Front Line Surgery - A Practical Approach

Chapter 1: Prehospital and Enroute Care

BLUF Box (Bottom Line Up Front)

Critical Tasks and Priorities

Psychology of Prehospital Care

Some Important Considerations for Treatment

Tourniquets (Fig. 1.2)

Thoracic Needle Decompression

Airway Treatment

IV Fluids for Resuscitation

Resuscitation Fluid Choice

En Route Considerations

Secure the Patient

Airway

Be Wary of the IV Drip

Wound Dressing

Chest Decompression

Hypothermia Prevention

General Considerations

Chest Seals

Hemostatic Dressings (Fig. 1.4)

Chest Tubes

Pre-hospital Antibiotics

Pain Control

Ketamine

Recombinant Factor VIIa

Prehospital Blood and Plasma

Summary

Chapter 2: Combat Triage and Mass Casualty Management

BLUF Box (Bottom Line Up Front)

Introduction

Resources

Security

Context

Trained and Ready Personnel

Culture

Supply and Transport

Rehearsal

Plan

Response

During the Event

Hospital Level Triage and the “Triage Officer”

Special Considerations: Mental, Behavioral Health and Spiritual Needs

Route

Reset

Ethics and Resiliency

Conclusion

Chapter 3: Initial Management Priorities: Beyond ABCDE

BLUF Box (Bottom Line Up Front)

Initial Management Priorities

Sick or Not Sick?

Hemorrhage Control Über Alles

Tension Pneumothorax

Open Pneumothorax

Airway

Massive Extremity Injuries

Unexploded Ordinance

Operating Room Priorities

The “Blood Vicious Cycle” Revisited

The Multi-System Combat Casualty: Putting It All Together

Chapter 4: Damage Control Resuscitation

BLUF Box (Bottom Line Up Front)

Introduction

Damage Control

Acute Coagulopathy of Trauma Shock (ACoTS)

Identification of Patients Requiring DCR

When Does DCR Start

Creation of DCR Protocol

Delivery of DCR

Termination of DCR

Fresh Whole Blood

Organization of Walking Blood Bank

Collection of Fresh Whole Blood

Recombinant Factor VIIa

The Aftermath of DCR

Forward Surgical Team Specifics

Chapter 5: To Operate or Image? (Pulling the Trigger)

BLUF Box (Bottom Line Up Front)

The Stable Patient

The “Rule Out” Head or Spine Injury

The Unstable Patient

The Sirens of Combat Trauma Imaging (Specific Pitfallsand How to Avoid them)

Final Points

Chapter 6: Ultrasound in Combat Trauma

BLUF Box (Bottom Line Up Front)

Why Ultrasound?

Advantages of US

Disadvantages of US (for the Average Ultrasonographer)

How to Perform an EFAST

Basic Terms and Knobology

Abdomen

RUQ (Perihepatic or Hepatorenal) View

LUQ (Perisplenic or Splenorenal) View

Pelvic View

Pericardial View

Pneumothorax Scan

Making Clinical Decisions with EFAST Findings

Other Useful Applications

Evaluation of Hemodynamic Status/CVP Measurement

Triage

Procedural

Foreign Body/Soft Tissue/Musculoskeletal Application

Other

Chapter 7: The Bowel: Contamination, Colostomies, and Combat Surgery

BLUF Box (Bottom Line Up Front)

Does the Patient Have a GI Tract Injury?

What to Do Once in the Operating Room?

Injuries to the Stomach

Injuries to the Small Intestine

Injuries to the Colon

Injuries to the Rectum

Timing of Reconstruction After Damage Control

“Used” Trauma

Tractotomies/Treatment of Entrance and Exit Wounds

Final Points

Chapter 8: Liver and Spleen Injury Management in Combat (Old School)

BLUF Box (Bottom Line Up Front)

Introduction

Basic Concepts

Diagnosis

Exposure

Are You a “Packer” or a “Sucker”?

