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+=== Chunk 0 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 45 chars
+
+Untitled Section
+BY: ROGENE BAJE & RICA ARADO...
+
+=== Chunk 1 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 118 chars
+
+AREAS COVERED:
+> What is First Aid? > Aims of First Aid > Chain of Survival »EMS >CPR >» AED » Scene safety assessment...
+
+=== Chunk 2 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 146 chars
+
+What is First Aid?
+The treatment given for any injury, or sudden illness before the arrival of an ambulance, doctor or any other qualified person....
+
+=== Chunk 3 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 99 chars
+
+Aims of First Aid
+* To Preserve life
+* To Prevent the condition getting worse
+* To Promote recovery...
+
+=== Chunk 4 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 331 chars
+
+First Aid Provider
+* Recognize, assess, and prioritize the need for first
+aid
+* Provide appropriate first aid care
+* Recognize limitations, and seek professional medical assistance when necessary
+Early Activation of : Recognition & Emergency High-Quality : Post-Cardiac : Prevention Response CPR Defibrillation Arrest Care Recovery...
+
+=== Chunk 5 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 222 chars
+
+CHAIN OF SURVIVAL
+Sepuring the scwue
+Before performing any First Aid,
+Check for:
+paca
+* 41. Electrical hazards hoo * 2. Chemical hazards * 3. Noxious & Toxic gases rae 4. ole hazards > - 5. Fire * 6. Unstable equipment sam...
+
+=== Chunk 6 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 169 chars
+
+ACTIVATE EMS FOR:
+1. Immediate threats to life.
+si Significant mechanisms of injury.
+Warning signs of serious illness.
+Bw Unsure of the severity of a person’s condition....
+
+=== Chunk 7 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 248 chars
+
+EMERGENCY SERVICES - 911
+1. Name and telephone 2. Give exact location 3. Type of incident 4. Seriousness of incident 5. Number of casualties 6. Condition of casualties 7. Any hazards
+number
+NOTE: DON'T HANG UP THE PHONE UNTIL YOU ARE TOLD TO DO
+SO!...
+
+=== Chunk 8 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 211 chars
+
+USE COMMON SENSE
+®@ Activate EMS (Emergency Medical @ Ifscene is unsafe, do not enter! ® Ask for permission ®@ Never exceed your training ® Once started, don’t stop until relieved
+System or emergency action plan...
+
+=== Chunk 9 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 175 chars
+
+PPE — Personal Protective Equipment
+=>
+is protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection....
+
+=== Chunk 10 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 679 chars
+
+How to remove contaminated gloves?
+«tee “St
+1. Grasp First Glove - avoid bare skin, pinch the glove at either palm with the gloved fingers of the opposite hand .
+2. Remove Inside Out - gently pull the glove away from the palm and towards the fingers, turning the glove inside out without snapping. Gather the glove you just removed with your gloved hand,
+3. Slide Finger Under Second Glove - carefully slide your bare index finger inside the wrist band of the gloved hand.
+4. Remove Inside Out - gent...
+
+=== Chunk 11 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 204 chars
+
+PREPARE:
+|. Place arm nearest you up alongside head.
+2. Bring far arms across chest and place back of hand against cheek.
+3. Grasp far leg just above knee and pull it up so the foot is flat on the ground,...
+
+=== Chunk 12 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 307 chars
+
+Roll
+Grasping shoulder and hip, roll person toward you in a single motion, keeping head, shoulders, and body from twisting.
+*
+* Roll far enough for face to be angled toward ground.
+Stabilize
+* Position elbow and legs to stabilize head and body. Ensure there us no pressure on chest that restricts breathing....
+
+=== Chunk 13 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 178 chars
+
+ASSESMENT
+* Keep person close to your * Avoid twisting * Consider person’s weight * Respect your limitations * Extremity drag * Clothing drag * Blanket drag
+* Avoid twisting
+body...
+
+=== Chunk 14 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 481 chars
+
+CONTROL OF BLEEDING
+¢ Apply Direct Pressure
+Using a clean pad, apply pressure directly on point of bleeding. Use just gloved hand if pad is not available,
+If the bleeding doesn't stop. Apply second pad, leave in place until the bleeding stops.
+* If Bleeding ts Controlled
+Consider a pressure bandage, Wrap a conforming bandage around limb and over dressings to provide continuous pressure.
+Avoid wrapping so tight that skin beyond bandage become cool to touch or blue in color.
+CPR...
+
+=== Chunk 15 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 22 chars
+
+PULMONARY
+RESUCITATION...
+
+=== Chunk 16 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 208 chars
+
+What is Cardiopulmonary Resuscitation?
+(CPR) is a lifesaving technique that's useful in many emergencies, such as a heart attack or near drowning, in which someone's breathing or heartbeat has stopped.
+NV. Ss...
+
+=== Chunk 17 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 584 chars
+
+SCENE SAFETY ASSESSMENT
+CATEGORY ADULT CHILD INFANT RATE 100 to 120 beats per minute DEPTH 2 to 2.4 inch 1.5 inch Sto6cm 4cem 1 rescuer: 30:2 COMPRESSION S cycles/2 minutes VENTILATION RATIO % 5 2 rescuer: 2 rescuer: 30:2 15:2 5 cycles/2 minutes 10 cycles/2minutes
+ve YS Se Scene safety - The scene is safe. . Check for Response - Hey, hey are you okay? (tap shoulder) Get Help - Help someone help. Check for Breathing - 1 1000, 2 1000, 3 1000, 4 1000, 5 1000 .... Activation - Activate EMS and get t...
+
+=== Chunk 18 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 503 chars
+
+Cardiopulmonary Resuscitation
+Parameters of High Performance CPR
+BLS ASSESSMENT Scene Safety & Assessment
+1. Push hard at a correct depth 2. Push fast at a rate of 100-120 compressions per minute. 3. Allow full chest recoil. 4. Minimize interruptions to less than 10secs.
+5. Avoid excessive ventilation.
+Check scene safety “Scene is safe”
+Check for responsiveness
+“Hey are you okay?”
+“Activate emergency response protocol and get an AED.”
+Check for breathing for 5 to 10 sec,
+Start High Performance C...
+
+=== Chunk 19 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 60 chars
+
+HOW TO PERFORM CPR FOR INFANTS (NEWBORN TO 1 YEAR)
+A s elias...
+
+=== Chunk 20 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 316 chars
+
+What is an Automated External Defibrillator?
+(AED)is used to help those experiencing sudden cardiac arrest. It's a sophisticated, yet easy-to-use, medical device that can analyze the heart's rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm....
+
+=== Chunk 21 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 309 chars
+
+Usage of AED — Automated External Defibrillator
+Turn on the AED Follow the prompts Apply the pads to the patient’s bare chest. Plug in the connector. Analyzing heart rhythm. “Clear” Shock is advised. Charging. (Resume HPCPR) Stay clear of the pt. Deliver shock now. “ Clear! Shocking on 3.1,2,3.” Resume HPCPR...
+
+=== Chunk 22 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 204 chars
+
+TAKE NOTES!
+Recognizing an Emergency — priority is personal safety Deciding to Help — if safe, take action Implied Consent — unresponsivement, need additional help “When in doubt, don’t drink medication.”...
+
+=== Chunk 23 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 35 chars
+
+SYMPTOMS OF SUDDEN CARDIAC ARREST
+a...
+
+=== Chunk 24 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 92 chars
+
+CARDIAC ARREST
+Y No warning ¥ Abnormal gasping Y Heart stops beating “No pulse ¥ Unconscious...
+
+=== Chunk 25 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 72 chars
+
+7 aeeeais
+* Early Defibrillator
+- electric shock
+- Itrestores blood flow...
+
+=== Chunk 26 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 243 chars
+
+Primary Assessment for Cardiac Arrest
+If breathing is not normal, perform CPR Recovery position 1. Ask—Are you alright? 2. Alert—-AED/EMS 3. Assess normal breathing 4. 2
+CPR Narre cn Leg bent lo Aem bert to
+support postion
+prevent rolling over...
+
+=== Chunk 27 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 125 chars
+
+Choking
+Mild blockage - cough Y Can take action on his own
+Severe ¥ Cannot take enough air Y Locate navel until he/she spills...
+
+=== Chunk 28 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 100 chars
+
+For infant:
+* Baby facing down * Support head * Rest in your lap * 5 back tap * Turn 5 press (chest)...
+
+=== Chunk 29 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 278 chars
+
+Control bleeding
+1. Pressure injured part with clean absorbent pads and wrap roller gauze 1. First Aid kit 2. Call EMS
+Note:
+¥ If pressure cannot control use TORNIQUETS ¥ TORNIQUETS — help control bleeding
+Once a tourniquet is applied, it is not to be removed , only by a doctor...
+
+=== Chunk 30 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 69 chars
+
+Absolute last resort in controlling bleeding. Remember
+Life over limb...
+
+=== Chunk 31 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 54 chars
+
+HOW TO TREAT SEVERE BLEEDING
+St John Arberoee
+Arberoee...
+
+=== Chunk 32 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 114 chars
+
+Shock
+* Internal bleeding (sweating) * Call EMS * Adequate clear breathing * Maintain body temperature * Keep calm...
+
+=== Chunk 33 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 230 chars
+
+Treatments:
+Treatments: * Halt the burning process * Relieve the swelling * Relieve the pain ¢ Wash with water * Minimize risk of infection * Seek medical advice
+¢ Wash with water
+* Minimize risk of infection
+* Seek medical advice...
+
+=== Chunk 34 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 243 chars
+
+Treatment:
+eFlood the area with slowly running water for at least ten minutes.
+eGently remove contaminated clothing while flooding injured area, taking care not to contaminate yourself.
+eContinue treatment for SEVERE BURNS
+eSeek medical advice...
+
+=== Chunk 35 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 121 chars
+
+Don't straighten break Treat the way you found it
+Must treat for bleeding first
+way you
+Do not push bones back into place...
+
+=== Chunk 36 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 89 chars
+
+DISLOCATIONS
+The most common dislocations occur in the shoulder, elbow, finger, or thumb....
+
+=== Chunk 37 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 342 chars
+
+LOOK FOR THESE SIGNS:
+1. swelling
+2. deformed look
+3. pain and tenderness
+4. possible discoloration of the affected area
+IF A DISLOCATION IS SUSPECTED...
+1. Apply a splint to the joint to keep it from moving.
+2. Try to keep joint elevated to slow bloodflow to the area
+3. Adoctor should be contacted to have the bone set back into its socket....
+
+=== Chunk 38 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 31 chars
+
+Two person carry
+sel
+——
+-_
+.¢ )...
+
+=== Chunk 39 ===
+Source: slidesaver.app_mzmoid.pdf
+Length: 186 chars
+
+REMINDERS!
+The goal of your training is to help you gain knowledge necessary to effectively manage a medical emergency until more advanced help is available.
+BY: ROGENE BAJE & RICA ARADO...
+
+=== Chunk 40 ===
+Source: first_aid_notes_2019.pdf
+Length: 917 chars
+
+An introduction to first aid
+Imagine: Whilst feeding your child, they start to gag and appear unable to breathe. You have tried slapping them on the back, with no success. They seem close to losing consciousness, their lips are turning a definite shade of blue.
+People rarely give first aid a thought, until the day they need it. The above scenario is the sort of every day occurrence that can so easily lead to tragedy.
+However, with the correct first aid training anyone could, in the short term (u...
+
+=== Chunk 41 ===
+Source: first_aid_notes_2019.pdf
+Length: 350 chars
+
+Preserve life
+This doesn’t just refer to the injured party, but yourself and anyone helping you. Far too often, a helper will inadvertently put themselves in danger and subsequently be another casualty for the emergency services to deal with. Please take a moment to assess the situation, and make sure there are no threats to you before you step in....
+
+=== Chunk 42 ===
+Source: first_aid_notes_2019.pdf
+Length: 344 chars
+
+Prevent the situation from getting worse
+If you are in no danger yourself, try to stop the situation from becoming worse by removing any obvious dangers (such as stopping traffic, clearing people away from the casualty, opening a window to clear any fumes, etc.). Also, act as quickly as you can to stop the casualty’s condition from worsening....
+
+=== Chunk 43 ===
+Source: first_aid_notes_2019.pdf
+Length: 328 chars
+
+Promote recovery
+Your role as a first aider is, after ensuring that the situation can not get worse, helping the casualty to recover from their injury or illness, or stop their condition from getting worse. If the injury is severe, then the best you can do is try to keep them alive until the emergency services arrive.
+Page | 1...
+
+=== Chunk 44 ===
+Source: first_aid_notes_2019.pdf
+Length: 2178 chars
+
+The priorities of treatment
+This is the course of action you should try to follow, providing the situation allows.
+Primary survey (Airway → Breathing):
+A. Make sure the casualty’s airway is clear. Do this by gently tipping their head back so that the front of the throat is extended.
+B. Check if they are breathing normally. You can do this by placing the back of your hand near their nose and mouth. You are looking for about two breaths every ten seconds. If the casualty is breathing, then their h...
+
+=== Chunk 45 ===
+Source: first_aid_notes_2019.pdf
+Length: 328 chars
+
+6. DIAL 999 FOR AN AMBULANCE NOW IF YOU HAVEN’T DONE SO ALREADY.
+7. RESUSCITATION: Give 30 chest compressions followed by 2 rescue breaths, continue giving cycles of 30 compressions to 2 breaths. If there is more than one first aider on hand, change over every 2 minutes to prevent fatigue. Continue until the ambulance arrives....
+
+=== Chunk 46 ===
+Source: first_aid_notes_2019.pdf
+Length: 5739 chars
+
+Resuscitation
+To maintain life, we need our hearts to pump oxygenated blood to our vital organs. To achieve this we need to be breathing and our hearts need to be pumping. Should either of these functions stop, our brain and other vital organs will start to deteriorate (brain cells usually die within 3-4 minutes due to lack of oxygen) which will eventually lead to death.
+‘Ventricular fibrillation’ is the most common result of cardiac arrest, caused by heart attack. When this happens, the best ch...
+
+=== Chunk 47 ===
+Source: first_aid_notes_2019.pdf
+Length: 401 chars
+
+Continue swapping between 30 chest compressions and 2 rescue breaths.
+Page | 6
+Should your rescue breaths not be effective, follow the steps below:
+Give a further 30 chest compressions.
+Remove any visible obstructions in the casualty’s mouth.
+Make certain their airway is clear by tilting their head back and lifting the chin. If the airway is not clear, the breath you give will not fill their lungs....
+
+=== Chunk 48 ===
+Source: first_aid_notes_2019.pdf
+Length: 498 chars
+
+Do not give the casualty more than two rescue breaths before continuing with chest compressions.
+If you have someone with you, take it in turns to administer chest compressions. Every 1-2 minutes, change over so one person administers chest compressions while the other gives the rescue breaths. Ensure there is as little delay in swapping as possible, so the casualty is constantly receiving CPR.
+Continue CPR until:
+The emergency services arrive to take over. You become too fatigued to continue....
+
+=== Chunk 49 ===
+Source: first_aid_notes_2019.pdf
+Length: 974 chars
+
+Resuscitation for babies and children:
+Understandably, some people are reluctant to perform CPR on a child or baby for fear of causing further harm to them. However, a child in this state is likely to suffer far worse consequences if CPR is not administered. Please keep that in mind should the situation ever arise.
+CPR on a child is very similar to CPR on an adult. There are only a few minor modifications to the process, which are detailed below:
+Give the child 5 rescue breaths before starting C...
+
+=== Chunk 50 ===
+Source: first_aid_notes_2019.pdf
+Length: 856 chars
+
+Resuscitation with chest compressions only
+An adult cardiac arrest casualty will probably still have oxygen in their blood stream. If there is any reason you cannot give the casualty rescue breaths, you can still help the casualty by giving them ‘chest compression only’ resuscitation. Although not ideal, it will still circulate the residual oxygen in their blood to their vital organs, so it is better than no CPR.
+If you are only giving chest compressions, the continuous rate should be 100- 120 c...
+
+=== Chunk 51 ===
+Source: first_aid_notes_2019.pdf
+Length: 1199 chars
+
+Vomiting during CPR:
+It is not uncommon for an unconscious casualty who has stopped breathing to vomit. This is an autonomic reaction from the unconscious casualty which you may not notice until you come to give a rescue breath, or their breath comes out with a gurgling noise.
+If this happens, turn their head to the side and allow the vomit to drain.
+Before continuing resuscitation, clean the casualty’s face, and if you have a face shield handy use it.
+Points of hygiene during resuscitation:
+Use...
+
+=== Chunk 52 ===
+Source: first_aid_notes_2019.pdf
+Length: 1011 chars
+
+Main causes of unconsciousness in a casualty:
+Unconsciousness is an interruption to normal brain activity. Unconsciousness disrupts the body’s autonomic reflexes such as coughing. The worst position for an unconscious casualty is lying on their back, as they may ‘swallow’ their tongue (the tongue slides back in the throat blocking the airway) which will
+Page | 8
+suffocate them, or they may asphyxiate on their vomit.
+If a casualty is unconscious, you need to take immediate action: clear the airwa...
+
+=== Chunk 53 ===
+Source: first_aid_notes_2019.pdf
+Length: 200 chars
+
+A Alert
+The casualty is fully alert
+The casualty is awake and fully aware of their surroundings (they will usually know the answer to general questions like the date, their name, where they are, etc.)...
+
+=== Chunk 54 ===
+Source: first_aid_notes_2019.pdf
+Length: 498 chars
+
+V Voice
+Confused
+The casualty may not be fully aware of their surroundings, but will ask and answer questions.
+Inappropriate words
+This refers to casualties who are conscious, but may not be able to string a coherent sentence together. Words may be in the wrong place or missing
+Page | 9
+altogether from responses.
+Making sounds
+The casualty is not able to respond verbally, but may make grunts or moans in response to painful stimuli.
+No sounds
+In this case the casualty will make no vocal sounds....
+
+=== Chunk 55 ===
+Source: first_aid_notes_2019.pdf
+Length: 328 chars
+
+P Pain
+Locating pain
+The casualty will be able to locate painful stimuli, and tell you where it is being applied (pinch on the underside of the arm, pressing firmly on a finger nail, etc.).
+Pain response (but not able to locate the pain) The casualty will respond to painful stimuli, but not be able to locate where the pain is....
+
+=== Chunk 56 ===
+Source: first_aid_notes_2019.pdf
+Length: 3135 chars
+
+U Unresponsive
+The casualty is not able to respond to pain or vocal stimuli. They will remain unresponsive.
+You can perform primary and secondary surveys of the casualty, which will help you to decide in which order to treat the casualty, the most urgent first. You can then go on to assess the casualty further, which may help with diagnosis and treatment. The more information you can give the ambulance crew the better.
+Primary survey:
+When you perform the DRAB check, this is usually the primary ...
+
+=== Chunk 57 ===
+Source: first_aid_notes_2019.pdf
+Length: 553 chars
+
+Mechanics of injury
+Before attempting to move a casualty, it is important to think about the ‘mechanics of injury’. This is the process of figuring out what has happened, and what injuries are likely to have been sustained by the casualty. If you suspect there is a neck injury involved, you must try to get someone to help you by keeping the casualty’s head in line with their body at all times, even when the casualty is lying still. Any movement can cause serious, irreparable damage. See page 55 ...
+
+=== Chunk 58 ===
+Source: first_aid_notes_2019.pdf
+Length: 2046 chars
+
+The recovery position
+When an unconscious casualty is lying on their back, their breathing can be hampered by them ‘swallowing their tongue’ (the tongue slides back in their throat, cutting off the airway). Or, the person can vomit while unconscious, and are not able to reflexively heave or expel the vomit, which can suffocate them. By placing the casualty on their side (the recovery position), this ensures the airway is clear by stopping the tongue sliding back in the throat and allowing vomit ...
+
+=== Chunk 59 ===
+Source: first_aid_notes_2019.pdf
+Length: 319 chars
+
+Things not to do:
+Never put anything into an unconscious casualty’s mouth.
+Never move a casualty without performing the checks mentioned first.
+Never place anything under the head of a casualty who is on their back. This could obstruct the airway.
+Never unnecessarily move a casualty as this could cause further injury....
+
+=== Chunk 60 ===
+Source: first_aid_notes_2019.pdf
+Length: 254 chars
+
+Head injuries
+Treat any suspected head injury with the utmost caution, as they have the potential to be very serious. Head injuries often lead to unconsciousness and all the attendant problems. Also, head injuries can cause permanent damage to the brain....
+
+=== Chunk 61 ===
+Source: first_aid_notes_2019.pdf
+Length: 1494 chars
+
+Head injuries may also be associated with neck and spinal injuries, so they must be treated with the utmost caution (see spinal injuries, page 55).
+The three main areas of concern with head injuries are concussion, compression and a fractured skull.
+Concussion
+Concussion occurs when the brain is violently shaken. Our brains are cushioned within our skulls by ‘cerebro-spinal fluid’ (CSF), so any blow to the head can cause the brain to bang against the skull which disrupts its usual functions. A c...
+
+=== Chunk 62 ===
+Source: first_aid_notes_2019.pdf
+Length: 1226 chars
+
+Possible signs and symptoms of head injury
+Concussion Compression Fractured Skull Casualty is unconscious for short Possible history of recent head trauma Casualty may suffer from concussion period, after which response levels are with recovery, followed by or compression also, so symptoms of back to normal, recovery is usually deterioration. these may be present. quick. Short term memory loss, groggy, Response level deteriorates as the Bleeding, swelling or bruising of the confused irritable. c...
+
+=== Chunk 63 ===
+Source: first_aid_notes_2019.pdf
+Length: 2254 chars
+
+Treatment of head injuries
+Keep in mind that a casualty with any head injury may well be suffering from neck and spine injuries also. Treat the casualty with the utmost care, and call for an ambulance immediately.
+If the casualty is or has been unconscious, you suspect a fractured skull, or their responses deteriorate CALL AN AMBULANCE IMMEDIATELY. Keep their airway clear and monitor their breathing.
+Page | 14
+If the casualty is unconscious, and you don’t wish to move them as you suspect a neck ...
+
+=== Chunk 64 ===
+Source: first_aid_notes_2019.pdf
+Length: 794 chars
+
+Stroke
+Strokes must always be treated as a medical emergency, and an ambulance called immediately. Any delay in the treatment of a stroke can have a dramatic effect on the casualty’s recovery. If you suspect a stroke, CALL AN AMBULANCE IMMEDIATELY.
+There are two types of stroke:
+1. A blood clot blocks a blood vessel that supplies part of the brain. This is the most common.
+2. A ruptured blood vessel in the brain. The build-up of blood ‘squashes’ an area of the brain.
+With either type of stroke t...
+
+=== Chunk 65 ===
+Source: first_aid_notes_2019.pdf
+Length: 73 chars
+
+F Facial weakness
+Can the casualty smile? Has their mouth or eye drooped?...
+
+=== Chunk 66 ===
+Source: first_aid_notes_2019.pdf
+Length: 48 chars
+
+A Arm weakness
+Can the casualty raise both arms?...
+
+=== Chunk 67 ===
+Source: first_aid_notes_2019.pdf
+Length: 90 chars
+
+S Speech problems
+Can the casualty speak clearly? Do they have problems understanding you?...
+
+=== Chunk 68 ===
+Source: first_aid_notes_2019.pdf
+Length: 532 chars
+
+Time to call 999
+T
+If the casualty fails any of these tests, call 999 immediately as a stroke is a medical emergency.
+There may be other signs to look for, but the FAST check is the quickest and may save time. However, please note the following may occur:
+One side of the face or body becomes suddenly numb.
+Loss of balance.
+Lack of co-ordination.
+Suddenly developing a severe headache.
+Sudden confusion.
+Problems seeing with one or both eyes.
+Pupil size becomes unequal
+Treatment of stroke:
+Clear th...
+
+=== Chunk 69 ===
+Source: first_aid_notes_2019.pdf
+Length: 431 chars
+
+DIAL 999 FOR AN AMBULANCE IMMEDIATELY.
+If the casualty is unconscious, place in the recovery position.
+If conscious, lay the casualty down with their head and shoulders raised.
+Be sure to talk to and reassure the casualty. Just because they may not be able to speak, they still may be able to understand and react to you.
+Monitor their breathing, pulse and response levels. Keep a record if possible for when the ambulance arrives....
+
+=== Chunk 70 ===
+Source: first_aid_notes_2019.pdf
+Length: 2083 chars
+
+Hypoxia
+Hypoxia means low oxygen in the blood stream. This condition has the potential to be fatal, so it is vital for a first aider to recognise the signs and know how to treat the casualty.
+Page | 16
+There are five categories for the causes of hypoxia. These are:
+External causes
+There is not enough oxygen in the air surrounding the casualty, such as:
+Suffocation by smoke or gas.
+Drowning.
+Suffocation by earth, sand or a pillow/cushion, etc.
+High altitude (lower oxygen levels)
+Airway causes
+The...
+
+=== Chunk 71 ===
+Source: first_aid_notes_2019.pdf
+Length: 559 chars
+
+How the body responds to hypoxia
+Adrenalin is released if the body detects that there are low levels of oxygen in the blood. The effect this has on a body is:
+Increases the heart rate.
+Increases the strength of the heartbeat, and therefore blood pressure.
+Diverts blood away from the skin, stomach and intestines.
+Diverts the blood towards the brain, heart and lungs.
+Dilates the air passages (bronchioles) in the lungs.
+Adrenaline being released into the body has a dramatic effect on the signs and ...
+
+=== Chunk 72 ===
+Source: first_aid_notes_2019.pdf
+Length: 1770 chars
+
+The respiratory system
+Air is taken in through the nose and mouth where it is warmed, filtered and moistened. It then travels through the throat and past the epiglottis (the flap of
+Page | 18
+skin at the back of the throat that closes over the airway when we swallow), where it enters the larynx (the voice box or ‘Adam’s apple’). It then continues between the vocal cords in the larynx and on into the trachea (windpipe). The trachea is protected by cartilage rings that surround it and stop it from...
+
+=== Chunk 73 ===
+Source: first_aid_notes_2019.pdf
+Length: 404 chars
+
+Choking
+Choking is a very common occurrence, and is probably one of the most useful skills you can have as a first aider. Choking can lead to tragedy if not dealt with properly.
+Signs and symptoms
+Casualty is unable to talk, breath or cough.
+They may be gasping and clutching their throat.
+They may appear distressed.
+They may become pale and show signs of cyanosis in later stages.
+Becoming unconscious....
+
+=== Chunk 74 ===
+Source: first_aid_notes_2019.pdf
+Length: 1457 chars
+
+Treatment of an adult or child over 1 year:
+Ask the casualty if they are choking firstly to establish this is the case. If they are not doing so already, ask them to cough as this will usually dislodge minor obstructions. However, if this doesn’t work, follow the steps below:
+1 – Back slaps
+If there is no help around, shout for help. Do not leave the casualty alone.
+Bend the casualty forward at the waist so their head is lower than the chest. If the casualty is a young child, you can place them ...
+
+=== Chunk 75 ===
+Source: first_aid_notes_2019.pdf
+Length: 1138 chars
+
+Choking in a baby under 1 year
+The baby may attempt to cough on their own. If the choking is not serious, this will clear the obstruction. The baby may cry which indicates they are now breathing properly.
+If the obstruction is not cleared by coughing, follow the steps below:
+1 – Back slaps
+Shout for help immediately, but do not leave the baby alone.
+Lay the baby over your arm facing downwards with their legs either side of your elbow with their head below their chest.
+Administer up to five slaps...
+
+=== Chunk 76 ===
+Source: first_aid_notes_2019.pdf
+Length: 343 chars
+
+Never administer abdominal thrusts on a baby.
+If the obstruction has still not dislodged repeat steps 1 and 2.
+If the casualty becomes unconscious make sure they are laying on the ground (or on a flat firm surface for a baby) and commence CPR. Make sure there is an ambulance on the way. Continue CPR until help arrives or you become fatigued....
+
+=== Chunk 77 ===
+Source: first_aid_notes_2019.pdf
+Length: 1357 chars
+
+Anaphylactic shock
+Anaphylaxis is an extreme allergic reaction which can be fatal. This is trigged by a massive over reaction by the immune system. Severe anaphylactic reaction is a rare occurrence, usually triggered by drugs such as penicillin, insect stings, nuts such as peanuts and shellfish such as prawns, latex, dairy produce, etc.
+When the body detects a ‘foreign protein’ the immune cells release histamine. Histamine can have the following effects on the body if released in massive quantit...
+
+=== Chunk 78 ===
+Source: first_aid_notes_2019.pdf
+Length: 9990 chars
+
+Dial 999 for an ambulance immediately.
+Lay the casualty in as comfortable position as possible. If the casualty is having problems breathing, they may want to sit up to ease this.
+If the casualty is feeling faint, do not let them sit up. Keep them lying flat and raise their legs.
+If the casualty is aware of their condition, they may be carrying an adrenaline shot. This can save the casualty’s life if administered promptly.
+The casualty can usually give themselves the adrenaline shot, but if they...
+
+=== Chunk 79 ===
+Source: first_aid_notes_2019.pdf
+Length: 2141 chars
+
+Asthma
+Asthma is a fairly common allergic reaction in the lungs, usually caused by pollution, dust, pollen or traffic fumes. The muscles surrounding the bronchioles spasm and constrict which makes it very difficult for the casualty to breathe. Asthma sufferers normally carry around medication in the form of an inhaler which when breathed in dilates the bronchioles helping to relieve the condition.
+Asthma attacks can be very traumatic for the casualty, especially children, so be sure to reassure ...
+
+=== Chunk 80 ===
+Source: first_aid_notes_2019.pdf
+Length: 1010 chars
+
+Croup
+This is a condition usually suffered by infants, where the larynx and trachea become infected and swell. These attacks usually occur during the night and can be very alarming but usually pass without any lasting harm being done to the child.
+Signs and symptoms
+Distressed, difficult breathing
+A loud pitched or whistling sound as the casualty breathes.
+A short ‘barking’ cough.
+Clammy, pale skin.
+Cyanosis, blue or greyish colour to the lips and skin.
+Use of muscles in the upper chest and neck...
+
+=== Chunk 81 ===
+Source: first_aid_notes_2019.pdf
+Length: 1651 chars
+
+Hyperventilation
+Hyperventilation means ‘excessive breathing’. When we breathe in we take in a trace amount of carbon dioxide and when we breathe out this rises to about 4% carbon dioxide. Hyperventilation results in low levels of carbon dioxide in the blood which is what causes the symptoms of this condition.
+Hyperventilation attacks can be brought on by anxiety, a panic attack or a sudden fright, and can be confused with an asthma attack. Asthma sufferers may hyperventilate after using their i...
+
+=== Chunk 82 ===
+Source: first_aid_notes_2019.pdf
+Length: 1699 chars
+
+Drowning
+It is a misconception that drowning victims breathe in a large amount of water.
+Page | 25
+In truth, 90% of drowning fatalities are caused by a relatively small amount of water in the lungs which interferes with the oxygen exchange in the alveoli (known as wet drowning). The other 10% are caused by spasms in the muscles near the epiglottis and larynx which blocks the airway (known as dry drowning). The casualty will have swallowed a large amount of water, which may be vomited during resu...
+
+=== Chunk 83 ===
+Source: first_aid_notes_2019.pdf
+Length: 2094 chars
+
+Collapsed lung / sucking chest wound
+The lungs are surrounded by two layers of membrane, known as the ‘pleura’. Between the membranes is a ‘pleural cavity’ which contains a very thin layer of ‘serous fluid’. This fluid enables the layers to move against each other as we breathe.
+A casualty with a penetrating chest injury will have had the outer layer of the pleura damaged. This causes air to be sucked in from the outside of the chest into the pleural cavity which in turn causes the lung to colla...
+
+=== Chunk 84 ===
+Source: first_aid_notes_2019.pdf
+Length: 557 chars
+
+Flail chest
+This refers to a condition where the ribs surrounding the chest have been fractured in several places creating a ‘floating’ section in the chest wall.
+As the casualty draws breath the chest moves normally, but the flail section will move inwards and outwards when the rest of the chest is moving outwards and inwards. These are known as paradoxical chest movements.
+Signs and symptoms
+Severe breathing difficulties.
+Painful, shallow breathing.
+Same signs and symptoms of a fracture.
+Page ...
+
+=== Chunk 85 ===
+Source: first_aid_notes_2019.pdf
+Length: 354 chars
+
+Dial 999 immediately for an ambulance.
+Place the casualty in the most comfortable position for them, preferably sat up and inclined towards the injury.
+Place large amounts of padding over the flail area.
+Put the arm of the injured side in an elevated sling, squeezing the arm gently against the padding to help provide gentle, firm support to the injury....
+
+=== Chunk 86 ===
+Source: first_aid_notes_2019.pdf
+Length: 1604 chars
+
+The circulatory system
+The circulatory system consists of a closed network of tubes (arteries, veins and capillaries) which are all connected to a pump (the heart).
+Arteries carry the blood away from the heart. They have strong, muscular, elastic walls which expand as the blood from the heart surges through them. The largest artery is the ‘aorta’, which connects directly to the heart. Veins carry the blood towards the heart. Their walls are thinner than artery walls as the blood they carry is un...
+
+=== Chunk 87 ===
+Source: first_aid_notes_2019.pdf
+Length: 866 chars
+
+The blood
+60% of blood is made up of a clear yellow fluid called ‘plasma’. Within the plasma are red blood cells, white blood cells, platelets and nutrients.
+Red cells contain haemoglobin, which carries oxygen that is used by the body’s cells. Red cells give blood its colour.
+White cells are what help us fight infections.
+Platelets trigger complicated chemical reactions if a blood vessel is damaged forming a clot.
+Nutrients are derived from food by the digestive system. When nutrients are combin...
+
+=== Chunk 88 ===
+Source: first_aid_notes_2019.pdf
+Length: 1137 chars
+
+The pulse
+Whenever the heart contracts, blood is pumped through the arteries. The elastic walls of the arteries expand as the blood flows through them, which can be felt wherever arteries come close to the skin.
+When you check a pulse use the pads of your fingers not your thumb, as thumbs have their own pulse. The first aider should make a note of the following when checking for a pulse:
+Page | 29
+Rate – Is the pulse slow or fast? Count how many beats there are in a minute.
+Rhythm – Is there a r...
+
+=== Chunk 89 ===
+Source: first_aid_notes_2019.pdf
+Length: 1044 chars
+
+Angina
+Angina (angina pectoris) is a condition that is usually caused by the build-up of cholesterol plaque on the lining of a coronary artery. Cholesterol is a fatty chemical that is part of the outer lining of cells in the body. Cholesterol plaque is a hard, thick substance which builds up from the deposits of cholesterol on the artery wall. Over time the build-up of cholesterol plaque causes the arteries to narrow and harden.
+When we exercise or get excited the heart requires more oxygen, but...
+
+=== Chunk 90 ===
+Source: first_aid_notes_2019.pdf
+Length: 3242 chars
+
+Heart attack
+A heart attack (myocardial infarction) is usually caused when the surface of a cholesterol plaque build-up in a coronary artery cracks and develops a ‘rough surface’. This may lead to a blood clot forming on the plaque which in turn completely blocks the artery resulting in the death of an area of the heart muscle.
+However, unlike angina, the death of the heart muscle from a heart attack is permanent and will not be eased with rest.
+Signs and symptoms
+Please bear in mind that each h...
+
+=== Chunk 91 ===
+Source: first_aid_notes_2019.pdf
+Length: 402 chars
+
+Dial 999 for an ambulance if:
+You have any reason to suspect it is a heart attack.
+The casualty has no history of angina.
+The symptoms suffered are different or worse than the casualty’s usual angina attacks.
+The pain from an angina attack is not relieved by the casualty’s medication and rest after 15 minutes.
+You have any doubts at all. It is always better to be safe than sorry in these situations....
+
+=== Chunk 92 ===
+Source: first_aid_notes_2019.pdf
+Length: 1023 chars
+
+Left ventricular failure
+Left ventricular failure (LVF) is where the left ventricular of the heart loses power and cannot empty itself. The right side of the heart is still working and pumping blood into the lungs. This causes a ‘back pressure’ of blood in the pulmonary veins and arteries in the lungs. Fluid from the back pressure of blood seeps into the alveoli which results in severe breathing difficulties.
+The condition may be brought on by a heart attack, chronic heart failure or high blood ...
+
+=== Chunk 93 ===
+Source: first_aid_notes_2019.pdf
+Length: 187 chars
+
+Dial 999 for an ambulance as soon as you can.
+If the casualty has it, allow them to take their own G.T.N. medication.
+Be prepared to perform CPR as this condition can deteriorate rapidly....
+
+=== Chunk 94 ===
+Source: first_aid_notes_2019.pdf
+Length: 568 chars
+
+Shock
+The usual association with the word shock is a nasty surprise, an earthquake or electrical shock.
+The medical definition of shock is ‘inadequate tissue perfusion, caused by a fall in blood pressure and blood volume’. This means there is an inadequate supply of oxygenated blood to the tissues of the body.
+Understanding what shock is can help understand why casualties who are in shock need immediate treatment, or the condition can result in death.
+The most common causes of life threatening s...
+
+=== Chunk 95 ===
+Source: first_aid_notes_2019.pdf
+Length: 1146 chars
+
+Hypovolaemic Shock
+Hypo = low
+vol = volume
+aemic = blood
+Hypovolaemic shock is caused by loss of bodily fluids, the result of which is low blood volume. Hypovolaemic shock is usually caused by:
+External bleeding.
+Internal bleeding.
+Burns.
+Vomiting and diarrhoea.
+Excessive sweating.
+Signs and symptoms
+Usually the first response is a release of adrenaline which will cause:
+Pulse rate to rise.
+Pale, clammy skin. For dark skinned casualties check the colour of the skin inside the lips.
+Page | 33
+As ...
+
+=== Chunk 96 ===
+Source: first_aid_notes_2019.pdf
+Length: 398 chars
+
+Cardiogenic Shock
+This form of shock occurs when there is a fall in blood pressure caused by the heart not pumping properly. This is the most common type of shock.
+Typical causes of cardiogenic shock are:
+Heart attack.
+Tension pneumothorax.
+Cardiac failure.
+Cardiac arrest.
+Heart valve disease.
+Signs, symptoms and treatment of cardiogenic shock See section on heart conditions (page 30).
+Page | 34...
+
+=== Chunk 97 ===
+Source: first_aid_notes_2019.pdf
+Length: 544 chars
+
+Anaphylactic Shock
+Anaphylaxis is an extremely dangerous allergic reaction which is brought on by a massive over-reaction of the body’s immune system (see page 22).
+An anaphylactic reaction may result in shock due to a large quantity of histamine. This can result in:
+Blood vessels dilating which causes blood pressure to fall.
+Blood capillary walls may become ‘leaky’ causing blood volume to fall.
+Weakening of the heart’s contractions which causes blood pressure to fall.
+Signs, symptoms and treatm...
+
+=== Chunk 98 ===
+Source: first_aid_notes_2019.pdf
+Length: 1397 chars
+
+Fainting
+This reaction is caused by poor nervous control of the blood vessels and the
+heart.
+When a casualty faints the blood vessels in the lower body usually dilate which slows the heart. This results in falling blood pressure and the casualty has a temporary reduction in blood supply to the brain.
+Typical causes of fainting are:
+Fright or pain.
+Extended periods of inactivity (such as standing or sitting).
+Lack of food.
+Emotional stress.
+Heat exhaustion.
+Signs and symptoms
+Temporary loss of co...
+
+=== Chunk 99 ===
+Source: first_aid_notes_2019.pdf
+Length: 2465 chars
+
+Wounds and bleeding
+A wound is an abnormal break in the continuity of the tissues of the body. Any wound will, to a greater or lesser extent, result in either internal or external bleeding. Severe blood loss could result in shock, so it is important to treat wounds promptly. There are several types of wound – identification and treatment are detailed here.
+Types and basic treatment of wounds
+Contusion is a bruise. Contusions are caused by ruptured capillaries bleeding under the skin. Typically t...
+
+=== Chunk 100 ===
+Source: first_aid_notes_2019.pdf
+Length: 655 chars
+
+Dial 999 for both an ambulance and the police.
+Clear the casualty’s airway and check for breathing first. Be prepared to commence CPR.
+Pack the wound with dressings if possible to prevent further bleeding.
+Amputation is the complete or partial removal of a limb.
+See the section on amputation (see page 43).
+De-gloved is the severing of the skin from the body, which results in a ‘creasing’ or a flap of skin coming away and leaving a bare area of tissue. These wounds are usually caused by the force...
+
+=== Chunk 101 ===
+Source: first_aid_notes_2019.pdf
+Length: 2536 chars
+
+Blood loss
+How much blood does a body have?
+The amount of blood in a body varies depending on the size of the person. However, a rough guide is that we have approximately a pint of blood for every stone in weight (0.5 litres per 7kg) so the average adult will have between 8 and 12 pints (4.5 to 6.5 litres) of blood depending on their size. However, this rule does not work for someone who is overweight.
+Bear in mind that children have less blood than adults and cannot afford to lose anywhere near...
+
+=== Chunk 102 ===
+Source: first_aid_notes_2019.pdf
+Length: 1215 chars
+
+The effects of blood loss
+Please see the table below for the effects, signs and symptoms of blood loss. The table gives the volume of blood loss as a percentage as we all have different quantities of blood, depending on the size of the person.
+Please note that a casualty who has lost 30% of their blood is in a critical condition, and will deteriorate rapidly from this point onwards. Blood vessels cannot constrict anymore and the heart cannot beat any faster so their blood pressure will fall, res...
+
+=== Chunk 103 ===
+Source: first_aid_notes_2019.pdf
+Length: 765 chars
+
+Treatment of external bleeding
+The aim of treating external bleeding is firstly to stop the bleed, then prevent the casualty from going into shock and finally to prevent infection.
+The acronym SEEP should help you to remember the following steps:
+Sit or lay Sit or lay the casualty down, ensuring they are in a position that is appropriate for the location of the wound.
+Page | 39
+Examine Examine the wound for foreign objects and make a note of how the wound is bleeding. Make sure to tell the medic...
+
+=== Chunk 104 ===
+Source: first_aid_notes_2019.pdf
+Length: 626 chars
+
+Direct pressure:
+Direct pressure to the wound is the best way of stemming a bleed. You can use your hands to do this, but you should take precautions to minimise the risk of coming in contact with the casualty’s blood, preferably by wearing disposable gloves. Keep pressure on the wound continuously for at least ten minutes. Using a firm bandage usually stops the bleeding with most minor wounds (make sure the bandage is not so tight as to cut off the circulation to the limb altogether). If there ...
+
+=== Chunk 105 ===
+Source: first_aid_notes_2019.pdf
+Length: 888 chars
+
+Indirect pressure:
+If it is not possible or effective to apply direct pressure to a wound, you can use indirect pressure as a last resort. This is achieved by applying pressure to the artery which is supplying blood to the limb, pressing it against the bone beneath, reducing the blood flow. This should be done for a maximum of ten minutes.
+There are two indirect pressure points:
+Brachial This artery runs along the inside of the upper arm. To help with this, ask the casualty to make a fist with t...
+
+=== Chunk 106 ===
+Source: first_aid_notes_2019.pdf
+Length: 816 chars
+
+Dressings:
+Dressings should be sterile and just large enough to cover the wound. They should be made out of a material that will not stick to the clotting blood and be absorbent (a ‘non-adherent’ dressing).
+Usually, a firmly applied dressing is enough to stem bleeding from the majority of minor wounds, but any dressing should not restrict the flow of blood to the rest of the limb (you can check the circulation with a ‘capillary refill’ test, see page 30).
+If the bleeding is severe, it may be nec...
+
+=== Chunk 107 ===
+Source: first_aid_notes_2019.pdf
+Length: 1331 chars
+
+Embedded objects
+Objects embedded in a wound:
+If there is an object embedded in the wound (other than a small splinter) you should not attempt to remove it as it may be stemming a severe bleed, or further damage may result.
+Use sterile dressings and bandages to build up around the object, which will supply the pressure needed to stem the bleed and help support the object. Take the casualty to hospital to have the object removed safely.
+Splinters:
+If there is a splinter deeply embedded, difficult...
+
+=== Chunk 108 ===
+Source: first_aid_notes_2019.pdf
+Length: 1115 chars
+
+Nose bleeds
+Nose bleeds are usually the result of weakened or dried out blood tissues in the nose. A nose bleed can be triggered by a bang to the nose, picking or blowing it. However, it can be the symptom of a more serious problem such as high blood pressure or a fractured skull.
+Have the casualty sit with their head tipped forward to allow the blood to drain.
+Gently pinch the soft part of the nose, and maintain constant pressure for 10 minutes.
+Tell the casualty to breathe through their mouth....
+
+=== Chunk 109 ===
+Source: first_aid_notes_2019.pdf
+Length: 686 chars
+
+Eye injury
+If there are small particles of dust or dirt in the eye, this can be easily washed out using cold tap water. Make sure the water runs away from the good eye.
+Page | 42
+Muscle Conjunctiva Sclera Cornea at Lens _ Pupil Optic Nerve Iris Retina
+For more serious eye injuries:
+Try to keep the casualty still and calm. Gently place a soft, sterile dressing over the injured eye. You can tape it in place if necessary.
+Ask the casualty to close both their eyes, as any movement of the good eye wi...
+
+=== Chunk 110 ===
+Source: first_aid_notes_2019.pdf
+Length: 425 chars
+
+If you can, take the casualty to A&E. Dial 999 for an ambulance if you cannot take the casualty to A&E yourself.
+For chemical eye injuries:
+Make sure you are wearing protective gloves if possible. Wash the injured eye with lots of clean tap water, making sure the water runs away from the good eye. Gently, but firmly try to open the casualty’s eye fully to wash it as much as possible. Dial 999 for an ambulance immediately....
+
+=== Chunk 111 ===
+Source: first_aid_notes_2019.pdf
+Length: 306 chars
+
+Amputation
+Amputation is defined as the full or partial severing of a limb, and is extremely traumatic for the casualty. The priority here is to stop the bleeding, then preserve the amputated limb and reassure the casualty.
+Immediately treat the casualty for bleeding (see page 36) and shock (see page 33)....
+
+=== Chunk 112 ===
+Source: first_aid_notes_2019.pdf
+Length: 860 chars
+
+Crush injuries
+This type of injury usually occurs on building sites or at road traffic accidents. If the flow of blood to a limb (such as an arm or leg) is restricted by a crushing weight, there is the serious danger of a build-up of toxins in the muscle tissue below the crushing weight.
+If the flow of blood is restricted to the limb for more than 15 minutes, the toxins will build to such a level that when the weight is removed, and the toxins released into the body, they may cause kidney failur...
+
+=== Chunk 113 ===
+Source: first_aid_notes_2019.pdf
+Length: 177 chars
+
+Dial 999 for an ambulance immediately. Give as clear and concise
+information about the accident as you can.
+Maintain their airway and monitor their breathing until help arrives....
+
+=== Chunk 114 ===
+Source: first_aid_notes_2019.pdf
+Length: 1014 chars
+
+Internal bleeding
+This is a very serious condition, but it can be very hard to recognise in the early stages. Internal bleeding can be attributed to lung or abdominal injuries, but can also happen spontaneously to someone who appears well, such as a bleeding stomach ulcer or a weak artery.
+Even though the blood is not lost from the body, it is lost internally out of veins or arteries and can quickly cause the casualty to go into shock.
+Internal bleeding can result in serious, life threatening co...
+
+=== Chunk 115 ===
+Source: first_aid_notes_2019.pdf
+Length: 2061 chars
+
+Poisons
+Poisons can be defined as a liquid, solid or gaseous substance that causes damage to the body when it enters in sufficient quantity.
+There are 4 ways a poison can enter the body:
+The substance is swallowed, either by accident or on purpose.
+Inhaled The substance is breathed in, entering the blood stream very quickly through the alveoli.
+Absorbed The substance comes in contact with skin (see chemical burns, page 49).
+Injected The substance is introduced through the skin directly into tiss...
+
+=== Chunk 116 ===
+Source: first_aid_notes_2019.pdf
+Length: 938 chars
+
+Never try to get the casualty to vomit as this may damage the airway.
+For non-corrosive substances:
+Dial 999 for an ambulance immediately. Give clear and concise information about the poison if possible. Follow any advice given by the ambulance operator.
+If the casualty becomes unconscious, immediately open the airway and check for breathing. If they are not breathing commence CPR using a protective face shield. If the casualty is breathing but unconscious, place them in the recovery position an...
+
+=== Chunk 117 ===
+Source: first_aid_notes_2019.pdf
+Length: 2015 chars
+
+Burns and scalds
+Estimating the severity of a burn: There are five factors that affect the seriousness of a burn:
+Page | 46
+Size The larger the area of the burn the more severe it is likely to be. The size is usually given as a percentage of the body’s surface area. An easy way to work out the percentage is to compare the size of the burn to the casualty’s hand. The casualty’s open hand (including the fingers) is the equivalent to 1% of their body area.
+Cause The cause of the burn will influence...
+
+=== Chunk 118 ===
+Source: first_aid_notes_2019.pdf
+Length: 1080 chars
+
+Causes of burns and treatment
+Burns can be separated into five different areas, the treatment for each burn will differ slightly depending on the cause.
+Electrical burns:
+These burns are caused by heat from an electrical charge flowing through the bodily tissue. You may be able to determine where the current entered the body, and the point of exit, but there will certainly be deep internal burns which are not visible to the eye between the entry and exit burns. The extent of the internal damage ...
+
+=== Chunk 119 ===
+Source: first_aid_notes_2019.pdf
+Length: 195 chars
+
+Seek medical advice for burns if:
+The burn is larger than 1 square inch.
+The casualty is a baby or child.
+The burn is all the way around a limb.
+Any part of the burn appears to be full thickness....
+
+=== Chunk 120 ===
+Source: first_aid_notes_2019.pdf
+Length: 488 chars
+
+You are not sure.
+Never do any of the following when burns are concerned:
+Burst a blister or blisters (the blisters are there to protect against infection).
+Touch the burn.
+Page | 50
+Apply lotions, ointments or fats to a burn as they may introduce infection and will need to be removed once the casualty is in hospital.
+Apply adhesive tape or dressings as the burn may be larger than it first appears.
+Remove clothing that is stuck to the wound, as this will invariably cause more damage....
+
+=== Chunk 121 ===
+Source: first_aid_notes_2019.pdf
+Length: 560 chars
+
+The skeletal system
+There are 206 bones in the human skeleton, the functions of which are:
+To provide support to the body’s soft tissue. This gives the body its shape.
+To provide protection for vital organs such as the brain, lungs and spinal cord.
+To allow movement by incorporating different types of joints and attachment for muscles.
+To produce red blood cells, some white blood cells and platelets within the marrow of bones such as the femur.
+To provide a store of minerals and energy, such as ...
+
+=== Chunk 122 ===
+Source: first_aid_notes_2019.pdf
+Length: 670 chars
+
+Causes of injury
+Different types of force can cause injury to the bones, muscles and joints.
+Direct force Damage will result at the location of the force, such as a kick or blow.
+Indirect force Damage will result away from the point where the force was applied, for example a fractured collar bone may result from landing on an outstretched arm.
+Twisting force Damage will result from torsion force on the bones and muscles, for example a twisted ankle.
+Violent movement Damage will result from sudde...
+
+=== Chunk 123 ===
+Source: first_aid_notes_2019.pdf
+Length: 733 chars
+
+Types of fracture
+A fracture is a ‘break in the continuity of the bone’. These are the basic categories for a fracture:
+A clean break or crack to the bone with no complications arising.
+Open A broken bone will break the skin, and may or may not still be protruding from the wound. Please bear in mind that these types of injury carry a high risk of infection.
+Complicated There are usually complications with this type of fracture, such as trapped blood vessels or nerves.
+Green stick These are more ...
+
+=== Chunk 124 ===
+Source: first_aid_notes_2019.pdf
+Length: 688 chars
+
+Dislocations
+A dislocation occurs when a bone becomes partially or completely dislodged at the joint, usually resulting from a wrenching movement or sudden muscular
+Page | 52
+contraction. The most common areas of dislocation are the jaw, thumb, knee cap, shoulder or finger.
+Fractures can occur at or near the site of a dislocation, along with damage to ligaments, tendons and cartilage. It is sometimes difficult to distinguish between a fracture and a dislocation.
+Never try to manipulate a disloca...
+
+=== Chunk 125 ===
+Source: first_aid_notes_2019.pdf
+Length: 4258 chars
+
+Sprains and strains
+A sprain is an injury to the ligament at a joint. A strain is an injury to a muscle. These types of injury are usually caused by sudden wrenching which causes the joint to over stretch tearing the surrounding muscles and ligaments.
+Minor fractures can be easily mistaken for a sprain or a strain. If you have any doubts, treat the injury as if it were a fracture to be on the safe side. The only way you can be sure if it is or is not a fracture is by x-ray.
+Signs and symptoms of...
+
+=== Chunk 126 ===
+Source: first_aid_notes_2019.pdf
+Length: 3123 chars
+
+Spinal injuries
+THE VERTEBRAL COLUMN Lo ceRVICAL wrkoracie ~~ ee sorwrrvic
+Approximately 2% of trauma (injury) casualties suffer spinal injury. Although this percentage appears to be fairly low, suspecting and correctly treating a spinal injury is essential. Poor treatment of a casualty with a suspected spinal injury may result in them being crippled for life, or even in death.
+The spinal cord is an extension of the brain stem, and is located down the back of the spinal vertebrae. The spinal cor...
+
+=== Chunk 127 ===
+Source: first_aid_notes_2019.pdf
+Length: 1621 chars
+
+Managing the airway with a spinal injury casualty
+If an unconscious casualty is laid on their back, the airway is in danger of becoming blocked by vomit or their tongue sliding back.
+An uninjured but unconscious casualty can simply be turned into the recovery position to help protect the airway. However, if a spinal injury is suspected, you must take great care not to move the spine.
+Page | 57
+If the casualty is already lying on their side (not on their backs) you may not need to move them at al...
+
+=== Chunk 128 ===
+Source: first_aid_notes_2019.pdf
+Length: 2245 chars
+
+Do not attempt the jaw thrust technique during CPR – tilt their head back instead to open the airway.
+Log roll:
+If you have to leave the casualty for any reason, if they begin to vomit or you are at all concerned about their airway being clear, the casualty will have to be put on their side. Always remember to keep the head, neck and upper body in line when you turn the casualty.
+The most effective method of turning a casualty with a suspected spinal injury is the log roll technique.
+However, yo...
+
+=== Chunk 129 ===
+Source: first_aid_notes_2019.pdf
+Length: 428 chars
+
+Effects of heat and cold
+This part of the notes deals with the effects of over exposure to both heat and cold on the body.
+Severe Hypothermia or Heat Stroke can be potentially fatal conditions and require skilful treatment from the first aider.
+Those who are most at risk from these conditions are babies, children, the elderly or infirm and people who take part in outdoor activities like hiking, sailing or running a marathon....
+
+=== Chunk 130 ===
+Source: first_aid_notes_2019.pdf
+Length: 1964 chars
+
+Body temperature
+The ideal temperature for the body to work at is 37°C (98.6°F). The temperature is maintained by an area of the brain known as the ‘hypothalamus’. If the body should become too hot we start to sweat, which evaporates from the skin cooling it down. Blood vessels near the surface of the skin dilate (which causes skin to flush) and the cooled blood is then circulated around the body.
+If the body should become too cold we start to shiver, which creates heat from
+Page | 59
+our muscle...
+
+=== Chunk 131 ===
+Source: first_aid_notes_2019.pdf
+Length: 1617 chars
+
+Hypothermia
+Hypothermia will occur when the core temperature of the body falls below 35°C. If the casualty is suffering from the mildest form of hypothermia, they will usually make a full recovery with professional treatment. Should the casualty’s core body temperature fall below 26°C, it will most likely be fatal. However, there have been cases of successful resuscitation of casualties with body temperatures of as low as 10°C, so it’s always worth the attempt.
+Page | 60
+The usual cause of hypot...
+
+=== Chunk 132 ===
+Source: first_aid_notes_2019.pdf
+Length: 1377 chars
+
+Frostbite
+This condition usually affects the extremities (such as fingers, toes, ears, etc.) when they are exposed to cold. The cells become frozen, causing ice crystals to form in the cells which in turn cause them to rupture and die. Frostbite can often be accompanied by hypothermia, which also needs to be treated. Severe frostbite can result in the loss of the affected area, normally fingers and toes.
+Signs and symptoms:
+Pins and needles, numbness.
+Skin hardens and stiffens.
+Skin colour chang...
+
+=== Chunk 133 ===
+Source: first_aid_notes_2019.pdf
+Length: 1027 chars
+
+Heat exhaustion
+This condition is the body responding to loss of water and salt through excessive sweating. The most common cause of heat exhaustion is working or exercising in a hot temperature (such as marathon runners).
+Signs and symptoms:
+Confusion and dizziness.
+Pale, sweaty skin.
+Nausea, loss of appetite and vomiting.
+Fast, weak pulse and breathing.
+Cramping in the arms, legs and abdomen.
+The casualty may complain of being cold, but will be hot to the touch.
+Treatment of heat exhaustion:
+R...
+
+=== Chunk 134 ===
+Source: first_aid_notes_2019.pdf
+Length: 796 chars
+
+Heat stroke
+This is a very serious condition which results from the hypothalamus failing (the temperature control centre) in the brain. The sweating mechanism fails resulting in the body being unable to cool down and the core temperature reaching a dangerously high level (over 40°C) in a relatively short time (around 10 to 15 minutes).
+Heat stroke can be caused by prolonged exposure to heat or a high fever, and usually follows heat exhaustion.
+Signs and symptoms:
+Severe confusion, restlessness.
+...
+
+=== Chunk 135 ===
+Source: first_aid_notes_2019.pdf
+Length: 748 chars
+
+Taking a temperature
+There are modern, easy to use thermometers available now, such as disposable strips that you place on the forehead, and digital thermometers. Follow the manufacturer’s instructions on how to use them. If, however, you have an old fashioned mercury thermometer, the following advice may be helpful:
+Be careful when using the thermometer as the mercury inside is poisonous.
+Make sure it is thoroughly cleaned before use.
+Hold it by the end opposite to the silver, mercury bulb.
+Sha...
+
+=== Chunk 136 ===
+Source: first_aid_notes_2019.pdf
+Length: 1097 chars
+
+Diabetes
+This condition occurs when the casualty does not produce enough of the hormone insulin naturally.
+The body uses insulin to break down the sugar that we digest, so that it can be used by the cells or stored for later use. Basically, insulin reduces the amount of sugar in the blood.
+Should diabetes go untreated, the casualty’s blood sugar levels will rise dangerously over 1 or 2 days (this depends on the severity of their condition).
+Page | 64
+Diabetes is split into three different types,...
+
+=== Chunk 137 ===
+Source: first_aid_notes_2019.pdf
+Length: 309 chars
+
+High blood sugar (hyperglycaemia)
+This occurs when the diabetes is not treated effectively with any of the methods mentioned above.
+The sugar levels in the blood climb and acids build up. The signs and symptoms displayed by a hyperglycaemic person are a result of the body trying to excrete the acid build up....
+
+=== Chunk 138 ===
+Source: first_aid_notes_2019.pdf
+Length: 2965 chars
+
+Low blood sugar (hypoglycaemia)
+This condition occurs mainly with diabetic people who are insulin dependent, as the level of insulin in the body is ‘fixed’ due to the dose administered by injection.
+Because the amount of insulin is fixed, they must balance it with the amount of food they eat.
+Blood sugar levels fall if:
+The person has not eaten enough food.
+The person over exerts (burns off the sugar in their blood).
+The person has injected a too high dose of insulin.
+Why low blood sugar is dang...
+
+=== Chunk 139 ===
+Source: first_aid_notes_2019.pdf
+Length: 537 chars
+
+Epilepsy
+People with this condition have a tendency to have seizures (fits) that come from a disturbance in the brain. However, bear in mind that one in twenty people will experience a seizure at some point in their lives, so the casualty may not be epileptic.
+The causes of a seizure are many, such as hypoxia, stroke, a head injury or even a high body temperature.
+Seizures are common in babies and children whose temperature is too high due to illness and fever. This is covered under the heading ...
+
+=== Chunk 140 ===
+Source: first_aid_notes_2019.pdf
+Length: 772 chars
+
+Minor seizures
+This condition is also known as ‘absence seizures’ or ‘petit mal’ seizures. The person may suddenly appear to be daydreaming (even in mid-sentence). This may only last a couple of seconds before recovery, and the person may not even realise what just happened. On some occasions a minor seizure may be accompanied by unusual movements such as twitching in the face, jerking of a limb or lip smacking. The person can at times make a noise such as a sudden cry.
+Treatment of minor seizur...
+
+=== Chunk 141 ===
+Source: first_aid_notes_2019.pdf
+Length: 3312 chars
+
+Major seizures
+This is the more serious type of seizure, resulting from a major disturbance in the brain which causes aggressive fitting throughout the body.
+Page | 67
+These types of fit can be very frightening to see, but try to remain calm as prompt action is essential for the casualty.
+Signs and symptoms:
+There is usually a pattern to a major seizure.
+Aura If the casualty has had a history of seizures, they may recognise when a fit is imminent. The warning signs (or aura) could include a tast...
+
+=== Chunk 142 ===
+Source: first_aid_notes_2019.pdf
+Length: 1148 chars
+
+Febrile convulsions
+The part of the brain that regulates temperature (the hypothalamus) is not yet fully developed in babies and young children, which can lead to the body’s core temperature reaching dangerously high levels, which may lead to a child having a fit.
+A child having a febrile convulsion can be a very frightening and distressing sight for a parent or guardian. When the child is in the ‘tonic’ phase, s/he may stop breathing as the diaphragm goes rigid resulting in the lips and face tu...
+
+=== Chunk 143 ===
+Source: first_aid_notes_2019.pdf
+Length: 239 chars
+
+Please remember:
+Never place anything in a fitting casualty’s mouth, especially your fingers.
+Never try to restrain them or hold them down – allow the fit to run its course.
+Never move a fitting casualty unless they are in imminent danger....
+
+=== Chunk 144 ===
+Source: first_aid_notes_2019.pdf
+Length: 856 chars
+
+Health & Safety (first aid) Regulations 1981
+Employer’s responsibility:
+It is the responsibility of the employer to make sure sufficient first aid provision is made in the workplace, under Health & Safety law. This includes:
+Assessing the first aid needs of the workplace – how many first aiders are needed, what type of training is required, are they following the guidance from the HSE (Health & Safety Executive).
+Provide training and re-qualification courses for the appointed first aiders.
+Ensur...
+
+=== Chunk 145 ===
+Source: first_aid_notes_2019.pdf
+Length: 1878 chars
+
+First aid kits
+The first aid kit should be easily accessible; preferably near somewhere the first aider can wash their hands. The kits should be easily identified by a large white cross on a green background. The container should protect the contents from dust and damp.
+Page | 70
+First aid kits should be available at all workplaces. However, larger sites will need more than one first aid kit to cover the greater amount of people. The kits should contain the following, as a guide only:
+A leaflet ...
+
+=== Chunk 146 ===
+Source: first_aid_notes_2019.pdf
+Length: 559 chars
+
+Travelling first aid kits
+If the employees travel, it is advisable to provide them with a first aid kit, which will typically include:
+A leaflet with general guidance on first aid.
+6 individually wrapped sterile plasters.
+2 individually wrapped triangular bandages, preferably sterile.
+2 safety pins.
+1 individually wrapped large, sterile wound dressing (approx. 18cm x 18cm).
+Individually wrapped moist cleansing wipes.
+1 pair of disposable gloves. Please remember some people are allergic to latex,...
+
+=== Chunk 147 ===
+Source: first_aid_notes_2019.pdf
+Length: 794 chars
+
+First aid needs assessment
+Employers must carry out a first aid needs assessment, which should answer the following questions:
+What is the nature of the work? What are the hazards and risks of the workplace?
+What is the size of the organisation?
+What is the nature of the workforce?
+What is the organisation’s history of illness and accidents?
+What are the needs of travelling, remote or lone workers, if applicable?
+What are the work patterns (such as shift work)?
+What is the distribution of the wo...
+
+=== Chunk 148 ===
+Source: first_aid_notes_2019.pdf
+Length: 1151 chars
+
+Workplace hazards and risks
+One of the more difficult areas of a first aid needs assessment is taking into consideration the nature of the work and workplace hazards and risks.
+Employers should take into consideration the risks and identify the possible injuries which could occur in order to ensure the first aid provision is sufficient. The table below, compiled using information from the HSE, should help in identifying some common workplace risks, and the possible resulting injuries:
+Risk Possi...
+
+=== Chunk 149 ===
+Source: first_aid_notes_2019.pdf
+Length: 637 chars
+
+First aiders
+An employer should consider a number of things when choosing an employee to be a first aider. Ideally, a first aider will have the following:
+Reliability, good disposition and communication skills
+An aptitude and ability to absorb new skills and knowledge
+An ability to cope with stressful and physically demanding emergency procedure
+Normal workplace duties that can be left if an emergency situation arises
+As of October 2009, there have been introduced a new training regime for first...
+
+=== Chunk 150 ===
+Source: first_aid_notes_2019.pdf
+Length: 923 chars
+
+Contents of HSE First Aid Courses:
+EFAW – Emergency First Aid at Work (1 day course) EFAW FAW – First Aid at Work (3 day course) 1 Day (6 hours) Acting safely, promptly & effectively in an emergency Y Cardio Pulmonary Resuscitation (CPR) Y Treating an unconscious casualty (inc seizure) Y Wounds & bleeding Y Shock Y Minor injuries Y Choking Y Preventing cross infection, recording incidents & actions & the use of Y available equipment Fractures X Sprains & strains X Spinal injuries X Chest injurie...
+
+=== Chunk 151 ===
+Source: first_aid_notes_2019.pdf
+Length: 251 chars
+
+Annual refresher training
+The HSE recommend that all employees trained in first aid attend an annual refresher course due to the evidence on the severity of ‘first aid skill fade’.
+The above flow chart shows the HSE’s recommended sequence of training....
+
+=== Chunk 152 ===
+Source: first_aid_notes_2019.pdf
+Length: 810 chars
+
+Reporting incidents at work
+All accidents in the workplace must be recorded in an accident book, no matter how small the resulting injury. The incident may need to be reported to the HSE under RIDDOR regulations.
+RIDDOR 1995 regulations
+Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.
+These regulations specify that it is the responsibility of the employer or person in control of the premises to report the following incidents directly to the HSE:
+Death (report immediate...
+
+=== Chunk 153 ===
+Source: first_aid_notes_2019.pdf
+Length: 1812 chars
+
+Accident book
+An accident at work must be recorded in an accident book, no matter how severe the injury. The accident book may be filled in by anyone on behalf of the casualty, or if they are capable the casualty themselves.
+The recorded information can help the employer to identify accident trends and possible areas for improvement in control of health and safety risks. It can also be used for future first aid needs, assessments and could also be helpful for insurance investigation purposes.
+Th...
+
+=== Chunk 154 ===
+Source: first_aid_notes_2019.pdf
+Length: 1511 chars
+
+First aid casualty report form
+It is useful for the first aider to complete a patient report form for all casualties. Please note that this is not in place of the accident report book, which still has to be completed for any accidents in the workplace.
+The casualty report form is designed to help the first aider keep an accurate record of the exact treatment provided. It is especially useful if the casualty refuses treatment against the advice of the first aid provider.
+If the casualty refuses t...
+
+=== Chunk 155 ===
+Source: first_aid_notes_2019.pdf
+Length: 299 chars
+
+Appendix: Resuscitation – child over 1 year:
+NOTE: This section deals with the differences between adult and child resuscitation.
+REMEMBER: If you are at all unsure, it is better to perform the adult sequence on a child who is unresponsive and not breathing than not to do anything at all.
+Page | 76...
+
+=== Chunk 156 ===
+Source: first_aid_notes_2019.pdf
+Length: 497 chars
+
+Child resuscitation:
+Danger
+Make sure you are safe to help, do not put yourself in danger
+Response
+Gently tap the child’s shoulders and shout ‘are you alright?’
+If the child does not respond shout for help, but don’t leave the child yet
+Airway
+Carefully ensure the airway is open by gently tipping the child’s head back with the ‘chin lift’:
+Place your hand on the child’s forehead and gently tilt their head back
+Using your fingertips under the point of the chin, lift the chin to open the airway...
+
+=== Chunk 157 ===
+Source: first_aid_notes_2019.pdf
+Length: 572 chars
+
+Breathing
+Ensuring the airway is kept open; look, listen and feel to ascertain whether the child is breathing normally. Do not take more than ten seconds to do this.
+If the child is able to breath normally, carry out a secondary survey and place the child in the recovery position (see page 12)
+Ensuring the airway is kept open; look, listen and feel to ascertain whether the baby is breathing normally. Do not take more than ten seconds to do this.
+If the baby is able to breath normally, consider t...
+
+=== Chunk 158 ===
+Source: first_aid_notes_2019.pdf
+Length: 787 chars
+
+If the child is not breathing normally:
+If you are not alone, ask the nearest person to dial 999 for an ambulance immediately. If you are alone and need to leave the child to ensure help is on the way, perform resuscitation for about 1 minute first:
+Maintain the child’s airway by tilting their head and lifting the chin
+Pinch the fleshy part of the nose and seal your mouth around the child’s
+Give 5 initial rescue breaths. Blow in just enough air to make the child’s chest rise visibly
+Combine resc...
+
+=== Chunk 159 ===
+Source: first_aid_notes_2019.pdf
+Length: 651 chars
+
+Continue to administer 30 chest compressions followed by 2 rescue breaths
+If your rescue breaths do not make the child’s chest rise effectively:
+Give a further 30 chest compressions before attempting the following:
+Check inside the mouth and remove any clearly visible obstruction (do not reach blindly into the child’s throat)
+Recheck that the head is adequately tilted back and the chin is lifted
+Do not administer more than 2 rescue breaths before resuming chest compressions
+Note: If there is ano...
+
+=== Chunk 160 ===
+Source: first_aid_notes_2019.pdf
+Length: 298 chars
+
+Appendix: Resuscitation – baby under 1 year:
+NOTE: This section deals with the differences between adult and baby resuscitation.
+REMEMBER: If you are at all unsure, it is better to perform the adult sequence on a child who is unresponsive and not breathing than not to do anything at all.
+Page | 77...
+
+=== Chunk 161 ===
+Source: first_aid_notes_2019.pdf
+Length: 217 chars
+
+Danger
+Make sure you are safe to help, do not put yourself in danger
+Response
+Gently tap the baby’s shoulders and shout to try to wake the baby
+If the baby does not respond shout for help, but don’t leave the baby yet...
+
+=== Chunk 162 ===
+Source: first_aid_notes_2019.pdf
+Length: 295 chars
+
+Airway
+Carefully ensure the airway is open by gently tipping the baby’s head back with the ‘chin lift’:
+Place your hand on the baby’s forehead and gently tilt their head back. DO NOT OVER- EXTEND THE BABY’S NECK
+Using your fingertips under the point of the chin, lift the chin to open the airway...
+
+=== Chunk 163 ===
+Source: first_aid_notes_2019.pdf
+Length: 556 chars
+
+If the baby is not breathing normally:
+If you are not alone, ask the nearest person to dial 999 for an ambulance immediately. If you are alone and need to leave the baby to ensure help is on the way, perform resuscitation for about 1 minute first:
+Maintain the baby’s airway by tilting their head and lifting the chin ensuring you do not over-extend the baby’s neck
+Seal your mouth around the baby’s nose and mouth
+Give 5 initial rescue breaths. Blow in just enough air to make the baby’s chest rise ...
+
+=== Chunk 164 ===
+Source: first_aid_notes_2019.pdf
+Length: 770 chars
+
+Combine rescue breaths with chest compressions:
+Use 2 fingers to depress the baby’s chest to a third of its depth
+Give 30 chest compressions at a rate of 100 compressions per minute
+Open the airway again by tilting the baby’s head and lifting the chin, and give 2 more rescue breaths
+Continue to administer 30 chest compressions followed by 2 rescue breaths
+Page | 78
+If your rescue breaths do not make the baby’s chest rise effectively:
+Give a further 30 chest compressions before attempting the fol...
+
+=== Chunk 165 ===
+Source: first_aid_notes_2019.pdf
+Length: 1357 chars
+
+Appendix: Resuscitation with an Automated External Defibrillator (AED):
+The most common cause of a heart stopping (cardiac arrest) is a ‘heart attack’ (see page 30). It is worth noting that a heart attack does not always result in cardiac arrest. The majority of heart attack victims remain conscious and survive.
+If a heart attack, or another cause, results in cardiac arrest, it is usually because it has interrupted the heart’s electrical impulses. When this happens the heart ‘quivers’ chaoticall...
+
+=== Chunk 166 ===
+Source: first_aid_notes_2019.pdf
+Length: 1436 chars
+
+Resuscitation with an AED
+Danger
+Make sure you are safe to help, do not put yourself in danger
+Consider the safety implications of using an AED in this situation
+Response
+Gently shake the shoulders and ask in a loud voice ‘Are you alright?’ If there is no response from the casualty:
+Shout for help immediately
+If you have people with you, ask one helper to dial 999 for an ambulance and ask the other to get the AED, but do not leave the casualty yourself just yet
+Airway
+Carefully ensure the airway...
+
+=== Chunk 167 ===
+Source: first_aid_notes_2019.pdf
+Length: 1473 chars
+
+Switch on the AED immediately and follow the voice prompts:
+Attach the leads to the AED if they are not already attached, and attach the pads to the casualty’s bare chest (if possible, do this while the person helping you continues CPR)
+It may be necessary for you to towel dry or even shave the casualty’s chest so the pads adhere to their skin properly. Only shave where the pads are going to go, try to delay defibrillation as little as possible
+Peel the backing from the pads one at a time and pl...
+
+=== Chunk 168 ===
+Source: first_aid_notes_2019.pdf
+Length: 286 chars
+
+Placements of the pads:
+Wet chest
+If the casualty’s chest is wet (from sweating for example) it must be dried before the pads can be applied so they can stick to the skin properly. Also be sure to dry the area of the chest between the pads, as electricity can ‘arc’ across the wet skin....
+
+=== Chunk 169 ===
+Source: first_aid_notes_2019.pdf
+Length: 400 chars
+
+Excessive chest hair
+Hair on the chest will stop the pads from sticking to the skin properly and will interfere with electrical contact. You only need to shave the chest if the hair is excessive, and even then take as little time as possible as you don’t want to delay defibrillation by any longer than is absolutely necessary. If there is no razor immediately available, do not delay defibrillation....
+
+=== Chunk 170 ===
+Source: first_aid_notes_2019.pdf
+Length: 519 chars
+
+Pad positioning
+Research shows that the position of the pad on the lower left side of the chest has an impact on the effectiveness of the shock. When placing the pad, make sure it is placed around the side of the chest (not on the front) and place it vertically. This will help ensure the maximum electricity flows through the heart rather than across the surface of the chest. If the AED has not been updated, the pads will have a diagram showing horizontal placement – ignore this advice and place ...
+
+=== Chunk 171 ===
+Source: first_aid_notes_2019.pdf
+Length: 2142 chars
+
+AED safety considerations:
+Electric shock
+Studies have shown that, providing the pads are stuck to a dry chest in the correct positions, the risk of electrical shock is very low as the electricity wants to travel from one pad to the other, not to ‘earth’ itself like mains electricity. However, to be on the safe side, always briefly check that no one is touching the casualty before a shock is delivered.
+DO NOT delay defibrillation because the casualty is lying on a wet or metal surface, providing...
+
+=== Chunk 172 ===
+Source: first_aid_notes_2019.pdf
+Length: 883 chars
+
+AED use on children:
+The AED pads are suitable for both adults and children older than 8 years. Smaller pads that reduce the current delivered in a shock are available for children aged 1 to 8 years. These should be used for the appropriate age range whenever possible. Some AEDs have a ‘paediatric’ setting.
+If the child is over 1 year and you do not have smaller pads, use the AED as it is. But please note that the use of adult sized pads on a child under 1 year old is not recommended.
+Most paedi...
+
+=== Chunk 173 ===
+Source: first_aid_notes_2019.pdf
+Length: 3847 chars
+
+Glossary
+Abdomen the area between the lowest ribs and the pelvis Acute sudden onset Adrenaline Hormone secreted by the body in times of shock Airway the passage from the mouth and nose to the lungs Alveoli minute air sacks in the lungs, through which the exchange of gasses take place Asphyxia deficiency of oxygen caused by an interruption in the passage of air to the lungs Atrium top, ‘collecting’ chamber of the heart (of which there are two) Baby person under 1 year old Breathing inspiration an...
+
+=== Chunk 174 ===
+Source: 0973_002-ebook.pdf
+Length: 329 chars
+
+Untitled Section
+WAR SURGERY WORKING WITH LIMITED RESOURCES IN ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE
+VOLUME 1
+SECOND EDITION, 2019
+C. GIANNOU
+M. BALDAN
+E C N E R E F E R
+ICRC
+WAR SURGERY WORKING WITH LIMITED RESOURCES IN ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE
+VOLUME 1
+SECOND EDITION, 2019
+C. GIANNOU
+M. BALDAN...
+
+=== Chunk 175 ===
+Source: 0973_002-ebook.pdf
+Length: 2393 chars
+
+PREFACE
+Many things change in a decade; many things stay the same. Despite advances in the management of severely injured patients, the challenge of providing timely, adequate and appropriate care for the victims of armed conflict remains.
+In the ten years since War Surgery: Working with Limited Resources in Armed Conflict and Other Situations of Violence was first published, it has become a basic reference text for surgeons facing the challenge of managing the war wounded – both civilians and c...
+
+=== Chunk 176 ===
+Source: 0973_002-ebook.pdf
+Length: 6718 chars
+
+TABLE OF CONTENTS
+SPECIAL CHARACTERISTICS OF SURGERY IN TIMES OF CONFLICT 1.1 Differences between surgery in times of conflict and civilian practice 1.2 How war surgery differs 1.3 “Surgeries” for victims of war 1.4 Differences between military and non-military war surgery: the ICRC approach ANNEX 1. A ICRC criteria for introducing a new technology APPLICABLE INTERNATIONAL HUMANITARIAN LAW 2.1 Historical introduction 2.2 International humanitarian law: basic principles 2.3 The distinctive emblem...
+
+=== Chunk 177 ===
+Source: 0973_002-ebook.pdf
+Length: 209 chars
+
+INTRODUCTION
+Our common goal is to protect and assist the victims of armed conflict and to preserve their dignity. This book is dedicated to the victims of situations which, in a better world, would not exist....
+
+=== Chunk 178 ===
+Source: 0973_002-ebook.pdf
+Length: 4296 chars
+
+Facing the challenges
+One night while on duty Dr X, an experienced surgeon working in an ICRC field hospital in the midst of a civil war, performed a craniotomy on one patient injured by a bomb, an amputation following an anti-personnel landmine injury on another, and a laparotomy after a gunshot wound on the third; not to mention the emergency Caesarean section that arrived, as always, at the most inopportune time, after midnight. She was the only surgeon available that night. This was common p...
+
+=== Chunk 179 ===
+Source: 0973_002-ebook.pdf
+Length: 1579 chars
+
+The ICRC’s experience
+The ICRC has been providing medical care for the war-wounded ever since its inception, for example during the Franco-Prussian War (1870). The 1970s and 80s, however, saw a tremendous increase in the already considerable humanitarian activities for the victims of war, armed conflict, and other situations of violence. These included relief efforts for refugees, internally displaced persons, and the affected resident population, and medical care for the sick and wounded. In ad...
+
+=== Chunk 180 ===
+Source: 0973_002-ebook.pdf
+Length: 3218 chars
+
+Independent ICRC-run hospitals.
+Support to local hospitals through the short-term presence of expatriate surgical teams, with a strong focus on training and capacity building; the provision of supplies and equipment; the renovation of infrastructure and water and sanitation facilities; and financial incentives and salaries for local staff when necessary.
+Organization of war surgery seminars, which provide opportunities for colleagues to exchange experiences and expertise.
+This three-pronged appr...
+
+=== Chunk 181 ===
+Source: 0973_002-ebook.pdf
+Length: 3282 chars
+
+Putting pen to paper
+To meet the challenge posed by these conditions, our predecessors in the surgical department of the Medical Division of the ICRC edited a basic reference manual for surgeons embarking on their first humanitarian mission: Surgery for Victims of War.
+The first three editions of this book have been extensively distributed and received wide acclaim the world over from surgeons who faced the challenge of treating war- wounded patients for the first time. The general surgeon in an...
+
+=== Chunk 182 ===
+Source: 0973_002-ebook.pdf
+Length: 3762 chars
+
+Acknowledgements
+This manual is based on Surgery for Victims of War, first published by the ICRC in 1988 and edited by Daniel Dufour, Michael Owen-Smith, and G. Frank Stening. The authors included:
+Bernard Betrancourt (Switzerland), Daniel Dufour (Switzerland), Ora Friberg (Finland), Soeren Kromann Jensen (Denmark), Antero Lounavaara (Finland), Michael Owen-Smith (United Kingdom), Jorma Salmela (Finland), Erkki Silvonen (Finland), Frank Stening (Australia), Björn Zetterström (Sweden), and was il...
+
+=== Chunk 183 ===
+Source: 0973_002-ebook.pdf
+Length: 1592 chars
+
+Note to the Second Edition
+A number of advances have been made in the management of war wounded patients since the publication of this volume. We have tried to bring the content up to date, without attempting to offer “cutting-edge” developments that are largely irrelevant to our colleagues working in difficult circumstances with limited resources. Nonetheless, we have attempted to be as professional as possible.
+Several colleagues at ICRC headquarters have contributed to this edition. Andreas W...
+
+=== Chunk 184 ===
+Source: 0973_002-ebook.pdf
+Length: 1509 chars
+
+SPECIAL CHARACTERISTICS OF SURGERY IN TIMES OF CONFLICT
+11
+WAR SURGERY
+20
+1
+SPECIAL CHARACTERISTICS OF SURGERY IN TIMES OF CONFLICT
+1.1 1.2 1.2.1 1.2.2 1.2.3 1.2.4 1.2.5 1.2.6 1.2.7 1.2.8 1.2.9 1.2.10 1.2.11 1.3 1.4 1.4.1 1.4.2 1.4.3 1.4.4 1.4.5 1.4.6 1.4.7 1.4.8 ANNEX 1. A Differences between surgery in times of conflict and civilian practice How war surgery differs IHL: protection of non-combatants and those “hors de combat” and the rights and obligations of medical personnel Specific epidemio...
+
+=== Chunk 185 ===
+Source: 0973_002-ebook.pdf
+Length: 3691 chars
+
+1.1 Differences between surgery in times of conflict and civilian practice
+The differences between civilian and war trauma are manifold – as are the differences between the experience of the ICRC and those of conventional military medical services.
+Most surgeons today, the world over, derive their trauma training from road-traffic accidents and much that applies to the management of casualties in civilian settings will also apply to the situation of armed conflict: war surgery follows classical ...
+
+=== Chunk 186 ===
+Source: 0973_002-ebook.pdf
+Length: 983 chars
+
+1.2 How war surgery differs
+War surgery is the management of an “epidemic of trauma”   in a series of steps: echelons.   N. I. Pirogov2
+A number of special features characterize the practice of surgery in time of war.3
+1. Special rules: international humanitarian law (IHL), i.e. the protection of the sick and wounded, and the rights and obligations of medical personnel.
+2. Specific epidemiology of war wounds.
+3. Predominance of emergency surgery.
+4. Surgery in a limited technical environment.
+5....
+
+=== Chunk 187 ===
+Source: 0973_002-ebook.pdf
+Length: 2219 chars
+
+1.2.1 IHL: protection of non-combatants and those “hors de combat” and the rights and obligations of medical personnel
+The Geneva Conventions of 1949 and their Additional Protocols of 1977 define categories of individuals who, by virtue of these treaties, are protected during armed conflict. These include non-combatants, combatants who no longer participate in hostilities – “hors de combat” – either through sickness, injury, shipwreck, or by becoming prisoners of war; and those who care for the ...
+
+=== Chunk 188 ===
+Source: 0973_002-ebook.pdf
+Length: 502 chars
+
+1.2.2 Specific epidemiology of war wounds
+The nature of warfare – on land, at sea or in the air – will create a particular epidemiology of the wounded. The nature of weapons, protective body armour, and any delay in transport will affect the anatomic distribution of injuries and their severity. The understanding of these epidemiological factors will have important consequences in terms of preparation and allocation of resources: i.e. standardized supplies and specialized personnel (see Chapter 5...
+
+=== Chunk 189 ===
+Source: 0973_002-ebook.pdf
+Length: 295 chars
+
+1.2.3 Predominance of emergency surgery
+War surgery primarily consists of emergency surgery, especially during early tactical field care. Sophisticated techniques or reconstructive procedures have no place here, except well after combat and in a distant referral hospital (see Chapters 6 and 8)....
+
+=== Chunk 190 ===
+Source: 0973_002-ebook.pdf
+Length: 847 chars
+
+1.2.4 Surgery in a limited technical environment
+The environment in times of war is bleak and harsh. The limits of surgical work are largely determined by the logistic difficulties attending the supply of remote and dangerous areas and the lack of maintenance, repair and spare parts. There is seldom enough technical support staff to ensure that infrastructure functions correctly.
+C
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+Figure 1.4
+Surgery in a limited technical environment.
+Despite lavish outlays for field h...
+
+=== Chunk 191 ===
+Source: 0973_002-ebook.pdf
+Length: 1569 chars
+
+1.2.5 Surgery in a hostile, violent environment
+The adverse conditions of a tactical situation may put the safety of patients and medical personnel at risk, and thereby create less than optimal working conditions. Dangerous evacuation routes may compromise transport and result in delays. Security must be ensured for patients and staff, by selecting suitable sites for first-aid posts and hospitals. Health facilities and ambulances should be clearly marked with the protective emblem of the red cro...
+
+=== Chunk 192 ===
+Source: 0973_002-ebook.pdf
+Length: 881 chars
+
+1.2.6 Mass casualties involving the principles of triage
+Much has been written about the carnage of the major wars of the twentieth century, and the role of triage in the management of thousands of casualties resulting from a single battle. These lessons are still relevant in contemporary conflicts. The logic followed must be to “do the best for the most” and not “everything for everyone”. This involves the most important change in the professional mindset of the surgeon.
+Triage decisions are am...
+
+=== Chunk 193 ===
+Source: 0973_002-ebook.pdf
+Length: 2984 chars
+
+1.2.7 Triage and surgery in successive echelons
+The sick and wounded are evacuated and transferred along a chain of casualty care. The principles of triage are applied at every stage in this chain. The initial surgery must not compromise the performance of later, definitive surgery. The prognosis will be much better if the wounded are evacuated rapidly to a higher echelon hospital structure. A surgeon in the field must understand the system and know what will happen to the patient at the next ec...
+
+=== Chunk 194 ===
+Source: 0973_002-ebook.pdf
+Length: 2408 chars
+
+Old lessons for new surgeons
+Save life and limb, sacrifice limb to save life, prevent infection, and render the casualty transportable to the next echelon.
+Heroic surgery will never replace good surgery.
+It is more important to provide proper first aid and render the injured fit for transport, than to give early but inadequate treatment, with insufficient means, and insufficient knowledge.
+C
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+Figure 1.7 Inadequate pre-hospital care.
+25
+WAR SURGERY
+26
+The best instr...
+
+=== Chunk 195 ===
+Source: 0973_002-ebook.pdf
+Length: 655 chars
+
+1.2.8 Outcome of hospital patient care depends on the efficiency of pre-hospital echelons
+First aid provided at the point of wounding – or at the safest place near the battlefield – and rapid evacuation are of vital importance; mortality and morbidity increase with delay. If first aid is inadequate or unavailable and the evacuation chain is long, then the outcome will be decided by nature. However, hospital mortality decreases as evacuation time increases; with very long delays, the severely inj...
+
+=== Chunk 196 ===
+Source: 0973_002-ebook.pdf
+Length: 1160 chars
+
+1.2.9 Specific wound pathology: bullets, bombs, blast, and non-conventional weapons
+War wounds are qualitatively different from trauma seen in civilian practice: all are dirty and contaminated. Projectiles may cause massive destruction of soft tissues, bones, and important organs. Infection is the great danger and the rules of septic surgery apply (see Chapters 3 and 13).
+Old lessons for new surgeons
+War wounds are dirty and contaminated from the moment of injury. The rules of septic surgery app...
+
+=== Chunk 197 ===
+Source: 0973_002-ebook.pdf
+Length: 2530 chars
+
+1.2.10 Specific techniques appropriate to the context and pathology
+The care of numerous patients, treated in many locations by different surgeons, in austere conditions demands simplicity, security, and speed of surgical procedures. The need for speed in dealing with mass casualties with inadequate numbers of staff should not lead to confusion and disorder. Phased wound care imposes standards and a systematic approach: doing the least amount of surgical work for the greatest results, saving “li...
+
+=== Chunk 198 ===
+Source: 0973_002-ebook.pdf
+Length: 1017 chars
+
+1.2.11 Increased prevalence of endemic disease
+Until World War I, more soldiers died of disease than of their wounds. Battle-injury attrition was usually around 20 %, and disease four times more common among soldiers. Non-battle injury attrition rates remain very high even today; infectious and communicable diseases differ according to the geography and climate, but psychological disorders and vehicle accidents are universal.
+The destruction, disruption and disorganization that accompany armed c...
+
+=== Chunk 199 ===
+Source: 0973_002-ebook.pdf
+Length: 2802 chars
+
+1.3 “Surgeries” for victims of war
+There is more than one type of war surgery. While the needs of the wounded are the same, the means and resources available to meet those needs vary widely from country to country and situation to situation, giving rise to different approaches to war surgery. The management of the war-wounded as performed by the military medical services of an industrialized country is not the same as that of a public rural hospital in a low-income country. Although the principl...
+
+=== Chunk 200 ===
+Source: 0973_002-ebook.pdf
+Length: 121 chars
+
+Figure 1.9
+Another type of surgery for victims of armed conflict.
+SPECIAL CHARACTERISTICS OF SURGERY IN TIMES OF CONFLICT...
+
+=== Chunk 201 ===
+Source: 0973_002-ebook.pdf
+Length: 1253 chars
+
+1.4 Differences between military and non-military war surgery: the ICRC approach
+Non-military war surgery is practised by civilian medical structures (health ministry, missionary and private hospitals) and those of the ICRC or other humanitarian agencies. This section details the ICRC’s experience and explains its approach.
+The aims of war surgery for the ICRC are to protect the sick and wounded and help maintain their dignity by ensuring access to adequate care; save “life and limb”; minimize r...
+
+=== Chunk 202 ===
+Source: 0973_002-ebook.pdf
+Length: 1209 chars
+
+1.4.1 Military-civilian cooperation
+Armed forces deployed in the field have a specific military mission. Their medical component aims primarily to give support to their soldiers in this mission, i.e. to achieve their tactical and strategic plans. The military may have many of the same “assistance and reconstruction” aims as civilian organizations, but medical criteria in a military context often must take second place to the tactical and strategic demands of military and political necessity.
+The...
+
+=== Chunk 203 ===
+Source: 0973_002-ebook.pdf
+Length: 1521 chars
+
+1.4.2 Constraints: security
+The ICRC often has little or no control over casualty evacuation because of security constraints. In many countries the wounded are transported by private means: taxis, donkeys, oxcarts or on foot. In some contexts, the ICRC has been able to set up first- aid posts, or assist a National Red Cross or Red Crescent Society in doing so. One extraordinary example was a 16-year medical evacuation system by fixed-wing aircraft run by the ICRC and United Nations’ Operation Li...
+
+=== Chunk 204 ===
+Source: 0973_002-ebook.pdf
+Length: 638 chars
+
+1.4.3 Constraints: logistics
+A hostile environment presents more than security risks. Remote areas with dangerous routes and extreme climates pose numerous logistic problems for the delivery of supplies and the maintenance of basic infrastructure, for both hospital and living quarters. The military often have lift, delivery and transport capacities that civilian institutions lack. Although the armed forces also have their logistic limits, they are of a different order of magnitude to those of th...
+
+=== Chunk 205 ===
+Source: 0973_002-ebook.pdf
+Length: 2054 chars
+
+1.4.4 Constraints: hospital equipment
+These limitations also affect hospital equipment. The military have lift constraints because they must also transport arms and munitions. For the ICRC, equipment limitations mean resorting to appropriate technology and mastering the tasks of maintenance, repair and availability of spare parts. This is particularly important when working in remote areas in a poor country with training programmes for local colleagues. The aim is to avoid creating a technologic...
+
+=== Chunk 206 ===
+Source: 0973_002-ebook.pdf
+Length: 723 chars
+
+1.4.5 Constraints: blood transfusion
+Blood for transfusion is often difficult to obtain in some countries because of cultural and religious restrictions and beliefs. With the steady increase in HIV infection around the world, testing must be adequate and indications for transfusion strictly limited. In some areas of the world, giving blood should probably be totally avoided. The use of blood should be restricted to vital needs and to patients with a good chance of survival, following the princip...
+
+=== Chunk 207 ===
+Source: 0973_002-ebook.pdf
+Length: 695 chars
+
+1.4.6 Constraints: geography and climate
+The geographic context may be important in terms of disease and the added burden it represents. The wounded may suffer from other illnesses, such as tuberculosis, malaria, typhoid and intestinal worms, as well as from malnutrition. In countries with chronic malaria infestation, there is often a peak of fever post-operatively. The surgeon must therefore try to acquire some basic knowledge of the diseases specific to the area and their treatment. Local heal...
+
+=== Chunk 208 ===
+Source: 0973_002-ebook.pdf
+Length: 1082 chars
+
+1.4.7 Constraints: culture shock
+Cultural constraints are another challenge that may add to the frustrations of medical work in a combat zone. In some societies, amputations and laparotomies can only be performed with the consent of the family of the patient. After a discussion in which the clear advantages are explained, the final decision must be left to the family. This procedure, which respects local cultural and social behaviour and norms, has to be followed and accepted even though it may ...
+
+=== Chunk 209 ===
+Source: 0973_002-ebook.pdf
+Length: 3847 chars
+
+1.4.8 Constraints: the human factor
+“War surgery is a surgery of complications, performed by doctors who are often ill-trained or without surgical training. It is surgery replete with adaptations and improvisations to replace that which is missing, a surgery of surprises that new means and methods of combat reveal.” 7
+This classic quotation from the Swiss army’s war surgery manual describes the situation for the new military surgeon and, as is more and more often the case in contemporary conflic...
+
+=== Chunk 210 ===
+Source: 0973_002-ebook.pdf
+Length: 184 chars
+
+1. Needs assessment
+What is the added value of this new technology? Are requested materials and articles “essential”, “important” or “nice to have”, or even “superfluous” and a luxury?...
+
+=== Chunk 211 ===
+Source: 0973_002-ebook.pdf
+Length: 99 chars
+
+2. Maintenance requirements
+What are the extra burdens for the daily maintenance of such equipment?...
+
+=== Chunk 212 ===
+Source: 0973_002-ebook.pdf
+Length: 71 chars
+
+3. Ease of repair
+Are specialized technicians necessary, and available?...
+
+=== Chunk 213 ===
+Source: 0973_002-ebook.pdf
+Length: 66 chars
+
+4. Availability of spare parts
+Is there a reliable local supplier?...
+
+=== Chunk 214 ===
+Source: 0973_002-ebook.pdf
+Length: 168 chars
+
+5. Cost
+Expense alone is not a criterion if the equipment is necessary. However, it is taken into account along with the other factors in a total cost/benefit analysis....
+
+=== Chunk 215 ===
+Source: 0973_002-ebook.pdf
+Length: 186 chars
+
+6. Competency required to use the technology in question
+Is the expertise widely mastered and available or does it correspond to the particular practice of an individual doctor or nurse?...
+
+=== Chunk 216 ===
+Source: 0973_002-ebook.pdf
+Length: 154 chars
+
+7. Continuity of the competency required
+Can successive surgical teams use the equipment or does it depend on the expertise of a limited number of people?...
+
+=== Chunk 217 ===
+Source: 0973_002-ebook.pdf
+Length: 203 chars
+
+8. Presence of the technology in the country
+To all intents and purposes, the ICRC shall not be the first to introduce a new technology to a country; some local practice or competency must already exist....
+
+=== Chunk 218 ===
+Source: 0973_002-ebook.pdf
+Length: 698 chars
+
+9. Professionalism and ethical concerns
+The supply of equipment and instruments must at all times meet demanding standards of professionalism in surgical care and address possible ethical concerns. (e.g. in Europe, following the outbreak of bovine spongio-encephalopathy – so-called “mad-cow disease” – catgut suture material has been banned by the European Union and Switzerland. It would not be ethical for the ICRC to continue to provide such sutures in its assistance programmes in other parts of...
+
+=== Chunk 219 ===
+Source: 0973_002-ebook.pdf
+Length: 130 chars
+
+10. Sustainability
+Only if the technologies can be sustained after ICRC withdrawal is it worth considering their utilization.
+33
+1...
+
+=== Chunk 220 ===
+Source: 0973_002-ebook.pdf
+Length: 919 chars
+
+Chapter 2 APPLICABLE INTERNATIONAL HUMANITARIAN LAW
+2
+WAR SURGERY
+36
+2 2.1 2.2 2.2.1 2.2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.9.1 ANNEX 2. A ANNEX 2. B APPLICABLE INTERNATIONAL HUMANITARIAN LAW Historical introduction International humanitarian law: basic principles Principles underlying IHL: the ‘‘law of war’’ IHL and human rights law The distinctive emblems The International Red Cross and Red Crescent Movement and its Fundamental Principles 41 Rights and duties of medical personnel according to IHL...
+
+=== Chunk 221 ===
+Source: 0973_002-ebook.pdf
+Length: 4011 chars
+
+2.1 Historical introduction
+“You may not be interested in war. War is interested in you.”   Leon Trotsky
+One of the specificities of the war-wounded and those who care for them is their relationship to international humanitarian law, mainly the Geneva Conventions and their Additional Protocols.
+In 19th century Europe, large-scale battles caused real carnage on the battlefields. Soldiers were regarded as cannon fodder and almost no medical services were available. Solferino, a town in northern It...
+
+=== Chunk 222 ===
+Source: 0973_002-ebook.pdf
+Length: 110 chars
+
+Figure 2.2
+I. Amelioration of the condition of the wounded and sick in armed forces in the field.
+C
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+R
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+I...
+
+=== Chunk 223 ===
+Source: 0973_002-ebook.pdf
+Length: 248 chars
+
+Figure 2.3
+II. Amelioration of the condition of wounded, sick and shipwrecked members of armed forces at sea.
+C
+R
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+Figure 2.4 III. Treatment of prisoners of war.
+C
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+Figure 2.5
+Figure 2.5 IV. Protection of civilian persons in time of war.
+38...
+
+=== Chunk 224 ===
+Source: 0973_002-ebook.pdf
+Length: 4393 chars
+
+International humanitarian law: basic principles
+Throughout history, humanity has known war. All human societies have developed customary rules that regulate how wars are fought. Over 500 cartels, codes of conduct, covenants and other texts designed to regulate hostilities had been recorded before the advent of contemporary humanitarian law. The first laws of war were proclaimed by major civilizations several millennia before our era: “I establish these laws to prevent the strong from oppressing...
+
+=== Chunk 225 ===
+Source: 0973_002-ebook.pdf
+Length: 1588 chars
+
+2.2.1 Principles underlying IHL: the ‘‘law of war’’
+• The human dignity of all individuals must be respected at all times.
+• Persons no longer involved in the fighting (sick, wounded and shipwrecked combatants, and prisoners of war) and those who do not take a direct part in hostilities (civilians) are entitled to respect for their lives and physical and moral integrity. They shall in all circumstances be protected and treated humanely without any adverse distinction.
+• The wounded and sick shal...
+
+=== Chunk 226 ===
+Source: 0973_002-ebook.pdf
+Length: 247 chars
+
+Figure 2.6
+Soldiers blinded by chemical weapons during World War I: an example of means of warfare that cause superfluous injury and unnecessary suffering.
+39
+WAR SURGERY
+C
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+Figure 2.7 Armed forces’ medical services.
+40...
+
+=== Chunk 227 ===
+Source: 0973_002-ebook.pdf
+Length: 1198 chars
+
+2.2.2 IHL and human rights law
+IHL applies in situations of armed conflict, whereas human rights, or at least some of them, protect the individual at all times, in war and peace alike. Some human rights treaties permit governments to derogate from certain rights in situations of public emergency and if strict conditions are fulfilled. However, certain fundamental human rights must be respected in all circumstances and may never be waived, regardless of the emergency: in particular the right to l...
+
+=== Chunk 228 ===
+Source: 0973_002-ebook.pdf
+Length: 1366 chars
+
+2.3 The distinctive emblems
+The distinctive emblems of the red cross, red crescent, and red crystal are meant to mark certain medical and religious personnel and equipment which must be respected and protected during armed conflict (protective use). They also serve to show that persons or objects are linked to the International Red Cross and Red Crescent Movement including in situations other than armed conflict (indicative use). Their use is strictly defined (see Annex 2. A: The distinctive emb...
+
+=== Chunk 229 ===
+Source: 0973_002-ebook.pdf
+Length: 1103 chars
+
+2.4 The International Red Cross and Red Crescent Movement and its Fundamental Principles
+The International Committee of the Red Cross and the International Federation of Red Cross and Red Crescent Societies, together with the National Red Cross and Red Crescent Societies, form the International Red Cross and Red Crescent Movement.
+Fundamental Principles of the Red Cross and Red Crescent Movement1  Humanity  Impartiality  Neutrality  Independence  Voluntary service  Unity  Universality
+In peaceti...
+
+=== Chunk 230 ===
+Source: 0973_002-ebook.pdf
+Length: 4842 chars
+
+2.5 Rights and duties of medical personnel according to IHL
+IHL provides medical personnel with rights in times of armed conflict, but also assigns duties to them. The duties incumbent on them are directly linked to the rights of the protected persons placed in their care. These provisions are a case-specific refinement of the basic rights and duties defined by medical ethics and the Hippocratic oath. Medical personnel are bound by medical ethics and IHL to treat patients solely on the basis of ...
+
+=== Chunk 231 ===
+Source: 0973_002-ebook.pdf
+Length: 2480 chars
+
+2.6 Responsibility of States
+As with any international agreement, the governments of States have a distinct responsibility whenever they become party to a treaty.
+• The Geneva Conventions and their Additional Protocols are both contracts with other States and commitments towards humankind by which governments have agreed to certain rules that regulate the conduct of armed hostilities and the protection of persons who are not (or are no longer) taking part in hostilities, what is known as “law in...
+
+=== Chunk 232 ===
+Source: 0973_002-ebook.pdf
+Length: 3108 chars
+
+Figure 2.10
+All too often the red cross emblem is used to indicate any health service without regard to its privileged legal status, which confers protection.
+43
+WAR SURGERY
+44
+that it requires States to seek out and punish any person who has committed a grave breach, irrespective of his nationality or the place where the offence was committed. This principle of universal jurisdiction is essential to guarantee that grave breaches are effectively repressed. Such prosecutions may be brought either...
+
+=== Chunk 233 ===
+Source: 0973_002-ebook.pdf
+Length: 1253 chars
+
+2.7 Reality check: some people do not follow the rules
+Given what the law dictates, what is the reality on the battlefield? Whether in conflict situations or in peacetime, and whether national or international law is applicable, laws are violated and crimes committed. There are many examples of violations of IHL: surrounding a military objective with medical units so that it will not be targeted; hiding weapons in a hospital; transporting able-bodied combatants in an ambulance; using an aircraft...
+
+=== Chunk 234 ===
+Source: 0973_002-ebook.pdf
+Length: 3174 chars
+
+Figure 2.12
+Unfortunately, hospitals are not immune to attack: this photo shows a blatant contravention of IHL.
+Red Cross and Red Crescent personnel are not immune to this lack of respect for IHL. Mussolini’s air force bombed a Swedish Red Cross field hospital during the invasion of Abyssinia on 30 December 1935, and 28 people were killed and 50 wounded. More recently, masked gunmen entered the residence of the ICRC hospital in the village of Novye Atagi, Chechnya (southern Russia), in December ...
+
+=== Chunk 235 ===
+Source: 0973_002-ebook.pdf
+Length: 2932 chars
+
+2.8 The neutrality of a National Red Cross/ Red Crescent Society
+Another major problem faced during armed conflicts of a non-international character, that is to say internal conflicts, is the question of neutrality, especially of a National Red Cross or Red Crescent Society. The requirement of non-discrimination is of particular concern to Red Cross/Red Crescent Societies, it is in fact a condition for their recognition. They must be open to all those who wish to become members and must permit a...
+
+=== Chunk 236 ===
+Source: 0973_002-ebook.pdf
+Length: 3172 chars
+
+2.9 The role and mandate of the ICRC in situations of armed conflict
+Established in 1863, the International Committee of the Red Cross (ICRC) is an impartial, neutral, and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of the victims of war and internal violence and to provide them with assistance. The ICRC endeavours to prevent suffering by promoting and strengthening international humanitarian law and universal humanitarian principles.
+The I...
+
+=== Chunk 237 ===
+Source: 0973_002-ebook.pdf
+Length: 82 chars
+
+Figure 2.13
+The assistance pyramid: public health analysis of population needs.
+48...
