Whether it isa warzone oc asters, nods dangerous world raumatic injures are hay tcc remote cen unsantay locations However 2s 3 modem emergency medicne —incdng mail hops Shdpidevocuation to establced trauma centers flo teach jr patents the eld sn jst such sero A yee physician arent found patent anspor i ‘measured dys instead of minutes, resoure {nd the environment host that he Pre owt Cae Provider PHCP}isin is orber element. ‘Ditch Meine covers advanced medal proche fied setting. Should the PHCP fd Himself ona ‘teflon the mide of some orm of bt fo employ the procedures coveredin this book # timely and competent manner can mean the diferene between lle and death Through graphic photog, professional rendered uration, and cave tales From Cerral Amari, Southeast Al, and Acs, ugh Coffee provides rao lessons and sep by ep Instruction for smal wound rept, care forte infected wound, decompression and rainage ofthe chest Intravenous therapy, emergency airway procedures, ‘Teatrnt for anaphylactic shock, pin contr, amputation {ueatment of bus, and nution and emotional suppor. ‘ich Medcne sa must forthe well prepared EMT, sate eel professionl, mel werk, or avon wt ‘nieterestin practical Nel appiations SBN 0-873b4-717-3 AMINFor KAREN ‘wih sei hk Sea, Fs, KenPa Din tnd ib Dick Maine Aancd Pld Pree Emerges opi © 120 Mah Cate ine ne Ud Ste Ameren Palate by Pain Pee i of Palla Ese PO Bee 07, ‘Boal Caras SG USA. Gaya. 7290 iets moron he sn de PALADIN PALADIN PRESS, ade“ Wades ste adem begin Pan Enea Aegis ered. Bac re a eve: Peso hbk may beep ny ‘ron Be exes aie msn oe abr ‘ester estrone ‘ey spony fre wear ee ‘wh by Gry la Deie Cg, Voit our We seat wading en Contents a 7 a ut 127 131 155 17 au Iermopucron, Chapter 1 SMALL Wounp Renae Chapter 2 (Cane FoR Tae Isrecren Wound Chapter 3 Drconpwassion ax Dranaci ov 7: CHEST Chapter Ibermavinous Tamer Chapter S [EMaRomNcy Aurway PRoceDURES Chapter ANAPHYLAcTIC SHOCK Chapter 7 PAIN Con. Chapters Chapter 9 Chapter 10 "NUTRINON ax EMOTIONAL SUPPORT BrmuioceariyWarninc sechfigus and procedures i this book are only tobe etre by certified medial profesional. This book is to be a ubstte for proper and thorough education ing in hed of medne and emergency Bit i thor, publisher, and distributors of this book di liability from any damages or injuries of any 7p that reader or user of information contained in this book ‘nay encounter fom the Us of mse of said sformation. -_ AckNoWLEDGMENTS PPh etching medical profesional were of tremendous sinnce, othe experine represented by tr arouse aig contbuted tothe technica accra of the ex. Rd Ate LN. MSN Ste Burns MD.~Piedmont Orthopedic Complex: Macon Goes ‘Sooo, Farm Siem Dome on el Dr. Me.—BaSvizeand Richard. Knuton, MD.—-Dels Medal Center, “The photographs used in this book were contribute by the {following individuals. Their photographs were indispensable, ‘they bring abouta greater understanding ofthe arate. Rose Akers, RN. MSN ‘CN. Allmark—~Tribal Refugee Welfare in Southeast Asia, “Mirrabooka Wester Australia James Byron Dawson, M.D—Deputy Director of thevm Drreu Mapica Division of Forensic Sclence/TThe Georgia Bureau of Investigation Gienn Domer| Shirley B. Fordham—Chief Forensic Photographer ofthe Division of Forensic Science/The Georgia Bureau of Investigation Gerald, Gowitt, M.D_—Chief Medical Examiner for Hall ‘and Henry Counties, Georgia Richard A. Knutson, M.D.—Del Greenville, Mississippi DE. Rosey Ronnie Stutrt—Coroner, Henry County, Georgia Hugh Wood—Austala, Medical Center, ‘The gifted hands of Gary Blot and Denise Chung pro- duced artwork for this book when available photographs ‘would have failed to give the reader a complete understanding ofatopic. [Lynn Fulop and Kathy Shuman’s methodical and pro sional arrangement of sentence format allowed the manuscript to move from subject to subject ina cear, concise manner. ‘Scott Coffee (brary research, Joh Cannon (subject of many staged photographs), Karen Coffee (photographer), Mike Mitchell (photographer and photographie develop- ‘ment), Gary Elite (artwork), and DE. Rossey (military his~ torian) deserve special acknowledgment for their enthusiastic and stadt commitment to this project. Tnrropuction ‘From the days ofthe Roman Legionnaire with his short a plum to the modeen-day infantryman with his tile and grenades, man’s ability to tear the fesh and the bones of his opponent has increased to new levels of ly efficiency. Fortunately, forthe soldier whose luck has ‘in out and in the blink ofan eye has been transformed fom, {combatant toa casualty, pre-hospital care of the injured has improved tremendously. Gone are the backward days when the field surgeon had more in common with an alchemist, protecting his “scientific secrets” of patient care From those ‘who sought to understand the appropriateness of treating 8 {gunshot wound with eg yolk, rose ol, and turpentine. ‘Along with technical advances in emergency medicine, patient care has entered new realms of delivery withthe medi- ‘al community's growing acceptance of medical paaprofes- Sonals. Without these paraprofessional atthe “scene” wo ini- tiate advanced emergency medical procedures, many ofthe ‘newest procedures in emergency medicine would be limited in their effectiveness because patient transport time would spoil ther effects, ‘Modern weapons of warare found in the hands of com- bbaants in the most remote regions. However, as aruleymod-2 Deve Mapiones ern military medicine, with its mobile hospitals and rapid patient evacuation to definitive health cae, fails to follow ‘combatants into the fields of confit. Iris in just such a sce- ‘nrio—where physicians are not to be found, patient trans- port toa hospital ie measured in days instetd of minutes, resources are ited, and the environments hostile—that the Pre-Hospital Care Provider (PHP) isin his element. “The subject matter in this book covers advanced medical procedures set ina field setting. Should the PHCP find him- felfon an slated batlefeld or in the mide of some form of. civil diester, his ability to employ the procedures covered in this book ina timely and competent manner will have a posi- tive impact upon his patents, For the wounded soldier who ses his strength ebbing into ‘the warm pool of liquid by his side and seeks relief from his ‘la by crushing the blades of gras in his hands, thoughts are ‘ffaily never be seen again and ai from whatever quar~ terhe ean find it. Ditch medicine—thediference berween life snd death—often start wih the thud of a pair of boots land ing beside the soldier anda PHCP simply grasping his patients hand and peering into hie ashen face Eee SMALL WOUND REPAIR For tht Pre-Hospital Care Provider (PEGE), mastery of yond repair techniques sof great importance in & From the laceration caused by an ax while chop- ‘wood to an avulsion caused by an exploding mine, the tions. The traumatized site, if not treated early, can quickly, develop into ife-endangering infection. Cosmetic distortion fad reduced usage of the wound site can result from an open. ‘wound where Sstues are lft ro heal wth no proper surpeal Intervention (Photo 1). The PHCP can eause all three of these debilitating patient conditions to oceur asa result of poor surgical practice. "The use of surgical tools and techniques used in mall wound repair is nor difficult to master. The basic manual Sills—such as cutting, clamping, grasping, ligation, and, tyingtecome secand nature with ite practice. curnine “Tissues are cut cleanly and perpendicular to their surfaces fo promote healing. When skin sto be cut itis first stretched qt, and the scalpel bade is held ata 90-degree angle