afterword

. . . Though nothing can bring back the hour 

Of splendour in the grass, of glory in the flower,

We will grieve not, rather find

Strength in what remains behind;

In the primal sympathy

Which having been must ever be;

In the soothing thoughts that spring

Out of human suffering;

In the faith that looks through death,

In years that bring the philosophic mind.

. . . Thanks to the human heart by which we live, 

Thanks to its tenderness, its joys, and fears, 

To me the meanest flower that blows can give 

Thoughts that do often lie too deep for tears.

 —William Wordsworth, 1807

Sunt lacrimae rerum et mentem mortalia tangunt.

 —Virgil

appendices | 405

AppendIX A Abbreviations and Acronyms

A

ABC: Acinetobacter baumannii-calcoaceticus complex

ABN: airborne

ACS: American College of Surgeons

AP: anteroposterior

APC: Armored Personal Carrier 

aPLTs: apheresis platelets

ATLS: Advanced Trauma Life Support

B

BAMC: Brooke Army Medical Center (Fort Sam Houston, TX)

b-hCG: b-human chorionic gonadotropin

BVM: bag valve mask

C

CAT: Combat Application Tourniquet

CATS: Combat Application Tourniquet System

CBC: complete blood count

CBF: cerebral blood flow

CCATT: Critical Care Air Transport Team

CEEG: continuous electroencephalogram

CENTCOM: Central Command

coag: coagulopathy

CONUS: continental United States

COT: Committee on Trauma

CPDA: citrate, phosphate, dextrose, adenine (solution)

CPGs: Clinical Practice Guidelines

CPNB: continuous peripheral nerve block

CRNA: certified registered nurse anesthetist

CSF: cerebrospinal fluid

CSH: combat support hospital

CT: computed tomography

CXR: chest X-ray

D

DCCS: Deputy Commander for Clinical Services

DOW: died of wounds

DPL: diagnostic peritoneal lavage

DVBIC: Defense and Veterans Brain Injury Center

E

EBL: estimated blood loss

ED: emergency department

EDTA: ethylenediamine tetraacetic acid

EMEDS: Expeditionary Medical Squadron

EMS: emergency medical system (or service)

EMT: Emergency Medical Treatment (area/section)

EOD: explosive ordnance disposal

EPW: enemy prisoner of war

ETT: endotracheal tube

evac: evacuation

EWS: Emergency War Surgery, Third United States Revision

(2004 manual)

F

FAST: Focused Abdominal Sonography for Trauma

FDA: Food and Drug Administration

FFP: fresh frozen plasma

FRSS: Fast Response Survey System

FST: Forward Surgical Team

FWB: fresh whole blood

G

GCS: Glasgow Coma Scale

GI: gastrointestinal

GIA: gastrointestinal anastomosis

GU: genitourinary

H

HBV: hepatitis B virus

HCV: hepatitis C virus

HIPAA: Health Insurance Portability and Accountability Act

HIV: human immunodeficiency virus

HMMWV: High-Mobility Multipurpose Wheeled Vehicle 

(“Humvee”)

HPMK: Hypothermia Prevention and Management Kit

HPPL: high-pressure pulsatile lavage

HTIG: human tetanus immunoglobulin
406 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

I

IBA: Individual Body Armor

ICH: intracranial hemorrhage

ICP: intracranial pressure

ICU: intensive care unit

IED: improvised explosive device

IFAK: Individual First-Aid Kit

INR: international normalized ratio

ISO: International Organization for Standardization 

(also called International Standards Organization)

ISR: (US Army) Institute of Surgical Research 

IV: intravenous

IVC: inferior vena cava

J

JTTS: Joint Theater Trauma System

K

KIA: killed in action

L

LRMC: Landstuhl Regional Medical Center 

(Landstuhl, Germany)

M

MASH: Mobile Army Surgical Hospital

MEDCOM: Medical Command

MEDEVAC: medical evacuation 

MFST: Mobile Field Surgical Team

MNC-I: Multi-National Corps-Iraq

MRE: Meal, Ready-to-Eat

MRI: magnetic resonance imaging

MRSA: methicillin-resistant Staphylococcus aureus

MT: massive transfusion

N

NATO: North Atlantic Treaty Organization 

NG: nasogastric

NNMC: National Naval Medical Center (Bethesda, MD)

NPA: nasopharyngeal airway

NSAID: nonsteroidal anti-inflammatory drug

O

OEF: Operation Enduring Freedom (Afghanistan)

OIF: Operation Iraqi Freedom

OMF: oral and maxillofacial 

OMFS: oral and maxillofacial surgeon 

OR: operating room

OSD-HA: Office of the Assistant Secretary of Defense for 

Health Affairs

P

PA: posteroanterior

Pco2: partial pressure of carbon dioxide

PDS: polydioxanone

PEEK: polyetheretherketone

PFA: profunda femoris artery

PLTs/plts: platelets

PRBCs: packed red blood cells (also pRBCs)

PT: prothrombin time

PTFE: polytetrafluoroethylene

PTT: partial thromboplastin time

R

RBC: red blood cell

RCT: randomized controlled trial

rFVIIa: recombinant Factor VIIa (also hrFVIIa)

R/O: rule out

RPG: rocket-propelled grenade

S

SFA: superficial femoral artery

SFV: superficial femoral vein

SG: Surgeon General

SOFTT: Special Operations Forces Tactical Tourniquet

s/p: status post (Latin for “after condition”)

STP: Shock Trauma Platoon

STSG: split-thickness skin graft

T

TAT: tetanus antitoxin

TCD: transcranial Doppler

THAM: tris-hydroxymethyl aminomethane (or tromethamine)

t.i.d.: three times a day 

TOA: total obligation authority

TRAC: Therapeutic Regulated Accurate Care

Tx: treatment

U

UXO: unexploded ordnance

V

VA: Veterans Administration

VAC: vacuum-assisted closure

VP: ventriculoperitoneal

W

WHMC: Wilford Hall Medical Center 

WRAMC: Walter Reed Army Medical Center
appendices | 407

AppendIX B Product Manufacturers

Argentum Medical LLC, Willowbrook, Illinois (Silverlon)

Arizant Healthcare, Inc, Eden Prairie, Minnesota (Bair 

Hugger)

AstraZeneca Pharmaceuticals LP, Wilmington, Delaware 

(Diprivan [propofol])

Bausch & Lomb, Rochester, New York (Optima FW Trial) 

Bayer Corporation, Pittsburgh, Pennsylvania (ciprofloxacin)

Belmont Instrument Corporation, Billerica, Massachusetts 

(rapid fluid infuser, blood and fluid warmer)

BlackHawk Products Group, Norfolk, Virginia (military 

outdoor gear)

Cloward Instruments Corporation, Honolulu, Hawaii 

(Hudson brace)

Derma Sciences, Inc, Princeton, New Jersey (Silverseal burn 

contact dressings)

DeRoyal Industries, Inc, Powell, Tennessee (Dermanet Wound 

Contact Layer)

Edward Weck Company, Research Triangle Park, North 

Carolina (Weck cell sponge)

E. I. du Pont de Nemours and Company, Wilmington, 

Delaware (Kevlar and Tyvek products/equipment)

Ethicon, Inc, Somerville, New Jersey (DERMABOND, 

VICRYL suture, Prolene suture)

GlaxoSmithKline, Research Triangle Park, North Carolina 

(Ancef [cephazolin])

Hospira, Inc, Lake Forest, Illinois (Hextend)

Integra LifeSciences Corporation, Plainsboro, New Jersey 

(DuraGen)

Integra NeuroSciences, Plainsboro, New Jersey (NeuroGen 

nerve guide, Mayfield pins, Sundt shunt)

Kendall Healthcare Products Company, Mansfield, 

Massachusetts (Kerlix rolls and sponges)

Kinetic Concepts, Inc/KCI Licensing, Inc, San Antonio, Texas 

(wound VAC [therapy system], VAC Abdominal Dressing 

System, TRAC Pad)

Kontur Kontac Lens Company, Richmond, California 

(Kontur55)

LifeCell, Branchburg, New Jersey (AlloDerm)

Mallinckrodt, Hazelwood, Missouri (Shiley tracheostomy 

tube)

McNeil Consumer Healthcare, Guelph, Ontario, Canada 

(Tylenol)

MEDICON, Tuttlingen, Germany (Javid shunt)

Medisave Services, Inc, Markham, Ontario, Canada (butyl 

cyanoacrylate [corneal glue])

Miltex, Inc, York, Pennsylvania (Penfield dissector)

Mopec, Oak Park, Michigan (Gigli saw)

North American Rescue Products, Inc, Greenville, South 

Carolina (Hypothermia Prevention and Management Kit 

[HPMK])

Novartis International AG, Basel, Switzerland (Sandostatin)

Parks Medical Electronics, Inc, Aloha, Oregon (Doppler 

ultrasound)

Pfizer, Inc–US Pharmaceuticals Group, New York, New York 

(Dilantin [phenytoin])

Phil Durango, LLC, Golden, Colorado (Combat Application 

Tourniquet System [CATS]) 

Polymed Chirurgical, Inc, St. Laurent, Quebec, Canada (MSIEpiDermGlu)

Procter & Gamble Pharmaceuticals, Inc, Cincinnati, Ohio 

(Didronel [etidronate])

Rocky National, Eau Claire, Wisconsin (Gerber “Seal ‘n Go” 

sterile bag)

Sanofi-aventis U.S. LLC, Bridgewater, New Jersey (Lovenox)

Sherwood Medical Company, Norfolk, Nebraska (Argyle 

shunt)

SonoSite, Inc, Bothell, Washington (SonoSite duplex 

ultrasound device)

Sorenson Medical, Inc, West Jordan, Utah (ambIT pain pump) 

Synthes, Inc, West Chester, New York (Synthes compression 

plate)

Velcro USA, Inc, Manchester, New Hampshire (Velcro strap)

Welch Allyn, Inc, Skaneateles Falls, New York (Propaq 

monitor)

W. L. Gore & Associates, Inc, Flagstaff, Arizona (GORE-TEX)

Z-Medica Corporation, Wallingford, Connecticut (QuikClot)
408 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

AppendIX C Glasgow Coma Scale

Component Response Score

Motor response Obeys verbal command 6 

(best extremity) Localizes pain 5

lexion (withdrawal) 4

lexion (decortication) 3

xtension (decerebration) 2

o response (flaccid) 1

 Subtotal (1–6)

Eye opening Spontaneously 4

o verbal command 3

o pain 2

one 1

 Subtotal (1–4) 

Best verbal response Oriented and converses 5

isoriented and converses 4

 Inappropriate words 3

 Incomprehensible sounds 2

o verbal response 1

 Subtotal (1–5)

 

 Total (3–15)
appendices | 409

Appendix D Clinical Practice Guidelines*

Burn Care

The large number of burn casualties treated by coalition 

forces in the Iraq theatre has prompted a reevaluation 

of the optimal treatment plan. Many lessons have been 

learned and relearned during the last 4 years of treating 

casualties during OIF/OEF. Burn patients are very labor 

intensive and consume significant personnel and class 

VIII (medical logistic supply materials) resources. Despite 

the best efforts of providers at every level of care, the 

mortality for burn casualties who cannot be evacuated 

out of the theater of operations is significantly higher than 

that experienced in US facilities (Table 1). Experience 

among US treatment facilities in the past 3-4 years reveals 

no survivors among host nation casualties sustaining full 

thickness burns to 50% or greater total body surface area 

(TBSA). The spread of infection in large open wards is 

a real concern, which can threaten the outcome of nonburn patients. Furthermore the average burn patient in 

Accredited Burn Centers in the US stays 1-2 days for each 

percent burn. The factors have prompted a reevaluation 

of the optimal treatment plan based on severity of injury, 

treatment facility capabilities and potential for evacuation. 

The following recommendations are provided to assist the 

physician in making patient management decisions unique 

to the deployment environment. Chapter 28 of the 2004 

edition of the Emergency War Surgery handbook is an 

excellent general reference for burn care. 

In every case, use of the Burn Patient Admission Orders 

(Appendix A) and the JTTS Burn Resuscitation Flow 

Sheet (Appendix B) is highly recommended, especially if 

the patient may transfer to another facility. 

1. Coalition Casualties Who Can Be Evacuated 

Out of Country

a. Protect airway early, using a large-sized endotracheal 

tube (ETT) as possible (i.e., 8 mm) is strongly preferred, 

especially if inhalation injury is noted on bronchoscopy. 

A large ETT tube ensures ease of bronchoscopy and 

facilitates pulmonary suction, which are critical with 

inhalation injuries. 

b. Calculate burn size using a Lund and Browder chart 

(Appendix C). 

c. Initiate resuscitation using a standard burn formula 

(1-2 mL/kg/%BSA—see Burn Resuscitation Flow 

Sheet) and avoid boluses if possible; uptitrate the 

rate of intravenous fluids to maintain adequate urine 

output (UOP) as described below. 

d. Monitor UOP closely and decrease or increase the LR

infusion 20% per hour to maintain a UOP of 30-50 

mL/hour. 

1) Overresuscitation is as harmful as underresuscitation; patients who receive over 6 mL/kg/%BSA

burn are susceptible to severe complications. 

2) Hour-to-hour fluid management is critical, especially during the first 24 hours. 

3) Use of the Burn Resuscitation Flow Sheet to record 

fluid intake and UOP is mandatory. Refer to 

Appendix D for the Burn Resuscitation Flow Sheet 

Protocol. 

e. Keep the patient warm. 

f. Debride in the operating room (OR) with hibiclens, 

removing all blistered or sloughing skin (do not 

perform excision). 

g. Perform escharotomy and/or fasciotomies early if 

pulses are not palpable and circumferential burns are 

present. 

*Reprinted from CENTCOM’s Clinical Practice Guidelines.
410 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

h. Wrap burns on scalp, trunk, neck, and extremities in 

5% Sulfamylon solution soaked dressings TID and as 

needed to keep dressings moist: 

1) There is less mess as opposed to Sulfamylon or 

Silvadene cream 

2) Easier for receiving institution to clean and evaluate on arrival 

i. Measure abdominal compartment pressure for 

casualties with large burns and those who receive a 

large resuscitation. Pressures > 25 mm Hg warrant 

intervention. 

j. Shave and debride face and scalp. 

k. Apply Sulfamylon cream to ear burns BID. 

l. Apply Bacitracin to face burns QID. 

m. If available, consult ophthalmology for all patients 

with deep facial burns or corneal injury by Wood’s 

lamp exam. 

1) Apply Bacitracin ophthalmic ointment to eye lids 

QID. 

