COMPLEX INJURY PATTERNS IN TRAUMA:

LESSONS FROM COMBAT

David J. Smith, Jr., M.D. Professor and Director, Division of Plastic Surgery

Department of Surgery University of South Florida Morsani College of Medicine CEO, CAMLS (Center for Advanced Medical Learning &

Simulation)

Adjunct Professor of Surgery Department of Surgery at

Uniformed Services University and

Walter Reed National Military Medical Center

Critical Elements of CCC

• Care at the Point of Injury

• Care During Transport

• Hospital-Based Care

• Integrated Trauma System

– Joint Trauma System

– CPG development, dissemination, and assessment

• Concept of “focused empiricism”

• Translational research investment

– Battlefield to bench

Elster EA, Butler FK, Rasmussen TE. JAMA. 2013 Aug 7;310(5):475-6.

Impact of Military Trauma Care and Research

J Trauma Vo.l 25 no. 2 August Supplement 2013

Care at the Point of Injury

• Adoption Of TCCC Principles – Liberal use of Tourniquets

– Hemostatic dressings

– Analgesia delivery

– Training

• 75th Ranger Regiment’s Implementation – 3% incidence of preventable death

– None of regiments 32 fatalities died of preventable causes

Arch Surg. 2011 Dec;146(12):1350-1358.

J Trauma Acute Care Surg. 2013 Aug;75(2 Suppl 2):S157-63

Care During Transport

• Current Platforms

– DUSTOFF (US Army)

– PEDRO (US Air Force)

– MERT-E (UK)

• Advanced en route care

– 47% reduction in mortality in patients evacuated by critical care flight paramedics

– Mid-ISS bracket, mortality was lower (12.2% vs 18.2%; P = 0.035).

– In the high-ISS category time to operation was lower

J Trauma Acute Care Surg 2012;73:S32-S37. Ann Surg 2013;257(2):330-334.

Care During Transport

Hospital Based Care

• Balanced Resuscitation – Survival benefit with administration of equal ratios of plasma, packed

red blood cells and platelets, and Tranexamic Acid (TXA)

• Damage Control Surgery – Definitive operations are delayed until the patient is in better

physiologic condition

• Parallel Operating – more than one surgical team simultaneously operating on an

individual patient

– Improved resource utilization without decrement in care

• Ongoing Operative Debridements/Critical Care

• Integrated Rehabilitation Ann Surg 2009;250(2):311-315.

Focused Empiricism

• Identifying what works and what does not, refining it over time and embracing a culture of continuous process improvement

• Military implementation

– Rapid adoption of life-saving strategies through practical, evidence-based, and cost-effective methods

– Base of evidence CPGs is formed by the results of basic science, translational large animal research and retrospective cohort analyses

– Follow-on RCT’s when appropriate

DOD Trauma Registry

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BAS

Role 1

FST, CRTS

Role 2

CSH, EMEDS, EMF, TAH

Role 3

OCONUS

Definitive Care

Role 4

Clinical Practice Guidelines & Registry Data

Education, Training, and Research

CASEVAC

1 Hour

TACTICAL

MEDEVAC

1-24 Hours STRATEGIC AE

24-72 Hours

USUHS - WRNMMC

SAMMC - MATC

Role 4

Currency in EMCs

Pre-Deployment Training

&

Sustainment Platforms

(C-STARS, NTC, ATC)

DCOEs (JTS)

Implication for Mass Casualties

• Care at the Point of Injury

– Adopt TCCC principles for 1st responders

– WH IED WG recommendations

• Care During Transport

– Advanced en route care for critically injured

• Hospital Based Care

– DCR, DCS, Dual operating, rehabilitation • Elements all recently adopted in Boston and at UCSF

• Systems based practice

– Collaborative effort with National Organizations

Next Steps

• Continue research investment

– Critical to future success

• Transfer into civilian care

– Partnership with national organizations (ACS, AAST)

– Research partnerships

– Disaster preparedness at every level

• Retain critical skills within standard trauma and surgical care paradigm

• Train the next generation

Dismounted Complex Blast Injuries

• MOI: Dismounted IED

• High bilateral lower extremity amputations +/- vascular injuries

• Associated open pelvic ring injuries/fractures

• Associated pelvic floor/perineal ST injuries

• Associated UG injuries

• High risk of intra-pelvic DVT / PE

J Am Coll Surg. 2016 Jul 29. pii: S1072-7515(16)30689-5

Initial Resuscitation

• Rapid transportation from point of injury

• CATT Tourniquets- lifesaving!