to the 34 Drees Memes hs Thi 27rd Burm pain was sh by hgh ok ou, anh ih ect onli eee Teich hb iqarl aff dp f mp, he nce pny Dao ‘kena ct eames aoe hae Bn tend pe ond na he carmen roa poy ‘thre ci hr a Pees of agh d) surface ofthe skin to ensure « clean cut (1). Ifthe skins held loosely ox the PHCP hesitates, a jagged wo result Il 2). Cuts hesl better if they are made p ‘wrinkle ines anal across the lines of muscle pul (ls. 3 end 4). Foc fine work and cutting of skin, the sealpelis the best too (ll. 5). When holding a #15 blade lke an ink pen, the PCP {sready for most cutting situations Il 6), raion 5: bing bent ‘sf rain he ome erson Common xf a as‘ mre Manica re ‘arin 7 Con \ \ \ = ‘Scissors ae used for cutting and dissecting the deeper tis- ses under the skin, Surgical scissors come in a varity of, ‘Configurations. For the PHCR, the curved Mecrenbaum and. fore heavily curved Mayo tcissors will be satisfactory for ‘most citing needs. A small par of ris and suture scissors are also useful 7). ‘Blunt-pointed scissors are used when cutting i the ‘wound. This reduces the accidental trauma of pointed blades “stabbing surrounding tissue. The blunt point will allow the ‘scssors to expose tse by thelr spreading action, ‘Sessors cut by crushing, Therefore, dll eissors are dan- ecru, wt they traumatize tissue. wats Wouro Renae 7 CLAMPING ‘During suturing; iis important to visualize all aspects of the wound. This is difficult to do ifthe wound continually ils With blood. Clamping the vessel closed to stop hemorrhage Into the wound i an easy way to maintain a dry fed in which towork. ‘When clamping a vesse!, the PHCP must be careful nt to lnclude surrounding tissue. Clamping crushes tissue and can okt which may interfere withthe healing ofthe wound It Jnbest toute te clamp with is concave side woward the issue ‘Clamps, as wells scissors, are best held withthe thumb land ring finger pushed only partially into the rings ofthe instrument. The index finger is used to stabilize the instru ment (ls. 8 and 9). ‘hon adm gr ‘rahe ny ora Spear ration 9: Tein i goed naiases tomo GRASPING Forceps are used for grasping, The fine-toothed Adson land the larger DeBakey allow the PHCP to hold tissue for ‘exploration ofthe wound (I. 10nd 11.LIGATURE Ligature is a critical technique for the PHCP who must stop life-endangering hemorshage or needs a dry field in ‘which to work. The bleeding artery ot vein is first clamped. ‘As the vessel i lifted and exposed, a fine absorbable suture (0 or 4-0) is ted below the clamp (I. 12). Once the PHCP Anas added an additional knot or two, the vesel is unclamped (o check for leakage I 13). y0 ‘Drreat Mieco ean 15 Th ft ase isin oe ad ee on bng op ain Te oe Se” ‘With larger vessels or persistent bleeders, a double- ‘clamp, double ligature technique is used. Two clamps are Shed, and the fist ligature is applied under che lowest eRe dil 14). Once this is secured, a second ligature is pulled under the remaining camp CU. 15)."The ast as? sees removed wo check for leakage (I. 16). When tight “ening the ligature, care should be taken not to cut the vessel in half, ‘TIES “There are several suture ties that would be applicable for PHCP usage ‘The instrument te is probably the most useful because it helps conserve the length of the surure when several stiches age uted (Ils. 17 through 26)- aston 17 Th inane Ie Taequre breton Babee abl Ain Wourn Runa Mersin 19— CLOSING THE WOUND rng awound closed is nt simply a macer of “ttch- oo fs together Fors wound to hel propery ten be given tothe appropriate time to elose« wound, mechanical cleansing, proper suture selection, Wound Closure closure timing i categorized as primary closure, closure, and healing by secondary intention closure of an open wound isthe direct suturing of wound in which there is no significant concern for on. Primary closure is generally indicated ifthe wound satisfactorily debrided and mechanically cleaned, es than 6 hours old." wyason 23 Baran 26“ ere Memeo Msi 27: Adapt fom rnd i Wound Cae Bator ‘Hames Lote C.K 198 963) 6 Spon Way ‘recy dare ra of nd at ho Shows ld algeria care Thon fs 8 2 er ir I lebepsand dealin} doe eng by scolar in Th ae fit son 2h airy. Itami eran an ton. ‘ld which allows sigoificant bacterial growth inthe wound. ‘The wound is left open and loosely packed with dressings. In 3 t05 days, the wound will develop enough resistance to infection that closing it should not lead to complications (I 28), "During World Wat It became common practice for Allied surgeons to teat ballistic wounds with debridement, ‘wound exesion, and delayed primary closure at3to'S days after primary surgery (I 29 through 33).* A SSuatz Worn Renan as —f aan 2: Delp prinarycaurof evan The sound paced onc ante cd io ae rae 29: High ale ehbatck. The emt has [amal iy andthe. Theundrbing damégd mat eso he ‘i pa at eo opto gren They oe ane ‘ela the ented in on a cand hed a ond om ‘ou apd2 = cag") ‘ars 30 To ne edd ond damaged al i, te bc at ‘asp $2 Wd he ean foe cu ies proper sig a Art rg and owe eho ao reer eck ond daa lin apa, The ma a eon ‘Sten dred ond open ‘emomol ener ane a sf ao ‘apt 3: Te nun tc th ale resin. st paced Musson 33 Dead primary ce te mundi 16 ay ant oa ache fof acd flame1 Drrcie Manco Healing by secondary intention is called for in wounds cover 12 hours old, "The wound is let open and allowed to ‘lose itself by contraction and epithelization. This approach to wound care is indicated forthe heavily contaminated, ‘wound with tisue loss and established infection. Wounds of {thi nature often require skin grafts a later date by a skilled suugeon. Temust be remembered that even if a wound isnot to be closed immediately it should sil be debeided and cleansed ‘completely to promote proper healing. An infested wound is always a contraindication to wound closure, regardles ofthe length of time since the wound was inflicted. Further nterven- ing factors that determine whether wound closure is appropri- ste ae the heath of surrounding tissue, general health ofthe patient, and de- ree of satisfac tory blood sup- ply tothe affect- dea Debridement ‘When the de- cision has been made to suture ¢ wound closed, ¢ procedure for ‘converting acon- Taminated wound to a clean one must be imple mented fist. De- bbridement of a wound, along with mechanical cleansing, isthe mostimportant step in decon- taminating a tenuate wound Photo 2). Debridement thas two main foals: 1) to re-‘a rea Metco tuminated by bacteria and foreign hod Photos 3 and), {nd 2) to remove permanently devitalized nse ee Photo 2Din Chapter?) ¢ "The den oF dying skin, mute and fot that eftn the wound acts caltue mum for both aerebe snd anaro- ticorgansma, These devitalized sracrres icy Become jnfeted and alo inhibit the body’ aby tight infection by Hindering the movement of white cells, ‘The traumatized ‘wound should be derided Soon as posible to prevent the Seralshaent of infection adits spread wo healthy et ‘Ribot are not replacment for debridement But adjunct. "Determining wat sue shouldbe dbrided sb upon identifying the demarcation between compromised and healthy time, Guidelines in determining ae visit are olor consistenc, andthe abi to bleed. Viable tissue wil ‘beredlsh ncaa, fm in consistency, nd fed with an ade- ‘hat Blood supply Healy muscle wil contract when sti- Ine bya cuing Bad. Sha pny me esr neion tn te i sues duc wits good blood supply. This allows the PHCP 0 te conservative the debridement of kn The debridement ‘Senex canbe trite oon a narrow manga on he geo the wound. : "nlc stn, nce must be removed more agressive. Des muscle ta perfect medium forthe development