Field Surgery




INTRODUCTION



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Field surgical procedures are for the most part relatively uncommon with few cases reported and published. Barriers to reporting likely include a preponderance of poor or unfavorable outcomes and the perceived risk of litigation in these high acuity scenarios. Although some hospital-based surgical “go teams” exist,1,2 it is more likely that an EMS physician will be responding to these incidents in most communities. Rather than task a system to make available an additional trauma surgeon it is seemingly more appropriate for EMS physicians (of all primary training backgrounds) to maintain their education and training in these potentially lifesaving procedures. The following text is meant as an introduction to these procedures as they are likely to be performed in the austere and limited environment of the prehospital setting and in no way meant to substitute for, or replace the need for, EMS physicians to study and train on these techniques in the controlled environment of the anatomy lab or operating theater.




FIELD SURGICAL PROCEDURES



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  • Extremity amputation



  • Thoracotomy



  • Escharotomy



  • Fasciotomy



  • Perimortem cesarean section





FIELD SURGERY KIT



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    EMS Physician Basic Instrument Kit (Centurion SUT17530)

  • 1 Fenestrated drape



  • 4 Cloth towels



  • 1 Spinal needle, 20 gauge × 3 ½ in



  • 1 Needle, 18 gauge ×1 ½ in



  • 1 Needle, 27 gauge × 1 ¼ in



  • 2 Syringes, 10mL



  • 20 Gauze sponges



  • 1 Safety scalpel with #11 blade



  • 1 Safety scalpel with #15 blade



  • 1 Safety scalpel with #21 blade



  • 1 Tracheal hook



  • 1 Tracheal dilator



  • 1 Forcep, 1:2 teeth



  • 1 Curved scissors



  • 1 Needle holder, 6 in



  • 1 Needle holder, 8 in



  • 3 Curved hemostats



  • 3 Straight hemostats




    Additional Instruments

  • 2 Gigli saw handles



  • 4 Gigli saw blades



  • 1 Safety scalpel with #10 blade



  • 1 Rib spreader



  • 4 Tourniquets (CAT or SOFT-T style)



  • 1 Disposable OB kit



  • 2 W35 skin staplers



  • 2 Syringes, 20mL




    Optional Instruments

  • 2 Army navy retractors



  • 1 Curved (Metzenbaum) scissors



  • 2 Russian forceps, 5½ in and 8 in



  • 1 Bladder retractor



  • Other instruments as preferred by EMS physician/team





FIELD AMPUTATION



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Field extremity amputation is a relatively uncommon procedure for any EMS physician to have to consider; however, there is a documented need for this capability in the prehospital setting.310 Because of the potential for an awake patient to possibly require such a drastic and potentially painful intervention, it is appropriate for the EMS physician to ensure the availability of sedatives (eg, ketamine, midazolam, etomidate) and analgesics (eg, fentanyl, morphine) on the scene, by either carrying them with them or having them available by other means within the system.



    Indication

  • When the entanglement of an extremity (or extremities) precludes timely rescue and patient care that is deemed necessary to sustain life, and it is believed that survival of the patient without the amputation of the extremity is doubtful, the choice must be made between life and limb. In cases where immediate rescue from the entanglement is not necessary for life preservation, care and time should be taken to exhaust all options for disentanglement before field amputation is considered. In some cases, where traumatic amputation is nearly complete and the patient has signs of potential life-threatening injuries it may be appropriate to consider field amputation if the partially amputated limb is unlikely to be salvaged. In this case the procedure is to complete, rather than perform, the amputation.



  • In cases where a living victim is entrapped by a deceased victims remains, it may be necessary to perform a dismemberment (by the same technique) in order to rescue the living victim.




    Equipment

  • Face mask with an eye shield or goggles



  • Povidone iodine or chlorhexidine solution



  • 2 Straight hemostats



  • Gauze pads



  • 2 Gigli saw handles



  • 1 Gigli saw blade



  • 1 Safety scalpel with #10 blade



  • 1 Curved scissors



  • 1 Tourniquet (CAT or SOFT-T style)




    Technique

  • After establishing intravenous access and addressing issues of sedation and analgesia, attempt one more disentanglement procedure by rescue personnel. If this fails or patient condition precludes it, optimize airway and ventilator management and proceed with the amputation.




