PRIORITIZATION AND SURGICAL TEAMS

DCBI patients undergo dozens of operations over their course of care. The goal of the first operation is simple but not easy: hemorrhage control and debride dead tissue while removing contamination (from the soil and device fragmentation). There must be coordination and communication between the anesthesia and surgical teams throughout the entire case. The OR should be warmed to as hot as it can get, since these casualties are always hypothermic, even if the ambient temperature is 100° Fahrenheit. Blood loss is ongoing throughout these cases and the anesthesia provider must keep up with transfusion requirements. Vasopressors should be avoided until it is clear the patient is euvolemic. There should be a low threshold to activate a WBB for warm fresh whole blood even if the blood bank has ample supply of stored blood.

Intraoperative management of DCBI patients requires a team approach, best achieved with general/trauma surgeons and orthopedic surgeons working concurrently when possible. For example, the general/trauma surgeon can achieve proximal vascular control if necessary and address any truncal injuries, if present, while the orthopedic surgeon deals with obtaining hemostasis in the wound, stabilizing the pelvis when indicated, and debriding dead and devitalized soft tissue. If the wounds are only in the extremities, two surgeons working together on each extremity is more efficient. Keeping OR times as short as possible, while achieving hemorrhage and contamination control, should be the goal. If there is a third team, they can address the upper extremity injuries. This approach maximizes efficiency and limits prolonged physiological insult to a severely injured patient. Without evidence of intraabdominal or visceral injury, colonic diversion should not be done during the first operation. Additionally, the wounds should not be placed in vacuum assisted closure (VAC) dressings on the initial operation since 1) they will be returning to the OR in <24 hours; 2) in patients who are coagulopathic and have a capillary leak – the negative pressure dressings can result in more bleeding and can create a detrimental cycle of blood loss and increase transfusion requirements. When VACs are placed on the patients, the blood loss might get underrecognized in a busy ICU, post-operatively. During the first operation: be expeditious and efficient, keep the casualty warm, get hemorrhage control in the wounds, debride dirt, particulate matter and tissue that is clearly dead or devitalized.

Dress the wounds with wet to dry or Dakin’s dressings. Using mesh gauze and staplers, dressings can be fashioned to fit these challenging wounds. If the casualty has an open pelvic fracture and the perineum and abdomen are connected or there is evisceration through the perineal injury, then laparotomy is needed to assess for and repair abdominal injuries. This approach, while successful, should be a planning factor when considering triage.