of es tmmgrone. Any discolored brused, or noncntacte maee ‘nostne casved otal, and al ockrs mast be ad open so the mond sacs dab drain ey ‘Specialized sue such as nerves and tendons, present special problem because these structures donot have the degree of reenerative poner that other structures have ‘When tha tsctures become contaminated, hgh-pressre iiation foloned by removal of agents that are no viable ithe bx course fasion. “The procedreof debridement is usually best cari ot vith scalpel A seapel gives precision and avid rushing eee ee a Se wait Wooo Rae a Action if scissors become dull. Effective debridement dependent upon exposure ofthe wound, 9 incisions made either end by the PHCP may be necessary to explore into deep wounds. Repetitive saline irrigation and sponging a also integral parts in the debridement process because iriga- tion loosens and fushes away contaminant while keeping ti ‘Mechanical Cleansing of the Wound ‘In conjunction with debridement, mechanical cleansing of the wound is necessary to ensure proper ascpsis. Mechanical ‘leansing is simple procedure of using hydraulic force and scrubbing the wound with an antiseptic solution in order to Physically remove contaminants and destroy microorganisms. ‘Joseph Lister, a surgeon who lived in Glasgow during the 1800s, is credited with discovering antseptie surgery." His tse of chemicals tol bacteria was a carnerstone in his work, ‘and some fel that his selection of the antiseptic phenol result ‘ed from its use in deodorizing the putrefying sewers of his time. Today, a mild solution of Betadine isthe antiseptic of choice for cleaning a wound. When Betadine is used, the HCP needs to be atentive tothe patient who is allergicto fdophor products. Also, high concentrations of Betadine can bbe toxic to healthy issue and retard healing. Phitohex is effective when Betadine is not avaiable oe cannot be used. ‘When the PHCP begins cleaning the wound, itis best to ‘wear a pair of sterile gloves, which are discarded and replaced with a new pair once the wound is ready for suturing. ‘Aggressive scrubbing is important, as ishigh-pressure isi sion in traumatic wounds (sarge syringe can be used inthe Feld for high-pressure isigation). However, care must be taken not to further traumatize wounded Uesue or surround ing healthy tissue ‘Once the wound ste has been cleaned, draping the wound or sunuring i of particular importance ia the field. Draping Aecreases the chance of infection by providing a sterile barrier (Gel) in which to work. Without a surgical drape over then Drea Manica ‘wound, the ends of suture would drag through contaminated treas and the PHP's sterile gloves would quickly become ‘iety from contact with surrounding tissue. Commercial drapes are available that ae disposable and have precut hoes. ‘Sterile towels work ast s well when clamped together on the ‘comers (See Photo 7). Suture Selection ‘Suture is broadly classified as cher absorbable or nonab- sorbable. Absorbable suture is used to close muscle and sub- ‘cutaneous tissue and toligate blood vessels. Absorbable ‘sutures broken down over ime by the body and therefore is ‘ef for tssues that le deep and cannot be reached lterin border to remove the suture, Catgut isthe old traditional ssbsorbabl surue; however, synthede sutures such as Dexon ‘and Vieryl are preferred by many due to their more pre~ dictable ate of breakdown, greater tensile strength, and ‘decreased tendency to caus inflammation. ‘Suggested Suture Size Usage For Related Anatomical Areas ‘in Seuteneous asus and muscle Fae Gonjon | #0.50deon ven ap ce ed Tune #Omyon | ‘90.40 der0n, owt Barentee | 40n7on | +0de0n vend Hands fo | 60,40n/en | 5-0 40 ‘le held perpendicular tothe nee- dle holder works well in limited space asthe nee alder is rotat- cdo is axis It's the position for general-purpose work. Placing the plane ofthe needle curve parallel the nade handle i useflin Sowing layers parle! tothe surface in deep wounds. Grasping ‘the ned near the end (oward the suture) is suitable for sof ‘issue, ait allows maximum needle length tobe inserted ‘hough the tissu. Tis action allows for reduced incidence of needle sippage- Grasping the needle near the point may be nec- ‘essary ifinereased driving fore i nesded to pierce tough sue. "The PHP will develop an “eye” for the procedure that ‘has as. goal a wound with a uniform wound line with no ‘wrinkled tissue atthe edges. For best results when closing the ‘wound, the PHCP should remember the following: 1 Appore the various layers accurately. 2. Tie the suture with minimum tension. 3. Use the fines practical sure size 4. Double te square knot Suni Woun Reva » ‘Suture Removal ‘Correct timing for suture removal is dependent upon the ‘patient’ healing powers. If the patient's overall healt is good, ‘emoval ofthe suture atthe earliest approprite time will help [prevent the “railroad track” scaring associated with suture ‘hat has been left in place too long (usually past the four- teenth day of wound closure) If there is uncertainty ato ‘whether the wound will hold up ifthe sutures are removed, ‘Scalp 58 days Face 25 days Back 710 days (chest 7-10 days ao frente Prowimal lomo etry 710 daysso Dre Meiers ‘iterating sutures can be removed and the wound rechecked ina few days. A general guide for timing suture removal is sven in Iusteation 4, ‘When removing s sunure, it may be necesary to it it with forceps before cuting, The sutures cut close to the skin (see Photo 18). The goal ofthe technique is to prevent surface ‘material fom being dragged ito the track once occupied by ‘he suture (ee Phow 19). Wound Drains "The application of «wound drain i not usually a step in suturing a wound closed. The PHCP willbe confronted with Seep puncture and penetrating wounds, and for that reason, ‘he would be lacking nis patient care sls ihe were notable toemploy the ure ofa drain ‘Wound drains ae used to remove fui or ps frm cavi= lies or abscesses. In the 1800s, dhe English surgeon Lawson “Tait was quoted a saying, “When in doubt, drain.” * Failure rouse a drain toremove pus was considered negligent in his time, where in that preantibiotic period the drain was often lifesaving. rains are most effective when placed ina deep wound with a narrow opening, which needs to hea fom below first. ‘Bucuse ofa drains not hazard-free. Sine it ia foreign body {nan infected ares, ican allow microorganisms to enter the ‘wound, This ean be compounded by dirty, moist, ong-stand- tng dressings. ‘One ofthe most commonly used drains isthe Penrose (Photo 5). Its a pliable, fla rubber tabetha varies in length, "The Penrose drain san overflow drain and as such should be placed as deep in the wound as possible. T secure the drain, ‘tis sutured wo the wound's edge anda safey pin placedin the ‘exposed end to prevent it from slipping into the wound (I 45), When the drain bocomes clogged, iis generally beter simply replace it with « new one ather than try @ open the obstructed drain Suara Wour Rerare a me Phow 5 Pome drain rion 5: Per of he Pare rin thas lcd ap the (eevnand ne ohn el ani has asf pv la2 Drea Menten ‘When drainage has stopped or slowed dramatically, the PHCP can consider removal ofthe drain. In determining ‘whether ar not to remove the drain, rt loorenitand slowly ‘advance it further into the wound cavity. If no further Ronald D. Miller, Aneitesia (New York, NY: Churchill ne, Inc, 1990), p. 1423. John Adriani, Teckigues and Procedures of Anesthesia infield, IL: Thomas Books, 1947), p. 306. > Tid. pp. 306-307, % Vincent J. Collins, Principles of Anesthesiology BA: Lea and Febiger, 1976), p. 999. John