management of limb injuries - icrc.aoeducation.org12 management of limb injuries during disasters...

MANAGEMENT OF LIMB INJURIESDuring disasters and conflicts

Every effort has been made to confirm the accuracy of the presented information. The authors and publisher are not responsible for errors of omission or for any consequences from the application of the information in this book, and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of this publication. Application of this information in a particular situation remains the professional responsibility of the practitioner.

WHO: TheWHOEMTSecretariatcontributedtotheconcept,design,meetings,writingandeditingofthiswork.

ICRC: InternationalCommitteeoftheRedCross 19,avenuedelaPaix 1202Geneva,Switzerland T + 41 22 734 60 01 F + 41 22 733 20 57 E-mail:[email protected] ©ICRC,December2016

AO: ThedevelopmentofthisFieldGuidehasbeenmadepossible byagrantoftheAOFoundation,Davos,Switzerland.

Photos:©ICRC,Coverpage:DidierRevolDesignandlayout:JoJamieson,NCCTRC.PrintedbyCOURAND&ASSOCIES,France.

preface

In2013,theWHOEMTInitiativepublishedtheClassification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters in response to concerns from the humanitariancommunitythattheworldhadlargelyfailedinitseffortstoprovidelife-andlimb-savingcarefollowingtheHaitiearthquakeandPakistanfloods.Manyoftheteamsarrivingonthegroundwereunabletoprovidecarethattrulymettheneedsofthepopulationtheyhopedtoserve.Theywereunfamiliarnotonlywiththeemergency-responsesystemand standards, but alsowith theparticular challenges of providing care in extremelyaustereenvironments.Nowherewasthismorepronouncedthan inthecareofpatientswith limb injuries.Althoughdataandhardevidenceweredifficulttoobtain,storiesaboundedofpatientswhounderwentsurgicalprocedureswithoutany follow-up,andmostdisturbing,patientswhoseamputationswereinappropriateorunnecessary.Lately,theEMTInitiativehasbeenhelpingcountriesandNGOssetupemergencymedicalteamsthatwillbeabletomaintainagreedstandardsofqualityandself-sufficiency,resultinginbetterpatientcare.Asmoreteamsstrivetoreachthesestandards,theyneedclearguidanceonbestpractice,particularly inmanagingpatientswith limb injuries,whichmakeup themajorityofcases.Thisconsensus-basedfieldguideisaimedatprovidingthatguidance.ItdrawsontheexpertiseoftheInternationalCommitteeoftheRedCross,whichhasalonghistoryofdeliveringcaretopatientsandprotectingtheminconflict.Italsocapturestheknowledgeofotherexpertswhoseexperiencewasforgedindisastersandconflictspast.Ultimately, thisguidewillhelpnationaland internationalemergencyteams improvethecaretheyprovide to thoseweall seek toserve:ourpatients– thevictimsofarmedconflictsandnaturaldisasters.

PETER MAURER President International Committee of the Red Cross

MARGARET CHAN Director General World Health Organization

introduction

Ithaslongbeenconventionalwisdomthatthelessonsofwarmustbere-learnedbyeachnewgenerationofsurgeons.Theselessons,particularlyregardingcarefor limbinjuries,followanalmostidenticalapproachtowhatisneededtocareforpeopleinjuredindisasters.Indeed,upto90%ofthesurgicalworkloadfacedbynationalandinternationalemergencymedicalteamsindisasters involves limb injury.Butasmedicalscience improvesandtraumaratesdecreaseinhigh-incomecountries,well-intentionedsurgicalteamscanfindthemselvesunpreparedfortherealitiesofausteresettings.Morethanever,theyneedclearpracticalguidanceonhowtoadaptwhattheydoonadailybasistoprovidesafeandeffectivelimb-injurycareinconflictsordisasters.Althoughrandomizedcontrolledtrailsarenotpossible inthesesettings,thereareanumberof senior surgeons who have decades of experience working under similar circumstancesforNGOs,militariesorpublichospitals around theworld. Theydon’t regularlypublish theirknowledge–oftenbecause theyare toobusy responding to thenext emergency.With thisshortfieldguide,weareseekingtobringtheseexpertstogetheranddistiltheirknowledgeforthebenefitofnationaland international responders.Thiswork is theresultofcollaborationbetweentheICRCandtheWHO’sEMTInitiative,withsupportfromtheAOFoundation.Itseekstorespondtocontroversiesandimprovetraumateams’practicalapproachestothewoundsandorthopaedicinjuriestheywillfacewhenrespondingtothenextdisasterorconflict.This text is a free,open-access resourceand is intended to servealongsideagrowingbodyof online training material to provide guidance for national and international emergencymedicalteamscaringforpatientsindisastersandconflicts.Itwillbeupdatedregularlyasnewcontroversiesariseandevidencegrows.Wethankyouforyourcommitmenttodeliveringcaretothosewhoneeditmostundertheworld’smostchallengingcontexts,andtrustthatyouwillfindthistextfit-for-purpose.

HARALD VEEN Chief Surgeon International Committee of the Red Cross

IAN NORTON Project Lead WHO Emergency Medical Teams Initiative

contributing authors

ALANKAY IANNORTON

HAYDARALWASH INGAOSMERS

AMANDA BAUMGARTNER-HENLEY JANEWIEDLER

ANNETTEHOLIAN JOHANVON SCHREEB

ARNAUDDAGAIN KRISTENBLAIR

BARBARARAU MICHAELSCHUETZ

CHRISTOPHERMULLIGAN NELSONOLIM

DAVIDHELFET NIEVESAMAT CAMACHO

DAVIDNOTT PATRICKHÉRARD

DÓNALO'MATHÚNA RACHAELCRAVEN

ELHANANBAR-ON RAM SHAH

ELONGLASSBERG RICHARDGOSSELIN

GUYJENSEN STEFANIEHAUTZ

HARALD VEEN STEVESCHWARTZ

HUGOORELLANA WASEEM SAEED

indexINTRODUCTION..................................................................................................................... 2 Abbreviations.....................................................................................9

CHAPTER 1CONTEXT................................................................................................. 11 Triage................................................................................................13Phasesofdisasters...........................................................................14Burdenofdiseaseinsuddenonsetdisasters...................................15Earthquakes/Tsunamis/Floods......................................................16Healthcareindanger........................................................................18Patientfactors..................................................................................21

CHAPTER 2BALLISTICS............................................................................................. 23 Ballistics&EnergyTransfer...............................................................25Bulletwounds..................................................................................26Blastinjuries....................................................................................27Managment .....................................................................................29

CHAPTER 3LOGISTICS, FIELD SUPPORT, AND TRAINING.................................. 31 Logisticsandself-sufficiency.............................................................33Logisticsstandards...........................................................................34TrainingforEMTS.............................................................................36Considerationsfortraining...............................................................38

CHAPTER 4ANAESTHESIA AND PERIOPERATIVE CARE....................................... 39 Initialassessment.............................................................................41Pre-operativecare............................................................................42Post-operativecare...........................................................................44Anaesthesia......................................................................................46Painmanagementandpatientrecords............................................47

CHAPTER 5DAMAGE CONTROL SURGERY AND RESUSCITATION....................... 51Principlesofdamagecontrolsurgeryandresuscitation...................53Resuscitationandpelvicfractures....................................................54Diagnosisandmanagement.............................................................55Placementofanteriorframesforpelvicfractures............................57

CHAPTER 6LIMB WOUNDS........................................................................................ 59 Wound management........................................................................61Wound surgery.................................................................................62Wounddebridementbylayers.........................................................63Dressings..........................................................................................66

CHAPTER 7CLOSED FRACTURES............................................................................. 69 Closedfracturemanagement...........................................................71Immobilization..................................................................................73After-careandfollowup...................................................................76Removingcasts.................................................................................77Traction.............................................................................................78Paediatricconsiderations.................................................................81Transfers...........................................................................................82Managementofclosedfractureswithinternalfixation...................83

CHAPTER 8OPEN FRACTURES................................................................................. 85 Wound debridement........................................................................88Fracturestabilization........................................................................89Externalfixationforopenfractures..................................................92Managementofopenfractures.....................................................103

CHAPTER 9COMPARTMENT SYNDROME AND CRUSH SYNDROME.................. 109 Compartmentsyndromediagnosis................................................111Compartmentsyndrometreatment...............................................112Crushsyndrome.............................................................................115CrushsyndromemanagementinSODs..........................................116

CHAPTER 10AMPUTATIONS...................................................................................... 119 Lowerextremityamputations........................................................121Specifictechnicalconsiderations....................................................124Upperextremityamputations........................................................127Specialconsiderations....................................................................128Complicationsofamputation.........................................................129Keymessagesregardingamputation..............................................131

CHAPTER 11BURNS.................................................................................................... 133Clinicalmanagementofburns........................................................135Surgicalmanagementofburns.......................................................146Chemicalandelectricalburns........................................................147

CHAPTER 12ETHICS OF HEALTHCARE IN DISASTERS AND CONFLICTS........... 151Mainethicaltheories.....................................................................153Toolstodealwithethicaldilemmas...............................................154EMTguidingprinciples...................................................................155Researchethicsindisasters............................................................156

CHAPTER 13REHABILITATION.................................................................................. 159Acutecaretreatment.....................................................................162Sub acute treatment.......................................................................164Chronic-longtermtreatent............................................................165Familyinvolvementandequipment...............................................167

ANNEX ..................................................................................... 169ICRCABCDinitialassessmentICRCBurnsOverviewICRCThromboprophylaxisguidelineICRCTriageICRCFemurFractureandTraction

abbreviations

AboveKneeAmputation................................AKAActivitiesofDailyLiving................................ ADLsAnti-personelMine........................................APMAnti-TankMine.............................................. ATM

BeatsPerMinute...........................................bpmBelowKneeAmputation.................................BKABreathsPerMinute............................. breaths/m

DeepVeinThrombosis....................................DVTDelayedPrimaryClosure...............................DPC

EmergencyMedicalTeam.............................EMTExplosiveFormedPerforator......................... EFP

FullMetalJacket............................................FMJ

Gastrointestinal................................................GIGunshot wound ........................................... GSW

ImprovisedExplosiveDevice.......................... IEDIntensiveCareUnit.........................................ICUInternallyDisplacedPerson............................IDP

InternationalCommitteeoftheRedCross...................................................... ICRC

Intravenous ....................................................... IV

LevelofConsciousness.................................. LOCLiters ...................................................................L

MassCasualtyIncident..................................MCIMedicalTreatmentFacilities........................MTFs

Milliliters......................................................... mLMillimetersofMercury..............................mmHgMinistryofHealth........................................ MoH

NegativePressureDressing.......................... NPDNoncommunicableDiseases........................NCDsNon-SteroidalAntiinflammatories...................................NSAIDs

OpenReductionandInternalFixation.........................................................ORIF

PlasterofParis...............................................POPPositionofSafeImmobilization....................POSISemiJacketed................................................... SJSilverSulfadiazine.......................................... SSDSplitThicknessSkinGraft............................. STSGStandardOperatingProcedure...................... SOPSuddenOnsetDisaster................................. SODSystemicInflammatoryResponseSyndrome......................................SIRS

TotalBodySurfaceArea............................... TBSATransexamicAcid........................................... TXATraumaticBrianInjury.................................... TBI

UnitedNations................................................ UNUrineOutput................................................ UOP

WalkingBloodBank......................................WBBWeaponsofMassDestruction................. WMDsWorldHealthOrganization..........................WHO

1SCENARIO

TRIAGEPHASESOFDISASTERS

BURDENOFDISEASEINSUDDENONSETDISASTERSEARTHQUAKES,TSUNAMIS,ANDFLOODS

HEALTHCAREINDANGERPATIENTFACTORS

SUGGESTEDRESOURCES

REFERENCES

CONTEXT

12 MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS

CHAPTER 1 I CONTEXT

TYPE 1

• Type1EMTsmustbepreparedtomanagelargenumbersofpatients.• Arecognizedsystemfortheassessmentofinjuryseverityshouldbeemployed

toidentifythoserequiringlife-savingfirstaid,urgentandnon-urgentsurgery,andminorinjurycare.

• Theuseofthe"expectant"categoryforpatientsshouldbedoneinconsulta-tionwiththeministryofhealthwheneverpossible.

TYPE 2

• Type2EMTsshouldconcentrateonsurgicaltriageandidentifyingthosewithlifethreateningmedicalandobstetricpresentations.

• TheEMTshouldbeabletotriageappropriately200casesdaily.• TheEMTmusthaveaplantodealwithoverwhelmingsituationsbyarranging

referraltohigherlevelsofcare.

TYPE 3

• Type3EMTsshouldreserveresourc-esforreferralfromotherfacilities.

• Type 3 EMTs must retain their abilitytomanagepatientswhoself-presentaswell.

• Amethodoftriageinvolvingavail-ablespecialistsshouldbeavailableforthetriageofcomplexpatientsreferredtothetype3facility.

SCENARIOYouhaverecentlysetupatype2EMTinan earthquake zone, when a significantaftershockoccurs.

You, your team, and your facility, areunaffected.Thedistricthealthofficercallstoalertyourteamtoexpectbetween25-50 casualties to be sent to your facility.Howshouldyoupreparefortheincomingwaveofpatients? Figure 1.ICRCstaffassistpatientsinahospitalstagingarea.(ICRC)

Triage at type 3 facilities is complex and often time consuming. It should be managed by specialists or the facility will quickly be over-run with cases that are inappropriate for type 3 specialty care.

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CHAPTER 1 I CONTEXT

MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS

TRIAGETERMINOLOGY Using common language is important for documentation and communication, particularlywhenarrangingpatienttransfers.Thecategoriesbelowareawidelyacceptedsystemfortriage.

» Category 1:Immediatemedicalorsurgicalmanagement

» Category 2: Patientswhoareabletowait

» Category 3:Patientsawaitingambulatorycare

» Category 4:Patientswithlittletonohopeofsurvivalregardlessofcaredelivered

COMMON TRIAGE MISTAKESTriage in austere situations, while never aneasytask,canbemademoredifficultbyspecificchallengesthatwillvarydependingonthesituation.

» Cultural:Differentcultureshavedifferentvalues. For example some cultures willprioritizecaringforthedeadovercaringfortheinjured.

» Ethical:Theideaofdecidingnottodelivercaretoanacutelyinjuredpatientcanbeuncomfortableformanyphysicians fromhigh income settings who are used todeliveringcaretoallornearlyallpatients.Additionally, it should not be forgottenthat these situations may be verydistressingtothelocalpopulationaswell.

» Contextual pressures: Individuals canface pressure from community leaders,armed groups or other influentialindividualswhenmakingtriagedecisions.

» Logistics: Even in well resourced andrehearsed facilities, triage areas arefrequentlychaoticwithlittleopportunityfor human dignity. Triage areas shouldnotbeusedforinitiatingtreatment. Figure 2.ICRCstaffteachlocalstafftotriageandmanagea

masscasualtyincident.(ICRC)


CHAPTER 1 I CONTEXT

PHASES OF DISASTERSTERMINOLOGY

TryingtoplacethefeaturesofaSODintermsofachronologicalsequenceisunhelpfulas,inreality,itismoreacaseofoverlappingphases.Acountrywithamoredevelopedhealthsystemmaybeabletorestoreat leastsomedegreeofservices fairlyquickly,whileacountrywitha lesswell-developedhealthsystemmayrequiremuchmoretimeandassistancetorecoverfromaSODofasimilarscale.

Therefore,itisusefultoviewthephasesofdisastersinaconceptualframeworkthatreflectsthestateoftheaffectedcountryandsociety.

» PHASE 1 Pre-Event Status–Assessingthedegreeofdamagethatasociety incursfollowinganevent is

impossiblewithoutabaselineforcomparison.Thisphasedescribestheexistinginfrastructure,hazards,populationprofile,culture,economyandsecurity.

» PHASE 2 Event–Theeventphasecapturestheimmediateevent,howeverlongitmightlast.Theeventcan

beasshortasanearthquakeoraslongasacivilwar.

» PHASE 3 Structural Damage–Thisphasecomprisesthephysicaldamagetostructuresorhumanbeings.

Likephase2,itcanbebrief,aswithanearthquake,orprolonged,aswithflooding.Thatiswhyusingtimetodescribetheseeventsissoproblematic.

» PHASE 4 Functional Damage–Thisphaseencompassesallthechangesfromaneventresultingfromthe

first3phases.An increase inburns followinganSOD is aprimeexample,because functionaldamagetoinfrastructureleadstoanincreaseincookingoveranopenflame.

» PHASE 5 Relief–Thephaseassociatedwitheffortstominimizetheeffectsofstructuralandfunctional

damage,primarilythroughthedeliveryofsecurity,water,food,shelter,sanitation,andmedicalcare.

» PHASE 6 Recovery –Thisphaseisassociatedwithrestoringpre-eventlevelsoffunctioningfortheaffected

population,andnotsimplyalleviatingimmediatepainandsuffering.

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CHAPTER 1 I CONTEXT


BURDEN OF DISEASE IN SUDDEN ONSET DISASTERSDepending on the situation the type of casualties expected by EMTs can vary. Understandingthesituationonthegroundandtheburdenofdiseaseitcreatesiscrucialtotheplanningofanyintervention.Largewavesofpatientscanbecreatedbothbydisasters(earthquakes)orbyconflicts(shorttermfocusedmilitaryinterventionsorterroristattacks).Incontrastsomesituationssuchasenduringconflicts(alongrunningcivilwar)ordisasters(droughtleadingtofamine)cancreateasteadylongtermflowofpatients.AprimarygoaloftheWHO'sEMTInitiativeistoaidgovernmentsandEMTsindeliveringtheappropriatetypeofmedicalsurgecapacitythatasituationrequires.Thiscanbestbeunderstoodbythinkingaboutburdenofdiseaseinwaves.

» WAVE 1 Days 1-3 –Thiswaveencompassesmanyofthehead,neck,chest,andabdominalinjuriesthat

arerapidlyfatalwithoutintervention.InternationalEMTsareunlikelytobeabletointerveneinthisphase.ProtectingpopulationsduringthiswaveisprimarilyachievedbybuildingresilienceintonationalhealthsystemsandthroughtheresponseoflocalorpossiblyregionalEMTs.

» WAVE 2 Days 4-20–Thiswaveconsistsofthoseinjuriesthatwerenotimmediatelylifethreatening,the

majorityofwhichwillbetothelimbs,andconstitutesthelargestgroupofvictims.Theseteamsmustbeprepared tomanagenotonly thesecasesbutother surgicalemergencies thatarise,particularlyabdominalcasesandC-sections.

» WAVE 3 Thiswaveactuallystartsatday1butpeakslater.Itconsistsoftheinfectiousdiseaseissuesfaced

byinternallydisplacedpersons(IDPs),aswellastheNCDsandmentalhealthissuesfacedbyapopulationrecoveringfromaSODrequiringasurgeinhealthcarecapacity.It is unacceptable for EMTs to come only for surgery and have no plans to address endemic and infectious diseases and their complications.

» WAVE 4 This wave has variable timing

dependingonthephase1healthneedsoftheaffectedpopulation.Wave4 refers to thebackgroundsurgical, oncological, and NCDneedsofthepopulationthathavelikely gone unaddressed due totheSOD.

Figure 3.Wavesofburdenofdiseaseduringadisastergraphedashospitalresourcesrequiredovertime. (von Schreeb J, Riddez L, Samnegård H, Rosling H. Foreign field hospitals in the recent sudden-onset disasters in Iran, Haiti, Indonesia, and Pakistan. Prehospital and disaster medicine 2008; 23(02): 144-51.)

1.DirectSODcausedtrauma2.Traumacomplications3.IndirectcausedInfectiousdiseases4.Accumulatedelectivecareneeds


CHAPTER 1 I CONTEXT

Deployment of surgical resources outside of the 2 week window following a disaster is unlikely to aid the population and will likely place an increased burden on the local infrastructure, a scenario that could possibly divert needed resources from the local health system or recovery efforts.

EARTHQUAKEEarthquakesaresomeofthehighestprofilesituationsthatEMTscanrespondto.Theirrelativeunpredictability, combined with the obvious destruction of buildings and infrastructuremaketheseeventswidelyreportedandoftenwidelyrespondedto.

It is crucial for EMTs to understand the needs and limitations of earthquakes when decidingwhethertorespondtotheseevents.

» ThepatientloadanddemandonEMTscandifferwidelydependingonthedegreeofpreparationofthesocietypriortotheevent.

» Earthquakescarrya lowdeath-to-injury ratiowithapproximately1death forevery3 injuries,meaning that surgical response can result in decreased morbidity and mortality by treatingwoundsandfractures.

» Earthquake victims frequently present with crush type injuries that can progress to crushsyndrome.Thisclinicalscenariocanpresentsomedifficultmanagementchallenges,particularlyforthoseinexperiencedindealingwiththesetypesofinjuries.ManagementmayrequireICUcareorevendialysis.

» ThecollapseofstructuresbroughtonbyearthquakeschangesthenatureofthedemandsforEMTs. If healthcare facilities aredestroyed then thedemand formore advanced, totally self-sufficienttype2and3EMTsbecomesgreater.

Figure 4.AnICRCandHaitianRedCrossTeamsurveydamageaftertheHaitiEarthquake.(ICRC)

17

CHAPTER 1 I CONTEXT


TSUNAMIS» Tsunamiscreateamuchdifferentcontextcomparedtoearthquakes.Theycarryamuchhigher

mortalityratioofapproximately9deathsforevery1injury.

» The relatively smallnumberof injuredpatientsmeans that fewer surgical teamsareneeded.However,theymaydemandothertypesofEMTssuchasmedicalorpublichealthteams.

» Thesurgicalneedthatdoesexistfollowingatsunamitendstocenteraroundsofttissueinjuriesandinfectionssustainedduringtheeventortheimmediateaftermath.Thesewoundsaremadeworsebycontinuousexposuretowet,contaminatedconditions.

» TheremaybesomeroleforbolsteringlocalsurgicalcapacitybyEMTsthatcandeploytemporarystructures while local structures are being rehabilitated, as the aftermath of Tsunamis caninvolvesignificantstructuraldamageduetoeitherthetsunamiitselfortheincitingearthquake.However,thisneedshouldnotbeassumedtobepresentunlessthehostgovernmentissuesaspecificrequest.

FLOODS» The need for a surgical response and the factors affectingwhat types of EMTs would be of

greatestvaluearehighlydependentonthecauseoftheflood,thestateofhealth-carefacilitiesandtherapidityoftheflooding.

Figure 5.ICRCvolunteerssearchforTsunamivictims.(ICRC)


CHAPTER 1 I CONTEXT

ARMED CONFLICT» Woundsobtainedinarmedconflicthavetheirownspecificepidemiologyanddemandprinciples

ofmanagementthatsometimesdifferfromcivilianpractices.

» UnlikeSODswheremanyorallofthepatientsareinjuredsimultaneously,conflictscandeliverasteadytideofpatientsthatebbsandflowsbasedonthesituationontheground.

» Areasofconflictpresenthostiledifficultenvironmentsthatcanchangerapidly.ThiscanplaceconstraintsonthelocationsandscopeofcarethatEMTsareabletodeliver.

» Manysurgeonsreceivetraininginlargeinstitutions,fromwhichthereisnohigherleveltotransferpatients to. Surgery in conflictareas isoftenprovidedasa seriesofoperationsperformed insuccessiveechelonsofcare,accordingtoresourcesandtheprinciplesofdamagecontrolsurgery.

» Inconflictsurgery,asinalltypesofSODs,thetraitsofprofessionalism,soundjudgment,commonsense,andadaptabilityarekeytosuccessfullydeliveringcare.

» Whilethelawsandprinciplesgoverningthedeliveryofcareinarmedconflictcanbecomplex,twosimpleprinciplesshouldguidetheactionsofhumanitarianactorsinthesesituations:

• The human dignity of all individuals should be respected at all times without any kind ofdiscrimination.

• Everythingthatcanbedoneshouldbedonetoalleviatethesufferingofthosewhotakenopartintheconflictorhavebeenputoutofactionbysickness,injury,orcaptivity.

HEALTHCARE IN DANGER» The Geneva Conventions protectmedical facilities and personnel. However, recent conflicts

haveseenadrasticincreaseinattacksonhealthcareprovidersandfacilities.Thisresultsinthedestruction of resources for populations that require care and inhibits future providers fromcomingtofillthesegaps.

» The minimum standards requireEMTs to provide their practitionerswithasafeenvironmentinwhichtooperate and to have a security riskmanagementsysteminplace.

» NationalEMTsandhealthproviders,sometimes with remote support,maybetheonly responders inveryhighrisksituations.

Figure 6.ThemainhospitalinAleppofollowingabombingraid.(ICRC)

19

CHAPTER 1 I CONTEXT


SCENARIOYouareinatype2EMTdeployedtoacountrystruckbyatsunamifourdaysago.Therearestilllargeamountsofstandingwaterthroughouttheareainwhichyourhospitalissetup.

A67-year-oldmanwithclearevidenceofvasculardiseaseanddiabetespresentswithaninfectedwoundonhislowerleg.

» Whatspecificconcernsdoyouhaveforthispatientgiventhecontextofthedisaster?

» Howshouldyourmanagementchange,giventhelikelydisruptionofthehealthcaresysteminthecountrytowhichyouaredeployed?

Figure 1.Softtissueinfectioninadiabeticfoot.(Norton)

TYPE 1

Type1EMTsmustbecapableandself-sufficienttomanageminorexacerbationsofchronicdiseasesthatrequireemergentcareonanoutpatientbasis.

TYPE 2

Type2EMTsmustbepreparedandself-sufficienttomanageacuteexacerbationsofchronicdiseasesrequiringinpatientadmission.

TYPE 3

Type3EMTsmustbepreparedandself-sufficienttomanageacuteexacerbationsofchronicdiseasesrequiringintensivecaremanagementasperthenormalstandardandcontextofthecountry.


CHAPTER 1 I CONTEXT

PATIENT FACTORS» Provision of good patient care requires the ability to

communicate. Thepatient’sown language shouldbeusedfor the discussion of all surgical interventions and clinicalmanagement.

» Identifyingindividualsfromthelocalpopulationorselectingteammembersfordeploymentwhospeaklocallanguagesisimportantforprovisionofsafe,ethicalpatientcare.

» Inmanyausteresettings,familymemberswillperformmanyofthefunctionsassociatedwithnursingstaffinhighincomecountries.

» It is important to demonstrate clearly to these familymembers how care should be provided to the patient.Oftenpictorialinstructionsmaybeuseful,particularlywhenlanguagebarriersarepresent.

» Tasks such as pressure care, limb elevation, ambulation,toileting,eating,anddrinkingwilllikelyrequiretheassistanceoffamilymembers,especiallyforpatientsintraction.

Figure 8.Patientsonahospitalward.(ICRC)

• A close family member of the patient may communicate his or her own thoughts rather than those of the patient when translating.

• Using a child to interpret is not advisable given what may be lost in translation, and because it may compromise the child.

21

CHAPTER 1 I CONTEXT


NONCOMMUNICABLE DISEASES A growing proportion of the world’s disease burden is noncommunicable diseases (NCDs).SODs or conflicts can lead exacerbate NCDs through destruction of healthcare infrastructure,displacement, lossofhousingand trauma fromwhichpatientswithco-morbidconditionsmayhaveamoredifficulttimerecovering.TheUNInteragencyTaskForcesplitsthemanagementoftheseissuesintotworesponsephases.

» FIRST 30-90 DAYS Thefocusshouldbeonthetreatmentoflife-threateningorseverelysymptomaticconditions.

» AFTER 90 DAYS Attemptstoexpandmanagementtoincludesub-acuteandchronicconditionsshouldbegin.This

may involve shifting fromEMTswith surgical capacities to thosedesigned to supplement theprimaryhealthcareportionofthehealthsystemwhileitrebuilds.

PRINCIPLES OF NCD MANAGEMENT NCDs should not be forgotten during a disaster. These conditions can result inmorbidity andmortalitywhenexacerbatedbystressortrauma.ObjectivesformanagementofNCDsduringtheinitialresponseare:

» Ensure clinical management via referral or by stabilizing the patient. EMTsstandardoperatingprocedures(SOPs)shouldincludeprocessesforidentifyingpatientsinneedofpalliativecareandpainrelief.

» Ensure identification for NCD patients for whom interruption of treatment could be fatal or critical. Thesepatients includepatients requiringdialysis, type1diabetics,patientswhoarestatuspostorgantransplant,orpatientswithmechanicalheartvalves..

» Avoid sudden discontinuation of careandprioritizeresources.

» Primary health clinics should be identified to triage and treat as many symptoms of NCDs as possible. Restorationof servicesat type1EMTsmayallow type2and3EMTs tomanageremainingsurgicalorcomplexmedialconditions.

SPECIAL CONTEXTSCHRONIC ARTERIAL OCCLUSIVE DISEASE» Alwaysassessandrecordthevascularstatusofafootor lower legpriortodebridinga lower

extremitywound.Ifapatientwithchronicischaemiaofthelowerlegpresentswithawound,debridementshouldbeperformedverycautiously.Thehealingprocesscanbeveryslowinthesepatients.


CHAPTER 1 I CONTEXT

SUGGESTED RESOURCES

1. von Schreeb J, Riddez L, Samnegård H, Rosling H. Foreign field hospitals in the recent sudden-onset disasters in Iran, Haiti, Indonesia, and Pakistan. Prehospital and Disaster Medicine 2008; 23(02): 144-51.

REFERENCES

1. Birnbaum ML, Daily EK, O'Rourke AP. Research and Evaluations of the Health Aspects of Disasters, Part III: Framework for the Temporal Phases of Disasters. Prehospital and Disaster Medicine 2015; 30(6): 628-32.

2. Bar-On E, Abargel A, Peleg K, Kreiss Y. Coping with the challenges of early disaster response: 24 years of field hospital experience after earthquakes. Disaster Medicine and Public Health Preparedness 2013; 7(05): 491-8.

3. Gerdin M, Wladis A, von Schreeb J. Foreign field hospitals after the 2010 Haiti earthquake: how good were we? Emergency Medicine Journal 2013; 30(1): e8-e.

4. Noji EK, Kelen GD, Armenian HK, Oganessian A, Jones NP, Sivertson KT. The 1988 earthquake in Soviet Armenia: a case study. Annals of Emergency Medicine 1990; 19(8): 891-7.

5. Chambers AJ, Campion MJ, Courtenay BG, Crozier JA, New CH. Operation Sumatra Assist: surgery for survivors of the tsunami disaster in Indonesia. ANZ Journal of Surgery 2006; 76(1-2): 39-42.

6. Norton I, Von Schreeb J, Aitken P, Herard P, Lajolo C. Classification and minimum standards for foreign medical teams in sudden onset disasters. Geneva: World Health Organization 2013.

7. Herard P, Boillot F. Triage in surgery: from theory to practice, the Medecins Sans Frontières experience. International Orthopaedics 2013; 37(8): 1429-31.

8. Trelles M, Stewart BT, Kushner AL. Attacks on civilians and hospitals must stop. The Lancet Global Health 2016.

9 . Giannou C, Baldan M. War surgery: Working with limited resources in armed conflict and other situations of violence, Volume 1. Geneva: International Committee of the Red Cross; 2009.

10. Noncommunicable Diseases in Emergencies. 2016. http://apps.who.int/iris/bitstream/10665/204627/1/WHO_NMH_NVI_16.2_eng.pdf (accessed 1 November 2016).

11. Demaio A, Jamieson J, Horn R, de Courten M, Tellier S. Non-communicable diseases in emergencies: a call to action. PLoS Currents Disasters 2013.

EMT Website: https://extranet.who.int/emt/page/homeAO/ICRC/WHO Training Resources: http://www.aofoundation.org/icrc

2SCENARIO

BALLISTICS&ENERGYTRANSFERBULLETWOUNDSBLASTINJURIES

SUGGESTEDRESOURCES

REFERENCES

BALLISTICS


CHAPTER 2 I BALLISTICS

SCENARIOYour EMT type 2 has recently deployed to arural area prone to insurgent activity and setupwithinasmalllocalhospitaltoaugmentthelocalhealthinfrastructure.Thelocalstaffinformyou that the surroundingareas are frequentlytargetedwithIEDs.Oncewordspreadsofyourteam'sarrival,itisnotlongbeforepatientswithmultiple traumaticamputations and large softtissueinjuriesstartbeingdeliveredtoyourEMTonaregularbasis.

» Howshouldyouplanforboththeshortandlongtermcareoftheseinjuries?

» What planning with regard to operativescheduleandsuppliesmustbeundertakentocareforpatientswiththisinjurypattern?

» What do you need to know regarding thisparticular typeofweapon to care for thesepatients?

Figure 1.RedCrossSocietyEmergencyactionteamstransferpatientstoambulances.(ICRC)

TYPE 1

• Triagepatientsandattempttoseparatethe“walkingwounded”fromtheseverelyinjuredinordertotransferandreferappropriately.

• Providestabilizationandeffectivetransferaswellaswoundcare.

TYPE 2

• Type2EMTsshouldtriagespecificallyforpatientsrequiringsurgicaltreat-mentofprimaryblastinjuriesandopenfracturesthatareunlikelytorequireprolongedintensivecare.

• Providedamagecontrolsurgeryandresuscitationofseverelyinjuredpatientsandpotentialtransfertoahigherlevelofcareifavailable.

TYPE 3

• Managementofseverelyinjuredpatientsrequiringmultipleoperationsorcomplexintensivecare.

• Provisionofintensivecareor,potentially,renalreplacementtherapyforpa-tientswithcrushsyndromesecondarytobuildingcollapse.

25



BALLISTICSBALLISTICS AND ENERGY TRANSFERInjuries sustained in conflict situations differ from those seen in civilian practice, particularlywithregardtothelimitedresourcesthatmaybeavailable.Aworkingknowledgeofthedifferentmechanisms of war related injury and their sequalae is therefore important for any surgeondeployingtoanareaofconflict.

THE PRINCIPLE OF ENERGY TRANSFER -Thetotalkineticenergyofaprojectileisthepotentialtocausedamage,thetransferofthiskineticenergyfromtheprojectiletothetissuesisthecapacitytocausedamage.Theactualdegreeoftissuedamagedependsontheefficiencyofthisenergytransfer.

