Background: Incomplete or delayed fasciotomies are associated with muscle necrosis and death in civilian trauma. Combat explosions severely damage tissue and distort normal anatomy making fasciotomies challenging. Rapid air evacuation may delay treatment of patients with evolving extremity compartment syndrome. We investigated the impact of fasciotomy revision and delayed compartment release on combat casualties after air evacuation. Methods: A retrospective review was performed of combat casualties who underwent fasciotomies in Iraq, Afghanistan, or at Landstuhl Regional Medical Center between January 1,2005 and August 31,2006. Outcomes were rates of muscle excision, major amputation, and mortality. Results: A total of 336 patients underwent 643 fasciotomies. Most were to the lower leg (49%) and forearm (23%). Patients who underwent a fasciotomy revision had higher rates of muscle excision (35% vs. 9%, p < 0.01) and mortality (20% vs. 6%,p < 0.01) than those who did not receive a revision. The anterior and deep compartments of the lower leg were the most commonly unopened. Patients who underwent fasciotomy after evacuation had higher rates of muscle excision (25% vs. 11%), amputation (31 vs. 15%), and mortality (19% vs. 5%) than patients who received their fasciotomies in the combat theater (p < 0.01). Patients who underwent revisions or delayed fasciotomies had higher Injury Severity Score and larger burns as well as lower systolic blood pressure, acidosis, and more pressor use during air evacuation. These patients also received more blood products at Landstuhl Regional Medical Center. Conclusion: Fasciotomy revision was associated with a fourfold increase in mortality. The most common revision procedures were extension of fascial incisions and opening new compartments. The most commonly unopened compartment was the anterior compartment of the lower leg. Patients who underwent delayed fasciotomies had twice the rate of major amputation and a threefold higher mortality.

Complications After Fasciotomy Revision and Delayed Compartment Release in Combat Patients. Discussion

Background: During the wars in Iraq and Afghanistan, extremity injuries have predominated; however, no systematic review of field and stabilization care with subsequent infectious complications exists. This study evaluates the infectious complications and possible risk factors of British military casualties with mangled extremities, highlighting initial care and infections. Methods: This is a retrospective cohort study of British military casualties in Iraq and Afghanistan between August 2003 and May 2008. Casualties with mangled extremities undergoing limb salvage were evaluated for management strategies at the time of injury through evacuation back to the United Kingdom and subsequent infections. Results: There were 84 casualties with 85 extremities (20 infected and 65 uninfected). Infected extremities had more Gustilo Classification IIIb. There were no differences by Injury Severity Score, age, durations from injury to evacuation, or surgery, or arrival in England, use of clotting materials, or method of extremity stabilization between infected and uninfected extremity injuries. Tourniquet use in the field and fasciotomy were associated with infections. Antimicrobial coverage was associated with infections. Staphylococcus aureus were recovered later in casualties' clinical course in contrast to early recovery of Acinetobacter. On multivariate analysis, tourniquet in the field, antibiotics during evacuation and in the operating room, and fasciotomy were associated with infection as were certain bacteria, notably, Pseudomonas aeruginosa. Conclusion: Infections occurred in 24% of those with mangled extremities including 6% with osteomyelitis. Certain procedures, likely reflective of injury severity, were associated with infections along with certain bacteria, P. aeruginosa and possibly S. aureus. Continued clarification is required for antimicrobial coverage (penicillin-based regimens vs. additional anaerobic coverage) and certain surgical procedures to improve casualty care.

Infectious Complications of Combat-Related Mangled Extremity Injuries in the British Military. Discussion

Les victimes de la guerre Iran-Irak ayant presente une blessure cranienne par projectile et ayant developpe une infection meningee ou cerebrale ont ete suivis pendant plusieurs annees. L'association morbide la plus importante etant le developpement d'une fistule osteomeningee

Causes of infections in penetrating head wounds in the Iran-Iraq War

The document introduces a simple classification, minimums standards and a registration form for Foreign Medical Teams (FMTs) that may provide surgical and trauma care arriving within the aftermath of a sudden onset disaster. These can serve as tools to improve the coordination of the foreign medical team response, and be the reference for registration on arrival as well as a possible global registration mechanism similar to what exists for urban search and rescue teams.

It provides benchmarks for international teams that they should meet when offering their services to affected countries. The standardization of services allows countries requiring such support to better communicate their needs, while countries offering FMTs can clearly state the services and capacities that they are offering. This will lead to better coordination between aid providers and aid recipients.

Classification and minimum standards for foreign medical teams in sudden onset disasters

The mechanisms of soft tissue injury by bullets are reviewed, in the belief that the current incidence of firearm injuries in many urban areas necessitates an understanding of wound ballistics on the part of trauma surgeons who may not be familiar with the wounding factors involved. Review of the literature, with technical information obtained from appropriate non-medical texts. Despite numerous publications concerning the treatment of gunshot wounds, relatively few papers contain details on the mechanisms of ballistic trauma, with the main body of evidence derived from previous laboratory and animal studies which have only recently been systematically appraised. These studies have shown that in rifle injuries the main wound tract is surrounded by an area of damaged tissue as a result of the temporary cavitation induced once the bullet becomes destabilized or deformed. On the other hand, the more commonly encountered non-deforming handgun bullets cause damage limited to the bullet’s path, mainly as a result of localized crush injury. The bullet’s construction and ballistic behavior within tissue determine to what extent the previously overestimated velocity factor may influence wound severity. The damage produced from temporary cavitation depends on the tensile properties of the tissues involved, and in high-energy injuries may lead to progressive muscle tissue necrosis. Therefore, the term “high-energy” should be reserved for those injuries with substantial tissue damage extending beyond the visible wound tract.

Wound ballistics 101: the mechanisms of soft tissue wounding by bullets.

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Marco Balden

Papers

War Surgery: Working With Limited Resources in Armed Conflict and Other Situations of Violence (Volume 2)