in Conflicts and Natural Disasters

Fig. 44.1

(a) X-ray of GSW of the knee and (b) metal pellets and plastic casing retrieved only after the second debridement because of insufficient initial incisions. (Courtesy of Tomoaki Atsumi, MD)

The extent and nature of injury from any GSW is determined by the speed of the bullet at impact, mass of the missile, size and shape of the projectile, and characteristics of the tissues through which it travels. Ballistic injuries obey the fundamental principle of E = mv² so that the velocity of the projectile matters more than its mass. High-velocity missiles not only cut and crush tissues but also produce sonic waves with cavitation effects that produce microscopic damage at a distance from the bullet path. High-velocity gunshot wounds need to be addressed by the protocols of war injury treatment [6].

Blast Injuries

The tissue damage from blast injuries (bombs, land mines) depends on the type of munitions, distance from the target, and environment in which they detonate, such as open space, inside a building, or underwater. The explosion causes injury in four ways [7, 8]:

Primary injury is caused by the blast wave. All persons within the lethal zone die, while those outside it may sustain severe, non-penetrating injuries. Air-containing viscera are particularly sensitive to the damaging effects of the blast.
Secondary injury is due to the direct effects of shrapnel or objects that become energized from the blast. Modern military munitions produce metallic fragments within a specific mass range to ensure consistent and effective damage over a large area.
Tertiary injury from the blast wind can project human bodies against objects or propel objects that hit humans. The wave can collapse buildings, resulting in crush injuries.
Quaternary mechanism or flash injury refers to the thermal wave, causing burns and inhalational injuries from smoke, including carbon monoxide.

Beyond these conventionally recognized mechanisms of blast injuries, biological contamination may take place purposely, such as a suicide bomber infected by hepatitis or HIV or by chance, if infected victims’ parts contaminate survivors. Barrel bombs, such as presently used in the Syrian conflict, are often loaded with human or animal feces with the hope of contaminating survivors’ wounds. Diethylenetriamine (DETA) sheet explosives contain pentaerythritol tetranitrate (PETN), which can cause a hyper-inflammatory syndrome.

Land Mines

Land mines are not designed to kill but rather to maim and destroy livelihoods. The majority of victims are civilians, and the toll is especially heavy among rural peasant farmers, nomads, livestock, children, and the poor who have little political voice. Despite huge efforts, clearing existing mines appears to be nearly impossible. Blast mines create damage through the blast wave, while fragmentation mines cause harm through propelled fragments.

Their clinicopathological effects have been grouped by ICRC into three patterns [4]. Pattern 1 occurs when the victim steps on the mine, resulting in a traumatic amputation of some part of the triggering lower limb and variable degrees of penetrating injuries and burns to the other leg, genitalia, and body. This pattern produces the “umbrella effect” [4], in which the blast strips the soft tissue attachments from the tibia so they are spread apart as in opening an umbrella (Fig. 44.2). The soft tissue damage extends more proximally than the level of bone injury.

../images/270913_2_En_44_Chapter/270913_2_En_44_Fig2_HTML.png — Fig. 44.2

(a) Typical land mine injury. (b) Umbrella effect with complete stripping of the tibia. (c) X-ray shows no tibial fracture

Pattern 2 occurs when the victim activates a fragmentation mine, spreading metallic fragments that randomly penetrate parts of the body. Pattern 3 occurs when the victim manipulates the mine, usually children or de-miners, resulting in injuries to the upper limbs, face, neck, and chest. More powerful mines are used to neutralize motorized vehicles (anti-tank mines, improvised explosive devices, etc.) and create a wide spectrum of injuries depending on location (inside vehicle or bystander) and distance from blast.

It is beyond the scope of this chapter to discuss injuries due to chemical, bacteriological or nuclear warfare.

Surgical Epidemiology of Conflicts

Generally, in conventional artillery warfare, guerrilla warfare, and civil conflicts, the distribution of injuries includes superficial injuries requiring no hospitalization (40%) and those requiring hospitalization (60%). Sixty percent of those hospitalized will have limb injuries. The longer the delay to reach medical care, the more limb injury rates increase, as those with central wounds often die without immediate medical care. Longer delays increase the likelihood of infection. Therefore, longer delays result in more limb wounds, many with fractures, more infected wounds, more stable patients, less inhospital mortality, and more need for orthopedic surgeons. This same scenario is true for natural disasters.

A wounding mechanism frequently overlooked is road traffic injuries (RTIs). These are frequent in both conflict zones and after natural disasters, caused by disruption of road traffic control; absence of liability, especially for fighting parties not belonging to regular, disciplined armies; and vehicles and roads in a poor state of maintenance or damaged by the disaster.

Many of the following principles for treating injuries sustained in conflict situations are the same for dealing with the victims of natural disasters. The cause of the injuries may be different, and some of the ballistic-specific concerns are of less importance, but the principles are worthwhile to follow.

