1. Acute Wounds: Lacerations, GSW’s and Blasts Better Acute Wound Care Better Patient Outcomes Better Collaborations John P. Kirby, MD, FACS Director Wound Healing Programs Coursemaster, Surgical Clerkships, ATLS Washington University School of Medicine

2. We stand on the shoulders of giants…. Increasing ISS Decreasing CFR : WW2 19% Vietnam 16% and now….8% US Army ISR J of Trauma Vol 75, 2, August Suppl 2013 LT Stuart Hitchcock, MSHS BSN, RN-BC, PhDc Division Officer, Complex Wound & Limb Center National Naval Medical Center, Bethesda

3. Disclosures K30 Program BJH and WUSM Foundations Merck, Inc----research funding for intra-abdominal infections Neumedicines, Inc---research for novel immunomodulation in injury states Musculoskeletal Transplant Foundation—research in AWR Ethicon, Inc—research in topical hemostasis Cook, Inc—developing wound infomatics analyses Wendi Gordon Shelist Foundation—NF, Surg Infections & WH None of these disclosures represent conflicts of interests for this presentation

4. For Governmental Compliance The information provided is as accurate as possible as of the date indicated. Numbers have been rounded Treatment modalities and preferences vary among surgical services No commercial interests Informational purposes only, not meant to be official recommendations of any government or private entity

5. Important Disclosure to consider Acute & Critical Care Surgery A new practice model…we have learned from military surgical services…. 10 BC ACCS Surgeons 24 X 7 X 365 in house attending coverage for the ED and inpatients …3/day 1/night “MOD” 36 Bed SICU covered in partnership with Anesthesia with in house attending coverage Multi-Specialty Outpatient Clinic 5 days a week Full teaching service: Students, Residents, Fellows and Nurses: Post Grad Training in CC, ACS, WC Complemented by APN’s, Clin RN Specialists, PA’s

6. Barnes-Jewish WUSM Acute & Critical Care Surgery Level I Trauma Center Affiliated with St Louis VA (shared with SLU) Wound Care in our group practice >2,000 traumas/yr 24 bed ICU now 36 Bed Allows us to care for a wide variety of wounds

7. What have we learned? Better Acute Care means Better Outcomes Better acute wound care mitigates later chronic wound problems Shared Goal: Treat the WHOLE patient not just the HOLE in patient Paradigms for better acute wound care – Lacerations – Gun Shot Wounds – Burn Wounds Summary—Blast Injuries

8. Acute Management Military has its own and accompanying manuals Multiple society based course offerings – ATLS, TEAMS, ABLS, FCCS, FDM Today, wound care is one way to stimulate your thoughts and appetite for the care improvements they represent

9. Primary and Secondary Surveys ABCDEFF: Airway—Breathing—Circulation— Deficits—Exposure—Fluids—Strip’em— Flip’em and Cover’em Up! Secondary Survey: Head to Toe physical exam with tubes and fingers in every orifice Follow up Exams—This is where Wound Care might come in a crucial role: double check to be sure all lacerations, GSW’s and injuries are accounted for

10. Keep focused on the Primary Survey Airway has been 1 st for more than 20 years… But military experience is moving Bleeding up… Stopping exsanguinating hemorrhage may be promoted up the primary survey Whole blood based resuscitation currently only possible in the military 1:1:1 ratio’d massive transfusion in civillian

11. Acute Wounds: Lacerations Lacerations – Assume contaminated, may not be recommended to be closed v. approximated – Tetanus Prophylaxis: Host and Injury Host: prior history of immunization Injury: quantity of Clostridium tetanii innoculation – Rusty Nail vs Soil contamination Recommendations – Tetanus treatment

12. Double Check on Tetanus 1 Rare, but if missed carries 13% mortality in US care, and 30 – 50% mortality world wide Complications usually in those not previously immunized, those who do not receive a timely booster or who have an overwhelmingly large innoculum 1. Centers for Disease Control and Prevention tetanus surveillance United States, 2001Y2008. MMWR Morb Mortal Wkly Rep 2011;60:365Y369.

