basic management of wounds in war & natural disaster
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BASIC MANAGEMENT OF WOUNDS IN WAR & NATURAL DISASTER. Christos Giannou Advanced Course in the Management of Disaster Victims Nicosia, October 2011. Outcome depends on :. Injury: severity of the wound & structures injured General condition of patient Pre-hospital care: evacuation time - PowerPoint PPT PresentationTRANSCRIPT
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BASIC MANAGEMENTOF WOUNDS
IN WAR & NATURAL DISASTER
Christos Giannou
Advanced Course in the Management of Disaster Victims
Nicosia, October 2011
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Outcome depends on:
Injury: severity of the wound & structures injured General condition of patient
Pre-hospital care: evacuation time Pre-hospital care: triage Pre-hospital care: first aid
Resuscitation & hospital triage & hygiene Surgery Post-operative nursing care
Physiotherapy & Rehabilitation
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Basic Principles 1
Examine the patient
resuscitation: ABCDE hypothermia
Examine the wound grade and type
Basic patient hygiene
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Basic Principles 2
Wound incision for drainage
Excision of devitalised tissues
Irrigation
Leave the wound open for drainage – no sutures
Large bulky dressing
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Basic Principles 3
No unnecessary dressing changes
Delayed Primary Closure (DPC: after 4-7 days)
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Basic Principles 4
Anti-tetanus
Antibiotics, as adjuvant
Analgesics
General condition of the patient + nutrition + hygiene
Physiotherapy + rehabilitation
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Laboratory: essential examinations
Hb / Hct Urine (sugar, pregnancy)
WBC total & differential Platelets Coagulation time, bleeding time Fasting blood sugar No bacteriology No blood gases
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Blood transfusion
No components
Whole blood, as fresh as possible
Walking blood bank: friends, family, clan
Autotransfusion
Forget recombinant Factor VIIa!
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Wound excision - debridement
Layer by anatomic layer
Skin: incision, excision
Subcutaneous tissues
Fascia, aponeurosis: drainage
Muscles: 4 C's
Periosteum
Bone
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Exceptions
Face, neck, scalp and genitals – PC after DBR
Soft tissue of the chest wall – muscles to close open pneumothorax
Head – brain injury by dura : closure should be effected if possible
Abdominal wall (open abdomen)
Joints – synovial membranes should be closed
Blood vessels, tendons, nerves – muscle cover
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Metallic foreign bodies
Should be left alone unless
Jeopardy to organ, major vessels and nerves
Inside of joints
Anterior chamber of eye
Superficial subcutaneous (painful movement)
Infection around FB (abscess)
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Principles for the Managementof Weapon Wounds
“Damaged tissues must be removed in time.”
Qanun fi el-Tib
(The Laws of Medicine)
Avicenna – Ibn Sinna
980 – 1036 CE
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Explore the wound
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Wound opened, track debrided,large foreign body
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Shell fragments and detached bone removed
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Supraclavicular bullet wound
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Multiple superficial fragments
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Serial debridement of large wound:line of demarcation of necrotic tissue apparent
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Excise skin wound & Extend the skin incision
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Fasciotomy & opening up of the wound cavity
After incision of fascia, protrusion of injured muscle
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Cavity excised & clean wound left open
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Bulky, absorbent and dry dressing
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Mismanaged wound: primary suture
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Mismanaged wound: primary suture
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Primary suture of heel without debridement:infection, tetanus, patient died
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Mismanaged wound: primary suture
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Mismanaged wound: signs of inflammation
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Stitches released,necrotic edges, subcutaneous oedema
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Re-debrided, wound is now larger than original injury
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5 days later, wound clean
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Partial closure with sutures
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Closure with split-skin graft
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Healing
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Well-managed patient: dirty wound
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Dirty wound debrided
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5 days later, removal of dressing
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Sticky dressing peals off
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Fully exposed wound 5 days after debridement
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Immediate skin graft as DPC
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Orthopaedics
No internal fixation / osteosynthesis
Plaster of Paris POP
Thomas splint
Skeletal traction
External fixation
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Vega cast
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Skeletal traction
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Thomas splint
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External fixation
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Old lessons for new surgeons
War wounds are dirty and contaminated, from the moment of injury.
The rules of septic surgery apply.
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Old lessons for new surgeons
The best antibiotic is good surgery.