1. By; Dr.Abrar Hussain Zaidi
In the name of ALLAH the most beneficent the most merciful
“The First” wound debridement in IED –blast injuries: The 7S’s Doctrine
By;
Dr.Abrar Hussain Zaidi

2. Prologue IED- blast injury wounds are unique
First wound debridement is the key to successful management in Every wounded But it needs special emphasis In case of IED- blast injuries
IED- blast injury wounds are unique
Wound are Contaminated and poisoned by organic and inorganic materials
Need - Thorough surgical debridement within six hours – under full anesthesia

3. Objectives of Presentations
Young surgeons must learn to apply The “7S’s” doctrine of wound debridement routinely while treating the IED-blast wounds

4. Types of IED blast wounds
Explosives Type -[high-order explosives (HE) or low-order explosives LE).
Primary : Blast effect/ Pressure wave injuries
Mutilating soft tissues , Amputations
Severe Structural damage of body.
Secondary : Splinter injuries/ wounds
May look minor but play a havoc inside
Tertiary injuries : Body displacement ,Fracture / Blunt injuries
Quaternary : Body entrapment – Building falls/Crushing/
Burns Combinations of different types can be seen in one patient

5. Peculiar features of IED blast wounds
Contamination with toxic materials & with metal objects
Tissue damage much more than apparent first outlook
Splinters make deep Burrows [ like rodents]
Extensive local & Systemic sepsis can occur even with small wounds- if neglected
Retained FBs often missed

6. IED’s - Composition Made from a variety of different materials :
Conventional Explosives
Commercial blasting materials
Fertilizer, fuel oil, other household ingredients.
Incorporating;
Metal fragments of different nature: nails, ball
bearings, screws,pieces of tin
Gravel, marble, stones-----[missiles]
Lubricants

7. Typical victims
Wounds may be found in one body region/ a limb or may be extensive multi regional

8. Typical victims

9. General principles of wound debridement
Wound toilet / Thorough washing and irrigation/ Remove –dirt, debris, devitalized tissue
Excise dead and potentially non-viable tissue
Locate and remove as many FB’s as possible
Gauze pack and leave the wounds open
Decide early for amputations
Vascular repair attempt only when distal viability is undoubted
Delay the nerve repair
Delay definitive fracture repair – temp. external fixations
Stabilize

10. Practical Application of Principles of debridement in operation theater
THE – “7S’s” – Doctrine
Saline Irrigation – Saline/Water jets/wound toilet
Scrubbing – Use Brush and gauze
Shaving Shaving machine / razor
Searching Scoops & forceps
For In depth FBs / gravel/ mud
Scissors &Scalpel Wound Extension
Salvage OR Excise – Wound Excision /Amputation
Stabilization – Dressing / Ext fixations

11. Team efforts

12. Saline irrigation Generous toilet /irrigation / removal of devitalized tissue

13. Scrubbing the wound Using Brush and gauze

14. Scrubbing the wound Using Brush and gauze

15. Scrubbing the wound Using Brush and gauze

16. Scrubbing the wound Using Brush and gauze

17. Shaving the wounds

18. Searching for FBs - Metals VS non metal
Metals can be left and observed but organic materials and stones should be removed

19. Searching - For FBs / gravel/ mud

20. Scooping- In depth search and cleansing
Small minor looking wounds are as dangerous as bigger ones

21. Scooping- In depth search and cleansing

22. Scissors & Scalpel Use for Wound Extension & Fasciotomies .

23. Scissors & Scalpel Use for Wound Extension & Fasciotomies .

24. Scissors & Scalpel Use for Wound Extension & Fasciotomies .

25. Scissors & Scalpel Use for Wound Extension & Fasciotomies .

26. Salvage OR Amputate - decisions
Timely decision have saved many lives
A few Late decisions have resulted in deaths

27. Salvage vs amputation- decisions

28. Salvage vs amputation level decisions and preservation
How much can be preserved/ salvaged
The level of Amputation

29. Stabilization and Dressings
Do not apply too tight dressings
Ensure proper seal and suction if vac- pack applied
Remove soaked dressings – sos/ bd /tds/
Dry dressings with good padding can be left for hours
Vac – packs - change/ reapply – 3-5 days
Crammer wire / plaster
Temporary fracture stabilization External fixators / K wires

30. Stabilization & Dressings
Pre-prepared dressing pads
Simple gauze dressing
Cotton and Gauze pads
Intermittent Suction – Guaze packed open wound
Vac-pack . Selective cases (Continuous or intermittent pressures, with levels varying between −125 and −75 mmHg depending on the material used and patient tolerance- adequate wound bed preparation skin grafting).

31. Practical application of principles of debridement in operation theater
THE – “7S’s” – Doctrine
Saline Irrigation – Saline/Water jets/wound toilet
Scrubbing – Use Brush and gauze
Shaving Shaving machine / razor
Searching Scoops & forceps
For In depth FBs / gravel/ mud
Scissors &Scalpel Wound Extension
Salvage OR Excise – Wound Excision /Amputation
Stabilization – Dressing / Ext fixations

32. Added procedures
Amputations / Revision amputations preserving healthy soft tissue flaps
Fecal diversion – wound over Perineum / thigh
Treatment of abdomino-thoracic/ spinal/ head injuries

33. Imaging

34. Relooks & Repeat debridement
Ist. Re- look and repeat debridement
After twenty four hour
2nd Re look – 48 hours.
Check for vitality and viability of tissues
Vital Decisions for limb preservation Vs Amputation
Repeat debridement- as per need
Subsequent dressings in ward / OT
Plan for definitive care:
Simple conventional wound closure
Skin Graft
Staged wound closure

35. Out come
Early recovery / minimal systemic and local complications / good wound healing

36. Out come
Early preparation of wound for definitive closure/ grafting

37. Wound closure
Prepared for early muscle flap and skin cover

38. Conclusion But This is only way we can save a patient’s life.
First wound debridement in IED blast injuries is pains taking & tiring
But
This is only way we can save a patient’s life.

39. The spirit of trauma care services

40. Thank you