Emergency War Surgery NATO Handbook: Part III: General
Considerations of Wound Management: Chapter XVI: Wounds and Injuries
of the Soft Tissues
Treatment Recommendations
United States Department of Defense
Peer Review Status: Internally Peer
Reviewed
Establish an adequate blood level of penicillin or an antibiotic
with a similar spectrum as soon as possible after wounding. Make
generous incisions of the wound to relieve mechanical pressure and
establish open drainage. Remove easily-accessible foreign bodies and
detached pieces of muscle, and irrigate the wound copiously. The
wound track is then inspected and any additional muscle whose gross
architecture is severely disrupted is excised. At the conclusion of
the procedure, complete hemostasis must be achieved to preclude the
subsequent development of collections within the wound that would
impede capillary perfusion of borderline tissues. The technique is
shown in Figure 24.
Figure 24
- Excise entrance and exit wounds with a narrow margin of skin
oriented parallel to the underlying muscle fibers. This excised
skin margin should include, in continuity, the underlying
subcutaneous tissue. These incisions should be generous, such that
optimal surgical exposure and adequate subsequent drainage will be
achieved.
- Through these openings, generously incise the fascia parallel
to the muscle fibers in both directions. The underlying muscle
surrounding the missile tract should be opened in the direction of
its fibers to the degree necessary to achieve exposure adequate to
inspect the track, remove foreign bodies, and excise non-viable
muscle These maneuvers are performed at both the wound of entry
and the exit wound. The muscle surrounding the central portion of
the track can usually be dealt with through the entry and exit
wounds. For example, a mid-thigh, through-and-through wound of the
soft tissues can generally be surgically managed by working
through the excised and extended wounds of entry and exit. This
approach precludes the necessity of cutting across good muscle
groups as is generally the case when one elects to connect the two
wounds. Appropriate drainage of war wounds is often easier said
than done. Liberal incisions tend to facilitate drainage from the
wound's deeper recesses. Whereas excision of skin, fascia,
arteries, nerves, veins, and bone is conservative, the excision of
muscle should be more liberal.
- As a dressing, dry sterile gauze should be laid lightly in the
wound. This should be no more than a wick. In no case should gauze
be "packed" into the wound since this additional pressure can
cause necrosis of any tissue that already has its blood supply
partially compromised.
- The single most important principle in the management of
battle wounds is their nonclosure following debridement. The
surgeon must not give in to the temptation to primarily close
certain "very clean appearing" war wounds. Such closure is ill
advised and inappropriate and can only be condemned. All wounds
must be left widely open with the following exceptions:
- Sucking chest wounds
- Joint capsules
- Wounds of the dura
- Some head and neck wounds; however, with severe
contamination it may be safer to leave these open.
- The delayed primary wound closure is usually performed in a
communication zone hospital 4-10 days after debridement, but
occasionally may be performed at the forward hospital when
evacuation has had to be delayed. The indication for delayed
primary closure is the clinically clean appearance of the wound.
Whereas most wounds are closed in the operating room utilizing the
interrupted wire technique and local or general anesthesia, some
may be very amenable to tape closure. This technique can be
initiated 4-6 days post debridement. Approximation of the skin
edges is accomplished with micropore paper tape or wide
"butterflies" applied in overlapping diagonal "basket weave"
fashion after the skin has been degreased with acetone, and
tincture of benzoin has been applied and allowed to dry
thoroughly. Edges of the wound may not come completely together
with the first tape application. This is not a problem, as they
will come progressively closer together with each reapplication of
tape, done at 48 hour intervals. Tape closure offers some
advantages over suture closure Even compression of wound edges
decreases skin edema, and the problem of cutting needles causing
additional tissue damage is avoided. The wound edges are very
vascular and needle passage can cause hematomas. Since tape
closure is, in reality, a gradual "encouragement" of the skin
toward closure rather than a total closure from the beginning, a
great margin for error is added and the potential complication of
wound breakdown, sometimes seen after suture closure, is almost
completely avoided. No anesthesia is needed for this procedure and
it can be performed by supervised ward nursing personnel.
It should be recognized that even though the surgeon diligently
attempts to excise all devitalized tissue, the dynamics of wound
physiology and the imperfections of ones ability to absolutely
identify nonviable tissue are such that some devitalized muscle
may be left behind or evolve over time in the wound. In the
appropriately drained wound, this minimal amount of devitalized
tissue will be absorbed or extruded. A small percentage of these
wounds will require a second debridement prior to delayed primary
closure. At worst, in the absence of adequate drainage, an abscess
that requires subsequent drainage may develop. In this situation,
antibiotics localize or isolate the deleterious effects of the
injury to the site of injury, thereby precluding systemic,
lifethreatening sepsis.
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