Spleen

Liver

Postop Pearls

Chapter 9: Pancreatic and Duodenal Injuries (Sleep When You Can…)

BLUF Box (Bottom Line Up Front)

Making the Diagnosis

Anatomy: The Key to the Battle Plan

The Body and Tail of the Pancreas

Injury to the Head of the Pancreas

The Pancreatic Duct

Duodenal Injuries

The Trauma Whipple

Chapter 10: Operative Management of Renal Injuries

BLUF Box (Bottom Line Up Front)

Introduction

Indications for Operation and Renal Exploration

Exposure and Injury Evaluation

Repair and Resection

Parenchymal Injuries

Vascular Injuries

Nephrectomy

Complications

Chapter 11: Major Abdominal Vascular Trauma

BLUF Box (Bottom Line Up Front)

Introduction

The Basics in the ER

In the OR: Getting Started

In the OR: Injuries Encountered

In the OR: Operative Technique

Zone 1 Supramesocolic Injuries

Specific Zone I Supramesocolic Vascular Injuries

Zone 1 Inframesocolic Injuries

Specific Zone I Inframesocolic Vascular Injuries

Zone 2 Vascular Injuries

Zone 3 Vascular Injuries

Damage Control in Abdominal Vascular Trauma

The Massive Pelvic Disruption

Tips and Tricks

Final Thoughts

Chapter 12: To Close or Not to Close: Managing the Open Abdomen

BLUF Box (Bottom Line Up Front)

Why Leave the Abdomen Open?

How to Temporarily Close the Open Abdomen

Serial Abdominal Closure

Complex Abdominal Wall Reconstruction: Component Separation

Specific Pitfalls and How to Avoid them

Final Points

Chapter 13: Choice of Thoracic Incision

BLUF Box (Bottom Line Up Front)

Why This Chapter Matters to You

Rules of Engagement

One Way In and Only One Way Out

Variation on BLUF #6: The Costal Margin is Just Cartilage

Bottom Line

Chapter 14: Lung Injuries in Combat

BLUF Box (Bottom Line Up Front)

Surgical Approach (“You Can’t Get There from Here”)

Damage Control Principles in the Chest (This Ain’t The Abdomen)

Pneumothorax and Hemothorax

Lung Parenchymal Injuries

The Pulmonary Hilum: Tread Lightly

Pulmonary Hilar Control

Pneumonectomy (It Is Not a Dirty Word)

Air Embolism

Evacuation

Final Points

Chapter 15: Diagnosis and Management of Penetrating Cardiac Injury

BLUF Box (Bottom Line Up Front)

Introduction

Diagnosis of Penetrating Cardiac Injury

Important Techniques in the Diagnosis and Management of PCI

Pericardial Window

Median Sternotomy

Pericardial Well

Identifying Penetrating Cardiac Injury

Repairing Penetrating Cardiac Injury

Intra-cardiac Injury

Summary

Chapter 16: Thoracic Vascular Injuries: Operative Management in “Enemy” Territory

BLUF Box (Bottom Line Up Front)

Introduction

Wounding Patterns and Physiology on the Modern Battlefield

Pre-operative Management

Patient Preparation

What Incision Do I Make?

Principles of Repair for Specific Injuries

Use of Heparin

Shunts

Surgical Technique

Conduits

Closure of Incisions

Endovascular Procedures

Required Equipment

Summary

Chapter 17: Chest Wall and Diaphragm Injury

BLUF Box (Bottom Line Up Front)

Chest Wall Injuries

Flail Chest

Diaphragmatic Injuries

Diagnosis

Treatment

Final Points

Chapter 18: Soft Tissue Wounds and Fasciotomies

BLUF Box (Bottom Line Up Front)