+
+=== Chunk 238 ===
+Source: 0973_002-ebook.pdf
+Length: 2445 chars
+
+ICRC activities
+1. Protection during armed conflict:
+• protection of civilians confronted with the violence of armed conflict;
+• protection and care of the wounded, sick, and shipwrecked;
+• protection of prisoners of war and other detainees (registration and visits);
+• as a neutral intermediary, facilitation and accompaniment of the release of prisoners of war;
+• re-establishment of family links through Red Cross messages;
+• re-establishment of family links through the tracing agency for the mis...
+
+=== Chunk 239 ===
+Source: 0973_002-ebook.pdf
+Length: 2420 chars
+
+Health services: assistance to the war-wounded and sick
+Although proper medical care of sick and wounded soldiers and civilians in times of armed conflict is taken for granted by many governments today, poverty may compromise a government’s efforts to provide such care. The ICRC maintains a capacity to aid States whose authorities show a willingness to assume their responsibilities towards their own soldiers and the civilian population.
+The ICRC has deployed many assistance and training programm...
+
+=== Chunk 240 ===
+Source: 0973_002-ebook.pdf
+Length: 22155 chars
+
+ICRC EXPERIENCE
+“We want to thank the doctors and nurses of the ICRC. Thank you for coming. And, thank you for leaving.”
+Rui Paolo 3
+3 Rui Paolo, Director of Hospital Services, Ministry of Public Health, Dili, Timor Leste, June 2001, on the occasion of the handover of the administration of the Dili General Hospital from the ICRC to the Ministry of Public Health.
+49
+WAR SURGERY
+50
+An ICRC admission sheet with Wound Score recorded.
+name A. Vier wm numecr: /69 32 a se a COMING FROM: Ti¢¢ bene AGE h...
+
+=== Chunk 241 ===
+Source: 0973_002-ebook.pdf
+Length: 3419 chars
+
+ANNEX 2. A The distinctive emblems
+The distinctive emblems of the red cross, red crescent and red crystal on a white ground are the symbols of impartial humanitarian work and do not represent any particular religious belief. They provide protection for military medical services and relief workers in armed conflicts. Moreover, they are also used for identification purposes by National Societies of the Red Cross and Red Crescent Movement in each country.
+In the event of armed conflict, the distinc...
+
+=== Chunk 242 ===
+Source: 0973_002-ebook.pdf
+Length: 15374 chars
+
+Please note:
+On 8 December 2005, a Diplomatic Conference adopted Protocol III additional to the Geneva Conventions, which recognizes an additional distinctive emblem. The “Third Protocol emblem”, also known as the red crystal, is composed of a red frame in the shape of a square on edge on a white background. According to Protocol III, all distinctive emblems enjoy equal status.4 The conditions for use of and respect for the Third Protocol emblem are identical to those for the distinctive emblems...
+
+=== Chunk 243 ===
+Source: 0973_002-ebook.pdf
+Length: 1445 chars
+
+ANNEX 2. B The International Red Cross and Red Crescent Movement
+The International Committee of the Red Cross and the International Federation of Red Cross and Red Crescent Societies, together with the National Red Cross and Red Crescent Societies, form the International Red Cross and Red Crescent Movement.
+Born of the compassion felt by a Swiss citizen, Henry Dunant, at the sight of the dead and wounded abandoned on the battlefield of Solferino, the International Red Cross and Red Crescent Move...
+
+=== Chunk 244 ===
+Source: 0973_002-ebook.pdf
+Length: 979 chars
+
+The International Committee of the Red Cross (ICRC)
+The International Committee of the Red Cross, created in Geneva, Switzerland in 1863, is the founding body of the Red Cross/Red Crescent Movement. It is an independent humanitarian organization. As a neutral intermediary and on the basis of the Geneva Conventions or the customary law of nations, which grant it the right of initiative, it endeavours to protect and assist the military and civilian victims of international and non-international ar...
+
+=== Chunk 245 ===
+Source: 0973_002-ebook.pdf
+Length: 742 chars
+
+The International Federation of Red Cross and Red Crescent Societies
+The International Federation is the permanent liaison body between National Red Cross and Red Crescent Societies. It attempts to prevent and alleviate human suffering through the promotion of activities by National Societies and so contribute to peace. The International Federation encourages the creation and assists the development of National Societies in providing services to the community.
+The International Federation organi...
+
+=== Chunk 246 ===
+Source: 0973_002-ebook.pdf
+Length: 1883 chars
+
+The National Red Cross/Red Crescent Society
+There are 186 National Red Cross/Red Crescent Societies around the world, with more currently being created. From the outset, the goal of the Red Cross/Red Crescent Movement has been to create relief societies which, in their capacity of auxiliaries to their countries’ armed forces’ medical services, would be called upon to tend wounded or sick soldiers. The establishment of such Societies was consistent with the aims of the original Geneva Convention ...
+
+=== Chunk 247 ===
+Source: 0973_002-ebook.pdf
+Length: 465 chars
+
+Humanity
+The International Red Cross and Red Crescent Movement, born of a desire to bring assistance without discrimination to the wounded on the battlefield, endeavours – in its international and national capacity – to prevent and alleviate human suffering wherever it may be found. Its purpose is to protect life and health and to ensure respect for the human being. It promotes mutual understanding, friendship, cooperation and lasting peace amongst all peoples....
+
+=== Chunk 248 ===
+Source: 0973_002-ebook.pdf
+Length: 262 chars
+
+Impartiality
+It makes no discrimination as to nationality, race, religious beliefs, class or political opinions. It endeavours to relieve the suffering of individuals, being guided solely by their needs, and to give priority to the most urgent cases of distress....
+
+=== Chunk 249 ===
+Source: 0973_002-ebook.pdf
+Length: 206 chars
+
+Neutrality
+In order to continue to enjoy the confidence of all, the Movement may not take sides in hostilities or engage at any time in controversies of a political, racial, religious or ideological nature....
+
+=== Chunk 250 ===
+Source: 0973_002-ebook.pdf
+Length: 320 chars
+
+Independence
+The Movement is independent. The National Societies, while auxiliaries in the humanitarian services of their governments and subject to the laws of their respective countries, must always maintain their autonomy so that they may be able at all times to act in accordance with the principles of the Movement....
+
+=== Chunk 251 ===
+Source: 0973_002-ebook.pdf
+Length: 103 chars
+
+Voluntary service
+It is a voluntary relief movement, not prompted in any manner by the desire for gain....
+
+=== Chunk 252 ===
+Source: 0973_002-ebook.pdf
+Length: 175 chars
+
+Unity
+There can be only one Red Cross or one Red Crescent Society in any one country. It must be open to all. It must carry out its humanitarian work throughout its territory....
+
+=== Chunk 253 ===
+Source: 0973_002-ebook.pdf
+Length: 471 chars
+
+Universality
+The International Red Cross and Red Crescent Movement, in which all Societies have equal status and share equal responsibilities and duties in helping each other, is worldwide.
+Humanity and Impartiality express the objectives of the Movement.
+Neutrality and Independence ensure access to those in need of help.
+Voluntary service, Unity and Universality enable the International Red Cross and Red Crescent Movement to work effectively all over the world.
+53
+2...
+
+=== Chunk 254 ===
+Source: 0973_002-ebook.pdf
+Length: 1827 chars
+
+Chapter 3 MECHANISMS OF INJURY DURING ARMED CONFLICT 1
+1 Acknowledgement: the ballistics portion of this chapter is largely based on the work of Doctor of Forensic Science Beat Kneubuehl, Institute of Forensic Medicine, University of Bern, in collaboration with Armasuisse, Centre for Military and Civilian Systems, Science and Technology, Ballistics Laboratory, Thun, Switzerland. His cooperation and collaboration with ICRC surgeons over the years have permitted a whole generation of war surgeons ...
+
+=== Chunk 255 ===
+Source: 0973_002-ebook.pdf
+Length: 571 chars
+
+The various mechanisms of injury
+The surgeon caring for the war-wounded will face a wide variety of injuries. During armed conflict, all the usual trauma of peacetime continues unabated and natural catastrophes occur as well. Armed conflict itself provokes blunt injuries and burns, and trauma that are specific to weapons and the circumstances of warfare. More specifically, combat involves penetrating and blast injuries; these will be the major focus of this book.
+Modern armed conflict causes spe...
+
+=== Chunk 256 ===
+Source: 0973_002-ebook.pdf
+Length: 263 chars
+
+3.1.1 Blunt injury in war
+Blunt trauma is common in war. Severe injury due to blunt trauma may be more difficult to detect than in cases of penetrating trauma, and X-ray diagnosis and other more sophisticated technologies are more valuable for patient assessment....
+
+=== Chunk 257 ===
+Source: 0973_002-ebook.pdf
+Length: 221 chars
+
+Vehicle accidents
+Military vehicles often drive at high speed over difficult terrain where safe roads do not exist. In addition, the environment of any accident may be hostile (presence of enemy forces, minefields, etc.)....
+
+=== Chunk 258 ===
+Source: 0973_002-ebook.pdf
+Length: 171 chars
+
+Collapsed buildings and falls
+The collapse of bombed buildings will cause blunt and crush injuries to anyone inside. People may fall from destroyed buildings or a balcony....
+
+=== Chunk 259 ===
+Source: 0973_002-ebook.pdf
+Length: 302 chars
+
+Explosions and anti-tank mines
+A bomb or shell explosion can throw people against objects. A car, bus or lorry carrying passengers may drive over an anti-tank mine. The explosion of the mine overturns or destroys the vehicle and people are thrown out and onto the ground, thus suffering blunt injuries....
+
+=== Chunk 260 ===
+Source: 0973_002-ebook.pdf
+Length: 116 chars
+
+Beatings
+Mistreatment of prisoners, officials, “suspected sympathizers” or other civilians is, alas, all too common....
+
+=== Chunk 261 ===
+Source: 0973_002-ebook.pdf
+Length: 299 chars
+
+3.1.2 Penetrating wounds caused by weapons of war
+A moving projectile has kinetic energy. When the projectile enters the human body, it releases energy to the tissues, thus causing a wound. There are two types of wounding projectile: bullets and metallic fragments (splinters, shards and shrapnel).2...
+
+=== Chunk 262 ===
+Source: 0973_002-ebook.pdf
+Length: 2048 chars
+
+Fragment wounds
+Exploding bombs, shells, rockets and grenades, submunitions (cluster bomblets) and some landmines produce metal fragments from the weapon casing (primary projectiles). In the past these fragments were usually irregular in size and shape. In many modern weapons, however, the inner lining of the casing is scored, creating weak points that break off easily on explosion. This generates a controlled fragmentation of large numbers of pre-formed fragments that are regular in size and sh...
+
+=== Chunk 263 ===
+Source: 0973_002-ebook.pdf
+Length: 1117 chars
+
+Bullet wounds
+Handguns and military assault rifles shoot bullets at high speed. Bullet wounds seen in the injured are usually single with a small entry; multiple bullet injuries are more likely to kill. There may be no exit wound but, if there is, the size is variable. The amount of tissue damage depends on a number of factors.
+Under international humanitarian law – both customary and treaty-based – the use of bullets that expand or flatten easily in the human body is prohibited during armed con...
+
+=== Chunk 264 ===
+Source: 0973_002-ebook.pdf
+Length: 610 chars
+
+Figure 3.2.2
+Examples of pistol ammunition:
+a. 5.45 x 19 mm
+b. 6.35 mm Browning
+c. 7.63 mm Mauser
+Examples of military rifle ammunition: a. 5.45 x 39 mm Kalashnikov b. 7.62 x 39 mm Kalashnikov c. 7.62 x 54R Dragunov
+d. 9 mm Luger
+e. 45 calibre automatic
+f. 50 calibre AE (Action Express) semi-jacketed bullet
+Figure 3.2.3
+Figure 3.2.4
+9mm Luger semi-automatic pistol (SIG-Sauer P 228).
+7.62 x 39 mm AK-47 Kalashnikov military
+assault rifle.
+3
+Paragraphs from the preamble to the St Petersburg Declara...
+
+=== Chunk 265 ===
+Source: 0973_002-ebook.pdf
+Length: 207 chars
+
+Cut wounds, “arme blanche”
+Apart from the modern soldier’s bayonet, knives, machetes or pangas4 may be used by combatants in “traditional” warfare in some societies. These produce incised or puncture wounds....
+
+=== Chunk 266 ===
+Source: 0973_002-ebook.pdf
+Length: 714 chars
+
+3.1.3 Anti-personnel landmine wounds
+Anti-personnel landmines (APM) come in two basic types: blast mines with a pressure plate, which explode when someone steps on them, and fragmentation mines, which explode when a tripwire is touched. Unexploded ordnance (the lethal remnants of war, consisting of cluster bomblets, bombs and shells that did not explode when fired) is often left on the battlefield and has injuring effects similar to those of fragmentation mines. These weapons continue to kill an...
+
+=== Chunk 267 ===
+Source: 0973_002-ebook.pdf
+Length: 141 chars
+
+Patterns of injury
+Anti-personnel mines cause three distinct patterns of injury according to the blast effect or the production of fragments....
+
+=== Chunk 268 ===
+Source: 0973_002-ebook.pdf
+Length: 390 chars
+
+Pattern 1
+A person steps on the pressure plate of a blast mine. The explosion and local primary blast effect cause a traumatic amputation or severe injury of the contact foot and leg. There may be wounds to the other leg, genitals, abdomen or pelvis, and the contralateral arm. The severity of the wound depends on the amount of explosive in the mine compared to the body mass (Figure 3.4)....
+
+=== Chunk 269 ===
+Source: 0973_002-ebook.pdf
+Length: 296 chars
+
+Pattern 2
+A person touches the tripwire attached to a fragmentation mine, which provokes its detonation. Fragmentation mines cause the same injuries as other fragmentation devices, such as bombs or grenades, and the severity of the injury depends on the distance of the victim from the explosion....
+
+=== Chunk 270 ===
+Source: 0973_002-ebook.pdf
+Length: 572 chars
+
+Pattern 3
+A person handles a mine: setting a mine; trying to clear a mine; a child playing with a mine. The explosion causes severe injury to the hand and arm, and frequent injuries to the face and eyes or chest.
+For further information on anti-personnel landmine injuries, see Chapter 21 in Volume 2.
+4 In some countries where a “traditional” form of warfare is still practised, a large, heavy knife – the machete or panga – is often used as a weapon. The overhead motion strikes the victim on the h...
+
+=== Chunk 271 ===
+Source: 0973_002-ebook.pdf
+Length: 318 chars
+
+Figure 3.4
+The “umbrella” effect of a blast mine: superficial tissues suffer less damage than deep-tissue planes. The wounds are all severely contaminated by mud, grass and pieces of the shoe driven deep into the tissues at the moment of explosion.
+59
+C
+Coupland /ICRC
+C
+.
+R
+WAR SURGERY
+e  r  u  s  s  e  r  P  0  Time...
+
+=== Chunk 272 ===
+Source: 0973_002-ebook.pdf
+Length: 75 chars
+
+Figure 3.5
+Blast wave overpressure followed by negative pressure trough.
+60...
+
+=== Chunk 273 ===
+Source: 0973_002-ebook.pdf
+Length: 746 chars
+
+3.1.4 Explosive blast injuries
+The detonation of high-energy explosives creates a travelling pressure blast wave in the air (or in water for underwater explosions). The wave causes rapid and large changes in the outside atmospheric pressure: the positive pressure shock wave is followed by a negative pressure phase (Figure 3.5). Immediately behind the pressure wave is a mass movement of air: the blast wind.
+As the blast wave passes any unprotected person it affects all parts of the body, especial...
+
+=== Chunk 274 ===
+Source: 0973_002-ebook.pdf
+Length: 89 chars
+
+Categorization of blast injuries
+Blast injuries are commonly categorized into four types....
+
+=== Chunk 275 ===
+Source: 0973_002-ebook.pdf
+Length: 212 chars
+
+Primary
+These are direct pressure effects. Rupture of the tympanic membrane is the most common injury. Rupture of the lung alveoli and their capillaries (“blast lung”) is the most lethal injury amongst survivors....
+
+=== Chunk 276 ===
+Source: 0973_002-ebook.pdf
+Length: 355 chars
+
+Secondary
+These injuries include missile wounds. Fragments may arise from the bomb casing or contents (primary missiles). Home-made bombs (improvised explosive devices, known as IEDs) may be packed with nuts, bolts, screws and ball bearings. In addition, the blast wind may mobilize various objects (secondary missiles) that then cause penetrating wounds....
+
+=== Chunk 277 ===
+Source: 0973_002-ebook.pdf
+Length: 309 chars
+
+Tertiary
+These effects are directly due to the blast wind. It can cause total body disintegration in the immediate vicinity of the explosion or traumatic amputations and evisceration further away. The wind can make buildings collapse or throw people against objects. Trauma may be blunt, crush or penetrating....
+
+=== Chunk 278 ===
+Source: 0973_002-ebook.pdf
+Length: 348 chars
+
+Quaternary
+Miscellaneous types of harm due to burns, asphyxia from carbon monoxide or toxic gases, or the inhalation of dust, smoke or contaminants.
+The various injuries caused by major blasts cover a whole spectrum of trauma and many patients suffer several injuries from a variety of effects: i.e. multiple injuries from one single weapon system....
+
+=== Chunk 279 ===
+Source: 0973_002-ebook.pdf
+Length: 1183 chars
+
+Other situations of blast injuries
+The blast wave travels more rapidly and much further in water than in air. Blast injuries in water occur at greater distances and can be more severe. Moreover, underwater explosions tend to cause pure primary blast injury. A “fuel air explosive” – the liquid explosive material is dispersed in the air like an aerosol and then ignited – also tends to bring about pure primary blast injury and quaternary effects due to the consumption of all oxygen in the nearby ai...
+
+=== Chunk 280 ===
+Source: 0973_002-ebook.pdf
+Length: 470 chars
+
+3.1.5 Burns
+A large explosion may cause flash burns or the carbonization of tissues. Bombing may start secondary fires in buildings and an anti-tank mine may ignite the fuel tank of a vehicle. Burns are common amongst the crews of tanks, ships and aircraft hit by missiles. Some types of anti-personnel blast mine provoke burning as well as traumatic amputation of the limb.
+Certain weapons cause specific burns: napalm and phosphorus bombs, magnesium flares and decoys....
+
+=== Chunk 281 ===
+Source: 0973_002-ebook.pdf
+Length: 974 chars
+
+3.1.6 Non-conventional weapons
+International humanitarian law prohibits the use of chemical and biological weapons. Despite this absolute prohibition, one cannot entirely exclude the possibility of a State or non-State armed group using them.
+A bomb surrounded by radioactive material – a “dirty bomb” – is not a nuclear bomb. The explosion is caused by conventional means but radioactive material may be spread over a wide area, depending on the force of the explosion. The bombing of nuclear medici...
+
+=== Chunk 282 ===
+Source: 0973_002-ebook.pdf
+Length: 1791 chars
+
+3.2.1 Introduction
+Blast and penetrating missile wounds occur in times of armed conflict and whenever the weapons of war are used in peacetime. Weapons cause specific but variable patterns of injury. While standard surgical techniques will suffice to treat simple wounds, the management of war wounds produced by high-energy weapons is based on an understanding of the mechanisms by which projectiles cause injury: wound ballistics. Only by understanding certain physical phenomena can the surgeon ap...
+
+=== Chunk 283 ===
+Source: 0973_002-ebook.pdf
+Length: 151 chars
+
+Basic definitions
+Ballistics is the part of the science of mechanics that studies the motion and behaviour of a projectile and its effects on a target....
+
+=== Chunk 284 ===
+Source: 0973_002-ebook.pdf
+Length: 278 chars
+
+Internal ballistics
+Internal ballistics deals with the processes that occur inside a gun barrel when a shot is fired: gas pressures on combustion of the propellant powder, the energy and heat released and the course of the projectile in the barrel are just some of its concerns....
+
+=== Chunk 285 ===
+Source: 0973_002-ebook.pdf
+Length: 339 chars
+
+External ballistics
+External ballistics describes the trajectory of the projectile once it has left the barrel. The influences affecting the flight include gravity, air resistance and crosswind deflection, stability of the projectile (spin and yaw), together with any contact prior to the projectile reaching the target, known as ricochet....
+
+=== Chunk 286 ===
+Source: 0973_002-ebook.pdf
+Length: 298 chars
+
+Terminal ballistics
+Terminal ballistics describes what happens when the projectile hits the target, as well as any counter-effects produced by the target on the projectile. If the target is biological tissues, terminal ballistics is called wound ballistics and describes the effects on the tissues....
+
+=== Chunk 287 ===
+Source: 0973_002-ebook.pdf
+Length: 450 chars
+
+Bullets: fundamental concepts
+Figure 3.6 shows the main components of a bullet cartridge. The primer is struck by a mechanism in the gun to produce a small detonation and flame that sets off the propellant in the case. This causes a very rapid burn with the production of a large volume of rapidly expanding gas, which pushes the bullet out of the barrel of the gun. The velocity with which the bullet leaves the barrel is called the muzzle velocity....
+
+=== Chunk 288 ===
+Source: 0973_002-ebook.pdf
+Length: 327 chars
+
+Bullet construction
+Bullets are classified according to a number of parameters; one is their manufacture: internal structure and composition (Figure 3.7). They vary in calibre and mass.
+l
+Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+K
+Millitary bullets   Hunting bullets  a    b    c    d    e    f
+Millitary bullets
+Hunting bullets
+a
+b
+c
+d
+e
+f
+.
+B...
+
+=== Chunk 289 ===
+Source: 0973_002-ebook.pdf
+Length: 1787 chars
+
+Figure 3.7
+Bullets according to construction.
+a. .303 British Mark II bullet produced in Dum Dum, India, 1896 (see footnote number 8).
+b. Full metal jacket (FMJ) bullet: military-issue bullets have a soft core (lead) with a full metal jacket of copper.
+d. Tracer bullet: contains a pyrotechnical substance at the tail end that burns up in flight and shows the trajectory. Used to identify and pinpoint the target.
+e. Semi-jacketed bullet (SJ): part of the point is not jacketed, thus exposing the lea...
+
+=== Chunk 290 ===
+Source: 0973_002-ebook.pdf
+Length: 704 chars
+
+Muzzle velocities
+Firearms are classically divided into two categories: high-velocity (rifles and machine guns) and low-velocity (handguns and sub-machine guns).The latter fire relatively heavy bullets at low muzzle velocities of 150 – 200 m/s. A typical military assault rifle fires a smaller bullet at 700 – 950 m/s. This, however, says nothing about the actual velocity when the bullet reaches the target.
+9 mm Luger pistol 350 m/s .38 Special handgun 260 m/s .44 Magnum handgun 440 m/s 5.56 x 45 ...
+
+=== Chunk 291 ===
+Source: 0973_002-ebook.pdf
+Length: 477 chars
+
+The gun barrel
+A bullet is a long cylindrical projectile that only flies with stability if a high spin around its longitudinal axis is attained, thus giving it a gyroscopic effect. To achieve this spin, gun barrels are constructed with interior spiral grooves (twists). This is a rifled barrel, used in all handguns and high-velocity rifles (Figure 3.9).
+The barrels of shotguns are smooth on the inside; they are not rifled. This limits their accuracy and range (Figure 3.10)....
+
+=== Chunk 292 ===
+Source: 0973_002-ebook.pdf
+Length: 1220 chars
+
+Design of firing
+Another classification of firearms is according to their design of firing. A weapon operated with a single hand is a “handgun”. If the barrel and cartridge chamber are in one piece, this is a “pistol”. If several chambers rotate behind the barrel, it is called a “revolver”. If both hands are required to operate the weapon, it is referred to as a “long weapon” (generally a rifle, shotgun or machine gun).
+Firing capacity refers to how individual shots are fired. In a single-shot w...
+
+=== Chunk 293 ===
+Source: 0973_002-ebook.pdf
+Length: 387 chars
+
+Figure 3.9
+Cross section of a rifled gun barrel: 5.56 x 45 mm M-16 A4 military assault rifle. The grooves and lands (the elevated sections between the grooves) are shown.
+on -
+Figure 3.10 Typical hunting shotgun with smooth barrel.
+63
+l
+Kneubuehl
+h
+e
+u
+b
+u
+e
+n
+K
+.
+B
+l
+Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+K
+.
+B
+l
+Kneubuehl
+h
+e
+u
+b
+u
+e
+n
+K
+.
+B
+WAR SURGERY
+b  a  Ψ  δ
+l
+B.Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+K
+.
+B...
+
+=== Chunk 294 ===
+Source: 0973_002-ebook.pdf
+Length: 250 chars
+
+Figure 3.11
+Angle of incidence and angle of impact:
+a. Longitudinal axis of bullet b. Direction of flight Ψ. Angle of incidence δ. Angle of impact
+l  h  e  u  b  u  e  n  K     .  B  c  a  b  Nutation  Precession  After contact  a~b~c  Before contact...
+
+=== Chunk 295 ===
+Source: 0973_002-ebook.pdf
+Length: 75 chars
+
+Figure 3.12
+Ricochet: effect on a bullet after contact with an obstacle.
+64...
+
+=== Chunk 296 ===
+Source: 0973_002-ebook.pdf
+Length: 805 chars
+
+Flight in air
+Once discharged, several variables affecting the projectile in flight tend to influence its stability, accuracy of targeting, or velocity. The most important variables include the following:
+• Spin about its own longitudinal axis, giving it gyroscopic stability.
+• Distance travelled and the effect of gravity, including the shooting angle – is the bullet fired upwards or is the trajectory flat?
+• Air drag: friction is responsible for 10 % of total area drag, while 90 % is due to pre...
+
+=== Chunk 297 ===
+Source: 0973_002-ebook.pdf
+Length: 521 chars
+
+Yaw
+A rifle bullet in flight does not travel in a simple straightforward motion. Because it is a spinning gyroscope, the bullet “wobbles” and undergoes some very complicated movements (nutation, precession), the most important being yaw: the nose of the bullet moves up and down, away from the line of flight, and describes an angle with the target surface at impact (Figure 3.11). This influences the wounding potential of the bullet, as a large degree of yaw will destabilize the motion of the bull...
+
+=== Chunk 298 ===
+Source: 0973_002-ebook.pdf
+Length: 1017 chars
+
+Ricochet
+A bullet may hit an obstacle during its flight. This may be a branch of a tree, a belt buckle, a concrete wall, the ground or a soldier’s helmet or body armour. This causes a ricochet; the bullet is given a small “push” that destabilizes it (Figure 3.12). There is an increase in the deviation of the nose of the bullet (yaw); the bullet may even tumble, rotating about its transverse axis. Such a large yaw angle at point of impact will have important consequences for the wounding potentia...
+
+=== Chunk 299 ===
+Source: 0973_002-ebook.pdf
+Length: 531 chars
+
+3.2.4 Summary
+There are, therefore, quite a number of variables involved in determining the characteristics of a projectile before it hits the target and these will influence its behaviour in the target and its efficiency in creating wounds. They include:
+• velocity at moment of impact and any residual velocity if there is an exit;
+• mass, shape, internal structure and composition of the projectile;
+• type of weapon, handgun or rifle;
+• stability of the projectile in flight;
+• any yaw at moment ...
+
+=== Chunk 300 ===
+Source: 0973_002-ebook.pdf
+Length: 1021 chars
+
+3.3.1 Role of kinetic energy
+Any moving object has kinetic energy, whether it is a hand-wielded knife or club, a bullet fired from a gun or a fragment given off by the explosion of a shell. This energy is described by the well-known formula:
+EK = ½ m v2
+This defines the total kinetic energy that the object possesses, but does not define the kinetic energy expended when the projectile passes into and through a target. For a bullet or fragment that does not change its mass, this is calculated from...
+
+=== Chunk 301 ===
+Source: 0973_002-ebook.pdf
+Length: 538 chars
+
+Weapons according to EK
+Yet another classification of weapons is based on the amount of kinetic energy available for transfer.
+• Low energy: knife or hand-energized missiles.
+• Medium energy: handguns.
+• High energy: military or hunting rifles, with a muzzle velocity above 600 m/s or a large mass of projectile.
+For metal fragments given off by an explosion the initial velocity is very high; this decreases rapidly with distance. The wounding potential depends on the mass of the fragment and the d...
+
+=== Chunk 302 ===
+Source: 0973_002-ebook.pdf
+Length: 1386 chars
+
+3.3.2 Laboratory experiments
+Many researchers have performed different experiments to describe the effect of projectiles on tissues. Targets have included human cadavers, various animals (pigs, dogs, goats) and tissue simulants.
+Tissue simulants are specially-prepared blocks of gelatine or glycerine soap, which have a density and/or viscosity close to that of muscle tissue. Soap is plastic and any deformation remains unchanged, representing the maximum effects. Gelatine is elastic and deformatio...
+
+=== Chunk 303 ===
+Source: 0973_002-ebook.pdf
+Length: 469 chars
+
+Figure 3.14
+The bullet tumbles in the gelatine or soap: it rotates 270° about a transverse axis that is perpendicular to the long axis. (Graphic demonstration of bullet superimposed on soap blocks. The proportions between bullet and trajectory are exaggerated for the sake of clarity.)
+66
+According to these laboratory studies, five categories describe the behaviour of projectiles – non-deforming and deforming bullets – be they from rifles or handguns, and fragments....
+
+=== Chunk 304 ===
+Source: 0973_002-ebook.pdf
+Length: 468 chars
+
+3.3.3 Non-deforming rifle bullet: full metal jacket (FMJ) military bullet
+When a standard military bullet hits a soft object while in stable flight, it produces a “shooting channel” that presents three distinctive phases: narrow channel; primary temporary cavity and terminal narrow channel (Figure 3.13).
+Phase 3:   end channel  Phase 1:   narrow channel  Phase 2:   temporary cavity  40 cm
+Phase 3:
+end channel
+Phase 1:
+narrow channel
+Phase 2:
+temporary cavity
+40 cm...
+
+=== Chunk 305 ===
+Source: 0973_002-ebook.pdf
+Length: 230 chars
+
+Phase 1
+Straight narrow channel with a diameter about 1.5 times the calibre of the bullet. The greater the velocity, the wider the channel. Different types of bullet have a different length of narrow channel, typically 15 – 25 cm....
+
+=== Chunk 306 ===
+Source: 0973_002-ebook.pdf
+Length: 1936 chars
+
+Phase 2
+The channel opens into the “primary temporary cavity”. The reported diameter of this cavity is anywhere between 10 and 15 times the calibre of the bullet.
+Figure 3.14 shows the motion of the bullet in a simulant. It starts to yaw, and tumbles, turning a full 270°, and then advances with its tail end forward. The whole lateral surface of the bullet comes into contact with the medium, which greatly decelerates the bullet and subjects it to a high level of stress.
+Temporary cavity  Narrow c...
+
+=== Chunk 307 ===
+Source: 0973_002-ebook.pdf
+Length: 725 chars
+
+Phase 3
+The tumbling slows down and the bullet continues in a sideways position at a considerably reduced speed. In some cases, a narrow straight channel is observed; in others, the tumbling seems to continue but backwards, the bullet again assuming a lateral position, and a second cavity occurs. This does not reach the size of the primary temporary cavity. The bullet then creeps forward and finally stops, always with the tail end facing forwards.
+In an elastic medium such as glycerine, what rem...
+
+=== Chunk 308 ===
+Source: 0973_002-ebook.pdf
+Length: 623 chars
+
+Tumbling (yaw) in the target medium
+Given a long enough shooting channel, all FMJ rifle bullets tumble. How early the tumbling motion begins determines the length of the narrow channel, and the onset of temporary cavity formation. This depends on the stability of the bullet (yaw) at the point of impact. The less stable the bullet in flight, the greater the yaw, which rapidly brings a larger bullet surface into contact with the medium, leading to early tumbling and a short narrow channel. How ear...
+
+=== Chunk 309 ===
+Source: 0973_002-ebook.pdf
+Length: 1398 chars
+
+Fragmentation of FMJ bullets
+It is during Phase 2 – the temporary cavity – that certain bullets deform or even break apart because of the enormous stress exerted on them. This occurs when the bullet-medium interface is at its maximum, the cavity is widest, and the transfer of kinetic energy is highest (Figures 3.15 and 3.16). While the projectile acts on the target medium, this is a good example of the medium acting on the projectile. This fragmentation occurs only at short ranges, up to 30 – 10...
+
+=== Chunk 310 ===
+Source: 0973_002-ebook.pdf
+Length: 251 chars
+
+Figure 3.15
+The sketch shows the position of the bullet and the extent of the shooting channel at different phases. The graph represents the transfer of kinetic energy along the bullet track: bullet fragmentation occurs at the peak of energy transfer....
+
+=== Chunk 311 ===
+Source: 0973_002-ebook.pdf
+Length: 192 chars
+
+Figure 3.16
+Fragmentation of FMJ bullet during Phase 2, i.e. creation of the temporary cavity.
+Figure 3.17 Jacket split apart, exposing the lead within.
+Figure 3.17
+67
+C
+Icrc
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+WAR SURGERY...
+
+=== Chunk 312 ===
+Source: 0973_002-ebook.pdf
+Length: 206 chars
+
+Figure 3.18
+Deforming semi-jacketed rifle bullet (SJ) in soap. The bullet “mushrooms” just after impact, then continues in a linear trajectory. (Graphic demonstration of bullet superimposed on soap blocks.)...
+
+=== Chunk 313 ===
+Source: 0973_002-ebook.pdf
+Length: 165 chars
+
+Figure 3.19
+Soap blocks showing comparison between ballistic profiles of FMJ and SJ bullets – the transfer of kinetic energy occurs far sooner with the SJ bullet.
+68...
+
+=== Chunk 314 ===
+Source: 0973_002-ebook.pdf
+Length: 2963 chars
+
+3.3.4 Deforming rifle bullets: dum-dum8
+Some bullets (e.g. hunting bullets) are constructed to always deform, for example by flattening: hollow-nosed, semi-jacketed, soft-pointed, etc. (Figure 3.7 e. and f.). These are usually grouped under the term “dum-dum” bullets and are illegal for military use according to international law.
+Deforming bullets are designed to change their shape readily (“mushrooming”), thus increasing their cross-sectional area, but without losing mass – the spent bullet we...
+
+=== Chunk 315 ===
+Source: 0973_002-ebook.pdf
+Length: 342 chars
+
+Ricochet effect
+When an FMJ bullet strikes an obstacle before hitting the target it is destabilized. After impact, there is almost no narrow channel and the shooting channel resembles what occurs with a deforming or dum-dum bullet (Figure 3.21). This phenomenon has important clinical consequences.
+l
+Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+K
+40 cm
+40 cm
+.
+B...
+
+=== Chunk 316 ===
+Source: 0973_002-ebook.pdf
+Length: 334 chars
+
+Figure 3.20
+Comparison between an FMJ bullet and an SJ bullet: synthetic bone at a shallow depth of gelatine. The FMJ bullet breaks the bone simulant during the narrow channel phase; the shooting channel is practically the same with or without the bone simulant. At the same depth, the SJ bullet shatters the bone simulant completely....
+
+=== Chunk 317 ===
+Source: 0973_002-ebook.pdf
+Length: 294 chars
+
+Figure 3.21
+FMJ rifle bullet after ricochet effect in soap. The large impact angle after ricochet destabilizes the bullet, which tumbles easily and early in the shooting channel. Note that the temporary cavity starts to form almost immediately on impact, similar to an SJ bullet.
+69
+WAR SURGERY...
+
+=== Chunk 318 ===
+Source: 0973_002-ebook.pdf
+Length: 162 chars
+
+Figure 3.22
+Standard military pistol bullet, full metal jacket in soap, no tumbling of the bullet. (Graphic representation of bullet superimposed on soap blocks.)...
+
+=== Chunk 319 ===
+Source: 0973_002-ebook.pdf
+Length: 132 chars
+
+Figure 3.23
+Deforming handgun bullet in soap: mushrooming effect. (Graphic representation of bullet superimposed on soap blocks.)
+70...
+
+=== Chunk 320 ===
+Source: 0973_002-ebook.pdf
+Length: 77 chars
+
+3.3.5 Handgun bullets
+Handgun bullets may be much heavier than rifle bullets....
+
+=== Chunk 321 ===
+Source: 0973_002-ebook.pdf
+Length: 259 chars
+
+Non-deforming bullet
+The shooting channel of a non-deforming handgun bullet shows little yaw and no tumbling; the tip of the bullet continues to point forward and the bullet penetrates deeply (Figure 3.22). The temporary cavity is long and narrow.
+40 cm
+40 cm...
+
+=== Chunk 322 ===
+Source: 0973_002-ebook.pdf
+Length: 372 chars
+
+Deforming bullet
+A soft point, deforming handgun bullet – as used by special police forces – mushrooms at entry (Figure 3.23). The large cross section area causes an abrupt reduction in velocity and great transfer of kinetic energy with an immediate, and large, temporary cavity.
+40 cm
+40 cm
+l
+Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+K
+.
+B
+l
+h
+3 3
+e
+u
+b
+u
+e
+n
+£
+K
+.
+B
+MECHANISMS OF INJURY...
+
+=== Chunk 323 ===
+Source: 0973_002-ebook.pdf
+Length: 1186 chars
+
+3.3.6 Fragment projectiles
+Fragments given off from the explosion of a bomb, rocket or grenade are not aerodynamic; they have an irregular shape. Their velocity decreases rapidly with distance owing to air drag. They have an unstable flight path with an irregular rotation around an indefinite axis. On impact, the biggest cross section comes into contact with the target surface, immediately transferring a maximum of kinetic energy. No yaw or tumbling occurs in the target.
+l
+Kneubuehl
+h
+e
+u
+b
+u
+e
+...
+
+=== Chunk 324 ===
+Source: 0973_002-ebook.pdf
+Length: 94 chars
+
+Figure 3.24
+Fragment profile in soap: the widest point is at entry, the cavity is cone shaped....
+
+=== Chunk 325 ===
+Source: 0973_002-ebook.pdf
+Length: 244 chars
+
+Figure 3.25
+Two fragments with the same kinetic energy – note the difference in energy deposition along the track, demonstrated by the difference in the cavities:
+a. Light, fast-moving fragment. b. Heavy, slow-moving fragment.
+71
+WAR SURGERY
+72...
+
+=== Chunk 326 ===
+Source: 0973_002-ebook.pdf
+Length: 319 chars
+
+3.4 Wound ballistics
+Moving projectiles cause wounds by a transfer of kinetic energy to the body that destroys, disrupts, and deforms tissue. One studies wound ballistics in order to understand the mechanisms that produce this injury.
+Potential for wounding is one thing; the actual wound facing the surgeon is another....
+
+=== Chunk 327 ===
+Source: 0973_002-ebook.pdf
+Length: 1206 chars
+
+3.4.1 Laboratory studies versus human body
+The experiments using tissue simulants as described above help one to understand the processes at work. Laboratory models are, nonetheless, only an approximation and show only the physical part of the process. The tissue structure of the human body is far too complex for a laboratory model to duplicate injuries. Tissue simulants have the disadvantage of being homogeneous media; living tissue is not, as described later. The laboratory results must be com...
+
+=== Chunk 328 ===
+Source: 0973_002-ebook.pdf
+Length: 1298 chars
+
+3.4.2 Projectile–tissue interaction
+When a bullet strikes a human body, a projectile–tissue interaction occurs that results in tissue damage, with a reciprocal influence of the tissues on the bullet. This interaction depends on a number of factors, which all result in the transfer of kinetic energy from the projectile to the tissues.
+This transfer of kinetic energy either compresses, cuts or shears tissue, causing crush, laceration or stretch. The local energy transfer at a given point along the...
+
+=== Chunk 329 ===
+Source: 0973_002-ebook.pdf
+Length: 1209 chars
+
+Crush and laceration injury
+A projectile causes physical compression and forcing apart of tissues along the shooting channel – crushing and laceration. This is the immediate physical effect of a penetrating foreign body; the bullet damages tissues with which it comes into direct contact, cutting through tissues as would a knife. This tissue damage is permanent and found in the final wound. This is the principal effect caused by low- and medium-energy weapons, such as handgun bullets.
+9 Much conf...
+
+=== Chunk 330 ===
+Source: 0973_002-ebook.pdf
+Length: 1995 chars
+
+Stretch injury
+Tissues have an elastic tensile strength that resists stretching. When a certain limit is reached, capillaries are ruptured and contusion of the tissues occurs. Beyond a critical limit, the tissues themselves are torn, just as laboratory gelatine shows fracture lines. The tissue damage from stretch may be permanent or only temporary.
+Tissue stretch occurs during formation of the temporary cavity, which takes place in all projectile wounds, whatever the energy, type or motion of th...
+
+=== Chunk 331 ===
+Source: 0973_002-ebook.pdf
+Length: 247 chars
+
+3.4.3 Tissue factors
+Resistance to crush, laceration and stretch differs widely among different types of tissue and anatomic structure. Tissue elasticity and heterogeneity are important factors in determining much of the bullet–tissue interaction....
+
+=== Chunk 332 ===
+Source: 0973_002-ebook.pdf
+Length: 1140 chars
+
+Tissue elasticity
+Elastic tissues tolerate stretch well, but may still suffer severe crush. The lung and skin have excellent tolerance, and leave relatively little residual damage after stretch. Skeletal muscle and the bowel wall of empty intestines have good tolerance. The brain, liver, spleen, and kidney are non-elastic, and shatter when stretched. Fluid- filled organs (heart, full bladder, full stomach and intestines) react badly owing to the incompressibility of the fluid contents; they may ...
+
+=== Chunk 333 ===
+Source: 0973_002-ebook.pdf
+Length: 207 chars
+
+Tissue heterogeneity
+Apart from these considerations of tissue elasticity, there is the particular local anatomy to consider. A block of gelatine approximates skeletal muscle in its elasticity
+73
+WAR SURGERY...
+
+=== Chunk 334 ===
+Source: 0973_002-ebook.pdf
+Length: 653 chars
+
+Figures 3.26.1 and 3.26.2
+Demonstration of boundary effect on the temporary cavity due to a high-energy rifle bullet: the apple literally explodes after the passage of the bullet.
+74
+and density, but it is homogeneous. A human limb or the face are a mixture of rigid and elastic tissues comprising fascial compartments enclosing muscles, tendons and ligaments, large blood vessels and nerves, and bones. Not only does each anatomic element have a different elastic tensile strength, but the mixture o...
+
+=== Chunk 335 ===
+Source: 0973_002-ebook.pdf
+Length: 1804 chars
+
+Bound together and boundaries
+How tightly tissues are bound together, and to nearby structures such as fascia of varying thickness, also affects the amount of permanent damage a cavity stretch can leave behind. If one side of a structure is fixed and the other side has free movement, a shearing force develops. Fascial planes may also serve as channels for the dissipation of energy – via the path of least resistance – to more remote tissues.
+Boundaries limiting the pulsation of a temporary cavity...
+
+=== Chunk 336 ===
+Source: 0973_002-ebook.pdf
+Length: 2287 chars
+
+3.4.4 Pathological description of the permanent wound cavity
+The permanent cavity of the final wound that the surgeon sees is the result of a mixture of crushing, laceration and stretching of the tissues. Most of the damage in the majority of ballistic wounds is due to direct crush and laceration.
+A number of macroscopic and microscopic changes occur. Severe vasoconstriction blanches the skin around the entry wound for 3 – 4 hours owing to the stretch. This is followed by a hyperaemic reaction t...
+
+=== Chunk 337 ===
+Source: 0973_002-ebook.pdf
+Length: 914 chars
+
+3.4.5 Clinical applications
+The external appearance of a bullet wound can be deceptive. Tiny entrance and exit holes can be associated with extensive internal damage.
+The length of the shooting channel in the body, the existence of an exit wound and the characteristics of the particular structures traversed will all greatly affect the final wound caused by a high-energy bullet that the surgeon sees.
+The position of the Phase 2 temporary cavity along the wound track is clinically very relevant. F...
+
+=== Chunk 338 ===
+Source: 0973_002-ebook.pdf
+Length: 283 chars
+
+Figure 3.27
+Schematic drawing of histopathological changes in the shooting channel:
+3.27.1 Geometric shooting channel 3.27.2 Phase of maximum temporary cavity 3.27.3 Final permanent wound channel
+a: Zone of destroyed tissues b: Contusion zone c: Concussion zone d: Unaffected tissues...
+
+=== Chunk 339 ===
+Source: 0973_002-ebook.pdf
+Length: 466 chars
+
+Figure 3.28
+Exit wounds may occur before, during or after temporary cavity formation, depending on the length of the shooting channel in the body.
+75
+WAR SURGERY
+76
+C
+2
+R
+C
+I
+/
+d
+n
+a
+l
+3
+p
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+o
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+.
+R
+The injured body part may not be long enough for a temporary cavity to occur. Figures 3.29.1 and 3.29.2 show small entry and exit wounds along the narrow channel of Phase 1, with little intervening tissue damage.
+R.Coupland/ ICRC
+Entry  Exit
+R.Coupland/ ICRC
+Fracture...
+
+=== Chunk 340 ===
+Source: 0973_002-ebook.pdf
+Length: 418 chars
+
+Figure 3.29.1
+Figure 3.29.2
+Small entry and exit wounds, through-and-through injury.
+The radiograph shows a small drill-hole fracture of the acromion: Phase 1 narrow-channel injury only.
+The exit wound is large when it coincides with the site of the temporary cavity (Figures 3.30.1 – 3.30.3).
+C
+2
+R
+C
+I
+/
+d
+n
+a
+l
+3
+p
+u
+o
+C
+2
+R
+C
+I
+/
+d
+n
+a
+l
+a
+p
+u
+o
+ae = a | a EL x8 cl F2 vO m2
+C
+C
+.
+.
+R
+R
+Figure 3.30.1
+Figure 3.30.2...
+
+=== Chunk 341 ===
+Source: 0973_002-ebook.pdf
+Length: 1095 chars
+
+Figure 3.30.3
+Gunshot wound to the thigh; the small entry is medial and the large exit on the lateral aspect.
+There is a severe comminuted fracture of the femur and fragmentation of the bullet.
+The exit coincides with the site of the temporary cavity. The fragmentation of the bullet is a tell-tale sign of severe tissue damage. Wound Score: Grade 3, Type F (see Chapter 4).
+When a small exit wound occurs after the temporary cavity, the intervening damage can be severe (Figures 3.31.1 and 3.31.2).
+...
+
+=== Chunk 342 ===
+Source: 0973_002-ebook.pdf
+Length: 150 chars
+
+Figure 3.32.1
+Small entry and exit wounds from an FMJ hand-gun bullet: demonstration in a soap block.
+Figure 3.32.2 Handgun bullet wound to the thigh....
+
+=== Chunk 343 ===
+Source: 0973_002-ebook.pdf
+Length: 1434 chars
+
+The case of bone
+The direct impact of a bullet on bone is different according to where this occurs in the shooting channel. Three clinical situations arise, corresponding to the phases of the shooting channel.
+• In the first case, the stable bullet of Phase 1 causes a small “drill-hole” fracture. A small temporary cavity occurs, and the bone then collapses on itself. The final hole is smaller than the calibre of the bullet (Figure 3.29.2).
+• In the second case, the bone is broken into multiple f...
+
+=== Chunk 344 ===
+Source: 0973_002-ebook.pdf
+Length: 248 chars
+
+Figure 3.34
+The wound from a ricochet FMJ bullet resembles that of a dum-dum bullet. The head of the humerus has literally exploded.
+77
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+&
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+I
+/
+d
+g 8
+n
+a
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+o
+C
+.
+R
+WAR SURGERY
+Figure 3.35 Bullet fragmentation: a “shower of lead”.
+78...
+
+=== Chunk 345 ===
+Source: 0973_002-ebook.pdf
+Length: 1286 chars
+
+Disruption of the bullet and secondary fragments
+At impact velocities above 700 m/s, standard FMJ bullets tend to fragment in tissues at short shooting distances (30 – 100 m). Some of these fragmented pieces make their own tracks of crushed and lacerated tissue. Tissue disruption from bullet fragmentation is then synergistic: the tissues are multiply perforated by the metallic fragments, thus weakening the tissue’s cohesiveness, before being subjected to the stretch caused by the temporary cavit...
+
+=== Chunk 346 ===
+Source: 0973_002-ebook.pdf
+Length: 747 chars
+
+3.4.6 Sonic shock wave in tissues
+A projectile in flight is accompanied by a series of waves propagated at the speed of sound (330 m/s in air). When the projectile strikes a person, this sonic wave is propagated throughout the body at the speed of sound in tissue (4 times the speed of sound in air).
+This sonic shock wave may have high amplitude but is of very short duration, not enough to move or injure tissue. However, researchers have noted microscopic cell changes and stimulation of periphera...
+
+=== Chunk 347 ===
+Source: 0973_002-ebook.pdf
+Length: 1078 chars
+
+3.4.7 Pressure wave in tissues and blood vessels
+The pressure wave is part of the phenomenon of the temporary cavity and should not be confused with the sonic shock wave. The outer boundary of the cavity consists of a “front” of compressed tissues, which creates a pressure wave at the limit of tissue compression. The wave develops fully only after the temporary cavity and decreases with distance. It is measured in milliseconds (i.e. its duration is 1,000 times that of the shock wave). The pressu...
+
+=== Chunk 348 ===
+Source: 0973_002-ebook.pdf
+Length: 1478 chars
+
+3.4.8 Fragment wounds
+Their non-aerodynamic shape means that fragments rapidly lose speed in air. While initial velocities are reported to be up to 2,000 m/s, the impact velocity in survivors is usually much lower. If the person is very close to the exploding device, the penetration is deep. If very far away, the casualty is only “peppered” superficially with multiple fragments.
+Fragments do not tumble in the tissues, as was demonstrated in the tissue simulants. Thus, most tissue damage is due t...
+
+=== Chunk 349 ===
+Source: 0973_002-ebook.pdf
+Length: 58 chars
+
+Figure 3.36.1
+Soap block demonstration of fragment injury....
+
+=== Chunk 350 ===
+Source: 0973_002-ebook.pdf
+Length: 1024 chars
+
+Wound channel: pathological description
+The sharp and irregular surfaces of fragments carry pieces of skin and clothing material into the wounds. As with gunshot wounds, fragment wounds show different zones of tissue injury. The cavity contains necrotic tissues surrounded by a zone of muscle fibre fragmentation with haemorrhage both within and between fibres, further surrounded by a region of acute inflammatory changes and oedema.
+The uneven distribution of tissue damage in the concussion and co...
+
+=== Chunk 351 ===
+Source: 0973_002-ebook.pdf
+Length: 2539 chars
+
+3.5 Wound dynamics and the patient
+The wound has a life history, from injury to complete healing. As we have seen, tissue damage depends on a number of physical factors. However, the physical effects of energy transfer do not tell us all the pathological and physiological consequences of the act of wounding.
+The tissues in and around the wound undergo reversible and irreversible pathological changes, together with inflammatory reactions. It can be extremely difficult to diagnose injured tissue t...
+
+=== Chunk 352 ===
+Source: 0973_002-ebook.pdf
+Length: 1211 chars
+
+4.1 Applications of the RCWS and classification system
+Surgeons from civilian practice usually have no previous experience of managing war wounds. Even experienced surgeons often do not find it possible to tell the true extent of tissue damage. As noted in Chapter 3, ballistics studies show that there is not a uniform pattern or degree of wounding. Preparation for war surgery involves an understanding of the translation of the kinetic energy of a wounding projectile into tissue damage, i.e. the ...
+
+=== Chunk 353 ===
+Source: 0973_002-ebook.pdf
+Length: 303 chars
+
+4.1.1 Assessment of and communication about war wounds in a standardized scheme
+The Wound Score is a useful clinical tool to communicate the severity of the wound to staff and colleagues without having to remove the dressings. It is also an element to take into consideration for the purposes of triage....
+
+=== Chunk 354 ===
+Source: 0973_002-ebook.pdf
+Length: 675 chars
+
+4.1.2 Establishing a scientific approach to war surgery
+The RCWS permits comparison of treatments and prognoses of similar wounds. An analogy can be made with the TNM (tumour, node, metastasis) staging of different cancers, allowing comparison of treatment regimes for a similar pathology. In the case of a gunshot wound to the thigh, treatment and prognosis will differ according to the amount of tissue damage, degree of bone comminution and whether there is injury to the femoral vessels. Other wo...
+
+=== Chunk 355 ===
+Source: 0973_002-ebook.pdf
+Length: 438 chars
+
+4.1.3 Surgical and hospital audit
+Wound Scores can be used to evaluate quality of care when combined with information on length of hospital stay, number of operations performed per patient or units of blood used, morbidity and mortality. An example relating to the adequacy of primary wound surgery is the number and cause of deaths associated with non-vital wounds, or the number of operations performed per patient for each Wound Grade....
+
+=== Chunk 356 ===
+Source: 0973_002-ebook.pdf
+Length: 780 chars
+
+4.1.4 Wound information from the field
+ICRC surgical teams treat thousands of war-wounded every year. Analysis of a larger number of scored wounds will eventually clarify the relationship between experimental laboratory wound ballistics and the clinical management of war wounds. Worthy of note is the fact that information gained in the field served as a scientific basis for the campaign to ban anti-personnel landmines, thus promoting new standards in international humanitarian law.
+This chapter ...
+
+=== Chunk 357 ===
+Source: 0973_002-ebook.pdf
+Length: 397 chars
+
+Figure 4.1
+The width of two fingers is approximately the length of a military rifle bullet.
+a i
+C
+Herkert/ ICRC
+.
+F
+Figure 4.2.1 Gunshot wound: F1 fracture of the ulna.
+C
+R.Coupland/ ICRC
+R
+C
+I
+/
+d
+n
+a
+l
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+o
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+.
+R
+Figure 4.2.2 Gunshot wound: F2 fracture of the femur.
+C
+R
+C
+I
+/
+d
+n
+a
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+.
+R
+Figure 4.2.3
+Gunshot wound: F 1 fracture (clinically insignificant comminution) of the fibula.
+86...
+
+=== Chunk 358 ===
+Source: 0973_002-ebook.pdf
+Length: 1917 chars
+
+Principles of the Red Cross Wound Score
+Wounds are given a six-figure Score according to several parameters. The Scores can then be translated into a classification system:
+• grading of the wound according to the severity of tissue injury and
+• typing of the wound according to the tissue structures injured.
+The RCWS is intended for quick and easy use in the field, its simplicity especially useful under conditions of stress. It is a simple clinical system that requires no extra equipment or sophi...
+
+=== Chunk 359 ===
+Source: 0973_002-ebook.pdf
+Length: 318 chars
+
+Figure 4.3
+Examples of Wound Scores.
+a. Simple bullet track.
+b. Track produced by bullet when the exit coincides with cavity formation.
+c. Simple track with involvement of a vital structure (artery).
+d. Low-energy transfer wound with simple fracture.
+e. High-energy transfer wound by fragment with comminuted fracture....
+
+=== Chunk 360 ===
+Source: 0973_002-ebook.pdf
+Length: 304 chars
+
+Figure 4.4
+Further examples of Wound Scores.
+a. Through-and-through bullet wound of soft tissue with central cavity formation.
+b. Through-and-through bullet wound with central cavity formation and comminuted fracture.
+c. High-energy transfer bullet wound with cavity formation and comminuted fracture.
+88...
+
+=== Chunk 361 ===
+Source: 0973_002-ebook.pdf
+Length: 460 chars
+
+4.2.1 Examples
+The following two sketches (Figures 4.3 and 4.4) present various wounds due to projectiles, and their assessment according to the ICRC’s wound scoring system.
+a  b  c  d  e
+a
+b
+c
+d
+e
+C
+IcRC
+R
+C
+I
+E X C F V Wound (a) 1 ? 2 0 0 0 Wound (b) 1 4 1 0 0 Wound (c) 1 0 0 0 H Wound (d) 1 0 0 1 0 Wound (e) 6 0 1 2 0 M 0 0 1 1 1
+a  b  c
+a
+b
+c
+C
+R
+C
+I
+E X C F V Wound (a) 1 ? 1 1 0 0 Wound (b) 1 ? 1 1 2 0 Wound (c) 1 6 1 2 0 M 0 0 2
+RED CROSS WOUND SCORE...
+
+=== Chunk 362 ===
+Source: 0973_002-ebook.pdf
+Length: 3309 chars
+
+4.2.2 Notes on wound scoring
+1. When it is impossible to differentiate between the entry and the exit wounds, put a (?) between the E and X Scores.
+2. With multiple wounds, only the two most serious are scored.
+3. If a wound cannot be scored (unclassifiable), U/C is written on the Score. This applies to a minority of wounds.
+4. When one missile causes two separate wounds (e.g. through the arm and into the chest), the 2 separate Scores are joined by a bracket.
+5. Include penetrating wounds only, ...
+
+=== Chunk 363 ===
+Source: 0973_002-ebook.pdf
+Length: 145 chars
+
+Figure 4.7
+Traumatic amputation of the forearm.
+E  X  C  F  V  M  20  ?  1  2  0  0
+89
+C
+IcRC
+R
+C
+I
+C
+R
+C
+I
+C
+Barrand / ICRC
+B
+.
+K
+WAR SURGERY
+90...
+
+=== Chunk 364 ===
+Source: 0973_002-ebook.pdf
+Length: 154 chars
+
+4.3 Grading and typing of wounds
+Once scored, the wound can be graded according to severity (E, X, C and F), and typed according to tissue type (F and V)....
+
+=== Chunk 365 ===
+Source: 0973_002-ebook.pdf
+Length: 104 chars
+
+4.3.1 Wound Grade according to amount of tissue damage
+The wound should be graded according to severity....
+
+=== Chunk 366 ===
+Source: 0973_002-ebook.pdf
+Length: 87 chars
+
+Grade 1
+E + X is less than 10 cm with Scores C 0 and F 0 or F 1.
+(Low energy transfer.)...
+
+=== Chunk 367 ===
+Source: 0973_002-ebook.pdf
+Length: 80 chars
+
+Grade 2
+E + X is less than 10 cm with Scores C 1 or F 2. (High energy transfer.)...
+
+=== Chunk 368 ===
+Source: 0973_002-ebook.pdf
+Length: 353 chars
+
+Grade 3
+E + X is 10 cm or more, with Scores C 1 or F 2.
+(Massive energy transfer.)
+These Grades represent the outcome of a simple clinical assessment that corresponds to the effective transfer of kinetic energy of projectiles to body tissues. Large wounds are more serious and require greater resources; this is particularly true of wounds to the limbs....
+
+=== Chunk 369 ===
+Source: 0973_002-ebook.pdf
+Length: 120 chars
+
+4.3.2 Typing wounds according to the injured tissues
+Once scored, the wound can be typed according to tissue structures....
+
+=== Chunk 370 ===
+Source: 0973_002-ebook.pdf
+Length: 40 chars
+
+Type ST
+Soft-tissue wounds: F 0 and V 0....
+
+=== Chunk 371 ===
+Source: 0973_002-ebook.pdf
+Length: 49 chars
+
+Type F
+Wounds with fractures: F1 or F 2, and V 0....
+
+=== Chunk 372 ===
+Source: 0973_002-ebook.pdf
+Length: 81 chars
+
+Type V
+Vital wounds putting the patient’s life at risk: F 0 and V = N, T, A or H....
+
+=== Chunk 373 ===
+Source: 0973_002-ebook.pdf
+Length: 123 chars
+
+Type VF
+Wounds with fractures and involving vital structures putting life or limb at risk: F 1 or F 2 and V = N, T, A or H....
+
+=== Chunk 374 ===
+Source: 0973_002-ebook.pdf
+Length: 982 chars
+
+4.4 Wound classification
+Combining Grades and Types gives rise to a classification system divided into 12 categories.
+Grade 1 Grade 2 Grade 3 Type ST 1 ST Small, simple wound 2 ST Medium soft-tissue wound 3 ST Large soft-tissue wound 1 F 2 F 3 F Type F Simple fracture Important fracture Massive comminution threatening limb Type V 1 V Small wound threatening life 2 V Medium wound threatening life 3 V Large wound threatening life 1 VF 2 VF 3 VF Type VF Small wound threatening limb Important wound ...
+
+=== Chunk 375 ===
+Source: 0973_002-ebook.pdf
+Length: 2749 chars
+
+4.5 Clinical examples
+Epidemiological studies from the ICRC surgical database of over 32,000 patients have shown that the Red Cross Wound Score gives excellent prognostic results for surgical workload and morbidity due to war wounds. As demonstrated in the statistical analysis in Chapter 5, the Wound Grade is highly relevant to the number of operations per patient. This is particularly the case for wounds to the extremities. Vital Wound Scores to the extremities (V = H) also give good measures f...
+
+=== Chunk 376 ===
+Source: 0973_002-ebook.pdf
+Length: 124 chars
+
+Figure 4.8.1
+Two fragment wounds to the thigh. The surgeon is assessing the larger wound cavity.
+rc
+C
+Coupland // ICRC
+C
+.
+R...
+
+=== Chunk 377 ===
+Source: 0973_002-ebook.pdf
+Length: 169 chars
+
+Figure 4.9.1
+Through-and-through gunshot wound to the knee.
+C
+Coupland / ICRC
+C
+.
+R
+Figure 4.9.3 The popliteal artery has been injured.
+C
+&
+R
+C
+I
+/
+d
+n
+a
+:
+l
+p
+u
+o
+C
+.
+R...
+
+=== Chunk 378 ===
+Source: 0973_002-ebook.pdf
+Length: 158 chars
+
+Figure 4.10.2
+The bullet is lodged in the scrotum. There is a small fracture of the right pubic bone.
+E1 x0 CO FO yO mt e7 3 x1 ct FO vO mo
+R.Coupland /ICRC
+R...
+
+=== Chunk 379 ===
+Source: 0973_002-ebook.pdf
+Length: 194 chars
+
+Figure 4.8.2
+Both wounds are Type ST. The smaller wound is Grade 1, and the larger Grade 2.
+Fracture
+Fracture
+R.Coupland /ICRC
+R
+Figure 4.9.2 There is a small fracture above the lateral condyle....
+
+=== Chunk 380 ===
+Source: 0973_002-ebook.pdf
+Length: 354 chars
+
+Figure 4.9.2
+C
+Coupland /ICRC
+R
+C
+I
+/
+d
+n
+a
+l
+p
+u
+o
+Ef xi cO Fi vH m0
+C
+.
+R
+Figure 4.9.4 The wound is Type V(H)F, Grade 1.
+C
+2
+R
+C
+I
+/
+d
+n
+a
+3
+l
+p
+u
+o
+£4x0 cl Fl va mi
+C
+.
+R
+Figure 4.10.3 This is a Grade 2 wound, Type V(A)F.
+RED CROSS WOUND SCORE
+C
+Coupland /ICRC
+£2 x3c1 0 v0 MO
+C
+Coupland /ICRC
+C
+.
+R
+Figure 4.11.2 This is a Grade 2, Type ST wound.
+.
+R...
+
+=== Chunk 381 ===
+Source: 0973_002-ebook.pdf
+Length: 232 chars
+
+Figure 4.11.1
+A bullet has grazed the left buttock and then entered the right buttock at the anal cleft. The exit is located laterally.
+C
+2
+R
+C
+I
+/
+d
+z
+n
+a
+l
+p
+u
+o
+C
+.
+R
+Y.¢ Ss Q £3 x0 CO F2 vNM1
+C
+Coupland /ICRC
+C
+.
+R
+Figure 4.12.1...
+
+=== Chunk 382 ===
+Source: 0973_002-ebook.pdf
+Length: 184 chars
+
+Figure 4.12.2
+Fragment wound to the head with entry right parietal. Note the severe linear fractures.
+The cone of tissue destruction extends to the occipital lobe. Grade 2, Type V(N)F....
+
+=== Chunk 383 ===
+Source: 0973_002-ebook.pdf
+Length: 883 chars
+
+4.6 Conclusions
+The Red Cross Wound Score enables medical staff to translate war wounds into surgical lesions rather than weaponry phenomena. It refines the heterogeneity of wounds and helps define them according to their clinical significance, and it is a good indicator of tissue damage due to the transfer of kinetic energy in penetrating wounds.
+The limitations of the scoring system are recognized; complete accuracy cannot be obtained. It should be emphasized that the RCWS is for rapid use und...
+
+=== Chunk 384 ===
+Source: 0973_002-ebook.pdf
+Length: 2522 chars
+
+Chapter 5 THE EPIDEMIOLOGY OF THE VICTIMS OF WAR
+5
+WAR SURGERY
+96
+5
+THE EPIDEMIOLOGY OF THE VICTIMS OF WAR
+5.1 5.1.1 5.2 5.2.1 5.2.2 5.2.3 5.2.4 5.3 5.3.1 5.3.2 5.3.3 5.3.4 5.3.5 5.4 5.4.1 5.4.2 5.4.3 5.4.4 5.4.5 5.5 5.5.1 5.5.2 5.5.3 5.6 5.6.1 5.6.2 5.6.3 5.6.4 5.6.5 5.7 5.7.1 5.7.2 5.7.3 5.7.4 5.7.5 5.8 5.8.1 5.8.2 5.8.3 5.8.4 Introduction: purpose and objectives The reader and this manual Public health effects of armed conflict Historical perspective The public health effects of social disrup...
+
+=== Chunk 385 ===
+Source: 0973_002-ebook.pdf
+Length: 644 chars
+
+Introduction: purpose and objectives
+Epidemiological studies are standard practice in medicine. Doctors need to understand the characteristics of their patient population and the relationships between particular circumstances and the outcome of treatment. These elements help to establish the high-risk factors.
+As regards the victims of war, the total effects of conflict must be analysed: the impact on civilian populations as well as on the armed forces, the direct effects of war trauma and the i...
+
+=== Chunk 386 ===
+Source: 0973_002-ebook.pdf
+Length: 1257 chars
+
+5.1.1 The reader and this manual
+Most readers of this manual will be civilian surgeons who are unacquainted with the practice of war surgery and its literature. Even among military surgeons many may have only a superficial acquaintance with these topics. This chapter on the epidemiology of victims of war presents a certain approach to the understanding of the many factors involved in patient care and outcome.
+First the public health repercussions of armed conflict will be dealt with briefly, the...
+
+=== Chunk 387 ===
+Source: 0973_002-ebook.pdf
+Length: 1854 chars
+
+5.2.1 Historical perspective
+It is commonly said that contemporary warfare causes more civilian victims than military, and that the public health effects are greater than those caused by trauma. In all major conflicts over the last one hundred years, with few exceptions (World War I), civilians have become a direct target and accounted for one-half to two-thirds of the casualties.
+“Throughout history there have been many small local wars, often involving wholesale starvation and occasionally the...
+
+=== Chunk 388 ===
+Source: 0973_002-ebook.pdf
+Length: 200 chars
+
+Figure 5.1
+Victims’ needs and available services during armed conflict.3
+98
+“Today’s armed conflicts are essentially wars on    public health.”  Rémi Russbach, former Chief Medical Officer at the ICRC...
+
+=== Chunk 389 ===
+Source: 0973_002-ebook.pdf
+Length: 800 chars
+
+5.2.2 The public health effects of social disruption
+Social disruption includes population displacement – either internal or refugee – pauperization, the breakdown of nutrition and sanitary conditions, the lack of safe drinking water and the disruption of medical systems (Table 5.1).
+Direct effects Indirect effects Death Economic pressure and disruption Disability Reduced food production and distribution Family disruption (orphans, abandoned children) Destruction of health services Refugees Psyc...
+
+=== Chunk 390 ===
+Source: 0973_002-ebook.pdf
+Length: 2700 chars
+
+Pathologies and the pathology of the health system
+Complex emergencies during armed conflict in poor countries tend to cause death by endemic communicable disease and malnutrition. In more developed countries, increased mortality rates due to trauma and chronic disease dominate. The lack of access to care, either because of poverty, the disruption of the medical system, or for reasons of security, aggravates the problems.
+To pre-conflict poverty and fragile health services are added the problems...
+
+=== Chunk 391 ===
+Source: 0973_002-ebook.pdf
+Length: 462 chars
+
+Public health effects on the armed forces
+Even among the conventional armies of industrialized countries, disease caused more deaths than combat until World War II. Mortality does not tell the whole story, however. Serious disease continues to affect modern armies, still accounting for high rates of non-availability of personnel for military duty. Of course, certain natural environments (jungle, high mountains) increase the incidence of non-battle pathology....
+
+=== Chunk 392 ===
+Source: 0973_002-ebook.pdf
+Length: 1295 chars
+
+5.2.3 The burden of war-wounded civilians
+Although trauma may account for only a small number of all war-related deaths in a given civilian population, the relative proportions of mortality and morbidity due to disease and trauma vary over time and between different war zones; refugee camps are different again.
+In some conflicts, the burden of war trauma is greater than the public health consequences. This was the case in the wars in the former Yugoslavia (1991 – 99) in Lebanon (1975 – 90) and i...
+
+=== Chunk 393 ===
+Source: 0973_002-ebook.pdf
+Length: 705 chars
+
+Demographics of the victims
+Historically, military casualty statistics concern young, fit and healthy men. In the past, women were not close to combat in most conventional armies, although this is now changing, and certain revolutionary guerrilla groups have long had female combatants.
+When a civilian population finds itself in the midst of war, the demographic profile of casualties is closer to its population pyramid. This has clinical consequences for the treatment of endemic diseases and chro...
+
+=== Chunk 394 ===
+Source: 0973_002-ebook.pdf
+Length: 1324 chars
+
+5.2.4 Methodology
+Public health monitoring and data collection are notoriously difficult during the chaotic and overwhelming conditions of complex emergencies. Missing and displaced persons, constraints of time, lack of access to populations and dangerous security situations all create formidable problems for a limited number of qualified personnel to conduct proper studies. Furthermore, the distinction between civilians and military personnel during a civil war is not always obvious.
+The ratio ...
+
+=== Chunk 395 ===
+Source: 0973_002-ebook.pdf
+Length: 564 chars
+
+Epidemiology for the war surgeon
+What should one look for in a study of epidemiology? What information will help the individual surgeon managing war wounds for the first time? What needs to be taken into consideration to set up an efficient system for the care of the war-wounded? Is it possible to determine the “normal” levels of morbidity and mortality during armed conflict?
+To respond adequately to the challenge requires preparation, on the part of the individual surgeon and of the institution...
+
+=== Chunk 396 ===
+Source: 0973_002-ebook.pdf
+Length: 1728 chars
+
+5.3.1 Preparation of the surgeon
+The surgeon facing war-wounded casualties for the first time will ask a number of questions: “What wounds should I expect? Which injuries kill? What will the surgical workload be like? What are the gaps in my training?”
+In many conflicts, civilian surgeons without previous military experience become heavily involved in the management of the war-wounded. Yet epidemiological studies clearly show that combat injuries differ from those in civilian practice: different...
+
+=== Chunk 397 ===
+Source: 0973_002-ebook.pdf
+Length: 1450 chars
+
+5.3.2 Preparation of the institution
+The institution involved – military medical services, public health ministry, the ICRC or any other humanitarian agency – must also be prepared.
+The standardization of protocols and knowledge of the workload permits the establishment of ready-made kits of equipment, medicines and supplies that are easily deployed in an emergency situation as a rapid response to well-known needs. This facilitates the setting up of a surgical hospital to treat the victims of wa...
+
+=== Chunk 398 ===
+Source: 0973_002-ebook.pdf
+Length: 1917 chars
+
+5.3.3 Surgical audit: monitoring
+Monitoring of the outcome of patient management in a context of armed conflict involves a surgical audit using an epidemiological approach: demographics, types of wounds, anatomic distribution, mechanism of injury, time since injury, post-operative mortality, number of operations and blood transfusions per patient, morbidity, etc. There are several reasons for this.
+• The adequacy of surgical expertise is important: the “fog of war” and the confusion and stress o...
+
+=== Chunk 399 ===
+Source: 0973_002-ebook.pdf
+Length: 1227 chars
+
+5.3.4 The surgeon and IHL
+Surgeons working for the ICRC believe that health professionals have a duty to gather data “to prevent and not just to treat” with regard to the law and norms of behaviour in the conduct of hostilities. They are not alone in this belief.
+Health professionals were instrumental in gathering the epidemiological data from clinical studies to make the humanitarian argument for the banning of blinding laser weapons, anti-personnel landmines and cluster munitions.6
+In the fiel...
+
+=== Chunk 400 ===
+Source: 0973_002-ebook.pdf
+Length: 873 chars
+
+5.3.5 The surgeon and the specialized literature
+“Statistics can be made to say whatever you want them to say” is a well-worn cliché. It is therefore important for the surgeon reading the vast literature on war surgery to understand what is being said, what the shortcomings are, and what some of the traps and pitfalls are.
+Most of the war surgery literature consists of large retrospective studies written by military surgeons of industrialized countries; some of the exceptions are included in the...
+
+=== Chunk 401 ===
+Source: 0973_002-ebook.pdf
+Length: 360 chars
+
+Differences
+In addition to the differences between war and civilian trauma there are disparities between the experience of the ICRC, other humanitarian agencies and public health facilities on the one hand, and the experience of conventional military medical services on the other. The rest of this chapter deals with some of these differences and disparities....
+
+=== Chunk 402 ===
+Source: 0973_002-ebook.pdf
+Length: 205 chars
+
+5.4 General questions of methodology
+There are a number of problems and difficulties relating to how epidemiological studies have been conducted. The surgeon reading the literature should be aware of them....
+
+=== Chunk 403 ===
+Source: 0973_002-ebook.pdf
+Length: 1214 chars
+
+5.4.1 Large and small numbers
+First it must be clear which phenomenon is being studied. Comparisons of data between a single battle and longer wars may not be valid; a small cohort may not be representative. Most clinical protocols take as a basis large numbers in big wars. On the other hard, the individual surgeon will face individual casualties from particular battles. Thus, the experience with small cohorts may help prepare the surgeon to face a novel situation or specific injuries.
+The Proto...
+
+=== Chunk 404 ===
+Source: 0973_002-ebook.pdf
+Length: 3292 chars
+
+5.4.2 Problems of data collection
+Trauma registries are notoriously difficult to maintain during war. Fatigue and lack of time, a shortage of trained staff and the personal danger that medical staff must often confront complicate the keeping of statistics. The administrative personnel and time and effort required to keep up full documentation and archives can appear to be a luxury when one is faced with the stress of caring for battle casualties. A telling comment about the American experience i...
+
+=== Chunk 405 ===
+Source: 0973_002-ebook.pdf
+Length: 944 chars
+
+Important first questions: who is counting whom?
+Foremost is the very important problem of different definitions of epidemiological categories. Some military definitions have changed over the last century or been replaced by other terms. Civilian authors have often invented their own epidemiological categories and definitions in articles on the subject. Who exactly composes the target population under study is different from one article to the next, although all deal with the “wounded” and durin...
+
+=== Chunk 406 ===
+Source: 0973_002-ebook.pdf
+Length: 652 chars
+
+Who is counting?
+Different hospitals – military, public, and other (mission hospitals, non-governmental organizations, the ICRC, etc.) – all have their own objectives, mandates and routines. They all collect statistics, but often for very different reasons, and they collect very different statistics (see ANNEX 5. A: ICRC Surgical Database).
+A well-organized conventional army can state how many of its soldiers were killed or disabled; pensions and allowances must be paid and the necessary adminis...
+
+=== Chunk 407 ===
+Source: 0973_002-ebook.pdf
+Length: 424 chars
+
+Who is being counted and where?
+Are casualties calculated at the point of wounding, at first-aid posts, first echelon or referral hospitals? The total number of wounded will depend on which level of the evacuation chain is counting, and what happens to them after injury.
+The wounded who arrive at hospitals – where most studies are made – are only a sample of the casualties; they do not represent the total reality of war....
+
+=== Chunk 408 ===
+Source: 0973_002-ebook.pdf
+Length: 1452 chars
+
+When is a wounded person a wounded person?
+Many studies in the military literature, even when dealing with the same war, define the wounded differently. One example: for World War II, the United States Surgeon General’s Statistical Health Report indicated 724,000 wounded and 228,000 battle- related deaths among American troops; a fatality rate of 23.9 %. The Adjutant General’s Report gave the figure of 593,000 battle injuries and 235,000 deaths; a rate of 28.4 %. The latter report excluded the l...
+
+=== Chunk 409 ===
+Source: 0973_002-ebook.pdf
+Length: 1242 chars
+
+5.4.4 Some definitions: the wounded and the dead
+Table 5.2 includes some basic epidemiological definitions intended to standardize reporting by the armed forces of the United States of America.
+Killed in action (KIA) Died from battle injuries before reaching a medical facility (MF). Comparable to civilian dead on arrival (DOA). %KIA = Died before reaching MF KIA + (WIA - RTD) ×100 Wounded in action Wounded who survive to reach (WIA) a medical facility staffed by a physician capable of trauma lif...
+
+=== Chunk 410 ===
+Source: 0973_002-ebook.pdf
+Length: 2150 chars
+
+5.4.5 Clinical and operational consequences and IHL
+A number of clinical and operational elements are significant as regards IHL.
+1. For armies, the total number of casualties – soldiers removed from active participation in combat or support – and the overall lethality of the battlefield as represented by the case fatality rate (CFR) are important in terms of medical planning and allocation of fighting resources.
+For civilian health facilities, the total number of casualties is only one measure ...
+
+=== Chunk 411 ===
+Source: 0973_002-ebook.pdf
+Length: 1913 chars
+
+5.5.1 Warfare scenarios
+The type of warfare greatly influences the kinds of wound the surgeon sees and the anatomic distribution of injuries, which obviously affects hospital workload. The widespread use of anti-personnel blast mines in guerrilla and counter-insurgency warfare results in many traumatic amputations of the legs. Close combat with assault rifles causes many gunshot wounds with severe single injuries; shelling and bombing from a distance produce multiple fragment wounds, many of whi...
+
+=== Chunk 412 ===
+Source: 0973_002-ebook.pdf
+Length: 262 chars
+
+Relevant clinical consequences
+The numbers and relative proportions of civilian and military wounded and dead depend to a large extent on combat strategy and operational tactics, geographical site of fighting, access to medical care and who is winning or losing....
+
+=== Chunk 413 ===
+Source: 0973_002-ebook.pdf
+Length: 2189 chars
+
+5.5.2 Definitions of weapon systems: methodology
+Some confusion arises in surgical literature because of differing categories and definitions for wounding agents and mechanisms of injury: there is no universally accepted standard and the distinction between agent and mechanism is not always made clear.
+“Landmines” include both anti-tank mines (ATM) and anti-personnel mines (APM); the two are not usually differentiated. ATM may be the agent of wounding, but the mechanism of injury can be blast, b...
+
+=== Chunk 414 ===
+Source: 0973_002-ebook.pdf
+Length: 96 chars
+
+Figure 5.3
+Different combat tactics produce very different distributions of wounding agents.
+108...
+
+=== Chunk 415 ===
+Source: 0973_002-ebook.pdf
+Length: 1387 chars
+
+5.5.3 ICRC statistics
+ICRC surgical teams have worked in many different wars and combat scenarios. Table 5.4 shows the mechanism of injury in different types of warfare.
+Hospital N = Fragments % Bullets % Mines % Butare 40 8 92 – Kabul 6,244 52 29 19 Kao-i-Dang 1,067 22 16 63 Kandahar 1,159 24 50 26 Novye Atagi 186 44 35 22 Peshawar 4,340 42 23 35 Quetta 6,570 33 39 28 Lokichokio 12,196 10 87 2 Monrovia (JFK Memorial) 867 38 62 – Peshawar 2 2,964 56 37 6
+Aetiology of war-wounded in a number of I...
+
+=== Chunk 416 ===
+Source: 0973_002-ebook.pdf
+Length: 382 chars
+
+5.6 Anatomic distribution of wounds
+The aetiology of wounds and their anatomic distribution change constantly depending on the development of new weapon systems, personal protective material (body armour), and the nature of combat. One constant, however, is the preponderance of wounds to the limbs amongst survivors. This distribution is important in determining surgical workload....
+
+=== Chunk 417 ===
+Source: 0973_002-ebook.pdf
+Length: 1760 chars
+
+5.6.1 Body exposure
+Body exposure to injury differs according to the type of weapon:
+• anti-personnel blast mines strike the legs (Pattern 1 APM injury);
+• manipulation of mines injures the upper limbs, face and chest (Pattern 3 APM injury) as described in Chapter 3;
+• fragmentation devices spray the whole body with multiple hits in a random fashion.
+EPIDEMIOLOGY
+Body exposure also varies according to the type of combat and military activity:
+• aimed sniper fire targets the head or chest;
+• tren...
+
+=== Chunk 418 ===
+Source: 0973_002-ebook.pdf
+Length: 1640 chars
+
+5.6.2 Definitions and methodology
+The anatomic distribution of wounds has been remarkably consistent over the last century. Reporting, however, has been remarkably inconsistent. Some studies cite only the primary site of injury if there is more than one; others include the category “multiple”. Some count the “wounds” and not the “wounded”, so that sites of injury exceed the number of patients. Many studies do not clearly define the counting method; in some reports only survivors are counted, whi...
+
+=== Chunk 419 ===
+Source: 0973_002-ebook.pdf
+Length: 1884 chars
+
+5.6.3 Historical results
+The reader going through the literature will find very different figures for the same war, depending on the source and the methodology. This can make for frustrating reading. Table 5.6 below nonetheless presents a number of historical approximations. Wounds to the limbs predominate, ranging from 50 % to 79 %.
+Conflict Head & neck % Thorax % Abdomen % Limbs % Other & multiple % World War I (Western Allies) 17 4 2 70 7 World War II (Western Allies) 4 8 4 79 9 World War II ...
+
+=== Chunk 420 ===
+Source: 0973_002-ebook.pdf
+Length: 1060 chars
+
+5.6.4 ICRC results
+The experience of ICRC surgical teams in various conflicts closely mirrors that of surgeons in other wars, particularly in relation to the type of conflict (Table 5.7). Many patients have multiple wounds; the distribution is given for injuries and not for patients, hence more wounds than patients. Only one wound is counted per anatomic region, however.
+EPIDEMIOLOGY
+Pelvis and buttocks, back and soft tissue are given separately. Head, face and neck are not differentiated furthe...
+
+=== Chunk 421 ===
+Source: 0973_002-ebook.pdf
+Length: 1396 chars
+
+5.6.5 Primary tissue injury
+The anatomic distribution of wounds and the analysis of primary tissue injury permit the assessment of the surgical workload. In both, wounds to the limbs predominate. The WDMET13 statistics from Viet Nam are eloquent (Table 5.8), as are the figures from a French military field hospital in Sarajevo, 1992 – 1996, (Table 5.9). The widespread use of improved body armour by American troops in Afghanistan and Iraq has changed certain percentages: note the great decrease in...
+
+=== Chunk 422 ===
+Source: 0973_002-ebook.pdf
+Length: 2573 chars
+
+ICRC results
+In the hospitals included in the ICRC database, where evacuation was difficult for numerous patients and many with minor soft-tissue wounds did not bother to come to hospital, soft-tissue injuries still represented 36 % of wounds, fractures of the extremities 46 % and vital central wounds 20 %.
+13
+In the military literature, the Wound Data and Munitions Effectiveness Team (WDMET) of the United States set a gold standard for data collection. A large number of administrative staff met...
+
+=== Chunk 423 ===
+Source: 0973_002-ebook.pdf
+Length: 1827 chars
+
+5.7.1 Site
+It is not a simple matter to determine cause of death and site of lethal injury. Multiple injuries tend to have a synergetic effect and it can be impossible to define which of several wounds was the direct cause of death. Furthermore, many fatal war injuries involve total body disruption or severe mutilation.
+A formal complete autopsy for every combat death is onerous even for the armed forces of a wealthy industrialized country, and this has rarely been common practice. Three example...
+
+=== Chunk 424 ===
+Source: 0973_002-ebook.pdf
+Length: 383 chars
+
+5.7.2 Trimodal distribution of trauma mortality
+Mortality in civilian trauma was classically described by D. Trunkey in 198323 as falling into three categories: immediate death (50 %), early death (30 %), and late death (20 %), see Figure 5.4.
+Number   of deaths  Immediate deaths  Early deaths  Late deaths  Hour 0  0.5  1  1.5  2  2.5  3  3.5  4  Week 1  2  3  4  Time after injury...
+
+=== Chunk 425 ===
+Source: 0973_002-ebook.pdf
+Length: 539 chars
+
+Peak 1: Immediate deaths
+Most deaths occur at the moment of injury or within minutes. These are due to overwhelming trauma incompatible with life (severe brain injury, massive haemorrhage).
+In war, in addition to severe injuries to the head and torso (heart, liver, and major blood vessels), some casualties suffer total body disruption or incineration through burns. It is estimated that 70 % of deaths occur within five minutes, and little to nothing can be done for these patients, who represent a...
+
+=== Chunk 426 ===
+Source: 0973_002-ebook.pdf
+Length: 584 chars
+
+Peak 2: Early deaths
+These occur between the first minutes and the first few hours after injury. This peak gave rise to the idea of the “golden hour”; if certain measures are implemented rapidly, the patient can be saved.
+In war trauma, there are three major causes of early death:
+• continuing exsanguinating haemorrhage;
+• inadequate/impaired airway due to survivable penetrating head injury;
+• compromised breathing due to tension pneumothorax.
+Many of these early deaths are avoidable within this...
+
+=== Chunk 427 ===
+Source: 0973_002-ebook.pdf
+Length: 373 chars
+
+Peak 3: Late deaths
+These occur a few days to weeks after injury and are the result of subsequent complications of infection, multiple organ failure and coagulopathy, and uncontrollable increased intra-cranial pressure due to post-injury cerebral oedema (closed injury).
+23 Trunkey DD. Trauma. Sci Am 1983; 249: 220 – 227.
+Figure 5.4 Trimodal distribution of trauma deaths....
+
+=== Chunk 428 ===
+Source: 0973_002-ebook.pdf
+Length: 669 chars
+
+Figure 5.4
+113
+WAR SURGERY
+114
+Good and early first-aid measures can decrease infectious and other complications in the setting of armed conflict where wounds are dirty and contaminated from the very beginning. Inadequate early care affects morbidity (sepsis, disability) as well as mortality.
+Understanding this trimodal distribution of deaths stimulated an improvement in emergency medical services and patient transport in civilian settings. Rapid evacuation times and early advanced life support ...
+
+=== Chunk 429 ===
+Source: 0973_002-ebook.pdf
+Length: 909 chars
+
+Applicability to the military war-wounded
+The armed forces have found that the trimodal distribution is relevant to armed conflict. They have tended to underline three categories of patients corresponding to what can be done under various operational scenarios in the field. This has an important influence on field triage categories.
+1. Unsalvageable injuries: i.e. KIA for whom nothing can be done (10 – 20 % depending on use of improved body armour).
+2. Severe but potentially survivable injury (1...
+
+=== Chunk 430 ===
+Source: 0973_002-ebook.pdf
+Length: 1150 chars
+
+Applicability to civilian war-wounded
+During the shelling of the Markale market place in Sarajevo on 28 August 1995, only minutes away from two referral hospitals, 104 persons were injured of whom 42 ultimately died; a fatality rate of 40.8 %.24
+Twenty-three died instantly and another ten were dead on arrival at hospital (79 % of deaths were first peak). Five patients succumbed during surgery (second peak 12 %) and another four a week later (third peak 10 %), as shown in Figure 5.5. The trimodal...
+
+=== Chunk 431 ===
+Source: 0973_002-ebook.pdf
+Length: 245 chars
+
+5.7.3 Ratio of dead to survivors
+Many authors have noted that the ratio of dead to survivors in modern conflicts tends to be about 1:4 over the long term. This corresponds to our threshold fatality rate of about 20 – 25 %.
+Dead = KIA + DOW
+= 1:4...
+
+=== Chunk 432 ===
+Source: 0973_002-ebook.pdf
+Length: 1190 chars
+
+Survivors = WIA – DOW
+Many factors can distort the specific results under given circumstances, including:
+• the inclusion of minor wounds in the calculations – the famous methodological problem;
+• the tactical situation (note the 40 % fatality rate of the Markale market place bombing mentioned above; burn injuries in tank crews or on ships; a successful surprise ambush, etc.);
+• the lethality of particular weapon systems (anti-personnel landmines, napalm, etc.);
+• any delay in medical evacuation...
+
+=== Chunk 433 ===
+Source: 0973_002-ebook.pdf
+Length: 809 chars
+
+5.7.4 Lethality of weapons
+If KIA equals about 20 % and DOW 5 %, this approximates the total lethality of weapons during combat on land (CFR). Sea and air warfare are different.
+It has long been recognized that different weapon systems have different lethality. In
+general, and over a large number of casualties, the percentages are as follows:
+• Military rifle bullets: 30 – 40 % lethality; or one death in every 3 – 4 wounded.
+• Randomly-formed fragments: 20 % for shells and 10 % for grenades.
+• P...
+
+=== Chunk 434 ===
+Source: 0973_002-ebook.pdf
+Length: 106 chars
+
+Figure 5.5
+Trimodal distribution of deaths after shelling of Markale Market, Sarajevo.
+115
+WAR SURGERY
+116...
+
+=== Chunk 435 ===
+Source: 0973_002-ebook.pdf
+Length: 1153 chars
+
+The particular case of anti-personnel landmines
+All studies indicate the heavy surgical and nursing burden of injuries due to anti- personnel landmines, especially blast mines. Specific types of APM – bounding mines that jump up one metre in the air before exploding – invariably kill their victim: lethality lies close to 100 %.
+Public health studies and ICRC surveys in poor countries where APM have been widely used in rural areas with little or no organized evacuation system and limited surgical...
+
+=== Chunk 436 ===
+Source: 0973_002-ebook.pdf
+Length: 1814 chars
+
+5.7.5 Conclusions of clinical relevance
+From this analysis and further extrapolations a number of conclusions can be drawn.
+1. Wounds to the head and torso are the most lethal; they represent most of the mortality. The great majority of survivors have injuries to the limbs; they represent the majority of surgical workload and morbidity.
+2. Despite the fact that the head represents only 9 % of exposed body surface area, it accounts for a disproportionate number (25 %) of all battle casualties. Th...
+
+=== Chunk 437 ===
+Source: 0973_002-ebook.pdf
+Length: 494 chars
+
+Conclusions for improvement of patient outcome
+1. Some immediate and early deaths can be prevented by personal protective armour covering the torso.
+2. Many early deaths can be prevented by simple measures to:
+• control limb haemorrhage;
+• relieve airway obstruction, especially in comatose patients after head injury;
+• relieve tension pneumothorax.
+3. Some early deaths due to haemorrhage, particularly of the abdomen, can be prevented by rapid evacuation to a surgical facility.
+EPIDEMIOLOGY...
+
+=== Chunk 438 ===
+Source: 0973_002-ebook.pdf
+Length: 839 chars
+
+5.8.1 Historical developments
+Possibly one of the most important developments in combat casualty care over the last half-century has been improved pre-hospital care and the timely evacuation of the wounded to a surgical facility. Lasting days during much of World War I, evacuations took an average of 10.5 hours during World War II; the use of helicopters by American troops lowered this to 6.3 hours in Korea and to an average of 2.8 hours in Viet Nam. Transfer of Israeli wounded during the 1982 w...
+
+=== Chunk 439 ===
+Source: 0973_002-ebook.pdf
+Length: 1504 chars
+
+5.8.2 Forward projection of resources
+Delayed evacuation may still result from operational contingencies, tactical situations, and difficult geography. Consequently, many armies have projected their surgical capacities forward, close to zones of actual combat, in an attempt to reach wounded soldiers earlier and avoid the mortality and morbidity related to any delay. The aim is primarily to reduce the number of “early” deaths.
+Soviet deployment of “Special Surgical Teams” in forward locations in ...
+
+=== Chunk 440 ===
+Source: 0973_002-ebook.pdf
+Length: 1149 chars
+
+5.8.3 Urban warfare: hospitals on front lines
+During urban warfare, fighting can take place literally in front of surgical facilities; more than once has a patient been wounded at the front door of a hospital. This was the case during much of the fighting in Beirut in the Lebanese civil war, often with evacuation times of only minutes. A French medical team in Sarajevo in 1992 – 96 (UNPROFOR – IFOR), serving military and civilian casualties, had evacuation times of 15 – 45 minutes.
+Comparable ti...
+
+=== Chunk 441 ===
+Source: 0973_002-ebook.pdf
+Length: 1839 chars
+
+5.8.4 The paradox of early treatment: changing mortality ratios and rates
+There is an apparent paradox as regards early evacuation and treatment: an increase in the absolute numbers who survive, but also an increase in the DOW and hospital mortality rates. Medics reach more injured patients in time who would have been KIA a few years ago, and a larger number of severely injured casualties enter the evacuation chain. However, this means that the natural automatic triage that weeded out the more s...
+
+=== Chunk 442 ===
+Source: 0973_002-ebook.pdf
+Length: 1876 chars
+
+A new ratio: critical area to extremity wounds
+A statistical method has been used to try to overcome this “bias” of logistical progress, in order to better evaluate the effect of “natural triage” due to a lack of appropriate surgical care and evacuation facilities in low-income countries. In such conditions pre-hospital mortality cannot be properly determined either. The ratio of wounds in critical areas (trunk, head and neck) to wounds of the extremities is calculated among survivors: CA: EXT:
+...
+
+=== Chunk 443 ===
+Source: 0973_002-ebook.pdf
+Length: 1097 chars
+
+5.9.1 Historical considerations
+As mentioned, rates of killed in action for armies have remained relatively stable over the last half-century at about 20 %. Hospital mortality, however, has diminished greatly with medical progress (safe anaesthesia, blood transfusion, better understanding of the physiology of shock, antibiotics and more aggressive surgical techniques) as shown in Table 5.17.
+Hospital mortality rate % 16.7 14.1 8.6 7.6 4.5 2.5
+Conflict
+Crimean War 1854 – 55 (UK casualties)
+Americ...
+
+=== Chunk 444 ===
+Source: 0973_002-ebook.pdf
+Length: 1314 chars
+
+5.9.2 Hospital mortality versus post-operative mortality
+A number of considerations must be taken into account if one wishes to use hospital mortality as an indication of the efficiency of patient management systems. In armed conflict, surgeons often face mass casualties. Some patients will be triaged into Category IV, and given supportive treatment only, to die without pain and with dignity (see Chapter 9). These patients are recorded as DOW and are often included in hospital mortality figures....
+
+=== Chunk 445 ===
+Source: 0973_002-ebook.pdf
+Length: 607 chars
+
+5.9.3 ICRC hospital mortality
+Austere working conditions, often a limited number of professional staff and at times a perilous security situation, all mean that work in ICRC hospitals resembles that commonly seen in public hospitals in a poor country. Military medical services from industrialized countries may also face these constraints, but they tend to be of a different order of magnitude.
+Post-operative mortality in ICRC hospitals varies from 2.2 % in Quetta and 3.1 % in Peshawar to 4.2 % in...
+
+=== Chunk 446 ===
+Source: 0973_002-ebook.pdf
+Length: 2114 chars
+
+5.10.1 Surgical audit: methodology
+Without control over the pre-hospital phase and the known inadequacies of data collection, the mortality rate is not a credible statistic in ICRC surgical programmes and hospitals. The same is true of most public civilian facilities. Far more substantial is the workload and morbidity, as represented by the number of operations and blood transfusions per patient and the duration of hospitalization.
+For statistical purposes, most patients, if well managed, underg...
+
+=== Chunk 447 ===
+Source: 0973_002-ebook.pdf
+Length: 818 chars
+
+5.10.2 Number of operations per patient: all patients
+The number of operations per patient for all patients with the relevant information in the ICRC database is given in Table 5.18.
+None 9 % 1 operation 16 % 2 operations 41 % < 2 operations 66 % 3 operations 14 % > 4 operations 20 %
+Table 5.18 Number of operations per patient (N = 16,172).
+To simplify, the number of operations is described as two or less, three, or four and more (Figure 5.6).
+Fully two-thirds of all patients in the database had...
+
+=== Chunk 448 ===
+Source: 0973_002-ebook.pdf
+Length: 1336 chars
+
+5.10.3 Number of operations according to delay in evacuation
+Table 5.19 shows the results for the number of operations per patient according to evacuation time to the ICRC hospital in Kabul during a period of major urban combat.
+Evacuation time N = 6,140 None 1 op 2 ops ≤ 2 ops 3 ops ≥ 4 ops < 6 hrs 3,214 7 % 30 % 47 % 84 % 7 % 8 % 6 – 24 hrs 1,606 7 % 23 % 51 % 81 % 9 % 11 % 24 – 72 hrs 605 6 % 24 % 50 % 80 % 7 % 12 % > 72 hrs 715 9 % 26 % 42 % 77 % 9 % 14 %
+Table 5.19 Number of operations per ...
+
+=== Chunk 449 ===
+Source: 0973_002-ebook.pdf
+Length: 520 chars
+
+5.10.4 Number of operations according to the Red Cross Wound Grade
+War wounds are categorized into one of three Grades of increasing severity according to the Red Cross Wound Score and classification system (see Chapter 4). The distribution in the ICRC surgical database is as follows.
+• Grade 1: 42 %.
+• Grade 2: 37 %.
+• Grade 3: 21 %.
+If one looks at the number of operations according to Wound Grade, an important difference appears (Table 5.21 and Figures 5.7.1 – 5.7.3).
+≥ 4 ops  (20%)  3 ops  (...
+
+=== Chunk 450 ===
+Source: 0973_002-ebook.pdf
+Length: 111 chars
+
+Figure 5.6
+Number of operations per patient, simplified (N = 16,172).
+≥ 4 ops  3 ops  (7%)  (9%)  ≤2 ops  (84%)...
+
+=== Chunk 451 ===
+Source: 0973_002-ebook.pdf
+Length: 121 chars
+
+Figure 5.7.1
+Number of operations per patient for Grade 1 wounds (N = 6,729).
+≥ 4 ops  (23%)  3 ops  (16%)  ≤2 ops  (61%)...
+
+=== Chunk 452 ===
+Source: 0973_002-ebook.pdf
+Length: 121 chars
+
+Figure 5.7.2
+Number of operations per patient for Grade 2 wounds (N = 5,974).
+≥ 4 ops  (41%)  ≤2 ops  (40%)  3 ops  (19%)...
+
+=== Chunk 453 ===
+Source: 0973_002-ebook.pdf
+Length: 619 chars
+
+Figure 5.7.3
+Number of operations per patient for Grade 3 wounds (N = 3,469).
+121
+WAR SURGERY
+122
+Severity of wound Number of operations per patient Patients None 1 op 2 ops ≤ 2 ops 3 ops ≥ 4 ops (N =16,172) % % % % % % Grade 1 n = 6,729 16 23 45 84 9 7 Grade 2 n = 5,974 4 12 44 61 16 23 Grade 3 n = 3,469 3 7 30 40 19 41
+Table 5.21 Number of operations per patient according to Red Cross Wound Grade.
+The number of operations required differs substantially according to RCWS grade. Surgical workloa...
+
+=== Chunk 454 ===
+Source: 0973_002-ebook.pdf
+Length: 1171 chars
+
+5.10.5 Number of operations according to Wound Grade and delay in evacuation
+If one now analyses the number of operations by combining the RCWS Wound Grade and the delay in evacuation, the results are telling (Table 5.22).
+Grade and evacuation time Number of patients ≤ 2 operations 3 operations ≥ 4 operations Grade 1 N = 6,729 < 6 hrs 1,124 93 % 5 % 3 % 6 – 24 hrs 1,694 84 % 9 % 7 % 24 – 72 hrs 1,182 82 % 11 % 7 % > 72 hrs 2,729 82 % 10 % 9 %
+Grade 2 N = 5,974 < 6 hrs 788 77 % 11 % 12 % 6 – 24 h...
+
+=== Chunk 455 ===
+Source: 0973_002-ebook.pdf
+Length: 1487 chars
+
+5.10.6 Number of operations according to weapon
+The results of an analysis of ICRC hospitals treating a variety of weapon-induced injuries (Kabul, Kandahar, Kao-i-Dang, Novye Atagi, Peshawar, and Quetta), are presented in Table 5.23.
+No distinction is made in the ICRC database between anti-personnel and anti-tank mines, or unexploded ordnance. Furthermore, some wounds classified as being caused by fragments may well have been from fragmentation anti-personnel mines. Hospital staff have only the ...
+
+=== Chunk 456 ===
+Source: 0973_002-ebook.pdf
+Length: 1447 chars
+
+5.11 Conclusions: lessons to be gained from a study of epidemiology
+From this brief overview of the epidemiology of the victims of war, a few conclusions affecting clinical work and humanitarian action may be drawn.
+1. For a civilian population in a poor country, the public health effects of war are usually greater than the effects of direct trauma. In some conflicts, war injuries carry a greater burden and post-traumatic morbidity may have more profound long-term effects than mortality. This is...
+
+=== Chunk 457 ===
+Source: 0973_002-ebook.pdf
+Length: 1527 chars
+
+Figure 5.8
+Number of operations per patient according to weapon, simplified.
+123
+WAR SURGERY
+124
+4. An efficient first-aid and evacuation system can prevent deaths from controllable haemorrhage and compromised airway. As pre-hospital care improves, the “killed in action” or “dead on arrival” may diminish slightly, only to see the “died of wounds” and hospital mortality rise; more casualties are saved, but the rates become distorted. This bias should be taken into account when judging the adequac...
+
+=== Chunk 458 ===
+Source: 0973_002-ebook.pdf
+Length: 395 chars
+
+5.11.1 Setting up a surgical database for the war-wounded
+Various military medical services have their own categories and charts for data collection. The ICRC offers civilian health facilities an example of categories that could be placed in a simple spreadsheet to allow the collection of data for further study (see ANNEX 5. B: Setting up a surgical database for the war-wounded).
+EPIDEMIOLOGY...
+
+=== Chunk 459 ===
+Source: 0973_002-ebook.pdf
+Length: 3908 chars
+
+ANNEX 5. A ICRC surgical database
+The ICRC set up a centralized wound database and trauma registry in 1990, originally designed to give the organization an indication of the surgical workload of its independent hospitals (i.e. hospitals that were established and run under ICRC administration). All war-wounded patients admitted to ICRC hospitals have routinely had a data form filled out on their death or discharge. Patients are not asked whether they are combatants or civilians.
+Age and sex, the ...
+
+=== Chunk 460 ===
+Source: 0973_002-ebook.pdf
+Length: 396 chars
+
+ANNEX 5. B Setting up a surgical database for the war-wounded
+The following categories can be recorded using database software or a spreadsheet. If a spreadsheet is used, the categories should be entered across the columns of the top row, with the patients recorded in the rows.
+Lessons have been learnt from shortcomings in the ICRC surgical database: this version has been modified accordingly....
+
+=== Chunk 461 ===
+Source: 0973_002-ebook.pdf
+Length: 267 chars
+
+Administrative data
+• hospital (if the database contains patients from more than one hospital)
+• patient hospital number
+• database number
+• date of admission
+• date of discharge
+• number of days hospitalized
+• re-admission of patient for the same injury?
+• age
+• sex...
+
+=== Chunk 462 ===
+Source: 0973_002-ebook.pdf
+Length: 95 chars
+
+Time since injury
+• hours (or < 6 ; 6 – 12 ; 12 – 24)
+• days (or 24 – 72 hrs ; >72 hrs)
+• weeks...
+
+=== Chunk 463 ===
+Source: 0973_002-ebook.pdf
+Length: 246 chars
+
+Weapon causing injury
+• firearm (rifle, pistol, machine gun, shotgun)
+• bomb, shell, mortar, grenade
+• anti-personnel mine (APM)
+• anti-tank mine (ATM)
+• unexploded ordnance (UXO), including cluster bombs
+• “arme blanche”: bayonet, machete, panga...
+
+=== Chunk 464 ===
+Source: 0973_002-ebook.pdf
+Length: 69 chars
+
+Mechanism of injury
+• gunshot (GSW)
+• fragment
+• blast
+• blunt
+• burn...
+
+=== Chunk 465 ===
+Source: 0973_002-ebook.pdf
+Length: 187 chars
+
+Clinical data
+• blood pressure on admission
+• number of operations
+• number of anaesthesias
+• number of units of blood transfused
+• outcome: healed, complications, death (including cause)...
+
+=== Chunk 466 ===
+Source: 0973_002-ebook.pdf
+Length: 358 chars
+
+Anatomic data
+Site of injury: if more than one, each injury is given a number and the appropriate number put in the column for the anatomic region. Only one injury per anatomic region is noted.
+• head
+• face
+• neck
+• thorax
+• abdomen
+• pelvis, buttocks
+• back and soft tissue of torso
+• upper limb left
+• upper limb right
+• lower limb left
+• lower limb right...
+
+=== Chunk 467 ===
+Source: 0973_002-ebook.pdf
+Length: 509 chars
+
+Red Cross Wound Score
+This should be entered for the two most important wounds, more if so desired. Wound 1 should correspond to Anatomic Region 1; Wound 2 should correspond to Anatomic Region 2.
+• Wound 1: Entry
+• Wound 1: Exit
+• Wound 1: Cavity
+• Wound 1: Fracture
+• Wound 1: Vital injury
+• Wound 1: Metallic fragment
+• Wound 1: Grade
+• Wound 1: Type
+• Wound 2: Entry
+• Wound 2: Exit
+• Wound 2: Cavity
+• Wound 2: Fracture
+• Wound 2: Vital injury
+• Wound 2: Metallic fragment
+• Wound 2: Grade
+• Woun...
