1. Blast and ballistic mechanisms of injury result in wounds that have different characteristics from those usually seen by orthoplastic teams.
2. Wound severity is proportional to the energy transferred and degree of contamination.
3. The amount of tissue damage may be significantly greater than the size of the obvious wound and is likely to evolve over time.
4. There is a greater likelihood of a systemic response than from other injury mechanisms and particular emphasis must be placed on general supportive care.
5. Perform initial wound surgery as early as feasible in the damage control process.
6. Repeated wound excision is often required in contrast to other mechanisms of injury.
7. Do not primarily close blast or complex ballistic wounds.
8. The decision to use complex reconstruction early should be made more cautiously than with other mechanisms.
9. In mass casualty incidents there might be difficulty in timely access to orthoplastic services and standard treatment pathways may need to be modified to provide a more population-based approach.
10. There are evidence preservation and forensic implications when dealing with these wounds.
Blast wounds are caused by variable combinations of the products of explosions (1):
◆ A shock wave.
◆ An expanding energetic mass of hot gases.
◆ Objects propelled by the explosion.
◆ Further damage from effects such as collapsing structures and fires.
Ballistic wounding refers to injuries caused by objects, often termed projectiles, flying through the air and then interacting with tissues. This includes bullets (2) and fragments energised by blast (1).
Since 2001 the UK military have gained significant and effective expertise in managing ballistic and blast injuries (3, 4). This hard-won knowledge has been shared with civilian practitioners and utilised in managing victims of terrorist attacks (5). Future attacks involving a range of wounding mechanisms, including blast and ballistic weapons, are inevitable (6). Therefore, it is vital that civilian practitioners understand how to manage the casualties produced by these types of mechanisms.
Survivable blast and ballistic injuries disproportionately involve the limbs, frequently resulting in complex open fractures (3, 7). This chapter will highlight the management of these injuries, including features associated with mass casualty incidents. The fundamental principles and methods of treatment are essentially the same as injuries encountered in usual practice but they need to be applied in a manner that is mindful of some unique features.
Features of ballistic and blast wounds that must be considered in any treatment plan are:
◆ The overall severity of the wound is related to the energy transferred and the amount of contamination.
◆ High-energy transfer wounds can cause massive amounts of tissue destruction, resulting in complex wounds that are typically heavily contaminated.
◆ The majority of blast wounds will include penetration by fragments.
◆ Blast effects may have systemic physiological consequences.
◆ Blast may drive contamination along tissue planes away from the wound.
◆ Blast effects on tissues may cause progressive necrosis and a ‘wound in evolution’.
◆ Bullet wounds have little or no blast component.
◆ Low-energy transfer bullet wounds may have little damage beyond the obvious tract.
◆ If the bullet is still present in the limb it means all of its energy will have been transferred, although it may also represent a bullet that lost most of its energy before impact.
◆ If the bullet itself has fragmented, or it has fractured bone, it is more likely that the energy transferred to the limb will have been high (8).
◆ All projectile penetration will have led to a degree of contamination, which may include biological material.
Knowledge of the method of wounding does not directly inform what injuries may have been sustained. The critical factor in determining the extent of damage is the amount of energy transferred. A bullet may pass through thigh muscle transferring little energy leaving only a simple tract, but if it strikes bone all its energy will be dissipated, resulting in a devastating injury (8).
Initial assessment and care
The standard approach to general trauma care should be followed but with an appreciation that patients exposed to blast and ballistic mechanisms are more likely to have sustained widespread injuries.
◆ Primary survey with heightened awareness of the need for haemorrhage control. This should include a whole body computed tomography (CT) scan, except for the most minor of isolated distal injuries (9).
◆ A secondary survey with special attention to identify subtle wounds. Even in the absence of clinical signs of a fracture, if a CT scan has not been performed, orthogonal plain radiographs are mandatory; projectiles can penetrate bone without causing discontinuity and bullet fragmentation is a significant finding. Using radio-opaque markers over the surface wounds is useful to predict likely bullet tracts and to plan surgery (10).
◆ A tertiary survey once a patient is fully aware with a review of all imaging and reports as a definitive check to exclude missed injuries.
Anticipate that the patient will exhibit a generalised systemic reaction to blast injuries with a similar degree of physiological derangement as seen with large burns. It is highly likely that patients from a blast incident will require critical care.
The key question in the surgical management of projectile wounds is whether this is a low-energy transfer wound, which could be described as benign, or has there been high-energy transfer, i.e. a complex wound?