Manyweapontypescanbeclassifiedbytheamountofenergyavailablefortransfer:

» Lowenergy:knifeorhandenergizedmissiles

» Mediumenergy:handguns

» Highenergy:militaryorhuntingrifleswithamuzzlevelocityofgreaterthan600m/soralargemassprojectile

Fragments given off by explosions are aspecial case. Immediately following theexplosion they can form high energyprojectiles, but the amount of energyavailable for transfer dissipates rapidlyover distance due to the poor aerodynamic propertiesofthefragments.

The transfer of energy occurs at theprojectile-tissue interaction. This transferof energy compresses, cuts, or shears thetissue, depending on the characteristicsof the projectile and its path as it passesthroughthetissue.

PAEDIATRIC CONSIDERATIONSAs more conflicts have become urban in nature with loosely defined or changing factions, the exposure of children to conflict induced injury has increased.

Figure 2.Achildinjuredbyalandmineisfittedforaprosthesis.(ICRC)



BULLET WOUNDSLikeciviliangunshotwounds(GSWs),militaryassaultstyleweaponorhandguninjuriesmayhaveexit wounds that are large, small, or absent. Munitions used during conflict are required byinternationallawtobefullmetaljacketed(FMJ)rounds.

» TheFMJroundshaveacoppercasingthatentirelysurroundsthebullet'sleadcore.

» Thesemunitionshavegreaterpenetratingpower,butdonoteasilydeformonimpactwithtissue.

Manycivilianvariantsofammunitionaresemi-jacketed(SJ)meaningthattheleadcoreisnotfullysurroundedbythecoppershell.

» SMJbulletscaneasilydeformonimpactcausinggreatertissuedamagebutwithlesspenetratingpower.

This distinction is important for the limb surgeon as these different types of munitions havedifferingeffectsonbone.

» AFMJbulletimpactingboneshortlyafterentryintothetissuewillbreaktheboneandcontinueonintodeepertissues.However,whenaFMJbulletricochetsortumblespriortoimpactitcancauseenormousamountsofsofttissueorbonyinjury.

» ASJbulletwillshatterthebonecompletelyiftheimpactisshallowduetothedeformingnatureofthebullet.

» FromtheperspectiveofthesurgeonthedifferencebetweenthetwotypesofroundsisthatwithSJroundsthemajorityoftheenergytransferismadewithinthefirstfewcmofpenetrationintothetissue,whilewithaFMJroundmostoftheenergytransferoccursdeeperinthetissue.Whenthisoccurs,atemporarycavityiscreatedthatcollapsesimmediatelyhidingtheinternalinjuries.

Figure 3.Theshowerofleadeffectdemonstratedonthisplainradiographisamarkerofseveretissuedamage.(ICRC)

If radiography is available, then the patient should be imaged to ensure that the sum of the number visible intact rounds and wounds adds to an even number.

27



BLAST INJURIESANTI-PERSONNEL MINESAnti-personnelmines are explosive devicesmeant to be triggered by a person, rather than avehicle.Becauseoftheirlackofprecision,theycommonlyinjurebothcombatantsandcivilians.Theycanstayonthebattlefieldlongafteraconflicthasended,injuringthecivilianpopulationforyearsafterwards.

Anti-personnelmines(APMs)tendtocauseinjuryinoneofthreespecificpatterns.

» PATTERN 1: Pressure plate trigger that resultsin traumatic amputation of the triggering leg,withseveresofttissueinjuriestopelvis,genitals,contralaterallimbandcontralateralarm.

» PATTERN 2: Tripwiretriggerinjurycausesinjuriesthatstemprimarilyfromfragmentationinjuriesasopposedtoprimaryblastinjuries.Theseverityofinjuryisinverselyproportionaltothedistancefromthedevice,asthefragmentsarenotaerodynamicandtheirenergydissipatesquicklyinflight.

» PATTERN 3: Anindividualhandlesamineeitherattemptingtoclearitorduetoachildplayingwithit.Thepatientsustainsinjuriestotheeyes,face,hands,andchest.

ANTI-TANK MINESTheseexplosivedevicesareintendedtobetriggeredbyavehicle.Thesedevicesfrequentlycauseaninjurypattern referred to as “pied de mine.” This injurypatterninvolvescomminutionofmanyofthebonesof the footdue to sharpupward forceof thefloorof the vehicle. This commonly occurs in occupantsofarmoredvehicles,butiscommoninoccupantsofnon-armoredvehiclesaswell.

Figure 4.Fromtoptobottom,patterns1,2,and3injuriesinvolvinginjuriesfromanti-personnel

landmines.(ICRC)



IMPROVISED EXPLOSIVE DEVICES

Improvised explosive devices (IEDs) are home-made rather than commercially manufactured.TheyhavebecomesynonymouswithrecentconflictsinIraqandAfghanistan.

Thesedevices areoftenmanufactured frommodified commercialmunitions. IEDs canpresentwithinjurypatternssimilartoAPMsorATMsdependingonthesizeofthecharge,thelocationofthedevice,andthetriggeringmechanism.

Adistinctcategoryof IED is theexplosive formedperforator (EFP)variant.Theseareashapedchargeweaponinwhichtheblastdeformsaportionofthecontainerresultinginapenetratingprojectile.

These injuries are often causedmore via the secondary blast injury due to the fragments asopposedtotheprimaryblast.

Theseinjuriesalsohaveatendencytopresentinan"allornothing"pattern,withvictimseitherdyingfrombeingstruckbytheshrapnelorsurvivingwithrelativelyminorinjuries.

SUICIDE BOMBINGS

Suicidebombingsoftencausedevastatingphysicalandemotionaldamagetoapopulationduetotheabilityofthebombertomobilizetheexplosiveintopopulatedareas.Suicidebombingscarrynearlydoublethemortalityrateofconventionallydeployedexplosives.

Patientspresentwithsevereinjuries,alteredLOC,multipleareasofbodilyinjury,andhypotensiononarrivalmoreoftenthanothertypesofblastinjuries.

SuicidebombingscancreateasuddenenormousdemandonEMTresources.

PAEDIATRIC CONSIDERATIONS

Children are more often severely injured compared to adults from blast injuries due to their proximity to the ground, curious nature, inability to effectively flee danger, increased head to body size, and decreased physiologic reserve.

29



MANAGEMENTThe management of the results of the aforementioned mechanisms of injuries is coveredthroughoutthistext,butsomegeneralnotes,specificallywithregardto limbinjuriesfollowingAPMordismountedIEDinjuries,bearmentioninghere.

» IED/APMinjuriesaredirty,contaminatedwoundsresultingfromthepropulsionoflargeamountsofsoil,clothing,andotherorganicmatterupwardintothewound.

» These wounds often require a level of amputation higher than what would initially appearnecessaryduetotheblastforcingdebrisverydeepintothetissuesandunderneathskinflapsthatappearhealthy.

» The blast can cause pressure waves within the blood and tissue column leading to venousthrombosiswithsubsequentcompartmentsyndrome.

» SmallAPMscanresultinincompletetraumaticamputationwithwideanddeepsofttissueinjuriestothefoot,Thesewoundsoftenresultinamputationandrequiremeticulousdebridementevery2-3daysifamputationistobeavoided.

Figure 5.TheumbrellaeffectofanantipersonnellandmineorgroundmountedIED.Notethewaythatdebrisisforcedintothewounddeeperthanmayappearpossibleoninitialexamination.(A. Kay)

Not all traumatic amputations require placement of a tourniquet. Tourniquets are intended to stop life-threatening haemorrhage when there is a higher level of care that a patient can be transferred to. If the patient is not haemorrhaging, no tourniquet is needed as this can cause tissue ischaemia or impede venous return, resulting in increased haemorrhage or compartment syndrome.



SUGGESTED RESOURCES

1. Ramasamy A, Hill A-M, Clasper J. Improvised explosive devices: pathophysiology, injury profiles and current medical management. Journal of the Royal Army Medical Corps 2009; 155(4): 265-72.

2. Aharonson-Daniel L, Klein Y, Peleg K. Suicide bombers form a new injury profile. Ann Surg 2006; 244(6): 1018-23.

REFERENCES

1. Stephenson J. Caring for the injured child in settings of limited resource. Seminars in Paediatric Surgery 2015.

2. Giannou C, Baldan M. War surgery: Working with limited resources in armed conflict and other situations of violence–Volume 1. Geneva: International Committee of the Red Cross; 2009.

3. Giannou C, Baldan M. War surgery: Working with limited resources in armed conflict and other situations of violence–Volume 2. Geneva: International Committee of the Red Cross; 2013.



3SCENARIO

LOGISTICSANDSELF-SUFFICIENCYLOGISTICSSTANDARDSTRAININGFOREMTS

CONSIDERATIONSFORTRAINING

SUGGESTEDRESOURCES

REFERENCES

LOGISTICS, FIELD SUPPORT AND TRAINING


CHAPTER 3 I LOGISTICS, FIELD SUPPORT AND TRAINING

SCENARIOYouarethedirectorofatype2EMTthathasansweredarequestforsurgicalsupportforacountrystruckbyalargeearthquake.

AttherequestoftheMoHyouweresenttoaremoteareaseveralhoursoutsidethecapitalcity,andhavebeenthereforapproximatelyoneweek.

Thecaseloadhasbeenslightlyheavierthanexpectedandyouarestartingtorunlowonafewkeysupplies.Unfortunately,recentrainshavemadetheroadsessentiallyimpassableforthetimebeing.

» Whatresponsibilitiesandoptionsareavailableregardingyourownresupply?

» WhatneedsmightasurgicalEMThavethatdifferfromotherhumanitarianoperations?

Figure 1.Transitandtransportcanbecomedifficultorimpassableresultinginincreasinglogisticschallenges.(Norton)

TYPE 1

STERILIZATION–MustbeabletoprovidebasicsteamautoclaveforinstrumentsLAB AND BLOOD BANK-Type1EMTsmustbeabletoprovidebasicoutpatienttestsbyfingerprickincludingglucose,pointofcarehemoglobinandwhitebloodcellcount,andsomeformofrapidmalariadetection.

TYPE 2

STERILIZATION –FullautoclavefunctionwithtraceabilityLAB AND BLOOD BANK–Type1leveltestsplusurinaryelectrolytes.Mustbeabletocollectbloodandmicrobiologyspecimensforoutsideanalysis.Mustbeabletoprovideforsafebloodtransfusionsfromvolunteersorfamilywithtestingforbloodtype,HIV,HepatitisBandC,Syphilisandanyendemicbloodbornediseases.

TYPE 3

Type3facilitiesmustbeabletoperformalloftheabovefunctionsalongwithelectrolyte,bloodgasandmicrobiologytesting.Theymustbeabletoprovidethesameservicesforsafebloodtransfusionsastype2EMTs.

33



LOGISTICS AND SELF-SUFFICIENCYEMTsmustbeself-sufficienttoarriveatandoperatewithinanSOD.Acorrectunderstandingofthetermself-sufficient is crucial to an understanding of thiscorestandard.

» EMTsshouldbringatleasta2weeksupplyoffood.Identifyingalocalfoodsupplycanbeverydifficultinthefirsthoursfollowingarrival.

» EMTs that have robust local supply chains thatare pre-planned and with a positive rather thana negative impact on the local economy can betermedself-sufficient.

FACILITIES» EMTs must articulate whether they are offering

toworkinsideanexistingfacilityorwillprovideafieldhospital.Fieldhospitalsmustbeself-sufficientforallsuppliesbutlocalfuelandwateraccesswillberequired.

» Teamsembeddingintoexistingfacilitiesrequireatleastsomesuppliestocovertheworkrequired.

» All facilities must comply with the WHO EMTminimumstandards.

Figure 2.TherunningofcomplexEMTssuchasthis,requirerobustlogisticsandsupportoperations.(Norton)

• The ability to have a local supply chain requires extensive experience and local connections particularly in the aftermath of a SOD. EMTs that do not have standard operating procedures (SOPs) and experience in developing such supply chains should be self-sufficient by bringing in sufficient supplies to care for the entire team.

• It is unacceptable for EMTs to comply with standards initially but allow their standard of care to deteriorate as they run low on supplies. The minimum standards must be met at all times. If circumstance arise during which teams cannot meet the standards then they should inform the MoH or plan to withdraw.



LOGISTICS STANDARDSEMTsmustprovideasafeenvironmentinwhichtooperateandavoidhavinganegativeimpactonthecommunity.ThebelowareasummaryoftheguidelinestoreachminimumstandardsasanEMT.

For completeguidelines,please refer to theWHO’s Classifications and Minimum Standards for Emergency Medical Teams in Sudden Onset Disasters.

WATER – Access to adequatewater for all teammembers for washing and drinkingmust beavailable.

POWER AND LIGHTING – Accesstoreliableelectricalpowershouldnotbeassumedandteamsshouldbepreparedtoprovideforlightingwithoutinterruptioninpatientareas,operatingtheatres,andforinstrumentsorpatientcaredevicesrequiringpower.

FOOD –Adequatefoodsupplyforstaffandpatientsmustbebroughtand/orpurchasedwithoutaffectingthelocalfoodsupply.

SHELTER - Staff should be housed inan area away from clinical work and insafe conditions that allow adequate restbetweenshifts.

MEDICAL WASTE DISPOSAL - The guiding principle remains that waste disposal should not have a negative impact on the community.

This is especially important for medicalwaste. EMTs are responsible for the safedisposal ofmedicalwaste from their ownfacilities. If operating from within a localfacility, teams should encourage the safedisposalofwastefromthatfacility.

Contaminated waste and sharps shouldbe separated into adequately designedyellow labeled receptacles and dealt withappropriately.

Formoreinformationonadequatelydealingwithmedicalwaste, see the ICRCorWHOpolicies on medical waste managementcitedattheendofthischapter. Figure 3.AppropriatestaffshelterforadeployedEMT.(Norton)

Ensuring an adequate water supply is a crucial part of EMT logistics. The water needs of an EMT will vary based on size and type of clinical activity. Water demands for surgical EMTs can be very high. For example, a type 2 EMT may require as much as 7,000 -10,000 L per day. A rough guide for calculating water needs is below:

• 60-100 L per person per day for staff• 100 L per surgical case• 5 L per outpatient visit• 50 L per inpatient per day

35



SANITATION –EMTsmustensurethattheyhaveplansformanagementofthesanitationneedsof theirownstaff,aswellasculturallyappropriatetoiletingfacilities forpatientsreceivingandawaitingcare.

Providingareasforhandwashingandscrubareasforsurgeryisacrucialpartofsanitationlogistics.Viableoptionsforwashingcanrangefromwashbasinswithreticulatingfaucetstopre-filledjerrycans.Thekeyistoprovideeasyandreliableaccesstocleanwaterforwashing.

The SPHERE standards state that ensuring the optimal use of all water supply and sanitationfacilities and practicing safe hygiene will result in the greatest impact on public health. Thestandardsprovideminimumstandardsandguidancetowardachievingthesegoals.

TRANSPORT – EMTs should state when andwhere theywill arrive and either arrange fortheir own transport to their agreed area ofwork, or arrange for support from the hostgovernmentorlocalpartners.

COMMUNICATIONS – EMTs must consider robust, redundant communications systemto be mandatory. This means prioritizing anability to communicate and coordinate withthe host government coordination center.Additionally,dailyreportingofactivitiestotheMoHordesignatedauthoritiesisanimportantconsideration.

Figure 5.Appropriatefacilitiesmustbeprovidedforbothstaffandpatients.Thefacilitiespictured includeaccessforinjuredordisabledpatients.(Jamieson)

Figure 4. Robust and redundant communicationsfor EMTs are mandatory. Consideration shouldbe given to having means of communications thatfunction independent of the potentially damagedinfrastructureofacountry.(Norton)



TRAINING FOR EMTSRECOMMENDED 3-STEP LEARNING PROCESS FOR EMT MEMBERSEMTsmustprepareand rehearse fordeliveryof careaswellas for theanticipatedcontextonthe ground. Thedevelopmentof bothprofessional skills aswell as situational preparedness isimportantforaneffectiveresponsetobothdisastersandconflict.

ToensureappropriateEMTperformanceallEMTmembersshouldgothroughalearningprocessencompassingthefollowingsteps:

1. Ensure professional competence and license to practice

2. Supportadaptationof technical andnon-technicalprofessional capacities into low-resourceand emergency contexts

3.PrepareforaneffectiveteamperformanceinthefieldaspartofanEMTorganization

EXAMPLE: AN ORTHOPAEDIC SURGEON DEPLOYING WITHIN AN EMT

TECHNICAL TRAINING

ADAPTIVE TRAINING

TEAM ORGANIZATION AND PRE-DEPLOYMENT TRAINING

• Validated medical degree and specialization in orthopaedic surgery with license to practice in the country of origin.

• Course in Global Health and/or Disasters

• Workshop about surgery in disaster contexts, with both theoretical and practical sessions

• Pre-deployment course provided by the EMT organization, including presentation of SOPs, safety procedures, equipment, preparation for life in the field, and team dynamics

37MANAGEMENT OF LIMB INJURIES DURING DISASTERS AND CONFLICTS

CHAPTER 3 I LOGISTICS, FIELD SUPPORT, AND TRAINING

CONSIDERATIONS FOR TRAINING» Bothindividual and team trainingareneeded.EMTtrainingimprovessurgicaloutcomes!

» Theoreticallessonsshouldalwaysbecombinedwithpracticalsessions.Role-playing,simulations,andvirtualrealityformatsareoptionsforputtingtheoryintopractice.Thedevelopmentofsoftskillsshouldbeencouragedthroughteambasedlearning.

» Theteamsshouldbeconstitutedbyprofessionalswithdifferentandcomplementaryknowledgeandskills,inaccordancewiththeneedsidentifiedinthefield.Memberswithdifferentlevelsofexperienceshouldbeincorporated(i.e.combineseniorandnewEMTmembers).

» JUST IN TIME TRAINING – effectivetrainingmethodtodisseminatenewconceptsorseldom-performed procedures. Just in time training modules will introduce additional skills andknowledgetothestaffbeforedeployingintoaspecificcontext(i.e.reviewnationalguidelinesofthedisasteraffectedcountry).

Figure 6.EMTsdeployedtoTacloban(NCCTRC)



SUGGESTED RESOURCES

1. Camacho NA, Hughes A, Burkle Jr FM, et al. Education and Training of Emergency Medical Teams: Recommendations for a Global Operational Learning Framework. PLOS Currents Disasters 2016.

2. Willems A, Waxman B, Bacon AK, Smith J, Kitto S. Interprofessional non-technical skills for surgeons in disaster response: a literature review. Journal of Interprofessional Care 2013; 27(5): 380-6.

REFERENCES

1. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010; 304(15): 1693-700.

2. Stoler GB, Johnston JR, Stevenson JA, Suyama J. Preparing emergency personnel in dialysis: A just-in-time training program for additional staffing during disasters. Disaster Medicine and Public Health Preparedness 2013; 7(03): 272-7.


4. ICRC: Sterilization Guidelines. ICRC: International Committee of the Red Cross; 2014.

5. Communicable disease control in emergencies: A field manual. Online: World Health Organization, 2005.

6. The sphere project: humanitarian charter and minimum standards in disaster response. 1st ed. Oxford: Oxfam; 2011.


4SCENARIO

INITIALASSESSMENTPRE-OPERATIVECARE

POST-OPERATIVECAREANAESTHESIA

PAINMANAGEMENTANDPATIENTRECORDS

SUGGESTEDRESOURCES

REFERENCES

ANAESTHESIA AND PERIOPERATIVE CARE


CHAPTER 4 I ANAESTHESIA AND PERIOPERATIVE CARE

AIRWAYA

B

C

D

E

BREATHING

CIRCULATION

DISABILITY

EXPOSURE

SCENARIOA30-year-oldwomanarrivesintheemergencyroomafterreceivingagunshotwoundintheleftarm.Sheisinseverepainandappearspaleandsweaty.Thearmisbleedingandcoveredwithadirtycloth.Youarethefirsthealthprovidersheencounterssincetheinjuryhappened.Whatarethefirststepsyoushouldtakenow?

INITIAL ASSESSMENT » Assessmentsof:Airway,Breathing,Circulation,Disability,Exposure(Figure1).

» Controlcatastrophic haemorrhagewithdirectpressure.

» Complete the adjuncts to the primary survey if they are available, particularly chest X-ray, C-spineorpelvicimages,ifindicated.

» Oncetheprimarysurveyiscomplete,providedthereisnoimminentunaddressedthreattolifeorlimb,proceedtothesecondary survey withadjuncts.

Figure 1.ABCDEstepsforInitialAssessment (ICRC)

41



HOW TO ASSESS A PATIENT WITH LIMB INJURY HISTORY » Past medical history, current medications, known

allergies,lastoralintake,beliefsaroundmedicalcare

» Descriptionof theeventcausingthe injury:mecha-nism,dateandtime,effectsonthepatient,interven-tionstodate

SIGNS AND SYMPTOMS

» Pain» Lossoffunction» Reducedmobility» Abnormalmovement» Crepitus

PHYSICAL EXAMINATION

» Look: Change of position pattern, gait pattern,bruising,swelling,jointeffusionandlimbalignment

» Feel: boney tenderness, joint effusion, distalcirculationandsensation

» Move:activebeforepassivemovement,donotforcepatienttomovebeyondwhattheycantolerate

INVESTIGATIONS» Plainradiologicalimagingintwoplanesat90degrees

to each other

» Include the joint above and below a suspectedfracture

» Radiological imagesarenotessential todiagnoseafracture

» Radiological images are not required to initiatetreatment

The clinical assessment of a limb must be adequate to evaluate for the presence of fractures or dislocations (deformity, tenderness, crepitus, active and passive range of movement), as well as joint stability, vascular status, nerve function, and distal status of the extremity.

• If patient is referred to your facility, do not assume the prior care provider fully assessed the patient and the limb and provided appropriate care.

• Absence of active movement does not confirm a fracture.

• Presence of active movement does not exclude a fracture.



PRE-OPERATIVE CONSIDERATIONS» Ensure patient privacyforallprocedures:amobilescreensystemisnecessaryinwardsandin

operatingtheatreswithmorethanonetable.

» Alwaysexplainallprocedurestothepatientbeforeanyintervention,repeatthismultipletimesandobtainatranslatorifnecessaryforunderstanding.

» Surgical stores should be kept adjacent to the operating room and protected from theenvironment.Ifthereisnotapharmacistwithintheteam,anotherhealthprofessionalshouldbe in charge ofmanaging allmedicines and disposables to avoid stock-outs. Laws regardingnarcoticsvarywidely,soteamsshouldbepreparedtoworkwithlocalgovernmentsinordertominimizedelaysatcustoms.

» Inthecaseofemergencysurgery,ensureaprepared trayofsterileinstrumentsisimmediatelyavailableforemergencylaparotomy,caesareansection,neurotrauma,thoracotomyandvascularinjuriesinlimbs.

» The planning of the day’s operating list should involve surgeons,anesthetistsandnurses foroptimalefficiencyandshouldbecommunicatedonacommunalwhiteboard.

» Theorderof theoperating listshouldreflectaprogressionthroughoutthedayfromcleantocontaminatedcaseswithchildrenbeingdonefirstwheneverpossible.

» Tooptimizepatientflow practiceingressandegressofmultiplepatientsthroughtheoperatingroom.

» Cleananddirtyareaswithintheoperatingroomshouldbedifferentiated.

» Preventionofhypothermiaisimportantinsurgicalpatients,particularlytrauma, burn, and paediatricpatients.Operatingtheatretemperaturesshouldbekeptbetween27-40°C.Allfluids,bloodproducts,andblanketsshouldbewarmedforsurgicalpatients. Figure 2.Operatingtheatrewithmultipleteams(Baumgartner-Henley)

43



PRE-OPERATIVE SCRUB PREPARATION FOR LIMB SURGERY » Placeanimperviouslayerbetweenthelimbandtheoperatingtable—ideallyanabsorbentlayer.

» Scrub the limb to removeskinandwoundcontamination.Aplainbrush, soapandwaterwillwork,aswellasiodinebasedorchlorhexidinescrubbrushes.

» Copiouslyirrigateanylimbwoundsoveralargedishwith3-12Loffluid,dependingonthedegreeofcontamination.

» Drythelimb.

» Discardtheabsorbentlayer.

» Apply a tourniquet proximally on the limb, set the inflationpressure but donot inflate untilrequired.

» Astaffmembershouldbeidentifiedwhoisresponsibleformarkingdownthetimethetourniquetisinflatedsothattourniquettimeisaccuratelyrecorded.

» Patientpressurepointsshouldbecheckedtoensureadequatepaddingpriortobeginningthecase.

EXPERT TIPS

Wound irrigation with lowpressure is preferred in mostcircumstances. Preserve anypulse lavage units for woundswithestablishedinfection.

Potable (drinkable) water isadequateforwoundwashouts;warm it to 38–41 degreesC. This temperature is thatof a warm shower. In otherwords, warm to the touch but tolerable to keep unglovedhandsimmersed.

Figure 3.Scrubpreparationforlimbsurgery(Kay)



POST-OPERATIVE CAREAn area for post-operatively recovery is mandatory.It should be located next to theatre, not on the ward.

MAIN TASKS FOR NURSING STAFF IN THE RECOVERY ROOM» Assessandrecordpatient'svital signs (HR,RR,BP,SpO2,andtemperature).

» Identifyandreportabnormalvitalsignsorevidenceofclinicaldeterioration.

» Prepareoxygenconcentratorandmasksforoxygentherapy.Patientsmustbeawakeenoughtoprotecttheirownairwaybeforereturningtotheward.

» Preparetosetupandusesuctiontoclearvomit/secretionsfromupperairway.

» Assess and record level of consciousness using AVPU scale (A=Awake, V=responds to verbalstimuli,P=respondstopainfulstimuli,U=unresponsive).

» Assesspain using agreed pain score and give prescribedmedications. Pain should be undercontrolbeforereturningtotheward.

» Assessnausea and vomitingandgiveprescribedmedications.

» Set up an IV infusionandrecordurineoutputifrequired.

» Observe and assess surgical sites and drains forbleeding.Reinforcedressingsasneededandinformsurgicalteamifconcerned.

» Understandandrecognizethecriteria for dischargefromrecovery,andinitiatephysiotherapyassoonaspossiblefollowingsurgery.

DEEP VEIN THROMBOSIS (DVT) PROPHYLAXISThe main options to prevent DVT and pulmonary embolism in adult surgical patients arepharmacologicalandmechanicalprophylaxis:

» Earlymobilizationandmechanicalprophylaxiswillcovermostshortsurgicalprocedures.

» Chemoprophylaxiswilladdalayerofcomplexityinthetreatmentbutwillberequiredinsomecases.

Recommendationsforclinicaldecisionmaking:

» Follow standardDVT guidelines and allow teams to adapt according to their resources, localprotocolsandindividualpatientfactors.

» ExampleICRCguidelinesforDVTprophylaxisisincludedinthisbookasanannex.(See page 178)

45



HEALTH STAFF CONSIDERATIONS» Physician assistantsmayfacecredentialingorlicensingissuesandifdeployedshouldalwaysbe

underthesupervisionofaqualifiedspecialist.

» Nurse anesthetists canfacesimilarissueswithcredentialing,dependingonindividualcountrylaws.Nurseanesthetistsmustworkunderthesupervisionofalicensedanesthetist.

» Medics and paramedicsareversatileteammembersindisasterresponse.Theirmedicaltrainingandunderstandingmakesthemidealforsupportingactivitiesinanemergencydepartmentorinanoperatingtheatre.Inanyoftheseroles,supervisionisrequired.

» Forperioperativenursestheteamisoftenbestservedbyhavingthemostexperiencedmemberoftheteamserveasthecirculatingnurse.

» Military medics or corpsmanworkingwithinamilitarymedicalteamcanoffersignificantmilitaryknowledgeandexpertisethatmaybeavitalpartoftheteamcompetenciesrequired.

Figure 4.Healthstaffinvolvedinpreoperativeprocedures(Baumgartner-Henley)



ANAESTHESIA & PAIN MANAGEMENTSAFE PRACTICE OF ANAESTHESIA

Currentinternationalstandardsapply:

World Federation of Societies of Anesthesiologist’s (WFSA) International Standards

for a Safe Practice of Anaesthesia, 2016

TYPE 1

» Nogeneralanaesthesiaprovided» Basiclifesupportcapacities» Localanaesthesiaforminorprocedures

» Analgesiafortreatment

» Analgesiafortransfer:• Appropriatedressingsandfracturesplinting• Peripheralnerveblockfortransferrecommended,withcleardocumentation

ofblockperformanceandpre-blockexamination

» Preventionofhypothermiaintransfer

TYPE 2

» Type1capacitiesplus:» Atleast1anesthetist» Damagecontrolresuscitationandadvancedlifesupportcapacities

» Regionalanaesthesia–spinalanaesthesia(mandatory),plexusandperipheralnerveblocks(recommended).Epiduralanaesthesia/analgesianotrecommend-edinthissetting

» Intravenousorinhalationalgeneralanaesthesiaforadultandpaediatric patients

» Analgesiaforinpatienttreatment

TYPE 3» Type2capacitiesplusfullICUfacilities

47



CONSIDERATIONS FOR THE PERFORMANCE OF REGIONAL BLOCKS» Clinicallyexaminethepatient'slimbforneurovascular statusandrecordthispriortoperforming

aregionalblock.

» Peripheralnerveblocksshouldbeperformedwiththeuseofultrasound guidance.

» Peripheralnerveblocksmask the symptoms of compartment syndrome—ifyoucannotwatchthepatientclosely,considerperformingafasciotomy.

PAIN ASSESSMENT» Pain score chartsareappropriateforadultsandchildrenandaremandatoryincaringforpatients

withlimbinjuries.Theymustbeunderstandableacrosscultures–forexamplechartsusingfaces,maybemoreusefulthannumberedscales.

» Painmustbeassessedandrecordedboth at rest and with movement.

» Monitorpatientswithregionalblockspost-operativelypayingparticularattentiontopainscores.

CONSIDERATIONS FOR ANALGESIA» Painreliefisahumanright!

» Distraction therapy is effective, as is splinting soft tissueinjuriesandfractures.

» Paracetamol,narcoticsandblocksarethepreferredpost-operativeanalgesia.

» Aketamineinfusionmaybeusedonanopenwardwithasyringepump—50mgin500mlover8hours.

» Ketaminecanbeasusefuldruginthemanagementofthelimb injuries. Teammembers should be familiar with itsside effects, including its propensity to induce dysphoricreactionsinadults.

• Avoid NSAIDs in the first 48hrs in trauma patients due to risk of renal injury particularly, in patients with severe dehydration, haemorrhage, crush or burns.

• Limit NSAIDs to short courses and consider GI ulcer prophylaxis with use.



PATIENT RECORDS» Patientsinvolvedinadisasterwithoutlocalcivilunrestmaysafelywearanidentificationbracelet.

» Recordsofallcareprovidedmustbekept.

» Patients need to have the original or a copy of their recordstokeepanduseforsubsequentcare.

» EMTsmaykeeptheirownrecordsbyphotographingpatientdocuments(notes,x-rays,imagesofinjuries)Imagesneedtobesecuredbytheauthorityandremovedfrompersonaldevicessuchasphones,tablets,andcamerasasquicklyaspossible.

» Theministryofhealthinthecountrymayrequestacopyofthemedical recordsforthecareprovidedinthefacility.

» Many patients require on-going care post disaster. Being registered by their government aspeoplewithdisasterrelatedinjuriesmayprovideincreasedaccesstocareinthereconstructivephase.

» Maintenanceofcareful,accuraterecordsisofextraimportanceinpatientswhowillrequirelongtermfollowuponcethesituationonthegroundhasstabilized,suchasamputeesorpatientswithspinalcordinjury.

» FormoreinformationonpatientrecordspleaserefertotheWHOClassificationandMinimumStandardsforEmergencyMedicalTeamsinSuddenOnsetDisastersandHandicapInternational’sRehabilitationinSuddenOnsetDisasters.

SPECIAL CONTEXTS: CONFLICT» Patientsinwarzonesmaybesaferiftheycarryacardwithanumericidentifierratherthantheir

name.Issuingacardthatcanbeconcealed,ratherthananIDbracelet,mayprotectpatientsinconflictzones.

» Considerprovidingde-identifieddatatoprotectpatientsifgovernmentsdemandarecordofthemedicalcareprovided.

49



SUGGESTED MAIN ITEMS IN DATA COLLECTION FORM» Dateofarrivalatthemedicalfacility

» IDnumber

» Surnameandfirstname

» Gender

» Age

» Mobilephonenumber

» Suddenonsetdisasterrelatedincident:yes/no

» Dateofinjury

» Dateofadmission

» Natureoffirstmedicalcareifprovidedprior tocurrentmedicalfacility

» Diagnosis

» Comorbidities

» Surgicalproceduresperformedinsideand outsidetheoperatingroom.

» Followup:nursing/rehab/physician/nonerequired

» Dateofdischarge

UPDATES IN DATA COLLECTION AND REPORTINGThe WHO has recently developed a standardized formtoallowEMTs toaccuratelyandefficiently report to therelevanthealthauthority.

POSSIBLE KEY PERFORMANCE INDICATORS TO USE

• Unplanned return to operating room: yes/no

• Fracture stabilized within 12 hours of admission: yes/no

Who should keep the medical records in disaster situations? The patient, the government of the affected country or the health provider? How to ensure the data is protected and confidentiality is preserved?



SUGGESTED RESOURCES

1. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International standards for a safe practice of anaesthesia 2010. Canadian Journal of Anaesthesia/Journal canadien d'anesthésie 2010; 57(11): 1027-34.

2. Berry RD, Birt DJ. Delivering anaesthetic services in UK military field hospitals. Anaesthesia & Intensive Care Medicine 2008; 9(9): 413-5.

REFERENCES

1. Initial Assessment of Life Threatening Conditions for Hospital Staff. Geneva: International Committee of the Red Cross: 1.

2. Lilaonitkul M, Boyd N. Paediatric & Obstetric Anaesthesia Pocket Handbook: World Health Organization; 2015.

3. Stundner O, Memtsoudis SG. Regional anaesthesia and analgesia in critically ill patients: a systematic review. Regional Anaesthesia and Pain Medicine 2012; 37(5): 537-44.

4. Humble S, Dalton A, Li L. A systematic review of therapeutic interventions to reduce acute and chronic post-surgical pain after amputation, thoracotomy or mastectomy. European Journal of Pain 2015; 19(4): 451-65.