Treatment

For fresh injuries, effective treatment depends on prompt evacuation and transfer, triage of injuries, vigorous resuscitation, and aggressive exploration and debridement of wounds. Definitive management of orthopedic injuries is never considered in the initial stage (Fig. 44.3).

../images/270913_2_En_44_Chapter/270913_2_En_44_Fig3_HTML.png — Fig. 44.3

(a, b) Triage tent of Emergency Hospital in Lashkargah, Afghanistan. (c) Patient ID tagged around the neck

In urban warfare in middle-income countries, such as Iraq, transfer of the wounded to civilian hospitals can be quick and effective, and injuries are seen while still fresh. In more austere environments such as Afghanistan, Yemen, and many sub-Saharan African countries, casualties often come from a distance. In theory, the site where civilian casualties are treated should be a safe and secure haven, but this is not always the case (Fig. 44.4).

../images/270913_2_En_44_Chapter/270913_2_En_44_Fig4_HTML.jpg — Fig. 44.4

A strictly enforced “No Weapons” sign at Emergency Hospital entrance, Kabul, Afghanistan

Mass Casualty Event and Triage

A mass casualty situation involves a large number of casualties presenting over a short period of time and overwhelming the facilities and resources. The general treatment principle is to “do the best for the most.” This is in contrast with the civilian practice of doing the “absolute best for every individual.” Triage, in a war surgery or natural disaster context, is a systematic way of placing patients into four groups (Box 44.1).

Box 44.1 ICRC Triage Categories

Category 1 injuries that have a reasonable chance of survival but require resuscitation and immediate surgery
Category 2 have the second priority for surgery
Category 3 have superficial wounds and can be managed as outpatients
Category 4 involves severe wounds with a poor prognosis and given supportive care

Assessment and Resuscitation

Whatever the mechanism of injury, it is essential to assess the patient according to ATLS principles of primary and secondary surveys. A common pitfall is concentrating on more evident and impressive wounds, while missing a small penetrating wound in a vital area. The apparent physiologic reserve in younger patients can be misleading. They require particular attention and aggressive resuscitation with frequent reevaluations.

Land mine blast injuries in particular are associated with significant blood loss, making initial, aggressive resuscitation essential, particularly if the transfer time has been prolonged. Hemodilution will occur rapidly with crystalloid and whole blood transfusion is usually required. Family members, friends, and fellow combatants are the best donor sources. The anticipation of a large transfusion requirement may be an indication for supportive treatment only.

Wound Debridement

Limb injuries account for around 60% of all surgical injuries in conflict and natural disaster settings and are dealt with only once life-threatening injuries have been addressed. War wounds require extensive debridement, what the ICRC calls “wound excision” [4]. Adequate access is mandatory, requiring extensile skin incisions. All foreign material and necrotic tissues must be debrided [9, 10]. While only nonviable skin should be excised, subcutaneous tissue is sensitive to infection and requires generous excision. Avoid undermining the skin, which can compromise its blood supply. A fasciotomy is usually required to access deeper structures and reduce the chance of compartment syndrome. Muscle that does not appear viable must be excised based on color, absence of contractility, poor consistency, and lack of bleeding. Bone fragments without periosteal attachment should be removed no matter how large. Debridement may need to be repeated every 48–72 h until clean, viable tissue is present.

Metallic fragments located in the wound or in pressure-sensitive areas such as palms or soles deserve removal, but leave the deeply seated fragments unless they are (1) intra-articular (impinging on joint function or a potential cause of lead-induced arthropathy) or (2) close to the main vessels, where their sharp edges can erode the vessel wall and cause delayed bleeding.

All war wounds or wounds from natural disasters are contaminated and are never closed primarily no matter when they present or how “clean” they appear. Edema causes increased tissue pressure, leading to impaired vascularization and wound breakdown; residual contaminants and necrotic tissue left after debridement promote infection. Wounds can ideally be closed 4–7 days post debridement. Primary closure may be difficult if delayed beyond 7–10 days, at which time wound edges and flaps have retracted. However, if in doubt about the status of the wound or wound infection, a re-debridement should be performed and other plans made for closure. The routine use of a tourniquet in wound debridement has been debated, but has been promoted by the ICRC, especially in environments where blood replacement is an issue. Consider using a tourniquet in the presence of active bleeding. It can be deflated later to reassess any “doubtful” tissues before applying a bulky dressing.

Dressings that absorb fluids, such as fluffed gauze held with a compression bandage and stabilized with a plaster slab or gutter splint, are simple and comfortable for the patient (Fig. 44.5). Extremity wounds need to be elevated using bed blocks to raise one end of the bed, pillows, or Bohler-Braun frame or supporting an arm on pillows or suspended from an IV pole. Drains are unnecessary as all extremity wounds are left open.