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VOLUME 2 VOLUME WAR SURGERY WORKING WITH LIMITED RESOURCES IN ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE VOLUME 2 C. Giannou M. Baldan Å. Molde International Committee of the Red Cross 19, avenue de la Paix 1202 Geneva, Switzerland T +41 22 734 60 01 F +41 22 733 20 57 E-mail: [email protected] www.icrc.org © ICRC, March 2013 Cover photos: M. Baldan / ICRC; Michael Zumstein / Agence VU’; E. Erichsen / Aira Hospital, Ethiopia WAR SURGERY WORKING WITH LIMITED RESOURCES IN ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE VOLUME 2 C. Giannou M. Baldan Å. Molde PREFACE It is with great pleasure that I welcome the completion of Volume 2 of War Surgery: Working with Limited Resources in Armed Conflict and Other Situations of Violence. As did Volume 1, this second volume has benefited from numerous remarkable professional collaborations and scientific contributions under the joint authorship and review of Drs Christos Giannou, Marco Baldan and Åsa Molde. I feel certain that it will provide a new point of reference for health professionals engaged in providing lifesaving services in often hazardous environments. Most fortuitously, the publication of Volume 2 coincides with the 150th anniversary of the founding of the International Committee of the Red Cross. The historical importance of this anniversary for professionals engaged in war surgery cannot be overstated. In 1863, a group of Swiss citizens created the International Committee of Geneva for the Relief of Wounded Soldiers, which heralded the dawn of a new consciousness regarding the fate of the wounded left incapacitated on the battlefield. The history of the ICRC and the Red Cross/Red Crescent Movement is intimately interwoven with the development of war surgery, both as a professional discipline and as an ethos in times of armed conflict. The ICRC’s future will be shaped by its commitment to continuous learning and to the enhancement of the professionalism of humanitarian action. This new manual bears testimony to the dedication of Red Cross and Red Crescent surgeons in articulating and sharing their experiences to prepare a new generation of professionals equipped and empowered to be the future standard-bearers for war surgery. Since the publication of Surgery for the Victims of War in 1985, the ICRC has accomplished a great deal – although much remains to be done – in defining the appropriate treatment protocols for the management of the war wounded when working in resource-poor settings: a continuous exercise of updating and expanding relevant and appropriate knowledge to help save lives and alleviate suffering in spite of the prevailing and often dire conditions. Consequently, this manual is first and foremost accountable to the people and communities it seeks to serve. In addition, in the pursuit of protecting and assisting the victims of armed conflict and other situations of violence, the ICRC insists on the safeguarding of medical neutrality and accessibility of medical care to those in need as a fundamental message of the International Movement of the Red Cross and Red Crescent and of all humanitarian work. Indeed, to use the words of the Health Care in Danger campaign: “It’s a matter of life and death”. Peter Maurer President International Committee of the Red Cross TABLE OF CONTENTS INTRODUCTION TO VOLUME 2 11 Part A BLAST PHENOMENA 17 A.1 Short history of the weapons of war and armed conflict 19 A.2 Munition composition 20 A.3 Open-air bomb explosion 20 A.4 Effects due ot the environment 21 A.5 Specific explosive devices 22 Chapter 19 EXPLOSIONS AND PRIMARY BLAST INJURIES 25 19.1 Introduction 27 19.2 The single bombing incident 27 19.3 Epidemiology 29 19.4 Pathogenesis and pathophysiology 32 19.5 Clinical presentations and management 34 19.6 The ear and ruptured tympanum 36 19.7 Blast lung 36 19.8 Arterial air embolism 39 19.9 Visceral injury 39 19.10 Eye and maxillo-facial injuries 40 19.11 Other injuries 40 19.12 Removal of unexploded ordnance 40 Chapter 20 INJURIES DUE TO ANTI-TANK MINES 43 20.1 Introduction 45 20.2 Epidemiology 45 20.3 ATM effects on an armoured vehicle 46 20.4 Clinical presentations 47 3 Chapter 21 INJURIES DUE TO ANTI-PERSONNEL MINES 51 21.1 Introduction: the humanitarian challenge 53 21.2 Mechanism of injury 54 21.3 Clinico-pathological patterns of injury 55 21.4 Epidemiology 57 21.5 Blast mine injury: pathogenesis and clinical implications 60 21.6 Clinical presentation and management 64 21.7 Surgical management of pattern 1 traumatic amputations 66 21.8 Special features of mine-blast injury to the foot 68 21.9 Special features of mine-blast injury to the hand: pattern 3 69 21.10 Surgical management of pattern 2 injuries 69 21.11 Physical and psychological rehabilitation 70 21.12 Conclusion: the humanitarian challenge 70 Annex 21. A Humanitarian repercussions of landmines 71 Part B LImbs 75 B.1 Introduction 77 B.2 Wound ballistics 78 B.3 Epidemiology 78 B.4 Emergency room care 80 B.5 Surgical decision-making 82 B.6 Patient preparation 85 B.7 Surgical treatment 86 B.8 Topical negative pressure and vacuum dressing 90 B.9 Crush injury