+
+=== Chunk 468 ===
+Source: 0973_002-ebook.pdf
+Length: 337 chars
+
+Major operation
+• craniotomy
+• thoracotomy
+• chest tube
+• laparotomy
+• peripheral vascular repair
+• amputation above-elbow left
+• amputation above-elbow right
+• amputation below-elbow left
+• amputation below-elbow right
+• amputation above-knee left
+• amputation above-knee right
+• amputation below-knee left
+• amputation below-knee right...
+
+=== Chunk 469 ===
+Source: 0973_002-ebook.pdf
+Length: 37 chars
+
+Comments
+EPIDEMIOLOGY
+129
+5
+Chapter 6...
+
+=== Chunk 470 ===
+Source: 0973_002-ebook.pdf
+Length: 1007 chars
+
+THE CHAIN OF CASUALTY CARE
+6
+WAR SURGERY
+132
+6 THE CHAIN OF CASUALTY CARE 6.1 The links: what kind of care, and where? 6.1.1 Protection: IHL 6.1.2 Levels and locations of medical care 6.2 Surgical hospital treating the war-wounded 6.2.1 Hospital A: rural hospital = basic trauma services 6.2.2 Hospital B: provincial hospital = advanced trauma services 6.2.3 Hospital C: major city hospital = comprehensive trauma services 6.2.4 Hospital assessment 6.3 Transport 6.3.1 Command, control and communicat...
+
+=== Chunk 471 ===
+Source: 0973_002-ebook.pdf
+Length: 1722 chars
+
+The links: what kind of care, and where?
+Modern armed conflict embraces conventional war between conventional armies, urban combat between militias, and isolated and sporadic but fierce guerrilla attacks in remote rural areas. It may involve mass conflict or chronic irregular, low-intensity combat, or individual terrorist attacks. Civilians often represent the majority of victims (see Chapter 5). Field situations vary considerably, but basic medical problems for the wounded are universal. A syst...
+
+=== Chunk 472 ===
+Source: 0973_002-ebook.pdf
+Length: 1166 chars
+
+6.1.1 Protection: IHL
+Protection and prevention from further injury come first and foremost in patient care.
+Article 3 common to the four Geneva Conventions and   article 7 of Additional Protocol II:  “The wounded and sick shall be collected and cared for.”
+The wounded and sick have the right to be cared for and to have access to appropriate medical care. The red cross, red crescent and red crystal emblems symbolize the legal protection afforded the casualty and the medical personnel, who have t...
+
+=== Chunk 473 ===
+Source: 0973_002-ebook.pdf
+Length: 2083 chars
+
+6.1.2 Levels and locations of medical care
+The following list defines the generic places where the wounded receive different levels of medical care in the multiple-phase treatment of war wounds.
+1. On the spot: first aid.
+2. Collection point: first aid with/without resuscitation.
+3. Intermediate stage: resuscitation with/without emergency surgery.
+4. Surgical hospital: primary surgical treatment.
+5. Specialized centre: definitive surgical treatment including reconstructive procedures, physiother...
+
+=== Chunk 474 ===
+Source: 0973_002-ebook.pdf
+Length: 102 chars
+
+Figure 6.3
+Transfer of patients to the ICRC hospital in Peshawar, Pakistan.
+THE CHAIN OF CASUALTY CARE...
+
+=== Chunk 475 ===
+Source: 0973_002-ebook.pdf
+Length: 510 chars
+
+Surgical hospital treating the war-wounded
+The level of sophistication of hospital care will depend on the degree of socio- economic development within the country before conflict breaks out. War will then usually degrade the functioning of any pre-existing hospital. Efficient evacuation of the wounded to deficient surgical facilities is not an effective chain of casualty care.
+Levels of hospital competency differ from country to country and between geographic regions. Three basic levels can be ...
+
+=== Chunk 476 ===
+Source: 0973_002-ebook.pdf
+Length: 652 chars
+
+6.2.1 Hospital A: rural hospital = basic trauma services
+A district hospital (Africa) or primary health centre (South Asia) without full-time specialist doctors, especially without a fully-trained general surgeon, is a typical example. These hospitals are usually staffed by general practitioners or medical assistants with some surgical training and equipped with a minimum of proper surgical facilities. Front-line hospitals with “field surgeons”1 exist in some military medical services and are th...
+
+=== Chunk 477 ===
+Source: 0973_002-ebook.pdf
+Length: 434 chars
+
+6.2.2 Hospital B: provincial hospital = advanced trauma services
+A regional hospital (Africa), district hospital (South Asia), or general hospital (Latin America) has a full-time general surgeon and proper operating theatre and sterilization facilities. Most life-threatening conditions can be dealt with adequately. The military equivalent is usually a forward field hospital specializing in damage control and resuscitative surgery....
+
+=== Chunk 478 ===
+Source: 0973_002-ebook.pdf
+Length: 374 chars
+
+6.2.3 Hospital C: major city hospital = comprehensive trauma services
+This is a referral facility offering a broad range of specializations and sub- specializations and usually represents the highest level of care in the country or administrative region. It is often a teaching or university hospital. In military terms, this is a referral facility far from the front lines....
+
+=== Chunk 479 ===
+Source: 0973_002-ebook.pdf
+Length: 1226 chars
+
+6.2.4 Hospital assessment
+ICRC programmes aim to maintain, and upgrade if possible, the competencies of these different levels of hospital care when necessary. The ICRC has developed an analytical tool for assessing the quality of hospital management and surgical work prior to providing assistance. This tool comprises a number of factors to be considered. There are factors external to the hospital, involving an analysis of the national and provincial health systems, and internal factors: hospita...
+
+=== Chunk 480 ===
+Source: 0973_002-ebook.pdf
+Length: 594 chars
+
+Figure 6.6
+Assessment of a surgical hospital caring for the war-wounded.
+Assessment results of a typical hospital in a low-income country disrupted by war, causing disorganization in the hospital.
+T.Gassmann /ICRC
+Figure 6.7.1
+The pie-charts above show the various factors that affect the functioning of a hospital dealing with the added burden of war-wounded patients, compounded by the constraints of a weakened health system, and help identify dysfunctional areas. An additional factor is the emot...
+
+=== Chunk 481 ===
+Source: 0973_002-ebook.pdf
+Length: 736 chars
+
+6.3 Transport
+C
+Petridis ICRC
+R
+C
+I
+/
+s
+i
+d
+i
+r
+t
+e
+P
+.
+L
+National Society volunteers transporting patients by boat.
+Transport of some sort provides the connection between the different echelons of the chain of casualty care. Moving a patient has a price: transportation is a trauma in itself. It uses up additional resources and involves security risks (“mortality of the ambulance ride”), and perhaps even exposure to military activity. These extra costs must be weighed up against the likely benef...
+
+=== Chunk 482 ===
+Source: 0973_002-ebook.pdf
+Length: 103 chars
+
+Figure 6.7.2
+Medical evacuation by plane from southern Sudan to the ICRC hospital in Lokichokio, Kenya....
+
+=== Chunk 483 ===
+Source: 0973_002-ebook.pdf
+Length: 1077 chars
+
+6.3.1 Command, control and communications: coordination
+C
+2
+R
+C
+I
+/
+n
+n
+a
+m
+s
+s
+a
+6 Fi
+G
+.
+T
+Figure 6.7.3
+National Society “Zero Mobile” horse-drawn carriage ambulance.
+A chain of command is necessary to make the various echelons function correctly. A central command or dispatch centre will assume overall coordination (e.g. decisions about transfer/evacuation destinations, engagement of resources, etc.), and be responsible for contacts with related command levels of various authorities (e.g. arm...
+
+=== Chunk 484 ===
+Source: 0973_002-ebook.pdf
+Length: 4126 chars
+
+Forward projection of resources
+Bringing more than basic first aid closer to the collection point is called “forward projection of resources”. The availability of advanced procedures closer to the battlefield has many advantages. It allows quicker access to “life- and limb-saving” emergency measures, thus decreasing both mortality and morbidity. The need for potentially dangerous transport is reduced. The projection of resources applies particularly to treatment at the intermediate stage, but ca...
+
+=== Chunk 485 ===
+Source: 0973_002-ebook.pdf
+Length: 3169 chars
+
+6.5 The reality: common war scenarios
+As mentioned in Chapter 1, there is more than one “surgery” for the care of the war- wounded. The exact number of levels of care and the path followed by casualties are determined on a case-by-case basis according to the sophistication of care and logistics available. In some armies or countries, the organization may be so efficient that a wounded soldier may expect to receive treatment virtually as sophisticated as the care available to him in peacetime.
+In...
+
+=== Chunk 486 ===
+Source: 0973_002-ebook.pdf
+Length: 491 chars
+
+Conflict preparedness and implementation
+Every country should have a disaster plan. Part of emergency preparedness is the capacity to respond to armed conflict, internal disturbances or natural disasters. This is normal procedure for most armed forces. Ministries of public health and National Red Cross/Red Crescent Societies usually also have a disaster plan, which should be integrated into the national emergency preparedness programme.
+Figure 6.8 The ICRC Field Surgical Team in Darfur....
+
+=== Chunk 487 ===
+Source: 0973_002-ebook.pdf
+Length: 3308 chars
+
+Figure 6.8
+The objective of planning is to ensure that wounded people get the right care, at the right place, and at the right time.
+Those who have to face the challenges of armed conflict should understand how to proceed in setting up a chain of casualty care. The best possible outcome for wounded people can only be achieved with proper planning and training. Plans must be realistic, flexible and reviewed regularly. Should a country be caught unawares at the outbreak of hostilities without havi...
+
+=== Chunk 488 ===
+Source: 0973_002-ebook.pdf
+Length: 1245 chars
+
+The pyramid of ICRC surgical programmes
+ICRC delegates are often called upon to help organize a chain of casualty care. At times this will be in support of existing governmental or non-governmental facilities. On occasion, the ICRC is required or asked to establish its own independently-run hospitals. The main reasons for doing so are either a question of protection – of the patients or medical services – or because of a dire shortage of local personnel.
+Unlike a military field hospital, an inde...
+
+=== Chunk 489 ===
+Source: 0973_002-ebook.pdf
+Length: 359 chars
+
+Figure 6.9
+The ICRC surgical pyramid. A number of factors are taken into consideration to ensure the neutrality and independence of ICRC activities on the one hand, and the quality and professionalism of care on the other. The same logic applies to other humanitarian agencies. These factors are summarized in this pyramid and the checklist in Section 6.7.1 ....
+
+=== Chunk 490 ===
+Source: 0973_002-ebook.pdf
+Length: 696 chars
+
+Political and operational considerations
+• Perception of neutrality and impartiality, i.e. ICRC image.
+• Acceptability of the ICRC by political factions, the armed forces and the population.
+• Possibility for negotiations: availability of and access to interlocutors (ministries of health, defence, foreign affairs and interior, faction chiefs); contacts with owners of facilities to be rented.
+• Role of the hospital in the protection of hospitalized patients.
+• Role of the hospital in protecting m...
+
+=== Chunk 491 ===
+Source: 0973_002-ebook.pdf
+Length: 418 chars
+
+Security
+• Hospital and staff security concerns owing to the conflict or possible developments in the fighting:
+- location and environment, i.e. distance from hostilities or military targets;
+- type of building, i.e. number of storeys, ground floor, underground cellar or bomb shelter, tents.
+• Incidence of banditry, hostage-taking, etc.
+• Patients’ safety, inside the hospital and upon discharge.
+141
+WAR SURGERY
+142...
+
+=== Chunk 492 ===
+Source: 0973_002-ebook.pdf
+Length: 341 chars
+
+Access
+• Distance and evacuation time.
+• Availability of means of transportation: roads, vehicles, air evacuation.
+• Safety of roads and checkpoints: military activity, political affiliation, banditry.
+• Possibility of setting up a system of first-aid posts.
+• Logistics: medical supply, fuel, food (local, regional, from ICRC headquarters)....
+
+=== Chunk 493 ===
+Source: 0973_002-ebook.pdf
+Length: 338 chars
+
+Infrastructure
+• Pre-existing hospital structure.
+• Building capable of being transformed into a hospital (school, factory); structural integrity, possibility of expansion.
+• Use of tents, prefabricated and/or temporary structures.
+• Water and sanitation, electricity.
+• Facilities: kitchen, laundry, residence for personnel.
+• Warehouse....
+
+=== Chunk 494 ===
+Source: 0973_002-ebook.pdf
+Length: 484 chars
+
+Local and expatriate personnel
+• Availability and number of local and expatriate Red Cross/Red Crescent medical personnel.
+• Recruitment of new national staff and the question of neutrality.
+• Professional competence and level of education.
+• Language problems: need for translators/interpreters.
+• Availability of support personnel: ICRC delegates, medical and general administration, water and sanitation engineers, builders, mechanics, electricians, etc.
+THE CHAIN OF CASUALTY CARE...
+
+=== Chunk 495 ===
+Source: 0973_002-ebook.pdf
+Length: 862 chars
+
+ANNEX 6. A Initial assessment of a surgical hospital treating the war-wounded
+This form should be regarded as a guide, a kind of checklist, to help the health professional responsible for the assessment of the hospital remember certain key points.
+Its purpose is to give a quick overview and understanding of the functioning of the hospital; to identify its capacity, limits and insufficiencies. It should allow for rapid and adequate decisions about the kind of support the hospital might need.
+The ...
+
+=== Chunk 496 ===
+Source: 0973_002-ebook.pdf
+Length: 251 chars
+
+The assessment is divided into six sections
+General
+Management and administration (including non-medical support services)
+Medical support services
+Clinical services (only the surgical component is dealt with in this annex)
+Further comments
+Conclusion...
+
+=== Chunk 497 ===
+Source: 0973_002-ebook.pdf
+Length: 993 chars
+
+General
+Name of the hospital:
+Town:
+Town:
+Country:
+Assessment done by:
+Date:
+Interlocutors:
+1. Type (MoPH, private, military, missionary, NGO, other):
+2. Catchment population:
+3. Assistance from entities other than the authority in charge:
+4. Level of reference (rural, district, regional):
+5. If rural or district hospital, number of primary facilities served (first-aid posts, dispensaries, health centres):
+6. Possibilities for further referral:
+7. Transport system for patients (in and out):
+8. R...
+
+=== Chunk 498 ===
+Source: 0973_002-ebook.pdf
+Length: 99 chars
+
+I General management
+1. Set-up (management team/board):
+2. How are decisions taken and implemented?...
+
+=== Chunk 499 ===
+Source: 0973_002-ebook.pdf
+Length: 242 chars
+
+II Personnel management
+1. Who is in charge?
+2. Do the staff receive salary/incentives?
+3. Total number of personnel/breakdown by function (MD, medical assistants, nurses, students, etc.):
+4. Is there a roster system in place in the hospital?...
+
+=== Chunk 500 ===
+Source: 0973_002-ebook.pdf
+Length: 199 chars
+
+III Financial management
+1. Management of finance (Is there a budget? How is the hospital financed?):
+2. Is there any cost participation, “cost-recovery system”? Do the destitute have access to care?...
+
+=== Chunk 501 ===
+Source: 0973_002-ebook.pdf
+Length: 589 chars
+
+IV Statistics
+1. Management of statistics and reporting:
+2. Are statistics available?
+3. Is there an annual report?
+4. Are there people specifically in charge of collecting data?
+V Infrastructure & utilities (general condition of):
+1. Walls and roof:
+2. Water (running water, wells, safety of water supply, etc.):
+3. Sanitation (type of toilets, etc.):
+4. Electricity and/or generator (number of hours per day, fuel supply, etc.):
+5. Heating/ventilation/air-conditioning:
+6. Maintenance team (number,...
+
+=== Chunk 502 ===
+Source: 0973_002-ebook.pdf
+Length: 143 chars
+
+VI Waste disposal
+1. Waste management systems (including toxics such as X-ray developer/fixator, etc.):
+2. Incinerator (type, condition, etc.):...
+
+=== Chunk 503 ===
+Source: 0973_002-ebook.pdf
+Length: 362 chars
+
+VII Non-medical support services
+1. Kitchen (staff, nutritionist, origin of food, number of meals served per day, special diets, etc.):
+2. Laundry (staff, washing by hand, machine, supplies, etc.):
+3. Tailor (staff, supplies, etc.):
+4. Cleaning and hygiene (system, staff, supplies, etc.):
+5. Morgue (infrastructure, management, etc.):
+THE CHAIN OF CASUALTY CARE...
+
+=== Chunk 504 ===
+Source: 0973_002-ebook.pdf
+Length: 571 chars
+
+I Pharmacy
+1. Pharmacy staff and management:
+2. Is there a standard list of medicines?
+3. Are stock cards used?
+4. Where do the drugs and medical equipment come from (regular supplier, local market, donations, etc.)?
+5. Is there a reliable system of communication between the pharmacy and the wards (request forms, delivery forms, etc.)?
+6. Did the pharmacy run out of basic drugs last month (penicillin, anti-malaria, paracetamol, ORS)?
+7. What are the storage conditions (air-conditioning, refriger...
+
+=== Chunk 505 ===
+Source: 0973_002-ebook.pdf
+Length: 356 chars
+
+II Laboratory
+1. Laboratory staff and management:
+2. Tests available (haematology, chemistry, parasitology, bacteriology, serology, etc.):
+3. Source of supplies:
+4. Is there a reliable system of communication between the laboratory and the wards (request and results forms)?
+5. Quality of the working relationship between the clinical and laboratory staff:...
+
+=== Chunk 506 ===
+Source: 0973_002-ebook.pdf
+Length: 302 chars
+
+III Blood transfusion
+1. Staff and management:
+2. Policy of blood sampling and transfusion: HIV/AIDS policy?
+3. Indications for blood transfusion/average number of requests:
+4. How are the blood units kept? Is there a functioning refrigerator to store the blood?
+5. Testing process and quality control:...
+
+=== Chunk 507 ===
+Source: 0973_002-ebook.pdf
+Length: 238 chars
+
+IV Imaging (X-ray & ultrasound)
+1. Staff and management:
+2. Average number of X-rays per day:
+3. Type and quality of machine(s):
+4. Are there guidelines for the prescription of X-rays?
+5. Is more sophisticated imaging equipment available?...
+
+=== Chunk 508 ===
+Source: 0973_002-ebook.pdf
+Length: 68 chars
+
+V Other diagnostic services
+1. ECG, EEG, etc.:
+145
+6
+WAR SURGERY
+146...
+
+=== Chunk 509 ===
+Source: 0973_002-ebook.pdf
+Length: 530 chars
+
+I Outpatient department (OPD)
+1. Role of the OPD (consultation, follow-up of patients, admission, emergency):
+2. Are there specialized OPDs?
+3. Are there criteria for admitting the patient to the OPD?
+4. Is there a register with data about all patients seen every day?
+5. Average number of cases seen every day (medical, paediatric, surgery, obstetric, etc.):
+6. Personnel in charge (MD, medical assistants, nurses):
+7. Is there a clear roster?
+8. Opening days and hours:
+9. Main pathologies:
+10. Acc...
+
+=== Chunk 510 ===
+Source: 0973_002-ebook.pdf
+Length: 433 chars
+
+II Admission/emergency department
+1. Number of beds:
+2. Is there a team on duty 24 hours a day; composition of the team?
+3. Is there an on-call system in place?
+4. Is there an admission book or regular procedure for admitting and registering patients?
+5. Is there a regular procedure for sending patients to the appropriate wards or to the OT?
+6. Number and type of emergencies per day:
+7. Are basic supplies and equipment available?...
+
+=== Chunk 511 ===
+Source: 0973_002-ebook.pdf
+Length: 544 chars
+
+III Operating theatre (OT)
+1. Staff and roster:
+2. Hygiene of the OT:
+3. Is there an accurate operation book? If yes, number of surgical operations in the last month:
+4. What kind of surgery is performed?
+5. What kind of instruments and sets are available (laparotomy, caesarean section, debridement, skeletal traction sets, etc.)?
+6. Number of operating rooms, tables:
+7. Surgical linen (availability and source of provision):
+8. Functioning surgical equipment (lamps, suction, diathermy, oxygen, et...
+
+=== Chunk 512 ===
+Source: 0973_002-ebook.pdf
+Length: 125 chars
+
+IV Sterilization
+1. Staff and roster:
+2. Equipment (autoclaves, dry ovens):
+3. Protocols in place?
+THE CHAIN OF CASUALTY CARE...
+
+=== Chunk 513 ===
+Source: 0973_002-ebook.pdf
+Length: 355 chars
+
+V Anaesthesia
+1. Staff and roster (MD and/or anaesthetist nurses):
+2. Is a laparotomy performed safely with full muscle relaxation (including endotracheal intubation) by a trained anaesthetist?
+3. Common anaesthesia (gas, ketamine, spinal, local):
+4. Types of anaesthesia machine:
+5. Availability of other equipment (pulse oxymeters, oxygen supply, etc.):...
+
+=== Chunk 514 ===
+Source: 0973_002-ebook.pdf
+Length: 507 chars
+
+VI Nursing care
+1. Is there 24-hour nursing supervision in the wards?
+2. Are the patient records complete?
+3. Is the nursing handover book used properly?
+4. Are drugs administered on time?
+5. Is a laparotomy performed safely with the patient supervised (vital signs) for 24 hours post-operatively in a room with light, and where he or she receives intravenous fluids and antibiotics?
+6. What do dressings look like (clean, smelly, etc.)?
+7. Are bedsores a problem?
+8. Are relatives involved in patien...
+
+=== Chunk 515 ===
+Source: 0973_002-ebook.pdf
+Length: 700 chars
+
+VII Frequently asked questions
+1. Availability of mosquito nets for all beds:
+2. Is there an admission book or regular procedure for admitting and registering patients in the ward? If yes, number of admissions to the ward in the last month?
+3. Is there a person in the admissions/ER and wards who controls a system whereby the patients are assessed and then go to the OT or receive treatment?
+4. Are new admissions systematically seen by a senior surgeon/MD and within what timeframe?
+5. Are there re...
+
+=== Chunk 516 ===
+Source: 0973_002-ebook.pdf
+Length: 674 chars
+
+VIII Surgical care
+1. Main pathologies present in the wards (fractures, burns, chest, abdomen, etc.):
+2. Management of the ward/hygiene:
+3. Personnel (number, composition, roster):
+4. Infrastructure and beds:
+5. Is a laparotomy performed safely – patients seen a few days after operation with healing wound and eating normally?
+6. Can five or more laparotomies be performed in 24 hours under good conditions including anaesthesia? If not, why?
+7. What type of orthopaedic treatment is present in the ...
+
+=== Chunk 517 ===
+Source: 0973_002-ebook.pdf
+Length: 141 chars
+
+IX Physiotherapy unit
+1. Are patients walking on crutches in the wards? If not, why?
+2. Management of physiotherapy department:
+3. Personnel:...
+
+=== Chunk 518 ===
+Source: 0973_002-ebook.pdf
+Length: 130 chars
+
+Further comments
+1. Particularities of the context:
+2. Do you have any requests for the ICRC (logic and rationale of the request)?...
+
+=== Chunk 519 ===
+Source: 0973_002-ebook.pdf
+Length: 291 chars
+
+Conclusion
+1. First general impression (cleanliness and hygiene, staff present, presence of patients):
+2. Main positive findings:
+3. Main negative findings:
+4. Capacity to cope with mass influx of wounded:
+5. Emergency/contingency plan:
+6. Proposals:
+7. Next step:
+THE CHAIN OF CASUALTY CARE...
+
+=== Chunk 520 ===
+Source: 0973_002-ebook.pdf
+Length: 2749 chars
+
+ANNEX 6. B Strategic assessment of a conflict scenario
+The main appraisals in a strategic assessment of a conflict situation aimed at identifying some of the factors influencing the chain of casualty care are as follows:
+1. Geography:
+a. Topography of the conflict area
+b. Routes of communication and transportation
+c. Distribution of medical facilities available and their safety
+2. Where is the fighting taking place? Safe areas, dangerous areas?
+3. Where do patients come from?
+4. How many wounded...
+
+=== Chunk 521 ===
+Source: 0973_002-ebook.pdf
+Length: 261 chars
+
+ANNEX 6. C Humanitarian action for the sick and wounded: typical settings
+Many factors affect the deployment of humanitarian medical teams: this ANNEX helps to analyse a number of them. The terms used are operational descriptions and have no legal significance....
+
+=== Chunk 522 ===
+Source: 0973_002-ebook.pdf
+Length: 734 chars
+
+Possible scenarios
+1. Military activity, natural disaster or major accident? (Is health infrastructure intact?)
+2. Military context: conventional front lines, guerrilla war, internal troubles, post-conflict (particularly the presence of landmines, cluster bombs and other unexploded ordnance)
+3. Urban or rural setting?
+4. Industrially-developed or low-income country: funds available?
+5. Personnel: are there sufficient, few or very few trained doctors, nurses, and first-aiders?
+There are three typ...
+
+=== Chunk 523 ===
+Source: 0973_002-ebook.pdf
+Length: 1380 chars
+
+3. Dire situation:
+Very poor access to care because of the violence and conflict, sometimes compounded with pre-existing poverty.
+OPTIMAL AUSTERE DIRE Location Urban in a developed Poor rural area Developing country country Major destruction Duration of trouble Single, isolated event Ongoing low-intensity Continuous heavy fighting (e.g. act of terrorism) fighting (e.g. guerrilla and/or bombardment warfare) Casualty flow Small irregular numbers Discontinuous/ Continuous but (compared to the inter...
+
+=== Chunk 524 ===
+Source: 0973_002-ebook.pdf
+Length: 1932 chars
+
+Types of situations of armed conflict and violence and their effects on humanitarian medical work4
+Example International armed Internal armed Civil disturbance/revolt Widespread conflict conflict/guerrilla banditry and warfare other crime Description A straightforward Intense fighting Unpredictable; hit and May coincide war between country within one country run skirmishes, often with with any of the X, and its allies, and a vested interest in the other situations country Y, and its allies conti...
+
+=== Chunk 525 ===
+Source: 0973_002-ebook.pdf
+Length: 167 chars
+
+Model scenarios
+In contemporary armed conflict, health staff and facilities are called upon to function in various scenarios: typical situations include the following....
+
+=== Chunk 526 ===
+Source: 0973_002-ebook.pdf
+Length: 580 chars
+
+1. Safe urban setting
+• Urban, developed environment
+• Single, isolated event
+• Casualty numbers relatively small compared to population of city
+• Infrastructure intact: roads, emergency vehicles
+• Health infrastructure intact, sophisticated hospitals
+• Short evacuation time: route is secure
+• Good communications
+• Personnel: adequate number and quality of trained health staff
+• Materials adequate
+• Environment good: weather, daytime
+• Final destination of the wounded is known
+4 The terms used a...
+
+=== Chunk 527 ===
+Source: 0973_002-ebook.pdf
+Length: 625 chars
+
+2. Unsafe urban setting
+• Low-income country: under-developed or destroyed urban setting
+• Continuing danger: street fighting and bombardment in city
+• Continuing and unpredictable casualty flow including massive influx of wounded
+• Poor infrastructure: potholed roads, debris in streets
+• Disrupted health infrastructure: hospitals damaged or looted
+• Availability and length of evacuation uncertain or unknown
+• No or poor communications
+• Minimum health personnel available
+• Material re-supply un...
+
+=== Chunk 528 ===
+Source: 0973_002-ebook.pdf
+Length: 631 chars
+
+3. Unsafe rural setting
+• Low-income country: under-developed rural area neglected in peacetime
+• Constant danger: ongoing combat, landmines
+• Continuing and unpredictable casualty flow
+• Poor infrastructure: badly maintained or no roads
+• Poor health infrastructure: few health posts, even fewer district hospitals
+• Availability and length of evacuation uncertain, long and arduous
+• No or poor communications
+• Minimum health personnel available
+• Material re-supply uncertain, irregular, or non-e...
+
+=== Chunk 529 ===
+Source: 0973_002-ebook.pdf
+Length: 579 chars
+
+4. Safe but austere setting
+• Low-income country
+• Continuing danger: ongoing low-intensity warfare
+• Discontinuous casualty flow; includes irregular mass evacuations
+• Poor infrastructure: few good roads and few vehicles
+• Minimum of health infrastructure: some rural clinics or health centres, fewer district hospitals
+• Evacuation predictable but long and arduous
+• Poor to moderate communications
+• Minimum to moderate number of health personnel available
+• Minimum material re-supply
+• Environme...
+
+=== Chunk 530 ===
+Source: 0973_002-ebook.pdf
+Length: 1051 chars
+
+FIRST AID IN ARMED CONFLICT
+7
+WAR SURGERY
+156
+7 7.1 7.2 7.3 7.4 7.4.1 7.4.2 7.4.3 7.5 7.5.1 7.5.2 7.5.3 7.5.4 7.6 7.7 7.7.1 7.7.2 7.7.3 7.7.4 7.7.5 7.7.6 7.8 FIRST AID IN ARMED CONFLICT First aid: its crucial importance First aid in the chain of casualty care First-aiders: an important human resource Essential elements of the first-aid approach and techniques Security first and always Basic actions Standard sequence of basic life support: ABCDE or C-ABCDE? Setting up a first-aid post Location In...
+
+=== Chunk 531 ===
+Source: 0973_002-ebook.pdf
+Length: 4202 chars
+
+First aid: its crucial importance
+Optimal management of the injured involves a continuum of care from the point of wounding to the surgical hospital: the chain of casualty care. The surgeon wishes to receive patients who arrive in good condition and well-stabilized, in a timely manner, and according to priority for treatment. To understand how this is achieved, or not, there are a number of things that need to be known about first aid. In addition, the surgeon working in a conflict area may well...
+
+=== Chunk 532 ===
+Source: 0973_002-ebook.pdf
+Length: 194 chars
+
+First aid in the chain of casualty care
+First aid starts at the point of wounding, but can be given anywhere and everywhere along the chain of casualty care to the place of definitive treatment....
+
+=== Chunk 533 ===
+Source: 0973_002-ebook.pdf
+Length: 306 chars
+
+Point of wounding
+On-the-spot first aid, often performed on the actual battlefield, may be self- or buddy- first-aid if combatants and other weapon bearers have received the proper training prior to deployment. Otherwise, it is practised by a military medic, civilian or Red Cross/Red Crescent first-aider....
+
+=== Chunk 534 ===
+Source: 0973_002-ebook.pdf
+Length: 427 chars
+
+Collection point
+It is common practice and convenient to bring all the wounded to one spot, depending on the tactical situation, to evaluate their condition, start first aid if it has not yet been given and stabilize those for whom lifesaving measures have already been undertaken, and then to decide who needs to be evacuated for further treatment according to triage priorities. This is best served by a first-aid post (FAP)....
+
+=== Chunk 535 ===
+Source: 0973_002-ebook.pdf
+Length: 282 chars
+
+Evacuation
+The decision to transport a casualty should be assessed carefully considering the dangers and difficulties inherent in situations of armed conflict. Whatever method of transport is used along the chain of casualty care, first-aid measures should be maintained throughout....
+
+=== Chunk 536 ===
+Source: 0973_002-ebook.pdf
+Length: 981 chars
+
+Hospital emergency room
+In the rural areas of a poor country and during urban warfare, the first site where any care is available is often the emergency reception of an established hospital. Even if there is an efficient emergency transport service, family and neighbours often do not wait for it and prefer to transport the wounded directly to the hospital, whose emergency room (ER) then serves as a first-aid post.
+The degree of development and sophistication of the emergency transport and EMS in...
+
+=== Chunk 537 ===
+Source: 0973_002-ebook.pdf
+Length: 1503 chars
+
+First-aiders: an important human resource
+Usually, first-aiders are organized into teams with proper supervision and equipment, such as those of the Red Cross or Red Crescent or of the armed forces. Civilian and Red Cross/Red Crescent first-aiders are an essential part of the health-care team, as they are members of the local community, reflect its characteristics, and are well accepted by society. They take on many roles from the front lines to the health-care facility, and their availability a...
+
+=== Chunk 538 ===
+Source: 0973_002-ebook.pdf
+Length: 2772 chars
+
+7.4.1 Security first and always
+One of the specific characteristics of armed conflict, as mentioned, is the particularly hazardous situations encountered, more dangerous than during natural catastrophes or industrial accidents. The situation is made even worse because of the will of weapon bearers to continue fighting and inflict harm after the initial damage has been done, and the increasing unwillingness of many fighters to recognize and obey the rules of armed conflict.
+First-aiders are expos...
+
+=== Chunk 539 ===
+Source: 0973_002-ebook.pdf
+Length: 131 chars
+
+7.4.2 Basic actions
+The basics of a routine first-aid deployment apply, while at the same time safety and security must be ensured....
+
+=== Chunk 540 ===
+Source: 0973_002-ebook.pdf
+Length: 559 chars
+
+Preventing further injury: removing casualties from danger
+A wounded person is more likely to be injured again or even killed, especially if the person cannot take measures of self-protection, such as seeking cover from shooting or bombing. The prevention of further injury thus involves removing casualties from the point of wounding, and putting patients and medical personnel in as safe a place as circumstances allow. Furthermore, conscious and walking wounded must be separated from the others a...
+
+=== Chunk 541 ===
+Source: 0973_002-ebook.pdf
+Length: 418 chars
+
+Preventing aggravation of the injury: sheltering the casualties
+Shelter offers some protection from further injury in a combat environment, and also provides a shield from the elements. Exposure to the sun and heat, or cold and rain, are deleterious to the wellbeing and stabilization of the injured. It is also easier and more efficient to deliver medical care when working under more comfortable physical conditions....
+
+=== Chunk 542 ===
+Source: 0973_002-ebook.pdf
+Length: 3212 chars
+
+7.4.3 Standard sequence of basic life support: ABCDE or C-ABCDE?
+“C” = Catastrophic peripheral haemorrhage A = Airway B = Breathing C = Circulation D = Disability (neurological status) E = Environment and Exposure
+ABCDE has become established as the ubiquitous first-aid paradigm. Although some injuries are inevitably un-survivable, there are many cases where death can be prevented by rapid and decisive first-aid care following this approach at the point of injury. However, ballistic and blast in...
+
+=== Chunk 543 ===
+Source: 0973_002-ebook.pdf
+Length: 292 chars
+
+7.5 Setting up a first-aid post
+The establishment and organization of a first-aid post (FAP) should rely on a large dose of common sense to determine what is practical and realistic in a given situation, and will depend on how long it will operate (from a few minutes to a few days or weeks)....
+
+=== Chunk 544 ===
+Source: 0973_002-ebook.pdf
+Length: 1017 chars
+
+7.5.1 Location
+Choosing a site for an FAP should follow certain rules. It should be placed in a secure position, far enough from the fighting not to be in danger, yet near enough to enable the rapid transfer of casualties to the post. For operational and security reasons, its location should be indicated as soon as possible to the dispatch or command centre of the chain of casualty care. Its presence should be made known to the local population and combatants and other weapon bearers, who are th...
+
+=== Chunk 545 ===
+Source: 0973_002-ebook.pdf
+Length: 496 chars
+
+7.5.2 Infrastructure
+An FAP is a functional unit: it can therefore be set up in a makeshift fashion in a tent, a school or any available building; or in an already existing dispensary or primary health-care centre. Certain minimum requirements should be fulfilled: appropriate shelter against the elements; adequate size to accommodate casualties on stretchers; easy access for the “walking wounded” (e.g. avoid long stairways); adequate in-and- out access for ambulances and ample parking space....
+
+=== Chunk 546 ===
+Source: 0973_002-ebook.pdf
+Length: 597 chars
+
+7.5.3 Staffing, equipment and supplies
+The level of technical expertise of the personnel in an FAP will depend on the circumstances and standards of the country. Anyone from a first-aider to a nurse, general practitioner or even a surgeon may be found working in an FAP. This allows for the “forward projection” of care for casualties (see Chapter 6). Equipment and supplies must meet minimum standards and be adequate for basic trauma care, and adapted to the personnel’s skills and local standards....
+
+=== Chunk 547 ===
+Source: 0973_002-ebook.pdf
+Length: 790 chars
+
+7.5.4 Organization
+The premises of the FAP should be organized – and the staff prepared – for dealing with a mass influx of casualties. The principles and practice of triage should be well understood by all present through simulation exercises (see Chapter 9).
+If the FAP stays open for a certain length of time, and the facilities allow for it, the following areas should be pre-arranged:
+• Admission area at the entrance to register and triage casualties.
+• Holding area to care for and monitor cas...
+
+=== Chunk 548 ===
+Source: 0973_002-ebook.pdf
+Length: 864 chars
+
+ICRC involvement in first-aid programmes
+The ICRC supports first-aid programmes and activities in contexts of armed conflict and other situations of violence. These programmes include:
+• deployment of medical staff to operate first-aid posts;
+• education and training where no other organization has access (e.g. for irregular guerrilla groups);
+• helping to adapt routine first-aid programmes of National Red Cross and Red Crescent Societies and other organizations to the context of conflict prepar...
+
+=== Chunk 549 ===
+Source: 0973_002-ebook.pdf
+Length: 303 chars
+
+7.7 Debates, controversies and misunderstandings
+Detailed first-aid techniques are described in the manuals listed in the Selected bibliography. The rest of this chapter deals only with a few topics that may give rise to controversy or misunderstanding or are specific to the scenario of armed conflict....
+
+=== Chunk 550 ===
+Source: 0973_002-ebook.pdf
+Length: 2545 chars
+
+“Scoop-and-run” versus “stay-and-treat”
+Like the rest of the chain of casualty care, the organization of first aid requires planning and training. A strategy for the efficient care and evacuation of the wounded must be established. Two well-known strategies are described by the expressions “scoop-and-run” and “stay-and-treat”. These derive largely from the civilian practice of emergency medical services in industrialized countries and may not be particularly relevant in a context of armed confli...
+
+=== Chunk 551 ===
+Source: 0973_002-ebook.pdf
+Length: 973 chars
+
+7.7.2 Mechanism of injury and the problem of the cervical spine
+The first-aider, or other medical personnel, must immediately determine whether the casualty has suffered blunt or penetrating trauma. Blunt trauma above the level of the clavicles or causing unconsciousness requires immediate observation and immobilization of the cervical spine, while still giving priority to the airway. A penetrating wound to the brain causing unconsciousness requires no special care of the cervical spine.
+In the ...
+
+=== Chunk 552 ===
+Source: 0973_002-ebook.pdf
+Length: 532 chars
+
+7.7.3 The tourniquet: when and how?
+Limb injuries with massive external bleeding from a severed artery are the most common cause of preventable death during armed conflict: bright red blood spurts from the wound and the patient can die within two to three minutes. Application of a tourniquet appears obvious. Yet no subject has caused so much debate in first aid as the use of tourniquets. In addition, a distinction is to be made between commercial manufactured tourniquets and improvised ones.
+C
+R...
+
+=== Chunk 553 ===
+Source: 0973_002-ebook.pdf
+Length: 4221 chars
+
+Figure 7.3.1
+Improvised tourniquet: how harmful? Here a tourniquet was applied for more than six hours, resulting in a very high above the knee amputation.
+Figure 7.3.2 Improvised tourniquet: how effective?
+Whilst it is widely accepted that tourniquets have saved countless lives in a military setting, their use among civilians is often misunderstood and bad practices are frequently still taught. The most important factor is the indication for tourniquet use: not every bleeding limb has arterial ...
+
+=== Chunk 554 ===
+Source: 0973_002-ebook.pdf
+Length: 831 chars
+
+7.7.4 Adjuvants in haemorrhage management
+Some armies are currently testing new locally-active haemostatic powders, sponges and compresses to promote clotting in traumatic wounds. However, direct pressure must still be applied. The ICRC has no experience with these and, like most others, awaits the definitive results of the field trials. Cost and availability will be factors when considering their use worldwide.
+Early in-hospital administration of tranexamic acid (TXA) has proven to reduce morta...
+
+=== Chunk 555 ===
+Source: 0973_002-ebook.pdf
+Length: 1754 chars
+
+7.7.5 Resuscitation or rehydration?
+The first-aider can only implement simple procedures in the field. The administration of intravenous fluids requires a certain degree of medical knowledge and specific equipment that are beyond the normal scope and competencies of a first-aider. He can be involved in the monitoring of a perfusion, however.
+The subject of pre-hospital i.v. fluids has given rise to considerable controversy. Maintaining adequate tissue perfusion and oxygenation is balanced off ag...
+
+=== Chunk 556 ===
+Source: 0973_002-ebook.pdf
+Length: 1018 chars
+
+Warning!
+Oxygen cylinders are the equivalent of a bomb if hit by a bullet or piece of shrapnel. In addition to the danger they represent, the cylinders are heavy and must be replaced, lasting only a short time at high flows. Furthermore, their replenishment is complex and requires special factory capacity.
+Oxygen cylinders must be ruled out in the event of any deployment to a dangerous area. This is now standard ICRC policy.
+Palestine Red Crescent Society
+ye Red Crescent Society
+Muscles that are...
+
+=== Chunk 557 ===
+Source: 0973_002-ebook.pdf
+Length: 401 chars
+
+Figures 7.4.1 and 7.4.2
+Ambulance destroyed by the detonation of an oxygen cylinder, which has gone through the roof like a rocket. The photos show the ambulance and the cylinder on the ground.
+Depending on security conditions, the collection point or intermediate station may have oxygen available. An oxygen concentrator (requiring an electrical supply) is preferable to compressed oxygen cylinders....
+
+=== Chunk 558 ===
+Source: 0973_002-ebook.pdf
+Length: 1435 chars
+
+7.8 Disability: the AVPU system
+Disability in this context refers to the neurological status of the casualty: the state of consciousness and any paralysis due to injury to the spinal cord.
+The Glasgow Coma Scale is the hospital standard (see Section 8.8). However, the AVPU system is a simpler means of assessing consciousness and it may be easier for first- aiders to use in the field. It easily translates into the Glasgow system when the patient arrives at the hospital and gives the surgeon a goo...
+
+=== Chunk 559 ===
+Source: 0973_002-ebook.pdf
+Length: 1053 chars
+
+Examination of the spinal cord and vertebral column
+This involves two phases: determining the movement of the limbs – comparing the two sides – and palpation of the bony prominences of the spine. Palpation of every vertebra – like “fingers playing on piano keys” – aims to identify any induration or deformity. If there is any danger to the spinal cord, then the four-person log-roll technique should be used to move the patient onto a stretcher. The cervical spine can be immobilized initially by ma...
+
+=== Chunk 560 ===
+Source: 0973_002-ebook.pdf
+Length: 2991 chars
+
+Figures 7.5.1 and 7.5.2
+Transportation of the wounded is always difficult, always takes longer than expected, adds to the trauma and can be dangerous to the patient and those transporting the casualty: the famous “mortality of the ambulance ride”. In situations of armed conflict, the danger of the ambulance ride is complicated by the risks of ongoing combat.
+Different means of patient evacuation: modern and traditional.
+C
+&
+R
+C
+I
+/
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+s
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+l
+l
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+M
+.
+Y
+Speed is less important than safety of transpo...
+
+=== Chunk 561 ===
+Source: 0973_002-ebook.pdf
+Length: 1080 chars
+
+Chapter 8 HOSPITAL EMERGENCY ROOM CARE
+8
+WAR SURGERY
+172
+8
+HOSPITAL EMERGENCY ROOM CARE
+8.1 8.2 8.3 8.4 8.4.1 8.4.2 8.4.3 8.4.4 8.5 8.5.1 8.6 8.6.1 8.6.2 8.6.3 8.6.4 8.6.5 8.7 8.7.1 8.7.2 8.7.3 8.7.4 8.7.5 8.8 8.9 8.10 C-ABCDE priorities Initial examination Catastrophic haemorrhage Airway Opening the airway Definitive patent airway: indications Definitive patent airway: endotracheal intubation Definitive patent airway: surgical airway Breathing and ventilation Assisted ventilation Circulation Pe...
+
+=== Chunk 562 ===
+Source: 0973_002-ebook.pdf
+Length: 1366 chars
+
+8.1 C-ABCDE priorities
+The framework for casualty management in a hospital emergency room (ER) is a continuation of the basic life-support procedures of first aid. The logic is the same; the diagnostic and treatment means available are simply more advanced. The “golden hour” begins at the site of trauma, not on arrival at the emergency room.
+If pre-hospital services were efficient, one would never see catastrophic haemorrhage from a limb wound in the ER. Unfortunately, such services are all too ...
+
+=== Chunk 563 ===
+Source: 0973_002-ebook.pdf
+Length: 182 chars
+
+1. Assess
+Initial examination: Catastrophic external haemorrhage Αirway Breathing Circulation Disability Environment and Exposure.
+Triage in a mass casualty situation: see Chapter 9....
+
+=== Chunk 564 ===
+Source: 0973_002-ebook.pdf
+Length: 67 chars
+
+2. Act
+Emergency resuscitation: act on life-threatening conditions....
+
+=== Chunk 565 ===
+Source: 0973_002-ebook.pdf
+Length: 80 chars
+
+3. Assess
+Complete examination: head-to-toe palpation, front and back and sides....
+
+=== Chunk 566 ===
+Source: 0973_002-ebook.pdf
+Length: 92 chars
+
+4. Act
+Definitive treatment, surgical or not: stabilization; damage control approach or not....
+
+=== Chunk 567 ===
+Source: 0973_002-ebook.pdf
+Length: 160 chars
+
+5. Assess and Act
+Treatment in situ or evacuation of the casualty, according to triage priority, to a higher-echelon hospital for specialized care if necessary....
+
+=== Chunk 568 ===
+Source: 0973_002-ebook.pdf
+Length: 3076 chars
+
+8.2 Initial examination
+The initial examination and emergency resuscitation are carried out simultaneously. The receiving ER doctor must automatically ask a series of questions.
+173
+WAR SURGERY
+174
+1. Is the patient dead or alive?
+2. Is the patient conscious or not?
+3. What is the mechanism of injury: penetrating or blunt?
+4. What are the life-threatening conditions, if any, according to the C-ABCDE algorithm?
+The natural reflex when faced with a wounded person is to look at the bleeding first, ...
+
+=== Chunk 569 ===
+Source: 0973_002-ebook.pdf
+Length: 798 chars
+
+Types of haemorrhage
+Haemorrhage may be arterial, venous or capillary and blood loss may be:
+• peripheral and obvious (a blood clot the size of a fist or an open wound the size of a hand represents 500 ml);
+• peripheral and hidden:
+– closed fractures of long bones (tibia = 500 ml, femur = 1.5 litres);
+– open wound with small entry that is blocked by a piece of torn muscle;
+• central (chest, abdomen, pelvis and retroperitoneum): a massive haemothorax can represent 2 – 3 litres of blood; a severe ...
+
+=== Chunk 570 ===
+Source: 0973_002-ebook.pdf
+Length: 1240 chars
+
+Blind clamping must never be attempted
+A pneumatic tourniquet, if available, is the best method of temporarily controlling severe arterial haemorrhage from the limb. Otherwise, one should resort to packing the wound. Digital pressure is applied to the artery proximal to the wound (pressure point), while the wound is carefully packed with gauze compress first, followed by a bulkier dressing, and finally a firm compressive elastic bandage in order to apply even pressure and thereby achieve haemost...
+
+=== Chunk 571 ===
+Source: 0973_002-ebook.pdf
+Length: 234 chars
+
+8.4 Airway
+Airway obstruction is an emergency that requires an urgent response. Some injuries cause an immediate problem; others may result in delayed impairment of the airway.
+Common conditions that can compromise the airway include:...
+
+=== Chunk 572 ===
+Source: 0973_002-ebook.pdf
+Length: 150 chars
+
+Head injury with decreased consciousness
+Apart from the danger of aspiration of vomitus, the tongue and epiglottis may fall back and block the airway....
+
+=== Chunk 573 ===
+Source: 0973_002-ebook.pdf
+Length: 277 chars
+
+Maxillo-facial injuries
+Blood, broken teeth, bone fragments or foreign bodies can impede air entry, Even if the patient can breathe adequately in the beginning, the development of oedema of the tongue, floor of the mouth and pharynx may obstruct air intake after several hours....
+
+=== Chunk 574 ===
+Source: 0973_002-ebook.pdf
+Length: 110 chars
+
+Penetrating wounds to the larynx or upper trachea
+If large enough, they will create a “traumatic tracheotomy”....
+
+=== Chunk 575 ===
+Source: 0973_002-ebook.pdf
+Length: 118 chars
+
+Blunt injury to the larynx (e.g. from a rifle butt)
+This may crush the cartilage, resulting in collapse of the airway....
+
+=== Chunk 576 ===
+Source: 0973_002-ebook.pdf
+Length: 128 chars
+
+Compressive haematoma in the neck
+This may accumulate quickly or slowly, compressing the hypopharynx or larynx from the outside....
+
+=== Chunk 577 ===
+Source: 0973_002-ebook.pdf
+Length: 248 chars
+
+Burns to the face and neck or inhalation burns of the larynx and trachea
+Whether due to flame and smoke or irritating chemical agents, these require close
+observation for delayed obstruction or respiratory failure due to oedema.
+175
+WAR SURGERY
+176...
+
+=== Chunk 578 ===
+Source: 0973_002-ebook.pdf
+Length: 1831 chars
+
+8.4.1 Opening the airway
+As in first aid, the standard treatment for an actual or potential obstruction applies.
+Basic steps for securing the airway   Open the mouth.   Displace the tongue forward.   Remove any blood or debris from the mouth and oropharynx.   Maintain the airway patent.
+To open and clean the mouth the standard manoeuvres are jaw thrust or chin lift: displace the tongue forward, and then finger-sweep the mouth while protecting the finger, aided by a suction apparatus if available...
+
+=== Chunk 579 ===
+Source: 0973_002-ebook.pdf
+Length: 939 chars
+
+8.4.2 Definitive patent airway: indications
+The following conditions require a definitively secured airway:
+• apnoea or cardiac arrest, whatever the cause (with assisted ventilation);
+• severe haemorrhagic shock (Class IV, see below);
+• Glasgow Coma Scale score of less than or equal to 8, which is equal to being unresponsive to pain;
+• continued seizures and convulsions (with assisted ventilation);
+• unstable fractures of maxilla or mandible (usually bilateral fractures of the mandible, or insta...
+
+=== Chunk 580 ===
+Source: 0973_002-ebook.pdf
+Length: 603 chars
+
+8.4.3 Definitive patent airway: endotracheal intubation
+The simplest technique to maintain a patent airway with protection from aspiration is endotracheal intubation, through either a nasal or oral approach. Deeply unconscious patients can usually be intubated easily. Others may be restless, irritable, and uncooperative. Intubation under these circumstances requires sedation. Various agents (diazepam, pentothal, propofol or ketamine) given intravenously will allow rapid intubation without aggrav...
+
+=== Chunk 581 ===
+Source: 0973_002-ebook.pdf
+Length: 585 chars
+
+8.4.4 Definitive patent airway: surgical airway
+The need for a surgical airway should be identified early and it should be performed quickly. This may be the primary effort (maxillo-facial injuries, wounds to the neck involving the larynx or pharynx or haematoma accumulation, etc.) or following failure of endotracheal intubation. A surgical airway is also beneficial where there are no facilities for mechanical ventilation.
+Cricothyroidotomy is preferable to tracheostomy, which can be a difficult...
+
+=== Chunk 582 ===
+Source: 0973_002-ebook.pdf
+Length: 600 chars
+
+Cricothyroidotomy
+This is a quick, safe, and relatively bloodless procedure (Figures 8.1.1 – 8.1.4). A vertical incision is made in the skin followed by a horizontal incision through the cricothyroid membrane. The handle of the scalpel is inserted and turned 90° to hold the membrane open until a small tracheostomy tube can be inserted. In extremis, a wide- bore needle can be inserted instead; this needle cricothyroidotomy is particularly useful in children.
+Thyroid cartilage Cricoid cartilage
+Su...
+
+=== Chunk 583 ===
+Source: 0973_002-ebook.pdf
+Length: 594 chars
+
+Figure 8.1.2
+Surgical landmarks: the patient’s neck should be placed in extension with a pad beneath the shoulders. The thyroid and cricoid cartilages are identified by finger palpation, the cricothyroid membrane is then identified as the depression in between them.
+A horizontal skin incision is made over the cricothyroid membrane. The wound is spread apart using the thumb and index finger. The incision is carried down through the membrane and widened by insertion of the scalpel handle, which is...
+
+=== Chunk 584 ===
+Source: 0973_002-ebook.pdf
+Length: 149 chars
+
+Figure 8.1.4
+A tracheostomy tube is placed through the opening and secured.
+The entire procedure should take no more than 30 seconds.
+177
+WAR SURGERY...
+
+=== Chunk 585 ===
+Source: 0973_002-ebook.pdf
+Length: 246 chars
+
+Figure 8.3
+Improvised Heimlich flutter valve: a wide bore cannula is inserted at the upper edge of a rib. A finger from a surgical glove, with a 1 cm-long incision in the end, is tied around the cannula.
+178
+C
+Icrc
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+a
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+PZylst
+s
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+P....
+
+=== Chunk 586 ===
+Source: 0973_002-ebook.pdf
+Length: 320 chars
+
+Tracheostomy
+Tracheostomy should be an elective procedure. The only specific indication for an emergency tracheostomy in missile wounds is direct laryngeal injury. The urgency of the problem and the experience of the surgeon will determine which technique is the safest and most appropriate for ensuring a secure airway....
+
+=== Chunk 587 ===
+Source: 0973_002-ebook.pdf
+Length: 557 chars
+
+8.5 Breathing and ventilation
+The cause of respiratory distress must be found and treated. Patients with head injuries often require intubation and ventilation to support respiration, as is the case for tetraplegia, blast lung, chemical injuries and inhalation of smoke fumes. Previous disease may also impair ventilation in an injured patient.
+Clinical examination may reveal a chest injury that decreases respiration, including:
+• flail segment of the chest;
+• open pneumothorax or sucking wound to...
+
+=== Chunk 588 ===
+Source: 0973_002-ebook.pdf
+Length: 415 chars
+
+Flail segment of the chest
+This condition should be treated initially by good analgesia, physiotherapy and positioning of the patient. More severe and complicated cases may require a chest tube and intubation with mechanical ventilation. It is usually the underlying lung contusion that causes the greatest difficulty in treatment.
+For further details on flail segment of the chest, see Section 31.10.2 in Volume 2....
+
+=== Chunk 589 ===
+Source: 0973_002-ebook.pdf
+Length: 233 chars
+
+Sucking wound or open pneumothorax
+A sucking wound requires a three-sided occlusive dressing in the ER. The patient then goes to theatre for placement of an intercostal drain and debridement and closure of the wound of the chest wall...
+
+=== Chunk 590 ===
+Source: 0973_002-ebook.pdf
+Length: 963 chars
+
+Tension pneumothorax
+This condition is rare in projectile injuries, more common in primary blast injuries and even more common after blunt trauma. The diagnosis of a tension pneumothorax with obvious respiratory distress is a purely clinical one (Table 8.1); no time should be wasted taking an X-ray (Figure 8.2). The condition requires an immediate wide- bore i.v. cannula to be inserted into the second or third intercostal space in the midclavicular line (needle thoracocentesis) attached to an im...
+
+=== Chunk 591 ===
+Source: 0973_002-ebook.pdf
+Length: 561 chars
+
+Figure 8.2
+Tension pneumothorax with respiratory distress: the only thing wrong with the X-ray film is that it was taken. The diagnosis should have been a clinical one.
+s
+a
+N
+.
+H
+HOSPITAL EMERGENCY ROOM CARE
+Needle thoracocentesis may fail, however. A negative trial does not necessarily rule out the presence of a tension pneumothorax. A simple finger thoracostomy in the 5th intercostal space at the midaxillary line is a good alternative. Again, a positive result is indicated by the hiss of air r...
+
+=== Chunk 592 ===
+Source: 0973_002-ebook.pdf
+Length: 420 chars
+
+Haemothorax
+A haemothorax should be drained using a wide-bore chest tube. When clinical signs of haemothorax exist, an intercostal tube should be inserted before X-rays are taken. Chest tubes are usually placed under local anaesthesia. If there is a wound to excise, ketamine anaesthesia would be more appropriate.
+For information on insertion of chest tube – thoracostomy – see Section 31.6 and ANNEX 31. B in Volume 2....
+
+=== Chunk 593 ===
+Source: 0973_002-ebook.pdf
+Length: 368 chars
+
+8.5.1 Assisted ventilation
+After intubation, assistance with respiration may be required. Common pathologies requiring such assistance include:
+• head injury;
+• large flail segment;
+• blast injury of lungs;
+• inhalation of toxic gases or smoke, or flash burn to the tracheo-bronchial tree;
+• aspiration pneumonitis;
+• other medical causes of respiratory insufficiency....
+
+=== Chunk 594 ===
+Source: 0973_002-ebook.pdf
+Length: 232 chars
+
+Figure 8.4.1
+Simple, but massive, pneumothorax. Patient lying comfortably and breathing without effort. X-ray films are justified.
+=
+Assisted ventilation may be manual:
+• mouth-to-mouth or -nose for infants (use a compress barrier);...
+
+=== Chunk 595 ===
+Source: 0973_002-ebook.pdf
+Length: 1086 chars
+
+Figure 8.4.2
+• mouth-to-mask;
+bag-valve-mask;
+• bag-valve-mask;
+• bag-valve-endotracheal tube or surgical airway;
+Antero-posterior radiograph showing large right-sided pneumothorax. The arrow marks the bullet.
+or mechanical, provided by a ventilator.
+In a hospital, it is possible to administer supplemental oxygen from a central supply, cylinders or an oxygen extractor/concentrator.
+The ICRC usually operates in situations of limited resources, and mechanical ventilators are not standard equipment...
+
+=== Chunk 596 ===
+Source: 0973_002-ebook.pdf
+Length: 1383 chars
+
+8.6 Circulation
+Figure 8.4.3 Lateral film.
+The main circulatory problem encountered in the war-wounded is hypovolaemic shock, usually due to haemorrhage or burns. In addition to any blood loss they cause, large soft-tissue wounds sequestrate large quantities of tissue fluids, with further loss of plasma and circulating volume. Dehydration complicates any previous fluid loss if evacuation is long and delayed.
+Neurogenic, anaphylactic and cardiogenic shock may also occur; septic shock is a late co...
+
+=== Chunk 597 ===
+Source: 0973_002-ebook.pdf
+Length: 1963 chars
+
+8.6.1 Pericardial tamponade and pericardiocentesis
+In the rare instance of constrictive haemopericardium with cardiac tamponade due to a penetrating missile wound to the heart, pericardiocentesis may be required if there is acute decompensation, but only to gain time until emergency thoracotomy can be performed.
+The procedure for pericardiocentesis is as follows.
+1. A 20 ml syringe is attached to a long over-the-needle cannula (or alternatively a spinal anaesthesia needle).
+2. The skin is punctu...
+
+=== Chunk 598 ===
+Source: 0973_002-ebook.pdf
+Length: 444 chars
+
+8.6.2 Haemorrhagic shock
+A pneumatic tourniquet is only necessary in case of catastrophic arterial haemorrhage from a limb. Wound packing is an excellent alternative and especially useful in a very large soft tissue wound. Otherwise, direct pressure and elevation of the limb will stop most cases of peripheral venous and capillary haemorrhage. Fractures should be splinted. Central bleeding into a body cavity requires a surgical intervention....
+
+=== Chunk 599 ===
+Source: 0973_002-ebook.pdf
+Length: 554 chars
+
+The body’s response and classes of shock
+Immediately after haemorrhage, the body initiates a number of homeostatic circulatory changes that aim to stop the bleeding and to compensate and preserve perfusion of the vital organs. The circulating blood volume represents 7 – 8 % of body weight in the adult (5 – 5.6 litres in the 70-kg male or 70 ml/kg body weight) and 9 % in children (80 ml/kg body weight).
+Haemorrhage and the shock response are traditionally graded into 4 classes according to the vo...
+
+=== Chunk 600 ===
+Source: 0973_002-ebook.pdf
+Length: 188 chars
+
+Class I
+Up to 15 % blood volume lost (750 ml or less). Mild tachycardia is the only clinical sign since the body’s normal homeostatic mechanisms are capable of fully compensating the loss....
+
+=== Chunk 601 ===
+Source: 0973_002-ebook.pdf
+Length: 260 chars
+
+Class II
+15 – 30 % blood volume lost (750 – 1,500 ml). Definite tachycardia, slight decrease in systolic blood pressure with rise of diastolic pressure (decreased pulse pressure), refilling of blanched capillary bed of fingers delayed, restlessness or anxiety....
+
+=== Chunk 602 ===
+Source: 0973_002-ebook.pdf
+Length: 185 chars
+
+Class III
+30 – 40 % blood volume lost (1,500 – 2,000 ml). Marked tachycardia, tachypnoea, hypotension, low urine volume, classic picture of shock. Compensatory mechanisms start to fail....
+
+=== Chunk 603 ===
+Source: 0973_002-ebook.pdf
+Length: 1217 chars
+
+Class IV
+> 40 % blood volume lost (> 2,000 ml). Full classic symptoms of shock are present: cold, clammy and pale skin, irritability, aggressiveness and confusion followed by loss of consciousness if the patient loses more than 50 % circulating volume.
+I II III IV Class Up to 750 ml 750 – 1,500 ml 1,500 – 2,000 ml >2,000 ml (<15 % loss) (15 – 30 % loss) (30 – 40 % loss) (>40 % loss) Pulse <100/min Full and bounding 100 – 120/min Full 120 –140/min Weak >140/min Thready Systolic blood 120 90 – 120...
+
+=== Chunk 604 ===
+Source: 0973_002-ebook.pdf
+Length: 1510 chars
+
+8.6.3 Fluid replacement
+The important point is to maintain adequate tissue perfusion until the haemorrhage is brought under control. Sufficient blood pressure to maintain this tissue perfusion is judged to be a systolic pressure of 90 mm Hg, equivalent to a palpable radial pulse.
+The great majority of war-wounded patients are relatively healthy young adults who suffer injuries to the extremities, and in whom the amount of blood loss is not lethal. They are haemodynamically stable (Class I blood ...
+
+=== Chunk 605 ===
+Source: 0973_002-ebook.pdf
+Length: 732 chars
+
+Monitoring of clinical response
+The estimation of blood loss is a very approximate measure. Rather than relying on this to guide resuscitation efforts, the doctor should observe the signs and symptoms of the clinical response to determine continuing fluid requirements. These include:
+• pulse;
+• systolic blood pressure;
+• pulse pressure difference between systolic and diastolic;
+• capillary refill;
+• urine output;
+• mental status.
+The most important simple measure of the adequacy of fluid replace...
+
+=== Chunk 606 ===
+Source: 0973_002-ebook.pdf
+Length: 499 chars
+
+Rapid and stable response
+The great majority of war-wounded patients suffer from limb injuries, with Class I or II shock. Simple crystalloids are sufficient for their resuscitation and the quantity (usually around 2 – 3 l) is determined by the clinical picture. The pulse falls below 100, the systolic blood pressure is above 100, and the pulse pressure widens. Urine output is good. These measurements remain stable. No further fluid resuscitation is required, but the i.v. line is maintained open....
+
+=== Chunk 607 ===
+Source: 0973_002-ebook.pdf
+Length: 559 chars
+
+Transient unstable response
+An initial positive response to crystalloid fluid resuscitation of the pulse, blood pressure, and pulse pressure is followed by a return to subnormal values. Urine output remains low. Further administration of crystalloids, or a plasma expander such as dextran, should be limited. Continuing subnormal shock values indicate continuing blood loss; the patient should be prepared for emergency surgery. This situation occurs in some patients who have suffered internal injur...
+
+=== Chunk 608 ===
+Source: 0973_002-ebook.pdf
+Length: 247 chars
+
+No response
+The patient remains in shock, indicating Class IV blood loss of more than 40 % blood volume, and requires emergency surgery – surgery as part of resuscitation – or is triaged to Category IV in a mass casualty situation (see Chapter 9);...
+
+=== Chunk 609 ===
+Source: 0973_002-ebook.pdf
+Length: 748 chars
+
+or
+other, less common pathologies that become manifest with time have been overlooked. The airway and breathing should be re-assessed to diagnose a possible cardiac tamponade, tension pneumothorax or myocardial injury. Neurogenic shock and acute gastric dilatation should not be overlooked.
+Time since injury should also be taken into account to evaluate the evolution of the shock state. If Class IV shock is present less than 1 hour after injury, emergency operation is needed for resuscitation. If...
+
+=== Chunk 610 ===
+Source: 0973_002-ebook.pdf
+Length: 1812 chars
+
+8.6.4 Hypotensive resuscitation and damage control approach
+Unstable responders and non-responders represent 5 % to 15 % of war-wounded patients, depending on evacuation time; the longer the delay, the more natural and automatic triage comes into play (see Chapter 5). These patients have continuing haemorrhage; it has been demonstrated that simple fluid replacement only compounds the problem.
+Giving all severely shocked patients a standard crystalloid fluid challenge of 2 litres or more in order...
+
+=== Chunk 611 ===
+Source: 0973_002-ebook.pdf
+Length: 1614 chars
+
+8.6.5 Adjuvant therapy
+Never give cold fluids by rapid intravenous infusion.
+No effort should be spared to prevent hypothermia in the shocked patient. Intravenous fluids should be warmed (see Section 8.9 and Chapter 18).
+Oxygen and small doses of i.v. analgesia are equally important. The best is morphine (5 mg i.v., repeated every 10 minutes as necessary). Morphine should not be given if there is any question of head injury or respiratory depression. A good alternative in this case would be tram...
+
+=== Chunk 612 ===
+Source: 0973_002-ebook.pdf
+Length: 3078 chars
+
+Blood transfusion where supplies are limited
+Where blood supplies are scarce, what should the role of blood transfusion be? This scenario is a far cry from optimal conditions, in which there are relatively few limits to blood or component administration, but it is common.
+The aim of blood transfusion is to save life or to prevent significant morbidity, and not to restore a normal haemoglobin level. Blood is a rare and expensive commodity with serious risks attached to its administration and shou...
+
+=== Chunk 613 ===
+Source: 0973_002-ebook.pdf
+Length: 1394 chars
+
+8.7.1 Clinical use of blood in ICRC practice
+If blood is in very short supply, it should not be administered until bleeding has been controlled; one must rely on hypotensive resuscitation.
+On table, if the patient remains haemodynamically unstable and the haemoglobin is less than 6 g/dl, blood is administered, while the surgeon performs damage control techniques (see Chapter 18). Haemoglobin less than 6 but in a stable patient is not an indication for transfusion. (However, there is a threshold ...
+
+=== Chunk 614 ===
+Source: 0973_002-ebook.pdf
+Length: 1038 chars
+
+8.7.2 Two unit rule
+It has been traditional practice to administer not less than 2 units of blood to any patient who requires transfusion. In the ICRC context, this rule is not always appropriate since extreme shortage of blood is so common. It is sometimes more appropriate to prescribe just one unit to certain symptomatic patients as this may improve their condition sufficiently, thus allowing supplies of this scarce resource to be kept for other patients in need. This is particularly true for ...
+
+=== Chunk 615 ===
+Source: 0973_002-ebook.pdf
+Length: 275 chars
+
+8.7.3 Fresh whole blood
+This is best when screened and given within one hour of collection. Fresh whole blood is especially reserved for:
+• massive haemorrhage;
+• coagulopathy;
+• septic shock;
+• non-trauma pathologies:
+• snake bite with haemolysis;
+• amniotic fluid embolism....
+
+=== Chunk 616 ===
+Source: 0973_002-ebook.pdf
+Length: 401 chars
+
+8.7.4 Autotransfusion
+When faced with inadequate blood supplies and patients suffering massive haemorrhage, ICRC surgical teams have practised recuperation of shed blood and autotransfusion. Haemothorax and haemoperitoneum from the spleen, liver or ruptured ectopic pregnancy are the most common indications.
+For further information on autotransfusion in acute haemorrhage, see Chapter 34 in Volume 2....
+
+=== Chunk 617 ===
+Source: 0973_002-ebook.pdf
+Length: 2986 chars
+
+8.7.5 Total blood requirements: the ICRC’s experience4
+ICRC colleagues studied total blood requirements for 4,770 patients in two hospitals treating the wounded from the war in Afghanistan during a six-month period in 1990–91. No differentiation was made for blood transfusion given pre-operatively, peri-operatively or immediately post-operatively: all were considered part of patient resuscitation given the difficulties and delay in obtaining blood. Guidelines at the time allocated a maximum of 6...
+
+=== Chunk 618 ===
+Source: 0973_002-ebook.pdf
+Length: 2551 chars
+
+8.8 Disability
+Any neurological deficit must be determined, whether central or peripheral. As mentioned previously, if the mechanism of injury is blunt trauma above the level of the clavicles then the cervical spine must be cared for in the usual manner.
+According to the nursing expertise available, the AVPU system may be used or one may proceed immediately to the Glasgow Coma Scale (GCS) to determine the level of consciousness and identify any traumatic brain injury (Table 8.4). Although the GC...
+
+=== Chunk 619 ===
+Source: 0973_002-ebook.pdf
+Length: 1140 chars
+
+8.9 Environment/exposure
+Hypothermia must be avoided at all costs – the patient should be examined rapidly but thoroughly – and treated aggressively. With a core body temperature of 37° C, an ambient temperature of 32 – 34° C is considered neutral. Less than this and the body loses heat to the environment. After examination, the patient should be kept covered, even in a tropical climate. Hypothermia (core temperature less than 35° C) is probably the most potent factor in causing the vicious cycl...
+
+=== Chunk 620 ===
+Source: 0973_002-ebook.pdf
+Length: 1382 chars
+
+8.10 Complete examination
+At this stage it is even more important than in the pre-hospital setting to undress the patient and perform a thorough examination, from head to toe, front and back and sides. In some societies, this may contravene certain cultural and religious traditions (male doctor examining a female patient). Compromises must be found.
+In the more accommodating atmosphere of a hospital emergency room, a systematic approach should be used to thoroughly examine the scalp and head (mo...
+
+=== Chunk 621 ===
+Source: 0973_002-ebook.pdf
+Length: 673 chars
+
+Figure 8.6
+Small
+temporo-zygomatic entry wound hidden by hair.
+a
+B
+.
+M
+HOSPITAL EMERGENCY ROOM CARE
+One should attempt to identify the likely path of the projectile through the body. This may involve any structure between the entry and exit wounds. Every attempt should be made to establish the position of the projectile on an X-ray if no exit exists. Remember that wounds to the chest, buttock, thigh or perineum may involve the abdominal cavity (Figures 8.7.1 – 8.7.3). X-rays should include, at t...
+
+=== Chunk 622 ===
+Source: 0973_002-ebook.pdf
+Length: 171 chars
+
+Figure 8.7.1
+Bullet wound to the pelvis: the entry is located on the right side. A defunctioning colostomy has been performed.
+Figure 8.7.2 Exit wound in the left buttock....
+
+=== Chunk 623 ===
+Source: 0973_002-ebook.pdf
+Length: 1325 chars
+
+Figure 8.7.3
+Any structure between entry and exit should be identified: here blood is seen in the rectum.
+A simple outline drawing of the body on the admission chart (homunculus), front and back, is useful for recording all injuries.
+Dressings on the limbs should not be removed if the casualty is haemodynamically unstable. Only once resuscitation has begun and the patient’s condition is under control is it safe to examine wounds to the extremities, preferably in the operating theatre.
+The ABCDE ...
+
+=== Chunk 624 ===
+Source: 0973_002-ebook.pdf
+Length: 1400 chars
+
+8.10.1 Complementary diagnostic examinations and monitoring
+Electrocardiogram (ECG) monitoring is not routinely available in ICRC surgical hospitals, neither are computerized tomography (CT) scans, angiography, sonography, Doppler blood flow or arterial blood gases. The use of central venous pressure lines carries too high a risk of septicaemia in most circumstances where the ICRC works. Diagnostic peritoneal lavage for abdominal injury is not practised routinely – in any case, it is unnecessary...
+
+=== Chunk 625 ===
+Source: 0973_002-ebook.pdf
+Length: 1457 chars
+
+HOSPITAL TRIAGE OF MASS CASUALTIES
+9
+WAR SURGERY
+194
+9 HOSPITAL TRIAGE OF MASS CASUALTIES 9.1 Introduction 9.1.1 The logic of triage 9.1.2 Where to perform triage 9.1.3 A delicate balance 9.2 Setting priorities: the ICRC triage system 9.2.1 The ICRC triage categories 9.2.2 Notes on triage categories 9.3 How to perform triage 9.3.1 “Sift” 9.3.2 “Sort” 9.3.3 Avoid undertriage and overtriage 9.3.4 Avoid confusion and disagreements within the team 9.4 Triage documentation 9.5 Emergency plan for mass...
+
+=== Chunk 626 ===
+Source: 0973_002-ebook.pdf
+Length: 3567 chars
+
+9.1.1 The logic of triage
+In daily, routine practice surgeons face patients one by one. They use all of the means, equipment, and supplies at hand to do the most they can for every patient; they try to do everything they possibly can for every single individual. The priority is high- intensity care for the sickest.
+In a single multiple-casualty incident means may be stretched to the limit, but one can still manage to do the best possible for all patients. With a massive influx of wounded, howeve...
+
+=== Chunk 627 ===
+Source: 0973_002-ebook.pdf
+Length: 1823 chars
+
+9.1.2 Where to perform triage
+As mentioned in Chapter 1, one of the special characteristics of surgery in times of war is the staged management of patients in a chain of casualty care. The principles of triage are applied at every stage.
+Triage takes place at every echelon of the chain of casualty care, including during evacuation.
+The organization of a casualty collection point and effective triage permits the orderly evacuation of the wounded, the most efficient use of stretchers, ambulances o...
+
+=== Chunk 628 ===
+Source: 0973_002-ebook.pdf
+Length: 445 chars
+
+9.1.3 A delicate balance
+To set priorities for patient management a number of factors must be taken into consideration to define the needs on the one hand, and the resources available on the other. The practice of triage is a fine balance between these two.
+Triage is a dynamic equilibrium between needs and resources:
+• needs = number of wounded and types of wounds;
+• resources = facilities at hand and number of competent personnel available....
+
+=== Chunk 629 ===
+Source: 0973_002-ebook.pdf
+Length: 566 chars
+
+Needs
+• How many patients are arriving? 10, 50 or 100?
+• Are they all suffering from penetrating injuries? Or are there many burn cases amongst them?
+The number of wounded and the different pathologies should be taken into account in the total workload. Penetrating wounds will require a great deal of surgery. Burn patients require relatively little immediate surgery, but a great deal of nursing care.
+1 For field triage, see Giannou C, Bernes E. First Aid in Armed Conflicts and Other Situations o...
+
+=== Chunk 630 ===
+Source: 0973_002-ebook.pdf
+Length: 514 chars
+
+Resources
+• How many surgeons and anaesthetists?
+• How many operating tables?
+• How many instrument boxes, and what is the efficiency of the sterilization system?
+• How many beds? etc.
+A hospital may have three fully-equipped operating theatres, but if there is only one surgeon then only one patient can be operated at a time. If there are three surgeons and three anaesthetists, but only one theatre, then the team must improvise extra operating facilities, if there are sufficient boxes of surgica...
+
+=== Chunk 631 ===
+Source: 0973_002-ebook.pdf
+Length: 1464 chars
+
+Setting priorities: the ICRC triage system
+There are a number of triage category systems used throughout the world today. Some are more sophisticated than others and depend on injury severity scores and physiological parameters. There are two important factors to keep in mind when deciding upon a system to use in a hospital.
+1. It should be kept as simple as possible – a mass influx of wounded always creates confusion, tension and anxiety.
+2. All members of the hospital team should understand th...
+
+=== Chunk 632 ===
+Source: 0973_002-ebook.pdf
+Length: 990 chars
+
+Category I: Serious wounds – resuscitation and immediate surgery
+Patients who need lifesaving surgery and have a good chance of recovery. Some examples include:
+• airway – injuries or burns to the face and neck requiring tracheostomy;
+• breathing – tension pneumothorax, major haemothorax;
+• circulation – internal haemorrhage, wounds to major peripheral blood vessels, traumatic amputation.
+Category II: Second priority wounds – can wait for surgery
+Patients who require surgery but not on an urgent...
+
+=== Chunk 633 ===
+Source: 0973_002-ebook.pdf
+Length: 418 chars
+
+Category III: Superficial wounds – ambulatory management
+Patients who do not require hospitalization and/or surgery because their wounds are so minor that they can be managed on an ambulatory basis.
+They are often called the “walking-wounded”. In practice, this is a very large group including those presenting superficial wounds managed under local anaesthesia in the emergency room or with simple first-aid measures....
+
+=== Chunk 634 ===
+Source: 0973_002-ebook.pdf
+Length: 966 chars
+
+Category IV: Severe wounds – supportive treatment
+Patients with injuries so severe that they are unlikely to survive or would have a very poor quality of survival. These include the moribund, or patients with multiple major injuries whose management could be considered wasteful of scarce resources in a mass casualty situation in terms of operative time and blood. Examples include:
+• penetrating head wound with GCS < 8;
+• quadriplegia;
+• burns > 50 % body surface area;
+• major blood loss and no b...
+
+=== Chunk 635 ===
+Source: 0973_002-ebook.pdf
+Length: 1418 chars
+
+9.2.2 Notes on triage categories
+The number of casualties who require urgent treatment may exceed the surgical capacity available. A second triage within Category I is then necessary (see Section 9.3.2). On the other hand, when evacuation time to the hospital is longer than 12 hours, few patients may fall into Category I.
+Many surgeons believe that all penetrating brain wounds are a Category I emergency; others believe that they are all hopeless Category IV. The use of the GCS helps to different...
+
+=== Chunk 636 ===
+Source: 0973_002-ebook.pdf
+Length: 513 chars
+
+9.3 How to perform triage
+Triage is a dynamic process: it requires a continuous reassessment of patients.
+Patients may change triage category: their condition may deteriorate, or improve over time and with pre-operative resuscitation. As a result, a continuous reassessment of patients is absolutely necessary.
+Triage is a multiple-step process: “sift and sort”, then re-examine, re-examine, re-examine. “Sift” involves placing the patient in a general Category; “sort” then decides priority within t...
+
+=== Chunk 637 ===
+Source: 0973_002-ebook.pdf
+Length: 3210 chars
+
+9.3.1 “Sift”
+On reception of the casualties in the hospital, the triage officer must perform a rapid examination of each patient – a maximum of 30 seconds – checking the whole body, including the back. Field dressings should be changed by the nursing team as part of the examination; except for obviously large and severe wounds whose dressings are removed only in theatre. Severity of injury and probability of survival are the keys to decision-making. Clinical experience with the war-wounded – not...
+
+=== Chunk 638 ===
+Source: 0973_002-ebook.pdf
+Length: 2665 chars
+
+9.3.2 “Sort”
+After “sifting” casualties into the general Categories, a second examination is performed: “sorting”. No two triage situations are equal and, therefore, according to the number of competent personnel available, the triage officer or a second physician-in-charge continues the reassessment of patients within the Category I cohort. “Sorting” decides which of the Category I patients to send to theatre first: priority amongst the priorities. The others, while waiting, remain under close ...
+
+=== Chunk 639 ===
+Source: 0973_002-ebook.pdf
+Length: 783 chars
+
+9.3.3 Avoid undertriage and overtriage
+In undertriage the assessment underestimates the severity of injury and the patient is not given sufficient priority. Overtriage overestimates the injury, and a patient is assigned to a higher Category than necessary. This will divert resources from the truly seriously injured and overburden the critical care services. Repeated re-examinations will correct these errors.
+201
+WAR SURGERY
+202
+It may be necessary to transfer minimal care patients to other sites...
+
+=== Chunk 640 ===
+Source: 0973_002-ebook.pdf
+Length: 682 chars
+
+Triage decisions must be respected.
+There is no time or place for disagreements during a triage of mass casualties. The decisions of the triage officer must be “dictatorial”. The post-triage evaluation session is the place for “democratic” discussion and constructive criticism.
+In spite of training, practising and planning, the unexpected will happen. The hospital team – led by the team leader, triage officer, head nurse – will at times have to improvise and invent new protocols and procedures t...
+
+=== Chunk 641 ===
+Source: 0973_002-ebook.pdf
+Length: 1773 chars
+
+9.4 Triage documentation
+Good records are essential and no effort should be spared to record important aspects of the wounds, treatment, and the patient’s triage category.
+Each casualty should be appropriately identified, numbered, and assigned a medical chart. Large plastic bags, labelled with the patient’s number, are used for clothing; smaller labelled plastic bags are used to collect patients’ valuables. They are stored separately and the valuables put in a safe place.
+Some system must be de...
+
+=== Chunk 642 ===
+Source: 0973_002-ebook.pdf
+Length: 196 chars
+
+9.5 Emergency plan for mass casualties: disaster triage plan
+Any hospital treating the war-wounded must be prepared to receive large numbers of casualties. Preparation means planning and training....
+
+=== Chunk 643 ===
+Source: 0973_002-ebook.pdf
+Length: 1715 chars
+
+9.5.1 Planning
+The triage tent in Figure 9.3 shows a number of key points:
+• there is enough space to move around;
+• the small lightweight beds/stretchers that are easily moved and inexpensive;
+• small carts for emergency medical supplies;
+• i.v. fluids hanging on a rope strung across the room, for flexibility of patient placement;
+• a patient carried on a stretcher by dedicated bearers;
+• relatively few staff members present, getting on with their allotted tasks in what appears to be a calm atm...
+
+=== Chunk 644 ===
+Source: 0973_002-ebook.pdf
+Length: 1141 chars
+
+9.5.2 The team
+The hospital team should hold a series of meetings, to discuss the organization of the disaster/triage plan. Everyone working in the hospital should be aware of the plan and their respective role during a crisis. The plan should be posted so that everyone is well acquainted with it.
+The plan should be put into operation as soon as notice is given of the expected arrival of mass casualties. It should include the mechanism for deciding who declares the emergency and under what condi...
+
+=== Chunk 645 ===
+Source: 0973_002-ebook.pdf
+Length: 133 chars
+
+9.6 Personnel
+There are three key leadership functions in a disaster triage scenario: triage team leader, triage officer, head nurse....
+
+=== Chunk 646 ===
+Source: 0973_002-ebook.pdf
+Length: 613 chars
+
+9.6.1 Triage team leader
+The triage team leader is the coordinator. He is usually designated to announce the onset of the hospital triage plan; he then coordinates the work of the different units and services, and makes sure that all departments are informed. The triage team leader maintains an overview of the situation, including a constant reassessment to determine the need for additional staff, supplies, and ward areas. In addition, he must be aware of events outside the hospital, maintaining...
+
+=== Chunk 647 ===
+Source: 0973_002-ebook.pdf
+Length: 1486 chars
+
+9.6.2 Triage officer
+The triage officer performs the actual clinical triage, assigning a category to each and every patient on entry. There has been much discussion about who should perform triage: surgeon or anaesthetist? Again, there is no strict rule. Each hospital team must decide according to its circumstances.
+The logic of triage demands that the most experienced and respected person willing and able to take on the responsibility should do so. This person must know how to organize the emer...
+
+=== Chunk 648 ===
+Source: 0973_002-ebook.pdf
+Length: 176 chars
+
+Triage Officer
+No task in medicine requires greater understanding, skill, and judgement than the categorization of casualties and the establishment of priorities for treatment....
+
+=== Chunk 649 ===
+Source: 0973_002-ebook.pdf
+Length: 373 chars
+
+9.6.3 Head nurse
+The head nurse organizes the nursing and paramedical personnel (laboratory, pharmacy, etc.) and non-medical support staff (trolley orderlies/stretcher-bearers, kitchen, laundry, cleaning, etc.). This is largely a coordination function. Any clinical role or supervision by the head nurse will depend on the particular circumstances of the hospital involved....
+
+=== Chunk 650 ===
+Source: 0973_002-ebook.pdf
+Length: 445 chars
+
+9.6.4 The team
+Whether one person fills more than one leadership function will depend on the availability of competent personnel. The triage team leader may be the same as the triage officer in a small hospital; in a larger facility, this coordination function is probably best assigned to someone else, for instance an administrative officer or the head nurse. In a very large hospital, three different people should assume the three functions....
+
+=== Chunk 651 ===
+Source: 0973_002-ebook.pdf
+Length: 844 chars
+
+9.6.5 Triage groups/nursing teams
+Such teams should be formed for the triage area, with responsibility for the following tasks.
+1. Setting up intravenous lines and taking blood for grouping and cross-matching.
+2. Administration of tetanus prophylaxis, antibiotics, analgesics and other medication as prescribed.
+3. Dressing wounds and splinting fractures.
+4. Bladder catheterization, if indicated.
+GENERAL DISASTER PLAN OF ADI-UGRI HOSPITAL  ORGANISATION OF DISASTER TEAMS  I.   TRIAGE (screening) TE...
+
+=== Chunk 652 ===
+Source: 0973_002-ebook.pdf
+Length: 582 chars
+
+Figure 9.5
+The disaster plan may be nominative, designating by name the triage officer and triage groups: who is in charge of setting up i.v. lines, dressing wounds, giving analgesics and antibiotics, etc. (Figure 9.5); or it may designate the function (ER doctor 1, ER nurse 3) regardless of who is on the roster that day. This depends on the staffing system, and availability of personnel, of the particular hospital.
+Example of a nominative disaster/triage plan in a small rural hospital.
+205
+a
+Gh...
+
+=== Chunk 653 ===
+Source: 0973_002-ebook.pdf
+Length: 414 chars
+
+9.6.6 Surgeons and theatre personnel
+These members of staff should have prepared the operating theatre and be ready and waiting for the casualties. The surgeon in theatre will see patients he or she has not previously examined and who may not have a known name or signed consent form. Outside the mass casualty situation this would be regarded as negligent practice, and so another “mental adjustment” is required....
+
+=== Chunk 654 ===
+Source: 0973_002-ebook.pdf
+Length: 665 chars
+
+9.6.7 Rest and relief
+Early consideration should be given to the rest and relief of staff. Triage is not an everyday routine activity. The shift system may need to be changed in order to deal with the increased workload: 2 twelve-hour shifts instead of 3 eight-hour ones, for example.
+During a crisis the hospital team will be under severe emotional and physical stress. All staff members will need to pace themselves in order to perform efficiently and maintain a professional attitude. As mentioned...
+
+=== Chunk 655 ===
+Source: 0973_002-ebook.pdf
+Length: 2810 chars
+
+9.7 Space
+During an influx of mass casualties the various hospital departments must be re-arranged according to the pre-decided plan. Besides the original hospital site, any alternative sites (building, underground shelter, etc.) must be included in the plan, should the hospital require evacuation for reasons of security. The equivalent in cases of natural disaster is the destruction of the hospital premises and/or its access routes (earthquake, landslide, tsunami, etc.).
+Aburabi /ICRC
+C
+2
+R
+C
+I...
+
+=== Chunk 656 ===
+Source: 0973_002-ebook.pdf
+Length: 1753 chars
+
+9.8 Equipment and supplies
+A large number of stretchers or trolleys are needed at the hospital entrance during triage, to accommodate the casualties left by incoming ambulances. Blankets and sheets are required in the triage area, as are lines on which to hang infusions. Complete sets of supplies for triage should be prepared and stored in boxes or trunks which can easily be carried to the triage area from an accessible storage space.
+Triage boxes should include:
+• disposable latex or plastic gl...
+
+=== Chunk 657 ===
+Source: 0973_002-ebook.pdf
+Length: 582 chars
+
+9.9 Infrastructure
+Plans must be made to ensure adequate supplies of water, sufficient electricity, proper sanitation, and the disposal of waste. This may include special reserves of fuel for electric generators. Spare parts are also important to keep in stock; things tend to break down in the middle of an emergency situation.
+The designation of roles, responsibilities and tasks is not limited to the medical personnel. Technicians and maintenance workers to run the generators and ensure the wate...
+
+=== Chunk 658 ===
+Source: 0973_002-ebook.pdf
+Length: 494 chars
+
+9.10 Services
+Hospital personnel, patients and their relatives, and volunteers must all eat. Hospital linen must be washed and theatre linen re-sterilized. The kitchen, cafeteria and laundry staff and facilities must all be included in the disaster plan. Relatives are a great nuisance in the triage area but their energies can be harnessed for the general good. They may be directed to give blood and engaged as volunteer stretcher- bearers, carriers of water, cleaners and kitchen staff, etc....
+
+=== Chunk 659 ===
+Source: 0973_002-ebook.pdf
+Length: 1001 chars
+
+9.11 Training
+The hospital team should regularly practise different triage scenarios, on its own and as part of any national disaster or conflict-preparedness plan. Volunteers from the National Red Cross or Red Crescent Society, and their first aiders, may be mobilized to work in the hospital and/or play the role of the injured.
+Clinical protocols and guidelines for triage and patient management must be standardized and understood by all doctors and nurses. This helps to avoid confusion and disa...
+
+=== Chunk 660 ===
+Source: 0973_002-ebook.pdf
+Length: 1265 chars
+
+9.12 Communication
+If the hospital is part of an integrated health system, then a means of coordination and communication with other health facilities may make it possible to transfer the wounded from the overwhelmed hospital to another which has received comparatively few patients. Alternatively, other health facilities may be able to provide help in the form of additional personnel.
+The plan should include the means to contact staff who are off duty, bearing in mind that if combat is occurring...
+
+=== Chunk 661 ===
+Source: 0973_002-ebook.pdf
+Length: 3823 chars
+
+9.13 Security
+Last, but certainly not least, is the safety and security of the hospital premises, patients and staff. When armed conflict results in mass casualties every wounded person transported to the hospital is accompanied, as a general rule, by two to four friends, relatives, comrades-in-arms, or bystanders who have helped in the evacuation or transport. Curious onlookers may try to enter the hospital as well. The civilian population may be in a state of panic and consider the hospital a ...
+
+=== Chunk 662 ===
+Source: 0973_002-ebook.pdf
+Length: 425 chars
+
+9.14 Summary of triage theory and philosophy: sorting by priority
+The triage process has three components.
+1. Clinical assessment to determine which patients take priority for the limited surgical time and resources available.
+2. The organization and management involved in admitting large numbers of wounded to the hospital.
+3. Re-assessment of the functioning of triage and its adaptation to the number of incoming wounded....
+
+=== Chunk 663 ===
+Source: 0973_002-ebook.pdf
+Length: 626 chars
+
+9.14.1 Triage system: a simple emergency plan organizing the personnel, space, infrastructure, equipment, and supplies
+The sudden arrival of large numbers of casualties may occur at any time. Prior planning and training prevents poor performance. Unless a plan exists for the reception and triage of mass casualties, chaos will result. Hospital staff should be prepared, however, to improvise when faced with a new evolving situation.
+Evaluation of hospital capacity is essential in emergency plannin...
+
+=== Chunk 664 ===
+Source: 0973_002-ebook.pdf
+Length: 400 chars
+
+9.14.2 Emergency hospital disaster triage plans differ and no two triage scenarios are the same
+Hospital teams must regularly practise receiving a mass influx of wounded, resulting from armed conflict or natural disaster. Simulation exercises should be organized covering a variety of scenarios, and adapted to the particular circumstances of the hospital involved.
+HOSPITAL TRIAGE OF MASS CASUALTIES...
+
+=== Chunk 665 ===
+Source: 0973_002-ebook.pdf
+Length: 558 chars
+
+9.14.3 “Best for most” policy
+Priority patients are those with a fair chance of “good survival” with the least amount of surgical work.
+Triage is essential to put some order into a chaotic situation.
+However good the disaster plan and extensive the training, a mass influx of casualties is always stressful and attended by confusion. Flexibility and adaptability of the hospital team are important. Triage is not a series of rules. It has a logic and philosophy that must be adapted to each particula...
+
+=== Chunk 666 ===
+Source: 0973_002-ebook.pdf
+Length: 182 chars
+
+ANNEX 9. A Sample triage card
+Triage Card No: _______________
+Mine: Fragment: Blast:
+Name:
+Coming from:
+Date:
+GSW:
+Time since injury:
+Male / Female / Age
+Time:
+Burn:[__|
+Burn:
+Other:...
+
+=== Chunk 667 ===
+Source: 0973_002-ebook.pdf
+Length: 160 chars
+
+General condition:
+Pulse:
+BP:
+Resp. rate:
+Consciousness:
+assessment:
+Wound assessment:
+Triage Category:
+Eel
+II
+O—EE Oe
+212212
+HOSPITAL TRIAGE OF MASS CASUALTIES...
+
+=== Chunk 668 ===
+Source: 0973_002-ebook.pdf
+Length: 1797 chars
+
+ANNEX 9. B Hospital emergency plan for a mass influx of wounded
+HOSPITAL EMERGENCY PLAN FOR A MASS INFLUX OF WOUNDED
+PHASE 1 2 3 4 5 6 Influx of wounded (number of patients) 1 – 10 11 – 20 21 – 30 31 – 40 41 – 50 > 50 Secrity + Porters/ stretcher - bearers Routine Extra guards at patients’ entrance Visitors leave Visiting hours suspended “ Call in extra porters/ stretcher- bearers “ TTL / TO / HN HN informed OT informed TTL informed TO: INITIATE TRIAGE HN: Inform wards, OT, administration Call i...
+
+=== Chunk 669 ===
+Source: 0973_002-ebook.pdf
+Length: 1081 chars
+
+SURGICAL MANAGEMENT OF WAR WOUNDS
+10
+WAR SURGERY
+216
+10 SURGICAL MANAGEMENT OF WAR WOUNDS
+10.1 10.2 10.3 10.4 10.5 10.5.1 10.5.2 10.5.3 10.5.4 10.5.5 10.5.6 10.5.7 10.5.8 10.6 10.7 10.8 10.8.1 10.8.2 10.9 10.9.1 10.9.2 10.9.3 10.9.4 10.9.5 10.9.6 10.10 10.10.1 10.11 Introduction Complete examination Preparation of the patient Examination of the wound Surgical treatment Technique of wound debridement Skin Subcutaneous fat Fascia and aponeurosis Muscle Haematoma Bone and periosteum Arteries, nerve...
+
+=== Chunk 670 ===
+Source: 0973_002-ebook.pdf
+Length: 979 chars
+
+10.1 Introduction
+There are many factors that determine the final outcome of the management of war- wounded patients:
+• the actual injury – the clinical significance of the wound is a function of the severity of tissue damage and the anatomic structures involved i.e. size and site;
+• the general condition of the patient – nutritional status, dehydration, concomitant diseases, host resistance, etc. ;
+• pre-hospital care: protection, shelter, first aid, triage, evacuation time;
+• resuscitation, es...
+
+=== Chunk 671 ===
+Source: 0973_002-ebook.pdf
+Length: 1641 chars
+
+Figure 10.1
+“Damaged tissues must be removed in time.” Ibn Sinna, Qanun fi al-Tib.2
+“The severity of these [war] wound infections is merely the result of the very extensive destruction of the tissues by the projectile, thus furnishing an admirable culture medium for the bacteria out of reach of the natural protective forces of the body, and if it were possible for the surgeon to remove completely this dead tissue I am quite sure the infections would sink into insignificance.”
+Alexander Fleming32...
+
+=== Chunk 672 ===
+Source: 0973_002-ebook.pdf
+Length: 1638 chars
+
+Figure 10.2.1
+Wound sutured primarily to “close the hole”, without debridement.
+Figure 10.2.2 Sutures removed: pus pours out.
+Wound ballistics teaches us that the formation of a cavity by a projectile conveys pathogenic organisms, pieces of dirty skin and clothing and dust into the depths of the wound. Anti-personnel blast mines drive pieces of the shoe or bones of the foot,
+1
+“Débridement” is a French term originally used to mean the removal of a constriction, or to unbridle, and thus to promot...
+
+=== Chunk 673 ===
+Source: 0973_002-ebook.pdf
+Length: 649 chars
+
+Figure 10.3
+Anti-personnel landmine injury: war wounds are dirty and contaminated.
+Entry  Exit wound
+Entry
+Exit wound
+Figure 10.4
+Entry and exit thoraco-abdominal wounds: think anatomy!
+218
+gravel, soil, leaves and grass, and pieces of the weapon into the proximal tissues. Although the wounds are contaminated, infection does not set in for the first 6 – 8 hours. Ideally, therefore, war wounds should be debrided within six hours; this is not often the case.
+Old lessons for new surgeons   War woun...
+
+=== Chunk 674 ===
+Source: 0973_002-ebook.pdf
+Length: 137 chars
+
+Examine the patient:
+• initial examination and resuscitation;
+• complete examination to identify all open wounds and any closed injuries....
+
+=== Chunk 675 ===
+Source: 0973_002-ebook.pdf
+Length: 170 chars
+
+Examine the wounds and damaged organs:
+• to operate or not to operate;
+• to establish priorities if more than one surgical procedure is required;
+• to plan the operation....
+
+=== Chunk 676 ===
+Source: 0973_002-ebook.pdf
+Length: 3447 chars
+
+10.2 Complete examination
+All wounds involve soft tissues, and many of them will be complicated by damage to other structures. War wounds are often multiple and the pathology often multiple: a bomb explosion can simultaneously cause primary blast injury, penetrating metallic fragments, blunt trauma and burns. Close and complete examination of the patient is important to determine the site and size of all wounds present, in order to determine which wounds require surgery and to best plan the sequ...
+
+=== Chunk 677 ===
+Source: 0973_002-ebook.pdf
+Length: 120 chars
+
+Figure 10.5
+Massive comminution of humerus showing characteristic “shower of lead particles” after bullet fragmentation....
+
+=== Chunk 678 ===
+Source: 0973_002-ebook.pdf
+Length: 1250 chars
+
+10.3 Preparation of the patient
+Not only are war wounds dirty and contaminated but battlefields are dirty places as well. The wounded do not have access to basic sanitary facilities and every precaution should be taken to meet fundamental hygiene standards. The majority of casualties have wounds to the limbs and are haemodynamically stable. All stable patients should be put through a warm shower upon admission; dressings are changed as necessary for examination and triage. Only critical cases go...
+
+=== Chunk 679 ===
+Source: 0973_002-ebook.pdf
+Length: 1430 chars
+
+Figure 10.6
+X-ray showing air in tissues in a patient not suffering from gas gangrene.
+Under anaesthesia, dressings and splints are carefully removed. The skin over a large surrounding area, including the whole circumference of the limb or torso, is cleansed with soap and water and a brush, shaved, dried, and then painted with povidone iodine. The wound is irrigated copiously.
+Sterile sheets are put in place. Drapes with holes should only be used for the smallest and most superficial wounds. Mos...
+
+=== Chunk 680 ===
+Source: 0973_002-ebook.pdf
+Length: 301 chars
+
+10.4 Examination of the wound
+Following the initial careful examination of the patient, full assessment of the wound(s) may require finger exploration in theatre under anaesthesia. In this era of HIV and Hepatitis B and C, the surgeon should take great care not to suffer injury from sharp bony edges....
+
+=== Chunk 681 ===
+Source: 0973_002-ebook.pdf
+Length: 803 chars
+
+10.5 Surgical treatment
+The surgical treatment of a major wound is performed in two stages:
+• wound debridement, leaving the lesion wide open, without any suturing of skin or deep structures;
+• delayed primary closure 4 – 5 days later.
+The surgical treatment of most war wounds is a staged process involving two main procedures, the first being wound debridement or excision. The resulting wound is left unsutured. The open wound then undergoes delayed primary closure (DPC) after 4 – 7 days, once th...
+
+=== Chunk 682 ===
+Source: 0973_002-ebook.pdf
+Length: 1943 chars
+
+10.5.1 Technique of wound debridement
+Basic principles of wound debridement
+1. Stop haemorrhage.
+2. Make adequate skin incisions and fasciotomies.
+3. Remove dead and severely contaminated tissues to prevent/control infection.
+Leave the wound open – unsutured.
+5. Re-establish physiological function.
+6. Handle gently and treat the tissues with respect, as always.
+Control of haemorrhage is the first priority. In a large wound with heavy bleeding, blind clamping in the depths of a blood-filled cavit...
+
+=== Chunk 683 ===
+Source: 0973_002-ebook.pdf
+Length: 1019 chars
+
+Wound debridement involves incision and excision.
+A basic instrument set is all that is needed in the vast majority of cases: scalpel, Metzenbaum (tissue) and Mayo (suture) scissors, toothed dissection forceps, non- toothed anatomic forceps, bone curette, six haemostats, and retractors. Diathermy is not necessary; absorbable ligature material is preferable.
+For the young surgeon, or one without experience of war wounds, it is best to excise the wound layer-by-anatomic-layer, proceeding from supe...
+
+=== Chunk 684 ===
+Source: 0973_002-ebook.pdf
+Length: 134 chars
+
+Figure 10.9.3
+Patient X: opening of the fascia throughout the length of the skin incision. Note the contused and necrotic muscles.
+222...
+
+=== Chunk 685 ===
+Source: 0973_002-ebook.pdf
+Length: 1029 chars
+
+10.5.2 Skin
+Skin is elastic, with a good blood supply, very resistant to damage and remarkably viable. It should be treated conservatively. Only skin that is grossly pulped should be cut away. Usually no more than 2 – 3 mm of the skin edge need be removed at both entry and exit sites.
+This is followed by as generous an incision as necessary of healthy skin in order to gain access to the depths of the wound (Figure 10.9.2). Small entry and exit wounds may hide considerable internal injury. The mo...
+
+=== Chunk 686 ===
+Source: 0973_002-ebook.pdf
+Length: 214 chars
+
+10.5.3 Subcutaneous fat
+Subcutaneous fat has a poor blood supply and is sticky, easily holding heavy contamination. This layer should be excised generously, 2 – 3 cm all the way around the original traumatic wound....
+
+=== Chunk 687 ===
+Source: 0973_002-ebook.pdf
+Length: 1184 chars
+
+10.5.4 Fascia and aponeurosis
+Shredded fascia should also be trimmed. Large amounts of damaged muscle may lie underneath a small hole in the fascia; therefore, the muscular compartment should be opened up by a large incision of the deep fascia parallel to the muscle fibres along the entire length of the skin incision (Figure 10.9.3). This essential step allows wide and deep retraction to expose the depths of the wound. It may be necessary to add transverse cuts to the deep fascia to improve acce...
+
+=== Chunk 688 ===
+Source: 0973_002-ebook.pdf
+Length: 432 chars
+
+Fasciotomy
+Compartment syndrome can occur in any fascial space, but is seen most commonly in the lower leg. Great care should be taken when dealing with any penetrating wound below the knee, with or without tibial fracture.
+If there is any suspicion of compartment syndrome, decompression must be performed without delay.
+For information on the technique of fasciotomy, see Section B10 in Volume 2.
+SURGICAL MANAGEMENT OF WAR WOUNDS...
+
+=== Chunk 689 ===
+Source: 0973_002-ebook.pdf
+Length: 453 chars
+
+10.5.5 Muscle
+Dead muscle is the ideal medium for the development of clostridial infection leading to gas gangrene or tetanus as well as for the growth of many other bacteria. The track of the missile through the muscles must be opened up, layer by layer, to be properly visualized. It is vital that all grossly contaminated, obviously necrotic and detached muscle lining the track be excised.
+All dead or heavily contaminated muscle must    be removed....
+
+=== Chunk 690 ===
+Source: 0973_002-ebook.pdf
+Length: 2091 chars
+
+Figure 10.9.4
+Patient X: wound cavity completely opened and excised.
+All muscle that is not healthy and red, that does not contract when pinched or bleed when cut, must be excised until healthy, contractile, bleeding muscle is found.
+However, confusion may arise because of certain pathological changes described below.
+• As mentioned in Chapter 3, wound ballistics studies have shown that there is an intense but transient vasoconstriction lasting several hours, followed by the reactive local hyper...
+
+=== Chunk 691 ===
+Source: 0973_002-ebook.pdf
+Length: 345 chars
+
+10.5.6 Haematoma
+The presence of a large haematoma generally implies that a major vessel has been damaged. Dislodging the haematoma can result in sudden heavy blood loss. It is wise to be prepared for vascular control before a haematoma is evacuated. If working under a pneumatic tourniquet, the anatomical structures must be clearly identified....
+
+=== Chunk 692 ===
+Source: 0973_002-ebook.pdf
+Length: 1662 chars
+
+10.5.7 Bone and periosteum
+The Haversian vascular system of bone is a fragile one. Fragments of bone with no attachment to periosteum or muscle are already sequestrated and should be discarded, but any bone still attached should be retained. Exposed medullary bone should be curetted back to firm marrow. Any bone left in situ must be cleaned of dead muscle and foreign material, dirty bone ends are trimmed by a bone-nibbling forceps (rongeur). Bone defect is not important at this stage, the wound ...
+
+=== Chunk 693 ===
+Source: 0973_002-ebook.pdf
+Length: 1730 chars
+
+10.5.8 Arteries, nerves and tendons
+As aforesaid, bleeding should be controlled if a major artery to the limb is damaged and either immediately repaired or replaced by a saphenous vein graft or temporary stent if a limb is to survive. The surgeon should pay particular attention to the possibility of a vascular injury near severely comminuted fractures with multiple fragments.
+All nerves must be preserved as far as possible. Large nerves are resistant to section, although they may suffer neurapra...
+
+=== Chunk 694 ===
+Source: 0973_002-ebook.pdf
+Length: 1992 chars
+
+10.6 Retained bullets and fragments
+Obviously, if the surgeon comes across a projectile during wound debridement then it should be removed, but healthy tissue should not be dissected in an attempt to find one. Otherwise, there are two conditions that require immediate removal of bullets and fragments, and these are related to specific proven risks and complications.
+1. Projectile situated in a synovial joint – the piece of metal will cause pain, disability and progressive destruction of the join...
