Acute Wounds: Lacerations, GSW’s and
Blasts
Better Acute Wound Care
Better Patient Outcomes
Better Collaborations
• John P. Kirby, MD, FACS
• Director Wound Healing
Programs
• Coursemaster, Surgical
Clerkships, ATLS
• Washington University
School of Medicine
We stand on the shoulders of giants….
Increasing ISS
Decreasing CFR : WW2 19% Vietnam 16% and
now….8%
US Army ISR
J of Trauma Vol 75, 2, August Suppl 2013
LT Stuart Hitchcock, MSHS BSN, RN-BC, PhDc
Division Officer, Complex Wound & Limb Center
National Naval Medical Center, Bethesda
Disclosures
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K30 Program
BJH and WUSM Foundations
Merck, Inc----research funding for intra-abdominal infections
Neumedicines, Inc---research for novel immunomodulation
in injury states
Musculoskeletal Transplant Foundation—research in AWR
Ethicon, Inc—research in topical hemostasis
Cook, Inc—developing wound infomatics analyses
Wendi Gordon Shelist Foundation—NF, Surg Infections & WH
None of these disclosures represent conflicts of interests for
this presentation
For Governmental Compliance
• The information provided is as accurate as
possible as of the date indicated.
• Numbers have been rounded
• Treatment modalities and preferences vary
among surgical services
• No commercial interests
• Informational purposes only, not meant to be
official recommendations of any government
or private entity
Important Disclosure to consider
Acute & Critical Care Surgery
• A new practice model…we have learned from
military surgical services….
• 10 BC ACCS Surgeons
• 24 X 7 X 365 in house attending coverage for the
ED and inpatients …3/day 1/night “MOD”
• 36 Bed SICU covered in partnership with
Anesthesia with in house attending coverage
• Multi-Specialty Outpatient Clinic 5 days a week
• Full teaching service: Students, Residents, Fellows
and Nurses: Post Grad Training in CC, ACS, WC
• Complemented by APN’s, Clin RN Specialists, PA’s
Barnes-Jewish
WUSM
• Acute & Critical Care
Surgery
• Level I Trauma Center
• Affiliated with St Louis
VA (shared with SLU)
• Wound Care in our
group practice
• >2,000 traumas/yr
• 24 bed ICU now 36 Bed
• Allows us to care for a
wide variety of wounds
What have we learned?
Better Acute Care means Better Outcomes
• Better acute wound care mitigates later
chronic wound problems
• Shared Goal: Treat the WHOLE patient not just
the HOLE in patient
• Paradigms for better acute wound care
– Lacerations
– Gun Shot Wounds
– Burn Wounds
• Summary—Blast Injuries
Acute Management
• Military has its own and
accompanying manuals
• Multiple society based
course offerings
– ATLS, TEAMS, ABLS, FCCS,
FDM
• Today, wound care is one
way to stimulate your
thoughts and appetite for
the care improvements
they represent
Primary and Secondary Surveys
• ABCDEFF: Airway—Breathing—Circulation—
Deficits—Exposure—Fluids—Strip’em—
Flip’em and Cover’em Up!
• Secondary Survey: Head to Toe physical exam
with tubes and fingers in every orifice
• Follow up Exams—This is where Wound Care
might come in a crucial role: double check to
be sure all lacerations, GSW’s and injuries are
accounted for
Keep focused on the Primary Survey
• Airway has been 1st for more than 20 years…
• But military experience is moving Bleeding
up…
• Stopping exsanguinating hemorrhage may be
promoted up the primary survey
• Whole blood based resuscitation currently
only possible in the military
• 1:1:1 ratio’d massive transfusion in civillian
Acute Wounds: Lacerations
• Lacerations
– Assume contaminated, may not be recommended
to be closed v. approximated
– Tetanus Prophylaxis: Host and Injury
• Host: prior history of immunization
• Injury: quantity of Clostridium tetanii innoculation
– Rusty Nail vs Soil contamination
• Recommendations
– Tetanus treatment
Double Check on Tetanus1
• Rare, but if missed carries 13% mortality in US
care, and 30 – 50% mortality world wide
• Complications usually in those not previously
immunized, those who do not receive a timely
booster or who have an overwhelmingly large
innoculum
1. Centers for Disease Control and Prevention tetanus surveillance United
States, 2001Y2008. MMWR Morb Mortal Wkly Rep 2011;60:365Y369.
Tetanus Treatment2-4
• Consider HTIG in suspected tetanus; tetanus-prone wounds;
• those with an incomplete primary vaccination series, or
unknown
• vaccination status. A single intramuscular dose of 500
• IU suffices.
