Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents Peep Talving, Joseph Dubose, Galinos Barmparas, Kenji Inaba, Demetrios Demetriades1

Home , Penetrating head injury, Stab wound

European Journal of Trauma and Emergency Surgery Review Article

Role of Selective Management of Penetrating Injuries in Mass Casualty Incidents Peep Talving, Joseph DuBose, Galinos Barmparas, Kenji Inaba, Demetrios Demetriades1

Abstract capabilities, including the capacity of the local health- Terrorist violence has emerged as an increasingly care facilities. A MCI may be caused by a variety of common cause of mass casualty incidents (MCI) due to etiologies, including natural occurrences, industrial the sequelae of explosive devices and shooting mas- accidents, or as the result of human criminal or ter- sacres. A proper emergency medical system disaster rorist acts. In the modern world, terrorist violence has plan for dealing with an MCI is of paramount impor- emerged as an increasingly common cause of MCI, due tance to salvage lives. Because the number of casu- to the sequelae of explosive devices and shooting alties following a MCI is likely to exceed the medical massacres [1–3]. Regardless of the etiology, a proper resources of the receiving health care facilities, pa- emergency medical system disaster plan for dealing tients must be appropriately sorted to establish with a MCI is of paramount importance to maximize treatment priorities. By necessity, clinical signs are the salvage of lives. likely to prove cornerstones of triage during MCI. An Any MCI disaster plan should be designed to effect appropriate and effective application of experiences appropriate triage and provide for the optimal utiliza- learned from the use of selective nonoperative man- tion of resources. During MCI, high volumes of casu- agement (SNOM) techniques may prove essential in alties delivered by Emergency Medical Services or this triage process. The present appraisal of the private conveyance may create an extremely chaotic available literature strongly supports that the appro- environment in the admittance area of the receiving priate utilization of these clinical indicators to identify facility. When facing these large numbers of casualties, patients appropriate for SNOM is essential, critical, the tendency to overtriage must be avoided, and and readily applicable. We also review the initial appropriate adaptation of triage principles be imple- emergent triage priorities for penetrating injuries to mented in an organized fashion [4]. the head, neck, torso, and extremities in a mass The concept of appropriate triage is the mainstay casualty setting. of the medical management of casualties. To achieve this goal, numerous triage systems based mainly on Key Words physiological parameters are utilized in MCIs [5]. In Polytrauma management including pre-hospital addition, numerous triage instruments employed in and shock room penetrating casualties in non-MCI environment are depicted in the literature [6–8]. To the best of our Eur J Trauma Emerg Surg 2009 knowledge, no speciﬁc algorithms for the management DOI 10.1007/s00068-008-8153-2 of penetrating wounds in a MCI-setting have been published. It should be emphasized that triage is not a solitary Introduction decision taken in the emergency room of the receiving A mass casualty incident (MCI) is deﬁned as any large facility; more frequently, it is a dynamic ongoing pro- number of casualties produced in a relatively short cess of serial evaluations and employment of available period of time that exceeds local logistic support imaging and monitoring resources. For patients who

1 Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, Los Angeles, USA.

Received: August 17, 2008; revision accepted: December 8, 2008; Published Online: February 4, 2009