of the limbs: rhabdomyolysis 90 B.10 Compartment syndrome and fasciotomy 91 B.11 Reconstructive surgery of the limbs 96 Annex B.1 Pneumatic tourniquet 97 Annex B.2 Crush injury 98 Chapter 22 INJURIES TO BONES AND JOINTS 103 22.1 Introduction 105 22.2 Wound ballistics 105 22.3 Epidemiology 109 22.4 Management of war wounds with fractures 112 22.5 Methods of bone immobilization: surgical decision-making 114 22.6 Wounds involving joints 121 22.7 Hand and foot injuries 123 22.8 Problematic cases 125 22.9 Bone infection 127 22.10 Bone grafting 131 Annex 22. A Plaster-of-Paris 133 Annex 22. B Traction 145 Annex 22. C External fixation 156 Annex 22. D ICRC chronic osteomyelitis study 163 Annex 22. E Bone grafting 166 Chapter 23 AMPUTATIONS AND DISARTICULATIONS 171 23.1 Introduction 173 23.2 Epidemiology 174 23.3 Surgical decision-making 175 23.4 Classical surgical procedure: initial operation 177 23.5 Delayed primary closure 180 23.6 Myoplastic amputations 181 23.7 Guillotine amputation 188 23.8 Specific amputations and disarticulations 189 23.9 Post-operative care 195 23.10 Patient rehabilitation 195 23.11 Complications and stump revision 197 4 Chapter 24 VASCULAR INJURIES 201 24.1 Introduction 203 24.2 Wound ballistics and types of arterial injury 203 24.3 Epidemiology 205 24.4 Emergency room care 208 24.5 Diagnosis and surgical decision-making 209 24.6 Surgical management 210 24.7 Post-operative care 217 24.8 Damage control and temporary shunt 217 24.9 Complex limb injuries: concomitant arterial lesion and fracture 219 24.10 Specific arteries 219 24.11 Venous injury 220 24.12 Arterio-venous fistula and pseudoaneurysm 221 24.13 Complications 223 Chapter 25 Injury to peripheral nerves 225 25.1 Introduction 227 25.2 Wound ballistics 227 25.3 Pathophysiology 227 25.4 Epidemiology 228 25.5 Clinical picture 229 25.6 Surgical management 230 25.7 Surgical technique of nerve suture 233 25.8 Post-operative care 235 25.9 Post-trauma sequelae 236 Part C HEAD, FACE, AND NECK 239 C.1 The general surgeon and the head, face and neck 242 Chapter 26 CRANIO-CEREBRAL INJURIES 245 26.1 Introduction 247 26.2 Mechanisms of injury and wound ballistics 248 26.3 Epidemiology 250 26.4 Pathophysiology 253 26.5 Clinical examination 254 26.6 Emergency room management 256 26.7 Decision to operate 257 26.8 Operating theatre 258 26.9 Cranio-cerebral debridement: “burr-hole” wound 260 26.10 Tangential wounds 263 26.11 Other penetrating wounds 266 26.12 Trepanation 268 26.13 Difficult situations 268 26.14 Post-operative and conservative management 272 26.15 Increased intracranial pressure 274 26.16 Cerebrospinal fluid fistula 275 26.17 Infection 275 26.18 Primary blast neurotrauma 276 26.19 Post-trauma rehabilitation 277 Annex 26. A Trepanation 278 5 Chapter 27 MAXILLO-FACIAL INJURIES 283 27.1 Introduction 285 27.2 Wound ballistics 286 27.3 Epidemiology 287 27.4 Clinical examination and emergency room care 288 27.5 Decision to operate 290 27.6 Haemostasis and debridement 292 27.7 Mandibular fractures 295 27.8 Midface fractures 301 27.9 Skin closure 304 27.10 Post-operative management 305 27.11 Complications 306 Chapter 28 INJURIES TO THE EAR 309 28.1 Epidemiology and mechanism of wounding 311 28.2 External ear 311 28.3 Middle ear 312 28.4 Inner ear 313 Chapter 29 INJURIES TO THE EYE 315 29.1 Introduction 317 29.2 Wounding mechanisms and ballistics 318 29.3 Epidemiology 319 29.4 First aid and emergency care 320 29.5 Clinical picture and examination 320 29.6 Primary management 323 29.7 Assessment of injury and decision to operate 323 29.8 Anaesthesia 324 29.9 Minor procedures 325 29.10 Intermediate injuries 327 29.11 Excision of the eye 329 29.12 Retrobulbar haemorrhage 331 29.13 Treatment of complications 332 29.14 Burns of the eyelids and eye 333 Annex 29. A Complete ocular examination 334 Chapter 30 INJURIES TO THE NECK 337 30.1 Introduction 339 30.2 Surgical anatomy 339 30.3 Wound ballistics 341 30.4 Epidemiology 341 30.5 Clinical presentations and emergency room care 343 30.6 Decision to operate 347 30.7 Patient preparation 347 30.8 Surgical management of vascular injuries 348 30.9 Surgical management of laryngo-tracheal injuries 352 30.10 Surgical management of pharyngo-oesophageal injuries 354 30.11 Post-operative care 355 30.12 Tracheostomy 356 Part D TORso 359 D.1 Introduction 361 D.2 Epidemiology 361 D.3 Thoraco-abdominal wounds 362 D.4 Injuries to the diaphragm 364 D.5 Transaxial injuries 365 D.6 Junctional trauma 365 D.7 The general surgeon and the chest: the psychological partition 366 6 Chapter 31 THORACIC INJURIES 369 31.1 Introduction 371 31.2 Wound ballistics 371 31.3 Epidemiology 373 31.4 Clinical presentation 376 31.5 Emergency room management 380 31.6 Intercostal chest tube drainage 381 31.7 Thoracotomy 385 31.8 Exploration of the chest cavity 390 31.9 Wounds of the chest wall 391 31.10 Injuries of the lung 391 31.11 Great vessels, heart and pericardium 395 31.12 Oesophageal injuries 398 31.13 Other injuries 399 31.14 Thoracic damage control 400 31.15 Post-operative care after thoracotomy 400 31.16 Retained haemothorax 401 31.17 Empyema 402 Annex 31.
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