+
+=== Chunk 695 ===
+Source: 0973_002-ebook.pdf
+Length: 2670 chars
+
+10.7 Final look and haemostasis
+The edges of the wound should be retracted, and gentle and copious irrigation under low pressure will wash out any residual debris and clot and dilute any bacterial load. Normal saline is preferable, but any potable water can be safely used. A plastic bottle with holes cut into the top squeezed manually with both hands provides sufficient pressure; depending on the size of the wound cavity, one to three litres of saline is used. Very large and complicated fracture...
+
+=== Chunk 696 ===
+Source: 0973_002-ebook.pdf
+Length: 1740 chars
+
+10.8.1 Management of minor Grade 1 wounds
+Many Grade 1 soft-tissue wounds, according to the Red Cross Wound Score, can be treated conservatively. Examples include:
+• perforating bullet wound with small entry and exit (narrow channel wound) without swelling of intervening tissues (haematoma/oedema) or other signs of injury to important structures (Figure 3.29.1);
+• multiple superficial wounds due to “peppering” with tiny fragments of obviously low velocity and low kinetic energy (e.g. hand grenad...
+
+=== Chunk 697 ===
+Source: 0973_002-ebook.pdf
+Length: 145 chars
+
+Figure 10.15.2
+Heterogeneity of war wounds: there is no single treatment that applies to all wounds. Wounds must be considered by Grade and Type....
+
+=== Chunk 698 ===
+Source: 0973_002-ebook.pdf
+Length: 2100 chars
+
+10.8.2 Serial debridement
+For some large wounds the line of demarcation between dead tissue and damaged, but viable, tissue is not clear. The life-history of a wound is such that apparently clean and living tissue may become necrotic after a few days, especially if there has been a delay between injury and debridement; and if the surgeon is not experienced in this type of surgery. The idea here is to debride obviously dead tissue; otherwise excise conservatively, and then re-examine the wound in...
+
+=== Chunk 699 ===
+Source: 0973_002-ebook.pdf
+Length: 513 chars
+
+Figure 10.17
+Serial debridement of a large wound: the line of demarcation of necrotic tissue has now become apparent.
+C
+z
+R
+C
+I
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+n
+a
+3
+d
+l
+a
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+.
+M
+Figure 10.18 Panga wound to the head.
+228
+The practice of serial debridement should not be confused with an incomplete or failed wound excision. In the latter case, the patient returns to theatre for delayed primary closure after five days and the wound is found to be infected with remaining necrotic tissue. It is not ready for suture and requires re...
+
+=== Chunk 700 ===
+Source: 0973_002-ebook.pdf
+Length: 144 chars
+
+10.9 Leaving the wound open: the exceptions
+As is usually the case in surgery, there are exceptions where wounds may, or even should, be closed....
+
+=== Chunk 701 ===
+Source: 0973_002-ebook.pdf
+Length: 1161 chars
+
+10.9.1 Head, neck, scalp and genitals
+The excellent blood supply and minimal soft tissue of these structures usually allows for immediate primary closure after wound excision. Only in the presence of severe contamination, or if in doubt, might it be wiser to leave these wounds open.
+In maxillo-facial wounds, the oral mucosa is an exception in all respects and every attempt should be made to close it primarily.
+Machete or panga wounds, especially to the face or scalp, are not incised wounds, but ...
+
+=== Chunk 702 ===
+Source: 0973_002-ebook.pdf
+Length: 252 chars
+
+10.9.2 Soft tissues of the chest (sucking chest wound)
+These wounds must be debrided, but healthy muscle and pleura should be closed to preserve a functional serous cavity. The skin and subcutaneous tissue should be left open and a chest tube inserted....
+
+=== Chunk 703 ===
+Source: 0973_002-ebook.pdf
+Length: 364 chars
+
+10.9.3 Soft tissues of the abdominal wall
+As with the chest, the wound should be excised and every effort made to secure peritoneal closure. Furthermore, if the development of abdominal compartment syndrome is suspected, temporary abdominal closure is preferable (Bogotá bag, etc).
+For further details on abdominal compartment syndrome see Annex 32. A in Volume 2....
+
+=== Chunk 704 ===
+Source: 0973_002-ebook.pdf
+Length: 341 chars
+
+10.9.4 Hand
+Excision should be very conservative and all viable tissue preserved to simplify reconstruction and improve the functional result. These wounds should be left open for DPC after 2 – 4 days; however, tendons and nerves should be covered by healthy tissue, through rotation flaps if necessary. Small wounds may be closed primarily....
+
+=== Chunk 705 ===
+Source: 0973_002-ebook.pdf
+Length: 224 chars
+
+10.9.5 Joints
+Synovial membranes should be closed; if this is not possible the capsule alone should be sutured. Little harm seems to be done if the synovium cannot be closed securely. The skin and muscle should be left open....
+
+=== Chunk 706 ===
+Source: 0973_002-ebook.pdf
+Length: 267 chars
+
+10.9.6 Blood vessels
+Blood vessels that have been repaired primarily or by vein graft should be covered by viable muscle if possible. The skin should be left open.
+For specifics of each anatomic region, see Volume 2.
+C
+R
+C
+I
+C
+R
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+I
+SURGICAL MANAGEMENT OF WAR WOUNDS....
+
+=== Chunk 707 ===
+Source: 0973_002-ebook.pdf
+Length: 1857 chars
+
+10.10 Dressings
+Once the wound has been adequately excised, it should be covered with a bulky absorbent dressing made of dry fluffed-up gauze re-enforced with a layer of absorbent cotton wool. This is held in place with a loose crepe bandage or non circumferential adhesive tape. A tight bandage wrapped around the limb and soaked with exudate that dries will have a tourniquet effect. The gauze compresses should not be packed tightly in the wound; this will only impede drainage. The aim is to draw...
+
+=== Chunk 708 ===
+Source: 0973_002-ebook.pdf
+Length: 727 chars
+
+10.10.1 The exceptions
+• Continuing haemorrhage requires immediate re-exploration; as do vascular changes indicating ischaemia.
+• Obvious signs and symptoms of infection: fever, toxicity, excessive pain and tenderness, warmth, redness or shiny surface in dark-skinned people, oedema and induration, or a moist wound dressing with an offensive smell. These indicate the need for further surgical excision, which should be attended to in the operating theatre, not by changing the dressing in the ward....
+
+=== Chunk 709 ===
+Source: 0973_002-ebook.pdf
+Length: 288 chars
+
+10.11 Anti-tetanus, antibiotics, and analgesia
+All patients should receive prophylaxis against tetanus (see Chapter 13).
+For proper rest of the injured part, and to make the patient ready for physiotherapy, good analgesia should be given (see Annex 17. E: ICRC pain management protocols)....
+
+=== Chunk 710 ===
+Source: 0973_002-ebook.pdf
+Length: 1690 chars
+
+10.12 Post-operative care
+It goes without saying that proper post-operative nursing is crucial. ICRC experience has shown that the most important factor limiting the sophistication of surgical procedures performed in an ICRC hospital is not the technical expertise of the surgeon, but rather the level of post-operative nursing care. This should not be underestimated in the context of a poor, war-ravaged country.
+In all cases where there is an extensive soft-tissue wound, even in the absence of a ...
+
+=== Chunk 711 ===
+Source: 0973_002-ebook.pdf
+Length: 663 chars
+
+Chapter 11 DELAYED PRIMARY CLOSURE AND SKIN GRAFTING
+11
+WAR SURGERY
+234
+11 11.1 11.1.1 11.1.2 11.1.3 11.2 11.2.1 11.2.2 11.2.3 11.2.4 11.2.5 11.2.6 11.2.7 11.2.8 11.3 11.3.1 11.3.2 11.4 DELAYED PRIMARY CLOSURE AND SKIN GRAFTING Delayed primary closure Methods of delayed primary closure Dead space Wound care Skin grafting Types of autologous skin grafts Requisites for skin grafting Partial thickness grafts Reverdin pinch grafts Application of grafts and graft meshing Graft take Graft care Dressin...
+
+=== Chunk 712 ===
+Source: 0973_002-ebook.pdf
+Length: 1398 chars
+
+11.1 Delayed primary closure
+Delayed primary closure (DPC) is wound closure performed four to seven days after debridement, which corresponds to the fibroblastic phase of wound healing. In the practice of ICRC surgical teams, the standard has been 4 – 5 days. The timing of wound closure is important; this is still defined as healing by primary intention.
+Attempts to close wounds before they are clean must be avoided; but DPC is seldom possible later than 8 days after wound excision because of fi...
+
+=== Chunk 713 ===
+Source: 0973_002-ebook.pdf
+Length: 150 chars
+
+Figure 11.1.3
+Five days later, removal of dressing – note the dried haemoserous discharge. As the dressing comes off, the muscle contracts and bleeds....
+
+=== Chunk 714 ===
+Source: 0973_002-ebook.pdf
+Length: 876 chars
+
+Figure 11.1.4
+Clean wound ready for DPC; in this case by split- skin grafting owing to the large area of skin loss.
+Figure 11.1.5 Wound covered by early split-skin graft.
+235
+C
+&
+R
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+e
+2 i 2
+n
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+d
+e
+r
+s
+a
+N
+.
+H
+WAR SURGERY
+Figure 11.2 Direct suture as DPC.
+236
+If the wound is infected, the dressing slides off with no resistance whatsoever because there is a film of pus between it and the wound surface, which may contain areas of necrotic tissue as well as pus. The surface is a dull- or gre...
+
+=== Chunk 715 ===
+Source: 0973_002-ebook.pdf
+Length: 401 chars
+
+11.1.1 Methods of delayed primary closure
+This is usually accomplished by direct suture: simple approximation of the deep structures and skin with minimal mobilization of the skin edges, and without tension (Figure 11.2). If there is tension in the suture line, the skin edges will become necrotic and the wound will break down. Small wounds may be closed using adhesive tape to approximate the edges....
+
+=== Chunk 716 ===
+Source: 0973_002-ebook.pdf
+Length: 387 chars
+
+The wound should not be closed under tension.
+Significant tissue loss prevents approximation of the deep structures and skin. Rotation skin flaps might be useful in some anatomic locations. If bone is exposed, a musculocutaneous flap may be necessary. Larger areas require skin grafting (Figure 11.1.5).
+Adequate primary surgical excision is vital for uncomplicated wound closure by DPC....
+
+=== Chunk 717 ===
+Source: 0973_002-ebook.pdf
+Length: 1258 chars
+
+11.1.2 Dead space
+As with all wounds, the obliteration of dead space is an accepted principle of DPC management. This may be technically difficult when there has been extensive loss of deep tissue. Absorbable sutures are used to approximate deep structures, but, here again, undue tension should be avoided as it will only result in local tissue ischaemia that decreases local resistance to the development of infection and impedes healing. It is not necessary to suture fascia or subcutaneous tissue...
+
+=== Chunk 718 ===
+Source: 0973_002-ebook.pdf
+Length: 530 chars
+
+11.1.3 Wound care
+After DPC, the wound should be covered with some layers of dry gauze which can be left until the time of suture removal. If signs of infection develop after closure, the patient is taken back to theatre where the wound is inspected, sutures removed, and the wound re-opened for drainage and redebridement if necessary. Avoid performing this procedure in the ward, where proper inspection and drainage are difficult, as it only favours the development of cross-infection.
+DELAYED PRI...
+
+=== Chunk 719 ===
+Source: 0973_002-ebook.pdf
+Length: 183 chars
+
+11.2 Skin grafting
+If the wound cannot be closed by direct suture or rotational flaps because of skin loss, a skin graft can be applied, sometimes combined with partial direct suture....
+
+=== Chunk 720 ===
+Source: 0973_002-ebook.pdf
+Length: 615 chars
+
+11.2.1 Types of autologous skin grafts
+Free skin grafts may be partial-thickness (epidermis and part of the dermis) or full- thickness (including all the dermis). Partial-thickness grafts, also called split-skin grafts (SSG), vary in thickness depending upon how much of the dermis is incorporated. The thicker the graft, the less it will contract and the more it will resemble normal skin in colour and texture; but the risk of the graft failing is greater. Conversely, thinner grafts are hardy and ...
+
+=== Chunk 721 ===
+Source: 0973_002-ebook.pdf
+Length: 145 chars
+
+Thin partial-thickness grafts
+These are used for large areas and when the development of a contracture or quality of skin cover is not important....
+
+=== Chunk 722 ===
+Source: 0973_002-ebook.pdf
+Length: 216 chars
+
+Thick partial-thickness grafts
+These are used when skin quality is important, such as over flexion creases where contractures should be avoided. However, the recipient area must be very healthy with good vascularity....
+
+=== Chunk 723 ===
+Source: 0973_002-ebook.pdf
+Length: 141 chars
+
+Full-thickness grafts
+These are best for a good cosmetic result in the face, or to cover a sensitive functional area on the hands or fingers....
+
+=== Chunk 724 ===
+Source: 0973_002-ebook.pdf
+Length: 1493 chars
+
+11.2.2 Requisites for skin grafting
+Skin grafts can cover any wound with enough vascularity to produce granulation tissue. This does not imply that fully mature granulation tissue must be present prior to skin grafting, and early grafting for DPC, when the wound is first opened on the fifth day post-debridement, is often used (Figure 11.1.5). Early SSG has advantages and disadvantages: the wound is closed preventing any infection from developing, which is particularly important in large wounds; ...
+
+=== Chunk 725 ===
+Source: 0973_002-ebook.pdf
+Length: 345 chars
+
+11.2.3 Partial thickness grafts
+Split-skin grafts (thin and thick) are taken from an area which can produce a broad area of skin. The common donor sites are the thighs, back, and arms and forearms (Figure 11.3).
+Figure 11.3 Donor sites for partial-thickness grafts.
+237
+C
+P.Zylstra/ ICRC
+P.
+WAR SURGERY
+C
+P.2ylstra/ ICRC
+R
+C
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+/
+a
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+P....
+
+=== Chunk 726 ===
+Source: 0973_002-ebook.pdf
+Length: 273 chars
+
+Figure 11.4
+A dermatome: various models, with disposable blades, are available – the thickness of the split skin graft harvested is controlled by the screw at the right end of the instrument; the setting is then locked using the screw at the left end.
+C
+P.Zylstra / ICRC
+P....
+
+=== Chunk 727 ===
+Source: 0973_002-ebook.pdf
+Length: 1107 chars
+
+Figure 11.5.1
+Harvesting a split skin graft from the medial side of the thigh – note the assistant’s left hand flattening the donor site by exerting upward pressure on the undersurface of the thigh.
+238
+Split-skin grafts should be taken using a dermatome, such as a Humby knife (Figure 11.4). A free hand knife, such as a De Silva knife which incorporates a razor blade, or scalpel, can be used if a dermatome is not available or if the area to be harvested is small.
+The principles for the use of al...
+
+=== Chunk 728 ===
+Source: 0973_002-ebook.pdf
+Length: 1709 chars
+
+Harvesting the SSG
+The area of skin to be removed is washed with soap and water and shaved if necessary; povidone iodine is applied. Intradermal saline or, better still, dilute adrenaline solution (1:500,000), is injected into the donor area prior to cutting, to facilitate harvesting and diminish local blood loss. The donor site, the cutting edge of the knife, and the edge of a skin board are greased with vaseline-gauze.
+An assistant applies an ungreased skin board to the distal end of the donor...
+
+=== Chunk 729 ===
+Source: 0973_002-ebook.pdf
+Length: 717 chars
+
+11.2.4 Reverdin pinch grafts
+These can be used to cover large areas of defect and where the recipient area is unfavourable, such as muscles moving in different planes. A full take is not expected and the gaps between the grafts will fill in as the skin spreads outwards and coalesces. The cosmetic result is poor.
+As with SSG, an intradermal infiltration of local anaesthetic with adrenaline is injected into the donor area. This helps to avoid cutting the grafts too deeply and is often all the anae...
+
+=== Chunk 730 ===
+Source: 0973_002-ebook.pdf
+Length: 152 chars
+
+11.2.5 Application of grafts and graft meshing
+The recipient bed is prepared by washing with saline and scraping clean any exuberant granulation tissue....
+
+=== Chunk 731 ===
+Source: 0973_002-ebook.pdf
+Length: 378 chars
+
+Figure 11.6
+Reverdin pinch grafts:
+C
+R
+C
+I
+a. The skin is picked up with a needle and round patches of thick SSG, 1 – 2 cm in diameter, are cut with a scalpel.
+b. If the patches are taken in a line, the area can be excised and the wound closed by primary suture.
+c. The patches are spread over the receptor site with gaps of a few millimetres between each piece.
+/
+n
+i
+s
+a
+S
+.
+V...
+
+=== Chunk 732 ===
+Source: 0973_002-ebook.pdf
+Length: 3450 chars
+
+Figure 11.7
+Recipient site prepared to receive SSG.
+The harvested partial-thickness skin is laid across the recipient bed and cut so that it is slightly larger than the site. This allows for the cut undersurface to be in complete contact with the recipient bed and for later graft contraction. Often a graft is placed on a wound that is deeper than the thickness of the graft. In these cases the edge of the graft at the base of the wound must be carefully approximated to include the entire height o...
+
+=== Chunk 733 ===
+Source: 0973_002-ebook.pdf
+Length: 1714 chars
+
+11.2.6 Graft take
+Grafts adhere initially by a thin layer of fibrin and are fed by “plasmatic imbibition” from the recipient bed granulation tissue until in-growth of capillaries occurs by about the fourth post-operative day. The new capillaries link with the graft and the fibrin clot is transformed into fibrous tissue. For these reasons, there are three major factors determining the success rate of split-skin grafts.
+1. A vascular recipient bed which is free of pathogenic bacteria. Normal bacte...
+
+=== Chunk 734 ===
+Source: 0973_002-ebook.pdf
+Length: 249 chars
+
+11.2.7 Graft care
+Grafts must be cared for by experienced personnel. A graft may be saved if a collection of serum or haematoma is evacuated early. Great care must be taken not to lose a good graft through clumsy or careless removal of the dressing....
+
+=== Chunk 735 ===
+Source: 0973_002-ebook.pdf
+Length: 1709 chars
+
+Grafts require careful nursing care.
+In ICRC practice, the graft is first inspected after 48 – 72 hours; the dressing is carefully removed using two pairs of tissue forceps: one holding the graft and keeping it applied to its bed, the other removing the dressing. Care must be taken not to tear away the graft. If the graft is healthy and adherent to the recipient base, another vaseline-gauze and compress are bandaged in place and no further dressing is necessary for another 10 days, until the tim...
+
+=== Chunk 736 ===
+Source: 0973_002-ebook.pdf
+Length: 1610 chars
+
+11.2.8 Dressing of donor sites
+Split-thickness donor sites can bleed briskly, and in children can result in significant blood loss. As mentioned above, the donor site should be infiltrated intradermally with a 1:500,000 solution of adrenaline or a local anaesthetic with adrenaline to decrease bleeding. They can also be extremely painful, especially when dressings become firmly adherent.
+241
+WAR SURGERY
+Figure 11.10 Donor sites for full-thickness skin grafts.
+242
+The following regimen minimizes d...
+
+=== Chunk 737 ===
+Source: 0973_002-ebook.pdf
+Length: 999 chars
+
+11.3 Full-thickness grafts
+Full-thickness skin grafts consist of the epidermis and entire dermis. These grafts are used principally for the head and neck and hands and feet to provide thicker, better- quality cover.
+Full-thickness grafts have a number of advantages apart from better texture and colour. They allow for the transfer of hair-bearing skin, as all the dermal adnexal structures are intact, and they contract less than split-skin grafts. The main disadvantages are a lower survival rate a...
+
+=== Chunk 738 ===
+Source: 0973_002-ebook.pdf
+Length: 411 chars
+
+11.3.1 Donor sites
+The best and most readily available donor sites are the supraclavicular fossa, in front of and behind the ear, and the flexor surface of the forearm or the groin creases. In older persons, the cheek or the neck in the line of a skin crease may also be used. The donor site is sutured primarily following harvesting of the graft.
+<@ \/
+P.Zylstra/ ICRC
+DELAYED PRIMARY CLOSURE AND SKIN GRAFTING...
+
+=== Chunk 739 ===
+Source: 0973_002-ebook.pdf
+Length: 2444 chars
+
+11.3.2 Technique
+The graft can be taken under local anaesthesia. The donor and recipient areas are cleansed in a sterile fashion and a template of cut gauze compress made to fit the defect exactly. The template is placed on the donor site and an outline drawn around its circumference. The donor area should be injected with local anaesthetic with adrenaline and the edge of the recipient area with local anaesthetic without adrenaline; both are left for five minutes before incision. The full-thickn...
+
+=== Chunk 740 ===
+Source: 0973_002-ebook.pdf
+Length: 785 chars
+
+11.4 Healing by secondary intention
+Some small wounds are difficult to suture without tension, or without very wide mobilization of skin flaps, because their surrounding edges are fibrotic. There is little benefit in another surgical operation, even skin-grafting. These wounds are best left to granulate and heal by secondary intention (Figure 12.10).
+A change of dressing and gentle washing with normal saline every 4 – 5 days is usually sufficient: every dressing is a trauma to a healing wound. D...
+
+=== Chunk 741 ===
+Source: 0973_002-ebook.pdf
+Length: 355 chars
+
+Chapter 12 NEGLECTED OR MISMANAGED WOUNDS
+12
+WAR SURGERY
+248
+12 12.1 12.2 12.3 12.3.1 12.3.2 12.3.3 12.4 12.5 NEGLECTED OR MISMANAGED WOUNDS General considerations Chronic infection: the role of biofilm Surgical excision Soft tissues Bone Irrigation Antibiotics To close or not to close? 247 249 251 252 253 253 254 254 255
+NEGLECTED OR MISMANAGED WOUNDS:...
+
+=== Chunk 742 ===
+Source: 0973_002-ebook.pdf
+Length: 835 chars
+
+12.1 General considerations
+As described in Chapter 10, in many war zones today, characterized by irregular bush warfare, rebellions and insurrections, neglected and mismanaged wounds are amongst the commonest injuries that the surgeon sees. First aid is not available, doctors and nurses are scarce, and health services have been disrupted by poverty and conflict. Distances are long and the terrain difficult with little in the way of organized transport. Many patients reaching hospital have wound...
+
+=== Chunk 743 ===
+Source: 0973_002-ebook.pdf
+Length: 931 chars
+
+Remove all sutures from previously sutured wounds.
+After delay, some Grade 1 minor soft-tissue wounds are found to be healing spontaneously. Most wounds, however, will be inflamed or frankly infected with a degree of chronic infection, and some will be grossly putrefying. This is often seen in mismanaged wounds. Tetanus, gas gangrene, and invasive haemolytic streptococcal infection are ever present dangers (see Chapter 13). These wounds require aggressive excision.
+Figure 12.1.1
+Patient A: The g...
+
+=== Chunk 744 ===
+Source: 0973_002-ebook.pdf
+Length: 287 chars
+
+Figure 12.2.2
+Patient B: primary suture was performed – note the tension in the wound due to tissue oedema and infection. Some sutures have been removed.
+All stitches have been removed – the skin edges are ischaemic and necrotic and the subcutaneous tissues oedematous.
+\ yY
+C
+2 op
+R
+C
+I...
+
+=== Chunk 745 ===
+Source: 0973_002-ebook.pdf
+Length: 345 chars
+
+Figure 12.2.3
+After redebridement – the wound is now larger than the original injury.
+Nasreddine /ICRC
+N
+.
+H
+Figure 12.3
+Neglected gunshot wound to the knee with frank infection.
+C
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+d
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+¥ g
+g 3 z 3
+.
+H
+=
+Figures 12.4.1 and 12.4.2
+Neglected wound to the scrotum with gangrenous tissue.
+NEGLECTED OR MISMANAGED WOUNDS:...
+
+=== Chunk 746 ===
+Source: 0973_002-ebook.pdf
+Length: 546 chars
+
+Figure 12.5
+There is much clinical and experimental evidence to back the claim that the early administration of antibiotics, penicillin in particular, can delay the advent of serious infection in war wounds. It is ICRC practice in first-aid posts to begin penicillin as soon as possible. However, adequate first-aid measures, as described in Chapter 7, are seldom available in many contemporary theatres of war and it is to this context that the present chapter is devoted.
+Maggot infestation of a wo...
+
+=== Chunk 747 ===
+Source: 0973_002-ebook.pdf
+Length: 1147 chars
+
+12.2 Chronic infection: the role of biofilm
+The chronic pyogenic infection of a neglected wound has its own particular pathology and bacteriology, and life history. Bacteria exist in discrete colonies only in a laboratory. The natural state of bacteria through natural selection is to become attached to surfaces, especially to inorganic or dead matter, such as sequestrated bone and cartilage. In chronic infection, bacteria secrete a glycopolysaccharide biofilm; this is the “slime” one feels on th...
+
+=== Chunk 748 ===
+Source: 0973_002-ebook.pdf
+Length: 731 chars
+
+Figure 12.6
+Schema of the chronic infective process.1
+l
+w
+o
+R
+.
+D
+The biofilm is secreted during the stationary phase of bacterial life. Physical disruption of this biofilm and surgical removal of the dead tissues are required to push the bacteria back into the rapid multiplication of the log phase when they are most susceptible to antibiotics and the body’s natural defence mechanisms.
+Rowley D.I., University of Dundee, Course on chronic bone infection, Seminar on the Management of War Wounds; I...
+
+=== Chunk 749 ===
+Source: 0973_002-ebook.pdf
+Length: 171 chars
+
+Figure 12.7.3
+Neglected wound to the arm with necrotic tissue, but dry.
+l
+l
+a
+4
+D
+.
+M
+Figure 12.7.2
+Neglected wound of a traumatic amputation stump, without biofilm layer....
+
+=== Chunk 750 ===
+Source: 0973_002-ebook.pdf
+Length: 1713 chars
+
+12.3 Surgical excision
+Surgical excision is a more difficult procedure in these neglected and mismanaged wounds. The line of demarcation between viable and non-viable tissue, especially in oedematous muscle and fascia, is less obvious, and the zone of post-traumatic inflammatory hyperaemia is compounded by that of infective inflammation and the presence of the biofilm. The extent of adequate excision is more difficult to assess since there is not only a “mosaic” of ballistic tissue damage in the...
+
+=== Chunk 751 ===
+Source: 0973_002-ebook.pdf
+Length: 1080 chars
+
+12.3.1 Soft tissues
+If present, all sutures must be removed and debridement performed as if no previous wound toilet had been done.
+All macroscopic contamination should be excised. Skin and subcutaneous fat must be cut back until they ooze blood. Grossly infected fascia is usually shredded and dull grey, while healthy fascia is a glistening white. The muscle compartments are in even greater need of decompression than those of a fresh wound.
+Contractility is the best indication of muscle viabilit...
+
+=== Chunk 752 ===
+Source: 0973_002-ebook.pdf
+Length: 2066 chars
+
+12.3.2 Bone
+If there is an underlying fracture in these infected wounds, it usually contains detached and necrotic bone fragments that provide the perfect “surface” for bacterial adhesion. It is vital that these be found and removed. A plain X-ray will assist in their identification (Figure 12.9.2).
+C
+&
+R
+C
+I
+/
+t
+e
+m
+a
+J
+C
+F.Jamet / ICRC
+C
+F.Jamet / ICRC
+.
+F
+F
+F
+Figure 12.8.1
+Gunshot wound 7 days after inadequate debridement.
+Figure 12.8.2
+Obvious sequestra presenting at the wound surface – note...
+
+=== Chunk 753 ===
+Source: 0973_002-ebook.pdf
+Length: 598 chars
+
+12.3.3 Irrigation
+The wound is now copiously irrigated and dressed as for routine surgical excision. The ICRC has tested irrigation with a high-pressure pulsatile lavage and daily showering of the open cavity in these neglected infected wounds. Although both techniques appeared to clear up the biofilm and afford a better assessment of tissue viability, the results were inconclusive. Both involve a great deal of time, effort, and nursing care, and are difficult to maintain if a large number of pa...
+
+=== Chunk 754 ===
+Source: 0973_002-ebook.pdf
+Length: 1164 chars
+
+12.4 Antibiotics
+Penicillin and metronidazole are given, according to the antibiotic protocol (see Chapter 13); and gentamycin is added if there are signs of active spreading inflammation. No topical antibiotics or antiseptics are used in ICRC practice.
+Bacterial culture should be done, if available. Good bacterial culture and sensitivity in a forward hospital is far more diffucult to accomplish than is usually realized. Note that clinical response does not always follow laboratory sensitivities...
+
+=== Chunk 755 ===
+Source: 0973_002-ebook.pdf
+Length: 1691 chars
+
+12.5 To close or not to close?
+The primary phase of wound healing begins at the moment of wounding. It is well established by the time of presentation if the wound is a few days old. Thus, several days after surgical excision, many wounds are past the time of healing by primary intention. There is already much fibrous tissue present (Figure 12.9.3) and even more by the time the wound is clean and ready for closure. If secondary suture is attempted there is usually considerable tension on the wou...
+
+=== Chunk 756 ===
+Source: 0973_002-ebook.pdf
+Length: 540 chars
+
+Chapter 13 INFECTIONS IN WAR WOUNDS
+13
+WAR SURGERY
+258
+13 13.1 13.2 13.3 13.3.1 13.3.2 13.3.3 13.3.4 13.3.5 13.4 13.4.1 ANNEX 13. A INFECTIONS IN WAR WOUNDS Contamination and infection Major bacterial contaminants in war wounds Major clinical infections of war wounds Definitions Gas gangrene Tetanus Invasive streptococcal infection Necrotizing soft-tissue infections Antibiotics Antibiotic prophylaxis in the primary treatment of war wounds ICRC antibiotic protocol 257 259 260 261 261 262 264 266 ...
+
+=== Chunk 757 ===
+Source: 0973_002-ebook.pdf
+Length: 3563 chars
+
+13.1 Contamination and infection
+All war wounds are grossly contaminated by bacteria. Bullets and fragments are not sterilized on discharge and, at the entry site, bacteria are carried into the tract by the contaminated projectile itself. Furthermore, the negative pressure of the temporary cavity at both entrance and exit wounds also sucks in bacteria.
+War wounds are dirty and contaminated from the moment of injury.
+Other contaminants found in war wounds include clothing fragments, dust, miscell...
+
+=== Chunk 758 ===
+Source: 0973_002-ebook.pdf
+Length: 534 chars
+
+13.2 Major bacterial contaminants in war wounds
+The relative preponderance of various bacterial species differs according to geography, topology of the terrain, and climate: agricultural land, urban environment, jungle, or desert; summer or winter. The presence of community-acquired resistance in “normal” body flora also differs from region to region, and with the passing of time.
+Nonetheless, certain constants remain, and the following list gives a general indication of the common pathogens inv...
+
+=== Chunk 759 ===
+Source: 0973_002-ebook.pdf
+Length: 254 chars
+
+Gram-positive cocci
+Staphylococcus aureus and β-haemolytic streptococcus. These are a normal part of the skin flora. In recent years, community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has become more of a problem in certain countries....
+
+=== Chunk 760 ===
+Source: 0973_002-ebook.pdf
+Length: 262 chars
+
+Gram-negative bacilli
+Escherichia, Proteus, Klebsiella, Pseudomonas, and Bacterioides are found in the gastro-intestinal tract. Acinetobacter baumannii is to be found in the soil and on the skin and has recently become important in causing nosocomial infections....
+
+=== Chunk 761 ===
+Source: 0973_002-ebook.pdf
+Length: 2402 chars
+
+Gram-positive bacilli
+The Clostridia species are spore-bearing obligatory anaerobes. They are widely distributed in the environment, especially in agriculturally fertile soils, and are carried in the faeces. They are the cause of gas gangrene and tetanus.
+Wounds to the upper thigh and perineum are particularly at risk from contamination by faecal organisms (Clostridia and Gram-negative bacilli), even without bowel perforation. Bowel injury demonstrably increases the risk of infection.
+War wounds...
+
+=== Chunk 762 ===
+Source: 0973_002-ebook.pdf
+Length: 520 chars
+
+13.3 Major clinical infections of war wounds
+The polymicrobial nature of wound contamination can result in a variety of infections. Several specific lethal infections are notorious in war wounds, especially in neglected or mismanaged wounds, and particularly if they have been stitched closed without proper excision. Common pyogenic wound infection runs through a spectrum of disease from the minor (superficial surgical site infection) to the severe (organ or space surgical site infection) and sys...
+
+=== Chunk 763 ===
+Source: 0973_002-ebook.pdf
+Length: 179 chars
+
+Simple contamination
+The surgical literature classifies wounds as clean, clean-contaminated, contaminated, and infected or dirty. War wounds are considered contaminated and dirty....
+
+=== Chunk 764 ===
+Source: 0973_002-ebook.pdf
+Length: 526 chars
+
+Cellulitis/local abscess formation
+Bacteria begin to spread to tissues that are contiguous to the wound, in the zone of contusion (see Chapter 3). Little systemic toxicity exists. Superficial erythema and seropurulent discharge occur; some necrotic tissue is evident, but this is related to the original injury and not to the infection. Eventually a mass of necrotic tissue and bacteria forms; if drainage is inadequate (small skin wounds), an abscess develops. In a large wound, the mass will be wal...
+
+=== Chunk 765 ===
+Source: 0973_002-ebook.pdf
+Length: 1897 chars
+
+Myositis/deep tissue infection
+Bacteria spread into muscles and tissues further than the permanent cavity and the zone of contusion and invade the zone of concussion and beyond. Systemic symptoms become more pronounced and, with certain infections, come to dominate the clinical picture. Overwhelming infections usually present with the classic signs of sepsis (fever, tachycardia, etc.); but they may also present without these signs, particularly in immune-compromised patients (HIV/AIDS, chronic d...
+
+=== Chunk 766 ===
+Source: 0973_002-ebook.pdf
+Length: 3749 chars
+
+13.3.2 Gas gangrene
+Gas gangrene as a particular complication of wounds has been known since the time of Hippocrates. Its occurrence in war wounds throughout history as well as in other trauma has been widely described mainly because of its dramatic manifestations and very high associated mortality. Delay to surgery, as may occur during war or after a natural disaster with mass casualties, greatly increases the risk of gas gangrene.
+Gas gangrene is a rapidly-spreading oedematous myonecrosis occu...
+
+=== Chunk 767 ===
+Source: 0973_002-ebook.pdf
+Length: 1258 chars
+
+Figure 13.1.1
+Figure 13.1.2 Gas gangrene of the arm.
+Rapidly, swelling oedema and toxaemia increase, the serous discharge becomes more profuse and a peculiar sweetish smell may be present. The smell is variable and not pathognomonic.
+Gas is usually produced at this stage and is partly responsible for the swelling of the affected part (Figure 13.2). It is produced in and between the muscle fibres, follows the fascial planes, and eventually escapes into the subcutaneous tissues under pressure thro...
+
+=== Chunk 768 ===
+Source: 0973_002-ebook.pdf
+Length: 3853 chars
+
+Management
+All patients with missile wounds should receive prophylactic antibiotics that are effective against Clostridia, such as penicillin, metronidazole, first generation cephalosporin, or erythromycin. But the antibiotics can only reach tissues with a blood supply and good tissue perfusion. Antibiotic concentrations in the dead muscle in the depths of an anaerobic environment are ineffective. Surgery as early as possible is the goal to be attained.
+The basis of management of established gas...
+
+=== Chunk 769 ===
+Source: 0973_002-ebook.pdf
+Length: 374 chars
+
+Figure 13.2
+X-ray showing gas collections between muscle groups.
+Immediate surgical intervention is essential in the   management of gas gangrene.
+Because of the severe toxaemia, supportive measures including oxygen, fluids and fresh whole blood should be instituted. Appropriate antibiotics should be continued.
+263
+C
+2
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+E
+WAR SURGERY
+C
+Molde /ICRC
+.
+Å...
+
+=== Chunk 770 ===
+Source: 0973_002-ebook.pdf
+Length: 69 chars
+
+Figure 13.4
+Risus sardonicus in a patient suffering from tetanus.
+264...
+
+=== Chunk 771 ===
+Source: 0973_002-ebook.pdf
+Length: 2080 chars
+
+13.3.3 Tetanus
+Tetanus is always a risk with any penetrating wound. The risk is greater for severely contaminated wounds, especially small, deep, punctate-type ones. Pyogenic infection in the depth of a narrow track can create the necessary anaerobic environment. The incubation period is 3 to 21 days, but can be as short as 1 day to as long as several months.
+C
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+E
+Figure 13.3
+Badly infected wound giving rise to tetanus.
+Virtually total protection can be obtained by active ...
+
+=== Chunk 772 ===
+Source: 0973_002-ebook.pdf
+Length: 1181 chars
+
+Prophylaxis
+The best precaution against tetanus is active immunization. However, many patients in developing countries where conflict has further disrupted public health programmes are not immunized and therefore the risk of tetanus in war wounds is great. In some countries, ICRC practice is to proceed with active and passive immunization for all patients.
+INFECTIONS IN WAR WOUNDS
+Early and adequate excision of dead tissue, and leaving wounds open, is vital to prevent its development. This is pa...
+
+=== Chunk 773 ===
+Source: 0973_002-ebook.pdf
+Length: 3808 chars
+
+Treatment of established tetanus
+Treatment of established tetanus should follow the steps listed below.
+1. Extensive debridement of the wound. Ketamine anaesthesia should be avoided if possible as patients waking from this form of anaesthesia are often restless and have hallucinations and this may stimulate spasms. Spinal anaesthesia or a regional nerve block are excellent methods.
+2. Antibiotics: crystalline penicillin G (5 MIU. i.v. QID) and/or metronidazole (500 mg i.v. TID). Erythromycin, te...
+
+=== Chunk 774 ===
+Source: 0973_002-ebook.pdf
+Length: 824 chars
+
+13.3.4 Invasive streptococcal infection
+Beta-haemolytic streptococcus produces powerful toxins that trigger a rapid progression of disease from local to systemic infection. It begins with a local cellulitis with severe pain out of proportion with physical findings, and advances rapidly to fever, tachycardia, disorientation and delirium. The wound is malodorous with large quantities of thin, blood-stained seropurulent discharge. The muscles suffer from a moist oedema, and turn from pale, to brigh...
+
+=== Chunk 775 ===
+Source: 0973_002-ebook.pdf
+Length: 2315 chars
+
+13.3.5 Necrotizing soft-tissue infections
+Various non-clostridial spreading gangrenous infections have been described in the surgical literature: necrotizing fasciitis, synergistic gangrene, anaerobic cellulitis, etc. There is necrosis of the skin, subcutaneous tissues and fascia, but not of the muscles. It can rapidly progress to systemic toxicity and even death. Spreading gangrene can follow trauma or thoracic and abdominal surgery (postoperative synergistic gangrene), and affect persons suffe...
+
+=== Chunk 776 ===
+Source: 0973_002-ebook.pdf
+Length: 3927 chars
+
+13.4 Antibiotics
+It is important to distinguish between the prophylactic use of antibiotics and their role in the therapy of established infection. The surgeon must also remember the life history of wounds and their changing bacterial flora.
+Prophylaxis is aimed at preventing a specific infection. It is impossible to find any reasonable cocktail of antibiotics that would be effective against the entire “polymicrobial cesspool” that can contaminate a war wound. Nor is it desirable to do so. Such ...
+
+=== Chunk 777 ===
+Source: 0973_002-ebook.pdf
+Length: 2074 chars
+
+13.4.1 Antibiotic prophylaxis in the primary treatment of war wounds
+Antibiotics do not reach the source of infection in a missile wound – i.e. the culture medium of dead tissue, debris and foreign material – they only affect the contusion and concussion zones around the wound. However, early administration of antibiotics seems to inhibit bacterial growth and delay invasive infection. Antibiotics especially help prevent spread to the blood stream. The efficacy of antibiotics in preventing invasi...
+
+=== Chunk 778 ===
+Source: 0973_002-ebook.pdf
+Length: 2597 chars
+
+ANNEX 13. A ICRC antibiotic protocol
+For many years, the ICRC antibiotic protocol attempted to address two problems: prophylaxis and therapy. The prophylaxis part was simple and straightforward, as mentioned in this chapter. Prevention was aimed at specific bacteria that cause the traditional lethal infections of warfare: tetanus, gas gangrene and invasive haemorrhagic infection: Clostridium tetani and perfringens, and β-haemolytic streptococcus. The best antibiotic to cover these, and to which ...
+
+=== Chunk 779 ===
+Source: 0973_002-ebook.pdf
+Length: 287 chars
+
+Chapter 14 RETAINED BULLETS AND FRAGMENTS
+14
+WAR SURGERY
+272
+14 14.1 14.2 14.3 14.4 RETAINED BULLETS AND FRAGMENTS The surgeon and the foreign body Early indications for removal Late indications Technique for the removal of a projectile 271 273 273 276 277
+RETAINED BULLETS AND FRAGMENTS...
+
+=== Chunk 780 ===
+Source: 0973_002-ebook.pdf
+Length: 2096 chars
+
+14.1 The surgeon and the foreign body
+There are hundreds of thousands of perfectly healthy people walking around the present and past war zones of the world who have retained projectiles in their body. These metallic foreign bodies often catch the attention of patients and relatives, who impute to them any pains and disabilities they suffer from and insist upon their removal, even after the wound has completely healed.
+It can be very difficult, and frustrating, for the surgeon to point out to an...
+
+=== Chunk 781 ===
+Source: 0973_002-ebook.pdf
+Length: 1619 chars
+
+14.2 Early indications for removal
+However, as stated previously, there are indications for removal of bullets and fragments, which may be divided into early and late. The most important early indications have been dealt with in Chapter 10: as an integral part of the primary operation or to address the possibility of erosion of an important structure (Figures 10.11, 10.12 and 14.1).
+As mentioned in the latter case, whether the removal is an immediate or planned procedure will depend on a number ...
+
+=== Chunk 782 ===
+Source: 0973_002-ebook.pdf
+Length: 391 chars
+
+Figure 14.5
+Bullet in the axilla: the vessels and nerves are intact.
+& S
+3 3
+: a
+=
+Figures 14.7.1 and 14.7.2 Extra-synovial bullet near the hip.
+C
+2
+R
+C
+I
+/
+t
+r
+e
+k
+r
+e
+H
+.
+F
+Figure 14.8
+Fragmented bullet in extraperitoneal muscle mass.
+RETAINED BULLETS AND FRAGMENTS
+C
+Coupland /ICRC
+C
+.
+R
+Figure 14.4.2
+Radiograph showing a fragment retained in the neck.
+C
+R
+&
+C
+I
+/
+n
+a
+d
+i
+l
+a
+B
+set)
+.
+M...
+
+=== Chunk 783 ===
+Source: 0973_002-ebook.pdf
+Length: 1493 chars
+
+Figure 14.6
+Fractured humerus with bullet retained in the subscapular muscles.
+& S
+3 3
+=
+275
+WAR SURGERY
+ar 2
+C
+Flrmay / ICRC
+F
+C
+Filrmay / ICRC
+F
+Figures 14.9.1 and 14.9.2
+Bullet retained in vertebral column, the patient is paraplegic.
+C
+R
+C
+I
+Figure 14.10
+Metallic fragment located in a pressure point: sole of the foot.
+276
+The following scenarios should be added to the early indications already mentioned.
+• A small fragment in a heart chamber – the concomitant pericardial tamponade is an urgen...
+
+=== Chunk 784 ===
+Source: 0973_002-ebook.pdf
+Length: 96 chars
+
+14.3 Late indications
+Late indications are largely the result of the complications listed below....
+
+=== Chunk 785 ===
+Source: 0973_002-ebook.pdf
+Length: 237 chars
+
+Infection
+If the projectile, along with surrounding contaminants, is acting as a nidus for infection: an abscess or sinus. The removal is performed as a planned operation after the necessary diagnostic procedures (X-ray, sinugram, etc.)....
+
+=== Chunk 786 ===
+Source: 0973_002-ebook.pdf
+Length: 587 chars
+
+Pain
+If located superficially, especially if over a pressure point (palm of hands, sole of foot, elbow, etc.), the projectile will cause true pain. The removal may be performed as an elective procedure after healing from the acute trauma.
+If the foreign body is impinging on a nerve and causing radicular pain or paraesthesia. As above, the removal is performed as a planned operation.
+C
+Icrc
+R
+C
+C
+Icrc
+R
+C
+I
+I
+Figure 14.11.1
+Bullet in antero-lateral compartment of the leg pressing on common perone...
+
+=== Chunk 787 ===
+Source: 0973_002-ebook.pdf
+Length: 975 chars
+
+Lead toxicity
+This is extremely rare, usually involves a synovial joint or intervertebral disc, and surgery should be contemplated only if there is documented elevation of serum lead level (above 5 micrograms/dl in children and 10 micrograms/dl in adults). The response to an EDTA (ethylene diamine tetra-acetic acid) challenge is a useful diagnostic test. Standard chelation therapy is instituted (EDTA, dimecaprol, d-penicillamine, succimer) and the surgical removal of the metal should not be perf...
+
+=== Chunk 788 ===
+Source: 0973_002-ebook.pdf
+Length: 1879 chars
+
+14.4 Technique for the removal of a projectile
+For those patients requiring removal of a deeply-seated metallic fragment or bullet, proper localization prior to surgery is of the utmost importance. Most rural or provincial hospitals do not have fluoroscopy or an image-intensifier in the operating theatre enabling the surgeon to operate under direct vision.
+A simple stereotactic technique to assist localization involves taping a series of radio- opaque objects (paper clips, injection needles, Kir...
+
+=== Chunk 789 ===
+Source: 0973_002-ebook.pdf
+Length: 968 chars
+
+Chapter 15 BURN INJURIES
+15
+WAR SURGERY
+280
+15 BURN INJURIES 15.1 Introduction 15.2 Pathology 15.2.1 Burn depth 15.2.2 Pathophysiological changes 15.2.3 Types of burns 15.2.4 Extent of burns 15.3 Burn management 15.3.1 First aid 15.3.2 Resuscitation 15.3.3 Initial fluid replacement therapy 15.3.4 Monitoring resuscitation 15.3.5 After 48 hours 15.4 Burns presenting late 15.5 Nutrition 15.6 Care of the burn wound 15.6.1 Initial wound management 15.6.2 Local care 15.7 Closure of the burn wound 15.7...
+
+=== Chunk 790 ===
+Source: 0973_002-ebook.pdf
+Length: 2004 chars
+
+15.1 Introduction
+Burns are a common event in a war environment. Flame weapons, explosive blast and ignition of combustible materials all create burn hazards. In addition, overcrowding, interrupted power supplies and use of kerosene for cooking often increase everyday burns. The causal agent may be thermal, chemical, electrical, or linked to radiation. Each cause has specific consequences that may require specific assistance.
+A serious burn injury is a painful and life-threatening event requirin...
+
+=== Chunk 791 ===
+Source: 0973_002-ebook.pdf
+Length: 144 chars
+
+15.2.1 Burn depth
+Burns involve varying amounts of injury to the skin, partial or full thickness, and varying degrees of severity (Figure 15.1)....
+
+=== Chunk 792 ===
+Source: 0973_002-ebook.pdf
+Length: 122 chars
+
+Superficial burns (formerly First degree)
+These burns are painful, red, and have no blisters. They will heal on their own....
+
+=== Chunk 793 ===
+Source: 0973_002-ebook.pdf
+Length: 399 chars
+
+Superficial partial-thickness burns (formerly Second degree)
+These are invariably blistered. The blister floor is usually pink or mottled red in appearance with a moist surface. The burn blanches with pressure. They are painful and have some sensation to pinprick. Hairs are difficult to pluck out since the base of the follicle is alive. Most should heal within 2 – 3 weeks by re-epithelialization....
+
+=== Chunk 794 ===
+Source: 0973_002-ebook.pdf
+Length: 473 chars
+
+Deep partial-thickness burns (formerly Second degree)
+Blisters are not present, and the burn does not blanch with pressure. They may or may not be painful and sensation to pinprick is reduced or absent. Hairs are easier to pluck out. Most will eventually heal by a combination of re-epithelialization and wound contraction but take longer than 2 – 3 weeks, and seriously disabling scar contracture often occurs. In general, they will benefit from appropriate skin grafting....
+
+=== Chunk 795 ===
+Source: 0973_002-ebook.pdf
+Length: 587 chars
+
+Full-thickness burns (formerly Third and Fourth degree)
+Destruction of the full thickness of the skin gives a charred, leathery or waxy appearance. Any surviving hairs pull out easily. The burns are usually dry and have no sensation. Injury may extend to the muscles and deeper tissues. They are normally caused by flames, immersion in very hot liquids, electric current or chemicals. Smaller full-thickness burns will eventually heal by contraction but this inevitably causes severe deformity and lo...
+
+=== Chunk 796 ===
+Source: 0973_002-ebook.pdf
+Length: 1095 chars
+
+Figure 15.2
+Different regions of a burn wound have different depths of damage: central eschar of full-thickness burn surrounded by areas of partial-thickness burn.
+282
+Superficial burn: epidermis.
+Superficial partial-thickness burn.
+Deep partial-thickness burn.
+Full-thickness burn: may extend beyond
+the dermis.
+Figure 15.1
+Histology of the skin and degree of burn depth.
+Different regions of a burn wound have different depths of damage. A burn is basically an ischaemic three-dimensional wound wit...
+
+=== Chunk 797 ===
+Source: 0973_002-ebook.pdf
+Length: 1860 chars
+
+15.2.2 Pathophysiological changes
+The most important pathophysiological change from thermal injury is increase in capillary permeability, which, if resuscitation is successful, returns to normal within 24 – 48 hours. Plasma water and proteins up to a molecular weight of 350,000 are freely exchanged between the intra- and extravas-cular compartments of the extracellular space. A strongly negative interstitial fluid pressure develops that creates a strong “suction” in the burnt tissue. If the affe...
+
+=== Chunk 798 ===
+Source: 0973_002-ebook.pdf
+Length: 1147 chars
+
+15.2.3 Types of burns
+Flame and scald burns are by far the most common. Flame burns are usually deep and appear so at presentation, whereas scald burns may appear much less severe at first; experienced burn surgeons usually withhold prognostication until they have inspected them on the third day. Contact flame burns are typically very deep at the centre, which should be taken into consideration if they are to be operated on.
+Electrical burns fall into two distinct categories. Flash burns occur w...
+
+=== Chunk 799 ===
+Source: 0973_002-ebook.pdf
+Length: 1075 chars
+
+15.2.4 Extent of burns
+The sequestration of large amounts of fluid and plasma proteins in the extravascular space is a function primarily of the extent of burnt tissues. It is thus important to estimate the total body surface area that has been burnt. The depth of the burn must also be taken into account; only partial and full thickness are included in the estimation of TBSA, not superficial epidermal burns.
+The simplest calculation is best done using the “Rule of Nines” (Figure 15.3). The size ...
+
+=== Chunk 800 ===
+Source: 0973_002-ebook.pdf
+Length: 85 chars
+
+Minor
+• Partial thickness, less than 15 % TBSA.
+• Full thickness, less than 3 % TBSA....
+
+=== Chunk 801 ===
+Source: 0973_002-ebook.pdf
+Length: 84 chars
+
+Moderate
+• Partial thickness, 15 – 25 % TBSA.
+• Full thickness, less than 10 % TBSA....
+
+=== Chunk 802 ===
+Source: 0973_002-ebook.pdf
+Length: 86 chars
+
+Major
+• Partial thickness, more than 25 % TBSA.
+• Full thickness, more than 10 % TBSA....
+
+=== Chunk 803 ===
+Source: 0973_002-ebook.pdf
+Length: 169 chars
+
+Figure 15.3
+Homunculus diagram showing the “Rule of Nines” to assess burnt surface area in an adult.
+9%  4.5%  4.5%  4.5%  18%  1%  7% 7%  7%
+9%  4.5%  4.5%  18%  7%  7%...
+
+=== Chunk 804 ===
+Source: 0973_002-ebook.pdf
+Length: 122 chars
+
+Figure 15.4
+Assessment of burnt surface area in a child homunculus.
+283
+C
+P.Zylstra / ICRC
+P.
+N.Papas/ICRC
+WAR SURGERY
+284...
+
+=== Chunk 805 ===
+Source: 0973_002-ebook.pdf
+Length: 345 chars
+
+15.3 Burn management
+The management of burns consists of a series of standard measures, as with any wound or trauma.
+1. First aid.
+2. Resuscitation:
+– airway;
+– breathing;
+– circulation / fluid replacement therapy.
+3. Analgesia.
+4. Tetanus prophylaxis.
+5. Nutrition.
+6. Prevention/treatment of hypothermia.
+7. Wound management.
+8. Rehabilitation...
+
+=== Chunk 806 ===
+Source: 0973_002-ebook.pdf
+Length: 862 chars
+
+15.3.1 First aid
+Rescuers should first ensure that the scene is safe and take suitable precautions if un-ignited fuel, explosives, electricity, or chemical agents are present. The patient should be removed to safety and clean fresh air, and the vital signs assessed. If available, oxygen should be provided if there is any indication of smoke inhalation.
+The burn should then be cooled with water or wet towels (for 20 minutes), and covered with clear plastic if available to reduce pain. The patient...
+
+=== Chunk 807 ===
+Source: 0973_002-ebook.pdf
+Length: 1267 chars
+
+15.3.2 Resuscitation
+The following elements should be determined:
+• nature of the causal agent – flame, scald, contact, electrical conduction, electrical flash, chemical;
+• possible aggravating factors – additional trauma, smoke inhalation (fire in an enclosed space equals smoke inhalation);
+• time since injury – fluid resuscitation is calculated from the time of burn, not the time the patient arrives at hospital.
+As with all injured persons, examination begins with the ABCDE sequence. Deep burn...
+
+=== Chunk 808 ===
+Source: 0973_002-ebook.pdf
+Length: 1303 chars
+
+15.3.3 Initial fluid replacement therapy
+Given adequate initial resuscitation with crystalloids, capillary integrity is mostly restored within 18 – 24 hours following the burn. At this point, colloid can be given and will stay within the vascular compartment, increasing the plasma volume. Cardiac output will respond to fluid replacement long before blood and plasma volumes return to normal and a first, mild diuresis begins at about 12 hours after fluid therapy. Red cell life is reduced and altho...
+
+=== Chunk 809 ===
+Source: 0973_002-ebook.pdf
+Length: 1664 chars
+
+The first 24 hours
+Ringer’s lactate is the fluid of choice. Administration should be divided into two periods.
+Ringer’s lactate solution 2 – 4 ml/kg/% burn = total volume for first 24 hours:
+• first eight hours: one half the volume;
+• next sixteen hours: one half the volume.
+Urine output should be 0.5 ml/kg/hour.
+Fluid creep (giving too much fluid) is a significant risk and has significant complications. Administration should therefore start at the low end of the formula (2 ml/kg/ %) and the hou...
+
+=== Chunk 810 ===
+Source: 0973_002-ebook.pdf
+Length: 684 chars
+
+After 24 hours
+During this phase, expansion of plasma volume can be   achieved.  Plasma should be administered: 0.3 – 0.5 ml/kg/%/day.
+If plasma is safe and available, theoretically it is best given at this stage. Albumin 5 % is an expensive alternative, but the evidence to support either strategy is slim. Otherwise, and in ICRC practice, it is best to keep things simple and Ringer’s lactate should continue to be given at the rate of one-quarter of the first day’s volume; intravenous fluid shoul...
+
+=== Chunk 811 ===
+Source: 0973_002-ebook.pdf
+Length: 477 chars
+
+15.3.4 Monitoring resuscitation
+Clinical evaluation is particularly important in the absence of sophisticated means and laboratory measures. A clear sensorium, good tissue perfusion, good pulse, and an adequate urinary output are all signs of good progress. Less and less fluid is needed at the end of resuscitation in order to maintain urine volume. A flow sheet should be used to monitor vital signs and fluid input/output. The patient should be serially weighed if possible....
+
+=== Chunk 812 ===
+Source: 0973_002-ebook.pdf
+Length: 609 chars
+
+15.3.5 After 48 hours
+Mobilization of burn wound oedema causes an expansion of the blood volume and results in massive diuresis, high cardiac output, tachycardia and anaemia. The better the fluid management in the first period – avoiding over-resuscitation – the less pronounced these clinical signs and the more stable the patient will be.
+Blood should be given to maintain haemoglobin greater than 70 g/l. Deep burns cause greater anaemia. Fresh whole blood is best. Potassium, calcium, magnesium a...
+
+=== Chunk 813 ===
+Source: 0973_002-ebook.pdf
+Length: 1299 chars
+
+15.4 Burns presenting late
+Often, patients with severe burns present late. Those presenting after a delay, but within the first 24 hours, should receive fluid resuscitation approaching the calculated volume; however, large amounts of fluid given rapidly may precipitate airway problems. Caution is required, and the patient must be monitored very carefully.
+2 Pruit BA Jr. Fluid and electrolyte replacement in the burned patient. Surg Clin N Am 1978; 48: 1291 – 1312.
+287
+C
+R
+5
+C
+I
+/
+s
+e
+k
+&
+y
+D
+.
+E
+...
+
+=== Chunk 814 ===
+Source: 0973_002-ebook.pdf
+Length: 1014 chars
+
+15.5 Nutrition
+Catabolism is particularly elevated in burn patients, especially those losing large amounts of protein through open wounds, and healing will require a large increase in caloric and protein intake for a lengthy period. Early enteral feeding is very important in maintaining gut function (reducing gastroparesis), and preventing complications. Major burn patients may require more than twice their normal protein and calorie intake until their wounds have closed. Nutritional requirement...
+
+=== Chunk 815 ===
+Source: 0973_002-ebook.pdf
+Length: 1783 chars
+
+15.6 Care of the burn wound
+After successful resuscitation of the patient has been achieved, the next greatest threats to life that must be addressed are the burn wound itself and the complications of infection and sepsis.
+The aim of treatment is to achieve healing of the burn by the following measures:
+1. Control of bacterial colonization by removal of all dead tissue.
+2. Prevention of accumulation of purulent fluid and debris.
+3. Prevention of secondary bacterial contamination.
+4. Maintenance ...
+
+=== Chunk 816 ===
+Source: 0973_002-ebook.pdf
+Length: 2705 chars
+
+15.6.1 Initial wound management
+Initial wound toilet should be undertaken after resuscitation has begun and proceed in parallel. Once the patient’s condition has stabilized, attention can be turned to more definitive measures.
+Any constricting agents (rings, wrist-watch, jewellery, etc.) should have been removed on admission. The patient should be sedated and the burn wound gently washed with soap and water. Freely running, clean water, without excess pressure but a regular flow and at a tempera...
+
+=== Chunk 817 ===
+Source: 0973_002-ebook.pdf
+Length: 1486 chars
+
+15.6.2 Local care
+Care of burn wounds involves an extraordinary amount of nursing care. The method used depends on the depth, extent, and location of the burn. ICRC surgical teams use occlusive dressings – and their plastic bag modification – and open therapy, both with a topical antibacterial agent.
+Many antibacterial compounds can be used. Silver sulphadiazine (Flamazine®) and silver nitrate solution are unique in that they can penetrate the wound surface and reach the bacteria beneath it; the...
+
+=== Chunk 818 ===
+Source: 0973_002-ebook.pdf
+Length: 1179 chars
+
+Occlusive dressings
+Bulky sterile dressings relieve pain and are comfortable for the patient, and protect the burn wound from infection. They absorb serum and exudate and foster a moist healing environment by keeping the injured part immobile and warm; they contain antibiotics able to penetrate the dead eschar (i.e. silver sulphadiazine ointment).
+The dressings have three components: an inner layer of a liberal application of silver sulphadiazine covered by fine-mesh gauze or paraffin gauze; a m...
+
+=== Chunk 819 ===
+Source: 0973_002-ebook.pdf
+Length: 726 chars
+
+The plastic bag or surgical glove method
+This method is used for burns to the hands and feet. After cleaning the burn and applying silver sulphadiazine, a plastic bag is used as a glove or a sock, tied around the wrist or ankle. It must not be too tight. The limb should be kept elevated to reduce swelling. The burnt area will be kept moist and movement of the joints, both passive and active, is encouraged. A surgical glove may also be used instead of a plastic bag. As an extension of this, a cel...
+
+=== Chunk 820 ===
+Source: 0973_002-ebook.pdf
+Length: 2143 chars
+
+Open therapy
+Hospitals may have to resort to the less than optimal “open” technique where, for logistic and financial reasons, resources are scarce. However, this method is the standard for treating burns of the face and perineum. It requires clean and isolated surroundings, and the ambient temperature must be warm; hypothermia is to be avoided at all costs.
+The patient is placed on clean sheets and the burnt area left completely exposed. Silver sulphadiazine ointment is applied to the burn woun...
+
+=== Chunk 821 ===
+Source: 0973_002-ebook.pdf
+Length: 1846 chars
+
+15.7 Closure of the burn wound
+The preparation of the burn wound and its subsequent closure are the two main steps in the surgical management of burns. The type of surgery required depends upon the skill and training of the surgeon, the specific burn injury, and the facilities available to support the treatment, especially the availability of blood for transfusion. Like all other injuries treated under difficult circumstances, great judgement is required to select the technical procedure that is...
+
+=== Chunk 822 ===
+Source: 0973_002-ebook.pdf
+Length: 832 chars
+
+15.7.1 Mechanical cleansing and debridement
+Thorough cleaning and removal of debris and fragments of eschar are performed at each dressing session. Gentle washing and sharp debridement of dead skin fragments should be combined with thorough irrigation with water. The surface can then be cleansed with a mild disinfectant (dilute hypochlorite solution, detergent soap) and thoroughly washed again with water. Silver sulphadiazine is reapplied. Where resources are scarce, the cycle of dressing and pl...
+
+=== Chunk 823 ===
+Source: 0973_002-ebook.pdf
+Length: 1004 chars
+
+15.7.2 Surgery
+The most difficult decisions in burn care involve the timing and extent of surgery. Judicious staging of burn surgery is highly important; factors to consider include co-morbidities, age, and occupation or livelihood, as these will all have an impact on decision making. Donor and graft areas should be matched in advance and the process broken down into manageable parts. Attention should be paid to how the body parts will be positioned for the operation: if the plan is to graft the...
+
+=== Chunk 824 ===
+Source: 0973_002-ebook.pdf
+Length: 2063 chars
+
+Tangential excision
+The removal of the full thickness of the burn wound is performed in a single session. Early tangential excision and immediate grafting of burns reduces mortality, morbidity, suffering and hospital stay while improving functional and cosmetic results, but it requires considerable resources and is impracticable for areas larger than 10–20 % TBSA, as a staged procedure, outside specialized burns centres. It is bloody surgery.
+Most field surgeons should be conservative with regar...
+
+=== Chunk 825 ===
+Source: 0973_002-ebook.pdf
+Length: 1211 chars
+
+Face
+The skin of the face, particularly the beard areas on males, is very thick and well populated with deep epidermal cells that will provide for re-epithelialization if given time. If there is any doubt about the depth of burn on the face it is best to wait two weeks before tangential excision.
+As mentioned, face burns are treated by the open technique with warm wet gauze soaks, followed by gentle cleaning and the application of a local antibiotic ointment, with shaving every second day. Sever...
+
+=== Chunk 826 ===
+Source: 0973_002-ebook.pdf
+Length: 3652 chars
+
+Hands, feet, and joint surfaces
+Tangential excision of the hands, feet and joint surfaces can be performed at three days onwards, once the patient is well resuscitated.
+Many severe hand burns will benefit from early escharotomy since deep partial- thickness or full-thickness burns heal with extremely disabling contractures; operating these early should be considered and good, thick skin for the grafts saved. Typically people clench their fists when they sustain a burn so the palmar skin extendin...
+
+=== Chunk 827 ===
+Source: 0973_002-ebook.pdf
+Length: 3067 chars
+
+Skin grafting
+The hands, feet, and joint surfaces are priority areas for skin grafting, with or without tangential excision. The anterior chest and neck take priority over the belly and buttocks. The back has very thick skin, and so burns to it may be observed for some time while waiting to see if they will heal on their own.
+Allowing burns to granulate and demarcate under dressings (2 – 6 weeks) is prudent practice where resources are scarce. This means accepting inevitable protein loss from op...
+
+=== Chunk 828 ===
+Source: 0973_002-ebook.pdf
+Length: 2998 chars
+
+15.8 Scar management and rehabilitation
+Burns frequently result in scars, especially when appropriate and effective treatment is delayed or unavailable. The longer a burn takes to heal, the greater the scarring and the higher the risk of contracture formation. Scar contractures can be devastating, leading to significant deformity, disfigurement and functional impairment. All efforts should be made to prevent significant scarring, and this starts with initial local care of the burn wound. Avoidin...
+
+=== Chunk 829 ===
+Source: 0973_002-ebook.pdf
+Length: 1506 chars
+
+15.9 Electrical burns
+As mentioned, there are two distinct categories. With flash burns, the patient typically presents with fairly deep burns to the face and one or both hands and forearms. Treatment is as with regular thermal injuries.
+High voltage (>1,000 volts) electrical conduction injuries have small cutaneous entry and exit wounds, which extend deep into the muscles causing myonecrosis. The rhabdomyolysis has a systemic effect (with myoglobinaemia and myoglobinuria leading to acute tubula...
+
+=== Chunk 830 ===
+Source: 0973_002-ebook.pdf
+Length: 603 chars
+
+15.10 Chemical burns
+A number of chemical substances cause specific burns. The presence of any of them on an injured person poses a danger to first-aiders, hospital staff and other patients. Careful removal of contaminated clothing and proper decontamination measures – covering the patient and any equipment used – must be undertaken, and specific protocols followed to protect the medical personnel treating the patient. See footnote 5.
+The wounding chemical agent constitutes a danger to first-aid...
+
+=== Chunk 831 ===
+Source: 0973_002-ebook.pdf
+Length: 875 chars
+
+15.10.1 Acid and alkali burns
+In general, acids cause coagulative necrosis of the skin, while strong alkalis cause liquefactive necrosis and burrowing of the chemical deep into the tissues. “Acid violence” involving the throwing of concentrated sulphuric acid into the face is an increasingly common phenomenon and the chemical is readily available wherever there is a motor vehicle garage. The acid burn should be washed with very large volumes of water and the eyes thoroughly irrigated. Strong alk...
+
+=== Chunk 832 ===
+Source: 0973_002-ebook.pdf
+Length: 2783 chars
+
+15.10.2 Phosphorus burns
+Some modern weapons contain white phosphorus. This element ignites on contact with oxygen, and fragments of phosphorus will be scattered throughout any wounds; it is lipid soluble and sticks to the subcutaneous fat. The burn is deep and painful and the phosphorus continues to burn as long as it is in contact with oxygen or until all the phosphorus is consumed. The white phosphorus fragment can dig a cavity all the way down to the bone. Local treatment is more urgent than...
+
+=== Chunk 833 ===
+Source: 0973_002-ebook.pdf
+Length: 1258 chars
+
+15.10.3 Napalm injuries
+Napalm is jellied petrol, an intensely flammable agent that clings to the clothing and skin while still burning and causes serious, deep and extensive burns. Its incomplete combustion of the oxygen in the air around the victim provokes an acute rise in carbon monoxide that can lead to a loss of consciousness and even death. The intense heat and benzene fumes easily cause inhalation burns.
+Napalm burns are invariably full thickness, with coagulation of muscles and other de...
+
+=== Chunk 834 ===
+Source: 0973_002-ebook.pdf
+Length: 519 chars
+
+15.10.4 Magnesium
+Flares released from aircraft to avoid heat-seeking missiles use magnesium, which gives off great heat when lighted. These may reach the ground and cause fires and injuries. The intense heat causes a full-thickness burn. The wound should be excised deep to the contaminant using the “no-touch” technique. Some reports from ICRC surgical teams (Kabul, Afghanistan) have mentioned toxic side effects due to absorption of magnesium, similar to phosphorus; this has not been confirmed.
+...
+
+=== Chunk 835 ===
+Source: 0973_002-ebook.pdf
+Length: 2333 chars
+
+15.10.5 Chemical weapons
+Unlike other agents causing specific burns, chemical weapons have been banned by international treaties.3 However, some States retain stockpiles, which may either be used militarily or released into the air if the storage facilities are bombed. Certain chemicals have a potential dual function: they can be used in weapons and are widely employed for civilian purposes (the disinfection of public water supplies in the case of chlorine).
+Traditional chemical weapons are clas...
+
+=== Chunk 836 ===
+Source: 0973_002-ebook.pdf
+Length: 460 chars
+
+Calorie requirements = Basal energy expenditure x stress factor x activity factor
+The basal energy expenditure is calculated as follows:
+[66 + (14 x weight in kg) + (5 x height in cm) – (6.8 x age in years)]
+Stress factors:
+• minor procedures: 1.3
+• skeletal trauma: 1.35
+• major sepsis: 1.6
+• major burns: 2.1.
+The activity factor is 1.2 for those in bed and 1.3 for those who are mobilizing. Women require about 4 % less than men for equal body size and age....
+
+=== Chunk 837 ===
+Source: 0973_002-ebook.pdf
+Length: 189 chars
+
+Example
+For a 25-year-old male weighing 60 kg and 170 cm tall, in bed with a major burn, the calorie requirements are:
+[66 + (14 x 60) + (5 x 170) – (6.8 x 25)] x 2.1 x 1.2 = 3,997 kcal/day...
+
+=== Chunk 838 ===
+Source: 0973_002-ebook.pdf
+Length: 937 chars
+
+Protein, glucose and fat requirements
+Daily protein requirement for acute burns is 2 g/kg in adults and 3 g/kg in children. Protein provides about 4 kcal/g (120 g and 480 kcal in the example given above).
+Daily glucose requirement is about 6 g/kg/day in burns. Glucose provides 4 kcal/g (360 g and 1,440 kcal in the example).
+The difference between the calculated energy requirement (3,997 kcal) and that provided by protein and glucose should be made up with fat.
+Daily fat requirement = 3,997 kcal ...
+
+=== Chunk 839 ===
+Source: 0973_002-ebook.pdf
+Length: 1025 chars
+
+Making a high-energy enteral feeding solution for burn patients
+Ingredients Glucose Protein Fat kcal Skimmed milk powder 110 g (244 ml) 44 g 40 g 385 Edible oil 80 g (80 ml) 80 g 720 Sugar 50 g (50 ml) 50 g 200 1 Banana (15 mEq potassium) 25 g 110 Add: Salt: 3 g Calcium-containing antacid: 3 tablets Multivitamin tablet: 1 daily Ferrous sulphate + folic acid tablets Codeine: 30 – 60 mg per litre provides analgesia and reduces diarrhoea Boiled and filtered water to make 1,000 ml of solution Total ...
+
+=== Chunk 840 ===
+Source: 0973_002-ebook.pdf
+Length: 377 chars
+
+Chapter 16 LOCAL COLD INJURIES
+16
+WAR SURGERY
+302
+16 16.1 16.2 16.2.1 16.2.2 16.2.3 16.3 16.3.1 16.3.2 16.3.3 LOCAL COLD INJURIES Physiology of thermal regulation Types of local cold injuries Non-freezing injury Freezing injury Local signs and symptoms Management First aid and transport Hospital treatment After care 301 303 303 303 303 303 304 304 304 305
+LOCAL COLD INJURIES...
+
+=== Chunk 841 ===
+Source: 0973_002-ebook.pdf
+Length: 1642 chars
+
+16.1 Physiology of thermal regulation
+The significance of prevention and treatment of local cold injuries during armed conflict cannot be overemphasized. Although most commonly seen in arctic and subarctic climates, cold injuries can occur whenever the combination of cold, wet, and immobility exists. High altitudes, even in tropical or temperate regions, can experience cold weather. Wind is an aggravating factor in all circumstances.
+Normal body temperature is maintained through a balance betwee...
+
+=== Chunk 842 ===
+Source: 0973_002-ebook.pdf
+Length: 166 chars
+
+16.2 Types of local cold injuries
+Local cold injuries can occur at temperatures above or below freezing point and are classified as non-freezing or freezing injuries....
+
+=== Chunk 843 ===
+Source: 0973_002-ebook.pdf
+Length: 538 chars
+
+16.2.1 Non-freezing injury
+This is also known as “immersion foot” or “trench foot”, and is seen in prolonged exposure to cold ambient temperatures above freezing, with high humidity and immobilization, as often witnessed during the trench warfare of World War I, hence the name. Prolonged wetness and cooling of the feet, as can occur in a jungle or rice paddy, can also provoke an “immersion foot” injury. Such injuries are diagnosed and treated like other cold injuries, except that the feet should...
+
+=== Chunk 844 ===
+Source: 0973_002-ebook.pdf
+Length: 362 chars
+
+16.2.2 Freezing injury
+This type of injury may be superficial (chilblain), in which only skin and subcutaneous fat are involved, or deep (frostbite), reaching structures such as muscle.
+Frostbite occurs in the extremities and exposed body parts: nose, ears, etc. In the early stages of injury, it is not easy to differentiate between superficial and deep wounds....
+
+=== Chunk 845 ===
+Source: 0973_002-ebook.pdf
+Length: 447 chars
+
+16.2.3 Local signs and symptoms
+These include:
+• paraesthesia;
+• numbness and insensitivity to pin prick;
+• pallor (wax-white or mottled blue discoloration);
+• impaired movement leading to paralysis;
+• firmness of the body part;
+• oedematous swelling (particularly in non-freezing injuries) followed by blister formation after 24 – 36 hours.
+Figure 16.1 Patient with “trench foot” affecting both feet.
+303
+C
+R
+C
+I
+/
+n
+i
+v
+t
+i
+L
+.
+O
+WAR SURGERY
+304...
+
+=== Chunk 846 ===
+Source: 0973_002-ebook.pdf
+Length: 1708 chars
+
+16.3.1 First aid and transport
+When a body part is frozen solid for hours it runs a lesser risk of tissue loss than when it is exposed to a cycle of thawing, refreezing, and thawing. A person can continue to walk on a frozen foot while it remains frozen; but will be unable to walk after thawing because of the pain and swelling. This should be kept in mind before pre-hospital treatment is attempted; it might be preferable to transfer the patient to adequate shelter and facilities rather than begi...
+
+=== Chunk 847 ===
+Source: 0973_002-ebook.pdf
+Length: 2025 chars
+
+16.3.2 Hospital treatment
+Central hypothermia should be dealt with first through external rewarming by blankets and warm water bath. In severe cases (core body temperature below 30° C) combined or not with frostbite, central warming has a priority over peripheral warming because of the risk of “after-drop”. This represents a situation where the core temperature tends to decrease during peripheral heating of the body. Rewarming of the limbs causes a local vasodilatation with shunting of cold stag...
+
+=== Chunk 848 ===
+Source: 0973_002-ebook.pdf
+Length: 100 chars
+
+16.3.3 After care
+Once rewarming is complete, little more can be done to alter the course of events....
+
+=== Chunk 849 ===
+Source: 0973_002-ebook.pdf
+Length: 1347 chars
+
+The basic treatement is conservative wound care.
+Good nursing care and physiotherapy is the essence of conservative treatment. The extremities should be kept on sterile sheets under cradles. Sterile cotton pledgets are placed between toes or fingers. Warm povidone iodine soaks twice daily help prevent superficial infection. As blebs appear, precautions are taken to avoid their rupture: they should not be allowed to dry up. The limb should be placed so as to avoid pressure on the injured part as ...
+
+=== Chunk 850 ===
+Source: 0973_002-ebook.pdf
+Length: 974 chars
+
+Chapter 17 ANAESTHESIA AND ANALGESIA IN WAR SURGERY 1
+1 Much of this chapter is based on the report of the Senior Anaesthetists Workshop held in Geneva, November, 2002 (see Introduction).
+17
+WAR SURGERY
+308
+17 ANAESTHESIA AND ANALGESIA IN WAR SURGERY 17.1 Introduction 17.2 Anaesthesia methods 17.3 Local and regional anaesthesia 17.4 Dissociative anaesthesia with ketamine 17.4.1 General considerations 17.4.2 Ketamine i.m. and i.v. bolus 17.4.3 Ketamine infusion anaesthesia 17.4.4 Ketamine analges...
+
+=== Chunk 851 ===
+Source: 0973_002-ebook.pdf
+Length: 2679 chars
+
+17.1 Introduction
+Standard anaesthetic practices, as utilized in trauma care, should be followed. However, providing safe and effective anaesthesia with limited resources is probably the most challenging task of hospital work. Many limitations must be accepted owing to security concerns, lack of infrastructure and difficult logistics.
+A reminder to surgeons: operations are “large” or “small”. All anaesthesia is potentially fatal.
+This chapter is not intended for anaesthetists, but rather present...
+
+=== Chunk 852 ===
+Source: 0973_002-ebook.pdf
+Length: 98 chars
+
+Figures 17.1.1 – 17.1.4
+Standard ICRC equipment for anaesthesia.
+C
+2
+R
+C
+I
+/
+y
+z
+a
+a | . _ ’
+H
+.
+H...
+
+=== Chunk 853 ===
+Source: 0973_002-ebook.pdf
+Length: 124 chars
+
+Figure 17.1.1
+Typical operating theatre. Note the inhalation anaesthesia machine and oxygen concentrator.
+C
+M.Baldan / CRC
+M...
+
+=== Chunk 854 ===
+Source: 0973_002-ebook.pdf
+Length: 236 chars
+
+Figure 17.1.2
+Pulse oxymeter for monitoring; laryngoscope and endotracheal tube, bag for manual ventilation.
+C
+Gerber /ICRC
+.
+C
+Figure 17.1.3 Foot-driven suction pump.
+C
+R
+C
+I
+/
+n
+a
+d
+l
+a
+a
+B
+.
+M
+Figure 17.1.4 Electric suction pump.
+310...
+
+=== Chunk 855 ===
+Source: 0973_002-ebook.pdf
+Length: 2048 chars
+
+17.2 Anaesthesia methods
+There are many different levels of sophistication for the provision of anaesthesia. Even when working in an austere environment, minimum mandatory standards should be followed to ensure safe anaesthesia. These include WHO safety checklists, World Federation of Societies of Anaesthesiologists standards and fasting rules for non- emergency surgery including DPC (ANNEX 17. A).
+Local and regional anaesthesia techniques are excellent and can be used in many patients, al-thoug...
+
+=== Chunk 856 ===
+Source: 0973_002-ebook.pdf
+Length: 2175 chars
+
+17.3 Local and regional anaesthesia
+The clinically significant point in all forms of local and regional anaesthesia is to allow sufficient time for the anaesthetic to work. The most common mistake is to make a local anaesthetic infiltration, and then incise immediately.
+Technique Use Drug of choice Recommended volume* Remarks 0.4 % oxybuprocaine Topical anaesthesia Ophthalmic or 0.5 % proxymetacaine (Alcaine) If not available, 2 % or 4 % lidocaine drops Mucosa 4 – 5 % lidocaine Nebulizer spray o...
+
+=== Chunk 857 ===
+Source: 0973_002-ebook.pdf
+Length: 291 chars
+
+17.4 Dissociative anaesthesia with ketamine
+The main components of safe and adequate general anaesthesia are:
+• unconsciousness (hypnosis);
+• analgesia;
+• amnesia;
+• immobility/muscle relaxation.
+Ketamine is the anaesthetic of choice for major war surgery in conditions of limited resources....
+
+=== Chunk 858 ===
+Source: 0973_002-ebook.pdf
+Length: 2551 chars
+
+17.4.1 General considerations
+Ketamine is very safe for both adults and children, and can be given intramuscularly or as an intravenous bolus or perfusion.
+It causes amnesia, analgesia, and a state of dissociation. The patient feels detached from the environment, but the reflexes are intact, particularly the laryngo-pharyngeal reflexes that protect the airway. Opening of the eyes, shouting, and limb movements are frequent and normal; the patient is nevertheless anaesthetized. It may cause halluc...
+
+=== Chunk 859 ===
+Source: 0973_002-ebook.pdf
+Length: 1799 chars
+
+17.4.2 Ketamine i.m. and i.v. bolus
+Both the intramuscular and the bolus intravenous routes are simple forms of ketamine administration. Table 17.2 compares the two.
+Ketamine i.m. Ketamine i.v. bolus Indications Short operation (10 – 20 minutes) Short operation (10 – 20 minutes) Anaesthesia in children (injected while the Induction of anaesthesia mother is holding the infant) Repeated injections for change of dressings in burn patients with poor i.v. access Premedication Preferable if time allow...
+
+=== Chunk 860 ===
+Source: 0973_002-ebook.pdf
+Length: 922 chars
+
+17.4.3 Ketamine infusion anaesthesia
+This is the preferred technique in ICRC practice. It is not only more economical of ketamine, but allows for a longer operation without re-injections. It can be used either after i.v. bolus induction of anaesthesia or as an induction method on its own.
+A solution is made of ketamine in normal saline and placed in a different vein from that used for fluid replacement. The rate of infusion is titrated against the patient’s response, both for induction and as ma...
+
+=== Chunk 861 ===
+Source: 0973_002-ebook.pdf
+Length: 386 chars
+
+17.4.4 Ketamine analgesia
+The analgesic effect of ketamine can be profitably used for a number of conditions. One noteworthy example is for repeated change of dressings in burn patients. For analgesia, a lower dose than that given for intramuscular anaesthesia is administered to those whose venous access is compromised, as is often the case with major burns (see ANNEXes 17. D and E)....
+
+=== Chunk 862 ===
+Source: 0973_002-ebook.pdf
+Length: 280 chars
+
+17.5 Post-operative pain management
+Good post-traumatic or post-operative pain relief not only helps to alleviate suffering, but also allows for rapid mobilization of the patient and early physiotherapy, which help attain as good a functional result as possible. (See ANNEX 17. E)...
+
+=== Chunk 863 ===
+Source: 0973_002-ebook.pdf
+Length: 1291 chars
+
+17.5.1 General guidelines
+1. Pain is managed by the three Ps: psychology (humanitarian), physical methods (surgical fixation, physiotherapy etc.), and pharmacology (drugs).
+2. Analgesia should be given before the pain starts and on an around-the-clock basis, at regularly scheduled intervals.
+3. Combination therapy is recommended. Analgesic drugs have a better effect in combination than alone, e.g. paracetamol and an NSAID have additive pain-relieving activity because of their different sites of ...
+
+=== Chunk 864 ===
+Source: 0973_002-ebook.pdf
+Length: 1166 chars
+
+REVERSED WHO PAIN MANAGEMENT LADDER
+SEVERE PAIN  Hurts worst  MORPHINE OR FENTANYL  MORPHINE  MODERATE PAIN  IV = 1-2mg dose, titrate to effect  S/C or I/M = 5-15mg, every 4 hours  TRAMADOL  Hurts whole lot  PO (fast acting) = 10-20mg, every 2-4 hours  FENTANYL  IM = 50-100 mcg, 1-2 hourly  IV/PO = 50-100mg, every 4-6 hours  Maximum dose = 600mg per day  MILD PAIN  PARACETAMOL  Hurts even more  plus PARACETAMOL  plus PARACETAMOL  PO/IV = 1g, every 6 hours  plus IBUPROFEN  plus IBUPROFEN  plus IB...
+
+=== Chunk 865 ===
+Source: 0973_002-ebook.pdf
+Length: 405 chars
+
+17.5.2 Pain scoring systems
+Pain intensity can be measured in various ways and the use of a system of measurement is recommended. The choice of scoring system depends on a number of factors, including cultural issues and the level of literacy and numeracy of patients and the nursing staff. In all of them it is the patient who assesses the intensity of pain.
+Common scoring systems include the following....
+
+=== Chunk 866 ===
+Source: 0973_002-ebook.pdf
+Length: 120 chars
+
+Verbal score
+The pain intensity is measured using words:
+• None
+• Mild
+• Moderate
+• Severe
+• Extreme
+315
+WAR SURGERY
+316...
+
+=== Chunk 867 ===
+Source: 0973_002-ebook.pdf
+Length: 99 chars
+
+Number scale
+Numbers from 0 to 10 should be used:
+0 means no pain and 10 the worst pain imaginable....
+
+=== Chunk 868 ===
+Source: 0973_002-ebook.pdf
+Length: 732 chars
+
+Visual analogue score
+This is analogous to the number scale. The pain intensity is measured on a 10 cm line. The left end indicates “no pain” and the right-hand side means “the worst pain imaginable”. The distance in cm from the left edge to the point the patient indicates is the pain score.
+The availability of particular drugs for pain relief in a given country is often subject to importation and distribution restrictions. The widespread abuse of opioids in particular has created many problems ...
+
+=== Chunk 869 ===
+Source: 0973_002-ebook.pdf
+Length: 1127 chars
+
+ANNEX 17. A Fasting rules for non-emergency surgeries, including delayed primary closure
+Fasting rules for non-emergency surgeries – adults Night before surgery Carbohydrate (CHO)* preloading up to 800 ml Up to 6 hours before anaesthesia induction Food (solids, milk, milk-containing drinks) Up to 2 hours before anaesthesia induction Clear fluids** * CHO – 10 % sugary water (10 g sugar/100 ml water) ** Clear fluids – fruit juices without pulp, lemonade, soft drinks, tea and coffee without milk.
+F...
+
+=== Chunk 870 ===
+Source: 0973_002-ebook.pdf
+Length: 1402 chars
+
+ANNEX 17. B Standard ICRC anaesthetic equipment
+Pre-op – all  General anaesthesia  •  Oxygen (concentrator ± cylinder)  •  Laryngoscope handles  •  Saturation monitoring  •  Laryngoscope blades 1 to 4 ± straight blades  •  ECG  •  Endotracheal tubes 3.0 – 8 mm  •  End-tidal CO2 monitoring  •  Guedel airways  •  BP monitoring  •   IV cannulae 24 g to 16 g  •  Suction  •  Tape / Elastoplast / Ties  •  Anaesthetic machine  •  Bougies  •  Self-inflating bag (Ambu bag)  •  Magill forceps, large and s...
+
+=== Chunk 871 ===
+Source: 0973_002-ebook.pdf
+Length: 1146 chars
+
+ANNEX 17. C ICRC recommendations for choice of anaesthetic techniques
+General General Spinal *** Peripheral Local Caudal anaesthesia anaesthesia nerve blocks anaesthesia/ anaesthesia. with with (ultrasound sedation Paediatric spontaneous intubation guided) cases (up to ventilation (ketamine ± 7 years old) (ketamine) * halothane) ** Upper +++ ± - +++ + - extremities Lower ++ ± +++ + + +++ extremities Lower + ++ +++ - - ++ abdominal surgery Upper ± +++ ± - - - abdominal surgery Neurotrauma + +++ -...
+
+=== Chunk 872 ===
+Source: 0973_002-ebook.pdf
+Length: 2135 chars
+
+ANNEX 17. D Ketamine delivery regimes
+Delivery (based on required duration) Induction and bolus maintenance for short procedures Intravenous infusion Analgesia Examples of different ketamine regimes Ketamine – either i.m. or i.v. – is the anaesthesia of choice for short procedures Intravenous ketamine recipes • Ketamine 1 – 2 mg/kg i.v.: produces dissociative anaesthesia; patient maintains own airway. • Midazolam 5 mg or diazepam 2 – 5 mg i.v. with a small dose of morphine i.v., followed by keta...
+
+=== Chunk 873 ===
+Source: 0973_002-ebook.pdf
+Length: 1583 chars
+
+Opioids
+1. When Level 3 analgesics (opioids) are used in a hospital, naloxone must also be immediately available.
+2. Morphine remains the gold standard for pain relief, intra-operatively as well as pre- and post-operatively.
+3. The use of opioids – morphine, fentanyl, pethidine and tramadol – should be restricted to trained health-care professionals because of the risk of respiratory depression.
+ICRC surgical teams use opioids only if nursing staff are sufficient in number and trained in patient...
+
+=== Chunk 874 ===
+Source: 0973_002-ebook.pdf
+Length: 261 chars
+
+Monitoring, diagnosis, and treatment of respiratory depression
+When using Level 3 opioids the patient must be monitored regularly for:
+• blood pressure;
+• pulse;
+• temperature;
+• respiratory rate;
+• sedation score;
+• pain score.
+All findings must be documented....
+
+=== Chunk 875 ===
+Source: 0973_002-ebook.pdf
+Length: 841 chars
+
+Respiratory depression
+1. Recognition
+Respiratory depression is diagnosed by:
+– sedation score of 3: this is the earliest and most reliable sign;
+– respiratory rate 8 or less: this comes later than sedation;
+– decreasing pO2, as shown by pulse oximetry: this is a late sign, especially if the patient is also being given oxygen.
+2. Treatment:
+– oxygen;
+– respiratory assistance with bag and mask if necessary;
+– naloxone i.v. in 50 mcg increments until clinical signs improve.
+321
+17
+WAR SURGERY
+3223...
+
+=== Chunk 876 ===
+Source: 0973_002-ebook.pdf
+Length: 341 chars
+
+Ketamine
+A low dose of ketamine is a good alternative analgesic where opioids are not available or for high-risk patients. Give repeated doses of 0.1 – 0.3 mg/kg i.v., titrated until the desired analgesia is achieved; or an i.m. bolus of 2 – 3 mg/kg. Ketamine in a low dose does not require routine atropine and diazepam as adjuvant therapy....
+
+=== Chunk 877 ===
+Source: 0973_002-ebook.pdf
+Length: 220 chars
+
+Pre-hospital care
+For pre-hospital first aid, often through National Red Cross/Red Crescent Societies,
+the ICRC distributes only:
+• paracetamol tablets/syrup;
+• tramadol injections (rarely causes respiratory depression)....
+
+=== Chunk 878 ===
+Source: 0973_002-ebook.pdf
+Length: 322 chars
+
+Emergency room
+The following are available in the emergency room:
+• paracetamol;
+• diclofenac injection;
+• tramadol injection.
+In a hospital with adequate nursing care, the following are also provided:
+• morphine injection;
+– adult: 1 – 3 mg i.v. titrated
+– child: 0.05 mg/kg i.v. titrated
+• low-dose ketamine (see above)....
+
+=== Chunk 879 ===
+Source: 0973_002-ebook.pdf
+Length: 568 chars
+
+Operating theatre
+All analgesic drugs are available and their intra-operative use is greatly encouraged. The choice of drug depends to a large extent on the quality of post-operative monitoring.
+1. Opioids
+Note the level of post-operative monitoring.
+2. NSAID
+It is advisable to administer an NSAID before the end of surgery.
+3. Ketamine
+0.1 – 0.3 mg/kg boluses can be used as analgesia if opioids are unavailable.
+4. Local and regional anaesthesia
+The use of local anaesthetic infiltration or local ...
+
+=== Chunk 880 ===
+Source: 0973_002-ebook.pdf
+Length: 791 chars
+
+Post-operative pain control
+The level of pain control needed depends on the psychology of the patient, the type of surgery and the time since surgery. The basic principles of post-operative analgesia are the following.
+1. Give analgesia regularly and not on an as-necessary basis (PRN).
+2. Do not wait for the pain to be felt, but start immediately once the patient has regained consciousness. This also means that analgesia should be started before spinal anaesthesia has worn off.
+3. Start with com...
+
+=== Chunk 881 ===
+Source: 0973_002-ebook.pdf
+Length: 96 chars
+
+SEVERE PAIN
+Paracetamol
++
+NSAID
++
+Opioid
++
+Local infiltration or block
+323
+17
+WAR SURGERY
+324324...
+
+=== Chunk 882 ===
+Source: 0973_002-ebook.pdf
+Length: 1728 chars
+
+Analgesic doses
+ADULT Paracetamol Oral 1 g QID Max. 4 g/day Caution in cases of asthma and renal Ibuprofen Oral 400 mg TID/QID Max. 2.4 g/day impairment Contraindicated in pregnancy Max. 72 hours Caution in cases of asthma and renal Diclofenac i.v./i.m. 75 mg BID Max. 150 mg/day impairment Contraindicated in pregnancy Max. 72 hours Tramadol Oral/i.v. 50 – 100 mg 4-hourly Max. 600 mg/day Pethidine i.m. i.v. 50 – 150 mg 3-hourly 10 mg increments Titrate to effect Morphine Subcutaneous / i.m. i.v. ...
+
+=== Chunk 883 ===
+Source: 0973_002-ebook.pdf
+Length: 391 chars
+
+DAMAGE CONTROL SURGERY AND HYPOTHERMIA, ACIDOSIS AND COAGULOPATHY
+18
+WAR SURGERY
+328
+DAMAGE CONTROL SURGERY AND HYPOTHERMIA, ACIDOSIS AND COAGULOPATHY 327
+18
+18.1 18.2 18.2.1 18.2.2 18.2.3 18.3 Introduction to damage control Hypothermia, acidosis and coagulopathy Hypothermia Acidosis Coagulopathy associated with trauma Damage control protocol 329 330 331 333 334 335
+DAMAGE CONTROL SURGERY...
+
+=== Chunk 884 ===
+Source: 0973_002-ebook.pdf
+Length: 356 chars
+
+Figure 18.3
+Another candidate for damage control surgery: anti-personnel mine injury with penetrating wounds to the abdomen, thorax, left thigh, left hand and face.
+Patient with anti-personnel mine blast injury: traumatic amputation of the left foot; penetrating injuries and burns to both legs, the perineum and genitalia, with penetration of the abdomen....
+
+=== Chunk 885 ===
+Source: 0973_002-ebook.pdf
+Length: 794 chars
+
+18.2 Hypothermia, acidosis and coagulopathy
+The effects of hypothermia in trauma patients have long been underestimated. It afflicts the injured even in tropical climates. While metabolic acidosis due to shock and coagulopathy are better known, the combined triad is far more prevalent than is often realized and its effects easily fatal. These three elements compound and reinforce each other, leading to a self-sustaining vicious circle.
+Early recognition of the risk is essential and simple preven...
+
+=== Chunk 886 ===
+Source: 0973_002-ebook.pdf
+Length: 1123 chars
+
+Physiology
+The body’s temperature is kept in a homeostatic balance between heat production and heat loss. Hypothermia is determined by central body – core – temperature, taken per rectum. A normal medical thermometer is useless; a special extended- range one beginning at 30° C is necessary. Classically, a core temperature below 35° C denotes hypothermia and medical classifications include profound states of 25° C or less (immersion in a cold lake, hypothalamic disorders, drug abuse, etc.). Cold ...
+
+=== Chunk 887 ===
+Source: 0973_002-ebook.pdf
+Length: 1956 chars
+
+Pathology2
+“It has been said that any wounded man in a state of   stupor whose temperature sinks below 36° C will die.”  E. Delorme, 18882
+This observation is not new, although the threshold has changed. It is very rare for patients suffering trauma and uncontrolled hypothermia lower than 32° C to survive; this temperature is recognized today as the crucial cut-off point. All enzyme systems in the body are temperature-dependent and therefore all organ systems will tend to fail at this low core t...
+
+=== Chunk 888 ===
+Source: 0973_002-ebook.pdf
+Length: 1271 chars
+
+Clinical picture
+Early signs include shivering and tremors, tachycardia and tachypnoea (with hypoventilation). Making the diagnosis is a challenge because most of the early signs are the normal sympathetic response to the stress of trauma and haemorrhage; the surgeon should be particularly attentive to the presence of shivering and tremors. It is also difficult to judge clinically when the patient passes from Stage I (36° – 35° C) to II (34° – 32° C) without close monitoring of the rectal temper...
+
+=== Chunk 889 ===
+Source: 0973_002-ebook.pdf
+Length: 894 chars
+
+High-risk cases
+Patients who have the following extrinsic factors are at high risk of developing post- traumatic hypothermia:
+• severely injured and subjected to a long delay in evacuation to hospital;
+• remained trapped under rubble and thus exposed to the environment.
+Iatrogenic extrinsic factors include:
+• haemorrhagic shock treated with large quantities of room temperature intravenous fluids or cold transfusions – banked blood is stored at 4° C and its administration acts as a heat sink that...
+
+=== Chunk 890 ===
+Source: 0973_002-ebook.pdf
+Length: 1787 chars
+
+18.2.2 Acidosis
+Hypotension will lead to tissue hypoperfusion and hypoxia with a subsequent rise in anaerobic metabolism. Oxygen delivery to the tissues is also impaired by the anaemia and peripheral vasoconstriction due to acute blood loss, compounded by hypothermia. In addition, resuscitation with large amounts of unbalanced crystalloids (normal saline, Ringer’s lactate) pushes the patient toward acidosis. The resultant anaerobic metabolism shows a raised level of serum lactate, a by-product o...
+
+=== Chunk 891 ===
+Source: 0973_002-ebook.pdf
+Length: 1781 chars
+
+18.2.3 Coagulopathy associated with trauma
+Thromboelastography, a technology that allows the study in real time of clot formation, strength, and dissolution (fibrinolysis), has proved important for a better understanding of the coagulopathy associated with trauma. This coagulopathy is of several types and involves various intrinsic and extrinsic factors, some of which are iatrogenic. The most obvious type is that which is provoked by the disruption of enzymatic and platelet activity due to hypot...
+
+=== Chunk 892 ===
+Source: 0973_002-ebook.pdf
+Length: 1251 chars
+
+18.3 Damage control protocol
+Damage control surgery is restricted to the very severely injured – a small minority. It is a highly individualized form of management, requiring the mobilization of considerable resources if applied on a regular basis. Indeed, a patient who would qualify for DCS in a context with a small number of casualties will in many cases be triaged into Category IV during a mass influx of wounded.
+In much of the world, the sophisticated ICUs and large quantities of blood requi...
+
+=== Chunk 893 ===
+Source: 0973_002-ebook.pdf
+Length: 1293 chars
+
+First stage: patient selection and damage control resuscitation
+“The treatment of bleeding is to stop the bleeding.”5 Resuscitation does not stop bleeding. The first step is to determine which patients would benefit from a staged damage control approach rather than a single definitive procedure. That decision may be taken in the ER or in the OT.
+The clinical picture is indicative of an unstable physiology:
+• A systolic blood pressure lower than 90 mm Hg.
+• A core temperature lower than 35° C.
+• ...
+
+=== Chunk 894 ===
+Source: 0973_002-ebook.pdf
+Length: 2666 chars
+
+Second stage: life-saving resuscitative surgery
+An initial operation should be performed to control haemorrhage and limit contamination from hollow organs. This operation should be as short as possible and should involve doing only what is strictly necessary to overcome life-threatening conditions. Priority is given to physiological recovery over anatomic repair.
+A patient in Stage I hypothermia (36° C – 35° C) may have definitive surgery completed, depending on the severity of injury. The strat...
+
+=== Chunk 895 ===
+Source: 0973_002-ebook.pdf
+Length: 1713 chars
+
+Third stage: restoration of physiology
+The aim is to achieve as complete a physiological resuscitation as possible, to stabilize the patient by correction of shock, hypothermia, acidosis, and coagulopathy. This is performed in the critical care area of the hospital and usually takes 24 to 48 hours.
+In many ways this stage may be the most challenging to organize under austere working conditions. Part 3F in Volume 2 describes the organization of a critical care area in the hospital. Centralization...
+
+=== Chunk 896 ===
+Source: 0973_002-ebook.pdf
+Length: 820 chars
+
+Fourth stage: definitive surgery
+As mentioned on numerous occasions in Volume 2, certain procedures require specialized surgical training, which is not always available. It is here that the possibility of transferring a patient for a second operation is of the utmost importance. An appropriate operating team must be mobilized, equipment and supplies prepared, and good communication among team members maintained.
+337
+WAR SURGERY
+338
+The second operation includes a search for any missed injuries a...
+
+=== Chunk 897 ===
+Source: 0973_002-ebook.pdf
+Length: 239 chars
+
+Fifth stage: reconstructive surgery
+More complicated reconstructive procedures are undertaken, especially reconstruction of the abdominal wall months later in those patients who were left with a large planned incisional hernia.
+18
+ACRONYMS...
+
+=== Chunk 898 ===
+Source: 0973_002-ebook.pdf
+Length: 2389 chars
+
+ACRONYMS
+ABCDE Airway, Breathing, Circulation, Disability, Environment/Exposure
+APM Anti-personnel mine
+ARDS Acute respiratory distress syndrome
+ATM Anti-tank mine
+ATP Adenosine triphosphate
+AVPU Alert, Voice responsive, Pain responsive, Unresponsive
+BID Bis in die (twice a day)
+CFR Case fatality rate
+CPD-A Citrate – phosphate – dextrose – adenine
+CRO Carded for record only
+CT Computerized tomography
+DOA Dead on arrival
+DOW Died of wounds
+DPC Delayed primary closure
+2,3-DPG 2,3-diphosphoglycerat...
+
+=== Chunk 899 ===
+Source: 0973_002-ebook.pdf
+Length: 120 chars
+
+General texts
+Please note:
+The publications listed under general texts serve as basic references throughout this manual....
+
+=== Chunk 900 ===
+Source: 0973_002-ebook.pdf
+Length: 859 chars
+
+Military publications
+Cubano MA, Butler FK, eds. Emergency War Surgery 5th ed. Fort Sam Houston TX: Borden Institute, US Department of Defense; 2018.
+Nessen SC, Lounsbury DE, Hetz SP, eds. War Surgery in Afghanistan and Iraq: A Series of Case Studies, 2003 – 2007. Washington, DC: Office of the Surgeon General, Borden Institute, US Department of Defense; 2008.
+Pons J, ed. Memento de chirurgie de guerre [War Surgery Primer]. Paris: École d’application du Service de santé pour l’armée de terre, ORA...
+
+=== Chunk 901 ===
+Source: 0973_002-ebook.pdf
+Length: 781 chars
+
+Civilian publications
+Brooks AJ, Clasper J, Midwinter MJ, Hodgetts TJ, Mahoney PF, eds. Ryan’s Ballistic Trauma: A Practical Guide 3rd ed. London: Springer-Verlag; 2011.
+Courbil L-J, ed. Chirurgie d’urgence en situation précaire [Emergency Surgery under Precarious Circumstances]. Paris: Editions Pradel; 1996.
+Geelhoed GW, ed. Surgery and Healing in the Developing World. Georgetown, TX: Landes Bioscience; 2005.
+Husum H, Ang SC, Fosse E. War Surgery: Field Manual 2nd ed. Penang, Malaysia: Third Wo...
+
+=== Chunk 902 ===
+Source: 0973_002-ebook.pdf
+Length: 1006 chars
+
+Trauma surgery references
+Boffard KD ed. Manual of Definitive Surgical Trauma Care 4th Edition. Boca Raton, FL: International Association for Trauma Surgery and Intensive Care, CRC Press; 2016.
+Hirshberg A, Mattox KL. Top Knife: The Art and Craft of Trauma Surgery. Shrewsbury, UK: tfm Publishing Ltd; 2005.
+Integrated Management for Emergency and Essential Surgical Care. E-Learning tool Kit. [CD-ROM]. Geneva: World Health Organization; 2005. Available at: https://www.who. int/surgery/publications...
+
+=== Chunk 903 ===
+Source: 0973_002-ebook.pdf
+Length: 1530 chars
+
+Chapter 1
+Standard Products Catalogue. Emergency Items Catalogue of the International Movement of the Red Cross and Red Crescent. Geneva: International Committee of the Red Cross and International Federation of Red Cross and Red Crescent Societies. Available at: https://itemscatalogue.redcross.int/index.aspx
+Bowyer GW. War surgery and the International Committee of the Red Cross: a historical perspective. Int J Orthop Trauma 1996; 6: 62 – 65.
+Burkle FM, Kushner AL, Giannou C, Paterson MA, Wren S...
+
+=== Chunk 904 ===
+Source: 0973_002-ebook.pdf
+Length: 1574 chars
+
+Basic references
+Dunant H. A Memory of Solferino. Geneva: ICRC; 1950.
+The Geneva Conventions of August 12, 1949. Geneva: ICRC; 1995, and the Protocols Additional to the Geneva Conventions of 12 August 1949, revised Edition. Geneva: ICRC; 1996.
+SELECTED BIBLIOGRAPHY
+Pictet J, de Preux J, Uhler O, Coursier H, eds. Commentary on the Geneva Conventions I – IV of 12 August 1949, 4 vol. Geneva: ICRC; 1952 – 1960.
+Pictet J, Pilloud C, de Preux J, Zimmermann B, Eberlin P, Gasser H-P, Wenger C, Junod S, ...
+
+=== Chunk 905 ===
+Source: 0973_002-ebook.pdf
+Length: 3485 chars
+
+IHL and the medical profession
+Annas GJ. Military medical ethics – physician first, last, always. N Engl J Med 2008; 359: 1087 – 1090.
+Annas GJ, Crosby S. US military medical ethics in the War on Terror. J R Army Med Corps Epub ahead of print: [24.01.2019]. [doi:10.1136/jramc-2018-001062]
+Briody C, Rubenstein L, Roberts L, Penney E, Keenan W, Horbar J. Review of attacks on health care facilities in six conflicts of the past three decades. Conflict and Health 2018; 12: 19. [doi:10.1186/s13031-018...
+
+=== Chunk 906 ===
+Source: 0973_002-ebook.pdf
+Length: 555 chars
+
+General references
+Kneubuehl BP, Coupland RM, Rothschild MA, Thali MJ. Wound Ballistics, Basics and Applications. [Translation of revised 3rd German edition Wundballistik, Grundlagen und Anwendungen. Berlin, Heidelberg: Springer-Verlag; 2011.
+Neuenschwander J, Coupland R, Kneubuehl B, Baumberger V. Wound Ballistics: An introduction for health, legal, forensic, military and law enforcement professionals. [Brochure and film on DVD]. Geneva: ICRC; 2008.
+Sellier KG, Kneubuehl BP. Wound Ballistics an...