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

have sustained penetrating injuries, appropriate and effectively dictated by three parameters: (1) clinical effective application of experiences learned from the findings, (2) CT findings, and (3) availability of neu- use of selective nonoperative management (SNOM) rosurgical intervention [surgeon, operating room principles may prove essential in this triage process. (OR), and personnel]. The most frequently and easily A policy of routine exploration of all penetrating utilized clinical variable for predicting mortality in injuries is likely to result in the majority of surgical these patients is GCS on admission. It is apparent that procedures yielding no clinical benefit, and could rap- there is a negative correlation between GCS on idly overwhelm the system by utilizing precious limited admission and mortality [12]. Patients admitted with resources and manpower. GCS £ 8 have mortality that ranges from 61 to 100% In the present review, we aim to illustrate how and unfavorable outcomes in 61–94% of cases [10–15]. application of principles learned from non-MCI In contrast, patients with GCS > 8 are likely to have SNOM management may prove essential in maximiz- better survival rates in most published series. Another ing patient survival during MCI. As the level I trauma prognostic parameter of outcome on neurologic exam facility with the highest number of annual admissions is the reactivity and size of the pupils. The presence of in the United States, a regional Disaster Medical unilateral or bilateral fixed and dilated pupils is highly Center for a region containing 13 million inhabitants, predictive of mortality. Pupillary findings, however, and a center with previous experience gained from the should only be considered prognostic when associated 1992 Los Angeles riots, our group has gathered con- with a low GCS, in order to exclude the possibility of siderable experience in the planning and implementa- ocular damage from the missile. tion of MCI management of penetrating injuries. The presence of respiratory distress in patients Based on our experiences and the available medical with penetrating brain injury may also be of particular literature, we will outline the initial emergent triage significance for triage. Jacobs et al. [16] reported a priorities for penetrating injuries to the head, neck, sevenfold higher mortality rates in patients who had a torso, and extremities. respiratory rate of less than 10 on admission. Similarly, Murano and colleagues found that respiratory arrest on admission was an independent risk factor for mortality Penetrating Head Injuries among trauma patients. Other clinical parameters, General Comments including the presence of hypotension (systolic blood The incidence of penetrating head injuries among civ- pressure < 90 mmHg) on admission, have also been ilians is unclear. Most of the available literature has associated with poor survival [10, 17]. It is important to focused on victims who arrive to the hospital alive, or note, however, that while these associations have pro- patients who sustain their injury in periods of conflicts ven significant in retrospective studies, they have not or war. Available data support that penetrating head reached statistical significance in the only prospective injuries in civilians result in better outcomes compared study reported [10, 13, 14]. to injuries sustained in military settings [9, 10]. This has Based on this spectrum of findings, utilization of traditionally been attributed to the fact that weapons sparse resources may not be recommended, due to resulting in civilian injuries most commonly utilize low- poor survival rates and the lack of evidence to support velocity missiles, in contrast to the higher velocity that aggressive management of these patients will re- projectiles commonly utilized during military conflict. sult in favorable outcomes. On the other hand, patients The distribution of outcomes from penetrating head with an absence of the aforementioned clinical findings injuries can probably best be described as an ‘‘all or should undergo noncontrast CT of the head as soon as nothing’’ phenomenon. Injuries of this type can most possible. Availability of neurosurgical consultation and commonly be characterized into categories of either intervention capabilities should be considered, how- (1) severe or lethal injury (GCS < 9, head AIS ‡ 3, ever. Without these resources and the ability to act bihemispheric injury), or (2) patients who have good upon the results of imaging, CT use may not be justi- recovery or moderate prognosis [9, 11, 12]. Patients with fied. severe disability or vegetative state after penetrating If available, CT imaging does permit the addition head injury represent the minority in this population. of other important prognostic indicators, including the determination of anatomical injury grading such as Management of Penetrating Brain Injuries head AIS. Demetriades et al. found that age over The triage and subsequent management of patients 55 years, GCS on admission, and head AIS are signifi- with penetrating head injuries during a MCI is most cant predictive factors for death in victims of penetrating

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

head injuries. Based on their investigation of 759 cases reduced fivefold after decompressive lobectomy when with penetrating head injuries, the probability of death compared to victims of blunt brain injury. It was also increased in linear association with increasing injury found that GCS £ 8 on admission and frontal lobec- severity [12]. The ability of CT to assist in these tomies were associated with poor outcomes. The sig- determinations may therefore significantly improve the nificant variability of these injuries and an absence of ability to appropriately match patient expected out- solid evidence, however, preclude recommendation on come to availability of resources. CT also permits the optimal management policies [20]. The most rational identification of specific injury patterns that may be approach for operative intervention in these cases is to associated with a higher likelihood of mortality, to in- proceed to operation as soon as the indications for clude the presence of multilobar injuries or involve- surgery appear, provided these resources are available ment of the ventricles. Bihemispheric trajectory has during a MCI. The use of a prophylactic broad-spec- also been associatedwith high mortality rates [11]. trum antibiotic and anticonvulsant therapy in order Exceptions to this may be bihemispheric injuries lim- to prevent infections and seizures is also mandated ited to the frontal lobes (Figure 1). [21–23]. All triage decisions following penetrating head injuries should be considered with the understanding In Summary that it remains unclear if early and aggressive surgical Survival rates of patients with penetrating head injuries management of these injuries has any beneficial effects admitted with respiratory arrest, hypotension, GCS on the outcomes of these patients. The role of surgery £ 8, fixed and dilated pupil(s), or any combination of is to obtain an efficient debridement with removal of these clinical findings, are expected to be low. Patients the missile and bone fragments [11]. Several authors with this constellation of signs should, therefore, be have suggested that aggressive and early intervention considered unsalvageable during a MCI. For all other of this kind may prevent infections and brain swelling patients, the use of noncontrast CT should be utilized if in patients with GCS > 5 on admission [11, 18]. In a such imaging and neurosurgical capabilities are avail- study conducted by Oncel et al. [19] scrutinizing out- able. The subsequent identification of multilobar, bi- comes in patients undergoing lobectomy for intractable hemispheric, or ventricular involvement increases intracranial hypertension, or brain stem herniation, the mortality rates; however, the need for a decompressive investigators noted that patients sustaining penetrating lobectomy does not seem to preclude a patient from head injury had a probability of death that was reduced further management after penetrating head injury sevenfold and a probability of vegetative state that was when capabilities warrant. Our proposed initial management algorithm for penetrating head injuries is depicted in figure 2.

