1Anesthesia & Resuscitation Department, Peace Hospital, Faculty of Health Sciences, Assane SECK University, Ziguinchor, Senegal
2Inter Army Medical Center of Ziguinchor, Senegal
3Anesthesia and Resuscitation Department, Aristide Le Dantec Hospital, Cheikh Anta Diop University, Dakar, Senegal
4 Anesthesia and Resuscitation Department, Regional Hospital of Saint Louis, Faculty of Health Sciences, Gaston BERGER University, Saint Louis, Senegal
Submission: June 11, 2018; Published: July 12, 2018
*Corresponding author: Barboza Denis, Anesthesia & Resuscitation Department, Peace Hospital, Faculty of Health Sciences, Assane SECK University, Ziguinchor, Senegal.
How to cite this article: Barboza Denis, Sow O, Diédhiou M, Diagne Lô S, Gaye I, et al. Perioperative Management of Wounds in Combat Area. J Anest
& Inten Care Med. 2018; 7(1): 555705. DOI: 10.19080/JAICM.2018.07.555705
Gunshot wounds are among the most traumatic injuries. It is difficult to assess the extent of damages caused by a bullet and these are usually far too serious to be treated with a first aid kit. That’s why the best option is to bring the victim to the hospital as soon as possible. Our study focuses on the victims during the raking operation in the southern zone. This was a retrospective and descriptive study ranging from the period of 7th of January 2018 to April 8th 2018. Were included all patients with gunshot wounds. The following parameters were studied: age, type of injury, delay of transfer, clinical and paraclinical data, perioperative management and short-term evolution. In total there were four victims, whose care was taken in the Inter-army Medical Center of Ziguinchor. There were two casualties by 12.7mm caliber firearms incidents and the others were injured by AK 47. The injuries were located in the lower limb for three of the victims and in the head for the fourth who had died in the field. Two patients had undergone surgery preceded by preoperative preparation. One patient was severely injured and had several transfusions. The medical evacuation by air was made as soon as possible to the level III hospital.
Gunshot wounds are among the most traumatic injuries. It is difficult to assess the extent of damages caused by a bullet and these are usually too serious to be treated with a first aid kit. The protective items of the fighter, Kevlar helmet, vests, have shown their effectiveness in transforming the nature of combat injuries . The health services of the armed forces have organized several levels of care for the war wounded in operations. The best option is to bring the victim to the hospital as soon as possible. Hemorrhage is the leading cause of death, representing a significant rate of “preventable” deaths. While there is consensus on intraoperative resuscitation of the bleeding hemorrhagic patient, the preoperative strategy is not unambiguous . We considered it necessary to have accurate data on the mechanisms and severity of the injuries, the diagnostic and therapeutic difficulties encountered, the morbidity and the mortality of the wounded in order to better guide the research programs and to improve the prevention of injuries and their treatment. Considering the early death cases, the evacuation time is of fundamental importance, partly conditioning the mortality on the battlefield. However, final care takes place in the structures of the back. Our study focused on the care of victims during search operations of the Senegalese army (Casamance).
This was a retrospective and descriptive study ranging from the period of 7th of January 2018 to April 8th 2018. All patients with gunshot wounds were included. The management strategy was to transfer casualties from the battlefield to the advanced command post. Then they were evacuated to the medical center for the first surgical procedures including hemodynamic stabilization and finally evacuated to the level III hospital by air. The team of the battalion’s medical and surgical center consisted of an anesthetist-intensive care physician, senior technicians in anesthesia, surgeons and block nurses. The center has been operational since 2015. It houses two operating rooms each with an anesthesia machine, a multiparameter scope, a surgical table and anesthesia drugs. It also has a chop room, with a cart containing emergency drugs, an X-ray room and an ultrasound machine. The parameters studied were age, type of injury, transfer delay, clinical and paraclinical data, perioperative management and short-term evolution.
Four gunshot victims were taken care of at the center. There were three lower limb injuries: two per 12.7mm caliber and 5.56mm (M16) firearms and one by AK 47 firearm. The fourth
victim had a head injury with an AK 47 weapon (Table 1). Patient
P1 arrived three hours after the incident. He was conscious and
hemodynamically unstable. He had a tourniquet and compressive
bandage in the left thigh, which had been removed by ablation
with muscle and bone lesions (Figure 1). Sensitivity and motor
skills were abolished. Blood tests found anemia (Table 2). The
X-ray showed a bifocal fracture common to the union of the upper
and middle thirds of the thigh. The patient was admitted to the
block for trimming and glued traction.
Patient P2 was received two hours after injury. He was
conscious and hemodynamically stable and had a tourniquet
at the right thigh and a compressive bandage. At removal of the
tourniquet and dressing, we noted an internal punctiform inlet
port and an external outlet of two centimeters with perceived
peripheral pulses and without impairing sensitivity or motor
skills (Figure 2). The preoperative assessment was normal (Table
2) and the X-ray found a displaced fracture of the middle third of
the right femur. He was admitted to the block for trimming and
Patient P3 had trauma to the right foot per shooting incident.
