Page 121 - JSOM Winter 2021

Afghanistan were reviewed to ensure planning and rehearsals hemorrhage, temporary control can be achieved with a cur-
6,7
were relevant. Casualty scenarios were rehearsed with the rently fielded combat tourniquet. Traumatic wounds are ex-
finalized kit to ensure all possible injuries were considered. tended, or separate incisions are made for proximal vascular
The following is a brief report of and reasoning behind the control. Retraction, dissection, vascular control, and shunting
final equipment set. It is important to note that the authors of are carried out similarly to cervical vascular injuries.
this paper do not recommend a specific brand for any item.
The equipment chosen was based on necessity to save life and Junctional Hemorrhage: There are several manufactured
limb, combined with availability. There was no ability to order junctional hemorrhage control devices currently on the mar-
different types or updated models due to time constraints. A ket. The authors have successful experience with the use of a
surgeon reviewing this report should take into consideration 10-cm-width Esmarch bandage combined with use of a Kerlix
their own experience, equipment available, and mission re- roll. Specifically, wrapping the Esmarch around the axilla or
quirements when planning a similar mission. The use of any inguinal region directly over a gauze roll to apply maximal
brand-named item does not support or advocate for one par- pressure directly over the vessel at the junction of shoulder
ticular device over another. girdle/arm or pelvis/groin. This maneuver renders the distal
extremity ischemic, however it will control exsanguinating
hemorrhage. This allows for evacuation of the casualty to
The Equipment
more robust surgical resources to manage the injury.
The bag we used was the TACOPS M9 bag (TSSi, https://www
.tssi-ops.com/shop/tacops-m-9-assault-medical-backpack). Tension Pneumothorax/Hemothorax: A 14-gauge, 3.25-inch
This bag has the ideal attributes of size, compartments, adapt- angiocatheter can be placed in the appropriate location for nee-
ability, and ability to fold out for rapid and easy use. Table 1 dle decompression. Alternatively, #10 blade scalpel and gloved
discusses the individual items in the equipment list, including finger can be used to perform finger thoracostomies to treat
the indications for inclusion in the kit. Figure 1 is provided tension physiology. Placement of a chest tube can be performed
to show a full equipment layout. Table 2 lists the organiza- expeditiously. In place of a water seal canister, or Heimlich
tion of the equipment packed within the bag itself. Subsequent valve, the finger of a glove may be taped to the open end of the
images show the bag with equipment loaded for a mission tube with the tip of finger cut open to create a one-way valve.
(Figures 2–4). The surgeon personally carried a rescue knife
and multipurpose rescue shears. Two 14-gauge angiocatheters Airway Compromise: A nasopharyngeal airway can be used
were secured to the outside of the bag for emergency use. The to temporize in the appropriate patient. For a surgical airway,
front compartment housed equipment to initiate assessment multiple manufactured surgical airway kits are available. In
of a casualty and included nonsterile gloves, a headlamp with addition, a standard approach to performing an emergency
extra batteries, and a permanent marker (Figure 2). The rear cricothyroidotomy involves either a transverse or vertical neck
compartment (Figure 3) stored oversized items including an incision over the cricothyroid (CT) membrane, incision in the
adult cervical collar, a 36 French chest tube, and a 10.5-inch CT membrane, dilation with the handle of the scalpel or Kelly
Debakey aortic clamp (Figure 3). There are six separate zip- clamp, and placement of 6-0 endotracheal tube, which is se-
pered compartments inside the bag (Figure 4). Table 2 outlines cured with a 0-silk suture.
the organization of the items packed in the bag. Items were or-
ganized into each compartment based on the following catego- Intrathoracic Hemorrhage: Finger thoracostomy with decom-
ries: resuscitation and other accessories for care, adjuncts for pression can assist in determining massive intrathoracic hemor-
airway and breathing, hemorrhage control, orthopedic care, rhage followed by anterolateral thoracotomy. Due to the bulk
and surgical supplies. The following is a discussion pertaining of self-retaining retractors for abdominal and thoracic surgery,
to individual injury scenarios and how we considered manag- retraction is performed using the gloved hands of one assistant
ing them according to the equipment included. on either side of the incision. Hilar clamping can be performed
using the large, atraumatic vascular clamp. Sources of hemor-
Cervical and Extremity Vascular Injury: The TACMED Surgi- rhage can be dealt with using hemostatic packing for chest wall/
cal Set/Advanced (Tacmed Solutions, https://tacmedsolutions. lung parenchyma, suture ligation using 3-0 Prolene, 2-0 Vicryl
com/products/tacmed-surgical-set) includes a prepackaged tube suture, 0 Vicryl, or 0-silk suture, and cardiac wounds can be
of four sizes (8, 10, 12, 14 French) of 6-inch vascular shunts, repaired with 3-0 Prolene or temporary use of skin staples.
Weitlaner retractor (1), Satinsky atraumatic tangential vas-
cular clamp (1), Rumel vascular tourniquets (2), and 0-silk Intraabdominal Hemorrhage: A damage control laparotomy is
ties. We added vessel loops (2 packs) and appropriate vascular performed using #10 blade scalpel. Temporary packing can be
suture. For a suspected cervical vascular injury with hemor- performed using laparotomy sponges, radiopaque topical he-
rhage, a cervical incision is made for exposure of the carotid mostatic gauze, or Kerlix rolls (retained packing material or
sheath. A Weitlaner self-retaining retractor is placed for ex- instruments must be communicated to the next echelon/role of
posure with dissection of the injured vessel using a Debakey care). Massive hemorrhage can be controlled using compres-
tissue forceps and Metzenbaum scissors. Proximal and distal sion and clamping of the subdiaphragmatic aorta using a large,
control is achieved using vessel loops, Rumel tourniquet, or atraumatic vascular clamp. Mesenteric vascular and internal/
a Satinsky atraumatic vascular clamp. The proximal and dis- external iliac vascular injuries can be managed with dissection
tal ends of the vessel are flushed (saline syringes are obtained and shunting methods outlined in the cervical and extremity
from the IV access kit or the anesthesia kit) and an appropri- vascular injuries section. Vascular control of the porta hepatis
ately sized vascular shunt is placed to restore flow. The shunt (Pringle maneuver) can be performed using a Rumel tourni-
can be secured with either 0-silk or umbilical tape. Bone wax quet. The intraabdominal aorta can be exposed and repaired
can be used to pack between transverse processes for bleeding by either a medial visceral rotation or central exposure of
vertebral artery injuries. For extremity vascular injury with the infrarenal aorta and suture repair using 3-0 Prolene. The
8
Ultramobile Surgical Set for Austere DC | 119