war surgery afghanistan & iraq atlas_chap5
TRANSCRIPT
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Cha VABDOMINOpelVICtrAuMA
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ABDOMINOpelVIC trAuMA | 159
V.1Indic effcs of
Wounding
CASE PRESENTATION
this 15-ya-od hos naion ma snd a ody
having bn sho onc wih an M-16. th wonds w
aan. A aa abdomina wond was h sscd
nanc wond (Fig. 1). two xi wonds w cad sconday
o agmnaion (Figs. 1 and 2). th ain ndwn xoaoy
aaoomy. In sgy, h was no vidnc o naion o hionm (Fig. 3). Nvhss, h was a 3-cm, -hicknss
injy o h ansvs coon (Fig. 4). this wond was iky casd
by caviaion commony associad wih high-vociy gnsho wonds.
Bcas o h ain’s aan good niiona sas and h isoad
xn o injy, h was ad wih xndd igh hmicocomy and
iocoosomy. Hos naion ains do no n h Amy vacaion
sysm and insad ncssaiy civ hi dniiv ca a a comba
so hosia (CSH). this ain’s wonds w on and
ad wih dssing changs. H covd wiho comicaions.
TEACHING POINTS
1. this is an xam o nonniom ngy ans o a high-vociyond. th widh o iss disbanc is an indicaion o h
magnid o ngy ans, which may incas aong h ajcoy
o a ojci.
2. th scic c invovd is caviaion. th hysica ois o
h ag iss dmin h dimnsions o h moay caviy. Fo
xam, h caviy may b sma in h ng, b ag in h iv.
Caviy siz can b imssiv—as mch as 20-od ga han h
diam o h b ha casd i.
3. this gnsho wond o h xaiona abdomina wa, which
casd an injy o h ndying bow, is aso an xam o indic
cs o wonding. psmd by is na o b a, h Wond Daa
and Mniions ecivnss tam (WDMet)—a daabas o Amicancasais in h Vinam Wa—cods ony v docmnd xams
o simia injy o 299 sviving casais wih inaabdomina
ama.
4. this cas aso cognizs h no ncommon scnaio in which, i oca
mdica aciiis a no avaiab o a d hosia is no sabishd
o ha so os, h CSH bcoms h highs v o mdica ca
avaiab o many aid miiay and civiians.
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160 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
Figure 1. (to)
M-16 entry and
exit wounds.
Figure 2. (Boom)
Close-up o M-16 entry
and exit wounds.
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ABDOMINOpelVIC trAuMA | 161
CLINICAL IMPLICATIONS
Sim, isoad coon injis a ncommon. In hos
naion casais and nmy combaans, oo niiona
sas o hs oaions may cd imay ai.
Divsion wih coosomy shod b songy considd
in a ains in h snc o any o h comicaing
acos isd bow:
1. Massiv bood anssion imn.
2. Ongoing hyonsion.
3. Hyoxia (sconday o a monay injy).
4. rsion (vasca) injy.
5. Mi oh injis.6. High-vociy injis.
7. exnsiv oca iss damag.
High-ngy angnia wonds a on o ogssiv
so-iss dviaizaion and may vov ino ncoizing
asciiis. ths wonds shod b siay dbidd and
aowd o ha by ih dayd imay cos osconday innion.
DAMAGE CONTROL
1. In h nsab ain, cono conaminaion
wih igaion/saing o h bow. esabishing
insina coniniy is no imaiv.
2. Day caion o h soma ni h ain is
sab.
3. Docmn amn o oima oow-
hogh a vs o ca.
SUMMARY this is an ncommon cas in which angnia injy
by a high-vociy ojci snd wih a aivy
bnign aaanc. An ndsanding o h indic
c o moay caviaion in high-vociy wonds
omd oma aaoomy. righ hmicocomy
wih iocoosomy was omd. In his cas,
Figure 3. Exploratory laparotomy. Note: There is no penetration o the refected peritoneal wall.
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Figure 4. The transverse colon has a large wound resulting rom the indirect eects o the gunshot wound.
oongd ca was ncssay bcas h ain was
a hos naiona and cod no b vacad.
No: S discssion o hs cass on ag 201.
SUGGESTED READING
Cha 17: Abdomina injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Bamy rF, Zajchk r, ds. Conventional Warare:
Ballistic, Blast, and Burn Injuries. In: Textbook o
Military Medicine. Washingon, DC: Damn o
h Amy, Oc o th Sgon Gna, Bodn
Insi; 1991.
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ABDOMINOpelVIC trAuMA | 163
V.2pnaing tauma o h
Somach and pancas
CASE PRESENTATION
Aca bombing occd na a comba so hosia (CSH).
A sa ad immdiay o a mass casay vn.
Iniiay, ony ains wih mino injis cam o h hosia.
Howv, sva hos a, a hos naion oicman snd wih
acia, abdomina, and xmiy injis. H was awak and a,
wih a midy nd abdomn and mi agmn wonds o h
ac ovying h aoid gand, h hoacoabdomina gion, and h
g (Fig. 1). His chs X-ay was signican o ai nd h
diahagm (Fig. 2). Ding sgy, a sing agmn was ond ha
had nd h abdomn, assd hogh h anio and osio
was o h somach, and mbddd in h ancas. th anio and
osio somach wonds w cosd in wo ays (Figs. 3–5), and a
disa ancacomy and sncomy w aso omd (Fig. 6).
th aoid injy was mino, and h ac acaion was cosd. th
g wond id ony washo, acking, and dssing changs.
TEACHING POINTS
1. this cas is an xcn xam o a ain who snd sva hosa injy bcas o h consion ny ncond oowing
an aack. A ims, h CSH was noid o ag-sca aacks and was
inomd o xc casais. Sisingy, hs ains may no aiv
o many hos.
2. In his cas, nogh im asd om h im o injy ni snaion
o h ain o aow ai o accma nd h diahagm and b
visib on h chs X-ay. pains wih naing abdomina injy and
ai nd h diahagm shod ndgo immdia aaoomy.
3. pnaing injis bow h nis, abov h symhysis bis, and
bwn h osio axiay ins ms b ad as injis o h
abdomn and manda xoaoy aaoomy.
4. Somach wonds i minima dbidmn and a cosd in woays. th agmn ha casd h injis was ond mbddd in
h disa ancas. I casd signican iss damag and ho
id disa ancacomy and sncomy.
CLINICAL IMPLICATIONS
th somach is w vascaizd and say has w wih imay cos.
Ais sying h somach a no nd ais and can b igad. th
oowing oins shod b mhasizd:
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Figure 1. Abdominal entrance wound beore surgery. The acial wound overlying the let parotid gland is also apparent.
Figure 2. Chest radiograph (AP) o ree air under the diaphragm. (Objects are visible outside the body.)
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ABDOMINOpelVIC trAuMA | 165
Figure 4. Anterior stomach wound closed in two layers.
Figure 3. Anterior stomach wound beore closure.
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1. en h ss sac o idniy osio somach and
ancaic body and ai injis. A Koch manv
shod b omd o hooghy vaa h
dodnm and had o h ancas. Aways
xamin h ancas in cass invoving naing
ama o h abdomn.
2. Dain a ancaic injis.
3. ta anscion o injy o h ancaic dc
by h oowing:
a. rscion (disa ancacomy, as in his
cas).
b. Ovswing o saing h oxima ancassgmn.
c. rox-n-Y dainag o h injy.
4. th somaosain anaog, ocoid aca (San-
dosain), adminisd sbcanosy (saing
dos, 50 mg .i.d.) can b iniiad i a ancaic
ak occs and may dcas o.
DAMAGE CONTROL
In an as nvionmn, onc hmohag is conod,
ancaic injy can b managd by dainag aon. I
h cinica siaion dicas, conoing bding wih
acking and imiing conaminaion by saing o
bow injis may b sd.
SUMMARY
this cas is an xam o a sing agmn assing
hogh h anio and osio was o h
somach and mbdding in h ancas. Managmn
o his cas was aivy saighowad, bcas hain snd wih a signican abdomina wa
injy, ndnss, and ai nd h diahagm.
this cas aso dmonsas ha a signican day
can occ bwn im o aca aack and aiva
o ains a a CSH, vn i ha hosia is wihin
cos oximiy o h aack. Mdica sa shod
Figure 5. Posterior stomach wound beore repair.
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ABDOMINOpelVIC trAuMA | 167
Figure 6. Distal pancreatectomy and splenectomy. Fragment is visible (aow) within the parenchyma o the pancreas.