Adrian, Tichniques and Procedures of Anesthesia16 rroa Menicone (Springfield, IL: Thomas Books, 1947), pp. 302-303. % Vincent J. Collins, Principles of Anesthesiology (Philadelphia, PA: Lea and Febiger, 1976), p. 986. John Adrian, Tichniques and Procedures of Anesthesia (Springfield, IL: Thomas Books: 1947), pp. 301-302, » Robert D. Dripps, James E. Echenhoff, and Leroy D. Vandam, Introduction io Anesthesia: The Principle of Safe ‘Practice Philadelphia, PA: W.B. Saunders Company, Inc., 1982), pp. 246-247. et bear, hors to see, and must leave the person on thas been performed ina mutilated imperfect sat.” ng this time, a surgeon's proficiency was based upon fequences of infection, lethal hemorchage, or, at Dest, 2 ently draining stump that healed poorly, fat al “The more enlightened surgeons practiced careful handling issues and the precise placement of ligatures. This resulted in leaving healthier issue and thus a quick- sod less complicated recovery. Ofcourse, such diligence longer than four minutes. For military surgeons who confronted with “dirtier” wounds than those found in lian petients, an amputation technique that allowed the mp edequate drainage and athe came time did notrequre 155156 rca Memeo an unusually high degree of technical sll was flt to be the safest approach to take. The open circular amputation first deseribed by Bellin 1788 became the amputation technique of choice for the ‘wound suffered ina combat theater (sometimes referred to as the gullotine amputation”). "The use of the open cteular amputation in malty theater hospitals became written pol <7 for the US. Army on April 26, 1943, when Major General Norman Kirk issued the directive in War Department Circular Letter 91," After evaluation of the catualtie from the African campaign, Kirk found that patients in whom an amputation was left open, properly drained, and healed by franulation recovered more quickly and with fewer fatalities than those who had their amputated stumps closed early with flap of skin Tes quite likely hat the PHICP will be ealled upon to render aid to the soldier who has suffered a traumatic Phos 71: Tis 7rd arma ait it i ot afer aving Sed ena ln mine ch dof rporoh ier ‘ch upingifmed wound Pha oar of ugh Wont) Ascrcramons 1s Amputation from sland mine or high-velocity rounds, ‘Mud, grass, and fragments of the mine will be driven into what tissues are left. Ifthe soldier does not die from blood Joss, his mangled limb has now become a fertile ground for infection. An open circular amputation performed on this leasualty can bea life-saving emergency procedure, given the parameters in which the PHICP must carry out medical fresiment (Photo 71, INDICATIONS FOR AN AMPUTATION" 1. Trauma tothe extremity: The patient inthis case as su ered extensive trauma to an extremity. The limb has been Blown, tora off, or so mangled that it has obviously become Dponviabe (Photo 72). In this situation, the PHP's function is simple revision of an amputation that ha already occurred. 2. Vascular insufficiency: The patient may have been Wounded in such a manner that major blood vessels have Ipeen destroyed (Il. 97). Portions ofthe extremity distal otheaston 97: Ganga ef on i a aad orl ary a ‘St ng) tnd hee for amp of 0 blood flow can quickly develop nutritional deficit, leading tothe development of ischemic gangrene. 3 Infection: Amputation of extremities suffering from massive ga gangrene or other types of infection can be life- Saving ia afield setting where antibiotics ae either not avail- Able or have not been effective. Aso, in an effort to remove tissue that had become necrotic due to extensive infection, ‘debridement may bave left an extremity damaged beyond hope of function. DETERMINING THE EXTENT OF AMPUTATION ‘Determining the level at which an amputation should take place will not only have an immediate effect upon the ably ofthe stump to heal propery it wil also have along term effect upon the ability of the patent robe receptive to prosthetic, ‘Traumatic wounds from things such as land mine explosions impart terrific impact forces to tissues. ‘Those impact forces can travel along muscle groups well, above the sight of dhe traumatic amputation and result in ‘evialied dssues, Sudies have shown that the type of foot~ ‘ware worn by the soldier atthe ime ofthe mine explosion is 1 determining factor in how these impact forces are trans- 159 red to the leg. The need for an above the knee (AK = labove the knee amputation/BK = below the knee amputa- ton) surgical amputation due to mine-related injuries in 'd was 100 percentif boots were worn, butonly 29 if sandals cr shoes were Worn.” “These devitalized taeues, if not propery identified, may Jeftintact after the surgical ampotation. Gas gangrene then develop inthe stump. Every efforts made to save and elbows nd to leave as much bone and tsue length possible. Iti easier forthe patent to be rehabilitated when [prosthetics used in conjunction with a functioning joint. the PHCP mutkeep in mind tat he will be performing ‘open circular amputation only ts aife-saving measur. It ja procedure tha, in etence, used to Torna contaminated, “amputation ino a clean, surgical amputation. "This surgical amputation is often revised or amputated fata slightly higher level with an amputation technique flaps of skin to cover the stump as well as early stump by sore ‘Presuming the patient may undergo later stump revision sisaged amputation” ina hospital the PHP in the fie st be careful to leave as much viable tissue and bone as “The appropriate level of amputation isthe most evel at which healthy tissues found, given tacit is fed fan intact arterial system, The incision is made through this thy tissue proximal to the damaged tissues. is not easy to ascertain the trac lowest level of viable tissue in {traumatic amputation. As one orthopedic team in the fediterranean Theater reported, "*Where to amputate! simple when twas followed by the statement ‘Atthe 9 possible level” * DETERMINING CIRCULATORY STATUS INTHE INJURED LIMB ‘As stated, determining whether there i proper blood flow the wounded extremity is a fundamental question to be Tests that would assist the PHICP in determining160 Drren Menicoxs Axcurarioss 1 the extent of circulation and at the same ime be applicable Conversely, an extremity suffering from poor crcula- for field use ar temperature of the ski, color ofthe skin and tion wil ain its pallor for many seconds, ‘condition of arteries. However, these are rough measures, ‘The PHCP can also elevate the wounded leg and foot. fit ‘and not sole determinants suffering from arterial deficiency, the imb will become very le. When the limb is lowered, the foot may become red ot Temperature of the Skin plish, Its generally advised tha if this deep Blush is pre ‘The line of temperature demarcation between the eat very far past the foot, amputation below the knee is not ‘warm, well-supplied tissues and the cool, deprived areas of visable. the extremity provide a general indication of where tssue is in the process of dying or has died due ta poor blood cireu- dition ofthe Arteries Jation. With no instruments to measure Where serious arte- ‘The presence ofthe dorsalis pedis and posterior tibi tial deficiency begins, the PHP will have to rely on his in the foot are important sign of sufficient arterial ow hhand to sense the changes in temperarure. Use of the hand the distal portions of the leg. ‘The status of eollateel cite ‘can only be expected to give a broad indication of setual in the injured limb is of importance, but the absence of skin temperature. ital pulse is an indication that amputation