Penetrating Neck Injuries (PNI) General Comments Penetrating neck injuries may present a challenging dilemma for care providers in the receiving facility during a MCI. The most commonly injured structures following penetrating trauma to the neck are, in descending order, the vessels (jugular veins, carotid arteries, and subclavian vessels), spinal cord, aerodigestive tract, and nerves [24]. Overall, approximately 35% of all gunshot wounds (GSWs) and 20% of stab wounds (SWs) to the neck are associated with signiﬁ- cant injuries to vital structures. Only about 17% of all GSWs and 10% of SWs not crossing the midline, however, require a therapeutic intervention [25]. Overall, mortality associated with PNI is approxi- Figure 1. Civilian gunshot wound to the head with GCS of 15 on mately 11% [26]. Keeping these ﬁgures in mind may admission. Nonoperative management was employed and the patient was discharged from the hospital two weeks after admission assist in minimizing the broad abundance of investi- with a GCS of 15, with minor behavioral changes. gations commonly utilized in the evaluation of these

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

Figure 2. The initial management algorithm for penetrating Penetrating Head Injury head injury. CT, computed tomography; GCS,GlasgowComa Scale; OR, operating room.

Stable hemodynamics Neurosurgical capability available Respiratory arrest GCS>8 Pupil(s) fixed and dilated Hypotension GCS≤8 Cardiac arrest Non-contrast head CT Yes No Associated lethal injury

Normal Indication for surgery Multilobar injuries Midline shift Bihemispheric trajectory Transventricular trajectory

Observation/ O Further evaluation/ Expectant/ Judgement R Resuscitation Deceased patients. Understanding the low incidence of clinically signiﬁcant injuries following penetrating trauma to the neck highlights the potential applicability of SNOM strategies during a MCI. Computed tomographic angiography (CTA) of the neck and chest provides valuable information regarding the missile tract, identifying missile trajectories away from the major vessels or the aerodigestive structures that do not need further evaluation [27, 28] (Figure 3).

Management of Penetrating Neck Injuries Aerodigestive Injuries Aerodigestive injuries due to penetrating mechanisms are rare, occurring in about 7 and 3% patients after cervical GSWs and SWs, respectively [24]. Oxygen administration by mask or a nasal cannula and rapid transportation to the receiving facility is the optimal approach. Figure 3. CT image of missile tract and vascular structures in a It has been suggested that there is a universal patient sustaining a GSW to the left neck. CCA, common carotid occurrence of signs and symptoms in signiﬁcant cervi- artery; IJV, internal jugular vein; VA, vertebral artery. cal airway injuries. These ‘‘hard signs’’ of cervical airway injury include air bubbling through a neck wound, Initial treatment priorities include rapidly correct- dyspnea, and major hemoptysis. The ‘‘soft signs’’ of ing sources of airway compromise, thus establishing a airway injury include subcutaneous emphysema, secured airway. Tension pneumothorax should be hoarseness, and odynophagia. Air bubbling through a treated immediately when signs are recognized. Oro- neck wound is pathognomonic of laryngotracheal in- tracheal rapid sequence intubation is the most common jury. It is our experience that manual compression with method of emergent airway management and is uti- occlusive gauze over the wound may reduce the air lized in approximately 80% of patients with penetrat- leak and result in improved oxygenation [25]. ing injuries with a high success rate [29]. However, in

