Hello, my name is Christy Hertel, and I am an advanced practice provider with trauma and surgical critical care at ECU Health Medical Center in Greenville, North Carolina. This session, I will be talking about trauma care during a humanitarian crisis. I have no financial disclosures. The objectives for this session are to describe principles of damage control surgery, discuss management of blast and crush injuries, and discuss use of ultrasound in austere environments. Humanitarian crises are plagued by limited resources, including lack of equipment and personnel. Mashed casualty events put further strain on the available resources. Creation of a system that allows for damage control surgeries close to the point of injury can save lives. Preparation of follow-up care at a different location will reduce strain on resources at the field hospitals. Damage control surgery was first introduced in the 1980s as a way to deal with the triad of death, acidosis, coagulopathy, and hypothermia in severely injured patients. Damage control consists of an initial surgery followed by ongoing resuscitation, and then later a definitive surgery. The goal of the initial surgery is to control hemorrhage, restore blood flow, and control contamination. For damage control orthopedic surgeries, this includes stabilization of fractures. Although damage control surgery was first used for abdominal trauma, it has now been extended to include thoracic, extremities, and spinal injuries. The principles for the initial surgery remain the same, control hemorrhage, restore blood flow, and control contamination. These images show various patients following various damage control surgeries. The top right corner is the algorithm for damage control spine. Spine stabilization depends on the degree of injury and begins with the initial decompression followed by further stabilization at a later time. This can include an anterior discectomy and fusion, followed later by a posterior fusion, replacement of a cervical traction for initial decompression. The top left corner shows a damage control thoracotomy. Initial surgery could include wedge resection and evacuation of a hematoma. Following resuscitation, further evaluation of the thoracic cavity with washout enclosure can occur. Thoracotomy tubes are placed at initial surgery and following definitive surgeries for lung re-expansion. The bottom right picture is a damage control abdomen with a negative pressure wound vac in place. Finally, the left lower corner is a damage control extremity with external fixator in place with further surgery for definitive open reduction and internal fixation to occur at a later time. In the operational environment, blast injuries result in severe injuries that will require damage control surgeries. Blast injuries result from four different types of trauma. The initial blast wave can cause internal damage to solid and hollow organs, especially in the thoracic and abdominal cavities, along with head injuries. The second trauma is caused from shrapnel from the blast that can lead to penetrating wounds. The body's displacement and subsequent impact lead to blunt trauma. And finally, a body can sustain burns as a result of the blast. Management of patients with blast injuries should be completed systematically. Initial management in blast injuries should be to control hemorrhage. Large open wounds and amputations are common. Use of tourniquets to extremities above the site of injury should be placed to control hemorrhage from amputations or injuries resulting in arterial hemorrhage. Open wounds that do not appear to have arterial bleeding can be treated with a Kalon impregnated gauze packed tightly into the wound. Following hemorrhage control, the airway should be secured. An orally placed endotracheal tube is the best option. If a difficult airway is present and transport time is not lengthy, a subglottic airway could be used in an unconscious patient. A cricoid thyroidotomy is an emergent surgical airway that is placed by experienced personnel. Control of bleeding includes providing oxygen and assessing for signs of hemo or pneumothorax or a sucking chest wound. A sucking chest wound should have a three-sided dressing place to allow air out but seal to prevent return of air with exhalation. Placement of a thoracostomy tube is optimal if supplies are available. If a thoracostomy tube is not available, a finger thoracotomy is an option that can be completed to reduce the air or blood causing tension. IV lines should be placed with initiation of whole blood transfusions if available. If whole blood transfusions is not available, then a one-to-one resuscitation with packed red blood cells, fresh frozen plasma, and platelets should occur. Trauma patients are considered in hemorrhagic shock until proven otherwise and should be treated with blood transfusions. Traumatic head injuries are common with blast injuries and trending Glasgow Coma Scale and pupillary reaction can help to detect increasing intracranial pressure. A humanitarian crisis that results from natural disasters or war zones can result in crush injuries from extremities being trapped under debris from falling buildings. Crush injuries result in damage to skin and soft tissues. Extremities have compartments that enclose muscles, tendons, and nerves within a fascial sheath. Swelling that occurs as a result of a crush injury can lead to increased pressures within these compartments. Assessment of the five Ps, pain, pallor, paralysis, paresthesia, and pulselessness to evaluate for compartment syndrome should occur frequently. If compartment syndrome is suspected and equipment to assess compartment pressures is not available, fasciotomy should be completed to prevent loss of limb. For crush injuries that have open wounds, removal of debris should occur and empiric broad-spectrum antibiotics should be administered. Operative irrigation and debridement with temporizing stabilization damage control should occur as soon as possible. Prior to mobilizing the patient, extremities should be placed in a split for immobilization. Rhabdomyolysis results from muscle damage and ischemia from crush injuries. Heart output should be monitored for amount and color. Rhabdomyolysis can lead to acute kidney injury. It is treated with forced diuresis using crystalloid fluid and extreme cases with AKI dialysis will be required. Point-of-care ultrasound developed in the 1990s with implementation of the FAST, focused abdominal sonograph for trauma exam in trauma patients. As the machines became more compact and affordable in the 2000s, they began to be utilized by providers throughout healthcare fields. Now handheld devices are available and will revolutionize the care of patients in pre-hospital and resource-limited settings. Point-of-care ultrasound can be utilized in the assessment of multiple organ systems. Cardiac function can be determined including estimated ejection fraction and hypokinesis of chambers if cardiac event is suspected including acute MI or blunt cardiac injury. Evaluation of respiratory variability within the vena cava is used to determine fluid status. Pulmonary edema, pleural effusions, and pneumothorax can all be detected using point-of-care ultrasound. Viewing the hepatic renal junction and spleen renal junction can assess for hemoperitoneum. Ultrasound has been utilized to measure the optic sheath and when it has increased diameter, this is an indication of increased intracranial pressure. Transcranial Doppler's measures the velocity of blood flow through the artery and increased flow velocity equals decreased flow and probable vasospasm. Deep vein thrombosis and arterial injuries can be identified in extremities utilizing ultrasound. Continued evaluation and research regarding current trends in trauma care during humanitarian crisis is needed to continually improve morbidity and mortality. Education and training of personnel involved in the care of the critically injured on new and evolving technologies and advancements in care is required to ensure optimal management for these patients. Thank you for your time and attention during this presentation. I would be happy to answer any questions. For more information, visit www.fema.gov

trauma care

humanitarian crisis

damage control surgery

blast injuries

crush injuries