5. Barrington MJ, Kluger R. Ultrasound guidance reduces the risk of local anesthetic systemic toxicity following peripheral nerve blockade. Regional Anaesthesia and Pain Medicine 2013; 38(4): 289-97.

6. Eichhorn JH. Review article: practical current issues in perioperative patient safety. Canadian Journal of Anaesthesia/Journal canadien d'anesthésie 2013; 60(2): 111-8.


8. Skelton P, Harvey A, eds. Rehabilitation in Sudden Onset Disasters. 1 ed. Online: Handicap International, UK Emergency Medical Teams; 2015.


DAMAGE CONTROL SURGERY AND RESUSCITATION

SCENARIOPRINCIPLESOFDAMAGECONTROLSURGERYANDRESUSCITATION

RESUSCITATIONANDPELVICFRACTURESDIAGNOSISANDMANAGEMENT

PLACEMENTOFANTERIORFRAMESFORPELVICFRACTURES

SUGGESTEDRESOURCES

REFERENCES

5


CHAPTER 5 I DAMAGE CONTROL SURGERY AND RESUSCITATION

SCENARIO

TYPE 1

• Avoidhypothermiabyremovingwetclothing,applyingclothorheatblankets.

• Covertheheadorscalp,especiallyinchildren• Gainhaemostasisoflifethreatingbleedingwithpres-

sure.Consideratourniquetif a transfer to a higher level of care is feasible

TYPE 2

• Allfluidscontactingthepatientshouldbewarmedto39-42°C.

• Anyairconditioningshouldbeturnedofffortraumapatients.

• Ontablewarmingshouldbeusedifpossibletoavoidhypothermia.

TYPE 3

• Preparetoacceptcomplexpatientsfromtype1andtype 2 teams

• Thiswilllikelyincludeundertakingcompletionandreconstructionofdamagecontrolproceduresdonetoavoidlossoflifeandlimbattype2facilities.

» Which injury should be addressed first?» Should a shunt be placed or definitive vascular repair be attempted?» Does the patient require fasciotomies?

A25-year-oldmanpresentswithagunshotwoundtothemedialthigh.Thereisanobviousopenfractureoftheshaftofthefemur,andnodistalpulses.Thetimeoftheinjuryisunclear,butatleasttwohoursandperhapsfourhourshavepassed.

Figure 1. LEFT:Largewound resultingfromGSWofthethigh (ICRC)

Figure 2. FARLEFT:DisplacedfemurfracturefollowingGSWto the thigh (ICRC)

» All trauma patients must have a full primary and secondary survey to ensure all injuries are identified. The physiology of the patient as a whole must be managed and not just the anatomical aspects of the injuries.

53



The principles of damage control surgery and resuscitation listed below are of tantamountimportanceforthecareofthepatientwhoishypothermic,coagulopathic,acidotic,andresistanttofluidresuscitation.Thegoalistominimizesurgerybyperformingrapidcontrolofhemorrhageandongoingcontamination.Oncethesegoalsareachieved,surgeryisstoppedtoallowforphysiologicrecovery through resuscitation and intensive care with anatomical correction of injuries to beaddressedlater.Initsessence,damagecontrolsurgeryissurgerywiththegoalofmaintainingphysiologycompatiblewithlife.Successfulpracticerequiresconstantcommunicationbetweenthesurgeonandanesthetistinorderto:» Minimizetimetosurgeryandtimeontheoperatingtable» Limittheearlyuseofcrystalloidsforresuscitationandusebloodproductsifavailable» Utilizepermissivehypotension,particularlyinvictimsofpenetratingtrauma» Managecoagulopathyusingtranexamicacidif

necessary and appropriate» Preventandmanagehypothermia» Reducecontamination» Improveoxygenation

SPECIAL CONTEXTS Damage control principles are applied for two reasons:1. Individualpatientconsiderations(above)2. InMassCasualityIncidents,SODs,conflictsandaustere

environments,duetotriageconsiderationsandunavailabilityofdefinitivecare.

Sudden Onset DisastersDuringdisasterspatientsreceivetheirinjurieslargelyaspartofasingleevent.EMTtype2and3teamsdonotarriveuntildayslater.

Many patients with severe head, thorax, and abdominalinjurieshavediedorbeendealtwithby localactorson theground.However,damagecontrolprinciplescanstillapplytopreservelimbsandsparepatientsthelifelongburdensofanamputation.

Figure 3.Severeopentibialfracturerequiringrapiddecisionmakingregardinglimbsalvage.(Bar-On)

PRINCIPLES OF DAMAGE CONTROL SURGERY AND RESUSCITATION

» Tranexamic acid (TXA) has been shown to reduce all cause mortality in bleeding trauma patients with, or at risk for, life-threatening hemorrhage.

» The medication should be given only in patients whose injury occurred within 3 hours of evaluation.

» Type 1 institutions must be aware of these constraints if administering TXA to patients with plans to transfer patients to a type 2 or 3 facility, and should ensure that the receiving facility knows TXA has been administered and when.



SPECIAL CONTEXTS CONFLICTEMTscaringforpatientsinsituationsofconflictaremorelikelytoreceivepatientssoonafterinjuryallowingforinterventioninlifethreateninginjuriestothehead,neck,thorax,andabdomen.

Thelimbsurgeonmustapplydamagecontrolprinciplestoremovecontaminatedtissue,temporarilystabilize bones, and restore circulation tomuscular compartments. In these contexts, the twosurgeonsandtheanesthetistmustcarefullycoordinatecareinordertoactinthebestinterestsofthepatientgiventheavailableresources.

PAEDIATRIC CONSIDERATIONSPredictionoftheneedfordamagecontrolsurgerycanbedifficultbutisguidedbyclinicalsignsandlaboratoryvalues.Paediatricvitalsignsdifferfromthoseofadults,andchildrenmustbeconsideredasadistinctpatientpopulationwhenmakingpatienttriagedecisions.

VITAL SIGN INFANT CHILD TEEN

age 0-6 months 6-12 months 1-5 years 6-11 years 12 years and up

heart rate 100-160 bpm 70-120 bpm 60-100 bpm

respirations 30-60 breaths/m

24-30 breaths/m

20-30 breaths/m

12-20 breaths/m

12-18 breaths/m

blood pressure

65-90/45-65mmHg

80-100/55-65mmHg 90-110/55-75mmHg 110-135/65-85

mmHg

temperature 37˚C 37˚C 37˚C

RESUSCITATION/TRANSFUSIONTheuseofcrystalloids/colloidsshouldbelimited.Transfusioncapabilityrequiresstandardpathologyservicesandshouldbebasedontheclinicalpictureratherthanhemoglobinlevelalone.Patientsindisasterproneareasmaybeaffectedbychronicanemiaduetomalnutrition,malariaorhelminthinfection.

Access to blood products will require family blood donation or a "walking blood bank." Bloodbanking indisastersandconflict requires significantplanning inorder toacquire,use,andstorebloodproductssafely.

Table 1.Referencefortheassessmentofpaediatricvitalsigns.

55



DIAGNOSIS OF PELVIC FRACTURESA significant amount of energy is required to fracture a human pelvis, therefore suspicion should be high for additional injuries. All trauma patients must receive a primary survey (Airway, Breathing, Circulation) no matter how impressive or distracting their presenting injuries.Pelvicfracturesofhemodynamicsignificancecanoftenbeclinicallydiagnosed.

» Palpatetheentirepelvicbrimtoidentifyanintactedge,tendernessoverthesacroiliacjointsorgapsatthepubicsymphysis

» Radiographs, if available, can help. It is important tolookatthewidthofthesacroiliacjointsbilaterally

» Rectalexaminationisavitalpartoftheassessmentofapelvicfracture.Bloodontheglovesindicatesanintesti-nalinjury.

» Lookforbruisingoverthepelvis and around the scrotum in men

» Pelviccompressioncaniden-tify fractures that show noobvioussignsoffracture

Heat sensitive paper for haemoglobin testing will “self-

develop” in hot environments

DO NOT test for stability of the

pelvis when a pelvic fracture is suspected

by palpation.

Figure 4.Picturedemonstratingscrotalbruisingdenotingbleedingfromapelvicfracture.Anexternalfixationframecanbeviewedat

thetopoftheimage. (E. de Loos)

SPECIAL CONTEXT WHOLE BLOOD TRANSFUSION» The“walkingbloodbank (WBB)”hasgainedpopularityduring recentconflictswithdeployed

militarieswho transfusewholeblood fromhealthyor “walkingwounded” soldiers to injuredsoldiersorciviliansrequiringmassivetransfusion.

» EMTstandardsrequirealltype2andtype3EMTstobeabletosafelytestandtransfusewholebloodinemergencies.(See Page 32)



• While pelvic binders may cause further displacement in central fracture and dislocation of the hip. They are more likely to help than cause harm.

• Pelvic binders must be centered on the greater trochanters, they are commonly applied too high.

Figure 5.Correctlyplacedpelvicbinder.Notetheurethralbleedingdenotingaurethralinjury

(E. de Loos)

DIAGNOSIS AND MANAGEMENTPelvic fractures can present a diagnostic and management challenge for EMTs in austereenvironments.Treatmentoptionsavailablemaydiffersignificantlybasedontheresourcesavailable.Theseinjuriesarefrequentlyassociatedwithlife-threateningvenousbleedingorinjuriestointernalviscera.

TYPE 1

• Pelvicbindersaretheoptimalinitialmanagementforsuspectedpelvicringdisruption.

• IfaurethralinjuryissuspectedthepatientshouldbeimmediatelytransferredtoanEMTtype2available.» Iftransfertimewillbelongthengentleplacementofaurinarycathetershouldbeundertaken.

» Ifpassageisdifficultdonotproceed,asuprapubiccathetermayberequired.

TYPE 2

TYPE 3

• Type2EMTsshouldevaluatepelvicfractureswithplainradiographsofthepelvis.• Pelvicbinderscanbemaintainedasatreatmentoptionwhentheinjuryisnotlife

threatening.• Beawareofpressuresoresunderneathbindersleftinplaceforprolonged

periods.• Ifthebindercannotberemovedwithouthypotension,thenananteriorframe

shouldbeplaced.Thismayrequiretransfer.

57



PLACEMENT OF ANTERIOR FRAMES FOR PELVIC FRACTURES» Anterior frames are generally placed with C-arm imaging

control in the operating room. Single supraacetabular pinsarepreferredbutrequireradiologiccontrol.

» Pinscanbeplacedinthesub-crystalplanebut,inanaustereenvironmentthisaddslittlebeyondapelvicbinder.

» If C-arm imaging isnot available, iliac crestpins are viablebut have a higher rate of infection, andmake for amoreproblematic frame. This type of frame can make sittingdifficult and limit abdominal access for concomitant intra-abdominalinjury.

» IfCarm imaging isavailable,bilateralsupraacetabularpinsarethepreferredmethodofexternalfixationplacement.

» At the type 3 EMT definitive surgery may be possible ifproperexpertisebecomesavailableorthesituationonthegroundimprovesorstabilizes.

Figure 6.Properplacementofpinsintheiliaccrest.(AO Foundation, Switzerland)

Figure 7.AlinediagramdenotingtheproperplacementofSchanzscrewsforexternalfixation.

(AO Foundation, Switzerland)

• Plating of the pelvis is not acceptable treatment in a tent or during response to a sudden onset disaster.

• When placing the anterior frame, ensure that space is left between the skin blocks and bars to allow for post-operative abdominal distension and abdominal access.

• Patients with open pelvic fractures carry a mortality rate of 50%.



SUGGESTED RESOURCES

1. Nott D. What Can I Do Here? Understanding Your Working Environment. Orthopaedic Trauma in the Austere Environment: Springer; 2016: 13-21.

2. Nott D, Veen H, Matthew P. Damage control in the austere environment. The Bulletin of the Royal College of Surgeons of England 2014; 96(3): 82-3.

3. Repine TB, Perkins JG, Kauvar DS, Blackborne L. The use of fresh whole blood in massive transfusion. Journal of Trauma and Acute Care Surgery 2006; 60(6): S59-S69.

REFERENCES1. Crash-2 Collaborators. The importance of early treatment with

tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomized controlled trial. The Lancet 2011; 377(9771): 1096-101. e2.

2. Lebel E, Blumberg N, Gill A, Merin O, Gelfond R, Bar-On E. External fixator frames as interim damage control for limb injuries: experience in the 2010 Haiti earthquake. Journal of Trauma and Acute Care Surgery 2011; 71(6): E128-E31.

3. Giannou C, Baldan M. War surgery: Working with limited resources in armed conflict and other situations of violence, Volume 2. Geneva: International Committee of the Red Cross; 2013.

4. Lennquist S. Management of major accidents and disasters: an important responsibility for the trauma surgeons. Journal of Trauma and Acute Care Surgery 2007; 62(6): 1321-9.

5. Blackbourne LH. Combat damage control surgery. Critical care medicine 2008; 36(7): S304-S10.

6. World Health Organization. Safe Blood and Blood Products: Guidelines and Principles for Safe Blood Transfusion Practice. http://www.who.int/bloodsafety/transfusion_services/Introductory_module.pdf. Accessed 21 November 2016. 2009.


SCENARIOWOUNDMANAGEMENT

WOUNDSURGERYWOUNDDEBRIDEMENTBYLAYERS

DRESSINGS

SUGGESTEDRESOURCES

REFERENCES

LIMB WOUNDS

6


CHAPTER 6 I LIMB WOUNDS

SCENARIO

TYPE 1

• Wounds that can be managed at an EMTtype1facilityinclude:

• Superficialwoundswithnonerve,tendon,boneorjointinvolvement.

• Wounds that can be washed out underlocalanaesthesia.

TYPE 2

• Woundsrequiringdebridementrequireaminimumoftype2facilitytoallowforsurgicalcarewithanaes-thesia.

TYPE 3

• Complexwoundsrequiringfrequentdressingchangesmayrequireatype3facilitytoallowforadvancednursingcare.

» All wounds in disaster and conflict situations must be assumed to be contaminated and treated as such. These wounds are at high risk for fatal infections including gas gangrene or tetanus (ACS class 3 and 4).

» No wound sustained in a disaster or conflict should be sutured primarily. They should be left open and undergo delayed primary closure on day 2-5.

A 4-year-old boy presents to youwithadilemma.Heisconsciousandalertwithanisolatedfootinjury.

Perhaps in aneffort to control thesubcutaneousinfection,alltheskinfromthelowercalfandthefoothasbeenexcised.

Thewoundisrelativelyclean,butatthepointoftheheel,thecalcaneuscanbeseen.

(ICRC)

61



EMT TYPE 1 WOUND MANAGEMENTInitialcareofawoundrequiressimplewashingtominimizecontaminationandalightdressingforprotectionofthewoundfromenvironmentalhazards.Anywoundthathasbeensuturedprimarilyshouldhavethesuturesremovedifthereisanysuspicionofinfection.Feelforcrepitusandfluctuanceinthesofttissues.Insomepatientsinfectionmaypresentwithpurulenceintheabsenceofswellingorerythema.» If pus is present in the wound, the patient must be transferred to a type 2 EMT for surgical debridement.

» Irrigatecopiouslywithbetween3and12Loffluid.Whileisotonicfluidisideal,drinkingwatercanbeusedifneededtopreserveresources.

» Wipethewoundsurfacegentlywithgauzewithinthepatient’stolerance.

» Wound cleaningmay be facilitated by providing analgesia or local anesthetic, however thisshouldalwaysbewithintheappropriatescopeofcareforyourlevelofEMT.

» Do not primarily suture any wound.

(Someexceptionscanbemadeforsimplewoundsoftheface,scalpandperineum).

» Antibiotics cannot replace cleaning and surgical debridement of wounds.

» Dressthewoundswithabulkyabsorbentdressing.

» Following suddenonset disasters, the injured survivors predominately presentwithwoundssustainedduringtheevent,orinthehoursordaysthatfollow,astheymovearoundindebris.

» In hot climates and in the absence of any immediate medical care, contaminated woundsprogressquicklytowoundinfectionandtissuenecrosis.

» Thisisseenclinicallyascellulitis,subcutaneousinfections,andpossiblynecrotizingfasciitiswithnecroticmuscleandgangrene.

» Wounds from tsunamis typically involvewound infections,whileearthquakes tend to createwoundswithcrushinjuries.Bothtypescanresultinnecrotictissuethatrequiresdebridement.

Alan

Kay

Figure 2.Initialirrigationandcleaningofawoundpriortoanysurgicaltreatment.



EMT TYPE 2

WOUND SURGERY

WHEN TO REFER FROM EMT TYPE 1 TO EMT TYPE 2 FACILITY: » Complexwoundsthatpenetratefascia

» Contaminatedwoundsduetorequirementsforsharpexcisionandanaesthesia

» Impairedsensationdistaltothewound

» Bleedingvesselwithinthewoundnotcontrolledby10minutesofpressure

» Infectedwoundswithobviouslynecrotictissuerequiringdebridement

» Palpablecrepitusinthesofttissuesorothersignsofdeepinfectionsuchasincreasedpainorfever

» Suspicionoffracture

» Notpossibletoadministeradequateanesthetictoproperlycleantheinjury

» Formalwoundsurgery(asopposedtowoundcleaning)mustnotbeperformedinanEMT type1facility.

» Thegoalofwoundcaresurgeryistoprovidethe optimal outcome as early as possible.Surgerywillpreventdeteriorationandallowtransferifavailable,acknowledgingthatthismaybedelayed.Antibiotics for wounds are an adjunct to surgery and wound cleaning not an alternative.

» Wound debridement must be performedin a designated room where safe sedationand anaesthesia can be provided. Surgerymustbeprovidedunderadequateanalgesiaand sedation, or anaesthesia as requiredensuringthatthepatientdoesnotsufferpainduringtheprocedure.

» Surgery in disaster and conflicts should still be undertaken with the same precautions as an elective operation in a high resource hospital.

Alan

Kay

Figure 3. Massivelowerlegwoundfollowingfullsurgicaldebridement.

63



TECHNIQUE FOR INITIAL WOUND EXCISION AND DEBRIDEMENT» Remove all dead, contaminated and infectedtissue but leave all viable tissue to assistwith

reconstructionformaximumfunction.

» WOUND EXTENSION:Everywoundmustbeextendedproximallyanddistallytoadequatelyexploreandexaminethetissuesfornecrosis,contamination,anddamageofvitalstructures.Extensionsshouldbeinthelongaxisofthelimb,andnottransverse,exceptwhencrossingaflexioncrease.Iftheyarerequiredalongthewholelengthofeithertheforearmorlowerleg,theyshouldbeplacedtojointhelinesofelectionforfasciotomies.

» Bemethodicalinexcisingthewound.Progressivelyexploreanddebrideinlayersfromsuperficialtodeep.

» Sharpdissectionusingascalpelorsharpscissorsshouldbeusedtoremoveanycontaminatedtissues.Electrocauterycanbeusedforexcisionoftissue,butkeepinmindthatitcanleavesomedeadtissueinthewound.

» Techniquesofexcisionthatminimizebleedingprovideanadvantage.Carefullyconsidertheuseofasurgicaltourniquetduringdebridement;thiscausesfurthertissueischemiaandcanimpairassessmentofviabletissuesbutthismustbebalancedwiththeneedforaclearviewofthewoundandpreventionofbloodloss.

Figure 4. Recommendedincisionsforfasciotomyandwoundextension (BOA/BAPRAS)

» Scraping the surface of damaged muscle with a sharp gynecological ring curette to remove surface necrosis or infection is efficient and effective without stimulating further bleeding.



Skinisveryforgivingandgenerallyhasaverygoodbloodsupply.Leavingsomedoubtfulskinisnotgoingtoresult inrapidsepsis,soexcisetheedges—amaximumof1–2mm,orwiderwherethetissueiscontusedandragged.Thismarginshouldonlybeexceededintheeventofobviousskinnecrosis.

Be very conservative on the face and upper limbs.Allviableskinshouldbeleftintactatthisstage,increasingthesubsequentreconstructionoptions.

Subcutaneous fat thatisundamagedandviableshouldbeleft,butbegenerouswiththeexcisionofnecroticandcontaminatedfat.

Fascia that is shiny and clean is left, but exciseanything impregnated with dirt or that appears ragged or dull. If the fascia is already grey andthickenedwithafurlikecoveringthenitneedstobeexcisedasthis is likely necrotizing fasciitis.Woundextensionsarerequiredtoexcisetheaffectedfasciaover thecompartment.Theseextensionsmaywellconvertasmallpuncturewoundtoa linearwoundoverthefulllengthofthefascialcompartment.

Muscleisunforgiving.Alldeadanddoubtfulmusclemustbeexcised.The timing of second surgery in a disaster or in conflict is never assured; so do not risk leaving doubtful muscle in a wound.Thenextwoundreviewismorethanlikelyfivedaysaway.

WOUND DEBRIDEMENT BY LAYERS

VIABLE MUSCLE IS:

COLOUR: is pink

CONTRACTS: when pinched with forceps

CONSISTENCY: is firm

CAPACITY: to bleed when cut

• Muscle can fail to contract when pinched if the patient is under the influence of a depolarizing paralytic.

• Acutely after blast injury, capillary circulation is impaired for several hours, but often returns.

65



» BONE – Remove only the contaminatedperiosteumtakingcaretopreserveasmuchaspossible.Thislayeristhickinchildrenbutthininadults.

Articular fragments with a soft tissueattachmentshouldbepreserved,but loosebonefragmentsmustberemoved.

» NERVES – Do not trim or tag the ends ofnervesasitrisksfurtherdamage.Perineuralrepairsshouldonlybeattemptedatthetimeof definitive operation, when the risk ofinfectionislower.

» TENDONS – Ragged ends may be sharplytrimmed.

» BLEEDING – All wound bleeding mustbe controlled to prevent formation ofhaematomas that canprecipitate infection.Electrocautery is acceptable if available.Alternativesincludesutureligation,clipandwait,orclipandtwist.

» WASHING – Pulse lavage is notrecommended.Lowpressurewashoutwithisotonicfluidispreferred.Intheabsenceofisotonicfluidscleanwatercanbeused.

» Wounds in the face, head, neck, perineumand possibly hand may be considered forprimaryclosure.

» Wounds involving nerves, brain/dura, orvessels (picture right) should not be leftwithoutsofttissuecoverage.

Figure 5.Exposedvascularrepairinanopenlegwound.

WOUND SURGERY

WOUND COVERAGE EXCEPTIONS

WOUND COVERAGE

Wounds sustained in conflict or disaster should be considered contaminated and almost never closed primarily, and then only if wound debridement is complete.

Alan

Kay



» Thesimplestdressingsaredrygauze,orabsorptive layersofcottonorwoolheld inplacebyelasticbandages.Dressings treatedwith iodoform,chlorhexidineorsodiumhypochloritearenotrequiredandhavebeenreportedtodamagehostcellsandinhibithealing.

» Bandagesshouldbeappliedinatraditionalfigureofeightpatternwithouttension.Thisavoidsacircumferentialbandagebecomingatourniquetwhenthelimbswells.

» Non-adhesivedressinglayerssuchaspetroleumjellyimpregnatedgauzemaybelaidnexttothewoundifthenextdressingchangeisplannedinawardarea.

Anegativepressurewoundsetupcanbecreatedwithgauzeandperforatedtubing.(Figure6)

A Loosely pack thewoundwith gauze and place a tubewith several holes overlying the gauze. This can runthroughthedressingasshownorsimplyexitononesideofthedressing.

B Coverthegauzeandtubingwithmoreloosegauze.

C Coverwithclearadhesivetapeandconnecttosuction.Thedressingshouldshrinkdownandbecomehardiftheseal iseffective.Intheabsenceofaformalproprietarypump,improvisedsolutionssuchaswallsuction,vacuumbottlesoravacuumcreatedbyusingasyringewiththeplungerheldoutwithsticks,maybeeffective.

DRESSINGS

NEGATIVE PRESSURE DRESSINGS IN AUSTERE SETTINGS Al

an K

ay

SPECIAL TOPIC: NEGATIVE PRESSURE WOUND DRESSINGS» Althoughthere isnopublishedevidencethatnegativepressuredressings improvehealing in

acutewounds,theiruseisofpracticalbenefit.Exudatesoakingthroughdressingsiseliminated,patientcomfortisimproved,anddressingchangefrequencyisreduced.

» Negativepressuredressingsshouldonlybeplacedonwoundsthathavebeenadequatelyde-brided.

» Foamshouldbeofopencelltypeandplacedonlyinthewound.Gauzecanbesafelyallowedtooverlapontonormalskin.

» Staffshouldonlyusenegativepressuredressingsiftheyhaveexperienceinthetechnique.

» Forlargewoundsandstumpdressingsitmaybenecessarytoholdthegauzeinplacewithcir-cumferentiallywrappedadhesivetape.Thisshouldbecarefullylaidonandnottightlywrapped.Adherencecanbeimprovedwithtinctureofbenzoinandapplicationofa2cmstripofdressingaroundthewoundedgestocreatea“window.”

A

B

C

67



DELAYED PRIMARY CLOSURE» Delayed primary closure, including skin grafting or repeat wound debridement, should be

planned.“Lookandsee”asaplannedprocedureisapoorapproach.

» Thetimingofthisnextinterventionisnotstrictlyfixed.Experiencesuggeststhatthewindowforclosure isbetweenday2andday5.Anearlyreturntotheoperatingroomis indicatedifthereareclinicalsignsofinfection:fever,tachycardia,painandmalodor—the“badsmell”—for re-debridement.

HEALING BY SECONDARY INTENTION» Ifthereisnoplantoclosethewound,inotherwordstoallowthewoundtohealbysecondary

intention,thendressingchangesinatreatmentareaorwardarepossible,aslongasacceptableanalgesiaisachieved.

» It is safer to allow a wound to heal by secondary intention if there is any doubt as to the adequacy of debridement or the presence of infection.

» Healingbysecondaryintentionmayoccurinlessthantwoweeksforwoundslessthan2.5cmindiameter.Ifhealingisexpectedinlessthantwoweeks,equivalenttothetimeforagrafttotakeandthedonorsitetoheal,thenskingraftingisnotindicated.

ANTBIOTICS» Antibioticsareanadjuncttosurgeryandgoodwoundcare.SeeOpenFractureschapterforICRC

antibioticguidelines.Forwoundssustainedinconflictanddisastersettingsthen3daysofbroadspectrumantibioticsareadvised.An open draining wound is more important than antibiotics.

NUTRITION» Thenutritionalstateofthepatientpre-disastermayhavebeensuboptimaltobeginwithand

injuryandsurgerycreateahighcatabolicstate.Goodnutritionisessentialforwoundhealing.Appropriate foodsrich incaloriesarerequired.Treatmentforparasitic infectionmayalsobeappropriate,aswellasironsupplements.

» Comorbiditiessuchasanaemiaanddiabetesneedtobeconsideredandaddressedassoonaspossibletofacilitatehealing.



SUGGESTED RESOURCES

1. Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Blast injuries. The Lancet 2009; 374(9687): 405-15

2. Foltz M, Semer NB, Gosselin RA, Walker G. Introduction to Trauma in Austere Environments. Global Orthopaedics: Springer; 2014: 125-38

3. Guthrie H, Clasper J, Kay A, Parker P. Initial extremity war wound debridement: a multidisciplinary consensus. Journal of the Royal Army Medical Corps 2011; 157(2): 170-5.

REFERENCES

1. Semer NB, Watts, HG. The HELP Guide to Basics of Wound Care, 2003 edition. Online: Global HELP Organization; 2003: 16.

2. Anglen JO. Wound irrigation in musculoskeletal injury. Journal of the American Academy of Orthopaedic Surgeons 2001; 9(4): 219-26.

3. Hayward-Karlsson J, Jeffery S, Kerr A, Schmidt H. Hospitals for the War Wounded: A practical guide for setting up and running a surgical hospital in an area of armed conflict. Geneva: International Committee of the Red Cross; 2005.

4. Merry AF, Cooper JB, Soyannwo O, Wilson IH, Eichhorn JH. International standards for a safe practice of anaesthesia 2010. Canadian Journal of Anaesthesia/Journal canadien d'anesthésie 2010; 57(11): 1027-34.

5 Nanchahal J. Standards for the management of open fractures of the lower limb: Royal Society of Medicine Press Limited; 2009.


CLOSED FRACTURES

SCENARIOCLOSEDFRACTUREMANAGEMENT

POPIMMOBILIZATIONPOPAFTER-CAREANDFOLLOWUP

REMOVINGCASTSTRACTION

PAEDIATRICCONSIDERATIONSTRANSFERS

MANAGEMENTOFCLOSEDFRACTURESWITHINTERNALFIXATION

SUGGESTEDRESOURCESREFERENCES

7


CHAPTER 7 I CLOSED FRACTURES

TYPE 1

• Treatnon-displacedclinicalfractureswithimmobilization(backslab,splint-ing)butNOTcircumferentialcasts.

• Provideanalgesiaandmobilityaidssuchascrutchesorwalkingframesfortheelderly.

• Referpatientstohigherlevelsofcarewith:limbdeformities,neurovascularinjury,majortrauma(tibial/femoralfractures)oranyinjurythatcannotbemanagedlocally.

• Ifavailable,radiographymaypreventunnecessarytransfers.

TYPE 2

• Plainradiographyrequired• Treatwithimmobilization(splints/

plaster),tractionwithpinsandexter-nalfixation

• Earlyphysicaltherapytoimprovefunctionaloutcomesandpreventcomplications

TYPE 3

• Noopenreductionandinternalfixation(ORIF)intemporary(tent)structures.• Treatcomplexfracturesthatmaybenefitfrominternalfixation(periarticularor

intraarticular),onlyiftheteamisintegratedintothelocalinfrastructure.• Providehigherlevelsofmedicalandintensivecare.

SCENARIOIt is 5 days post earthquake.

A25-year-oldmanwithaclinicaldiagnosisofaclosedfractureofthemid-shaftoftheleftfemurisbroughttothemedicalfacility.

Anelderlywomanwithaswollen,unstablekneepresents.Shefellduringtheearthquakeandhasbeenunabletobearweightsinceherfall.

A 6-year-old girl presents after a fall fromadamagedbuilding thenight prior.Her leftelbow isgrosslyswollen,deformed,andnoradialpulseispalpable.

The goals of treatment of closed fractures should include:

» Avoid infection – first do no harm (such as through unsafe internal fixation).

» Optimize functional outcomes and minimize pain.

» Promote fracture union with acceptable length, rotation and alignment.

» In the upper limb, mobility is a priority over stability.

» In the lower limb, stability is a priority over mobility.

71



CLOSED FRACTURE MANAGEMENT

TYPE 1

Iflimbalignmentisnormalbutafractureissuspectedorconfirmedonradiology,asplintorcastshouldbeappliedtomaintainthepositionandreducepain.

NON-DISPLACED FRACTURES» Applicationofcastsandsplintsforfractureswithacceptablepositioninthewrist,forearmand

humerusmaybeappliedwithoutsedation.

» Applicationofcastsfornon-displacedfracturesofthetibiaisdifficultandshouldbeperformedinadesignatedroomwheresedationcanbeprovidedifnecessary.

TYPE 2

Allpatientswhorequireclosedreductionoffracturesandapplicationofsomeformofimmobilizationshouldbemanagedinadesignatedareawheresafeanaesthesiaorsedationcanbeprovided.

DISPLACED FRACTURES REQUIRING REDUCTION » Intheimmediatepostinjuryperiod,backslabsratherthanfullcircumferentialcastsarepreferred.

» Abi-valvedplastercastofthistypeiseasierforfamilytoremoveifnecessary,buthasahigherincidenceoflossoffracturereduction.

» Onmostoccasionsthisbivalveapproachisthesaferoptioniffollowupisofconcern.

» Followupwithallpatientswithlimbsimmobilizedinfullcastsisessential.

» Ifthisisnotpossible,selectthosepatientsmostlikelytohavecomplicationsduringthehealingprocess:

• Patientswithfracturesthatrequiredreduction• Allpatientswithcircularcastsinordertoruleoutissueswithcastpressure• Patientswithfracturesinvolvingtheelbow• Patientswithfracturestreatedveryclosetothetimeofinjury,asthesecanhaveanincreasedriskofproblematicswelling.

• Patientswhounderwentclosedreductionwhileasignificantamountofswellingandoedemawerestillpresent.



SPECIALIST SURGICAL TEAMS» If possible, all closed fractures should be initially treated in a closed fashion to minimize

complications, particularly infection, despite the longer treatment times associated with thisapproach.

» Articularandperiarticularfractureswhichcouldbenefitfromdelayedinternalfixationshouldonlybeperformedinfacilitieswiththeexpertise,sterilityandequipmenttodothissafely.

» Surgical techniques must be adapted to the local environment. Exceeding the local technicalcapabilityinfracturemanagementcreatesproblemsforpatientsandstaffalikewhencomplicationsarise.Any patient that has a fracture immobilized must have a follow up plan for review.

» Internal fixation uses up limited resources and carries a high risk of infection in disasters and in conflict.

» ORIF should only be performed at appropriate facilities with a safe water supply, sterile of equipment, specialist surgical teams, appropriate nursing support, and physical therapy following surgery.

» Non-operative fracturemanagement andavoiding internal fixationmethods in the initial threeweekspostdisaster isnota reflectionof the technical capabilityof the surgeonbutof relatedresourcessuchas:

• contaminatedwatersupplies• co-locationof“clean”patientsinwardswithpatientswhohavewoundinfections.

TYPE 1

EMTtype1Facilitiesshouldhavetheequipmentandexpertiseavailabletoapplyandmanagearangeoflowerandupperlimbimmobilizationtechniquesinclud-ingsplintsandPlasterofParisbackslabsorcasts.

APPLYING CASTSCASTING MATERIALS

» Plaster of Paris (POP) is the casting and splinting material of choice.

» Itcanberemovedbysoakingandcuttingthewetplaster.

» Medicalteamswhocarryfiberglassasafracturemanagementsolutionshouldonlyusethismaterialforsplintsandnever for full castsinadisasterorinaconflictzone.

» Powerfailures,plastersawbreakage,andtransferofthepatienttoafacilitywithoutaplastersawallplacethepatientatriskofhavingacastthatcannotberemovedwithoutseriousrisktothecastedlimb.

73



PATIENT INFORMATION

» Patientswho have splints or casts appliedmust be providedwith a plain language statement,in theirfirst language, regardingcarewhile in thesplintorcast.Emphasis shouldbeplacedonreturningformedicalcareifpainisnotcontrolledbytheanalgesicsprovided.

