Much has been written about the theory and principles of war surgery as practised by military medical units. This book, which summarizes the practical experience of eminent special- ists from different parts of the world, aims to provide a broad introduction to the subject for members of surgical teams, whether military or civilian, who may be faced with the treat- ment of wounded in situations or armed conflict - situations which demand a quite different approach from that normally found in civilian practice. Among the subjects covered are: first aid, triage and reception of casualties, skin grafts, infection, treatment of neglected and mismanaged wounds, the treatment of wounds to different parts of the body, burns, reconstructive surgery and anaesthesia. One of the chief characteristics of warfare is that sophis- ticated weapons cause highly damaging wounds, for the most part contaminated, in a context in which the medical infrastruc- ture is poor. Field hospitals, such as those set up by the Red Cross in conflict zones, have to serve both as hospitals of first contact and as referral units, combining primary, secondary and D. DUFOUR basic reconstructive surgery. As the authors of this book point S. KROMANN JENSEN out, these circumstances require surgeons to have an all-round M. OWEN-SMITH approach and to be able to use very simple means of treatment, J. SALMELA often improvising to achieve maximum care under difficult conditions. G.F. STENING B. ZETTERSTRÖM The International Committee of the Red Cross (ICRC), founded in 1864 with the express purpose of improving med- ical care for the wounded in wartime, has published this book in the hope that its own experience in this field - and that of the book’s authors - will help give victims of warfare the best possible chance of survival and recovery. ICRC 0446/002 10/02 1000 ICRC D. DUFOUR S. KROMANN JENSEN M. OWEN-SMITH J. SALMELA G.F. STENING B. ZETTERSTRÖM Third edition revised and edited by Å. MOLDE ICRC International Committee of the Red Cross 19 Avenue de la Paix, 1202 Geneva, Switzerland T +41227346001 F +41227332057 E-mail: [email protected] www.icrc.org Original: English AUTHORS Bernard Betrancourt, Physiotherapist, Switzerland Daniel Dufour, M.D., Switzerland Soeren Kromann Jensen, M.D., Denmark Ora Friberg, M.D., Finland Antero Lounavaara, M.D., Finland Michael Owen-Smith, FRCS, United Kingdom Jorma Salmela, M.D., Finland Erkki Silvonen, M.D., Finland G. Frank Stening, FRACS, Australia B. Zetterström, M.D., Sweden First edition edited by DANIEL DUFOUR Michael Owen-Smith G. Frank Stening Second edition edited by ROBIN GRAY, FRCS, ICRC surgical coordinator, Geneva Third edition revised ÅSA MOLDE, M.D., and edited by ICRC surgical coordinator, Geneva Illustrated by PENELOPE L. ZYLSTRA, S.R.N., Australia ISBN 2-88145-010-5 © International Committee of the Red Cross Geneva, September 1988, September 1990 (second edition) and October 1998 (third edition) IV PREFACE The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and the dignity of vic- tims of war and internal violence and to provide them with assis- tance. The ICRC assists the wounded when war prevents society from providing them with the health care they need. It may furnish exist- ing health facilities with medicines, equipment or staff, or set up independent ICRC hospitals. It may also help evacuate the wounded or treat them in first-aid posts. It provides training of all kinds to the medical staff involved, either on the spot or by orga- nizing or participating in courses, seminars and conferences around the world. Since the early 1970s, the ICRC has sent many civilian surgeons to war-torn countries. Most of them have no previous experience of war surgery, yet they are called upon in the course of their mis- sion to treat all types of war-related injuries to different parts of the body. Moreover, given the early subspecialization of modern med- ical training, few surgeons have hands-on experience of head or maxillo-facial injuries, chest or abdominal wounds, or the different kinds of fractures. This book is intended for surgeons who have volonteered to work with war wounded or who might suddenly find themselves in a situation where they have to deal with war wounded. It was writ- ten by surgeons with firsthand experience of war surgery. This third edition takes into account the comments made by the many surgeons who have used the manual over