Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XVI: Wounds and Injuries of the Soft Tissues

Treatment Recommendations

United States Department of Defense

Establish an adequate blood level of penicillin or an antibiotic with a similar spectrum as soon as possible after wounding. Make generous incisions of the wound to relieve mechanical pressure and establish open drainage. Remove easily-accessible foreign bodies and detached pieces of muscle, and irrigate the wound copiously. The wound track is then inspected and any additional muscle whose gross architecture is severely disrupted is excised. At the conclusion of the procedure, complete hemostasis must be achieved to preclude the subsequent development of collections within the wound that would impede capillary perfusion of borderline tissues. The technique is shown in Figure 24.

Figure 24

1. Excise entrance and exit wounds with a narrow margin of skin oriented parallel to the underlying muscle fibers. This excised skin margin should include, in continuity, the underlying subcutaneous tissue. These incisions should be generous, such that optimal surgical exposure and adequate subsequent drainage will be achieved.

2. Through these openings, generously incise the fascia parallel to the muscle fibers in both directions. The underlying muscle surrounding the missile tract should be opened in the direction of its fibers to the degree necessary to achieve exposure adequate to inspect the track, remove foreign bodies, and excise non-viable muscle These maneuvers are performed at both the wound of entry and the exit wound. The muscle surrounding the central portion of the track can usually be dealt with through the entry and exit wounds. For example, a mid-thigh, through-and-through wound of the soft tissues can generally be surgically managed by working through the excised and extended wounds of entry and exit. This approach precludes the necessity of cutting across good muscle groups as is generally the case when one elects to connect the two wounds. Appropriate drainage of war wounds is often easier said than done. Liberal incisions tend to facilitate drainage from the wound's deeper recesses. Whereas excision of skin, fascia, arteries, nerves, veins, and bone is conservative, the excision of muscle should be more liberal.

3. As a dressing, dry sterile gauze should be laid lightly in the wound. This should be no more than a wick. In no case should gauze be "packed" into the wound since this additional pressure can cause necrosis of any tissue that already has its blood supply partially compromised.

4. The single most important principle in the management of battle wounds is their nonclosure following debridement. The surgeon must not give in to the temptation to primarily close certain "very clean appearing" war wounds. Such closure is ill advised and inappropriate and can only be condemned. All wounds must be left widely open with the following exceptions:

   1. Sucking chest wounds

   2. Joint capsules

   3. Wounds of the dura

   4. Some head and neck wounds; however, with severe contamination it may be safer to leave these open.

5. The delayed primary wound closure is usually performed in a communication zone hospital 4-10 days after debridement, but occasionally may be performed at the forward hospital when evacuation has had to be delayed. The indication for delayed primary closure is the clinically clean appearance of the wound. Whereas most wounds are closed in the operating room utilizing the interrupted wire technique and local or general anesthesia, some may be very amenable to tape closure. This technique can be initiated 4-6 days post debridement. Approximation of the skin edges is accomplished with micropore paper tape or wide "butterflies" applied in overlapping diagonal "basket weave" fashion after the skin has been degreased with acetone, and tincture of benzoin has been applied and allowed to dry thoroughly. Edges of the wound may not come completely together with the first tape application. This is not a problem, as they will come progressively closer together with each reapplication of tape, done at 48 hour intervals. Tape closure offers some advantages over suture closure Even compression of wound edges decreases skin edema, and the problem of cutting needles causing additional tissue damage is avoided. The wound edges are very vascular and needle passage can cause hematomas. Since tape closure is, in reality, a gradual "encouragement" of the skin toward closure rather than a total closure from the beginning, a great margin for error is added and the potential complication of wound breakdown, sometimes seen after suture closure, is almost completely avoided. No anesthesia is needed for this procedure and it can be performed by supervised ward nursing personnel.

   It should be recognized that even though the surgeon diligently attempts to excise all devitalized tissue, the dynamics of wound physiology and the imperfections of ones ability to absolutely identify nonviable tissue are such that some devitalized muscle may be left behind or evolve over time in the wound. In the appropriately drained wound, this minimal amount of devitalized tissue will be absorbed or extruded. A small percentage of these wounds will require a second debridement prior to delayed primary closure. At worst, in the absence of adequate drainage, an abscess that requires subsequent drainage may develop. In this situation, antibiotics localize or isolate the deleterious effects of the injury to the site of injury, thereby precluding systemic, lifethreatening sepsis.

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Operational Medicine 2001

Health Care in Military Settings

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