PERIOPERATIVE MANAGEMENT

NEED FOR RADIOLOGIC IMAGING

These injuries are associated with a significant transfer of energy to the casualty, resulting in high risk for associated injuries of a blunt and penetrating nature. Once the patient is physiologically stabilized, complete imaging including “Pan Scan” CT and plain film examination should be obtained to evaluate for occult injury,5 this is rarely completed prior to the first operation.

NEED FOR REPEATED DEBRIDEMENTS

The treatment team must appreciate the phenomenon of wound evolution and the high risk for invasive fungal infection and expectation that viability of the soft tissues will fluctuate over the course of several days. In the acute phase (<72 hours from injury) wounds should be frequently inspected in the operation room every 24 hours. In the later, sub-acute phase (3-7 days from injury) wounds may require less frequent treatment based on the presence of viable tissue and absence of ongoing necrosis or persistent contamination. Multiple debridements are routinely required and the severely injured, physiologically deranged patient should not undergo excessive surgical procedures during the initial operation other than those required to control hemorrhage and gross contamination.

Refer to JTS War Wounds: Wound Debridement and Irrigation and Invasive Fungal Infection in War Wounds CPGs for further guidance.22,18

ROLE OF SYSTEMIC AND TOPICAL ANTIBIOTICS

Initial antibiotic selection should avoid empiric broad spectrum coverage but rather focus on narrow spectrum antibiotics, such as first generation cephalosporins. The liberal use of topical antibiotic delivery via powder or antibiotic beads and/or Dakin’s-soaked gauze, pending available resources, is encouraged.

There is no data that supports the use of broad-spectrum antibiotics in these casualties. The most important consideration for antisepsis in the wound is adequate surgical debridement and repeated trips to the operating room. The risk with the overuse of broad-spectrum antibiotics is the development of antibiotic resistant infections. Topical antibiotics might have some efficacy, but the paucity of data does not allow for a strong recommendation.

Refer to the JTS Infection Prevention in Combat-Related Injuries CPG for further guidance.26

ROLE OF VENOUS THROMBOEMBOLISM (VTE) PROPHYLAXIS

Utilizing the DoDTR, the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in the U.S. military combat casualty population with DCBI is 3.3% and 3.6%, respectively. In those severely injured who required lower extremity amputation(s), the DVT and PE incidence increased to 11.2% and 13.7%. Every patient with a proximal amputation has, by definition, a DVT. Therefore, it is recommended that DCBI patients be started on appropriate VTE prophylaxis as soon as coagulopathy is resolved. If contraindications to prophylactic anticoagulation persist, prophylactic inferior vena cava filter placement should be considered.

Refer to JTS Prevention of Venous Thromboembolism CPG for further guidance.27

TRANSFER OF CARE

Downrange surgeons should make every effort to coordinate dressing changes and necessary repeat debridement in anticipation of required patient transport to a higher echelon of care. Given the propensity for wounds to evolve in their acute phase, downrange surgeons must maintain a low threshold to perform additional debridement prior to evacuating the casualty to avoid an unacceptable delay between debridements. Given the unpredictable nature of the air evacuation system and to optimize timing of subsequent serial debridements, the patient should remain NPO for flight so that they are prepared for the next operation. Additionally, since wound healing and nutritional support are a challenge in these casualties, early enteral feeding should occur thought a nasoenteric tube. If the tube is post-pyloric and the casualty has a functioning nasogastric tube, then feeding can occur throughout the continuum of care, as long as strict aspiration precautions are maintained.