2) Apply Erythromycin ophthalmic ointment QID

in the eyes. 

n. Change dressings every day until evacuated. 

o. Consult the Army Burn Center at the USAISR at DSN

312-429-2876 or burntrauma.consult@us.army.mil. 

2. Host Nation Burn Casualties

a. Triage casualties with full thickness burns of 50% 

or greater TBSA as expectant and provide adequate 

comfort measures. This requires careful and accurate 

calculation of burn size using a Lund and Browder 

chart (Appendix C). 

b. Remember that inhalation injury, comorbidities, and 

extremes of age, in addition to the burn, increase 

mortality. Take these factors into consideration as 

treatment plans are initiated. 

c. For patients with combined partial and full thickness 

burns of 50% TBSA or greater, with less than half of 

the burn being full thickness, initially treat the patient 

as above (section 1) and allow the partial thickness 

component to declare itself after 2 days. It is initially 

sometimes difficult to determine the full extent of 

the full thickness burn. After 48 hours, reassess the 

percentage of full thickness burn. 

d. For patients with a less than 50% TBSA burn, attempts 

at early excision and grafting are recommend. 

e. Presently, no allograft (cadaveric skin) or xenograft 

(Pig skin) are available in theater; therefore, the extent 

of excision should be guided by amount of autograft 

donor skin available, meshing no wider than 3:1. 

f. Consider using a Negative Pressure Wound Dressing 

(NPWD) over fresh graft with intervening nonadherent layer (i.e. Dermanet, Silverlon) and leave in 

place for 3-5 days. 

g. Following NPWD removal, use Sulfamylon moistened 

gauze dressings for next 5-7 days before transitioning 

to Bacitracin. 

h. Initially excise only as much as donor skin is available 

to cover. 

1) Do not excise wounds and leave open. If patients 

arrive in this state, re-excise and apply a NPWD

until granulation tissue is present. 

2) Rarely need to mesh skin wider than 2:1. 

i. Take the patient to the OR for staged excisions and 

grafting of the full thickness burns with a goal of 

complete excision within 1 week of injury. 

j. Once grafts are healed, continue to keep patient clean 

using showers, when available. 

k. Early ambulation and physical therapy, with range of 

motion of all affected joints, is critical to the longterm functioning of these casualties. 

l. Early and continuous nutrition are key to wound 

healing. Use a nasoenteric feeding tube and supplement with high protein, low fat tube enteral feedings, 

even when patient is able to eat. Utilize nutritionist 

whenever available. Supplement diet with a daily 

multivitamin. 

m. Questions about burn care in theater can be answered 

by the in-theater burn consultant who can be reached 

at DSN 318-239-7664. 

3. Pitfalls 

a. Excising uninfected full thickness burns before having 

donor skin to cover the wound. 

b. Pseudomonas infections: 

1) High rate of graft loss. 

2) Ominous sign. 

3) Liberal use of Dakin’s solution. 

4) Delay subsequent grafting until topical pseudomonas is well-treated. 

c. Transition from aggressive care to comfort care: 

1) Difficult decision. 

2) Initial burn may appear survivable but graft loss, 

topical infections, or donor site conversion may 

convert a potentially survivable situation into a 

nonsurvivable injury. 

3) Be aware of this possibility and the need for 

potential change to an expectant category. 

4) Elicit opinions from medical leaders, partners, 

and nurses, as this is a decision that should not 

be made solely by the treating physician. 
appendices | 411

d. Consider inhalational injury in relationship to the 

TBSA burned when deciding whether to treat the 

patient or deem the patient expectant. (i.e., a patient 

with a 40% TBSA burn and an inhalational injury 

will likely not do well as a patient with a 40% TBSA

burn and no inhalational burn) 

e. Perform large dressing changes in the OR (not ICU or 

ICW), especially early in the treatment process: 

1) Better evaluation. 

2) Improved ability to clean wounds. 

3) Improved pain control. 

f. Initial burn may appear survivable but graft loss, 

topical infections, or donor site conversion may lead to 

transition from a potentially survivable situation into a 

nonsurvivable injury. Be aware of this possibility and 

the need for potential change to an expectant category. 

g. The decision to do less than everything possible should 

not be viewed as failure, but rather part of reality in 

a combat zone. The attending physician should not 

feel isolated about making the decision to decrease the 

level of care but should seek the opinions of leaders, 

partners, and nurses. Consult the Chaplain and, if 

needed, an interpreter to counsel the patient’s family 

about the prognosis and plans. 

4. Recommendations for Complicated Burn Care

a. Recommendations for the difficult fluid resuscitation: 

1) At 12-18 hours post-burn, calculate the PROJECTED 24-hour resuscitation if fluid rates 

are kept constant. If the projected 24-hour 

resuscitation requirement exceeds 6 mL/kg/% 

TBSA, the following steps are recommended: 

a) Initiate 5% albumin early as described 

previously in the Emergency War Surgery 

handbook. 

b) Check bladder pressures every 4 hours. 

c) If available, strongly consider placing a 

pulmonary artery (PA) catheter to guide 

resuscitation with specific PCWP and SvO2

goals (Goal PCWP 10-12 mm Hg, SvO2

65-70%). If PA catheter placement is not 

practical, consider monitoring central venous 

pressures from a subclavian or IJ catheter 

along with central venous O2 saturations 

(Goal CVP 8-10 cm H2O, ScvO2 60-65%). 

• If CVP or PCWP is not at goal, increase 

fluid rate. 

• If CVP or PCWP is at goal, consider 

vasopressin 0.02-0.04 units/min to 

augment MAP (and thus UOP) or 

dobutamine 5 mcg/kg/min IV (titrate until 

SvO2 or ScvO2 at goal). The maximum 

dose of dobutamine is 20 mcg/kg/min. 

• If both CVP or PCWP and SvO2 or ScvO2

are at GOAL, stop increasing fluids (EVEN

if UOP < 30 mL/hr). Consider the patient 

hemodynamically optimized and that the 

oliguria is likely a result of an established 

renal insult. Tolerate and expect some 

degree of renal failure. Continued increases 

in fluid administration despite optimal 

hemodynamic parameters will only result 

in “resuscitation morbidity” that is often 

times more detrimental than renal failure. 

d) If the patient becomes hypotensive and 

oliguric (UOP < 30 mL/hr), then follow the 

hypotension guidelines. 

e) Every attempt should be made to minimize 

fluid administration while maintaining organ 

perfusion. If UOP > 50 mL/hr, then decrease 

the fluid rate by 20%. 

2) After 24 hours, titrate LR infusion down to 

maintenance levels and continue albumin until 

the 48-hour mark. 

3) War burn patients have exhibited multisystem 

injury to include soft tissue injury secondary to 

blunt/penetrating injury/blast and inhalational 

injury, which all affect resuscitation amounts and 

may result in marked increased fluid needs above 

and beyond standard burn resuscitation formulas. 

The air evacuation environment may also increase 

fluid requirements and wound edema. 

b. Recommendations for hypotension: 

1) The optimal minimum blood pressure for burn 

patient must be individualized. Some patients 

will maintain adequate organ perfusion (and 

thus have adequate UOP) at MAPs lower than 

70 mm Hg. True hypotension must be correlated 

with UOP. If a MAP is not adequate (generally < 

55 mm Hg) to maintain the UOP goal of at least 

30 mL/hr, the following steps are recommended. 

a) Vasopressin 0.02-0.04 units/min IV drip 

(DO NOT TITRATE). 

b) Monitor CVP (Goal 8-10 cm H2O). 

c) If CVP not at goal, increase fluid rate. 

d) If CVP at goal, add Levophed (norepinephrine) 

2-20 mcg/min IV. 

e) If additional pressors are needed, consider 

inserting a PA catheter to guide resuscitation 

with specific PCWP and SvO2 goals (goal 
412 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

PCWP 10-12 mm Hg, SvO2 65-70%). These 

patients may be volume depleted, but also 

suspect a missed injury. 

• If PCWP at goal, consider a dobutamine 

drip at 5 mcg/kg/min IV (titrate until 

SvO2 at goal). The maximum dose of 

dobutamine is 20 mcg/kg/min. 

• If hypotension persists, look for a missed 

injury. 

• Consider adding epinephrine or neosynephrine as a last resort. 

f) If the patient exhibits catecholamine-resistant 

shock, consider the following diagnoses: 

• Missed injury and on-going blood loss. 

• Acidemia. If pH < 7.20, adjust ventilator 

settings to optimize ventilation (target 

PCO2 30-35 mm Hg). If despite optimal 

ventilation, patient still has a pH < 7.2, 

consider bicarb administration. 

• Adrenal insufficiency. Check a random 

cortisol and start hydrocortisone 100 

mg every 8 hours. 

• Hypocalcemia. Maintain ionized calcium > 1.1 mmol/L. 

c. Recommendations for inhalational injury: 

1) Inhalation injury is further exacerbated by 

retained soot and chemicals. Remember, inhalation injury is mostly a chemical injury that will 

benefit from removing the chemical. 

2) Upon arrival, if patients are found to have 

visible soot in the airways, make every attempt 

to debride through bronchoscopic suction as 

much soot as possible. In addition, keep in mind 

that irrigation may actually make the injury 

worse by transporting injurious substances 

to new, uninjured parts of the lung, so irrigate 

judiciously. 

3) If a diagnosis of inhalation injury is made, use 

aerosolized heparin 5,000 units every 4 hours. 

Mix heparin with albuterol as heparin can induce 

bronchospasm. 

d. Recommendations for abdominal compartment 

syndrome: 

1) Massive fluid replacement (> 6 mL/kg/% burn) 

has led to abdominal compartment syndrome 

(increased bladder pressure, increased airway 

pressures, decreased UOP, hypotension) and 

extremity compartment syndromes (beyond 

standard escharotomy treatment). 

2) If the patient requires a decompressive laparotomy, do a full midline incision (NOT a small minilaparotomy incision) followed by a temporary 

abdominal closure. If the abdominal wall skin is 

burned, Ioban dressing will not adhere to burnt 

skin. Use a traditional Bogotá bag or 3 L NS IV 

bag sewn to the skin (keep loose). 

e. Recommendations for escharotomy/fasciotomy: 

1) The requirement for escharotomy or fasciotomy 

usually presents in the first few hours following 

injury. If the need for either procedure has not 

presented in the first 24 hours, then circulation 

is likely to remain adequate without surgical 

intervention. For this reason, it would be unusual 

for a patient to require a new escharotomy or 

fasciotomy by the time of arrival at an Level IV 

facility. 

2) More likely, a patient with previous escharotomy 

or fasciotomy performed in the field might 

require extension of the incision or placement 

of a second incision on the other side of an 

extremity to restore circulation. This can occur if 

significant volumes of intravenous fluid are given 

in transit between the time of initial escharotomy 

and patient arrival at a rear medical facility. 

3) On arrival, assess distal circulation of all extremities by palpating the radial, dorsalis pedis and 

posterior tibial arteries. If a pulse is palpable in 

one or more arteries in each extremity, neither 

escharotomy nor fasciotomy is indicated, and 

serial assessments are appropriate. Elevate injured extremities 30-45°. Use Doppler ultrasound to assess distal circulation in the absence 

of palpable pulses. Absent Doppler signals 

or pulses that are diminishing on serial exam 

30 minutes to one hour apart should prompt 

consideration of escharotomy. 

4) Escharotomy is normally performed when an 

extremity has a circumferential full thickness burn. If the burn is superficial or not circumferential and pulses are absent, consider 

inadequate circulation from other causes such as 

hypovolemia, hypotension, or occult traumatic 

injury. 

5) Extend escharotomy incisions the entire length of 

the full-thickness burn and carry across the joint 

when the burn extends across the joint. In the 

lower extremity, make a mid-lateral or mid-axial 

incision with a knife or electrocautery through 
appendices | 413

the dermis to the level of fat. It is not necessary 

to carry the incision to the level of fascia. 

Although full-thickness burn is insensate, the 

patient will often require intravenous narcotics 

and benzodiazepines during this procedure. 

Give morphine 2-5 mg IV and midazolam 1-2 

mg IV at 5- to 10-minute intervals as needed. 

On completion of midlateral or midmedial 

escharotomy, reassess the pulses. If circulation 

is restored, bleeding should be controlled with 

electrocautery and the extremity dressed and 

elevated at a 30-45° angle. Assess pulses hourly 

for at least 12-24 hours. If circulation is not 

restored, perform a second incision on the 

opposite side of the extremity. 

6) For upper extremities, place the hand in the 

anatomic position (palm facing forward) and 

make an incision in the midradial or mid ulnar 

line. Ulnar incisions should stay anterior (volar) 

to the elbow joint to avoid the ulnar nerve, 

which is superficial at the elbow. If pulses are 

not restored, a second incision may be necessary 

on the opposite side of the extremity. If both the 

hand and arm are burned, continue the incision 

across the mid ulnar or midradial wrist and onto 

the mid ulnar side of the hand or to the base of 

the thumb and then the thumb webspace. 

7) Finger escharotomies are controversial. Before 

performing finger escharotomies, consider 

that there is little other than bone and tendon 

in the fingers and that fingers burned badly 

enough to require escharotomy frequently end 

up as amputations. If finger escharotomies are 

performed, avoid functional surfaces (radial 

surface of the index and ulnar surface of the little 

finger). Place the fingers in a clenched position 

and note the finger creases at DIP and PIP joints. 

Escharotomy incisions should be just dorsal to a 

line drawn between the tops of these creases. 

8) If bilateral extremity incisions do not restore 

circulation, re-evaluate the adequacy of the 

patient’s overall circulation. A well-resuscitated 

adult burn patient should have a clear sensorium, 

a heart rate in the range of 110-130 beats per 

minute, and a UOP of 30 mL/hr or more. 

9) In unusual cases, following escharotomy, fasciotomy may be necessary to restore circulation. 

This is more common in electrical injuries and in 

crush or other traumatic injuries. Leg fasciotomies 

should release all four compartments. Forearm 

fasciotomies should decompress all three 

compartments. The dorsal compartment may 

be accessed via a 3 inch longitudinal mid dorsal 

forearm incision. Dissect to the fascia, enter the 

fascia and then slide a Metzenbaum scissor distal 

to the level of the wrist and proximal to the upper 

forearm. The volar compartment is approached 

via a lazy-S curved incision from the elbow to 

wrist. Avoid straight incisions on the volar 

surface as these may lead to later contractures. 

Also use the volar incision to access the mobile 

compartment, which is the fascia overlying the 

brachioradialis muscle. If escharotomies have 

already been performed, it may be possible to 

access the dorsal, volar, and mobile compartments 

by dissection between the dermis and fascia 

from the escharotomy site to the desired areas. 

