Severe secondary blast injuries –

contemporary surgical approaches

Mutafchiyski V

Hepato-Biliary-Pancreatic and Transplant Surgery

Military Medical Academy – Sofia, Bulgaria

Blast trauma -key factors

Amount of explosive

Distance from explosion

Type of explosive

Structure collapse

Personal protective equipment

Indoor / Outdoor

Fragments

Blast injuries (n=114)

Secondary blast

injuries

More frequent

Caused by flying

fragments

Usually multiple

Affects all body

structuresPBI SBI TBI QBI

Mutafchiyski V. Management of blast trauma, 2009

Military trauma

Complexity

Multiple injuries

Massive haemorrighe

Staged approach

Damage control surgery

Fast assessement

War wounds - Red Cross Wound Score

Simple clinical system that requires no extra

equipment or sophisticated procedures

Standardized scheme for assessment and communication

of war wounds

Establishing a scientific approach to war surgery

Possibilities for surgical and hospital audit

Bring wound information from the battlefield

War wounds - Red Cross Wound Score

Evaluate six parameters – E (entry of wound – cm), X

(exit of wound), C (cavity), F (fracture), VS (vital

structure), M (metallic body)

Grading of wounds according to severity

G1 – E+X less than 10 cm and CO, FO or F1

G2 – E+X less than 10 cm and C1 or F2

G3 – E+X more than 10 cm and C1 or F2

Typing of wounds depending on injured tissues – ST (soft

tissue), F (fracture), V (vital structure), VF (fractures

involving vital structures)

Wound classification

Stages of Damage Control Surgery

Control of bleeding and wound contamination

(R2-R3)

Intensive care (R2-R4)

Planed reoperations for control of wound

infection and treatment of sepsis, followed by

reconstructive and plastic procedures (R4)

Material and methods

5 patients – males

Average age 28 years (vary from 25 to 36)

TNT equivalent of the explosive – average 3,2 (from 0,4 to 7)

4 cases – high order explosive

1 case – improvised explosive device

ISS of the injured – average 19,4 (from 12 to 29)

The fragments affect the abdomen in 2 cases

Transitory injury of the rectum

Liver rupture

Material and methods

N Wound Е X C F V M Severity ClassificationISS

1

1- pelvis, abdomen

12 25 C1 F2 VA M0 G3VF3 large woundthreatening live 27

2- tight 2 0 C0 F1 V0 M1 G1 F1 simple fracture

2

1- face 2 0 CO F1 V0 M1 G1 F1 simple fracture

172- tight 5 0 C1 F0 VH M1 G2

ST2 medium soft tissue wound

3

1- abdominal wall

4 0 C1 F0 V0 M1 G2ST2 medium soft tissue wound

12

2- tight 5 0 C1 F0 VH M1 G2V2 medium wound threatening live

4

1- forearm 12 0? C1 F2 VH M0 G3VF3 large wound threatening live

29

2- shank 5 0 C1 F0 V0 M1 G2ST2 medium soft tissue wound

5

1- face 3 0 C0 F0 V0 M1 G1 ST1 simple wound

122- shank 6 0 C1 F0 V0 M1 G2

ST2 medium soft tissue wound

Damage control surgery (Role 2)

The forward teams strived to evacuate the victims till one hour “gold hour”, but it’s not always possible

Primary surgical treatment War wounds are usually contaminated and they must be treated

without primary closure

Wound packing – limits

the hemorrhage and allows

surgical treatment to be

postponed up to 6 hours

The so-called

“Swiss cheese surgery”

should be avoided

Role 4 hospital treatment

The presence of multiple wounds, frequently

associated with gross tissue damages is the basic

reason for prolongation of hospital stay

This period could be decreased by using of

contemporary methods for wound treatment

Inter pulse jet irrigation

Irrigation with NaCl 0,9% in quantity 1000ml/10 cm2

The procedure require repetition on each 48 hours

Inter pulse jet irrigation

Microbiological evaluation of wound should be made

regularly before debridement

The most frequently isolated bacteria were

P. aeruginosa

K. pneumoniae

E. cloacae

Decrease of level of colonization with 40% after irrigation

with 500ml/10 cm2 was observed

Decrease with 70% after application of 1000ml/10cm2

was observed

V.A.C. pack

Negative pressure

dressing

Decreases

contamination

Ensures good drainage

of wound secretion

Stimulates formation of

granulations

V.A.C. pack

125mm negative pressure was used

Redressing on every 48 hours

It’s correct application increase the rate of granulation up to 50%

Results

All patients were with severe hemorrhage – average

level 1152 ml (vary from 620 to 2100)

Four of them underwent blood transfusions

Blood losses were compensated according to 1:1:1 formula

Secondary and tertiary blast injuries were the most

severe

The usage of personal protective equipment

decrease the number of the secondary blast injuries

of thorax and abdomen

Results

Distribution of severity of blast trauma depending on affected tissues (n=114)

Mutafchiyski V. Management of blast trauma, 2009

Head and neck

Face Thorax Abdomen Extremities Burning

Minor trauma (ISS 1-8)

Severe trauma (ISS 15-24)

Moderate trauma (ISS 9-14)

Critical trauama (ISS>25)

Results

Mortality - 0

N AgeBlood

loss (ml)Blood

transf (n)Stayin R2

Stay in R4

Wound’s healing

Complications

1 36 1400 5 2 51 48Sepsis, wound

infection

2 25 950 2 1 23 19 Wound infection

3 26 620 - 3 17 16Neuritis of auditory

nerve, otalgia

4 28 2100 12 1 42 34Sepsis, wound

infection, stress

5 25 690 1 2 19 18 Wound infection

Results

Conclusion

Treatment of secondary blast injuries is a challenge for the

surgeons despite of the contemporary resources of medicine,

because of the multidimensional effects of the blast

The presented cases demonstrate the complexity of blast

trauma

The initial treatment must follow the principles of DCS

The final stages should be made by multidisciplinary team

capable to apply the contemporary achievements of surgery

and reconstructive medicine