below the “To help accentuate the Tine of temperature demarcation, eis seldom sae: " For wounds to the arm, the integrity of ‘the PHCP can expore both the wounded and uninjured leg adal pulse in the wrist would need to be evaluated. ‘orvom temperature for 15 to 20 minutes. The portions of ‘The reuls ofthese test are rough measures of arterial blood ‘the wounded limb that are suffering arterial flow insu ‘The PHP would do wellte employ allo these tests as he ciency will become coo! in comparison to the uninjured to determine where arterial circulation has come to an end limb and “supplied” portions of the wounded limb. Next, en in best-case itacon, this determinetion inthe id may ‘both limbs are covered with Blankets for another 15 t0 20 dificult. The PHCP could be foreed to settle for an amp ‘minutes. Once the blankets are removed, the deprived por- site higher than he would ike, The PHP must not over- tions ofthe limb wil have failed to warm up withthe rest of| the fact that dislocations and fractures of timbs or pressure the extremity. Asa rule, the PCP should not perform an ‘bandages spins, or swelling ean impede blood flow and amputation below the line of established temperature fore must be investigated thoroughly. ‘demarcation, © ‘TECHNIQUE FOR AN ABOVE THE KNEE Golor ofthe Skin OPEN CIRCULAR AMPUTATION #9 ‘A patient who has suffered traumatic wound may quite naturally havea pale appearance deta shock, However, en 1. The limb is draped so the PHCP hae circumferential area deficient in arterial blood supply will usually have & 30 ro all portions ofthe thigh. If practical, the thigh is e- cadaveric pallor. The PHCP can carry out further evaluation during the amputation to save as much distal venous by pressing hs finger firmly against dhe extremity in question, das possible, ‘When the arterial low tothe area pressed is sufficient, the 2. A tourniquet is applied. Iran be removed at that point pallor produced by the pressure should be replaced with no he procedure when major vests have been ligated and ‘mal skin color just few seconds aftr the PHCP removes his feding controlled,| « pronsiorcns I ssovrione 1° dic Asn aac e2aceete tama | Seeremntetoeetectanecss oats eee ee eet cee: Ses eee point where the superficial muscle has retracted. Blood ves- els are clamped and ligated as they are encountered. Major Arterial stumps receive double ligation, 7. Upward pressure is now placed on the proximal muscle ‘stump with gauze or amputation shield. This upward move ‘ment ofthe muscle stump in combination with the natural retraction that is characteristic of incised muscle tissue will Ihep ensure thatthe end ofthe wansected femur wil rest sev feral centimeters proximal tothe muscle stump once the mus e's allowed 1 return to its natural postion 8. After the deep muscles have been retracted, the perio ‘eum of the bone i incised and the femur sawn through fash ‘with the retracted muscles, just slightly distal othe perios- _teum incision site, The femur end should remain covered ‘with periostcum, as bone denuded of periosteum often will Marti 38 Airmen incision ing made oe he hat. Tis. ‘reton pon opus hrs made moumeicompaon itera 4."The fascia is then citcumnfereatilly incised at the level ‘to which the skin has retracted. '5, The nuperfichl layer of muscle is eutat the end of the fascia and allowed to retract 6. Once the superficial layer of muscle has retracted, the cep layers of muscle are circumferential incised atthery Dron Mumcase devate or tear the periosteum by rough handling. 9. When the bone is being sawn through, it should beisi- ‘gated with Normal Saline solution to protect from the heat ‘generated by the sawing (II. 99). Major nerve stumps are pulled forward by forceps and eut st the uppermost level that ‘can be reached. Occasionally they must be ligated due to bleeding. Drainage from the femur ean be controlled with bone wae or gauze, ‘Once the amputation has been completed, the stump shouldbe concave in appearance. The femur end should be shorter than the muscles and the muscles shorter than the skin (ls. 100 and 101). ‘Mueson 10 Ne rope oa aparece me th meer rman he acd im i ‘POST-PROCEDURE STUMP CARE ‘Once the amputation has been completed, the recess of the stump is packed loosely with gauze-‘This recess packing is 20 the gnuze docs not ove the skin edges. layer rotective gauze is now placed over the recess packing. “The pure is changed at needed, wth special attention given ‘tp eile technique during dressing changes. ‘Following the amputation, the prevention of skin retra tion on the stump is absolutely essential. Along withthe development of infection and massive hemorrhage, skin ferraction isa serious complication. As the wound heals the ‘skin will retract and expose muscle and bone if traction tothe kin ie not applied. Obviouly, the stump can never heal prop ‘ery with muscle and bone exposed. "Traction upon the skin of the leg stump can be accom- plished by placing adhesive tape on all four sides of the186 Dro Menicase stump. This tape then fashioned into strips that, in combi- ‘ation with a Thomas splint and additonal tape or Ace ban ages as deemed necessary, can be used to apply traction ‘The Thomas splint is only aplicable for mainaining traction ‘on the leg and is somewhat awkward 10 apply and easily mis- ‘Positioned during patient transport. ‘Teas found daring World War Il that, when possible, tac- ‘ton was better maintained bythe use of alight plaster cast and built-in wire ladder splint. "The cst was formed over a stock ‘nett that was “ued” tothe skin of the stamp. The ends of the ‘stocknette were then run to the wire ladder splin, where tac- tion could then be applied (Ils. 102 and 103). The cast was always designed to include the joint above the amputation. ‘tion 108 Usaha, cin and wie lap maine ‘Shromcun onan ama. srs 103: ofa cat,eckine, nd aepitmain Perino mal cone ‘The PHCP's mos difficult task is no so much the actual pplication ofthe traction device ba the prevention of sip= In iny, humid environments, the traction tapes cannot expected to hold long. Joseph Serleti's technique forthe ‘of tincture of benzoin, Ace wraps, and stockinett is an that will not result in slippage as readily as tape. * "The tincture of benzoin is applied to the skin of the ‘stump about 1 inch proximal to the end of the stump. Itis 0 applied to the groin ares, abdomen, umbilicus, and the feral and posterior aspects of the spine. A 6-inch stock- is applied over the stump up tothe point ofthe low- ib. The stockinette will have to be split to a degree ite sides to reach the rib. The tinewure of benzain is ‘moment to adhere tothe stockinette. Ace wraps are ‘used around the body, hip, and stump to further the stockinete,168 ero Mamie ‘Care must abways be taken with constrictive wrapping not ‘tw restrict blood flow, particularly around joint. The portion fof the stockinerte that falls below the stump is split along its ‘Sides up tothe stump end to guin acces for dressing changes. ‘The ends ofthe stockinete are ted tether and then tied toa ength of ope. The rope is run over the bed through a pulley ‘and weighted down with about Sto 6 pounds to achieve trac- ‘on (104). thar 04 Cf ers nat and might 0 ‘mete rc ‘An acceptable traction arrangement i one chat will not tip over a course of several days of usage. I also allows easy access for dressing changes ofthe stump, can be reapplied feasly, and ean be mated with 5 to 6 pounds of weight. Even the best traction devices will need replacing periodically due tw slippage. The ability ofthe patient to maintain personal Asworarions 16 hygiene must not