+
+=== Chunk 907 ===
+Source: 0973_002-ebook.pdf
+Length: 4249 chars
+
+Journal articles
+Amato JJ, Syracuse D, Seaver PR Jr, Rich N. Bone as a secondary missile: an experimental study in the fragmenting of bone by high-velocity missiles. J Trauma 1989; 29: 609–12.
+Bowyer GW, Cooper JG, Rice P. Small fragment wounds: biophysics and pathophysiology. J Trauma 1996; 40 (3suppl.): S159 – S164.
+Brismar B, Bergenwald L. The terrorist bomb explosion of Bologna, Italy, 1980: an analysis of the effects and injuries sustained. J Trauma 1982; 22: 216 – 220.
+Cheng XM, Liu YQ, Gu...
+
+=== Chunk 908 ===
+Source: 0973_002-ebook.pdf
+Length: 1134 chars
+
+Chapter 4
+Bowyer GW, Stewart MPM, Ryan JM. Gulf war wounds: application of the Red Cross Wound Classification. Injury 1993; 24: 597 – 600.
+Bowyer GW. Afghan war wounded: application of the Red Cross Wound Classification. J Trauma 1995; 38: 64 – 67.
+Coupland RM. The Red Cross classification of war wounds: the EXCFVM scoring system. World J Surg 1992; 16: 910 – 917.
+Giannou CP. Penetrating missile injuries during asymmetric warfare in the 2003 Gulf conflict. [Correspondence]. Br J Surg 2005; 92: 1...
+
+=== Chunk 909 ===
+Source: 0973_002-ebook.pdf
+Length: 2918 chars
+
+Public health
+Aboutanos MB, Baker SP. Wartime civilian injuries: epidemiology and intervention strategies. J Trauma 1997; 43: 719 – 726.
+Coupland RM. The effects of weapons on health. Lancet 1996; 347: 450 – 451.
+Coupland RM, Meddings DR. Mortality associated with use of weapons in armed conflicts, wartime atrocities, and civilian mass shootings: literature review. BMJ 1999;
+319: 407 – 410.
+Coupland RM, Samnegaard HO. Effect of type and transfer of conventional weapons on civilian injuries: retr...
+
+=== Chunk 910 ===
+Source: 0973_002-ebook.pdf
+Length: 2555 chars
+
+Civilian war surgery literature
+Bhatnagar MK, Smith GS. Trauma in the Afghan guerrilla war: effects of lack of access to care. Surgery 1989; 105: 699 – 705.
+Cutting PA, Agha R. Surgery in a Palestinian refugee camp. Injury 1992; 23: 405 – 409.
+Dardagan H. Recording casualties of war: why better data are important. BMJ 2015; 351: h5041. [doi:10.1136/bmj.h4736]
+De Wind CM. War injuries treated under primitive circumstances: experiences in an Ugandan mission hospital. Ann R Coll Surg Engl 1987; 69:...
+
+=== Chunk 911 ===
+Source: 0973_002-ebook.pdf
+Length: 5263 chars
+
+Military war surgery literature
+Acosta JA, Hatzigeorgiou C, Smith LS. Developing a trauma registry in a forward deployed military hospital: preliminary report. J Trauma 2006; 61: 256 – 260.
+Bellamy RF. Combat trauma overview. In: Sajtchuk R, Grande CM, eds. Textbook of Military Medicine, Anesthesia and Perioperative Care of the Combat Casualty. Falls Church, VA: Office of the Surgeon General, United States Army; 1995: 1 – 42.
+Belmont PJ Jr, McCriskin BJ, Sieg RN, Burks R, Schoenfeld AJ. Combat w...
+
+=== Chunk 912 ===
+Source: 0973_002-ebook.pdf
+Length: 1247 chars
+
+ICRC war surgery articles
+Andersson P, Muhrbeck M, Veen H, Osman Z, von Schreeb J. Hospital workload for weapon-wounded females treated by the International Committee of the Red Cross: more work needed than for males. World J Surg 2018; 42: 93 – 98.
+Bowyer GW. Management of small fragment wounds: experience from the Afghan border. J Trauma 1996; 40 (3suppl.): S170 – S172.
+Coupland RM. Hand grenade injuries among civilians. JAMA 1993; 270: 624 – 626.
+Coupland RM. Epidemiological approach to surgi...
+
+=== Chunk 913 ===
+Source: 0973_002-ebook.pdf
+Length: 1203 chars
+
+Chapter 6
+Garber K, Stewart BT, Burkle FM Jr, Kushner AL, Wren SM. A framework for a battlefield trauma system for civilians. Ann Surg 2018; 268: 30 – 31.
+Hayward-Karlsson J, Jeffery S, Kerr A, Schmidt H. Hospitals for War-Wounded: A Practical Guide for Setting up and Running a Surgical Hospital in an Area of Armed Conflict. Geneva: ICRC; 1998.
+Hayward-Karlsson J. Hospital and System Assessment. In: Mahoney PF, Ryan JM, Brooks AJ, Schwab CW, eds. Ballistic Trauma: A Practical Guide 2nd Edition. ...
+
+=== Chunk 914 ===
+Source: 0973_002-ebook.pdf
+Length: 2580 chars
+
+Chapter 7
+Butler FK Jr. Tactical combat casualty care: combining good medicine with good tactics. J Trauma 2003; 54 (suppl.): S2 – S3.
+Clough RAJ, Khan M. Initial CABC: Advances that have led to increased survival in military casualties. Trauma 2019. [doi: 10.1177/1460408619838438]
+Coupland RM. Epidemiological approach to surgical management of the casualties of war. BMJ 1994; 308: 1693 – 1696.
+Coupland RM, Molde Å, Navein J. Care in the Field for Victims of Weapons of War: A Report from the Wor...
+
+=== Chunk 915 ===
+Source: 0973_002-ebook.pdf
+Length: 1149 chars
+
+Cervical spine immobilization
+Arishita GI, Vayer JS, Bellamy RF. Cervical spine immobilization of penetrating neck wounds in a hostile environment. J Trauma 1989; 29: 332 – 337.
+Barkana Y, Stein M, Scope A, Maor R, Abramovich Y, Friedman Z, Knoller N. Prehospital stabilization of the cervical spine for penetrating injuries of the neck – is it necessary? Injury 2000; 31: 305 – 309.
+Klein Y, Arieli I, Sagiv S, Peleg K, Ben-Galim P. Cervical spine injuries in civilian victims of explosions: should ...
+
+=== Chunk 916 ===
+Source: 0973_002-ebook.pdf
+Length: 2067 chars
+
+Tourniquet use
+Baruch EN, Kragh JF Jr, Berg AL, Aden JK Rd, Benov A, Shina A, Shlaifer A, Ahimor A, Glassberg E, Yitzhak A. Confidence-competence mismatch and reasons for failure of non-medical tourniquet users. Prehosp Emerg Care 2017; 21: 39 – 45.
+Brodie S, Hodgetts TJ, Ollerton J, McLeod J, Lambert P, Mahoney P. Tourniquet use in combat trauma. J R Army Med Corps 2008; 153: 310 – 313.
+Kauvar DS, Miller D, Walters TJ. Tourniquet use is not associated with limb loss following military lower ext...
+
+=== Chunk 917 ===
+Source: 0973_002-ebook.pdf
+Length: 594 chars
+
+Trauma training
+Skinner DV, Driscoll PA, eds. ABC of Major Trauma 4th ed. London: BMJ Books; 2013.
+American College of Surgeons, Committee on Trauma. Advanced Trauma Life Support for Doctors, Student Course Manual (ATLS) 7th ed. Chicago, IL: American College of Surgeons; 2004.
+SELECTED BIBLIOGRAPHY
+Kortbeek JB, Al Turki SA, Ali J, et al. Advanced Trauma Life Support, 8th ed. The evidence for change. J Trauma 2008; 64: 1638 – 1650.
+International Association for Trauma Surgery and Intensive Care (...
+
+=== Chunk 918 ===
+Source: 0973_002-ebook.pdf
+Length: 679 chars
+
+Trauma training in low-income countries: some examples
+Aboutanos MB, Rodas EB, Aboutanos SZ, Mora FE, Wolf LG, Duane TM, Malhotra AK, Ivatury RR. Trauma education and care in the jungle of Ecuador, where there is no advanced trauma life support. J Trauma 2007; 62: 714 – 719.
+Basic Emergency Skills in Trauma (B.E.S.T.). Manila: Philippine College of Surgeons.
+Emergency Room Trauma Course (ERTC). Organized by the ICRC with local partners, in various countries.
+National Trauma Management Course (NT...
+
+=== Chunk 919 ===
+Source: 0973_002-ebook.pdf
+Length: 111 chars
+
+Pneumothorax
+Leigh-Smith S, Harris T. Tension pneumothorax – time for a re-think? Emerg Med J 2005; 22: 8 – 16....
+
+=== Chunk 920 ===
+Source: 0973_002-ebook.pdf
+Length: 2731 chars
+
+Shock resuscitation
+Alam HB, Koustova E, Rhee P. Combat casualty care research: from bench to the battlefield. World J Surg 2005; 29 (suppl.): S7 – S11.
+Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331: 1105 – 1109.
+Champion HR. Combat fluid resuscitation: introduction and overview of conferences. J Trauma 2003; 54 (suppl.): S7 – S12.
+Daniel Y, ...
+
+=== Chunk 921 ===
+Source: 0973_002-ebook.pdf
+Length: 2508 chars
+
+Blood transfusion
+Auten JD, Lunceford NL, Horton JL, Galarneau MR, Galindo RM, Shepps CD, Zieber TJ, Dewing CB. The safety of early fresh, whole blood transfusion among severely battle injured at US Marine Corps forward surgical care facilities in Afghanistan. J Trauma Acute Care Surg 2015; 79: 790 – 796.
+Eshaya-Chauvin B, Coupland RM. Transfusion requirements for the management of war injured: the experience of the International Committee of the Red Cross. Br J Anaesth 1992; 68: 221 – 223.
+Kieb...
+
+=== Chunk 922 ===
+Source: 0973_002-ebook.pdf
+Length: 899 chars
+
+Tranexamic acid
+CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23 – 32.
+CRASH-2 trial collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet 2011; 377: 1096 – 101.
+Cole E, Davenport R, Willett K, ...
+
+=== Chunk 923 ===
+Source: 0973_002-ebook.pdf
+Length: 3800 chars
+
+Chapter 9
+Further practical information for the organisation of hospital management in a triage situation is available in: Hayward-Karlsson J, Jeffrey S, Kerr A, Schmidt H. Hospitals for War Wounded. Geneva: ICRC; 1998.
+Please note:
+In a military context, all standard war surgery manuals written by and for armed forces deal with the organization and implementation of triage under military constraints.
+Almogy G, Belzberg H, Mintz Y, Pikarsky AK, Zamir G, Rivkind AI. Suicide bombing attacks: updat...
+
+=== Chunk 924 ===
+Source: 0973_002-ebook.pdf
+Length: 3134 chars
+
+Chapters 10 and 11
+Anglen JO, Gainor BJ, Simpson WA, Christensen G. The use of detergent irrigation for musculoskeletal wounds. Int Orthop 2003; 27: 40 – 46.
+Baldan M, Giannou CP. Basic surgical management of war wounds: the ICRC experience. East Cent Afr J Surg 2003; 8: 35 – 38.
+Bewes P. The Management of Wounds in Developing Countries. Health Development e-TALC [CD – ROM]. January, 2004. No. 5. [TALC: Teaching-aids At Low Cost Web site]. Available at: http://www.talcuk.org.
+Bowyer GW, Cooper G...
+
+=== Chunk 925 ===
+Source: 0973_002-ebook.pdf
+Length: 1095 chars
+
+Chapter 12
+Bhaskar SN, Cutright DE, Hunsuck EE, Gross A. Pulsating water jet devices in debridement of combat wounds. Mil Med 1971; 136: 264 – 266.
+Bhatnagar MK, Smith GS. Trauma in the Afghan guerrilla war: effects of lack of access to care. Surgery 1989; 105: 699 – 705.
+Coupland RM, Howell P. An experience of war surgery and wounds presenting after 3 days on the border of Afghanistan. Injury 1988; 19: 259 – 262.
+Craig G. Treating the Afghan war wounded. J Roy Soc Med 1993; 86: 404 – 405.
+Gross...
+
+=== Chunk 926 ===
+Source: 0973_002-ebook.pdf
+Length: 628 chars
+
+Biofilm
+Evans LV, ed. Biofilms: Recent Advances in their Study and Control. Amsterdam: Harwood Academic Press; 2000.
+Fletcher M, ed. Bacterial Adhesion: Molecular and Ecological Diversity. New York: John Wiley & Sons; 1996.
+Monroe D. Looking for chinks in the armor of bacterial biofilms [Public Library of Science Web site]. Available at: http://www.plos.org. PLoS Bio. 2007; 5: e307.
+Percival SL. Importance of biofilm formation in surgical infection. 2017 BJS; 104: e85 – e94. [doi: 10.1002/bjs.10...
+
+=== Chunk 927 ===
+Source: 0973_002-ebook.pdf
+Length: 2776 chars
+
+Chapter 13
+Bingham JR, Bowyer MW. Combat soft tissue injuries. Curr Trauma Rep 2018; 4: 333. [doi: 10.1007/s40719-018-0139-x]
+Dahlgren B, Berlin R, Brandberg A, Rybeck B, Seeman T. Bacteriological findings in the first 12 hours following experimental missile trauma. Acta Chir Scand 1981; 147: 513 – 518.
+Dahlgren B, Berlin R, Brandberg A, Rybeck B, Schantz B, Seeman T. Effect of benzyl- penicillin on wound infection rate and on the extent of devitalized tissue twelve hours after infliction of exp...
+
+=== Chunk 928 ===
+Source: 0973_002-ebook.pdf
+Length: 379 chars
+
+Tetanus
+Oladiran I, Meier DE, Ojelade AA, OlaOlorun DA, Adeniran A, Tarpley JL. Tetanus: continuing problem in the developing world. World J Surg 2002; 26: 1282 – 1285.
+Thwaites CL, Yen LM, Loan HT, Thuy TTD, Thwaites GE, Stepniewska K, Soni N, White NJ, Farrar JJ. Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial. Lancet 2006; 368: 1436 – 1443....
+
+=== Chunk 929 ===
+Source: 0973_002-ebook.pdf
+Length: 316 chars
+
+Necrotising fasciitis
+Angoules AG, Kontakis G, Drakoulakis E, Vrentzos G, Granick MS, Giannoudis PV. Necrotising fasciitis of upper and lower limb: a systematic review. Injury 2007; 38 (suppl.): C18 – C25.
+Hasham S, Matteucci P, Stanley PRW, Hart NB. Necrotising fasciitis: clinical review. BMJ 2005; 330; 830 – 833....
+
+=== Chunk 930 ===
+Source: 0973_002-ebook.pdf
+Length: 559 chars
+
+Chapter 14
+Baldan M, Giannou CP, Sasin V, Morino GF. Metallic foreign bodies after war injuries: should we remove them? The ICRC experience. East C Afr J Surg 2004; 9: 31 – 34.
+Linden MA, Manton WI, Stewart RM, Thal ER, Feit H. Lead poisoning from retained bullets: pathogenesis, diagnosis, and management. Ann Surg 1982; 195: 305 – 313.
+Rhee JM, Martin R. The management of retained bullets in the limbs. Injury 1997; 28 (3suppl.): C23 – C28.
+Rich NM, Collins GJ, Andersen CA, McDonald PT, Kozloff L...
+
+=== Chunk 931 ===
+Source: 0973_002-ebook.pdf
+Length: 1629 chars
+
+Chapter 15
+Arturson G: Pathophysiology of the burn wound and pharmacological treatment. The Rudi Hermans Lecture, 1995. Burns 1996; 22: 255 – 274.
+Cartotto R, Musgrave M, Beveridge M, Fish J, Gomez M. Minimizing blood loss in burn surgery. J Trauma 2000; 49: 1034 – 1039.
+Guilabert P, Usúa G, Martín N, Abarca L, Barret JP, Colomina MJ. Fluid resuscitation management in patients with burns: Update. Br J Anaesth 2016; 117: 284 – 296.
+Hettiaratchy S, Dziewulski P: ABC of burns: pathophysiology and t...
+
+=== Chunk 932 ===
+Source: 0973_002-ebook.pdf
+Length: 150 chars
+
+Chapter 16
+Britt LD, Dascombe WH, Rodriguez A. New horizons in management of hypothermia and frostbite injury. Surg Clin North Am 1991; 71: 345 – 370....
+
+=== Chunk 933 ===
+Source: 0973_002-ebook.pdf
+Length: 2085 chars
+
+Chapter 17
+Ariyo P, Trelles M, Helmand R, Amir Y, Hassani GH, Mftavyanka J, Nzeyimana Z, Akemani C, Bagura Ntawukiruwabo I, Charles A, Yana Y, Moussa K, Kamal M, Lamin Suma M, Ahmed M, Abdullahi M, Wong EG, Kushner A, Latif A. Providing Anesthesia care in resource-limited settings: a 6-year analysis of anesthesia services provided at Médecins Sans Frontières facilities. Anesthesiology 2016; 124: 561 – 569.
+Bion JF. An anaesthetist in a camp for Cambodian refugees. Anaesthesia 1983; 38: 798 – 801...
+
+=== Chunk 934 ===
+Source: 0973_002-ebook.pdf
+Length: 1196 chars
+
+Ketamine anaesthesia in head trauma
+Bourgoin A, Albanese J, Wereszczynski N, Charbit M, Vialet R, Martin C. Safety of sedation with ketamine in severe head injury patients: comparison with sulfentanyl. Crit Care Med 2003; 31: 711 – 717.
+Gofrit ON Leibovici D, Shemer J, Henig A, Shapira SC. Ketamine in the field: the use of ketamine for induction of anesthesia before intubation of injured patients in the field. Injury 1997; 28: 41 – 43.
+Green SM, Clem KJ, Rothrock SG. Ketamine safety profile in t...
+
+=== Chunk 935 ===
+Source: 0973_002-ebook.pdf
+Length: 2399 chars
+
+Damage control surgery and resuscitation
+Burch JM, Ortiz VB, Richardson RJ, Martin RR, Mattox KL, Jordan GL Jr. Abbreviated laparotomy and planned reoperation for critically injured patients. Ann Surg 1992; 215: 476 – 483.
+Damage Control Surgery. Surg Clin North Am 1997; 77: 753 – 952.
+Hirshberg A, Mattox KL. Planned reoperation for severe trauma. Ann Surg 1995; 222: 3 – 8.
+Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, Cox ED, Gehrke MJ, Beilman GJ, Schreiber M, Flaherty SF, ...
+
+=== Chunk 936 ===
+Source: 0973_002-ebook.pdf
+Length: 5151 chars
+
+Hypothermia and coagulopathy
+Bernabei AF, Levison MA, Bender JS. The effects of hypothermia and injury severity on blood loss during trauma laparotomy. J Trauma 1992; 33: 835 – 839.
+Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma 2003; 54: 1127 – 1130.
+Brohi K, Cohen MJ, Ganter MT, Matthay MA, Mackersie RC, Pittet J-F. Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway? Ann Surg 2007; 245: 812 – 818.
+Brohi K, Cohen MJ, Gan...
+
+=== Chunk 937 ===
+Source: 0446_002-ebook.pdf
+Length: 2192 chars
+
+Untitled Section
+SURGERY FOR VICTIMS OF WAR
+Much has been written about the theory and principles of war surgery as practised by military medical units. This book, which summarizes the practical experience of eminent special- ists from different parts of the world, aims to provide a broad introduction to the subject for members of surgical teams, whether military or civilian, who may be faced with the treat- ment of wounded in situations or armed conflict - situations which demand a quite differ...
+
+=== Chunk 938 ===
+Source: 0446_002-ebook.pdf
+Length: 179 chars
+
+ICRC
+International Committee of the Red Cross 19 Avenue de la Paix, 1202 Geneva, Switzerland T +41227346001 F +41227332057 E-mail: icrc.gva@icrc.org www.icrc.org
+Original: English...
+
+=== Chunk 939 ===
+Source: 0446_002-ebook.pdf
+Length: 797 chars
+
+AUTHORS
+Bernard Betrancourt, Physiotherapist, Switzerland Daniel Dufour, M.D., Switzerland Soeren Kromann Jensen, M.D., Denmark Ora Friberg, M.D., Finland Antero Lounavaara, M.D., Finland Michael Owen-Smith, FRCS, United Kingdom Jorma Salmela, M.D., Finland Erkki Silvonen, M.D., Finland G. Frank Stening, FRACS, Australia B. Zetterström, M.D., Sweden
+First edition edited by
+DANIEL DUFOUR
+Michael Owen-Smith
+G. Frank Stening
+Second edition edited by
+ROBIN GRAY, FRCS,
+ICRC surgical coordinator, Gene...
+
+=== Chunk 940 ===
+Source: 0446_002-ebook.pdf
+Length: 1751 chars
+
+PREFACE
+The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and the dignity of vic- tims of war and internal violence and to provide them with assis- tance.
+The ICRC assists the wounded when war prevents society from providing them with the health care they need. It may furnish exist- ing health facilities with medicines, equipment or staff, or set up independent ICRC hospitals. I...
+
+=== Chunk 941 ===
+Source: 0446_002-ebook.pdf
+Length: 1109 chars
+
+ACKNOWLEDGEMENTS to the 1st edition
+The ICRC thanks the editors and all the authors of this manual on war surgery, particularly Mr. Frank Stening who wrote the first draft for it in 1982.
+The wide experience in war surgery brought by all the contribu- tors made it possible to define and establish the major aspects of the treatment of war wounded. Without the time and energy they gave on a voluntary basis the book would never have materialized.
+Thanks are especially due to Mr. Soeren Kromann Jens...
+
+=== Chunk 942 ===
+Source: 0446_002-ebook.pdf
+Length: 599 chars
+
+ACKNOWLEDGEMENTS to the 3rd edition
+This 3rd edition was brought out in response to the demands of many surgeons around the world. It is not just a reprint of the 2nd edition, but a thoroughly revised version, the text having been modified to take into account current ICRC thinking on matters pertaining to war surgery. It was edited for language and lay-out by Ms Angela Haden. Many thanks goes to her, to Ms Jacqueline Kopp, who did the initial typing, and to the two previous editors, Dr Daniel D...
+
+=== Chunk 943 ===
+Source: 0446_002-ebook.pdf
+Length: 16318 chars
+
+LIST OF CONTENTS
+1. INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
+2. FIRST AID AT THE POINT OF WOUNDING
+7 AIRWAY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 BREATHING . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Ventilation . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Chest wounds . . . . . . . . . . . . . . . . . . . . . . . 8 CIRCULATION . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Heart . . . . . . . . . . . . . . ....
+
+=== Chunk 944 ===
+Source: 0446_002-ebook.pdf
+Length: 891 chars
+
+INTRODUCTION
+1.
+Surgery for victims of war is different from the type of surgery practised for civilian injuries. War wounds are always extremely contaminated, and missiles may cause massive destruction of soft tissues, bones and other structures.
+The principles of surgery for war wounds have been known for decades but need to be relearned by each new generation of sur- geons working in a war situation.
+The aims of war surgery are to: • save life; • avoid infectious complications; • save limbs; ...
+
+=== Chunk 945 ===
+Source: 0446_002-ebook.pdf
+Length: 3821 chars
+
+ORGANIZATION
+The outcome of war surgery is influenced by:
+• type of injury;
+• general condition of the patient;
+• first aid;
+• time needed for transport to hospital;
+• quality of treatment (surgery, post-operative care, rehabilitation);
+• possibility of evacuation to a better equipped hospital with more experienced staff.
+1
+All the above factors are supposed to be taken into consideration by the military.
+In some countries, the organization of care is so efficient that any soldier who is wounded...
+
+=== Chunk 946 ===
+Source: 0446_002-ebook.pdf
+Length: 1597 chars
+
+EQUIPMENT
+In poor countries, the level of technology is usually low before the war. In other countries, the level may go down because of the war, with disrupted communication lines, unavailability of spare parts, and lack of knowledge about repair and maintenance. Never- theless, ICRC experience shows that it is possible to perform good quality surgery with basic technology, such as simple X-ray, but without equipment for electric monitoring in the operating theatre and the postoperative ward.
+M...
+
+=== Chunk 947 ===
+Source: 0446_002-ebook.pdf
+Length: 2300 chars
+
+ENVIRONMENTAL CONSTRAINTS
+Security is a major concern, and must be ensured for patients and staff by selecting suitable places for first aid posts and hospitals. Health facilities should be clearly marked with the protective emblem of the Red Cross or Red Crescent.
+In a war situation, with few doctors and staff, and with wounded pouring in, hospital facilities may be overwhelmed. Stocks may run out, with the result that optimal treatment cannot be given. It is important to realize that surgeons ...
+
+=== Chunk 948 ===
+Source: 0446_002-ebook.pdf
+Length: 556 chars
+
+2. FIRST AID AT THE POINT OF WOUNDING OR FIRST AID POST
+The essentials of first aid are to prevent death and to avoid fur- ther injury. Most deaths resulting from injuries from bullets and explosions are caused by loss of cardio-respiratory function and from haemorrhage. If these two problems can be controlled at the point of wounding, there is an excellent chance that the patient will survive evacuation to a hospital where surgical care can be pro- vided.
+The most important elements of first ai...
+
+=== Chunk 949 ===
+Source: 0446_002-ebook.pdf
+Length: 818 chars
+
+AIRWAY
+Respiratory obstruction is an emergency that requires an imme- diate response. Speed in relieving respiratory obstruction is of the utmost importance. Maintaining an adequate flow of air to the lungs is essential.
+Respiratory obstruction can result from:
+– Aspiration of blood, foreign bodies or vomitus.
+– Obstruction by the tongue. This can usually be controlled by extending the neck and placing the patient in the semi-prone position. An oropharyngeal airway will maintain an adequate airw...
+
+=== Chunk 950 ===
+Source: 0446_002-ebook.pdf
+Length: 566 chars
+
+Ventilation
+When breathing stops as a result of primary injury, it is vital to restore ventilation immediately. Artificial respiration should be continued until normal breathing returns, but at a first aid post it is not possible to continue this treatment for more than a maximum of twenty minutes.
+The simplest methods for use as first aid are the mouth to mouth method and the mouth to nose method. A third option is mouth to mouth, using a specially designed oropharyngeal airway with a mouthpiec...
+
+=== Chunk 951 ===
+Source: 0446_002-ebook.pdf
+Length: 2368 chars
+
+Chest wounds
+Penetrating chest wounds may have a serious effect on respira- tion if the lungs are damaged. The heart and mediastinal structures may also be damaged. They always create a pneumothorax, which may be small or large but generally closed, and mostly there is some degree of haemothorax.
+A penetrating wound of the chest may create a wound which remains open. This causes an open pneumothorax, in which air passing in and out of the pleural cavity, and bubbling through the blood coming fro...
+
+=== Chunk 952 ===
+Source: 0446_002-ebook.pdf
+Length: 278 chars
+
+Heart
+If the heart has stopped as an indirect result of the injury, exter- nal cardiac compression must be initiated. This will often have to be carried out in conjunction with artificial respiration. It is usually not possible to combine the two procedures in a first aid post....
+
+=== Chunk 953 ===
+Source: 0446_002-ebook.pdf
+Length: 1437 chars
+
+Bleeding
+A dressing or any available material can be packed closely and carefully into a wound, and this will usually stop bleeding. If a blood vessel can be seen in the depths of the wound, and it is con-
+9
+tinuing to bleed, direct control may be obtained manually or with artery forceps, if available. Blind clamping must never be attempted. Pressure applied to pressure points over an artery may be of use in reducing haemorrhage until control can be obtained. Elevation of the wounded part will r...
+
+=== Chunk 954 ===
+Source: 0446_002-ebook.pdf
+Length: 730 chars
+
+DRESSINGS AND SPLINTS
+Wounds should be covered by clean dressings to avoid further soiling.
+Fractures should be stabilized to avoid further damage to sur- rounding tissue, bleeding and pain.
+The majority of fractures do not need complicated splinting when evacuation is going to be rapid. The upper limbs may be splinted in a sling or by using the patient’s clothing. The leg may be splinted effectively by binding it, using any available material,
+10
+to the good leg. If there is any delay in evacua...
+
+=== Chunk 955 ===
+Source: 0446_002-ebook.pdf
+Length: 528 chars
+
+EVACUATION
+With all forms of trauma, including penetrating wounds, the patient’s condition should be stabilized before evacuation. Skilled first aid at the site of injury should allow stability to be achieved in the majority of cases.
+The major cause of exsanguination and death is likely to be a penetrating wound of the abdomen or central chest, in which access to control haemorrhage is not possible.
+Delay in evacuation will contribute to an increase in mortality. This remains a major problem in...
+
+=== Chunk 956 ===
+Source: 0446_002-ebook.pdf
+Length: 3394 chars
+
+3. TRIAGE AND RECEPTION OF LARGE NUMBERS OF CASUALTIES
+CASUALTY SORTING
+The experience of two World Wars has demonstrated the impor- tance of sorting casualties. The French term triage, which means to sort into groups according to quality, has been applied to the sort- ing of battle casualties since that time. It is the process of catego- rizing patients according to the degree of severity of injury, so that priorities can be established in order to use the available facilities most efficiently ...
+
+=== Chunk 957 ===
+Source: 0446_002-ebook.pdf
+Length: 1832 chars
+
+SETTING PRIORITIES
+The categorization of patients into priority groups should be simple, as in the scheme below.
+Category I – serious wounds – resuscitation and immediate surgery
+Those patients for whom urgent surgery is required and for whom there is a good chance of recovery. In practice many of these patients will have abdominal or thoracic injuries or wounds of peripheral blood vessels.
+Category II – second priority wounds – can wait for surgery
+Those patients who require surgery but not on ...
+
+=== Chunk 958 ===
+Source: 0446_002-ebook.pdf
+Length: 446 chars
+
+EMERGENCY PLAN FOR MASS CASUALTIES
+The sudden arrival of large numbers of casualties may occur at any time. Prior planning prevents poor performance. Unless a plan exists for the reception and triage of mass casualties, chaos will result.
+Security must be ensured by having guards at the gate of the hospital. Only wounded persons, possibly accompanied by a close relative, should be allowed to enter. All weapons must be left out- side the gate....
+
+=== Chunk 959 ===
+Source: 0446_002-ebook.pdf
+Length: 631 chars
+
+Triage area
+A large space should be prepared for the immediate reception of casualties.
+The area should be cleared of all in-patients, and be large enough to permit easy movement of casualties and medical per- sonnel.
+All necessary equipment should be prepared and located in or close to the triage area.
+There should be a plan for the relocation of in-patients from the designated reception area, and the plan should be put into operation as soon as notice is given of the expected arrival of mass c...
+
+=== Chunk 960 ===
+Source: 0446_002-ebook.pdf
+Length: 1227 chars
+
+Personnel
+Triage should be performed by an experienced nurse or doctor with a good understanding of the functioning and capacity of the hospital. He or she has full responsibility for categorizing the casu- alties, and should be supported by a team consisting of a nurse and an assistant.
+16
+The duty of the head nurse is to make plans for all staff, includ- ing the non-medical staff working in the kitchen and the laundry, covering their role in the triage situation. Nursing teams should be formed...
+
+=== Chunk 961 ===
+Source: 0446_002-ebook.pdf
+Length: 1229 chars
+
+Equipment
+At least 100 sets of routine patient folders, each with a unique number, should be prepared and maintained in readiness for a major influx of casualties. Each folder should include an admission chart, a fluid balance chart, and laboratory and X-ray request forms. A body stamp or which injuries can be marked improves recording.
+Containers of emergency equipment should be stocked in a clean and easily accessible place. The stocks should include:
+• venepuncture equipment,
+• i.v. therapy e...
+
+=== Chunk 962 ===
+Source: 0446_002-ebook.pdf
+Length: 1830 chars
+
+HOW TO PERFORM TRIAGE
+Each casualty should be appropriately identified and assigned a medical chart. Good records are essential and every effort must be made to record the important aspects of the wounds, the treatment and the patient’s triage category.
+Each patient must be checked and the whole body, including the back, must be examined.
+The person performing the triage should not treat the patients. Initial treatment is started by the nursing team, and the patient should be transferred as quic...
+
+=== Chunk 963 ===
+Source: 0446_002-ebook.pdf
+Length: 2942 chars
+
+4. ASSESSMENT AND RESUSCITATION IN HOSPITAL
+The wounded arriving in hospital without any previous treat- ment should be given first aid as described in chapter 2. If first aid has already been given, more skilful resuscitation can be done in the hospital where greater expertise and better equipment are usu- ally available. Efforts should again concentrate initially on life- saving treatment for asphyxia and shock.
+The first priority in treatment must always be the airway and breathing.
+AIRWAY
+Th...
+
+=== Chunk 964 ===
+Source: 0446_002-ebook.pdf
+Length: 3877 chars
+
+BREATHING
+The cause of respiratory distress must be found and treated. Clinical examination may reveal a sucking wound of the chest, pneumothorax, tension pneumothorax, haemothorax or a flail seg- ment of the chest.
+Asucking wound may be treated by the application of an airtight sealed dressing, best made with a piece of vaseline gauze or plas- tic sheeting covered with a bulky dressing, firmly taped into place. An intercostal drain may be required in such patients if they develop a tension pneu...
+
+=== Chunk 965 ===
+Source: 0446_002-ebook.pdf
+Length: 1938 chars
+
+BLOOD
+Blood should be taken immediately for grouping and cross- matching.
+It is unusual for a patient to require whole blood during the first ten minutes of resuscitation, but moribund exsanguinated patients may rapidly be given group O blood together with Hartmann’s solution, as the threat of death outweighs the potential morbidity from transfusion reactions. Type-specific whole blood should be available in ten minutes, and crossmatched blood in 30-40 min- utes.
+When blood is used for major tra...
+
+=== Chunk 966 ===
+Source: 0446_002-ebook.pdf
+Length: 954 chars
+
+OBJECTIVE OF RESUSCITATION
+The aims of resuscitation are:
+• to restore circulating blood volume and intracellular fluid;
+• to restore normal blood flow and tissue perfusion;
+• to attain a urinary output of 30-50 ml/h without overloading the lungs and adding to post-traumatic pulmonary insufficiency. Arapid response to resuscitation allows surgery to be performed at the optimum time according to the priority for treatment. Failure to respond usually occurs as a result of internal bleeding: urgent...
+
+=== Chunk 967 ===
+Source: 0446_002-ebook.pdf
+Length: 835 chars
+
+5. WOUND CLASSIFICATION
+Surgeons who treat war wounded often find it impossible to tell from examining the wound what kind of weapon caused the injury. The Red Cross wound classification is therefore based on the fea- tures of the wound itself and not on the weaponry or the presumed velocity of the missile.
+Wounds are given a six-figure score according to the size of the entry and exit wounds of the skin, and whether there is a cavity, fracture, injury to a vital structure or any metallic body. ...
+
+=== Chunk 968 ===
+Source: 0446_002-ebook.pdf
+Length: 290 chars
+
+E = entry in centimetres
+X = exit in centimetres (X = 0 if no exit)
+before surgery? C 0 = no C 1 = yes
+C = cavity
+Can the cavity of the wound take two fingers
+27
+F = fracture F 0 = No fracture comminution F 2 = Clinically significant comminution
+F 1 = Simple fracture, hole or insignificant...
+
+=== Chunk 969 ===
+Source: 0446_002-ebook.pdf
+Length: 931 chars
+
+V = vital structure V 0 = no
+V N = (neurological) penetration of the dura of the brain or spinal cord V T = (thorax or trachea) penetration of the pleura or of the trachea in the neck V A = (abdomen) penetration of the peritoneum V H = (haematological) injury of a major peri- pheral blood vessel down to Brachial a. or
+Popliteal a.
+M = metallic body Are bullet or fragments visible on X-ray? M 0 = no M 1 = yes, one metallic body M 2 = yes, multiple metallic bodies
+FIGURE 1
+Examples of wounds: (a) ...
+
+=== Chunk 970 ===
+Source: 0446_002-ebook.pdf
+Length: 280 chars
+
+SOME WOUND CHARACTERISTICS OF DIFFERENT WEAPONS
+The wounding power of a missile depends on how much kinetic energy is given up when it strikes tissue. The energy is given by the formula E = mv2 where m is the mass and v the velocity. This deter- mines the extent of tissue damage....
+
+=== Chunk 971 ===
+Source: 0446_002-ebook.pdf
+Length: 275 chars
+
+Bullets
+A typical bullet injury is wound (b) in Figure 1, with a small entrance wound and a large exit wound. The different patterns shown in Figure 1 depend on the energy deposit at the time of wounding. Fragmentation of the bullet will cause severe wounds, as in wound (e)....
+
+=== Chunk 972 ===
+Source: 0446_002-ebook.pdf
+Length: 407 chars
+
+Fragments
+Fragment injury may be caused by explosive devices, such as bombs, mortars, shells, rockets and grenades. The distance between the wounded person and the explosion determines the outcome.
+The blast wave from an explosion might cause rupture of the ear drums and of gas-containing viscera, such as the stomach or bow- els, as well as haemorrhagia in the lungs, without any penetrating wound.
+M
+1
+29...
+
+=== Chunk 973 ===
+Source: 0446_002-ebook.pdf
+Length: 678 chars
+
+Mines
+Mines are exploding devices which, by their design, cause trau- matic amputation of foot or leg, often combined with multiple severe wounds. The wounds are all severely contaminated by mud, grass, pieces of shoes and clothes driven deep into the wounds at the time of explosion. These injuries draw heavily on resources because they need a long operation time, many operations per patient, blood transfusions, dressing material, a long hospital stay, and a difficult period of rehabilitation, w...
+
+=== Chunk 974 ===
+Source: 0446_002-ebook.pdf
+Length: 792 chars
+
+6. WOUND EXCISION
+All wounds involve soft tissues, and most of them will be com- plicated by damage to other structures. War wounds are often mul- tiple. Wounds in the buttock, thigh or perineum may enter the abdominal cavity; a chest wound may enter the abdomen.
+The entire patient should be thoroughly examined, paying particular attention to the back and buttocks.
+All clothing should be removed in so far as possible, bearing in mind local religious and cultural factors. Careful clinical examina...
+
+=== Chunk 975 ===
+Source: 0446_002-ebook.pdf
+Length: 751 chars
+
+TECHNIQUE OF WOUND EXCISION
+Wound excision is the process whereby dead and damaged tis- sue which is grossly contaminated with bacteria and debris from the surface is completely cut away. This leaves an area of healthy
+31
+tissue, with a good blood supply, capable of combating residual surface infection provided the wound is not sutured.
+Clothing, dressing and splints are carefully removed and a ster- ile gauze pad is held over the wound. The skin over a large sur- rounding area and the whole cir...
+
+=== Chunk 976 ===
+Source: 0446_002-ebook.pdf
+Length: 703 chars
+
+Skin and subcutaneous tissues
+Skin is very resistant to damage and is remarkably viable. It should be treated conservatively. Only skin that is grossly pulped should be excised. Usually no more than 1 mm of the skin edge need be removed. In order to gain access to the depths of the wound, the skin should be incised generously. In limbs, the inci- sion should be made in the long axis, but not over subcutaneous bone, and at flexion creases it should deviate in the usual way. The subcutaneous fat h...
+
+=== Chunk 977 ===
+Source: 0446_002-ebook.pdf
+Length: 767 chars
+
+Fasciotomy
+The deep fascia must be incised along the length of the skin inci- sion. This essential step allows wide and deep retraction, and exposes the depths of the wound. It may be necessary to add trans- verse cuts to the deep fascia to improve access. Deep to the fascia, the gloved finger is the best and most gentle probe, and can often be used to follow the track and to estimate the extent of the damage.
+Fascial compartments may need decompression by fascio- tomy to avoid muscle ischaemia....
+
+=== Chunk 978 ===
+Source: 0446_002-ebook.pdf
+Length: 1502 chars
+
+Haematoma
+The presence of a large haematoma generally implies that a major vessel has been damaged. Dislodging the haematoma can result in sudden heavy blood loss. It is wise to be prepared for vas- cular control before a haematoma is evacuated.
+Muscle
+All dead muscle must be excised.
+Dead muscle is the ideal medium for the development of clostridial infection leading to gas gangrene. The track of the mis- sile can be seen, and this track may be surrounded by dead muscle. It is absolutely vital ...
+
+=== Chunk 979 ===
+Source: 0446_002-ebook.pdf
+Length: 791 chars
+
+Foreign bodies
+The edges of the wound should be retracted and blood clot, dirt, debris and missile fragments removed from the sides and depths of the wound. Gentle and copious irrigation with saline must be used to wash out the residual debris and blood clot. Explore the wound with the fin- ger to identify foreign bodies or unexpected extensions of the wound.
+• DO NOT open fresh planes in healthy tissue.
+• DO NOT explore unnecessarily for metallic fragments; they may be left in situ.
+• It is abs...
+
+=== Chunk 980 ===
+Source: 0446_002-ebook.pdf
+Length: 523 chars
+
+Tendons, nerves, bones and arteries
+Tendons should be trimmed and only grossly destroyed fibres removed. Tiny fragments of bone with no attachment should be discarded, but any bone attached to periosteum or muscle should be retained.
+• No attempt should be made at primary tendon, nerve or bone repair, as success is unlikely in these grossly contam- inated wounds.
+• An injury to a major artery to the limb must be either repaired or replaced by a saphenous vein graft immediately if a limb is to su...
+
+=== Chunk 981 ===
+Source: 0446_002-ebook.pdf
+Length: 333 chars
+
+PERFORATING LIMB WOUNDS
+These must be dealt with by excising the wound on each side of the limb separately. Simple through and through wounds in which
+34
+there is minimal soft tissue damage do not require major surgical exploration. Where there is significant tissue damage or damage to major vessels, the wounds require exploration....
+
+=== Chunk 982 ===
+Source: 0446_002-ebook.pdf
+Length: 1035 chars
+
+LIMITATION OF CLOSURE
+Wounds should be left wide open, without any suture of skin or deep structures.
+The only exceptions might be wounds in:
+– Face, neck, scalp and genitals. These wounds may be closed primarily after wound excision.
+– Soft tissues of the chest wall. These wounds must be excised, but healthy muscle must be closed over a sucking chest wound in order to make an airtight closure. The skin is left open.
+– Head. The dura can rarely be closed directly, but closure should be effected ...
+
+=== Chunk 983 ===
+Source: 0446_002-ebook.pdf
+Length: 1154 chars
+
+DRESSINGS
+Once the wound has been adequately excised, it should be cov- ered with a bulky absorbent dressing made of dry fluffed-up gauze and held in place with a loose crepe bandage or non circumferen- tial adhesive tape. The aim is to draw inflammatory fluid out of the wound and into the dressing.
+35
+Vaseline gauze should not be used, and the wound should not be “packed” in any way with the dressing since this will form a plug and prevent the free outflow of fluid.
+The dressing should not be r...
+
+=== Chunk 984 ===
+Source: 0446_002-ebook.pdf
+Length: 235 chars
+
+ANTIBIOTICS
+Penicillin, 5 mega-units 6-hourly intravenously, should be given from the time of admission. When feasible, this should be substi- tuted by oral penicillin, 500 mg 6-hourly for a total of 5 days treat- ment (see chapter 8)....
+
+=== Chunk 985 ===
+Source: 0446_002-ebook.pdf
+Length: 192 chars
+
+IMMOBILIZATION
+In all cases where there is an extensive soft tissue wound, even in the absence of a fracture, the entire limb should be immobilized. This can be achieved by plaster back slabs....
+
+=== Chunk 986 ===
+Source: 0446_002-ebook.pdf
+Length: 778 chars
+
+TERMINOLOGY
+The English word excision means to cut off or cut out. Debride- ment is a French word meaning to lance, incise or unbridle. It is
+36
+also used in the sense of releasing. Debridement is used, perhaps incorrectly, in the English medical literature of war wound surgery to mean the removal of dead tissue. A further misunderstanding may be caused by the fact that excision, when used with reference to cancer surgery, tends to mean “excision en bloc” with a wide margin of surrounding tissue...
+
+=== Chunk 987 ===
+Source: 0446_002-ebook.pdf
+Length: 748 chars
+
+DELAYED PRIMARY CLOSURE
+Delayed primary closure (DPC) is wound closure performed within seven days of injury. This is accomplished by simple approximation of the deep structures and skin, without tension.
+No wound should be closed if there is persistent contamina- tion or infection.
+If there has been significant tissue loss, and simple approxima- tion of the deep structures and skin cannot be performed, skin grafts, or skin or musculocutaneous flap will be required. These wounds cannot be manage...
+
+=== Chunk 988 ===
+Source: 0446_002-ebook.pdf
+Length: 597 chars
+
+Optimum timing
+The aim of DPC is to close the wound during the fibroblastic phase of wound healing. This occurs between the 3rd and 6th days
+39
+following injury. Some wounds can be closed with safety earlier than others. For example, wounds of the face, neck and scrotum (3rd day) can be closed earlier than torso or upper extremity wounds (4-5th day) which in turn can be closed earlier than wounds of the lower extremities (5-7th day).
+The timing of wound closure is important. Wounds must not be c...
+
+=== Chunk 989 ===
+Source: 0446_002-ebook.pdf
+Length: 1068 chars
+
+Dead space
+As with all wounds, the obliteration of dead space is an accepted principle of DPC management. This may be technically difficult when there has been loss of deep tissue secondary to the injury of surgical excision. Absorbable sutures are used to approximate deep structures but undue tension should be avoided, as it will result in local tissue ischaemia which can impair local tissue resistance to the development of infection.
+Drains should be avoided wherever possible in DPC. Drains ac...
+
+=== Chunk 990 ===
+Source: 0446_002-ebook.pdf
+Length: 1316 chars
+
+Wound care
+After DPC, the wound should be covered with some layers of dry gauze which can be left until the time of removal of sutures.
+SKIN GRAFTS
+If the wound cannot be closed by DPC because of skin loss, a skin graft can be used to close the wound, sometimes combined with partial DPC.
+40
+Free skin grafts may be partial thickness (epidermis and part of the dermis) or full thickness (epidermis and all dermis). Partial thickness grafts vary in thickness depending upon how much of the dermis is i...
+
+=== Chunk 991 ===
+Source: 0446_002-ebook.pdf
+Length: 505 chars
+
+Choice of graft depth
+Thin partial thickness grafts are used when the quality of the recipient area is doubtful to support the graft, or when the devel- opment of a contracture is not important.
+Thick partial thickness grafts are used when the recipient area is healthy with good vascularity, and over flexion creases where con- tractures should be avoided.
+Full thickness grafts are used for the best cosmetic result in facial injuries, or to cover an area on a flexor surface with a good recipient ...
+
+=== Chunk 992 ===
+Source: 0446_002-ebook.pdf
+Length: 3883 chars
+
+Partial thickness grafts
+Split skin grafts (thin and thick partial thickness grafts) are taken from an area which can produce a broad area of skin. The common sites are the upper medial, posterior and lateral thigh, and the arm and forearm (Figure 1).
+Split skin grafts should be taken using a dermatome. They can also be taken by either free hand knives or scalpels, if dermatomes (Figure 2) are not available.
+When small areas of split skin are required a small free hand knife, such as a De Silva ...
+
+=== Chunk 993 ===
+Source: 0446_002-ebook.pdf
+Length: 1910 chars
+
+Application of grafts
+Once the partial thickness graft has been cut to its required depth it is either (a) applied immediately if the recipient bed is clean and haemostasis is secure, or (b) applied after 24-48 hours if there is a persistent capillary ooze, or it is felt the quality of the recipient bed can be improved.
+The graft is laid across the recipient bed and cut approximately so that it is slightly larger than the bed. This is important as it allows for graft contraction. Grafts tend to ...
+
+=== Chunk 994 ===
+Source: 0446_002-ebook.pdf
+Length: 1785 chars
+
+Graft take
+There are three major factors determining the success rate of split skin grafts:
+(a) A vascular recipient bed which is free of pathogenic bacteria. Normal bacterial flora will not necessarily interfere with graft survival. But a small concentration of pathogens will usually result in failure. The most common pathogens causing graft failure are coagulase positive staphylococci and pseudomonas. Beta-haemolytic streptococci, even in small amounts, will result in graft dissolution.
+Grafts...
+
+=== Chunk 995 ===
+Source: 0446_002-ebook.pdf
+Length: 748 chars
+
+Graft meshing
+In cases where there is insufficient autograft to completely cover raw areas, such as large burns, graft meshing is useful (see Figure 5).
+46
+It can also provide for drainage of exudate and blood through the graft. Grafts are meshed by placing them on a surface, preferably a wooden board, undersurface facing upwards, and making numerous incisions through the graft with a No. 15 scalpel blade. The fenes- trations can, with tension, be made as wide as required. Optimally, the ratio o...
+
+=== Chunk 996 ===
+Source: 0446_002-ebook.pdf
+Length: 891 chars
+
+Dressing of grafts
+Once the graft has been sutured or placed on the recipient bed, it should be covered with a sheet of vaseline gauze followed by small pieces of cotton wool or gauze soaked with saline. These pledgets should be pressed into the concavities of the defect to ensure that there is complete apposition between the graft and the bed. The dressing should then be either anchored in place by tie- over sutures, or covered with a thick layer of cotton wool held in place by a crepe bandage....
+
+=== Chunk 997 ===
+Source: 0446_002-ebook.pdf
+Length: 636 chars
+
+Storage of split skin grafts
+It is always advisable, if possible, to take more than the required quantity of split skin when harvesting. The excess, and skin taken for delayed application, can be stored for up to three weeks in an ordinary domestic refrigerator at 4°. The skin is placed on a moist piece of gauze with the cut, or undersurface, away from the gauze. The grafts should be placed in sterile jars with or without normal saline. If saline is not included in the jar, the gauze must be kep...
+
+=== Chunk 998 ===
+Source: 0446_002-ebook.pdf
+Length: 1374 chars
+
+Graft care
+Grafts must be cared for by experienced personnel. Agraft may be saved if a seroma or haematoma is evacuated early. It is also possible to lose a good graft by clumsy or careless removal of the dressing.
+Grafts require careful nursing care.
+48
+When a graft is inspected, the dressing should be carefully removed using two pairs of tissue forceps: one holding the graft and keeping it applied to its bed, the other removing the dressing.
+• If a graft has been applied to a doubtful area, it...
+
+=== Chunk 999 ===
+Source: 0446_002-ebook.pdf
+Length: 1324 chars
+
+Dressing of donor sites
+Split thickness graft donor sites can bleed briskly, and in chil- dren can result in significant blood loss. Donor areas can be extremely painful, especially when dressings become firmly adher- ent. The following regimen minimizes discomfort:
+(a) Immediately apply a dressing, kept in place if necessary with an elastic bandage, and leave while the graft is being applied.
+(b) Remove the dressing, by which time haemostasis will have been achieved. If there is persistent blee...
+
+=== Chunk 1000 ===
+Source: 0446_002-ebook.pdf
+Length: 919 chars
+
+Full thickness grafts
+Full thickness free skin grafts consist of the epidermis and entire dermis. These grafts are used principally in the head and neck, but they can also be used on extremities to provide thicker cover.
+The advantages of a full thickness graft include its better texture and colour. Full thickness grafts also allow for the transfer of hair- bearing skin, as all the dermal adnexal structures are intact. They contract less than split skin grafts. The main disadvantage is a lower s...
+
+=== Chunk 1001 ===
+Source: 0446_002-ebook.pdf
+Length: 259 chars
+
+Donor sites
+The donor sites will generally be above the clavicle, in front of and behind the ear. In older people, the cheek in the line of a skin crease may also be used. The donor site is primarily sutured fol- lowing harvesting of the graft (see Figure 6)....
+
+=== Chunk 1002 ===
+Source: 0446_002-ebook.pdf
+Length: 1707 chars
+
+Technique
+The graft can be taken with the aid of local anaesthetic. The recipient area should be cleansed in a sterile fashion and a template made exactly to fit the defect. The template is to be placed on the donor site and an outline drawn around its circumference. The area should be injected with local anaesthetic with adrenaline 1:300- 400,000 and left for five minutes before incision. The full thick- ness skin should then be excised exactly. The graft should be kept moist with saline impreg...
+
+=== Chunk 1003 ===
+Source: 0446_002-ebook.pdf
+Length: 1083 chars
+
+GENERAL CONSIDERATIONS
+All war wounds are grossly contaminated with bacteria and will inevitably become infected unless treated quickly and cor- rectly. Ideally, these wounds should be treated surgically by excision of the wound within six hours. Up to that time the wound is simply contaminated, but delay allows invasive infec- tion to become established and successful treatment becomes protracted.
+The major bacterial contaminants in war wounds are:
+(a) Gram-positive pyogenic cocci, causing stap...
+
+=== Chunk 1004 ===
+Source: 0446_002-ebook.pdf
+Length: 174 chars
+
+ANTIBIOTIC PROPHYLAXIS
+Penicillin is the drug of choice.
+Clostridia are sensitive to penicillins, erythromycin and tetra- cyclines.
+The doses recommended below are for adults...
+
+=== Chunk 1005 ===
+Source: 0446_002-ebook.pdf
+Length: 790 chars
+
+The best antibiotic is good surgery
+I. Compound Fractures, Amputations, Major Soft Tissue Wounds PNC-G 5 MIU IV x 4 for 48 hours, followed by PNC-V 2 tablets x 4 until Delayed Primary Closure (total five days). Continue PNC-V for five days if closure is per- formed with a split skin graft. If redebridement is performed instead of delayed pri- mary closure: stop antibiotic unless there are signs of systemic infection or active local inflammation (fever, pain, oedema, heat, redness).
+II. Antiperso...
+
+=== Chunk 1006 ===
+Source: 0446_002-ebook.pdf
+Length: 156 chars
+
+III. Haemothorax
+Ampicillin 1 gm IV x 4 for 48 hours, followed by Amoxycillin tab 500 mg x 4 to be continued until two days after removal of the chest tube....
+
+=== Chunk 1007 ===
+Source: 0446_002-ebook.pdf
+Length: 2428 chars
+
+IV. Penetrating Cranio-cerebral Wounds
+PNC-G MIU IV x 4 and Chloramphenicol 1 gm IV x 3 for at least 72 hours, Continue IV or oral according to condition of the patient for a total of 10 days.
+V. Abdominal Wounds
+A: SOLID ORGANS ONLY; LIVER, SPLEEN, KIDNEY (and isolated bladder) PNC-G 5 MIU IV x 4 for 3-5 days depending on drainage
+B: STOMACH, SMALL INTESTINES
+Ampicillin 1 gm IV x 4 and Metronidazole 500 mg IV x 3 for 3-5 days.
+C: COLON, RECTUM, ANUS
+Ampicillin 1 gm IVx 4 and Gentamycine 80 mg I...
+
+=== Chunk 1008 ===
+Source: 0446_002-ebook.pdf
+Length: 1026 chars
+
+Tetanus prophylaxis
+All patients whatever their immunization status:
+(a) benzylpenicillin 5 million units i.v. 6-hourly;
+(b) thorough excision of the wound.
+Immunized patients:
+booster dose of tetanus toxoid 0.5 ml i.m.
+Non-immunized patients:
+(a) anti-tetanus human immunoglobulin 500 I.U. i.m. (adults) or 250 I.U. (children under 15 years old) if more than 24 hours since injury;
+(b) tetanus toxoid 0.5 ml i.m.
+(c) tetanus toxoid 0.5 ml to be repeated at four weeks and again six months later.
+Tre...
+
+=== Chunk 1009 ===
+Source: 0446_002-ebook.pdf
+Length: 5463 chars
+
+GAS GANGRENE
+Gas gangrene as a peculiar complication of wounds has been known since the time of Hippocrates. Its occurrence in all the wars of history, as well as from other traumatic causes, has been widely described, mainly because of its dramatic manifestations and very high associated mortality.
+56
+Gas gangrene is a rapidly spreading oedematous myonecrosis occurring characteristically in association with severe wounds of extensive muscle masses contaminated with pathogenic sporebear- ing ana...
+
+=== Chunk 1010 ===
+Source: 0446_002-ebook.pdf
+Length: 537 chars
+
+ANAEROBIC CELLULITIS
+Anaerobic cellulitis is an infection involving necrotic tissue resulting from ischaemia or direct trauma.
+Spreading superficial gangrene of the abdominal wall is a simi- lar condition causing necrosis and gangrene of the superficial tis- sues.
+In neither case are healthy muscles involved, and the clinical picture is less dramatic than in gas gangrene. Treatment required is:
+• the excision of necrotic tissue and the relief of tension,
+• leaving the wound open for delayed prim...
+
+=== Chunk 1011 ===
+Source: 0446_002-ebook.pdf
+Length: 699 chars
+
+9. TREATMENT OF NEGLECTED AND MISMANAGED WOUNDS
+Many patients arriving at hospitals in war zones have wounds which were inflicted more than 24 hours previously, and some have wounds that are many days old. Some of these wounds will have received no treatment other than inadequate dressing, some will have had cursory excision and dressing, and some will have been sutured, generally without any form of excision. All these wounds require excision, and all sutured wounds, no matter how clean they ap...
+
+=== Chunk 1012 ===
+Source: 0446_002-ebook.pdf
+Length: 1709 chars
+
+SURGICAL EXCISION
+Surgical excision is a more difficult procedure in these wounds. The distinction between viable and non-viable tissue, especially muscle and fascia, is less obvious, and the extent of adequate exci- sion is more difficult to assess than in a fresh wound. But the prin- ciples are the same, and excision is directed towards the removal of all non-viable tissue.
+Contractility is still the best indication of muscle viability, but this is only valid if the patient is not under the in...
+
+=== Chunk 1013 ===
+Source: 0446_002-ebook.pdf
+Length: 905 chars
+
+CLOSURE
+The primary phase of wound healing begins at the time of wounding and is, therefore, well established by the time of presen- tation if the wound is several days old. With the addition of surgi- cal excision, many wounds cannot be closed within seven days, in total, from the time of injury. If direct suture is attempted the wound edges can only be approximated under considerable ten- sion, and extensive undermining of the skin edges to allow closure will often be associated with a large s...
+
+=== Chunk 1014 ===
+Source: 0446_002-ebook.pdf
+Length: 866 chars
+
+10. WOUNDS OF LIMBS
+Some 50-75% of all missile wounds and blast injuries involve the limbs. The management of soft tissue damage is described in chapter 6. Special consideration must be given to the frequently associated fractures, and damaged blood vessels and nerves.
+FIRST AID
+Open missile wounds should be covered by a sterile, or clean, dressing before application of splints. Splints should be simple and effective. They are intended to immobilize the limb so as to reduce pain and prevent furt...
+
+=== Chunk 1015 ===
+Source: 0446_002-ebook.pdf
+Length: 390 chars
+
+MANAGEMENT IN ADMISSION AREA
+Careful assessment of the probable blood loss must be made and measures must be taken to prevent haemorrhagic shock. A vascu- lar and neurological assessment of the extremity distal to the injury must be made. Tetanus toxoid and penicillin should be given. X-rays are not required routinely, and judgement is necessary to determine which patients need X-ray.
+63...
+
+=== Chunk 1016 ===
+Source: 0446_002-ebook.pdf
+Length: 1589 chars
+
+INITIAL WOUND MANAGEMENT
+Access should be through generous skin incisions, usually in the long axis of the extremity, with deviation in the usual manner if incisions cross flexion creases. Deep fascia must be divided throughout the length of the incision to allow adequate exposure.
+There is often a large haematoma with considerable pulped mus- cle tissue, debris and foreign material. Bone will commonly be shattered into numerous fragments, either with soft tissue or periosteum attachment. Fragme...
+
+=== Chunk 1017 ===
+Source: 0446_002-ebook.pdf
+Length: 2454 chars
+
+TECHNIQUE OF DECOMPRESSION (Figure 1)
+If there is any suspicion of compartment syndrome, decom- pression must be performed without delay.
+64
+Fascial compartment compression most commonly occurs with small penetrating wounds of the leg. It is frequently unrecognized. Anaesthesia dorsally between the first and second toes (anterior tibial nerve) may be the only clinical indication of lateral compart- ment compression.
+Signs of compartment syndrome:  • severe pain;  • impaired movement of toes and ...
+
+=== Chunk 1018 ===
+Source: 0446_002-ebook.pdf
+Length: 245 chars
+
+METHODS OF IMMOBILIZATION
+All severe wounds of extremities must be immobilized by splinting. Fractures should initially be immobilized using plaster of Paris (POP) or by skeletal traction, according to conventional practice.
+66
+Plaster splinting...
+
+=== Chunk 1019 ===
+Source: 0446_002-ebook.pdf
+Length: 2154 chars
+
+Principles of cast application
+Swelling occurs in a limb within the first 24 – 48 hours after a fracture, severe sprain, wound or operation; slabs or cylinders that have been well split are the only safe plasters to apply in these cases.
+Never put a complete, unsplit, unpadded cylinder on a freshly fractured, wounded or operated limb.
+Circulation can be impaired by tight bandages applied to a limb over a plaster slab, or applied directly over skin flaps. Tight bands over the front of the ankle o...
+
+=== Chunk 1020 ===
+Source: 0446_002-ebook.pdf
+Length: 1851 chars
+
+Tools and equipment
+The basic essentials needed to perform satisfactory plaster splinting are:
+(a) Plaster bandages: should be kept in airtight containers because plaster absorbs moisture and quickly becomes crumbly. Do not put wet hands or damp rolls of plaster in the container.
+(b) Stockinet: of various widths to fit forearm, arm, leg, thigh and trunk (5, 7.5, 10, 12.5 and 20 cm).
+(c) Plaster wool: also known as cellulose padding (10 and 15 cm widths).
+(d) Adhesive and nonadhesive orthopaedic ...
+
+=== Chunk 1021 ===
+Source: 0446_002-ebook.pdf
+Length: 10013 chars
+
+Techniques
+Padded plaster of Paris slab splint (Figure 2)
+A most useful “slab” splint for short arm, long arm, short leg or long leg is made as a plaster and wool sandwich. First a layer of dry cellulose padding is taken, then a slab of wet plaster is placed on it, then another layer of dry padding completes the sandwich. This splint is then bandaged to the limb and allowed to harden. It does not adhere to the patient, or to the bandage, and can be removed and reapplied easily.
+FIGURE 2
+Padded p...
+
+=== Chunk 1022 ===
+Source: 0446_002-ebook.pdf
+Length: 330 chars
+
+Traction
+Traction is a simple and safe method of fracture-holding, espe- cially for fractures of the lower limb. It can be used for initial and definitive stabilization, and allows easy wound access and joint mobilization. The disadvantages are long bed rest and sometimes difficulties in getting a good alignment of the fracture....
+
+=== Chunk 1023 ===
+Source: 0446_002-ebook.pdf
+Length: 1147 chars
+
+Postoperative check-up
+The position in bed should be checked several times a day for the first few weeks.
+After one week, X-ray will show whether the fracture is in a good position. If not, weights might be added or removed and padding under or around the fracture applied to support the position.
+Pin care is essential. Dressings must initially be changed every second or third day. If there are signs of infection, such as pain, pus or loosening of the pin, the pin must be removed.
+Infected pins m...
+
+=== Chunk 1024 ===
+Source: 0446_002-ebook.pdf
+Length: 1109 chars
+
+Wound
+The wound should be left untouched for five days. If signs of infection develop, such as increased oozing with an offensive smell and pyrexia, the wound should be checked earlier. After five days the wound should be clean and healthy, provided surgical excision has been adequate. The oedema of soft tissues should have settled and it is the optimum time for delayed primary clo- sure. If the wound cannot be closed without tension, skin grafting and/or local skin flaps should be used.
+76
+Cons...
+
+=== Chunk 1025 ===
+Source: 0446_002-ebook.pdf
+Length: 612 chars
+
+Definitive fracture holding
+At the time of delayed primary closure, a decision can be made about which method should be used for the definitive holding of fractures:
+(a) Plaster of Paris (POP). Continue backslab or convert to a cylinder, with window if necessary.
+(b) Continued traction. It is possible to adjust the position of the fracture, as the patient is anyway under light anaesthesia.
+(c) External skeletal fixation. Now is the proper time to apply an external fixator for fractures which are...
+
+=== Chunk 1026 ===
+Source: 0446_002-ebook.pdf
+Length: 5250 chars
+
+External skeletal fixation
+External fixation is useful:
+• in compound or open fractures,
+• especially in fractures associated with major soft tissue defects. The bone best managed by external fixation is the tibia. Exter- nal fixation is also useful in the management of pelvic disruption. There are several external fixation systems. The Mini-Set fixa- tion system can be used to treat fractures of the lower arm, wrist, hand, foot and mandible. The system used in ICRC hospitals is the AO/ASIF tubu...
+
+=== Chunk 1027 ===
+Source: 0446_002-ebook.pdf
+Length: 140 chars
+
+HAND AND FOOT WOUNDS
+Injuries to the hands and feet are common in cases of multiple wounds but they are often the last to receive attention....
+
+=== Chunk 1028 ===
+Source: 0446_002-ebook.pdf
+Length: 143 chars
+
+First aid
+After covering the wounds with sterile or clean dressings, and necessary splinting, the limb should be elevated to minimize swelling....
+
+=== Chunk 1029 ===
+Source: 0446_002-ebook.pdf
+Length: 2246 chars
+
+Primary surgery and management
+Examination of the injured limb should be performed without anaesthesia in a good light. The presence of soft tissue damage, neurological defects and vascular injury must be recorded.
+Wound exploration should be performed under adequate anaes- thesia, with tourniquet control, in the theatre. The wound should be washed copiously with saline. A minimal amount of skin edge should be excised and all viable skin should be saved, remember- ing that skin is the most valua...
+
+=== Chunk 1030 ===
+Source: 0446_002-ebook.pdf
+Length: 418 chars
+
+INJURIES OF PERIPHERAL NERVES
+Peripheral nerves may be injured alone or, more commonly, in association with vascular damage or long bone fractures. In multi- ple injuries, nerve repair is of the lowest priority. Nerve repairs are performed when wounds are healthy and clean, which is generally at least 6 weeks after injury. Repair can safely be deferred for 3 months but contractures must not be permitted to develop....
+
+=== Chunk 1031 ===
+Source: 0446_002-ebook.pdf
+Length: 325 chars
+
+Primary surgery
+Nerve injuries should be noted during wound excision and the divided ends may be tacked to surrounding tissue to prevent retrac- tion. Exposed nerves should be covered with muscle or fat. The limbs should be elevated to lessen oedema and padded plasters can be used to prevent the development of contractures....
+
+=== Chunk 1032 ===
+Source: 0446_002-ebook.pdf
+Length: 465 chars
+
+Delayed primary suture
+Nerve repair is contra-indicated at the primary stage because:
+• there is a risk of infection;
+• the extent of the damage to the nerve may be greater than macro- scopically apparent;
+• the extensive dissection to mobilize a nerve for suture without tension may spread infection;
+• the nerve sheath is friable and becomes stronger later.
+The aim of surgery at the primary stage is to obtain uncom- plicated wound healing with minimum scarring....
+
+=== Chunk 1033 ===
+Source: 0446_002-ebook.pdf
+Length: 2902 chars
+
+Postoperative care
+The object of treatment is to maintain mobility of joints affected by paralysed muscles. Active and passive joint movements are
+82
+commenced as soon as possible. Patients must be instructed to per- form movements by themselves.
+Splints should be simple:
+• metal or POP splint to prevent wrist-drop is used in radial nerve palsy;
+• small improvised finger splints of metal prevent clawing of the fingers, in ulnar nerve lesions;
+• a piece of adhesive tape to hold the thumb in oppos...
+
+=== Chunk 1034 ===
+Source: 0446_002-ebook.pdf
+Length: 762 chars
+
+VASCULAR INJURIES
+A high index of suspicion of vascular damage in any limb injury is essential. The position of the missile track, or the presence of a subfascial haematoma, indicates possible vascular injury. If, after resuscitation, distal pulses remain impalpable, urgent surgical exposure of the possible site of vascular injury is indicated.
+“LOOK AND SEE” is wiser than “wait and see”.
+Types of vascular injury:
+• Complete transection: usually accompanied by loss of a variable length of vessel...
+
+=== Chunk 1035 ===
+Source: 0446_002-ebook.pdf
+Length: 3727 chars
+
+Management of arterial injury
+Every effort should be made to repair arterial damage, because after major arterial ligation the incidence of limb gangrene is very high: 45-60% after axillary and brachial artery ligation; 80% after common femoral artery ligation; 45% after superficial femoral artery ligation; and 85% after popliteal artery ligation.
+83
+Arterial injuries should be treated as early as circumstances allow, preferably within six hours of injury. Bleeding vessels should be controlled b...
+
+=== Chunk 1036 ===
+Source: 0446_002-ebook.pdf
+Length: 1264 chars
+
+General indications for amputation
+Amputation is generally indicated when there is:
+(a) severe damage:
+upper extremity: no chance of recovery of function of any part of the hand, fingers or thumb;
+lower extremity: mangled, grossly contaminated wounds;
+(b) overwhelming infection;
+(c) established gangrene;
+(d) continued infection associated with severe nerve and bone injury;
+(e) secondary haemorrhage, uncontrollable by other measures;
+(f) multiple injuries, where amputation is the simplest and fas...
+
+=== Chunk 1037 ===
+Source: 0446_002-ebook.pdf
+Length: 1157 chars
+
+Level of amputation
+The level of amputation should be at the lowest possible level of viable tissue. Good viable skin and soft tissue distal to the point of bone division should be saved for use in subsequent stump closure. Short tibial stumps can often be saved by posteriorly based skin flaps.
+Guillotine amputation should not be performed. Long posterior flaps of skin, fascia and obliquely dissected muscles give a much better stump.
+When deciding on the level of amputation, the surgeon must con...
+
+=== Chunk 1038 ===
+Source: 0446_002-ebook.pdf
+Length: 2615 chars
+
+Procedure
+At the primary amputation, as much bone and soft tissue as pos- sible are conserved. Standard flaps may not be possible and “flaps of opportunity” may have to be made.
+Stockinet traction is not recommended.
+In standard amputations, skin flaps should be cut longer than the thickness of the limb, from the level of bone section. The follow- ing guidelines are based on experience:
+• fascia should be cut through at the same level as the skin;
+• muscle should be cut obliquely back to the lev...
+
+=== Chunk 1039 ===
+Source: 0446_002-ebook.pdf
+Length: 1997 chars
+
+11. CHEST INJURIES
+Wounds of the thorax constitute 15-20% of all combat injuries. Many patients die from cardiac or major vascular injuries before reaching medical assistance. In a forward hospital, 7-10% of all war wounds may be expected to be chest injuries.
+Establishment of adequate ventilation takes absolute precedence over all other therapeutic measures. Bleeding may also be critical. The treatment aims at re-establishing normal physiological functions.
+More than 90% of all penetrating ches...
+
+=== Chunk 1040 ===
+Source: 0446_002-ebook.pdf
+Length: 1146 chars
+
+HAEMOTHORAX
+Haemothorax or haemopneumothorax is present in most patients with intrathoracic war injuries. Operative control of the bleeding is seldom necessary. Haemorrhage from the lung parenchyma will stop spontaneously. Only laceration of a large hilar vessel, or an intercostal or internal mammary artery, or a subclavian vein or artery will continue to bleed and require operative haemostasis. In patients with perforation of the diaphragm, continued haemorrhage often has an intra-abdominal sou...
+
+=== Chunk 1041 ===
+Source: 0446_002-ebook.pdf
+Length: 589 chars
+
+PNEUMOTHORAX
+Less than 20% of patients with penetrating war injuries of the chest have pneumothorax alone.
+Air leaks will not be large if only the pulmonary parenchyma is injured. When full lung expansion and pleural apposition is achieved, the leak will cease within two or three days.
+92
+Tension pneumothorax is seldom seen in missile injuries. In stab wounds it occurs in less than 3% of cases. Acute tension pneu- mothoraces are managed by the creation of a vent made from a needle or a plastic c...
+
+=== Chunk 1042 ===
+Source: 0446_002-ebook.pdf
+Length: 369 chars
+
+Insertion of chest tubes
+Properly placed chest tubes are life saving and should be inserted as soon as possible.
+When clinical signs of haemothorax or haemopneumothorax exist, insertion of intercostal tubes should be done before X-rays are taken.
+Tubes are usually inserted under local anaesthesia but when there is a wound to excise ketamine might be more appropriate....
+
+=== Chunk 1043 ===
+Source: 0446_002-ebook.pdf
+Length: 2032 chars
+
+Insertion of mid-axillary (basal) chest tubes (Figure 1 a-c)
+A straight size F 36 or F 40 tube, with multiple holes, should be placed through the fifth or sixth intercostal space in the mid-axil- lary line.
+(a) Thoracostomy sites should be positioned away from missile wounds and planned incisions. Clean the skin and give local anaesthesia. Anaesthetize the chest wall from the skin to the parietal pleura, including the neurovascular bundle.
+(b) Incise the skin in the mid-axillary line at or above...
+
+=== Chunk 1044 ===
+Source: 0446_002-ebook.pdf
+Length: 1578 chars
+
+Insertion of mid-clavicular (apical) chest tube (Figure 1 a)
+A size F 20 or F 24 tube should be inserted through the second intercostal space in the mid-clavicular line anteriorly, using the same technique as for mid-axillary tubes. The tube should be advanced upwards to the apex of the pleural space.
+Trocar chest tubes are as dangerous as thoracocentesis needles and are often mistakenly placed in an upper abdominal or medi- astinal organ. To avoid additional injury, trocar tubes should never be...
+
+=== Chunk 1045 ===
+Source: 0446_002-ebook.pdf
+Length: 687 chars
+
+Postoperative controls
+The clinical condition of the patient should be checked several times a day.
+Deep-breathing exercises should be administered, preferably by a trained physiotherapist, for the period during which the inter- costal tubes are in position. Adequate pain relief is essential.
+The functioning of the drains must be checked. The fluid inside the drains should swing with each breath. If the drains are blocked, they can be flushed with normal saline. If this does not work, it might b...
+
+=== Chunk 1046 ===
+Source: 0446_002-ebook.pdf
+Length: 736 chars
+
+Removal of chest tubes
+The decision to remove chest tubes is based on the following:
+(a) clinical assessment that the lung has re-expanded and tube drainage is very small (less than 75 ml/24 hours); or
+(b) radiographic evidence that the lung has adequately expanded and collections have drained to a minimum; and
+(c) the underwater seal has stopped swinging, but is not blocked. Clamp the drains for one more day. If a pneumothorax does not recur, the tube may be removed. It is important to have the...
+
+=== Chunk 1047 ===
+Source: 0446_002-ebook.pdf
+Length: 2263 chars
+
+WOUND EXCISION
+Entrance and exit wounds should be excised removing all devi- talized tissue. Intercostal vascular bleeding is easily handled by ligation. The pleura and the deep muscle layer should be closed to ensure an airtight seal, leaving the outer layers open for delayed primary closure on the fifth day.
+THORACOTOMY
+Few patients need immediate thoracotomy.
+97
+The indications for thoracotomy are:
+(a) massive bleeding (more than 1000-1500 ml at the time of inser- tion of chest drains, and 20...
+
+=== Chunk 1048 ===
+Source: 0446_002-ebook.pdf
+Length: 2378 chars
+
+CARDIAC INJURY
+Of those reaching hospital alive, the majority will have a small wound with self-limiting haemorrhage. If pericardiocentesis (using the subxiphoid approach with a large-bore needle inserted at an angle of 45° directed towards the left shoulder) is unsuccessful in relieving cardiac tamponade, immediate thoracotomy is indicated.
+If the initial aspiration was successful but signs of cardiac tam- ponade recur, surgical exploration is indicated.
+Great care must be taken to identify and...
+
+=== Chunk 1049 ===
+Source: 0446_002-ebook.pdf
+Length: 678 chars
+
+THORACIC EMPYEMA
+With vigorous conservative treatment of chest injuries using wide enough chest drains, empyema should rarely occur. The cause of empyema is failure to achieve complete evacuation of intratho- racic blood and re-expansion of the lung. If these are not achieved, antibiotics and other measures will not prevent empyema.
+If empyema occurs, the well-established techniques of closed chest tube drainage followed by segmental rib resection and open thoracostomy drainage should be carried...
+
+=== Chunk 1050 ===
+Source: 0446_002-ebook.pdf
+Length: 1433 chars
+
+THORACOABDOMINAL INJURY
+Thoracoabdominal wounds occur in 10-40% of thoracic injuries. In about 90% of thoracoabdominal wounds, the site of entry in the chest is below the sixth rib posteriorly and fourth rib anteriorly. In any penetrating wound at the level of the fourth intercostal space or lower, an intra-abdominal injury must be sus- pected.
+Patients with thoracoabdominal injuries have thoracic wounds that can usually be managed by closed tube chest drainage and abdominal wounds that require ...
+
+=== Chunk 1051 ===
+Source: 0446_002-ebook.pdf
+Length: 1236 chars
+
+INTERCOSTAL NERVE BLOCK (Figure 4)
+Intercostal nerve blocks are useful methods of analgesia in all kinds of thoracic wall pain.
+They only last a few hours, and repeated blocks are often neces- sary.
+hb Oo ON e
+FIGURE 4
+Intercostal nerve block.
+101
+The injection site should be dorsal of the posterior axillary line and lateral of the erector muscles.
+The needle should be aimed at the lower margin of the rib. When contact with the rib is felt, the syringe is angled 30-45° upwards and the needle is ...
+
+=== Chunk 1052 ===
+Source: 0446_002-ebook.pdf
+Length: 2935 chars
+
+12. ABDOMINAL WAR WOUNDS
+About 10% of the patients brought to the field hospital alive have abdominal wounds. The percentage may be much smaller where there are long transfer times. The high energy transfer by bullets from rifles and machine guns, as well as shell fragments and shotgun pellets hitting at close range, cause extensive injuries, particularly in parenchymatous organs. These lesions are almost always instantly lethal. Therefore the majority of patients with abdominal lesions will hav...
+
+=== Chunk 1053 ===
+Source: 0446_002-ebook.pdf
+Length: 961 chars
+
+MANAGEMENT PRIORITY
+Laparotomy should be as early as the patient’s condition per- mits, the time factor being of vital importance. Mortality and mor- bidity increase as the time interval between wounding and surgery lengthens.
+Patients with intra-abdominal bleeding who are shocked should take priority over those who have intestinal perforations alone. Both conditions are potentially fatal.
+104
+Bleeding is the more immediate concern and is usually evi- dent at an early stage through abdominal pai...
+
+=== Chunk 1054 ===
+Source: 0446_002-ebook.pdf
+Length: 4539 chars
+
+GENERAL SURGERY PLAN
+1. The operation site is prepared so that the incision can be extended upwards to the thorax and downwards to the thighs.
+2. Midline incisions are preferred; these may be extended from the xiphoid to the symphysis pubis. They are quick and provide excellent access.
+As a general rule, a formal incision should be used rather than an extension of the abdominal wound.
+Separate abdominal and thoracic incisions are preferred to a thoracoabdominal incision.
+3. If the patient’s cond...
+
+=== Chunk 1055 ===
+Source: 0446_002-ebook.pdf
+Length: 840 chars
+
+STOMACH
+The stomach is injured in 10-15% of abdominal wounds. Single lesions are not common but easily dealt with because of the rich vascularization of the organ. Injury of the stomach is often associ- ated with lesions of adjacent organs: the liver, spleen, colon, pan- creas, duodenum, great vessels and kidney, resulting in a high mor- tality rate. Lesions of the posterior surface may be the only lesion in patients wounded from behind.
+If a lesion is found at the anterior surface, a posterior ...
+
+=== Chunk 1056 ===
+Source: 0446_002-ebook.pdf
+Length: 1237 chars
+
+DUODENUM
+Injuries of the duodenum are usually associated with lesions of other major visceral structures, namely the inferior vena cava, the colon, liver, stomach and pancreas. One half of the injuries occur in the second part of the duodenum.
+The duodenum is visualized by a Kocher manoeuvre (Figure 1) and by carefully incising the omentum of the transverse colon.
+Minor wounds can be closed by suture in two layers at a right angle to the duodenal axis.
+Wider wounds needing excision can be closed...
+
+=== Chunk 1057 ===
+Source: 0446_002-ebook.pdf
+Length: 1153 chars
+
+SMALL BOWEL
+Injuries to the small bowel are present in about 30% of pene- trating abdominal wounds and are often multiple. Perforations may be small and sealed off by protruding mucous membrane. The only evidence of perforation at laparotomy may be a small amount of blood without intestinal content. If the injury is old, it might be covered by fibrin and omentum.
+The principles of treatment are as follows. The small bowel must be inspected carefully throughout its entire length before making any...
+
+=== Chunk 1058 ===
+Source: 0446_002-ebook.pdf
+Length: 392 chars
+
+FIGURE 5
+Sump drainage. A thin nasogastric tube is inserted through a larger round tube with multiple perforations distally. The nasogastric tube should not extend beyond the larger tube. The nasogastric tube is fixed to the larger tube and the larger tube is sutured to the patient. If the nasogastric tube becomes obstructed it can be easily replaced, leaving the larger outer tube in situ....
+
+=== Chunk 1059 ===
+Source: 0446_002-ebook.pdf
+Length: 1235 chars
+
+COLON
+The colon is the second most frequently injured organ as a result of penetrating abdominal trauma. Injuries to additional structures are common (75-80%) and influence the management and progno- sis.
+The diagnosis is usually not evident until laparotomy; however, blood on the examining finger after rectal examination is diagnos- tic. Proctosigmoidoscopy is then indicated but often reveals noth- ing but blood and stool as the rectum is unprepared. Barium enema is not indicated.
+Colonic injur...
+
+=== Chunk 1060 ===
+Source: 0446_002-ebook.pdf
+Length: 6158 chars
+
+Treatment
+Colonic wounds can be managed by:
+• suture repair;
+• exteriorization of the damaged colon;
+• resection of the damaged colon with anastomosis;
+• resection with colostomy and distal mucous fistula.
+Colonic anastomoses, as with all intestinal anastomoses, should not be under tension and should be accompanied by adequate mobilization.
+A colostomy or ileostomy proximal to the site of repair has been the rule in war surgery, but the ICRC’s working experience has shown that it is rarely neces...
+
+=== Chunk 1061 ===
+Source: 0446_002-ebook.pdf
+Length: 385 chars
+
+Right colon
+(a) Wounds of the right colon can be treated with primary suture in two layers.
+(b) If there is a big disruption, resection of the damaged colon and primary end-to-end ileo-transverse colostomy anastomosis is acceptable. If direct anastomosis is considered to present too high a risk in the circumstances, an alternative such as Muir’s procedure can be utilized (Figure 6)....
+
+=== Chunk 1062 ===
+Source: 0446_002-ebook.pdf
+Length: 243 chars
+
+FIGURE 6
+ABDOMINAL WALL
+Muir’s colostomy.
+(c) In extensive right-sided colonic injuries, with associated lesions of adjacent organs, it might be necessary to perform a resection of the right colon with an ileostomy and a distal mucous fistula....
+
+=== Chunk 1063 ===
+Source: 0446_002-ebook.pdf
+Length: 258 chars
+
+Transverse colon
+(a) Small lesions should be treated by suture.
+(b) Extensive injuries should be treated with resection of the seg- ment involved. If primary anastomosis is not possible, a proxi- mal colostomy and distal mucous fistula should be constructed....
+
+=== Chunk 1064 ===
+Source: 0446_002-ebook.pdf
+Length: 995 chars
+
+Left colon
+The left colon can easily be exteriorized, but adequate mobi- lization is mandatory.
+113
+(a) Small lesions of the left colon should be closed.
+(b) In extensive injuries of the left colon, the damaged segment should be resected and the proximal end brought to the surface as a colostomy. The distal end should be exteriorized as a mucous fistula. The stomas should be adjacent to each other, thus facilitating closure at a later date.
+(c) In extensive lower colonic lesions, it may be neces...
+
+=== Chunk 1065 ===
+Source: 0446_002-ebook.pdf
+Length: 1200 chars
+
+RECTUM AND ANAL CANAL
+Wounds of the rectum are associated with high morbidity because of the high incidence of unrecognized injury and the com- mon associated visceral damage to adjacent structures such as the bladder, urethra, pelvis and great vessels. Suspicion should be increased if a wound involves the perineum or the buttocks, or if rectal bleeding occurs.
+114
+Colostomy is mandatory in rectal injuries.
+Treatment includes:
+• closure of the rectal wound, if possible;
+• defunctioning proximal ...
+
+=== Chunk 1066 ===
+Source: 0446_002-ebook.pdf
+Length: 616 chars
+
+COLOSTOMY CLOSURE
+Patients with minor injuries and uncomplicated recovery can
+normally have colostomy closure performed in four to six weeks. When the postoperative course is complicated by ileus, peritoni- tis, fistulas or intra-abdominal infection, the closure must be post- poned for as long as it takes the patient to recover fully and regain weight. This might be as long as several months.
+While closing a double-loop colostomy can be an easy proce- dure, connecting a proximal colostomy with a...
+
+=== Chunk 1067 ===
+Source: 0446_002-ebook.pdf
+Length: 509 chars
+
+LIVER
+Hepatic injuries are present in about 5% of abdominal wounds. In most cases, there are injuries to other abdominal viscera.
+Liver tissue is particularly susceptible to the cavitation effect of the energy transmitted by missiles with high velocity. These mis- siles cause extensive pulping of the liver substance and are almost always fatal.
+The major cause of death in liver wounds is uncontrollable haemorrhage. However, in about 50% of cases, active bleeding will have ceased by the time of o...
+
+=== Chunk 1068 ===
+Source: 0446_002-ebook.pdf
+Length: 2107 chars
+
+Complications
+Complications include secondary haemorrhage, subphrenic, intrahepatic or subhepatic infection and biliary fistulas. Complica- tions are usually caused by inadequate excision of devitalized parenchyma, or unrecognized associated injuries to other abdomi- nal organs, especially the colon. When a major liver resection has been performed there is nearly always postoperative jaundice. This resolves spontaneously after 8 to 10 days.
+118
+SPLEEN
+Injuries of the spleen should be treated by ...
+
+=== Chunk 1069 ===
+Source: 0446_002-ebook.pdf
+Length: 1240 chars
+
+PANCREAS
+Pancreatic lesions are present in 1%-2% of all intra-abdominal injuries.
+The pancreas must be carefully inspected in its entirety. This requires incision of the gastrocolic omentum and mobilization of the head and tail of the organ so that the posterior surface can be visualized. The inferior margin is inspected by incising the trans- verse mesocolon.
+Many wounds of the pancreas are associated with major vascu- lar damage.
+Treatment
+The principles of treatment are: haemostasis, excision...
+
+=== Chunk 1070 ===
+Source: 0446_002-ebook.pdf
+Length: 584 chars
+
+PELVIC FRACTURES
+Pelvic fractures are normally of minor importance unless the fracture is unstable. Displacement of the fragments seldom needs reduction. Fractures of the pelvic ring require immobilization for eight to twelve weeks.
+A canvas sling suspended by crossed wires from a beam is usu- ally sufficient. External fixation is a possibility if the fracture is unstable.
+The major problem with pelvic wounds is bone fragments which penetrate the pelvis viscera and veins. Profuse oozing from the...
+
+=== Chunk 1071 ===
+Source: 0446_002-ebook.pdf
+Length: 572 chars
+
+Nutrition
+As a general rule, nasogastric tubes should be removed as soon as possible and intake of fluids and food by mouth started. If there are no injuries to the stomach or small bowel, this can be done the day after the operation. When these organs have been injured, most surgeons will wait until there are clear bowel move- ments. Some water by mouth can, however, be allowed for these patients.
+Intravenous feeding with amino acids or fat solutions is rarely possible in war conditions but ent...
+
+=== Chunk 1072 ===
+Source: 0446_002-ebook.pdf
+Length: 769 chars
+
+Drains
+Large-bore tube drains, with several side holes, and/or corru- gated rubber drains can be used. They should be brought out through separate dependent incisions.
+Drains should be dependent.
+If suction is available, sump drainage is useful when dependent drainage is not possible. A large-bore rubber tube with lower side holes is provided with a thinner inner tube to which suction is con- nected. The inner tube has one hole close to the distal end (Figure 5). Gentle suction is applied. This ...
+
+=== Chunk 1073 ===
+Source: 0446_002-ebook.pdf
+Length: 378 chars
+
+Urinary catheter
+A urinary catheter put in for monitoring during the operation should be removed as soon as possible, to avoid infection. In severely dehydrated cases, however, it is wise to keep the catheter for monitoring the fluid balance. In most cases, the catheter can be removed after 24 hours.
+After bladder injuries, the catheter should be kept for a week (chapter 13)....
+
+=== Chunk 1074 ===
+Source: 0446_002-ebook.pdf
+Length: 398 chars
+
+Laparotomy incision
+If dressings are dry, there is no need to change them until the time for removal of the sutures. If dressings are soaked by blood or pus, the wound must be inspected. If bleeding is continuing, it should be stopped by compression or an extra stitch. Sometimes, the wound has to be opened to find the bleeding spot. If there is pus around the sutures, they should be removed.
+122...
+
+=== Chunk 1075 ===
+Source: 0446_002-ebook.pdf
+Length: 94 chars
+
+Excised wound
+Dressings should be left undisturbed until the day of delayed pri- mary closure....
+
+=== Chunk 1076 ===
+Source: 0446_002-ebook.pdf
+Length: 356 chars
+
+Physiotherapy
+Early mobilization of patients is important to avoid complica- tions such as pneumonia, thrombosis, stiffness of joints and wast- ing of muscles. Skilled staff are needed who understand the impor- tance of getting the patient out of bed, because most patients cer- tainly prefer to stay inactive after major operations such as laparo- tomies....
+
+=== Chunk 1077 ===
+Source: 0446_002-ebook.pdf
+Length: 548 chars
+
+Painkillers
+In a war situation, the demand for painkillers is not as pressing as in civilian practice. Most patients seem to accept the situation and some are just happy to be alive. After major operations such as laparotomies, there will be a need for painkillers as injections for at least 24 hours. In many countries, it is very difficult or impossi- ble to get permission to bring in narcotics, so the choice of pain- killers is limited. Suppositories are rarely accepted for cultural rea- sons a...
+
+=== Chunk 1078 ===
+Source: 0446_002-ebook.pdf
+Length: 529 chars
+
+Fever
+Fever can result from all well-known causes, such as urinary tract infection, atelectases, pneumonia, thrombosis and wound infection, which are treated as elsewhere. Intra-abdominal abscesses might be difficult to find in the absence of ultrasound but if there is fever and a palpable tender mass, drainage is necessary. In countries where malaria is endemic, fever 48 hours after an operation usually means that the patient has malaria. Even if a first malaria smear is negative, it may be wis...
+
+=== Chunk 1079 ===
+Source: 0446_002-ebook.pdf
+Length: 95 chars
+
+Abdominal dehiscence
+Dehiscence should be treated by immediate laparotomy and mass closure.
+123...
+
+=== Chunk 1080 ===
+Source: 0446_002-ebook.pdf
+Length: 388 chars
+
+Fistulas
+Small bowel fistulas and biliary fistulas will heal if there is no distal obstruction. Conservative treatment, including correction of nutritional deficiencies such as anaemia, should be tried. But if the amounts coming through the fistula are big or increasing, an oper- ative intervention is necessary. Most importantly, an abscess caus- ing distal obstruction must be drained....
+
+=== Chunk 1081 ===
+Source: 0446_002-ebook.pdf
+Length: 435 chars
+
+Peritonitis
+Peritonitis with deteriorating condition of the patient after war injuries is often the result of a perforation that was not found dur- ing the first laparotomy. Relaparotomy in these cases carries a high risk of mortality (50% according to some authors). If the cause is a leaking bowel anastomosis, the anastomosis area might be exte- riorized or, if this is not possible, repaired with a proximal colostomy or ileostomy....
+
+=== Chunk 1082 ===
+Source: 0446_002-ebook.pdf
+Length: 174 chars
+
+Postoperative intra-abdominal bleeding
+Since blood for transfusion is often scarce in war, relaparo- tomies to stop bleeding should be performed without too long a delay.
+124...
+
+=== Chunk 1083 ===
+Source: 0446_002-ebook.pdf
+Length: 2264 chars
+
+13. URO-GENITAL LESIONS
+Wounds of the uro-genital system are not common, occurring in only 1-2% of the wounded..
+Management of uro-genital injuries is similar to that for other wounds and includes:
+• wound excision;
+• dependent drainage;
+• diversion of the urinary flow above the injury.
+Kidney damage must always be suspected after blunt trauma to the lumbar region. This will be confirmed if haematuria develops. Surgery is only indicated if severe macroscopic haematuria persists over 48 hours and...
+
+=== Chunk 1084 ===
+Source: 0446_002-ebook.pdf
+Length: 630 chars
+
+KIDNEY
+Isolated penetrating lesions of the kidney are very rare. Operation through a long median incision gives excellent access to the kidney. Following incision of the paracolic peritoneum, the colon is mobilized and the kidneys are exposed.
+When a perirenal haematoma is encountered, the perirenal fas- cia should not be opened before the renal vessels have been
+126
+exposed and vascular clamps are available. Releasing the tampon- ade provided by the perirenal fascia may result in massive haem- ...
+
+=== Chunk 1085 ===
+Source: 0446_002-ebook.pdf
+Length: 401 chars
+
+Nephrectomy
+Nephrectomy is sometimes necessary to achieve haemostasis.
+Indications for nephrectomy are:
+• avulsed kidney;
+• damage to the vascular pedicle;
+• uncontrollable haemorrhage.
+When nephrectomy is performed, the vessels should be doubly ligated, preferably ligating the vein and artery separately, and always ligating the artery first. The ureter should be divided and the distal end ligated....
+
+=== Chunk 1086 ===
+Source: 0446_002-ebook.pdf
+Length: 1461 chars
+
+Partial nephrectomy
+Partial nephrectomy is indicated only when the injured kidney is the patient’s only kidney.
+The vascular pedicle should be controlled and the artery to the damaged part of the kidney should be divided. Non-viable tissue should be removed by the finger-fracture method, and bleeding vessels should be ligated. The pelvis and calyces should be closed by interrupted sutures. The resected surface should be compressed with interrupted mattress sutures. In cases of doubtful haemostas...
+
+=== Chunk 1087 ===
+Source: 0446_002-ebook.pdf
+Length: 1920 chars
+
+URETER
+Isolated injuries of the ureter are very rare.
+In complete ureteric division, the ends are trimmed and anasto- mosed end to end with fine absorbable sutures over a ureteric catheter, with the ends obliquely cut or spatulated (Figure 3). A watertight closure is preferable but not necessary.
+Diversion of urine is achieved by nephrostomy, pyelostomy, or a ureteric catheter (Figure 4).
+Dependent external drainage of the anastomosis is essential. In larger defects in the middle or upper end of...
+
+=== Chunk 1088 ===
+Source: 0446_002-ebook.pdf
+Length: 1390 chars
+
+BLADDER
+Bladder lesions may be intra- or extra-peritoneal. Not uncom- monly, bladder lesions are not discovered until the catheter balloon is seen in the laparotomy wound.
+131
+Minor extra-peritoneal lesions can be treated with an indwelling catheter only for one week.
+All other bladder wounds must be excised and sutured in two layers. A large part of the bladder can be resected without subse- quent severe capacity problems. The surgeon must be very careful not to compromise the ureteric outflow ...
+
+=== Chunk 1089 ===
+Source: 0446_002-ebook.pdf
+Length: 3311 chars
+
+URETHRA
+Principles of treatment:
+• Urine should be diverted by suprapubic cystostomy.
+• Excise the wound but be careful not to remove the remain- ing urethra.
+• Leave the wound open.
+• Inspect at time of delayed primary closure (DPC) and decide whether to:
+(a) accept permanent urethrostomy;
+(b) consider late repair (after 6 weeks) if damage is mini- mal and success can be assured.
+Wounds of the anterior urethra, that is the urethra below the uro- genital diaphragm, may be closed at right angles ...
+
+=== Chunk 1090 ===
+Source: 0446_002-ebook.pdf
+Length: 591 chars
+
+EXTERNAL GENITALIA
+The external genitalia can be treated with primary suture after excision, because of the excellent vascularization. The aim is to re- establish anatomical conditions.
+The scrotum should be drained dependently.
+Bilateral testicular lesions are very rare. For hormonal reasons, it is important to leave some viable testicular tissue, but the tunica albuginea must always be closed carefully, otherwise a fistula will develop.
+When all the scrotal skin has been lost but the testes ar...
+
+=== Chunk 1091 ===
+Source: 0446_002-ebook.pdf
+Length: 232 chars
+
+WOUNDS OF THE HEAD
+Most severe penetrating head wounds will be fatal. But a per- centage will survive and present a daunting challenge to those with little or no neurosurgical experience. The following principles should be followed....
+
+=== Chunk 1092 ===
+Source: 0446_002-ebook.pdf
+Length: 846 chars
+
+Emergency care
+1. Intubate unconscious patients to protect the airway.
+2. Control haemorrhage. Apply clean dressings over large open wounds, including the scalp.
+3. Assume that a cervical spine injury is present until proven oth- erwise. Keep the head and neck in the neutral position.
+4. Assume that hypotension is a result of hypovolaemia. Look for a cause of bleeding, such as bleeding into the chest or abdomen, or bleeding from the extremities. Remember that a head injury alone does not produce...
+
+=== Chunk 1093 ===
+Source: 0446_002-ebook.pdf
+Length: 591 chars
+
+Clinical assessment
+Consciousness
+The Glasgow Coma Scale is a simple and useful tool for record- ing the degree of coma and the changes over time.
+Glasgow Coma Scale Eye opening response spontaneous 4 to voice 3 to pain 2 none 1 Best verbal response oriented 5 confused 4 inappropriate words 3 incomprehensible sounds 2 none 1 Best motor response obeys command 6 localizes pain 5 withdraws (pain) 4 flexion (pain) 3 extension (pain) 2 none 1 Total score 3-15
+Patients with a Glasgow Coma Scale score ...
+
+=== Chunk 1094 ===
+Source: 0446_002-ebook.pdf
+Length: 180 chars
+
+Respiration
+An acute rise in intracranial pressure is reflected by a slowing of the respiratory rate. As the intracranial pressure continues to rise, the respiratory rate quickens....
+
+=== Chunk 1095 ===
+Source: 0446_002-ebook.pdf
+Length: 143 chars
+
+Blood pressure
+A rise in intracranial pressure is usually associated with a rise in systolic pressure and a widening of the pulse pressure.
+138...
+
+=== Chunk 1096 ===
+Source: 0446_002-ebook.pdf
+Length: 161 chars
+
+Pulse
+Elevations in intracranial pressure produce bradycardia. Arising pulse rate is a grave sign unless it is the result of another cause, such as hypovolaemia....
+
+=== Chunk 1097 ===
+Source: 0446_002-ebook.pdf
+Length: 177 chars
+
+Temperature
+A swinging temperature can be a sign of brain stem damage. Hyperthermia can be treated by cooling of the patient and chlor- promazine 50 mg 6-hourly intramuscularly....
+
+=== Chunk 1098 ===
+Source: 0446_002-ebook.pdf
+Length: 1110 chars
+
+General physical assessment
+1. Identify any associated injuries. Examine the whole patient care- fully.
+2. Note small puncture wounds in the skull. These might be the only indication of a penetrating brain injury.
+3. Palpate all lacerations of the scalp. This may be the only way to discover depressed fractures of the skull.
+4. Look for peri-orbital ecchymoses which will suggest an orbital roof fracture. Look for bleeding from the ears or haemotympa- num which will suggest a temporal fracture. Lo...
+
+=== Chunk 1099 ===
+Source: 0446_002-ebook.pdf
+Length: 1107 chars
+
+Penetrating missile injuries
+These wounds are not treated differently from missile wounds to other areas of the body. The main aim is to remove all dirty and necrotic tissues by thorough wound excision.
+139
+(a) The patient should be placed supine except when there is a pos- terior fossa injury.
+(b) Non-viable skin and subcutaneous tissues must be excised.
+(c) The damaged bone edges must be removed with bone nibblers.
+(d) Remove all bone fragments, clot and accessible foreign mater- ial by carefu...
+
+=== Chunk 1100 ===
+Source: 0446_002-ebook.pdf
+Length: 454 chars
+
+Depressed skull fractures
+If the patient has no symptoms and you are not an experienced neurosurgeon, it might be wise not to operate these cases under war conditions.
+If the patient has symptoms of compression and/or he has a pen- etrating wound that you will operate on anyhow, you should also try to elevate depressed fragments.
+Large depressed bone fragments, if removed, should be replaced, as well as any large fragments removed during craniectomy....
+
+=== Chunk 1101 ===
+Source: 0446_002-ebook.pdf
+Length: 2579 chars
+
+Closed intracranial haematoma
+These are rare in war surgery but can be seen, for example, after a fall from a tank. Closed head injuries must be closely and repeat- edly assessed, and any deterioration in level of consciousness should be an indication to make burr holes (Figure 1). Other signs are development of one-sided weakness or dilated pupil, rising blood pressure and slowing of the pulse. Restlessness and headache can also indicate intracranial haematoma.
+140
+Deteriorating consciousness a...
+
+=== Chunk 1102 ===
+Source: 0446_002-ebook.pdf
+Length: 277 chars
+
+MAXILLO-FACIALAND NECK WOUNDS
+Wounds of the face can be very complicated and sometimes life- threatening because of the risk of airway obstruction and serious bleeding from areas difficult to access. These are real emergencies and a challenge for both anaesthetist and surgeon....
+
+=== Chunk 1103 ===
+Source: 0446_002-ebook.pdf
+Length: 2162 chars
+
+Emergency treatment
+1. Establish airway.
+Asphyxia resulting from airway obstruction is the major cause of death from facial injuries.
+The portals for air entry can be obstructed by vomitus, blood, foreign bodies and the like. Injuries to the mandible and larynx are the major causes of airway obstruction.
+(a) Remove dentures, broken teeth, blood and mucus from the mouth and throat.
+(b) Nurse the unconscious patient on the side or face down.
+(c) Check the position of the tongue, especially with ma...
+
+=== Chunk 1104 ===
+Source: 0446_002-ebook.pdf
+Length: 270 chars
+
+General treatment
+• Wound excision. Primary closure if possible without tension.
+• Scrubbing with hard brush to remove superficial tattooing parti- cles.
+• Devascularized skin flaps may be excised at the point of demar- cation, defatted and replaced as free skin grafts....
+
+=== Chunk 1105 ===
+Source: 0446_002-ebook.pdf
+Length: 908 chars
+
+Specific localities
+Eyebrows. Never shave an eyebrow as it may not regrow. Lip. Attempt to realign the skin-vermilion junction accurately. The mucosa, muscle and skin should be closed in separate lay-
+ers.
+Tongue. Deep lacerations should be repaired with nonabsorbable sutures.
+Eyelid. Closure can be difficult but should be performed in lay- ers making an attempt to approximate precisely the grey line at the
+144
+ciliary margin. The canthal ligaments should be repaired and fixed to the orbital wal...
+
+=== Chunk 1106 ===
+Source: 0446_002-ebook.pdf
+Length: 1201 chars
+
+Mandible
+Most mandibular fractures will be grossly comminuted. All mandibular fractures should be copiously irrigated. All foreign bodies and loose teeth should be removed but any bone attached to periosteum or muscle with an intact blood supply should be left in situ. Skin and/or mucosa should be used to cover all bone. There are a number of methods available to immobilize mandibu- lar fractures but if the general condition of the patient is bad or there is a lot of bleeding and oedema, final i...
+
+=== Chunk 1107 ===
+Source: 0446_002-ebook.pdf
+Length: 1587 chars
+
+FIGURE 3
+\ < >
+Eyelets made with soft stainless steel wire.
+The wire should be pre-stretched and the eyelets made by twisting about a dental burr.
+The two ends are passed between two teeth so that the eyelet is on the buccal side.
+« >
+The posterior wire is brought towards the front of the mouth and through the eyelet.
+All twists should be in the same direction. Tie wires are of thinner gauge than the eyelet wires and join the upper and lower eyelets.
+146
+Internal fixation with wire at the time o...
+
+=== Chunk 1108 ===
+Source: 0446_002-ebook.pdf
+Length: 1294 chars
+
+Maxilla
+There is a great variety of maxillary fractures. Often, they are not as complex as they seem. Reduction should be attempted at the time of delayed primary closure. Fractures should be immobilized by means of wiring the fracture site, combined with interdental eyelet wiring as described above, especially if the direct fracture wiring is unstable.
+Mini set external fixators placed in the frontal, zygomatic and nasal bones provide excellent stability. Fibrous union occurs rapidly, allowing ...
+
+=== Chunk 1109 ===
+Source: 0446_002-ebook.pdf
+Length: 1483 chars
+
+Neck wounds
+All neck wounds should be explored to inspect major vessel and main structure integrity.
+Oesophageal wounds: small lacerations should be sutured, hav- ing excised the edges. It is a good rule to protect the wound for 10-14 days, with either nasogastric tube feeding or gastrostomy. The wound should be left open for delayed primary closure. A large wound of the oesophagus can be converted into a controlled cervical oesophagostomy, or pharyngostomy, and closed at a later time.
+FIGURE 6
+...