    • Step 1: Place a tourniquet to the proximal limb and mark the time (Figure 64-1).



    • Step 2: Choose a location as distal as possible and perform a prep with antiseptic solution if time and environment allow.



    • Step 3: Incise the skin circumferentially with the #10 Scalpel blade, cut through the subcutaneous tissue, and open the fascia (Figure 64-2).



    • Step 4: At this point some EMS physicians might proceed by identifying muscle groups and attempting to divide with scissors, identify likely blood vessels, and apply clamps.11 Alternatively, the muscle groups and vessels can be divided sharply with the #10 Scalpel blade if the tourniquet is properly in place (Figure 64-3). If there is any question of hemostasis, then clamping major arteries may be appropriate.



    • Step 5: (Optional) Wrap two gauze pads or sterile towels around the extremity at the incision site and apply a clamp to hold the ends of each together and use to gain purchase of the bone and retract the surrounding soft tissues.



    • Step 6: Place the Gigli saw wire around the bone(s) (Figure 64-4), connect the saw handles, and with smooth long strokes divide the bone(s) (Figure 64-5).



    • Step 7: Evaluate the stump and address bleeding if present (Figure 64-6).



    • Step 8: Apply a padded dressing the wound and allow rescue of the patient to be completed and the patient transported to the trauma center.



    • Step 9: If it can be recovered, transport the amputated limb to the hospital.




  • Patients undergoing field amputation should receive tetanus prophylaxis and broad spectrum antibiotics to reduce risks of infection.





FIGURE 64-1.


Tourniquet placement. Place a tourniquet to the proximal limb. Here a combat application tourniquet (CAT) is used.






FIGURE 64-2.


Circumferential skin incision. Incise the skin circumferentially with the #10 Scalpel blade, cut through the subcutaneous tissue.






FIGURE 64-3.


Sharp division of tissues. The circumferential wound is extended through the deep tissues and down to the bones.






FIGURE 64-4.


Placing the Gigli saw wire. The Gigli saw wire is slid underneath and looped back and then hooked onto the handles






FIGURE 64-5.


Dividing the bones.






FIGURE 64-6.


Evaluate the stump. Evaluate the stump and address bleeding if present address by tightening the tourniquet, then apply clamps only if necessary. The patient is now able to be rescued and transported. Apply a dressing and transport.





    Complications

  • Intentional loss of offending limb



  • Loss of life/death



  • Hemorrhage



  • Nerve damage



  • Operator/assistant injury





PREHOSPITAL THORACOTOMY



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Although emergency resuscitative thoracotomy is traditionally considered a somewhat heroic measure with relatively poor outcomes the practice of prehospital thoracotomy continues.12,13 A number of successful cases have been reported individually and in series and the practice is considered routine in some services when criteria are met.1417 These authors advocate for the continued practice and review of outcomes associated with this presumably earliest possible intervention scenario. However, some consideration should be given to the risk to providers and the potential for a delayed transport to the hospital.



In a paper by Seamon et al a statistical comparison was made between penetrating trauma victims transported by private care or the police and those transported by EMS and survival rates were worse in the EMS group (4 patients [5.1%] vs 19 patients [18.6%] patients).18 Despite the expected difference in response time and over time from injury to arrival to the hospital that should be expected when not awaiting EMS arrival, the authors ascribe this mortality benefit to the lack of prehospital procedures and advocate for a “scoop and run” approach. The so-called Philadelphia model cannot be supported based on this limited data; however, common sense would dictate that procedures, when done in this population of patients, should probably occur en route to the hospital. Therefore, if the same can be asserted for prehospital thoracotomy, the potential for injury to the operator and assistants during an attempt to perform this procedure in a moving vehicle should be considered prior to initiating the procedure. It is impossible to speculate on whether the same result would be found if thoracotomy was one of the potential procedures provided to the study population.

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Jan 22, 2019 | Posted by in EMERGENCY MEDICINE | Comments Off on Field Surgery
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