» Patientsshouldbeencouragedtomobilizeevenwithoneextremitysplintedorcasted.

» Write the POP calendar on the cast –includingdateofapplicationofthecast,dateofremovalandX-ray.

DIFFERENT EXPECTATIONSWrite on tape secured to the cast the suspected diagnosis, name of provider,place, date, and a line drawnwhere thefracture is. This transcends languagebarriers and helps patient and familyunderstandthediagnosis. Figure 1.PlasterofPariscastwithpatientinforecordedonit.(ICRC)

POP IMMOBILIZATIONFABRICATION PROCEDURE OF POP CASTS AND SLABS PREPARATION OF THE NECESSARY MATERIALS » Prepareagoodnumberofplasterbandagesratherthanjustafewrolls,asthePOPshouldbemade

allatoncetoassurethecontinuityofitsstructure.

POSITION OF THE PATIENT » Adjustpositionwithcushionsandpillowsifrequired.» Morethanonepersonmayberequiredtosupportthefracturedlimb.» Themedicalprofessionalshouldbeinasuitablepositiontoworkwithoutobstructionordifficulty.

PROTECTION OF SENSITIVE AREAS » Cleananddrytheskinaswellaspossibletoavoidodouranddiscomfortinsidethecast. » ApplythestockinetovertheentireareatobecoveredwithPOP,plusanextralengthforfolding

backatbothextremities.

APPLY ADDITIONAL PADDING (COTTON WOOL OR SOFT BAND) OVER SENSITIVE AREAS» Areasthatshouldneverbecompressedandmustbewellpadded:

• Fracture site • Bonyprominences

• Nerves• Vessels

• Wounds



GENERAL PRINCIPLES» Neverputplasterdirectlyonunprotectedskin.» TheedgesofthePOPshouldbecoveredandnotchafeorpuncturetheskin.» Moldingshouldbedonewiththepalmsofthehandsandnotthefingertips.» Applicationshouldbecontinuoustoallowthecasttodryasasingle,solidpiece.» Checkanddocumenttheanatomicalandfunctionalpositionofthelimb.» ForunstablepatientsimmobilizationwithaPOPbackslaborskeletaltractionisfasterandeasier

thanplacinganexternalfixator.

DURATION OF IMMOBILIZATION» Ifproperlydiagnosedandtreatedwithimmobilization,fractures

ofdifferentbonesrequirevaryingperiodsofimmobilizationtoachieveunion.

BONEMOST COMMON

IMMOBILIZATION PROTOCOLS WITH

NO COMPLICATIONS

AVERAGE HEALING PERIOD WITH NO COMPLICATIONS

ADULT CHILD < 10 YEARS ADULT CHILD < 10

YEARS

Metacarpal 4-6weeks 2-3weeks 6weeks 4-6weeks

Scaphoid 8-12 weeks

8-10 weeks

15-20 weeks 12weeks

Carpal 4-6weeks 2-3weeks 6weeks 4-6weeks

Ulna 4-6weeks 3-4weeks 6-8weeks 4-6weeks

Radius 4-6weeks 3-4weeks 6-8weeks 4-6weeks

Humerus 4-6weeks 3-4weeks 6-8weeks 4-6weeks

Clavicie 4weeks 2-3weeks 4weeks 2-3weeks

Scapula 4weeks 2-3weeks 4weeks 2-3weeks

Ribs 4-6weeks 2-4weeks 4weeks 2-3weeks

Vertebral bones 6-8weeks 4-6weeks 12weeks 6-8weeks

Pelvic bones 6-8weeks 4-6weeks 6-8weeks 4-6weeks

Femur 6-8weeks 4-6weeks 12weeks 6-8weeks

Tibia 6-8weeks 4-6weeks 12weeks 6-8weeks

Talus 6-8weeks 4-6weeks 12weeks 6-8weeks

Calcaneus 6-8weeks 4-6weeks 12weeks 6-8weeks

Phalanges 4-6weeks 2-3weeks 6weeks 4-6weeks

Figure 2.LengthofImmobilizationtimes.(ICRC)

» When applying POP, the drying time depends on the quantity of water left in the plaster.

» If there is too much water in the plaster, the POP becomes fragile after drying.

» Increasing the water temperature shortens the drying time. For long POP, cold water should be used to allow the different layers to dry as one solid cast.

» The higher the water temperature, the higher the temperature generated inside the cast:

» If the water temperature is 24°C, the POP temperature increases to 38°C. If the water temperature is 38°C, the POP temperature increases to 57°C.

» With a water temperature over 50°C, the heat produced inside the POP could burn the skin.

75



APPLYING BACK SLABS» Position thepatient appropriately, obtain

materials,andpreptheskin.» Stockinetisappliedtothelimbtocoverall

jointssurroundingfracture.» Padding is applied over the stockinet to

padhighriskpressurepoints.» The first wetted plaster slab is applied

alongthelengthoftheposterioraspectoftheinjuredlimb.

» A second slab is applied in the samefashionas thefirstusingafigure-of-eightorX-crossingof thetwoslabstogivethelightweightposteriorsplintitsstrength.

» Anyexcessplaster is trimmed forpatientcomfortandtopreventanyskinirritation.

» Gauze or elastic bandage is gently butfirmlyappliedtokeeptheslabsinposition.

» Thebackslabishelduntiltheplasterhassetwith theappropriate jointposition tofacilitatefracturehealing.

APPLYING CIRCULAR CASTS» Theskinshouldbethoroughlywashedand

driedbeforeapplication.» Stockinet is applied and the necessary

amountofpaddingforprotectionofboneyprominencesisapplied.

» The plaster bandages should be appliedby rollingwithout tension. Eachbandagecovers one-half of the previous bandagewithoutwrappingcircumferentially.

» The palm of the hand is used, not thefingers,tomoldthewetbandagestoavoidpressuresoresthroughthecast.

» The limb is held in the appropriate jointpositioninguntilthecastisset.(Figure5)

» When dry, the calendar time, fracturelocation, and other documentation iswrittenonthecast.

Figure 3.Forearmslabwithfingerssplintedinthesafeposition.(ICRC)

Figure 4.Moldingatibialcastbyindentingthumbsintobothsidesofthepatellartendon.(ICRC)

Figure 5.Allowingtheplastertosetonatibialcast.(ICRC)



POP AFTER-CARE AND FOLLOW UPADVICE AND INSTRUCTION FOR PATIENTS

Givethefollowingadvicetothepatientandhisorherfamily.» Respectdryingtimebeforeambulation.» POPshouldnotbecoveredwithcloth,varnish,orablanketuntilitisdry.» ThePOPmustnotcomeincontactwithwateroranyotherliquid.» RaiseorelevatethelegwithPOPonapillowtodecreaseswelling.» PerformisometriccontractionunderthePOPtoprotectagainstmuscleatrophyandphlebitis.» Mobilizefreejoints.» Neverwalkonthecastwithoutarockerortip.

CAST VITAL SIGNS

» Pain » Strength» Odour » Colour,heat,sensationandmobilityofextremities» Cleanliness » Generalfeverandheartrate

DANGER SIGNS IN CASTED FRACTURES

» Increasing pain » Increasingswelling» Motor or sensory changes » Seepage through or around the cast

FOLLOW UP AND SUPERVISION

» Ideallyhaveonefollowupafter24hours» Providebasicphysicaltherapyexercisesifneeded» Tellthepatient(andfamily)toreturnifthereareanyconcerns» AllPOPnottoleratedbythepatientshouldberemoved» Ensurepatientshaveplansthatallowforclinicalreviewandcastremoval» Ensuremobilityaidsareprovidedifneeded

POSSIBLE COMPLICATIONS

» Skin(pain,burns,soresduetopressure)» Bones(secondarydisplacement,

osteomyelitis)» Joints(stiffness,osteoporosis)» Musclesatrophy(amyotrophy)» Neurovascularcomplications(complex

regionalpainsyndrome,localcompressions, compartment syndrome, thromboembolism). Figure 6.SkinreactiontoPOP.(ICRC)

77



REMOVING CASTSIMMEDIATE REMOVAL OF THE POP

» Ifswelling,diffusepainor lackofsensationoccurs,immediatelysplitthePOPalongitslength.

» Should localpainoccur,openawindowandchecktheskin.ClosethewindowwithanelasticbandageorPOPifthereisnowound.Theincidentshouldberecordedinwritingonthecast.

REMOVING CAST TECHNIQUES

» The cast may be removed by an electric cuttingdeviceorplastershears.

» Forchildren,orifelectricityisnotavailable,plastershearsarenecessary.

» Priortoremoval,gatherallmaterialsneeded.Theseincludescissors, removal tools (Figure7),materialstowashthelimbafter,andsupportivematerial.

» Positionanddrapethepatient.Forupperextremitycasts the patient can be in the sitting or supineposition.Forthelowerextremitythepatientshouldbeinthesupineposition.

» Determinecuttinglines,anddonotcutoverboneyprominences.

» When using plaster shears, ensure correct bladealignmentwitheachcut,andafter4-6cutscleartheblades,utilizethebenders,andcontinue.Nevercutaroundcorners,removethebladeandcutfromtheoppositedirection.

» Whenusinganelectriccutter,ensurethepatientiscomfortableandunderstandsthebladewillnotcuttheirskin.

» After the cast is removed, assess the skin for anydamage from removal and assess the form of thelimbfollowingimmobilization.

» Wash and dry the area, and apply oil or lotion toassistinrestorationofnormalskinnutrition.

» The patient needs to be educated about care oftheskinandoftheinjuredlimbasthemuscletonereturns.

» Areferralforrehabilitationisstronglyadvised.

Figure 7.ToolsneededforremovalandmanipulationofPOP.Fromtoptobottom,oscillatingsaw,castspreader,plastershears,castbreaker.(ICRC)

If a window is cut to assess the skin under a cast, or for treatment of a small (type 1) open fracture, the plaster should be reapplied and fixed in place with elastic bandage to prevent the formation of "window edema".



TRACTION

TYPE 2

Surgicalteamsprovidingcareindisasterresponseandinconflictzonesmust be familiar with the principles of managing patients with fractures in traction,whichmaybeusedasatemporarymethodtomanageafractureorasadefinitivetechnique(SeeICRCmanualonPOPandTractionforadditionalinformation).

SKIN TRACTION» Skin traction can be used temporarily in adultswith femur fractures (for nomore than 48–72

hours).

» Itcanserveasamethodtoallowforplacementoftractionfortransfertoahigherlevelofcare.

» Skin traction can serve as a definitivemethod of treatment formany femoral fractures in thepaediatricgroup.

SKELETAL TRACTION» Skeletaltractioncanbeusedasdefinitivemanagementforadultswithopenlongbonefractures,

although external fixation provides better stabilization and optimizesmanagement of the softtissueinjury(seechapteronopenfractures).

» Skeletaltractionforchildrenwithhipfracturesiseffectiveandcommonlyused.

» Althoughdefinitivetreatmentwithtractionisnotaseffectiveinadults,itmaybetheonlylocallyavailabletreatmentforadultswhosustainfracturesoftheproximalfemur,andismoreeffectivethanskintraction.

PLACEMENT OF TRACTION PINS» Traction pins should have a centrally

threaded section, as this will preventslippinginthebone.

» Thiscanbeinsertedunderlocalanesthesiawithahanddrill(forsafepininsertionseethesectiononopenfractures).

» Traction should not be applied across anunstablejoint.

» When placing a Denham pin for skeletal traction in a deployment scenario, place a piece of tape on the pin and write “threaded.” This is important as you cannot guarantee that you will be the one to remove the pin.

» Always check the stability of the knee joint prior to placing a traction pin for a femoral shaft fracture.

79



TECHNICAL ASPECTS» Tractionpinsshouldnotpassthroughasynovialjointspaceoranopenphysealplate.

» Bewaretheproximalextentofthekneejointandtheproximaltibialphysisinchildren.

» Checkstabilityofthekneepriortoinsertingatractionpinforafemoralshaftfracture.

» Ifthekneeisunstable,insertthepininthedistalfemoralmetaphysis.

» Duringinsertion,startfromthesafeside—wherethevesselsandnervesatriskcanbelocalizedandavoidedbycarefulselectionoftheinsertionpoint.

» Distal femoral traction pins should beinserted frommedial to lateral to avoidtheadductorcanalandfemoralartery.

» Proximal tibial pins should be insertedfrom lateral to medial to avoid thecommon peroneal nerve as it passesaroundtheneckofthefibula.

» Calcanealpinsshouldbeinsertedmedialto lateral to avoid the posterior tibialneurovascularbundle.

» AThomassplintorvariantcanbeusedfortemporary stabilization, or for definitivecare for a patient with a femoral shaftfracture.

• Thesearecommonlyusedfortemporarytreatment, either until femoral nailingcanbesafelyperformed,ortotransportapatienttoanothersurgicalcentre.

» If using a Thomas splint as a treatmentoption (more common in children), thering must fit the patient, and attentionmust be paid to correctly padding andadjusting the traction equipment topreventpressureareasinthegroin.

Figure 8.Thomassplint.(ICRC)

Figure 9.Tractionpinplacedinthefemoralmetaphysisandanemptyvialusedasapinguard.

(ICRC)

Figure 10.Thelargerforceappliedinskeletaltractionistransmittedalongtheaxisofthelimbviaa

pin,pulleyandaweight.(ICRC)



» AdultswithfemoralshaftfracturesbeingmanagedinskeletaltractionareoftenonaBöhler-Braunframe.

» Thisallowselevationofthelowerlimb,andkneeflexionduringtraction.Theframemustfitthepatientandbesuitablylined.

» IntheabsenceofaBöhler-Braunframe,asplitHamiltonRusselloraThomassplintcanbeusedfortraction.

Figure 12.Alternativemethod to a Böhler-Braunframeforaproximalfemurfracture.(ICRC)

Figure 13.PreparationofaBohler-BraunFrame.(ICRC)

Figure 11.Constructionofatractionframeinthefield.(J. von Schreeb)

» Patients in traction often develop an equinus deformity of the foot.

» This can be prevented with active and passive physiotherapy using bands and/or foot slings.

» Pressure sores of the heel and sacrum should be prevented, and DVT prophylaxis, if available, is indicated.

81



PAEDIATRIC CONSIDERATIONSTRACTION AS DEFINITIVE CARE

» Childrenwhohavefemoralshaftfracturesarecommonlytreatedintractionwithunionoccurringinapproximatelythepatient'sageinyearsplusoneweek.

» Patients less than 8 should be treated with early Spica casting under sedation 1-3 days afterfracture.

» Fixed traction using adhesive skin or skeletal traction in a Thomas splint is possible. HamiltonRussellTractionispossibleaswellanddoesnotrequireaThomassplint.

» SomesurgeonsviewtheThomassplintasprimarilyusefulfortransportasthedevicecanleadtopressuresoresinthegroin.

» Childrenundertheageof2yearswithafemoralshaftfracturecanbemanagedinGallowstraction.» Children under the ageof 6months canbemanaged in a "Soft Spica" builtwith padding and

bandagesorbyusingaPavlikharnessifavailable.» Weightsrequiredareminimal(1-2kg)andshouldbeoverapulleyonanoverheadbar,nottiedoff

tothebar.

SKELETAL TRACTION

» Skeletaltractionforchildrenwithhipfracturesiseffectiveandcommonlyused.» Skeletaltractionisthebestchoicefor:

• Initialimmobilizationofmostfemoralandsometibialandhumeralfractures• Definitiveimmobilizationoffracturesofthefemur• Definitiveimmobilizationofparticularlydifficultfracturesofthetibianearthekneeandofthe

humerusneartheelbow• Tractionpinsinchildrenshouldnotbeplacednearthetibialtuberosityastheymaycausean

anterior growtharrestand subsequent recurvatumdeformity. They shouldbeplaced in thedistalfemur1cmproximaltothegrowthplate.

Figure 14.Gallowstractionfromabeam.(ICRC)

Figure 15.Patientinskeletaltraction.(ICRC)

DISADVANTAGES OF SKELETAL TRACTION AND CONSIDERATIONS

» Theprincipaldisadvantageofskeletaltractionisprolongedbedrest,alongwithincreaseddemandsonbothnursingandphysiotherapycare.



TRANSFERS» Aninjuredpatientmayhavetheopportunityforevacuationfromthefirsthospitaltoahigherlevel

ofcare.

» Thepatientneedstobeconsultedaboutatransferandthetransfershouldbediscussedwiththeirfamilyorsupportsystem.

SKIN TRACTION AND TRANSFERS

» Transportofapatientwithalongbonefracturecanbefacilitatedbyusingskintractionforalimitedamountoftimeduringthetransport.Skintractionfortransportshouldbeadhesiveinchildrenandnon-adhesiveintheadult.

» Femoralshaftfracturesinadultscanbemanagedduringashortdistancetransferbycontinuingtractionwithaweightonatractionpin,butthisshouldbeavoidedifpossible.

» AnalternativeistheapplicationofaDonway,HareorThomassplint.These splints cannot be used in the presence of ipsilateral pelvic fracture.

» Anotheroptionisbandagingthefracturedlimbtotheintactlimbwithslingsorstripsoffabric.

AIR TRANSPORT

» Consideraprophylacticfasciotomyofthecalfpriortotransferduetopressurechanges.

TRANSFERS IN CASTS

» Anypatientinafullcastshouldhavethecastsplittoskinfortransfer.

• This isdoneduetoswellingandtominimizetheriskofatightcast/compartmentsyndromeduringthetransfer.

» Elevatethepatient’shandorfootasappropriatetopreventdistallimbswelling.

» Avoidhanginganarminfabriconapolebesidethebed.

• Theedgeof that fabricwill causeanulnarnerveneuropathy if it isallowedtocompress theposterio-medialaspectoftheelbow.

• Simplyelevatethehandontheabdomen,orpropittobewellabovetheelbowatrest.

83



MANAGEMENT OF CLOSED FRACTURES WITH INTERNAL FIXATION

TYPE 3BEWARE THE RISKS OF INTERNAL FIXATION

LIMITED INDICATIONS IN DISASTER AND EMERGENCY SITUATIONS

» Onlyindicatedifthesituationhasstabilizedandatype3teamisintegratedintoalocalfacilitywithpriorhistoryofperforminginternalfixation.

» Incidenceof50-80%ofinfectionhasoccurredwheninternalfixationwasusedasaprimarymeansoftreatment.

» Considertransferringthepatienttoamoreadvancedfacilityifinternalfixationisnecessary.

» Evaluationofpatient’snormalenvironment,safety,riskofcomplications,andavailableresourcesmustbeconsideredbeforeclosedfractureinternalfixationisperformed.

» TheprincipalmethodsofPlaster-Of-Paris,skeletaltraction,andexternalfixationareviableoptionsformanyfracturesandshouldbethefirstchoiceindisasterandconflicts.

Figure 16.Puspoursfromawoundtreatedwithinternalfixation.Theplatesandscrewsmustnowberemoved.(ICRC)



SUGGESTED RESOURCES

1. Gosselin RA. War injuries, trauma, and disaster relief. Techniques in Orthopaedics 2005; 20(2): 97-108.

2. Ngota DO, Friedel F. Plaster of Paris and Limb Traction: ICRC Physiotherapy Reference Manual. ICRC; 2009. p.101.

REFERENCES1. Giannou C, Baldan M. War surgery: Working with limited resources

in armed conflict and other situations of violence, Volume 2. Geneva: International Committee of the Red Cross; 2013.


3. Norton I, Von Schreeb J, Aitken P, Herard P, Lajolo C. Classification and minimum standards for foreign medical teams in sudden onset disasters. Geneva: World Health Organization; 2013.

4. Herard P, Boillot F. Amputation in emergency situations: indications, techniques and Médecins Sans Frontières France’s experience in Haiti. International Orthopaedics 2012: 1-3.

5. Dufour D, Jensen SK, Owen-Smith M, Salmela J, Stening GF, Zetterström B. Surgery for victims of war. 1998.

6. Coupland RM. War wounds of limbs: surgical management. 1993.

7. Hayward-Karlsson J, Jeffery S, Kerr A, Schmidt H. Hospitals for the War Wounded: a practical guide for setting up and running a surgical hospital in an area of armed conflict. Geneva: International Committee of the Red Cross; 2005.

8. ICRC Guidelines for Teaching Nursing Care. Internal Document: International Committee of the Red Cross ICRC.


OPEN FRACTURES

SCENARIOWOUNDDEBRIDEMENT

FRACTURESTABILIZATIONEXTERNALFIXATIONFOROPENFRACTURES

MANAGEMENTOFOPENFRACTURES

SUGGESTEDRESOURCES

REFERENCES

8


CHAPTER 8 I OPEN FRACTURES

SCENARIO

TYPE 1

• Lavage,dress,alignandsplintwounds

• Administerantibioticsandtetanusprophylaxis

• DONOTCLOSETHESEWOUNDSPRIMARILY

TYPE 2

• Formalwounddebridement• Applycastwithwindoworexternal

fixationforcontinuationofmanage-mentofopenwoundmanagement

TYPE 3

• Receivedressedandsplintedwoundfromtype1or2EMT.

• Providedefinitivetreatmentwithplanforlongtermfollowup

» Assess every patient and every injury that presents to your facility.

» This includes removing bandages, changing dressings, and adjusting splints.

» Every injury gets a priority and a plan!

Yourteamarrivedthreedaysago,48hoursaftertheearthquakestruck,andbynowthehundredsofpatientsintheparkinglotofthepartlydestroyedhospitalhavebeenmanaged,butnewpatientskeeptricklinginregularly.

Amobile surgical facility 25 kilometers away is now operational. One of the new patients is a23-year-oldfemalewithawoundoverthedistallegandexposedfractureofthetibia.Thereispusinthewoundbutnocrepitus,andthepatientisfebrileat38.5°C.

Where should this patient be managed, at a EMT type 1? EMT type 2? type 3?

(ICRC) (Bar-On)

87



SPECIAL CONTEXTS

DIFFERENT EXPECTATIONS

TRIAGE MATTERS…HAVE A PLAN

» Patients with open fractures should be considered to have a soft-tissue wound with an underlying bone injury.

» Treatment of soft tissue injury is as important as treatment of the fracture.

» The outcome for the patient will depend on the degree of injury of the soft tissues around the fracture.

EARTHQUAKESEarthquakes can result in crush type injuries. Thesemechanismsofinjurycausenotonlyfracturesbutsignificantsofttissueinjuries,whichcanoftengounrecognizedattheinitialevaluation.Crush injuriesshouldbeexpected inallpatientswithinjuriescausedbyfallingdebrisorentrapmentunderbuildingorlandsliderubble.

FLOODS AND TSUNAMISFloodsandtsunamismorefrequentlyproducelacerationsin largenumbers,but theproportion related to fracturesis reduced compared to earthquakes or conflict. Tibialfractures infloodsandtsunamisareoftenopen.Femoralfracturesfromtsunamisandfloodsareoftenclosed.

ARMED CONFLICTInjuriessustainedinconflictmayincludesofttissueinjuriesoropenfractures.Thetypeofinjurydependsonthetypeofweaponryused.InjuriesfromGSWs,blastinjuries,shrapnelinjuries,andlandmineinjuriesshouldbeexpected.

Openfracturesmanagedincivilianpracticeoutsideofconflictzonesareoftencausedwhenthebonepenetratestheskin—or‘fromwithin.’Limbsurgeons inhigh-resourcesettingsarefamiliarwith dealingwith these injurieswith little contamination and a lower risk of infection than indisastersandconflict.Asofttissueinjurywithabreakintheskinremovesthebiologicalprotectionofthesofttissueandofbone,openingthepatienttoinfectionofthesofttissue,theboneorboth.

Open fractures in conflict areusually from theoutside to in and therefore at increased riskofcontamination.Thisisexacerbatedbythecontaminatedsurroundingsandthedelayintreatmentinitiation.Therefore,allopenfracturesshouldbeassumedtobeinfecteduponarrival.

Therateatwhichpatientspresentcaninfluencethesurgicalplanbyrequiringabbreviatedoptions.Knowyour situation. Patients froma SOD tend topresent all at once,while thetideof patientspresentingfromconflictsebbsandflows.



DIFFERENT EXPECTATIONSWhile sterile isotonic solutions are used inhospitals,theyareoftenimpracticalforuseinadisastersetting.Cleandrinkingwaterfromataporbottleissuitableforusewashouts.

FIGURE 3 Lowpressureirrigationduringdebridement.(ICRC)

WOUND DEBRIDEMENT FOR PATIENTS WITH OPEN FRACTURES» Washingofboneendswitha syringeofwateror saline ismosteffectivewhendonewitha

syringewithasmalloutletorthroughaneedle,ratherthanthroughalargeboreoutlet.

» Eachboneendmustbevisuallyinspectedforcontaminationandcleansing.

» Bonedebridement:removealldetached,devitalized,non-articularbonefragments.

» Leavearticularfragmentsunlesstheyaregrosslycontaminated.

» Avoid damaging the remaining soft tissue attachments of bone fragments.

» Agauzesquarecanbeusedtoabradetheboneendsandremovevisiblecontaminants.

» Adentalpickisequallyeffectiveinremovingmaterialontheboneends.

» Use a bonenibbler or rongeur to remove the remaining contaminated ends of the fracturefragments.

» Incaseswithsignificantboneloss,acuteshorteningcanbeperformed.Thiswillalsoassistinbonecoveragebysofttissues.

» Volume is more important than pressure for washout, a minimum of 3-12 L per wound isrequired.

» Bonesandjointsshouldbecoveredbysofttissuewhenpossible. Softtissuesshouldnotbesuturedundertension.

» Skinshouldneverbeclosedprimarily.

TYPE 2

Debridementofallwounds,includingopenfracturesshouldbeperformedbyasurgeon at an EMT type 2 or3facility.

Paediatric ConsiderationsPreserveallperiosteumwhenpossible,evenifonlyanemptysleeveispresent.Childrencanundergoremarkableregenerationofboneoverseveralcentimeterswithinaperiostealsleeve.

WOUND DEBRIDEMENT

89



EXTERNAL FIXATIONCasting and external fixation can both provide managementstrategiesforopenfractures.Inaustereenvironmentsthesimplesttechnique should always be considered first. For example, a castwitha“window”cutinthePOPforwoundcaremaybeasafeandacceptableoption.

External fixation of open fractures can be useful for wound management.However,theeaseofaccesstowoundsprovidedbyexternal fixation is not a replacement for good wound management with debridement, appropriate DPC, or other safe wound coverage.Externalfixationofanopenlongbonefractureprovidesstabilityofthesofttissues,alignmentof the fracture,protectsneurovascularstructures,maintainslimblength,andcanreducetheinfectionriskin comparison to longitudinal traction when used as a definitivetreatment.

Thegoalofcareoftheopenfractureistoprovidealignmentofthefractureinastableenvironmentforwoundmanagementandwoundhealingorearlywoundclosure,inthesimplestandsafestwaypossible.

TYPE 2

TYPE 3

Applicationofexternalfixationisbeyondthescopeofatype1EMTandshouldbeperformedatatype2or3facility

FEMURIfexternalfixation is requiredfor fracturesof thefemoralshaft,fixationshould include2–3pinsaboveandbelowafracture.Thepinscanbeeitheranteriororlateral.

Anteriorispreferredifinternalfixationmayfollowasitavoidsthesurgicalincisionsitesforinternalfixation.Twopinsareadequatefortemporaryfixation.Alateralpositionandthreepinsarepreferredifitispossiblythedefinitivemanagement.Donotplacepinswithin2fingerbreadthsoftheproximalborderofthepatella.Thiswillavoidplacingthemthroughthesuprapatellarpouch.Ifneeded,placethemoredistalpinslaterally.

DO NOT INTERNALLY FIX OPEN FRACTURES PRIMARILY IN CONFLICT RELATED WOUNDS OR DISASTER ENVIRONMENTS.

FRACTURE STABILIZATION

» External fixators applied initially as "temporary" may be become definitive, so they should be constructed for that circumstance.

» When applying external fixation to a femur fracture with a small distal femoral segment, the external fixation construct should span across the knee joint to the proximal tibia.



Figure 6. Mono-axialside-tubemethod:thefourSchanzscrewsarewell-alignedinarow.(ICRC)

Figure 5.ADeltaframeoveranopenfracture.Thelateralfasciocutaneousflaphasbeenraisedtoprovidetemporarylooseimmediatecoverfortheunderlyingvascularrepair.(A.Kay)

TIBIAA standard construct for a tibial shaft fracture shouldinclude 2–3 pins above and below a fracture on theanteromedialsurfacebypreference,andasinglebar.

More stability is provided by a second bar bridging thefracturesite.Thismaybedesirableforthemanagementofpainrelatedtomovementatthefracturesite.

DISTAL TIBIAFixation should span from the proximal tibia across theankle joint to the footwhen the distal tibial segment issmall,oradistallegwoundpreventspininsertioninthedistaltibia.

Constructadeltaframebetweenthetibialshaftabovethefractureandthefoot.

Acalcanealpinisrequiredaswellasoneormorepinsinthemetatarsalstotriangulatetheframeandpreventthedistaltibiaandfootslippingforwardorbackwardofftheplaneoftheproximaltibia.

» It is important to avoid bars that are too long, impeding joint motion or extending beyond the plantar surface and impeding weight bearing.

Figure 4.Insertionsiteforcalcanealpin.(AO Foundation Switzerland)

91



Figure 8.Standarduniplanarexternalfixationofthetibiashowingthelastpinbeingplaceddistaltothefracturesite.


Figure 7. Modulartechnique:thetwomodulesaremanoeuvredintoposition,aligningthebone,bothaxiallyandrotationally,andthetwoshorttubesjoinedtogetherwithacross-tube.Asecondtubemaythenbeappliedtomakethedevicemorerigid.(ICRC)

BIPLANARThepinsabovethefractureareconnectedbyashortbartocreatea‘handle’andthesametechniqueusedbelowthefracture.Thefractureisreducedandthehandlesarethenconnectedbyathirdrod.

Thisrodmayconnectthebarabovetothebarbelow,apinabovetoapinbelow,orabaronesideofthefracturetoapinontheoppositesideofthefracture.

UNIPLANARAsinglepinisinsertedproximallyandanotherdistally,looselyconnectedbyasinglebar.

The fracture is then reducedand the frame locked.A secondpinaboveandanotherbelow thefractureareinsertedfreehandwiththedrillorpinrestingonthebarasaguidetolineupthebarandthebone.

» The further apart the pins on each side of the fracture, and the closer to the fracture the bar is, the more stable the construct. Leave room to allow for soft tissue swelling, wound care and dressing.

» Constructs may also be attached only to the fractured bone, or span a joint.



PIN SELECTION» Do not use conical pins—if inserted too far, they cannot be backed off without losing their

fixationinbone.There-useofthreadedhalfpinsorShanz-typepinsisnotrecommendedduetothedifficultyincleaning,sterilizingandtrackingthepins.

» Choosethreadedhalfpinsappropriatetothesizeoftheboneandthepatient(around1/3ofthebonediameter).Adult lower limb: 5mm pins for almost all circumstances, and 3–4 mm in the hand and arm.

» Pinsmaybeself-drillingandself-tapping,ornot—checkthepins.Ifpointedandfluted,theyareself-drillingself-tapping,ifroundwithoutflutestheyarenot.

PIN PLACEMENTPowerdrills,ifavailableshouldonlybeusedbyexperienced surgeons. For surgeonswith lessorthopaedicexperience,itispreferabletoinsertpins by hand using a Hudson brace system or a handdrill.Pre-drillingwillfacilitatetheinsertionof pins infit, healthypeople.A size 3.2or 3.5drill is adequate for the purpose. Self-drilling,self-tappingpinsshouldbeusedwhenavailable.

If pins are not self-drilling, self-tapping, pre-drilling before pin insertion is required. Useonlysharpdrills.Bluntdrillsusedonhighspeedproducesignificantheatandtheheatwillkilltheboneinaringaroundthepin.

EXTERNAL FIXATION FOR OPEN FRACTURES


Children can have the same sized pins as adults from age 5. Under age 5, use 4 mm pins in the lower limb and 3 mm in the upper limb, if available.

Figure 9.

A: SelfTappingSchanz screw

B: Conventionalthreaded pin


Figure 10. HandChuck(ICRC)

Figure 11. Placementofapinwithahanddrill(ICRC)

93



» Ring Sequestra: Drilling by hand limits the drill speed, and therefore heat generation. It will quickly be recognized if a blunt drill is in use. If using a power drill, ensure every drill bit is sharp to reduce heat generation and the risk of ring sequestra. These ring sequestra harbor infection when a pin site becomes infected and can become the source of osteomyelitis and continuous discharge of pus.

» Pin Length: Check the two pins for each bone segment before you insert the first. The second pin will give you a guide as to how much of the pin is engaged in the bone—or projecting beyond the far side of the bone.

PIN SELECTIONPin length needs to be long enough to attachtheconnectorsandallow thewearingof looseclothingbutnotsolongthattheyinterferewithjointmovement.

The thicker the softtissues, the longer thepinrequired to clear these before the blocks areadded—femoralfracturesneedlongerpinsthantibialfractures.

Apinthatistooshortneedstobechanged.Apinthatistoolongcanbecutwithboltcutters,butthis leavesasharpendthatcauses thepatientdifficulty with protecting themselves, theirclothingandbeddingfrominjury.

Pins can be inserted under local anaesthesia,5mLoflidocaine1%oneachside,fromtheskindown to the bone, as the periosteum is richlyinnervated.

Wait5minutesforthelocaltotakeeffect,andmake generous longitudinal skin incisions (atleast 1 cm, not just a knife stab) so therewillbenotensionontheskinfromthepinaftertheconstruct is secured. When inserting the pin,“walk” it on the bone to feel the anterior andposterior cortices, and triangulate to feel themid-portionofthebone,wherethepinshouldbeinserted.

Figure 12. Correctdepthinsertionmaybeachievedbyfeelingtheoppositecortex.If self-drilling screws are used (far left), they areinserted through the near cortex until they justpenetratethefarcortex.Donotbreakthroughthefarcortex.




SELECTION OF PIN ENTRY POINTPinsshouldpreferablybeinsertedseparatefromthewound,ratherthanthroughthewound.Pinsplacedthroughthewoundmaycausefurthersofttissuedamageandinterferewithwoundcareandcoverage.

Allpinsitesareconsideredcontaminatedandsomebecomefranklyinfected.

