Page 33 - JSOM Summer 2020

not coming all the way across the carpal tunnel in the upper Additional Considerations
extremity. Even without evidence of compartment syndrome,
early prophylactic fasciotomy may be considered in the setting Resuscitation
of vascular injury with a temporary repair and may improve Large-bore IV access is one of the most critical components of
limb salvage rate, especially in patients who are going to be initial resuscitation. On insertion of IV access, blood is used
transported and do not have immediate access surgical care. 66 for typing on an Eldon Card. All team members should be
proficient in peripheral IV and intraosseous (IO) placement.
Initial resuscitation through an IO catheter can be a bridge
Extremity Trauma to IV catheter placement. The damage-control resuscitation
Extremity trauma is the most common injury on the battle- CPG algorithm should be followed. See “JTS Damage Control
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field. Having proficiency with bony, soft tissue and vascular Resuscitation.” Ultrasound-guided peripheral IV placement
techniques in the extremities is extremely important for the is another useful option. It also is recommended to become
ARSC surgeon—and not always thoroughly trained in gen- familiar with conversion of peripheral IV catheters to rapid in-
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eral surgery residencies. The surgeon in an austere environ- fusion catheters (e.g., Arrow RIC ; Teleflex Inc, https://teleflex
ment must be familiar with all open surgical and nonsurgical .com/usa/en/). Central catheter access should be considered
techniques to control hemorrhage and reperfuse injured limbs. only when peripheral IV or IO access is limited or when mul-
Transport of a patient with a tourniquet should be avoided. tiple sites for infusion are not readily available. Most patients
When tourniquets are left in place for more than 4 to 6 hours, can be rapidly resuscitated through large-bore peripheral IV
the risk of severe rhabdomyolysis, kidney failure, limb loss, or IO access. Rapid blood typing as part of the WBB, blood
and death are high. Closed reduction, splinting and/or trac- product storage, transfusion, and efficient blood warming is
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tion are often adequate temporary stabilization techniques of essential capabilities of ARSC teams.
long-bone fractures if these procedures adequately align the
bony injury. Burns
Protect the airway early; early intubation is necessary in pa-
External Fixation tients with greater than 40% total body surface area burns,
For combined orthopedic and vascular injuries, consider ex- facial burns, or if there is any concern for inhalation injury.
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ternal fixation of long-bone fractures after shunting and be- Video laryngoscopy (e.g., GlideScope ; Verathon, https://
fore definitive repair. Pelvic binder placement is effective for www.verathon.com/glidescope/) should be heavily used to ob-
temporary control of most pelvic hemorrhage. In delayed tain an early definitive airway and may help diagnose inhala-
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evacuation scenarios, pelvic binders optimally should remain tional injuries in patients with facial burns. Burn resuscitation
in place no longer than 48 to 72 hours. should be started as early as possible using the rule of 10s.
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See “JTS Burn Care CPG.” The volume of IV resuscitation
Mangled Extremity fluid available may be limited. Plasma may be used to supple-
Every effort should be made to temporize the mangled extrem- ment resuscitation fluid. Patients with significant burns should
ity and transfer the patient to a higher level of care. However, be transferred rapidly to the next level of care. Maintain a
when blood product and resource availability are limited, limb low threshold to perform escharotomy early in the transport
salvage may not be feasible. Initial management of the man- process, especially with circumferential full-thickness burns.
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gled extremity includes hemorrhage control, irrigation, and Silverlon (Argentum Medical, https://www.silverlon.com/) is
debridement of clearly nonviable tissue. Traumatic amputa- a lightweight burn dressing that can stay in place 3–5 days and
tions should not be formalized in the austere setting, though is useful for other abrasions and shallow wounds. When burn
familiarity with formal amputations is required to anticipate dressings are not available, avoid debridement of blistered
future soft tissue coverage needs. Wounds should be left open partial-thickness burns and cover burns with dry sterile dress-
in anticipation of repeated exploration and debridement. See ings. Maintain normothermia because patients with burns are
“JTS Amputation: Evaluation and Treatment CPG.” 69 susceptible to hypothermia even in the warmest environments.
Notify the US Army Institute of Surgical Research Burn Cen-
Soft Tissue Wounds ter as early as possible (DSN 312-429-2876) or email: burn-
Early debridement of soft tissue wounds and burns improves trauma.consult.army@mail.mil.
outcomes and morbidity. However, the ability to fully debride
soft tissue wounds may be limited in the ARSC setting because Hypothermia
of limited access to surgical energy devices, blood products, Maintenance of normothermia is crucial for survival of com-
sterility, and irrigation fluid. Aggressive management of soft bat casualties. Active warming or cooling devices such as
tissue injuries should be weighed against the available re- heaters or air conditioners have significant electrical power or
sources and operational considerations such as resupply and fuel requirements and will not be available in the ARSC envi-
overall sustainment of the mission. In general, the ARSC team ronment. Hypothermia management kits (HPMKs) should be
is not resourced to treat large soft tissue wounds that require used frequently; they contain chemical warming blankets that
serial debridement. Potable water is as effective as sterile fluid generate heat on exposure to air. These blankets should not be
for surgical irrigation. Sharp debridement is the standard of placed directly on the skin, however, due to the risk of thermal
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practice for soft tissue wounds. Commercial negative-pressure burns. Hypothermia in the patient with trauma is directly re-
dressings are unlikely to be available in the ARSC environ- lated to degree of blood loss. Hypothermia will continue until
ment. Standard gauze (or hemostatic gauze) or occlusive dress- adequate blood volume is restored.
ings over closed suction drains are suitable for transport. See
“JTS Initial Management of War Wounds CPG” and “JTS Pediatrics
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Acute Traumatic Wound Management in the Prolonged Field ARSC teams may be required to care for pediatric patients in-
Care Setting CPG.” 71 cluding neonates, depending on the medical rules of eligibility.

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