◆ A large (>3 cm diameter) ragged skin defect or surface wound.
◆ Obvious significant tissue disruption or destruction.
◆ A large (>3 cm diameter) cavity in muscle.
◆ Evidence of bone strike, including multi-fragmentary fractures.
◆ Fragmentation or retention of a projectile.
◆ Compartment syndrome.
A wound is complex irrespective of energy transfer if the following are seen:
◆ It has been directly caused by blast.
◆ Injuries to nerves, vessels, and tendons that require repair.
◆ Significant contamination.
◆ Systemic effects of blast.
Not all markers of complexity are absolute; a degree of surgical judgement is required and this is best informed by experience. The safest option is to have a low threshold for assuming any projectile wound is complex.
All wounds suspected of being complex should undergo surgical assessment under appropriate anaesthesia in an operating theatre. Successful reconstruction will depend on getting the wound assessment correct and this should be thought of as providing a ‘wound diagnosis’. This requires a more extensive approach than might be implied by simply using the term wound excision or debridement. The section on ‘Initial Wound Surgery’ describes this procedure.
In the critically ill trauma patient, priority should be given to applying damage control principles to halt blood loss, minimise contamination, and improve the physiology. Initial Wound Surgery may not be the first surgery in this sequence of interventions. However, due to the level of contamination complex ballistic and blast wounds should be addressed as soon as possible.
Imminently life- or limb-threatening injuries
Victims of blast and ballistic injuries have a greater risk of life- or limb-threatening vascular injury compared with more usual mechanisms. When associated with an open fracture the suggested order of surgical intervention is:
1. Rapid temporary control of haemorrhage. In the limb this is most often achieved with a tourniquet. If open surgical access is required to stem haemorrhage both proximal and distal vascular control are needed; often best achieved away from the wound.
2. Fasciotomies. Other required procedures all take time and compartment pressure will be rising. Releasing the compartments can be achieved very rapidly and is best done before blood flow is restored.
3. Formal surgical exposure of the injured vessel segment and temporary vascular shunting if indicated.
4. Full wound assessment, decision making, and wound excision.
5. Initial skeletal stabilisation, usually by external fixation.
6. Definitive vascular repair.
If during this sequence physiological control of the patient is not achieved the procedure should be truncated using damage control surgery principles.
Initial wound surgery
For ease of description the various components of acute surgical management are discussed in a sequence. In reality they are often performed simultaneously.
Most victims of blast are covered with dirt; the social wash should cover the entire body. This also gives an opportunity to check for other wounds.
Wound extension and release
Excise the skin edge of the defect minimally but adequately. Injured tissue will extend beyond the apparent area of damage and this will swell. To permit the swelling to occur without raising the tissue pressures, the skin and fascial envelope need to be incised to extend the wound beyond the obvious zone of injury. This is the original meaning of the term debridement—to unbridle, or release, the wound. In the leg there should be an extremely low threshold for formally releasing all four compartments as described in Chapter 11. Wound extension incisions should be made along the lines of election for fasciotomies. Where wounds are not close to these lines or there are several wounds, use judgement to plan the skin and fascial extensions such that the desired release is complete without sacrificing reconstructive options. Raise the skin and fascial extensions as a single unit in the sub-fascial plane to ensure they constitute a robust flap rather than degloved skin.
Wound exploration and assessment
Wound extension facilitates full wound exploration, which is essential for complete assessment of the wound. All damaged structures need to be identified and the exposure should be wide enough to permit this. Avoid dividing non-injured muscle horizontally to open up a tract; gain access to the deeper parts of the wound by splitting muscle longitudinally.
With an evolving wound, excision of non-viable tissue and contamination is likely to be multi-staged. The aim is to get macroscopic clearance at the first procedure but pragmatically a point is reached where chasing every last small piece prolongs the operative time for minimal benefit. Dubiously viable tissue may improve and, ideally, excision should be limited to definitely non-viable tissue. Detailed evaluation of tissue can take time; in the physiologically unstable patient or in a mass casualty event the threshold may shift to a more rapid and necessarily radical excision.
Bullets and small metallic fragments can be left in limb wounds without detriment. Attempts to retrieve them may cause additional injury. Exceptions to this are where they are intra-articular or impinge on movement and these should be removed. Environmental contamination, particularly non-metallic, tends to cause abscess formation if left. If minor, this does not always progress to invasive infection. The contamination driven up tissue planes by blast tends to impregnate adventitial layers and is not easily wiped off or irrigated out. This normally requires sharp excision of connective tissue.