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

12% the orotracheal intubation may fail and an alter- spective study of predominantly GSWs to the neck, native procedure will be required [30]. In rare cases of 72% of patients showed no clinical signs suggestive of visible large laryngotracheal wounds, the endotracheal vascular trauma. In the absence of clinical signs, none tube can be inserted under direct visualizaton into the of these patients required an operative intervention, distal injured or transected segment through the neck for a NPV of 100% [24, 31]. wound. When these situations occur, the distal larynx In suspected carotid artery injury, repair and or trachea should be grasped and secured with tissue revascularization or ligation are the available options. forceps before insertion of the tube in order to avoid Although some earlier reports warned against per- complete transection or retraction into the mediasti- forming revascularization in the presence of neurologic num. deficits due to the concern over converting an ischemic In the absence of any clinical findings suspicious for infarct to a hemorrhagic infarct, subsequent studies airway injuries, it is highly unlikely that a significant suggest that the best chance for neurologic improve- airway injury exists, with a reported negative predictive ment in these patients is timely revascularization value (NPV) of 100% [24]. Unlike airway trauma, [35–38]. We believe that the best chance for neurologic however, there are no ‘‘hard signs’’ that are diagnostic of recovery, even in the patient who presents in coma, is cervical or mediastinal digestive tract injuries. Signs that urgent revascularization unless other victims are pri- require evaluation of the pharynx and esophagus include oritized for life-threatening emergencies. Patients who odynophagia, subcutaneous emphysema, and hematem- present with a normal neurologic examination have an esis. These symptoms may be present in approximately excellent prognosis and should be managed selectively. 23% of patients; however, only approximately 18% of Transcervical GSWs are associated with a much patients with these findings have pharyngoesophageal higher incidence of significant injuries compared to trauma [25]. Such injuries need to be addressed in a those not crossing the midline (73 vs. 31%) [39]. For timely fashion, after all life-threatening conditions have this reason, it has been suggested in the past that all been resolved in salvageable victims. patients with transcervial GSWs should undergo an operation regardless of the clinical examination [40]. Vascular Injuries Even among these injuries that do cross the midline, The most prominent and life-threatening cervical vas- however, only 21% require a therapeutic procedure, cular injuries following PNI are carotid and subclavian thus should undergo selective management [39]. vessel trauma. The on-scene death rates associated Nerve, spinal cord and other injuries that commonly with these injuries are approximately 56 and 61%, occur following transcervical GSWs frequently do not respectively. Injury to the carotid artery occurs rela- require an operation [39]. tively infrequently, in approximately 4–15% of all penetrating neck injuries, and accounts for 20–80% of all Nervous System Injuries cervical vascular injuries. Injuries to the subclavian The evaluation of GCS and focal neurological deficits vessel are also uncommon, occurring in 4% of GSWs is conducted during the initial evaluation. Spinal frac- and 2% of stab wounds to the neck. In one-third of tures are infrequently encountered in patients sus- cases, associated intrathoracic injuries also occur taining GSWs or SWs, occurring in about 1 and 0.1%, [31–33]. ‘‘Hard signs’’ of significant cervical vascular respectively [41]. Plain radiographs may provide trauma include severe active bleeding, large expanding information on spinal fractures, trajectory, and re- hematoma, absent or diminished peripheral pulse, tained missile sites in the neck. Spinal cord injuries bruit on auscultation, and unexplained hypotension. follow closely fracture rates after penetrating trauma These injuries are associated in almost 100% of cases and are reported to be present in approximately 0.1% with significant vascular trauma, and need immediate of patients. It is rare that low-velocity gunshot wounds intervention in the OR if any salvage is to be expected result in spinal instability; however, high-velocity [25]. Emergency department thoracotomy (EDT) for wounds may cause destructive spinal injuries that are penetrating neck injuries renders poor survival [34]. readily apparent on initial examination [42]. Several ‘‘Soft signs’’ of vascular trauma include stable, small to reports conclude that fully evaluable patients without moderate size hematomas, moderate/minor bleeding, neurological signs following PNI do not subsequently mild hypotension responding to fluid resuscitation, require spinal immobilization or imaging [43]. If a and proximity wounds. Only approximately 3% of devastating injury has occurred with neurological def- cases presenting with ‘‘soft signs’’ are associated with icit, no meaningful recovery is expected and airway an injury requiring an intervention [24]. In one pro- management and control of hemorrhage always take

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

priority. The neck should be protected against further thoracostomy tube drainage only [8]. The remaining damage with a collar. GSW to the brachial plexus or 10–15% may require a formal thoracotomy/sternot- cranial nerves may also occur following PNI, but can omy. Nevertheless, GSWs to the chest require urgent be managed in delayed fashion. Stab wounds to those thoracotomy more frequently than SWs [45]. Auto- structures can be explored when resources become transfusion is of paramount value in MCI, as transfu- available. sion resources may become rapidly exhausted in these settings [46, 47]. To achieve this purpose, all trauma In Summary chest drainage systems should be prepared with 100 ml Penetrating neck injuries should be managed selec- citrate into the collection compartment of the chest tively in a MCI. All life-threatening emergencies should drainage unit. Major air leaks following penetrating be recognized and addressed immediately. Airway chest trauma have also been frequently cited as an management is a vital component of the initial evalu- indication for thoracotomy. The vast majorities of these ation and any injuries compromising the airway require leaks, however, heal spontaneously and can be man- immediate attention. Secondly, hemorrhage control aged selectively [48]. A short overview of some intra- needs to be obtained. Only casualties with ‘‘hard signs’’ thoracic injuries is delineated below. of vascular injuries need immediate operation. Victims with soft signs of vascular trauma may be managed Management of Penetrating Thoracic Injuries selectively when resources become available, including Urgent Thoracotomy evaluation and treatment of the digestive tract and The indication for EDT in MCI is a penetrating injury neurological injuries in the neck. Our primary man- to the chest with cardiac arrest occurring in the ER of agement algorithm is depicted in ﬁgure 4. the receiving facility. No survival is expected when vital signs are absent at the scene [49, 50]. The mean survival rate in patients subjected to EDT after pene- Penetrating Chest Injuries trating trauma is about 9% and is related to the General Comments mechanism of injury, the location of the major injury, Thoracic trauma is one of the leading causes of death in and the pre-hospital clinical status. Stab wounds are all age groups, and accounts for 25–50% of all traumatic associated with better prognosis after EDT as com- injuries [44]. Severe penetrating trauma to the chest pared to GSWs [50]. In the setting of EDT for pene- may be rapidly fatal because of cardiac injury, massive trating trauma, the best prognosis is expected in hemothorax, or tension pneumothorax. Many of these patients with isolated cardiac stab wound who present injuries lead to death on-scene, and survivability is not with vital signs on arrival [51]. Indications for urgent expected without an immediate intervention. However, OR thoracotomy are persistent shock unresponsive to the vast majority of patients (85–90%) who reach the ﬂuid therapy and thoracostomy tube output exceeding receiving facility can be safely managed by simple 1.5 l initially [44, 50]. The hope that children may have

Figuer 4. The initial management algorithm for penetrating Penetrating Neck Injury neck injury. OR, operating room.