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consid his whn aniciaing a mass casay vn.
A ama sysm shod b in ac o ns ha
s cycs a mainaind and ha sonn do no
xhas hmsvs waiing o ains o aiv.
No: S discssion o his cas on ag 201.
SUGGESTED READINGCha 13: Fac and nck injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 16: thoacic injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 17: Abdomina injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Sgon Gna, Bodn
Insi; 2004.
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ABDOMINOpelVIC trAuMA | 169
V.3Blun Abdominal
tauma
CASE PRESENTATION
this ma ain was invovd in a moo vhic cash. H
was ansd o a comba so hosia (CSH) a an
iniia vaaion a a hos naion mdica aciiy. tyica o
hs ys o accidns, dais w no avaiab whn h ain
aivd a h hosia. On admission, h was hmodynamicay and
noogicay ncomomisd. H had a nd abdomn. Imagingcaabiiy was imid o a cvica sin sis, a oab chs X-ay,
and a vis adiogah (a noma). A dcision was mad o xo
h ain’s abdomn. On ning h abdomn, vgab ma was
nod hogho h iona caviy, as w as 500 ml o bood. th
abdomn was hooghy xod, and a injis w imid o h
abdomn. th mos aan injis w o h somach and
dodnm. th somach was amos comy anscd bwn h
body and anm, and ony 1 cm o somach maind inac aong
h ss cva (Fig. 1). th dodnm was comy disd
bwn h scond and hid oions. th sio msnic vin
(SMV) was aso injd js cada o h ancas, and h ibay
vins had bn on fsh wih h SMV. Bding om h SMV wasmanagd wih n pon ss a h sis o h avsd banchs.
th bding nds o h ibais w managd wih igaion, and
h SMV maind an a h ai. On visa inscion, h
ancas was injy-. No oh abdomina injis w idnid.
Damag cono aaoomy was omd. No o was mad
o imay ai o h gasoinsina ac. th on nd o h
oxima somach was sad cosd. th on nd o h disa
somach was aso sad. In addiion, h wo anscd nds o h
dodnm w sad. this anaomica congaion h ain
wih a bind och consising o h disa somach and h oxima
dodnm. tmoay abdomina cos was omd, and h
ain was ssciad in h innsiv ca ni. A ssciaion,h was akn back o h oaing oom. Immdia soaion o his
gasoinsina anaomy was no omd. th oxima somach
was managd wih b gasosomy, and h disa somach and
oxima dodna och w managd wih b dainag. A 24-
Fnch Maco cah was acd hogh a s-sing sich in h
anio wa o h disa somach, and h cah advancd hogh
h yos ino h dodnm. th disa somach was bogh
o h igh adan o h abdomina wa and scd o h
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Figure 1. With the patient’s head to the let, the Babcock on the patient’s right (A) is on the distal stomach
remnant. The two Babcock clamps on the let side o the patient are on the proximal gastric remnant (B). The
duodenal injury is not shown.
aia ionm. Ahogh h ancas had no
bn injd, wo dains w acd adjacn o h
ancas, and h abdomina wa ascia was on.
A wo mo days, h ain ndwn a hid
oaion. th SMV maind an. Nonhss,
bow dma vnd abdomina wa cos.
Abdomina ingiy was sod wih VICrYl msh.
Vacm dssing was aid o omo ganaion.
two days a, a achosomy was omd o assis
in waning h ain om h vniao. th ain
was ansd o a hos naion mdica aciiy. H
had good siaoy ncion, jjnosomy dings a
goa, and no vidnc o ssis a h im o ans.
TEACHING POINTS
1. Bn injis o h dodnm may b associad
wih massiv abdomina ama, as in his
cas. eay ding h iniia oaion, considaion
shod b givn o sagd damag cono sgy.
2. Whn odcd by bn oc, gasic s a
on ag wih coios inaiona soiing.3. Wih massiv oxima insina injy a iniia
oaion, ony bow ha is nsionaby
dvascaizd o ncoic shod b scd.
Ahogh bow o sionab viabiiy can b
assssd inaoaivy (Do fow, foscin), a
scond-ook oaion in 24 hos is commndd.
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ABDOMINOpelVIC trAuMA | 171
REFERENCE
1. 86h Comba So Hosia. exinc o h
86h Comba So Hosia. Oaion Iai
Fdom-1. Janay 2003 hogh Jn 2003.
unbishd daa.
SUGGESTED READING
Cha 1: Waons cs and aach injis. In:Emergency War Surgery, Third United States Revision.
Washingon, DC: Damn o h Amy, Oc o
th Sgon Gna, Bodn Insi; 2004.
Cha 11: Ciica ca. In: Emergency War Surgery,
Third United States Revision. Washingon, DC:
Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 17: Abdomina injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th SgonGna, Bodn Insi; 2004.
Cha 34: Ca o nmy isons o wa/inns.
In: Emergency War Surgery, Third United States
Revision. Washingon, DC: Damn o h Amy,
Oc o th Sgon Gna, Bodn Insi;
2004.
uS Amy Cn o Hah pomoion and pvniv
Mdicin. Clinical Practice Guidelines. Abdn
poving Gond, MD: uSACHppM; Mach 2005.
44h Mdica Command.
CLINICAL IMPLICATIONS
1. evn hogh Amy mdica asss can b gad
owad comba ama in a comba zon, noncomba
ama si occs. Aoximay 40% o sgis
omd by on CSH ding comba doymn
w noncomba ad.1
2. Amy mdica sonn doyd in h comba zon
a socd o ovid ca o comba casais.Howv, many ama ains wi b hos naionas
dnding on h mdica s o ngagmn and
socs avaiab. Whn socs a avaiab and
sciy mass in ac, oviding ca o h oca
oaion may b ossib.
DAMAGE CONTROL
1. this cas is yica o h y o damag cono
sgy ha is id in comba hosias.
2. Cinica acic gidins sggsing damag
cono aaoomy incd h oowing:
a. Mi i-haning injis.
b. Acidosis (H < 7.2).
c. Hyohmia (ma < 36°C).
d. Hyonsion and shock.
. Combind hoow viscs and vasca injy.
. Coagoahy.
SUMMARY
this ain had a combind hoow viscs and a
majo vasca injy. H id 8 nis o ackd
d bood cs. His ioaiv sas incdd
hyonsion, and h snd a iad o hyohmia(34.6°C), acidosis (H 7.27), and coagoahy
(aia homboasin im, 54 sconds). th
ain’s Injy Sviy Sco (ISS) was 16. H
was ad wih damag cono aaoomy, and
damag cono chnis sd ay in his amn
sd in a sccss ocom. tams aing o
doymn nd o anicia oviding ca o h
oca oaion and o noncomba ama ains.
No: S discssion o his cas on ags 201–202.
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V.4Missd Duodnal
Injuy
CASE PRESENTATION
this 20-ya-od main was ansd—a aaoomy and
ai o naing gasic injy—om a v II Fowad Sgica
tam (FSt) o a v III comba so hosia (CSH) mdica
amn aciiy. Whi awaiing aomdica vacaion, h xhibid
achycadia and hyonsion, wih a sma amon o biios dainag
om h osio xi wond (ow back). th ain’s abdomn wasxod io o aomdica vacaion. A aaoomy, bi saining
was nod a h si o gasic ai. A Koch manv was omd.
A missd hogh-and-hogh dodna injy was aso discovd (Fig.
1). In addiion, a sio o acaion o h igh kidny was ond
(Fig. 2). th dodna injy was aid wih a wo-ay cos
anioy and osioy (Figs. 3 and 4). th na injy was dbidd,
and bding was conod wih cocay. Boh injis w
xnay daind. th ain imovd cinicay and was a vacad.
TEACHING POINTS
1. lv II sgy nis (g, FSts) oa in as and soc-
consaind nvionmns. On, hy om isaving oaions invy dic condiions. I is ciicay imoan ha mdica sonn
om a hoogh xoaion (i im mis) whn oaing on
naing abdomina ama.
2. I h cinica siaion o condiion o h ain dos no mi his
xaminaion, i is ssnia ha h v II mdica amn aciiy
commnica in som way (vn i i invovs wiing on h abdomina
dssing; Fig. 5) wih h civing v III aciiy o mak s ha
h nx v o ca sonn ndsand ha xoaion io o
h vacaion is mandaoy.
3. I is ciica ha v III mdica amn aciiis cay vaa
ains civd and consid ay oaion whn ains main
nsab o dioa a aiva. Sia xaminaions and anivobsvaion o osoaiv ains a mandaoy hogho h
MeDeVAC sysm.
