Blast mine injuries

Modified on 2009/07/23 09:07 by Ole Losvik — Categorized as: Uncategorized

Approach¶

Save the life¶

Beware of fragment wounds. Many people think that a blast mine injury is an amputation injury – and that’s it. People from the minefields know better: They see blast mine victims dying on the way to hospital, not from amputation bleeding, but from fragment injuries. Amputations in the lower part of the limbs seldom bleed much. However, high-speed fragments from the mine, the ground, or pieces of the limb can hit the victim anywhere. Look especially between the legs: A fragment may penetrate from here into the belly. These are the wounds which kill. The bleeding amputation wound is less dangerous, it is easier to find and easier to treat.

Save the limb¶

For most mine victims artificial limbs are a dream. Job no. 2 – Save every centimeter you can of the amputated limb Most amputees in poor communities do not get artificial limbs. Child amputees need to have a new artificial limb fitted every second year. That is beyond the reach of a poor farmer’s family living far away from the city. We care for the farmer. So our job is to take care of the injured farmer and get him to the hospital alive. Our job is also to get the farmer back to the village with as long an amputation stump as possible. He can feed his family and have a decent life with a belowelbow stump. And he can drive his oxen with a good ankle stump. But with a short arm or leg stump and no prosthesis, he cannot support his family. Traditional farming in poor communities is labor-intensive, so all family members have to take part. To have one key family member lose a limb is the same as having the entire family lose their limbs. The family’s only future may be as big-city beggars.

Stop chopping off limbs.¶

There is no such thing as an “ideal level of amputation”. The present situation is a tragedy. Most blast mine survivors arrive at the surgical centers after hours or days with oxygen starvation, in pain, and without nutrition. Many of them have had tourniquets that shut off the limb blood supply and damaged what the mine left undamaged. Next, many overseas surgeons on brief “mine victim assistance” visits to poor countries chop off the injured limb at preset “ideal levels” to make amputation stumps fit a “standard prosthesis”. With good life support in the field without tourniquets and caring surgeons at the hospital, the same farmer may have been able to continue farming with a good ankle stump (without need for a prosthesis). So, even though he only lost 15 cm of the foot to the mine, our farmer ends up losing the entire limb to the “health” workers.

Prevent wound infections¶

It is a problem when the amputation wound doesn’t bleed. Most mine amputations are due to light blast mines. In both upper and lower-limb amputees, the mine amputates the victim at or below the wrist or the ankle in 2/3 of the cases.

The amputation wound is ragged and extremely dirty. Soil and pieces of shoe and cloth are shot into the soft tissues around the wound. This makes a good base for wound infection. The blast wave crushes blood vessels and muscles – dead tissue is an even better base for infection. But the main problem is that most low-level amputation wounds do not bleed. Without a blood supply to the wound, white blood cells that eat bacteria and dirt and red blood cells carrying oxygen have no way to reach the wound. A poor blood supply is the main cause for wound infection and unnecessary loss of limb length.

The "hidden" wound"¶

Why amputations don’t bleed: There is a “hidden” wound in the muscles. The blast wave from a mine travels along the bones from the level of amputation into the limb above. To get an idea of how it works: put your ear to a long steel tube and let your friend hit the tube at the other end with a hammer. The bang hits your ear and it hurts. The pressure wave from the hammer travels along the tube just like the mine blast wave inside the limb. The blast wave enters the surrounding soft tissue from the bone and causes a “hidden” wound in the muscles.

This is how the hidden wound develops:

Muscle is crushed and starts swelling.
Blood vessels are torn and start bleeding inside the limb – increasing the swelling.
Arteries are stretched and become blocked. But the muscles in the foot, lower leg, and hand are enclosed inside tight fibrous sheaths (the muscle fascia). So swelling in these limbs causes more pressure inside the muscle. This compresses the blood vessels and reduces the blood supply to the amputation wound even more. The patient needs someone able to split the muscle fascia (fasciotomy), so that the pressure will immediately fall and the blood flow improve.

Note that the skin is not damaged! The skin is elastic (stretches easily) and can take the shock from the blast wave without tearing. That is why we call it a “hidden” wound. When you look at the limb above the amputation, it seems uninjured. But if you looked under the skin, you would find a major swollen wound that blocks the blood supply to the amputation wound below.

In brief¶

First, life support for the fragment injuries:

Open the airway. Support the breathing. Give pain relief.
Stop the fragment wound bleeding if possible. Give warm IV infusions.

Then, limb support for the amputation injury:

Stop the bleeding from the amputation wound by gauze packing. But don’t use tourniquets!
If it takes more than 4 hours to get to the hospital – do fasciotomy in-field!