Page 56 - JSOM Winter 2025

care team, which may consist of both medics and non-medical granulation tissue formation. This phase is also an opportunity
assistants. to reassess antimicrobial therapy, ensure proper nutrition and
hydration, and prepare for delayed primary closure. Primary
Infection Risk in Prolonged Casualty Care surgical interventions at this phase aim to stabilize the wound
and the Role of MDRO for potential prolonged holding or transfer.
Prolonged casualty care scenarios are commonly associated
with increased wound complexity, prolonged patient holding Plane: Evacuation and Tertiary Integration
time, and reduced medical access. Wounds sustained in dirty Evacuation should be accompanied by clear documentation
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environments may be contaminated with soil and/or organic of wound care, microbiological findings, and antibiotic use.
debris, leading to anaerobic or polymicrobial infections. Mod- In-transit wound care—including re-irrigation and dressing
8
ifiable factors on the part of medical providers include im- maintenance—may reduce infection exacerbation en route.
proper dressings or wound care techniques, reported overuse Field studies have demonstrated that poorly managed transfers
of tourniquet application for non-life-threatening hemorrhage increase nosocomial infection risk at higher echelons of care.
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(leading to prolonged ischemia, necrosis and devitalized tis- Therefore, MDRO containment measures during transport,
sues), and lack of prophylactic antibiotics; unmodified, these including barrier precautions, are essential. Medical treatment
factors exacerbate the risk of complex wound infection. 9,10 facilities may offer basic diagnostic support and field micro-
Modern microbiology confirms that MDROs, particularly biology. According to recent studies, point-of-care molecular
gram-negative organisms, are emerging as dominant pathogens diagnostics can identify MDROs even in austere environ-
in war wound infections. Infection control is further compli- ments. 17,18 Infections confirmed at this phase should trigger
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cated by the lack of laboratory capacity and real-time diagnos- empiric antibiotic regimens aligned with JTS sepsis guidelines,
tics in the field impeding the development of theater specific which recommend source control, hemodynamic support, and
antibiograms, further inhibiting the ability to adjust antibiotic antimicrobial de-escalation based on culture results. Basic in-
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selection to the resistance profile(s). The prevalence of infec- fection control protocols, even in limited settings, are essential
tions caused by MDROs in the context of warfare is a major to prevent facility-wide spread.
problem, drawing increasing scrutiny. 12
Table 1 summarizes the different stages of the Ruck-Truck-
Ruck: Point-of-Injury Measures House-Plane model for preventing combat-related wound in-
At the point of injury, wound management begins with careful fections and spread of multidrug-resistant organisms.
assessment of penetrating injuries and determination of need
for hemorrhage control techniques, to include assessment of Conclusion
applied tourniquets and pressure dressings as well as depth
and complexity of wounds. For those wounds that appear Wound infection in prolonged casualty care and prolonged
deep or with vascular compromise, large irrigation and rough care conditions could emerge as another cause of preventable
debridement can be attempted early to minimize contamina- death in the died-of-wounds population in future LSCOs. Fur-
tion. All wounds sustained in a combat or operational envi- thermore, this risk is associated with the spread of MDROs,
ronment should be assumed to be grossly contaminated, and representing a global issue that transcends theater borders. A
removal of debris is essential. For irrigation, potable water can dedicated application of a Ruck-Truck-House-Plane progres-
be used and is generally acceptable, if typical sterile irrigation sion model, as described above, during prolonged care, from the
solution is not available. According to Joint Trauma System point of injury through to definitive hospital transfer, provides
(JTS) guidelines, early cleansing reduces bacterial load and a phased approach for combat medics, nurses, and physicians
prevents infection progression. Early prophylactic antibiotics to limit the risk of secondary infection as well as the spread
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should be considered for open fractures or high-risk penetrat- of multidrug-resistant organisms. Simple initial procedures to
ing wounds, as endorsed in recent trauma guidelines. In the clean the wound with rough debridement and irrigation should
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austere settings implied in prolonged casualty care, medics or be combined with timely surgery when indicated. Such strate-
medical teams can implement these basic interventions to de- gies require further studies to assess their potential impact on
lay or reduce the severity of infection before evacuation. the outcome of combat casualties as well as dedicated training
to improve skills and knowledge of this emerging risk.
Truck: Continuation of Basic Medical Procedures
The Truck phase was originally designed as a CASEVAC plat- Author Contributions
form: a truck with a small compartment, with no surgical PP designed the study, conducted the literature search and
capabilities. Due to ongoing movement, it is very difficult to wrote the manuscript. PP, PL, MD, GV, TA, FJ, and SK criti-
perform even the most basic procedures, particularly surgical cally revised the manuscript.
ones (wound debridement or substantial irrigation), during
transport. Interventions can be limited to the most basic med- Disclosures
ical procedures, with a focus on wound assessment and reas- The authors declare that they have no conflicts of interest.
sessment, tourniquet evaluation, and attempting conversion as
soon as possible, including during this Truck phase. Disclaimer
The opinions or assertions expressed herein are the private
House: Initial Surgical Access and views of the authors and are not to be considered as reflecting
Field Interventions Field Hospitals and Surveillance the official views of the French Military Medical Service, and
Once the casualty reaches a basic facility or a building of op- the different institutions.
portunity, wound inspection and further debridement should
be performed. Necrotic tissue must be excised to prevent sep- Funding
sis. Clean, moist dressings protect wound edges and promote This study did not receive any funding.
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54 | JSOM Volume 25, Edition 4 / Winter 2025