CLINICAL IMPLICATIONS
Injis o h dodnm a on associad wih massiv abdomina
ama. Damag cono chnis shod b considd ay.
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ABDOMINOpelVIC trAuMA | 173
Figure 1. Through-and-through injury to the duodenum ater Kocher maneuver. Note bile staining o
surrounding tissue.
1. Missd injis o h dodnm hav dvasaing
mobidiy and a associad wih high moaiy.
2. Bi saining o hmaoma in h idodna
isss mandas xoaion o h dodnm.
3. Mino injis can b aid imaiy.
4. Majo injis shod b aid i h mn
wi no b naowd by mo han 50%.1
5. Consid h oowing o injis invoving mo
han 50% o h mn1:
a. Dain h injy hogh a rox-n-Y jjnaimb.
b. Avoid ancaicododncomy.
c. Div h gasic sam wih a gasosomy
and cos h yos. Do no divid h yos.
d. Widy dain a injis wih cosd-scion
dains.Figure 2. Injury to the kidney.
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Figure 3. Duodenal injury in the process o being closed.
. Cos h dodnm aond a Maco cah
sing 2-0 VICrYl (b dodnosomy).
DAMAGE CONTROL
1. pnaing na injis can b managd by dbidmn
and dainag. th shod b a ow hshod o
nhcomy in h nsab ain.
2. Dodna injis shod b cosd imaiy i asib
and naowing o h mn ss han 50% can b
obaind. A dodna injis shod b daind.
SUMMARY
In his cas, dsi h ack o commnicaion ny
ncond in comba nvionmns, sgons cocy
dmind ha his ain id xoaion. this
acion vnd h wosning o his condiion, sciay
a h os o oongd vacaion.
No: S discssion o his cas on ag 202.
THE KOCHER MANEUVER
Namd o Nob piz-winning
sgon D emi thodo Koch
(1841–1917), h Koch manv
(o Koch’s manv) is a sgica
ocd o xos scs in
h oionm bhind h
dodnm and ancas. In his
manv, h had o h ancas
is mobiizd and accssd ding
an oaion. to b y cad aKoch manv, h who scond
a o h dodnm has o b
mobiizd wih h oionm
ba o inscion a h way o h
aoa.
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ABDOMINOpelVIC trAuMA | 175
REFERENCE
1. Cha 17: Abdomina injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004: . 17-9.
SUGGESTED READING
Cha 2: lvs o mdica ca. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 4: Aomdica vacaion. In: EmergencyWar Surgery, Third United States Revision. Washing-
on, DC: Damn o h Amy, Oc o th
Sgon Gna, Bodn Insi; 2004.Figure 5. Communication involving writing on
abdominal dressing rom level II to level III medical
treatment acility.
Figure 4. View o closed duodenum.
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V.5taumaic eviscaion
CASE PRESENTATION
A30-ya-od hos naion ma ssaind a bas injy o his
fank. I ook 12 hos o ach h Fowad Sgica tam
(FSt) oaing bas. A d dssing had bn acd ov
h wond, b no oh ssciaiv os w iniiad. Whn h
ain aivd, h was a and oind, wih noma via signs and
no achycadia. A sconday svy vad a signican abdomina
wa injy wih viscad sma bow (Fig. 1). H had mi
noomis in h viscad sgmns o h sma bow. th
was an isod o biios msis, and a nasogasic b was acd o
dcomss h somach. th ain was sad on inavnos fids
and givn a scond-gnaion chaosoin inavnosy. H was
hn akn o sgy. th abdomn was xod hogh a midin
incision, and no goss ca conaminaion o h ionm was ond.
th w no oh visca o vasca injis nod. th viscad
sma bow was addssd by s cosing h noomis moaiy
wih sik ss osid o h abdomn and hn dcing h bow
ino h abdomina caviy. th bow was assssd o ischmia, and
gossy ischmic-aaing bow and nonviab bow w scd(Fig. 2). Bow coniniy was sabishd ding sgy wih
imay anasomoss. th abdomn was washd o wih 6 is o
noma sain and hn cosd. H was xbad and ansd o h
innsiv ca ni (ICu). th ain had an nvn osoaiv
cos; was sad on a ga di on osoaiv day 4; and had no
sho-m, osoaiv comicaions.
TEACHING POINTS
1. phosia managmn shod b imid o coving viscad
abdomina conns wih moisnd gaz o oh si dssings
and hn scing h conns wih a o vn h
viscaion. Mdics shod no am dcion o conns,bcas his can s in dcion o gangnos o oad
bow ino h iona caviy.
2. Whn h ain aivs wih viscaion o abdomina conns,
h hysician shod no b disacd by h obvios injy and
shod ocd wih Advancd tama li So (AtlS)
ooco. Ony a hoogh imay and sconday svys is h
amaic viscaion addssd.
Cosy David lson, The Dallas Morning News
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ABDOMINOpelVIC trAuMA | 177
Figure 1. Wound showing evisceration o the small intestine.
CLINICAL IMPLICATIONS
Onc h dcision is mad o ak h ain o h
oaing oom, managmn o a sim viscaion is
saighowad.
1. th ain can b d widy, and h viscad
bow can b d wih badin a hoogh
iigaion.
2. Any oh immdiay i-haning abdomina
injis shod b addssd s—hn dc h
bow and assss viabiiy.
3. th ocd shod bgin wih a midin incision.
4. th viscad bow can b xamind osido h abdomina caviy. I h a noomis,
cono conaminaion by cosing h dcs wih
a sim s bo dcing h bow back
ino h abdomn.
5. rmmb, as in an incacad hnia, sim
dcion o h insins may b a ha is
ndd o n bood fow o ischmic aas.
6. A anky ncoic bow is movd, and a i-
may anasomosis o an osomy may b omd.
Choic o imay anasomosis vss osomy and
dayd imay ai dnds on many acos
(g, h snc o associad injis, hyonsion,
and dg o inaabdomina conaminaion). pi-
may ai in yong, hahy ains who a
hmodynamicay sab is accab. An osomy
and dayd ai a svd o nsab ains
o sv, goss ca conaminaion, as in a coon
o ca injy.
DAMAGE CONTROL1. Cono aiway and hmohag s in hmo-
dynamicay nsab ains.
2. Cono goss conaminaion by cosing no-
omis wih sim ss o sas.
3. rsc dad and ischmic bow and day anaso-
mosis o caion o an osomy ni ains a
hmodynamicay sab.
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178 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
Figure 2. Removal o necrotic and ischemic bowel.
SUMMARY
In h comba sing, h managmn o viscad
abdomina conns is said ino wo cagois:
(1) ay mandaoy aaoomy and (2) nongn
aaoomy. unik in h civiian sing, nonoaiv
amn o hs ains is no aoia.
No: S discssion o his cas on ag 202.
SUGGESTED READING
Aikan S, Kocaksak A, a. A osciv comaison o
h sciv obsvaion and oin xoaion mhods
o naing abdomina sab wonds wih ogan o
omnm viscaion. J Trauma. 2005;58(3):526–532.
Bnissa N, Zobidi M, a. Abdomina sab wond injy
wih omnm viscaion. Ann Chir. 2003;128(10):
710–713.
Cha 3: tiag. In: Emergency War Surgery, Third
United States Revision. Washingon, DC: Damn
o h Amy, Oc o th Sgon Gna, Bodn
Insi; 2004.
Cha 17: Abdomina injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
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ABDOMINOpelVIC trAuMA | 179
V.6pnaing rcal
Injuy
CASE PRESENTATION
this 35-ya-od ma ain was iding in a miiay vhic whn
an imovisd xosiv dvic (IeD) was donad. H was
ad by mdics in h d and hn bogh o h comba
so hosia (CSH) by MeDeVAC hico. H aivd awak
and comaining o ain in his g. A hoogh xaminaion vad
an obvios m ac wih a aa nanc wond and a
mdia xi wond. th ain’s ss w noma, wih no vidnc
o aia injy. Fh xaminaion vad a scond naing
wond ha nd h bock, cad a ag sbcanos ac
wih aab cis, and xid hogh a ag wond in h igh
bock. examinaion o h inm showd no bising, and no
oh injis w nod. th ain id xna xaion o h
m ac and xoaion o h saca wond. I was ca ha h
ocd wod ak som im o om. A bood div was iniiad
o 8 nis o who bood. Bcas h was minima bding om
h saca wond, xna xaion o h m ac was omd
o minimiz bood oss om ha wond. thn h ain was acd
in h on osiion. th saca wond was addssd by oning hwond ac bwn h nanc and xi wonds. th ojcis
(ocks) had assd hogh h sacm a h S2 v and comy
dividd h bony sacm (Fig. 1). th msca bding was ackd.