There are no peculiarities of blast or ballistic injury that alter the decision making on bone viability but extensive periosteal stripping in high-energy-transfer wounds and deep impregnation of contamination should be anticipated. In common with all wounds, copious irrigation after wound excision is essential.
Initial skeletal stabilisation
Stabilising the fracture conveys stability to the soft tissue envelope and reduces infection. This is usually achieved using external fixation. It is preferable to have pins entering the bone through intact skin but this may not be possible with some defects. If wounds are extensive, temporary stabilisation with an internal plate can be performed, anticipating that this will be revised at definitive surgery.
Limb salvage decisions
Definitive decisions about amputation should not be made at initial wound surgery. Definitely non-viable tissue is excised, and if this results in ablation of the limb, then that should be viewed as a wound excision and not an amputation (12). No attempt should be made to influence decision making on skin excision based on trying to plan for specific amputation levels, i.e. all viable skin should be retained until the definitive closure. Similarly, the presence of a fracture should not influence amputation level; fractures proximal to the amputation level can be fixed in the presence of adequate soft tissue cover.
No immediate closure or repairs
No matter how clean or small the wound appears after appropriate initial wound surgery, for complex ballistic and all blast wounds, immediate wound closure is contraindicated. Vascular repairs require cover with viable tissue and this should be achieved by formally mobilising tissue rather than trying to achieve coverage with tension. It is essential that such tissue is only loosely placed to cover the repair and it must not impede free drainage or restrict wound swelling.
Repairs of functional structures such as nerves and tendons, definitive bony fixation, and soft tissue reconstruction must all be delayed until the wound has fully evolved to reveal the full extent of non-viability.
There is no conclusive evidence to inform decisions on any specific dressing that might be best for ballistic and blast wounds (13). Nearly a decade of collective military experience in using Kerlix AMD™ gauze in a topical negative pressure dressing has shown it to be excellent for managing large complex three-dimensional wounds in long evacuation chains. The main benefits were ease of nursing and patient comfort. The observation of more rapid wound stabilisation has not been subject to trials.
Wounds that have no evidence of features suggesting complexity, particularly small isolated bullet wounds, can be managed in a relatively conservative manner; the laying open of such wounds is not necessary (8, 11). This involves:
◆ Minimal, if any, excision of damaged skin edge.
◆ Confirmation that, if deep fascia has been breached, the underlying muscle looks healthy. This may require a minimal extension of the fascial defect.
◆ Irrigation of the wound augmented by physical agitation using gauze as a mild abrasive along the wound tract, so-called flossing.
◆ A simple dressing.
◆ Delayed primary closure or healing by secondary intention.
A full description of all wounds including exact size and location must be documented. Virtually all ballistic and blast events will be subject to investigation and this information will constitute evidence. Avoid making any comment on opinions as to the causation of wounds and reference to if a wound is an entrance or exit. This may well be interpreted as an expert assessment of direction of fire and can have very significant legal ramifications. Simply describe what is seen. Removed bullets and other fragments should be retained in such a manner as to make them admissible as evidence. It is best to try and avoid using grasping metal instruments directly to extract bullets as this can alter surface markings of forensic importance. It is recommended that hospitals develop a protocol for the management of evidential material.
There is no evidence that blast or ballistic factors directly influence the species types of microbiological contamination, although the likelihood of deeply penetrating contamination is higher. The prophylaxis regime described in Chapter 1 will suffice for isolated limb injuries. For wider injuries, Public Health England (PHE) have published antimicrobial prophylaxis guidelines for bomb blast victims (14). Any subsequent evidence of infection should prompt the collection of deep tissue samples for prolonged culture and histological analysis. The request form should clearly state that the wound is as a result of an explosion and investigation for fungal species requested; most laboratories now have automated systems that will not culture for unusual organisms unless specifically requested.
There is a possibility that projectiles may pass through other victims. Dismembered body parts may become projectiles. This presents a risk of inoculating wounds with biological matter that carries viable viral material. PHE have published specific guidelines for managing this risk (14).
A return to theatre for another thorough wound exploration should be planned for about 48 hours. It will be unusual to have to extend wounds further but all wound recesses need to be revisited. It should be anticipated that some further excision of non-viable tissue will be required. The presence of necrotic muscle is not necessarily a reflection of poorly judged initial excision; it is part of the process of wound evolution. It is unusual to see evidence of invasive infection at this stage. Even at this early stage, pus like exudate is seen around residual contamination, although this is nearly always sterile. This phenomenon helps identify and remove the contamination.