Air bubbling through the wound Diminished radial pulse Cardiac arrest Severe hemorrhage Bruit Associated lethal injury Shock, not responding to fluid bolus Widened mediastinum Absent radial pulse Shotgun injury

Yes No

O Further evaluation/ Observation/ Expectant/ R Resuscitation Judgement Deceased

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

a more favorable outcome than adults following pneumo/hemothoraces must be drained, and auto- emergency thoracotomy has not been borne out by transfusion should be utilized whenever available. In published evidence. Overall survival rates in children the MCI setting, patients with suspected great vessel following emergency thoracotomy for penetrating injuries are managed according to their hemodynamic thoracic trauma are 11–12% [52]. status, chest tube output, and ability to ventilate. Failure of initial components of resuscitation mandates Cardiac Injuries an operation to facilitate salvage [49]. Patients with cardiac injuries leading to rapid exsanguination or cardiac tamponade will most likely expire Pulmonary and Diaphragmatic Injuries at the MCI scene. Approximately 80% of cardiac Penetrating pulmonary injuries rarely require opera- injuries after stab wounds originate from the precordial tive management [48]. The bleeding is usually region. Following gunshot wounds, however, a missile self-limiting, due to the low-pressure nature of the may strike the heart from almost any point of entry, pulmonary vasculature and a rich concentration of rendering almost universally a poor outcome. In the tissue factor within the pulmonary tissues. Patients MCI setting, selective management becomes a vital with major hemorrhage may need surgical intervention algorithm, even in suspected cardiac injuries. A chest performed rapidly with a stapling device. Anatomic radiograph is of paramount value to evaluate for the resections do not improve outcome, and in most cases presence or absence of pneumothorax, hemothorax, or lung sparing techniques such as a stapler tractotomy or suspicious missile tract. Radiographic signs of pericar- wedge resection are very useful and the only required dial violation and suspected tamponade are enlarged procedures [60]. Patients with persistant respiratory cardiac contour, pneumopericardium, and widened distress, subcutaneous emphysema, hemoptysis, or upper mediastinum due to distended superior and persistent air leak through the chest tube are suspicious inferior vena cava. The ultrasound or FAST exam for tracheobronchial injuries and may need surgical should, therefore, be used to rapidly and conclusively intervention if conventional treatment with a chest exclude or confirm intrapericardial fluid. The identifi- tube fails. Penetrating injuries violating the diaphragm cation of pericardial fluid thus alters further manage- are usually minor lacerations, which may be managed ment and eliminates in most instances the need for a when resources become available [61]. If a diaphrag- subxiphoid pericardial window. Some authors have matic injury needs to be excluded in a patient with suggested that the majority of hemodynamically stable normal clinical findings after injury, they are observed patients with cardiac stab wounds may be managed at least 6 hours for the development of peritonitis prior nonoperatively [53]. The gold standard for treatment to laparoscopy. If peritonitis develops during the of these injuries, however, remains sternotomy/thora- observation period, a laparotomy rather than a lapa- cotomy for relief of pericardial tamponade and repair roscopy is performed. of the cardiac wound [51, 54]. If any salvage is expected in patients with marked hypotension and pericardial Esophageal Injuries tamponade, an emergent operation must be instituted After penetrating injuries to the neck, chest, or abdo- [52, 55]. men, only 0.2% of patients are likely to sustain an esophageal injury [62]. Transmediastinal GSW, how- Thoracic Great Vessels ever, require special attention to rule out an esophageal Injuries to the thoracic great vessels occur in about 5% injury in the subsequent work-up, using detailed tra- of GSWs and 2% of SWs to the chest [56, 57]. Most of jectory imaging [63]. In MCI, these injuries are treated these patients die from hemorrhage and shock before as any other intrathoracic injury; however, further arrival at the receiving facility [57]. In order of investigation with esophagography must be performed decreasing frequency, the most commonly encountered expediently when resources become available [25]. thoracic great vessel injuries are those to the sub- There has been some concern that esophagography clavian artery, descending aorta, pulmonary artery, may miss small esophageal injuries [64]. In our experi- subclavian vein, intrathoracic vena cava, innominate ence, we have not encountered any missed esophageal trunk, and pulmonary vein. The initial resuscitation injuries by esophagography in the last 14 years. should follow ATLS protocol [58]; however, several investigators advocate controlled permissive hypoten- In Summary sion in patients with potentially fatal penetrating chest Thoracic injuries are managed initially depending on injuries without immediate access to OR [59]. Any patients’ hemodynamic status, chest tube output, and

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

(Figure 5). The initial management algorithm for penetrating thoracic injuries is depicted in ﬁgure 6.