A -hicknss, 50% cicmnia osio ca injy—wih
goss ca conaminaion—was idnid. th was bding om h
ain’s sid bwn h cm and aa vic wa. th
svd nds o h hyogasic ay w idnid wih dicy
and igad. th saca vnos xs o h and ow saca
agmns was comssd wih acks. Wih hmohag conod,
h ain’s hysioogica sas was assssd. His ma was
34°C, and h was cinicay coagoahic and acidoic. th dcision
was mad ho o ocd wih damag cono by aidy cosingh ca wond wih VICrYl s, aying qikCo hmosaic
agn, and acking h wond. th skin was cosd ov h acks o
ay ss (Fig. 2), and h ain was hn akn o h innsiv
ca ni (ICu) o ssciaion and waming (Fig. 3). A ha im,
h CSH did no hav aciv waming dvics (g, Bai Hggs), so
inavnos cah bags had in a micowav ovn and acivad
Mre (Ma, rady-o-ea) has wad in ows w sd o wam
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180 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
Figure 1. Pelvic radiograph. Note numerous oreign
bodies. The sacrum is transected at S2.
h ain. H was givn who bood anssions
ni his a v was abov 50,000 s/ml. Wih
ssciaion, h ain’s ma and via signs
nomaizd and acidosis imovd. Howv, h ain’s
abdomn bcam incasingy disndd, and sia
asond xaminaions vad incasing amons
o inaiona fid. Onc sabiizd, h ain was
nd o h oaing oom (Or) o aaoomy
o o inaabdomina hmohag and o om
a diving coosomy o a h cosaca wond.
No inaabdomina wond was idnid, and an nd
dscnding coosomy was omd (Fig. 4). th disa
coon was cosd, oowd by cos o h abdomn.
th oowing moning, 24 hos a iniia injy, h
ain was hmosaic. evacaion was annd, b h
iming o ha vacaion is ndicab; ho,
h ain was akn back o h Or o washo and
dbidmn o h ca wond. th saca acks wmovd (Fig. 5). th aw sacs w hmosaic, wih
h sandik mnans o h qikCo in ac. Coios
iigaion was sd o mov h aics and ncoic
iss. Maniaion o h saca body vad a
cbosina fid ak, and inaoaiv consaion
wih a nosgon was obaind. Dniiv amn
o ha injy was dd o v V. tho, h
wond was cosd ov cosd-scion dains. la ha
vning, h ain was vacad o a v IV mdica
amn aciiy wih his sgon anding and wih
CCAtt (Ciica Ca Ai tanso tam) assisanc.
TEACHING POINTS
1. Comba-injd ains on sn wih mi
comx wonds. A vaiabs ms b considd
whn caing o hs ains. I can b agd
ha h saca injy shod hav bn addssd
s. Howv, i was ca ha, whn his ain
snd, h wod i sagd ocds and
damag cono chnis.
2. th nd o who bood and oh bood odc
anssions ms b idnid ay.
3. th nd o damag cono sgy ms b mad
bo ivsib acidosis and coagoahy dvo.us a o yo socs—hysicians, nss, and
anshiss—o sscia and sabiiz h ain.
4. ligaion o inna iiac ais may b civ in
managing ohwis nconoab vic hmo-
hag. I can b omd hogh h osio
wond in som siaions. Biaia igaion o h
inna iiac ais is o b avoidd, i ossib.
5. In h comba sing, om h as amon
o sgy ossib. In his cas, h cbosina
fid ak was conod, and dniiv ai was
dd o a v V mdica amn aciiy. I
ossib, am imay cos o h hca sac.
In many cass, his canno b don bcas dic
accss may b dic, o bcas h da nds o
b diahanos and ams a siching can nag
h a. Insad, consid a da sbsi (g,
DaGn). Foow wih a bin saan.
Figure 2. Damage control. Skin temporarily closed
over packing.
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ABDOMINOpelVIC trAuMA | 181
6. CSHs a dsignd o a comba ama. p-
doymn and acim aining ms incd
ain ca wihin h d amn aciiis. In his
cas, imn as ndamna as ain wams
w no incdd in his hosia’s invnoy. Amy
sgons ms disciin hmsvs o aicia in
doymn aining and h ocss ha dvos
d hosias and h imn s.
CLINICAL IMPLICATIONS
Whn caing o ains wih mi comx wonds,
mmb h basics:
1. Cono h aiway, obain ada inavnos
accss, and sscia h ain wih wam fids,
incding who bood whn aoia.
2. Idniy socs o hmohag and cono
hmohag by h sims mans avaiab.
this may incd sabiizing xmiy and vic
acs. Hmosaic agns (g, chiosan) may bs. Fsh ozn asma and combinan aco
VII may b avaiab. tama sgons nd o
ndsand h aaion and s o a avaiab
bood odcs.
3. Cono goss conaminaion and ibay d
dniiv ai o bow injis ni h ain is
sab. A moay cos wih acks and dains
in ac is on h. Whn h ain is sab,
annd oaion is s.
4. rca wonds can b dic o diagnos. Injy
shod b sscd i ama has occd in
oximiy o h cm, i h is an abnoma caxaminaion, o i a adiogah sggss injy. th
oowing incis ay:
a. A ca injis shod hav oxima
divsion. Sigmoid nd coosomy is say
ada. I h injy has no vioad h
ionm, xoaion o h xaiona
cm shod no b don a aaoomy nss
indicad o an associad nonbow injy.
this avoids conaminaing h iona caviy
wih soo.
b. A ca wonds shod b daind. psaca
dains shod b sd o xaiona ca
injis. Fca conaminaion o h ica
sac mandas saca dainag.
c. Disa washo o h cm is say ncs-
say o assss h injy. Gn ss whn
iigaing wi minimiz conaminaion o h
ica sac.
d. Dbidmn and cos a no ncssay insma- o mdim-sizd wonds ha hav bn
divd and daind.
. Hmaoma in h ica sac shod b
daind ih ansminay by aving h
injd cm on o by acing dains ans-
abdominay o hogh saca dains.
. pionaizd ca injis a asiy accssd
ansabdominay and shod b aid and
ocd wih divsion.
DAMAGE CONTROL
this cas ay isas h incis o damag
cono. Damag cono is dnd as h aid iniia
cono o hmohag and conaminaion, moay
cos, ssciaion o noma hysioogy in h ICu,
and sbsn xoaion and dniiv ai.
Concning h cbosina fid ak: sw in a ach
ga o ay on down and saa i wih ascia and a.
Figure 3. Rewarming and stabilization o the patient
in ICU.
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182 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
Figure 4. Surgery; exploratory laparotomy and diverting colostomy.
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ABDOMINOpelVIC trAuMA | 183
Div cbosina fid wih a mba dain. pack h
wond. K h ain fa.
SUMMARY
In his cas, a ain wih sv injis svivd
hos wonds by civ s o damag cono
chnis, incding ay aggssiv ssciaion
wih who bood and cono o hmohag and
goss conaminaion. Whn sab, h ain was
nd o h Or o h id sgy and hn
vacad. pom Ct/myogahy a v V o
o sdomningoco.
No: S discssion o his cas on ags 202–203.
SUGGESTED READING
Cha 4: Aomdica vacaion. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 6: Hmohag cono. In: Emergency War
Surgery, Third United States Revision. Washingon,DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 12: Damag cono sgy. In: Emergency
War Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Figure 5. Third surgery; sacral packs are removed.
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184 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
Cha 17: Abdomina injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 22: So-iss injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
THREE PHASES OF DAMAGE CONTROL
th goa o damag cono is o so noma hysioogy ah han noma anaomy. I is sd o
h miy injd ain, wih combinaions o abdomina, vasca, gnioinay, noogica,
ohoadic, and/o hoacic injy in h saa and disinc hass.
1. pimay Oaion and Hmohag Cono—sgica cono o hmohag and mova o
conaminaion; aaoomy minad, abdomn ackd, and moay cos; dniiv
ai is dd.a. Cono o hmohag.
b. exoaion o dmin xn o injy.
c. Cono o conaminaion.
d. thaic acking.
. Abdomina cos.