13. Tetanus Treatment 2-4 Consider HTIG in suspected tetanus; tetanus-prone wounds; those with an incomplete primary vaccination series, or unknown vaccination status. A single intramuscular dose of 500 IU suffices. & A protective serum antitoxin antibody level, commonly accepted as 0.01 IU/mL (in vivo) or 0.15 IU/mL (in vitro), makes the diagnosis of tetanus less likely, but not impossible. 2.Biological products. Bacterial vaccines and toxoids; implementation of efficacy review; proposed rule. Fed Regist 1985;50:51002Y51117. 3. Simonsen O, Bentzon M, Heron I. ELISA for the routine determination of antitoxic immunity to tetanus. J Biol Stand 1986;14:231Y239. 4. Borrow R, Balmer P, Roper MH. Tetanus update 2006. In: Immunization,Vaccines and Biologicals (Immunological Basis for Immunization Series; Module 3). Geneva: World Health Organization; 2006: 1Y35.

14. Tetanus: A Review Nice review article Ataro, Mushatt, et. Al in J. Of the Southern Medical Association, Vol 614, 2011

15. Assess, Clean and Dress Assessment – Association with deeper structure injury Connective tissue Arteries Veins Nerves Lymphatics Cavities: Peritoneal, joint capsules – Document Position, Length, Width, Depth, peri- wound: Essentially the same as a Pressure Ulcer

16. Assess & Clean I assess the wound from outside in: Evaluate and Treat the WHOLE patient not just the HOLE in the patient See the location of the wound and begin with the whole patient, look fore and aft – Pulses, range of motion – Allows me to think about what might be at depth or behind or associated structures – Now you look at the wound

17. Basic Vascular Exam “Dorsalis pedis pulse was weakly/faintly palpable” This really means…. The doppler ultrasound was somewhere else Everyone should be familiar with a basic Ankle Brachial Index: ABI

18. Ankle Brachial Index Take the systolic blood pressure in each arm, select the higher of the two Take the systolic blood pressure above the ankle and below any injury Ankle value is the numerator of the two Ration should be > 1.0, ratios less than that and sometimes greater reflect injury or disease This gives a value that can be tracked (like the GCS for an extremity)

19. Clean Water, normal saline, antibiotic with saline Simple irrigation Pulse lavage Combination of lavage, low energy pulse lavage, high energy lavage-debridement Sharp debridement Combinations Hard to show value in antibiotic solution(s)

20. Clean, debride, and stabilize

21. J. Of Trauma Infection Prevention and Control in Deployed Military Medical Treatment Facilities Duane R. Hospenthal, MD, PhD, FACP, FIDSA, Andrew D. Green, MB, BS, FRCPath, FFPH, FFTravMed, RCPS, DTM&H, Helen K. Crouch, RN, MPH, CIC, Judith F. English, MSN, RN, CIC, Jane Pool, MS, RN, CIC, Heather C. Yun, MD, FACP, Clinton K. Murray, MD, FACP, FIDSA Prevention of Combat-Related Infections Guidelines Panel

22. Journal of Trauma Prevention of Combat-Related Infections Guidelines Panel All wounds and all patients should be assumed to be contaminated Universal Precautions Good clinical practice guidelines Immediate treatment for healing Mitigating later pathogenic and resistant bacteria

23. Personal Practice Habits NS lavage with low pressure pulse lavage, no high pressure to avoid driving debris Small surface areas—lavage with ultrasound Local lidocaine gels and soaks, regional anesthetic blocks over general First dressing often iodine based antimicrobial—but for hemostasis, not for antimicrobial Tissue approximation over complete closure OCT antibiotic ointment/xeroform early then Collagen based/foam protective dressings Common NPWT use

24. Gunshot Wounds = GSW’s Wound Care stresses examination of the whole person: treat the whole not the just the hole GSW’s are a microcosm of many wounding mechanisms Let’s combine acute care with wound care

25. GSW 101 A gunshot wound is the hole in the surface of the body from the projectile, not the trajectory – Count the wounds and then posit on the trajectories – One gunshot yields two GSW’s or one GSW and one retained bullet – Number of holes plus bullets should be an even number— unless shot before (increasingly common)_ The severity of the gunshot is largely determined by the transfer of Kinetic Energy to the body of the patient – KE = ½ MV 2 – Mass v. Velocity

26. Elephant gun v Assault Rifle Stopping Power 1916 Mauser KE = ½ Mass X VELOCITY 2 Contemporary M16 Large projectile Heavy Mass for “stopping power” Fewer rounds carried Single action Smaller rounds, but more rounds Automatic—every man gets a machine gun >1000 feet / sec Sound barrier, sonic boom Potential space behind projectile