Penetrating Abdominal Injuries General Comments The management of penetrating abdominal trauma at civilian medical facilities has continued to evolve over the last several decades. Speciﬁcally, SNOM has been utilized with increasing frequency in these settings. Widely practiced for SWs, evidence has even accu- mulated that the nonoperative management of GSWs is also a safe and cost-effective management option for select groups of these patients [65–78]. In the majority of studies documenting the successful use of SNOM after penetrating abdominal trauma, detailed trajec- Figure 5. CT image of a GSW to the right chest. Chest tube and tory imaging and serial clinical examination have been autotransfusion were the only interventions employed. utilized to safely and effectively exclude intra-abdominal injuries and avoid the need for a nontherapeutic ventilatory status. Only 10–15% of patients with laparotomy. penetrating thoracic injury will need an operation, The application of SNOM principles in the setting making chest injuries manageable with selective con- of a MCI, however, may be more difﬁcult. In these servative approaches. In most instances, chest tube situations, imaging capabilities may be overwhelmed or insertion will be the most effective initial procedure. unavailable. Manpower limitations may also preclude Autotransfusion of drained intrathoracic blood should the utilization of effective serial exams. Operative be utilized early. CT imaging has an important role in capabilities themselves may initially be overwhelmed. visualizing the missile tract and delineating the need Nevertheless, comprehensive knowledge of the data for further investigation or surgical intervention [63] regarding SNOM of penetrating abdominal trauma

Figure 6. The initial management algorithm for penetrating Penetrating Chest Injury chest injury. HTX, hemothorax; OR, operating room; PTX, pneumothorax.

Unstable hemodynamics Stable hemodynamics Cardiac arrest en route

O2 Saturation > 90% Associated lethal injury

Severe Mild

Signs of HTX/PTX

Chest tube Fluid bolus Autotransfusion

Yes No

No Response Chest tube response Autotransfusion

O Further evaluation/ Observation/ Expectant/ R Resuscitation Judgement Deceased

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

provides the MCI team with the opportunity to adapt abdominal injury. In this investigation, the only diag- these principles to the capabilities of their situation, nostic tool was clinical evaluation. These figures are and can assist in the triage of patients with these important ones to remember in the setting of a MCI, injuries. where many manpower issues and evaluations limitations may initially predominate. Management of Penetrating Abdominal Injuries Stab Wounds Gunshot or Projectile Wounds Approximately 60 and 30% of stab wounds to the Approximately 60% of GSWs to the abdomen require anterior abdomen and the back, respectively, require surgical intervention [74]. Most of the aforementioned operative intervention [65, 66, 68, 76]. The initial criteria for the initial evaluation of stab wounds also evaluation of abdominal stab wounds, even in the most hold true for injuries due to projectiles. Nevertheless, austere of MCI settings, begins with the clinical exam. clinical examination alone can be very reliable tool in Peritonitis, visceral evisceration and hypotension re- detecting injuries requiring operative intervention after main clear indications for emergent operation. Select GSW to the abdomen [73–75, 82]. Peritonitis and cases of omental evisceration have been safely man- hemodynamic instability remain clear operative indi- aged with techniques of SNOM, provided the patient is cations. Due to the greater forces and unpredictable evaluable and without other clear indications for trajectories involved, however, intra-abdominal injury operation [79]. The inability to adequately conduct a is more likely following projectile injury. physical exam due to decreased mental status in The use of imaging modalities following GSWs is hemodynamically stable patients mandates exploratory similarly limited. Gross free air detected on upright laparotomy or expeditious imaging of the abdomen. plain radiography raises suspicion for intra-abdominal Imaging utilization in the setting of a MCI will depend injury, as does a focused ultrasound exam visualizing upon local resource capabilities. In the absence of gross fluid. In many instances, however, basic imaging of the free air, plain radiography may frequently prove nor- abdomen has the potential to miss significant injury. mal, even in cases of significant intra-abdominal injury. For this reason, the majority of recent reports of suc- Focused ultrasonography that clearly identifies free cessful SNOM principles have relied upon the use of fluid after penetrating abdominal trauma may prove advanced imaging to define trajectory and exclude in- useful in determining the need for further imaging or tra-abdominal injury. A positive FAST exam, a clear operation. Due to the poor NPV of this study following operative indication in the setting of hemodynamic penetrating trauma, however, it should not be utilized instability, warrants expiditious CT imaging in a com- in isolation. In one retrospective study of ultrasound pletely stable patient. Computed tomography remains and CT use, investigators found that when used to- the gold standard for this endeavor; however, CT gether, these modalities have only a 78% sensitivity in imaging may be not readily available in a MCI setting predicting the need for operation [80]. CT may also be [83]. Given appropriate capabilities, all evaluable pa- useful in identifying free fluid suspicious for hemor- tients without peritoneal signs or hypotension should rhage or hollow viscus injury. CT also provides for be triaged to receive CT as soon as possible. In the identification and triage of solid organ injuries. If no absence of these capabilities, the clinical need for contrast blush or significant hemoperitoneum is pres- operation should be heightened. ent, the vast majority of these injuries may be managed Lesser interventional evaluations, such as diag- nonoperatively provided the patient remains stable and nostic peritoneal aspirate (DPA), may prove useful as without peritonitis. The presence of contrast extrava- an adjunct for the reasons mentioned previously. Due sation mandates angiographic embolization or opera- to these significant limitations, MCI patients with tive intervention [76, 81]. Overall, several studies have projectile injuries to the abdomen should have shown that the need for operation following abdominal heightened clinical suspicion of the need for abdominal stab wounds can be effectively made exclusively on exploration. clinical criteria. In a study of 651 patients with these injuries reported by Demetriades et al. [34], the In Summary investigators found that among evaluable patients For triage purposes, all patients with hypotension or without peritonitis, only 3.6% required subsequent peritonitis should undergo emergent operation. operation and no mortalities occurred. Even among Hemodynamically stable patients who are not evalu- the 467 patients with proven peritoneal penetration, able due to decreased mental status or significant dis- the authors found that 28% had no significant intra- tracting injuries should be triaged to expeditious CT