Circulation should not be compromised by a 

desire to avoid additional incisions; however, the 

burned tissue will be excised later during burn 

surgery. When performing an arm fasciotomy, 

some hand surgeons prefer to also decompress 

the median nerve at the carpal tunnel and/or the 

ulnar nerve at the Canal of Guyon. 

10) Following escharotomy or fasciotomy, late bleeding may occur as pressure is decompressed and 

circulation restored. Examine the surgical site 

every few minutes for up to 30 minutes for signs 

of new bleeding, which is usually easily controlled 

with electrocautery. 
414 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

MEDICAL RECORD – PROVIDER ORDERS 

For use of this form, see MEDCOM Circular 40-5 

DIRECTIONS: The provider will SIGN, DATE, and TIME each order or set of orders recorded. Only one order is allowed per line. Orders completed 

during the shift in which they are written will be signed off adjacent to the order and do not require recopying on other ITR forms.

DATE / TIME ORDERS 

(SIGNATURE REQUIRED FOR EACH ORDER/SET OF ORDERS. SIGNATURE MUST BE LEGIBLE; PROVIDER WILL USE 

SIGNATURE STAMP OR PRINT NAME). 

BURN PATIENT ADMISSION ORDERS (Page 1 of 5)

MEDCOM FORM 688-RB (TEST) (MCHO) JUL 07 PREVIOUS EDITIONS ARE OBSOLETE MC V2.00 

PATIENT IDENTIFICATION (For typed or written entries 

note: Name – last, first, middle initial; grade; DOB; hospital or 

medical facility) 

Nursing Unit Room No. Bed No. Page No.

Complete the following information on page 1 of provided orders 

only. Note any changes on subsequent pages. 

Diagnosis: 

Allergies and reaction: 

Height: _________________________ 

 

Weight (Kg): _____________________ 

Diet: ___________________________ 

1. Admit/Transfer to ICU ( 1 / 2 / 3 ), SDU, ICW (1 / 2 / 3) to Physician ________________________ 

2. Diagnosis: 

3. Condition: VSI SI NSI Category: Nation/Service (e.g., US/USA, HN/IA)_______________ 

4. Allergies: Unknown NKDA Other: 

5. Monitoring 

5.1 Vital signs: Q ____ hrs 

5.2 Urine output: Q ____ hrs 

5.3 Transduce bladder pressure Q ____ hrs 

5.4 Neurovascular/Doppler pulse checks Q ____ hrs 

5.5 Transduce: ____ CVP ____ A-line ____ Ventriculostomy 

5.6 Neuro checks: Q ____ hrs 

5.7 Cardiac monitor: Yes / No 

6. Activity 

6.1 ____ Bedrest ____ Chair Q shift ____ Ad lib ____ Roll Q 2 hrs 

6.2 ____ Passive ROM to UE and LE Q shift 

6.3 Spine precautions: ____ C-Collar/C-Spine ____ TLS spine 

7. Wound Care 

7.1 ____ NS wet to dry BID to: ________________________________________________ 

7.2 ____ Dakin’s wet to dry BID to: ____________________________________________ 

7.3 ____ VAC dressing to: ____ 75 mm Hg ____ 125 mm Hg 

7.4 ____ Abdominal closure drains to LWS 

7.5 ____ Other: ____________________________________________________________ 

8. Tubes/Drains 

8.1 ____ NGT to LCWS or ____ OGT to LCWS 

8.2 ____ Place DHT ____ Nasal ____ Oral and confirm via KUB 

8.3 ____ Foley to gravity 

8.4 ____ Flush feeding tube Q shift with 30 mL water 

8.5 ____ JP(s) to bulb suction; strip tubing Q 4 hrs and PRN 

8.6 ____ Chest tube to: ____ 20 cm H20 suction (circle: R L Both) or ____ Water seal (circle: R L Both) 

Physician Signature ___________________________________ Date/Time _____________________________ 
appendices | 415

MEDICAL RECORD – PROVIDER ORDERS 

For use of this form, see MEDCOM Circular 40-5 

DIRECTIONS: The provider will SIGN, DATE, and TIME each order or set of orders recorded. Only one order is allowed per line. Orders completed 

during the shift in which they are written will be signed off adjacent to the order and do not require recopying on other ITR forms.

DATE / TIME ORDERS 

(SIGNATURE REQUIRED FOR EACH ORDER/SET OF ORDERS. SIGNATURE MUST BE LEGIBLE; PROVIDER WILL USE 

SIGNATURE STAMP OR PRINT NAME). 

BURN PATIENT ADMISSION ORDERS (Page 2 of 5)

MEDCOM FORM 688-RB (TEST) (MCHO) JUL 07 PREVIOUS EDITIONS ARE OBSOLETE MC V2.00 

PATIENT IDENTIFICATION (For typed or written entries 

note: Name – last, first, middle initial; grade; DOB; hospital or 

medical facility) 

Nursing Unit Room No. Bed No. Page No.

Complete the following information on page 1 of provided orders 

only. Note any changes on subsequent pages. 

Diagnosis: 

Allergies and reaction: 

Height: _________________________ 

 

Weight (Kg): _____________________ 

Diet: ___________________________ 

9. Nursing 

9.1 Strict I & O and document on the JTTS Burn Resuscitation Flow Sheet Q 1hr for burns > 20% TBSA 

9.2 ____ Clear dressing to Art Line/CVC, change Q 7D and prn 

9.3 ____ Bair Hugger until temperature > 36° C 

9.4 ____ Lacrilube OU Q 6hrs while sedated 

9.5 ____ Oral care Q 4hrs; with toothbrush Q 12 hrs 

9.6 ____ Maintain HOB elevated 45° 

9.7 ____ Fingerstick glucose Q ____ hrs 

9.8 ____ Routine ostomy care 

9.9 ____ Ext fix pin site care 

9.10 ____ Trach site care Q shift 

9.11 ____ Incentive spirometry Q 1 hr while awake; cough & deep breath Q 1 hr while awake 

10. Diet 

10.1 ____ NPO 

10.2 ____ PO Diet: ________________________ 

10.3 ____ TPN per Nutrition orders 

10.4 ____ Tube Feeding: ______________________ @ ________ mL/hr OR ____ Advance per protocol 

11. Burn Resuscitation (%TBSA > 20%) 

11.1 Post Burn 1-8 hrs: LR at _____ mL/hr IV (0.13 mL x Wt in kg x %TBSA) 

11.2 Post Burn 8-24 hrs: LR at _____ mL/hr IV (0.06 mL x Wt in kg x %TBSA) 

11.3 Titrate resuscitation IVF as follows to maintain target UOP (Adult: 35-50 mL/hr; Children: 1.0 mL/kg/hr) 

- Decrease rate of LR by 20% if UOP is greater than 50 mL/hr for 2 consecutive hrs 

- Increase rate of LR by 20% if UOP is less than 30 mL/hr (adults) or pediatric target UOP for 2 consecutive hrs 

11.4 If CVP > 10 cm H2O and patient still hypotensive (SBP < 90 mm Hg), begin vasopressin gtt at 0.02 – 0.04 Units/min 

11.5 Post burn day #2 (Check all that apply) 

____ Continue LR at _____ mL/hr IV 

____ Begin ____________________ at ______ mL/hr IV for insensible losses 

____ Start Albumin 5% at ______ mL/hr IV ((0.3 – 0.5 x %TBSA x wt in kg) / 24) for 24 hrs 

Physician Signature ___________________________________ Date/Time _____________________________ 
416 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

MEDICAL RECORD – PROVIDER ORDERS 

For use of this form, see MEDCOM Circular 40-5 

DIRECTIONS: The provider will SIGN, DATE, and TIME each order or set of orders recorded. Only one order is allowed per line. Orders completed 

during the shift in which they are written will be signed off adjacent to the order and do not require recopying on other ITR forms.

DATE / TIME ORDERS 

(SIGNATURE REQUIRED FOR EACH ORDER/SET OF ORDERS. SIGNATURE MUST BE LEGIBLE; PROVIDER WILL USE 

SIGNATURE STAMP OR PRINT NAME). 

BURN PATIENT ADMISSION ORDERS (Page 3 of 5)

MEDCOM FORM 688-RB (TEST) (MCHO) JUL 07 PREVIOUS EDITIONS ARE OBSOLETE MC V2.00 

PATIENT IDENTIFICATION (For typed or written entries 

note: Name – last, first, middle initial; grade; DOB; hospital or 

medical facility) 

Nursing Unit Room No. Bed No. Page No.

Complete the following information on page 1 of provided orders 

only. Note any changes on subsequent pages. 

Diagnosis: 

Allergies and reaction: 

Height: _________________________ 

 

Weight (Kg): _____________________ 

Diet: ___________________________ 

12. IVF (% TBSA < 20%): ___ LR ___ NS ___ D5NS ___ D5LR ___ D5 .45NS ___ + KCl 20 meq/L @ ____ mL/hr 

13. Laboratory Studies & Radiology 

13.1 ____ CBC, Chem-7, Ca/Mg/Phos: _____ ON ADMIT _____ DAILY @ 0300 

13.2 ____ PT/INR ____ TEG ____ Lactate: _____ ON ADMIT _____ DAILY @ 0300 

13.3 ____ LFTs ____ Amylase ____ Lipase: _____ ON ADMIT _____ DAILY @ 0300 

13.4 ____ ABG: ____ ON ADMIT ____ 30 mins after ventilator change ____ Q AM (while on ventilator) 

13.5 ____ Triglyceride levels after 48 hours on Propofol 

13.6 ____ Portable AP CXR on admission 

13.7 ____ Portable AP CXR Q AM 

14. Prophylaxis 

14.1 ____ Protonix 40 mg IV Q day 

14.2 ____ Lovenox 30 mg SQ BID OR ____ Heparin 5000 U SQ BID starting ____________________ 

14.3 ____ Pneumatic compression boots 

15. Ventilator Settings 

15.1 Mode: ____ SIMV ____ CMV ____AC ____ CPAP 

15.2 FiO2: _____ % 

15.3 Rate: _____ 

15.4 Tidal Volume: _____ cc 

15.5 PEEP: _____ 

15.6 Pressure Support: ____ 

15.7 Insp Pressure: _____ 

15.8 I/E Ratio: _____ 

15.9 ____ APRV: Phi ____ Plow ____ Thi ____ Tlow ____ FiO2: ____ % 

15.10 ____ Maintain patient in soft restraints while on ventilator 

15.11 ____ Wean FiO2 to keep SpO2 > 92% or PaO2 > 70 mm Hg 

15.12 ____ Nebulizer/MDIs: ____ Albuterol ____ Atrovent ____ Xopenex Unit Dose Q 4 hrs 

Physician Signature ___________________________________ Date/Time _____________________________ 
appendices | 417

MEDICAL RECORD – PROVIDER ORDERS 

For use of this form, see MEDCOM Circular 40-5 

DIRECTIONS: The provider will SIGN, DATE, and TIME each order or set of orders recorded. Only one order is allowed per line. Orders completed 

during the shift in which they are written will be signed off adjacent to the order and do not require recopying on other ITR forms.

DATE / TIME ORDERS 

(SIGNATURE REQUIRED FOR EACH ORDER/SET OF ORDERS. SIGNATURE MUST BE LEGIBLE; PROVIDER WILL USE 

SIGNATURE STAMP OR PRINT NAME). 

BURN PATIENT ADMISSION ORDERS (Page 4 of 5)

MEDCOM FORM 688-RB (TEST) (MCHO) JUL 07 PREVIOUS EDITIONS ARE OBSOLETE MC V2.00 

PATIENT IDENTIFICATION (For typed or written entries 

note: Name – last, first, middle initial; grade; DOB; hospital or 

medical facility) 

Nursing Unit Room No. Bed No. Page No.

Complete the following information on page 1 of provided orders 

only. Note any changes on subsequent pages. 

Diagnosis: 

Allergies and reaction: 

Height: _________________________ 

 

Weight (Kg): _____________________ 

Diet: ___________________________ 

16. Analgesia/Sedation/PRN Medications 

16.1 ____ Propofol gtt at ____ mcg/kg/min, titrate up to 80 mcg/kg/min for SAS 3-4. 

16.2 ____ Versed gtt at ____ mg/hr, titrate up to 10 mg/hr for SAS 3-4; may give 2-5 mg IVP Q 15 minutes for acute 

agitation or burn wound care. 

16.3 ____ Ativan gtt at ____ mg/hr, titrate up to 15 mg/hr for SAS 3-4; may give 1-4 mg IVP Q 2-4 hours for acute 

agitation. 

16.4 ____ Fentanyl gtt at ____ mcg/kg/hr, titrate up to 250 mcg/kg/hr; for analgesia may give 25-100 mcg IVP Q 15 

minutes for acute pain or burn wound care. 

16.5 ____ Morphine gtt at ____ mg/hr, titrate up to 10 mg/hr, for analgesia may give 2-10 mg IVP Q 15 minutes for pain 

or burn wound care 

16.6 Important: Hold continuous IV analgesia/sedation at 0600 hrs for a SAS  4. If further analgesia/sedation is 

indicated, start medications at 1⁄2 of previous dose and titrate for a SAS 3-4. 

16.7 ____ Morphine 1-5 mg IV Q 15 minutes prn pain 

16.8 ____ Fentanyl 25-100 mcg IV Q 15 minutes prn pain 

16.9 ____ Ativan 1-5 mg IV Q 2-4 hrs prn agitation 

16.10 ____ Percocet 1-2 tablets po Q 4 hrs prn pain 

16.11 ____ Motrin 800 mg po TID prn pain 

16.12 ____ Toradol 30 mg IV loading dose, then 15 mg IV Q 8 hrs for 48 hours 

16.13 ____ Tylenol _____ mg / Gm PO / NGT / PR Q _____ hrs PRN for fever or pain 

16.14 ____ Morphine PCA: Program (circle one): 1 2 3 4 

16.15 ____ Zofran 4-8 mg IVP Q 4 hrs PRN for nausea/vomiting 

16.16 ____ Dulcolax 5 mg PO / PR Q day PRN for constipation 

17. Specific Burn Wound Care 

17.1 Cleanse and debride facial burn wounds with Sterile Water or (0.9% NaCl) Normal Saline Q 12 hrs, use a 

washcloth or 4x4s to remove drainage/eschar 

17.2 Cleanse and debride trunk and extremities with chlorhexidine gluconate 4% solution (Hibiclens) and Sterile Water or 

Normal Saline, before prescribed dressing changes 

17.3 Change fasciotomy dressings and outer gauze dressings daily and as needed; moisten with sterile water Q 6 hours 

and as needed to keep damp, not soaking wet 

Physician Signature ___________________________________ Date/Time _____________________________ 
418 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

MEDICAL RECORD – PROVIDER ORDERS 

For use of this form, see MEDCOM Circular 40-5 

DIRECTIONS: The provider will SIGN, DATE, and TIME each order or set of orders recorded. Only one order is allowed per line. Orders completed 

during the shift in which they are written will be signed off adjacent to the order and do not require recopying on other ITR forms.