be overlooked, since patients who have ‘undergone an open circular amputation can remain in trac- tion for several weeks (CLOSURE OF THE STUMP FOLLOWING AN OPEN ‘CIRCULAR AMPUTATION ‘Stump closure is generally earried out by one of three techniques. The stump may be allowed to simply granulate (Gear) over, the skin of the stump end may be undermined ‘enough at its edges to allow closure by suture, or the stump, ‘can undergo reamputation with an amputation technique that, incorporates the ute of skin Naps snd early closure tis best forthe PHP to restric hime tothe use of taction and. granulation for stump closure. ‘When the seump is simply allowed to granulate over, con- ‘ined traction isthe key to success. In a "best case” scenario, ‘continued traction wll esuit in secondary intention skin clo- sure over the stump (Il. 105). Effective traction allows grow~ fing tissue tobe held i place forthe formation of scar issue. “Healing by granulation takes the longest of all approaches to Dring about stump closure. Ie isnot unusual forthe ptint to ‘emain in traction for 14 weeks. * "An open circular amputation thats left to heal by eran ‘lation soften criticized forthe larg scar let long healing, period, musele retraction, exposure of bone, prolonged “drainage, car adherence to bone, and reinfection. These ‘complications usually can be avolded with proper traction "and wound maintenance ofthe stump. Although there are “Shortcomings with closure ofthe sump by granulation, itis all he best approach forthe PHP ina forward care arca totake ‘The open circular amputation is often thought of as a “temporary “fre break” procedure against infection tht, in ‘cases is expected to undergo secondary amputation toctffect final repair ofthe stump. The PHCP would have served his patient when, after extended transport the ded soldier is delivered tothe hospital-based surgeonBhan 15: Comin hin ein hase in par oft Sb ons cn with a stump as long as possible, not infected, and in advanced stages of healing. Proper traction and careful attention to maintaining a clean, well-drained stump should accomplish these goals ACASESTUDY ‘This 22-year-old laborer suffered «crushing blow to is Jeft index finger while iting pipe. The end of the finger was severed throtgh the bone, leaving only @ small lp of skin ‘that connected the mangled finger. ‘The patient arrived ata makeshift clinic within 10 minutes of the injary. The finger was anesthetized with Lidocaine ‘employed asa repional nerve block. The finger was thoroagh- ly leaned in Betaine. Once it was established that twas not possible to reattach the fingertip, a surgical amputation sitem eres Manica Pht 7: Wh racers in pla on rap eng ad arne ‘opr ari Ne oe a ang as he ao a. Peo ener ‘55.f len Dorr) Phot 7A hay has on fiom ad ad cla th nd fh ger {Ph ny of Cl Dore Ascurarions ” ‘was chosen. The PHOP clected to fashion a skin lap which hp used to close the finger. The patient was placed on oral antibiotics and the finger healed without complications (Photos 73 through 76).v4 Deca Mamie NOTES "Warten H. Cole and Robert Elman, Textbook of General ‘Surgery (New York, NY: Appleton-Century-Croft, Ine. 1948), p. 246. Ibid. p. 246, ° M.C, Wilber, LLY. Willett Je, and F Buono, “Combat ‘Amputees;" Clinical Onthopadics and Related Research, 1970, p10. “Henry H. Kessler, “Amputation Lessons From The ‘War American Journal of Surgery, 1947, p. 309. + Emergency War Surgery (Fullerton, CA: S.B.A. ‘Publications, 1982), p. 240. ‘M.C, Wilber, LV. Wile, Jr, and F Buono, “Combat Amputee," Clinical Orchopadics and Related Research, 1970, pal * Kenneth L. Mattox, Emest Eugene Moore, and David V. Feliciano, Trauma (San Mateo, CA: Appleton and Lange, 1988), p. 786. * Oscar P. Hampton, Surgery in World Wir Il: Orthopedic ‘Surgery Mediterranean, Theater of Operations (Medical ‘Deparment, United States Army; 1957), pp. 246-247 *L, Wiliam Traverso, Arthur Fleming, David E. Johnson, ‘and B. Wongrukmitr, “Combat Casualties in Northern ‘Thailand: Emphasis on Land Mine Injuries and Levels of Amputation,” Miliary Medicine 1981, p. 683. ‘Daniel Fisher, Je, G. Patrick Clagett, Richard E. Pry, ‘Theodore H. Humble, and Wiliam Fry,"“One-stage versus Aururanions ns ‘o-stage amputation for wet gangrene of the lower extremi- 'y: A randomized study,” Journal of Viscular Surgery, 1988, p. 428. Oscar P-Hampton, Surgery in World Wer I: Orthopedic. ‘Surgery, Mediterranean Theater of Operations (Medical ‘Department, United States Army, 1957). 249. "= Warren H. Cole and Robert Elman, Textbook of Ger ‘Surgery (New York, NY: Appleton-Century-Crofts, Inc, 1948), p25 Tid. p.254. ‘Ibid. p. 254. thi. p. 254. U.S. Army Special Frees Medical Handbook (Boulder, Colorado: Paladin Press, 1982), pp. 16.5-16.6. * Oscar P. Hampton, Surpery in World Wr I: Orhopadic ‘Surgery, Mediterrancan Theater of Operations (Medical ‘Department, United Sutes Army, 1957),p. 251. \" Morst-Bberhard Grewe and Karl Kremer, Atl of Surgical Operation Philadelphia, PA: W.B. Saundert ‘Company, 1980), pp. 426-428 “1.8. Speed and Hugh Smith, Campbells Operative Orthopedics (St.Louis, MO: The C.V. Mosby Company, 1939), p.831. ® Warren H. Cole and Robert Elan, Textbook of Geeal ‘Surgery (New York, NY: Appleton-Gentury-Crofts, Ine, 1948), pp. 257-258.m6 ere Mico * Oscar R Hampton, Surry in World Wir I: Orthopedic Surgery, Mediterranean Theater of Operations (Medical Department, United States Army, 1957),p. 254 2 Joseph C. Serletti, “An Effective Method of Skin ‘Traction in A-K Guillotine Amputation,” Clinieat Orthopacics and Related Revearch, 1981, pp. 213-214. > thid. p 214. » Emergency War Surgery (Fullerton, G: Pubsicaions, 1982), p. 242 BA. » US. Army Special Force: Medical Handbook (Boulder, ‘Colorado: Paladin Press, 1982),p. 16.6. % Joseph C. Serletti, “An Effective Method of Skin ‘Traction in A-K Guillotine Amputation,” Clinical Onthopacics and Related Research, 1981, p. 212. Burns smell of seared flesh and the sight of its charred ‘remains evoke the mixed emotions of revulsion and pity in the altending PHP. Incendiary weapons are well known, ‘or their ability to inflict horrific burns upon combatants ‘The soldier who bas “tripped” a canister of fougasse or ‘been showered with molten phosphorus from a grenade ‘represents a traumatic emergency thet often affects multiple ‘systems in the body. "With the improvement and proliferation of incendiary ‘weapons, there isa strong probability that the PHP wil find ‘himself caring for a severely burned patient." Once confront- ‘ed with this patient, the PHCP must be able to render emer- ‘gency care quickly, determine the severity of the burn, and {nate a course of treatment. ANATOMY OF THE SKIN “The skins considered the largest organ ofthe body: Tis described as having two layers. The outer layer which serves fas a barrier between the environment andthe body, is elled the epidermis. The dermis is below the epidermis. The der- ‘nis Contains the sveat glands, hai follicles, oil glands, and sensory nerves. Of particular importance tothe recovering 718 Drrcae Mroncase ‘bum patients how the dermis contains those cells rexponsi- ble forthe creaion of ew kin. PATHOLOGY OF THE BURN ‘Theskia's myriad of vil functions (eg, temperature reg- ‘lation, barrier to bacteria sensory input, exe) ae easly dis- rupted by burns. ven seemingly minor localized burns have the potential to cause dysfunction in eritical body processes. Depending upon the severity ofthe burn, body structures such as blood vessels undergo dramatic changes. Cll death snd damage cause increased capillary permeability and loss cof vascular integrity. The escape of