• & A protective serum antitoxin antibody level, commonly
accepted
• as 0.01 IU/mL (in vivo) or 0.15 IU/mL (in vitro), makes
• the diagnosis of tetanus less likely, but not impossible.
2. Biological products. Bacterial vaccines and toxoids; implementation of efficacy review; proposed rule. Fed Regist
1985;50:51002Y51117.
3. Simonsen O, Bentzon M, Heron I. ELISA for the routine determination of antitoxic immunity to tetanus. J Biol Stand
1986;14:231Y239.
4. Borrow R, Balmer P, Roper MH. Tetanus update 2006. In: Immunization,Vaccines and Biologicals (Immunological Basis for
Immunization Series; Module 3). Geneva: World Health Organization; 2006: 1Y35.
Tetanus: A Review
• Nice review article
• Ataro, Mushatt, et. Al in J. Of the Southern
Medical Association, Vol 614, 2011
Assess, Clean and Dress
• Assessment
– Association with deeper structure injury
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Connective tissue
Arteries
Veins
Nerves
Lymphatics
Cavities: Peritoneal, joint capsules
– Document Position, Length, Width, Depth, periwound: Essentially the same as a Pressure Ulcer
Assess & Clean
• I assess the wound from outside in: Evaluate
and Treat the WHOLE patient not just the
HOLE in the patient
• See the location of the wound and begin with
the whole patient, look fore and aft
– Pulses, range of motion
– Allows me to think about what might be at depth
or behind or associated structures
– Now you look at the wound
Basic Vascular Exam
• “Dorsalis pedis pulse was weakly/faintly
palpable”
• This really means….
• The doppler ultrasound was somewhere else
• Everyone should be familiar with a basic Ankle
Brachial Index: ABI
Ankle Brachial Index
• Take the systolic blood pressure in each arm,
select the higher of the two
• Take the systolic blood pressure above the ankle
and below any injury
• Ankle value is the numerator of the two
• Ration should be > 1.0, ratios less than that and
sometimes greater reflect injury or disease
• This gives a value that can be tracked (like the
GCS for an extremity)
Clean
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Water, normal saline, antibiotic with saline
Simple irrigation
Pulse lavage
Combination of lavage, low energy pulse
lavage, high energy lavage-debridement
• Sharp debridement
• Combinations
• Hard to show value in antibiotic solution(s)
Clean, debride, and stabilize
J. Of Trauma
• Infection Prevention and Control in Deployed Military
Medical Treatment Facilities
• Duane R. Hospenthal, MD, PhD, FACP, FIDSA,
• Andrew D. Green, MB, BS, FRCPath, FFPH, FFTravMed,
RCPS, DTM&H, Helen K. Crouch, RN, MPH, CIC,
• Judith F. English, MSN, RN, CIC, Jane Pool, MS, RN, CIC,
Heather C. Yun, MD, FACP,
• Clinton K. Murray, MD, FACP, FIDSA
• Prevention of Combat-Related Infections
Guidelines Panel
Journal of Trauma
• Prevention of Combat-Related Infections
Guidelines Panel
• All wounds and all patients should be assumed to
be contaminated
• Universal Precautions
• Good clinical practice guidelines
• Immediate treatment for healing
• Mitigating later pathogenic and resistant bacteria
Personal Practice Habits
• NS lavage with low pressure pulse lavage, no high
pressure to avoid driving debris
• Small surface areas—lavage with ultrasound
• Local lidocaine gels and soaks, regional anesthetic
blocks over general
• First dressing often iodine based antimicrobial—but for
hemostasis, not for antimicrobial
• Tissue approximation over complete closure
• OCT antibiotic ointment/xeroform early then
• Collagen based/foam protective dressings
• Common NPWT use
Gunshot Wounds = GSW’s
• Wound Care stresses examination of the
whole person: treat the whole not the just the
hole
• GSW’s are a microcosm of many wounding
mechanisms
• Let’s combine acute care with wound care
GSW 101
• A gunshot wound is the hole in the surface of the body
from the projectile, not the trajectory
– Count the wounds and then posit on the trajectories
– One gunshot yields two GSW’s or one GSW and one
retained bullet
– Number of holes plus bullets should be an even number—
unless shot before (increasingly common)_
• The severity of the gunshot is largely determined by
the transfer of Kinetic Energy to the body of the patient
– KE = ½ MV2
– Mass v. Velocity
Elephant gun v Assault Rifle
Stopping Power
1916 Mauser
Large projectile
Heavy Mass for “stopping power”
Fewer rounds carried
Single action
KE = ½ Mass X VELOCITY
Contemporary M16
2
Smaller rounds, but more rounds
Automatic—every man gets a machine gun
>1000 feet / sec
Sound barrier, sonic boom
Potential space behind projectile
High Velocity
• Projectile has a blast
zone trailing behind it
• Injury from not only
penetration of the
projectile
• But from KE transferred
• Larger soft tissue
injuries
50 cal to leg Traumatic Wound
Number of holes (GSW’s) plus number
of bullets must be an even number
• If not…
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You are missing a hole or
You are missing a bullet or
You are miss identifying a graze or a fragmentation
Or the patient has been shot before
• Note …we now leave bullets IN
• Just double checking holes plus bullets pays off
• Now sometimes the holes plus bullets are
impossible to track = an exploratory laparotomy
or laparoscopy
Clean, debride, and stabilize
GSW’s are usually left open
• They can be simply cleaned
• They can be packed with an iodoform gauze
packing strip or normal saline wet to moist
– This may keep them being observed
– This may keep them open—especially for long
tracts this may be beneficial
– They should be changed 1 – 2 times q 24 hours
• GSW’s can assist us with their blast effects
GSW’s v. Lacerations
• A knife will cut or puncture with very little
transfer of energy—less damage to see on CT,
more need for careful examination
• A GSW will have a blast effect related to its
velocity
– More gas in the tissues
– More tissue disruption
– More associated fluid/hematoma
Normal Saline Wet to….