the years. It is dedicated to all the surgeons working in conflict areas to alleviate the suffer- ing of the wounded. Dr. Pierre Perrin Chief Medical Officer V VI ACKNOWLEDGEMENTS to the 1st edition The ICRC thanks the editors and all the authors of this manual on war surgery, particularly Mr. Frank Stening who wrote the first draft for it in 1982. The wide experience in war surgery brought by all the contribu- tors made it possible to define and establish the major aspects of the treatment of war wounded. Without the time and energy they gave on a voluntary basis the book would never have materialized. Thanks are especially due to Mr. Soeren Kromann Jensen for all the work he did in planning the illustrations, which were com- pleted by Ms. Penelope Zylstra, to Ms. Irène Deslarzes for her great patience and persistence in typing the text, and to Ms. Elisa- beth Nyffenegger for her diplomacy and efficiency in organizing the two meetings in Geneva and enabling the authors to maintain regular contact with each other. Appreciation must go to all the surgeons, anaesthetists, nurses, physiotherapists and nursing aides, whether from the ICRC and the National Societies or locally recruited, without whose dedicated work this manual would not have been possible. ACKNOWLEDGEMENTS to the 3rd edition This 3rd edition was brought out in response to the demands of many surgeons around the world. It is not just a reprint of the 2nd edition, but a thoroughly revised version, the text having been modified to take into account current ICRC thinking on matters pertaining to war surgery. It was edited for language and lay-out by Ms Angela Haden. Many thanks goes to her, to Ms Jacqueline Kopp, who did the initial typing, and to the two previous editors, Dr Daniel Dufour and Dr Robin Gray, who gave their permission for me to work freely on this edition. Å. M. VII LIST OF CONTENTS Page 1. INTRODUCTION . 1 2. FIRST AID AT THE POINT OF WOUNDING OR FIRST AID POST . 7 AIRWAY . 7 BREATHING . 8 Ventilation . 8 Chest wounds . 8 CIRCULATION . 9 Heart . 9 Bleeding . 9 BASIC TREATMENT . 10 DRESSINGS AND SPLINTS . 10 EVACUATION . 11 3. TRIAGE AND RECEPTION OF A LARGE NUMBER OF CASUALTIES . 13 CASUALTY SORTING . 13 SETTING PRIORITIES . 15 EMERGENCY PLAN FOR MASS CASUALTIES . 16 Triage area . 16 Personnel . 16 Equipment . 17 HOW TO PERFORM TRIAGE . 18 4. ASSESSMENT AND RESUSCITATION IN HOSPITAL . 19 AIRWAY . 19 BREATHING . 22 SHOCK . 22 FLUID REPLACEMENT . 23 VIII BLOOD . 24 OBJECTIVE OF RESUSCITATION . 25 5. WOUND CLASSIFICATION . 27 SOME WOUND CHARACTERISTICS OF DIFFERENT WEAPONS . 29 Bullets . 29 Fragments . 29 Mines . 30 6. WOUND EXCISION . 31 TECHNIQUE OF WOUND EXCISION . 31 Skin and subcutaneous tissues . 32 Fasciotomy . 32 Haematoma . 33 Muscle . 33 Foreign bodies . 34 Tendons, nerves, bones and arteries . 34 PERFORATING LIMB WOUNDS . 34 LIMITATION OF CLOSURE . 35 DRESSINGS . 35 ANTIBIOTICS . 36 IMMOBILIZATION . 36 TERMINOLOGY . 36 7. DELAYED PRIMARY CLOSURE AND SKIN GRAFTS . 39 DELAYED PRIMARY CLOSURE . 39 Optimum timing . 39 Dead space . 40 Wound care . 40 SKIN GRAFTS . 40 Choice of graft depth . 41 Partial thickness grafts . 41 Application of grafts . 45 Graft take . 45 Graft meshing . 45 Dressing of grafts . 48 Storage of split skin grafts . 48 IX Graft care . 48 Dressing of donor sites . 49 Full thickness grafts . 50 Donor sites . 50 Technique . 50 8. INFECTION IN WAR WOUNDS . 53 GENERAL CONSIDERATIONS . 53 ANTIBIOTIC PROPHYLAXIS . 54 TETANUS . 55 Prophylaxis . 55 Treatment of established tetanus . 56 GAS GANGRENE . 56 ANAEROBIC CELLULITIS . 59 9. TREATMENT OF NEGLECTED AND MISMANAGED WOUNDS . 61 SURGICAL EXCISION . 61 CLOSURE . 62 10. WOUNDS OF LIMBS . 63 FIRST AID . 63 MANAGEMENT IN ADMISSION AREA . 63 INITIAL WOUND MANAGEMENT . 64 TECHNIQUE OF DECOMPRESSION . 64 METHODS OF IMMOBILIZATION . 66 Plaster splinting . 67 Principles of cast application . 67 Tools and equipment . 68 Techniques . 68 Traction . 75 Techniques . 75 Postoperative check-up . 76 POSTOPERATIVE FOLLOW-UP . 76 Wound . 76 Definitive fracture holding . 77 External skeletal fixation . 77 JOINTS . 79 HAND AND FOOT WOUNDS . 80 X First aid . 80 Primary surgery and management . 80 INJURIES OF PERIPHERAL NERVES . 82 Primary surgery . 82 Delayed primary suture . 82 Postoperative care . 82 VASCULAR INJURIES . 83 Management of arterial injury . 83 Postoperative care . 87 AMPUTATIONS . 87 General indications for amputations . ..