DATE/ TIME ORDERS 

(SIGNATURE REQUIRED FOR EACH ORDER/SET OF ORDERS. SIGNATURE MUST BE LEGIBLE; PROVIDER WILL USE 

SIGNATURE STAMP OR PRINT NAME). 

BURN PATIENT ADMISSION ORDERS (Page 5 of 5)

MEDCOM FORM 688-RB (TEST) (MCHO) JUL 07 PREVIOUS EDITIONS ARE OBSOLETE MC V2.00 

PATIENT IDENTIFICATION (For typed or written entries 

note: Name – last, first, middle initial; grade; DOB; hospital or 

medical facility) 

Nursing Unit Room No. Bed No. Page No.

17. Specific Burn Wound Care (continued) 

Face & Ears 

____ Bacitracin ointment BID & PRN 

____ Sulfamylon cream to ears BID & PRN 

____ 5% Sulfamylon solution dressing changes Q AM & 

wet downs Q 6 hrs 

____ Bacitracin ophth ointment: apply OU Q 6 hrs 

BUEs & Hands, BLEs, Chest, Abdomen & Perineum 

____ Silvadine cream Q AM & PRN (deep partial & full 

thickness) 

____ Sulfamylon cream Q PM & PRN (deep partial & 

full thickness) 

____ 5% Sulfamylon solution - change Q AM & wet 

downs Q 6 hrs (superficial partial thickness, 

perineal burn wounds, or Pt O/C to OR/AE) 

____ Silverlon dressing & Sterile Water wet downs Q 6 

hrs (apply dressing and DO NOT remove for 72 

hrs) 

Back

____ Silvadine cream Q AM & PRN (deep partial & full 

thickness) 

____ Sulfamylon cream Q PM & PRN (deep partial & 

full thickness) 

____ 5% Sulfamylon powder dressing changes Q AM & 

wet downs Q 6 hrs (superficial partial thickness, 

Pt O/C to OR/AE) 

18. Other Orders 

18.1 _________________________________________________________________________ 

18.2 _________________________________________________________________________ 

18.3 _________________________________________________________________________ 

19. Notifiy Physician if: SBP < _________ , MAP < __________ , HR < __________ or > __________ , 

 SaO2 < _____% , T > _____, UOP < 30 mL for 2 consecutive hours 

Physician Signature ___________________________________ Date/Time ____________________________

Complete the following information on page 1 of provided orders 

only. Note any changes on subsequent pages. 

Diagnosis: 

Allergies and reaction: 

Height: _________________________ 

 

Weight (Kg): _____________________ 

Diet: ___________________________ 
appendices | 419

one side--

anterior

one side--

posterior

Adult adult adult 1st 2nd 3rd TBSA

Head 7 3.5 3.5 0

Neck 2 1 1 0

Anterior trunk* 13 13 0 0

Posterior trunk* 13 0 13 0

Right buttock 2.5 na 2.5 0

Left buttock 2.5 na 2.5 0

Genitalia 1 1 na 0

Right upper arm 4 2 2 0

Left upper arm 4 2 2 0

Right lower arm 3 1.5 1.5 0

Left lower arm 3 1.5 1.5 0

Right hand 2.5 1.25 1.25 0

Left hand 2.5 1.25 1.25 0

Right thigh 9.5 4.75 4.75 0

Left thigh 9.5 4.75 4.75 0

Right leg 7 3.5 3.5 0

Left leg 7 3.5 3.5 0

Right foot 3.5 1.75 1.75 0

Left foot 3.5 1.75 1.75 0

100 48 52 0 0 0 0

Age:__________

Sex: __________

Weight: _______

Total Area 

front/back

(circumferential)

BURN ESTIMATE AND DIAGRAM
420 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

Birth to1 

year 1st 2nd 3rd TBSA

Head 19 0

Neck 2 0

Anterior trunk* 13 0

Posterior trunk 13 0

Right buttock 2.5 0

Left buttock 2.5 0

Genitalia 1 0

Right upper arm 4 0

Left upper arm 4 0

Right lower arm 3 0

Left lower arm 3 0

Right hand 2.5 0

Left hand 2.5 0

Right thigh 5.5 0

Left thigh 5.5 0

Right leg 5 0

Left leg 5 0

Right foot 3.5 0

Left foot 3.5 0

Total Area 

front/back

(circumferenti

BABY BURN ESTIMATE AND DIAGRAM
appendices | 421

1 to 4 5 to 9 10 to14 15

years years years years 1st 2nd 3rd TBSA

Head 17 13 11 9 0

Neck 2222 0

Anterior trunk* 13 13 13 13 0

Posterior trunk* 13 13 13 13 0

Right buttock 2.5 2.5 2.5 2.5 0

Left buttock 2.5 2.5 2.5 2.5 0

Genitalia 1111 0

Right upper arm 4444 0

Left upper arm 4444 0

Right lower arm 3333 0

Left lower arm 3333 0

Right hand 2.5 2.5 2.5 2.5 0

Left hand 2.5 2.5 2.5 2.5 0

Right thigh 6.5 8 8.5 9 0

Left thigh 6.5 8 8.5 9 0

Right leg 5 5.5 6 6.5 0

Left leg 5 5.5 6 6.5 0

Right foot 3.5 3.5 3.5 3.5 0

Left foot 3.5 3.5 3.5 3.5 0

Total Area 

front/back

(circumferential)

CHILD BURN ESTIMATE AND DIAGRAM
422 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

JTTS Burn Resuscitation Flow Sheet Protocol

Purpose: The JTTS Burn Resuscitation Flow Sheet provides clinicians with a tool to track burn resuscitation over 

a 72-hour period. Conceptually, the flow sheet creates a 

continuum between clinicians during the resuscitation 

phase. This format allows clinicians to accurately trend 

intake and output, hemodynamics and vasoactive medications, and promotes optimal outcomes through precise 

patient management. 

I. The clinicians at the first medical facility where the 

patient receives treatment will initiate the JTTS 

Burn Resuscitation Flow Sheet. This treatment 

facility will be listed in the “Initial Treatment Facility” block. Clinicians at any level of care may 

initiate the flow sheet. 

II. Record today’s date in the “Date” block according to the current date where the recorder is located (do not adjust this date based on the patient’s 

origin or destination; use the local date). 

III. Record the patient’s full name and social security number in the “Name” and “SSN” blocks. 

Document name and SSN on all three pages of 

the flow sheet. 

IV. Record the patient’s weight in the “Pre-burn 

est. wt (kg)” block. In theater, record the estimated weight based on the patient’s weight prior 

to injury or “dry weight.” If a patient presents 

prior to initiating resuscitation and an accurate 

weight can be easily obtained without delaying 

care, providers are urged to weigh the patient 

and record the result. 

V. Record the total body surface area burned in the 

“% TBSA” block. Clinicians will assess the burn 

size and use this value to determine fluid resuscitation requirements. Following the patient’s 

transfer to another facility, the receiving clinicians are required to “re-map” the burn, considering that burn wound may “convert” between 

assessments at one facility or during transport 

between two facilities. 

VI. Burn Fluid Resuscitation Calculations: Use the 

ABLS guidelines to determine fluid requirements 

for the first 24 hours post-burn. At 8-12 hours 

post-burn, reevaluate resuscitation efforts and 

recalculate fluid resuscitation needs. If fluid resuscitation needs exceed ABLS formula calculations, 

consider the guidelines established in the Emergency War Surgery handbook and the addendum 

to the handbook, “Recommendations for Level 

IV Burn Care.” [LRMC specific: USAISR/BAMC 

Burn Unit Guidelines can also be found in the 

LRMC Burn Care Guide] 

a. Clinicians at the first medical facility to 

treat the patient will calculate the fluid 

requirements for the first 24 hours postburn and record the amount in the block 

on page 1 labeled “Estimated fluid vol. pt 

should receive.” 

b. Clinicians will record the “fluid volume 

ACTUALLY received” during the first 24 

hours of resuscitation in the block labeled as 

such at the top of page 2. This amount will 

equal the actual volume delivered during the 

first 24 hours (as recorded on page 1). 

c. Clinicians will transcribe the 24-hour fluid 

volume totals recorded on pages 1 and 2 of 

the flow sheet onto page 3 in the block labeled “fluid volume ACTUALLY received.” 

This allows clinicians to see the first 48-hour 

totals as the patient enters into the last 24 

hours of the 72-hour period. 

VII. Record the local date and time that the patient 

was injured in the “Date & Time of Injury” block. 

This date and time IS NOT the time that the patient arrived at the medical facility, but rather the 

date and time of INJURY. 

VIII. Record the facility name and/or treatment team in 

the “Tx Site/Team” block. The facility name/team 

name is the team of clinicians who managed the 

patient during each specified hour on the flow 

sheet. This team may reside within a facility, in 

which case the facility name is recorded, or be a 

transport team (e.g., Medevac, CCATT, Aerovac). 

IX. “Hr from burn” is defined as the number of hours 

after the burn injury occurred. If a patient does 

not arrive at a medical facility until 3 hours after 

the burn occurred, clinicians do not record hourly 

values for hours 1-3 but begin recording in the 

row marked “4th” hour post-burn. To the extent 

possible, clinicians should confer with level I and 

II clinicians to determine fluid intake and urine 

output. These totals may be recorded in the 3rd 

hour row. 
appendices | 423

X. Record the current local time of the recorder in the 

“Local Time” block, be it Baghdad Time, Berlin 

Time, ZULU, or CST. As with date, do not adjust 

this time based on the patient’s origin or destination; use the local time. 

XI. Record the total volume of crystalloids and colloids administered in the “crystalloid/colloid” 

column, not the specific fluids delivered. Clinicians should refer to the critical care flow sheet to 

determine the fluid types and volumes. This burn 

flow sheet is designed to track total volumes. Examples of crystalloid solutions are LR, 0.45% 

NS, 0.9% NS, D5W, and D5LR. Examples of 

colloids are Albumin (5% or 25%), blood products, and other volume expanders such as dextran, hespan, or hextend. 

XII. Document the name, dosage, and rate of vasoactive agents in the “Pressors” block. Patients who 

receive vasoactive agents may also have invasive 

pressure monitoring devices (e.g., arterial line, 

central venous line, pulmonary artery catheter), 

in which case significant values should be recorded in the “BP” and “MAP (>55)/CVP” columns

XIII. For additional burn resuscitation guidelines refer 

to the Emergency War Surgery handbook and the 

“Recommendations for Level IV Burn Care.”
424 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

Pre-burn Est. 

Wt (kg) %TBSA 1st 8 hrs 2nd 16th hrs 24 hr Total

Fluid Volume ACTUALLY received

Page 2 (24-48 hrs) Page 3 (48-72 hrs)

Pre-burn Est. 

Wt (kg) %TBSA 1st 24 hrs 2nd 24 hrs 48 hr Total

Fluid Volume ACTUALLY received

[11] [13] [15] [16] [17] [18] [19] [20]

[14a]

[12]

[1] Date: Today's date

[2] Initial Treatment Facility: Where this form is initiated

[3] Name: Patient’s name

[4] SSN: Patient’s social security number

[5] Weight (Kg): Estimated weight PRE-BURN “dry weight”

[6] % TBSA: Total body surface area burned

[7] 1st 8 Hrs: 1⁄2 total calculated fluids per burn resuscitation 

formula (ABLS), given over 1st 8 hrs post-burn

[8] 2nd 16 Hrs: Remaining 1⁄2 of the calculated fluids over the 

next 16 hrs

[9] Estimated Total Fluids: Total fluids calculated for the first 

24 hrs post-burn injury

[10] Time of Injury: Time the patient burned, NOT the time 

patient arrived at the facility

[11] Treatment (Tx) Site/Team: Facility, CCATT or care team 

providing care at specified hour

[12] Hour From Burn: “1st” hour is the first hour post burn. For 

example: pt arrives @ facility 3 hrs post-burn. Clinicians will 

start their charting for the “4th” hour. Enter IVF & UOP totals 

from level I & II care, prior to arrival at the current facility, in 

the “3rd” hour row. 

[13] Local Time: Current time being used by recorder

[14a] Crystalloid (mL): Total crystalloid volume given over last 

hour (LR, NS, etc.)

[14b] Colloid (mL): Total colloid volume given over the last 

hour (Albumin 5%-25%, blood products, Hespan, etc.) Note 

when using Albumin: With large resuscitations, start 5% 

Albumin at the 12 hour mark; with normal resuscitations, start at 

the 24 hour mark.

[15] Total: Total volume (crystalloid + colloid) for the hour

[16] UOP: Urine output for last hour

[17] Base Deficit: enter lab value, if avail. (indicates acidemia) 

[18] BP: Systolic BP / Diastolic BP

[19] MAP/CVP: MAP and/or CVP if available.

[20] Pressors: Vasopressin, Levophed, etc., and rate/dose

[21] 12-hr Total: Total IVF & UOP for 1st 12 hours post-burn

[22] 24-hr Total: Total IVF & UOP for 1st 24 hours post-burn

[14b]

Burn Flow Sheet Documentation

The guidelines for page 2 remain the same as for page 1, with 

the exception of the calculation table. On page 2, the values in 

[a] and [c] are the actual volumes delivered and recorded from 

page 1, blocks 21 & 22. [b] is the actual volume delivered 

from the 9th hour through the 24th hour. These values allow 

caregivers to re-calculate the mL/kg/% TBSA, and evaluate for 

over-resuscitation

[a] [b] [c] [d] [e] [f]

The guidelines for page 3 remain the same as for pages 1 & 2, 

with the exception of the calculation table. On page 3, the values 

in [d] and [e] are the actual 24 hour fluid totals recorded from 

pages 1 & 2. [f] is the total volume delivered over the first 48 

hrs ([d] + [e]). Once again, these values allow caregivers to recalculate the mL/kg/% TBSA, and evaluate for over-resuscitation

JTTS Burn Resuscitation Flow Sheet Page 1

Date: Initial Treatment Facility:

Name SSN

Pre-burn est. 

wt (kg) % TBSA 1st 8 hrs 2nd 16th hrs Est. Total 24 hrs

[5] [6] [7] [8] [9]

[2]

[3] [4]

[1]

Date & Time of Injury [10] BAMC/ISR Burn Team DSN 312-429-2876

Estimated fluid vol. pt should receive

Tx Site/ 

Team

HR from 

burn

Local 

Time

UOP Base 

Deficit

BP Pressors

(Vasopressin 0.02-0.04 

1st u/min)

2nd

3rd

4th

5th

6th

7th

8th

9th

10th

11th

12th

13th

14th

15th

16th

17th

18th

19th

20th

21st

22nd

23rd

24th

Total Fluids:

Total Fluids 1st 12 hrs:

Crystalloid

Colloid TOTAL MAP 

(>55) (ml) CVP

[21]

[22]
appendices | 425

Management of Patients with

Severe Head Trauma

Severely head injured patients are those comatose 

patients with Glasgow Coma Scores (GCS) of 3 to 8. 

