Complicated issues of wound management

Debridement is dictated by the magnitude of tissue destruction and contamination, the presence of foreign material (e.g. shotgun wadding) and/or tissue necrosis, and the time interval between injury and definitive treatment ( Fig 4). Low-velocity wounds usually only require local debridement of the entrance and exit sites. Wounds secondary to high-velocity missiles and bombs, and multifragment wounds (shotgun, grenade), require operative debridement more frequently.

Fig. 4 Management of soft tissue wounds.

High-velocity injuries alone are not an indication for debridement as many can be managed by drainage, antibiotics, and dressing changes ( Blel!lam.y...§nd Z§iíCh.y„k 1991). During debridement, devitalized tissue, determined by loss of muscle contractility, cyanosis, and/or lack of bleeding, should be carefully resected. Entrance and exit sites should be opened longitudinally, and the wound possibly opened to the deepest point. Fasciotomy and a second-look procedure should be considered for extreme injuries. If tissue destruction and/or contamination is too extensive, 'guillotine' amputation may be required, with the amputated limb being a potential source for donor skin. Defects in the chest and abdomen can be closed using muscle flaps, prosthetic mesh, and/or methylmethacrylate sandwiches. Tetanus prophylaxis should be given early. Systemic antibiotics appear to be effective in controlling initial contamination but do not prevent subsequent colonization of an open wound. Topical antibiotics and burn cream, such as silver sulfadiazine, are useful in small superficial wounds, while frequent saline dressing changes and/or whirlpool treatments can keep larger wounds clean. If necrotizing infections or wound sepsis develop radical debridement, systemic antibiotics and aggressive resuscitation directed by invasive monitoring may be required. Hyperbaric oxygen therapy is still unproven. High-velocity injuries to the gluteal area present a particular risk for massive tissue infection and a diverting colostomy may be required ( B®JJ.§m.y.§Od...Z§itchuk...1991). Ultimately, all wounds can be closed by secondary intention, skin grafts, omental grafts, or musculocutaneous flaps (pedicle, advancement, and/or free).

Myoglobinuria can be a complication of both compartment syndrome and massive soft tissue destruction. Prevention includes early fasciotomy and amputation rather than attempts at limb salvage. The aim is to prevent renal failure and to maintain a urine flow rate above 100 ml/h with aggressive hydration. Mannitol may be useful, acting as an osmotic diuretic as well as an O2 radical scavenger. The use of sodium bicarbonate and furosemide (frusemide) remains controversial. Diuresis should be maintained until serum creatine phosphokinase levels return to near normal and the urine myoglobin clears ( Fig 5). Electrolytes, particularly potassium and calcium, should be monitored.

Fig. 5 (a) This patient required fasciotomies of the calf and thigh compartments following an electrical injury that resulted in compartment syndrome. (b) Dark urine characteristic of myoglobinuria in the patient in Fig 3(a).

Retained missiles and foreign objects may present a particular problem. 'Dum-dum', hollow-point, and other missiles become deformed and lose up to 30 per cent of their mass after impact, resulting in complex injury tracts. 'Exploding' bullets may be triggered by ultrasound or cautery. If such a bullet is imbedded in an organ, resection of the organ rather than direct removal is the safest method of retrieval ( Sykes ei a/ 1988). Lead poisoning is rarely seen with modern bullets, but the risk is increased if the bullet is retained in a synovial joint or is imbedded in the bones of a patient with osteoclastic lesions. Phosphorus grenades and bombs filled with soap may leave residue in the wound, so that debridement in a water bath is required. Until definitive surgery, the area should be soaked in saline gauze.

Missile embolization is a rare event that may occur following shotgun or small-bullet injury. In the Vietnam War, missile embolization occurred in 22 of 7500 vascular trauma patients with 80 per cent arterial embolization and 90 per cent migrating antegrade (i.e. towards the lung) ( B.®.J!am.y a.Dd..Zaitchuk...1991,; Shackford §nd R.ich 1991). If the missiles are large and/or are associated with pulmonary symptoms, treatment involves extraction by interventional radiology or operatively. In those rare patients with a patent foramen ovale, the missiles may cross to the systemic circulation, subsequently embolizing to coronary, cerebral, or other vessels. Small pellets entering the coronary circulation can result in myocardial ischemia that may be severe enough to warrant operative extraction and coronary bypass ( Fig 6).

Fig. 6 A patient who had sustained a shotgun wound to the right thigh without obvious vascular trauma developed chest pain 24 h later. ECG suggested acute ischemia in the anterolateral area (left anterior descending distribution). This chest radiograph demonstrates pellets in the left chest. Coronary angiography confirmed coronary artery embolization, presumably through a patent foramen ovale. Operative removal was successful.

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