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

infectious risk. Traditional management of open fractures mandated emergent debridement and irrigation [89]. Recently, however, several large series have re- futed this principle, finding no increase in osteomyelitis if debridement was completed within the first 24 h following injury, provided appropriate antibiotics are begun in the emergency department [90–92]. In the setting of a MCI, all fractures should be splinted for immobilization and appropriate antibiotics (first-gen- eration cephalosporin and gentamicin) administered in addition to proper pain management [93, 94]. Opera- tive intervention for debridement, irrigation and fixa- tion (if required) should be accomplished as soon as triage of available resources permits.

Figure 7. Civilian transhepatic GSW. Nonoperative management was employed. Nerve Injuries Nerve injuries are not uncommon following projectile injuries, more commonly occurring following pene- imaging or exploratory laparotomy. All other patients trating trauma to the upper extremities [95]. Among should be triaged to CT. In the absence of this imaging survivors of the initial trauma, nerve injury likely ac- capability, these patients should be triaged for abdo- counts for the majority of the functional deficits ob- minal exploration after more pressing cases have been served [96]. Early repair of nerve injuries is ideal for cared for. The primary management algorithm for stab wounds; however, such endeavors are not part of penetrating abdominal injuries is depicted in figure 7. initial MCI care. As manning permits, a thorough physical exam should be documented and neurosurgical or appropriately trained orthopedic consultation Penetrating Extremity Injuries obtained. If an initial operation is undertaken for General Comments concomitant vascular injury by a surgeon lacking the Trauma to the extremities may be the most common skill set or resources for nerve repair, identified nerve injuries arising from large-scale disasters [84]. In endings should be clearly tagged with visible sutures disasters due to either human conflict or natural causes, for delayed repair. these types of injuries may result in injuries to bones, nerves, soft tissue structures and vessels. Acute se- Soft Tissue Injuries quelae of these injuries may include severe hemor- Penetrating injuries, including blast or missile injuries, rhage and infection [85]. In the civilian setting, may be associated with significant soft tissue injury that mortalities from isolated penetrating extremity injuries may be underestimated by external exam alone. are rare. Such injuries most likely result from proximal Effective debridement at the earliest possible juncture injuries to the lower extremities leading to subsequent is the mainstay of therapy. Appropriate antibiotics exsanguination [86]. However, even low projectile should be administered as soon as possible. Infection in injuries may commonly result in fractures, vascular this setting can have devastating effects. Severe injuries injuries, compartment syndromes and nerve injuries may warrant amputation [97, 98]. [87]. In the setting of a MCI, available resources must be used effectively to optimize the outcomes of these Vascular Injuries injuries, as the majority of survivors of extremity Vascular injuries account for the majority of early trauma will achieve good functional recovery with deaths following extremity trauma. Unabated hemor- appropriate management [88]. rhage from any significant extremity vessel may result in considerable blood loss. Injury to larger inflow ves- Management of Penetrating Extremity Injuries sels, such as the femoral, popliteal or brachial arteries Orthopedic Injuries may result in both profound hemorrhage and limb loss Even low velocity projectile injuries may commonly [99, 100]. Subclavian and axillary vessel injuries, due to result in fracture [87]. By definition, these fractures are their size and difficult locations for control, are par- considered open and are associated with increased ticularly lethal [101]. Initial control via tourniquet use

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

Figure 8. The initial management algorithm for penetrating Penetrating Abdominal Injury abdominal injury. FAST, focused abdominal sonography for trauma. Unstable hemodynamics Unevaluable Cardiac arrest and/or peritonitis Hemodynamically stable Associated lethal injury

FAST

Positive Negative

CT available

No Yes

Definite injury Negative Suspicious tract

O Observation/ Further evaluation/ Expectant/ R Judgement Resuscitation Deceased

Figure 9. The initial management algorithm for penetrating Penetrating Extremity Injury extremity injury. ABI, ankle– brachial index; CT, computed tomography; OR, operating room

Severe active hemorrhage Stable hematoma Cardiac arrest Shock Minor bleeding Associated lethal injury Large, expanding hematoma Proximity injury Pulsatile hematoma ABI abnormalities Absent peripheral pulse after fracture reduction