nonformed blood cle- ‘nents (plasma) into the ssues Soon brings about the charac- teristic edema and blistering found in burns, The extravasa- ton of bodily ids through the burn wound in combination ‘with shifts in peripheral vascular resistance can lead to burn shock. The patients condition can be further antagonized by ‘decrease in cardiac output. Reduced circulation to the dam aged tissues due toa loss of “pumping capacity” and physical 25 percent of total body surface 2, Thitdedegree burns involving >10 percent of total body surface 3. Burns complicated by respiratory tract injury, frac- tures, or those involving critical areas such a face, Ihands, feet and perineum 4, High-volage electrical burns 5. Lesser burs inpatient with sgifcant preexisting disease “Moderte Burns: 1. Seconid-degree burns involving 15 25 percent of tra body surface 2. "Third-degree burns involving 2t0 10 percent of total body surface 3. Arets above not fvolving face, ands, feet, perineurn Minor Burns: 1. Second- degree burns <15 percent of total body surface 2. Third-degree burns <2 percent of toa body surface EMERGENCY CARE FOR THE BURNED PATIENT “The PHCP's inital three goals in rendering eare to the ‘burned patient ae to remove the victim from the source of the burn, limit burn wound progression, and maintain air- Bows 1 way patency, When removing the patient from the burn Touree (be iethermal, chemical, or electrical), the PHCP. ‘must be attentive to his own safety as well as his patient’ in ‘Order to remain a useful component of the emergency med- Seal system. Limiting Burn Wound Progression “After the patient has been removed from the scene of injury the progression of the burn wound is inhibited by cooling the burned skin, Burns not cooled can continue 0 ‘radiate heat to surrounding tissues extending from the ‘wound. Cool water shouldbe applied tothe wound for one to two minutes, Prolonged cooling of the burn may cause hhypothermia and shock. Ice is never used singe it eonstrics ‘vessels, causing further damage due to inhibiting blood flow tothe burn. Butter, oils ete, should also not be applied to the burn. ‘Chemical bums receive extensive irrigation with water to die and wash away the chemical. Particle ofthe chemical that adhere tothe skin are wiped away. Contact lenses are ‘emoved ftom the eyes for effective irrigation. ‘Once the burn has been cooled, clothing and jewelry are removed. Clothing that adheres tothe bur x cut around and {eft in place. While the burn site is exposed, a quick patent ‘assessment is made to determine the typeof bur, its severity, tnd whether there i ther trauma tothe patient. Although the ‘burn can look devastating, ther wauma or respiratory com= plications are more likely to cause immeat death. ‘After cooling and astessment, the burns are covered with ‘dry bandages and the patient covered with sheets or blanket {keep him warm. Ital possible, sterile material should be ‘laced against the burn Even in a warm environment, dam- ‘ged skin having lost its temperature-regulation capacity should be covered. Burn patents should never be transported in wet bandages. An occasional moist compress for small, areas is acceptable for easing the patient’ pain. Ifat hand, ‘oxygen and IV therspy are begun.us Dron Munsee ‘Burns to the Respiratory System Tahalation injuries as associated with burns result from the {inhalation of superheated gaes ot stear. A bura to the rsp ratory system is moat often caused by prolonged exposure ‘the hazardous environment. Patient entrapment isthe prima- ry caute for this prolonged exposure. Death can be rapid as the upper sway wells shut andor the kings with Dud Signe and symptoms of expiratory system burns are: 1. Severe head and neck burns, charted flesh, burned tal hats, swollen lps te 2. Hoarseness and coughing 3, Soot in and around the mouth and nose 44. Rapid respirations 5.Cyanosis 6, Fluid in the lungs 17. Seidor (high-pitched breathing) Emergency intervention for the respicatory-distressed patient focuses on maintaining a viable airway. Endotracheal Intubation or a ricothyreidotomy ae the best options for main- taining an open airway when itis beginning to swell shut (I 111), There are some who feel that nasotrachea intubation is the intubation method of choice forthe burned patient. When the PHP isattempting ointbate his patient, he may run into dificult bur iran to the airway may cause lethal laryngo Spasms when the endotracheal tube youches the laryngeal area. ‘hea 11 Hainan ir et ny arco ying ‘pp iro pc ner win ih aan ‘Som pra ioc es Rows 189 Fluid buildup in the lungs can quickly endanger the ‘patent life. The PHP should elevate the patient's torso t0 pool the fluid in the lower portion ofthe ings. Suetioning ‘ia the endotracheal tube often helps remove some of the ‘uid buildup, ‘Oxygen therapy is of vital importance in any trauma case, ‘Severe burns can destroy the red blood calls’ bility to trans- port oxygen, Some ofthe inhaled smoke may have contained ‘carbon monoxide (Photo 79). Unfortunatly forthe PHCP's patient, tis highly unlikely thathe has “humped” an E-size fxyen cylinder in hie rucksack. When high-flow oxygen is ‘ot avilable for administration, the PHCP must ensure that the patient is completly removed from the smoke-flled envie ‘ronment to avoid any farther damage.190 eres Manica EMERGENCY TREATMENT FOR THE BURN PATIENT ‘Manegement of the bura ste in the field is generally restricted tothe emergency “care” of cooling and dressing ‘the burn along with airway maintenance. Should the situa- tion at hand rule out immediate patient transport, the PHCP must be ready to provide emergency “treatment” in the following areas: 1. Fluid therapy forthe bam patient 2. Nasopastic tube insertion 3. Antibiotic therapy or burns ‘the antecubital fossa unusuble. A cut down to the greater saphenous vein in the ankle often is the best IV site avail- sable sit usually has been protected from flames bythe sol- ier leather boots. ‘Even if transport time to a hospitals short (half'an hour cores), css a good practice o establish an TV. Burn shock does take some time to develop, but an TV in place at minimal ‘ow is one less procedure tobe initiated should the patient's ‘blood pressure drop. When the patient must face extended ‘uation tothe burned patient. The Ringer's Lactate formula provides a guideline by which to administer IV fds during the first 24 hours after the burn.* Ringer's Lactate formule: ‘A. Percent body surface area burn x kg body weight x4 ml = ec of Ringer's Lactate to be administered for the first 24 hours ems 1 'B. One-half ofthe totale given in the frst 8 hours fol- owing the burn (C. One-quarter ofthe totals given in the following ‘wo 8-hour periods For example, a 70 kg man who has suffered burns to 60 percent of his body would receive 16,800 cc (almost 17 liters) ff fuid over the upcoming 24-hour period. "To determine whether or not the fui therapy is adequate, the PHICP needs to monitor urine output as wells vial signs. CCatherization of the urethra and collection ofthe urine are ‘essential. When there have been burns tothe groin, the ure- thea should always be catherized with a Foley catheter. Groin ‘burns can cause the urethra to swell closed, thus preventing ‘urine from being expelled from the body. Once the catheters in place, the patient should expel 25 to $0 ml of urine per hour ifthe uid therapy is adequate. "The paint should also ‘be exhibiting normal vital signs. Acute rena failure in burs ‘patients i generally the result of hypovolemia. ‘After the firs. 24 hours of fluid administration, the low should be adjusted to maintain proper