2. Ciica Ca Considaions—noma hysioogy sod in h ICu by co waming, coc-
ion o coagoahy, and hmodynamic nomaizaion.
a. Co waming.
b. rvsa o acidosis.
c. rvsa o coagoahy.
3. pannd roaion—xoaion o com h dniiv sgica managmn o vacaion.
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 23: exmiy acs. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
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ABDOMINOpelVIC trAuMA | 185
V.7rnal tauma
CASE PRESENTATION
A23-ya-od hos naion ma snd wih a sing gnsho
wond oowing a sni incidn. th ain was a
and sonding aoiay o sions. Iniia via signs
vad h oowing: bood ss, 90/60 mm Hg; ha a,
115 bas min; and ma, 36ºC. pimay and sconday
svys vad dis abdomina ndnss and bond, and a sing
nanc wond in h osio axiay in on h js bow h
12h ib. th ain wn dicy o sgy, wiho imaging, basd
on h cinica xaminaion. exoaoy aaoomy was ngaiv, o
incd no obvios oiona hmaoma. th ain civd 2
nis o ackd d bood cs inaoaivy. posoaivy, his via
signs sabiizd. Aoximay 10 hos osoaivy, h ain’s
via signs bcam nsab, wih bood ss o 80/60 mm Hg and
a ha a o 130 bas min. ra aboaoy vaaion
vad h oowing: hmogobin, 7.5 g/dl; innaiona nomaizd
aio (INr), 3.1; and aia homboasin im (ptt), 68 sconds.
A Ct scan was obaind (Fig. 1) and vad a gad III igh na
injy (tab 1) wih no inay xavasaion and inac vsss. thb is shown. Bcas o h cn ons o hmodynamic insabiiy
and coagoahy, a ia o nonoaiv managmn was cd.
th ain was givn 2 addiiona nis o ackd d bood cs,
4 nis o sh ozn asma, and 7,500 µg o acivad Faco VII.
Fid ssciaion conind. Ov h nx sva hos, in o
incasd and via signs sabiizd. th coagaion aams aso
nomaizd. th ain was dischagd hom on osoaiv day 5.
TEACHING POINTS
1. Signican oiona injis can b missd a xoaoy
aaoomy. Consid ay imaging wih ngaiv ndings a
xoaion.2. th majoiy o gad III na injis do no i oaion.
Coagoahy was a comicaing aco in his cas.
3. In ains wih gad III o IV na injis—wih no oh indicaion
o oaiv xoaion—a ia o aggssiv ssciaion wih
cysaoid and bood odcs is h s in o invnion. Oaiv
xoaion o h oionm is svd o nonsonds.
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186 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
4. th s o acivad Faco VII is conovsia; in
his cas, i may hav bn ogan-saing.
CLINICAL IMPLICATIONS
1. Managmn o bn and naing na ama
is dicd by h gad o injy. Gads I o III
invov vaying dgs o acaion and hmaoma
wih no dision o h majo vsss o cocing
sysm. Gad V sns avsion o h dic
and is amos aways managd oaivy. Gad IV
invovs vaying dgs o cocing sysm and/o
vasca injy. Managmn o gad IV injis
can invov ih immdia oaiv xoaion
o a ia o aggssiv ssciaion wih cysaoid
and bood odcs, dnding on h avaiabiiy
o socs and h v o xis o avaiab
sgons.2. rna ama ains shod hav a Foy cah
in ac and shod main on bd s ni goss
hmaia cas.
DAMAGE CONTROL
In h absnc o a Ct scann, a FASt xaminaion
o h oionm may dc a oiona
hmaoma. I no imaging is avaiab, a high indx
o ssicion o oiona injy ms b
mainaind basd on h ocaion o nanc and xi
wonds. I h ain sonds o fid and bood
odc ssciaion, immdia vacaion o h
nx v o ca shod b iniiad. I hmodynamics
mains nsab, mgn oaiv invnion is
id, wih ca anion o assssmn o h
oionm. Nhcomy may b h bs soion
o majo na injis whn oh i-haning
injis a sn. Dmining h ncion o h
conaaa kidny (conmd by conas sdy) is
dsiab io o nhcomy.
SUMMARY
th kidnys and oh oiona scs aa isk wih bn and naing abdomina, back,
and fank ama. I oaiv managmn is no
immdiay indicad, h imaging modaiy o choic
is a h-has Ct scan o h abdomn and vis.
Basd on Ct scan ndings, na ama can b gadd
on a sca o I o V. Gads I o III and many gad IV
grade Type oF injury descripTion
Minor
I Consion Micoscoic o goss hmaia; oogica sdis noma
Hmaoma Sbcasa, nonxanding wiho anchyma acaion
II Hmaoma Nonxanding ina hmaoma connd o na oionm
lacaion <1.0-cm anchyma dh o na cox wiho inay xavasaion
Major
III lacaion >1.0-cm anchyma dh o na cox wiho cocing
sysm o inay xavasaion
IV lacaion panchyma acaion xnding hogh na cox, mda,
and cocing sysmVasca Main na ay o vin injy wih conaind hmohag
V lacaion Comy shad kidny
Vasca Avsion o na him ha dvascaizs kidny
Table 1. Renal Injury Scale
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ABDOMINOpelVIC trAuMA | 187
Figure 1. Abdominal CT images obtained postoperatively. A large perinephric fuid collection and air lucencies
(l) , as well as bullet ragment (righ) are evident.
injis can b managd nonoaivy wih aggssiv
fid and bood odc ssciaion.
SUGGESTED READING
Cha 17: Abdomina injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 18: Gnioinay ac injis. In: Emergency
War Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
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188 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
V.8pnaing plvic
tauma
CASE PRESENTATION
A27-ya-od ma ssaind injis a xos o a bas om
an imovisd xosiv dvic (IeD). H was h on-sa
assng in a vhic, and h bas occd a h igh on
i. On aiva, h was a and answing sions aoiay.
Via signs w sab. pimay and sconday svys vad a igh
ank bas injy and naing wonds o h osio igh
high (Figs. 1 and 2) and mdia high. Abdomn, gnioinay,
and ca xaminaions, as w as h maind o h hysica
xaminaion, w noma. A ain m was obaind o h igh oo
and ank and h igh high. An anoosio vis adiogah
was odd. two ag shan agmns w idnid ovying
h vis (Fig. 3). Wih his inomaion, a Ct scan was hn obaind
o h abdomn and vis. th Ct scan showd wo agmns: on
agmn was adjacn o h bas o h badd on h igh, and h
oh agmn was adjacn o h inio bic ams and osio
asc o h igh cos cavnosm (Fig. 4). th ocaion o h
agmns aisd concn o h ingiy o boh h inay ac
and ow gasoinsina (GI) ac. H was bogh o h oaingoom o washo o h igh ank and h invsigaion o h
ow inay and GI acs. pocoscoy was ngaiv. Cysoscoy and
ogad conas sdis vad no injy in h ha, badd,
o disa igh . H was obsvd ovnigh and vacad in 24
hos o h nx high v o ca.
TEACHING POINTS
1. IeD agmns may hav a signican disanc o xcsion om
h nanc wond. Consny, ain ms shod b obaind
ibay in h ama bay.
2. Whn vic agmns a idnid, h ingiy o h inayand ow GI acs ms b considd. Fh diagnosic sing
shod b annd basd on adiogahic and hysica xaminaion
ndings.
CLINICAL IMPLICATIONS
pnaing injis o h vis a on associad wih abdomino-
vic ogan injy. Diagnosis o associad injis may i
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ABDOMINOpelVIC trAuMA | 189
Figure 1. Penetrating blast injury, right ankle.
Figure 2. Penetrating wounds, right posterior thigh.
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190 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
Figure 3. AP pelvis radiograph. Note the two ragments.
Figure 4. Pelvic CT image. Note ragment (with associated scatter eect) at right posterior corpus cavernosum.
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ABDOMINOpelVIC trAuMA | 191
xoaoy aaoomy. Cahizaion is conain-
dicad ni ha ingiy is conmd by o-
gad hogahy.
DAMAGE CONTROL
Fo cass o sscd ha ama (bood a h
mas, scoa hmaoma, high-iding osa), a
ogad hogam shod b omd ioo insion o a Foy cah. I a ha injy is
discovd, a sabic cah is commndd.
SUMMARY
IeD bass a h mos common mchanism o
injy in Oaion Iai Fdom. thy may s
in mi sis o ama o a givn ain. th
ocaion o h nanc wond oms vaying vs
o concn o adjacn scs basd on ocaion.