O Further evaluation/ Expectant/ R Resuscitation Deceased has proven useful in both the civilian and military temporary shunts without ligation of critical vessels. settings, and is a recommended adjunct during initial Almost any signiﬁcant vein injury may be ligated with transport and stabilization if manpower or profuse impunity [103]. In addition, a tight compartment bleeding precludes control with direct pressure [102]. should be considered for decompression after vascular ‘‘Hard signs’’ of vascular injury require emergent injury; however, we do not perform mandatory fasci- operation. These include active hemorrhage, absent otomies in such instances. ‘‘Soft signs,’’ including a distal pulse, expanding or pulsatile hematoma, a new stable hematoma and suspicious trajectory, mandate bruit or thrill, and distal ischemia (manifested by pain, additional imaging to exclude vascular injury. The paresthesia, pallor, poikilothermia, or pulselessness). physical exam alone, however, may not effectively The highest priorities in such instances are to arrest exclude vascular injury, particularly in austere settings. hemorrhage and to restore perfusion by liberal use of In one recent review of military extremity vascular

Eur J Trauma Emerg Surg 2009 URBAN &VOGEL Talving P, et al. Role of Selective Management of Penetrating Injuries

injuries, the positive predictive value of physical exam clinical suspicion. If suspected, direct measurements of alone was 85% or higher. The sensitivity and NPV of compartment pressures should be undertaken percu- physical exam, however, were 15 and 60%, respectively taneously. [104]. Prospective studies have demonstrated that appropriately utilized Doppler pressure indices, com- In Summary monly referred to the ankle–brachial index (ABI) or Initial interventions for extremity vascular injuries brachial–brachial index (BBI), may improve the iden- during a MCI should be designed to prevent exsan- tification of patients for further studies such as duplex guination and limb loss. Limb preservation does come sonography, arteriography or CTA [105, 106]. As this secondary to preservation of life. As mentioned test can be rapidly performed and is easily reproduc- previously, judicious application of tourniquets to ible, it should be performed for all patients. hemorrhages that cannot be completely controlled by Color duplex sonography is a widely available, direct pressure is advisable. Any patient with ‘‘hard noninvasive and accurate technique for evaluating signs’’ of vascular injury requires operation if no other vascular injuries, and can serve as a very effective first- life-threatening injuries are present in other patients. line imaging modality for most patients with extremity The algorithm for the primary management of pene- trauma [107]. Particularly in circumstances in which trating extremity injuries is depicted in figure 8. conventional radiography is unavailable, such as MCIs, or at the bedside of unstable patients, sonography can provide unique and essential information that assists in Conclusion patient triage and diagnosis [108]. The appropriate disaster plan is critical for salvaging For many years, angiography has served as the life in the MCI setting. An accurate triage in the gold standard for the identification of vascular receiving hospital delineates the management of the injuries. Endovascular techniques have also evolved, injured. By necessity, clinical signs are likely to prove facilitating the treatment of many vascular injuries cornerstones of triage during a MCI. The present re- at the time of angiographic identification. Angio- view of the available literature strongly supports that graphic capabilities may, however, prove unavailable the appropriate utilization of these clinical indicators or be overwhelmed in the setting of a MCI. CTA to identify patients appropriate for SNOM is essential, has emerged as a very effective diagnostic alterna- critical, and readily applicable when they do not tive to traditional angiography [109–112]. CTA may, mandate immediate intervention. Knowledge of these however, also be unavailable or overwhelmed during principles assists in the efficient utilization of limited MCIs. CTA also has some important potential resources such as blood products, OR, and imaging limitations; in particular, significant fragmentation options that are crucial to mass-casualty management. within the extremity may make accurate diagnosis difficult. Compartmental pressures in excess of 30 mmHg References are consistent with the diagnosis. Patients with com- 1. Malik ZU, Hanif MS, Tariq M, Aslam R, Munir AJ, Zaidi H, Akmal partment syndrome require emergent fasciotomy. M. Mass casualty management after a suicidal terrorist attack Delay in fasciotomy may result in both systemic (acute on a religious procession in Quetta, Pakistan. J Coll Physicians renal failure from myoglobinuria/rhabdomyolysis) Surg Pak 2006;16:253–6. 2. Peleg K, Aharonson-Daniel L, Stein M, Michaelson M, Kluger Y, and local complications. 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J Trauma 2007;62:1234–9. extremity muscle compartments and symptoms of 5. Jenkins JL, McCarthy ML, Sauer LM, Green GB, Stuart S, Thomas compartment syndrome should be promptly evaluated TL, Hsu EB. Mass-casualty triage: time for an evidence-based approach. Prehospital Disaster Med 2008;23:3–8. and treated to prevent limb loss. Classic symptoms of 6. Feliciano, DV, Mattox, KL, Moore EE, Demetriades D, Velmahos compartment syndrome include pain, pallor, pulse- GC. Indications for and techniques of laparotomy. Trauma lessness, paresthesias or paralysis in the setting of 2008.

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