+
+=== Chunk 1110 ===
+Source: 0446_002-ebook.pdf
+Length: 492 chars
+
+SPINAL CORD INJURIES
+The spinal cord can be damaged by missiles either directly, or indirectly as a result of fractures or dislocations. Those with para- plegia are seen more commonly than those with tetraplegia, as the latter will frequently die during the transfer to a field hospi- tal.
+Paralysed patients are often low on the evacuation priority list and will reach hospital later than the average.
+Wound excision, and the basic principles of wound care, are the same as for all injuries....
+
+=== Chunk 1111 ===
+Source: 0446_002-ebook.pdf
+Length: 1740 chars
+
+Paraplegia
+Long-term care must be planned from the outset. In situations where no paraplegic centre is available, the patient and family must be provided with sufficient means to return home and survive in the best possible physical condition.
+The major complications to avoid are:
+• deterioration of the general condition;
+• pressure sores;
+• bladder and urinary tract infections.
+150
+The following principles apply to the treatment of paraplegic patients of less than 6 weeks duration:
+1. Avoid lam...
+
+=== Chunk 1112 ===
+Source: 0446_002-ebook.pdf
+Length: 221 chars
+
+Tetraplegia
+The care of tetraplegia in developing countries is an almost impossible task. Thus a realistic approach is to give the patient minimal care, allowing him to live an acceptable life for as long as possible.
+151...
+
+=== Chunk 1113 ===
+Source: 0446_002-ebook.pdf
+Length: 1620 chars
+
+Pressure sores
+Ahigh proportion of spinal cord injury patients suffer from pres- sure sores over the sacro-iliac and trochanteric areas, heel and patella prominences.
+The prevention of pressure sores involves:
+– awareness by the hospital staff and the family of the potential problem;
+– the immediate involvement of a relative in active preventive management, 24 hours per day;
+– the utilization of simple measures to avoid pressure on high risk parts of the skin (Figure 7):
+FIGURE 7
+Prevention of p...
+
+=== Chunk 1114 ===
+Source: 0446_002-ebook.pdf
+Length: 556 chars
+
+Surgery
+Large pressure areas can be very effectively healed by the use of appropriate cutaneous and musculo-cutaneous flaps. No flap should be fashioned before the wound area is clean. This includes removing any osteomyelitic bone. Deep areas of defect will require musculo-cutaneous flaps to obliterate dead space. More superficial defects can be covered by full thickness cutaneous flaps. Split skin grafts should not be used.
+Musculo-cutaneous flaps are highly effective, but good nursing care and...
+
+=== Chunk 1115 ===
+Source: 0446_002-ebook.pdf
+Length: 848 chars
+
+Bladder and urinary tract problems
+Treatment objectives are:
+• prevention of infection;
+• prevention of urethral fistulas;
+• early removal of urinary catheter, and bladder regulation;
+• prevention of epididymitis.
+The incidence of infection is lessened by:
+• maintaining a fluid input of at least 3 litres a day;
+• changing catheters every 10 days if silicone catheters are not available;
+• keeping the urine bag below the level of the bladder (Figure 8).
+Urethral fistulas are prevented by:
+• checki...
+
+=== Chunk 1116 ===
+Source: 0446_002-ebook.pdf
+Length: 3100 chars
+
+Early removal of the bladder catheter and bladder regulation
+One of the causes of infection is the presence of a catheter. The catheter should therefore be removed as early as possible, which is as soon as the spinal shock phase is over (that is, 6-8 weeks after the accident) and the urine is clear.
+The bladder tone must be determined. This can be done with simple tests that do not require sophisticated apparatus. The fol- lowing three tests can be used to determine if the bladder is spas- tic o...
+
+=== Chunk 1117 ===
+Source: 0446_002-ebook.pdf
+Length: 366 chars
+
+Prevention of epididymitis
+Epididymitis is a common complication resulting mainly from a prolonged ventral position of the patient and/or late removal of the urinary catheter.
+Prevention is best achieved by:
+• early removal of the urinary catheter;
+• a mattress fashioned so that the penis and the testicles are free from pressure (a 15-20 cm deep hole allows this)....
+
+=== Chunk 1118 ===
+Source: 0446_002-ebook.pdf
+Length: 607 chars
+
+Urinary infection
+Urine should be kept acid when a urinary catheter is in place. This can be achieved using ammonium chloride.
+157
+In minor infections:
+– increase the quantity of fluid drunk (up to 3 litres per day);
+– bladder irrigation with a normal sterile saline solution (a total of 1 litre in 200 ml aliquots is effective).
+In heavy infections, add antibiotic treatment to the management:
+– sulphamethoxazole plus trimethoprim: 2 tabs twice daily (960 mg) for 10 days.
+If no response:
+– ampicil...
+
+=== Chunk 1119 ===
+Source: 0446_002-ebook.pdf
+Length: 489 chars
+
+Equipment needed
+The equipment needed for effective paraplegic management is simple and of low cost. Some of it can be manufactured in the hos- pital workshop and made by local craftsmen:
+• condoms (can be bought);
+• plastic tubes (from perfusion sets);
+• sponge mattress;
+• sheepskins;
+• standing frames (to be made);
+• parallel bars (to be made);
+• plaster of Paris bandage (for posterior splint);
+• wheelchair;
+• crutches;
+• simple caliper.
+FIGURE 11
+Model of simple standing frame.
+158...
+
+=== Chunk 1120 ===
+Source: 0446_002-ebook.pdf
+Length: 546 chars
+
+15. WOUNDS AND INJURIES OF THE EYE
+About 5-10% of all casualties in a war zone have an injury to the eye. Many are isolated injuries to the eye and orbit, but nearly 20% are associated with penetrating wounds of the brain, skull or face. Corneal abrasions, foreign bodies and conjunctival lacerations are very common. About half of all wounds of the eye are penetrating wounds of the globe. The surrounding structures are commonly injured, 25% have eyelid or facial wounds and about the same pro- por...
+
+=== Chunk 1121 ===
+Source: 0446_002-ebook.pdf
+Length: 4730 chars
+
+FIRST AID
+The difficult circumstances in a war zone are such that skilled first aid is usually not available.
+Basic advice:
+– avoid rubbing or squeezing eyes or eyelids;
+– close the lid to protect the cornea, if possible;
+– apply a clean pad and bandage to cover the eye before evacuation.
+EXAMINATION AND DIAGNOSIS
+A penetrating ocular injury should be suspected in every wound around the eye and of the upper part of the face.
+159
+The preliminary examination should be done with the lids retracted....
+
+=== Chunk 1122 ===
+Source: 0446_002-ebook.pdf
+Length: 1907 chars
+
+MANAGEMENT
+Ideally, all eye injuries should be treated primarily by an oph- thalmologist, even if a considerable delay (up to several days) is involved. In the absence of an ophthalmologist, treatment of major eye injuries in ICRC hospitals has to be the responsibility of the general surgeon.
+In this case, measures aimed at prevention of infection within the eye should be instituted. Systemic antibiotics, either penicillin, 5-10 units, or chloramphenicol, 1 g, i.v. every 6 hours, should be given...
+
+=== Chunk 1123 ===
+Source: 0446_002-ebook.pdf
+Length: 1259 chars
+
+Assessment of injury
+An eye is potentially useful so long as it retains perception of light. Gross reduction of vision may result from temporary causes which may clear up. The eye may eventually recover sufficiently to allow some vision. This is a matter of great importance in cases where both eyes are injured.
+Any penetrating eye wound is dangerous as it is liable to cause sympathetic ophthalmia.
+This is particularly so when the penetrating wound of the globe involves the ciliary region, and es...
+
+=== Chunk 1124 ===
+Source: 0446_002-ebook.pdf
+Length: 2064 chars
+
+Minor injuries
+Conjunctival foreign bodies and lacerations
+Wash out the conjunctival sac with copious quantities of sterile saline or water, and pick out any loose foreign material. Non-pen- etrating conjunctival lacerations will heal and 1% chloramphenicol eye drops should be instilled into the conjunctival sac 4 times daily. No pad is required because when the conjunctival sac is closed it is an ideal incubator of organisms.
+Corneal foreign body and/or corneal abrasions
+Instil two drops of loc...
+
+=== Chunk 1125 ===
+Source: 0446_002-ebook.pdf
+Length: 3699 chars
+
+Major injuries
+Lid lacerations
+Repair should be attempted only if fine instruments and suture material are available. The following basic principles of plastic surgical techniques must be observed:
+(a) copious irrigation of the wound;
+(b) minimal excision of any dead tissue;
+(c) anatomical apposition of the lid margin in two layers:
+• an initial 5/0 or 6/0 absorbable suture between the lash line and the mucocutaneous junction of the lid margin (the grey line);
+• interrupted 6/0 or 5/0 absorbable...
+
+=== Chunk 1126 ===
+Source: 0446_002-ebook.pdf
+Length: 1328 chars
+
+Skin grafting
+Whole thickness skin burns of the eyelid should be excised and grafted at the earliest possible moment. This gives the best chance of healing and reduces subsequent scarring to a minimum. If this is not done at an early stage, skin grafts should be applied to the raw surfaces of the lids as soon as granulation tissue appears, in order to reduce scarring. If the grafts fail, they should be repeated.
+The purpose and techniques of obtaining skin cover are as detailed in chapter 7.
+The...
+
+=== Chunk 1127 ===
+Source: 0446_002-ebook.pdf
+Length: 121 chars
+
+Protection of the cornea
+The cornea must be kept covered, if necessary by tarsorrhaphy, during the whole time of healing....
+
+=== Chunk 1128 ===
+Source: 0446_002-ebook.pdf
+Length: 202 chars
+
+Treatment of complications
+Complications, such as traumatic cataract, intra-ocular foreign bodies, detached retina and secondary glaucoma, can only effec- tively be managed by an ophthalmic surgeon.
+166...
+
+=== Chunk 1129 ===
+Source: 0446_002-ebook.pdf
+Length: 462 chars
+
+16. INJURIES OF THE EAR, NOSE AND THROAT
+EAR
+The ear may be divided into three parts: the external ear, the middle ear and the inner ear. There are four functions related to the ear: the cosmetic appearance, hearing, balance, and facial expres- sion mediated through the facial nerve. Missiles and explosive blast injury can affect all four functions. Bomb blast explosions will deafen many patients and it will therefore be difficult to com- municate with them....
+
+=== Chunk 1130 ===
+Source: 0446_002-ebook.pdf
+Length: 1288 chars
+
+External ear
+Trauma to the external ear is usually quite obvious but unless treated correctly it may well result in considerable deformity.
+In simple lacerations, the damaged tissues of the auricle should be carefully excised. The laceration should then be closed primar- ily in layers, being careful to retain good apposition of the cartilage using absorbable suture material. The skin and subcutaneous tissue should be closed with fine atraumatic sutures.
+If the auricle is partially avulsed, caref...
+
+=== Chunk 1131 ===
+Source: 0446_002-ebook.pdf
+Length: 1320 chars
+
+Middle ear
+Injury to the tympanic membrane is common and is often asso- ciated with other more serious injuries. The damage may be caused by:
+• direct penetration of the missile;
+• fracture of the base of the skull involving the tympanic ring;
+• sudden compression of the air in the external auditory meatus as a result of blast.
+Blast can damage the hearing in the following ways:
+• rupture of the tympanic membrane;
+• dislocation of the ossicles;
+• damage to the inner ear.
+Many of the hearing-dama...
+
+=== Chunk 1132 ===
+Source: 0446_002-ebook.pdf
+Length: 1177 chars
+
+Inner ear
+Trauma to the inner ear may occur in combination with the above injuries or as an isolated injury secondary to penetrating or blunt trauma. Such an injury may be accompanied by total hearing loss, severe vertigo, high-pitched tinnitus or facial nerve palsy.
+The most dramatic dizziness occurs after complete destruction of the vestibular apparatus. The clinical picture is that of vomiting,
+168
+associated with severe dizziness, even when still, and increasing with the slightest movement o...
+
+=== Chunk 1133 ===
+Source: 0446_002-ebook.pdf
+Length: 35 chars
+
+NOSE AND PARA-NASALAIR SINUSES
+Nose...
+
+=== Chunk 1134 ===
+Source: 0446_002-ebook.pdf
+Length: 466 chars
+
+Haematoma of the nasal septum
+Neglect of a septal haematoma leads to infection, abscess for- mation, cartilaginous necrosis and nasal deformity. After thorough cleansing of the anterior nares, a free incision should be made, under aseptic conditions, into the anterior and dependent portion of the haematoma, which is then evacuated. A small roll of sterile gauze should then be fixed over the nostrils, being held in place by tapes tied around the back of the head....
+
+=== Chunk 1135 ===
+Source: 0446_002-ebook.pdf
+Length: 1458 chars
+
+Fractures of the nose
+Simple fractures
+If these fractures are treated within 48 hours, reduction and maintenance of the fragments in position will seldom present much difficulty. Accurate replacement of fragments requires complete disimpaction if it is to be successful. External splintage will be required and this is conveniently made from plaster of Paris (T- shape).
+Compound fractures
+Thorough cleansing of the wound, excision of any dead tissue and early reduction are essential. Primary closur...
+
+=== Chunk 1136 ===
+Source: 0446_002-ebook.pdf
+Length: 179 chars
+
+Simple effusions
+Simple effusions of blood into the sinus are usually absorbed and best left alone. If infection occurs, the sinus should be punc- tured and thoroughly washed out....
+
+=== Chunk 1137 ===
+Source: 0446_002-ebook.pdf
+Length: 265 chars
+
+Depressed fractures
+In the case of fracture with depression of the orbital floor and/or anterior wall, it will be necessary to elevate the fragments and retain them in position by means of an antral pack impregnated with penicillin or an appropriate antiseptic.
+170...
+
+=== Chunk 1138 ===
+Source: 0446_002-ebook.pdf
+Length: 604 chars
+
+Frontal sinus
+Injuries to the forehead which involve the frontal sinus require operation to restore function and to effect a good cosmetic repair. In severe injuries, a scalp incision which follows the hairline will usually give the best exposure. All loose fragments of bone, debris, foreign bodies and blood clots should be removed from the sinus, which should then be drained into the nose by a plastic or rubber tube surrounded by a split skin graft.
+When the posterior wall of the frontal sinus ...
+
+=== Chunk 1139 ===
+Source: 0446_002-ebook.pdf
+Length: 241 chars
+
+Ethmoidal labyrinth
+When injury occurs to the ethmoid, operation should be avoided if possible for 14 days. There is usually a profuse CSF leak. In all these injuries, appropriate antibiotic cover, as described in chapter 8, should be given....
+
+=== Chunk 1140 ===
+Source: 0446_002-ebook.pdf
+Length: 2595 chars
+
+PHARYNX
+Wounds of the nasopharynx and oropharynx are often compli- cated by other penetrating wounds of the neck, head or trunk. The main immediate threat is inhalation of blood. Later, there is a dan- ger of haematoma and infection in the retro-pharyngeal space.
+Wounds involving the laryngopharynx tend to cause gross con- tamination of the tissue planes of the neck with saliva or other secretions.
+In all cases, careful and wide exposure is necessary to get at the depths of the wound and excise ...
+
+=== Chunk 1141 ===
+Source: 0446_002-ebook.pdf
+Length: 2525 chars
+
+17. BURN INJURIES
+Burns are a common event in the environment of war. Flame weapons, explosive blast and ignition of combustible materials all create a burns hazard for those involved.
+Aserious burn injury is a very painful and life-threatening event. The immediate threat is from shock, infection and the complex pathophysiological effects which follow the injury. It is associated with many complications, prolonged morbidity, multiple opera- tions, and great utilization of equipment, materials, m...
+
+=== Chunk 1142 ===
+Source: 0446_002-ebook.pdf
+Length: 1732 chars
+
+Initial replacement therapy
+The most important pathophysiological change as a result of thermal injury is widespread increase in capillary permeability.
+176
+Plasma water and numerous plasma proteins up to a molecular weight of 350,000 are freely exchanged between the intra and extra-vascular compartments of the extracellular space.
+The loss from the vascular compartment in large burns occurs at an approximate rate of 4 ml/kg/hour.
+This loss is most marked in the region of the burn wound and acco...
+
+=== Chunk 1143 ===
+Source: 0446_002-ebook.pdf
+Length: 1251 chars
+
+The first 24 hours
+Use Ringer’s lactate solution 4 ml/kg/% burn.
+• First eight hours: 2 ml/kg/%.
+• Second eight hours: 1 ml/kg/%.
+• Third eight hours: 1 ml/kg/%.
+177
+Measure the urine output and aim to keep it between 30- 50 ml/hr for adults and 20-30 ml/hr for children.
+If the output goes above these levels, reduce the rate of infusion to avoid pulmonary oedema. If the urinary output is low and does not respond to increased infusion in the second eight hour period, then replace the third eight ...
+
+=== Chunk 1144 ===
+Source: 0446_002-ebook.pdf
+Length: 852 chars
+
+After 48 hours
+Mobilization of burn wound oedema takes place with diuresis, high cardiac output, tachycardia and anaemia. All these are related to the expansion of blood volume by mobilization of the oedema fluid.
+178
+After 48 hours, there are normal water and electrolyte re- quirements, plus replacement of evaporative water loss at 1-2 ml/kg/%/day of 5% Dextrose in water.
+If available, plasma or albumin should be given to maintain serum albumin of 3 g/100 ml and blood to maintain a haematocrit ...
+
+=== Chunk 1145 ===
+Source: 0446_002-ebook.pdf
+Length: 1701 chars
+
+Monitoring resuscitation
+Clinical evaluation of the response to effective correction of the hypovolaemic state is vital.
+Clinical evaluation is particularly important in the absence of sophisticated means and laboratory measures. A clear sensorium, good tissue perfusion, good pulse, and an adequate urinary output are all signs of good progress.
+CARE OF THE BURN WOUND
+Following successful resuscitation of the patient, the burn wound and the complications of burn sepsis present the greatest threat...
+
+=== Chunk 1146 ===
+Source: 0446_002-ebook.pdf
+Length: 985 chars
+
+Initial wound management
+When the burn wound has been assessed and resuscitation has started, attention can be turned to cleaning the wound.
+The patient should be sedated and the burn wound washed with detergent soap or povidone iodine scrub solution if available. Blis- ters should be left undisturbed but broken blisters and non-viable tissue should be removed. Large burn wounds may be more easily cleaned by placing the patient in a bath or shower.
+During the first 48 hours, the increasing oedem...
+
+=== Chunk 1147 ===
+Source: 0446_002-ebook.pdf
+Length: 249 chars
+
+Local care
+The methods of primary burn wound care depend on the depth, extent and location of the burn. They include: exposure treatment; occlusive dressings; wet dressings; open therapy with topical antibacterial agents; and the plastic bag method....
+
+=== Chunk 1148 ===
+Source: 0446_002-ebook.pdf
+Length: 1755 chars
+
+Exposure treatment
+This method is used to control bacterial colonization without the aid of topical agents by utilizing a warm dry environment. It is par- ticularly suitable for burns involving the face, perineum and for unilateral trunk or limb burns. The patient is placed on a clean dry sterile surface and the burned area is completely exposed. The ambient temperature needs to be 35-40°C in order to prevent the patient shivering, and the air should be dry.
+Eschar formation is usually complete ...
+
+=== Chunk 1149 ===
+Source: 0446_002-ebook.pdf
+Length: 297 chars
+
+Wet dressings
+These are dressings soaked in saline or 0.5% silver nitrate solu- tion, which are applied to the burn eschar and left in place. The dressings are soaked every two hours or so to keep them wet, and they are changed once or twice a day. This method is impractical for field conditions....
+
+=== Chunk 1150 ===
+Source: 0446_002-ebook.pdf
+Length: 1008 chars
+
+Open therapy with topical antibacterial agents
+For extensive burns this is the method of choice.
+The advantage of this method of treatment is that it allows easy examination of the burn wound so that infection may be recog- nized and treated early. It also allows early mobilization by phys- iotherapy, hyperthermia is avoided, and it is easier for nursing pur- poses.
+The disadvantages are delayed eschar separation and significant pain from some of the topical agents. Hypothermia has to be pre- ve...
+
+=== Chunk 1151 ===
+Source: 0446_002-ebook.pdf
+Length: 331 chars
+
+The plastic bag method
+This method is used for burns to hands and feet. After cleaning, any plastic bag can be used as a glove or a sock, tied around the wrist or ankle. It must not be too tight, so as to allow for swelling. The burned area will be kept moist and movement of the joints, both passive and active, is encouraged.
+182...
+
+=== Chunk 1152 ===
+Source: 0446_002-ebook.pdf
+Length: 471 chars
+
+EXCISION OF ESCHAR AND SKIN GRAFTING
+The preparation of the burn wound and its subsequent closure are the two main steps in the management of burns. The type of surgery required depends upon the skill and training of the sur- geon, the burn injury and the facilities available to support the treatment. Like all other injuries treated under difficult circum- stances, great judgement is required to select the technical proce- dure which is both possible and practicable....
+
+=== Chunk 1153 ===
+Source: 0446_002-ebook.pdf
+Length: 266 chars
+
+Removal of dead tissue
+The dead tissue or eschar produced by thermal injury may be removed completely in a single procedure or in a number of stages. The aim of treatment is to prepare the wound for eventual closure and to prevent colonization by bacteria and fungi....
+
+=== Chunk 1154 ===
+Source: 0446_002-ebook.pdf
+Length: 453 chars
+
+Mechanical methods
+Thorough cleaning and removal of debris and fragments of eschar, as described above, should be done at each dressing ses- sion. Gentle scraping or picking away the fragments should be combined with thorough irrigation with water or in a bath. The sur- face can then be cleansed with a detergent solution (half a cup of detergent powder, one litre of 0.9% saline, 500 ml of 3% hydrogen peroxide) and thoroughly washed again with water....
+
+=== Chunk 1155 ===
+Source: 0446_002-ebook.pdf
+Length: 1032 chars
+
+Excision
+The removal of the full thickness of the burn wound has to be done at some time in order to prepare the site for eventual skin cover.
+Early excision of full thickness burns and immediate auto- graft has enormous benefits, but is impracticable for areas greater than 10% TBS, outside specialized burns centres.
+The emphasis for most field surgeons should be on conservatism in relation to this technique.
+Tangential excision is the process whereby the superficial layers of the burned tissue ...
+
+=== Chunk 1156 ===
+Source: 0446_002-ebook.pdf
+Length: 1701 chars
+
+PHOSPHORUS BURNS
+Many anti-personnel weapons used in warfare contain white phosphorus. This element ignites on contact with air, and frag- ments of phosphorus will be scattered throughout any wounds caused by such weapons. Most of the injury results from the igni- tion of clothing, which causes a conventional burn. It is a real prob- lem to deal with a wound in which the embedded particles of phos- phorus will ignite as soon as the tissue dries out. Medical teams as well as patients are in dange...
+
+=== Chunk 1157 ===
+Source: 0446_002-ebook.pdf
+Length: 289 chars
+
+18. COLD INJURIES
+The significance of prevention and treatment of cold injuries as a military medical problem cannot be overemphasized. Although most commonly seen in arctic and subarctic climates, cold injuries can occur whenever the combination of cold, wet, wind and immo- bility exist....
+
+=== Chunk 1158 ===
+Source: 0446_002-ebook.pdf
+Length: 1016 chars
+
+PHYSIOLOGY OF THERMAL REGULATION
+Normal body temperature is maintained through a balance between heat production and heat loss, and is regulated by a hypo- thalamic “thermostat”. At least 95% of the heat produced by metabolism is normally lost to the environment by conduction, convection, radiation and evaporation.
+The skin primarily acts to dissipate heat by regulating its blood flow which may vary from 50 ml/min to 7000 ml/min. The lungs are also a significant source of heat loss.
+In a cold en...
+
+=== Chunk 1159 ===
+Source: 0446_002-ebook.pdf
+Length: 163 chars
+
+LOCAL COLD INJURIES
+Local cold injuries can occur at temperatures above or below freezing point and are classified as non-freezing injuries or freez- ing injuries....
+
+=== Chunk 1160 ===
+Source: 0446_002-ebook.pdf
+Length: 276 chars
+
+Non-freezing injury
+This type of cold injury, also known as “immersion foot” or “trench foot”, is seen in prolonged exposure to cold ambient tem- peratures above freezing, with high humidity and immobilization. Such injuries are diagnosed and treated like other cold injuries....
+
+=== Chunk 1161 ===
+Source: 0446_002-ebook.pdf
+Length: 294 chars
+
+Freezing injury
+This type of injury, also known as frost-bite, may be:
+• superficial, in which only skin and subcutaneous fat are involved;
+• deep, where structures such as muscle are involved.
+It is not easy to differentiate, in the early stages of injury, between superficial and deep wounds....
+
+=== Chunk 1162 ===
+Source: 0446_002-ebook.pdf
+Length: 208 chars
+
+Symptoms and signs
+These include:
+• paresthesia (numbness);
+• pallor (wax-white or mottled blue discoloration);
+• paralysis (impaired movement);
+• hardness;
+• swelling (particularly in non-freezing injuries)....
+
+=== Chunk 1163 ===
+Source: 0446_002-ebook.pdf
+Length: 1240 chars
+
+First aid and transport
+Place the patient in a shelter as soon as possible. Remove boots and socks, avoiding trauma to the skin.
+As some degree of hypothermia generally co-exists with local cold injury, the general body temperature should be raised by hot drinks, etc. Further loss of heat should be prevented by blankets or skin-to-skin contact. When a local cold injury co-exists with hypothermia, the frozen extremity should be gently packed in ice and prevented from thawing before normal core te...
+
+=== Chunk 1164 ===
+Source: 0446_002-ebook.pdf
+Length: 822 chars
+
+19. RECONSTRUCTIVE SURGERY
+War wounds, like other major trauma, will often require major reconstructive surgery to obtain a reasonable functional result. Lack of adequate facilities, experienced operators and time will often limit the extent to which reconstructive surgery can be per- formed. Moreover, many reconstructive procedures require sev- eral operations spaced over many months to be completed. It is pointless to start a protracted set of procedures if the operator’s length of mission is ...
+
+=== Chunk 1165 ===
+Source: 0446_002-ebook.pdf
+Length: 1048 chars
+
+SOFT TISSUE DEFECTS
+A significant degree of tissue loss will often prohibit simple approximation of wound edges. Or wound edge approximation might be possible but large areas of dead space beneath make direct wound edge suture inappropriate. In wounds where there has been major tissue loss, skin grafts (chapter 7) or flaps will be required to close the defect. When avascular areas, such as exposed bone without periosteum or tendon without peritenon, need cover- age, or when vital structures are ...
+
+=== Chunk 1166 ===
+Source: 0446_002-ebook.pdf
+Length: 980 chars
+
+Local flaps
+Local flaps with random blood supplies are used when tissue adjacent to or very near a wound is used for skin closure. There are four main types of local flaps:
+• Advancement flaps. These are performed by undermining the edge of a wound, incising the tissue for a distance along the lines of greatest tension, and advancing the tissue to cover the defect.
+• Rotation flaps. These are designed along an arc which is incised adjacent to the wound. This arc is undermined and the tissue is r...
+
+=== Chunk 1167 ===
+Source: 0446_002-ebook.pdf
+Length: 362 chars
+
+Arterialized flaps
+Arterialized flaps have a central vascula bundle which supplies blood flow to the skin of the flap. Examples of these are:
+• the groin flap supplied by the circumflex iliac artery and vein;
+• the deltopectoral flap based on the perforating branches of the internal mammary artery;
+• the forehead flap based on the superficial temporal vessels....
+
+=== Chunk 1168 ===
+Source: 0446_002-ebook.pdf
+Length: 667 chars
+
+Musculo-cutaneous flaps
+Musculo-cutaneous flaps are composed of muscles and their overlying skin, blood supply to the skin being supplied by perfo-
+192
+rating musculo-cutaneous vessels. The commonly used musculo- cutaneous flaps include the tensor fascia lata and either medial or lateral heads of the gastrocnemius muscles in the lower extremi- ties, latissimus dorsi, sternomastoid or pectoralis major flaps in the upper body.
+BONE PROBLEMS
+Nearly all bone wounds seen will be compound injuries, so...
+
+=== Chunk 1169 ===
+Source: 0446_002-ebook.pdf
+Length: 485 chars
+
+Malunion
+Some fractures will be quite old at the time of presentation, with fairly well-established malunion having occurred. In these situa- tions, a decision must be taken on whether to accept the degree of malunion present, especially considering the risks involved with attempted correction. In some cases, malunion will be such that reasonable function is not possible and reconstructive surgery is advisable. The decision must be made by the surgeon and the patient in each case....
+
+=== Chunk 1170 ===
+Source: 0446_002-ebook.pdf
+Length: 422 chars
+
+Non-union
+Non-union of fractures is common. It may be the result of soft tissue interposition between fracture ends. Fresh cases should be explored and the interpositioned tissue removed. If there is no radi- ological evidence of union after three months, the fracture site should be inspected and freshened and a bone graft inserted. If there is less than 50% union after six months, the same procedure should be adopted....
+
+=== Chunk 1171 ===
+Source: 0446_002-ebook.pdf
+Length: 202 chars
+
+Osteomyelitis
+Bone infection complicating fractures is a common problem. Basic principles apply, especially concerning the use of antibiotics. Antibiotics are of no value when sequestra are present.
+193...
+
+=== Chunk 1172 ===
+Source: 0446_002-ebook.pdf
+Length: 456 chars
+
+Exploration:
+• non-union: in fresh cases where it is impossible to get proper alignment of fracture ends, the area must be (re)explored to remove soft tissue stuck between the bone ends.
+• osteomyelitis: surgical excision, including curettage (small draining sinus), sequestrectomy and fenestration.
+In any situation where there is a persistent discharging sinus, surgical excision of necrotic tissue, including bone, is required before healing will occur....
+
+=== Chunk 1173 ===
+Source: 0446_002-ebook.pdf
+Length: 1126 chars
+
+Bone grafting is used in:
+• the correction of malunion;
+• cases of non-union;
+• order to fill gaps between fractures, where sequestra have been removed.
+The donor site will generally be the ilium and cancellous bone will generally be used. Cortical grafts and bicortical grafts consisting mainly of cancellous bone can also be taken from the ilium but will only be required when more complicated surgery, such as mandibular reconstruction, is involved. The ilium is used because a generous amount of ...
+
+=== Chunk 1174 ===
+Source: 0446_002-ebook.pdf
+Length: 3866 chars
+
+SKIN CONTRACTURES
+Secondary surgery to improve function following burns is always indicated. Most of these scars will be over flexures where, because of shortage of skin, addition of skin will be required.
+194
+These contractures will not improve with the passage of time or by splinting alone. Scars over extensor surfaces will seldom lead to loss of function, with the possible exception of the back of the hand. In this case, treatment is wide excision and grafting.
+The two methods of correcting f...
+
+=== Chunk 1175 ===
+Source: 0446_002-ebook.pdf
+Length: 1094 chars
+
+Arterio-venous fistulas (Figure 2)
+Arterio-venous (A-V) fistulas can be largely avoided if pene- trating wounds are adequately explored, especially those near large vessels, such as the axilla and groin. An injured major vein should be repaired, if possible, especially when there is associated arterial injury. Small isolated venous injuries are not critical and may be ligated.
+If an A-V fistula is encountered, it should be repaired. This is done by adequate exposure of the area to allow for prox...
+
+=== Chunk 1176 ===
+Source: 0446_002-ebook.pdf
+Length: 717 chars
+
+Pseudoaneurysms
+An arterial injury will result in bleeding and haematoma forma- tion. Sometimes the haematoma will be transformed into an aneurysm and the patient will present with a pulsating mass. Vas- cular control above and below the aneurysm must be secured. After clamping, the aneurysm is opened and the hole identified. If the hole is small and the wall of the vessel is healthy, simple suture of the hole can be done. If there is a big hole and the wall is soft, a resection with an interpos...
+
+=== Chunk 1177 ===
+Source: 0446_002-ebook.pdf
+Length: 198 chars
+
+20. ANAESTHESIA IN WAR SURGERY
+The standard anaesthetic practices, as utilized in trauma care, should be followed. The points listed below are particularly impor- tant in the context of war surgery....
+
+=== Chunk 1178 ===
+Source: 0446_002-ebook.pdf
+Length: 705 chars
+
+PREOPERATIVE PREPARATIONS
+• The presence of a good interpreter is essential.
+• Assessing the time the patient last ate is difficult, especially with breast-fed babies.
+• Many wounded, especially in hot climates, will be severely dehydrated. Correct hypovolaemia before surgery, if time allows.
+• Unfamiliarity with anaesthetic equipment and local conditions increases the likelihood of complications. Make certain that an assistant, if available, is at hand.
+• Routine premedication will not be neces...
+
+=== Chunk 1179 ===
+Source: 0446_002-ebook.pdf
+Length: 267 chars
+
+ANAESTHESIA METHODS
+Oxygen, nitrous oxide and volatile anaesthetics may be in short supply. Consider the possibility of using local and regional anaes- thesia, and ketamine. Oxygen concentrators are very useful.
+199
+The following are the anaesthetic agents of choice....
+
+=== Chunk 1180 ===
+Source: 0446_002-ebook.pdf
+Length: 139 chars
+
+Surface anaesthesia
+Ophthalmic: 0.4% oxybuprocaine or, if not available, 0.25-0.5% cocaine or 0.5% proxymetacine.
+Mucosa: lignocaine jelly....
+
+=== Chunk 1181 ===
+Source: 0446_002-ebook.pdf
+Length: 170 chars
+
+Infiltration anaesthesia
+Lignocaine 1% with adrenaline. If a volume greater than 30 ml is required, the lignocaine can be diluted with an equal volume of isotonic saline....
+
+=== Chunk 1182 ===
+Source: 0446_002-ebook.pdf
+Length: 97 chars
+
+Nerve block
+Digital: lignocaine 2% without adrenaline. Axillary: lignocaine 1.5% with adrenaline....
+
+=== Chunk 1183 ===
+Source: 0446_002-ebook.pdf
+Length: 79 chars
+
+Regional intravenous anaesthesia
+Prilocaine (Citanest) 0.5% without adrenaline....
+
+=== Chunk 1184 ===
+Source: 0446_002-ebook.pdf
+Length: 354 chars
+
+Regional anaesthesia
+Spinal subarachnoid block with hyperbaric lignocaine 1.5-2.0 ml or 0.5% bupivacaine 2.5-4.0 ml.
+Spinal puncture is performed with a thin 25 gauge needle with the patients on their unaffected side. The classical sites are:
+• L 3-4 for lower limbs;
+• L 2-3 for hip and pelvis.
+If bradycardia develops: atropine 0.5-1.0 ml can be given....
+
+=== Chunk 1185 ===
+Source: 0446_002-ebook.pdf
+Length: 695 chars
+
+Ketamine
+This is very safe, especially for children.
+Dosage: Intramuscular 10 mg/kg body weight.
+Intravenous bolus 2 mg/kg body weight.
+These doses give analgesia for 10-20 minutes. For longer procedures, an intravenous infusion can be added at a dose of 2-6 mg/hour/kg body weight, the rate being titrated against the response.
+200
+Hallucinatory side effects do occur with ketamine, especially in adults, and once encountered are likely to be repeated on other occasions in the same patient. The inc...
+
+=== Chunk 1186 ===
+Source: 0446_002-ebook.pdf
+Length: 1102 chars
+
+General anaesthesia
+Induction
+• Analgesia with fentanyl 0.1 mg, pethidine 50 mg, or morphine 5 mg.
+• Atropine 0.5-1.0 mg if indicated.
+• Thiopentone 2.5% solution, titrated against response.
+• Ketamine is available for induction. It is indicated especially if the patient is shocked because it does not cause hypotension as thiopentone does.
+• Succinylcholine 1 mg/kg body weight facilitates rapid tracheal intubation.
+Cricoid oesophageal compression should always be utilized until the endotracheal ...
+
+=== Chunk 1187 ===
+Source: 0446_002-ebook.pdf
+Length: 485 chars
+
+DOSAGE GUIDE
+Indication Drug Infiltration Lignocaine +/- adrenaline 0.5-1% Brachial Lignocaine with plexus adrenaline 1-1.5% or block bupivacaine 0.5% with adrenaline Peripheral Lignocaine or blocks bupivacaine without adrenaline 0.5-1% Recommended Comments volume up to 50 ml Do not use adrenaline for penis, digits or ears. 15-35 ml Where early movement is desired. Provides prolonged sensory analgesia. 5-20 ml Bupivacaine should be used where prolonged anaesthesia
+is required.
+202...
+
+=== Chunk 1188 ===
+Source: 0446_002-ebook.pdf
+Length: 987 chars
+
+FURTHER READING
+Coupland, R.M. (1991) The Red Cross wound classification, International Committee of the Red Cross, Geneva.
+Coupland, R.M. (1992) Amputation for war wounds, International Committee of the Red Cross, Geneva.
+Coupland, R.M. (1993) War wounds of limbs: surgical management, Butterworth Heinemann, Oxford.
+Gray, R. (1994) War wounds: basic surgical management, International Committee of the Red Cross, Geneva.
+Hayward-Karlsson, J., Jefferey, S., Kerr, A., Schmidt, H. Hospitals for war w...
+
+=== Chunk 1189 ===
+Source: 0446_002-ebook.pdf
+Length: 2614 chars
+
+Mission
+The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of the victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian...
+
+=== Chunk 1190 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 104 chars
+
+SENIOR EDITOR
+Richard J. Ingebretsen, MD, PhD University of Utah School of Medicine Salt Lake City, Utah...
+
+=== Chunk 1191 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 138 chars
+
+EDITORS
+Paul Schmutz, DDS Salt Lake City, Utah
+CONTRIBUTORS University of Utah School of Medicine Jonny Woolstenhulme, MD Justin Coles, DO...
+
+=== Chunk 1192 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 318 chars
+
+Copy/Format Editor
+Lisa Plante M.Ed.
+Edition 2.0 Copyright © 2025 by
+Richard J Ingebretsen MD PhD and The University of Utah School of Medicine All Rights Reserved. No part of this book may be reproduced in any manner without the express written consent of the author or the School of Medicine.
+ISBN: 978-1-7359710-3-2...
+
+=== Chunk 1193 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 280 chars
+
+Table of Contents
+Click on a chapter to advance
+J
+Basic First Aid Chapter Patient Assessment Vital Signs Wound Management Bleeding and Shock Airway and Breathing Musculoskeletal Injuries Medical Problems
+Chapter 1: Chapter 2: Chapter 3: Chapter 4: Chapter 5: Chapter 6: Chapter 7:...
+
+=== Chunk 1194 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 782 chars
+
+Chapter 1: Patient Assessments
+The management of someone injured or sick in the wilderness is probably the most important topic in all of wilderness medicine. Imagine that you are enjoying a back-country jog and you see another runner fall hard. When you get to her, she is clearly confused and incoherent. You note a bruise on her forehead and her lower leg is bleeding profusely from a deep gash. There is already quite a bit of blood. In this situation, what should you do first? What medical issu...
+
+=== Chunk 1195 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1101 chars
+
+Scene Survey
+The first survey technique is the scene survey. When you first approach a scene, the tendency is to approach the patient immediately and start rendering aid. Don’t. You must first make sure that the scene is safe before you enter to assess the victim. Don’t put yourself in harm’s way and potentially become a victim yourself. Look around and consider physical dangers such as snow, ice, rocks, fire, and animals. Other potential hazards include bikers on single track, climbers above, o...
+
+=== Chunk 1196 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 2059 chars
+
+Primary Survey
+The second survey technique is the primary survey. The purpose of the primary survey is to keep the victim alive. To help prioritize the treatment of injuries during the primary survey, refer to the table below which uses the MARCH acronym. It’s important to note that preventing major hemorrhage is the top priority, even coming before Airway.
+If the patient is awake and alert, you should ask the patient if she/he would like your help. It is good practice that before you start trea...
+
+=== Chunk 1197 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 672 chars
+
+Secondary Survey
+The third survey technique is the secondary survey. This survey is done after the Primary survey and can be remembered using the SAMPLE acronym.
+Secondary Survey using SAMPLE
+S Symptoms/Subjective A Allergies M Medicine P Prior medical history L Last oral intake E Events leading up to illness/injury
+Address these items to the victim as questions and pay close attention to what they say. It they cannot answer, ask if family, friends, or people at the scene might be able to help w...
+
+=== Chunk 1198 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 493 chars
+
+Ongoing Survey
+The fourth survey technique is the ongoing survey. You should repeat this survey as often as needed. If the patient is unstable, go through the survey more frequently. Until the patient is in the hands of medical help you should keep assessing them with the Ongoing survey.
+If at any time there is a change in the patient’s status you should always go back and repeat the primary assessment. This is essential to determine what caused the change in the patient’s medical status....
+
+=== Chunk 1199 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 64 chars
+
+Ongoing Survey using AVPU
+A Alert V Verbal P Pain U Unresponsive...
+
+=== Chunk 1200 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 568 chars
+
+Summary of Surveys
+These are the four effective survey techniques recommended to use in your initial assessment of a sick or injured person in the wilderness. However, there are often other issues that present themselves and may need to be addressed during these four survey techniques. The victim may have an altered mental state, or be in a significant amount of pain. They may be unconsciousness and remain that way. They may have nearly drowned or have fallen from a cliff. Let’s explore these ty...
+
+=== Chunk 1201 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 931 chars
+
+Altered Mental Status
+There are many reasons that can lead to an altered mental status, and often there can be multiple causes for one patient. A well-known pneumonic to use is AEIOU Tips. There are some minor, but important additions for its use in wilderness medicine.
+Start at the top of this list and work your way down to come up with a differential of potential causes for a victim’s mental status. Victims with an altered mental status, or who are unresponsive, can be some of the most challen...
+
+=== Chunk 1202 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 328 chars
+
+Pain
+Pain is often a common presenting sign in a victim. Understanding the caliber of someone’s pain may well be the key to a diagnosis of what is causing it. The acronym, COLDERR, is used to characterize a victim’s pain.
+Pain checklist using COLDERR
+C Character O Onset L Location D Duration E Exacerbation R Relief R Radiation...
+
+=== Chunk 1203 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 674 chars
+
+Recovery Position
+Another situation you may encounter is that of an injured and unconscious victim. If you are alone, you may realize that your only option is to leave the victim and go get help. Before you go, put the victim on their side in the recovery position. This helps keep the airway open and prevents them from aspirating if they vomit.
+Airway is assessed with C-spine in the MARCH acronym. The victim is on their side with the top arm forward and the top leg forward. This position will he...
+
+=== Chunk 1204 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1107 chars
+
+Drowning
+After performing a scene survey, if you pull someone from the water and suspect drowning, what should you do? Your thought might be to conduct the Primary survey, using the acronym MARCH. However, in the case of a potential drowning victim, they need air in their lungs quickly. Therefore, you should perform rescue breaths if the patient has a pulse. Since there is no massive hemorrhage, airway and respirations are the next steps for the primary assessment.
+A submersion injury is a speci...
+
+=== Chunk 1205 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1091 chars
+
+Scene Safety
+In a case where the scene is not safe for the victim, you may need to move them to a safe location. For example, consider a situation where a person falls a short distance off of a rock-climbing cliff. This fallen person is now below the cliff, and other people are still climbing with the potential to
+dislodge loose rocks. These falling rocks could be a danger to the victim lying below. Should you move the patient to a safer location and risk causing a potential spinal injury? Clear...
+
+=== Chunk 1206 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 936 chars
+
+Blood Sweep
+In the example above where someone has fallen from a cliff, they could easily have cuts on their skin. A quick look will determine if they are bleeding. This is known as the blood sweep and allows you to identify any major bleeding. It’s important to look under layers of clothing when doing your sweep, as blood can collect between these layers, especially if the clothing is waterproof. It’s recommended to perform the sweep in small segments to determine where the blood is coming from...
+
+=== Chunk 1207 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 421 chars
+
+Blood sweep checklist using CARTS
+C Chest A Abdomen R Renal T Thigh S Skin/street
+There is often little you can do if someone is bleeding to death inside their body, other than evacuate them very quickly. At least you will know to do this. Remember also, that people will often bleed on the ‘street’ or they will bleed in one place and then stumble to another place. Be sure to look on the ground or the street for blood....
+
+=== Chunk 1208 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 862 chars
+
+Wound Irrigation
+If the patient’s wound need to be treated, irrigation can be very messy, even when done correctly. Even if you are irrigating away from yourself, the liquid can still splash backward. Protect yourself with proper Body Substance Isolation (BSI) any time you are treating a patient. You might need to improvise BSI in the wilderness. You should cover yourself with waterproof clothing, even if you borrow the patient’s gear. Using the waterproof clothing ensures that your gear does no...
+
+=== Chunk 1209 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1151 chars
+
+Exposure
+You should always look under the patient’s clothes for additional injuries. However, proper exposure is a double-edged sword in the wilderness. It’s important to check the whole body for any hidden injuries, but it’s also important to ensure that the patient stays protected from the environment. Avoid damaging the patient’s clothes, which are a valuable resource when it’s cold outside. In fact, cutting off the patient’s clothes for better exposure could be a waste of resources. If the p...
+
+=== Chunk 1210 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 867 chars
+
+Medical documentation
+Medical documentation is an essential part in caring for a patient. The most common method for creating a document is to use the acronym SOAP. A SOAP note is considered a standard in medical documentation.
+Medical documentation using SOAP
+S Subjective O Objective A Assessment P Plan
+Be prepared to give a verbal presentation when the patient is handed off to medical personnel. The verbal presentation should be structured the same way as a SOAP note. The SOAP note and verbal ...
+
+=== Chunk 1211 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1096 chars
+
+What are vital signs?
+The word “vital” refers to items that are essential for life. The vital signs are the measurements. Some vital signs are easy to measure like the pulse. Some require instruments like a blood pressure cuff to measure the blood pressure. Most people don’t carry a blood pressure device with them. So, most often we must rely on other measurement. Some are subjective such as the level of consciousness. The main vital signs are:
+• Level of consciousness / level of responsiveness ...
+
+=== Chunk 1212 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 749 chars
+
+Level of Consciousness / Responsiveness
+This is a measure of the brain’s ability to relate to the outside world. It is important for many reasons. It is the first vital sign to change. It is usually subjective. The acronym that is most often used is:
+• A - Alert
+• V - Verbal
+• P - Pain
+• U - Unresponsive
+Alert
+This looks a whether the patient is awake and able to answer questions appropriately. You should ask tif he patient is “oriented” to who they are and some basic situational information
+Eac...
+
+=== Chunk 1213 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 206 chars
+
+Verbal
+The looks at whether the patient can talk or not. You might comment if they follow simple commands.
+Pain
+This assesses that if the patient does not react to talking but does react to painful stimuli....
+
+=== Chunk 1214 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 116 chars
+
+Unresponsive
+This look at if the patient does not respond to any stimuli, to include verbal and painful stimulation....
+
+=== Chunk 1215 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 320 chars
+
+Heart Rate / Pulse
+Normal pulse is 60-100 bpm in adults. The heart rate can be taken anywhere you can feel a pulse. The radial pulse at the wrist is usually the easiest to check. Children typically have a higher heart rate with newborns ranging from 100-150 bpm. Count the pulse for 15 seconds and then multiply by four....
+
+=== Chunk 1216 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 265 chars
+
+Respiratory Rate
+Normal between 12-20 breaths per minutes. Breathing in and out counts as one breath. Count the number of breaths for 30 seconds and multiply by two. You should make a comment about the quality of the breathing, such as labored or shallow breathing....
+
+=== Chunk 1217 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 364 chars
+
+Skin Color, Temperature, Moisture
+The color of the skin in non-pigmented areas hold a key to that patient’s status. Red skin could mean fever or hyperthermia. Blue skin could mean hypothermia or a lack of oxygen in the blood. You can feel the skin to check temperature. And you can feel for moisture. If your patient is sweating it could mean fever or hypothermia....
+
+=== Chunk 1218 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 193 chars
+
+Body Temperature
+Most people don’t take thermometers with them. But is you do, a thermometer that does not break and one that goes lower is the best. You might have to estimate the temperature....
+
+=== Chunk 1219 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 305 chars
+
+Recording Vital Signs
+Here is an example of what you might record if you took vitals on a young, healthy person with
+normal vitals.
+⚫ LOC = Awake and oriented to person, place, time and events (A+O×4)
+⚫ HR = 70 bpm, regular, strong
+⚫ RR = 15 breaths per minute, regular, unlabored
+⚫ SCTM = pink, warm, dry...
+
+=== Chunk 1220 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 667 chars
+
+Chapter 3: Wound Management
+Wound management in the wilderness backcountry is different than wound management in an urban setting. One significant difference is that backcountry wounds are often dirty or may become dirty. There’s often a lack of first aid material too. A single abrasion wound may use up all the gauze pads in your entire kit, leaving nothing for other injuries. You may not have the appropriate first aid material for closing a wound, such as sutures or steri-strips. And, if the in...
+
+=== Chunk 1221 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1244 chars
+
+Hemostasis
+The next step is to stop the bleeding. This is called hemostasis. If the wound is such that a person is going to bleed out, this becomes emergent and is first in the primary survey using the MARCH protocol, where ‘M’ stands for massive hemorrhage. Direct pressure is the first step in stopping any blood loss. The application of direct pressure controls bleeding from most wounds. Use the cleanest materials available and apply direct pressure to the source of bleeding. This may take seve...
+
+=== Chunk 1222 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 570 chars
+
+How to Place a Tourniquet
+• Place the tourniquet over clothing if possible, about two to four inches above the wound.
+• Do not place the tourniquet on a joint or directly over a wound or a fracture.
+• Once the tourniquet is in place, it should be tightened so that all bleeding stops. Secure the windlass so that it does not unwind.
+• Mark the time that you placed the tourniquet on the patient’s forehead, so it is rapidly visible to other personnel when the care for the victim.
+• There is no need ...
+
+=== Chunk 1223 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1441 chars
+
+Cleaning/Debridement
+All wounds need to be cleaned. “High-pressure” irrigation is the most important intervention to prevent infection and decrease bacteria content for most wounds. A wound should not be closed by any means prior to proper irrigation and decontamination. Leaving the wound to dry and scab over has the potential to form a larger scar and become infected over time.
+Irrigate the wound with a solid stream of the cleanest water available. Tap water has been shown to be as effective as...
+
+=== Chunk 1224 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1492 chars
+
+Dressing a Wound
+Dressing a wound is difficult in the wilderness but very important. It protects wounds from the dirty wilderness environment, helps with the prevention of infection, and can be accomplished in a number of ways. If a commercial pad or dressing is not available, improvise using a 4 x 4 pad covered in an antibiotic ointment. Cover this dressing with an absorbent gauze dressing, then secure with tape. If the injury is on a flexible part of the body you might want to immobilize the j...
+
+=== Chunk 1225 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1348 chars
+
+When to Evacuate a Wound
+The injuries that require considerations for evacuations are:
+• Complex or mutilating wounds
+• Grossly contaminated with penetrating debris
+• Laceration of eye lid, ear or cartilage
+• Penetration of bone, joint or tendon
+• Bites of hands, legs or feet
+• Amputations
+Scabs
+Contrary to popular belief on letting a wound scab over, recent studies have shown that keeping the wound environment moist promotes wound healing and reduces scar formation. This can be done
+with daily ...
+
+=== Chunk 1226 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 3377 chars
+
+Closing a Laceration
+Closing a laceration in the wilderness is difficult. The decision to close a wound is broken down to two courses of action:
+1. Primary closure: You can close it with sutures, staples, tape, or skin glue.
+2. Delayed primary closure: You can pack it with gauze, wrap it and clean it often until you can get to definitive care.
+Closing the wound with sutures, staples, tape, or tissue adhesive has the advantage of immediate treatment with better mobility and less pain. However, th...
+
+=== Chunk 1227 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 445 chars
+
+Treatment of Superficial Burns
+Treat superficial burns with aloe-vera gel and for comfort, cool the area with damp, wet cloths. Aloe vera has no antimicrobial properties, however. Leaving the wound to dry increases scar formation and slows wound healing, so keep the burn moist. It is essential to avoid further exposure to heat and sunlight. Patients with these types of burns might be able to stay in the backcountry if the pain is controlled....
+
+=== Chunk 1228 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 802 chars
+
+Treatment of Partial and Full Thickness Burns
+Partial and full-thickness burns are more serious and will be painful. Gently clean the burn with cool water to remove loose skin and debris and trim away all loose skin. Apply a thin layer of antibacterial Ointment (i.e. Silvadene) to the burn and cover it with a non-adhesive, sterile dressing. Inspect the wound and change the dressing at least once a day. These might be too painful to keep in the backcountry. Do not apply ice directly to burns for ...
+
+=== Chunk 1229 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 2571 chars
+
+When to evacuate a burn
+Burn injuries that require evacuation consideration are:
+• Partial-thickness burns greater than 10% body surface area
+• Full-thickness burns greater than 1% body surface area
+• Partial- or full-thickness burns involving the face, hands, feet or genitals
+• Electrical burns
+If the burn victim is medically ill
+•
+• Uncontrolled pain
+• Burns complicated by smoke or heat inhalation (evidence of smoke inhalation include difficulty breathing, hoarse voice, singed nasal hairs, or ...
+
+=== Chunk 1230 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 282 chars
+
+Amputated digits
+An amputated digit should be transported promptly. It should never be placed directly on ice, nor should an attempt be made to reattach the finger in the wilderness. Placing an amputated finger in milk has no benefit. (Placing tooth in milk is good to preserve it.)...
+
+=== Chunk 1231 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 725 chars
+
+Penetrating objects
+Never try to pull a penetrating object out of the patient in the field. Use gauze or similar material, alone or with a bulky dressing, to stabilize the object as best you can and evacuate as soon as possible. Removal of the object in the field may cause additional damage and/or cause bleeding and result in serious harm to the patient. Although the surface of a puncture wound should be cleaned to facilitate examination, puncture wounds themselves should generally not be irriga...
+
+=== Chunk 1232 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1528 chars
+
+What Ointment should be used on a wound?
+Honey has been used in wound care for thousands of years to prevent infection and speed the healing process. Medihoney works by keeping the wound bed moist and slow-releasing an antibacterial agent into the wound site. Most normal honey has varying levels of hydrogen peroxide, but Medihoney specifically uses Manuka honey, which also contains methylglyoxal. This helps it to fight a broader range of bacteria strains.
+Lodosorb is an advanced wound care gel u...
+
+=== Chunk 1233 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 781 chars
+
+Chapter 4: Bleeding and Shock
+Everyone reading this chapter has cut or scraped themselves and has bled. Bleeding is also called hemorrhage. It can happen inside the body where it is called internal bleeding, or outside of the body, where it is called external bleeding. When you look at someone bleeding you can usually tell which type of vessel has been ruptured.
+• Capillary bleeding – slow oozing and bright red in color
+• Venous bleeding – steady flow and dark maroon (due to lower oxygen in the ...
+
+=== Chunk 1234 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 552 chars
+
+First Step: Direct Pressure
+The first method is to apply direct pressure on the wound. When applying direct pressure, remember to follow these rules:
+⚫ Use gloves and sterile dressing if available to reduce infection
+⚫ Apply pressure with the heel of hand directly onto wound
+WY y = \\
+Certain wounds are more difficult to control the bleeding, Such as large wounds because of the large number of blood vessels involved. And it is harder to put pressure on the entire wound. Scalp wounds bleed a lot ...
+
+=== Chunk 1235 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 571 chars
+
+Second Step: Pressure Dressing
+A pressure bandage should be applied if there is continued bleeding or if you need your hands to provide other care to the patient. Wrap and hold the dressing in place with an elastic bandage (Ace® wrap) or tape that you wrap around the extremity. If the patient continues to bleed through the pressure dressing, then you should remove the elastic bandage and place additional dressing on top of the dressing that is already on the wound. After applying a pressure band...
+
+=== Chunk 1236 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 703 chars
+
+Third Step: Using a Tourniquet
+While widely viewed as a last resort, in the wilderness a tourniquet can be used initially to stop bleeding. It will hurt where you apply it, but it might save a life. After it is on, you can assess the wound and determine the best approach of treatment and evacuation. If you have tried the other methods to stop the bleeding and the wound continues to bleed a lot through the dressing, then you should consider a tourniquet as well. Always note the time the tournique...
+
+=== Chunk 1237 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 828 chars
+
+Internal bleeding
+Bleeding into a body cavity is life-threatening, so getting the patient to surgical help is essential. Patients can bleed internally anywhere, but there are specific areas of the body (CARTS) that more easily allow for life threatening bleeding
+• Chest (from a broken rib)
+• Abdomen / Pelvis (usually due to a spleen and/or liver injury or pelvis fracture)
+• Renal/Retroperitoneal (kidney area in the back)
+• Thigh (From a broken thigh bone)
+• Skin / Street (Blood is seen on the sk...
+
+=== Chunk 1238 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 216 chars
+
+Shock
+Shock has many meanings in the real world. But in medicine, it is defined as the lack of blood flow to vital organs, particularly the brain. This is why people going into shock will be confused and lightheaded....
+
+=== Chunk 1239 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1625 chars
+
+Causes of Shock
+If you suspect someone is going into shock or is already in shock, you should determine the cause so you can best treat them. Here are the most common causes of shock. Remember that all shock results from failure of one or more of the components of the cardiovascular system.
+Cardiogenic Shock. This is failure of the heart to pump normally. A heart attack is the most common cause. This is where there is muscle damage due to lack of blood supply to the heart muscle.
+Hypovolemic Sho...
+
+=== Chunk 1240 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 320 chars
+
+Special Risk Factors of Shock
+It can be difficult to tell if children and teenagers are in shock as their bodies tend to be more resilient and compensate for a longer period. But the elderly are the opposite of children and young adolescents, as their bodies do not compensate as well and have an earlier onset of shock....
+
+=== Chunk 1241 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 412 chars
+
+Management of Shock
+Anticipate and treat for shock until you have ruled it out. Early intervention is very important. Y9ou should treat the underlying cause if possible. Stop the bleeding, and splint fractures. Insulate from cold or protect from heat and monitor vital signs frequently. Patients with a good level of consciousness should drink to keep hydrated. But most importantly evacuate as soon as possible....
+
+=== Chunk 1242 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 671 chars
+
+The Airway
+You will hear the expression “open airway.’ This term means that air can flow freely from the mouth or nose to the lungs. A lot of things can block the airway, including debris, blood, teeth, and dentures. A very common problem is that the tongue often blocks the airway in cases where the patient is unconscious and laying on their back. The unconscious victim does not “swallow their tongue”. Instead, the tongue is attached to the mouth but will relax backwards and may block full flow ...
+
+=== Chunk 1243 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 337 chars
+
+Head-Tilt/Chin-Lift Maneuver
+1. Tilt the head back by placing pressure on the forehead and lift the chin as shown.
+2. When lifting the chin, apply upward pressure on the bone (avoid pressing on the soft tissue below as this may further block the airway).
+3. Continue until chin points to sky. In children, place head in neutral position....
+
+=== Chunk 1244 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 514 chars
+
+Jaw-Thrust Maneuver
+1. Kneel at the victim’s head facing the victim’s feet.
+2. Put arms in such a position that creates a continuous line with the patient’s spine.
+3. Place thumbs on cheekbones and two or three fingers at the corner of the patient’s jaw (at the angle between chin and ear).
+4. Use counter pressure from your thumbs on the patient’s cheekbones to pull the jaw forward with your fingers.
+• Assess the patient’s breathing.
+• A breathless patient requires foreign-body removal and/or res...
+
+=== Chunk 1245 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 436 chars
+
+Foreign-Body Airway Obstruction: Conscious Adult and Child (Heimlich Maneuver)
+1. Wrap arms around the person’s waist from behind (keep elbows out from ribs).
+2. Make a fist and place thumb in on midline abdomen above navel and well below the bottom of the sternum (breastbone).
+3. Grab your fist with your second hand and pull quickly in and up in a powerful motion.
+4. Repeat until airway clears or until the patient goes unconscious....
+
+=== Chunk 1246 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 125 chars
+
+Foreign-Body Airway Obstruction: Unconscious Adult
+1. The victim should be lowered to the ground and CPR should be initiated....
+
+=== Chunk 1247 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 619 chars
+
+Foreign-Body Airway Obstruction: Conscious Infant Less than One Year Old
+1. Determine why there is a lack of breath
+2. Hold infant as shown in the image above, supporting the head with the head positioned lower than the trunk.
+3. Give five forceful blows between shoulder blades with the heel of your hand.
+4. Using the hand that was used to give the blows, support the neck and back of the baby’s head while turning the baby on its back, then give five chest thrusts with the finger of your free han...
+
+=== Chunk 1248 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 591 chars
+
+Foreign-Body Airway Obstruction: Unconscious Infant Less than One Year Old
+1. Open the airway using tongue-jaw lift maneuver. Look for obstruction—DO NOT blind finger sweep.
+2. Open the airway and ventilate by sealing your mouth over the patient’s mouth and nose and breathe out slowly so the baby’s chest rises.
+3. If the first attempt fails, reposition the airway and try a second time.
+4. If the airway is still blocked, give five back blows then five chest thrusts.
+5. Repeat steps 1-3 until the ...
+
+=== Chunk 1249 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1011 chars
+
+Rescue Breathing Review
+In most situations, hands only CPR should be performed without any rescue breathing. Those unique wilderness situations that may require rescue breathing as part of CPR include drowning, lightning strike, and avalanche burial. If you are going to perform rescue breathing on a victim, you should use barrier protection to keep yourself safe. This is especially true because rescue breathing is only really indicated in drowning, lightning, and avalanche burial.
+1. Pinch the p...
+
+=== Chunk 1250 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 467 chars
+
+Rescue Breathing Exceptions in Children and Infants
+When performing rescue breaths on children, do not tilt the child’s head too far back as this may block the airway in young patients. If you are going to perform rescue breathing on a victim, you should use barrier protection to keep yourself safe.
+1. Seal off mouth and nose with your mouth.
+2. Use small puffs instead of full breaths.
+3. Watch the patient’s chest and abdomen.
+4. Use one breath per three seconds....
+
+=== Chunk 1251 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 626 chars
+
+Chapter 6: Musculoskeletal Injuries
+Sprains
+A sprain involves the ligaments (tissue that connects bone to bone) of a joint and means that the ligaments have been stretched or even torn. A sprain usually occurs when a joint is twisted or wrenched beyond the normal range of motion which causes the ligaments to stretch or tear. While sprains can occur in any joint in the body they happen most often in the knees and the ankles. Symptoms include pain, swelling, and discoloration of the injured joint ...
+
+=== Chunk 1252 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 773 chars
+
+Strains
+Strains, unlike a sprain, involve tendons which are the fibrous bands that connect muscles to bones and facilitate the movement of our limbs. A strain, simply put is fatigue due to overuse or strenuous movements. While strains are usually considered to be minor injuries, they can cause pain and discomfort.
+While strains are not as severe as the other injuries that have been mentioned there is treatment for them. The best way to deal with strains is to try and minimize the use of the limb...
+
+=== Chunk 1253 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 358 chars
+
+Dislocations
+A dislocation occurs when a sufficient force (a push or a pull) is placed on a joint which causes a bone to come out of its socket. Dislocations are most common in the shoulder, elbow, finger, and kneecap. While dislocations themselves can create quite an ordeal the real damage is usually caused to blood vessels, nerves, muscle, and ligaments....
+
+=== Chunk 1254 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1947 chars
+
+Fractures
+A fracture is any break or crack in a bone. There are two general types of fractures:
+1. Closed fracture: In this case the bone is broken but has not punctured the skin exposing the bone. If a closed fracture is left untreated or handled improperly, it can quickly progress into an open fracture.
+2. Open (compound) fracture: Just like a closed fracture the bone is broken except in this case the fractured bone has punctured the skin creating an open wound. Be aware that the bone does not...
+
+=== Chunk 1255 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1008 chars
+
+Pelvic Fractures
+Fractures sustained to the pelvis or pelvic area is serious because they are usually accompanied by significant internal bleeding. This bleeding can result in shock or even death. Along with internal bleeding, pelvic fractures can also cause damage to other internal organs such as the intestines or bladder. Symptoms of a pelvic fracture include pain in the pelvis, hip, or lower back. with the inability to bear weight or significant pain around the hip or waistline. And there wil...
+
+=== Chunk 1256 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 351 chars
+
+Femur (Thigh Bone) Fractures
+Due to the presence of very large thigh muscles and arteries that surround the femur, a broken femur can be life threatening due to bleeding. They are very painful. When the bone breaks, the thigh muscles strongly contract and force the broken bone ends into the muscle, which causes extreme pain and increased blood loss....
+
+=== Chunk 1257 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 700 chars
+
+Treatment
+General
+If the mechanism of injury is unknown or such that a neck or back injury is suspected, immobilize the neck immediately upon reaching the victim. Completely uncover the injured area to look for deformity, swelling, discoloration, breaks in the skin consistent with an open fracture, and other associated injuries. Gently feel the injured area for tenderness, abnormal movement, and crepitation. Check for numbness or altered sensation beyond the injury. Check circulation beyond the ...
+
+=== Chunk 1258 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1089 chars
+
+Splinting Basics
+The main reason for splinting an injury is to immobilize a limb to not exacerbate an injury. Splints can also help to reduce pain that accompanies various musculoskeletal injuries. Please note that while splinting is not only good practice but is also necessary to reduce pain and protect the injury from worsening. It is also only a preliminary treatment used in the event to evacuate a victim to seek further medical care. General principles regarding splinting include:
+A splint s...
+
+=== Chunk 1259 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1273 chars
+
+General guidelines for splinting
+⚫ Remove ALL (including sentimental) jewelry and accessories, such as watches, bracelets, and rings, before applying a splint. Swelling due to injury will make these objects very hard to remove if left in place.
+⚫ Use padding within the splint to make it as comfortable as possible for evacuation. Use plenty of padding at bony protrusions, such as elbows, knees, and ankles.
+⚫ Splints should be made from rigid, sturdy material. Examples are sticks, boards, skis, pa...
+
+=== Chunk 1260 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 617 chars
+
+Sprains
+RICES was the acronym that is used to treat sprains: Rest, Ice, Compression, Elevation, and Stabilization. The problem is that prolonged ice application may prevent blood flow to the area and retard healing, So, ice should be applied initially only Compression also, prevents blood flow into the area so this is discouraged. Stabilizing the injury is important and elevation will help with the swelling. Rather then rest, a patient can start to use the injured area as the pain decreases.
+Thi...
+
+=== Chunk 1261 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 560 chars
+
+Realignment of a Closed Fracture
+It is not necessary to realign a fractured limb unless distal function and circulation is restricted or in the case that deformity makes it impossible to splint and transport. However, if it can be easily realigned here are some things to consider:
+⚫ Numbness, tingling, and/or blue discoloration of the skin beyond the injury, all of which indicate poor blood flow (circulation) indicate the need to realigned the fractured limb.
+⚫ Realignment is easier if it is don...
+
+=== Chunk 1262 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 385 chars
+
+Realignment of a closed fracture
+⚫ Straighten the limb by pulling on it below the fracture in a direction that will straighten it. This
+should be done while someone else holds the limb above the fracture.
+⚫ While continuing to hold the limb straight, apply a splint to prevent further motion.
+⚫ Check distal function and sensation after realignment often and track the limb’s progress....
+
+=== Chunk 1263 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1425 chars
+
+Realignment of an Open Fracture
+Reasons for realigning an open fracture are fundamentally the same as for realigning a closed fracture. The procedure for aligning a closed fracture is like an open fracture but also includes the following:
+⚫ The wound and extruding parts of the bone should be thoroughly irrigated and removed of all foreign matter. Although risk of infection is present, it may be necessary to replace the exposed bone end back into the wound during traction for proper realignment.
+...
+
+=== Chunk 1264 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 314 chars
+
+Femur Fractures
+⚫ Use a traction splint if available. The traction splint will pull the overlapped bone ends into alignment and help to relieve pain.
+⚫ If a traction splint is not available, then splint the injured leg to the good leg by tying them together and recheck sensation and circulation in the foot often....
+
+=== Chunk 1265 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 430 chars
+
+Evacuation Guidelines
+Reasons for evacuating victims with musculoskeletal injuries from the wilderness include:
+⚫ Sprains that are significant enough to prevent further activities in the wilderness.
+⚫ All suspected fractures, whether open or closed.
+⚫ Any victim who has loss of sensation or impaired circulation beyond the site of the injury.
+⚫ Any suspected fracture that is in an area that would be considered life threatening....
+
+=== Chunk 1266 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 577 chars
+
+Chapter 7: Medical Problems
+Think of the differences in having a serious medical problem while you are home, knowing there is medical help nearby, to having a serious medical issue when you are in a remote section of the backcountry, and have no clue how to get help. Some medical problems occur with higher frequency in the backcountry, while others occur about the same rate while at home. By being able to recognize the signs and symptoms of serious medical conditions, you can provide a proper tr...
+
+=== Chunk 1267 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 589 chars
+
+CARDIAC EMERGENCIES
+Not long ago in the mountains surrounding Chamonix, France, a 56-year-old man began having chest pain while hiking on the famed Tour du Mt. Blanc. Friends and family were the only people nearby. The man survived and was ultimately brought out by a rescued team, but it was only after many hours. Evaluating and treating cardiac problems can be difficult in a hospital setting where the full spectrum of diagnostic equipment and treatments are available. It is even much more diffi...
+
+=== Chunk 1268 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 945 chars
+
+Angina
+Angina is the term given to chest pain that is associated with diminished blood flow to a portion of the heart that does not cause actual damage. It is cardiac ischemia (low blood flow) but not infarction (death of heart muscle). Angina results from an imbalance between cardiac muscle oxygen demand and oxygen supply. This supply may be restricted due to atherosclerotic disease. But there are many reasons for an imbalance in oxygen supply and demand to occur in the wilderness. For example,...
+
+=== Chunk 1269 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 3002 chars
+
+There are two types of angina:
+1. Stable angina is chest pain due to cardiac ischemia that is well known to the patient for a period of several weeks, months, or even years. It is commonly due to stable atherosclerosis in the coronary arteries. The patient knows the symptoms and usually knows what level of activity causes these symptoms.
+2. Unstable angina is new chest pain that is concerning for cardiac ischemia or a changing pattern in formerly stable angina. This is commonly attributed to a w...
+
+=== Chunk 1270 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 3361 chars
+
+Acute Myocardial Infarction (MI)
+Acute Myocardial Infarction (MI) is the term given to chest pain that is associated with absent or diminished blood flow to a portion of the heart that causes myocardial tissue death (infarction).
+The most common etiology for an MI is an atherosclerotic plaque in one of the coronary arteries that rupture, causing the formation of a clot within the artery.
+This clot obstructs the flow of blood distal to that obstruction. If that clot is not relieved as soon as pos...
+
+=== Chunk 1271 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 358 chars
+
+RESPIRATORY EMERGENCIES
+The inability to breathe normally is a scary feeling and causes anxiety for many. Respiratory issues are common in the wilderness for a variety of reasons, including increased allergens, smoke from
+campfires, lower oxygen and drier air associated with higher altitudes, increased exertion, and increased physical and emotional stress....
+
+=== Chunk 1272 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1582 chars
+
+Asthma
+Asthma is a chronic, non-progressive lung disorder characterized by increased airway reactivity to irritants, airway inflammation, and reversible airway obstruction. In the wilderness, asthma can be triggered by a multitude of potential etiologies such as increased strenuous activity, exposure to cold, changes in humidity, exposure to
+mance muscle tightens muscle swelling mucus Normal Airway Asthmatic Airway
+environmental allergens, exposure to camp smoke, and medication noncompliance due...
+
+=== Chunk 1273 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 626 chars
+
+Pneumonia
+Pneumonia in the wilderness is a clinical diagnosis based on the patient’s history and exam findings. The patient will have chest pain that may be dull or sharp, may have a pleuritic component, and a cough that may be dry or productive of sputum. They will have shortness of breath, and also on exertion. They will have a fever and chills and an increased respiratory rate.
+If you suspect that someone has pneumonia, you should start antibiotics, even if unsure. Azithromycin or doxycycline...
+
+=== Chunk 1274 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1557 chars
+
+Pulmonary Embolism (PE) & Deep Venous Thrombosis (DVT)
+Pulmonary Embolism (PE), or a blood clot to the lung, can be seen in wilderness activities. Traveling a long distance with relative immobilization places someone at risk of developing a deep venous thrombosis (DVT) and/or a PE. This is an essential consideration for those who traveled great distances to begin their wilderness adventure. High-altitude climbers are more susceptible to PE, particularly if they are dehydrated. Risk factors for D...
+
+=== Chunk 1275 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 187 chars
+
+Cerebral Vascular Accident (Stroke)
+Cerebral Vascular Accident (CVA), or stroke, can occur anywhere but are seen in the wilderness for a variety of reasons. There are two types of stroke:...
+
+=== Chunk 1276 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 250 chars
+
+Ischemic
+This is the most common type of stroke. Obstruction of blood flow to a portion of the brain leads to one-sided weakness, paralysis, trouble talking, or facial droop. This obstruction is most commonly due to a small intra-arterial blood clot....
+
+=== Chunk 1277 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1979 chars
+
+Hemorrhagic
+This stroke is due to intra-cerebral bleeding, most often from high blood pressure or a ruptured brain aneurysm. Patients usually have a significant headache and a denser neurologic deficit, or complete loss of consciousness.
+The signs and symptoms of each are not consistent enough to allow one to discern an ischemic stroke from a hemorrhagic stroke in the wilderness. The only accurate way to tell the difference between ischemic and hemorrhagic strokes is by brain imaging (CT or MRI)...
+
+=== Chunk 1278 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 2450 chars
+
+Seizures
+Seizures are an uncommon medical problem in the wilderness because most people with this disorder tend to avoid wilderness activities. Either that or they are well controlled. In general, patients should be seizure-free for approximately six months before attempting to trek into the wilderness for any significant amount of time. There are numerous reasons for a patient with a known seizure disorder to seize in the wilderness, including:
+• Fatigue and lack of adequate sleep.
+• The risk o...
+
+=== Chunk 1279 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 3241 chars
+
+DIABETIC EMERGENCIES
+Diabetic patients who travel in the wilderness have very few limitations. Most diabetics know their diabetes well and are usually able to manage it appropriately on their own. Diabetics should carry a method to measure their serum glucose level on their trips. The diabetic should educate other people on how to use their glucose monitoring equipment in case they are unable to measure it themselves. This is especially important for you to know if you are going to be the medica...
+
+=== Chunk 1280 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 2939 chars
+
+ALLERGIC REACTIONS AND ANAPHYLAXIS
+Allergic reactions are common in the backcountry. On a spectrum, there are three types of allergic reactions that exist: local, generalized, and anaphylaxis. Any of these reactions can occur within seconds of exposure to an allergen.
+Local reactions are very common in the wilderness setting. They are characterized by red and swollen areas of the skin that are usually pruritic. Topical corticosteroids provide relief and should be carried in a first aid kit. Bena...
+
+=== Chunk 1281 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 295 chars
+
+ABDOMINAL EMERGENCIES
+Any cause of abdominal pain in a city can also be a cause of pain in the backcountry. However, there are some causes that are more common in the backcountry. It can be a challenge to know what is causing the pain, and if a person should be evacuated out of the backcountry....
+
+=== Chunk 1282 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 587 chars
+
+Severe Constipation / Fecal Impaction
+This is more common in the wilderness than most people realize. A person can become dehydrated easily, which leads to hard stools. They may feel awkward defecating outdoors, the delay of which can lead to impaction.
+Symptoms are no stooling for several days, gradually increasing the pain. The treatment is high levels of hydration plus increased fiber. Bowel stimulants are indicated. Caffeinated drinks can stimulate bowel motility. Fecal impaction is not an i...
+
+=== Chunk 1283 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1194 chars
+
+Gastritis / Gastroenteritis
+This is a very common cause of backcountry abdominal pain. It is often caused by a virus or a bacterium that is ingested with food.
+Symptoms include nausea, vomiting, and abdominal pain or discomfort. The patient often has, or will have, diarrhea that may be watery and contain mucus and blood. They may have a fever. Patients may have significant malaise and fever. Dehydration may occur from an inability to take liquids and considerable fluid loss from diarrhea. While ...
+
+=== Chunk 1284 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1209 chars
+
+Ectopic pregnancy
+Ectopic pregnancy is probably the most urgent cause of abdominal pain due to its potential to take a life. The symptoms are not subtle. There is lower abdominal pain or abnormal vaginal bleeding in a sexually active fertile female. The pain may be in the midline or unilateral in location, depending on where the ectopic pregnancy is located. Initially, the pain may be mild in nature. Not all patients will have vaginal bleeding or specific vaginal symptoms. An over-the-counter ur...
+
+=== Chunk 1285 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 876 chars
+
+Appendicitis
+Appendicitis does occur in the backcountry, and it is difficult to diagnose. It’s difficult to diagnose appendicitis in the hospital setting, even with diagnostic testing, so you can imagine the difficulty with making a diagnosis in a wilderness setting.
+Symptoms often start as epigastric discomfort that may be associated with anorexia, nausea, and possibly vomiting. The abdominal pain progressively worsens over the next 6 to 24 hours as it localizes to the right lower quadrant. The...
+
+=== Chunk 1286 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 927 chars
+
+Gallstones
+Gallstones have occurred in people on a wilderness trip, but no more frequently than if one is at home. Most people know if they have gallstones, or have had gallstones, and will recognize the pain. This will help in making decisions. Gallstones present with abdominal pain that is typically located in the middle of the abdomen. The pain may radiate to the back or into the right shoulder. Nausea and vomiting are common and may be the initial symptoms before the pain.
+Treatment is to fi...
+
+=== Chunk 1287 ===
+Source: Basicfirstaidunchunk.pdf
+Length: 1314 chars
+
+Kidney stones
+Kidney stones can occur in the backcountry, and possibly with more frequency in people who are prone to them. The reason is dehydration. People will who have had kidney stones should make sure they stay hydrated. Symptoms are the sudden onset of severe pain in the flank or back or unilateral abdominal pain. The pain is colicky and may radiate to the groin. The patient has difficulty finding a comfortable position and will be writhing in pain. Treat them with pain relief. Ibuprofen ...
+
+=== Chunk 1288 ===
+Source: 0880_002-ebook.pdf
+Length: 36 chars
+
+Untitled Section
+Revised and Updated...
+
+=== Chunk 1289 ===
+Source: 0880_002-ebook.pdf
+Length: 233 chars
+
+iter Boilies after Disasters: A Field Manual for First Ps TEES UC
+Second Edition
+Ss
+é le >) Cc
+iy Pan American Cee SUC CUCL
+International Federation of Red Cross and Red Crescent Societies
+World Health Organization
+1
+ay Ce Erte Cec
+]...
+
+=== Chunk 1290 ===
+Source: 0880_002-ebook.pdf
+Length: 2851 chars
+
+A FIELD MANUAL FOR FIRST RESPONDERS
+SECOND EDITION
+Editors
+Stephen Cordner
+Professor of Forensic Pathology, Monash University and Victorian Institute of Forensic Medicine
+Rudi Coninx
+Health Emergency Programme, World Health Organization
+Hyo-Jeong Kim Health Emergency Programme, World Health Organization
+Dana van Alphen Disaster Preparedness and Response, Pan American Health Organization
+Morris Tidball-Binz Head of Forensic Services, International Committee of the Red Cross
+Pan American Health ex...
+
+=== Chunk 1291 ===
+Source: 0880_002-ebook.pdf
+Length: 3774 chars
+
+FOREWORD
+Natural disasters can have catastrophic consequences, causing large numbers of deaths and overwhelming local and even regional emergency response services. Local organizations and communities are usually the first to respond to a disaster, which includes rescuing and caring for survivors and managing the dead.
+The humanitarian community recognizes that proper management of the dead is a key component of disaster response, together with the recovery and care of survivors and the supply o...
+
+=== Chunk 1292 ===
+Source: 0880_002-ebook.pdf
+Length: 1720 chars
+
+CONTRIBUTORS
+Marc Bollman Rudi Coninx Stephen Cordner Simon Djidrovski Eric Dykes Serge Eko Oran Finegan William Goodwin Hyo-Jeong Kim Maria Mikellide Pierre Perich Jose Luis Prieto Morris Tidball-Binz Forensic Pathologist, Centre Universitaire Romand de Médicine Légale and member of the Swiss DVI Team Health Emergencies Programme, World Health Organization, Geneva, Switzerland Professor of Forensic Pathology, Monash University; Head of International Programmes, Victorian Institute of Forensic M...
+
+=== Chunk 1293 ===
+Source: 0880_002-ebook.pdf
+Length: 8621 chars
+
+TABLE OF CONTENTS
+Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . III Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V 1 . Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....
+
+=== Chunk 1294 ===
+Source: 0880_002-ebook.pdf
+Length: 2556 chars
+
+Aims
+1. To promote effective leadership and coordination among agencies to plan and deliver the response.
+2. To ensure that available resources are used effectively and efficiently to manage the dead bodies.
+1. To promote the safe handling of dead bodies.
+2. To improve the understanding that the risk to first responders and to the public generally of infectious disease spreading from dead bodies is very low.
+Note: This chapter does not cover disasters involving chemical or radiation hazards. The...
+
+=== Chunk 1295 ===
+Source: 0880_002-ebook.pdf
+Length: 7775 chars
+
+Overview
+1. Disaster management plans should be developed in advance (see Annex 4).
+The plans should include special arrangements for dead bodies (e.g. see Annex 5), which are then imple- mented by first responders:
+2.
+✶ Planning should be initiated by the senior emergency management, health or police official respon- sible for disaster planning, or by the professional responsible for forensic medicine.
+✶ Special arrangements should be developed jointly with police, faith representatives, govern...
+
+=== Chunk 1296 ===
+Source: 0880_002-ebook.pdf
+Length: 52 chars
+
+Box 1. Items for the recovery of the dead
+Protective...
+
+=== Chunk 1297 ===
+Source: 0880_002-ebook.pdf
+Length: 418 chars
+
+Protective equipment:
+1. Impermeable aprons*
+2. Disposable overalls: XXL, XL and L sizes preferable
+19. Axe/machete
+20. T-sound (metal ground probe), at least 2 metres long
+21. Communications equipment
+3. Protective eye-wear (i.e. goggles)
+4. Gloves (heavy duty and mortuary types, large sizes)*
+5. Rubber (washable) boots*
+6. Masks (surgical disposable)
+7. Masks (chemical/fume protection) + supplies (i.e. canisters)...
+
+=== Chunk 1298 ===
+Source: 0880_002-ebook.pdf
+Length: 371 chars
+
+Record-keeping equipment:
+1. Cable ties, ankle size*
+2. Body-tags (see Annex 3), waterproof with printed numbers. Otherwise use tags with writing surface to write unique body code (sturdy, plastic or metal, with holes for cable ties and writing surface)*
+8. Insect repellent
+9. Sunscreen
+10. Hand and surface disinfectants (soap, liquid)*
+11. Wet wipes
+12. First-aid kit*...
+
+=== Chunk 1299 ===
+Source: 0880_002-ebook.pdf
+Length: 1534 chars
+
+Recovery, transportation and storage equipment:
+1. Body-bags (carrier bags with handles)*
+2. Stretcher/s
+3. White sheets
+4. Zippered plastic bags, with writing surface (evidence collection bags ideal), 3 sizes*
+5. Screw-top containers for sealed storage of samples
+6. Paper bags, 3 sizes
+7. Industrial garbage bags
+8. Cardboard boxes (for skeletal remains)
+9. Water-resistant adhesive tape
+10. Cutter/s or scissors
+11. Sample tubes (plastic, with writing surface)
+12. DNA sample collection kits (FTA/...
+
+=== Chunk 1300 ===
+Source: 0880_002-ebook.pdf
+Length: 2023 chars
+
+Effective local coordination
+♦ As soon as possible, and in accordance with existing disaster management plans, identify the agency and name the person to serve as the local coordinator with full authority and responsibility for the manage- ment of the dead (e.g. local governor, police chief, military commander or mayor).
+♦ The selection of medical or hospital directors as coordinators should be discouraged as their primary responsibility is the care of the living and the injured.
+♦ Establish a t...
+
+=== Chunk 1301 ===
+Source: 0880_002-ebook.pdf
+Length: 1129 chars
+
+Effective regional and national coordination
+♦ As soon as possible, name a person as national or regional coordinator with the appropriate authority for the management of the dead (e.g. minister, governor, police chief, military commander or mayor).
+♦ Refer to the mass fatality section of your disaster management plan.
+♦ Establish a coordination group including key individuals to advise on:
+✶ liaison with the local agency and responsible person;
+✶ logistical support (e.g. military or police);
+✶ ...
+
+=== Chunk 1302 ===
+Source: 0880_002-ebook.pdf
+Length: 3629 chars
+
+DO’S AND DON’TS
+♦ Do include the management of the dead in every disaster response plan.
+♦ Do plan in advance for a disaster where first responders will need to deal with the dead.
+ref
+♦ Do understand that a good early response enables and certainly increases the number of identifications.
+♦ Do not ignore the dead in disaster planning.
+♦ Do not ignore the needs of the families of the dead.
+5
+3.  HEALTH AND SAFETY –    INCLUDING INFECTIOUS   DISEASE RISKS OF DEAD BODIES
+♦ Do allocate a unique cod...
+
+=== Chunk 1303 ===
+Source: 0880_002-ebook.pdf
+Length: 696 chars
+
+Infectious disease transmission and dead bodies
+♦ Victims of natural disasters usually die from injury, drowning or fire, and not from disease.
+♦ At the time of death, victims of such disasters are not likely to be sick with infections that cause epidem- ics (e.g. plague, cholera, typhoid, anthrax, Ebola).
+♦ Some victims may have chronic bloodborne infections such as hepatitis or HIV, or may have tuberculo- sis, or diarrhoeal or other infectious diseases.
+♦ Infectious organisms survive for a var...
+
+=== Chunk 1304 ===
+Source: 0880_002-ebook.pdf
+Length: 214 chars
+
+Risk to the public
+♦ There is a risk (which has never been measured or documented) of drinking water from sources becom- ing contaminated by faecal material released from dead bodies and possibly causing diarrhoea....
+
+=== Chunk 1305 ===
+Source: 0880_002-ebook.pdf
+Length: 1024 chars
+
+Risk to body-handlers
+♦ The bodies of people killed in disasters may be bloodstained and/or leaking faeces and other body fluids (e.g. stomach contents).
+♦ Persons who have direct contact with blood, faeces or other body fluids have a small risk of infection while handling dead bodies with the following diseases:
+✶ hepatitis B and C
+✶ HIV/AIDS
+✶ diarrhoeal diseases.
+♦ High risks exist when handling dead bodies in epidemics due to highly infectious diseases. Examples include Ebola, other viral ha...
+
+=== Chunk 1306 ===
+Source: 0880_002-ebook.pdf
+Length: 1681 chars
+
+Safety precautions for body-handlers
+♦ Health and safety precautions should take into account existing environmental hazards.
+♦ Basic hygiene helps to protect workers from diseases spread by blood and other body fluids.
+♦ Workers should also be trained, preferably prior to the disaster, to:
+✶ use basic personal protection equipment, including at least waterproof gloves, an apron and boots (see Fig. 3.1);
+✶ not wipe face or mouth with hands;
+✶ understand that face masks are not essential;
+✶ wash ...
+
+=== Chunk 1307 ===
+Source: 0880_002-ebook.pdf
+Length: 1123 chars
+
+DO’S AND DON’T
+♦ Do seek security clearance of the site before proceeding with the search and recovery of dead bodies.
+♦ Do ensure that first responders are aware of the risks of entering potentially hazardous environments.
+eff
+♦ Do treat bodies carefully and with respect.
+♦ Do understand that in deaths from natural disasters (earthquakes, floods, typhoons) the risk of infectious disease transmission is extremely low, especially with the basic precautions outlined above.
+♦ Do inform people that ...
+
+=== Chunk 1308 ===
+Source: 0880_002-ebook.pdf
+Length: 212 chars
+
+Aim
+1. To explain how to allocate a unique code to the dead bodies
+1. To describe the approach to the recovery of dead bodies.
+1. To describe the purpose and possible options for temporary storage of dead bodies....
+
+=== Chunk 1309 ===
+Source: 0880_002-ebook.pdf
+Length: 932 chars
+
+Process
+♦ Assign a unique code (it should include text and a sequential number) to each body or body part.
+♦ Unique body codes must not be duplicated.
+“of
+♦ Prior agreement on a standard approach to creating unique body codes is recommended.
+♦ An example of a unique body code is a composite of three items: i) the name of the place where the body was found; ii) the name of the team which located the body; and iii) a number.
+♦ Inclusion of the specific place where the body was found and the name o...
+
+=== Chunk 1310 ===
+Source: 0880_002-ebook.pdf
+Length: 503 chars
+
+Label
+♦ Annex 3 is an example of a label which could be used to record the unique body code as well as record the chain of custody of the dead body. Write the unique body code on two waterproof labels (or paper sealed in plastic) and securely attach the labels to:
+✶ the body (e.g. the wrist or ankle) or body part, and to
+✶ the container for the body or body parts (e.g. body bag, cover sheet or bag for the body part).
+11
+12
+rs: A Field Manual for First Responders Management of Dead Bodies after D...
+
+=== Chunk 1311 ===
+Source: 0880_002-ebook.pdf
+Length: 1437 chars
+
+General principles
+♦ Visual recognition of dead bodies is relied upon in normal circumstances, in the period before the onset of decomposition and with the assistance of professionals, as a means of formal identification. In circum- stances following disasters without expert oversight, visual recognition can be mistaken. These mistakes cause serious distress and legal difficulties for the bereaved, and embarrassment to the authorities.
+♦ Injuries, decomposition, or the presence of blood, fluids ...
+
+=== Chunk 1312 ===
+Source: 0880_002-ebook.pdf
+Length: 2548 chars
+
+Photograph (mandatory if situation allows and photographic equipment is available)
+♦ The importance of early photography prior to the onset of decomposition cannot be overstated. If at all possible, the photographs of the body should be taken as soon as the unique body code is allocated, at the time of recovery of the body. This is likely to be the single most important contribution enabling the body to be identified.
+♦ The unique body code must be included, and must be readable, in all photogra...
+
+=== Chunk 1313 ===
+Source: 0880_002-ebook.pdf
+Length: 1390 chars
+
+Data from dead bodies
+♦ Basic data about the dead body, such as his/her general condition, state of preservation, physical charac- teristics and external appearance, must be collected as soon as possible. While realising that often it will be difficult, every effort should be made to do this before the onset of decomposition.
+♦ Data should be recorded as soon as the recovery operation starts. Recovery teams are advised to assign a person to be responsible for recording information on dead bodies...
+
+=== Chunk 1314 ===
+Source: 0880_002-ebook.pdf
+Length: 540 chars
+
+Record (mandatory)
+♦ Always record the following data, together with the unique body code, using the Dead Body Information Form in Annex 1:
+✶ sex (if recognizable without full body search)
+✶ approximate age range (infant, child, adolescent, adult or elderly)
+✶ personal belongings (jewellery, clothes, identity card, driver’s licence, etc.)
+✶ obvious specific marks on the skin (e.g. tattoos, scars, birthmarks) without removing clothes
+✶ any obvious deformity.
+♦ Also record:
+✶ height
+✶ colour and l...
+
+=== Chunk 1315 ===
+Source: 0880_002-ebook.pdf
+Length: 219 chars
+
+Secure (mandatory)
+♦ After examination, recording and photographing of personal belongings from the body, these should be left on the body or in the clothing where they were found.
+♦ Clothing should be left on the body....
+
+=== Chunk 1316 ===
+Source: 0880_002-ebook.pdf
+Length: 1138 chars
+
+Identification and release of body to relatives
+♦ Identification and release of dead bodies is under the responsibility of the authorities.
+♦ The scientific identification of the bodies is the domain of forensic experts, applying Interpol DVI Guidelines. Such experts should be involved in the identification process if they are available.
+♦ However, it is recognized that in some contexts forensic experts may not be available.
+♦ In such circumstances, to increase the reliability of any visual reco...
+
+=== Chunk 1317 ===
+Source: 0880_002-ebook.pdf
+Length: 584 chars
+
+Locating dead bodies
+♦ This is often done by surviving family, friends and other first responders.
+♦ Later, organized and experienced search and recovery teams may arrive.
+♦ The risks of removing dead bodies from collapsed building or other dangerous places which usually accompany disasters need to be emphasized. Injury and death that occur in many phases of the disaster response, particularly recovery, are well recognized. Health and safety precautions should prevail as the operation proceeds.
+...
+
+=== Chunk 1318 ===
+Source: 0880_002-ebook.pdf
+Length: 663 chars
+
+Body recovery
+♦ Rapid body recovery is a priority because it aids later identification and reduces the psychological burden on survivors. However, it should not interrupt other interventions aimed at helping survivors.
+♦ Ideally, allocating the unique body code, taking photographs, documenting dead body data, and secur- ing the documentation should occur around the same time as moving the body (see chapters 4 and 5).
+♦ Dead bodies of adults are difficult to handle and normally at least two peopl...
+
+=== Chunk 1319 ===
+Source: 0880_002-ebook.pdf
+Length: 980 chars
+
+Body bags or similar storage items available
+♦ The dead body should be placed in a body bag at the place of recovery. Generally at least two people are needed to move an adult in a body bag (Fig. 6.1 – 6.6).
+RECOVERY OF DEAD BODIES
+Fig. 6.1
+Fig. 6.2
+Fig. 6.3
+Fig. 6.4
+Fig. 6.5
+Fig. 6.6
+Fig. 6.1 – 6.6: Side-roll movement for placing a body in a body bag: The body, tagged around the wrist with its unique body code, having been placed on the ground (Fig. 6.1), is rolled to its side (Fig. 6.2). The b...
+
+=== Chunk 1320 ===
+Source: 0880_002-ebook.pdf
+Length: 586 chars
+
+No body bags or similar storage items available
+♦ If no body bags are available, the best way to move a dead body is with one person on each side of
+the body.
+♦ One person supports the head and pelvic area while the other supports the upper back and lower thighs for both lifting the body and moving it.
+♦ Alternatively, for heavier bodies or with a third person helping, one stands at the head end of the body supporting the head and shoulders, while the other two are on each side of the body suppo...
+
+=== Chunk 1321 ===
+Source: 0880_002-ebook.pdf
+Length: 403 chars
+
+After recovery of the body
+♦ After dead bodies are recovered, they should be kept in the coolest possible area, protected from direct sunlight, scavengers and public viewing and should be secured.
+♦ Ideally, if not already in one, each body should be in a body bag or similar storage item.
+♦ If a collection centre is established (see Chapter 7), the bodies should be taken there for further processing....
+
+=== Chunk 1322 ===
+Source: 0880_002-ebook.pdf
+Length: 773 chars
+
+Storage options
+♦ Whichever storage option is used, each body or body part should be kept in a body bag or similar stor- age item before storage.
+♦ Waterproof labels or paper in sealed plastic with the unique body code should be used. Do not write the unique body code directly on bodies or body bags/sheets only as it may be easily erased, or the sheet separated from the body, during storage.
+♦ The preferred storage option is refrigerated containers which should be placed in a suitable location (...
+
+=== Chunk 1323 ===
+Source: 0880_002-ebook.pdf
+Length: 481 chars
+
+Refrigeration
+♦ Refrigeration between 2oC and 4oC (35.6oF and 39.2oF) is the best option.
+♦ Refrigerated transport containers used by commercial shipping companies can be used, with suitable
+racking, to store up to 50 bodies.
+♦ Enough containers are seldom available at the disaster site and alternative storage options, such as a cool and protected room or environment, should be used until refrigeration becomes available.
+23
+24
+Management of Dead Bi rs: A Field Manual for First...
+
+=== Chunk 1324 ===
+Source: 0880_002-ebook.pdf
+Length: 1201 chars
+
+Temporary burial
+♦ Temporary burial, following allocation of the unique body code, taking photographs and completion of the Dead Body Information Form, provides a good option for early storage where no other method is avail- able, where longer-term temporary storage is needed and where it does not conflict with cultural norms.
+♦ The underground temperature is usually lower than that at the surface, thereby providing a form of natural cooling and protection, including from scavengers.
+♦ Temporary...
+
+=== Chunk 1325 ===
+Source: 0880_002-ebook.pdf
+Length: 550 chars
+
+Ice
+♦ The use of dry ice (frozen carbon dioxide) is not recommended as it produces toxic carbon dioxide, can cause cold “burns”, and is a major logistical problem.
+♦ The use of ice (frozen water) should be avoided where possible because:
+✶ In hot climates ice melts quickly and large quantities are needed.
+✶ Melting ice produces large quantities of dirty waste-water that may cause diarrhoeal disease.
+✶ Disposal of this waste-water creates additional management problems.
+✶ The water may damage bod...
+
+=== Chunk 1326 ===
+Source: 0880_002-ebook.pdf
+Length: 191 chars
+
+Method of disposal/long-term storage
+♦ Burial is the preferred option in the case of mass casualties and the most effective method as it preserves evidence for possible future identification....
+
+=== Chunk 1327 ===
+Source: 0880_002-ebook.pdf
+Length: 1076 chars
+
+Burial conditions
+♦ A specific location should be identified as a burial area, with boundaries clearly established and pro- tected (see Annex 7).
+♦ Careful thought must be given to the location, the customs and wishes of the local community, and land ownership.
+♦ Use of the site should be acceptable to those living in nearby communities.
+♦ The site should be close enough for members of the affected community to visit.
+♦ The burial site should be clearly marked and surrounded by a buffer zone tha...
+
+=== Chunk 1328 ===
+Source: 0880_002-ebook.pdf
+Length: 1174 chars
+
+Grave construction
+♦ Human remains should be buried in clearly marked individual graves.
+♦ For extreme disasters (i.e. very large numbers of fatalities with limited resources and/or capacity to dig individual graves), trench burial may be unavoidable.
+♦ Burial sites should be at least 30 m from springs or watercourses and 200 m from any well or source of drinking water.
+♦ Prevailing religious practices may indicate preference for the orientation of the bodies (e.g. heads facing east, or towards ...
+
+=== Chunk 1329 ===
+Source: 0880_002-ebook.pdf
+Length: 1317 chars
+
+Traceability
+♦ Careful documentation and mapping of the burial site are important to ensure that the dead bodies can be traced throughout the process. In this way, the place of final disposal of those remaining unidentified is accurately recorded.
+♦ Make sure that each dead body, and its body bag or coffin, is securely tagged with its unique body code on a waterproof label or paper in plastic before burial.
+♦ On the surface place a permanent sign, marked with the unique code of the dead body bur...
+
+=== Chunk 1330 ===
+Source: 0880_002-ebook.pdf
+Length: 948 chars
+
+Identification of victims
+♦ A family liaison focal point should be established to support relatives.
+♦ Families should be allowed to report a missing relative and should be provided additional information.
+♦ Families of the dead and missing must be given realistic expectations of the process, including the meth- ods used and time frames for recovery and identification of remains.
+♦ Identification efforts should be started as speedily as possible.
+cree
+♦ Children should not be expected to aid in ...
+
+=== Chunk 1331 ===
+Source: 0880_002-ebook.pdf
+Length: 651 chars
+
+Cultural and religious aspects
+♦ The overwhelming desire of relatives in all religions and cultures is to identify their loved ones.
+♦ Advice and assistance should be sought from religious and community leaders to improve understanding and acceptance of the recovery, management and identification of dead bodies.
+♦ Undignified handling and disposal of dead bodies may further traumatize relatives and should be avoid- ed at all times. Careful and ethical management of dead bodies, including disposa...
+
+=== Chunk 1332 ===
+Source: 0880_002-ebook.pdf
+Length: 796 chars
+
+Providing support
+♦ Psychosocial support should be adapted to needs, culture and context, and should consider local coping mechanisms.
+♦ Local organizations such as the national Red Cross/Red Crescent societies, nongovernmental organiza- tions (NGOs) and faith groups can often provide emergency psychosocial care for those affected.
+♦ Priority care should be given to unaccompanied minors and other vulnerable groups. Where possible, they should be reunited with, and cared for by, members of their ...
+
+=== Chunk 1333 ===
+Source: 0880_002-ebook.pdf
+Length: 1347 chars
+
+Organizational arrangements
+♦ Information centres should be established at regional and/or local levels as part of the immediate imple- mentation of disaster management plans.
+♦ Within the locality, people dealing with information management should be quickly appointed to com- pile a missing persons list.
+♦ Their responsibilities include consolidation and centralization of information as well as outreach with the public. They are particularly necessary for receiving tracing requests and informat...
+
+=== Chunk 1334 ===
+Source: 0880_002-ebook.pdf
+Length: 1029 chars
+
+Information on missing persons
+♦ At the same time as a consolidated missing persons list is being created, it is important to begin collect- ing individual information on each missing person. Such information is obtained from family members, friends or other sources and is recorded on the Missing Person Information Form. A simple Missing Persons Form, sections of which can be edited to better suit the particular context, can be found in Annex 2. Ideally the process of information collection shou...
+
+=== Chunk 1335 ===
+Source: 0880_002-ebook.pdf
+Length: 683 chars
+
+Centralization of information
+♦ Information on missing persons and unidentified human remains may be stored centrally in an electronic database, under the guidance of a data management specialist, to assist in the tracing and identification efforts.
+♦ The consolidation of data in one central database makes it easier for forensic experts to compare the information on unidentified human remains with information on missing persons to seek a possible match.
+♦ Subsequently, by managing both the dead ...
+
+=== Chunk 1336 ===
+Source: 0880_002-ebook.pdf
+Length: 727 chars
+
+Informing the relatives
+♦ An information centre for relatives of the missing and the dead should be set up as soon as possible so that relatives can be informed regularly about the search and recovery operations.
+♦ Only final results of identifications should be provided, along with more general information at all stages of the recovery and identification process.
+♦ Families of identified victims should be informed individually prior to the release of information to the
+media.
+♦ When dealing wit...
+
+=== Chunk 1337 ===
+Source: 0880_002-ebook.pdf
+Length: 518 chars
+
+Working with the media
+♦ Generally, journalists want to report responsibly and accurately. Keeping them informed will minimize the likelihood of inaccurate reporting.
+♦ Engage proactively and creatively with the media:
+✶ Media liaison officers should be appointed to deal with both local and international media.
+✶ Establish a media liaison officer as near as possible to the affected area
+♦ Cooperate proactively (prepare regular briefings, facilitate interviews, etc.).
+33
+34
+Mar A Field Manual for...
+
+=== Chunk 1338 ===
+Source: 0880_002-ebook.pdf
+Length: 397 chars
+
+Working with the public
+♦ The information centre should make available a consolidated, updated list of confirmed dead and con- firmed survivors, with details of missing individuals recorded by official staff.
+♦ Information should be provided about the processes of recovery, identification, storage and disposal of
+dead bodies.
+♦ Arrangements for death certification may also need to be explained....
+
+=== Chunk 1339 ===
+Source: 0880_002-ebook.pdf
+Length: 573 chars
+
+Working with relief agencies
+♦ Humanitarian workers and relief agencies – including United Nations agencies, the International Committee of the Red Cross and national Red Cross/Red Crescent societies – have direct contact with affected communities and may act as a source of local information.
+♦ Aid workers are not always well informed and may give conflicting information, especially about the infectious risk of dead bodies.
+♦ Providing correct information to aid agencies on management of the dea...
+
+=== Chunk 1340 ===
+Source: 0880_002-ebook.pdf
+Length: 317 chars
+
+Information management
+♦ Care is needed to respect the privacy of victims and relatives.
+♦ Journalists should not be allowed direct access to photographs, individual records, or the names of victims. However, authorities may decide to release this information in a managed way to help with the identification process....
+
+=== Chunk 1341 ===
+Source: 0880_002-ebook.pdf
+Length: 556 chars
+
+1. Do dead bodies cause epidemics?
+No, dead bodies from natural disasters generally do not cause epidemics. This is because victims of such disas- ters usually die from trauma, drowning or fire and do not normally harbour organisms which cause epidemics.
+The exception to this is when deaths have occurred from highly infectious diseases (such as Ebola, Lassa fever, cholera), or when the disaster occurred in an area that is endemic for such highly infectious diseases. In these circumstances, the p...
+
+=== Chunk 1342 ===
+Source: 0880_002-ebook.pdf
+Length: 406 chars
+
+2. What are the health risks for the public?
+Unless the deceased has died from a highly infectious disease, the risk to the public is negligible. However, there is a risk of diarrhoea from drinking water contaminated by faecal material from dead bodies. Routine disinfection of drinking water is sufficient to prevent waterborne illness. (See question 6 for the health risks to those handling dead bodies.)...
+
+=== Chunk 1343 ===
+Source: 0880_002-ebook.pdf
+Length: 237 chars
+
+3. Can dead bodies contaminate water?
+Yes they can, as do live bodies. Dead bodies often leak faeces which may contaminate rivers or other water sources, causing a risk of diarrhoeal illness which adequate treatment of water can prevent....
+
+=== Chunk 1344 ===
+Source: 0880_002-ebook.pdf
+Length: 207 chars
+
+4. Is spraying bodies with disinfectant or lime powder useful?
+Lime powder does not hasten decomposition and, since dead bodies are generally not an infectious risk to the public, disinfectant is not needed....
+
+=== Chunk 1345 ===
+Source: 0880_002-ebook.pdf
+Length: 780 chars
+
+5. Local officials and journalists say there is a risk to the public of disease from dead bodies. Are they correct?
+The risk from dead bodies after disasters due to natural hazards is misunderstood by many professionals and the media. Even local or international health workers are often misinformed and contribute to the spread of unfounded rumours about outbreaks and epidemics. Dead bodies from natural disasters generally do not cause epidemics. The risk of disease from dead bodies is real only ...