Large Soft Tissue Wounds

Small Multiple Wounds

Fasciotomies

Upper Extremity Fasciotomy

Lower Extremity Fasciotomy

How to Manage the Fasciotomy Wound

Pulley Suture: Trick of the Trade

Final Thoughts

Chapter 19: Extremity Injuries and Open Fractures

BLUF Box (Bottom Line Up Front)

Anatomy

Open Fractures

Stabilization

External Fixation

Compartment Syndrome: A Contrarian Opinion

Nerve and Tendon

Final Thoughts

Chapter 20: Mangled Extremities and Amputations

BLUF Box (Bottom Line Up Front)

Initial Assessment and Resuscitation

Amputation Vs. Limb Salvage

Amputation: Forward Techniques

Debridement

Skeletal Stabilization

Definitive Amputation Closure

Transtibial Amputation Technique: Long Posterior Myofascial Flap

Transfemoral Amputation Technique

Care for Local Nationals

Final Thoughts

Chapter 21: Peripheral Vascular Injuries

BLUF Box (Bottom Line Up Front)

Initial Assessment & Operative Planning: Peripheral Vascular Injury

Surgical Management: General Tips & Techniques

Specific Injuries and Approaches

Femoral and Popliteal Vessels

Upper Extremity Vessels

Pseudoaneurysms

Postoperative Care & Evacuation

Final Points

Chapter 22: The Neck

BLUF Box (Bottom Line Up Front)

Why Is the Neck an Important Area to Understand the Anatomy and Injury Patterns?

Mechanisms and Types of Injuries to the Neck

What Are the Life Threatening Neck Injuries?

What Are the Injuries that Are Easy to Miss but Can Lead to Late Morbidity or Death?

How Should I Evaluate a Patient with a Neck Wound?

Techniques of Exposure, Exploration and Repair of the Common Injuries

Vascular Injuries: Common, Internal, and External Carotid Arteries, Jugular Vein

Esophagus

Trachea

Vertebral Arteries

Final Thoughts

Chapter 23: Genitourinary Injuries (Excluding Kidney)

BLUF Box (Bottom Line Up Front)

What Genitourinary Injuries will I have to Deal with in Combat?

What Do I Need to Assess in a Patient with Scrotal or Penile Wound?

How Can I Best Diagnose a Bladder or Urethral Injury?

Management for the General Surgeon

Penis

Urethra

Scrotum and Testicles

Bladder

Ureter

Tips and Techniques

Difficult Foley Placement

The “Hyperlube” Technique of Foley Catheter Placement

Suprapubic Tube Placement

Open Suprapubic Tube

Percutaneous Placement of the Suprapubic Tube

Performance of the Retrograde Urethrogram

Performance of the Cystogram

Summary

Chapter 24: Neurosurgery for Dummies

BLUF Box (Bottom Line Up Front)

Introduction

The Basics

When Do I Need a CT Scan/What If I Don’t Have a CT Scan?

How Do I Know If There Is an “ICP Problem”?

The Isolated Severe Head Injury

Severe Head Injury in the Multiple Trauma Patient

Placement of ICP Monitor “Bolt” or EVD (Required Kits Must Be Available)

Preparation

Marking the Patient

Placing the Device (ICP Monitor)

Placing an EVD

Decompressive Craniectomy Tips

Preparation

Final Thoughts

Chapter 25: Spine Injuries

BLUF Box (Bottom Line Up Front)

Assessing Spinal Cord Injuries

Shocking: Spinal Shock vs. Neurogenic Shock

Steroids

Managing Closed Spine Trauma

Managing Open Spine Trauma

A Is for Airway

Spinal Immobilization and Spinal Stability

Spinal Cord Syndromes

No Spine Consult Needed

Final Comments

Chapter 26: Face, Eye, and Ear Injuries

BLUF Box (Bottom Line Up Front)

Getting Started

The Basics: Airway

The Basics: Hemostasis

The Eyes

Imaging

The Soft Tissue

The Bones

The Ears

Finally

Chapter 27: Burn Care in the Field Hospital

BLUF Box (Bottom Line Up Front)

