Emergency Management of Landmine Injuries Adam L. Kushner

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Emergency Management of Landmine Injuries

• Adam L. Kushner MD, MPH
• Physicians for Human Rights
• Landmine Victim Seminar
• Bogotá, Colombia
• November 12, 2003

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Weapon of mass destruction in slow motion
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Prevention is the First Priority
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What are some Differences?

• Trauma care
• Locations
• Resources
• Management
• First aid
• Tourniquet
• Assessment
• Surgery
• Post-operative
• Rehabilitation
• Mental health

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Transport Time
ICRC data
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Length of Stay (LOS) and Blood Transfusion Rate
ICRC data
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Amputation Rate per 100,000 Population
ICRC data
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Amputation Rates

• Amputees in population
• Cambodia 1 in 236
• Angola 1 in 470
• Somalia 1 in 650
• USA 1 in 22,000

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Injury Patterns

• Pattern I Traumatic amputation from blast mine
  (30)
• Pattern II Injuries from fragmentation mine
  (50)

• Pattern III Upper extremity injury and
• blinding from handling or demining (20)

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Pattern I Injury
International Committee of the Red Cross
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Typical Injuries

• Traumatic amputation
• Lower extremity soft tissue injury
• Extremity fractures
• Perineal/genital injury
• Abdominal injury
• Upper extremity soft tissue injury
• Finger/hand amputation
• Eye injury/blindness
• Hearing loss
• Pneumothorax
• Burns

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Integrated Approach
Local Communities Health Care Workers Government
Officials Transportation Communications
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GUIDELINES FOR THE CARE AND REHABILITATION OF
SURVIVORS

• EMERGENCY MEDICAL CARE
• Healthcare and community workers in mine-affected
  areas should be trained in emergency first aid to
  respond effectively to landmine and other
  traumatic injuries.
• First aid training to respond to traumatic
  injury and severe bleeding increases the chance
  of mine victims living long enough to receive
  emergency medical care. First aid training should
  be conducted by qualified medical professionals
  who can uphold standards and provide follow-up
  training. Where appropriate, mine awareness
  educational materials could incorporate basic
  instructions for first aid response to traumatic
  injury and massive bleeding. Preparation should
  integrate a public sector and community plan of
  action and investment in communication and
  transportation systems to improve access to
  medical care.
• CONTINUING MEDICAL CARE
• Medical facilities should have medical care and
  supplies that meet basic standards.
• Surgery and additional medical care is required
  to rehabilitate survivors and make it possible
  for an amputee to use a prosthesis. Facilities
  should meet certain basic and minimal
  requirements, such as clean instruments and
  water, to be operational. Due to the special
  nature of mine injuries, care should be given to
  build a cadre of skilled surgeons and other
  health personnel. Useful training tools for
  surgeons include a surgical theater and manual
  for emergency care and follow-up, including
  proper amputation procedures and reconstructive
  surgery.

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Hospital with general orthpaedic surgeon
Hospital w/ general, orthpaedic and specialty
surgeons
GP staffed hospital w/ surgery capability
Tertiary care w/ limited resources
Hospital w/general surgeon
Village health post
Tertiary care w/ full
GP staffed hospital
Clinic w/ nurse
Clinic w/ doctor
Basic
GP Hospital
Specialty Hospital
Tertiary Hospital
Spectrum of Health Care Facilities
Essential Trauma Care Guidelines p.
99 www.iss-sic.ch World Health Organization (WHO)
and International Association for the Surgery of
Trauma and Surgical Intensive Care (IATSIC)
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Rights of the Injured Patient

• 1. Life threatening injuries are appropriately
  treated, according to appropriate priorities and
  in a timely fashion, to maximize the likelihood
  of survival.
• 2. Potentially disabling injuries are treated
  appropriately so as to minimize functional
  impairment and to maximize return to independent
  and participating community life.
• 3. Pain and psychological suffering are minimized

World Health Organization (WHO) and International
Association for the Surgery of Trauma and
Surgical Intensive Care (IATSIC)
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Interventions
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Care Where Injury Occurs

• 1. Wait
• 2. Remove injured person
• 3. Keep airway clear
• 4. Stop bleeding
• 5. Wash wounds
• 6. Keep wounds wet
• 7. Splint limb
• 8. Look
• 9. Report
• 10. Transport

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Tourniquet Use
Controversial!!
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Care at the Health Clinic-Basic

• Primary Survey
• A - Airway
• B - Breathing
• C - Circulation
• D - Disability
• E Exposure
• Secondary Survey
• Interventions
• Record Data
• Transport for Definitive Care

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Hospital Management

• Assessment
• ABCs
• Resuscitation
• Early Surgical Intervention
• Examine in OR
• Debridement
• Delayed Primary Closure

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Preoperative Considerations

• Resuscitation
• Antibiotics, anti-tetanus serum and tetanus
  toxoid
• Radiography
• Anesthetic considerations
• Spinal
• General
• Operative planning

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All War Wounds are Contaminated
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Wound Management

• Debride all dead and contaminated tissue
• Remove all foreign material
• Keep skin
• Liberal fasciotomy
• Remove unattached bone
• Vessels need flaps, nerves can remain exposed
• Absorbable suture for hemostasis, doubly ligate
  large vessels

Coupland, RM, Br J Surg, 1989, 76 663-7
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Delayed Primary Closure

• Leave wounds for 5 days
• Fever
• Tachycardia
• Purulence
• Remove dressing in OR
• Close if not infected

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Rehabilitation

• Early ambulation
• Prosthetics
• Social reintegration
• Mental health

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Guidelines

• Guidelines for Essential Trauma Care
• World Health Organization (WHO)
• International Association for the Surgery of
  Trauma and Surgical Intensive Care (IATSIC)
• http//www.iss-sic.ch/pdf/etc_guidelines.pdf
• Pre-hospital Trauma Care Guide (WHO)
• In press.

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Trauma Courses

• Advanced Trauma Life Support www.facs.org
• National Trauma Management Course www.iss-sic.ch
  
• Definitive Surgical Trauma Course www.iss-sic.ch
• Essential Surgical Skills www.cnis.org
• Primary Trauma Care www.asa.org.au
• Trauma Nursing Core Course www.ena.org
• Trauma Team Training Course www.cnis.org

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Conclusions

• Landmine injuries are similar and different!
• Integrated approach
• Health care workers and local communities
• Transportation and communication
• Education and training programs
• Pre-hospital management
• Trauma care
• Knowledge of wounds and management
• Debridement and delayed closure
• Early physiotherapy and rehab