+
+=== Chunk 1346 ===
+Source: 0880_002-ebook.pdf
+Length: 722 chars
+
+6. Is there a risk for those handling dead bodies?
+For people handling dead bodies (rescue workers, mortuary workers, etc.), there is a risk if the deceased are infected with highly infectious disease (such as Ebola, Lassa fever, cholera). The infectious agents responsible for these diseases last for varying periods after death. The internal organs that harbour organisms such as tuber- culosis, which can survive for very long periods after a person’s death, are usually handled only by trained pe...
+
+=== Chunk 1347 ===
+Source: 0880_002-ebook.pdf
+Length: 381 chars
+
+7. Should workers wear a mask?
+The smell from decaying bodies is unpleasant, but the smell itself is not a health risk in well-ventilated areas, and in such areas wearing a mask is not generally required for health reasons. However, special masks may be required for health and safety purposes in some circumstances, including in the presence of toxic gases, smoke, particles, etc....
+
+=== Chunk 1348 ===
+Source: 0880_002-ebook.pdf
+Length: 746 chars
+
+8. How urgent is the collection of dead bodies?
+Body collection is not the most urgent task after a disaster from natural hazards. The priority is to rescue and care for survivors. Nevertheless, bodies should be collected and photographed as soon as possible (and preferably before decomposition has commenced), basic information about the bodies should be collected and recorded, unique body codes allocated, and the bodies should be temporarily stored to protect them and to assist possible identif...
+
+=== Chunk 1349 ===
+Source: 0880_002-ebook.pdf
+Length: 646 chars
+
+9. Should mass graves be used to speed up disposal of dead bodies?
+Rapid mass burial of victims on public health grounds is not justified. Rushing to dispose of bodies without having taken photographs and relevant information from them, and without keeping track of the location of each body, traumatizes families and communities. If these simple steps to identify the greatest possible num- ber of bodies are taken, serious social and legal consequences for families can be avoided. In exceptional c...
+
+=== Chunk 1350 ===
+Source: 0880_002-ebook.pdf
+Length: 468 chars
+
+10. What should the authorities do with dead bodies in the short term?
+Dead bodies should be collected and stored, using refrigerated containers where possible, or temporary burial. The simple steps required to help identify all the dead bodies should be taken. Photographs should be taken and descriptive information recorded for each body. Remains should be stored or buried temporarily to allow for the possibility of an expert forensic investigation in the future....
+
+=== Chunk 1351 ===
+Source: 0880_002-ebook.pdf
+Length: 1184 chars
+
+11. What are the minimum steps needed to identify as many dead bodies as possible?
+Identifying dead bodies following disasters can be complex. The minimum steps needed to identify as many dead bodies as possible are set out in the Management of Dead Bodies after Disasters manual. In general terms, identifying a dead body is done by comparing information about the person while alive with informa- tion about the dead body. Thus, information about those who are missing or presumed to be dead is nee...
+
+=== Chunk 1352 ===
+Source: 0880_002-ebook.pdf
+Length: 571 chars
+
+12. What are the potential mental health issues for the bereaved?
+The overwhelming desire of relatives (from all religions and cultures) is to identify their loved ones. All efforts to identify the bodies will help. Grieving and traditional individual burial (or other means of disposal of the body) are important factors for the personal and communal recovery or healing process. In the case of epidemics, traditional burial rites may not be appropriate because of the health risks involved. The psy...
+
+=== Chunk 1353 ===
+Source: 0880_002-ebook.pdf
+Length: 599 chars
+
+13. How should bodies of foreigners be managed?
+Overseas families of visitors killed in a disaster, just like local families, will be hoping their loved one is identified and the body is returned to them. Proper identification has family, social, economic and diplo- matic implications. The simple steps required (allocation of a unique body code, photographs, data from the dead bodies collected and stored) will maximize the number of foreigners identified. Foreign consulates and embassies should ...
+
+=== Chunk 1354 ===
+Source: 0880_002-ebook.pdf
+Length: 515 chars
+
+14. I am a volunteer: how can I help?
+To be helpful you could promote the proper recovery and management of dead bodies and assist in recording necessary information. You could also assist with the recovery and disposal of the dead, under the direc- tion of a recognized coordinating authority. However, you would first need to be briefed, advised, trained, equipped and supported for this difficult task. The field manual on Management of Dead Bodies after Disasters should be the framework for your...
+
+=== Chunk 1355 ===
+Source: 0880_002-ebook.pdf
+Length: 504 chars
+
+15. I represent an NGO: how can I help?
+Providing support for families and collecting information in collaboration with the coordinating authority will best help the surviving relatives. You may also promote proper identification and treatment of the dead, including through dissemination of the field manual on Management of Dead Bodies after Disasters. NGOs should not be asked to manage the dead unless they are trained for this task and work for and under the direct supervision of a legal author...
+
+=== Chunk 1356 ===
+Source: 0880_002-ebook.pdf
+Length: 340 chars
+
+16. I am a health professional: how can I help?
+The survivors need you more than the dead. Any professional help in fighting the myth of epidemics caused by dead bodies will be appreciated. Talk about this with your colleagues and representatives of the media with reference to the field manual on Management of Dead Bodies after Disasters....
+
+=== Chunk 1357 ===
+Source: 0880_002-ebook.pdf
+Length: 454 chars
+
+17. I am a journalist: how can I help?
+If you hear comments or statements regarding the need for mass burial or incineration of bodies to avoid epidemics, challenge them. Promote an understanding of the field manual on Management of Dead Bodies after Disasters, including by referring to it in your reports. If necessary, do not hesitate to consult the appro- priate persons at WHO, PAHO, ICRC, IFRC or the local Red Cross/Red Crescent office.
+37
+ANNEXES...
+
+=== Chunk 1358 ===
+Source: 0880_002-ebook.pdf
+Length: 374 chars
+
+ANNEX 1. DEAD BODY INFORMATION FORM
+ANNEX 2. MISSING PERSON INFORMATION FORM
+ANNEX 3. LABEL FOR THE DEAD BODY WITH UNIQUE BODY CODE AND CHAIN OF CUSTODY RECORD
+ANNEX 4. MASS FATALITY PLAN CHECKLIST
+ANNEX 5. COORDINATION PLAN FLOWCHART FOR MANAGEMENT OF THE DEAD: AN EXAMPLE
+ANNEX 6. DEALING WITH THE BODIES OF PERSONS WHO DIED FROM AN EPIDEMIC OF INFECTIOUS DISEASE
+ANNEX 7....
+
+=== Chunk 1359 ===
+Source: 0880_002-ebook.pdf
+Length: 306 chars
+
+CEMETERIES
+ANNEX 8. PROCESSES ENABLING THE USE OF FORENSIC DNA ANALYSIS IN A LARGE MASS FATALITY DISASTER
+ANNEX 9. THE MANAGEMENT OF DEAD FOREIGN NATIONALS FOLLOWING A LARGE MASS FATALITY DISASTER
+ANNEX 10. SUPPORTING PUBLICATIONS
+ANNEX 11. INTERNATIONAL ORGANIZATIONS
+39
+40
+s: A Field Manual for First Res...
+
+=== Chunk 1360 ===
+Source: 0880_002-ebook.pdf
+Length: 768 chars
+
+ANNEX 1 DEAD BODY INFORMATION FORM
+Unique code:  (Use this same code on    associated files, photographs or stored objects.)  Possible identity of body (Explain reasons for attributing a possible identity):   Person completing this form  Name:                                                                                    Official status:                                                                       Place & date:                                                                      Sig...
+
+=== Chunk 1361 ===
+Source: 0880_002-ebook.pdf
+Length: 1273 chars
+
+A. PHYSICAL DESCRIPTION
+A.1
+General
+General
+a)
+|
+Complete body
+Incomplete body
+(describe):
+(describe):
+Body part (describe):
+condition (mark
+one):
+one):
+b) Well preserved Decomposed
+Partially
+skeletonized
+|
+Fully
+skeletonized
+Burnt
+A.2 Apparent sex
+(mark one
+Male
+Male
+Female
+Female
+Undetermined
+Undetermined
+and describe
+and describe
+Describe evidence (genitals, beard, etc):
+evidence): A.3 Age group (mark one): Infant Child Adolescent Adult Elderly A.4 Physical Height (crown to heel with units): ...
+
+=== Chunk 1362 ===
+Source: 0880_002-ebook.pdf
+Length: 706 chars
+
+B. ASSOCIATED EVIDENCE
+B.1 Clothing: B.2 Footwear: B.3 Eyewear: B.4 Personal items: B.5 Identity Documents Type of clothes, colours, fabrics, brand names, repairs. Describe in as much detail as possible Type (boot, shoes, sandals), colour, brand, size. Describe in as much detail as possible Glasses (colour, shape), contact lenses. Describe in as much detail as possible Watch, jewellery, wallet, keys, photographs, mobile phone (include number), medication, cigarettes, etc. Describe in as much det...
+
+=== Chunk 1363 ===
+Source: 0880_002-ebook.pdf
+Length: 138 chars
+
+C. RECORDED INFORMATION
+C.1 Fingerprints: Yes No Taken by whom? Stored where? C.2 Photographs of body: Yes No Taken by whom? Stored where?...
+
+=== Chunk 1364 ===
+Source: 0880_002-ebook.pdf
+Length: 834 chars
+
+D. STATUS OF BODY
+Stored: (mortuary, refrigerated container, temporary burial). Describe location Under whose responsibility: Released: To whom and date: Authorized by: Final destination:
+ANNEX 1
+43
+44
+ANNEX 2
+MISSING PERSONS INFORMATION FORM  Missing person’s name and unique number for this file:  (If name, give family name first followed by comma then other names)   (Use unique number on associated files, photographs or stored objects.)  Interviewer name:   Interviewer contact details:  Interv...
+
+=== Chunk 1365 ===
+Source: 0880_002-ebook.pdf
+Length: 633 chars
+
+A. PERSONAL DETAILS
+A.1 Missing person’s Include surname, father’s and/or mother’s name, nicknames, aliases name: A.2 Address/place of Last address, plus usual address if different from the former residence: A.3 Marital status: Single Married Divorced Widowed Partnership A.4 Sex: Male Female Other A.5 If female: Unmarried name: Pregnant Children How many? A.6 Age of missing Date of birth: Age: person: A.7 Place of birth, nationality, principal language A.8 Identity document: If available, enclos...
+
+=== Chunk 1366 ===
+Source: 0880_002-ebook.pdf
+Length: 446 chars
+
+B. EVENT
+B.1 Circumstances leading Place, date, time, events leading to disappearance, other victims to disappearance: (use additional sheet if necessary) and witnesses who last saw missing person alive (include name and address) Has this case been With whom/where: registered elsewhere? Yes No B.2 Are other family members List name, relationship, status: missing; if so, have they been registered/identified?
+ANNEX 2
+45
+46
+Manual for First Res}...
+
+=== Chunk 1367 ===
+Source: 0880_002-ebook.pdf
+Length: 1018 chars
+
+C. PHYSICAL DESCRIPTION
+C.1 General description (indicate exact measure, or approximate AND circle the corresponding group): C.2 Ethnic group/skin colour: C.3 Eye colour: C.4 a) Head hair: b) Facial hair: c) Body hair C.5 Distinguishing features: Physical – e.g. shape of ears, eyebrows, nose, chin, hands, feet, nails, deformities Skin marks – Scars, tattoos, piercings, birthmarks, moles, circumcision, etc. Past injuries/ amputations – include location, side, fractured bone, joint (e.g. knee), an...
+
+=== Chunk 1368 ===
+Source: 0880_002-ebook.pdf
+Length: 1058 chars
+
+MP N°/Code:
+Dental condition: Please describe general characteristic, especially taking into account the following: • Missing teeth • Broken teeth • Decayed teeth • Discolorations, such as stains from disease, smoking or other • Gaps between teeth • Crowded or crooked (overlapping) teeth • Jaw inflammation (abscess) • adornments (inlays, filed teeth etc) • any other special feature Dental Treatment: Has the Missing Person received any dental treatment such as • Crowns, such as gold-capped teeth ...
+
+=== Chunk 1369 ===
+Source: 0880_002-ebook.pdf
+Length: 1849 chars
+
+D. PERSONAL EFFECTS
+D.1 Clothing: (worn when last seen/ Type of clothes, colours, fabrics, brand names, repairs. at time of disaster) Describe in as much detail as possible D.2 Footwear: (worn when last seen/ Type (boot, shoes, sandals), colour, brand, size. Describe in at time of disaster) as much detail as possible D.3 Eyewear: Glasses (colour, shape), contact lenses. Describe in as much detail as possible D.4 Personal items: Watch, jewellery, wallet, keys, photographs, mobile phone (include n...
+
+=== Chunk 1370 ===
+Source: 0880_002-ebook.pdf
+Length: 343 chars
+
+ANNEX 3 LABEL FOR THE DEAD BODY WITH UNIQUE BODY CODE AND CHAIN OF CUSTODY RECORD
+UNIQUE BODY CODE  PLACE OF RECOVERY  PERSON/TEAM  NUMBER  Date  Time  CHAIN OF CUSTODY  Received from  To  Date  Time  Received from  To  Date  Time  Received from  To  Date  Time
+ANNEX 3
+49
+50
+after Disasters: A Field Manual for First Res| Management of Dead B...
+
+=== Chunk 1371 ===
+Source: 0880_002-ebook.pdf
+Length: 911 chars
+
+Mass fatality plan checklist – an annex to a National Disaster Management Plan
+The Pan American Health Organization has developed a checklist on mass fatalities that can serve as the elements to be included in an annex to any National Disaster Management Plan. The checklist is based on the London Resilience Mass Fatality Plan 2006 and on this manual.
+The checklist contains the essential elements that should be addressed by ministries of health or disaster management offices as they develop a mas...
+
+=== Chunk 1372 ===
+Source: 0880_002-ebook.pdf
+Length: 365 chars
+
+I. Introduction and purpose
+♦ Outline the purpose of the mass fatality plan.
+♦ List the assumptions of the plan.
+♦ Define the scope of the plan and local hazards that can create mass fatalities – i.e. type, frequency, level of impact, etc.
+♦ List members of mass fatality coordination committee/key partners, stakeholders in the planning and implementation process....
+
+=== Chunk 1373 ===
+Source: 0880_002-ebook.pdf
+Length: 352 chars
+
+II. Activation
+♦ Describe the activation process and identify who, or which agency, will be responsible for activat- ing the mass fatality plan. (Make sure this is the same authority that is listed in the National Disaster Management Plan.)
+♦ Include a call-out chart and attach roles and responsibilities to each individual for this phase of the plan....
+
+=== Chunk 1374 ===
+Source: 0880_002-ebook.pdf
+Length: 716 chars
+
+III. Command and control
+♦ Discuss with local health, law enforcement and disaster management officials where/how the mass fatal- ity plan fits in with national plans.
+♦ Discuss the role of health authorities, NGOs and national disaster offices during mass fatalities.
+♦ Discuss the legal authority for handling of dead bodies from the point of examination by a physician/ pathologist to the actual burial process. Consider the investigative needs of law enforcement agencies. ♦ Outline the local inc...
+
+=== Chunk 1375 ===
+Source: 0880_002-ebook.pdf
+Length: 987 chars
+
+IV. Logistics
+♦ Outline arrangements for transporting the dead bodies and related personal effects.
+♦ Outline arrangements for temporary body storage; this may involve the commandeering of 20/40 ft refrigerated containers. Remember that each container has limited capacity and requires considerable
+quantities of electricity/fuel.
+♦ Describe the means for emergency communications between all relevant parties; this must involve secure channels that are not easily accessible by the media and general...
+
+=== Chunk 1376 ===
+Source: 0880_002-ebook.pdf
+Length: 842 chars
+
+V. Welfare
+♦ Identify the provisions that will be made for handling the welfare needs of family and friends, including a designated area for viewing bodies (consider cases where bodies have to be isolated as in the case of some epidemics).
+♦ Outline the process involved in releasing or allowing for burial of the dead and the recognized forms of burial in the country. This needs to be agreed in advance with the relevant forensic pathology/medi- cal examiner/coroner/police/judicial agency responsi...
+
+=== Chunk 1377 ===
+Source: 0880_002-ebook.pdf
+Length: 1454 chars
+
+VI. Identification and notification
+Identify a team of persons from law enforcement, health authority, social services, etc. who can serve to identify the deceased (with use of forensic procedures), securing the remains and reuniting them with fam- ily/friends. Consider the local rescue and recovery procedures in place and how these will be linked to the work of this team. A physician or pathologist should determine how body parts should be handled and these decisions should be included in the p...
+
+=== Chunk 1378 ===
+Source: 0880_002-ebook.pdf
+Length: 1464 chars
+
+VII. International dimensions
+♦ Mass fatality incidents may involve foreign nationals: foreign workers, tourists, immigrants or visiting relatives of affected families.
+♦ The mass fatality plan should be shared with foreign embassies.
+♦ Dealing with immigrants should include provision for repatriation of bodies of victims to their home country. Consult with the Immigration and Attorney General’s Departments.
+♦ The Department of Foreign Affairs or Governor’s Offices should be consulted on arrange...
+
+=== Chunk 1379 ===
+Source: 0880_002-ebook.pdf
+Length: 1254 chars
+
+VIII. Site clearance and recovery of deceased victims
+a. Clearly define procedures for photographing dead bodies/body parts and placement of proper identification tags, as well as what tagging system will be used (in accordance with police procedures) and who will be responsible for keeping accurate records of the tags. Also con- sider where these procedures will take place (e.g. collection centre) and provision of adequate security measures.
+b. Procedures for photographing, labelling and securi...
+
+=== Chunk 1380 ===
+Source: 0880_002-ebook.pdf
+Length: 1305 chars
+
+IX. Mortuary
+e. For storage and body preparation, local mortuary facilities and funeral homes – location, ca- pacity, resources, etc. – should be listed in the plan with relevant contact details. Transportation to these facilities must be considered. The plan should consider the development of national/ regional stocks of coffins, body bags, etc. A memorandum of understanding (MOU) can be developed with private mortuary/funeral homes and included as part of the plan. Consult with the Attorney Ge...
+
+=== Chunk 1381 ===
+Source: 0880_002-ebook.pdf
+Length: 560 chars
+
+X. Disposal: final arrangements
+♦ Procedures for returning the deceased to families must be clearly defined – these can be provided by the physician/pathologist. The wishes of the family for returning partial remains must also be considered.
+♦ Discussions should take place with the physician/pathologist and social welfare or other relevant local agencies regarding the disposal/burial of unclaimed victims/remains. The legal issues must be consid- ered and discussed with the Attorney General’s cha...
+
+=== Chunk 1382 ===
+Source: 0880_002-ebook.pdf
+Length: 789 chars
+
+XI. Chemical, biological, radiological, nuclear (CBRN) disasters
+♦ Include procedures for handling such events, including how dead bodies should be handled, the training and personal protective equipment requirements, decontamination procedures, and ongoing monitoring of the site and any remains or items removed and where cold storage facilities can be located.
+♦ Consider decontamination arrangements for vehicles and other storage equipment and facilities, and environmental impacts along with re...
+
+=== Chunk 1383 ===
+Source: 0880_002-ebook.pdf
+Length: 1013 chars
+
+XII. Public information and media policy
+♦ Many countries have national public information plans and policies. These can be applied to this element of the plan. Official statements should be channelled through the relevant media centres at either the National Emergency Operations Centre (NEOC) or the incident command post in the field. Information from all sites – i.e. mortuary, hospital, family viewing areas – should be channelled to the NEOC for compilation.
+♦ Media should be restricted from e...
+
+=== Chunk 1384 ===
+Source: 0880_002-ebook.pdf
+Length: 612 chars
+
+XIII. Health and safety
+♦ Consider provisions for the welfare and psychological needs of responders; the local crisis intervention teams or mental health services can give support in this area. Consider how volunteers from the Red Cross and other similar services can be accommodated to provide such support – once they are trained.
+♦ There may be a need to identify and equip rest areas. Responsibility for this and how the resources will be acquired should be established locally.
+♦ Provision shoul...
+
+=== Chunk 1385 ===
+Source: 0880_002-ebook.pdf
+Length: 1042 chars
+
+XIV. Disaster mortuary plan
+♦ In many countries it is the responsibility of the police to set up and manage the documentation of the deceased at the mortuary and for evidential continuity. Relevant forms, procedures and a layout of the mortuary should be included in the plan.
+♦ In the event of a large-scale event involving numerous victims it may be necessary to establish a mortu- ary management team. The composition of the team should be included in the plan, along with call-out procedures and ...
+
+=== Chunk 1386 ===
+Source: 0880_002-ebook.pdf
+Length: 1868 chars
+
+ANNEX 5 COORDINATION PLAN FLOWCHART FOR MANAGEMENT OF THE DEAD: AN EXAMPLE
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+yoRIUOD ‘ssuoyd ‘SeweU 9}0U OL
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+
+=== Chunk 1387 ===
+Source: 0880_002-ebook.pdf
+Length: 568 chars
+
+Introduction
+This is a manual for first responders. Untrained first responders should not be involved in the management of dead bodies in an infectious disease epidemic such as is caused by Ebola virus disease. First respond- ers or non-experts can be trained to handle such dead bodies but the training must be provided by those experienced in handling the disease which caused the epidemic. This annex sets out the main principles, the steps to take and the materials available to guide such traini...
+
+=== Chunk 1388 ===
+Source: 0880_002-ebook.pdf
+Length: 572 chars
+
+Principles
+Handling the bodies of those who have died in an epidemic of a highly infectious disease such as Ebola is an exercise in infection control. This means that the body-handler requires:
+✶ an understanding of the disease, the organism which causes it and its modes of transmission;
+✶ knowledge of the correct procedures in handling potentially infectious dead bodies, including the donning and removal of personal protective equipment (PPE);
+✶ self-discipline to follow the procedures correctl...
+
+=== Chunk 1389 ===
+Source: 0880_002-ebook.pdf
+Length: 1835 chars
+
+Understanding infectious diseases – Ebola virus disease
+In infectious disease outbreaks, it is important to understand the mode of transmission of the disease. Some diseases may be transmitted by aerosol, while others are transmitted through direct contact with bodily fluids. Understanding the mode of transmission will help first responders to protect themselves against the disease.
+Some pathogens that causing disease die shortly after leaving the body of the dead, reducing the risk of transmiss...
+
+=== Chunk 1390 ===
+Source: 0880_002-ebook.pdf
+Length: 1607 chars
+
+Personal protective equipment (PPE)
+This is a short introduction to some basic recommendations on using PPE when handling bodies possibly harbouring Group 4 pathogens.10 However, handlers must undertake properly supervised training before using this equipment.
+When handling bodies possibly harbouring Group 4 pathogens, all body-handlers should:
+1. Have the mucous membranes of their eyes, mouth and nose completely covered by PPE.
+2. Use either a face shield or goggles.
+3. Wear a fluid-resistant m...
+
+=== Chunk 1391 ===
+Source: 0880_002-ebook.pdf
+Length: 4956 chars
+
+Safe handling and burial
+WHO has developed a protocol on the safe handling, including burial, of those who have died from sus- pected Ebola virus disease.12 These measures should be applied by all who handle the dead body, however briefly, or are involved in its transportation or burial. Only trained personnel should handle such bodies.
+This procedure is very sensitive for the family and the community. It can be the source of trouble or even open conflict. Before starting any procedure, the fami...
+
+=== Chunk 1392 ===
+Source: 0880_002-ebook.pdf
+Length: 2723 chars
+
+ANNEX 7 CEMETERIES
+This annex provides considerations and recommendations to address the main issues in choosing a burial ground for short- or long-term storage of dead bodies following disasters. In extreme circumstances it may not be possible to follow them all. Following epidemics from infectious diseases, further specialist advice must be sought.
+Criteria / risks to be taken Measures into account Contamination of drinking water 1. Contamination of the water may occur from buried human from d...
+
+=== Chunk 1393 ===
+Source: 0880_002-ebook.pdf
+Length: 4013 chars
+
+ANNEX 8 PROCESSES ENABLING THE USE OF FORENSIC DNA ANALYSIS IN A LARGE MASS FATALITY DISASTER
+Forensic human identification should be approached in a holistic fashion, using all available lines of evi- dence to identify the dead following a disaster. If DNA technology is to be used to help identify large num- bers of bodies following a disaster then the following considerations should be borne in mind. DNA profiling is the biggest single advance in forensic science since the discovery of fingerp...
+
+=== Chunk 1394 ===
+Source: 0880_002-ebook.pdf
+Length: 2197 chars
+
+ANNEX 9 THE MANAGEMENT OF DEAD FOREIGN NATIONALS FOLLOWING A LARGE MASS FATALITY DISASTER
+Visitors, or residents who are citizens of other countries, will have families who are desperate for news of their fate. As stated in the Interpol General Assembly resolution AGN/65/RES/13, “human beings have the right not to lose their identities after death”.18 Obtaining news of a relative’s death and receiving the body are equally important for local families and international ones. It is therefore reaso...
+
+=== Chunk 1395 ===
+Source: 0880_002-ebook.pdf
+Length: 3674 chars
+
+ANNEX 10 SUPPORTING PUBLICATIONS
+1 Tidball-Binz, M. Managing the dead in catastrophes: guiding principals and practical recommendations for first responders. International Review of the Red Cross. 2007, 89 (866): 421-442.
+2 Principles of good DVI governance. Interpol Disaster Victim Identification. Lyon: Interpol. (http://www. interpol.int/INTERPOL-expertise/Forensics/DVI).
+3 The cluster approach. Humanitarian response. Geneva: United Nations Office for the Coordination of Humanitarian Affairs. ...
+
+=== Chunk 1396 ===
+Source: 0880_002-ebook.pdf
+Length: 543 chars
+
+ANNEX 11 INTERNATIONAL ORGANIZATIONS
+World Health Organization http://www.who.int/en/
+Pan American Health Organization http://www.paho.org/hq/
+International Committee of the Red Cross http://www.icrc.org
+International Federation of Red Cross and Red Crescent Societies http://www.ifrc.org/
+Interpol http://www.interpol.int/
+ANNEX 11
+65
+68
+ST ria) Organization Pee icy
+&
+World Health Organization
+ICRC
+International Federation of Red Cross and Red Crescent Societies
+ISBN 978-92-75-31924-6
+9!'789275'3...
+
+=== Chunk 1397 ===
+Source: 0820_002-ebook.pdf
+Length: 70 chars
+
+Untitled Section
+f Pye | SLI he A ih a tigi ro Pq m4 BP sn pp na aid 4...
+
+=== Chunk 1398 ===
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+Length: 279 chars
+
+NUTRITION MANUAL FOR HUMANITARIAN ACTION
+Alain MOUREY
+Alain MOUREY
+International Committee of the Red Cross Assistance Division 19, Avenue de la Paix 1202 Geneva, Switzerland T +41 22 734 6001 F +41 22 733 2057 E-mail : icrc.gva@icrc.org www.icrc.org
+August 2008
+NUTRITION MANUAL...
+
+=== Chunk 1399 ===
+Source: 0820_002-ebook.pdf
+Length: 1054 chars
+
+ACKNOWLEDGEMENTS
+Dr Rémi Russbach, former chief medical offi cer at the ICRC and head of the medical division prompted the writing of this manual which was generously sponsored by the Geneva Foundation.
+The author warmly thanks Françoise Bory and David Laverrière for editing the book, Barbara Boyle Saidi and Archie William Charles Boyle for translating it into English, and Christiane de Charmant for coordinating the English version.
+In addition, he wishes to thank the following people for their i...
+
+=== Chunk 1400 ===
+Source: 0820_002-ebook.pdf
+Length: 3058 chars
+
+CONTENTS
+(Contents are presented in detail at the head of each chapter)
+FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
+PART ONE: THE PRINCIPLES OF HUMAN NUTRITION . . . . . . . . . . . . . . . . . . . . . . 2 CHAPTER I: NUTRITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 CHAPTER II: INTROD...
+
+=== Chunk 1401 ===
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+Length: 3226 chars
+
+LIST OF ANNEXES
+Annex 1 Annex 2 Annex 3 Annex 4.1 Annex 4.2 Annex 4.3 Annex 4.4 Annex 5 Annex 6 Annex 7 Annex 8 Annex 9 Annex 10 Annex 11 Annex 12 Annex 13 Annex 14 Annex 15 Annex 16 Annex 17 Annex 18 Annex 19 Energy cost of specifi c occupations: examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606 Food groups containing the four major vitamins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 608 The use of artifi cial milks in relief actions ....
+
+=== Chunk 1402 ===
+Source: 0820_002-ebook.pdf
+Length: 9584 chars
+
+LIST OF FIGURES
+Figures have been given two numbers: the fi rst corresponds to the chapter in which they appear and the second to the order in which they appear within the Chapter. Figures presented in the annexes have been labelled A. followed by the number of the annex.
+have been labelled A. followed by the number of the annex. Figure 2.1 General formula for amino acids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Figure 4.1 The frequenc...
+
+=== Chunk 1403 ===
+Source: 0820_002-ebook.pdf
+Length: 899 chars
+
+Figures in the annexes
+Figure A.8.1 Probability density function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651 Figure A.8.2 Normal distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651 Figure A.9 The QUAC stick – example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 652 Figu...
+
+=== Chunk 1404 ===
+Source: 0820_002-ebook.pdf
+Length: 7521 chars
+
+LIST OF TABLES
+Tables have been given two numbers: the fi rst corresponds to the chapter in which they appear and the second to the order in which they appear within the chapter. Tables presented in the annexes are labelled A. followed by the number of the annex.
+Table 3.1 Equations for the calculation of basal metabolism, according to weight (W), age and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Table 3.2 Amount of nitrogen from different pr...
+
+=== Chunk 1405 ===
+Source: 0820_002-ebook.pdf
+Length: 2124 chars
+
+Tables in the annexes
+Table A.1 Table A.2 Table A.3.1 Table A.3.2 Table A.4.1.1 Table A.4.1.2 Table A.4.2.1 Table A.4.2.2 Table A.4.3 Table A.4.4.1 Table A.4.4.2 Table A.7 Table A.9.1 Table A.9.2 Table A.19 Energy cost of male occupations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606 Vitamin content . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 608 Foo...
+
+=== Chunk 1406 ===
+Source: 0820_002-ebook.pdf
+Length: 443 chars
+
+FOREWORD
+The image of armed confl ict often evokes visions of malnutrition arising from deliberate starvation policies, neglect, or the helplessness of parties to the confl ict to cope with the humanitarian consequences of war.
+For decades now, nutritional action has been confi ned to the immediate response to malnutrition. Food aid and nutritional rehabilitation have been the humanitarian reaction to major crises, based on a simple equation:...
+
+=== Chunk 1407 ===
+Source: 0820_002-ebook.pdf
+Length: 2660 chars
+
+crisis = food shortage = malnutrition.
+This simplistic view did not shed light on either the causes or the mechanisms of crisis.
+This Manual departs from such a restrictive view. The author approaches nutrition from two different angles, from which he derives practical recommendations for humanitarian action.
+The fi rst provides an in-depth understanding of nutrition, based on a coherent range of information on the notions of nutritional need and food intake that goes beyond the usual checklists ...
+
+=== Chunk 1408 ===
+Source: 0820_002-ebook.pdf
+Length: 2026 chars
+
+PART ONE THE PRINCIPLES OF HUMAN NUTRITION
+The fi rst part of this Manual discusses the area of science that deals with nutrition. It may seem lengthy and of limited operational relevance. However, sound conceptual and theoretical bases are necessary in order to address nutritional disorder encountered in the fi eld: to paraphrase Ernst Mach, “there is nothing so practical as a good theory”. Each operational gesture must make sense and comply with the logic of the specifi c feeding process of the p...
+
+=== Chunk 1409 ===
+Source: 0820_002-ebook.pdf
+Length: 151902 chars
+
+TABLE OF CONTENTS
+The subject . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 The object . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 The method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...
+
+=== Chunk 1410 ===
+Source: 0820_002-ebook.pdf
+Length: 24464 chars
+
+INTRODUCTION
+Nutrition is frequently ill-defi ned, probably because it is a developing contemporary fi eld in search of its own identity (Rivers, 1979; Waterlow, 1981; Pacey & Payne, 1985).
+Modern nutrition has evolved from very different approaches.
+9 Man recognized early that growth and development are the main characteristics of childhood, and that these processes depend directly on feeding. Thus, nutrition has always been closely associated with paediatrics. As of 1550 B.C., Egyptian medical t...
+
+=== Chunk 1411 ===
+Source: 0820_002-ebook.pdf
+Length: 115 chars
+
+The subject
+Nutrition is the science of the exchange of matter and energy between the organism and its environment....
+
+=== Chunk 1412 ===
+Source: 0820_002-ebook.pdf
+Length: 404 chars
+
+The object
+Nutrition considers the nutritional need, which provides the basis for the exchange, the conditions determined by the need, and the feeding process through which the exchange occurs. Its perspective is not confi ned to the biology of the human organism, but includes the cultural characteristics of the group, because individuals are usually immersed in the cultural framework of a given group....
+
+=== Chunk 1413 ===
+Source: 0820_002-ebook.pdf
+Length: 275 chars
+
+The method
+The method used in nutrition consists in taking a multidisciplinary approach which allows the exchange to be understood as a whole: the phenomena dictating the exchange, the completion of the exchange, and the performance of the exchange.
+6
+Defi nition of nutrition...
+
+=== Chunk 1414 ===
+Source: 0820_002-ebook.pdf
+Length: 297 chars
+
+The scope of investigation
+The scope of investigation covers human behaviour, both biological and social, from the search for nutrients that constitute feeding, to their digestion, absorption and utilization, in addition to the excretion of their by-products and what amounts to inevitable losses....
+
+=== Chunk 1415 ===
+Source: 0820_002-ebook.pdf
+Length: 212 chars
+
+The prediction capacity
+The observation of the completion of the exchange within its environment should therefore facilitate the prediction of the survival probability of the organism and the group it belongs to....
+
+=== Chunk 1416 ===
+Source: 0820_002-ebook.pdf
+Length: 520 chars
+
+Ethics
+Nutrition arises from the desire to understand – and, if possible, resolve – the problems that may appear at the different stages of the exchange. Nutrition thus intends to identify threats to health in its broadest sense, and to offer relevant interventions accordingly. This approach rests on a moral value: it is universally recognized that poverty is accidental, that the malnutrition that can result from it causes suffering, and that it is necessary to protect and care for its victims.
+...
+
+=== Chunk 1417 ===
+Source: 0820_002-ebook.pdf
+Length: 1989 chars
+
+INTERACTIONS OF THE ORIGINS
+The nutritional need originates in the chemical reactions that obey the principles of thermodynamics,1 and arose during the billion years following the formation of the earth. The different energy sources that existed at the time enabled chemical compounds such as water and water vapour (H2O), methane (CH4) and ammonia (NH3) to interact and combine, thus generating the basic components of living matter. Laboratory simulations of the chemical and energy conditions assu...
+
+=== Chunk 1418 ===
+Source: 0820_002-ebook.pdf
+Length: 1165 chars
+
+1.2 THERMODYNAMIC DETERMINISM
+The evolution from the original simple gases to superior animals occurred in successive stages of association between compatible elements. Each level of association brought a new structure, but also new forms of organization, because interaction takes different forms that are specifi c to each level: atoms do not interact like particles do, nor molecules like atoms, nor polymers like basic molecules, any more than societies interact like their components do. However,...
+
+=== Chunk 1419 ===
+Source: 0820_002-ebook.pdf
+Length: 2450 chars
+
+1.3 THE APPEARANCE OF THE LIVING CELL
+One crucial stage of association was the combination of constitutive elements to form a structure which became a specifi c entity: the living cell. Indeed, the living cell incorporates and specifi cally organizes energy interactions complying with thermodynamic determinism within a material structure limited by a semi-permeable membrane.
+This entails several consequences, three of which are of particular interest here.
+1. Thermodynamic reactions imply the pres...
+
+=== Chunk 1420 ===
+Source: 0820_002-ebook.pdf
+Length: 4427 chars
+
+1.4 THE PHENOMENON OF ORGANIZED ASSOCIATION
+The nutritional need is the effective and direct consequence of the confi nement of molecular interactions to a specifi c spatial structure – that is, the cell or living organism. More generally, from a conceptual perspective, it results from the phenomenon of organized association.
+Its principles are as follows.
+1. The association occurs within a defi ned structure in which the elements of the association perform activities.
+2. This structure makes sense...
+
+=== Chunk 1421 ===
+Source: 0820_002-ebook.pdf
+Length: 390 chars
+
+2.1 DEPENDENCY ON ENERGY
+The fi rst level of nutritional dependency concerns the provision of energy, because life developed from the interaction of energies available at the beginning of earth. Without entering into excessive detail in the fi elds of physics and biology, it is important to improve understanding of the energy conversions of living things by recalling some basic principles....
+
+=== Chunk 1422 ===
+Source: 0820_002-ebook.pdf
+Length: 396 chars
+
+2.1.1 General principles relating to energy
+1. Matter and energy make up the universe, and they are inter-related.2
+2. Energy can take many forms: mechanical, electrical, thermal, and radiant (such as solar energy radiated to the earth). Energy can be converted from one form to the next while conserving the total amount of energy involved, as expressed by the fi rst principle of thermodynamics:...
+
+=== Chunk 1423 ===
+Source: 0820_002-ebook.pdf
+Length: 919 chars
+
+the total energy of the universe remains constant.
+3. Conversion from one form of energy into another always results in an increase of thermal energy through friction. Thermal energy is thus the ultimate or degraded form (for our purposes) of energy. For example, an engine powered electrically to perform mechanical work necessarily overheats; its energy input cannot be entirely converted into kinetic energy, as part of it is lost in thermal form. Likewise, chemical energy used in muscular contra...
+
+=== Chunk 1424 ===
+Source: 0820_002-ebook.pdf
+Length: 3300 chars
+
+universal entropy increases.
+2 Einstein’s E = mc2.
+12
+2. The components of nutritional need
+2.1 Dependency on energy
+Entropy is the ultimate, degraded and – for our purposes – unusable form of energy. Entropy is also said to represent the degree of universal disorder or chaos. Chaos or disorder is understood here as meaning energy dissipated at random. Indeed, thermal energy dissipates spontaneously in a chaotic manner. For example, a hot body spontaneously transfers its heat to its cooler envir...
+
+=== Chunk 1425 ===
+Source: 0820_002-ebook.pdf
+Length: 326 chars
+
+1 kilocalorie (kcal) = 4.18 kilojoules (kJ)
+The advantage of using different units to express different forms of energy is clarity: what the unit refers to is known. Standardization is therefore not always an asset. This Manual uses both units, kcal and kJ, the former taking precedence, the latter indicated between brackets....
+
+=== Chunk 1426 ===
+Source: 0820_002-ebook.pdf
+Length: 2297 chars
+
+2.1.2 Energy and life
+Beyond philosophical debates on the topic, it is now scientifi cally established that the laws of physics govern the entire universe, including biological mechanisms. Life in all its forms complies with the two types of reaction described above:
+13
+I I
+I
+I
+NUTRITION MANUAL Chapter II – Introduction to the nutritional need
+2. The components of nutritional need
+2.1 Dependency on energy
+9 its environment provides it with the energy to create highly reactive chemical bodies, the...
+
+=== Chunk 1427 ===
+Source: 0820_002-ebook.pdf
+Length: 1557 chars
+
+2.1.3 The energy fl ux in the biosphere
+It is important to examine the fl ow of energy in the biosphere more closely to gain a comprehensive understanding of the nutritional need. The notion of energy fl ux implies a beginning (i.e. an initial state) one or several intermediate stages, and an ending (fi nal state).
+The primary source of energy is solar radiation, and it undergoes two intermediate stages in the biosphere:
+9 in the fi rst stage, the radiant energy is converted into chemical energy by m...
+
+=== Chunk 1428 ===
+Source: 0820_002-ebook.pdf
+Length: 379 chars
+
+carbonic acid gas (CO2) + NADPH + H+ + ATP 1 glucose + NADP+ + ADP + Pi
+This second reaction enables the production of a reduced compound (rich in available chemical energy),5 thanks to the chemical energy of the ATP acting on oxidized molecules (i.e. poor in available chemical energy).
+It is now possible to consider the entire equation for photosynthesis, as usually provided:...
+
+=== Chunk 1429 ===
+Source: 0820_002-ebook.pdf
+Length: 3187 chars
+
+6 CO2 + 6 H2O 1 C6H12O6 (glucose) + 6 O2
+The glucose then provides the intermediary to produce the other organic compounds of plants (glucides, lipids and proteins) during reactions that also require energy provided by ATP. For proteins, nitrogenous molecules are also required, they are taken from the soil but come from the atmosphere through nitrogen fi xing bacteria.
+The animal kingdom is not capable of photosynthesis. It nevertheless needs ATP to perform its biological work. Animals obtain it ...
+
+=== Chunk 1430 ===
+Source: 0820_002-ebook.pdf
+Length: 2711 chars
+
+2.2 DEPENDENCY ON MATTER
+The fl ow of energy through the living organism implies energy conversions, and these require a material intermediary. Furthermore, they must occur in the material structure of the organism.
+The energy fl ow and the existence of the organism generate a twofold material requirement.
+1. The requirement related to the energy fl ow implies adenosine recycling through the oxidation of a material intermediary, during fermentation and breathing;
+2. The requirement related to the d...
+
+=== Chunk 1431 ===
+Source: 0820_002-ebook.pdf
+Length: 1663 chars
+
+2.2.2 Amino acids
+There are 20 basic amino acids. All have an acid group (COOH) and a nitrogen atom (N) on the fi rst carbon atom (i.e. alpha carbon) in their carbon chain. The name “amino acids” thus comes from the combination of the acid group with “amine” (the name of the nitrogen group in the organic compounds). They differ in the rest of the chain (R). Their general formula is provided in Figure 2.1 below.
+16
+2. The components of nutritional need
+2.2 Dependency on matter
+Figure 2.1 General f...
+
+=== Chunk 1432 ===
+Source: 0820_002-ebook.pdf
+Length: 660 chars
+
+2.2.3 The bases
+The purine (2 molecules) and pyrimidine (3 molecules) bases are the fi ve basic components of nucleotides, of which there are eight. Four provide the infrastructure of desoxyribonucleic acid (DNA), which is the support of the genetic code. The other four provide the infrastructure for ribonucleic acid (RNA), which translates the genetic code into amino-acid sequences for protein synthesis. DNA and RNA are therefore nucleotide chains, just as proteins are chains of amino acids. Mor...
+
+=== Chunk 1433 ===
+Source: 0820_002-ebook.pdf
+Length: 624 chars
+
+2.2.4 Glucides
+Glucides, erroneously also referred to as carbohydrates because of their general formula (CH2O)n, practically all originate from glucose (C6H12O6). Glucose is the main fuel of most organisms, and the infrastructure for starch and the cellulose of plants. Starch is the prime form of energy storage, whereas cellulose is the rigid external component of the cell wall, and is fi brous, ligneous tissue. Glucides are also associated with, or precursors of, very important molecules in term...
+
+=== Chunk 1434 ===
+Source: 0820_002-ebook.pdf
+Length: 641 chars
+
+2.2.5 Lipids
+Lipids are defi ned as molecules that are insoluble in water. There are several lipid groups, but all share the characteristic that a signifi cant part of the molecule is in reality a hydrocarbon. Lipids too perform various functions: they contribute to the structure of the cell membrane, they are elements of energy storage and transport, they provide a protective layer, and determine the identity and biological activity marker as hormones or vitamins.
+17
+I I
+I
+I
+NUTRITION MANUAL Chap...
+
+=== Chunk 1435 ===
+Source: 0820_002-ebook.pdf
+Length: 724 chars
+
+2.2.6 Vitamins
+Vitamins and coenzymes are small organic substances (carbon structures) that are indispensable to the functioning of living cells, owing to their vital contribution to many physiological processes, in particular enzyme catalysis, an indispensable process for practically all the chemical reactions of the cell. Their importance has been recognized because many species cannot synthesize them all independently and must, therefore, obtain them from their environment. Vitamins and coenz...
+
+=== Chunk 1436 ===
+Source: 0820_002-ebook.pdf
+Length: 887 chars
+
+2.2.7 Minerals
+Minerals are likewise indispensable to the functioning of the organism, and their functions vary considerably depending on their specifi c chemical properties. As they cannot be created, they must be found either directly or indirectly in the mineral environment shaped by the nature of the soil and the effects of groundwater.
+To exist, living beings must obtain all these molecules. This is the essence of material nutritional need. Apart from water and minerals, they all originate i...
+
+=== Chunk 1437 ===
+Source: 0820_002-ebook.pdf
+Length: 579 chars
+
+2.3 DEPENDENCY ON LIVING SPECIES
+The third level of nutritional dependency developed in parallel with the evolution of species. Specialization, differentiation and adaptation to the environment entailed nutritional specifi cities that implied unilateral dependencies and, more importantly, symbiotic interdependencies with major consequences for the survival of the living world in general. The interdependency of species can take many different forms that fall into two main categories: dependency on...
+
+=== Chunk 1438 ===
+Source: 0820_002-ebook.pdf
+Length: 1206 chars
+
+2.3.1 Dependency on energy fl ow
+The fi rst stage of energy fl ow in the biological world belongs to the realm of photosynthesis that uses solar radiation to create organic compounds, and the latter are the primary source of energy of organisms that are incapable of photosynthesis. The realm of photosynthesis is thus at the basis of all the energy used by the rest of the biosphere. In a way, there exists a form of “energy parasitism” in stages: the world of photosynthesis is a parasite (or predator...
+
+=== Chunk 1439 ===
+Source: 0820_002-ebook.pdf
+Length: 984 chars
+
+2.3.2 Dependency on matter
+As discussed above, energy fl ows in an organism cause fl uxes of matter. The latter fl ows from one type of organism to another, not necessarily through trophic dependency (downstream-upstream), but according to a cyclical rhythm – in other words, an interdependency. In these cycles, organisms exchange the nutrients required for their survival. Without entering into detail as to the sometimes highly complex nutritional interdependencies that govern the biosphere, this di...
+
+=== Chunk 1440 ===
+Source: 0820_002-ebook.pdf
+Length: 418 chars
+
+The carbon and oxygen cycle
+Organisms capable of photosynthesis combine carbonic acid gas with water to generate organic compounds, giving off oxygen in the process. On the other hand, organisms that are incapable of photosynthesis consume organic compounds and oxygen, and give off carbonic acid gas and water in the process of breathing and fermentation. This introduces a carbon and oxygen cycle into the biosphere....
+
+=== Chunk 1441 ===
+Source: 0820_002-ebook.pdf
+Length: 3703 chars
+
+The nitrogen cycle
+Nitrogen contributes to the formation of the genetic code, proteins, and other molecules essential to life. It accounts for 80% of the composition of the atmosphere, in the form of molecular nitrogen gas (N2). In this form, it can only be absorbed by a few specifi c organisms, while others must obtain it in a combined form, such as ammonia, nitrites and nitrates, or from complex compounds such as amino acids or urea. Its cyclical exchanges are more complex than those of carbon ...
+
+=== Chunk 1442 ===
+Source: 0820_002-ebook.pdf
+Length: 215 chars
+
+DEPENDENCY ON OTHER SPECIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
+23
+Chapter III – The nutritional need of humans
+Introduction 1. Dependency on energy...
+
+=== Chunk 1443 ===
+Source: 0820_002-ebook.pdf
+Length: 1900 chars
+
+1. DEPENDENCY ON ENERGY
+Like all living things, man needs energy to recycle ATP 1 in order to perform the biological work that is necessary for his survival. Two methods are used to assess energy needs as follows:
+9 the balance method, i.e. the observation of what an individual must eat to maintain a constant weight;
+9 the factorial method, i.e. the assessment of energy use specifi c to the organism’s energy phenomena (that is, according to each use factor): the corresponding overall requirement ...
+
+=== Chunk 1444 ===
+Source: 0820_002-ebook.pdf
+Length: 1105 chars
+
+1.1.1 Basal energy expenditure
+Warm-blooded animals (i.e. mammals and birds) in particular tend to maintain a constant temperature; the idling (i.e. the minimum functioning) rate of their biological machine is therefore rather stable. It is referred to as basal metabolic rate or, more simply, basal metabolism.2 The basal metabolism thus implies a consumption of energy, to be likened to the fuel consumption of a stationary car whose engine is idling. The basal metabolism represents the energy and...
+
+=== Chunk 1445 ===
+Source: 0820_002-ebook.pdf
+Length: 74 chars
+
+seventy times their body weight elevated to the power of three-quarters
+or...
+
+=== Chunk 1446 ===
+Source: 0820_002-ebook.pdf
+Length: 1831 chars
+
+daily basal metabolism (kcal) = 70 × body weight3/4 (kg)
+Weight to the power of three-quarters is also expressed as weight to the power 0.75 (i.e. weight0.75).
+This general rule expresses the direct proportional relation between the energy fl ow in the organism of warm-blooded animal and their mass. Mass is understood here as active – in other words excluding the obese with a signifi cant inert adipose mass. Indeed, the basal metabolism relates to the active cells in the organism that produce work...
+
+=== Chunk 1447 ===
+Source: 0820_002-ebook.pdf
+Length: 427 chars
+
+Age
+The basal metabolism per kilogram of body weight increases during the fi rst year, then slowly decreases until sexual maturity. The fast basal metabolism of the young child is partly explained by its faster cell renewal rate. Among adults, it remains constant until approximately 40 to 50 years, then slowly diminishes; among the elderly (over 60 years), it is 15 to 20% lower by unit of body weight than among young adults....
+
+=== Chunk 1448 ===
+Source: 0820_002-ebook.pdf
+Length: 1617 chars
+
+Sex
+Per unit of body weight, the adult male basal metabolism is 15 to 20% higher than the female rate. This is partly due to the fact that the proportion of fatty tissue is greater in women than in men.
+In fact, the more individuals are included, the more relevant the standard measure of the basal metabolism; it is then a statistical measure to extrapolate (with a 10% uncertainty margin) the basal metabolism of the average individual, representative of his age group and sex. Basal metabolism has...
+
+=== Chunk 1449 ===
+Source: 0820_002-ebook.pdf
+Length: 544 chars
+
+basal metabolism = (0.0615 × 55) + 2.08 = 5.4625 MJ
+In contrast, the metabolism of a 3-year-old girl weighing 14 kg is 814 kcal (3.4 MJ). From this viewpoint, one can say that the girl’s basal metabolism is 60% of the woman’s – but this says little about their respective energy needs. The comparison is more relevant if the energy use is expressed in kcal (kJ) per kg of body mass, that is, 58.1 kcal (243 kJ)/kg for the little girl, and 23.7 kcal (99 kJ)/kg for the woman. This shows that the latte...
+
+=== Chunk 1450 ===
+Source: 0820_002-ebook.pdf
+Length: 743 chars
+
+1.1.2 Energy use due to food consumption
+The consumption of food involves the use of energy related both to the functioning of the digestive system, and to the nature of the foods and their storage. The increase of the energy use related to the nature of the food is also referred to as “specifi c dynamic action” (SDA). Statistically, the SDA is 30% for proteins, 6% for glucides, and 4% for lipids. In other words, the consumption of proteins providing 100 kcal, for example, increases the metabolic...
+
+=== Chunk 1451 ===
+Source: 0820_002-ebook.pdf
+Length: 1209 chars
+
+1.1.3 Energy use due to muscular work
+Mechanical muscular work, also called physical activity, can account for much of an individual’s daily energy use. The use related to physical activity depends on the type of effort, but also on the manner in which it is made (movement effi ciency, emotional tension), the food intake and adaptation to the environment (e.g. ambient oxygen pressure, that diminishes with increasing altitude). Therefore, major variations exist between individuals and societies, a...
+
+=== Chunk 1452 ===
+Source: 0820_002-ebook.pdf
+Length: 4688 chars
+
+1.1.4 Energy expenditure due to thermo-genesis
+The heat produced through entropic 4 loss in the course of biological work is not directly usable from a physiological perspective. It nevertheless plays a vital role among mammals and birds because their biological system must maintain a temperature of 35 to 42°C to operate normally. Temperature maintenance requires a very reliable supply of energy – this is indeed a dependency, but allows the organism to adapt to extreme climatic conditions. On ea...
+
+=== Chunk 1453 ===
+Source: 0820_002-ebook.pdf
+Length: 395 chars
+
+1.1.5 Energy need due to synthesis
+Biological synthesis is a permanent phenomenon, mainly related to the renewal of cell and tissue components (i.e. maintenance synthesis). From this angle, its energy cost is taken into consideration in the basal use. But the synthesis of new tissue related to individual growth, pregnancy, breastfeeding and the recovery of lost tissue must also be considered....
+
+=== Chunk 1454 ===
+Source: 0820_002-ebook.pdf
+Length: 1363 chars
+
+Growth
+Growth is the development of living beings to reach their adult physical stature. The assessment of the energy need specifi c to growth poses three main problems:
+9 measurement,
+9 distinction between the energy expenditure for normal functioning and the energy used for the accumulation of tissue,
+9 composition of the average deposited tissue – which varies according to age and sex.
+In fact, the attempt to calibrate growth accurately encounters the validity limitations of the factorial appr...
+
+=== Chunk 1455 ===
+Source: 0820_002-ebook.pdf
+Length: 1670 chars
+
+Pregnancy
+Pregnancy includes the growth of the foetus and the placenta, as well as the growth and change of maternal tissues, which obviously requires energy. Normal pregnancy is generally accepted to involve a weight gain of the order of 10 ± 2 kg, and an approximately 20% increase in the basal metabolism during the last quarter (Trémolière, 1977). Classic estimations set the overall cost of pregnancy at 80,000 kcal (335,000 kJ), of which 36,000 kcal (151,000 kJ) represent the deposit of approx...
+
+=== Chunk 1456 ===
+Source: 0820_002-ebook.pdf
+Length: 2020 chars
+
+Breastfeeding
+The production of maternal milk varies considerably from one woman to another; commonly quoted values range from 750 to 850 ml/day. The energy value of maternal milk varies signifi cantly according to the origin of the women under consideration; it also varies according to the duration of breastfeeding (Waterlow, 1992). Food composition tables provide values ranging from 67 kcal (280 kJ) to 75 kcal (313 kJ) per 100 ml. The cost of synthesis is calculated based on an 80% minimum synt...
+
+=== Chunk 1457 ===
+Source: 0820_002-ebook.pdf
+Length: 1316 chars
+
+Recovery
+Recovery follows the loss by an individual of part of his body mass owing to illness, accident, or a food supply that is insuffi cient to maintain normal body weight. “Nutritional recovery” and “catch-up growth” are common terms for the recovery process that follows malnutrition. The cost of catch-up growth varies according to the composition of the synthesized tissue and the yield of the synthesis. Tissue composition varies greatly, the yield of protein synthesis is unclear, and rapid w...
+
+=== Chunk 1458 ===
+Source: 0820_002-ebook.pdf
+Length: 1301 chars
+
+1.1.6 Maintenance requirements
+The energy cost of maintenance is a useful notion in nutrition; it includes basal use, specifi c dynamic action, and the use resulting from minimal physical activity (e.g. eating, personal hygiene, clothing, etc.). Maintenance requirements amount to the minimal need to remain alive when doing nothing special; the idle time spent between sleep and professional activities, leisure or house cleaning. Initially, the expression “maintenance requirements” was used only in...
+
+=== Chunk 1459 ===
+Source: 0820_002-ebook.pdf
+Length: 2135 chars
+
+1.2 CALCULATING DAILY ENERGY REQUIREMENTS
+Energy requirements over 24 hours are determined by assessing daily energy use based on the following stages.
+1. Calculation of the daily basal metabolism according to body mass, age and sex, based upon the equations provided in Section 1.1.1 above.
+2. Calculation of the hourly basal metabolism, that is, the daily basal metabolism divided by 24.
+3. Assessment of the number of hours spent daily on the following occupations: sleep, maintenance, professiona...
+
+=== Chunk 1460 ===
+Source: 0820_002-ebook.pdf
+Length: 3501 chars
+
+1.3 LIMITATIONS OF THE FACTORIAL APPROACH
+The factorial approach consists in the breaking down of energy use into factors related to understandable physical entities: temperature, work, growth. It states that the overall energy requirement can be extrapolated, provided each factor of the daily energy use is defi ned accurately.
+32
+1. Dependency on energy
+1.3 Limitations of the factorial approach
+This approach nevertheless has two weaknesses.
+1. The arithmetic or algebraic sum of expenses is artifi...
+
+=== Chunk 1461 ===
+Source: 0820_002-ebook.pdf
+Length: 1505 chars
+
+SUMMARY OF ENERGY REQUIREMENTS
+Factorial analysis must be applied to need in order to understand man’s energy requirements properly. This analysis consists in identifying and quantifying the factors of energy use, notably:
+9 basal metabolism, amounting to the energy use of the organism at rest;
+COU
+9 specifi c dynamic action related to food consumption;
+9 physical activity;
+9 thermo-genesis;
+9 growth, production (pregnancy and breastfeeding) and recovery.
+The measure of the basal metabolism aims ...
+
+=== Chunk 1462 ===
+Source: 0820_002-ebook.pdf
+Length: 1789 chars
+
+2. DEPENDENCY ON MATTER
+Energy fl owing through the living organism implies energy conversions, and these require a material intermediary. Furthermore, they must occur in the material structure of the organism.
+Energy fl ow and the existence of the organism generate a twofold material requirement.
+1. The requirement related to the energy fl ow including the recycling of adenosine.
+2. The requirement related to the development and renewal of the material, architectural and functional structure that ...
+
+=== Chunk 1463 ===
+Source: 0820_002-ebook.pdf
+Length: 252 chars
+
+2.1.1 The nature of fuel
+Adenosine recycling defi nes the needs of the organism for fuel or oxidizable matter and, obviously, oxidizing matter, that accept electrons.
+The different forms of fuel carried in the blood for use by the organs are as follows....
+
+=== Chunk 1464 ===
+Source: 0820_002-ebook.pdf
+Length: 556 chars
+
+Main source
+9 Glucose, which is found in food, glycogen reserves or is synthesized in the liver from specifi c amino acids and glycerol.
+9 Fatty acids, that make up complex lipids and, specifi cally the triglycerides present in oils and fats found in food or which are synthesized from glucose, some amino acids and the produce of the breakdown of other fatty acids.
+9 Amino acids that are present in food in the entirety of circulating amino acids or that are synthesized from other amino acids reacti...
+
+=== Chunk 1465 ===
+Source: 0820_002-ebook.pdf
+Length: 173 chars
+
+Secondary source
+9 Ketone bodies formed from the oxidation products of fatty acids and some amino acids, when the available glucose is insuffi cient (for example in fasting)....
+
+=== Chunk 1466 ===
+Source: 0820_002-ebook.pdf
+Length: 151 chars
+
+Minor source
+9 Lactic acid, formed from the anaerobic oxidation of glucose.
+9 Glycerol, from the triglycerides splitting into fatty acids and glycerol....
+
+=== Chunk 1467 ===
+Source: 0820_002-ebook.pdf
+Length: 1250 chars
+
+Additional source
+9 Ethyl alcohol, found in food.
+9 Fructose and galactose, both glucides found in food.
+The main electron acceptor is oxygen.
+Fuel molecules transfer their energy through the oxidation of their carbon and hydrogen atoms during fermentation (i.e. anaerobic glycolysis) and breathing (the citric acid cycle combined with the respiratory chain). As suggested by its name, anaerobic glycolysis does not require oxygen, but
+35
+I I I
+I
+I I
+NUTRITION MANUAL Chapter III – The nutritional ne...
+
+=== Chunk 1468 ===
+Source: 0820_002-ebook.pdf
+Length: 3059 chars
+
+2.1.2 Energy produced by combustion
+The energy use of the organism can only be measured in energy units, and not in ATP molecules converted into ADP. Energy produced by combustion is therefore expressed in kcal or kJ. To this end, it is necessary to fi nd conversion factors between fuel grams and produced energy expressed in kcal (or kJ). In line with the principles of thermodynamics, the complete combustion of a nutrient 9 always produces the same amount of energy, whatever its course (direct co...
+
+=== Chunk 1469 ===
+Source: 0820_002-ebook.pdf
+Length: 2036 chars
+
+2.1.3 Calculating fuel requirements
+An individual whose maintenance requirement is 2,000 kcal (8,360 kJ) can meet it by burning 500 g of amino acids or glucides (2,000 kcal/(4 kcal/g) = 500 g) or 222.2 g of fatty acids (2,000 kcal/(9 kcal/g) = 222.2 g).
+In fact, this individual burns a blend of glucides, amino acids and fatty acids for an overall consumption of between 222 and 500 g of nutrients. Man does not eat nutrients, strictly speaking, but food; therefore, fuel requirements are extrapolat...
+
+=== Chunk 1470 ===
+Source: 0820_002-ebook.pdf
+Length: 2333 chars
+
+Storage systems
+Following a meal, the food absorbed by the organism is processed in part to address the immediate need, while the excess is stored for later utilization.
+Excess glucose can be either assembled in glycogen chains, to be stored in the liver and muscle tissue, or converted into fatty acids to be stored in the fatty tissue in the form of triglycerides (three fatty acids bound to glycerol). The quantitative importance of the latter is proportional to the input because the glycogen res...
+
+=== Chunk 1471 ===
+Source: 0820_002-ebook.pdf
+Length: 2362 chars
+
+Available reserves
+As discussed above, the energy reserves of the organism are glycogen, proteins and fatty tissue. The latter is the ultimate storage of excess food energy, since glucides and amino acids are eventually stored as fat. It is only through this storage that the organism can manage food excesses. As a result, fatty tissue has a real capacity to expand or shrink according to energy excess and defi ciency.
+Cahill’s study of fasting (Cahill, 1970) has shown that the potential energy res...
+
+=== Chunk 1472 ===
+Source: 0820_002-ebook.pdf
+Length: 151 chars
+
+2.1.5 Fuel utilization in the organism
+The utilization of fuel in the organism depends on the organ under consideration, the anticipated work and diet....
+
+=== Chunk 1473 ===
+Source: 0820_002-ebook.pdf
+Length: 1190 chars
+
+Utilization by the organs
+9 The liver is the fi rst organ to receive nutrients after their absorption by the intestine. It is the
+organism’s chemical plant par excellence and, as a result, adapts with ease to any available fuels (except ketone bodies that it produces itself). The energy consumption by the liver of an individual at rest amounts to approximately 25% of the basal expenditure.
+9 The activity of the skeletal muscle at rest accounts for approximately 30% of the basal expenditure. Some ...
+
+=== Chunk 1474 ===
+Source: 0820_002-ebook.pdf
+Length: 444 chars
+
+Utilization of fuel according to work done
+Mechanical work changes the energy consumption of both heart and muscle. The heart adapts easily to effort: its predominant consumption of fatty acids at rest is simply replaced by a predominant consumption of glucose within mere seconds after the beginning of a major effort; a few minutes later, its energy again derives mainly from fatty acids. The skeletal muscle adapts to effort in the same way....
+
+=== Chunk 1475 ===
+Source: 0820_002-ebook.pdf
+Length: 899 chars
+
+Utilization of fuel according to diet
+Since this aspect is discussed in Chapter VIII, the present section only deals with utilization principles. The food input from different meals is uneven and can even be suspended for several days without serious consequences for the organism. Breathing, on the other hand, if suspended for more than three minutes entails death. The organism therefore accommodates mechanisms for the mobilization and redistribution of nutrients to ensure continuous and constan...
+
+=== Chunk 1476 ===
+Source: 0820_002-ebook.pdf
+Length: 6568 chars
+
+2.2 NEED RELATED TO THE DEVELOPMENT AND RENEWAL OF THE MATERIAL STRUCTURE
+Energy fl ows in the biosphere occur in the material structure of living organisms. The mere existence of this structure implies the use of materials.
+39
+I I I
+I
+I I
+NUTRITION MANUAL Chapter III – The nutritional need of humans
+2. Dependency on matter
+2.2 Need related to the development and renewal of the material structure
+As is the case for energy expenditure, and with the same limitations, one can analyse the utilization...
+
+=== Chunk 1477 ===
+Source: 0820_002-ebook.pdf
+Length: 704 chars
+
+2.2.1 Water and oxygen
+Water is just as essential to the body structure as oxygen is to the energy metabolism – to the point that it is often not mentioned. Oxygen is not yet rationed, and does not demand specifi c discussion in this study. The need for water, on the other hand, is vital particularly in view of the limitations imposed on the planet by human expansion. Nowadays, water is free in only a few privileged places. Everywhere else, its acquisition process is becoming just as costly econo...
+
+=== Chunk 1478 ===
+Source: 0820_002-ebook.pdf
+Length: 333 chars
+
+2.2.2 Glucides
+There are no essential glucides in human nutrition. They can all be produced from glucose that can itself be synthesized from some amino acids.
+41
+I I I
+I I I
+NUTRITION MANUAL Chapter III – The nutritional need of humans
+2. Dependency on matter
+2.2 Need related to the development and renewal of the material structure...
+
+=== Chunk 1479 ===
+Source: 0820_002-ebook.pdf
+Length: 2492 chars
+
+2.2.3 Amino acids
+Of all the components of the nutritional need, the requirement for amino acids is the one whose analysis and understanding are the most complex, to the point where we still lack a comprehensive model. The protein metabolism is one of the most complicated elements of the physiology of nutrition. In spite of his extensive research, Professor Waterlow chooses not to provide estimates of the required daily protein intake in grams among children, because of the uncertainties related...
+
+=== Chunk 1480 ===
+Source: 0820_002-ebook.pdf
+Length: 237 chars
+
+Protein digestibility
+The most convenient way of quantifying the digestibility of proteins is to measure their nitrogen content. All proteins contain roughly the same amount, and it is thus possible to deduce protein quantity as follows:...
+
+=== Chunk 1481 ===
+Source: 0820_002-ebook.pdf
+Length: 1159 chars
+
+proteins = nitrogen × 6.25
+The digestibility of proteins can be calculated by measuring the nitrogen contained in food, and then the amount of nitrogen contained in the faeces after digestion (allowing for faecal nitrogen loss that exists even without eating protein). Without entering into detail as to the calculation of digestibility, one can say that animal protein (milk, eggs, meat and fi sh) have a 95% digestibility
+13 Essential amino acids.
+42
+2. Dependency on matter
+2.2 Need related to the ...
+
+=== Chunk 1482 ===
+Source: 0820_002-ebook.pdf
+Length: 3458 chars
+
+Protein value according to amino-acid composition
+The amino acids that are constantly circulated in the course of protein turnover can provide the organism with fuel. This is incidentally probably one of the reasons for protein turnover, otherwise quite costly in energy. The primary function of amino acids nevertheless remains related to synthesis (fi rstly the synthesis of renewed proteins, then pregnancy, breastfeeding, recovery and growth).
+Human proteins combine different amino acids in speci...
+
+=== Chunk 1483 ===
+Source: 0820_002-ebook.pdf
+Length: 4976 chars
+
+Adults
+Trémolière has compiled balance studies that show how the nitrogen requirements of adults can be met by proteins from different diets. The results are presented in Table 3.2 below, in order of decreasing yield (Trémolière, 1977).
+Table 3.2 Amount of nitrogen from different protein sources needed to ensure the nitrogen balance in adults
+Protein source
+mg of nitrogen to be ingested per kg of bodyweight
+Milk 66 Soy fl our 68 Eggs 71 70% cereals 28% milk and meat 71 50% rice 45% milk 75 5% oth...
+
+=== Chunk 1484 ===
+Source: 0820_002-ebook.pdf
+Length: 3845 chars
+
+Children
+The needs for essential amino acids decrease from birth to adulthood. However, in the overall perspective of protein and energy needs, adults require more proteins per energy unit dissipated than children do. If the child’s consumption of the foods and food groups described in Table 3.2 above is suffi cient to cover its energy needs, then its requirements in nitrogen and essential amino acids are necessarily also met.
+Excluding the severe shortage situations discussed above for adults, r...
+
+=== Chunk 1485 ===
+Source: 0820_002-ebook.pdf
+Length: 143 chars
+
+Infants
+It is commonly accepted that the infant’s essential amino-acid needs are met by breastfeeding, provided the latter covers energy needs....
+
+=== Chunk 1486 ===
+Source: 0820_002-ebook.pdf
+Length: 773 chars
+
+2.2.4 Lipids
+Most lipids in the organism can be synthesized from glucose or fatty acids. Two lipids are essential – linoleic acid and α-linoleic acid – and must be absorbed to avoid various disorders. Linoleic acid is a precursor of arachidonic acid, and together they account for a signifi cant proportion of the fatty acids of the cell membrane and the white matter of the central nervous system. Linoleic acid is also a precursor of the prostaglandins, hormones whose spectrum is extremely vast. α-...
+
+=== Chunk 1487 ===
+Source: 0820_002-ebook.pdf
+Length: 1426 chars
+
+Defi nition
+Vitamins are molecules that man cannot synthesize himself. The word is derived from “vital amine”. The clarifi cation of the structure of some agents indispensable to life has shown that they contain an amine group. It later became apparent that all vitamins do not contain an amine group. The expression “vitamin”
+16 This Section provides general information about each type of vitamin, but recommended intakes are provided in Chapter IV. Annex 2 lists the foods that contain the four most...
+
+=== Chunk 1488 ===
+Source: 0820_002-ebook.pdf
+Length: 1488 chars
+
+History
+The discovery of vitamins is due to contemporary science. In the early 20th century, essential factors were noted to provide growth accessories in addition to conventional nutrients (glucides, lipids and proteins). Some fi fty were consigned between 1915 and 1945. They were progressively identifi ed with a letter, sometimes combined with a number to distinguish them, and later a specifi c name as soon as one of these factors was isolated and its chemical structure clarifi ed. When it became ...
+
+=== Chunk 1489 ===
+Source: 0820_002-ebook.pdf
+Length: 754 chars
+
+Classifi cation and nomenclature
+Vitamins are usually distinguished according to whether they are water-soluble or fat-soluble (i.e. liposoluble). This distinction is interesting from a nutritional perspective: the organism can store fat-soluble vitamins, but not (or only little) water-soluble vitamins. Water-soluble vitamins can be further broken down into vitamins of the B group and vitamin C. The B group comprises vitamins with several molecules whose common characteristics are that they are c...
+
+=== Chunk 1490 ===
+Source: 0820_002-ebook.pdf
+Length: 225 chars
+
+Unit of measurement
+The main recognized unit of measurement is the weight of the active substance. For some vitamins, former international units are still in wide use and appear in this Manual with their equivalent in weight....
+
+=== Chunk 1491 ===
+Source: 0820_002-ebook.pdf
+Length: 14879 chars
+
+Water-soluble vitamins
+Vitamin C or ascorbic acid
+Source: vitamin C is synthesized by almost all living organisms, apart from primates, guinea pigs, one type of bats and some birds. As a result, it is found in most animal and vegetable tissue. Berries, citrus fruits and capsicum are the richest sources, followed by greens and vegetables in the cabbage family.
+17 Non-protein organic substance, indispensable for the activity of some enzymes.
+47
+I I I
+I I I
+NUTRITION MANUAL Chapter III – The nutrit...
+
+=== Chunk 1492 ===
+Source: 0820_002-ebook.pdf
+Length: 12625 chars
+
+Pantothenic acid or Vitamin B5
+Source: pantothenic acid is found in all natural foods. It is particularly abundant in beer yeast, egg yolk, offal (especially liver) and is found in more moderate quantities in cereals and legumes. It is one of the constituents of coenzyme A, into which it is usually integrated. In food, it is found in both its free and integrated forms.
+23 Pellagra is discussed in Chapter VIII.
+51
+I I I
+I I I
+NUTRITION MANUAL Chapter III – The nutritional need of humans
+2. Depend...
+
+=== Chunk 1493 ===
+Source: 0820_002-ebook.pdf
+Length: 9066 chars
+
+Cobalamin or Vitamin B12
+Source: vitamin B12 is found in food as different forms of cobalamin. The long-held view that cobalamin is absent from vegetables is questioned today: some legumes may contain small amounts, although it is believed that these plants host micro-organisms that can synthesize them. The greatest concentrations of vitamin are found in offal (kidneys, liver and brain), less in egg yolk, oysters, crab and salmon. Other animal tissues and fi sh contain slighter concentrations. It...
+
+=== Chunk 1494 ===
+Source: 0820_002-ebook.pdf
+Length: 8700 chars
+
+= 6 μg or 10 IU of β-carotene or 10 IUc
+= 12 μg of other carotenoids
+In view of the above, units should be clearly defi ned when consulting recommended intakes and food composition tables.
+Absorption: in the stomach, vitamin A and its provitamins combine with the other lipids to produce globules that pass into the small intestine. There, globules combine with bile salts to produce emulsions that permit the splitting of complex lipids into simple lipids owing to the action of digestive enzymes; th...
+
+=== Chunk 1495 ===
+Source: 0820_002-ebook.pdf
+Length: 8444 chars
+
+Cholecalciferol or Vitamin D3
+Source: vitamin D3 is not really a vitamin, because it is synthesized by man through solar ultraviolet radiation on his skin. Ultraviolet irradiation transforms provitamin D3 (7-dehydrocholesterol) into an intermediary, which spontaneously converts into vitamin D3 within one or two days simply because of the organism’s heat. In adults, synthesis occurs mainly in the outer layer of the skin (epidermis), whereas in infants it also occurs in the deep inner layer of the...
+
+=== Chunk 1496 ===
+Source: 0820_002-ebook.pdf
+Length: 5527 chars
+
+Tocopherols or Vitamin E
+Introduction: vitamin E is the generic reference to 8 related molecules (isomers) whose biological activities differ; the four most common are α-tocopherol, β-tocopherol, γ-tocopherol and δ-tocopherol. Little is still known about vitamin E. Various signs of defi ciency have been documented for animals, but human defi ciency appeared to be non-existent – vitamin E has only recently proven to be a real vitamin, and thus essential, for man.
+Source: α-tocopherol and γ-tocopher...
+
+=== Chunk 1497 ===
+Source: 0820_002-ebook.pdf
+Length: 4083 chars
+
+Phylloquinone or Vitamin K
+Source: vitamin K (the generic name of a range of compounds whose vitamin activity is the same as phylloquinone or vitamin K1) is common in the vegetable, animal and bacterial kingdoms. However, only plants and bacteria can synthesize the essential part of the molecule. This is found in high concentration in green vegetables (spinach, cabbage, caulifl ower, broccoli, and lettuce), dairy and meat products, fruits and cereals. Major differences exist between foods belongi...
+
+=== Chunk 1498 ===
+Source: 0820_002-ebook.pdf
+Length: 3087 chars
+
+2.2.6 Minerals
+Minerals are elementary chemical compounds whose atomic characteristics make them indispensable to the organism. Minerals include trace elements and are essential because they cannot be produced by the organism and therefore must be found, through food and drinking water in the mineral environment; this depends on the nature of the soil and the surface water. Minerals include major elements such as calcium and phosphorus, and trace elements of which the organism contains less than...
+
+=== Chunk 1499 ===
+Source: 0820_002-ebook.pdf
+Length: 3978 chars
+
+Electrolytes
+The three main electrolytes are sodium, potassium and chlorine. They account for the osmotic pressure of fl uids in the organism,42 and their repartition in the body determines their volume within (intra-cellular) and outside (extra-cellular) cells.
+40 Recommended intakes are discussed in Chapter IV.
+41 See Chapter VIII.
+42 Sometimes referred to as osmolality.
+64
+2. Dependency on matter
+2.2 Need related to the development and renewal of the material structure
+9 Sodium is specifi cally...
+
+=== Chunk 1500 ===
+Source: 0820_002-ebook.pdf
+Length: 161 chars
+
+Bone minerals
+The three minerals predominant in the bones are calcium, bound in the bones to phosphorus (in a crystal form called hydroxyapatite), and magnesium....
+
+=== Chunk 1501 ===
+Source: 0820_002-ebook.pdf
+Length: 4388 chars
+
+Calcium
+Source: calcium is found (in decreasing order of concentration) in hard cheese (750 mg/100 g), oilseeds and in particular almonds, walnuts and hazelnuts (175 mg/100 g), soft cheese and milk (130 mg/100 g), and fi nally dried fruit (100 mg/100 g) (Randoin, 1982).
+Absorption: calcium is absorbed in two ways. One is active, and is regulated by vitamin D, mainly in the duodenum; the other is passive and occurs throughout the intestine, but mainly in the ileum. Calcium absorption also depends ...
+
+=== Chunk 1502 ===
+Source: 0820_002-ebook.pdf
+Length: 2771 chars
+
+Phosphorus
+Source: phosphorus is abundant in animal products, oilseeds, legumes and cereals. It is therefore improbable for its defi ciency to be caused by an inadequate diet.
+Absorption: man absorbs between 60 and 70% of ingested phosphorus, and the absorption of animal phosphorus is more effi cient than that of vegetable origin. Like calcium, the smaller the amount of phosphorus supplied by the diet, the more effi cient its absorption is. To date, phosphorus absorption remains ill-known; however,...
+
+=== Chunk 1503 ===
+Source: 0820_002-ebook.pdf
+Length: 10898 chars
+
+Magnesium
+Source: all unprocessed foods contain magnesium, but concentrations vary greatly. Milk, wholemeal cereals, legumes, vegetables and potatoes contain particularly high concentrations of magnesium. Vegetables are generally rich in magnesium (its role to chlorophyll is analogous to that of iron to haemoglobin).
+Absorption: the absorption of magnesium, as is the case for other minerals, occurs through an active mechanism for moderate intakes, and this mechanism saturates as intakes increase...
+
+=== Chunk 1504 ===
+Source: 0820_002-ebook.pdf
+Length: 2753 chars
+
+Iodine
+Source: the iodine content of food is mainly determined by the iodine concentration in the soil and groundwater, and this concentration is related to geology. During the formation of the earth, iodine was quite widespread, but was subsequently leached by rain, erosion, glaciations and fl oods. As a result, most terrestrial iodine is now found in the seas and in deep terrestrial layers, in the chemical form of iodide. Solar radiation transforms marine iodine into elementary iodine, which is...
+
+=== Chunk 1505 ===
+Source: 0820_002-ebook.pdf
+Length: 4776 chars
+
+Zinc
+Source: zinc is found in most foods, but its concentration varies greatly. Its major sources include animal products (3–5 mg/100 g), cereals and legumes (2–3 mg/100 g). In countries where the consumption of animal products is high, the diet contains an adequate amount of zinc. In contrast, where animal products are not a major component of the diet, cereals and legumes provide most of the required zinc; this can prove inadequate if the cereals are overly processed or refi ned, because zinc i...
+
+=== Chunk 1506 ===
+Source: 0820_002-ebook.pdf
+Length: 2261 chars
+
+Copper
+Source: most foods contain copper, the richest sources (0.3–2 mg/100 g) being shellfi sh, oilseeds (including cocoa powder), legumes, and wholemeal cereals.
+Absorption: like other metals, the absorption of copper increases with intake, but in decreasing proportions. Zinc inhibits the absorption of copper.
+Metabolism, storage and excretion: following its absorption, copper is transported to the liver where it binds with a protein called ceruloplasmin, which transports it to the tissues. It ...
+
+=== Chunk 1507 ===
+Source: 0820_002-ebook.pdf
+Length: 1267 chars
+
+Selenium
+Source: selenium is found mainly in sea products, offal, meat, cereals, and legumes.
+Absorption: selenium is usually ingested together with methionine and cysteine, and is well absorbed. Selenium homeostasis does not depend on its absorption.
+Metabolism, storage and excretion: little is known about the selenium metabolism, but its excretion is mainly urinary, and its regulation determines selenium homeostasis.
+Function: the main function of selenium is to act as an antioxidant agent. It...
+
+=== Chunk 1508 ===
+Source: 0820_002-ebook.pdf
+Length: 232 chars
+
+Chrome
+Chrome is today recognized to be an essential nutrient that promotes the action of insulin and thus infl uences the mechanisms of glucides, lipids and proteins (Shils, 1994). Human defi ciency has not been demonstrated to date....
+
+=== Chunk 1509 ===
+Source: 0820_002-ebook.pdf
+Length: 668 chars
+
+Other trace metals
+Other trace metals appear to be essential and their defi ciency poses no particular problem because their intake is usually adequate. These include boron, which infl uences the mineral metabolism, manganese, an enzyme activator and a constituent of some enzymes, molybdenum, also a constituent of some enzymes, and silicon, which contributes to the synthesis of bones and cartilage. Vanadium, bromine, fl uorine, lead and tin could also be essential trace metals, but this remains to ...
+
+=== Chunk 1510 ===
+Source: 0820_002-ebook.pdf
+Length: 3067 chars
+
+3. DEPENDENCY ON OTHER SPECIES
+Chapter V discusses the living species that man depends on to meet his nutritional need. This section only recalls a number of important points related to this dependency.
+Beyond philosophical and religious considerations, man belongs to the biosphere like all other species. He accounts for approximately 4% of the animal biomass on earth. As such, he consumes
+53 See Chapter VIII.
+73
+I
+I
+I
+I
+I I
+NUTRITION MANUAL Chapter III – The nutritional need of humans
+3. Depend...
+
+=== Chunk 1511 ===
+Source: 0820_002-ebook.pdf
+Length: 1150 chars
+
+1. ENERGY
+Daily energy needs are expressed in Average Requirements as opposed to Population Reference Intakes. Indeed, using PRIs as the basis for the calculation of intake leads to an obesity risk for approximately 90% of the population under consideration. Obesity is a major public health problem in industrialized societies, and it is therefore preferable to base recommendations on average requirements. On the other hand, converting average requirements into actual intake removes the correspon...
+
+=== Chunk 1512 ===
+Source: 0820_002-ebook.pdf
+Length: 550 chars
+
+1.1 AVERAGE REQUIREMENTS FOR MEN AGED 19–30 YEARS
+Weight BM/kg Light occupation Moderate occupation Heavy occupation 1.55 BM 1.78 BM 2.10 BM (kg) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) 50 29 121.2 2,250 9,390 2,580 10,790 3,050 12,730 55 27.5 115 2,350 9,800 2,690 11,260 3,180 13,280 60 26.5 111 2,460 10,320 2,830 11,850 3,340 13,990 65 26 108.7 2,620 10,950 3,010 12,580 3,550 14,840 70 25 104.5 2,710 11,340 3,120 13,020 3,680 15,360 75 24.5 102.4 2,850 11,900 3,270 13,670 3,860 16,130 ...
+
+=== Chunk 1513 ===
+Source: 0820_002-ebook.pdf
+Length: 814 chars
+
+1.2 AVERAGE REQUIREMENTS FOR MEN AGED 31–60 YEARS
+Weight BM/kg Light occupation Moderate occupation Heavy occupation 1.55 BM 1.78 BM 2.10 BM (kg) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) 50 29 121.2 2,250 9,390 2,580 10,790 3,050 12,730 55 27.5 114.9 2,340 9,800 2,690 11,250 3,180 13,270 60 26 108.7 2,420 10,110 2,780 11,610 3,280 13,670 65 25 104.5 2,520 10,530 2,890 12,090 3,410 14,260 70 24 100.3 2,600 10,880 2,990 12,500 3,530 14,740 75 23.5 98.2 2,730 11,420 3,140 13,110 3,700 15,470...
+
+=== Chunk 1514 ===
+Source: 0820_002-ebook.pdf
+Length: 542 chars
+
+1.3 AVERAGE REQUIREMENTS FOR MEN AGED OVER 60 YEARS
+Weight BM/kg Light occupation Moderate occupation Heavy occupation 1.55 BM 1.78 BM 2.10 BM (kg) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) 50 23 96.1 1,780 7,450 2,050 8,550 2,420 10,090 55 22.5 94 1,920 8,010 2,200 9,200 2,600 10,860 60 21.5 89.9 2,000 8,360 2,300 9,600 2,710 11,330 65 21 87.8 2,120 8,850 2,430 10,160 2,870 11,980 70 20.5 85.7 2,220 9,300 2,550 10,680 3,010 12,600 75 20 83.6 2,330 9,720 2,670 11,160 3,150 13,170 80 19.5 8...
+
+=== Chunk 1515 ===
+Source: 0820_002-ebook.pdf
+Length: 589 chars
+
+1.4 AVERAGE REQUIREMENTS FOR WOMEN AGED 19–30 YEARS
+Weight BM/kg Light occupation Moderate occupation Heavy occupation 1.56 BM 1.64 BM 1.82 BM (kg) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) 40 27 112.8 1,680 7,040 1,770 7,400 1,970 8,220 45 25.5 106.6 1,790 7,480 1,880 7,870 2,090 8,730 50 24.5 102.4 1,910 7,990 2,010 8,400 2,230 9,320 55 23.5 98.2 2,020 8,430 2,120 8,860 2,350 9,830 60 23 96.1 2,150 9,000 2,260 9,460 2,510 10,500 65 22.5 94 2,280 9,540 2,400 10,030 2,660 11,130 70 22 92 2...
+
+=== Chunk 1516 ===
+Source: 0820_002-ebook.pdf
+Length: 691 chars
+
+1.5 AVERAGE REQUIREMENTS FOR WOMEN AGED 31–60 YEARS
+Weight BM/kg Light occupation Moderate occupation Heavy occupation 1.56 BM 1.64 BM 1.82 BM (kg) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) 40 29.5 123.3 1,840 7,690 1,940 8,090 2,150 8,980 45 27.5 114.9 1,930 8,070 2,030 8,480 2,250 9,410 50 25.5 106.6 1,990 8,310 2,090 8,740 2,320 9,700 55 24 100.3 2,060 8,610 2,160 9,050 2,400 10,040 60 22.5 94 2,110 8,800 2,210 9,250 2,460 10,270 65 21.5 89.9 2,180 9,110 2,290 9,580 2,540 10,630 70 20.5...
+
+=== Chunk 1517 ===
+Source: 0820_002-ebook.pdf
+Length: 588 chars
+
+1.6 AVERAGE REQUIREMENTS FOR WOMEN AGED OVER 60 YEARS
+Weight BM/kg Light occupation Moderate occupation Heavy occupation 1.56 BM 1.64 BM 1.82 BM (kg) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) (kcal) (kJ) 40 25.5 106.6 1,590 6,650 1,670 6,990 1,860 7,760 45 23.5 98.2 1,650 6,900 1,730 7,250 1,920 8,050 50 22.5 94 1,760 7,340 1,850 7,710 2,050 8,560 55 21.5 89.9 1,840 7,710 1,940 8,110 2,150 9,000 60 20.5 85.7 1,920 8,020 2,020 8,430 2,240 9,360 65 19.5 81.5 1,980 8,270 2,080 8,690 2,310 9,640 70 19 79....
+
+=== Chunk 1518 ===
+Source: 0820_002-ebook.pdf
+Length: 1160 chars
+
+1.7 AVERAGE ENERGY REQUIREMENTS FOR ADOLESCENTS AGED 11–18 YEARS
+Energy requirements are determined by the physical activity – or occupation – that is deemed desirable by the authors of the FAO/WHO/UNU report (WHO, 1985). They allow for the signifi cant energy use of adolescents, and also for their growth. In calculating the requirements for a given population, it is preferable to do so on the basis of weight rather than age group, as adolescent growth surges occur at different ages.
+Age Median w...
+
+=== Chunk 1519 ===
+Source: 0820_002-ebook.pdf
+Length: 492 chars
+
+1.8 AVERAGE ENERGY REQUIREMENTS FOR INFANTS AND CHILDREN AGED 3 MONTHS TO 10 YEARS
+Age Median weight Average energy requirements (kg) (kcal/kg) (kJ/kg) (kcal/day) (kJ/day) Months 3 – 6 7 100 418 700 2,930 7 – 9 8.5 95 397 810 3,380 10 – 12 9.5 100 418 950 3,970 Years 2nd year 11 105 439 1,160 4,830 3rd year 13.5 100 418 1,350 5,640 4 – 5 16.5 95 397 1,570 6,550 Boys 6 – 7 20.5 90 376 1,850 7,710 8 – 10 27 78 326 2,110 8,800 Girls 6 – 7 20.5 85 355 1,740 7,280 8 – 10 27 67 280 1,810 7,560...
+
+=== Chunk 1520 ===
+Source: 0820_002-ebook.pdf
+Length: 346 chars
+
+2. PROTEIN
+Protein requirements discussed here are drawn from the FAO/WHO/UNU report (WHO, 1985); they refer to safety intakes, in accordance with the above Population Reference Intake (PRI) as defi ned by the European Commission. Requirements are expressed in protein of equivalent quality and digestibility with reference to egg or milk protein....
+
+=== Chunk 1521 ===
+Source: 0820_002-ebook.pdf
+Length: 38 chars
+
+Adult men:
+0.75 g/kg of body mass/day....
+
+=== Chunk 1522 ===
+Source: 0820_002-ebook.pdf
+Length: 40 chars
+
+Adult women:
+0.75 g/kg of body mass/day....
+
+=== Chunk 1523 ===
+Source: 0820_002-ebook.pdf
+Length: 169 chars
+
+9 additional requirements related to pregnancy: 10 g/day.
+9 additional requirements related to breastfeeding:
+q fi rst 6 months: 16 g/day;
+q following 6 months: 12 g/day....
+
+=== Chunk 1524 ===
+Source: 0820_002-ebook.pdf
+Length: 975 chars
+
+Children between 4 months and 10 years:
+4–6 months: 1.86 g/kg of body mass/day 7–9 months: 1.65 g/kg of body mass/day 10–12 months: 1.48 g/kg of body mass/day 13–18 months: 1.26 g/kg of body mass/day 19–24 months: 1.17 g/kg of body mass/day 3rd year: 1.13 g/kg of body mass/day 4th year: 1.09 g/kg of body mass/day 5th year: 1.06 g/kg of body mass/day 6th year: 1.02 g/kg of body mass/day
+84
+2. Protein 3. Vitamins
+3.1 Ascorbic Acid (C)
+7th year: 1.01 g/kg of body mass/day 8th year: 1.01 g/kg of bod...
+
+=== Chunk 1525 ===
+Source: 0820_002-ebook.pdf
+Length: 1067 chars
+
+3.1 ASCORBIC ACID (C)
+Adults Average Requirement (AR) Population Reference Intake (PRI) Lowest Threshold Intake (LTI) PRI for pregnancy PRI for breastfeeding mg/day 30 45 12 55 70
+Children and adolescents 6 – 11 months 1 – 3 years 4 – 6 years 7 – 10 years 11 – 14 years 15 – 17 years PRI (mg/day) 20 25 25 30 35 40
+85
+V
+I
+V I
+NUTRITION MANUAL Chapter IV – Reference intakes or recommended intakes
+3.2 Thiamine (B1) 3.3 Ribofl avin (B2) 3. Vitamins
+3.4 Nicotinic acid (Niacin, B3, PP)
+3.2 THIAMINE (B1 ...
+
+=== Chunk 1526 ===
+Source: 0820_002-ebook.pdf
+Length: 2919 chars
+
+3.3 RIBOFLAVIN (B2 )
+Like thiamine, ribofl avin is largely associated with the energy metabolism, but not only; this may explain why needs do not increase signifi cantly with energy requirements beyond maintenance thresholds. The two values are 0.5 mg/1,000 kcal for adults, and 0.6 mg/1,000 kcal for children. Additional requirements associated with pregnancy are 0.3 mg/day, and those associated with breastfeeding are 0.5 mg/day. The European Commission defi nes the following daily requirements in m...
+
+=== Chunk 1527 ===
+Source: 0820_002-ebook.pdf
+Length: 712 chars
+
+3.8 FOLIC ACID
+Values allow for the fact that the bio-availability of dietary folic acid is limited to approximately 50%.
+Adults μg/day Average Requirement (AR) 140 Population Reference Intake (PRI) 200 Lowest Threshold Intake (LTI) 85 PRI for pregnancy 400a PRI for breastfeeding 350
+a In the form of tablet supplements, because the diet alone cannot provide an adequate intake of folic acid in the late stages of pregnancy.
+87
+V I
+V
+I
+NUTRITION MANUAL Chapter IV – Reference intakes or recommended ...
+
+=== Chunk 1528 ===
+Source: 0820_002-ebook.pdf
+Length: 322 chars
+
+3.9 COBALAMIN (B12 )
+Adults μg/day Average Requirement (AR) 1 Population Reference Intake (PRI) 1.4 Lowest Threshold Intake (LTI) 0.6 PRI for pregnancy 1.6 PRI for breastfeeding 1.9
+Children and adolescents PRI (μg / day) 6 – 11 months 0.5 1 – 3 years 0.7 4 – 6 years 0.9 7 – 10 years 1 11 – 14 years 1.3 15 – 17 years 1.4...
+
+=== Chunk 1529 ===
+Source: 0820_002-ebook.pdf
+Length: 1683 chars
+
+3.10 RETINOL (A)
+Requirements are expressed in RE (μg of retinol equivalent per day) and the IU value is indicated between parentheses.
+Adults Men Women Average Requirement (AR) 500 (1,660) 400 (1,330) Population Reference Intake (PRI) 700 (2,330) 600 (2,000) Lowest Threshold Intake (LTI) 300 (1,000) 250 (830) PRI for pregnancy 700 (2,330) PRI for breastfeeding 950 (3,160)
+88
+3. Vitamins
+3.10 Retinol (A) 3.11 Cholecalciferol (D3) 3.12 Tocopherols (E)
+Children and adolescents PRI 6 – 11 months 35...
+
+=== Chunk 1530 ===
+Source: 0820_002-ebook.pdf
+Length: 710 chars
+
+3.12 TOCOPHEROLS (E)
+Vitamin E requirements are associated with the dietary supply of polyunsaturated fatty acids. Generally speaking, the higher the ingestion of unsaturated fatty acids, the greater the associated intake of vitamin E. It could be left at that, and recommendations discarded as superfl uous. However, based upon the relation between the dietary supply of polyunsaturated fatty acids and vitamin A supply, a daily intake of 4 mg of α-tocopherol equivalent is recommended for men, and 3...
+
+=== Chunk 1531 ===
+Source: 0820_002-ebook.pdf
+Length: 221 chars
+
+3.13 PHYLLOQUINONE (K)
+Human vitamin K defi ciency is rare, and thus complicates the calculation of requirements. A daily intake of 1 μg/kg of body mass is considered adequate, and is in principle ensured by a normal diet....
+
+=== Chunk 1532 ===
+Source: 0820_002-ebook.pdf
+Length: 576 chars
+
+4.1 SODIUM
+There are no signifi cant PRI or AR for sodium, but instead a range of acceptable intakes5 (0.6 to 3.5 g/day; 25 to 150 mmol/day), and these only apply to adults. Sodium defi ciency cannot arise from the diet, but from a pathological state; recommendations are therefore not useful, other than to warn against an intake above 3.5 mg for adults, owing to the risks of high blood pressure beyond this threshold. In common salt, the equivalent of the acceptable intake range is 1.5 to 8.8 g/day...
+
+=== Chunk 1533 ===
+Source: 0820_002-ebook.pdf
+Length: 794 chars
+
+4.2 POTASSIUM
+Potassium defi ciency caused by diet is unlikely. However, potassium plays an important part in the regulation of sodium excretion, and in mitigating the risks of arterial tension; its intake should therefore remain above the LTI.
+Adults mg/day mmol/day Population Reference Intake (PRI) 3,100 80 Lowest Threshold Intake (LTI) 1,600 40 PRI for pregnancy 3,100 80 PRI for breastfeeding 3,100 80
+Children and adolescents mg/day mmol/day 6 – 11 months 800 20 1 – 3 years 800 20 4 – 6 years ...
+
+=== Chunk 1534 ===
+Source: 0820_002-ebook.pdf
+Length: 309 chars
+
+4.3 CHLORINE
+Chlorine is closely associated with sodium (common salt is sodium chloride), both in the diet and in the metabolism, and recommendations for the two are therefore identical: daily intakes range between 25 and 150 mmol, that is, between 0.9 and 5.3 g of chlorine, or between 1.5 and 8.8 g of salt....
+
+=== Chunk 1535 ===
+Source: 0820_002-ebook.pdf
+Length: 368 chars
+
+4.4 CALCIUM
+Adults mg/day Average Requirement (AR) 550 Population Reference Intake (PRI) 700 Lowest Threshold Intake (LTI) 400 PRI for pregnancy 700 PRI for breastfeeding 1,200
+Children and adolescents PRI (mg/day) 6 – 11 months 400 1 – 3 years 400 4 – 6 years 450 7 – 10 years 550 Boys 11 – 14 years 1,000 15 – 17 years 1,000 Girls 11 – 14 years 800 15 – 17 years 800...
+
+=== Chunk 1536 ===
+Source: 0820_002-ebook.pdf
+Length: 204 chars
+
+4.5 MAGNESIUM
+Magnesium is abundant in a normal diet, and defi ciency is unlikely. A daily intake of between 150 and 500 mg is acceptable for adults, and these values allow for pregnancy and breastfeeding....
+
+=== Chunk 1537 ===
+Source: 0820_002-ebook.pdf
+Length: 701 chars
+
+4.6 PHOSPHORUS
+Little is known about the organism’s phosphorus requirements; however, phosphorus is mostly associated with calcium in the skeleton, and the same recommendations apply as for calcium, according to a molar equivalence.
+Adults mg/day Average Requirement (AR) 400 Population Reference Intake (PRI) 550 Lowest Threshold Intake (LTI) 300 PRI for pregnancy 550 PRI for breastfeeding 950
+91
+V I
+V I
+NUTRITION MANUAL Chapter IV – Reference intakes or recommended intakes
+4. Minerals
+4.6 Phosph...
+
+=== Chunk 1538 ===
+Source: 0820_002-ebook.pdf
+Length: 1773 chars
+
+4.7 IRON
+The table below applies to all groups, except to women of childbearing age (see below). It indicates the intakes necessary to cover the requirements of 95% of the individuals in each group. Intake levels are provided in terms both of absorbed quantities and of ingested amounts, based upon a 15% bio-availability of dietary iron.
+Category Requirements absorbed (mg/day) Equivalent requirements ingested (mg/day) 0.5 – 1 year 0.93 6.2 1 – 3 years 0.58 3.9 4 – 6 years 0.63 4.2 7 – 10 years 0....
+
+=== Chunk 1539 ===
+Source: 0820_002-ebook.pdf
+Length: 310 chars
+
+4.8 IODINE
+Adults Average Requirement (AR) Population Reference Intake (PRI) Lowest Threshold Intake (LTI) PRI for pregnancy PRI for breastfeeding μg/day 100 130 70 130 160
+Children and adolescents 6 – 11 months 1 – 3 years 4 – 6 years 7 – 10 years 11 – 14 years 15 – 17 years PRI (μg/day) 50 70 90 100 120 130...
+
+=== Chunk 1540 ===
+Source: 0820_002-ebook.pdf
+Length: 532 chars
+
+4.9 ZINC
+Values are expressed in mg/day.
+Adults Average Requirement (AR) Population Reference Intake (PRI) Lowest Threshold Intake (LTI) PRI for pregnancy PRI for breastfeeding Men 7.5 9.5 5 Women 5.5 7 4 7 12
+Children and adolescents Boys Girls 6 – 11 months 1 – 3 years 4 – 6 years 7 – 10 years 11 – 14 years 15 – 17 years 11 – 14 years 15 – 17 years PRI (mg/day) 4 4 6 7 9 9 9 7
+93
+V I
+V I
+NUTRITION MANUAL Chapter IV – Reference intakes or recommended intakes
+4. Minerals 4.10 Copper
+4.11 Seleniu...
+
+=== Chunk 1541 ===
+Source: 0820_002-ebook.pdf
+Length: 313 chars
+
+4.10 COPPER
+Adults mg/day Average Requirement (AR) 0.8 Population Reference Intake (PRI) 1.1 Lowest Threshold Intake (LTI) 0.6 PRI for pregnancy 1.1 PRI for breastfeeding 1.4
+Children and adolescents PRI (mg/day) 6 – 11 months 0.3 1 – 3 years 0.4 4 – 6 years 0.6 7 – 10 years 0.7 11 – 14 years 0.8 15 – 17 years 1...
+
+=== Chunk 1542 ===
+Source: 0820_002-ebook.pdf
+Length: 305 chars
+
+4.11 SELENIUM
+Adults μg/day Average Requirement (AR) 40 Population Reference Intake (PRI) 55 Lowest Threshold Intake (LTI) 20 PRI for pregnancy 55 PRI for breastfeeding 70
+Children and adolescents PRI (μg/day) 6 – 11 months 8 1 – 3 years 10 4 – 6 years 15 7 – 10 years 25 11 – 14 years 35 15 – 17 years 45...
+
+=== Chunk 1543 ===
+Source: 0820_002-ebook.pdf
+Length: 114 chars
+
+4.12 MANGANESE
+Manganese defi ciency in humans is unlikely. Acceptable daily intakes range between 1 and 10 mg/day....
+
+=== Chunk 1544 ===
+Source: 0820_002-ebook.pdf
+Length: 210 chars
+
+4.13 MOLYBDENUM
+Molybdenum requirements remain unknown. Intakes appear to be adequate, and recommendations are therefore not called for.
+94
+4. Minerals 5. Essential lipids
+4.14 Chrome 4.15 Fluoride 4.16 Sulphur...
+
+=== Chunk 1545 ===
+Source: 0820_002-ebook.pdf
+Length: 226 chars
+
+4.14 CHROME
+Available data is insuffi cient to deduce an accurate range of chrome requirements. A daily intake of 50 μg of chrome is probably adequate for the vast majority of individuals to remain in good health (Shils, 1994)....
+
+=== Chunk 1546 ===
+Source: 0820_002-ebook.pdf
+Length: 241 chars
+
+4.15 FLUORINE
+It is as yet unclear whether fl uorine is an essential element for man. On the other hand, its effectiveness in tooth cavity prevention is well known. Acceptable intakes range between 1.5 and 4.0 mg/day for adults (Shils, 1994)....
+
+=== Chunk 1547 ===
+Source: 0820_002-ebook.pdf
+Length: 268 chars
+
+4.16 SULPHUR
+Sulphur is undoubtedly essential to man; its defi ciency has however never been demonstrated, because it is always supplied in adequate amounts by the sulphurous amino acids of the proteins. Recommendations specifi c to sulphur are therefore not called for....
+
+=== Chunk 1548 ===
+Source: 0820_002-ebook.pdf
+Length: 805 chars
+
+5. ESSENTIAL LIPIDS
+Essential lipid requirements are expressed as a percentage of the energy supplied daily by the diet. For example, the daily consumption of 2,250 kcal (9,400 kJ) combined with a 2.5% PRI implies that 56.25 kcal (235 kJ – i.e. 6.25 g) must be in the form of essential lipids.
+Adults n-6 polyunsaturated lipids* n-3 polyunsaturated lipidsa Average Requirement (AR) 1 0.2 Population Reference Intake (PRI) 2 0.5 Lowest Threshold Intake (LTI) 0.5 0.1 PRI for pregnancy 2 0.5 PRI for br...
+
+=== Chunk 1549 ===
+Source: 0820_002-ebook.pdf
+Length: 2391 chars
+
+1. FOOD CATEGORIES
+Human food is highly varied. Many processes change the rough ingredients found in nature into actual meals; these processes include extraction, transformation, combination, preparation and cooking, and they all contribute to the diversity of food. Vast cultural diversity has resulted in a multitude of products that can be diffi cult to distinguish. A classifi cation of rough foods is therefore required. In terms of satisfying the nutritional need, what counts above all else is t...
+
+=== Chunk 1550 ===
+Source: 0820_002-ebook.pdf
+Length: 1126 chars
+
+1.1 CEREALS
+Cereals are the staple food of most of mankind. As such, they contribute to covering most energy, protein and B group vitamin requirements.
+Cereals belong to the grass family (Gramineae) whose grains are edible. These grains have certainly contributed to the diet of mankind since its origin, but they have been used massively – and later cultivated – only for the last fi fteen to twenty thousand years. Nowadays, cereals account for most of
+100
+1. Food categories
+1.1 Cereals
+the world’s...
+
+=== Chunk 1551 ===
+Source: 0820_002-ebook.pdf
+Length: 2242 chars
+
+1.1.1 The food value of cereals
+The nutritional characteristics of 100 g of dried, edible (i.e. husked), unprocessed cereal grain are provided in Table 5.1 below.
+Table 5.1 The food value of rough cereals / 100g2
+Cereal Energy kcal (kJ) Protein g Calcium mg Iron mg Thiamine mg Ribofl avin mg Niacin mg Barley 339 (1,417) 12 35 4 0.5 0.2 7 Maize 363 (1,517) 10 12 2.5 0.35 0.13 2 Millet 355 (1,484) 10 20 5 0.6 0.1 1 Oats 388 (1,622) 12 60 5 0.5 0.15 1 Rice, brown 360 (1,505) 7.5 40 2 0.32 0.06 4.6 R...
+
+=== Chunk 1552 ===
+Source: 0820_002-ebook.pdf
+Length: 3766 chars
+
+1.1.2 The structure of cereal grains
+The structural description of cereal grains is important, because nutrients are not equally distributed within the grain. The processing of cereals affects grain components that are rich in some of its essential nutrients as well as fi bre, and thus destroys most of them. Serious defi ciencies may result; some are fatal, many are of epidemic proportions. Such defi ciencies usually strike the poor, as theirs is a less diversifi ed diet and is essentially based on ...