Immediate Care in the Field (Tactical Combat Casualty Care)

Acute Burn Care (In the Trauma Bay)

Burn Critical Care (The ICU Phase)

Areas of Special Interest (Face and Hands)

Transport of the Burn Casualty

Keys To Success for the Burn Casualty Who Has Nowhere Else To Go

Final Points

Chapter 28: The Pediatric Patient in Wartime

BLUF Box (Bottom Line Up Front)

Intravenous Access

Special Considerations in the ER

Special Considerations in the OR

Special Considerations in the ICU

Humanitarian and Non-trauma Care

Chapter 29: The Combat ICU Team

BLUF Box (Bottom Line Up Front)

Introduction

When Do You Need an ICU?

Who Should Staff the ICU?

How Should the ICU Work?

How Do You Set Up a Forward ICU and What Pieces of Equipment/Supplies Do I Need?

What If I Have Scarce Resources and Too Many Critical Patients?

Random but Practical and Important Points for the ICU

Final Thoughts

Chapter 30: Postoperative Resuscitation

BLUF Box (Bottom Line Up Front)

Introduction

Principles of Combat Resuscitation

What Fluids Should I Use? When Do I Give Blood Products?

How Do I Tell If I Am Winning or Losing the Battle? What Is the Best Endpoint?

Who Does Not Need Resuscitation?

When Do I Need to Go Back to the OR?

Final Thoughts

Chapter 31: Monitoring

BLUF Box (Bottom Line Up Front)

Introduction

Pulse Oximetry

Electrocardiography/Telemetry

Central Venous Pressure

Venous Oxygen Saturation

Pulmonary Artery Catheters

Arterial Lines

Assessing Volume Status: The Holy Grail

Intracranial Pressure Monitors (ICP)

Monitoring for Shock and Adequacy of Resuscitation

Correction of Coagulopathy

Advanced Continuous Monitors

Closed-Loop Systems

Summary

Chapter 32: Ventilator Management

BLUF Box (Bottom Line Up Front)

Which Combat Casualties Need Mechanical Ventilation?

Respiratory Failure in Combat Casualties: The Role of Blast Lung Injury

Initiation of Mechanical Ventilation

Lessons Learned from a Senior Respiratory Therapist

Equipment and Planning

Maintenance

Patient Care

Helpful References

Troubleshooting Common Ventilator Problems

Hypercapnea and Respiratory Acidosis

Hypoxemia and ARDS

Final Points

Chapter 33: Practical Approach to Combat-Related Infections and Antibiotics

BLUF Box (Bottom Line Up Front)

Introduction

Prevention of Infection

Care at Point of Injury (Level I)

Professional Medical Care Without Surgical Support (Levels I and IIa)

Care with Surgical Support (Levels IIb and III)

Care of Personnel Not Evacuated Rapidly Out of the Combat Zone

Final Points

Chapter 34: Stabilization and Transfer from the Far Forward Environment

BLUF Box (Bottom Line Up Front)

Advanced Trauma Life Support

Secondary Survey

Resuscitation

Forward Surgical Intervention

Evacuation

Command

Conclusion

Chapter 35: Humanitarian and Local National Care

BLUF Box (Bottom Line Up Front)

Medical Rules of Engagement Qualified

Medical Civic Assistance Programs

Local National Clinics

Educational Opportunities

Final Points

Chapter 36: Expectant and End of Life Care in a Combat Zone

BLUF Box (Bottom Line Up Front)

Combat Care and the “God Complex”

Determining Expectant Status

Location of Expectant Care

Delivery of Expectant Care

Aftermath of Expectant Care

Appendix A: Improvise, Adjust, Overcome: Field Expedient Methods in a Forward Environment

Appendix B: Combat Burn Flowsheet andOrder Set

Appendix C: Resources, References, and Readiness