Approaches to reconstruction
Patients may well require critical care for prolonged periods and physiological fragility has been observed to persist for many months. The impact of repeated surgical and anaesthetic interventions should not be downplayed.
There are no absolute contraindications to specific methods of reconstruction due to the wound being sustained by blast or ballistic mechanisms. The fact the wound may still be evolving and the patient systemically unwell means that decisions on method and timing of reconstruction may have to be made well past the advocated timeframes described elsewhere in this book.
The aim remains to get the wound closed as early as is safe but the chosen method must be compatible with the patient’s condition. Rather than continue with dressings until the patient can tolerate complex reconstruction, it may be preferable to use quick and simple techniques early (such as split skin grafting and external fixation) and accept that revision reconstruction is likely several months later.
Once wound progression appears to have stopped it may become apparent that local flaps are a safe simple option if the patient remains too unwell for a free flap. It should be appreciated that, in the case of a systemic response to blast, the whole body is effectively the zone of injury. The concept of reconstructing from outside the zone of injury is therefore relative. An experienced microvascular surgeon should be able to assess the suitability of a vessel for microsurgical anastomosis by direct visualisation under magnification.
There is evidence that bone healing is impaired following ballistic and blast injury and the risk of infection is greater (15). These factors need to be considered when making decisions on definitive skeletal fixation. Fixation constructs should be planned with the assumption of delayed union and therefore suitably robust to be load-bearing for a prolonged time. An exception to this is in the case of tibia fractures with large soft tissue loss. In these instances, a thin, unreamed nail can be placed as an ‘internal fixator’ to rapidly confer some stability, allowing soft tissue reconstruction. This can then be revised to a larger, stiffer-reamed nail once the soft tissue envelope had matured.
Experience from managing combat casualties
During recent conflicts, several hundreds of blast wounded service personnel were treated by a single UK hospital over more than a decade (3, 4). Certain approaches to management emerged through experiential learning and became regular practice based on recurring success. Although not subject to clinical trials and based on a specific cohort, some of the learning points are likely to be applicable when managing such injuries in a civilian situation (16).
◆ In patients too unwell for complex reconstruction, injured tissues were encouraged back to anatomical alignment gradually by using a combination of topical negative pressure dressings and elasticated vascular sloops in a ‘bootlace’ fashion. This was not used as a primary method of achieving wound closure.
◆ New appearance of significant progressive necrosis (as opposed to small marginal areas) raised suspicion of fungal infection. In this case excised tissue was sent for histological examination as well as microbiological culture.
◆ Each anaesthetic has an impact; patients were not taken back to theatre just to see how wounds were progressing. There had to be a reconstructive goal for each theatre trip, even if only to reduce the size of the wound. The interval between theatre trips was often about 5 days, with topical negative pressure dressing remaining undisturbed in the interval.
◆ Topical negative pressure dressings were used as a means of controlling wound exudate and splintage, particularly of skin grafts. There was no intent to try and make non-graftable wounds graftable by producing granulation tissue.
◆ In general, early wound cover was advocated. Rather than waiting for the patient to become sufficiently stable for complex reconstruction, this was often achieved by a combination of staged delayed primary closure, meshed split skin grafting, and by rearrangement of the flaps raised during wound extensions—so-called flaps of opportunity.
◆ Biosynthetic dermal templates (Integra™ or Matriderm™) took extremely well on muscle and resulted in very pliable amputation stumps.
◆ Some early free flaps were used with success. If the patient was still requiring inotropic support, free flaps were not considered.
◆ In patients with amputations and a requirement for free flaps, consideration was given to donor site morbidity. Latissimus dorsi and rectus abdominus flaps in particular compromise core strength impacting on future mobility and rehabilitation.
◆ The principle of achieving prompt rigid fixation to allow early mobilisation is nugatory if the severity of the injuries made it likely that the patient would not be rehabilitating rapidly. In this situation minimalistic bone fixation was achieved in a manner that reduced further insult to the soft tissue envelope through minimal exposure; for example, with a single lag screw and small neutralisation plate.
Mass casualty incidents
NHS England (and similar applies for the health services of the devolved administrations) defines a mass casualty incident for the health services as an incident (or series of incidents) causing casualties on a scale that is beyond the normal resources of the emergency and healthcare services’ ability to manage. Unlike major incidents, mass casualty incidents are infrequent; the last one in the UK probably being the multiple London bombings on 7 July 2005 (17).