Considerthesurgicalapproachforanyfutureinternalfixationorsofttissuereconstructionandavoidplacingpinsinthisline.Internalfixationisanunlikelyoptionfollowinganopenfractureandwouldonlybeconsideredafterthewoundhashealed.

Consideralsowhatstructuresareatriskonentryandattheexitpointonthefarsideofthebone.Safezonesaredescribedtoassistinpinplacementinthetibia.

Figure 13.Safezonesforaccesstotheproximaltibia (AO Foundation, Switzerland)

95



PIN DEPTHPinsareofteninsertedindisasterresponseandconflict environments without the benefit ofradiologicalcontrol.

Depth of pin insertion is important as a pininsertedtoodeeplycandamagestructuresonthefarsideofthebone.Correctionofanoverlydeep pin requires anaesthesia. Correct depthat the time of first insertion is desirable. It isfar easier to judge pin depthwhen the pin isinserted by hand.

Tibial pin depth can be estimated from thebreadth of the subcutaneous border of thetibia.Thetibiaisroughlytriangular.

Thedepthofinsertionshouldapproximatethepalpable bone breadth. With one pin on thebone,asecondpinofequal lengthputontheskinwillgiveyouanideaofhowmuchfurtheryouneedtogo.

As thepinengages the farcortex, itbecomesmoredifficulttoturn.

Three and a half full turns from this point should have the pin fully engaged in the far cortex, but not projecting beyond it bymorethanafewmillimetres.

Ifusingapowertooldrilltoinsertpins,imagingwouldideallybeobtainedtocheckdepthwhilstthepatientisanaesthetized.

FAILING TO CHECK THE NEUROVASCULAR STATUS AFTER PIN INSERTIONAlways check the neurovascular status of the limb after the patient has recovered from the anesthetic and record this in the clinical notes.

Ensure that there has been no deterioration compared to the patient's pre-operative exam.



» Always use a soft tissue protection guide when drilling or inserting pins. This prevents winding up neurovascular tissues on the drill or pin.

KEYS TO PLACEMENT OF EXTERNAL FIXATION» Thecloserpinsaretoafracture,themorestabletheconstruct.

» Thefurtherapartpinsareoneachsideofthefracture,themorestabletheconstruct.

» Twopinsasetdistanceaparthaveahigherpulloutstrengththemoredistanttheyarefromthefracture.

» Theclosertheframeistothebone,themorestabletheconstruct.Keeptheframeaslowaspossiblewithinthelimitsofneedingtotendtothewound.

» Insertingpinsthroughablockprovidedinsomeexternalfixationsystemsrequiresthatthepinsbeperfectlyparallelandasetdistanceapart.Usetheblockandanytissueprotectorsastheguidetoperfectpinplacement.

» Ifinsertingpinsasindividualpins,theydonotneedtobeatrightanglestothebone.Anglingthemapartmaybettersuittheconstructionofahandle,andavoidinsertionofthetipofthepinintoajointorthefracturesite.

Figure 14.Imagedemonstratingtheuseofasofttissueprotectionguidefortheprotectionofsofttissuesuperficialtopinplacementsite(AO Foundation, Switzerland)

97



SAFE ZONES OF THE FEMUR

» Posterolateral pin insertion is possible but should be avoided as it places the sciatic nerve at risk and so that the external fixator frame does not interfere with sitting or lying supine.

Proximal 1/3Withthepatientsupine, the greater trochanterispalpatedand, depending on the fractureconfiguration,the pin is directed through the vastus lateralis,eitheraimingtowardsthelessertrochanter(15A)orthefemoralneck(15B).

MidshaftAnterolateral Approach (Figure 16D) Vastuslateralisandrectusfemorisarepalpatedwiththepatientinsupineposition.Thedirectionofthepinshouldbeintheplanebetween these two muscles.TheDirectLateralApproach(16E).

Distal 1/3Direct lateral approach (17F)Thelateralareaofthedistalpartofthefemuriseasilyaccessibleforpininsertion.Thedistalpartofvastuslateralisistheonlystructureofthesoft-tissueenvelopetoconsider.Thedirectionofthepinshouldfollowpath(F).

Figure 15A Figure 15B




Figure 16D Figure 16E

Figure 17F



ProximalNeurovascular structures (NVS) Inthedepthofthepoplitealfossawefindtheneurovascularstructuresincloseproximitytothebone.Theexactdistanceoftheneurovascularstructurestotheboneandtothemiddleofthetibiaisvariable.

Knee joint capsulePinplacementshouldrespectthekneejointcapsuleandthereforebebelow2cmofthetibialplateau.Ifamoreproximalpinfixationisnecessaryforveryhighfractures,pinplacementshouldbeasanterioraspossibleduetotheshorterextentofthekneejointcapsuleinthisarea.(Figure18)

Tibiofibular jointTransfixation Atthelevelofthefibularheadtheonlysafezonesfortransfixationofthetibiaarethemedialandlateralzones.

Unilateral fixation

Atthelevelofthefibularheadbothsidesofthepatellarligamentareasafezoneforunilateralframefixation.Therefore,onecanconstructaT-framewithgoodstabilitywithonlyaminorriskofintra-articularpinplacement.(Figure19)

Distal to tibial tuberosityTominimizetheriskofinfection,itisbesttoinsertthepinswheresoft-tissuecoverageisminimal.Therefore,distaltothetibialtuberclethesafezonesforpininsertionarethetibialcrestandthemedialfaceofthetibia.Onemustbecarefulandavoiddeeppenetrationbeyondthefarcortex.(Figure20)




Figure 20

Figure 19

Figure 18

99



Tibial shaftTheneurovascularbundle(theanteriortibialarteryandveintogetherwiththedeepperonealnerve)runanteriortotheinterosseousmembraneclosetotheposterolateralborderofthetibia.

Theyareatriskifthepinisinsertedin thedirectionasindicatedbythereddottedlineapproximatelyhalfwaybetween the anterior crest and the medialedgeofthetibia.(Figure21)

Tibiofibular jointWheninsertingSchanzscrewsinthe distalzonetakeintoaccountthepositionoftheanteriortibialarteryandvein.

PercutaneousinsertionofSchanzscrewsinthisareaisdangerous.Aminimalincisionwillallowpreparationandsafeinsertion.(Figure22)

Metatarsal placementAsmallSchanzscrew(4mm)canbeplacedinthesecondmetatarsal.

However,rememberthatthedorsalispedis artery and veins and deep peronealnervelieonthemedialside ofthesecondmetatarsalbase.

Apininsertedhererequiresbluntdissectiontotheboneandcarefulretraction.




Figure 23

Figure 22

Figure 21



PLACEMENT OF CALCANEAL PINSUseafulllengthDenhampin.ThislookslikeaSteinmanpinbuthasacentralthreadedsectiontopreventslippageinthebone.

ASteinmanpincanbeused,butwillhaveareducedperiodofeffectivenessuntilitstartstoslipinthebone.Placethispin2/3ofthewayalongalinebetweenthetipofthemedialmalleolusandthetipoftheheel.Theneurovascularbundleis1/3ofthewaydownthisline.Theneurovascularbundleisnearerthemedialmalleolus.Insertthecalcanealpinfromthemedialsidetoreducetheriskofinadvertentlyimpalingtheneurovascularbundle.Ensurethatthepinisinsertedinplane90degreestothelongaxisofthetibia.


» External fixation pins in children with open growth plates should be inserted in the metaphysis, 1 cm from the growth plate. The growth plate and epiphysis should be avoided in order to prevent iatrogenic growth disturbances.

» Remember that the anterior proximal tibial growth plate extends into the tibial tuberosity.

» As a rough guide, the long bones in boys cease growth around 16 years of age and girls around 14 years of age. However, delayed onset of menarche due to being underweight or having poor nutrition will prolong the years of growth in girls.

(AO Foundation, Switzerland) Figure 24. Calcanealpinplacementsite.

101



TECHNIQUE FOR BRIDGING THE WRIST» Forearmpins—4mmpinsx2 in the radius,placedunderdirectvision,avoiding thedorsal

branchoftheradialnerve

» 3mm pins in the 2nd or 3rdmetacarpal dorsally, ensuring the extensor tendons are notimpaledorwounduponthepins.

» Constructahandleontheforearm,andasecondhandleonthemetacarpalandconnectthe2handleswitha3rdbar.(Figure25A)

» Alternativelythetechniqueusingasinglepinproximallyanddistallycanbeimplemented,andtheadditional2pinscanbeaddedafterreduction.(Figure25B)

A

B

(AO Foundation, Switzerland) Figure 25. Externalfixationofthewrist



PIN CARE» Allmanagementtechniquesareintendedtopreventtheboneortissuesaroundthepinsfrom

becominginfected.

» Absorbentdressingstosoakupearlyoozingofbloodareusuallyappliedintheoperatingroomatthetimeofinsertion.Thisdischargeusuallystopsat24–48hours.

» Adrysquareofspongewithasmall ‘L’cut into itfitsneatlyaroundthepin,soaksuptissuefluidandiseasilyremovedat48hours.Noadditionalsupporttokeepitinplaceisneeded,butdressingsforthelimbwoundscanbeeasilyappliedovertopoftheL-cutsponges.

» Dressingpinsites,withgels,ointments,orocclusivedressingsshouldbeavoidedastheywillpreventdrainagefromaroundthepinsites.Erringonthesideofaslightlylargerincisionsduringpinplacementcanaidwithdrainage.

» After48hours,theabsorbentpindressingcanberemoved.Carefromthismaybedictatedbythelocalinfrastructureandaccessibilityofavailablemedicalcare.

» Dailyroutinesofpinwashingandremovingofcrustsbythepatientareoftenadvised,andthepatientmaybepermittedtoshowerorbatheanddrythepinsitesafterwards.Thewashingofpinsitesshouldbedoneusingasafewatersupply.

» Theskinaroundthepinshouldbemobilizeddailytopreventtheskinfrom"closing”onthepin.

» Pinsite infectionsifcaughtearlycanbemanagedbyashortcourseofantibiotics. However,persistentinfectionshouldbetreatedbyIVantibiotics,localdebridementorpinchangeinordertopreventdeepinfectionandchronicosteomyelitis.

» Establishedinfectionresultsinpinloosening.Ifthefractureisnotunitedthismaynecessitatere-sitingthepinandreconstructingaframe.

» Oncethewoundoveranopentibialfractureishealedandstable,theexternalfixatorcanbereplacedbyacast(usuallyaround6weeksfollowingthefracture).

» Inremoteandruralareas,wherecleanwater isafiniteresourceandpreservedfordrinking,externalfixationpinsareoftencovered in swathesofbandages inaneffort topreventdustgettingintothetissuesalongsidethepins.

103



MANAGEMENT OF OPEN FRACTURES

TYPE 3

Treatmentoflongsegmentdefectsrequireslongtermfollowupandshouldbesenttoatype3ifpossible.

SEGMENTAL DEFECTS IN LONG BONES» Intheeventoflossofasegmentofalongboneshaftof<5cm,consideranacuteshorteningto

allowtheboneendstocontactandfacilitateprimaryunion.

» Laterlengtheningmaybeanoption.

» An alternative if swelling is already a problem is to apply an external fixatorwith the bonesegmentatthenormallengthtorestthesofttissuesandmakeaplantoacutelyshortenthesegmentwhentheswellingresolvesandtheriskofcompartmentsyndromehasbeenminimized.

» Segmental loss of greater than 5 cm, particularly if associated with significant soft tissuedamageandnerveinjury(mangledextremity)oftenresultsinpoorfunctionaloutcomes.Earlyamputationcouldbeconsideredbasedonthesofttissueinjury.

Figure 26.Opentibialfracturewithnon-viableboneandsofttissueloss.(Bar-On)

Figure 27.FracturefromFig.26followingextensiveboneandsofttissuedebridement,shorteningandexternalfixation.(Bar-On)

In the event of open fracture with

interruption of vascular supply

vascular shunting (see next page)

should be a standard skill.

However, the duration of shunting

remains an open question without

consensus.



OPEN FRACTURES WITH VASCULAR INJURY» Thereturnofcirculationtodistaltissuesistimecritical.

Warmischaemictimeshouldnotexceed4hours.

» Some bone stabilization is required if any vascularreconstructionorrepairisperformed.Externalfixationwouldbethemostlikelypreferredoption.

» Iftimepermits,thenexternalfixationpriortovascularrepair prevents bonemovement during pin insertionand fracture reduction from stressing the vascularrepair.

» Forthisapproachtobeeffective,patientsmustbeabletobeevacuatedpromptlytoahigherlevelofcare.

» Ifthelimbisviable,shuntwithalongerthanrequiredshunt, then apply an external fixator and perform adistalfasciotomy.

» Converttheshunttovascularrepairatasuitabletime.Ifformalvascularshuntsarenotavailable,anytubeofappropriate size will do (IV or paediatric nasogastrictubing).

Figure 29. Temporaryvascularshuntsecuredwithsuture(ICRC)

Figure 28. Linedrawingofplacementoftubingfortemporaryvascularshunt(ICRC)

105



KEYS TO VASCULAR SHUNTS» Thecriteriatoinstallatemporaryshuntasabridgetodefinitiverepairwill

dependontheclinicalevaluationofhardandsoftsignsofvascular injury,but the most important factors to consider are the presence of ischemia or hemorrhage.

» Manypatientswithvascularinjuriescanhavea"containedlesion"withnoischemiaoractivehemorrhage,and theyshouldbemoved to theproperfacilitywithnoproceduresbeyondimmobilizationoffractures.

» DURATION OF THE SHUNT:Theshuntshouldbeinplaceuntilthesecondstageofdamagecontrolcanbesafelycompletedinunstablepatients,andforstablepatients,untilexternalfixationcanbeobtained.

» HEPARINIZATION: Distal shunts such as those below the knee tend toobstructmoreeasilythan largercaliber,moreproximalshunts.Therefore,thedecision forheparinizationshouldbetakenbasedonthepresenceorabsenceofothermajorinjuriesandtheexpectedtimetodefinitiverepair.

Figure 30. Effectivecontrolandexposureiscrucialforsuccessfulcontrolorrepairofvascularinjuries.(ICRC)



OPEN REDUCTION AND KIRSCHNER WIRE (K-WIRE) FIXATIONUseonlysingleendedK-wiresforsafetyoftheoperatingroomstaff.Doubleendedwireshaveahighriskofinjurytostaffthatoutweighsanyperceivedbenefit.Sizesneededare1.6and1.1mm,andcerclage wire 16 and 18 Gauge.

K-wirefixationmaybeconsideredearlyinopenfracturesof the hands, and less oftenwith open fractures of thefeet.

Hand injuries often appear worse than they are andeveryattemptshouldbemadetokeepasmanydigitsaspossible,especiallythethumb.

Using k-wires may mean that badly injured fingers aresalvaged that would otherwise have been lost throughinstabilityandfurtherinjurytotheirvascularsupply.Theyshouldnotbeusedinopenlongbonefractures.

Theinsertionofk-wiresunderpowerismoreaccurateandfasterthanusingahanddrill.Theyaredifficultto insertwithahanddrillasonehandisnecessarytostabilizethesegmenttobepinned.

Early use of K-wires in open fractures raises the riskof colonization of the wires and subsequent infection.Consider timing of K-wire fixation tominimize infectionrisk in fractures of the olecranon, patella and to securelargearticularfragments.

Theolecranonandpatellafracturesmaybeamenabletowaiting untilwounds have healed before proceeding tointernalfixationwithwires.

However,earlyusemaybeadvisableinsecuringarticularfragmentswhere the lossof those fragments isaworseoutcomethanifthewiresbecomeinfected.

NO INTERNAL FIXATION OF FRACTURES OTHER THAN K-WIRE FIXATION IN HANDS AND FEET SHOULD EVER OCCUR IN A TENT.Refer local patients needing ORIF (i.e. for intra-articular fracture) to local services. The local teams will be providing follow up and should be involved in the care from the early stages.

107



Figure 31.AntibioticProtocolforAdultswithconflictinjuries(ICRC)

ANTIBIOTICS IN OPEN FRACTURES

» Antibiotics are an adjunct to wound surgery and not an alternative. The use of antibiotics for open contaminated fractures is limited to 24-72 hours, unless clinical evidence of infection is present.

» Tetanus prone wounds and uncertainty regarding past immunization should prompt treatment with Immunoglobulin 500 units and administration of the tetanus vaccine



SUGGESTED RESOURCES

1. Gosselin RA. War injuries, trauma, and disaster relief.Techniques in Orthopaedics 2005; 20(2): 97-108.

2. Herard P, Boillot F. Amputation in emergency situations: indications, techniques and Médecins Sans Frontières France’s experience in Haiti. International Orthopaedics 2012: 1-3..

REFERENCES



3. Dufour D, Jensen SK, Owen-Smith M, Salmela J, Stening GF, Zetterström B. Surgery for victims of war. 1998.


5. Menelaus MB. The management of limb inequality. Churchill Livingstone; 1991.

6. AO Surgery Reference. 2016. https://www2.aofoundation.org/wps/portal/surgery2016.


COMPARTMENT SYNDROME AND CRUSH SYNDROME

SCENARIOCOMPARTMENTSYNDROMEDIAGNOSISCOMPARTMENTSYNDROMETREATMENT

CRUSHSYNDROMECRUSHSYNDROMEMANAGEMENTINSODS

SUGGESTEDRESOURCES

REFERENCES

9


CHAPTER 9 I COMPARTMENT SYNDROME AND CRUSH SYNDROME

SCENARIO

TYPE 1

• Analgesia&Splinting.• Recordtheneurovascularstatusofthelimb.• Elevateonmaximum1pillow.• Urgenttransfertosurgicalfacility.

TYPE 2 • Fasciotomyifindicatedandlessthan24hourssincetimeofinjury.• Minimallimbelevationtoreducecompartmentbloodflow.• Delayedclosureorcoverageoffasciotomyincisions.

TYPE 3

YourEMTtype2justsetup48hoursafteranearthquakehasstruck.Thereare five patients on stretchers withclosedlowerlimbfracturesrequiringyourcare.

The first patient, a 24-year-old girl,has a mid-tibia and possibly fibulafracture.

Thelegisswollenandtenderandthedistalstatusisdifficulttofullyassess,althoughthereseemstobeafaintlypalpableposteriortibialpulse.Shecan,withpain,slightlymovehertoesandhassensation,butthetranslationregardinghersensationisnotexact.

Theremainingfourpatientshavesimilarstatus;theyhaveallhadextremitiescrushedundertherubblewithvaryingdegreesoffunctionaldistalstatus.Yoususpectthattheyallhavecompartmentsyndrome,butwhattodo?Athome,allthepatientswouldgetanacutefasciotomy.Buthere,inthiscontext,andmorethan2daysaftertheinjury?

CASE CONTROVERSIES:» Willfasciotomybenefitthepatientandsavethelimborcreatemoresuffering?

» Whatisyoursurgicalstrategy?

» Howaccurateistheclinicalexaminationindiagnosingcompartmentsyndrome?

» IsthereanyroleatallforcompartmentpressuretestinginSOD’s?

(Bar

-On)

111



DIAGNOSISEarly diagnosis of compartment syndromemust bemade based on the clinical picture and thesuspicionthatacutecompartmentsyndromemaybepresent.

Earlysymptomsinclude:

» Painoutofproportiontoexam(i.e.excessivepain)

» Lessthanexpectedresponsetoanalgesia

» Painwithpassivestretching

» Tenseswellingoverthecompartment

» Distalparaesthesiainperipheralnervedistribution

SPECIAL CONTEXTSCompartment Pressure Checks in Disasters and Conflicts

» Measuringcompartmentpressurescannotexcludecompartmentsyndrome.

» Measurementandinterpretationrequiresexperienceandequipmentthatisnotalwayspresent.

» Thevalueofimplementingthesechecksinanausteresettinghasnevertrulybeenevaluated.

» Conclusion: unless in very experienced hands, in specific situations, compartment pressuremeasurementsarenotrecommendedinthedisastersandconflicts.

PATHOPHYSIOLOGY» Increasedmusclecompartmentpressuresresultinimpairedcellularoxygenation.

» Anymovementthatincreasesthevolumeofthecompartmentorstretchestheischaemicfibersresultsinpain.

» Subsequentfluidextravasation results in increasedpressureonsensorynervesyieldingdistalparaesthesia.Furtherpressureincreasesovercometheprotectivebarrierofthemotorneuron’smyelinsheathyieldinglossofmotorfunction.

» Furtherpressureincreasescanovercomearterialpressuresresultinginlimbischaemiaandloss.



TYPE 3

MISSED OR VERY LATE PRESENTING COMPARTMENT SYNDROME: For patientswithclinicalevidenceofmusclenecrosisandpossibleclinicalevidenceofcrushsyndrome,urgentandmassivedebridementofmuscletissuemayberequired.Additionally,thesepatientsmayrequireintensive care and renal protective strategies.InthesecasesanamputationandEMTtype3levelcaremaybetheonlyoptiontosparethepatient’slife.

» Late sequelae of “missed” compartment syndrome may cause fibrosis and contracture of muscles.

» In the forearm this may result in “Volkmann's contracture.”

There are 2 treatment options following the diagnosis of acute compartment syndrome: fasciotomy and immobilization.

These need to be guided by the context with regard to resources as well as the overall clinical picture.

SPECIAL CONTEXTS AND COMPARTMENT SYNDROME TREATMENTInaSOD,patientsmaypresentwithcompartmentsyndromeinaverydelayedfashion.Fasciotomywillcreatewoundsrequiringcareandmakeaclosedfractureintoanopenfracture.

Thus,fasciotomyshouldnotbea“knee-jerkresponse”toanysuspectedcompartmentsyndrome.Thefactoroftimesinceinjurymust be included in the decision on type of treatment.

» 0–8h:Aninjurywithclinicalsignsofcompartmentsyndromeshouldreceiveanurgentfasciotomy.

» 8-24h:Itremainscontroversialwhetherfasciotomywillbenefitthepatient.Carefulassessmentshouldbedoneforsignsofextremityviability(e.g.painonpassivestretchingofcompartment,somesensation,capillaryrefill)andhowthepatienthasprogressedbeforeadecisionismaderegardingfasciotomy.

» ›24h:injuriesatthistimepointaretreatedbyobservationandsplintinginafunctionalposition,withslightelevation(i.e.onepillow).

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LOWER LIMB FASCIOTOMY

Figure 3. ThestandardanteriorfasciotomyincisionextendsoverthecarpaltunnelandGuyon'scanaldistally(inordertodecompressthemedianandulnarnerves),continueswithacurvedincisiontowardstheradialsideofthemid-forearmandbacktotheulnarsideoftheproximalforearm.Itmaybeextendedproximallyacrosstheelbowifwideraccessisrequired.


FOREARM FASCIOTOMY

Performatwoincision, fourcompartment fasciotomyby:

» A:Makeanincisionthroughtheskin2 cmsmedial to the subcutaneousposteromedial edge of the tibiafrom the tibial flare to just behindthe medial malleolus. Withoutundermining the skin, deepen thisincisionthroughthefascia.

Thiswillopenthesuperficialposteriorcompartment.Identifytheposteriortibialneurovascularbundleandincisethethinnerfasciaoverit.Extendthisalongthewholelengthofthefasciotomywound toopen thedeepposterior compartment. In themoreproximalpart thiswill involveincisingthroughthetibialoriginofthesoleusmuscle.

» B:Makethesecondincisionthroughtheskin2cmsanterolaterallytothesubcutaneousanterioredgeofthetibiafromthetibialflaretojustabovethelateralmalleolus.Withoutunderminingtheskin,deepenthisincisionthroughthefascia.Thiswillopentheanteriorcompartment.Sweepthemuscle bellies anteromedially to identify the intramuscular septum. Incise this along thewholelengthofthewound.Thiswillopenthelateralcompartment.

This technique preserves the vascularity of fasciocutaneous flaps that can be used for laterreconstruction.

Figure 2.Illustrationofthecompartmentsofthelowerleg,aswellastheincisionsrequiredforperformanceofa2incision,fourcompartmentfasciotomy. (BOA/BAPRAS)



POST OPERATIVE MANAGEMENT OF FASCIOTOMY INCISIONS» Dressingcareissimilartootheropenwounds.Drygauzedressingswithorwithoutanon-stick

dressingonthemusclebedarereasonable.

» Negativepressurewoundtherapyisalsoappropriateifresourcesareavailable.

» Most fasciotomy wounds can be closed with delayedprimaryclosure.Thiscanbeassistedbyutilizingavarietyoftechniquesdesignedtograduallyclosethewound.

» Ifdelayedprimaryclosureisnotpossiblethensplitthicknessskingrafting(STSG)mayberequired.

FASCIOTOMY• There is no role

for subcutaneous fasciotomies in a disaster or in conflict, nor in acute trauma.

• Do not be tempted to close the wounds in the absence of early swelling—reperfusion after the fasciotomy will result in more swelling than observed at the time of fasciotomy.

Figure 4.Dermatomebeingusedtoharvest skin from themedial thigh.Note the assistants hand applyingupwardpressuretoflattenthedonorsurface.(ICRC)

Figure 5.Scalpelbeingusedtomeshasplitthicknessskingraft.(ICRC)

SPLIT THICKNESS SKIN GRAFTING» Takesmallsplitthicknessgraftswitharazorbladeheldwithforceps,forlargergraftsuseaskin

graftknife(pictured).Applytractionusingthegraftingboardandhaveanassistantapplycountertraction.Thegraftknifeisusedwithabackandforthsawingmotion.

» Exposedfatindicatesfullthicknessgraft,theareashouldhaveahomogenousbleedingsurfaceifthedepthisappropriateforasplitthicknessgraft.

» Thegraftcanbeperforatedinordertopreventhematomaformationunderthegraft.

» Aftercleaningtherecipientarea,laythegraftinandsutureitatafewpointsforalignmentthensutureallgraftedges.Thesuturescanberemovedin7-10days.

» Itispreferabletoleaveskingraftdonorsitedressingsinplaceuntiltheareahashealed,evenforseveralweeks.

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SPECIAL CONTEXT: EARTHQUAKE» Crush syndrome canbe a commonpresentation following an earthquake and canpresent in

advancedstagesduetothelengthoftimerequiredtolocateandextricatevictims.

» Latepresentationsof crushsyndromeinclude:

• hypovolaemicshock

• hyperkalaemia

• metabolicacidosis

• disseminated intravascularcoagulation(DIC)inverylatecases

CRUSH SYNDROME» Crush syndrome is the severe systemicmanifestation of trauma and ischemia involving soft

tissues,principallyskeletalmuscle,duetoprolongedcrushingoftissues.

» Theprolongedmuscleischaemiaincreasescellmembranepermeabilityandleadstothereleaseofpotassium,enzymesandmyoglobinfromcells.

» This, combined with systemic hypotension, results in renal dysfunction with acute tubularnecrosisanduremia.

Figure 6. Woman crushed and entrapped by rubble.Thispatientrequiredafieldamputationoftheupper right arm in ordertoextricateher. (Bar-On)

Figure 7.Aswollenlegwithsloughingskin,concerningforunderlyingmusclenecrosis(Bar-On)



When transfer to a higher level of care is available, tourniquet application to the crushed limb may prevent loss of life from hemorrhage or electrolyte abnormalities secondary to crush syndrome.

TYPE 2

• Continuefluidreplacementwithcrystalloidandsodiumbicarbonate• Electrolytemanagementtocontrolhyperkalaemiaandhypercalcaemia• Continuetoforcediuresiswithfurosemide,mannitol,oracetazolamide.• Monitorurineoutputandurinemyoglobin.• Assessinjuryforneedforpossiblefasciotomy,debridement,oramputation.

TYPE 3

• Continueallmedicalandsurgicalmanagementasatlevels1and2.• Considerperitonealdialysis• Considertransfertoacenterwherehaemodialysisisavailable.• Assessandplanforreconstructionorcompletionofadvancedwoundcarefor

injuredlimb.

CRUSH SYNDROMEManagementofcrushsyndromecanrequirehighlevelresourcesincludingintensivecareandrenalreplacementtherapy.

Thus,theprogressionofcareforthesepatients isoftendependentonappropriatemanagementateachEMTlevelofclassificationandpropertransferbetweenthelevels depending on availableresources.

TYPE 1

Thetype1EMTreceivingcrushpatientsisoftenasearchandrescueteam(SAR).Theseunitsshouldbepreparedto:• Securetheairway.• Securevascularaccessandcommence

resuscitationwithnormalsaline1000-1500mL/hmodifiedbyweight.

• Monitorurineoutput.Ifnooutputfor3hoursfollowinginitiationoffluidsthengivefurosemide40mgor1mg/kgIV.Repeatthedoseifnooutputonehourafteradministration.

• MonitorpulseandBP.Iftherearesignsofcongestionoranuriathenslowtheinfusionto500-1000mL/24hr,beyondthepatient'scalculatedlosses.

• Placementofaurinarycatheterisnotrecommendedatthislevel.

• Providebasicwoundcareandsplintingifnecessary.

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SUGGESTED RESOURCES

1. Zhang X, Bai X, Zhou Q. First-aid treatments of crush injuries after earthquake: 2 special cases. The American Journal of Emergency Medicine 2014; 32(7): 817 e3-4.

2. Gerdin M, Wladis A, von Schreeb J. Surgical management of closed crush injury-induced compartment syndrome after earthquakes in resource scarce settings—an overview of reviews. The Journal of Trauma and Acute Care Surgery May 2012.

3. Sever MS, Vanholder R. Management of crush victims in mass disasters: highlights from recently published recommendations. Clinical Journal of the American Society of Nephrology 2013; 8(2): 328-35.

4. Bartal C, Zeller L, Miskin I, et al. Crush syndrome: saving more lives in disasters: lessons learned from the early-response phase in Haiti. Archives of Internal Medicine 2011; 171(7): 694-6.

REFERENCES1. von Keudell AG, Weaver MJ, Appelton PT, et al. Diagnosis and treatment of

acute extremity compartment syndrome. The Lancet 2015; 386(10000): 1299-310.

2. Surgical care at the district hospital: World Health Organization; 2003.

3. Lindberg DA, Humphreys BL, McCray AT. The Unified Medical Language System. Methods of Information in Medicine 1993; 32(4): 281-91.

4. Schwartz DS, Weisner Z, Badar J. Immediate Lower Extremity Tourniquet Application to Delay Onset of Reperfusion Injury after Prolonged Crush Injury. Prehospital Emergency Care 2015; 19(4): 544-7.

5. Nanchahal J. Standards for the management of open fractures of the lower limb: Royal Society of Medicine Press Limited; 2009.

6. Sever MS, Vanholder R. Management of crush victims in mass disasters: highlights from recently published recommendations. Clinical Journal of the American Society of Nephrology 2013; 8(2): 328-35..



9. AO Surgery Reference. 2016. https://www2.aofoundation.org/wps/portal/surgery2016.


AMPUTATIONS

SCENARIOLOWEREXTREMITYAMPUTATIONS

SPECIFICTECHNICALCONSIDERATIONSUPPEREXTREMITYAMPUTATIONS

SPECIALCONSIDERATIONSCOMPLICATIONSOFAMPUTATION

KEYMESSAGESREGARDINGAMPUTATION

SUGGESTEDRESOURCES

REFERENCES

10


CHAPTER 10 I AMPUTATIONS

SCENARIO

TYPE 1

• Managementofinjuriesthatmayrequireamputationattype1facilitiesprimarilyconsistsofwoundcare,analgesia,possibletourniquetplacementtostoplifethreateninghemorrhageandtransfertoahigherlevelfacility. Patientswithvascularcompromiseshouldhaveahighpriorityfortransfer.

TYPE 2 • Amputationisasurgicalandreconstructiveprocedurethatisalastresort.Evaluationbyexpertsattype2and3facilitiestoassessforpossibleoptionsforlimbsalvageshouldbeobtainedwheneverpossible.

TYPE 3

A20-year-oldfemalewasavictimofblastinjurytoherrightlowerlegfourhourspriortopresentationatanEMTtype1.

Thereissofttissuelossovertheanterioraspectoftheanklewithlossofthetibialpilonandexposedfragmentsofbonefromthedistaltibia. Inthefoottherearenopalpablepulses,withveryslowcapillaryrefill.Thereisnosensationovertheplantaraspectofthefoot.

Afterwashout,dressing,andsplintingthepatientarrivesatanEMTtype2,twelvehourslater.Notourniquetwasappliedbutthepatient’stoesarenowcyanoticandthereisnolongercapillaryrefill.Anamputationisrecommendedbutthepatient’shusbandcategoricallyrefusestoconsent.

Figure 1.TraumaticAmputationoftheleftleg(Bar-On)

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SPECIAL CONTEXTS» Thecase scenariodiscussedat theopeningof this chapter is,unfortunately,notuncommon.

Amputation is not just a surgical procedure, it is a process through which the patient, thepatient’sfamily,andtheentiresocialcirclemustnavigatefortheremainderofthepatient’slife.

» Thedecisiontoamputatemusttakeintoaccountsocio-cultural,religious,economicandethicaldimensions.

» Inmanyplacesaninsensateanduseless,evenpainful,limbispreferredtoanamputation.Youngmaleamputeesmayneverwork,youngfemaleamputeesmaynevermarry.

» The humanitarian community has been criticized recently for having too low a threshold toamputate,particularlyfollowingthe2010earthquakeinHaiti.

» Thevariousscoringsystemsusedtopredicttheneedforamputationmaynotbeapplicableindisasterandausteresettings.

» The availability of reconstructive surgery should be taken into account when planning thetreatment.

GENERAL CONSIDERATIONS» The amputation stump should be painless, well

padded,balanced,andeasytofitwithaprosthesis.

» Prosthetics should be comfortable, light, durableand built from locally available materials by localprosthetists.

» Upper extremity amputees always lose somedegreeof function,andsocial reintegrationmaybecompromisedwheremuchoftheworkismanualinnature.

» Loss of function in lower extremity amputeesdependslargelyontheprostheticsandrehabilitationcapacityofthelocalsystem.

» In the absence of an appropriate prosthesis, lowerextremity amputees can move only with assistivedevicesthatoccupybothupperextremities.

» Amputations should never be performed without the written and witnessed consent of the patient and/or guardian, and when possible, additional family members should be included in the decision process.

» Photographic evidence and a second opinion should be obtained when possible in order to strengthen the documentation.



There is disagreement among surgeons

as to whether the local prosthetics and

rehabilitation capacity should dictate the level

and type of an amputation. Some advocate always

taking these factors into account, while others feel that in conflicts and SODs

it is often impossible to know what services may

be present in the months and years ahead.