I ms b mhasizd ha agmns may com o
s a signican disanc om hi nanc wonds.
liba s o ain adiogahy and coss-scionaimaging shod b iizd wih his mchanism o
injy.
SUGGESTED READING
Cha 18: Gnioinay ac injis. In: Emer-
gency War Surgery, Third United States Revision.
Washingon, DC: Damn o h Amy, Oc o
th Sgon Gna, Bodn Insi; 2004.
Cha 21: pvic injis. In: Emergency War
Surgery, Third United States Revision. Washingon,DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 22: So-iss injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 26: Injis o h hands and . In: Emer-
gency War Surgery, Third United States Revision.
Washingon, DC: Damn o h Amy, Oc o
th Sgon Gna, Bodn Insi; 2004.
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192 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
V.9pnaing Scoal
tauma
CASE PRESENTATION
A23-ya-od hos naion ma snd as a o a mass
casay vn a a sicid bomb aack. th ain was
a and comaind o igh hand, igh goin, and igh high
ain. His injis incdd a igh-hand ac and an avsion o
skin and sbcanos iss in h oxima/mdia igh high wih
a oign body vidn on xaminaion (Fig. 1). th ni and scoa
xaminaions vad dis dma and cchymosis. th sic
was aab and nmakab. th igh sic was nonaab.
A adiogah o h vis/ow xmiis vad a oign body
simosd on h inio bic ams on h igh (Fig. 2). A Ct
scan o h abdomn and vis vad an abnoma aaanc o
h igh sic, ai in h scom, and h oign body osio o
h scom (Fig. 3). th ain was bogh o h oaing oom
o sabiizaion o h igh hand, washo o h igh high wond,
and—basd on adiogahic ndings and hysica xaminaion—
scoa xoaion. On xoaion, h oign body was movd and
was consisn wih a hman ib agmn wih aachd incosa
msca (Fig. 4). th scom was xod hogh a midinincision a h mdian ah. th ain had a d igh sic.
An ochicomy was omd. H covd w and was dischagd
on osoaiv day 2.
TEACHING POINTS
1. pains injd in sicid bomb aacks a a isk o boh
mchanica injy om bas cs and agmns. thy a aso
a bioogica isk om “missi-izd” body as.
2. th absnc o a aab sic a bn naing ama
shod om scoa xoaion.
CLINICAL IMPLICATIONS
1. In many cass o scoa ama, as in his cas, h a associad
injis oming Ct scan. Ct scan and asond o h scom
a insnsiiv o sica and oh scoa ahoogy. A
high indx o ssicion basd on mchanism o injy and hysica
xaminaion ndings shod om scoa xoaion.
2. tsica savag a is ossib. Dmining acos a
h dg o maining vasca sy o h b mass and
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ABDOMINOpelVIC trAuMA | 193
Figure 1. Scrotum refected to show proximal medial thigh wound. Note oreign body in wound (aow).
Figure 2. Coned pelvic radiograph demonstrates oreign body overlying the right pubic ramus (aow).
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194 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
Figure 3. Pelvic CT image demonstrates air in right scrotum with the oreign body located posteriorly. Right
testicle is abnormal.
Figure 4. Fragment o human rib removed rom right
scrotum.
Figure 5. Avulsed right testicle.
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ABDOMINOpelVIC trAuMA | 195
h avaiabiiy o maining nica abgina o
consc h sic. In his cas, h was
amos com avsion o h b mass
(Fig. 5); ho, ochicomy was omd.
Howv, as soon as h nica abgina (o
ididymis o vas dns) is vioad, h is a
bach o h bood–sis bai, and h xiss
onia o h omaion o anism anibodisgadss o h disosiion o h sic (savag
o mova). this dos no gaan iniiy,
b cas h isk o sbiiy. I iiy
bcoms a cinica obm o hs ains in
h , ay a o an iniiy sciais
is indicad.
3. In ms o sica ncion, h maining
noma sic odcs nogh soson o
noma ma hysioogica ncion.
DAMAGE CONTROL
In as condiions, scoa injis a no mgnas ong as hmosasis is achivd. I sica savag
is o b naind, h ain shod b sn by a
sgon wihin 3 o 4 hos o injy. I h mission
cds immdia a o a sgon, i cod b
managd consvaivy indniy ni oogica
vaaion is ossib.
SUMMARY
pains injd in sicid bomb aacks a a isk
o boh mchanica and bioogica injis. th
xamining ovid ms dvo an indx o ssicion
o sica injy basd on mchanism and hysica
xaminaion ndings. Ct scan and asond a
on nsaisying in diagnosing sica injy.
tsica savag shod b h goa, i mission aows,and h ain shod b vacad o h nas
oogis wihin 3 o 4 hos o injy. I immdia
a is no ossib, and oaiv aciiis a no
immdiay avaiab, scoa injis can b managd
consvaivy indniy ni a is ossib.
SUGGESTED READING
Cha 17: Abdomina injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Cha 18: Gnioinay ac injis. In: Emer-
gency War Surgery, Third United States Revision.
Washingon, DC: Damn o h Amy, Oc o
th Sgon Gna, Bodn Insi; 2004.
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196 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
V.10Gnial Sof-tissu
tauma
CASE PRESENTATION
Whi on ao, a 29-ya-od ma sodi ssaind mi
bas injis whn his vhic was sck by an imovisd
xosiv dvic (IeD). H was ssciad a h Fowad
Sgica tam (FSt) aciiy and ansd o a v IV mdica aciiy.
In addiion o damaic so-iss injis o h nis and scom, h
sd had, ac, igh hand, and biaa ow xmiy injis.
th ain ndwn wond dbidmn and gnia conscion
ha incdd a ochicomy, ai o h d igh sic,
ha conscion ov a 12-gag Fnch ha cah, ni
gans conscion, and skin cos (Fig. 1). H was vacad o
h unid Sas on h h day oowing his injy. th ni and
ha conscions aid wih ogssion o nonviab iss, and
h ais w akn down o addiiona dbidmn (Fig. 2). Dayd
conscion was sad 2 wks a h injy by acmn o a
si-hicknss skin ga o h wond bd (Fig. 3).
TEACHING POINTS
1. High-ngy injy o h so iss o h gniaia can cas dayd
iss ncosis.
2. eay conscion has a ga isk o ai.
3. Cos o h cos cavnosm is advisab o sma injis.
4. tnsion- aoximaion o h ha and cos songiosm
wih absobab s is commndd.
5. Gnia skin shod b aoximad oosy a is anaomica si.
6. Gnos s o dains is commndd.
CLINICAL IMPLICATIONS
1. Gnia wond dbidmn can b don icky ding damag
cono sgy. this is accomishd hogh jdicios mova o
nonviab iss wih coios iigaion o ss avag o hwond. tiss dviaizaion om high-vociy ojcis is no
aways aan a iniia vaaion. Dayd ncosis can joadiz
ay consciv os. Dniiv wond cos shod,
ho, no b amd in his ay iod. Fina cosmic and
nciona ss, howv, a nhancd i oos aoximaion o
h iss is accomishd wih sva widy saad nyon ss
ha can b movd a h nx sgy o h dbidmn. th
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ABDOMINOpelVIC trAuMA | 197
Figure 1. (to l)
Intraoperative appearance
o genital trauma rom
blast. The let testicle
has been removed and
the right one repaired.
The glans penis is
traumatically divided with hal partially
attached by a skin bridge.
The transected corpus
cavernosum is visible
below a small intact
segment o glans. The
proximal urethral
opening is visible at
the base o the shat
near the penoscrotal
junction. (to righ) An
aggressive, early attempt at reconstruction. Little
o the reconstructed
tissue would survive.
Figure 2. (Boom)
Subsequent intra-
operative appearance
o the injury ater all
nonviable removed.
The scrotum is nearly
reapproximated in
this image.
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198 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
oosy aoximad wond shod b daind
comy wih pnos dains, sma scion
dains, o a wond vacm.
2. Injy o h cos cavnosm and ha
is mo daid anion a h im o injy.
th ingiy o h ha can b dmind by
ogad hogahy o hoscoy. Cavno-
sa injis shod b sscd whn a ag ni
hmaoma is sn. exoaion and ai o h
nica abgina can imov na ncion. this
ai can b comd hogh h ni wond,
by ni skin dgoving, o by a vica incision inh nis a h si o cooa injy. I is imoan
o mmb ha h novasca bnd o h
gans ns aong h dosm o h nis. A vna
aoach o h nica abgina can dc injy
o hs scs.