Normal major incident planning requires trauma-receiving hospitals that are part of a trauma network predicting in advance how many cases they can deal with in a given timeframe such that normal care pathways can be followed. This would imply that the recommendations for managing complex limb injuries described throughout this publication could be adhered to in a major incident. The major incident plan should include a mechanism to distribute cases such that a single hospital is not burdened beyond its declared capacity. Although it would seem sensible to ensure all complex open fractures would only be taken to those hospitals with an orthoplastic service, there is no formal requirement for this to be the case. Under major incident circumstances there should be opportunities for secondary transfers soon enough to allow compliance with these standards.
When the volume of cases overwhelms the major incident plan, a mass casualty situation exists (18). This is likely to occur when numbers are in the hundreds and in this situation an adjustment to normal clinical pathways is required. Major trauma centres may be filled up with multiply injured patients and isolated, albeit complex, limb injuries could be triaged for transfer to trauma units. Because of the scale of the event, secondary transfer of these patients to facilities with orthoplastic services may not be feasible for many days.
Not all mass casualty incidents will involve blast and ballistic mechanisms. Worldwide, sudden onset natural disasters generate the greatest number of casualties but these are unlikely in the UK. Terrorists have used blunt trauma mechanisms to inflict scores of injuries by driving vehicles into crowds. Historical patterns suggest that about 25% of casualties will need immediate life-saving interventions, 25% will need essential interventions that can wait, and 50% will be walking wounded or minor injuries.
The recommendations in this publication are focused on achieving the best possible outcomes for the individual patient. In a mass casualty scenario the emphasis shifts to a more population-based approach. A crude example would be the difference between using an all-day list to perform a complex reconstruction for a single patient or, instead, amputate that limb and do several more simple reconstructions on many patients. Similarly, the conversion of temporary external fixation to a definitive modality may have to be delayed beyond what is normally considered ideal.
Essential surgical procedures take precedent and the completeness of the first surgical intervention may be truncated. In true damage control surgery the amount of intervention is limited by the patient’s physiological condition. In a mass casualty incident an additional limit is access to resources, which includes the availability of surgical teams and operating theatres. Even a physiologically stable patient may have their surgery limited and this is more accurately referred to as abbreviated surgery. This means that at the end of the first surgical intervention, initial wound surgery may not have been completed and this must be clearly documented. If possible, at least gross contamination should be removed from wounds. Antibiotics will still need to be administered but this does not replace the need for surgery. All wounds at some point, even if delayed, must undergo initial wound surgery.
A requirement in the early phases of a mass casualty incident, which may extend into many days, is to be as efficient as possible with the available resources. The main surgical contribution to this is to avoid having to unnecessarily repeat work. It is important to not let the heat of the moment force rushed decisions that impact on later workload.
Approaches that help manage resources include:
◆ Senior and expert decision making is essential. Be very wary of delegating procedures to unsupervised inexperienced surgeons.
◆ In the presence of large numbers of surgical patients, a slightly more aggressive approach to tissue excision may be required to reduce the risk of subsequent urgent, unplanned take-backs.
◆ A surgical command team should keep track of all cases requiring ongoing surgery so there is oversight of the workload. Twice daily surgical planning meetings involving representatives of all relevant specialties should allocate appropriate patients to appropriate resources. To assist this, accurate documentation is essential to record what has been done but also why it was done and what has not been done.
◆ Do not burden the system with unnecessary changes of dressings and wound inspections. Choose a dressing regime that can be left in place for many days. Every trip to theatre must be planned to make progress with the wounds.
◆ Be responsive to the patient’s general condition; unexplained deterioration may indicate wound issues that could require a return to theatre.
◆ Immediate wound closure is contraindicated (this does not included providing viable cover for certain tissues).
◆ Do not commence on definitive reconstruction until wound evolution appears to have ceased.
◆ Do not make decisions on definitive amputation levels too early.
If specific features of wounding patterns are beyond the normal experience of the treating teams, they should not be reticent in seeking assistance from external sources. There is a formal system in place to enable military aid to the civil authorities, which is requested through the incident command chain, but this is unlikely to be able to yield an additional workforce to deliver clinical care. What is more effective is making available niche expertise for advice and guidance. This was successfully demonstrated following the Manchester bombing of June 2017; a team of combined military and civilian experts from Queen Elizabeth Hospital Birmingham, who had extensive experience in managing blast injured military patients, made visits to involved hospitals to discuss patient pathways and clinical dilemmas (5).
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