Figure 2.Severesofttissuedamageandopenfractureofthelowerlimbthatrequiredamputation (Bar-On)

GENERAL PRINCIPLES» Thedefinitiveindicationsforamputationare:

• Avascularlimbintheabsenceofvascularreconstructioncapabilities• Uncontrollableinfection• Mangledextremityintheabsenceofreconstructivecapabilities

» Evenindisastermanagementsettings,amputationscangenerallybedelayedexceptinthecaseofseverewoundsthatarecomplex,infected,contaminated,orhavenoviabledistaltissues.

Principles of Amputation in

conflict and disasters

» Guillotine amputation is almost never indicated except as a last resort to extricate an entrapped patient.

» Preserve limb length» Use flaps of convenience

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» Theprinciplesofwounddebridementapplywhenperforminganamputation:removealldevitalizedtissues,leaveasmuchskinaspossibleforflaps,andcreateaslongastumpaspossible.

» Apneumatictourniquetshouldbeusedifavailable.Careshouldbetakentodeflatetourniquetpriortoflapclosuretoensureadequatehaemostasisofthelowerlimb.

» Namedvesselsshouldbeligatedindividuallywithtransfixingsutures.» Nervesshouldbesharplytransectedundergentletraction,allowingthetipofthenervetoretract

orbeburiedinthemusclebelly.» Whenselectingthelevel,rememberthatashortstumpthatpreservesajointispreferabletoa

moreproximalamputation.» Adisarticulationispreferabletoamoreproximalthroughtheboneamputation,asthestumpendis

alreadyaweightbearingsurfaceandprostheticfittinghasimprovedwithmoremoderntechniquesandmaterials.

DELAYED CLOSURE» Theamputationstumpshouldbetreatedasanyotherwoundandneverclosedprimarily.» Delayedprimaryclosureoftheamputationstumpshouldbeattemptedwhenthewoundisclean,

usually2-5daysfollowingtheinitialoperation.» Ifneeded,stumpscanbepartiallyclosedandallowedto

healbysecondary intention.Additionaloptions includeskingraftsorflaps.

» Effortstopreservemaximumlimblengtharenotalwayssuccessful. However, bone ends should always haveadequate soft tissue coverage. Bone shortening ispreferabletoinadequatesofttissuepaddingofthestumpend.

NURSING, REHABILITATION AND PHYSIOTHERAPY» Preventionofjointcontracturesisofparamountimpor-

tance.» For above-knee-amputations (AKA) flexion and

abduction contractures can be prevented throughpropersurgicaltechniqueandearlyactiveandpassivephysiotherapy.

» TheAKApatientshouldlieproneforseveralhourseachday.

» For below-knee-amputations (BKA), knee flexioncontractureisamajorconcern.ItcanbepreventedbysplintingthejointinextensionuntilthetimeofDPCorhavingtheclosedstumprestonapillow

CULTURAL CONTEXT

» Ensure that proper arrangements are made for the disposal of an amputated limb. These practices will vary between cultures and religions.

NEVER put a pillow directly under the knee

joint of a BKA patient.



Figure 3.Severeinjurywithnochanceofre-implantationisanindicationforamputation.(Bar-On)

SPECIFIC TECHNICAL CONSIDERATIONSFOOT AMPUTATIONS–Whenfeasible, toe, ray,andtrans-metatarsalamputationsresult inasensateandweightbearingstumpandshouldbeemployedwhenpossible.

» Moreproximalamputationsrelyonthepreservationofthehighqualityheelpadandbalancingtheopposingdorsalandplantarflexors.

» Mid-tarsalamputationsarenotrecommended.

» Iftheheelpadisintactacalcaneo-talo-tibialfusioncanprovideastableweightbearingstump.

ANKLE DISARTICULATION – Symeamputationoftenprovides the best result if an ankle disarticulation isrequired.Theprocedureprovidesanendbearingstump.

» The procedure requires an intact heel pad which issecuredtothedistaltibiaanteriorlywithtrans-osseoussutures.

» If the heel pad is lost, severely damaged or missing then a distal BKA should be undertaken.

Figure 4.LinediagramofaSymeamputation.Thistechniqueutilizesanintactheelpadtoprovidepatientswithastableweightbearingstump.Theoperationpreserves thephysealplateand canbefittedwithaprosthesis for aestheticreasons. (ICRC)

Many surgeons prefer excising the talus and doing a tibio-calcaneal fusion to a tibio-talo-calcaneal fusion. However, other surgeons feel that in austere conditions fusions should be avoided due to risks of infection and non-union and a Syme amputation may be preferable.

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1/3 1/3 1/3

TRANS-TIBIAL AMPUTATIONS – BKA is themost common amputation performed inmostdisastersettings.TheclassicBurgessstepcutisoftennotpossible,howeverlessorthodoxstumpscanstillprovideexcellentresults.

» Thedistal1/3ofthetibiaisnotusefulinweightbearing,butthestumpshouldbeleftaslongaspossibleuptothispoint.

» Proximally,amputationlessthan6cmbelowthetibialtuberclewilloftenrequireconversiontoakneedisarticulation.

» Theanteriortibialcrestshouldbebeveledata45degreeangleandtheedgessmoothedwitharasp.

» Thefibulashouldbe1.5 -2centimetresshorter thanthetibia,andthedeepposterior fasciasuturedtotheanterioraspectofthetibia.

» Skinshouldbeclosedoveradraininaninterruptedfashion,withcaretakentoavoid“dog-eared”skinedges.

» Thestumpshouldbesplintedinextensionandrehabilitationbegunassoonaspossible.

Figure 5.ICRCillustrationoftheidealstumplengthforBKA,emphasizingthefactthatthemiddlethirdofthetibiamakesfortheidealstump.(ICRC)



Figure 6. Image demonstratingtheimportance

ofgoodsofttissuecovering.Theleftstumpiswellcovered,

therightislacking.(ICRC)

KNEE DISARTICULATION –Thisprocedureproducesasturdyend-bearingstump.Inthepasttechnical problemswith the prosthetic knee joint have discouraged its use. However, recenttechnicaladvancesinmaterialsandprostheticscanallowprosthetiststoaddressthisissue,eveninaustereenvironments.

» Closure of knee-disarticulation incisions utilizes a standard fish mouth incision with patellartendonsuturedtotheposteriorcruciateligamentposteriorly.

TRANS-FEMORAL AMPUTATIONS–Trans-Femoralorabovekneeamputations(AKA)arethesecondmostcommonamputationthatrequirescuttingalongbone.Thesestumps,likeBKAsarenotendbearingandmustbecontactfitted.

» The femur is usually cut at or near the distalmetaphyso-diaphyseal junction in a transversefashion.

» ThekeytosuccessfulAKArequiresappropriatebalancingofagonisticandantagonisticforces,asamputationsatthemidordistalfemoralshaftareatriskofdevelopinganabductioncontractureofthehipfromanunopposedgluteusmedius.

» ThebellyoftheadductormagnusiscutatornearHunter’scanalandfixedonthelateralsideof the femur, preferablywith trans-osseous sutures. Thismaneuver serves to counteract theabductorforces.Thequadricepsisattachedposteriorlyinasimilarfashion.

» Thesuturingof thequadricepsdirectlytothehamstringshouldbeavoidedas itcancreatea“slinging”effectovertheboneendthatispainful.

» Amputationsthroughtheproximal1/3ofthefemurareatriskofdevelopingaflexioncontracturefromunopposedactionsof thepsoasmuscle.Topreventthiseveryeffortshouldbemadetokeeporreattachthegluteusmuscletothelineaasperaposteriorly.

» Hip disarticulation and pubo-sacro-iliac disarticulation are rare procedures and should bereservedforinstancesinwhichnootherprocedureispossible.

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UPPER EXTREMITY AMPUTATIONSHAND INJURY » Handfunctionispreciousandeverymillimeterofmovementandlengthisofhighvalue.Therefore,

debridementshouldbeasconservativeaspossibleandeveryeffortmadetopreservethemaximumnumberofdigits,particularlythethumb.

» Asmallphalangealstumpprovidesbetterfunctionthanametacarpalphalangealdisarticulation.

» Kwirescanbeusedtostabilizefractures,andsecondlookoperationsshouldbeutilizedwheneverpossibleinordertoallowdeadtissuetodeclareitself.

» Dressingsshouldconsistofabsorbent,fluffy,drydressingsthatallowforvisualizationofthefingertips.

» Ifawristdisarticulationisrequiredthethickerpalmarskinshouldbeusedtocoverthestump.

» Thereareamultitudeofcoveragetechniquesthatcanprovetobedigit-saving(V-Yadvancementflaps,fingertofingerflaps,handinbellytechnique).

ARM INJURY » Forearm Amputations –thelongerthestumpofforearmpreserved,thehigherdegreeofpronation

andsupinationfunctionwillbepreserved.

» The radius and ulna should be amputated at the same level. There are no indications for theKrukenbergor“lobsterclaw”technique.

» An elbow disarticulation is preferable to athroughthehumerusamputation.

» Upper Arm Amputations – amputationsthrough the distal half of humerus allow forpinchingbetweenthearmandchest.

» Proximal amputations often result in anabductioncontracturethatlimitsfunctionality.

» Shoulder disarticulation and scapula-thoracicdisarticulationshouldnotbeconsideredexceptininstancesoflife-savingemergencysurgery.

» All upper extremity amputees must startrehabilitationassoonaspossible.

» In resource poor environments basic prostheses arenormallyavailable.

» Patientsoftenrequireonlyacosmetichandornoprosthesisatall.

Figure 7.Upperextremityamputationinayoungpatient.(Bar-On)



Figure 8.Amputationsinchildrenrequirespecialattentionduetothefactthatthe

bonesareoftenstillcapableofgrowth.(Bar-On)

Figure 9.Intheeventofmangledextremities(orbeyondclassificationtrauma),proximalanddistalinjuriesshouldbe

dealtwithseparatelywheneverpossible(Bar-On)

PAEDIATRIC CONSIDERATIONS» If the physeal plate is intact, the limb will

continuetogrow.Therefore,boneresectioninchildrenshouldbeveryconservative.

» In children, disarticulations do better thanthroughtheboneamputations,duetothefactthat exostosis and overgrowth are commonwithAKAandBKA.

» If possible, a long periosteal sleeve should bepreservedand sutured to itselfover theboneend.

» The open bone end should be “capped” byplugging the open medullary cavity with apiece of bone harvested from the amputatedsegment.

Mangled Extremity» In the event of

mangled extremities, the distal extremity should be amputated as if it were an isolated problem and proximal fractures treated as if they were an isolated problem (i.e. fix with sling, external fixation, or traction).

» DO NOT amputate through the fracture.

129



Figure 10.Aninfectionofanamputationstump.(ICRC)

WOUND ISSUES COMPLICATIONS» Acutewounddehiscenceandnecrosisoccurifthewoundissuturedunderexcesstension.This

canbepreventedbyleavingthewoundopen,wrappingthestumpandrevisitingthewoundwhenswellinghasdecreased.

» Negativepressuredressingsareaveryeffectivemeansofshapingastumpandreducingswelling.

» Purulentdrainagemeansthatnecroticmaterialhasbeenleftbehindandthewoundrequiresre-debridement.Unlesstheinfectionisverysuperficial,antibioticsalonewillproveinadequate.

» Chronicwoundsoverboneyprominencesoccurduetopoorlyshapedorpaddedstumps,duetoexcessive pressure in the prosthesis. Prostheticmodificationmay circumvent the problem, butstumprevisionisoftennecessary.

CONTRACTURES» Contracturesdevelopwhensurgicalbalanceofagonisticandantagonisticforcesisnotachievedor

whenappropriaterehabilitationcapacityisnotpresent.Theycanbepreventedbyphysiotherapy,splinting,orcasting.

» Equinuscontractureoftheankleorflexioncontractureofthekneecanbeparticularlycripplingandaremoreeasilypreventedthantreated.Theyrequiresurgicalreleasewhentheyarerigid.

NEUROMAS» Neuromasoccurontransectednervesaspartofthephysiologicprocessofrepair.Painfulneuromas

are often transient but some never disappear. They can prove difficult to differentiate fromphantomlimbpain.

» Painduetoneuromasoccursinthe stump rather than the am-putated limb, and can worsenwithprostheticuse. Diagnosticblockscanbehelpfulinmakingthediagnosis.

» If socketmodificationdoesnotresolve the issue, surgical re-vision is indicated. The neuro-ma is resected and the neuralstumpallowed to retractproxi-mallyorburiedinamusclebelly.



PHANTOM LIMB PAIN» Phantom pain is a common complication of limb amputation, occurring in nearly half of all

amputees.

» Thepainisfelttobecomingfromtheamputatedsegmentratherthanthestumpitself.

» Itiscommonlypresentatrest,butoftenworsenswiththeuseofaprosthesis.

» Itcanbedifficulttofullydifferentiatefromphantomsensation,ageneralsensebytheamputeethatthelimbisstillpresent.Phantomsensationgenerallydisappearsbetween6and12monthspostoperatively.

» Manytechniqueshavebeenattemptedtotreatphantompain,buttricyclicantidepressantsandgabapentinhavegenerallyproventobeaneffectiveregimen.

OVERGROWTH/EXOCYTOSIS» Overgrowthandosteophytesappearmainly

in children, but canoccur in adult patientswhenperiostealstrippinghasbeenoverzeal-ous.Thepressurepointsgeneratedbythisconditionoftenrequiresurgicaltreatmentoftheovergrowtharea.

MENTAL HEALTH» Allpatients indisastersandconflict sustain

psychological as well as physical trauma. The additional trauma of undergoing anamputation can precipitate mental healthproblemssuchasdepression,aggressivenessor substance abuse. The entire treatmentteam should be vigialant regarding theseissues.

PROSTHESIS ISSUES» Theamputeebecomesalifelongpatient.A20-year-oldmalewitha50yearlifeexpectancymay

require20differentprosthesesoverthecourseofa lifetime.Maintenance,repair,replacement,andprovisionofsoftgoodsallneedtobeprovidedforinasustainableanddurablemanner.

Figure 11.Osteophyteformationonthetibia,andoverlylongfibulacausingpainandstumperosioninaBKApatient.

(ICRC)

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KEY MESSAGES» Primaryamputationsareindicatedif:

• Theextremityisnotviableandrevascularizationiseithernotavailableornotindicated.

• Itisalife-savingprocedurefortreatmentofaninfectionsuchasgasgangreneordecompensatedsystemicsepsis.

» Amputationsforindicationsotherthanthosecoveredabovecanbeperformedinadelayedfashion.

» NoamputationshouldbeperformedatanEMTtype1facility.

» Whendiscussingamputationwiththepatientandhisorherfamilyorsupportsystem,itisimportanttobeveryclearabout theoptionsandalternativessurrounding theoperation. Giveyourbestsurgicaladviceandavoidgivingunrealisticorfalsehope.

» Ifpossibleobtainaseconddocumentedopinionandphotographicdocumentation.

» Neveramputatewithoutsignedconsentfromthepatientorguardian.

» Theviabilityofdistaltissuesshoulddeterminetheindicationforamputation,notthedistalsensoryormotorfunctionorthepresenceofboneloss.

» Theamputationshouldalwaysbeasdistalasissafelypossible.

» Donotprimarilyclosethestumpindisasterandconflictsituations,planfordelayedprimaryclosureat2-5days.

» Neverclosethestumpundertension,partialclosureandrepeatattemptatDPCispreferabletoahightensionwoundclosure.

» Beawareofthepsychologicalrepercussionsforthepatientandprovidesupportassoonaspossible.

» Startphysiotherapyandrehabassoonaspossible.

» Ensure that proper arrangements are made for the disposal of the amputated segment. The“properarrangements”willvaryacrosscultures.



SUGGESTED RESOURCES

1. Knowlton LM, Gosney JE, Chackungal S, et al. Consensus statements regarding the multidisciplinary care of limb amputation patients in disasters or humanitarian emergencies: report of the 2011 Humanitarian Action Summit Surgical Working Group on amputations following disasters or conflict. Prehospital and Disaster Medicine 2011; 26(06): 438-48.

REFERENCES2. Michael JW, Bowker JH. Atlas of amputations and limb deficiencies: surgical, prosthetic, and

rehabilitation principles. American Academy of Orthopaedic Surgeons; 2004.



5. Gray R. War wounds: basic surgical management: the principles and practice of the surgical management of wounds produced by missiles or explosions. 1994.

6. Coupland RM. War wounds of limbs: surgical management. 1993.

7. Pasquina PF, Cooper RA. Care of the combat amputee. Government Printing Office; 2009.

8. Guidelines for the Care and Rehabilitation of Survivors. International Campaign to Ban Landmines –Working Group on Victim Assistance; 1999. http://www.essex.ac.uk/armedcon/story_id/Guidelines%20for%20the%20care%20and%20Rehabilitation%20of%20Survivors.pdf(accessed 18 October 2016).

9. Smith DG, Wilson LS, conference chairs. Experts Reach Consensus on Amputation Techniques for War Injuries. inMotion 2003; 13(3). http://www.amputee-coalition.org/inmotion/may_jun_03/military.html.

10. Handicap International. The Rehabilitation of Amputees, Victims of Landmines. http://www.apminebanconvention.org/fileadmin/APMBC/IWP/SC_may06/speeches_va/HI_Promotion_first_aid_9May06.pdf (accessed 18 October 2016).

11. Department of Veterans Affairs and Department of Defence Clinical Practice Guideline for Rehabilitation of Lower Limb Amputation. Online: Department of Veterans Affairs; 2007: 166.

12. World Health Organization. Best practice guidelines on emergency surgical care in disaster situations. World Health Organization; 2005.

13. Surgical care at the district hospital. World Health Organization; 2003.

14. AO Surgery Reference. 2016. (https://www2.aofoundation.org/wps/portal/surgery2016).



BURNS

SCENARIOCLINICALMANAGEMENTOFBURNSSURGICALMANAGEMENTOFBURNS

SKINGRAFTINGFORBURNSSPECIALCASES

CHEMICAL&ELECTRICAL

SUGGESTEDRESOURCES

REFERENCES

11


CHAPTER 11 I BURNS

SCENARIOYou are in a type 2 facility in an area of internal conflict where the normal health service hascollapsed.Sixchildrenarrivewithburninjuriesfromahousefiresustainedsixhoursago.Nofirstaidhasbeenadministered.A10yearoldhas75%TBSAdeepburnswithevidenceof inhalationinjuryandisinextremis,a10yearoldhas50%TBSAmixeddepthburnsandishypovolemic,an8yearoldhas30%TBSAsuperficialburns,a5yearoldwith10%TBSAsuperficialburnsandtwoveryyoungchildrenpresentwitherythematousfacesandhands.Thereisafacilityinthecountrythathascriticalcarebedsbutit isuncertainifthereisburnsurgeryexpertise.Traveltothatfacilityisunreliableandrisky.

What are your priorities in allocating your limited resources to these patients?

Figure 2.Atypicalwardsetting,withoutventilatorsupport(Baumgartne - Henley)Figure 1.Fullthicknessburnswitheschar(ICRC)

TYPE 1

• Superficialburnsupto5%canbetreatedattheseoutpatientfacilities,astheseburnscanhealwithoutsurgery.

• Burnsthathealspontaneouslyinlessthan2weeksareunlikelytoscarnor requiresurgery

TYPE 2

• Burnsupto20%TBSAastheycanoftenbemanagedwithoutICUcapabilities.• IfsomedegreeofICUcareispresentattype2thenstraightforwardburnsup

to 40% can be managed at the type 2

TYPE 3

• Allburnsgreaterthan40%TBSA• Burnstotheface,hands,perineum,genitalsandsolesoffeet• Ifpossibletointegratethetype3withlocalservicesthenmostburnpatients

requiringlengthyadmissionswillbenefitfromtransfertoatype3.

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CHAPTER 11 I BURNS


Thebestresultssurroundingburnsurvivalhavebeenachievedinhighresourcecentresofexcellenceabletodeliveranaccurateearlyassessmentandaggressiveinitialtreatment.Thiscentralizationofcare,whileusefulforpatientsatthesecentres,andthespecializedstaffatburncentres,hasreducedtheburncareexperienceofthemedicalcommunityatlarge.

» In underdeveloped health systems, the expected outcome from burn injuries is poor andexpertiseisnotavailable.

» Itcanbeanticipatedthatthemanagementofburninjuryrelatedtodisastersandconflictwillpresentsignificantchallenges.

» AssetstomanagelargeburninjurieswillbescarceinconflictsandSODsandmustbeallocatedtothepatientwhowillbenefitmostfromthem.

» Simpleburnsshouldbemanagedinanoutpatientsettingandnotreferred,andpatientswithextensiveburns and a low likelihoodof survival should receive their comfort careoutsideofspecialistcenters.

DIFFICULTIES OF BURN CARE IN CONFLICTS AND DISASTERS» Burninjuriesareunpleasantandapartfromthesimplestcasesrequireexpertiseandexperience

tomanage.

» Burnscanplacesignificantburdensonstaff,timeandresources.

» Survivabilityis,inpart,relatedtotheavailabilityofcareandresourcesthatcanbeallocatedtoanindividualpatient.

» Inhalation injury and even moderatesize burns can stimulate significantphysiological derangement makingmanagement difficult without ICU ca-pabilities.

» Thefullclinicalmanifestationofaburninjurymay take hours to develop andpatientswithburninjurysoseverethatsurvival isnotexpectedmaystayaliveformanyhours.

DEPLOYED TEAMSIt is a general principle of EMTs deployed in response to SODs and conflict that they match their care delivery to the pre-event capabilities of the country to which they are deployed.

Figure 3.AdultandPaediatricdiagramsforcalculatingTotalBodySurfaceAre(TBSA).DiscussionsanddecisionsregardingsurvivabilityandrequiredlevelofcareforburnsareoftenmadebasedonTBSA,thereforeanaccurateestimateoftheextentofaburnisimportant.

(ICRC)


CHAPTER 11 I BURNS

SODS

» Burn injuriesarecommonlyencountered innaturaldisastersbutarenotoftenrelatedto theprimaryincident.

» Oftenburnincidentsarearesultofalterationstohumanbehavioursecondarytothesocialshockofthedisaster.

» Muchoftheprotectionfromburninjuryinnormalsocietycomesfrompublichealthandsafetypractices,bothlegislativeandpractical.AllofthiscanbelostfollowingaSOD.

» Newactivitiesofdailyliving(ADLs),suchascookingoveranopenflame,canbemadenecessarybydisastersandcanincreasetheriskofburninjury.

MASS BURN CASUALTY EVENTS

» Massburncasualtyeventsareusuallytheresultofhumanactivityandcanthemselvesbethemainfeatureofman-madedisasters.

» Examplesincludetheregularoccurrenceofmultipleburninjuriesduetopipelinefuelincidents.

CONFLICT

» The incidence of burn injury in conflictsvaries with the type of military activity, withexperience suggesting thatbetween2-10%ofcasualties arriving alive at medical treatmentfacilities(MTFs)canbeexpectedtohaveaburninjury.

» Dismounted infantry fighters in open areassustainfewburnsbuttheincidenceriseswiththeuseofprotectivevehiclesorships.

» Non-combatants may be caught up in thefightingandsustainburnsduetodirectmilitaryaction.

» Theuseof specific incendiaryweapons is stillencountered, however it is the impact on normal patterns of life thatmost change theincidenceofcivilianburninjury.

» Apart from mass casualty events, populations in SODs and conflict will have a sustained higher incidence of burns compared to normal for that society.

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CHAPTER 11 I BURNS


SPECIAL CONTEXTS: WEAPONS OF MASS EFFECTNUCLEAR DETONATION

» Anuclearblast isnot totallybeyond the realmofpossibilityandvery largenumbersofburninjuriescouldbegeneratedveryquickly.

» ThepooroutcomesfromburninjuriesfollowingHiroshimaandNagasakiweremostlikelyduetothedisruptionofhealthservicesratherthananyspecificconsequencesofacombinedthermalandradiationinsult.

CHEMICAL WEAPONS

» VesicantchemicalwarfareagentssuchasSulfurMustardareeasytomanufactureandhavebeenutilizedinrecentconflicts.

» ItispossiblethatbothSODsandconflictsmayincreasetheriskofexposuretotoxicindustrialchemicalsandcorrosivedomesticproducts.

» Itshouldbeanticipatedthatchemicalburnsmaybeencounteredinunstableenvironments.

ELECTRICAL BURNS

» Similarlytoburnsingeneral,changestonormalsocietymayincreasetheriskofelectricalburnstobothchildrenandadults.

ELEMENTS AND PRIORITIES OF BURN INJURY AND CARETHERE ARE 3 ELEMENTS OF BURN INJURY

1. Cutaneousburnwounds2. Systemiceffects

3. InhalationInjury

THERE ARE 4 PRIORITIES OF BURN TREATMENT

1. Protect the upper airways from obstructionduetoswelling

2. Ensureadequatetissueperfusionthroughfluidadministrationandmonitoringofresponsetothefluid

3. Provide optimal conditions to ensure burnwoundhealing

4. Providegeneral supportivemeasuressuchasanalgesia,feedingandphysiotherapy

Early assessment of burn depth and extent of burns may not be accurate. Often an overestimation of depth and extent is made when inexperienced practitioners make the assessment.

The danger lies in overestimating the extent of the burns on first look without formal cleansing in an operating theatre. This can result in deliberately limiting the care in a patient with survivable burns.


CHAPTER 11 I BURNS

ASSESSMENTThe treatment of burn injuries will be driven by 3 key assessments:

WHAT IS THE EXTENT OF THE BURN?

» Thismeasuredrivestheinitialrequirementsforfluidresuscitation.

» Thesizeoftheburnisexpressedasthepercentageofthebody’stotalsurfacebodyarea(%TBSA)thatisburnt.

» ThiscanbecalculatedusingtheRuleofNinesoraLundandBrowderChart

» Thepatient’spalmandfingerstogetherrepresent1%TBSA

» Burnsover20%TBSAwillresultinclinicallysignificantalterationsinphysiology

» Burnsover30%TBSAmaytriggeraSystemicInflammatoryResponse.

WHAT IS THE DEPTH OF BURN ?

» Thedepthoftheburndictatesthewoundcareregimen.» Burnsmustbescrubbedcleanpriortoanyassessmentbeingmade.» Accurate estimation of burn depth in the first 24-48 hours can be difficult, particularly for

practitionersinexperiencedinburncare.» Differingareasofdepthcanbeseenonasinglewound.» Simpleskinerythemawithblisteringisnotaclinicallyrelevantburn.» Wet appearing, blistered areas with marked erythema and brisk capillary refill are often

superficialpartialthicknessburns.» Dryappearingareaswithnonblanchingredness(fixedstaining)usuallyrepresentdeeperburns,

whilefullthicknessburnscanbewhite.» Painisnotagoodindicatorofburndepth.» Superficialpartialthicknessburnsshouldhealwithoutsurgeryifmanagedcorrectly.» Burnsthathealspontaneouslyinlessthan2weeksdonotnormallyresultinscarring.

IS AN INHALATION INJURY PRESENT?

» Ahistoryofreceivingtheburninanenclosedspacewithflameorsmoke,ahoarsevoice,cough,stridor,perior intra-oralburns,soot inthesputumandanotherwiseunexplainedorreducedlevelofconsciousnessallindicatethepossibilityofaninhalationinjury.

» InhalationinjuriesaregenerallyafatalinjuryinanenvironmentwithoutanICU.

» An upper airway inhalation injury is a true thermal burn with a risk of subsequent airwayobstructioncausingobstruction.

» Lowerairwayinjuryiseffectivelyachemicalinsultfromthenoxiousproductsofcombustionandcanleadtoprogressivepulmonaryfailure.

» Absorptionoftheproductsofcombustioninthecirculationleadstosystemicintoxication.

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CHAPTER 11 I BURNS


ASSESSMENTFIRST AID FOR BURNS

» Stoptheburningprocess:Removethesourceoftheinjury,cooltheaffectedareatopreventon-goingburning,removeclothesandotherarticlesthatmaystillbehot,removeanyconstrictingitemssuchasbelts,boots,watches,orrings.

» Continuetocooltheaffectedareawithnormaldomestictemperaturewater(thiscanbecleantapwater,itdoesnotneedtobesterile)forabout30minutesaftertheinjury.Thisreducestheinflammationandpainandisappropriateforchemicalburnsasitdilutesthedamagingagent.

» Giveanalgesiaandcoverthewounduntilmedicalcareisreached.

EMT TYPE 1 » Burnsthatappeartobesuperficialpartialthicknessatlessthan5%TBSA(upto10%inadults)

canbetreatedintheoutpatientsetting.

» Adequateanalgesiashouldbeadministeredandtheburnwashedwithantisepticsolution.

» Blistersshouldbeburstandblisterroofsremovedandacleandressingapplied.

» Prophylacticantibioticsarenotroutinelyusedforsimpleburncare,but itmaybeprudenttoadminister a three-dose course of a broad-spectrum antibiotic such as amoxicillin/clavulanicacid,ifgoodwoundhygienecannotbeensured.

» Theburnwillbepainfulforseveraldayssoadequateanalgesiashouldbegiven,e.g.amixtureofparacetamolandcodeine.

» Patients should be advised to return to amedical facility if theybecomeunwell or developsobvioussignsofinfection(fever,spreadingerythema,increasingpain).

» Theburnshouldbeassessedatamedicalfacility2daysfollowingtheinitialvisitinordertoassessthedepthandsizeandassessforsignsofinfection.Theburnshouldbecleanedandhaveafreshdressingappliedaswell,andfamiliesgivenwoundcareinstructionsatthistime.

» Patientsshouldbeadvisedtoseekmedicalcareiftheburnhasnothealedwithintwoweeks.Ifatthe2weekpoint,thereareconfluentareasaddingto1%TBSAthenthepatientshouldbereferredforsurgicalevaluation.

» Healedburnsshouldhaveamoisturizingagentappliedfortwoweeksafterinjuryorlongeriftheskinremainsdry.Sunprotectionisimportanttoavoidpermanentchangesinskinpigmentationforoneyearfollowinginjury.

» Whentransferringaburnedpatient,ifthereisminimalconcernfordelaysintransportthenthewounddoesnotrequirea formaldressing. Layingclearplasticfoodwrapovertheburnwillsufficefor12-24hoursaslongasthewoundwasthoroughlywashed.Thelimbshouldnotbecircumferentiallywrapped.


CHAPTER 11 I BURNS

EMT TYPE 1 CRITERIA FOR TRANSFER

» Burnsgreaterthan10%TBSAirrespectiveofdepth,deeppartialthicknessorfullthicknessburnsgreaterthan1%TBSA,anyevidenceof inhalationinjury,evidenceof infectionorconcomitantsignificantinjuriesneedtobetransferredtoatype2facility.

» Ideally,patientsbeingtransferredtoamorecapablefacilityshouldbemovedwithoutdelay.

» Patientsshouldhaveadequateanalgesiafortransportandmustbekeptwarm.

» Ifthereisanyconcernabouttheadequacyoffluidinputandforallburnsover20%TBSA,IVfluidsshouldbeadministeredat10mLperhourforevery10%TBSA.

EMT TYPE 2BURN CARE AT THE EMT TYPE 2

Thecareofsimpleburnsatthetype2doesnotdifferfromthemanagementattype1facilities.

RE-ASSESSMENT

» Ahistoryshouldbetakenandaclinicalexaminationperformedwithparticularattentionpaidto excluding other injuries and illnesses. A detailed assessment of size and depth for largerburnsrequiresthewoundtoscrubbeddownunderadequateanalgesiaandpreferablyageneralanaestheticinanoperatingtheatre.

» There are some smartphone based applicationsavailable to help in burn size mapping with somelimitedevidencethattheyareeasiertouseandmoreaccuratethanaLund&Browderchart.

» Upper airway assessment can be made by directlaryngoscopyatthetimeofinductionforanaesthesia.Thereisnowaytodefinitivelyassesthelowerairwayswithout the aid of bronchoscopy. Therefore, muchof the diagnosis of inhalation injury relies on clinicalexaminationsupplementedbyradiologyandbloodgasanalysisifavailable.

» For burns over 20% TBSA secure IV access, a nasogastric tube and a urinary catheter for monitoring of urine output (UOP) should all be placed.

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CHAPTER 11 I BURNS


ESCHAROTOMY

» Circumferentialdeepburnsaroundthetorsoandlimbsmustbeidentified.

» As swelling increases the unyielding burn escharcan lead to a rise in tissue pressure with associated reductioninperfusion,andrespiratoryexcursioncanbe compromisedinthetorso.

» In this instance escharotomiesmust be performed to relievethepressure(Figure4)

» Thisshouldbeperformedinanoperatingtheatreasaformalsurgicalprocedureundergeneralanaesthetic.

» Ifperformedcorrectlythereisoftensignificantbleedingandmeticulousattentionmustbepaidtohaemostasis.

» Itisimportantthattheescharotomiesextendalongthewholelengthoftheburntareaandintonormaltissue.

» Thehorizontaltorsoincisionshouldbe,atleastinpart,belowthecostalmargintoallowabdominalexpansion.

» Burnsofanydepthover10%willmostlikelyneedsignificantanalgesiaforthefirstcoupleofdaysand,therefore,admission.

DIFFICULT DECISION MAKING IN CONFLICTS AND DISASTERSBurn management is a resource intensive process and decisions must be made quickly where or if continued care of a patient should occur.

» Attemptsshouldbemadetoestablishwhatexpertburncarefacilitiesareavailable(orlikelytobecomeavailablesoon)andconsiderreferral.

» Outsideofcentersofexcellencedefinitesevereinhalationinjuryanddeepburnsgreaterthan60%TBSAareunlikelytosurvive.

» Suchpatients shouldbediscussed toavoid transferring caseswhenon-going care isdeemedfutile.

Figure 4. Lines ofelectionfor

escharotomies (Kay)


CHAPTER 11 I BURNS

Thirst alone is a poor indicator of hydration status

Administration of excessive fluids can be just as detrimental to the patient as under-resuscitation with fluid.

FLUID MANAGEMENT AND RESUSCITATION

» Burnsupto20%canbemanagedwithoralrehydration.

» ItisimportanttostillmakeanassessmentofhydrationstatusandprovideIVfluidsifitisapparentthatoralrehydrationaloneisnotprovidingadequateinput.

» Burnsover20%TBSAshouldbegivenintravenouscrystalloidinthefirst24hoursasprophylacticfluidstoreducethechancesofdevelopingburnshock.