3. Sma agmn injis o h nis may no i
xnsiv dbidmn. exinc shows ha
aggssiv xoaion o hs sma agmns
is no waand in h ac sing and can b
accomishd a i symomaic.
DAMAGE CONTROL
Gnia wonds a sn ny wih concn
wonds o h abdomn and ow xmiis. Iniia
amn on is damag cono incis.
raid mova o obvios dviaizd iss, coios
iigaion o h wond, oos aoximaion o ni
skin wih maxima wond dainag, and Foy cah
acmn—whn asib—can b accomishd swiy
in h siosy injd ain. rai o h ha
and cos cavnosm wih absobab ss may
dc bding and aid in damag cono. Daying
cos, howv, is somims ncssay whn iss
oss is sv, iss viabiiy is ncain, o h ain
is hmodynamicay nsab.
SUMMARY
So-iss injis o h gniaia a dvasaing.
eay sgica invnion shod nai jdicios
wond dbidmn ha avos obsvaion o isso ncain viabiiy ah han aggssiv mova.
Dayd conscion aas sio o ma
ams a ni and scoa skin coss. loos
aoximaion o iss wih iba s o dains
aids conscion. eay aoximaion o
ha and cos cavnosa injis may assis in
hmohag cono and imov ncion.
SUGGESTED READING
Cha 18: Gnioinay ac injis. In: Emergency
War Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th SgonGna, Bodn Insi; 2004.
Cha 22: So-iss injis. In: Emergency War
Surgery, Third United States Revision. Washingon,
DC: Damn o h Amy, Oc o th Sgon
Gna, Bodn Insi; 2004.
Figure 3. Final
reconstruction
ater staged
buccal and split-
thickness skin
grats are ormed
into a new
urethra.
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ABDOMINOpelVIC trAuMA | 199
COMMeNtArY
Damag Conol by COL George E. Peoples, MD
A hm o his cha is damag cono sgy
as i ains o h injd abdomn. usay
aid o h nsab ain, and visid
hogho his book, his aoach is a w-accd
conc among civiian and miiay ama sgons.
Is basic imn is a sagd aoach o h svy
injd ain a isk o h ha iad o hyohmia,
acidosis, and coagoahy. In gna, h a h
hass o damag cono sgy: (1) imay sgy ha
asssss h xn o injy and conos hmohag and
goss conaminaion; (2) innsiv ca ni ssciaion
o addss waming, o vs acidosis, and o coc
coagoahis; and (3) annd oaion o mo
dniiv managmn o injis. th a ss may
nd o b ad as on as ncssay o coc h
injis wiho ndy sssing h ain.
th a, howv, som noab dincs in h civiian
and miiay aicaions o h damag cono conc.th mos ominn among hs is ova managmn
o h ain. In h civiian am, a sing sgon say
manags h ni damag cono snc. H knows
shand h xn o h injis, wha was and was no
don a h s sgy, and whn bs o ak h ain
back o h oaing oom, basd on cay obsvd
and masd hysioogy. Conas ha o h comba-
wondd sodi who may hav his s ocd
omd in a n a h Fowad Sgica tam (FSt)
aciiy, is hn vacad immdiay o a Comba
So Hosia (CSH) o aggssiv ssciaion,
hn fown o a v IV mdica amn aciiy whh nx ocd is omd, and nay civs
dniiv ai a a v V hosia in h unid Sas.
Fh comond his snc by comssing i ino 4
o 5 days. Fo oima ca, h miiay snc is
cis commnicaion and coodinaion. unonay,
his chain o commnicaion is no aways asib, givn
h consicions o h acica siaion, h ncssiy
o sabishing inmdiay vs o ca, and h
ncainy o nconsd aomdica vacaion. In
h absnc o samss anss, miiay ama sgy
is dndn a is co on h ndsanding, acic,
and fxib aicaion o damag cono sgy by a
aiciaing miiay sgons.
evn wih his docin my sabishd in h miiay
am, doyd miiay sgons ms si b xa
consvaiv in hi sgica dcisions. pains ms
b hooghy assssd a ach v o vacaion.
Mos imoany, miiay sgons ms b fxib and
innovaiv in hi managmn o injd sodis.
Many o h concs ha hav bn advancd in civiian
ama cns ading o nonoaiv managmn o
cain injis (snic acaion), ianc on sciaizd
svics ik invniona adioogy (mboizaion), andai dniiv ai (coon ai vs coosomy) may
b imossib in comba-wondd sonn bcas o
h navaiab imaging o invnion chnoogis,
and/o i-advisd bcas o h inabiiy o condc
coninos cos oow-, as oind in h snc
abov. Comba wonds a aso din om hos
sn in civiian ama cns wh hs advancs in
chnoogy hav bn immnd. Comba ama
is on a s o high-ngy ojcis. Mi
comx injis a h nom. Iniia managmn on
occs in an as nvionmn wih imid socs
and oongd vacaion ims. th ain’s condiionon aiva o h miiay sgon is on no comaab
wih h civiian mgncy damn.
On o h gas changs o any vacaion sysm is
h imn o mainain h fow o van mdica
inomaion hogh ach v o ca in ac wih h
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200 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
ain’s movmn. th dision o his inomaion
fow ss in missd injis, comamn syndoms,
dayd amns, and oniay nncssay oc-
ds. th vacaion sysm ms siv o imov h
convyanc o a-im amn inomaion om v
o v. Foow- inomaion sn backwads, so ha
sgons and mdica nis can assss and adjs hi
ova aiy o ca, is aso an ssnia imn.
A miiay-van agoihm o how bs o ca o any
scic injy, incding h inaabdomina injis cid
in his cha, is viay imossib bcas h a
oo many vaiabs ha a nconoab. Many o h
amn dcisions o a scic injy wi b ncssaiy
infncd by h oowing:
• patient’scondition,
• resourcesavailable(mostoftendeterminedbywhich
v o ca h sgon nds hims),
• availability of the next higher level of care (oftendicad by h has o h confic), and
• timetoevacuation(determinedbythetacticalsituation
and wah).
A sgon a a FSt who is acd wih h sam injy
as a coag a a CSH, may—by ncssiy—a i
comy diny. In h absnc o inn and
s amn agoihms, w y on incis.
th miiay vsion o damag cono sgy, as w
as h ova sgica managmn o h injd sodi,
is on h mis ha h ain shod hav ony
ha sgy ncssay o sabiiz him o sa vacaion
o h nx v o ca. this may man no sgy a an
FSt aciiy i h ain is sab. th inci giding
which injis shod b addssd and whn is ha o
scaaing invnion. Fo a vasca injy, scaaionmay man igaion i ncssay, ai i cicmsancs
mi, o byass i no aab (shn i xdinc is
id). Fo a coon injy, scaaion migh b sim
ai, xioaion, oma coosomy, ai wih
ociv osomy, scion wih osomy, o scion
wih anasomosis. this gna conc is aicab o
mos injd ogans and ais h incasing comxiy
o h ocd wih h sohisicaion o socs
avaiab, and h im id o com i. th
dcision o wha ocd o om o any givn
injy wi b dicad no ony by h sa aams
o h ain’s condiion, sviy o h scic injy,and associad injis; b aso by h v o ca,
socs avaiab, acica siaion, and avaiabiiy
o vacaion. Miiay sgons ms hav a woking
knowdg o scaaing invnions o h wid aay
o scic inaabdomina injis. thy ms mbac
h conc o damag cono sgy, ndsand h
vs o ca and h vacaion sysm, and acia
and anicia h consany changing nvionmns
in which hy may nd hmsvs whn caing o h
comba wondd.
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ABDOMINOpelVIC trAuMA | 201
COMMeNtArY
Abdominolvic tauma, Cass rviw by LTC Brennan J. Carmody, MD
th cass in his cha highigh h vas dincs
bwn abdomina ama ncond in
miiay and civiian sings. High-vociy o-
jcis and combinaions o bas and naing injis
can s in xnsiv iss dscion ha may no b
immdiay aan. An ndsanding o hs injy
ans and h aicaion o damag cono incis
a ccia in minimizing mobidiy and moaiy.