At admission, the patient was conscious and presented a dorsal,
linear, three centimeter regular-edged wound and a punctiform
outlet on the plantar surface (Figure 3). There were no sensory or mobility disorders. The X-ray revealed an incomplete fracture of
the base of the second phalanx of the second toe. Wound trimming
and suture had been performed. Patient P4 had died with a parietal
bullet wound with irregular edges caused by a bullet. All three
patients received antitetanus serum. P1 and P2 had undergone
preoperative preparation (Table 2). The evolution was favorable
in two patients (P2 and P3). However, one patient (P1) presented
a severe anemia requiring postoperative transfusion. The medical
evacuation by air was made for the two thigh wounded to a level
III hospital within four hours.
Ballistic trauma is a transfer of energy between a moving
projectile and the body. Several tissue factors play an important
role in the morphology of the injuries observed, particularly the
density and elasticity of the tissues involved in the trauma. The
higher the tissue density and the lower their elasticity, the greater
the energy transfer is. However, the severity of the injury will
depend more on the affected organ than the type of wounding
projectile. In our study, three of the received victims had lower
limb injuries. They are the most frequent locations [3,4]. The
functional prognosis is mainly related to the risk of amputation,
which is 28% , related to osteoarticular lesions. Vascular
lesions occur in 2.5% of cases in limb trauma. These lesions are not
assessable in the field whence the interest of an evacuation in the
shortest time. The transfer delay for the two seriously injured (P1
and P2) with the tourniquet was 3 hours and 2 hours, respectively.
This long delay is explained by the fact that the evacuations were
carried out during a war that is characterized by long periods of
evacuation. The tourniquet can cause ischemia. Similarly it can
kill the wounded by the revascularization syndrome of Cormier
and Legrain or Bywatters and Beall . Thus a wounded with a
tourniquet is a casualty of extreme urgency (Figure 4).
The use of the tourniquet requires a balance between the vital
prognosis and the functional prognosis because the tourniquet
has saved more life, said Leriche, that it has cost of limb. The
severity of a ballistic injury depends on its clinical impact, the site
of the lesion or the mechanism of injury. For example, unstable
hemodynamic injuries, injuries to the neck, trunk and in particular
the heart area, the groin area, as well as injuries sustained by
high-velocity bullets or hunting guns at short distance, must be
transported as quickly as possible to the operating room for a
prospective surgical procedure while continuing resuscitation.
Perioperative management has allowed us to do hemodynamic
stabilization, haemostasis and medical evacuation in the shortest
possible time for our patients. Emergency surgical procedures
often require filling and massive transfusions, which are of great
importance in ballistic trauma [6,7]. It is thus necessary to be able
to dispose rapidly of erythrocyte concentrates, then secondarily of
platelets and fresh frozen plasma.
However, the beneficial effect in terms of survival of
preoperative massive filling by crystalloid or colloid solutions
before surgical hemostasis is controversial. Some authors 
recommend initial contributions limited to the maintenance
of a minimum hemodynamic balance before the passage in the
operating room. The filling was limited because our patients had
benefited from the installation of a tourniquet and a compressive
bandage from the place of the incident. On the anesthetic level there
is no ideal agent. As with closed trauma, the choice will depend on
the clinical condition of the injured person, the site of the injury,
the urgency of the situation and the type of intervention. Both P1
and P2 patients had spinal anesthesia. Management of arterial
hypotension, hemostasis disorders, bleeding, hypothermia and
their consequences are the main tasks of the anesthetist .
In our study both patients had benefited from vascular filling.
But only P1 patient with peri-operative hemorrhagic shock was
transfused. The vital prognosis is function of exsanguination but
also of the seat of the lesion. Injuries to the feet or hands are usually
less life-threatening. The fourth victim died instantly because he
had received a bullet at the skull. Head injuries caused by firearms
are serious, life-threatening injuries. In fact, cephalic lesions have
a heavy mortality of more than 80% . Both P1 and P2 patients
received third-generation cephalosporin antibiotic prophylaxis.
Prevention of infection is a key element in the management of
ballistic trauma. Although early mortality has greatly decreased
thanks to optimization of initial care (resuscitation, surgery),
infection remains the leading cause of secondary mortality
. The optimal care should go through the improvement of the tools of protection, the good control and better handling of
the weapons, the reduction of the time of evacuation by the
availability of adequate logistical means, the reinforcement in
human and material resources, in particular: scanner , MRI, blood
bank with availability of labile blood products, external fixator
and resuscitation equipment.
Quote from France’s 2008 White Paper on Defense and
National Security: Protecting the Forces is not only a human
imperative, but also a strategic necessity to maintain adherence
and tactics to ensure success. Health support is a moral obligation
that the State undertakes with respect to its nationals, especially
when faced with increased risk.