• Conflicted as a wound care professional—but
this is where some judgement comes in
• Normal Saline wet to moist often becomes
wet to dry
– This should be viewed as a non-specific
mechanical debriding dressing—almost antihealing
– I say almost because most patients with acute
open wounds heal with NS wet to dry dressings
GSW’s in particular
• Most of our acute GSW patients are younger—
they are going to heal
• Most GSW’s have some level of contamination in
the wound tract and periwound
• The mechanical debridement of the NS works
well: >2,000 traumas per year—1-2 wound
infections
• Calls attention if increasing pain drainage
– Most of the 1-2 that get infected are either long
trajectories or have some retained material (clothing)
Enlightened NS wet to moist
• Use in setting of need for frequent dressing
changes
• Utilize adjuncts: wound gels or even otc
topical antibiotic ointments as lubricants
when no longer needing mechanical
debridement
• Topical collagen based dressings for large soft
tissue areas
• Negative pressure dressings when clean
Case Presentation
• 24 year old male shot
through the calf
• Right through and
through
• What is notable about
these wounds?
• Is this a high velocity
bullet?
• Compartment
syndromes
Compartment Syndromes
• Increased energy
transfer will lead to
compartment
syndromes
• Calf, forearm, thigh &
buttock and abdominal
• Better management
strategies with NPWT
NPWT plus Mechanical traction to
preserve tissue and coverage5
5. Penn-Barwell, Fries, Street et al
Use of Topical Negative Pressure in British
Servicemen with Combat Wounds, Aug 2011
Open Access Plastic Surgery On-line
Large soft tissue wounds
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Leave open initially
Frequent assessment
At risk for infection—look for tip-offs
Life over limb should frame your discussions
with both patient and family
• 52 year old weekend warrior…..
Four Quarter Amputation of Arm
Shoulder, clavicle, scapular…
Notice we could resect, but preserve entire flap that was then closed with NPWT
Abdominal Compartment Syndrome
managed with home made vac pack
• Fenestrated x-ray cassette
cover over bowel
• Omentum over bowel
• Get edges as far laterally as
possible
– Cut slits for lateral drains or
feeding tubes
• Get mass of viscera to sit
down
• Gauze and suction drains or
cut NGT tubes
Ioban and then wall suction
• Central sucked in wound
should be hard
• Good wall integrity—
patients can be extubated
• Place abdominal binder
over this to back up suction
• Can be combine with
multiple other modalities
• Why here in wounds--–
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Weakened patients salvaged
Enterocutaneous Fistulas
Herias
More wounds in our future
Fasciotomies
Military Success
• Going to see more fasciotomies being done
• Better technologies coming on line to
diagnose
• Increasingly being done
• Acute care
– Assess if adequate
– Clean and re-debride: NS wet to moist
Summation of GSW
• Fragmentation of primary projectile may
lacerate
– Both patient and caregiver
• KE transferred may have a blast effect
– Thermal burn usually at surface with close range
– Sound barrier potential space behind bullet
– Retained bullet has transferred all of its kinetic
energy to the patient
• Proximity may also have a burn component
All GSW mechanisms added together
Blast Injuries
• Blast Injury is particularly devastating
– Thermal component
– Physical (crush) component
– Contamination component
– Sonic boom component
– Penetrating component
• How do (we) think (someone) gets the biggest
bang for a bomb blast?