• Reverse Hypotensive Shock – Especially with pelvic component

• ATLS protocols – Initial access with IO’s sometimes

needed

• Massive transfusion protocol

• Role of ED thoracotomy

• Pre-operative studies – CXR - AP Pelvis

– FAST - +/- CT Head

• Assess Viability before OR - Cardiac activity (EKG)

- Cardiac volume (FAST)

- Pupillary Reaction

• Assess Resources/ Triage

Operative Approach

• Pelvic floor/perineal disruption – Celiotomy – Proximal vascular control – Ligation/clipping internal iliacs – Colonic diversion – Pelvic stabilization – Debridement / packing – Revision amputations – Address associated injuries – Temporary Abdominal closure

• No pelvic floor/perineal disruption – ± Retroperitoneal vessel control – Evaluate for rectal/urologic injuries – Pelvic stabilization – Debridement – Revision amputations

A concurrent general surgery and

orthopaedic team approach maximizes

operative efficiency and resuscitation

Operative Approach

• Multiple surgical teams • Prioritize procedures • Vascular control • Need to prone patient • Extent of debridement • Level of amputation • Role of packing • Address urologic injuries if

possible • Bladder • Scrotum • Penile • Ureteral/Urethra

Orthopaedic Approach

• Hemorrhage Control Sources: - traumatic amputations

- peri-pelvic vessels - long bone fractures

- CATT tourniquet Pneumatics

- Celiotomy vs. retroperitoneal control - Vessel ligation vs. repair - Pelvic / Perineal packing - Combat gauze? - Angiography with embolization?

• Pelvic Volume Control - Volume= ⅓πr2h

- Toe taping < sheet < Binder < Ex-fix

- ASIS pins vs. AIIS pins - Reduction thru celiotomy exposure - Stabilize before turning prone - Plan ostomies / catheters with definitive fixation incisions

Orthopaedic Approach

• Revision Amputations – Conserve length when possible

– Flaps rather than guillotine

– Account for all vessels & nerves

• Soft tissue Challenges – If it’s alive, keep it!

• Adequate Debridement – Most important I&D is the 1st one!

– Systematic approach: skin SQ tissue fascia muscle bone

• Dressing Considerations – Wound Vac if possible

– Antibiotic bead pouch

– Dakin’s soaked gauze

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Orthopaedic Approach

• Fracture stabilization - Pelvis long bones periarticular fxs

small bones / joints - External fixation / pinning

• Fasciotomies - Always be systemmatic

• Don’t be a hero during the

index procedure! - Save a life 1st, safe a limb 2nd

- Damage control orthopaedics initially - Index procedure ICU 2°

surgeries

DCBI Summary Points

• Systematic team approach

• Prioritize critical lifesaving measures

• Balance operative 2nd hit phenomena with critical care resuscitation

• Continuum of operative care

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.

E.G.

Demographics: KAF 2009 to 2010

Blood Product Utilization

Operative Volume

Mechanisms of Injury

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Key Elements of Multidisciplinary Trauma Care

• Involvement in trauma team activations

– Radiology as part of the trauma team

• Daily rounds by Role III members

• Involvement of Role III members in quality assurance

– Morbidity and Mortality/Weekly VTC

• Concurrent multidisciplinary care

– DCBI and “team operating”

• Facilitates communication, high quality care and expedited disposition of casualties.

Injury. 2012 Dec;43(12):2072-7.

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