The current Coalition referral center for patients with 

severe head injuries is the 332nd EMDG in Balad. All 

severely head injured Coalition and civilian patients are 

referred to Balad for definitive neurosurgical care. Several trends have been observed since 2003, warranting 

the standardization of care for these patients. The mortality of American service members with severe head 

injuries is 30% for GCS 3–5 and 10% for GCS 6–8. Of 

these survivors, progression to independent living in the 

United States is 30% for GCS 3–5 and 60% for GCS 

6–8. These excellent outcomes are achieved through 

rapid evacuation from the battlefield, timely neurosurgical intervention, meticulous critical care, and team 

rehabilitation that often continues for months. On the 

contrary, many Iraqi patients cannot be afforded even 

basic critical care and rehabilitation. During the past 

four years, approximately 90% of severely head injured 

patients treated in Balad are Iraqi Nationals. After resuscitative surgery and initial critical care, all comatose Iraqi 

patients are transported to Baghdad. Those with isolated 

head injures are treated at the “CNS” hospital. Those 

with multi-system injuries are treated at “Medical City.” 

Personal communication with staff neurosurgeons at 

these facilities confirms that patients who fail to quickly 

recover to independent or minimally-assisted living will 

not be aggressively treated. Given this standard of care, 

all Coalition patients with GCS 3–8 and Iraqi patients 

with GCS 6–8 should be referred to Balad for definitive 

neurosurgical care. Transfer of Iraqi patients with GCS 

3–5 is optional, as these patients are likely to be treated 

expectantly. 

Recommendations

1. Always address immediate life-threatening injuries 

and begin resuscitation using ATLS protocols. 

a. Normal saline is the preferred crystalloid solution. 

b. Blood products are preferred over albumin 

and hespan if colloids are necessary. 

c. Consider recombinant Factor VIIa for life 

threatening intracranial bleeding. 

d. Consider hyperventilation (goal PaCO2 30–35 

mm Hg) to decrease ICP. 

e. Antibiotics are unnecessary for isolated closed 

head injuries. Patients with open head injuries should receive 2 grams (child 50 mg/kg) 

cefazolin (Ancef) IV on admission and every 8 

hours until wounds are closed. 

f. Steroids provide no benefit to head injured 

patients. 

2. Two most important factors to manage: 

a. Hypotension: keep SBP > 90 mm Hg. 

b. Hypoxemia: keep SpO2 Sat > 93%. 

3. Document neurological examinations. These should 

include: 

a. Glasgow Coma Score (GCS). 

b. Size and reactivity of pupils. 

c. Presence of gross unilateral weakness, 

paraplegia, or quadriplegia. 

d. Interval changes while at your facility. 

4. Neurosurgeons in Balad prefer to examine patients 

when they arrive. Avoid medications which cause 

long lasting sedation or paralysis. 

Note: at no time should these preferences 

override the need for safe transport 

a. Vecuronium (Norcuron) 5–10 mg (child 0.1 

mg/kg) IV is preferred for paralysis. Avoid 

redosing within one hour of arrival in Balad. 
426 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

JTTS Clinical Practice Guideline For Severe Head Trauma 

MONITORING & LAB EVALUATION INDICATIONS & GUIDELINES

INTRACRANIAL PRESSURE (ICP) Glasgow Coma Score 8 or less. 

ARTERIAL LINE Any head trauma that requires tracheal intubation or other definitive airway. 

CENTRAL VENOUS PRESSURE When ICP or CPP management requires mannitol (Osmitrol) or hypertonic saline.

NEUROIMAGING Non-contrast head CT upon admission then at 6-24 hours after admission. 

EEG Continuously when barbiturates are employed to manage ICP. 

LABS ABG, CBC, Chem 10, PT, PTT, and INR at least q12 hrs during the first 48 hours of care. 

GENERAL MANAGEMENT PRINCIPLES

PHILOSOPHY 

• Maintain continuous communication between the care teams. 

• Aggressively avoid hypotension, hypoxemia, fever, and hyponatremia. 

• Remember, the longer the ICP is elevated and the MAP/CPP are low, the worse the 

outcome. 

RESUSCITATION FLUID Prefer Normal Saline. (Beware of iatrogenic, hyperchloremic acidosis) 

MAINTENANCE FLUID Prefer Normal Saline 1 cc/kg/hr. (Child use 4/2/1 rule X 80%) 

SEDATION 

• Prefer propofol (Diprivan) 10-50 mcg/kg/min IV. 

• Consider other short-acting agents such as fentanyl (Sublimaze) 1 mcg/kg/hr IV or 

midazolam (Versed) 1-2 mg/hr IV.

ULCER PROPHYLAXIS • All patients should receive pantoprazole (Protonix) 40 mg QD. 

• Child dosing for pantoprazole (Protonix) is 1 mg/kg to maximum of 40 mg QD. 

DVT PROPHYLAXIS 

• Pneumatic stockings for all adults. 

• Consider enoxaparin (Lovenox) 30 mg SC bid 24 hours after injury. 

• DVT Prophylaxis is not indicated in children (age < 16 yrs). 

SEIZURE PROPHYLAXIS 

• For all patients with injuries penetrating the cortex or blunt injuries with abnormal CT. 

• Minimum treatment 7 days. 

• Fosphenytoin (Cerebyx) loading dose: 18 mg/kg IV over 10 minutes. Adult maintenance: 

100 mg q8h (child 2 mg/kg q8h). Therapeutic level: 10-20 ȝg/ml: [Phy corrected] = [Phy 

measured]/(0.2 x [albumin]) + 0.1. 

• Phenytoin (Dilantin) causes irritation of peripheral veins; run IV bolus over 20 minutes.

ANTIBIOTICS Cefazolin (Ancef) 1 gm IV (child 25 mg/kg) q8h X 5 days for all open injuries. 

NURSING Assess neurologic status hourly; document ICP/CPP ventriculostomy output. 

STEROIDS

• Steroids are not recommended for head trauma. 

• High dose methylprednisolone (Solu-Medrol) is contraindicated in penetrating injuries. 

• Consider methylprednisolone (Solu-Medrol) in blunt trauma with incomplete cervical 

spinal cord injuries. This protocol is not recommended for thoracic and lumbar trauma. 

• The protocol for methylprednisolone (Solu-Medrol) is 30 mg/kg bolus IV, then 5.4 

mg/kg/hr. 

NUTRITION §140% of basal energy expenditure by seventh day post injury. Give 15% of calories as 

protein. 

GENERAL MEDICAL MANAGEMENT GOALS

Intracranial 

Pressure (ICP) < 20 mm Hg 

NEUROLOGIC Cerebral

Perfusion 

Pressure (CPP) 

> 60 mm Hg 

See page 2 
appendices | 427

Mean arterial 

pressure (MAP) Maintain CPP

Central venous 

pressure (CVP) HEMODYNAMIC > 5 mm Hg 

Cardiac index 

(CI) > 2.5L/m/m2

• Hypotension (SBP < 90 mm Hg) worsens 

mortality and outcome 

• Provide a rapid physiologic resuscitation 

utilizing Normal Saline, Hypertonic 

Saline, or colloids. 

Oxygen saturation 

(Sp02 %) > 93% Aggressively avoid hypoxemia PULMONARY 

PaC02 30-35 mm Hg First 24-48 hours of care 

INR < 1.5 Transfuse fresh frozen plasma 

Platelets > 100,000/mm3 Transfuse platelets 

HEMATOLOGIC

Consider titrating components using 

thromboelastography (TEG) Hemoglobin > 10 g/dL Transfuse packed red blood cells 

METABOLIC Glucose > 80 & < 150 mg/dl Have low threshold for insulin drip 

Serum osmolarity > 280 & < 320 mOsm 

RENAL Serum sodium > 135 & < 150 mEq/L 

• sOsm = (2 x Na) + (Glucose/18) + 

(BUN/2.8) 

• See sodium disorders on page 2 

INTRACRANIAL PRESSURE MANAGEMENT

GENERAL

MEASURES 

Keep head in neutral position, avoid of tight cervical collars and circumferential ETT ties, elevate the head of the 

bed to 30-60 degrees. 

SEDATION • Propofol (Diprivan) preferred during first 72 hours (see above for dosing). 

• Confirm level of sedation when intracranial pressure increases. 

TEMPERATURE Consider cooling measures (Tylenol, cooling blanket) even for modest temperature elevations (100-101° F). 

INTRACRANIAL 

HYPERTENSION 

MANAGEMENT

• Treat elevations  20 mm Hg sustained for > 5 minutes. 

• Always consider repeat CT scan with ICP elevations refractory to medical therapy. 

1. Deep sedation/analgesia Propofol/fentanyl/midazolam (see above for dosing). 

2. Chemical paralysis Cisatracurium (Vecuronium): Loading dose 0.2 mg/kg IV. 

Maintenance infusion 1-3 mcg/kg/hr IV. 

3. Modest hyperventilation • PaC02 30-35 mmHg during evaluation or evacuation. 

• Discontinue after 24-48 hours. 

4. Hypertonic saline 

• Recommended during the first 24-48 hours. 

• 3% NS 250-500 cc bolus over 15 minutes (child 5 cc/kg). 

• 3% NS infusion 40 cc/hr (child 0.5 cc/kg/hr). 

5. Mannitol • Avoid in dehydration and hypotension. 

• 1 gm/kg IV fast push, then 0.25 gm/kg push q4h. 

6. Ventricular drainage When open, ventriculostomy may drain as much as 10-20 cc/hr. 

GOAL: ICP < 20 mmHg 

TITRATE TO EFFECT 

7. Decompressive craniectomy Discuss indications with neurosurgeon on call. 

CEREBRAL PERFUSION PRESSURE MANAGEMENT (CPP = MAP – ICP)

1. Ensure euvolemia Utilize endpoints of resuscitation (exam, vital signs, urine output, CVP, PCWP, CI). 

2. Control the ICP Beware of mannitol use in hypovolemic patients. 

GOAL 

> 60

mm Hg 3. Consider pressors Dopamine preferred, 0.5 mcg/kg/min IV. 

ACUTE CLINICAL DETERIORATION 

(e.g. Mental status change, unilateral dilated pupil, new focal neurological deficit, progressive or refractory ICP elevation)

1. Confirm level of sedation 

2. Verify oxygenation and ventilation

3. Hyperventilate bag with 100% O2; 

goal PaC02 20-30 mmHg 

UNCAL HERNIATION SYNDROME (Commonly seen in head trauma) 

• Unilateral dilating pupil ĺ progression to fixed and dilated 

• Altered mental status ĺ progression to comatose 

• Contralateral babinski ĺ contralateral weakness ĺ bilateral flexor or extensor posturing 

• Tachycardia/hypertension ĺ bradycardia/hypertension ĺ bradycardia/hypotension 

4. Re-bolus 3% saline or mannitol 

5. Repeat CT/call neurosurgery

6. Consider damage control crani 
428 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

GLASGOW COMA 

SCORE Eye Opening Best Verbal Effort Best Motor Effort 

1 None None No response to pain 

2 To Pain Nonspecific sounds Extensor posturing 

3 To verbal stimuli Inappropriate words Flexor posturing 

4 Spontaneously Confused Withdraws to pain 

5 - Oriented Localizes pain 

6 - - Follows commands 

COMMON SODIUM DISORDERS SEEN IN HEAD TRAUMA

Disorder Na+ Diagnostic Clues Treatment 

SIADH Ļ Low Sosm, usually euvolemic, Ĺ Uosm Restrict free water, administer hypertonic saline if severe 

Cerebral

salt wasting Ļ

Sosm may be normal, Ĺ UOP, signs of 

volume depletion & hemoconcentration, 

very high U Na 

Replace volume with Normal Saline or hypertonic saline. Administer oral 

sodium. Beware of rapid sodium correction. 

Mannitol 

use Ĺ Polyuria, Ĺ [Na+] & Sosm Hold mannitol if Sosm > 320. 

Diabetes 

Insipidus Ĺ Polyuria (> 250 cc/hr), Ĺ [Na+] & Sosm, 

U Sp Gr <1.005 DDAVP § 2-4 ȝg SQ bid.

BRAIN DEATH DETERMINATION – Adhere to separate “Guidelines for Diagnosing Brain Death.”

b. Propofol (Diprivan) 5–10 mcg/kg/min IV is 

preferred for sedation. 

c. Intermittent administration of narcotics is preferred over continuous intravenous drips for 

pain control. 

5. If therapy for intracranial hypertension is needed 

prior to transfer: 

a. Consider 23% NS 30 cc one time bolus IV 

over 15 minutes (child 0.5 cc/kg). 

b. If 23% sodium chloride is unavailable, consider 3% NS 250-500 cc IV bolus (child 5 cc/kg) 

followed by continuous infusion 40 cc/h (child 

5 cc/kg/hr). 

c. If signs of herniation or severe edema are present, consider Mannitol 1 g/kg bolus IV, followed by 0.5 g/kg rapid IV push q4h. 

Note: do not use mannitol in hypotensive or 

under-resuscitated patients

6. Antiepileptic medications for seizure prophylaxis: 

a. Consider for all patients with intracranial 

hemorrhage, penetrating brain injury, seizure 

following the injury, or GCS 3–8. 

b. Fosphenytoin (Cerebyx) is the preferred parenteral (IV or IM) medication: 

i. Adults: load 1 gram IV over 10 minutes, 

followed by 100 mg IV q8h. 

ii. Children: load 20 mg/kg over 10 minutes, 

followed by 2 mg/kg IV q8h. 

c. Discontinue after 7 days if no penetrating 

brain injury, no prior seizure history, and no 

development of seizures since the injury.
appendices | 429

DAMAGE CONTROL RESUSCITATION 

AT LEVELS IIb AND III 

The leading cause of potentially preventable death 

on the battlefield is noncompressible hemorrhage. 