urine ouput and vital Sins while at the samc time no causing Mid oerioad. Ate 48 ‘hours, the welling and growing edema stage ofthe bur should Degin to subside, This wll allow fuid administration tobe redisced, IfafterV therapy hasbeen iniiated tbe patient's signs fof shock are still present, the PCP should reevaluate bis patient fr other forms of trauma he has overiooked. (Oral intake of electrolyte solutions can be of help to patients with minor burns, However, the severely burned patient may suffer paralytic ews and vomiting, Oral adminis {ration of electrolyte solutions to these patients is generally ‘notadvisable. Inthe absence of [V solutions, oral intake of ‘dectroiyt solutions maybe life-saving. Nasogastrie Tube Insertion Tn severe bur cases, gastric distention and vomiting are often encountered. The PCP must be cautious abour givin his patient fluids orally. Tt isa good practice to place 8 n880-12 Drow Mace ‘aati tube down the patient’ esophagus. This tube can help Feliewe the discomfort of a distending bell. Some feel that ‘administration of antacids wll help prevent the development ofstomach ulcers." Antibiotic Therapy for Buerns ‘Burn patients are very susceptible wo infection. The burn site, duc tots poor circulation and abundant dead tissue, eas Aly supports bacteria growth, Infection that i left unchecked ‘an cause addtional tissue destruction or lead tthe death of the patent. ‘Vancomycin or penicilin, administered via TV infusion, sare commonly used for protection against and combating of staphylococcus aureus as well as other bacteria found in ‘burn wound infections. Topical pplication of infection fighting creams such as Silvadene Cream, Furacin Cream, ‘and Sulfamylon Cream are effective and ealy applied. The ‘use of topical creams that possess bactericidal propertis is particularly important in deep burn cates where systemic 'mnsibiotics may not be able to reach the sight of infection in sufficient levels due to the avascular nature ofthe wound, ‘The antibacterial properties of these ereams have been, ‘reported to allow healing of partal-thickness burns by pre~ venting conversion of the partiai-thickness burn to full thickness duet sepsis.” “Topical creams are applied to burns with a gloved hand, spatula, or tongue depressor while paying strict atenion to sterile technique. The creams do not have tobe covered with a dressing. The burn should remain covered with ‘cream until healing is well advanced, Since the cream should remain intact, dressing the burn while stil in a for- ‘ward area is a good idea. This dressing will prevent the ‘ream from being wiped off due to patient movement and provide a barrier toa less than sterile environment, The {opal ream ar ape once wis daly toa ines ut 1/16 inch, * The eream i, ofcourse, reapplied after scheduled cleaning ofthe burn, Bows: wa In deep severe burns skin protein may become denatured and hard, leaving a firm, leatherike covering known as an fschar. An eschar presents a hazard to the patient when it ‘circles an extremity o the chest wall Wren edema deve! ‘ops under the constrictive band of eschar, blood circulation t2 the distal portion of the limb may be restricted tothe point of ‘causing death to otherwise healthy tissue. Developing edema ‘with a circumferential exchar tothe chest capable of inhbit- ‘ng respiratory efforts In those cates where a limb is suffering fom insufficient circulation ar respiratory distress is endan- ‘ering the life of the patient, an escharotomy i a corrective procedure often wed. ‘An escharotomy is an appropriate course of action when 9 lim is exhibiting los of color, decreased pulse strength, Thomas R, Konjoyan, “White Phosphorus Burns: Case ‘Report and Literature Review” Military Medici, 1983, . 881Ee NotRrITION AND EMOTIONAL SUPPORT the PHP has stabilized his patient and there is a geen from the batlefield, the focus of patent care must riod of convalescence. Convalescenee isan inte= Beehicmasste cnt obgnccceeser “course theveare of the wounded is modified by conditions and circumstances that govern the tactical situation at hand, ‘Aid tactical situation inevitably leads to a patent conva- lescing in an expedient base camp that is often primitive at best (Photo 86). Given such a backarop, the PHCP's con- valescent care of his patient may be limited to nucritionat and emotional support ‘NUTRITION ‘As the body begins to lay down anew framework ofcapil- laries and tosue inthe wound, it must be able to draw nutsi- ‘ents from the body. Theresa ditet correlation between the ‘body's nutritional state and is ability to fight infection and ‘generate new tissue. Troops inthe field frequently consume Insufficient calories, whieh, compounded by stress, has a etrimental impact on the body's regenerative powers Photo 87), Ifmore than 2 percent of body weight i lost simply to sweat, both performance and recovery from physical activity canbe affected.” 20s206 rcs: Mepicose ‘Noramos Ab ENomIoNAL SuPPoRT a0 ‘The PHCP must be diligent to maintain a balanced nutri- tional supply to the patient, whether this is via an oral or 1V outer may be necessary to add vitamins to the IV solution or feed a patient by a nasogastric tbe, Patients should be encouraged t drink plenty of fluids (dependent upon their ‘rounds, as studies have found that, when Mid intake i im- ed, field personnel wil reduce food intake voluntarily.” EMOTIONAL SUPPORT ‘Extreme behavioral and emotional reactions tothe sess of batlehave been recorded for as long as men hve fought with fone another. For the wtinded soldier, sires mined with despair ‘an destroy his wil o survive rate is behavior so that he is ‘table to respond 1 the medical sport given him (Photo 88). Phat 8: Amerson ‘cam mane sf ‘eg priate in ‘Tobe of aid, the PHCP must establish com- ‘munication with his patient, give fan honest ap- Praisal of the boundaries of help available, convey a sense ‘that he is wellin control, and,208 Drreu Mupteose most importantly, generate the hope that there is way out of| this circumstance with confidence to know it can be done. “Truth on the part of the PHCP i a defense against anxiety. ‘There is no quickes way to seta patient emotionally adrift than fortwo separate PHCP¢ to answer a patient's questions with completely diferent responses. ‘The PHCP should remember that distraught patients can be left feeling very embarrassed after “unloading.” The PHCP must at this time reinstil self-worth, Allowing the patient to participate inthe decisions affecting him i reme- 4y fora tarnished self-image. This gives the patient feeting ‘of participation and an ability to cope. Providing emotional support to a patiatis probably more the Use of Sugar in Treating Infected Wounds,” Anti- ‘microbial Agents and Chemotherapy: May 1983. ffi, William G. and Basil A. Pruitt. “Aeromedical “Transport of the Thermally Injured Patient” Medical Corps Inernaional March 1989. ie, Warren H. and Robert Elman. Textbook of General | Surgery. New York, NY: Appleton-Century-Crofts, Ine 1948. a2 Deven Maptcoe Cetin, Vine Prinip of Aes, Pci, ‘PA: Lea and Febiger Company, 1976. 5 Combat ond Survival Westport, OT: 11S, Staten, Inc, 7981, Cooper Gi. and LM Ryan, “ntact of penetrating mi ‘with tissues: some common misapprehension’ and feria eset aeongeneans i Sar ‘Surgery June 1990, Cullen, Stuart C. and C, Philip Larson, Jr Essentials of ‘Anesthetic Practice. Chicago, IL: Year Book Medical Publishers Inc, 1974, ‘Demling, Robert H. and Cheryl LaLonde, Burn Trauma, ‘New York, NY: Thieme Medical Publebers, Ine, 1989, Dripps, Robert D., James E. 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