

• Calf, forearm, thigh & buttock and abdominal

• Better management strategies with NPWT

NPWT plus Mechanical traction to preserve tissue and coverage5

5. Penn-Barwell, Fries, Street et alUse of Topical Negative Pressure in British Servicemen with Combat Wounds, Aug 2011 Open Access Plastic Surgery On-line

Large soft tissue wounds

• Leave open initially• Frequent assessment• At risk for infection—look for tip-offs• Life over limb should frame your discussions

with both patient and family• 52 year old weekend warrior…..

Four Quarter Amputation of ArmShoulder, clavicle, scapular…

Notice we could resect, but preserve entire flap that was then closed with NPWT

Abdominal Compartment Syndrome managed with home made vac pack

• Fenestrated x-ray cassette cover over bowel

• Omentum over bowel• Get edges as far laterally as

possible – Cut slits for lateral drains or

feeding tubes

• Get mass of viscera to sit down

• Gauze and suction drains or cut NGT tubes

Ioban and then wall suction

• Central sucked in wound should be hard

• Good wall integrity—patients can be extubated

• Place abdominal binder over this to back up suction

• Can be combine with multiple other modalities

• Why here in wounds---– Weakened patients salvaged– Enterocutaneous Fistulas– Herias– More wounds in our future

FasciotomiesMilitary Success

• Going to see more fasciotomies being done• Better technologies coming on line to

diagnose• Increasingly being done• Acute care– Assess if adequate– Clean and re-debride: NS wet to moist

Summation of GSW

• Fragmentation of primary projectile may lacerate– Both patient and caregiver

• KE transferred may have a blast effect– Thermal burn usually at surface with close range– Sound barrier potential space behind bullet– Retained bullet has transferred all of its kinetic

energy to the patient • Proximity may also have a burn component

All GSW mechanisms added togetherBlast Injuries

• Blast Injury is particularly devastating– Thermal component– Physical (crush) component– Contamination component– Sonic boom component– Penetrating component

• How do (we) think (someone) gets the biggest bang for a bomb blast?

Postulated Ways to get more bang for your terrorist buck

• Closed space blast injury– Focuses the energy on the people in that space– Detonate a bomb with shrapnel– Make the shrapnel contaminated: biological, chemical or dirty

nuclear—non-metal shrapnel, too– Detonate the bomb within an enclosed space to get a secondary

effect of collapsing the structure around everyone and nearby structures

• Secondary Device– Initial detonation brings IN many people– Secondary Device will catch First Responders and increase

effectiveness of both detonations, crippling responses, increasing lethality…

Blast Injuries 101

• Is the area secure?• Are you ready to protect yourself—is there

decontamination needed?• Examination of blast injuries– ABCDEF’s do NOT change– Severity of the blast concussion: tympanic

membrane ruptures, corneal abrasions• Sonic boom concussion• Rapidity of blast--airbag

Blast injuries

• Direct tissue trauma• Direct burn injury• Indirect effects on gas filled spaces: bladder,

bowel• Penetrating injuries from multiple projectiles,

shrapnel– Unexploded ordinance

• Contamination

Contamination

• High volume irrigation• Leave soft tissue defects open—can now be

managed with negative pressure• Look for signs of other contaminants– Desaturation despite oxygen– Early vomiting– Coagulation defects– Early Liquefactive necrosis of tissues

Summary of Injuries

• Large soft tissue defects• Usually on extremities due to body armor• Often concomitant orthopedic injury• Potentially traumatic/guillotine amputation• Often due to blast exposure (IED or RPG)• May have traumatic brain injury (TBI)• Associated abdominal injuries

What Makes a Wound Complex?

• Multiple mechanisms–Blast–Burn–Shrapnel–High Velocity–Crush

50 cal to leg Traumatic Wound

Traumatic Wound with Negative Pressure Wound Therapy (NPWT)

Traumatic Wound with NPWT

Wound Bed Preparation

Grafting

Graft After NPWT Bolster

Resolved

Limb Salvage

• The goal of limb salvage is to preserve a limb that will be more functional than a prosthetic if the limb is amputated

• If the extremity cannot be salvaged, the goal is to maintain the maximum functional length

Warrior Recovery from Complex Wounds

• Trauma centers are leveled—we are now beginning to level their affiliated rehab centers—the highest level are what we now seeing in the military:

• COL Alexander Stojadinovic, M.D., FACS, Director, Combat Wound Initiative Program, Director, Complex Wound & Limb Salvage Center

• Christian E. Paletta MD FACS, Complex Wound Limb Salvage Center, Walter Reed Army Medical Center

How can we learn together?• This is a 60 year diabetic foot

wound that failed to heal resulting in a through ankle amputation pending a BKA….

• We used local therapies, local antibiotics, negative pressure and HBOT—Everything we talked about today

• He closed with a functional stump

• This was in 1999• What was once heroic,

controversial is fasting becoming standard

References and credits• Textbook of Military Medicine (2009). Care of the Combat Amputee.• War Surgery in Afghanistan and Iraq: A series of cases (2003-3007).• The Next Step. The rehabilitation journey after lower limb amputation.• Vetelli, B. RN, CNS. WRNMMC Military Amputee Treatment Center.• Crumbley, D., CDR, NC, USN, CWCN. VA Federal Recovery Program.• Howard, R., CDR, MC, USN. Assistant Deputy Director, Plastics and

Reconstructive Surgery WRNMMC.• Deptuy Director, Orthopedics and Trauma, WRNMMC.• Deyoung, P., LCDR, NC, USN. 2nd MEF (FWD), 2nd MLG, Al Taquadum Iraq

(2007).• Tingue, A., LTJG, NC, USN. Multinational Force, Kandahar Regional

Military Hospital, Kandahar, Afghanistan (2010).

References• www.ameriburn.org • www.aawcone.com• www.aawm.org• www.woundheal.org• www.uhms.org• www.facs.org• AORN• National Research Council of Nat’l Academy of Science• Wendi Gordon Shelist Foundation : www.wgsf.org

Trends to keep an eye on…• Damage Control Resuscitation with MTP/RRP,

circulatory ECMO type support with RRT• Forward critical care projections = FAME with

MoREMTORN (DUSTOFF, PEDRO, MERT)• Topical Hemostatics for both intra-cavitory as

well as wound healing applications• Advancing wound healing technologies—

cultured STSG’s• Better longer term rehab concentration for

functional outcomes

Thank You

• BJH-WUSM, Department of Surgery, Dr. Eberlein, Section of Acute & Critical Care Surgery

• Walter Reed Besthesday and the leadership with Drs. Paletta and Stojanovich and LCDR Hitchcock

• FISIG• AMSUS