Following Tactical Combat Casualty Care (TCCC) 

guidelines, tourniquets and hemostatic dressings are 

being used by medics to treat compressible hemorrhage, 

thus truncal bleeding is the unmet problem. At the FST

and CSH level many physicians use the standard ATLS 

guidelines, starting resuscitation with crystalloid, then 

moving to PRBC and only after liters of these fluids 

adding plasma. For the severely injured a new method 

of resuscitation utilizes objective criteria outlined 

below to initiate rFVIIa, thawed plasma and RBC

use in the ED, within minutes of arrival. Crystalloid 

infusion is extremely limited. rFVIIa has recently 

shown improved hemostasis (decreasing blood loss 

by 23%) in combat casualties. Likewise increased 

use of plasma has recently been shown to improve 

mortality rates in combat casualties. These products 

are very safe in trauma patients and are currently in 

widespread use, both in military and civilian trauma 

patients. Conversely, excessive crystalloid has resulted 

in a greater incidence of abdominal compartment 

syndrome (16% vs 8%), multiple organ failure (22% 

vs 9%), and death (27% vs 11%) in a large series of 

civilian trauma patients. Administration of rFVIIa, 

PRBC, thawed plasma, platelets and cryoprecipitate 

and fresh whole blood at the FST and CSH, within 

the confines of the tactical situation, may decrease 

hemorrhagic morbidity and mortality of casualties 

with truncal hemorrhage. 

ED/EMT Resuscitation

rFVIIa and plasma and PRBC (1:1 ratio) are indicated 

for any one of the following findings: 

1. Truncal/axillary/neck or groin bleeding not controlled with tourniquets, HemCon dressings or 

QuikClot 

2. Large soft tissue injuries not controlled with 

tourniquets, HemCon dressings or QuikClot 

3. A proximal amputation or mangled extremity 

4. > 1000 cc blood out of a chest tube, or > 200 

cc/hr for 4 consecutive hours 

5. Physical exam findings: 

a. decreased mental status from injury and 

shock 

b. severe head injury 

c. clinically coagulopathic 

6. Objective physical exam or laboratory findings: 

a. an INR ≥ 1.5 

b. a base deficit ≥ 6 

c. a Hgb ≤ 12 

d. hypothermic from blood loss (T < 96°F) 

e. hypotensive from blood loss (SBP < 90 mm 

Hg) or a weak/absent radial pulse 

7. Need for fresh whole blood transfusion: 

a. bilateral proximal amputations 

b. large hemoperitoneum and significant shock 

Casualties with any one of these parameters have 

> 25% mortality and should be given rFVIIa and 

RBC:thawed plasma in a 1:1 ratio as soon as possible. 

OR resuscitation

Most of the seriously injured casualties that receive 

hemostatic resuscitation in the ED will require the 

massive transfusion protocol, outlined in another CPG. 

In general this calls for coolers of products from the blood 

bank containing 6 units of PRBC, 6 units of plasma, 6 

units of platelets and 10 packs of cryoprecipitate. Again 

crystalloid resuscitation is minimized, and rFVIIa is 

given when the INR is > 1.0. THAM is administered 

to keep the pH > 7.2 and Ca++ is given after every 4 

units of PRBC, and/or to keep ionized Ca++ > 1.0 (on the 

ISTAT). The goal of OR resuscitation is to normalize all 

laboratory parameters, patient temperature, INR and 

base deficit. The operating room must be kept as warm 

as possible, usually 108°F. Major resuscitations in the 

OR (20–40 units) frequently only receive 3–4,000 cc of 

crystalloid. 

ICU resuscitation

Patients treated in the above fashion frequently arrive 

in the ICU warm (98), a base deficit of –3 and an INR

of 1. This is after receiving an average of 17 PRBC, 

13 plasma, 20 cryoprecipitate, 18 platelets, 7.2 mg 

rFVIIa and 4 liters crystalloid. Occasionally the patients 

require ongoing plasma and rFVIIa resuscitation, for an 

elevated INR and volume deficit. These patients are put 

on 50 cc/hr of crystalloid and because they are much less 

edematous than after traditional resuscitation regimens 

are able to extubate within 10 hours on average. 
430 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

Dose of rVIIa: 

1. The usual trauma dose is 100 mcg/kg rFVIIa IV 

push 

a. this dose can be safely repeated as many as 

3–4 times in 20 minute intervals or greater 

Route: 

1. rFVIIa can be given through an IV or an intraosseous line. 

Contraindications: 

1. patient with active cardiac disease 

Storage of rFVIIa: 

1. Keep rVIIa refrigerated at 2–8 degrees C/36-46 

degrees F prior to reconstitution with sterile H2O. 

2. May store rFVIIa for up to 3 hours at room 

temperature (15–30 degrees C/59–86 degrees F) 

after reconstitution. If not maintained at these 

temperatures, the rVIIa is rendered inactive. 

Plasma: 

See separate guidance on use of plasma from Joint 

Theater Blood Program USCENTCOM/CCSG. 

Thawed plasma not used under the precise conditions 

listed here may cause serious harm to the patient 

(infection or transfusion reactions); thus, it should be 

administered only by those trained to do so. 

Infuse 250 cc plasma IV or IO after the rFVIIa; this 

can be by drip or by IV/IO push. No more than two 

units of un-typed plasma should be administered under 

these conditions; thus, immediately send blood to lab 

for typing, as all subsequent transfusions should be 

done with type-specific plasma where possible. 

Storage of Thawed Plasma (see separate guidance 

on use of plasma from Joint Theater Blood Program 

USCENTCOM/CCSG) 

Plasma not stored under the precise conditions listed 

here may cause serious harm to the patient (infection 

or transfusion reactions) and should be properly 

discarded immediately. 

1. FFP can stay thawed (Thawed Plasma) for up to 5 

days but it must be relabeled as “Thawed Plasma” 

complete with a new expiration annotated and 

stored at 1–6 degrees C. 

2. Thawed plasma for emergency use should be type 

AB or A; DO NOT allow more than 2 emergency 

plasma units to be administered until an ABO

forward type or complete ABO type has been 

performed. 

3. Administer plasma through standard blood administration set. 

4. Use the HemaCool® Mobile Blood Storage Refrigerator/Freezer* or other refrigeration device to 

safely store these products (see further information 

as noted* below).

*HemaCool® Mobile Blood Storage Refrigerator/Freezer Model: 

HMC-MIL-1. NSN: 4110-01-506-0895 

Helmer Rapid Plasma Thawer has a 4 plasma unit model (DH4) 

and an 8 plasma unit model (DH8). NSN for the DH4 is 6640-01-

510-3136. There is no NSN currently for the 8-unit model.
appendices | 431

military acute concussion

evaluation (MACE)

Military Acute Concussion 

Evaluation (MACE)

Defense and Veterans Brain Injury Center

08/2006 DVBIC.org 800-870-9244

This form may be copied for clinical use.

Page 1 of 6

Patient Name: ___________________________________________

SS#: _______-_______-_______Unit: _________________________ 

Date of Injury: _____/_____/_____ Time of Injury: ______________ 

Examiner: ______________________________________________

Date of Evaluation: _____/_____/_____ Time of Evaluation: _____ 

History: (I – VIII)

I. Description of Incident

Ask:

a) What happened?

b) Tell me what you remember.

c) Were you dazed, confused, “saw stars”? R Yes R No

d) Did you hit your head? R Yes R No

II. Cause of Injury (Circle all that apply):

1) Explosion/Blast 4) Fragment 

2) Blunt object 5) Fall

3) Motor Vehicle Crash 6) Gunshot wound 

7) Other _________________

III. Was a helmet worn? R Yes R No Type ______________

IV. Amnesia Before: Are there any events just BEFORE the 

injury that are not remembered? (Assess for continuous 

memory prior to injury) 

R Yes R No If yes, how long __________

V. Amnesia After: Are there any events just AFTER the 

injuries that are not remembered? (Assess time until

continuous memory after the injury)

R Yes R No If yes, how long __________

VI. Does the individual report loss of consciousness or 

“blacking out”? R Yes R No If yes, how long __________

VII. Did anyone observe a period of loss of consciousness or 

unresponsiveness? R Yes R No If yes, how long _______

VIII. Symptoms (circle all that apply)

1) Headache 2) Dizziness

3) Memory Problems 4) Balance problems 

 5) Nausea/Vomiting 6) Difficulty Concentrating 

7) Irritability 8) Visual Disturbances 

9) Ringing in the ears 10)Other __________________

Military Acute Concussion 

Evaluation (MACE)

Defense and Veterans Brain Injury Center

08/2006 DVBIC.org 800-870-9244

This form may be copied for clinical use.

Page 2 of 6

Examination: (IX – XIII)

Evaluate each domain. Total possible score is 30.

 

IX. Orientation: (1 point each)

 Month: 0 1

 Date: 0 1

 Day of Week: 0 1

 Year: 0 1

 Time: 0 1

Orientation Total Score ______/5

X. Immediate Memory:

Read all 5 words and ask the patient to recall them in any order. 

Repeat two more times for a total of three trials. (1 point for each 

correct, total over 3 trials)

List Trial 1 Trial 2 Trial 3

Elbow 0 1 0 1 0 1

Apple 0 1 0 1 0 1

Carpet 0 1 0 1 0 1

Saddle 0 1 0 1 0 1

Bubble 0 1 0 1 0 1

Trial Score

 

Immediate Memory Total Score ______/15

XI. Neurological Screening

As the clinical condition permits, check

Eyes: pupillary response and tracking

Verbal: speech fluency and word finding

Motor: pronator drift, gait/coordination

Record any abnormalities. No points are given for this.

Reprinted courtesy of the Defense and Veterans Brain Injury Center (DVBIC), Walter Reed Army Medical Center, 

Washington, DC.
432 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

Military Acute Concussion 

Evaluation (MACE)

Defense and Veterans Brain Injury Center

08/2006 DVBIC.org 800-870-9244

This form may be copied for clinical use.

Page 3 of 6

XII. Concentration

 Reverse Digits: (go to next string length if correct on first trial.

Stop if incorrect on both trials.) 1 pt. for each string length.

4-9-3 6-2-9 0 1

3-8-1-4 3-2-7-9 0 1

6-2-9-7-1 1-5-2-8-5 0 1

7-1-8-4-6-2 5-3-9-1-4-8 0 1

Months in reverse order: (1 pt. for entire sequence correct)

Dec-Nov-Oct-Sep-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan 

0 1

Concentration Total Score ____/5

XIII. Delayed Recall (1 pt. each)

Ask the patient to recall the 5 words from the earlier memory test 

(Do NOT reread the word list.)

Elbow 0 1

Apple 0 1

Carpet 0 1

Saddle 0 1

Bubble 0 1

Delayed Recall Total Score ____/5

TOTAL SCORE ______/30

Notes: 

Diagnosis: (circle one or write in diagnoses)

No concussion

850.0 Concussion without Loss of Consciousness (LOC) 

850.1 Concussion with Loss of Consciousness (LOC) 

Other diagnoses ______________________________________

 ______________________________________

Defense & Veterans Brain Injury Center

1-800-870-9244 or DSN: 662-6345

Military Acute Concussion 

Evaluation (MACE)

Defense and Veterans Brain Injury Center

08/2006 DVBIC.org 800-870-9244

This form may be copied for clinical use.

Page 4 of 6

Instruction Sheet

Purpose and Use of the MACE

A concussion is a mild traumatic brain injury (TBI). The purpose of the 

MACE is to evaluate a person in whom a concussion is suspected. 

The MACE is used to confirm the diagnosis and assess the current

clinical status. 

Tool Development

The MACE has been extensively reviewed by leading civilian and 

military experts in the field of concussion assessment and management. While the MACE is not, yet, a validated tool, the examination 

section is derived from the Standardized Assessment of Concussion

(SAC) (McCrea, M., Kelly, J. & Randolph, C. (2000). Standardized 

Assessment of Concussion (SAC): Manual for Administration, 

Scoring, and Interpretation. (2nd ed.) Waukesa,WI: Authors.) which is 

a validated, widely used tool in sports medicine. Abnormalities on the 

SAC correlate with formal comprehensive neuropsychological testing 

during the first 48 hours following a concussion.

Who to Evaluate

Any one who was dazed, confused, “saw stars” or lost consciousness, even momentarily, as a result of an explosion/blast, fall, motor 

vehicle crash, or other event involving abrupt head movement, a 

direct blow to the head, or other head injury is an appropriate person 

for evaluation using the MACE.

Evaluation of Concussion

History: (I – VIII)

I. Ask for a description of the incident that resulted in the injury; 

how the injury occurred, type of force. Ask questions A – D.

II. Indicate the cause of injury

III. Assess for helmet use. Military: Kevlar or ACH (Advanced 

Combat Helmet). Sports helmet, motorcycle helmet, etc.

IV – V Determine whether and length of time that the person 

wasn’t registering continuous memory both prior to injury and 

after the injury. Approximate the amount of time in seconds, 

minutes or hours, whichever time increment is most appropriate. 

For example, if the assessment of the patient yields a possible 

time of 20 minutes, then 20 minutes should be documented in 

the “how long?” section.

VI – VII Determine whether and length of time of self reported loss 

of consciousness (LOC) or witnessed/observed LOC. Again, 

approximate the amount of time in second, minutes or hours, 

whichever time increment is most appropriate.

VIII Ask the person to report their experience of each specific

symptom since injury.
appendices | 433

Military Acute Concussion 

Evaluation (MACE)

Defense and Veterans Brain Injury Center

08/2006 DVBIC.org 800-870-9244

This form may be copied for clinical use.

Page 5 of 6

Examination: (IX – XIII)

Standardized Assessment of Concussion (SAC): 

Total possible score = 30

Orientation = 5

Immediate Memory = 15

Concentration = 5

Memory Recall= 5

IX Orientation: Assess patients awareness of the accurate time

Ask: WHAT MONTH IS THIS?

 WHAT IS THE DATE OR DAY OF THE MONTH?

 WHAT DAY OF THE WEEK IS IT? 

 WHAT YEAR IS IT?

 WHAT TIME DO YOU THINK IT IS?

One point for each correct response for a total of 5 possible points. It 

should be noted that a correct response on time of day must be 

within 1 hour of the actual time.

X Immediate memory is assessed using a brief repeated list learning test. Read the patient the list of 5 words once and then ask 

them to repeat it back to you, as many as they can recall in any 

order. Repeat this procedure 2 more times for a total of 3 trials, 

even if the patient scores perfectly on the first trial.

Trial 1: I’M GOING TO TEST YOUR MEMORY, I WILL READ 

YOU A LIST OF WORDS AND WHEN I AM DONE, REPEAT 

BACK AS MANY WORDS AS YOU CAN REMEMBER, IN ANY 

ORDER.