27. High Velocity Projectile has a blast zone trailing behind it Injury from not only penetration of the projectile But from KE transferred Larger soft tissue injuries

28. 50 cal to leg Traumatic Wound

29. Number of holes (GSW’s) plus number of bullets must be an even number If not… – You are missing a hole or – You are missing a bullet or – You are miss identifying a graze or a fragmentation – Or the patient has been shot before Note …we now leave bullets IN Just double checking holes plus bullets pays off Now sometimes the holes plus bullets are impossible to track = an exploratory laparotomy or laparoscopy

30. Clean, debride, and stabilize

31. GSW’s are usually left open They can be simply cleaned They can be packed with an iodoform gauze packing strip or normal saline wet to moist – This may keep them being observed – This may keep them open—especially for long tracts this may be beneficial – They should be changed 1 – 2 times q 24 hours GSW’s can assist us with their blast effects

32. GSW’s v. Lacerations A knife will cut or puncture with very little transfer of energy—less damage to see on CT, more need for careful examination A GSW will have a blast effect related to its velocity – More gas in the tissues – More tissue disruption – More associated fluid/hematoma

33. Normal Saline Wet to…. Conflicted as a wound care professional—but this is where some judgement comes in Normal Saline wet to moist often becomes wet to dry – This should be viewed as a non-specific mechanical debriding dressing—almost anti- healing – I say almost because most patients with acute open wounds heal with NS wet to dry dressings

34. GSW’s in particular Most of our acute GSW patients are younger— they are going to heal Most GSW’s have some level of contamination in the wound tract and periwound The mechanical debridement of the NS works well: >2,000 traumas per year—1-2 wound infections Calls attention if increasing pain drainage – Most of the 1-2 that get infected are either long trajectories or have some retained material (clothing)

35. Enlightened NS wet to moist Use in setting of need for frequent dressing changes Utilize adjuncts: wound gels or even otc topical antibiotic ointments as lubricants when no longer needing mechanical debridement Topical collagen based dressings for large soft tissue areas Negative pressure dressings when clean

36. Case Presentation 24 year old male shot through the calf Right through and through What is notable about these wounds? Is this a high velocity bullet? Compartment syndromes

38. Compartment Syndromes Increased energy transfer will lead to compartment syndromes Calf, forearm, thigh & buttock and abdominal Better management strategies with NPWT

39. NPWT plus Mechanical traction to preserve tissue and coverage 5 5. Penn-Barwell, Fries, Street et al Use of Topical Negative Pressure in British Servicemen with Combat Wounds, Aug 2011 Open Access Plastic Surgery On-line

40. Large soft tissue wounds Leave open initially Frequent assessment At risk for infection—look for tip-offs Life over limb should frame your discussions with both patient and family 52 year old weekend warrior…..

41. Four Quarter Amputation of Arm Shoulder, clavicle, scapular… Notice we could resect, but preserve entire flap that was then closed with NPWT

42. Abdominal Compartment Syndrome managed with home made vac pack Fenestrated x-ray cassette cover over bowel Omentum over bowel Get edges as far laterally as possible – Cut slits for lateral drains or feeding tubes Get mass of viscera to sit down Gauze and suction drains or cut NGT tubes

43. Ioban and then wall suction Central sucked in wound should be hard Good wall integrity— patients can be extubated Place abdominal binder over this to back up suction Can be combine with multiple other modalities Why here in wounds--- – Weakened patients salvaged – Enterocutaneous Fistulas – Herias – More wounds in our future

44. Fasciotomies Military Success Going to see more fasciotomies being done Better technologies coming on line to diagnose Increasingly being done Acute care – Assess if adequate – Clean and re-debride: NS wet to moist

45. Summation of GSW Fragmentation of primary projectile may lacerate – Both patient and caregiver KE transferred may have a blast effect – Thermal burn usually at surface with close range – Sound barrier potential space behind bullet – Retained bullet has transferred all of its kinetic energy to the patient Proximity may also have a burn component

46. All GSW mechanisms added together Blast Injuries Blast Injury is particularly devastating – Thermal component – Physical (crush) component – Contamination component – Sonic boom component – Penetrating component How do (we) think (someone) gets the biggest bang for a bomb blast?