» Hartmann’s / Lactated Ringers is preferable to Normal Saline. The formula of 2mL x %TBSAburnedxbodyweight inkilogramsshouldbeusedasastartingpoint.ThiscalculationgivesavolumeofcrystalloidinmLthatislikelytoberequiredinthefirst24hoursfromthetimeofinjury.

» Thefirsthalfofthetotalfluidcalculatedshouldbeadministeredoverthefirst8hoursfromthetimeofinjuryandthesecondhalfofthefluidgivenoverthesubsequent16hours.

» Urineoutputisthebestguidetoadequacyofinputwithatargetof0.5ml/Kg/hr(1ml/Kg/hrinchildren).Theurineoutputshouldbemeasuredhourly.

» Two consecutive hours of either toomuch or too little urine compared to the target outputshouldinitiateachangeofintravenousinputeitherdownorupby20%.

» If there has been a significant delay in presentation, avoid catching up on fluid as a bolus, spread the volume out over several hours.


» Historically, children with >20% TBSA have beenresuscitated with 3 mL/kg x %TBSA, this frequentlyleads to fluid overload. The 2% mL/kg x %TBSAguidelineshouldbeusedinchildrenaswellasadults.

FLUID REQUIREMENTS IN FIRST 48 HOURS

HOURS SINCE BURN

FLUID REQUIREMENTS

0-24 HOURS

2ml/kgx%TBSAofRingersLactate

(1/2infirst8hours,1/2in

following16hours

TargetUrine Output=

0.5ml/kg/hr

24-48 HOURS To be guided by urine output

SPECIAL CONSIDERATIONS:• Burns > 50% TBSA: Use 50% TBSA in calculations above• Inhalation injury/electric burns: Have increased fluid

requirements, use 3ml/kg x %TBSAFigure 6.ResuscitationforICRCburnprotocol(ICRC)

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CHAPTER 11 I BURNS


SUPPORTIVE MEASURES FOR BURNS

» Patientswithlargeburnsareparticularlysusceptibletohypothermiaandalleffortsshouldbemadetopreventthis.

» Burnsarepainfulandpsychologicallydistressing. It isessentialtomaintainadequatelevelsofanalgesiaincludingopiatesifnecessary.

» Aprotocolof continuousbackground levelsof analgesics shouldbeestablishedwith topupsadministeredasneededforstimulatingactivitiessuchasphysiotherapyorattentiontodressings.

» NSAIDsshouldbeavoidedforatleast48hourspostinjurybecauseoftheriskofrenalinjury.

» Itisbeneficialtomaintaingutfunctionandadequatenutritionfromasearlyonaspossible.Thisisbestachievedbyestablishingearlyfeedingandinlargerburnsthiswillonlybeachievedviaanasogastrictube.

» Prophylaxisagainstpepticulcerationshouldbeadministeredinadditiontofeeding.

» Initiallythepatientwithalargeburnwillhaveacoagulopathy.Theriskfromvenousthrombo-embolismsoonrisesandprophylaxisisindicatedfromday2unlessthereareothercontraindica-tions.

» Antibioticprophylaxisbeyondthreedosesisnotadvocated.Furtheradministrationofantibioticsshouldbelimitedtotreatmentdosesforclinicallysuspectedinfection.Itshouldbenotedthatatachycardiaandpyrexiacanbepartofthenormalresponsetosystemicinflammationanddonotnecessarilyindicateinfection.

» Keepingapatientsittingupwithlimbselevatedwillhelpreduceswelling.

NUTRITION

» Nutritioninburnpatientsisextremelyimportant, however enteric or tube feedsmaynotbeavailable.

» Itispossibletoimproviseliquidtubefeedsbycrushingbiscuitsintomilkorbeaten eggs if proprietary formulasareunavailable.

Figure 5.Patientwithescharotomyincisionoftherightarm.Theheadofthebedshouldbeelevatedandthearmelevatedto

protectagainstfurtherswelling(ICRC)


CHAPTER 11 I BURNS

WOUND MANAGEMENT

» Deep burns ofmore than 1%will do betterwith surgery. In ideal circumstances this is bestperformedearly,butwhen resources and clinical capability are limited it can be preferable to wait for at least two weeks before embarking on surgery.

» Thedelaywillallowmoresuperficialburnstohealwithdressingsaloneandprovidesconfirmationoftheinitialassessmentofdepth.

» Thisapproachhelpsreducethetotalareathatrequiressurgicalexcisionandskingrafting.

» Burnwoundsrequiredressings.Treatmentofburnsby“exposure”isnotadvocated.

SELECTION OF BURN DRESSINGS

Therearenumerousmethodsofdressingaburnwoundandthereisnouniversallyagreeddressingregime.Policyindisasterandconflictsituationsshouldbedictatedbythefollowingprinciples:

» Dressingsmustbeapplicableforallburndepths.

» DressingsshouldhaveantisepticpropertiesandminimizethedriveoftheSystemicInflammatoryResponse.

» Dressingsshouldbeeasytoapplyandcomfortableforthepatient.

» Dressingsshouldnotrequirefrequentchangesorlaboriousnursingcare.

SELECTION OF BURN DRESSINGS

» In generalointments, suchas Silver Sulfadiazine (SSD),areeasiertoapplythansheets.

» Preparations of SSD that contain Cerium Nitrate arethoughttoreducethesystemiceffectsofaburnwoundandalsogenerateadryescharthatiseasiertomanage.

» Theseointmentsshouldbeappliedinathicklayerthencoveredwithfluffygauze.

» Silverbasedsheetdressings,canbe leftonwounds foralongertimeandprovideeaseofmanagement,butaregenerallyexpensive.

» Themostbasicdressingscanbemadeofparaffingauzestainedwithanantisepticsuchaspovidone-iodine.

» Dressingsmustbe inspecteddaily forslippage,comfortandexcessivestrike-through.

» Any suspicion of sepsis must prompt an inspection ofwoundsandexchangeofdressings.

Wounds must be thoroughly scrubbed and cleaned prior to the application of any dressing.

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HAND BURNS

» Elevation of hand burns is very important tominimizeswelling

» The use of bags to dress hand burns is notused frequently now. The advantageof handbagdressingswasthattheawakepatientcouldassist in their own nursing care, particularlyinmass casualty situationsor longevacuationjourneys when the availability of professionalstaffmaybelimited.

» Unconsciousorheavily sedatedpatients shouldhavehands fullydressedasaccording to theprinciplesdescribedinthistextandsplintedinthePositionofSafeImmobilization(POSI).

» Circumferentialhandburnsrequirecarefulmonitoringforpotentialescharotomy.Warning signs includethehandbecomingpale,cool,andassumingaclawlikeposition.

» Ifavailable,aDopplermonitorcanbeusedtoassessforalackofdigitalflow,ifflowbecomesabsentadigitalescharotomymayberequired.

FACE BURNS

» Facialburnsshouldbescrubbedasdescribedpreviouslyandapetroleumbasedointmentappliedregularlytopreventdesiccation.

» Thereisnoevidencethatanantisepticpreparationissuperiortoplainpetroleumjellyfortheface.

» Earsshouldbecoveredwithanantisepticagenttopreventchondritis.

» Itisdifficulttoassessandcareforscalpburnsunlesstheheadisshaved.

HYPOTHERMIA

» Burnpatientsareatveryhighriskofhypothermia.Thisisespeciallytrueofchildren.

» Thismaybeparticularlytrueindisastersituationswherepermanentstructuresmaybeseverelydamagedorlackingheat.

Figure 7.Safepositionforsplintingofthehand(ICRC)


CHAPTER 11 I BURNS

SURGICAL MANAGEMENT OF BURNS» Ifembarkingon surgery in constrained situations it isbeneficial toperformexcisionand skin

graftinginsmallstagesratherthantryingtodealwithalargeburnwoundinasinglesession.

» 10% TBSA of burn wound for each theatre session is a good target with 10 – 14 days in between surgeries.

» This helps reduce blood loss,minimizes the further physiological insult, and generatesmoremanageabledressingswhichreducesthenursingworkload.

» Itisimportanttomakesuretherewillbesufficientskingraftavailabletocoverareasplannedforexcision.Itispreferabletohaveanunexcisedburnwoundwithappropriatedressingratherthananun-graftedexcisedwound.

» Excisionofburnsonthefaceandhandsshouldbeperformedbythosewithspecificexperienceinburnsurgery.

EXPERT TIP» Perioperativebloodlosscanalsobereducedbyliberaluseof1:1,000,000adrenalin(epinephrine)

solutioninjectedbeneathboththeburnwoundtobeexcisedandskingraftdonorareas.

» Thisismadebymixing1mgofadrenalin(1mlof1:1,000)in1Lofnormalsaline.

SKIN GRAFTING FOR BURNS» Skin graft should be routinely meshed

1.5:1 asthisreducestheamountrequiredto be harvested, thereby reducing the size ofthesecondarywoundbutalsoimprovesthechanceofthegrafttaking.

» Ifthereisashortageofdonorareas,thena3:1meshcanbeused.

» Mesh ratios above this are technicallydifficult and should be reserved forspecialistcentres.

» Donor sites can be re-harvested once re-epitheliazedbutitisrecommendedtowaitforatleasttwoweeksifthesurgeonisnotfamiliarwiththis.

» Thenumberoftimesagivenareacanbere-harvestedisdictatedbyhowmuchdermisisremovedeachtime.

Figure 8.MeshedSTSGinplace.Thegraftcanbeseenontheleftsideofthepicture.ThemeshingprocessnotonlyallowsforgraftingofmoreTBSAbutreducesthechancesofhematomaformationunderthegraftwhichcanleadtograftfailure.(ICRC)

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CHAPTER 11 I BURNS


» Itispreferabletoleaveskingraftdonor site dressingsinplaceuntiltheareahashealed,evenforseveralweeks.

» Theroutinechangeofdressingsearlierthanoneweeksimplycausesmorepain,bleeding,anddamagetothenewepithelium.

» Skin grafted areasshouldhaveafirstchangeofdressingatfivedaysunlessthere isaclinicalindicationtodosoearlier,e.g.signsofnewsystemicinfection.

CHEMICAL BURNS» Solidparticlesorpowdercanbebrushedofffirst.

» Theinjuringagentshouldthenberemovedassoonaspossiblewithcopiousirrigationbywater.

» Irrigation should be prolonged but beware ofinducinghypothermia.

» Once decontamination is complete, the burnwoundistreatedthesameasathermalburn.

» Chemicalburnscancauseadifferinginflammatoryresponse fromthermalburns soclosemonitoringoffluidrequirementsisessential.

» SulfurMustardburnstakemanyweekstohealandskingrafting isproneto failure.Allvesicantburnsshouldbereferredforspecialistcare.

ELECTRICAL BURNS» In the case of electrocution, if an initial ECG is normal there is no evidence to suggest

continuedcardiacmonitoringisnecessaryinaresourcelimitedenvironment.

» Electricalburnscancausemuchmoreextensivetissuedamagethantheskinsignsmightsuggest.

» Deepnecrosisisnotuncommonandthereshouldbeaverylowthresholdforperformingfasciotomies. It is common toencounterprogressivenecrosisand fulldebridementmayrequireastagedapproach.

If more than 40% TBSA requires excision and skin grafting, complex surgical strategies are required.

Patients with over 40% full thickness burns in low resource situations have a very poor chance of survival, particularly in a field hospital environment.


CHAPTER 11 I BURNS

EMT TYPE 3» Themajorityofburnsthatrequiresurgerywillneed longperiodsof inpatientadmissionwith

significantinputfromnursingandphysiotherapy.

» Itwillbeappropriatetotransfercasestotype3facilitiesassoonassuchcapabilitiesbecomeavailable.Ifpossible,type3EMTsshouldintegratewithpre-disaster/conflictservices.

» Delivery of specialist multidisciplinary care will be required for burns to the face, hands,perineum/genitalsandsolesoffeetinadditiontothosewithlarge%TBSA.

» Theorganizationofsuchspecialistserviceswillneedcarefulplanningandcontroltoensureitdoesnotdelivercarethatisincongruouswiththehostnation’scapabilitiesandnorms.

SPECIAL CONSIDERATIONS» Burnpatientscancreatedifficultdecisionsregardingendoflifecare.Itisimportantthatanopen

dialogueoccurbetween,patients,families,andEMTteamsinseverelyburnedpatients.

» Itmaybehelpfultohaverespectedmembersofthelocalcommunityonthedecisionmakingteam.

» Theselinesofcommunicationareimportantduringtransferaswell.Burncareforsevereburnsoftentakesmonthsandisveryresourceintensive.AnEMTreceivingburnpatientsshouldstrivetoidentifyalocalorregionalcentrewiththeexperienceandresourcestotreatburnpatients.

» However,patientsshouldnotbetransferredwithoutdiscussionwiththefamilyandtheconsentofthepatientandfamily.

REHABILITATION» Rehabilitation of burn patients is a crucial part of the

treatmentprocessandshouldbeginassoonaspossible.

» Adequatepainmanagementiscompulsoryforsuccessfulrehabilitation.

» Woundcompressionandmobilizationshouldbeutilizedwhenrecommendedbythesurgeon.

» Latestagerehabilitationisnotterriblycomplex,butlikeallofburnsurgery,professionalstrainedinburncarearenecessarytoobtaintheoptimalaestheticandfunctionaloutcome.

Burn injury is distracting and other injuries must be identified and treated along with the burn injury. Primary and secondary surveys for trauma are required in burn patients as in all trauma patients.

149

CHAPTER 11 I BURNS


SUGGESTED RESOURCES

1. Chung KK, Blackbourne LH, Wolf SE, et al. Evolution of burn resuscitation in operation Iraqi freedom. Journal of Burn Care & Research 2006; 27(5): 606-11.

2. Pruitt Jr BA. Protection from excessive resuscitation:“pushing the pendulum back”. Journal of Trauma and Acute Care Surgery 2000; 49(3): 567-8.

3. Total Burn Care 4th Edition; Edited by David N. Herndon. Saunders-Elsevier, 2012.

REFERENCES

1. Giannou C, Baldan M. ICRC war surgery: working with limited resources in armed conflict and other situations of violence - Volume 2. Geneva: International Committee of the Red Cross 2009

2. ICRC Burns Protocol: Hospital Team. ICRC International Committee of the Red Cross.

3. Norton I, Von Schreeb J, Aitken P, Herard P, Lajolo C. Classification and minimum standards for foreign medical teams in sudden onset disasters. Geneva: World Health Organization 2013

4. Schulze SM, Weeks D, Choo J, et al. Amputation Following Hand Escharotomy in Patients with Burn Injury. Eplasty 2016; 16.



CHAPTER 11 I BURNS

ETHICS OF HEALTHCARE IN DISASTERS AND CONFLICT

SCENARIOMAINETHICALTHEORIES

TOOLSTODEALWITHETHICALDILEMMASEMTGUIDINGPRINCIPLES

RESEARCHETHICSINDISASTERS

SUGGESTEDRESOURCES

REFERENCES

12


CHAPTER 12 I ETHICS OF HEALTHCARE IN DISASTERS AND CONFLICT

SCENARIOA23-year-oldwoman is admittedat yourhealthcare facilitywith a fracture forwhich a surgicalinterventionisindicated.Accordingtotheculturalvaluesinhertribeshecannotgiveconsentforthesurgerybeforeherhusbandispresentandagreeswiththeprocedure.

Sofar,ithasnotbeenpossibletolocatethepatient’shusband.Herexamindicatesthatthebloodsupplytoherdistalextremityistenuous,anditisclearthatsurgeryshouldoccurassoonaspossible.

Whatethicalissuesdoesthissituationraise?

Howshouldtheteamreachafinaldecision?

LACK OF RESOURCESAcceptanceofhigherrisksUnqualifiedhealthcareworkersDifficultymaintainingcontinuity ofcareFrustrationwithpolicyoraidagencyEarlydischargetosuboptimalconditions

TRIAGEDifferentcriteriaNosenior/trainedstaffinvolvementShort-termvslong-termoutcomesPremature,lowbirthweightbabies

CULTURAL ISSUESStrongreligiousbeliefsGenderrolesPerceptionsofhealthandqualityoflifePaintolerance

INFORMED CONSENTDifficultissueswithgenderorcombatantsChildrenwithoutparentsUnconsciouspatients

LOCAL CAREGIVERSReputationFinancial,livelihooddifferencesPositioninginconflicts

COMMON ETHICAL DILEMMAS IN DISASTER AND CONFLICT

HEALTHCARE WORKERS FACING ETHICAL DILEMMAS CAN EXPERIENCE:» Moral distress –whenoneknowstheethicallycorrectactionbutfeelspowerlesstotakethat

action.

» Vicarious traumatization-resultsfromempathicengagementwithpatient’ssuffering.

» Compassion fatigue-secondarytraumaticstress,graduallesseningofcompassionovertime.

» Burnout–exhaustionanddifficultycopingduetoseverestress.

153



MAIN ETHICAL THEORIES FOR HEALTHCARE IN DISASTERS AND CONFLICTUTILITARIANISM» The right thing to do is to try to generate the greatest overall good for a group or population.

» Focus on the consequencesofactions,notongoodintentions.Decisionmakinginhumanitarianhealthcareshouldbeinformedbymeasuringandcalculatingthebenefitsandburdensresultingfromanaction.

» Limitations:uncertainandunpredictablenatureofcontextindisasters,difficultiesincollectingdataandconductingresearchtoaidinformeddecisions.

DEONTOLOGY» Duties and rules are thebasis for ethical action.Aduty is anobligation to always react in a

specifiedmanner,regardlessofconsequence,becausetoactinthedeterminedwayistherightthingtodo.

» Limitations:difficulttoknowwhattodowhentworesponsibilitiesareconflict.Deontologydoesnot consider the consequences resulting fromanaction toevaluatewhether the choicewascorrect.

IDEAL MORAL THEORY» Does not consider the specificities of a situation or issue, instead identifies general ethical

principlesandemphasizesrationalapproaches.

» It is understood that moral goodness is always possible.

» Limitations: reality is complex,especially inconflictordisaster settings.Sometimes todo theideal‘right’isnotpossibleundercertainconditions.

NON-IDEAL MORAL THEORY» Understandsthattheworld is complex,andincludesrational,emotionalandrelationalfactorsin

alldecisionsandsituations.

» Assumessometimesunfavorable conditions will not allow us to reach a ‘right’ solution,sowhenchoosingbetweenundesirablealternativesweshoulddecidefortheleastdetrimentaloption.

» Limitations:nodefinitiveanswersregardingonclinicaldecisionmaking.

VIRTUE ETHICS» Virtueethicsislessfocusedonwhatweshoulddo,andmoreconcernedwiththekindofpeople

weshouldbe.Virtueisatypeofpracticalwisdominwhichgoodcharactertraits(virtues)andtherightoutcome(action)cometogether.

» Limitations: can bemore subjective (more focusedon case discussion thanbalancing ethicalprinciplesorrules).Emphasizesthedevelopmentofindividualmoralcharacter(likehonestyorcourage),butdoesnotoftenprovideclearanswerstoconcretedilemmas.



TOOLS TO DEAL WITH ETHICAL DILEMMASEMTsshouldconsiderhowtoapproachethicallychallengingcases,especiallyamputationsandendoflifedecisions.Someteamsusean"ethicscommittee"approach.Thecommitteeoftenconsistsoftheteamleader,thetreatingclinician,alocalclinician,andanotherseniorcliniciannotinvolvedindirectpatientcare.Thecommitteeshouldagreeonthebestapproachforthepatientinconsultationwithrelevantfamilymembers.

» Followagreeduponcodesofbehaviourandguidelinescoveringhumanitarianethics

» Communicatewith localpeople,organizations,andhealthcarecolleagues tounderstand localcustomsandstandardoperatingprocedures

» Consultwiththeethicscommitteeinyourorganizationifpresent

» Consultwithseniorcolleagueswhenfeasible

» Engageinopendiscussionswithcolleaguesandseekasecondopinion

HUMANITARIAN ETHICS ANALYSIS TOOLAvailablefrom:http://www.humanitarianhealthethics.net/

1. Identify/clarify ethical Issue

Is thistrulyanethical issue?What isatstakeandforwhom?Howis the issue perceived from different perspectives? When must adecisionbemade?Whoisresponsibleformakingit?Whathasbeendonesofar?

2. Gather Information

Whatinformationisneededtodeliberatewellaboutthisissueandenableustomakeawell-considereddecision?Whatconstraintstoinformationgatheringexist?Consider:-Participation,perspectivesandpower-Community,projectandpolicies-Resources,clinicalfeatures&obstacles

3. Review Ethical IssueDoestheprocessrevealnewaspectsoftheethicalissueorsuggestthe need to reformulate or redefine the issue? Have our biases/interestsaffectedhowweseetheissue?

4. Explore ethics resources

Whatcanassistustoevaluatetheethicalaspectsofthisissue?Whatvaluesandnormsoughttoinformourdecisionmaking?Consider:Codes of ethics (NGO, interagency, professional bodies); local &internationallaw;statementsofvalues/principles;agencypolicies

5. Evaluate and select the best option

Whatoptionsarepossible inthissituationandwhatethicalvaluessupport each option?What consequencesmight result from eachoption?Canconsequences,valuesandobligationsbereconciled?

6. Follow up What can we learn from this situation? What support do thoseinvolvedrequire?

155



EMT GUIDING PRINCIPLESAll EMTsshouldcomplywiththeguidingprinciplesstatedintheWHO‘ClassificationandminimumstandardsforEMTsinSODs.

» TheEMTprovidessafetimely,effective,efficient,equitableandpatientcenteredcare.

» TheEMToffersa“needsbased”responseaccordingthecontextandtypeofSODintheaffectednation.

» TheEMTadoptsahumanrightsbasedapproachtotheirresponseandensuretheyareaccessibletoallsectionsofthepopulationaffectedbytheSOD,particularlythemostvulnerable.

» EMTsundertaketotreatpatientsinamedicallyethicalmannerconsistentwiththeWorldMedicalAssociation’sMedicalEthicsManual. Inparticular,EMTsundertaketomaintaindoctor-patientconfidentialityand,unlessobviously impossible, to communicatewithpatients ina culturallyappropriatefashionandinanlanguagethatthepatientunderstandswheninformingpatientsabouttheirmedicalconditionandprognosis,discussingtheirtreatmentoptionsandobtainingtheirinformedconsentformedicalprocedures.

» AllEMTsareaccountabletothepatientsandcommunitiestheyassist,thehostgovernmentandMoH,aswellastheirownorganizationanddonors.

» EMTscommittobeintegratedintoacoordinatedresponseunderthenationalhealthemergencymanagementauthorities,andtocollaboratewiththenationalhealthsystemandMoH.

» EMTs commit to collaborate with their fellow EMTs as well as the rest of the internationalhumanitariancommunity.

ETHICS TRAINING FOR HEALTH CARE PROVIDERS» Mustbeprovidedinpre-deploymenttrainingforEMTs.

» Purpose: to prepare providers for the ethical dilemmastheywillinevitablyface,tobuildresiliencetomoraldistressandprovidetoolsforclinicaldecisionmakingwhenethicalissuesareencountered.

ETHICAL DEBRIEFING» Debriefingmustbeavailableforallhealthcareworkers.It

shouldincludethediscussionofethicaldilemmasfacedandaddressanymoralguiltorstressfeltbythehealthprofes-sional.

» Itwillhavesimilaritiestopsychologicaldebriefing.

» Realcasesmustbediscussedafterwardsingroupstohelpfutureethicaldecisions.

Ethical training and debriefing are especially relevant for type 3 EMT staff.

While challenging ethical situations regarding withdrawal of care can occur in all levels of EMT, these scenarios often occur at the type 3 level. Type 3 EMTs should have protocols in place regarding end of life decisions and amputations.



Analyzing an ethical dilemma from different points of views may lead to different conclusions, for example

• Clinical ethics focus on the individual

• Public health ethics focus on the common good

LIMITS OF CARE» EMTs should only provide care appropriate

for their level and capacities (infrastructure,equipment and trained personnel), adhering toWHO Classification andminimum standards forEMTsinSOD.

» AsageneralruleonlystarttreatmentthatcanbemaintainedbythelocalhealthcaresystemafterEMTdeparture.

» The limits of care provided by a teammust beclarified by the coordinator beginning patient care. This will avoid discussions once patientshave already been admitted and personnel areconfrontedbysituationsbeyondtheircapacity.

RESEARCH ETHICS IN DISASTERS» Researchindisastersisrequiredtoimprovepreparationandresponse.Itisanethicalrequirement

tocollectdataandgatherevidencetoguidefutureresponsestosimilarevents.

» Anyplansforresearchanddatacollectionbeyondpatientcareandmandatoryreportingshouldbeanticipatedpriortodeployment.

» Thereisanethicalimperativetoprotectpatientconfidentialityandprovidetimelyandeffectivetreatment.Datacollectionprocessesmustalwaysplacepatientdignitybeforeresearchpurposes.

» Documentation of interventions should be recorded, as it is an ethical imperative to auditpracticewhereveranethicalissueoccurs.

» Whileitisethicaltoconductresearchindisastersandconflict,patientneedsmustbeprioritized.

» Local communities should be engagedwith to themaximum extent possible in all stages ofresearch.

» All researchshould receive researchethicsapprovalprior tocommencing,and ideally shouldreceiveethicalapprovalfromalocalresearchethicscommitteeorauthority.

157



SUGGESTED RESOURCES

1. Fraser V, Hunt M, Schwartz L, Laat Sd. Humanitarian Health Ethics Analysis Tool: HHEAT Handbook. 2014. www.humanitarianhealthethics.net (accessed 20 October 2016).

2. O’Mathúna D. Ideal and Nonideal Moral Theory for Disaster Bioethics. Human Affairs 2016; 26(1): 8-17.

3. Slim H. Humanitarian ethics: A guide to the morality of aid in war and disaster: Oxford University Press; 2015.

4. O’Mathúna DP, Gordijn G, Clarke M (eds.). Disaster bioethics: Normative issues when nothing is normal. Springer; 2014.

REFERENCES

1. Momoh P. World Medical Association, Medical ethics manual. 2006.


3. Ethical Principles of Healthcare in Times of Armed Conflict and Other Emergencies. https://www.icrc.org/en/download/file/9567/ethical_principles_of_health_care.pdf (accessed 20 October 2016).

4. Alexander DA, Klein S. First responders after disasters: a review of stress reactions, at-risk, vulnerability, and resilience factors. Prehospital and disaster medicine 2009; 24(02): 87-94.

5. Bothe M, Partsch KJ, Solf WA. New rules for victims of armed conflicts: commentary on the two 1977 protocols additional to the Geneva Conventions of 1949: Martinus Nijhoff Publishers; 1982.

6. British Medical Association. Ethical decision-making for doctors in the armed forces: A tool kit. BMA 2012.

7. Schwartz L, Hunt M, Redwood-Campbell L, de Laat S. Ethics and Emergency Disaster Response. Normative Approaches and Training Needs for Humanitarian Health Care Providers. Disaster bioethics: Normative issues when nothing is normal: Springer; 2014: 33-48.

8. Mezinska S, Kakuk P, Mijaljica G, Waligóra M, O’Mathúna D. Research in disaster settings: A systematic qualitative review of ethical guidelines. BMC Medical Ethics 2016;(1):1-11.


PHYSIOTHERAPY

SCENARIOACUTECARETREATMENT/CONSIDERATIONS

SUBACUTETREATMENTCHRONIC-LONGTERMMANAGEMENT

FAMILYINVOLVEMENTANDEQUIPMENT

SUGGESTEDRESOURCES

REFERENCES

13


CHAPTER 13 I REHABILITATION AND PHYSIOTHERAPY

SCENARIOA25-year-oldmanpresentstoatype2facilityfollowingagunshotwoundresultinginaleftfemurfracturewithoutvasculardamage.

He subsequently undergoes wound debridement and is placed in traction. The team has onlyrecentlybecomeoperationalandisstillintheprocessoffindingreferralpathwaystoahigherlevelofcare.

Figure 1.Physiotherapyforapatientintraction.(ICRC)

TYPE 1

Type1EMTsshouldbeabletoprovidebasicrehabilitationcareorreferpa-tientstoanappropriateEMTorexistinglocalfacility.

TYPE 2

Musthaveatleastonerehabilitationprofessionalper20beds

TYPE 3

Musthaveatleastonerehabilitationprofessionalper20beds

» EMTs offering rehab services need to be self-sufficient for 2 weeks

» Supply list should include 6 wheelchairs and 20 crutches per 20 beds.

» Rehab decisions must take into account the likely logistical constraints of regard the deployment.

161



TYPE 2

TYPE 3

DELIVERY OF PHYSIOTHERAPY TYPE 2 AND 3 FACILITIES:• Physicaltherapybenefitsbedboundpatientswithlongbonefracturesby

preventingcomplicationssuchaspneumoniaandmusclecontractures.• Theearlymobilizationofpatientsoncrutches,orsimplytransferringbedto

chairenhancesthepatient’sperceptionofrecoveryandhelpssetthepatientupforasaferdischarge.

NURSING AND RESPIRATORY CARE» Patientsneedtobenursedinanupright

positionasmuchaspossibletooptimizerespiratoryeffort.

CONSIDERATIONS FOR AUSTERE ENVIRONMENTS» Water bottles can be used as spacers

to deliver aerosolized medications toindividuals.

» In bed-bound patients, it is importanttoencouragere-expansionofthelungs,preventingpostoperativepneumonia.

» A bubble positive expiratory pressure(PEP) set up can be easily constructedbypartiallyfillingacontainerwaterandsubmergingatubeorstraw.

» When a patient exhales through thetube the bubbles provide a stimulus toencouragegoodairmovement.

Figure 2.Chestphysiotherapycanbeanimportanttooltopreventpostoperativecomplications(ICRC)



ESTABLISH EARLY MOBILIZATION» Dependingontheinjuryandpatient’sstability,thereisevidenceofimprovedsystemic

functionandfasterfunctionalrecoverywithearlymobilization.» Establish early with medical team the weight bearing status of the patient of all

extremities

DEVELOP A PROGRAM TO ENCOURAGE MOBILITY ACCORDING TO WEIGHT BEARING STATUS» Workwithintheweightbearingstatustobeginsittingupunsupportedandmechanisms

fortransfersoutofbedastolerated.

DEVELOP A PROGRAM FOR ACTIVITY BOTH IN AND OUT OF BED» Outofbedactivityimprovesrespiratorystatus,earlyweightbearingreducesstrength

lossandimprovesrecovery,andincreasespatientwellbeing» Inbedpositioning, topreventcontracture,preventionofpressureulcers,andpain

managementisimperative.

Figure 3.ICRCpatientsreceiveinformationinpreparationforrehabilitationfrominjury(ICRC)

ACUTE REHABILITATION NEEDS TREATMENT 1-2 TIMES A DAY FOR 30-60 MINUTES

163



PREVENTION OF COMMON CONTRACTURESEQUINUS CONTRACTURE» Allpatientswhoplantoweightbearinthefutureneed

tohaveaplantigradefootposition.» Equinus contractures, which are common in bed-

bound,patientswilllimitrehabilitationpotential.» These contractures can be prevented by actively

dorsiflexingtheankles.» If the patient cannot actively dorsiflex, they should

passively dorsiflex the foot by wrapping bandage orfabricaroundthetoeofthefootandpullingthefreeendtoprovidedorsiflexion.

» Patients who have no active movement should besplintedintoaneutralpositionunlessthecalfmusclesarebeingpassivelystretched.

» In any patient who cannot easily dorsiflex the foot past the neutral position, the foot should be splinted into a neutral position when not actively engaged in dorsiflexion exercises, in order to prevent the formation of Equinus contracture.

A well placed pillow has many advantages. It can protect the heels from developing decubitus ulcers and relieve back pain. However, A pillow to flex the knees must be avoided in patients with periarticular knee injuries, femoral shaft fractures, tibial shaft fractures, and below knee amputations. A pillow causing persistent flexion of the knee can result in a contracture that limits the patients future ambulation.

Figure 4.Strengtheningtheupperbodyisessentialinpatientswithlowerextremityinjuries(V. Hasselman/ ICRC)



KEY TENANTS OF SUB-ACUTE REHABILITATION OF THE LOWER EXTREMITY

» Initiatethepatient’sactivitiesofdailylivingasableandcreateascheduleforgettingoutofbed.

» Emphasizerangeofmotionwork,progressingfrompassivetoactiverangeofmotionactivities.

» Increaseweightbearingasappropriatedependingonpatienttolerance.

» Exerciseuninvolvedlimbsandgraduallyincreasetheexerciseoftheinvolvedlimbasappropriate.

» Continuedpositioningandstretchingofpatientwheninbed.

» Introducestumpwrappingforamputees,toencouragestumpshapingandpreparethelimbforeventualprosthetictraining.

KEY TENANTS OF SUB-ACUTE REHABILITATION OF THE UPPER EXTREMITY

» Jointsnot involved in the injuryshouldbemobilizedearlyandoften, i.e.apatientwithexternalfixationofaforearmfractureshouldreceiveroutinemobilizationoftheshoulderandscapula.

» Mobilityoftheupperextremityiscrucial.Patientsmusthaveassistancewith,andlearntopositiondistalandproximaljointswhenatresttopreventsofttissuecontractures.

» Theextremitiescontralateraltotheinjuryshouldroutinelyundergofullactiverangeofmotion,evenwhilethepatientrequiresassistedrangeofmotionfortheinjuredlimb.

» Introduce stumpwrapping foramputeesand continue training forperformanceofactivitiesofdailylivingfollowingupperextremityamputation.

SUB ACUTE REHABILITATION NEEDS DAILY TREATMENT 30-60 MINUTES 1-2 TIMES PER DAY

165



AMPUTATIONS

» Dischargeplanningmustbeestablishedearlytopreparethepatientandfamilyforsuccessfultransitiontohomecare.

» Followingearlierrehabilitationphasesthecontinuedrehabilitationneedsforpatientsfollowingamputationinclude:Continuedgaittraining,teachingforactivitiesofdailyliving,strengthtraining,andprosthesisandlimbpreservationtraining.

» Allactivitiesshouldinvolvethepatient’ssupportsystemasmuchaspossible.

PROSTHETIC PLANNING AND TRAINING

» ItisimportanttoconsiderthelengthofdeploymentandprostheticandrehabilitationresourceswithinanEMTwhenplanning foramputee rehabilitationandprosthetictraining.