Trial 2 &3: I AM GOING TO REPEAT THAT LIST AGAIN. AGAIN, 

REPEAT BACK AS MANY AS YOU CAN REMEMBER IN ANY 

ORDER, EVEN IF YOU SAID THEM BEFORE.

One point is given for each correct answer for a total of 15 possible points.

XI Neurological screening

Eyes; check pupil size and reactivity.

 Verbal: notice speech fluency and word finding

Motor: pronator drift- ask patient to lift arms with palms up, ask 

patient to then close their eyes, assess for either arm to “drift” 

down. Assess gait and coordination if possible. Document any 

abnormalities.

No points are given for this section.

Military Acute Concussion 

Evaluation (MACE)

Defense and Veterans Brain Injury Center

08/2006 DVBIC.org 800-870-9244

This form may be copied for clinical use.

Page 6 of 6

XII Concentration: Inform the patient:

I’M GOING TO READ YOU A STRING OF NUMBERS AND 

WHEN I AM FINISHED, REPEAT THEM BACK TO ME BACKWARDS, THAT IS, IN REVERSE ORDER OF HOW I READ 

THEM TO YOU. FOR EXAMPLE, IF I SAY 7-1-9, YOU WOULD 

SAY 9-1-7.

 If the patient is correct on the first trial of each string length,

proceed to the next string length. If incorrect, administer the 2nd 

trial of the same string length. Proceed to the next string length if 

correct on the second trial. Discontinue after failure on both trials 

of the same string length. Total of 4 different string lengths; 1

point for each string length for a total of 4 points.

NOW TELL ME THE MONTHS IN REVERSE ORDER, THAT IS, 

START WITH DECEMBER AND END IN JANUARY.

1 point if able to recite ALL months in reverse order.

0 points if not able to recite ALL of them in reverse order.

Total possible score for concentration portion: 5.

XIII Delayed Recall

Assess the patient’s ability to retain previously learned information 

by asking he/she to recall as many words as possible from the 

initial word list, without having the word list read again for this trial.

DO YOU REMEMBER THAT LIST OF WORDS I READ A FEW 

MINUTES EARLIER? I WANT YOU TO TELL ME AS MANY 

WORDS FROM THE LIST AS YOU CAN REMEMBER IN ANY 

ORDER.

One point for each word remembered for a total of 5 possible 

points.

Total score= Add up from the 4 assessed domains: immediate 

memory, orientation, concentration and memory recall.

Significance of Scoring

In studies of non-concussed patients, the mean total score was 28. 

Therefore, a score less than 30 does not imply that a concussion 

has occurred. Definitive normative data for a “cut-off” score are

not available. However, scores below 25 may represent clinically 

relevant neurocognitive impairment and require further evaluation 

for the possibility of a more serious brain injury. The scoring system 

also takes on particular clinical significance during serial assessment

where it can be used to document either a decline or an improvement 

in cognitive functioning. 

Diagnosis

Circle the ICD-9 code that corresponds to the evaluation. If loss 

of consciousness was present, then circle 850.1. If no LOC, then 

document 850.0. If another diagnosis is made, write it in.
434 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

urologic trauma

JTTS CLINICAL PRACTICE GUIDELINES FOR UROLOGIC TRAUMA 

GUIDELINE ONLY—NOT A SUBSTITUTE FOR CLINICAL JUDGEMENT 

UPDATED JULY 2006

MONITORING & LAB 

EVALUATION 

INDICATIONS & GUIDELINES 

HEMATURIA x During trauma evaluation, place foley catheter unless contra-indicated. Perform 

RUG first if blood at the meatus, high riding prostate or other evidence urethral injury 

RUG- Obtain a KUB plain film first, then 14-16 fr foley, primed with contrast to 

rid air, is placed in the urethra past the balloon. 1-2 cc saline to fill the balloon 

snugly in the fossa navicularis. A pelvic film in a semi-lateral position is 

obtained after injecting approximately 30cc of straight contrast (con-ray) under 

steady, gentle pressure. Study is considered normal only if contrast enters the 

bladder without any extravastaion.

x If anterior urethral injury, plan to repair in OR. If posterior urethral injury, attempt to 

gently place a foley catheter. If unable, then place supra-pubic tube in EMT or in 

OR.

x If catheter passes, and gross hematuria noted, proceed with GU diagnostic evaluation 

for bladder injury or a renal/ureteral source. CT scan with delayed images + a CT 

cystogram is ideal imaging study (see technique description following). 

LABS x CBC, Chem 10, PT, PTT, UA. Type and Screen or Type and Cross x 4 units. 

GENERAL MANAGEMENT PRINCIPLES 

RENAL INJURY 

Penetrating renal injury 

=

Abdominal exploration 

x Blunt trauma with gross hematuria or microscopic hematuria in a patient with a SBP 

<90, should be imaged with contrast enhanced CT. 

x Renal Injury Grading

Grade 1: Sub-capsular hematoma 

 Grade 2: Small parenchymal laceration 

Grade 3: Deeper parenchymal laceration without entry into collecting system 

Grade 4: Laceration into collecting system with extravasation; vascular injury with 

contained hemorrhage 

Grade 5: Shattered kidney or renal pedicle avulsion 

x Hemodynamically stable patients can usually be managed without operation. 

x Vascular repair is indicated for salvageable kidneys with renal artery or vein injury. 

x Ureteral stent may need to be placed for persistent urinary extravasation. 

RENAL EXPLORATION 

DURING ABDOMINAL 

OPERATION 

x Absolute indications: persistent bleeding or expanding/pulsatile hematoma 

x Relative indications: urinary extravasation, nonviable tissue (> 20%), and segmental 

arterial injury on pre-op study. 

x Urinary extravasation from a grade IV parenchymal laceration or forniceal rupture 

can be managed nonoperatively in most patients. 

RENAL REPAIR AND 

PARTIAL 

NEPHRECTOMY 

PRINCIPLES 

x Complete renal exposure, débridement of nonviable tissue, hemostasis by individual 

suture ligation of bleeding vessels, watertight closure (absorbable suture), drainage 

of the collecting system, and coverage/approximation of the parenchymal defect. 

Perform partial nephrectomy if reconstruction not possible: the collecting system 

must be closed and the parenchyma covered with omentum. 

x Place ureteral stent for persistent urinary extravasation 

NEPHRECTOMY x Total nephrectomy is immediately indicated in extensive renal injuries when the 

patient's life would be threatened by attempted renal repair: vascular control of 

renal pedicle prior to exploration is paramount.

x Damage control by packing the wound to control bleeding and attempting to correct 

metabolic and coagulation abnormalities, with a plan to return for corrective surgery 

within 24 hours is an option.
appendices | 435

JTTS CLINICAL PRACTICE GUIDELINES FOR UROLOGIC TRAUMA 

GUIDELINE ONLY—NOT A SUBSTITUTE FOR CLINICAL JUDGEMENT 

UPDATED JULY 2006

URETERAL INJURIES x Hematuria not universal: a high index of suspicion must be maintained. 

x Can be diagnosed with IV contrast and a delayed KUB or CT 

x Middle and upper 1/3 ureteral contusion is treated by excision and 

ureteroureterostomy: mobilize injured ureter, sparing adventitia widely to prevent 

devascularization; débride ureter liberally until edges bleed; repair ureter 

(absorbable suture) under magnification with spatulated, tension-free, stented, 

watertight anastomosis, and drain. Consider omental interposition to isolate repair. 

x UPJ avulsion injuries should undergo re-anastamosis of the ureter to the renal pelvis. 

A stent and drains need to be placed. 

x Lower 1/3 ureteral injuries should be reimplanted into the bladder. Use a psoas 

hitch or Boari flap if required. 

BLADDER INJURIES x Most patients will present with gross hematuria. If CT is planned for other injuries, 

a CT cystogram (use DILUTED conray) should be performed. If no CT, obtain a 

plain film cystogram. (need minimum 300cc to be adequate study)

x Cystogram: Obtain scout film. Fill bladder via foley by gravity with at least 350cc 

contrast (7 cc/kg for pedi). Obtain AP image + Oblique view. Drain bladder 

completely and obtain AP image. Many bladder injuries are detected only on the 

post-drainage film. 

x Extraperitoneal extravasation of contrast can be managed with foley catheterization 

alone, unless: bone fragment projecting into the bladder, open pelvic fracture, or 

rectal perforation. Open repair is indicated in these cases (see below). 

x Intraperitoneal ruptures require open repair, two-layer closure with absorbable 

suture and perivesical drain placement. Last, place a large-bore suprapubic catheter 

and a urethral catheter to maximize bladder drainage of blood and clots.

POSTERIOR URETHRAL 

INJURIES

x Initial Management- Surgeon to attempt foley placement, consider urethroscopicassisted stenting of the injury with a urethral catheter.

x If unable to pass a urethral foley catheter, operatively place an open suprapubic tube. 

At the time of open s-p tube placement, inspect the bladder to rule out injury. 

ANTERIOR URETHRAL 

INJNURIES

x Diagnosis- As with posterior urethral injury, a high index of suspicion must be 

maintained in all patients with blunt or penetrating trauma in the urogenital region, 

and a RUG should be performed in any case of suspected urethral injury. 

x Anterior urethral injuries may also be associated with large hematoma or swelling 

from extravasated urine. In severe trauma, Buck's fascia may be disrupted, resulting 

in blood and urinary extravasation into the scrotum. 

x Management- Initial suprapubic urinary diversion is recommended after highvelocity gunshot wounds to the urethra, followed by delayed reconstruction. 

EXTERNAL GENITALIA 

INJURIES

x Penis- superficial wounds can be irrigated and closed primarily. Corporal injures 

are repaired by approximation of the tunical margins with absorbable sutures. 

Associated anterior urethral injuries should be closed primarily with a watertight, 

spatulated, catheter-stented technique and absorbable suture; posterior urethral 

injuries should be managed in staged fashion with suprapubic catheterization. 

x Scrotum/Testicle- Diagnosis by physical exam and ultrasound. Equivocal cases 

should be explored. Explore all testicles with overlying shrapnel on pelvic film or if 

there is a scrotal laceration and any abnormality on exam. Necrotic testicular tissue 

should be débrided and the capsule closed with running absorbable suture. In some 

cases, loss of capsule requires removal of intratesticular tissue to allow closure. 

inDEX

A

Abdomen

closure with bag, 135 (photo), 184

penetrating trauma, 159, 163

surgery in children, 366, 367

Acinetobacter infection, 281, 284

Advanced Trauma Life Support (ATLS), 71

Aeromedical evacuation, 6, 400

Airway

emergency, 24, 74

in burns, 238

in children, 366, 399

AK-47, wounds, 39, 125, 392

AlloDerm, 202

Alveolar nerve, inferior, 65

American College of Surgeons

 Committee on Trauma, 2, 7

Amputation, 314, 315

considerations, 293

“internal” of arm, 346

length-preserving, 314

traumatic, 19, 33

traumatic below the knee, 286

umbrella effect, 292

Anastomosis

bowel, 176, 177

Anesthesia. See Peripheral nerve block

in unexploded ordnance (UXO) cases, 373–376

regional, 383

Angiography (arteriography), 346, 353, 356 (photo), 361

Apheresis, platelets, 45

Arch bars, 68, 70, 73 (photo), 76 (photo)

Arteriovenous fistula, 337–339, 360

Astigmatism, 61

B

Ballistics of wounding, 23, 151, 201

indirect effects, 159

Basilar skull fracture, 90

Battalion Aid Station, 3

Battle’s sign, 91

“Behind Armor Blunt Trauma” (BABT), 146

Bent table, 128

Blast, 28, 30, 257

umbrella effect, 292

Blood. See Massive transfusion

collection procedure, 47

fresh whole, 43, 44 

Blood, type O, 47

Blood volume, in children, 371, 399

Brachial artery, 269

Blunt trauma, 346–349, 360

shunt, 334 (photo)

transection, 340

Brachial plexus, 269

Brain. See Traumatic brain injury

herniation, 86

injury, 85, 93

Brooke Army Medical Center, 284

Burn Team, 238

Broselow/Hinkle Pediatric Resuscitation System, 371, 372

Burn

cases, 28, 238

children, 243, Appendix

facial, 78

management, Appendix, 245, 246

 Rule of Nines, 243

80%, 238–244

Burr holes, 89, 101, 103 (photos)

Buttocks

wound, 211

C

Canthotomy, 78

Casualty, data interpretation, 11

Cavitation, 159

Cerebrospinal fluid leak, 112, 181

Cesarean section, in trauma, 392–398, 398 (illustration), 

400

Chest, surgical approaches to, 151, 154

Ciprofloxacin, in eye injuries, 64

Civilian

care vs. American, xx, 74, 312

“Clamshell” thoracotomy, 151, 154

Coagulopathy, 38, 49. See Triad (of hypothermia, 

coagulopathy, acidosis)

Colostomy, 181

Combat Application Tourniquet (CAT). See Tourniquet

Combativeness, steps, 22

Combat Support Hospital (CSH), xx 

defined, 3

28th CSH, 244

86th CSH, 171

Compartment syndrome, 308, 312, 353

forearm, 306

gluteal, 353–358, 361

lower extremity, 207, with tibia fracture, 281

management, 245, 308

pressures, 207

signs, 209, 307

Compartments, of the hand, 280

index | 437
438 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

Computed tomography

heterotopic ossification, 295

in facial trauma, 75

in thoracoabdominal trauma, 128, 129

scrotum, 194

three dimensional, 76, 78, 104, 295

Concussion, 113

Continuous Positive Airway Pressure (CPAP), 90

Cornea, perforation, 61

Coronary arteries, 119

Corpus cavernosum, 188, 190 (photo), 196, 197 (photos), 

198 (photos)

spongiosum, 196

Costochondral grafting, 66, 67

Craniectomy

of trauma, 85, 88 (photo)

Craniotomy, manual, 101, 107

Cricothyroidotomy, 25, 74

Critical Care Air Transport Team (CCATT), 6

Crystalloid resuscitation, 50

CT. See Computed tomography

Cushing, Harvey, 89

Cyanoacrylate, 61

D

Dakin’s solution, 208

Damage control, 199

laparotomy, 171

phases, 184

resuscitation, xix, 40, Appendix, 50

Delayed effect, of blast, 337

Dermabond. See Cyanoacrylate

DOW (died of wounds), rate, 11

Duodenostomy, 202

Duodenum, injury, 135, 136 (illustration), missed, 172, 173 

(photo), 175 (photo)

Dura, 97 (photo)