CASE V.1 (Indic ecs o Wonding) is an xcn
xam o h cs o combind bas-naing
injis. Dsi h absnc o iona ny, h
caviaion odcd by his high-vociy abdomina wa
injy d o a -hicknss coon injy. th nd o
o inaiona ny d o abdomina xoaion
and managmn o h coon injy. A high v o
ssicion ms b mainaind wih hs mchanisms
o injy, bcas miiay bs av in xcss o
3,000 /s. Dsi a aivy bnign-aaing wondand h absnc o objciv vidnc o inaabdomina
naion, on shod hav a ow hshod o aao-
omy. ths high-ngy angnia wonds a on
o ogssiv so-iss dviaizaion and may vov
ino ncoizing asciiis. ths wonds shod b siay
dbidd and aowd o ha by ih dayd imay
cos o sconday innion.
Anoh imoan aching oin invovs h dincs
in managmn o coon injis, dnding on whh
h ain wi main in ha o n h vacaion
chain. Mos sgons wod consid i asonab oom a sgmna cocomy wih iocoosomy in
h absnc o hyonsion, signican ca soiag, and
signican associad injis in any ain who wod
main in ha nd cos svision. In ains
who wi b vacad o high chons o ca, nd
coosomy shod songy b considd, givn h
onia o oongd vacaion ims, h bak in
coniniy o ca, and h high-injy mchanisms o
ngy ny ncond.
CASE V.2 (pnaing tama o h Somach and
pancas) isas h high ikihood o associad
injis in abdomina naing ama. I is
ciica o xo a aas o h abdomn, incding
h ss sac. ros o accss his sac incd h
gasocoic and gasohaic igamns. Addiionay, a
Koch manv shod b omd oiny o assss
h osio ascs o h dodnm and ancas. In
damag cono sings, dainag o ancaic fid is
a ha shod b don. Mo dniiv invnions can
b omd whn h ain has bn aoiay
ssciad. Givn h onsiy o ancaic anaso-
moss o ak, disa ancacomy shod b considd
bo sing ancaicojjnosomy o h disa
ancaic mnan. th somaosain anaog ocoidaca (sandosain), adminisd sbcanosy (sa-
ing dos: 50 µg .i.d.), can b iniiad i ancaic ak
occs and may dcas os; h dos can b iad
o h oin o chosasis.
CASE V.3 (Bn Abdomina tama) ony
dscibs sagd managmn o a comx dodna
injy. Combind gasoinsina and vasca injis a
common, and ains who hav ssaind sch ama
on sn in shock wih vad Injy Sviy
Scos, hyonsion, coagoahy, acidosis, and hyo-
hmia. Sgons managing his cas ook h aoiainiia acions o cono hmohag and gasoinsina
soiag, and mad no os o sabish gasoinsina
coniniy. Foowing ssciaion and n o h
oaing oom, dainag o h isoad oions o
h og was sabishd, aong wih acmn o a
jjnosomy o na ds. Visca dma cdd
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202 | WAr SurGerY IN AFGHANIStAN AND IrAq: A SerIeS OF CASeS, 2003–2007
dniiv abdomina wa cos, and an absobab
msh was acd wih ans o sbsn skin ga and
annd vna hnia. th ain was hn ansd
o a hos naion mdica aciiy.
this cas isas sva aching oins. Fis,
dniiv gasoinsina conscions shod ony
b omd a ada ssciaion, soion o visca dma, and soaion o oin sos. this
ain’s sas sd in ans o a oca hosia
io o ming hs ciia. In ains ning h
vacaion chain, moay abdomina cos shod
b sabishd in ha wih dniiv conscion
omd a high vs o ca (wh h ain wi
b mo iky hysioogicay ady o sch comx
sgy). Dniiv conscion oions wod incd
rox-n-Y gasojjnosomy wih dodnojjnosomy
o aow o dainag o biioancaic fids.
Scond, o managmn o h on abdomnconins o vov. Whas acmn o absobab
msh wih skin gaing and annd vna hnia
main an oion, oh chnis ha avoid h
mobidiy o h annd vna hnia a bcoming
mo widy sd. Vs and coags1 od
hi xinc wih sia abdomina cos sing
oyafoohyn msh as a moay cos. In
his chni, h msh aows abdomina domain o
b sabishd, and h msh is ighnd a invas
ading o ay dniiv abdomina cos. Sch
coss invovd ih imay cos o an onay
inosiion sing oyoyn msh. No sadvod, ahogh h avag im om iniiaion o
sia abdomina cos o dniiv cos was 45 days
(ang: 15–160). A mo nov aoach invovs h s
o bioohss, sch as AoDm (an aca dma
maix ha can b sd o consc abdomina wa
dcs). this oshic sos vasca and coagn
ingowh. I is aivy sisan o incion and can b
sd o dniiv abdomina cos. Advanags incd
a onia sho inva bwn injy and dniiv
abdomina cos, and s in viosy conaminad
ds. Mo ong-m daa gading is dabiiy a
ndd. rgadss o h chni sd o abdomina
cos, ky incis incd ay s o a vacm-
assisd, nonadhn coving o h abdomn (i, h
VAC Abdomina Dssing Sysm) o a Bogoa bag ha
ocs h visca and aows accss o h ni
abdomn. Vacm and scion dssings aso imov
visca dma and aow anicaion o fid osss.
Sch ay managmn wi aow a ang o oions
o abdomina cos.
CASE V.4 (Missd Dodna Injy) ias h nd
o hoogh xoaion oowing naing
abdomina injy. th cos oximiy o gasoinsina,
vasca, and oogica scs maks concomian
injy iky. Day in diagnosis o dodna injis isassociad wih sbsania mobidiy and moaiy.
Occasionay, infammaoy changs wi cd
imay ai o an ohwis mino injy. In sch cass,
acmn o an aoiay sizd Maco dain can
conv h injy o a b dodnosomy ha aows
cono o scions. this oion shod b combind
wih a gasosomy b and wid dainag. Anaivs
incd ai wih dodna divicaizaion o yoic
xcsion. this cas aso highighs h nd o om
commnicaion bwn sgons and aciiis in cass
in which xoaion was no asib. rgadss o
h hooghnss o io ocds, a ow hshodo xo nsab o dioaing ains shod b
mainaind, givn h onia o missd o voving
injis, cn o sisn hmohag, o ndaind
cocions. this is sciay ciica in ains who wi
n h vacaion sysm wh coniniy o ca can
b comomisd.
In CASE V.5 (tamaic eviscaion), sgons
ncon and manag amaic viscaion oowing
bas injy. Ky oins incd hosia managmn
(sain gaz, no os o dc h visca), cono
o noomis io o dcion, abdominaxoaion, and scion o anky nonviab insin.
Whn viabiiy is sionab, h abdomn can b
moaiy cosd wih assssmn in 24 o 48 hos.
Occasionay, dma o h viscad bow may i
nagmn o h ascia dc (anaogos incacad
vna hnias). Managmn o h ascia dc a
h viscaion si can b obmaic, sciay in
h sing o bas injy o high-vociy ojcis.
poshss sch as VICrYl o AoDm sabish
abdomina wa ingiy and dcas h ikihood o
osoaiv viscaion hogh h nanc wond.
pogssiv dviaizaion o so iss is common, and
h wond shod b siay washd o and dbidd
as ncssay.
CASE V.6 (pnaing rca Injy) incds many
o h wa sgy ns viosy dscibd: damag
cono chnis o combind visca and vasca
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ABDOMINOpelVIC trAuMA | 203
injis, ay ssciaion and waming, and n o
h oaing ha o h id sgy. pom
iniiaion o a who-bood div was a ky dcision. As
simia dvasaing injis hav bcom mo common,
doyd aboaois and bood banks hav bcom
incdiby cin in aciing and aing who
bood. Acivad Faco VII is aso now widy avaiab
and has a o in simia siaions. ligaion o hinna iiac ais is civ in managing ohwis
nconoab vic hmohag and can b omd
hogh h osio wond in som siaions. I is mo
commony omd ansabdominay. rca injy
shod b sscd in nay a sings o naing
bock wonds and d o wih igid ocoscoy.
Sma xaiona ca wonds do no nd o b
aid; oxima divsion, saca dainag, and
gn disa ca washo shod sc.
this cas isas h caiviy disayd by hosia
sonn o acivy wam hi ain sing Mre
(Ma, rady-o-ea) wams. I hav aso sonay sn
sac has and hai dys sd in simia scnaios.
I is sch innovaion ha w ms consany s as w
ca o h wondd, wih incasingy sv injis, in
as nvionmns.
REFERENCE
1. Vs A, Kic D, a. eay dniiv
abdomina cos sing sia cos ch-
ni on injd sodis ning om Agha-
nisan and Ia. J Am Coll Surg. 2006;202:
762–772.
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Cosy David lson, The Dallas Morning News