» Patientswillrequireresourcesforlongtermmaintenanceprostheses.Therehabilitationprofessionalshouldengagewithlocalresourcestomaketheseconnectionstoenablethepatienttocontinuewithhis/hermanagementinthecommunity.

OTHER CONSIDERATIONS

» Thegreaterthecomorbiditiesorotherinjuriesofapatient,thelongertheamputeerequiresforpositioningandthelongertimethepatientshouldspendinearlierphasesofrehabilitation.

» Otheradaptiveequipmentmustbe requiredoradjusted forcomplicationssuchasmultipleamputations,traumaticbraininjury,orspinalcordinjury.

CHRONIC LONG REHABILITATION NEEDS DAILY TREATMENT 30-60 MIN BY REHABILITATION PROFESSIONAL WITH PERFORMANCE OF HOME REGIMEN BY PATIENT



Figure 5.Apatientreceivesadjustmentstoherprostheticleg.Shewas14yearsoldwheninjuredbyalandmine.(ICRC)

ORTHOTICS» Orthoticsareimportantbutoftenoverlookeddevicesthatfacilitateimprovementsin

functionafterperipheralnerveinjuryinthelimbs.» Orthoticsareutilizedbothduringhealingaswellasduringthereturntomobility.» Orthoticsassistinpositioningduringhealingaswellascompensatesforthelossor

weaknessofmuscleactiontoimprovefunctionalcapacity.» Orthotics can be easily fabricated withmoldablematerials and soft bandages for

positioning,comfort,andpreventionofskinbreakdown.» Orthoticsareaninexpensiveassistivedevicesthatcanmakelargeimprovementsin

functionalstatusfollowinglimbinjury.» Patients with nerve damage following injury, require orthotics just as amputees

requireprosthetics.

COMMUNITY CARE» Continued long term treatment and follow up by a medical professional and

rehabilitationspecialistisappropriateforuptooneyearfollowingalimbinjury.» The EMT rehabilitation specialist will need to gather and provide information for

theirpatientsregardinghowtoengagelocalcareresourcesfollowingthedisasterorconflict.

CHRONIC LONG REHABILITATION NEEDS TREATMENT DAILY 30-60 MIN BY REHABILITATION PROFESSIONAL AND HOME PROGRAM BY PATIENT

167



FAMILY INVOLVEMENT AND EQUIPMENTFAMILY INVOLVEMENT

» Familiesneedtobeinvolvedinpatienttreatment.

» Familiesareanimportantmemberofthedischargeplanning.

» Forcarryoverandconsistencyandtocombatcomplications,familiesmustbetrainedintheirlovedonescare.

» Teaching family positioning, mobility, and pain management practices improved patientoutcomesandcompliance.

SUGGESTED ALTERNATIVES

» Ifcertainequipmentisunavailableinareasofdisasterandconflict:

» Wheelchairalternative• Chairwithsomethingtoelevatelowerextremities

» Walkeralternative-crutches

» Crutchesalternative-Walkingsticks

» Slideboardalternative-Boardwithasheet

» Platformwalkeralternative-Pushingatraytableorwheelchair

» Canealternative-Walkingstick

» Gaitbeltalternative-Sheet,belt

» AFO/Orthotics-Woodorplasticuprightswithbandagedwrap.

Figure 6.Fittingawheelchairboundpatientwithwalkingsplints(ICRC)



SUGGESTED RESOURCES

1. Skelton P, Harvey A, eds. Rehabilitation in Sudden Onset Disasters. 1 ed. Online: Handicap International, UK Emergency Medical Teams; 2015.

REFERENCES

1. Landry MD, O'Connell C, Tardif G, Burns A. Post-earthquake Haiti: the critical role for rehabilitation services following a humanitarian crisis. Disability and rehabilitation 2010; 32(19): 1616-8.

2. Clini E, Ambrosino N. Early physiotherapy in the respiratory intensive care unit. Respiratory medicine 2005; 99(9): 1096-104.

3. Rathore FA, Gosney JE, Reinhardt JD, Haig AJ, Li J, DeLisa JA. Medical rehabilitation after natural disasters: why, when, and how? Archives of physical medicine and rehabilitation 2012; 93(10): 1875-81.


5. Chackungal S, Nickerson JW, Knowlton LM, et al. Best practice guidelines on surgical response in disasters and humanitarian emergencies: report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space. Prehosp Disaster Med 2011; 26(6): 429-37.

6. Walsh L, Subbarao I, Gebbie K, et al. Core competencies for disaster medicine and public health. Disaster medicine and public health preparedness 2012; 6(01): 44-52.

7. Reinhardt JD, Li J, Gosney J, et al. Disability and health-related rehabilitation in international disaster relief. Global health action 2011; 4.


AnnexesEQUIPMENTLISTFORTHELIMBINJURYMANAGMENT

ICRCABCDEINITIALASSESSMENTICRCBURNSOVERVIEW

ICRCTHROMBOPROPHYLAXISGUIDELINEICRCTRIAGE


ANNEX I EQUIPMENT LISTS FOR LIMB INJURY MANAGEMENT

QUANTITY DESCRIPTION

PLASTER CASTING MATERIAL (1 kit for 25 wounded patients)24 BANDAGE, PLASTER OF PARIS, 10cm x 3 cm60 BANDAGE, PLASTER OF PARIS, 15cm x 3 cm1 BANDAGE, TUBULAR, co:on, eached, 08cm x 25 cm for POP

100 GLOVE, EXAMINATION, NITRILE, non-sterile, medium (7-8)1 BANDAGE, TUBULAR, co:on, eached, 06cm x 25 cm for POP

12 BANDAGE PADDING, for POP, 10cmx2.7m, viscose 100%36 BANDAGE PADDING, for POP, 15cmx2.7m, viscose 100%

SPLINTS (for 15-20 cases)20 BANDAGE, GAUZE, 08cmx4m, elasVc, non-sterile5 SPLINT, KRAMER, 08 cm x 80 cm

10 SPLINT, KRAMER, 12 cm x 100 cm5 SPLINT, KRAMER, 15 cm x 100 cm

10 BAG, PE plasVc, for garbage, 100L, black, 0.07 mm4 COTTON, UNBLEACHED, 1 kg for padding2 CARTON BOX int.200x160x1100mm, double corrugaVon

PLASTER CASTS REMOVAL (1 kit for 50 Patients)1 SCISSORS, PLASTER SHEARS, BRUNS, 24 cm1 SCISSORS, PLASTER SHEARS, STILLE, 37 cm, reinforced blade1 KNIFE, PLASTER, ESMACH, 18 cm1 SPREADER, PLASTER, HENNIG, 27cm1 BREAKER, PLASTER CAST, WOLFF-BOEHLER, 18 cm1 SCISSORS, PLASTER SHEARS, STILLE-mini, 20 cm for small POP

TRACTION (1 kit for 50 patients)1 BIT, DRILL, 3.2 mm. Jacobs chuck, 180/165 mm1 CHUCK, UNIVERSAL (3-jaw) with T-Handle + locking device2 ROPE, TRACTION, 3mm x 15m, bow, extension, Boehler

2 BOW, EXTENSION, BOEHLER, 9 x 16 cm

7 NAIL, EXTENSION, STEINMANN, 210 x 4 mm, trocar point

8 BOW, EXTENSION, BOEHLER, 15x21 cm

3 PIN, STEINMANN, 4.0 mm x 150 mm

5 SPLINT, ICRC tracVon frame, ICRC

171




SET, DPC, instruments (2 kit for 50 patients)1 SCALPEL, HANDLE, No 3 (for blades 10/11/15)1 SCISSORS, MAYO, 17 cm, curved

1 NEEDLE HOLDER, MAYO-HEGAR, 15 cm, standard

4 FORCEPS, HEMOSTATIC, CRILE, 14 cm, curved

2 FORCEPS, HEMOSTATIC, KOCHER, 14 cm /1x2 teeth, straight

5 FORCEPS, TOWEL CLAMP, BACKAUS, 13 cm

2 FORCEPS, SPONGE, FOERSTER, 24cm, serrated jaws, straight

1 BOWL, ROUND, 100 ml, 80 x 35 mm, stainless steel

1 KIDNEY DISH, large, 275x150x45mm, stainless steel

1 FORCEPS, DRESSING, BLANK, 14.5 cm, atraumaVc serraVon

1 FORCEPS, TISSUE, LANE, 14cm, 1x2 teeth

1 CURETTE, BONE, VOLKMANN, 22 cm, double ended

AMPUTATION SET (2 kits for 50 patients)1 SCALPEL, HANDLE, No 4 (for 20 blades)1 SCISSORS, MAYO, 17 cm, curved

1 SCISSORS, METZENBAUM, 18 cm, curved

1 NEEDLE HOLDER, MAYO-HEGAR, 15 cm

6 FORCEPS, HEMOSTATIC, CRILE, 14 cm curved

4 FORCEPS, HEMOSTATIC, R-OCHSNER,


2 FORCEPS, SPONGE, FOERSTER, 24cm serrated jaws, straight

1 RETRACTOR, VOLKMANN, 22 cm, 3 sharp prongs 10 mm curve

1 RETRACTOR, VOLKMANN, 22 cm, 1 sharp prong, 20 mm curve

1 FILE, BONE, 22 cm x 20 mm, flat

1 RASPATORY, FARABEUF, 150x13mm, light curve, sharp


1 RONGEUR, BONE, LUER, 18 cm x 10 mm heavy

1 FORCEPS, BONE CUT., LISTON, 17 cm, standard , straight




AMPUTATION SET (2 kits for 50 patients) continued1 FORCEPS, BONE CUT., LISTON-STILLE, 27 cm, double acVon, straight

1 BOWL, ROUND, 100 ml, 80 x 35 mm stainless steel

1 SAW GIGLI, HANDLE, inpairs

10 SAW GIGLI, WIRE, 50 cm

1 BIT, DRILL, 3.2 mm. Jacobs chuck, 180/165 mm

1 BASKET, STERILIZING

1 SCISSORS, MAYO, 15.5 cm, straight

1 FORCEPS, DRESSING, BLANK, 14.5cm atraumaVc serraVon


1 KIDNEY DISH, medium, 250x140x40mm stainless steel

2 FORCEPS, TISSUE, ALLIS, 15 cm/4x5 teeth, standard

1 PHOTOMACROGRAPHIC AUTOCLAVABLE SCALE, right angle

BASIC BONE SURGERY, complementary (2 kit for 50 patients)1 RETRACTOR, VOLKMANN, 22 cm, 1sharp prong 20 mm curve

1 FILE, BONE, 22 cm x 20 mm, flat

1 RASPATORY, FARABEUF, 150x13mm, light curved, sharp

1 MALLET, 23 cm x 28 mm, 490 g, solid

1 OSTEOTOME, STILLE, 20 cm x 15, mm straight

1 OSTEOTOME, STILLE, 20 cm x 20, mm straight

1 GOUGE, STILLE, 20 cm x 15 mm, straight

1 GOUGE, STILLE, 20 cm x 20 mm, straight

1 CURETTE, BONE, VOLKMANN, 22 cm, double-ended

1 RONGEUR, BONE, LUER, 15 cm x 5mm strong curve

1 RONGEUR, BONE, BANE, 18 cm x 5mm curved

1 RONGEUR, BONE, LUER, 18 cm x 10 mm, heavy pa:ern

1 RONGEUR, BONE, STILLE- LUER, 23 cm x 10 mm, double acVon

1 FORCEPS, BONE CUT., LISTON, 17 cm, standard, straight

173




BASIC BONE SURGERY, complementary (2 kit for 50 patients) continued1 FORCEPS, BONE CUT., LISTON-STILLE, 27 cm, double acVon, angled

2 FORCEPS, BONE HOLD., VERBRUGGE, 27 cm x 12 mm, dismountable

2 RETRACTOR, BONE, HOHMANN, 29 cm x 34 mm

BONE WIRING & KIRSHNER, (1 kit for 50 patients)10 WIRE, KIRSCHNER, Ø 1.60mm x 15cm, trocared + round end

10 WIRE, KIRSCHNER, Ø 2.00mm x 15cm, trocared + round end

10 WIRE, KIRSCHNER, Ø 2.50mm x 15cm, trocard + round end

10 WIRE, KIRSCHNER, Ø 1.00mm x 15cm, trocard + round end

1 WIRE, CERCLAGE, 1.00 mm x 10 m, stainless steel, coil

1 WIRE, CERCLAGE, 1.25 mm x 10 m, stainless steel, coil

1 WIRE PASSER, DEMEL, diam. 45 mm x 28 cm, blunt

1 WIRE PASSER, diam 45mm x 23cm, curved to the lei, blunt

1 PLIERS, FLAT NOSE, 16 cm, serrated jaws, heavy pa:ern

1 VICE GRIP, 18 cm, self locking

1 PLIERS, FLAT NOSE, 14cm, serrated jaws

1 CASE, STERILIZING, 300x140x40mm, perforated with texVle filter


1 PLIERS, WIRE CUTTING, 26cm, hard wire up to 3.2 mm diameter

PLASTER CASTS REMOVAL (1 kit for 50 Patients)1 SCISSORS, PLASTER SHEARS, BRUNS, 24 cm

1 SCISSORS, PLASTER SHEARS, STILLE, 37 cm, reinforced blade

1 KNIFE, PLASTER, ESMACH, 18 cm

1 SPREADER, PLASTER, HENNIG, 27cm

1 BREAKER, PLASTER CAST, WOLFF-BOEHLER, 18 cm

1 SCISSORS, PLASTER SHEARS, STILLE-mini, 20 cm for small POP




TRACTION (1 kit for 50 patients)1 BIT, DRILL, 3.2 mm. Jacobs chuck, 180/165 mm

1 CHUCK, UNIVERSAL (3-jaw) with T-Handle + locking device

2 ROPE, TRACTION, 3mm x 15m, bow, extension, Boehler

2 BOW, EXTENSION, BOEHLER, 9 x 16 cm

7 NAIL, EXTENSION, STEINMANN, 210 x 4 mm, trocar point

8 BOW, EXTENSION, BOEHLER, 15x21 cm

3 PIN, STEINMANN, 4.0 mm x 150 mm

5 SPLINT, ICRC tracVon frame, ICRC

SKIN GRAFT (2 kit for 50 patients)5 (dermatome Humby), BLADE

1 SCISSORS, METZENBAUM, 14 cm, cuved


1 DERMATOME, HUMBY

2 (dermatome Schink) PLATE, for skin holding

1 CASE, STERILIZING, 300x200x50mm perforated with texVle filter


1 BOWL, ROUND, 200ml, 9.5 x 5 cm, stainless steel

1 FORCEPS, DRESSING, BLANK, 14.5 cm atraumaVc serraVon

SET, DEBRIDEMENT, instruments1 SCALPEL, HANDLE, No 4 (for blades 20)

1 SCISSORS, MAYO, 17 cm, curved



1 NEEDLE HOLDER, MAYO-HEGAR, 15cm, standard

1 NEEDLE HOLDER, MAYO-HEGAR, 18cm, standard

8 FORCEPS, HEMOSTATIC, CRILE, 14cm, curved

3 FORCEPS, HEMOSTATIC, R-OCHSNER, 16 cm 1x2 cm teeth, straight

175




SET, DEBRIDEMENT, instruments continued5 FORCEPS, TOWEL CLAMP, BACKAUS, 13 cm

2 FORCEPS, SPONGE, FOERSTER, 24cm, serrated jaws, straight

2 RETRACTOR, LANGENBECK, 21 cm, 13x42 mm

1 RETRACTOR, SELF-RET., WEITLANER, 16 cm, 3x4 cm, blunt prongs


1 RONGEUR, BONE, LUER, 18 cm x 10 mm, heavey pa:ern


2 FORCEPS, TISSUE, ALLIS, 15 cm/4x5 teeth, standard

1 KIDNEY DISH, large, 275x150x45mm stainless steel

1 FORCEPS, DRESSING, BLANK, 14.5cm, atraumaVc secVon


2 RETRACTOR, VOLKMANN, 22 cm, 3 sharp prongs, 10 mm curve

SET, LOWER EXTREMITY EXTERNAL FIXATION (1 kit for ~16 patients, depending on injury pa`erns)

30 LARGE CLAMP

4 ROD D 12 mm L 150 mm




15 SELF-DRILLING, SELF-TAPPING BONE SCREW L 150/40 mm Thread D 6.0-5.6mm

4 SELF-DRILLING SELF-TAPPING L 260/50 mm Thread D 6.0-5.6mm

8 SELD DRILLING CORTICAL SCREW 120/40 mm Shai D 6 mm Thread D 4.5-3mm

2 SELF-DRILLING PIN 80 mm Thread length 80mm, Thread Ø7 mm, Shai Ø6mm

1 BONE SCREW HAND DRILL

1 ALLEN WRENCH 6 mm

1 SCREW GUIDE, Length 80 mm




SET, LOWER EXTREMITY EXTERNAL FIXATION continued1 SCREW GUIDE, Length 60 mm

1 UNIVERSAL T-WRENCH

1 DRILL BIT D 48 mm X 240 mm Quick Connect

1 STERILIZATION TRAY

SET, UPPER EXTREMITY EXTERNAL FIXATION (1 kit for ~ 11 patients, depending on injury pa`erns)

30 Small Clamp

3 Rod D 6 mm L 200 mm




20 Self-Drilling, Self-Tapping Cylindrical Screw Shai D.4mm THREAD 3mm L 100/200 QC

6 Self-Drilling, Self-Tapping Cylindrical Screw Shai D.4mm THREAD 3mm L 120/25 QC

1 T Wrench AO QC Quick Connect

1 Allen Wrench 5 mm

1 Wrist Guide Template With Handle

1 Drill Bit D 2.7 mm L 127 mm Tin Coated – Quick Connect

1 Drill Guide Diameter 2.7 mm

1 SterilizaVon Tray

SET, DRESSING MATERIALS (SINGLE USE)2 Bag PE, plasVc for garbage 35 L, grey, 0.06 mm, 58x60cm

2 Iodine Povidone, 10% SoluVon 1L bo:le

60 Bandage, ElasVc, 10 cm x 5 cm, constraining

60 BANDAGE, GAUZE, 08cmx4m, elasVc, non sterile

10 BANDAGE, TRIANGULAR, 136 x 96x 96 cm

250 COMPRESS, GAUZE, 10 x 10 cm, 8 plys, 17 thr., ster., 2 pcs

177




SET, DRESSING MATERIALS (SINGLE USE) continued300 COMPRESS, GAUZE, 10 x 20 cm, 12 plys, 17 threads, non-ster.

2 COTTON WOOL, 1kg, 100% co:on, hydrophilic

1 DRESSING, ADHESIVE BANDAGE, wound plaster, 6cm x 5m, roll

6 TAPE, ADHESIVE PAPER, 2.5 cm x 10 m, roll

3 TAPE, ADHESIVE PAPER, 5 cm x 10 m, roll

200 GLOVE, EXAMINATION, NITRILE, non sterile, medium (7-8)

1 FORCEPS, DRESSING, BLANK, 14.5cm, atraumaVc serraVon

1 SCISSORS, DRESSING, LISTER, 18 cm



ANNEX I ICRC ABCDE INITIAL ASSESSMENT

INIT

IAL

ASS

ESSM

ENT

OF

LIFE

TH

REA

TEN

ING

C

ON

DIT

ION

SFO

R H

OS

PIT

AL

STA

FF

•B

e sy

stem

atic

, do

not m

iss

any

inju

ry•

Trea

t life

-thre

aten

ing

cond

ition

s be

fore

mov

ing

on•

Com

plet

e in

itial

ass

essm

ent,

then

re-a

sses

s

A B C D E

•Is

the

patie

nt ta

lkin

g?•

Look

and

list

en fo

r sig

ns o

f ai

rway

obs

truct

ion:

st

ridor

/gur

glin

g/sn

orin

g

•Ai

rway

ope

ning

man

oeuv

res/

ad

junc

ts/d

efin

itive

airw

ay c

ontro

l•

Hig

h flo

w o

xyge

n an

d su

ctio

n•

C-s

pine

pro

tect

ion

•Ex

pose

the

ches

t: Lo

ok, f

eel,

perc

uss,

aus

culta

tefo

r sig

nsof

re

spira

tory

dist

ress

•Po

sitio

n of

trac

hea,

RR

, sat

s,

ABGAS

SESS

MEN

TIN

TER

VEN

TIO

NS

TO

CO

NSI

DER

EXC

LUD

E

Airw

ay o

bstru

ctio

n

Pne

umot

hora

x H

aem

otho

rax

•O

xyge

n•

Bag-

Valv

e-M

ask

vent

ilatio

n•

Nee

dle

deco

mpr

essi

on•

Che

st tu

be in

serti

on

•Le

vel o

f con

scio

usne

ss•

Skin

col

our,

tem

p, p

ulse

(rad

ial,

fem

oral

), BP

, EC

G•

Cap

illary

refil

l tim

e, h

eart

soun

dsH

aem

orrh

age

•St

op b

leed

ing

•IV

acc

ess

+ ta

ke b

lood

•R

esto

re v

olum

e: IV

flui

ds +

blo

od•

Targ

et s

ysto

lic B

P ~9

0 (e

xcep

t in

case

of h

ead

inju

ry)

•C

onsc

ious

ness

(AVP

U/G

CS)

•Pu

pils

, mot

or fu

nctio

n, b

lood

gl

ucos

e•

Patie

nt m

edic

atio

ns

•C

ompl

etel

y un

dres

s: e

xam

ine

front

to b

ack

•X

-Ray

s

•An

tidot

es•

Glu

cose

•Av

oid

hypo

tens

ion

•W

arm

the

room

•W

arm

IV fl

uids

/blo

od•

Cov

er p

atie

nt•

Con

side

r ana

lges

ia

Hyp

othe

rmia Th

en m

ove

onto

sec

onda

ry s

urve

y…

Hyp

ogly

caem

iaA

lcoh

ol a

buse

Dru

g re

actio

ns

CAT

AST

RO

PHIC

BLE

EDIN

G: <

c>AB

CD

ED

irect

pre

ssur

e/ to

urni

quet

AIR

WAY

BR

EATH

ING

CIR

CU

LATI

ON

DIS

AB

ILIT

Y

EXPO

SUR

E


ANNEX I ICRC BURNS OVERVIEW

SU

PERF

ICIA

L SU

PER

FIC

IAL

PA

RTI

AL

THIC

KN

ESS

DEE

P

PAR

TIAL

TH

ICK

NES

S FU

LL T

HIC

KN

ESS

SKIN

DEP

TH

Supe

rfici

al e

pide

rmis

C

ompl

ete

epid

erm

is,

supe

rfici

al (p

apilla

ry)

derm

is

Com

plet

e ep

ider

mis

, de

ep d

erm

is

Com

plet

e ep

ider

mis

and

derm

is, m

ay e

xten

d

beyo

nd th

e de

rmis

APPE

ARAN

CE

Eryt

hem

a, n

o bl

iste

rs, d

ry

Eryt

hem

a, m

oist

, blis

ters

,

ra

pid

capi

llary

refil

l

Blot

chy

red/

pale

, ext

ensi

ve

blis

ters

, slu

ggis

h ca

pilla

ry

re

turn

, dry

er th

an s

uper

ficia

l pa

rtial

thic

knes

s bu

rns

Whi

te, c

harre

d, le

athe

ry,

es

char

, dry

TREA

TMEN

T

Firs

t aid

Firs

t aid

C

onsi

der c

lean

up

unde

r

anae

sthe

sia

Dre

ssin

g

Firs

t aid

C

lean

up

unde

r ana

esth

esia

D

ress

ing

May

requ

ire s

kin

graf

ting

Firs

t aid

C

lean

up

unde

r ana

esth

esia

D

ebrid

emen

t Sp

lit s

kin

graf

ting

Dre

ssin

gs: A

pply

1%

silv

er s

ulfa

diaz

ine

(3-5

mm

thic

k) d

irect

ly b

y ha

nd in

all

burn

ed a

reas

, th

en a

pply

gre

asy

dres

sing

. Cov

er w

ith s

teril

e co

mpr

esse

s (d

o no

t enc

ircle

lim

b w

ith o

ne

com

pres

s) a

nd w

rap

with

loos

e cr

epe

band

age

Pr

ovid

e al

l pat

ient

’s a

ppro

pria

te te

tanu

s an

d, in

cas

e of

sur

gica

l int

erve

ntio

n, s

urgi

cal a

ntib

iotic

pr

ophy

laxi

s

HEA

LIN

G T

IME

<5 d

ays

5-21

day

s Va

riabl

e M

onth

s-ye

ars

OU

TCO

ME

No

resi

dual

sca

rring

M

inim

al s

carri

ng

Scar

ring

If un

treat

ed:

seve

re d

isfig

urem

ent,

pe

rman

ent i

mpa

irmen

t

SPEC

IAL

CO

MM

ENTS

Su

perfi

cial

epi

derm

al b

urns

are

NO

T in

clud

ed in

the

asse

ssm

ent o

f % T

BSA

burn

t.

BU

RN

S O

VERV

IEW

FO

R H

OSP

ITAL

STA

FF

FLU

ID R

EQU

IREM

ENTS

IN F

IRST

48

HO

UR

S

SIM

PLIF

IED

CAL

CU

LATI

ON

OF

PER

CEN

TAG

E

TO

TAL

BO

DY

SUR

FAC

E AR

EA (%

TBSA

)

Chi

ld H

omun

culu

s fo

r %TB

SA

Adul

t Hom

uncu

lus

for %

TBSA

HO

UR

S SI

NC

E B

UR

N

FLU

ID R

EQU

IREM

ENTS

0-24

HO

UR

S 2

ml/k

g x

%TB

SA o

f

R

inge

rs L

acta

te

(1/2

in fi

rst 8

hou

rs,

1/2

in fo

llow

ing

16 h

ours

)

Targ

et U

rine

O

utpu

t =

0.5

ml/k

g/hr

24

-48

HO

UR

S To

be

guid

ed b

y ur

ine

outp

ut

SPEC

IAL

CO

NSI

DER

ATIO

NS:

Bur

ns >

50%

TBSA

: Use

50%

TBSA

in c

alcu

latio

n ab

ove

In

hala

tion

inju

ry/e

lect

ric b

urns

: Hav

e in

crea

sed

fluid

requ

irem

ents

, use

3 m

l/kg

x %

TBSA

OR

USE

PAT

IEN

T’S

PALM

TO

CAL

CU

LATE

%TB

SA

1 PA

LM (W

ITH

OU

T FI

NG

ERS)

= 1

%TB

SA


ANNEX I ICRC THROMBOPROPHYLAXIS GUIDELINE

ADULT VENOUS THROMBOEMBOLISM PROPHYLAXIS FOR HOSPITAL STAFF

ASSESS DVT RISK FOR ALL ADULT PATIENTS ON ADMISSION AND ON CHANGE IN CLINICAL CONDITION

PATIENT DVT RISK ASSESSMENT Score Major abdominal or thoracic surgery OR Surgery involves pelvis or lower limb and total anaesthetic and

surgical time >60 minutes OR Total anaesthetic and surgical time >90 minutes

2

Acute multiple trauma/spinal cord injury/hip, pelvis or leg fracture 2 Acute surgical admission with inflammatory condition 2 Burns >20% BSA 2 Reduced mobility >3 days 1 Age >40 years 1 Dehydration 1 1/+ Significant medical comorbidity (i.e. cardiac/metabolic/endocrine/respiratory/inflammatory conditions)

1

Personal/family history of DVT/PE 1 Obese (BMI >30kg/m2) 1 Active cancer/treatment 1 Hormone therapy (CoC/HRT) 1 Varicose veins with phlebitis 1 Pregnancy or <6 weeks post partum 1

Regardless of patient risk, encourage early mobilization and ensure adequate hydration

PATIENT LOW RISK FOR DVT

Keep patient well hydrated, encourage early mobilization

Re-assess if clinical situation changes

SCORE = 0 or 1

SCORE = ≥ 2 PATIENT AT INCREASED RISK OF DVT

ASSESS BLEEDING RISK FACTORS Active bleeding Uncontrolled systolic hypertension (≥230/120mmHg) Acute stroke Acquired bleeding disorders (acute liver failure, liver failure

with coagulopathy, be aware LFT monitoring will not always be available)

Untreated inherited bleeding disorders (haemophilia, von Willebrand’s disease)

Concurrent use of anticoagulants Unacceptable consequences of potential bleeding into vital

sites i.e. brain/spinal cord/eye Acute thrombocytopenia (platelets <75x109/L, be aware

platelet monitoring will not always be available)

YES

MECHANICAL DVT PROPHYLAXIS Provide patient with graduated compression

stockings Only consider pharmacological DVT prophylaxis

if risk of DVT outweighs the risk of bleeding.

PHARMACOLOGICAL DVT PROPHYLAXIS

ENOXAPARIN 40mg SC/OD (Unless contraindicated i.e. allergy, GI ulcer)

(20mg SC/OD in case of severe liver/kidney impairment/patient <45kg)

If possible: check platelets prior to starting Enoxaparin

YES TO ANY RISK FACTOR?

NO

NO

MAJOR RECONSTRUCTIVE ORTHOPAEDIC

SURGERY PERFORMED?

YES CONTINUE

PHARMACOLOGICAL PROPHYLAXIS FOR 14 DAYS (OR UNTIL MOBILIZED IF > 14

DAYS)

CONSIDERATIONS FOR SURGERY

Last dose of Enoxaparin to be given 12 hours before lumbar puncture/epidural/spinal anaesthesia

For all surgeries listed in ‘Patient DVT Risk Assessment’, graduated compression stockings are to be used during surgery (unless surgery is on lower limbs)

Enoxaparin to re-commence 12 hours post surgery

BEWARE!

PE Signs: Breathlessness, chest pain,

sudden collapse

DVT Signs: Pain, swelling, erythema and

tenderness of affected limb

*HEPARIN INDUCED THROMBOCYTOPENIA

Signs: External bleeding, purpura, petechia CONTINUE PHARMACOLOGICAL

PROPHYLAXIS FOR 7 DAYS

DISCHARGE

Do not delay discharge due to DVT prophylaxis

Do not continue DVT prophylaxis on discharge Counsel patient on signs and symptoms of

DVT/PE

MONITOR PATIENT FOR CLINICAL SIGNS OF HEPARIN INDUCED

THROMBOCYTOPENIA*

If platelet monitoring available: check platelets twice a week from

day 4-14


ANNEX I ICRC TRIAGE

TRIA

GE

FOR

HO

SPIT

AL S

TAFF

TR

IAG

E FO

R H

OSP

ITAL

STA

FF

SET

UP

AND

OR

GAN

IZAT

ION

OF

TRIA

GE

ICRC TRIAGE CLASSIFICATIONS

I PA

TIEN

TS W

ITH

LIF

E / L

IMB

THR

EATE

NIN

G

SU

RG

ICAL

CO

ND

ITIO

NS

AND

EM

ERG

ENC

Y

M

EDIC

AL C

ON

DIT

ION

S R

EQUI

RIN

G IM

MED

IATE

IN

TERV

ENTI

ON

II PA

TIEN

TS R

EQU

IRIN

G S

UR

GIC

AL O

R

M

EDIC

AL IN

TERV

ENTI

ON

S W

HIC

H C

AN W

AIT

PATI

ENTS

WIT

H IN

JUR

IES

BEY

ON

D TH

E C

APAB

ILIT

ES O

F TH

E M

EDIC

AL F

ACIL

ITES

AVA

ILAB

LE.

IF

AD

EQU

ATE

RES

OU

RC

ES B

ECO

ME

AVAI

LAB

LE P

ATIE

NTS

C

AN B

E R

ECLA

SSIF

IED

AS

TYPE

I

IV

III

PATI

ENTS

WIT

H S

UPE

RFI

CIA

L W

OU

ND

S

(ALL

WAL

KIN

G P

ATIE

NTS

NO

T PR

EVIO

USL

Y C

LASS

IFIE

D)

V TH

E D

EAD

A

TRIA

GE

POIN

T SH

OU

LD B

E ES

TAB

LISH

ED O

UTS

IDE

OF

THE

EMER

GEN

CY

RO

OM


ANNEX I MANAGEMENT OF FEMUR FRACTURES

MANAGEMENT OF FEMUR FRACTURES FOR HOSPITAL STAFF

MEMBER OF MULTIDISCIPLINARY TEAM MANAGING PATIENT WITH A FEMUR FRACTURE

*BROUN-BÖHLER FRAME

TRACTION IS APPLIED THROUGH A TIBIAL PIN 2.5cm distal to and 2.5cm posterior to the tibial tubercle

WEIGHT CALCULATION Weight depends on fracture type Guide: 1kg per 10kg/body weight to start

CORRECT LEG POSITION Hip: Slight abduction, flexion and 30˚ external rotation Knee: On angle of frame

SURGEON NURSE PHYSIOTHERAPIST

DAY 3

WEEK

1 AFTER IN

JURY

DAY 1

DAY 5

DAY 7

Debridement Reduction

Skeletal Traction*

Decrease traction weight to 7% body

weight

Delayed Primary Closure

X-ray and if required, adjust traction

position +/- weight

WOUND: No dressing changes. Inspect

dressing, if signs of infection inform the surgeon

PIN SITE:

Clean with saline solution and dress daily. Inform surgeon if

signs of infection

GENERAL: Check leg position 2x/day. Beware of

pressure sores

NON-AFFECTED BODY PARTS: Active mobilizing and strengthening as well as functional care to prevent

bedrest complications

AFFECTED LEG: After discussion with surgeon and considering pain level, mobilise

affected leg: aim for passive assisted knee flexion/

extension

WEEK

3

WEEK

S AFTER IN

JURY

WEEK

2 W

EEK 6

X-RAYS: Weekly for week 1-3,

then monthly until consolidation

CONSIDER REMOVAL OF TRACTION: Based on clinical and

X-Ray evidence of

consolidation

Review patient’s clinical

condition. Perform

re-debridement if necessary

Consider patient’s mental health status

AFFECTED LEG: Aim for assisted active knee

maximum range of movement

AFFECTED LEG: Aim for active knee maximum range of

movement

According to guidelines, provide walking aids and start gait training

with gradual increase of weight-bearing

DAILY

DAILY

DAILY

NOTE: In some situations, portable X-Rays are not available. In this case patients should not be removed from traction in order to perform an X-ray, assessment of consolidation should then be clinical

management of limb injuries - icrc.aoeducation.org12 management of limb injuries during disasters...

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