Duraplasty, 85, 87

E

Ectopic pregnancy, 377–379, 400

Elbow, GSW, 251

Embolization, 353–356

Energy

high-energy wounding, 23

kinetic, 23

Erich arch bar. See Arch bars

Escharotomy

chest wall, 28

Ethmoid air cells, 90

Evisceration, traumatic, 176, 202

Explosive ordnance disposal (EOD), 373

External fixation, 312. See Specific fracture

Extremity compartment syndrome, 312. See Compartment 

syndrome

Eye trauma

percentage of casualties, 63

survey, 55

F

Facial, wounds, 65

blast, 257

lacerations, 58

primary closure, 56, 57

Facial artery, damage, 59

Facial nerve, lacerations, 59, 65

repair, 67

Factor VIIa, 47, 345

Fasciitis, necrotizing, 161, 201, 214–218

Fasciotomy 

four-compartment (lower extremity), 207, 208, 209 

(photos), 281, 285, 387

gluteal, 353

hand, 280 (illustration)

FAST (Focused Abdominal Sonogram for Trauma), 19, 119, 

120 (photo), 125, 127, 134, 138, 148, 186

Femoral, arteries, 34 (photo)

artery, superficial, 21, 31, 325

vein, 342–344, 343 (photo), 360

vein, superficial, 21

Femoral neck fractures, 309

Femur, open fracture, 262

external fixation, 263 (photo)

Fetus assessment, 392–398, 400, 401

Fibrillar hemostatic, 99 (photo), 100, 101

Fibula fracture, 306

Flaps

abdominal skin, 228, 229 (photos), 251, 253 (photos)

coverage of combat wounds, 223–237

gastrocnemius, 235, 236 (photos)

hand, 261 (photo), 268 (photo)

median forehead, 219–222 (photos)

pectoralis major, 81 (photos), 225 (photos)

sural nerve flap, 231, 232 (photos)

 Tagliacozzi, 228, 232

tensor fascia lata, 223, 224 (photos)

Foot trauma, 297

Forearm trauma, 300

Forward Surgical Team (FST), 3, 20

limitations, 22

Frontal sinus, 90

G

Galea (Galea aponeurotica), 87, 101

Gastric. See Stomach

Gastrointestinal anastomosis (GIA) stapler

in lung injury, 130, 131

Genital trauma, 196

Gigli saw, 101, 103 (photos), 107, for clavicle, 323

Glasgow Coma Scale, 86, Appendix

limitations, 113

Glue, corneal, 61

Guillotine amputation, 314

H

“H” incision, 312

Hand trauma

cases, 257, 265, 277
INDEX | 439

Head trauma, penetrating, 35, 93, 101

Heart, trauma, 122, repair, 144 (illustration)

Heineke-Mikulicz repair, 134, 137

HemCon, xix 

Hemicraniectomy, 111

See Craniectomy

Hemoperitoneum, 39

Hemorrhage, control, xix 

cause of death, xix 

Hemostatics, topical, 181

See QuikClot and HemCon

Hepatitis B virus, 46

Heterotopic ossification, 294, 295

High-pressure pulsatile lavage (HPPL). See Irrigation 

High-velocity wounds, facial, 74

defined, 23

Hilar twist, 130, 132 (illustration)

Human immunodeficiency virus (HIV), screen, 46

Humerus trauma, with brachial artery injury, 346, 347

case, 269

external fixation, 271

Hydrocephalus, 111, 112

Hypogastric artery, 179

Hypothermia, 32. See Triad (of hypothermia, acidosis, 

coagulopathy) in children, 371

I

Iliac arteries, ligation, 177, 203

Iliac vein, injury, 325, 359

Improvised explosive devices, 74

Innominate vein injury, 319, 359

International normalized ratio (INR), 38, 49

Interosseous hydration, in children, 371, 399

Intracranial pressure, 89, 112

Iridoplegia, 86

Irrigation

of open fractures, 309

of war wounds, 279

pulsatile lavage, 75, 279

J

Jejunostomy, 202

Joe Hall Morris device, 77, 78

Joint, open trauma, 307

Joint Theater Trauma System (JTTS), 2, 50

K

KIA (killed in action)

rate, 11

Kidney. See Renal

Kidney transplant incision, 325, 328 (illustration)

Kirschner wires, 257, 259 (photo), 261, 268, 277

Kocher maneuver, 166, 172, 174, 201, 366

L

Landstuhl Regional Medical Center, 5

Laparotomy, for evisceration, 178

in thoracoabdominal trauma, 129

Larré, Baron Dominique Jean, 1

Level of care, 3

Lobectomy, pulmonary, 145

Lung, isolation (one lung ventilation), 155

M

M-16, 159

MACE (Military Acute Concussion Evaluation), 113, 

Appendix

Malecot drain, 169, 202

Mandible, trauma, 70–73 (photo), 365, 366

Martin-Gruber anastomosis, 251

“MASH,” xviii, 1

Massive blood transfusion, 39

and death, 49

defined, 43, 44

Maxillofacial trauma, percentage of trauma, 25

reconstruction, 65

Maxillomandibular, fixation, 65, 67, 68, 76, 78

Mayfield pins, 101

Meal, Ready-to-Eat (MRE), heaters, 179, 203

Medevac, 111

Mediastinum, trauma, 150

Mendelson, Dr Janice, 23

Mesenteric vein, hemorrhage, 169

Middle meningeal artery, 97 (photo)

Morel-Lavalleé lesion, 306, 310

Mortar, trauma, 33

N

Nasopharyngeal airway, 25

contraindications, 27

Neck, zones, 65, 319, 322 (illustration), 323

trauma, 323

Necrotizing fasciitis. See Fasciitis

Nephrectomy, 186

Nerve block, continuous peripheral, 380–384

NeuraGen tube, 252

Nicardipine, 112

Nonsteroidal antiinflammatory drugs

with eye injuries, 64

heterotopic ossification, 294

O

Octreotide, 166, 201

Operating room (OR)

resuscitation, 37

Orbital compartment syndrome, 78

Orchiectomy, 192

Orthopaedic polytrauma, 306, 312

Orthopaedic reconstruction, 104

Ossification. See Heterotopic ossification

Ostomy, 177

Otorrhea, 90
440 | WAR SURGERY IN AFGHANISTAN and iraq: A SERIES OF CASES, 2003–2007

P

Pain control, 382

Pancreas, trauma, 163, 201

Pancreatectomy, 166, 167 (photo)

Parotid duct, repair, 58, 66

fistula, 58

Partial thromboplastin time (PTT), 38

Pectoralis major flap, 81 (photos), 225 (photos)

Pediatric cases, 108, 159, 297, 332, 365, 369, 385

Pediatric trauma management, 365–372, 386, 399–401

PEEK. See Polyetheretherketone

Pelvis, trauma, 188

stabilization, 315

with gluteal compartment syndrome, 354

Penis, trauma, 196–198

Pericardial, tamponade, traumatic, 138

effusion, 140 (photo)

Peripheral nerve block, 380–384, 400

Perirectal space, 181

Peritoneal tamponade, 43

Petrous bone fracture, 90

Phenytoin, 100

Phrenic nerve, 155

Plasma, typing, 40

as resuscitation fluid, 49

transfusion, 41, 43

Platelets, 4, vs. fresh whole blood, 44

Pneumocephaly, 90, 91 (photo)

Pneumonectomy, 149

Pneumothorax, xix, tension, 134

Polyetheretherketone cranioplasty, 87

Polymethyl methacrylate (PMMA) cranial plate, 104 

(photo), 105

Polytetrafluoroethylene mesh, 202, pledgets, 329, 330

Polytrauma, case, 19, 257

Popliteal artery trauma, 385–388, 388 (illustration)

Pregnant patient, trauma, 392–398

Presacral drains, 181

Pringle maneuver, 39

Proctoscopy, in perirectal injuries, 328

Profunda brachii, 341

Profunda femoris artery, 325

Prothrombin time (PT), 38

Prototyping, medical, 104

Pseudoaneurysm, 112, 337, 360

Q

QuikClot, xix, 179, 180

R

Raccoon eyes, 91

Radius fracture

external fixation, 300

open, 300–305

Recombinant Factor VIIa. See Factor VIIa

Rectum, trauma, 179, 203

Renal, trauma, 185

injury scale, 186 (table)

Reperfusion injury, 49

Rewarming, 181 (photo), 184

Rhinorrhea, 91

Right hemisphere trauma, 93

Roux-en-Y, 137, 166, 173, 202; children, 366

S

Sacrum, trauma, 179, 180 (photo)

Salpingectomy, 378

Salpingostomy, linear, 378

Saphenous vein graft, 334, 340, 360, 387

Scalp, hemorrhage, 85

Sciatic nerve trauma, 211

Scrotal trauma, 21, 192, 194 (photos)

Sella, 90

Shock, 33, 292

classes of, 293 (table)

in children, 366

Shunts, vascular, 332–336, 359, 360

brachial artery, 334

Javid, 336

saphenous interposition graft, 334 (photo), 340, 387

Sundt, 336

Sialography, 58, 60

Skin graft

split thickness (STSG), 301

Skin traction, 286, 290 (photo), 315

Somatostatin (Sandostatin), 166, 201

Sphenoid bone fracture, 90

Spinal cord, injury, 108

transaction, 134

Stenson’s duct, repair, 67, 68

Stereolithography, 78, 104

Sternotomy, 151, 154; median, 329, 330, 359

Stomach, trauma, 163, 165 (photo)

rupture, 170

Subarachnoid hemorrhage, 95 (photo)

Subclavian artery injury, 329–331, 350–352, 359–361

Subdural hematoma, 85, 87 (photo), 107

Sugar tong splint, 305

Suicide bomb, 192

biologic risk, 192

Supine hypotensive syndrome of pregnancy, 396

Synthes, 300, 301

T

Team approach, 34, 67, 180, 257

Temporalis muscle flap, 96 (photo)

Testicle, 195

Tetanus, 389–391

Thoracic penetrating trauma, 138, 145, 150

Thoracoabdominal trauma, 119, 125, 134

trajectory of injuries, 136 (illustration)

Thoracostomy, 127
Index | 441

Thoracotomy, for hemothorax, 130

choices, 154

contraindications, 30

drainage, 142, 145

emergency, 30, 127, 148

indications, 30

resuscitative, 29

Tibia fracture

external fixation, 283 (photo), 311 (photo)

open, 281, 306

Tourniquet, 286, 288, 289

Tracheostomy, avoid, 24, ideal in facial trauma, 67, 74

Tractotomy, pulmonary, 131, 132 (illustration), 155

Transfusion. See Massive blood tranfusion

risk of infectious disease in, 46

Transplant incision. See Kidney transplant incision

“Trapdoor” approach to chest, 154, 329, 351, 359

Trauma

blunt, 146, 169, 201

combat vs. civilian, 29

foot, 297

hand, 257, 265, 277

head, 85, 93, 101

noncombat, 171

pediatric, 365–372, 399–401

pelvic, 188

penetrating, 119, 125, 134, 138, 145, 150, 163, 179, 

188, 297, 329, 36

pregnancy, 392

rectal, 179

registry, 8, 10

renal, 185

Traumatic brain injury (TBI), 115

Triad, of hypothermia, acidosis, coagulopathy, xix, 20, 37, 

49, 130, 171

Tunica albuginea, 195

U

Ulna fracture

external fixation, 274 (photos), 275 (photos), 300, 302 

(photo)

internal fixation, 273, 276 (photo)

open, 272, 300

Ulnar nerve, 251

Umbrella effect of blast, 292, 296 (illustration)

Unexploded ordnance, penetrating trauma, 373–376

Urethra, 196, 198

Urinary catheter, to stop chest bleeding, 350, 351 (photo)

Uterus, in trauma, 392

UXO. See Unexploded ordnance

V

Vacuum-assisted closure (VAC), 108, 217, 218 (photo), 227 

(photo)

heterotopic ossification, 237, 245, 294, 297, 301

Vascular

access in children, 366

exposures, 361

repair, to do or not to do, 20, 31

Velocity, “high-velocity” wound, 23

Venorrhaphy, 321, 342, 352

Ventriculostomy, 86, 111

Vietnam War, 1

Vital signs

and shock, 34

W

Walter Reed Army Medical Center, 5, 104

Weck cell vitrectomy, 61

Wet-to-dry dressings, 299

Wordsworth, William, Afterword

Wound Data and Munitions Effectiveness Team (WDMET), 

159

XYZ

“Zone of injury,” in amputation, 314

Zones of neck, 319, 322 (illustration)

Zygomatic arch, 65, 67
about the editors

Shawn Christian Nessen, DO, FACS 

LTC, MC, US Army

Dr Nessen is a graduate of Idaho State University in Pocatello and the College 

of Osteopathic Medicine at Des Moines University in Des Moines, Iowa. He 

did his general surgery residency at William Beaumont Army Medical Center 

in El Paso, Texas. In 2003, he served as a staff surgeon with the 10th and 28th 

Combat Support Hospitals in Iraq. As this book went to press, LTC Nessen was 

completing a 15-month deployment as Commander of the 541st FST (ABN) in 

Afghanistan.

Dave Edmond Lounsbury, MD, FACP

COL, MC, US Army (Ret.)

Dr Lounsbury is a graduate of Bates College in Lewiston, Maine, and the 

University of Vermont College of Medicine in Burlington, Vermont. He did 

his residency training in medicine and neurology at Letterman Army Medical 

Center in San Francisco. He was assigned to the 300th Field Hospital (EPW) 

in the first Gulf War (1991) and served as Brigade Surgeon in the Balkans 

(UNPREDEP) in the winter of 1995–1996. In 2003, Colonel Lounsbury was 

Deputy Commander of the 10th Combat Support Hospital in Kuwait. He retired 

from the US Army Medical Department in 2005. Dr Lounsbury is presently 

Developmental/Consulting Editor at the Borden Institute at Walter Reed Army 

Medical Center in Washington, DC.

Stephen P. Hetz, MD, FACS

COL, MC, US Army (Ret.)

Dr Hetz is a graduate of the US Military Academy at West Point and the Uniformed 

Services University of the Health Sciences in Bethesda, Maryland. He did his general 

surgery residency at Dwight David Eisenhower Army Medical Center in Augusta, 

Georgia. In the first Gulf War (1991), he served as a staff surgeon with the 12th US 

EVAC Hospital. In 2004, Dr Hetz was Commander of the 31st Combat Support 

Hospital in Balad, Iraq. He retired from the US Army in 2006. Dr Hetz remains 

on the general surgery teaching staff and is the Director of Medical Education at 

William Beaumont Army Medical Center in El Paso, Texas.