Postulated Ways to get more bang for
your terrorist buck
• Closed space blast injury
– Focuses the energy on the people in that space
– Detonate a bomb with shrapnel
– Make the shrapnel contaminated: biological, chemical or
dirty nuclear—non-metal shrapnel, too
– Detonate the bomb within an enclosed space to get a
secondary effect of collapsing the structure around
everyone and nearby structures
• Secondary Device
– Initial detonation brings IN many people
– Secondary Device will catch First Responders and increase
effectiveness of both detonations, crippling responses,
increasing lethality…
Blast Injuries 101
• Is the area secure?
• Are you ready to protect yourself—is there
decontamination needed?
• Examination of blast injuries
– ABCDEF’s do NOT change
– Severity of the blast concussion: tympanic
membrane ruptures, corneal abrasions
• Sonic boom concussion
• Rapidity of blast--airbag
Blast injuries
• Direct tissue trauma
• Direct burn injury
• Indirect effects on gas filled spaces: bladder,
bowel
• Penetrating injuries from multiple projectiles,
shrapnel
– Unexploded ordinance
• Contamination
Contamination
• High volume irrigation
• Leave soft tissue defects open—can now be
managed with negative pressure
• Look for signs of other contaminants
– Desaturation despite oxygen
– Early vomiting
– Coagulation defects
– Early Liquefactive necrosis of tissues
Summary of Injuries
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Large soft tissue defects
Usually on extremities due to body armor
Often concomitant orthopedic injury
Potentially traumatic/guillotine amputation
Often due to blast exposure (IED or RPG)
May have traumatic brain injury (TBI)
Associated abdominal injuries
What Makes a Wound Complex?
• Multiple
mechanisms
–Blast
–Burn
–Shrapnel
–High Velocity
–Crush
50 cal to leg Traumatic Wound
Traumatic Wound with Negative
Pressure Wound Therapy (NPWT)
Traumatic Wound with NPWT
Wound Bed Preparation
Grafting
Graft After NPWT Bolster
Resolved
Limb Salvage
• The goal of limb salvage is to
preserve a limb that will be
more functional than a
prosthetic if the limb is
amputated
• If the extremity cannot be
salvaged, the goal is to
maintain the maximum
functional length
Warrior Recovery from Complex
Wounds
• Trauma centers are leveled—we are now
beginning to level their affiliated rehab centers—
the highest level are what we now seeing in the
military:
• COL Alexander Stojadinovic, M.D., FACS, Director,
Combat Wound Initiative Program, Director,
Complex Wound & Limb Salvage Center
• Christian E. Paletta MD FACS, Complex Wound
Limb Salvage Center, Walter Reed Army Medical
Center
How can we learn together?
• This is a 60 year diabetic
foot wound that failed to
heal resulting in a through
ankle amputation pending a
BKA….
• We used local therapies,
local antibiotics, negative
pressure and HBOT—
Everything we talked about
today
• He closed with a functional
stump
• This was in 1999
• What was once heroic,
controversial is fasting
becoming standard
References and credits
• Textbook of Military Medicine (2009). Care of the Combat
Amputee.
• War Surgery in Afghanistan and Iraq: A series of cases (2003-3007).
• The Next Step. The rehabilitation journey after lower limb
amputation.
• Vetelli, B. RN, CNS. WRNMMC Military Amputee Treatment Center.
• Crumbley, D., CDR, NC, USN, CWCN. VA Federal Recovery Program.
• Howard, R., CDR, MC, USN. Assistant Deputy Director, Plastics and
Reconstructive Surgery WRNMMC.
• Deptuy Director, Orthopedics and Trauma, WRNMMC.
• Deyoung, P., LCDR, NC, USN. 2nd MEF (FWD), 2nd MLG, Al Taquadum
Iraq (2007).
• Tingue, A., LTJG, NC, USN. Multinational Force, Kandahar Regional
Military Hospital, Kandahar, Afghanistan (2010).
References
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www.ameriburn.org
www.aawcone.com
www.aawm.org
www.woundheal.org
www.uhms.org
www.facs.org
AORN
National Research Council of Nat’l Academy of Science
Wendi Gordon Shelist Foundation : www.wgsf.org
Trends to keep an eye on…
• Damage Control Resuscitation with MTP/RRP,
circulatory ECMO type support with RRT
• Forward critical care projections = FAME with
MoREMTORN (DUSTOFF, PEDRO, MERT)
• Topical Hemostatics for both intra-cavitory as
well as wound healing applications
• Advancing wound healing technologies—
cultured STSG’s
• Better longer term rehab concentration for
functional outcomes
Thank You
• BJH-WUSM, Department of Surgery, Dr.
Eberlein, Section of Acute & Critical Care
Surgery
• Walter Reed Besthesday and the leadership
with Drs. Paletta and Stojanovich and LCDR
Hitchcock
• FISIG
• AMSUS