47. Postulated Ways to get more bang for your terrorist buck Closed space blast injury – Focuses the energy on the people in that space – Detonate a bomb with shrapnel – Make the shrapnel contaminated: biological, chemical or dirty nuclear—non-metal shrapnel, too – Detonate the bomb within an enclosed space to get a secondary effect of collapsing the structure around everyone and nearby structures Secondary Device – Initial detonation brings IN many people – Secondary Device will catch First Responders and increase effectiveness of both detonations, crippling responses, increasing lethality…

48. Blast Injuries 101 Is the area secure? Are you ready to protect yourself—is there decontamination needed? Examination of blast injuries – ABCDEF’s do NOT change – Severity of the blast concussion: tympanic membrane ruptures, corneal abrasions Sonic boom concussion Rapidity of blast--airbag

49. Blast injuries Direct tissue trauma Direct burn injury Indirect effects on gas filled spaces: bladder, bowel Penetrating injuries from multiple projectiles, shrapnel – Unexploded ordinance Contamination

50. High volume irrigation Leave soft tissue defects open—can now be managed with negative pressure Look for signs of other contaminants – Desaturation despite oxygen – Early vomiting – Coagulation defects – Early Liquefactive necrosis of tissues

51. Summary of Injuries Large soft tissue defects Usually on extremities due to body armor Often concomitant orthopedic injury Potentially traumatic/guillotine amputation Often due to blast exposure (IED or RPG) May have traumatic brain injury (TBI) Associated abdominal injuries

52. What Makes a Wound Complex? Multiple mechanisms – Blast – Burn – Shrapnel – High Velocity – Crush

53. 50 cal to leg Traumatic Wound

54. Traumatic Wound with Negative Pressure Wound Therapy (NPWT)

55. Traumatic Wound with NPWT

56. Wound Bed Preparation

57. Grafting

58. Graft After NPWT Bolster

59. Resolved

60. Limb Salvage The goal of limb salvage is to preserve a limb that will be more functional than a prosthetic if the limb is amputated If the extremity cannot be salvaged, the goal is to maintain the maximum functional length

61. Warrior Recovery from Complex Wounds Trauma centers are leveled—we are now beginning to level their affiliated rehab centers— the highest level are what we now seeing in the military: COL Alexander Stojadinovic, M.D., FACS, Director, Combat Wound Initiative Program, Director, Complex Wound & Limb Salvage Center Christian E. Paletta MD FACS, Complex Wound Limb Salvage Center, Walter Reed Army Medical Center

62. How can we learn together? This is a 60 year diabetic foot wound that failed to heal resulting in a through ankle amputation pending a BKA…. We used local therapies, local antibiotics, negative pressure and HBOT— Everything we talked about today He closed with a functional stump This was in 1999 What was once heroic, controversial is fasting becoming standard

63. References and credits Textbook of Military Medicine (2009). Care of the Combat Amputee. War Surgery in Afghanistan and Iraq: A series of cases (2003-3007). The Next Step. The rehabilitation journey after lower limb amputation. Vetelli, B. RN, CNS. WRNMMC Military Amputee Treatment Center. Crumbley, D., CDR, NC, USN, CWCN. VA Federal Recovery Program. Howard, R., CDR, MC, USN. Assistant Deputy Director, Plastics and Reconstructive Surgery WRNMMC. Deptuy Director, Orthopedics and Trauma, WRNMMC. Deyoung, P., LCDR, NC, USN. 2 nd MEF (FWD), 2 nd MLG, Al Taquadum Iraq (2007). Tingue, A., LTJG, NC, USN. Multinational Force, Kandahar Regional Military Hospital, Kandahar, Afghanistan (2010).

64. References www.ameriburn.org www.ameriburn.org www.aawcone.com www.aawm.org www.woundheal.org www.uhms.org www.facs.org AORN National Research Council of Nat’l Academy of Science Wendi Gordon Shelist Foundation : www.wgsf.org

65. Trends to keep an eye on… Damage Control Resuscitation with MTP/RRP, circulatory ECMO type support with RRT Forward critical care projections = FAME with MoREMTORN (DUSTOFF, PEDRO, MERT) Topical Hemostatics for both intra-cavitory as well as wound healing applications Advancing wound healing technologies— cultured STSG’s Better longer term rehab concentration for functional outcomes

66. Thank You BJH-WUSM, Department of Surgery, Dr. Eberlein, Section of Acute & Critical Care Surgery Walter Reed Besthesday and the leadership with Drs. Paletta and Stojanovich and LCDR Hitchcock FISIG AMSUS