+
+=== Chunk 1553 ===
+Source: 0820_002-ebook.pdf
+Length: 1515 chars
+
+1.1.3 Wheat
+Wheat is the most widely cultivated cereal, and is produced mainly for human consumption. Two types of wheat are distinguished: soft wheat (Triticum aestivum or vulgare), and hard or durum wheat (Triticum durum). Wheat is an excellent staple food thanks to its food value. A diet in which 75% of the energy is provided by wheat fl our (whatever its extraction), 20% from vegetables and 5% from animal products is balanced and adequate for child growth – assuming that the energy supply is ...
+
+=== Chunk 1554 ===
+Source: 0820_002-ebook.pdf
+Length: 4662 chars
+
+1.1.4 Rice
+Two main rice species are known to be cultivated: Oryza sativa (or Asian rice), predominant by far owing to the extent of its cultivation, and Oryza glaberrima, produced in West Africa. Originally rice was a tropical plant, but it has spread worldwide and adapted to a wide variety of climates. Rice is cultivated in four main modes: in irrigated paddies, rain-fed lowland cultivation, dry cultivation in non-fl ooded paddies (where moisture is provided by rain or fl ood recession residue),...
+
+=== Chunk 1555 ===
+Source: 0820_002-ebook.pdf
+Length: 3574 chars
+
+1.1.5 Maize
+Maize (Zea mays) originated in Central America and is the third most cultivated cereal worldwide. Only one-third of this production is for human consumption, the rest is used as animal feed and in industrial starch production (FAO, 1989a). Maize is a staple food in Central America, some South American countries, and in Southern and East Africa. In Africa, it has often replaced more traditional cereals, such as sorghum and millet, because of its higher yield and the fact that its cob ...
+
+=== Chunk 1556 ===
+Source: 0820_002-ebook.pdf
+Length: 1934 chars
+
+1.1.6 Sorghum
+Sorghum (Sorghum spp.) originated in Africa, where it is most commonly eaten as a staple food, particularly in Sahelian countries, owing to its tolerance to heat and semi-arid conditions. Its food value is similar to that of maize in terms of protein: exclusive sorghum consumption – but insuffi cient to cover energy needs – can cause pellagra epidemics as has been seen in Angola, for instance. However, pellagra appears rather to arise from an amino-acid unbalance: excessive leucine ...
+
+=== Chunk 1557 ===
+Source: 0820_002-ebook.pdf
+Length: 2935 chars
+
+1.1.7 Millet
+Millet includes several, sometimes botanically distinct, plants that all produce minute seeds. Like sorghum, millet originated in Africa, and they are very similar cereals. Millet is mainly produced in low income, hot and semi-arid countries – it is the most resistant cereal to heat and erratic rainfall. It is however vulnerable to birds, which cause tremendous damage because millet cobs fan out and offer the birds an irresistible source of food. Moreover, as they ripen, the grains ...
+
+=== Chunk 1558 ===
+Source: 0820_002-ebook.pdf
+Length: 1029 chars
+
+1.1.8 Barley
+Barley (Hordeum vulgare) was a predominant staple food from the early days of agriculture. In Europe, its consumption began to decline in the Middle Ages, giving way fi rst to wheat (bread), and later to new foods such as maize and potato, whose high yields protected against scarcity and famine. The increased production of such new foods did not improve the quality of the diet, however, because their high yield caused the diet to revolve almost exclusively around them, to the detrime...
+
+=== Chunk 1559 ===
+Source: 0820_002-ebook.pdf
+Length: 461 chars
+
+1.1.9 Oats and rye
+Oats and rye (Avena sativa and Secale cereale) were staple foods in Europe, being cheap and good- yield alternatives to wheat. They are nutritious, climate resistant and were formerly a pauper’s food. However, their importance has declined since the Second World War because of increased food availability and diversity, and improved purchasing power. Nowadays, they are growing more popular again, as tasty diet foods (e.g. porridge, bread)....
+
+=== Chunk 1560 ===
+Source: 0820_002-ebook.pdf
+Length: 3703 chars
+
+1.2 STARCHY PLANTS
+Starches can constitute staple foods, cereal complements or reserves when the cereal production is insuffi cient. Starchy plants above all provide a source of energy, but also of protein and vitamins according to species.
+Starchy plants are not necessarily related botanically, but all have edible parts such as the tuber,8 the fruit or the stem that all mainly contain glucides in the form of starch. By decreasing order of worldwide production, starchy plants are the following: t...
+
+=== Chunk 1561 ===
+Source: 0820_002-ebook.pdf
+Length: 3465 chars
+
+1.2.1 The food value of starchy plants
+Table 5.3 below provides the food value of 100 g of the main edible fresh starchy plants (Platt, 1962).
+Table 5.3 The food value of starchy plants / 100g
+Plant Energy Protein Calcium Iron Thiamine Ribofl avin Niacin Vitamin C (kcal) (g) (mg) (mg) (mg) (mg) (mg) (kJ) Cassava 153 (640) 0.7 25 1 0.07 0.03 0.7 30 Common potato 75 (313) 2 10 0.7 0.1 0.03 1.5 15 Plantain 128 (535) 1 7 0.5 0.05 0.05 0.7 20 Sweet potato 114 (476) 1.5 25 1 0.1 0.04 0.7 30 Taro 113 (4...
+
+=== Chunk 1562 ===
+Source: 0820_002-ebook.pdf
+Length: 968 chars
+
+1.2.2 The utilization of starchy plants
+Foods derived from starchy plants are not eaten raw; they must be prepared and cooked to make them more digestible and appetizing, extend their preservation and, in the case of cassava, reduce their toxicity. Preparation methods differ, and transformation involves several stages such as peeling prior to or following cooking, washing, soaking, drying, milling, crushing, grating, and fermentation. Cooking can involve roasting, grilling, boiling, steaming, an...
+
+=== Chunk 1563 ===
+Source: 0820_002-ebook.pdf
+Length: 824 chars
+
+1.2.3 Common potato
+The most extensively cultivated starchy plant is the common potato (Solanum tuberosum). It thrives in temperate climates where nights are cool. Its nutritional qualities have been discussed above. It can be boiled, fried, roasted, baked or braised; it is eaten whole, in chunks of all shapes and sizes, mashed, and even dried. Recipes and accompaniments for potatoes are innumerable; its fl our and starch also provide the basis for many dishes. The importance of potato is both cu...
+
+=== Chunk 1564 ===
+Source: 0820_002-ebook.pdf
+Length: 4387 chars
+
+1.2.4 Cassava
+Cassava (Manihot esculenta and M. dulcis) tolerates drought but not freezing; it is therefore found in the tropics where it is both a staple food and a food security product. Cassava is mainly a source of energy, and must therefore be eaten in combination with foods that are rich in protein, vitamins and minerals. Alas, this is rarely feasible in times of drought or armed confl ict when it is often the only remaining source of food, resulting in defi ciency diseases such as dietary k...
+
+=== Chunk 1565 ===
+Source: 0820_002-ebook.pdf
+Length: 925 chars
+
+1.2.5 Sweet potato
+Sweet potato (Ipomoea batatas) is akin to the common potato, and its cultivation spread at the same time as cassava and the common potato, with the return of the navigators of the 16th century. In Europe, its popularity was surpassed by that of the common potato, but it rapidly gained ground in Asia; its progress in Africa was slower. In Papua New Guinea, the huge yield of sweet potato per hectare eventually made it the number one energy source among cultivators. This particul...
+
+=== Chunk 1566 ===
+Source: 0820_002-ebook.pdf
+Length: 644 chars
+
+1.2.6 Yam
+Yam (Discoroae species) requires considerable rainfall, and is thus found in the humid tropics and equatorial regions. It is considered to be the tastiest tuber, and is highly popular (FAO, 1989b). Common yam forms large tubers that can weigh up to 20 kg. Some varieties produce bitter and toxic molecules (they are called bitter yam), and are usually cultivated in anticipation of scarcity or to deter thieves. They are detoxifi ed by washing, fermenting and roasting. Yam is usually eaten ...
+
+=== Chunk 1567 ===
+Source: 0820_002-ebook.pdf
+Length: 576 chars
+
+1.2.7 Plantains
+Plantains are bananas picked unripe and eaten like other starchy plants: boiled, braised or baked, made into paste, roasted, fried or made into fl our. All bananas grow sweet if allowed to ripen. The plantain variety called Musa paradisiaca is very similar to the sweet banana Musa sapientum that is most commonly eaten raw; it is simply mealier than the latter, and is preferred green (i.e. unripe). In Central and East Africa, plantains are also widely cultivated to produce local be...
+
+=== Chunk 1568 ===
+Source: 0820_002-ebook.pdf
+Length: 205 chars
+
+1.2.8 Taro
+Taro (Colocasia esculenta) is the staple food in the Pacifi c islands and some regions of Asia and Africa; it is used in the same way as yam.
+112
+1. Food categories
+1.2 Starchy plants 1.3 Legumes...
+
+=== Chunk 1569 ===
+Source: 0820_002-ebook.pdf
+Length: 492 chars
+
+1.2.9 Sago
+The sago tree is a South-East Asian palm tree (Metroxylon sagu); sago is the pulp extracted from the felled tree trunk. The pulp is washed and pressed to produce a paste that contains practically only starch. The paste can be fermented or not, and is then steamed, baked, roasted, fried or dried to produce fl our whose energy content is approximately 350 kcal (1,463 kJ) per 100 g. Fermenting improves the fl avour of the paste, and simultaneously increases its nutritional quality....
+
+=== Chunk 1570 ===
+Source: 0820_002-ebook.pdf
+Length: 1822 chars
+
+1.3 LEGUMES
+In terms of ingested amounts, legumes (or pulses) only seldom provide a staple food; their role in human nutrition is nevertheless central, as an indispensable complement of staple foods so as to balance the diet. This point is particularly important during weaning.
+Legumes are plants that bear edible seeds in pods or shells; however some legumes such as beans can be eaten whole. Strictly speaking we eat legume grains, and not – usually – legumes, just as it would be more accurate to...
+
+=== Chunk 1571 ===
+Source: 0820_002-ebook.pdf
+Length: 624 chars
+
+1.3.1 The food value of legumes
+The food value of legumes is excellent; thus, even if their importance is secondary in terms of ingested amounts, their role is essential in balancing cereal-based diets or enriching starch-based diets. The many edible legume varieties all share a similar chemical composition, lending them similar food characteristics. Table 5.5 below indicates typical nutrient values of legumes (peas, beans and lentils) generally.
+13 Cultivar: a variety of a plant developed from ...
+
+=== Chunk 1572 ===
+Source: 0820_002-ebook.pdf
+Length: 9871 chars
+
+Table 5.5 Food value of dry legumes / 100 g
+Nutrient Range of values Standard reference value Comments Energy (kcal) 320 – 370 340 Groundnut/peanut: 580 ((kJ)) (1,340 – 1,550) (1,420) (2,425) Protein (g) 20 – 26 23 Soy: 35 Lipids (g) 1 – 5 3 Groundnut/peanut: Soy: 45 18 Glucides (g) 50 – 60 55 Calcium (mg) 60 – 180 120 Iron (mg) 4 – 8 6 Thiamine (mg) 0.2 – 0.7 0.5 Ribofl avin (mg) 0.1 – 0.3 0.2 Niacin (mg) 1.5 – 2.5 2 Groundnut/peanut: 17
+Dried legumes are rich in protein (twice as much as cereal...
+
+=== Chunk 1573 ===
+Source: 0820_002-ebook.pdf
+Length: 1187 chars
+
+B group vitamin supplements
+Legume seeds contain slightly more thiamine and ribofl avin than cereal seeds; however, they complement the latter mainly because they usually suffer no losses during grinding, and much lower losses during preparation (especially in comparison to rice). Legumes therefore provide a
+116
+1. Food categories
+1.3 Legumes
+good protection against pellagra and beriberi when they complete diets based primarily on maize or rice, especially if the latter is not steamed prior to hu...
+
+=== Chunk 1574 ===
+Source: 0820_002-ebook.pdf
+Length: 1867 chars
+
+Vitamin C supplements
+As mentioned above, the germination of legumes causes signifi cant vitamin C synthesis. A simple technique used in drought and famine settings, for example in India and Ethiopia, consists in soaking approximately 40 g of unshelled legumes per person for 12 to 24 hours. The grains are then removed from the water, spread in a thin layer between two wet blankets that are then kept wet by regular water sprinkling. The legumes sprout and produce ascorbic acid, and its maximum con...
+
+=== Chunk 1575 ===
+Source: 0820_002-ebook.pdf
+Length: 1873 chars
+
+Combining legumes and starchy plants
+In starch-based diets, legume complements offer the double advantage of varying the meals and improving their fl avour. They also increase the protein content of such diets, without however signifi cantly enhancing the quality of the ingested protein in terms of amino-acid content. Like legumes, starchy plants are poor in sulphurous amino acids in terms of human requirements. Unlike cereals therefore, the combination of legumes and starchy plants does not resul...
+
+=== Chunk 1576 ===
+Source: 0820_002-ebook.pdf
+Length: 704 chars
+
+Legume varieties
+There is a vast variety of legumes, and it is impossible to discuss them comprehensively here. Rather, fi eld investigation should determine locally used varieties in each specifi c context, together with acceptable alternatives. This Manual only discusses the most common, those whose international trade has spread widely. However, more marginal, lesser-known varieties exist; they are local specialities whose yield is often lower or that are more complicated to utilize, but they a...
+
+=== Chunk 1577 ===
+Source: 0820_002-ebook.pdf
+Length: 1919 chars
+
+Table 5.7 Common legumes and consumption regions
+Legume Main consumption regions Groundnut (peanut) Arachis hypogaea West Africa, North America, Indonesia Hyacinth bean (Lablab bean) Dolichos lablab West Africa, India Broad bean Vicia faba Europe, Mediterranean, Middle East Grass pea Lathyrus sativus India Common bean Latin America, Caribbean, North America, Central and Phaseolus vulgaris Southern Africa, Europe Lima bean (butter bean) Phaseolus lunatus All humid tropical and subtropical regions...
+
+=== Chunk 1578 ===
+Source: 0820_002-ebook.pdf
+Length: 299 chars
+
+Problems arising from the utilization of legumes
+In spite of their excellent food value, legumes are less used than would seem logical; they usually only serve as complements for staple diets, but not as staple foods themselves. Several reasons – taken in combination or in isolation – explain this....
+
+=== Chunk 1579 ===
+Source: 0820_002-ebook.pdf
+Length: 526 chars
+
+Yield
+In the subsistence economy of poor countries, the surface yield of legumes is half or one-third that of cereals, and one-tenth (or less) that of starchy plants. Where the cultivated surface matters, farmers need to optimize the overall return on their labour and make choices. Staple foods obviously take precedence. On the other hand, intercropping can result in interesting improvements for cereals, starchy plants and legumes; the former protect the legumes from heat and cold, the latter en...
+
+=== Chunk 1580 ===
+Source: 0820_002-ebook.pdf
+Length: 335 chars
+
+Flatulence
+The consumption of legumes other than groundnuts causes fl atulence, which can entail considerable discomfort particularly for infants during weaning. This is one of the main reasons for legumes not being consumed in larger amounts. There is no solution to this problem, other than – to a certain extent – protracted cooking....
+
+=== Chunk 1581 ===
+Source: 0820_002-ebook.pdf
+Length: 650 chars
+
+Preparation
+Dried legumes require much time and work before they can be eaten. They also harden during drying and storage, and therefore demand lengthy cooking. This involves expenses in time and other resources to secure the required fuel, and the cooking time itself discourages a more intensive use of legumes.
+119
+V
+V
+NUTRITION MANUAL Chapter V – Food
+1. Food categories
+1.3 Legumes
+Husking and preliminary soaking with or without baking soda are two methods aimed at reducing cooking times signi...
+
+=== Chunk 1582 ===
+Source: 0820_002-ebook.pdf
+Length: 561 chars
+
+Losses resulting from storage
+Storage can expose legumes to rodents and insects. In the case of domestic storage, losses often reach 20%, and can exceed 50%.
+Where possible, the use of insecticides during plant growth signifi cantly reduces the risk of infestation during storage. Moreover, the quality of the drying process is very important, as are fumigation and storage temperature. In subsistence agriculture, small-scale farmers can reduce storage losses by fi rmly packing clean and dry grains i...
+
+=== Chunk 1583 ===
+Source: 0820_002-ebook.pdf
+Length: 881 chars
+
+Digestion
+The protein and starch contained in legumes are more diffi cult to digest than those of cereals and starchy plants, and sometimes cause bloating and discomfort.
+Protracted cooking reduces these effects, as do preliminary treatments such as husking, sprouting, malting, crushing, fermenting and roasting.
+Adverse factors concerning the food itself
+Inhibitors of the protein digestion enzymes
+These substances inhibit digestion by blocking the digestive enzymes. Boiling eliminates the inhibit...
+
+=== Chunk 1584 ===
+Source: 0820_002-ebook.pdf
+Length: 380 chars
+
+Phytohaemagglutinin (PHA)
+Also called lectin, PHA agglutinates mammalian red blood cells (erythrocytes) and destroys them, causing food poisoning; it also impairs the quality of ingested protein (Aykroyd, 1982). Soaking before cooking, followed by covered boiling for several hours alters PHA and, therefore, reduces its negative effects. Sprouting also alters PHA to some extent....
+
+=== Chunk 1585 ===
+Source: 0820_002-ebook.pdf
+Length: 191 chars
+
+Phytates
+Phytates signifi cantly reduce the absorption of calcium, iron and zinc, and impair protein digestibility. Normal cooking destroys phytates, whereas sprouting only partly alters them....
+
+=== Chunk 1586 ===
+Source: 0820_002-ebook.pdf
+Length: 684 chars
+
+Cyanogens
+Legumes, particularly Lima beans, contain linamarin that produces hydrogen cyanide under the action of an enzyme. In addition to its toxic effect itself, hydrogen cyanide is transformed in the organism into thiocyanate, a substance inducing goitre. Hydrogen cyanide is a water-soluble toxin; as a result, soaking followed by rinsing and boiling eliminates the toxin almost entirely. Lima beans contain high levels of hydrogen cyanide, but also of its precursor, linamarin, which is resistan...
+
+=== Chunk 1587 ===
+Source: 0820_002-ebook.pdf
+Length: 431 chars
+
+Miscellaneous
+Other factors worth mentioning include the allergenic potential of legumes (particularly soy milk for infants), their content in anti-vitamin and anti-mineral substances, and the presence of protein digestion inhibiting tannins. In most cases, husking, soaking and boiling mitigate most of these anti-nutritional factors, allowing the organism to eliminate the remainder harmlessly.
+120
+1. Food categories
+1.3 Legumes...
+
+=== Chunk 1588 ===
+Source: 0820_002-ebook.pdf
+Length: 1391 chars
+
+Lathyrism
+Lathyrism is an irreversible paralysis of the nervous system resulting from the excessive consumption of grass pea (Lathyrus sativus), which is particularly drought-tolerant. In the arid areas of India, it is planted at the same time as cereals to serve as a reserve in case of a poor cereal harvest. Normally, grass pea is consumed in far smaller amounts than the staple food, and thus presents no danger. When grass pea accounts for more than 30% of the diet, however, lathyrism develops ...
+
+=== Chunk 1589 ===
+Source: 0820_002-ebook.pdf
+Length: 858 chars
+
+Favism
+Favism is associated with the excessive consumption of broad beans (Vicia faba) and the inhalation of the plant’s pollen. The condition only affects individuals suffering from a genetic defi ciency in the enzyme glucose-6-phosphate dehydrogenase (G6PD), which infl uences the stability of the red blood cell membrane. The reaction manifests itself in haemolytic anaemia and high fever within minutes following pollen inhalation, or within the hours following the ingestion of the bean. It can be...
+
+=== Chunk 1590 ===
+Source: 0820_002-ebook.pdf
+Length: 1963 chars
+
+Afl atoxins
+Afl atoxins are produced by a fungus (Aspergillus fl avus) and are the most potent known causes of cancer. The fungus develops on almost all grains stored in humid and hot conditions and handled without due consideration for hygiene. The quality of the grain drying is also essential in arresting the development of the fungus. Afl atoxins contaminate cereals and legumes alike, but particularly maize and groundnuts. Moreover, they can then pass into the food chain, for example through the ...
+
+=== Chunk 1591 ===
+Source: 0820_002-ebook.pdf
+Length: 248 chars
+
+Legume preparation
+Problems arising from the utilization of legumes require the development of indispensable preparation methods. Traditional age-old methods have resulted in the production of nutritious and tasty dishes to complement staple foods....
+
+=== Chunk 1592 ===
+Source: 0820_002-ebook.pdf
+Length: 567 chars
+
+Soaking
+The process of soaking prior to cooking is widespread. In Rwanda, nevertheless, groups met by the author refrained from soaking as they believed that the beans would thereby lose their fl avour. Soaking contributes to eliminating the envelope, reduces toxin levels, and shortens the cooking time by saturating and softening the grain. Soaking times change according to variety, and must be proportional to the storage time. A common practice is to soak the legumes overnight at room temperatur...
+
+=== Chunk 1593 ===
+Source: 0820_002-ebook.pdf
+Length: 760 chars
+
+Husking
+Husking is the removal of the sometimes hard envelope of legumes, in order to improve fl avour and digestion, but mainly to shorten their cooking. Husking consists of detaching the envelope through roasting, the application of oil and drying, or soaking and drying. The envelope is then removed by abrasion with different techniques ranging from the domestic mortar to industrial machines. In India, husked legumes are called “dhal”, a word that has spread and is now commonly used in referenc...
+
+=== Chunk 1594 ===
+Source: 0820_002-ebook.pdf
+Length: 410 chars
+
+Cooking
+Cooking is the most important stage to enable the consumption of legumes, because it destroys most of the toxins and enhances both fl avour and digestibility. The two main methods are wet cooking (boiling or braising) and dry cooking (roasting or frying). Wet cooking allows legumes to retain approximately 70% of their water-soluble vitamins and 80% of their minerals other than sodium (Aykroyd, 1982)....
+
+=== Chunk 1595 ===
+Source: 0820_002-ebook.pdf
+Length: 720 chars
+
+Sprouting and malting
+Sprouting is common in Asia, especially in the Far East. To sprout, the non-husked grain must be soaked, then patted dry and placed on a humid surface. The process takes a few days during which the grains are frequently rinsed. Sprouting splits the envelope, which is then easy to remove, and causes biochemical reactions that improve the food value and the fl avour of the grain, while resulting in a partial degradation of the phytates, lectins and enzyme inhibitors. As mentio...
+
+=== Chunk 1596 ===
+Source: 0820_002-ebook.pdf
+Length: 1224 chars
+
+Fermenting
+Fermenting is an age-old process involving legumes as the basis for highly digestible and tasty foods and spices; the best known is probably soy sauce. Fermentation techniques vary greatly and can be quite sophisticated; they usually concern legumes that are still not really edible after soaking, husking and cooking. This is particularly true for soybeans, which are mainly eaten fermented in some way or other, or sprouted.
+122
+1. Food categories
+1.3 Legumes 1.4 Oilseeds
+Finally, legum...
+
+=== Chunk 1597 ===
+Source: 0820_002-ebook.pdf
+Length: 1161 chars
+
+1.4 OILSEEDS
+The listing of oilseeds follows no set rule; this manual simply describes a number of energy-rich foods whose common denominators are their high lipid content and the fact that the lipids are extracted from them. Their protein concentration is also quite high. Soybean and groundnut are sometimes associated with them because they are oil-producing legumes. This Manual adopts the botanical approach, and the latter two plants are therefore discussed in the previous section on legumes. ...
+
+=== Chunk 1598 ===
+Source: 0820_002-ebook.pdf
+Length: 1640 chars
+
+1.4.1 Oilseeds for consumption and oil extraction
+This category includes nuts and what is commonly referred to as seeds. Nuts include walnuts, hazelnuts, almonds, pistachios, cashew nuts, Brazil nuts, macadamia nuts in addition to other, less familiar exotic varieties such as the Mongongo nut common in southern Africa. An edible portion of 100 g of dried nuts provides on average 650 kcal (2,717 kJ), for 14 g of protein, 60 g of lipids, and 14 g of glucides. Nuts are good sources of thiamine and ...
+
+=== Chunk 1599 ===
+Source: 0820_002-ebook.pdf
+Length: 744 chars
+
+1.4.2 Oilseeds as sources of lipids
+Cocoa beans, Illipe nut (Shorea spp.) and shea nut (Butyrospermum parkii) are used to extract fatty matter called “butter” (cocoa, Illipe, shea butter). They are rather congealed – although their viscosity depends largely on room temperature, preparation mode and their degree of refi ning. The fruit of the oil palm provides the β-carotene rich palm oil, the fruit of the olive tree provides the healthy15 mono-unsaturated oleic acid, and the fruit of the coconut ...
+
+=== Chunk 1600 ===
+Source: 0820_002-ebook.pdf
+Length: 1445 chars
+
+1.5 VEGETABLES
+Intuitively, everyone knows what vegetables are; it is however diffi cult to defi ne them from a nutritional perspective, and they escape all botanical classifi cation. They are edible plants – entirely or in part – that do not keep well, implying that they must be eaten fresh or dried or preserved, and that cannot serve as staple foods owing to their low energy density. Nevertheless, garden vegetables that are extremely cheap to produce can play a major role in the rural daily diet....
+
+=== Chunk 1601 ===
+Source: 0820_002-ebook.pdf
+Length: 1041 chars
+
+1.5.1 The food value of vegetables
+The average food value of vegetables is approximately 35 kcal (146 kJ)/100 g of edible parts, for 1.8 g of protein. These values vary greatly, however, according to samples, origin, freshness, season, soil, and the same applies to all the nutrients of vegetables. The nutritional importance of vegetables relates to their high concentrations of β-carotene (the β-carotene content is roughly proportional to the vegetable colour intensity), ascorbic acid (of which a...
+
+=== Chunk 1602 ===
+Source: 0820_002-ebook.pdf
+Length: 1343 chars
+
+1.5.2 The utilization of vegetables
+Vegetables can be prepared in many different ways. Usually, their preparation involves rinsing and peeling to remove the fi brous or bitter parts. They can then be eaten raw with some form of
+15 Notions of “healthy” and “unhealthy” are relevant mainly for environments characterized by excessive calorie intake and lack of energy expenditure through exercise.
+124
+1. Food categories 1.5 Vegetables
+1.6 Fruits 1.7 Mushrooms 1.8 Fats
+dressing, or be cooked and spiced...
+
+=== Chunk 1603 ===
+Source: 0820_002-ebook.pdf
+Length: 1994 chars
+
+1.6 FRUITS
+In botany, a fruit is the ripened ovary – together with seeds – of a fl owering plant; in cuisine, the term usually refers to plant products that are sweet and fl eshy (such as mangoes, bananas, and apples). Even more so than vegetables, people eat fruit because they like its fl avour, smell, its refreshing and thirst- quenching quality and, to a lesser extent, texture. The nutritional importance of fruit arises from its high vitamin C content; most fruit are also rich in β-carotene (all...
+
+=== Chunk 1604 ===
+Source: 0820_002-ebook.pdf
+Length: 378 chars
+
+1.7 MUSHROOMS
+Mushrooms are used mainly to vary and spice dishes, conferring on them a well-deserved distinction. But fresh mushrooms only provide 10 to 15 kcal (42 to 63 kJ) and between 1 and 3 g of protein/100 g. They cannot, therefore, contribute signifi cantly to meeting nutritional needs, even if some varieties contain B group vitamins, ascorbic acid and vitamins D and E....
+
+=== Chunk 1605 ===
+Source: 0820_002-ebook.pdf
+Length: 1539 chars
+
+1.8 FATS
+Fats are lipid substances used in cooking that are not found in the natural state – they are extracted from animal and vegetable products. Fats include butter and lard (that are congealed at room temperature because of their high saturated fatty acid content), and oils (groundnut oil, cod liver oil), that are liquid
+125
+V
+V
+NUTRITION MANUAL Chapter V – Food
+1. Food categories
+1.8 Fats 1.9 Animal products
+at room temperature because they contain polyunsaturated fatty acids. The average e...
+
+=== Chunk 1606 ===
+Source: 0820_002-ebook.pdf
+Length: 1389 chars
+
+1.9 ANIMAL PRODUCTS
+Animal products fi rst and foremost constitute an excellent source of protein for humans; they are also a signifi cant source of vitamins and minerals. However, like fats, animal products are often very expensive, and the poor are usually unable to consume them regularly in reasonable amounts. It is therefore useful to remember that animal products are not indispensable to man, who can balance his diet with vegetal products – for example by combining cereals and legumes. In add...
+
+=== Chunk 1607 ===
+Source: 0820_002-ebook.pdf
+Length: 4045 chars
+
+1.9.1 Meat and offal
+Meat and offal constitute the edible fl esh of warm-blooded animals – although the fl esh of reptiles, where they are eaten, can also be referred to as meat. The expression meat refers to skeletal muscle, and is subdivided into red (beef, mutton, horse), white (poultry, veal, pork, rabbit), and black (game such as boar, hare, deer, dikdik, woodcock, agouti, bush rat, possum, and monkey meat). Offal refers to everything edible in an animal other than skeletal muscle, that is th...
+
+=== Chunk 1608 ===
+Source: 0820_002-ebook.pdf
+Length: 1974 chars
+
+1.9.2 Fish and other cold-blooded animals
+The quality of the protein provided by fi sh and other cold-blooded species is just as good for man as that supplied by meat and offal. Sea fi sh and freshwater fi sh contain the same amount of protein: 17.8 ± 1.7 g/100 g of edible fl esh. On the other hand, the calorie values vary according to the lipid content, ranging from fi sh virtually devoid of lipids such as pike, tench, codfi sh, bream and sole – whose approximate energy value is 80 kcal (334 kJ)/100 ...
+
+=== Chunk 1609 ===
+Source: 0820_002-ebook.pdf
+Length: 719 chars
+
+1.9.3 Insects and larvae
+Many insect species are edible: the best-known include termites, locusts, grasshoppers, crickets and caterpillars, besides many other species that constitute local delicacies. Insects and their larvae are very good sources of protein (10 to 50 g/100 g), lipids (approximately 10 g/100 g), B group vitamins and iron. They are usually gathered at specifi c times in the year, coinciding with a specifi c stage in their development or in the overall food availability. Dried, salt...
+
+=== Chunk 1610 ===
+Source: 0820_002-ebook.pdf
+Length: 287 chars
+
+1.9.4 Blood
+Blood is an important food in many pastoral societies, and is used to produce sauces and sausages; it contains high levels of iron (50 mg/100 g), as much protein as meat (18 g/100 g), and its calorie value is 80 kcal (334 kJ)/100 g.
+128
+1. Food categories
+1.9 Animal products...
+
+=== Chunk 1611 ===
+Source: 0820_002-ebook.pdf
+Length: 719 chars
+
+1.9.5 Eggs
+All bird eggs share the same approximate food value, except for energy that varies according to their lipid content. Eggs contain all the nutrients required for the development of the embryo up to hatching. For man, its greatest appeal lies in the fact that it provides best quality protein in relation to his need (13 g/100 g). Eggs also provide lipids (12 g/100 g for chicken eggs). They contain no glucides, but fair amounts of thiamine, ribofl avin, vitamins A and D and iron (but the l...
+
+=== Chunk 1612 ===
+Source: 0820_002-ebook.pdf
+Length: 4105 chars
+
+Milk
+Milk alone can feed mammal young from birth up to an age that varies according to species. Milk composition varies according to species and its specifi c growth requirements – all differences resulting from a functional aspect proper to the species under consideration. Milk composition further varies during suckling and the nursing. Different milk types can be substituted for one another, but none will provide the same quality as that species’ own. There is no better milk for a calf than its...
+
+=== Chunk 1613 ===
+Source: 0820_002-ebook.pdf
+Length: 3192 chars
+
+Lactose intolerance
+Lactose intolerance is frequently mentioned – it manifests itself through abdominal pain, fl atulence and osmotic diarrhoea. It results from an activity defi ciency of lactase, the enzyme enabling the digestion of lactose. Three reasons explain lactase defi ciency. The fi rst and rarest is congenital (i.e. genetic), owing to a complete absence of lactase at birth. It is usually fatal which is why it is so rare.
+The second is due to the fact that mammals usually lose their capacit...
+
+=== Chunk 1614 ===
+Source: 0820_002-ebook.pdf
+Length: 572 chars
+
+Dairy products
+Milk is a highly perishable commodity because it is a liquid medium that can be rapidly infested by micro-organisms and because it contains lactose, free amino acids and vitamins making it an ideal culture medium for the rapid multiplication of micro-organisms. Man has thus developed milk conservation methods, the commonest being pasteurization or uperization (thermal treatments to destroy micro-organisms and allow a longer conservation in a sterile and closed container), fermenta...
+
+=== Chunk 1615 ===
+Source: 0820_002-ebook.pdf
+Length: 906 chars
+
+Fermented milk
+Among the many types of fermented milk, the most widespread are yoghurt (resulting from fermentation mainly producing lactic acid from lactose) and kefi r (resulting from a fermentation that inter alia produces alcohol). The principle of milk fermentation involves the seeding of the milk with an adequate amount of a selected bacteria strain, for it to develop faster than the other germs contaminating the milk. By so doing, less and less lactose is available for these germs, whereas...
+
+=== Chunk 1616 ===
+Source: 0820_002-ebook.pdf
+Length: 746 chars
+
+Cheese
+Cheese varieties are innumerable. Cheese production involves three stages: clotting, draining and maturing – the latter is not done in the case of fresh cheese. Fabrication produces curds (the cheese itself), and lactoserum, or whey, which is either discarded or used as animal feed or commonly in industrial food production. Whey contains most of the lactose lost in the process, up to 90% of the water-soluble vitamins, the uncurdled water-soluble protein, and small amounts of lipids and mi...
+
+=== Chunk 1617 ===
+Source: 0820_002-ebook.pdf
+Length: 1246 chars
+
+Fats
+The fats drawn from milk are cream, butter and ghee (butter oil). The cream is separated from the milk either by spontaneous concentration or by centrifugation. The result is skimmed milk, and cream – the latter is no more than milk with a fat content ten times higher. A 100 g portion of
+131
+V
+V
+NUTRITION MANUAL Chapter V – Food
+1. Food categories
+1.9 Animal products
+30% fat cream contains 300 kcal (1,254 kJ), approximately 3 g of protein and 4 g of glucides. Butter is extracted from cream ...
+
+=== Chunk 1618 ===
+Source: 0820_002-ebook.pdf
+Length: 3882 chars
+
+Condensed and powdered milk
+The crucial importance of water quality and hygiene in reconstituting milk is discussed below. Powdered skimmed milk keeps better and is considerably cheaper than full milk. For use in humanitarian action the former, nevertheless, must be enriched as discussed below. It is also worth noting that the use of powdered milk in humanitarian action is restricted.22
+The concentration of milk by evaporation produces condensed milk (sweetened or unsweetened) or powdered milk (...
+
+=== Chunk 1619 ===
+Source: 0820_002-ebook.pdf
+Length: 1618 chars
+
+1.10 SUGARS
+Sugar, syrup, honey and treacle are popular because of their sweetness, their preservation qualities, their digestibility and their high energy value. However, they provide nothing besides calories in the form of glucides and their excessive intake is deleterious for health (risk of diabetes, cardio-vascular disease, obesity and dental decay).
+Commercial sugar comes from the sugarcane and the sugar beet; both contain approximately 16% sugar (saccharose). Industrial extraction methods...
+
+=== Chunk 1620 ===
+Source: 0820_002-ebook.pdf
+Length: 4069 chars
+
+1.11 BEVERAGES
+Man needs only still water for his hydration. He nevertheless prefers other beverages, be they natural or chemical, for their fl avour and because many have pharmacological effects. This explains the popularity of sodas, alcohols, sweet or chocolate drinks, tea, coffee and fruit juice, and the huge diversity of artisan and industrial beverages. This popularity often translates into habits and social or religious rituals, which are sometimes deep-rooted and can have major economic a...
+
+=== Chunk 1621 ===
+Source: 0820_002-ebook.pdf
+Length: 1639 chars
+
+1.12 HERBS, SPICES AND SEASONINGS
+Herbs (e.g. thyme, rosemary, laurel, oregano and tarragon) are leaves, whereas spices (nutmeg, pepper, cumin, chilli, cinnamon, ginger, saffron and vanilla) are seeds, fruits, pistils, bark or roots. Seasonings are preparations such as mustard, chutney or stock in cubes, but salt is a seasoning too. These three categories of condiments serve primarily to enhance and fl avour dishes. They play virtually no nutritional role other than to make food appetizing – and ...
+
+=== Chunk 1622 ===
+Source: 0820_002-ebook.pdf
+Length: 1885 chars
+
+2.1 FOOD COMPOSITION DATA
+Understanding food composition in terms of its nutritive value is useful in several respects. First, it enables the extrapolation of nutrient intake from food consumption data and it then facilitates the defi nition of diets and food rations to provide the specifi ed nutrients. Food composition is found in tables or in computerized databases. Data is expressed in weight (g, mg, μg) for 100 g of edible portion of the commodity under consideration. Data is “representative” ...
+
+=== Chunk 1623 ===
+Source: 0820_002-ebook.pdf
+Length: 2853 chars
+
+2.2 FOOD PROCESSING AND COOKING
+Food processing is defi ned here as including cooking; processing is intended to improve digestibility and appeal, preservation and transport, and enrich the foodstuffs thus treated. Processing methods are innumerable and highly interesting – this Manual restricts itself to discussing the effects of the commonest methods on food. Losses are largely proportional to the duration and intensity of exposure, but they are diffi cult to quantify.
+The nutritional value of p...
+
+=== Chunk 1624 ===
+Source: 0820_002-ebook.pdf
+Length: 6055 chars
+
+2.3 FOOD TOXICITY
+Food can cause poisoning or infection for a number of reasons.
+1. The plants or animals that they are derived from naturally produce toxins:
+q cassava contains cyanide;26
+q Lathyrus sativus (grass pea) contains a neurotoxin that causes lathyrism (see above);27
+q other legumes contain haemagglutinins that attack red blood cells and intestinal cells;
+q some sea fi sh contains potentially lethal neurotoxins;
+q some fi sh, such as tuna, must be rapidly processed after its catch, or i...
+
+=== Chunk 1625 ===
+Source: 0820_002-ebook.pdf
+Length: 606 chars
+
+2.4 FOOD MEASUREMENT UNITS AND THE EFFECTS OF COOKING
+The mass (effective weight) of solids and the volume of liquids must be measured in order to calibrate food consumption. Food composition tables then provide the tool to determine nutrient intake. Possible food processing – and its impact on food value – is integrated into this analysis. Humanitarian action sometimes lacks the measuring tools and conversion factors required to measure food and appraise the effects of specifi c processing. Some...
+
+=== Chunk 1626 ===
+Source: 0820_002-ebook.pdf
+Length: 480 chars
+
+2.4.1 Food measurement units
+Abbreviations
+microgram
+milligram mg
+μg
+gram
+kg millilitre ml centilitre cl dl litre l fl oz pound lb ounce oz qt gallon ga pint pt l
+kilogram
+decilitre
+fl uid ounce
+quart
+g
+Weight and volume conversion
+1 kg = 1,000 g 1 g = 1,000 mg 1 mg = 1,000 μg 1 l = 10 dl 1 dl = 10 cl 1 cl = 10 ml 1 gal = 4 qt 1 qt = 2 pt 1 pt (UK) = 20 fl oz 1 pt (US) = 16 fl oz 1 gal (UK) = 4.8 l 1 gal (US) = 3.8 l 1 oz = approx. 30 g 1 fl oz = approx. 30 ml 1 lb = approx. 450 g...
+
+=== Chunk 1627 ===
+Source: 0820_002-ebook.pdf
+Length: 2773 chars
+
+2.4.2 The effects of cooking
+Boiled foods tend to absorb some of the cooking water, and thereby dilute their energy content. A conversion factor can thus be applied to the weight of cooked foods versus raw foods. For example, the conversion factor of white fl our into bread is roughly 1.4 (i.e. bread prepared with 100 g of fl our weighs approximately 140 g). Conversion factors, obviously, are not absolute values – they vary according to the quality of the ingredients and cooking methods. But they ...
+
+=== Chunk 1628 ===
+Source: 0820_002-ebook.pdf
+Length: 2720 chars
+
+THE BIOLOGICAL UTILIZATION OF FOOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
+5.1 ACTIVITIES ASSOCIATED WITH THE BIOLOGICAL UTILIZATION
+OF FOOD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203 5.1.1 Digestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....
+
+=== Chunk 1629 ===
+Source: 0820_002-ebook.pdf
+Length: 494 chars
+
+THE THREE PARAMETERS OF THE FEEDING PROCESS
+The feeding process initially involves the organism interacting with its environment to obtain food, and this interaction is conditioned by the culture of the organism itself. This is represented in Figure 6.2 below.
+Figure 6.2 Parameters of the feeding process
+ENVIRONMENT  CULTURE  ORGANISM
+The importance of these three parameters arises from their infl uence on the feeding process, and the different types of determinism that they impose upon it....
+
+=== Chunk 1630 ===
+Source: 0820_002-ebook.pdf
+Length: 558 chars
+
+1.1 DETERMINISM SET BY ORGANISM AND CULTURE
+The feeding process is determined by the phenomenon of organized association. This determinism is related to the preconditions for a specifi c behaviour, and to the requirements of association.3 The fi rst level of association, that of the living organism, obeys biological determinism; the second is that of society as defi ned by its culture, and obeys cultural determinism as an extension of biological determinism. These two determinisms manage human life...
+
+=== Chunk 1631 ===
+Source: 0820_002-ebook.pdf
+Length: 1555 chars
+
+1.1.1 Biological determinism
+Biological determinism is specifi c to life and expresses itself fi rstly in vital needs. In higher animals it subjects individuals to largely involuntary functions such as breathing, rest, nutrition, excretion and reproduction. Man has however gradually departed from his initial lifestyle, in which he was a “naked ape”, and his biological determinism thus translates into the concept of basic needs. Malinowski defi nes this concept as “the system of conditions in the hu...
+
+=== Chunk 1632 ===
+Source: 0820_002-ebook.pdf
+Length: 685 chars
+
+1.1.2 Cultural determinism
+Cultural determinism appears as soon as individuals resort to social organization to increase their chances of survival and, if possible, to improve their living standards through an enhanced coverage of their basic needs.
+In principle, society is an organized association, implying that the behaviour of the individuals that make it up is itself organized and regulated in all its forms of activity. This behaviour is nothing more than the culture that defi nes the society...
+
+=== Chunk 1633 ===
+Source: 0820_002-ebook.pdf
+Length: 4847 chars
+
+Corresponding cultural responses
+1. Metabolism
+q
+Commissariat4
+2. Reproduction
+q
+Kinship
+3. Bodily comforts q Shelter
+4. Safety
+q
+Protection
+5. Movement q Activities
+6. Growth q Training
+7. Health q Hygiene
+Organized and regulated organization (i.e. culture) implies that the conduct of activities satisfy the four conditions discussed in Chapter II,5 that is:
+9 anchorage on a material support enabling the coverage of basic needs;
+9 compliance with standards of behaviour that satisfy these needs;
+...
+
+=== Chunk 1634 ===
+Source: 0820_002-ebook.pdf
+Length: 1232 chars
+
+1.2 DETERMINISM SET BY THE ENVIRONMENT
+The determinism imposed by the environment is different from both biological and cultural determinisms insofar as it arises from confrontation rather than organization. Society attempts to free itself from environmental constraints by responding to its own needs and familiar environmental limitations as effi ciently as possible. This shapes the culture itself: lifestyle, architecture, technology, neighbourhood relations, social structure and hierarchy, spiri...
+
+=== Chunk 1635 ===
+Source: 0820_002-ebook.pdf
+Length: 957 chars
+
+FEEDING PROCESS ACTIVITIES
+The feeding process is the practical expression of the nutritional fl ow. Theoretically, the nutritional fl ow is continuous within the organism: if it ceases, the organism dies. In reality, however, stops and starts occur well back from where the elementary thermodynamic reactions take place. For example, the liver works continuously, as does the brain, but man only drinks and eats a couple of times per day – and he only cultivates his land twice or three times yearly. ...
+
+=== Chunk 1636 ===
+Source: 0820_002-ebook.pdf
+Length: 1566 chars
+
+2.1 ACTIVITY SEQUENCE
+The activities of the feeding process follow a specifi c sequence, from the individual confrontation with the natural and human environment to secure food, to the excretion of stool and urine, and the release of carbon gas and thermal energy.
+149
+I V
+I V
+NUTRITION MANUAL Chapter VI – The feeding process
+2. Feeding process activities
+2.1 Activity sequence 2.2 The organization and determinism of activities
+These activities all share causal relations in the following sequence.
+...
+
+=== Chunk 1637 ===
+Source: 0820_002-ebook.pdf
+Length: 2728 chars
+
+2.2 THE ORGANIZATION AND DETERMINISM OF ACTIVITIES
+The activities of the feeding process are organized and determined, because they occur within the framework of the organism and culture. They therefore rest on a specifi c material base, comply with execution standards, and submit to some form of control; these are all conditions that express the determinism of activities. Table 6.2 briefl y summarizes this analysis and illustrates the logic that connects all activities and ensures the consistency...
+
+=== Chunk 1638 ===
+Source: 0820_002-ebook.pdf
+Length: 803 chars
+
+2.3 ACTIVITY PERFORMANCE
+Each activity of the feeding process must be performed effi ciently enough to enable the organism to live. Performance is thus associated with specifi c conditions, which are diffi cult to meet because the organism (interior) does not control them, no more than the individual (exterior). As a result, effi ciency is not automatic, and the organism, the individual and society must develop adaptation mechanisms to face risks of poor performance (or counter-performance itself). ...
+
+=== Chunk 1639 ===
+Source: 0820_002-ebook.pdf
+Length: 4535 chars
+
+2.4 STAGES OF THE FEEDING PROCESS
+Some activities of the feeding process are shared by all humans. They include the digestion and absorption of food, and urinating, and they result mainly from biological determinism. Others tend towards a common objective, for instance the securing of food, but can differ signifi cantly in nature or manifestation: these relate mainly to cultural determinism. This Manual proposes a model for the feeding process within any society, in spite of differences. This pro...
+
+=== Chunk 1640 ===
+Source: 0820_002-ebook.pdf
+Length: 1872 chars
+
+3.1 INTRODUCTION
+The securing of food involves activities aiming at obtaining food from the environment. The performance – or success – of such activities is crucial, because the rest of the feeding process depends on it. It is therefore a key stage in terms of the nutritional functioning of a given society; it has also, in man’s recent history, undergone changes with fundamental consequences on the functioning of society and the relation between man and his environment.
+The search for food has ...
+
+=== Chunk 1641 ===
+Source: 0820_002-ebook.pdf
+Length: 9947 chars
+
+3.2 THE EVOLUTION OF FOOD SECURING ACTIVITIES TOWARDS MORE ECONOMIC ACTIVITIES
+For hundreds of thousands of years, man was a hunter-gatherer who found his food by collecting, hunting and fi shing whatever the environment produced spontaneously. In terms of the securing of food resources, the human diet was quite similar, to that of many other higher animals.
+The Neolithic revolution allowed man to manage his environment in order to secure his food through production activities such as agriculture...
+
+=== Chunk 1642 ===
+Source: 0820_002-ebook.pdf
+Length: 2993 chars
+
+3.2.1 The increase in cultural demands
+The diversifi cation of the cultural apparatus of implements and consumer goods increases dependency on these implements and goods, and cultural demands therefore grow proportionately. This infl uences the coverage of all basic needs that depend on the economy (i.e. basic economic needs) including food, according to the income available7 to cover all associated expenses. The following example drawn from the Swiss Federal Statistics Offi ce illustrates the aver...
+
+=== Chunk 1643 ===
+Source: 0820_002-ebook.pdf
+Length: 968 chars
+
+3.2.2 The need for market transactions
+The specialization of production activities causes a loss in self-suffi ciency to varying degrees. Social partners thus accept mutual dependencies in order to meet their basic economic needs: those who produce food need implements, those who produce implements need food, and both need the clothing they purchase from suppliers; the latter in turn must secure food and implements, and so on. These interdependencies call for transactions during which commodities...
+
+=== Chunk 1644 ===
+Source: 0820_002-ebook.pdf
+Length: 860 chars
+
+Money
+Money appears in all societies based on economic specialization; it deprives specialized partners of their independence in terms of meeting their basic needs, making them dependent on services. Money nevertheless provides a standard, and also a form of payment. It is a purchasing power reserve, because one of its main functions is to separate individual exchange operations. Expressed in prices, it also indicates the value attached by consumers and producers to a given commodity. Initially,...
+
+=== Chunk 1645 ===
+Source: 0820_002-ebook.pdf
+Length: 705 chars
+
+The market
+The market is an arrangement allowing supply and demand to meet in transactions. It fi nds a compromise between the confl icting interests of producers who attempt to fetch the highest price, and of consumers aiming at the lowest price. Such arrangements can be made in the market-place. Understood as an arrangement, however, the market does not necessarily suggest a specifi c location, and there are as many markets as there are transaction types: the goods and services market, the labour...
+
+=== Chunk 1646 ===
+Source: 0820_002-ebook.pdf
+Length: 9280 chars
+
+The terms of trade
+Terms of trade8 set prices for transaction levels – they are the laws of supply and demand. They represent the reactions of all producers (supply) and all consumers (demand), and not of specifi c individuals. Generally speaking, the laws of supply and demand are expressed as follows: supply increases if prices rise, and demand increases if prices drop, as illustrated in Figure 6.4 below.
+Figure 6.4 Supply and demand (1)
+SUPPLY  EQUILIBRIUM  DEMAND
+PRICE
+>
+QUANTITY
+Supply and de...
+
+=== Chunk 1647 ===
+Source: 0820_002-ebook.pdf
+Length: 223 chars
+
+3.3.1 The activities
+Economic activities are those required for survival, i.e. to meet all basic economic needs, including food. Typical activities enabling survival today – alone or in combination – are the following fi ve....
+
+=== Chunk 1648 ===
+Source: 0820_002-ebook.pdf
+Length: 898 chars
+
+Tapping the natural environment
+This consists in collecting the food resources produced directly and without signifi cant human intervention. Such activities include hunting, gathering, and fi shing. Hunter-gatherers depend on this, and their survival depends directly on the renewal of natural food resources, and on the extent of the territory available. Some groups still rely exclusively on hunting and gathering; they are however disappearing because they lack the means of defending both their cu...
+
+=== Chunk 1649 ===
+Source: 0820_002-ebook.pdf
+Length: 444 chars
+
+Non-industrial animal and plant production
+Subsistence agriculture and pastoralism are livelihoods in which the direct product of agricultural and pastoral activities provides the basis for the diet. These livelihoods are vanishing in highly industrialized countries; elsewhere, subsistence agriculture and, more still, pastoralism, are increasingly eroded owing to the deterioration of the environment by man and modern forms of globalization....
+
+=== Chunk 1650 ===
+Source: 0820_002-ebook.pdf
+Length: 3188 chars
+
+Activities generating a purchasing power
+These activities enable people to acquire the goods and services produced by others, in cash or kind. Purchasing power in kind results in barter based on agreed trade-offs. Purchasing power in cash results in purchases; this facilitates access to various goods and services, but the trade-off is accordingly more complex than for barter. Production activities that generate purchasing power are highly varied and include the following:
+9 the production of raw...
+
+=== Chunk 1651 ===
+Source: 0820_002-ebook.pdf
+Length: 1384 chars
+
+Behavioural activities and/or the absence of production activities
+These prompt individuals (or the society) to refund, donate or lend food, or the means to secure it. Such behaviour is dictated by kinship, reciprocity, pity, interest, bad conscience or charity, or by a mutual assistance contract. Examples include the protest of infants, the deliberate subservience of a beggar, the fl attery of a customer intending to take advantage, the threats issued by a crowd to guarantee the price of bread, ...
+
+=== Chunk 1652 ===
+Source: 0820_002-ebook.pdf
+Length: 1347 chars
+
+Tapping the human environment
+This consists in stealing food or the means to secure it. Within a given society, petty larceny (such as stealing fruit or eggs) may be forgiven; but systematic theft is usually not tolerated because it entails no viable reciprocity. However, it can be imposed out of fear of the thief or his background, for example. Theft can thus be more or less accepted, but it always implies some form of reciprocity, and certainly never provides the basis for subsistence. History...
+
+=== Chunk 1653 ===
+Source: 0820_002-ebook.pdf
+Length: 2968 chars
+
+3.3.2 The necessary means for the activities
+Economic activities imply the use of means to produce economic resources in a regular manner. These means are the household production assets, and are referred to here as “means of production”.
+Means of production are those enabling the continuation of production activities, in a way consistent with the rate of consumption of goods and services. In other words, they provide access to food and all essential goods and services in a renewable way. They c...
+
+=== Chunk 1654 ===
+Source: 0820_002-ebook.pdf
+Length: 247 chars
+
+3.4 THE ORGANIZATION AND DETERMINISM OF ECONOMIC ACTIVITIES
+Economic activities carried out through the use of means of production must take place within a culture. They can thus be analysed by following their organization and determinism schemes....
+
+=== Chunk 1655 ===
+Source: 0820_002-ebook.pdf
+Length: 402 chars
+
+3.4.1 The function of economic activities
+Man resorts to economic activities in order to meet his essential economic needs (including food) directly or indirectly. However, the relation between this activity and the covering of needs is not automatic; the observation of individual economic behaviour must therefore always involve an understanding of its underlying reasons, and resulting expectations....
+
+=== Chunk 1656 ===
+Source: 0820_002-ebook.pdf
+Length: 1776 chars
+
+3.4.2 Community
+The community involved in economic activities depends mainly on the use of its resources and its culture. However, all economic producers share two characteristics: they must participate in activities, and each family unit must include at least one producer. Families are understood here as households, the smallest sustainable social unit: individuals living alone or groups living together voluntarily. The household unit is central to this Manual, being the smallest common denomin...
+
+=== Chunk 1657 ===
+Source: 0820_002-ebook.pdf
+Length: 3541 chars
+
+3.4.3 Structure
+The structure is the basic organization unit required to fulfi l a function. The structure that supports the active economic contributors is determined mainly by the means of production available to households to meet their basic needs (in turn shaped by the economic development and the social structure of the society). In practical terms, hunter-gatherer families each represent a structural unit, because each is self-suffi cient in satisfying its own basic needs. The same comment ...
+
+=== Chunk 1658 ===
+Source: 0820_002-ebook.pdf
+Length: 65 chars
+
+3.4.4 Norm
+The concept of norm defi nes what can be done, and how....
+
+=== Chunk 1659 ===
+Source: 0820_002-ebook.pdf
+Length: 2243 chars
+
+Acceptable activities
+The relationship between man and the cultural apparatus of implements and consumer goods is based fi rst and foremost on ownership; the ultimate objective is to appropriate existing economic resources. In every society, anything can only be appropriated in relation to one’s own available means, which must be recognized by the rest of the community as one’s own, thus conferring upon them a varnish of legitimacy. The means of production described above must comply with this no...
+
+=== Chunk 1660 ===
+Source: 0820_002-ebook.pdf
+Length: 1322 chars
+
+Rules of conduct and implementation techniques
+Every type of effective activity has to be organized in one way and one way only, through which it becomes culturally stabilized, that is, incorporated into the cultural heritage of a group (Malinowski, 1994). This implies the presence of an educational apparatus, which is just as differentiated as production activities are. In any culture worthy of the name, this apparatus is not confi ned to teaching techniques only; it also aims at conveying a set...
+
+=== Chunk 1661 ===
+Source: 0820_002-ebook.pdf
+Length: 1112 chars
+
+3.4.5 Enforcement
+All societies give themselves strong means (authorities and representatives) to ensure that the securing of resources obeys the ownership norms that it (or the power in place) has recognized; it can deal with non-compliance if necessary. The great Irish famine resulted from this phenomenon: the State rejected the survival mechanisms that threatened to violate existing rules, and instead allowed millions to starve or be forced into exile. This shows that in crises (certainly at ...
+
+=== Chunk 1662 ===
+Source: 0820_002-ebook.pdf
+Length: 791 chars
+
+INTRODUCTION TO ACTIVITY PERFORMANCE
+For a household to eat adequately, its economic activities must return an average 0.6 kg of varied food per day, per person, in compliance with its eating habits. Achieving this restrictive objective is determined by the performance of its activities.
+Generally speaking, performance is defi ned by the ratio between the actual and the expected output. The performance of economic activities can be expressed as the ratio between the food resources actually produc...
+
+=== Chunk 1663 ===
+Source: 0820_002-ebook.pdf
+Length: 87 chars
+
+Food resources produced
+Performance = –––––––––––––––––––––––––––––––––––––––––– / Time...
+
+=== Chunk 1664 ===
+Source: 0820_002-ebook.pdf
+Length: 2184 chars
+
+Food resources required
+However, this approach is rather simplistic, and does not entirely refl ect reality, as illustrated by the example below.
+On the basis of the above “food produced/food required” ratio as infl uenced by time limitations, a daily worker must secure every day a salary that he can then use to buy food in an adequate quantity and of adequate quality to feed himself and his dependants. Likewise, a farmer must obtain from one or two yearly harvests a yield that is adequate to cove...
+
+=== Chunk 1665 ===
+Source: 0820_002-ebook.pdf
+Length: 172 chars
+
+Σa Economic resources produced
+Σa Economic resources produced Σ Economic resources required
+Overall economic performance = –––––––––––––––––––––––––––––––––––––––––– / Time...
+
+=== Chunk 1666 ===
+Source: 0820_002-ebook.pdf
+Length: 2588 chars
+
+Σ Economic resources required
+a Σ is the mathematical symbol for “sum”.
+In the above formula, the “sum of economic resources produced”, the “sum of economic resources required”, and “time” are the terms of performance. Timeframes apply both to produced and required resources, and could in principle be removed from the equation accordingly. This removal might however conceal the fact that timeframes are common to both types of resources; it expresses the production rate of goods and services, the...
+
+=== Chunk 1667 ===
+Source: 0820_002-ebook.pdf
+Length: 261 chars
+
+3.6 FACTORS DETERMINING ACTIVITY PERFORMANCE
+The economic resources required and the timeframe can be viewed as the two major constraints forcing households to produce a given minimum quantity of resources, at a rate that is consistent with their possibilities....
+
+=== Chunk 1668 ===
+Source: 0820_002-ebook.pdf
+Length: 654 chars
+
+3.6.1 Factors determining the economic resources required (denominator)
+Economic goods and services required for the coverage of basic needs can be quantifi ed to a certain extent. This should enable the appraisal of the economic resources required for this coverage to be adequate, that is, to set an objective to be met with the production of resources in cash and kind. Special attention must nevertheless be paid to the fact that needs vary between and within cultures (and according to the enviro...
+
+=== Chunk 1669 ===
+Source: 0820_002-ebook.pdf
+Length: 612 chars
+
+Cultural variability
+The cultural apparatus of goods and services, like the set of values specifi c to each culture, entails expenses that vary from one culture to another. Marriage can involve a cost here, and a profi t there; housing and schooling do not involve the same constraints everywhere; political, economic, and social status may – or may not – entail obligations involving an economic cost; furthermore, cultural value can make some commodities indispensable when, at fi rst sight, they are ...
+
+=== Chunk 1670 ===
+Source: 0820_002-ebook.pdf
+Length: 379 chars
+
+The magnitude of needs
+The need for clothing, shelter, heating and food depends on climate. Transport costs depend on the distance between the home and the workplace. Finally, household needs will also vary according to the evolution of the family.
+169
+I V
+I V
+NUTRITION MANUAL Chapter VI – The feeding process
+3. The securing of food
+3.6 Factors determining activity performance...
+
+=== Chunk 1671 ===
+Source: 0820_002-ebook.pdf
+Length: 308 chars
+
+Economic status
+As illustrated by Engel’s law (see Section 3.2.1 above), the proportion of the budget allocated to different needs varies according to the resources that are available to the household, that is, according to the economic status within the culture and the range of choices that result from it....
+
+=== Chunk 1672 ===
+Source: 0820_002-ebook.pdf
+Length: 1241 chars
+
+Behaviour
+The economic behaviour of individuals in the same economic bracket varies according to their spending habits (i.e. wasteful or sparing). Lifestyle does not have the same meaning for everyone, translating into different preferences or priorities (i.e. utility) and, thus, different costs. Households do not all seek the same forms of wellbeing and safety. This behavioural aspect is particularly relevant to the nutritional need. Chapter III has discussed the fact that the nutritional need ...
+
+=== Chunk 1673 ===
+Source: 0820_002-ebook.pdf
+Length: 1995 chars
+
+Economic circumstances
+Economic situations vary according to season, the markets of goods, employment, capital, dividends and exchange rates, and according to politics. Such variations lead to different types of budget utilization and needs coverage behaviour; a given expense may be considered exaggerated and unnecessary today, and normal tomorrow.
+This highlights the differences in the economic needs of households, social groups and cultures, but also how these vary over time. The concept of ba...
+
+=== Chunk 1674 ===
+Source: 0820_002-ebook.pdf
+Length: 782 chars
+
+3.6.2 Factors determining timeframe
+The timeframe in which performance is appraised is determined by the time unit specifi c to the production rate, related to the renewal of economic activities: hunting, fi shing, gathering, and agricultural seasons, paydays, the time required for the production of a given good or the provision of a service, or the recovery of capital interest. Households sometimes conduct several economic production activities simultaneously: performance is in this case determin...
+
+=== Chunk 1675 ===
+Source: 0820_002-ebook.pdf
+Length: 2563 chars
+
+3.6.3 Factors determining the economic resources produced (numerator)
+To produce resources regularly, economic activities must allow for means of production. Production is determined by:
+9 the return on, or productivity of, activities (return, or yield, is defi ned as the output per input unit of a specifi c means of production);
+9 the number of production units activated.
+Thus, resources produced within a given timeframe correspond to the resources produced per input unit, multiplied by the numbe...
+
+=== Chunk 1676 ===
+Source: 0820_002-ebook.pdf
+Length: 2976 chars
+
+The yield of production activities
+The basic defi nition of productivity, or yield, is simple: it is the ratio of output to a selected input. In the case of household economy, yield is not so obvious because households can usually secure their economic resources through various activities, involving different means of production, to produce different types of resources according to their degree of self-suffi ciency. As seen above, most households must produce economic resources in both cash and ki...
+
+=== Chunk 1677 ===
+Source: 0820_002-ebook.pdf
+Length: 305 chars
+
+General parameters
+Four parameters can infl uence the yield of household production activities, but they may not all peak together.
+1. The value of activities on the labour market and the goods and services market.
+PYwnNr
+2. Productivity inputs.
+3. Individual factors.
+4. Contextual and structural factors....
+
+=== Chunk 1678 ===
+Source: 0820_002-ebook.pdf
+Length: 2345 chars
+
+Activity value
+Clearly, resources produced within the same timeframe but by different professions vary considerably.
+The capacity of a given profession to produce economic resources is determined by what is referred to here as its qualitative value in the economy of the culture under consideration. This value determines the trade-offs between what is sold and what is bought in exchange for this production.
+It is defi ned by three main types of power.
+1. The economic power associated with the acti...
+
+=== Chunk 1679 ===
+Source: 0820_002-ebook.pdf
+Length: 1958 chars
+
+Productivity inputs
+Productivity inputs infl uence the yield of production activities per production unit. They permit the increase of production per time or surface unit. The household, or economic unit in charge of the activity, must secure them and cover the costs associated with their utilization. Table 6.5 below provides some examples of productivity inputs.
+173
+I V
+I
+V
+NUTRITION MANUAL Chapter VI – The feeding process
+3. The securing of food
+3.6 Factors determining activity performance
+Tabl...
+
+=== Chunk 1680 ===
+Source: 0820_002-ebook.pdf
+Length: 562 chars
+
+Individual factors
+In spite of identical activities, means of production and health condition, major productivity differences can appear, because individuals are not equal in terms of their own capabilities (will, manual and intellectual capacity), nor are they in terms of their professional training. Moreover, the compensation for equal work can nevertheless refl ect discriminatory inequalities according to the social status attached to individual factors such as racial or ethnic segregation, an...
+
+=== Chunk 1681 ===
+Source: 0820_002-ebook.pdf
+Length: 351 chars
+
+Contextual and structural factors
+Contextual and structural factors are independent of the will of the individual, of their activities and their productivity inputs. They include, in particular, geo-climatic parameters, and the conditions of supply and demand that set the market forces and the terms of trade at both micro- and macro- economic level....
+
+=== Chunk 1682 ===
+Source: 0820_002-ebook.pdf
+Length: 1621 chars
+
+Parameters specifi c to activities
+The yield of gathering activities is determined by climate and the availability of game and plants; the input unit refers to the surface covered.
+174
+3. The securing of food
+3.6 Factors determining activity performance
+The yield of food production is determined by the cultivated species, climate, natural soil fertility, and agricultural techniques. The input unit refers to the cultivated surface.
+The yield of activities that generate purchasing power is determin...
+
+=== Chunk 1683 ===
+Source: 0820_002-ebook.pdf
+Length: 4103 chars
+
+Number of input units activated
+The input units of the means of production are essential in defi ning yield, or productivity. The number of units activated determines the overall mass of economic resources that a given household can produce. This number is directly defi ned by the importance of the means of production engaged in terms of basic resource and production inputs;17 this is called the household productive or active assets (Table 6.6 below). This number of assets is also determined, to a...
+
+=== Chunk 1684 ===
+Source: 0820_002-ebook.pdf
+Length: 3156 chars
+
+In short
+The overall household economic performance is determined by its capacity to transform its productive assets into the resources required to meet its basic economic needs: consumable goods and services, goods and services to be converted into purchasing power, and purchasing power to be converted into consumable goods and services that the household does not produce itself. This capability is determined on one hand by the active assets and the productivity of their transformation into nec...
+
+=== Chunk 1685 ===
+Source: 0820_002-ebook.pdf
+Length: 2238 chars
+
+3.7.1 Introduction
+The overall household economic performance is determined by the variables V1…Vn, bound by the different productivity levels (P1…Pn), as illustrated in Figure 6.9 below.
+Figure 6.9 Productivity variables and factors affecting performance
+V1  V2  V6  V7  TIME  MEANS OF  PRODUCTION  GOODS AND SERVICES  TO BE EXCHANGED  FOR PURCHASING POWER  BASIC ACTIVITIES  V3  V4  V8  P3  NON-ECONOMIC  ECONOMIC  LABOUR MARKET,  P2  PURCHASING POWER  TO BE EXCHANGED  GOODS AND  SERVICES MARKET  ...
+
+=== Chunk 1686 ===
+Source: 0820_002-ebook.pdf
+Length: 442 chars
+
+3.7.2 The concept of security
+Economic security is achieved when a household has the sustainable means to obtain all the goods and services that it requires to meet its basic economic needs, according to its cultural and physiological standards.19 The economic security of a given household is therefore determined by its access to consumable goods and services, and the conditions for security demand that this access be adequate and stable....
+
+=== Chunk 1687 ===
+Source: 0820_002-ebook.pdf
+Length: 1693 chars
+
+Adequate access
+As discussed above with respect to the denominator of performance in Section 3.6, the notion of adequacy is very diffi cult to outline in terms of basic needs, including the nutritional need.
+This being said, and assuming the household is well aware of this diffi culty, adequate access is determined by four main parameters.
+18 See Chapter VII.
+19 Cultural standards are defi ned by values transmitted by tradition and translate the coverage of physiological needs into the specifi c pra...
+
+=== Chunk 1688 ===
+Source: 0820_002-ebook.pdf
+Length: 3284 chars
+
+Stable access
+Access stability is determined mainly by the sustainability of the household’s means of production – in other words, on the condition that the means of production permit the renewal of access to resources: the land, thanks to sun and rain, provides one or several harvests per year; labour regenerated by rest and food, is able to conduct paid activities every day; invested capital produces regular interest; herd reproduces. But the stability of access is also infl uenced by the stabi...
+
+=== Chunk 1689 ===
+Source: 0820_002-ebook.pdf
+Length: 1118 chars
+
+3.7.3 Security mechanisms
+Economic security concerns all households, without exception. However, households are usually bound to others by family, economic, cultural or political ties; while at the same time, public or private enterprises have the mandate to ensure the security of specifi c groups. In other words, different groups set up different security systems – they are grouped as follows: individuals, households, communities and professional groups, non-governmental organizations, States an...
+
+=== Chunk 1690 ===
+Source: 0820_002-ebook.pdf
+Length: 2008 chars
+
+Origins of security mechanisms
+Security mechanisms are not improvised, they refl ect an accurate knowledge of the hazards that usually threaten economic performance. They arise within a culture in response to events registered in its collective memory. They usually correspond to an organized behaviour specifi c to each culture, where they form part of tradition and are specifi cally carried over from one generation to the next. The purpose of such mechanisms is to reduce or remove vulnerability to ...
+
+=== Chunk 1691 ===
+Source: 0820_002-ebook.pdf
+Length: 2120 chars
+
+The corporatism of mechanisms
+Security as defi ned above constitutes an ideal that is only rarely attained. Households strive for it, but its prerequisites are numerous, complicated and often impossible to satisfy. This holds true within cultural groups whose cohesion appears to be strong, but in which the specialization of roles and activities leads to corporatism, diverging opinions and consequently the appearance of social classes competing for political power. These factors are nothing but ma...
+
+=== Chunk 1692 ===
+Source: 0820_002-ebook.pdf
+Length: 2837 chars
+
+3.7.4 Household security mechanisms
+Foundations of household security mechanisms
+Between World War II and the 1980s, the industrialized West provided a unique example of economic stability and social security, in which most of the active population only performed one economic activity (in the form of wage labour) during most of its working life. Relatively low unemployment rates, the reasonable price of basic consumer goods, and insurance against unemployment, accidents and sickness ensured stab...
+
+=== Chunk 1693 ===
+Source: 0820_002-ebook.pdf
+Length: 1089 chars
+
+The purpose of security mechanisms
+Security mechanisms clearly serve to ensure the stability of an adequate access to consumable goods and services. The underlying concern, however, reaches well beyond the immediate coverage of basic needs: it is a matter of preserving the active and passive household assets as the only real guarantee for survival. The plough, the land, the tool, the herd and the store are more important than food or clothing, because the former are required to obtain the latter...
+
+=== Chunk 1694 ===
+Source: 0820_002-ebook.pdf
+Length: 437 chars
+
+The functioning of security mechanisms
+Security mechanisms protect active and passive household assets according to a strategy revolving around the three following axes.
+1. Managing the means of production to ensure a suffi cient and stable economic performance.
+2. Constituting reserves in order to face possible counter-performance periods with minimal damage.
+3. Establishing and using social obligation networks, for the same purpose....
+
+=== Chunk 1695 ===
+Source: 0820_002-ebook.pdf
+Length: 5987 chars
+
+Managing the means of production
+Ensuring a suffi cient and stable performance is the overall priority in the survival of a household; economic performance, as discussed above, is primarily determined by the means of production enabling basic economic activities. Means of production can suffer a loss in productivity, or may even become unusable. This happens when droughts reduce the yield of agricultural production, or when competition grows intolerable on the labour market or the goods and servi...
+
+=== Chunk 1696 ===
+Source: 0820_002-ebook.pdf
+Length: 5149 chars
+
+The constitution of reserves
+The constitution of reserves is essential to the protection of the household’s means of production and assets. Reserves (or passive assets, or fi xed household capital) include anything that can be consumed, exchanged, or sold to meet basic needs, when the means of subsistence22 do not permit a suffi cient economic performance. The constitution of reserves is possible when the production of goods and services is equal to or higher than what is required. As long as prod...
+
+=== Chunk 1697 ===
+Source: 0820_002-ebook.pdf
+Length: 6449 chars
+
+Establishing and using social obligation networks
+In terms of security mechanisms, social obligations form part of mechanisms that are external to the household, since they exist for it and are directed towards it from outside. Households nevertheless play an active role in this framework, as follows:
+9 fi rstly, on an individual level, by invoking these obligations and being able to demonstrate that they amount to a right;
+9 secondly, by using and creating them on a participatory basis: the hous...
+
+=== Chunk 1698 ===
+Source: 0820_002-ebook.pdf
+Length: 1745 chars
+
+3.7.5 External security mechanisms
+External mechanisms have been mentioned above; they result from the same concerns and follow the same purpose as household mechanisms. Household mechanisms are overall quite similar, to the point of providing scope for a set formula; external mechanisms on the other hand vary considerably depending on the country, the region, and the economic group under consideration. They must therefore always be appraised individually. Variations result mainly from the polit...
+
+=== Chunk 1699 ===
+Source: 0820_002-ebook.pdf
+Length: 1986 chars
+
+Ensuring adequate economic performance
+At local and regional level, workforces, resources and negotiating groups (e.g. trades unions) are associated in order to increase the productivity of economic activities, and to ensure an equitable allocation of produced resources.
+At national level, the role of the State is crucial. Stabilizing prices, implementing a participative growth policy, exerting economic power over weaker States, authorizing unions and negotiating with them, promoting employment,...
+
+=== Chunk 1700 ===
+Source: 0820_002-ebook.pdf
+Length: 1450 chars
+
+3.8 A SYNOPTIC APPROACH TO THE SECURING OF FOOD
+All the above elements illustrate the complexity of the fi rst stage of the feeding process (i.e. the securing of food); this fi rst stage must be considered within the modern context of diversifi ed economies. It is nevertheless possible to apply a relatively simple model to all households. In order
+188
+3. The securing of food
+3.8 A synoptic approach to the securing of food
+to achieve its purpose (i.e. to provide a set formula for the securing of foo...
+
+=== Chunk 1701 ===
+Source: 0820_002-ebook.pdf
+Length: 1607 chars
+
+The securing of food is an essentially economic phenomenon.
+When man distances himself from nature by evolving from the status of hunter-gatherer to that of producer, he develops the cultural apparatus of implements and consumer goods – that is, his economy. He also generates cultural needs in the wake of his elementary needs; he diversifi es his production activities, specializes and so loses autonomy in terms of meeting his elementary and cultural needs (shortened here to his basic needs). In o...
+
+=== Chunk 1702 ===
+Source: 0820_002-ebook.pdf
+Length: 11922 chars
+
+The securing of food rests on the resources that enable economic production activities.
+Economic production activities that permit the securing of the goods and services required to meet basic economic needs must be sustainable; to this end, both time and production means (or active assets) are necessary, and the latter are made up of basic resources and inputs. “Sustainable” is understood here as responding regularly to the renewal rate of needs in the long run. Goods and services are acquired ...
+
+=== Chunk 1703 ===
+Source: 0820_002-ebook.pdf
+Length: 2896 chars
+
+With respect to food, the household economic system becomes the feeding system.
+Having set the economic household framework, it is possible, without becoming overly simplistic, to direct the approach specifi cally on the securing of food. This is done by resorting to a model of feeding system that illustrates the key points of household feeding (Figure 6.15 below).
+This model, extended to the overall economic operations of households, is a crucial tool in attempting to understand how the latter m...
+
+=== Chunk 1704 ===
+Source: 0820_002-ebook.pdf
+Length: 1279 chars
+
+THE CONSUMPTION OF FOOD 28
+The securing of food is the most crucial stage in the feeding process, because inadequate performance at this level results in insuffi cient consumption. Moreover, to secure food, man must come to terms with his environment, which can be more or less hostile to him. Individual and household behaviour is by no means the determining factor at this stage, it is rather the availability of resources. On the other hand the activities associated with the consumption of food ar...
+
+=== Chunk 1705 ===
+Source: 0820_002-ebook.pdf
+Length: 163 chars
+
+4.1 THE ACTIVITIES ASSOCIATED WITH FOOD CONSUMPTION
+The consumption of food consists of a series of activities that range from the choice of food to its ingestion....
+
+=== Chunk 1706 ===
+Source: 0820_002-ebook.pdf
+Length: 2230 chars
+
+4.1.1 The choice of food
+The choice of food is infl uenced by the following parameters:
+9 the performance of the securing of food, which is mainly determined by purchasing power, and food production and gathering;30
+9 culture-specifi c eating habits;
+CO
+9 foods available locally;
+9 personal attitude, as determined by the interest in food, preferences, priorities in the allocation of resources, level of education, dietary knowledge, and trends and fashions in feeding.
+Most of the world’s population...
+
+=== Chunk 1707 ===
+Source: 0820_002-ebook.pdf
+Length: 527 chars
+
+4.1.2 The processing of food
+The processing of food is limited here to household practices, and includes the following:
+9 treatment and storage after harvest or purchase;
+COdg
+9 cooking or other culinary preparation;
+9 serving;
+9 storage of prepared food and leftovers.
+Food processing methods are important on several accounts (especially in terms of culinary preparation), but their major aspect in terms of humanitarian operations is their infl uence on food hygiene,31 food conservation, and the p...
+
+=== Chunk 1708 ===
+Source: 0820_002-ebook.pdf
+Length: 255 chars
+
+4.1.3 The sharing of food
+The sharing of prepared food is a fundamental activity in the feeding of dependants. It refl ects the social structure and hierarchy, and the cultural norms in force – bearing in mind that standards may change in case of crisis.33...
+
+=== Chunk 1709 ===
+Source: 0820_002-ebook.pdf
+Length: 443 chars
+
+4.1.4 Feeding infants, children and other dependants
+Dependants are defi ned here as individuals who are incapable of feeding themselves independently. Such individuals therefore require someone to take charge and do so properly; possibilities include the following:
+9 households themselves in the case of infants, small children, the sick and elderly living under the same roof;
+9 institutions such as hospitals, homes, orphanages and prisons....
+
+=== Chunk 1710 ===
+Source: 0820_002-ebook.pdf
+Length: 328 chars
+
+Households
+Clearly, this is where the feeding of infants and small children is crucial, with breastfeeding or its substitute, terminated by the weaning process.
+31 See Chapter XV.
+32 See Chapter V, cereal milling and cooking.
+33 See Chapter VII.
+196
+4. The consumption of food
+4.1 The activities associated with food consumption...
+
+=== Chunk 1711 ===
+Source: 0820_002-ebook.pdf
+Length: 962 chars
+
+Weaning35
+Weaning follows breastfeeding, and replaces it (or bottle feeding) with foods that are increasingly those of adults. But weaning is not only a change in diet; it is also a fundamental transformation in the child’s lifestyle and its relation to its mother. This shift can be traumatic, especially if it coincides with the arrival of a sibling. In developing countries, weaning is the most crucial period in the survival of infants for the following reasons:
+9 their exposure to infectious di...
+
+=== Chunk 1712 ===
+Source: 0820_002-ebook.pdf
+Length: 347 chars
+
+Feeding other dependants
+This category includes the elderly, the sick and the helpless wounded. The determining factors in the diet of the elderly are appetite, the specifi c care they may require, and the portion of food allocated to them. The same factors apply to the sick and wounded, in addition to the dietary requirements of their condition....
+
+=== Chunk 1713 ===
+Source: 0820_002-ebook.pdf
+Length: 1373 chars
+
+Institutions
+Institutions call for a service that ensures food of adequate quality and quantity. In the case of specialized facilities such as hospitals, they must also provide an appropriate response to the dietary needs of their patients.
+The factors determining institutional food consumption include the budget available, possible domestic food production, kitchen equipment, and the quality and availability of their staff. This is important here, because humanitarian operations sometimes invol...
+
+=== Chunk 1714 ===
+Source: 0820_002-ebook.pdf
+Length: 366 chars
+
+4.1.5 The ingestion of food
+The ingestion of available food is determined by appetite, which in turn depends on physical and emotional health, the appeal of the diet and the quality of its processing and, fi nally, the social environment. The ingestion of food is the culmination of all the earlier activities (both deliberate and involuntary) in the feeding process....
+
+=== Chunk 1715 ===
+Source: 0820_002-ebook.pdf
+Length: 1941 chars
+
+4.2 THE PRECONDITIONS FOR CONSUMPTION
+These include fi rstly the means of storage and preservation that enable the keeping of food after harvest, slaughter, catch or purchase. The storage quality of staples is essential. Hazards such as rodents, birds, insects, mould and bacteria must all be protected against. Foodstuffs must also be protected from excessive moisture, light, and heat; they must be stored in a closed but ventilated place, sheltered from humidity, weather, and infestation. Time mus...
+
+=== Chunk 1716 ===
+Source: 0820_002-ebook.pdf
+Length: 284 chars
+
+4.3 THE ORGANIZATION AND DETERMINISM OF ACTIVITIES
+Like the securing of food, the conduct of activities associated with consumption is always set by a given culture and its acquired behaviours; they can therefore be analysed by following their pattern of organization and determinism....
+
+=== Chunk 1717 ===
+Source: 0820_002-ebook.pdf
+Length: 571 chars
+
+4.3.1 The function of food consumption activities
+Activities associated with food consumption complete those related to the securing of this food, in order for man to satisfy his nutritional need. This function involves, fi rstly, the selection of foods among existing resources, then their preparation to make them more comestible, then their sharing among the members of the community and, fi nally, their ingestion. But meals usually have a social and sometimes political additional role.
+198
+4. The...
+
+=== Chunk 1718 ===
+Source: 0820_002-ebook.pdf
+Length: 248 chars
+
+4.3.2 Community
+As seen above in relation with the securing of food, the community involved at the consumption stage is confi ned to the household, or to several related households. But an institution can also be regarded as a community in this way....
+
+=== Chunk 1719 ===
+Source: 0820_002-ebook.pdf
+Length: 141 chars
+
+4.3.3 Structure
+Structure is the elementary organization unit required to perform a function; as such, it is often merges into the community....
+
+=== Chunk 1720 ===
+Source: 0820_002-ebook.pdf
+Length: 4045 chars
+
+4.3.4 Norm
+The food consumption norm is defi ned mainly by eating habits, which also set the following:
+9 the choice of food (where possible);
+COURCEL
+9 the different ways of preparing food;
+9 the sharing of food;
+9 the ingestion of food;
+9 the nutritional care provided to dependants, particularly breastfeeding, infant feeding and weaning methods.
+Eating habits also include dietary taboos that can affect the choice of food and its attribution to different family members, in addition to the weanin...
+
+=== Chunk 1721 ===
+Source: 0820_002-ebook.pdf
+Length: 474 chars
+
+4.3.5 Enforcement
+In Western countries, the control of food consumption is primarily a private domestic matter, and only to a certain extent is it individual. But in more traditional societies, this control can also be enforced by religious and lay authorities. Furthermore all countries have food quality control mechanisms and associated regulations at national level; these regulations must be respected strictly when importing foodstuffs to assist populations in crisis....
+
+=== Chunk 1722 ===
+Source: 0820_002-ebook.pdf
+Length: 100 chars
+
+4.4 ACTIVITY PERFORMANCE
+The performance of food consumption is expressed in the following equation:...
+
+=== Chunk 1723 ===
+Source: 0820_002-ebook.pdf
+Length: 73 chars
+
+nutrients consumed
+–––––––––––––––––––––––––––––––––––––––––– / timeframe...
+
+=== Chunk 1724 ===
+Source: 0820_002-ebook.pdf
+Length: 740 chars
+
+nutrients required to satisfy the nutritional need
+This equation is infl uenced fi rstly by the analysis of activities related to the securing of food, in order to determine whether the food thus obtained is suffi cient for a given family or community. A positive answer does however not necessarily suggest that each individual receives a portion that is adequate to cover his nutritional need. Performance must therefore also be verifi ed in relation to the various members of the community, particular...
+
+=== Chunk 1725 ===
+Source: 0820_002-ebook.pdf
+Length: 949 chars
+
+4.4.1 Nutrients required to meet the nutritional need
+The sum of nutrients required to meet the nutritional need in fact represents the nutritional need itself. Nutrients must therefore be expressed as available amounts of food, once prepared and directly ready for consumption (in other words, when they have already lost some of their initial nutrient content through storage, refi ning and cooking36). The calculation is not complicated but requires the use of food composition tables, a limited nu...
+
+=== Chunk 1726 ===
+Source: 0820_002-ebook.pdf
+Length: 799 chars
+
+4.4.2 Timeframes
+Man usually consumes food on a daily basis, and timeframes are thus usually set for 24 hours. This does not mean that a nutritionally healthy individual must absolutely eat every day although, if he does not, he must then compensate for the resulting reserve loss. This is rather easy for adults, whatever the available foods; but it can be impossible for small children fed on low energy-density foods such as cassava, during weaning. When people eat less frequently than once a day...
+
+=== Chunk 1727 ===
+Source: 0820_002-ebook.pdf
+Length: 1676 chars
+
+4.4.3 Nutrients consumed
+The nutrients that are actually consumed are determined by the following factors.
+1. The overall economic performance in the securing of basic economic goods, which in turn infl uence:
+q the quantity, quality and diversity of the regularly available food, in turn affecting appetite;
+q the material means necessary to prepare food;
+q in part, the time required to prepare and distribute food to the family members;
+q the mental disposition to prepare attractive food and share...
+
+=== Chunk 1728 ===
+Source: 0820_002-ebook.pdf
+Length: 946 chars
+
+4.5 PERFORMANCE SECURITY
+It is accepted that to varying degrees all peoples who have survived had eating habits and cultural behaviours that ensured an adequate, suffi cient, balanced and comprehensive diet. The notion of varying degrees introduces that of vulnerability for those on the brink of sustainability in terms of means and customs. There is no direct security mechanism that ensures food consumption. The latter can, however, be ensured indirectly by the mechanisms that govern the securing...
+
+=== Chunk 1729 ===
+Source: 0820_002-ebook.pdf
+Length: 1697 chars
+
+4.5.1 Conditions for physical health
+Good physical health is determined by the following factors:
+9 a good nutritional status;
+9 a healthy diet, that is, supplying all the required nutrients in suffi cient quantity but without excess and in a balanced manner – foods that provide them must not be harmful, they must be prepared in a way that preserves nutrient quality and prevents toxicity; fi nally, their processing and handling must be hygienic;
+202
+4. The consumption of food 5. The biological uti...
+
+=== Chunk 1730 ===
+Source: 0820_002-ebook.pdf
+Length: 302 chars
+
+4.5.2 Conditions for mental health
+Mental health is fi rstly determined by physical health, and then by living conditions. Children need affection and a reassuring environment; adults need security – political, economic and social – in order to be able to cope with the long-term diffi culties they face....
+
+=== Chunk 1731 ===
+Source: 0820_002-ebook.pdf
+Length: 438 chars
+
+THE BIOLOGICAL UTILIZATION OF FOOD
+Man’s biological utilization of food is involuntary, because it is subjected to biological and thermodynamic determinism. Humanitarian action can infl uence it indirectly by addressing the conditions that defi ne it; these include, mainly, health, domestic food availability, and care of dependants. The infl uence of humanitarian action can also be direct, in the form of therapeutic nutrition measures.38...
+
+=== Chunk 1732 ===
+Source: 0820_002-ebook.pdf
+Length: 332 chars
+
+5.1 ACTIVITIES ASSOCIATED WITH THE BIOLOGICAL UTILIZATION OF FOOD
+The activities associated with biological utilization can be classifi ed in four major stages: digestion, absorption, functional utilization and excretion. These activities are not particularly relevant to humanitarian operations, and are only discussed briefl y here....
+
+=== Chunk 1733 ===
+Source: 0820_002-ebook.pdf
+Length: 1849 chars
+
+5.1.1 Digestion
+Digestion is defi ned as the sum of the chemical and mechanical transformations undergone by food in the digestive tract. Digestion transforms food into its basal molecular units, thus allowing it to be absorbed.
+38 See Chapter XIII.
+203
+I
+vi
+V
+I V
+NUTRITION MANUAL Chapter VI – The feeding process
+5. The biological utilization of food
+5.1 Activities associated with the biological utilization of food
+The digestive tract includes the mouth, the oesophagus, the stomach, the small int...
+
+=== Chunk 1734 ===
+Source: 0820_002-ebook.pdf
+Length: 449 chars
+
+5.1.2 Absorption
+Absorption is the transfer of the nutrients contained in the intestine into the organism through the intestinal mucous membrane. Most nutrients are transported actively through their own mechanisms – regulated mostly by their level of intake and their concentration in the organism. In addition, passive absorption can set in beyond a certain intestinal concentration. Nutrient absorption is complex and is not yet fully understood....
+
+=== Chunk 1735 ===
+Source: 0820_002-ebook.pdf
+Length: 599 chars
+
+5.1.3 Functional utilization
+After their absorption, nutrients are stored and/or transported to the organs to be utilized according to their respective functions. Some, such as sugars, are consumed in metabolism and must therefore be replaced as fast as they are consumed. Others, such as iron, are recycled regularly and effi ciently; they are however lost sooner or later, be it specifi cally through metabolic pathways, or through the unavoidable losses that result from “organic leakage” and tissue...
+
+=== Chunk 1736 ===
+Source: 0820_002-ebook.pdf
+Length: 1377 chars
+
+5.1.4 Excretion
+Having fulfi lled their function in the organism, or when they are present in excessive concentrations, nutrients or the produce of their degradation are excreted through urine, stool, perspiration and the gases produced by breathing. Furthermore, the “leakage” of some metabolic pathways, intestinal and skin desquamation, and hair and nail growth are also forms of nutrient (or their metabolites) excretion; as such, they also constitute unavoidable losses. Urine contains most solub...
+
+=== Chunk 1737 ===
+Source: 0820_002-ebook.pdf
+Length: 275 chars
+
+5.2 THE ORGANIZATION AND DETERMINISM OF ACTIVITIES
+The organization and determinism of activities in the biological utilization of food have been discussed above, in Table 6.2. There is no need to dwell on the points that are not particularly relevant to humanitarian action....
+
+=== Chunk 1738 ===
+Source: 0820_002-ebook.pdf
+Length: 2712 chars
+
+5.3 ACTIVITY PERFORMANCE
+The performance of the biological utilization of food can be expressed as the ratio of the use by the organism of consumed nutrients, on the one hand, and what it should be in order to achieve an adequate nutritional and health state, over a given period, on the other. At this stage in the activities in the organism, such an approach to performance makes little sense, because it cannot be used in practice, except in laboratory conditions. However, attention must be paid ...
+
+=== Chunk 1739 ===
+Source: 0820_002-ebook.pdf
+Length: 600 chars
+
+5.4 PERFORMANCE SECURITY
+Like food consumption, there is no direct security mechanism for the biological utilization of food. The only way of achieving this security is to ensure an adequate nutritional status and mental and physical health at individual level. The conditions for this are themselves related to the performance achieved during the two previous stages of the feeding process (the securing of food and its consumption), the integrity and security of the family and social structure, su...
+
+=== Chunk 1740 ===
+Source: 0820_002-ebook.pdf
+Length: 1555 chars
+
+6. NUTRITIONAL STATUS
+The living organism must meet its nutritional needs through a feeding process. The degree to which these needs are met defi nes the nutritional status of a given organism. The nutritional status, in other words, is set by the performance of the feeding process, and the factors that infl uence it. Together with health, the nutritional status however also defi nes the functional capacity of the organism, which in turn infl uences the biological utilization, the consumption, and t...
+
+=== Chunk 1741 ===
+Source: 0820_002-ebook.pdf
+Length: 910 chars
+
+6.1 NUTRITIONAL STATUS AND ITS MEASUREMENT
+The picture that springs to mind in relation to the nutritional status is one opposing “thin” and “fat” persons, neither of whom is considered “normal”. This image refers to the status of the lean mass (i.e. muscle and organs) and the fatty (or adipose) tissue. But this approach remains restrictive, because the nutritional status relates to the condition of all the parts of the organism. The “thin/fat” image in particular ignores the vitamin and mineral...
+
+=== Chunk 1742 ===
+Source: 0820_002-ebook.pdf
+Length: 941 chars
+
+6.1.1 Investigation of clinical signs
+Clinical signs include those that are visible at the level of the skin, eyes, hair, the mouth lining, of palpable organs such as the liver and the thyroid, and of the reaction (or absence thereof) to stimulation. These signs provide sometimes useful defi ciency indicators and permit the quantifi cation (to a certain extent) of defi ciency, because they usually appear when defi ciency is advanced. The absence of such signs suggests the absence of obvious defi cien...
+
+=== Chunk 1743 ===
+Source: 0820_002-ebook.pdf
+Length: 624 chars
+
+6.1.2 Nutritional anthropometry
+This method consists in measuring the physical dimensions of the organism and, often, in combining them in order to determine the adequacy of growth or nutritional status with respect to the lean mass and adipose tissue, on the basis of reference data. Anthropometry however only provides an estimate of the lean mass and adipose tissue and, like clinical signs, does not enable absolute quantifi cation of the fat and protein reserves available to the organism. Resort...
+
+=== Chunk 1744 ===
+Source: 0820_002-ebook.pdf
+Length: 646 chars
+
+6.1.3 Biochemical tests
+Biochemical tests applied to blood and urine samples in particular can, directly or indirectly, provide a fairly accurate idea of the status of many constituents. Humanitarian agencies do not use them widely, however, because they are not suited to most encountered fi eld conditions; their use must be left to well-equipped laboratory facilities.
+42 Some are discussed in greater detail in the Chapters devoted to nutritional disorders (VIII) and assessments (X).
+207
+I V
+I V
+...
+
+=== Chunk 1745 ===
+Source: 0820_002-ebook.pdf
+Length: 634 chars
+
+6.1.4 Biophysical methods
+Biophysical methods, like the extrapolation of lean mass from the potassium isotope 40 content, are even more accurate than biochemical tests, but they cannot be applied in humanitarian operations.
+It is thus worth noting that the nutritional status of individuals cannot be assessed comprehensively; for assessments to be as accurate as possible, a full battery of methods must be applied, most of which are impractical in the fi eld. Clinical defi ciency signs and anthropom...
+
+=== Chunk 1746 ===
+Source: 0820_002-ebook.pdf
+Length: 7735 chars
+
+6.2 ADEQUATE NUTRITIONAL STATUS
+An adequate nutritional status may be described as one that is not improved by administering essential nutrient supplements. This defi nition implies a satisfactory functional capacity of the organism, because it is determined by the nutritional and health states. Functional capacity is determined by the presence of all the components of the organism, in suffi cient amounts, and according to specifi c proportions. Furthermore, functional capacity must be defi ned acco...
+
+=== Chunk 1747 ===
+Source: 0820_002-ebook.pdf
+Length: 1877 chars
+
+PART TWO NUTRITIONAL CRISIS
+The meaning of the word “crisis” seems obvious: it indicates that something is wrong. The Oxford English Dictionary (2002) however provides two different defi nitions: “a time of intense diffi culty or danger”, or “the turning point of a disease, when it becomes clear whether the patient will recover or not”. The expression clearly refers to several notions simultaneously: that of a given moment in time, of diffi culty or pathological disorder, of attack, situation or st...
+
+=== Chunk 1748 ===
+Source: 0820_002-ebook.pdf
+Length: 5915 chars
+
+1.1 DEFINITION
+A defi nition of the word “crisis” must fi rst be agreed on. Among its different meanings, that of a “grave phase” in the evolution of events appears to be most fi tting to the intuitive notion of a crisis in terms of humanitarian intervention.
+Humanitarian action is the assistance, usually without compensation, extended to individuals, groups, or populations who face crisis because they have become vulnerable to problems that prevent them from meeting their basic needs, thereby thre...
+
+=== Chunk 1749 ===
+Source: 0820_002-ebook.pdf
+Length: 256 chars
+
+1.2 GENERAL CHARACTERISTICS OF CRISES
+A crisis does not arise from nothing, nor is it due to chance. It develops more or less rapidly according to a cause and effect process, referred to as the crisis process, which is characterized by specifi c conditions....
+
+=== Chunk 1750 ===
+Source: 0820_002-ebook.pdf
+Length: 948 chars
+
+1.2.1 The crisis process
+A crisis process develops in the course of events which, in turn, makes history and blends into it.
+The limits of the process must therefore be identifi ed, and to do this, three phases are defi ned.
+1. The preliminary phase, in which the crisis emerges and develops. During this phase, to a certain extent, adaptation occurs and, if necessary, is followed by the utilization of reserves and defence mechanisms.
+2. The acute phase, which amounts to the crisis as such. Reserves...
+
+=== Chunk 1751 ===
+Source: 0820_002-ebook.pdf
+Length: 2307 chars
+
+The preliminary phase
+This phase is frequently unobtrusive, and it might even go unnoticed when the primary causes for the crisis are such that they result directly in crisis, or when they occur without obvious warning signals – this is sometimes the case in earthquakes, tidal waves, or volcanic eruptions. The duration of this phase can vary. It is contingent upon circumstances and/or events integrated into the crisis process, and which herald and prepare the acute phase. From a prevention persp...
+
+=== Chunk 1752 ===
+Source: 0820_002-ebook.pdf
+Length: 589 chars
+
+The acute phase
+This is the crisis itself, the phase of real threat for those experiencing it. Its duration is variable, and the crisis develops according to the nature and progress of its causes, according to the appearance (or not) of new crisis factors, and to available reserves and defence mechanisms. This development can take several forms as follows:
+9 a rapid shift to recovery, thanks to appropriate assistance measures;
+9 stabilization through coping mechanisms,1 but this entails increase...
+
+=== Chunk 1753 ===
+Source: 0820_002-ebook.pdf
+Length: 1842 chars
+
+The recovery phase
+This phase can take many forms, but can only begin when the causes of the crisis have vanished or diminished substantially. The recovery phase is contingent upon what remains of the victims’ coping mechanisms and potential outside assistance. Possible scenarios include rapid and sustainable improvement, a restored status (roughly equivalent to that preceding the crisis), or a resumption of precarious but suffi cient living conditions, with an aggravated weakness (increasing the...
+
+=== Chunk 1754 ===
+Source: 0820_002-ebook.pdf
+Length: 2763 chars
+
+1.2.2 Conditions leading to crisis
+1. In the cause and effect chain characterizing the crisis process, one or several causes must stand out at some stage as crisis factors. To use the terminology developed by Dr Pierre Perrin, we shall refer to such causes as “phenomena” (Perrin, 1996) or, to borrow from physics, “perturbations”.
+2. For a phenomenon to result in a crisis, it must fi rst strike a target.
+3. The target must be vulnerable to the phenomenon. The action of the phenomenon on the target...
+
+=== Chunk 1755 ===
+Source: 0820_002-ebook.pdf
+Length: 1154 chars
+
+Figure 7.2 Crisis concept
+COURSE OF EVENTS
+CRISIS PROCESS  PRELIMINARY  ACUTE PHASE  RECOVERY  PHASE  PHASE  CRISIS  PHENOMENON  PROBLEM ARISING  FROM AN  TARGET  INADEQUATE  VULNERABILITY  TO THE  RESPONSE TO     VULNERABILITY  PHENOMENON  TO THE IMPACT  IMPACT  CONDITIONS FOR CRISIS
+If crises result from inadequate response to an aggression, then the available means are inadequate to cover the needs whatever they may be. There is thus a discrepancy between the needs and the means, and the grea...
+
+=== Chunk 1756 ===
+Source: 0820_002-ebook.pdf
+Length: 237 chars
+
+1.3 FORMULATION OF CRISES
+From a conceptual perspective, the occurrence of crises obeys the following principles.
+1. The crisis process develops following the combination of a phenomenon and vulnerability, generating an (adverse) impact:...
+
+=== Chunk 1757 ===
+Source: 0820_002-ebook.pdf
+Length: 800 chars
+
+phenomenon × vulnerability = impact
+This formula (Perrin, 1996) demonstrates that impact is directly proportional to the magnitude of both the phenomenon and vulnerability. It also means that one or several phenomena can act on different types of vulnerability, and that this can result in several impacts.
+2. The impact constitutes damage which, in itself, poses a problem.
+3. The victims of the damage attempt to respond to the problem, according to two different scenarios: q their response is ade...
+
+=== Chunk 1758 ===
+Source: 0820_002-ebook.pdf
+Length: 542 chars
+
+a problem addressed inadequately results in crisis.
+4. Damage without adequate response increases vulnerability, or leads to new types of vulnerability.
+219
+I
+I
+V
+I I V
+NUTRITION MANUAL Chapter VII – A conceptual approach to crises
+1. A conceptual framework for crises
+1.3 Formulation of crises
+5. In the cause and effect logic, impacts – insofar as it is impossible to respond to the problems they generate – turn into new phenomena acting upon other types of vulnerability, or on the increase of a ...
+
+=== Chunk 1759 ===
+Source: 0820_002-ebook.pdf
+Length: 1552 chars
+
+phenomenon × vulnerability = impact1 impact1 × vulnerability = impact2 impact2 × vulnerability = impact3
+etc.
+In this chain reaction, each impact – which can convert into a new phenomenon – will:
+9 exploit existing vulnerability;
+9 increase vulnerability;
+9 provide existing phenomena with new opportunities for aggression, thus creating ramifi cations towards new and different problems.
+Owing to the multiplicity of cause and effect reactions, crisis is characterized by increasing problems, combini...
+
+=== Chunk 1760 ===
+Source: 0820_002-ebook.pdf
+Length: 1848 chars
+
+2.1 DEFINITION OF NUTRITIONAL CRISES
+The human being’s nutritional need is met by the feeding process. Nutritional crises can thus only develop if the feeding process is unable to cover this need (unbalance between needs and means as illustrated in the scale model above). Nutritional crises can therefore be explained as follows.
+A nutritional crisis is a serious situation that results from the inadequacy of the feeding process performance, to the point of creating problems which those confronted...
+
+=== Chunk 1761 ===
+Source: 0820_002-ebook.pdf
+Length: 2271 chars
+
+2.2 THE PHENOMENA
+A phenomenon is anything amounting to the aggression of factors determining the performance of the different steps of the feeding process. Phenomena inducing nutritional crises affect the following:
+9 the resources that are necessary to carry out the activities;
+9 the implementation of these activities;
+9 the resources produced by these activities.
+Phenomena can come from two sources: the human community and the natural environment. Those originating in the human community rela...
+
+=== Chunk 1762 ===
+Source: 0820_002-ebook.pdf
+Length: 3884 chars
+
+2.2.1 Human phenomena
+Political phenomena
+Among political phenomena, war is the main trigger of nutritional crises. Looting, destruction, danger, restrictions of access and movement, population displacements, confi nement, occupation, terror and harassment, compulsory levies, embargo and conscription... all these elements may undermine the household economy and, thus, the securing of food. Indeed, they directly infl uence the means of production, production activities and the resources thus genera...
+
+=== Chunk 1763 ===
+Source: 0820_002-ebook.pdf
+Length: 6039 chars
+
+Economic phenomena
+Economic phenomena are major factors of nutritional crises, either by causing famine directly, or by inducing poverty and restricting choice. Several types of phenomena exist among which the most important relate to (or result from) the market and speculation, competition or economic subjection, economic policies imposed by the State or international economic bodies, adverse economic development, competition over scarce resources, and international aid, in particular food aid....
+
+=== Chunk 1764 ===
+Source: 0820_002-ebook.pdf
+Length: 1857 chars
+
+Social phenomena
+Population (or demographic) growth is beyond doubt the most worrying phenomenon. Already in the 19th century, Malthus had predicted that if the planet’s population adjustment did not occur in a managed way (birth control), it would occur through famine and war, because population grows geometrically,4 while the production of resources grows arithmetically. In industrialized countries, Malthus’s theory has not yet been verifi ed, because industrial and agricultural development has...
+
+=== Chunk 1765 ===
+Source: 0820_002-ebook.pdf
+Length: 978 chars
+
+Cultural phenomena
+Distinguishing between social and cultural phenomena is not easy. Social phenomena can be observed in any society, while cultural phenomena relate to specifi c acquired types of behaviour. For example, the Somali individualistic and clanic behaviour resulted in a confl ict which caused one of the last century’s most devastating famines. This behaviour is acquired, and thus eminently cultural. Some cultural weaning and infant care practices also have serious consequences on the c...
+
+=== Chunk 1766 ===
+Source: 0820_002-ebook.pdf
+Length: 761 chars
+
+Accidents and illness
+Accidents resulting in massive pollution (Minamata in Japan, Bhopal in India, and Chernobyl in the former USSR) can make entire regions improper for human settlement, or contaminate resources and result in serious problems in terms both of the economy and health. However, the most common accidents affect individuals: workplace and traffi c accidents, mainly. Such accidents can infl uence all three steps of the feeding process, and endanger the survival of the household when t...
+
+=== Chunk 1767 ===
+Source: 0820_002-ebook.pdf
+Length: 782 chars
+
+2.2.2 Climatic environmental phenomena
+Climatic environmental phenomena generally have the greatest consequences on the primary sector of the economy. Therefore, they affect primarily those who depend upon it for a living, and then those who depend on it through exchange. Some climatic phenomena owe their importance – even their existence in specifi c regions – to the deterioration and pollution resulting from the growth of human activity. It is therefore no longer easy to differentiate with cert...
+
+=== Chunk 1768 ===
+Source: 0820_002-ebook.pdf
+Length: 4216 chars
+
+Drought
+Among natural climatic phenomena, drought causes the greatest number of nutritional crises. Combined with war – and, occasionally, non-human predators – it can be absolutely devastating, as seen in Ethiopia, Angola, Mozambique, Somalia and Sudan. Drought is fi rst and foremost a climatic occurrence. These occurrences show three types of variation:
+9 yearly variations, involving short time scales;
+9 pendulum systems, where periods of relatively humid years alternate with other, relatively ...
+
+=== Chunk 1769 ===
+Source: 0820_002-ebook.pdf
+Length: 1022 chars
+
+Floods
+Floods result from abnormally abundant rainfall saturating the soil’s absorption capacity, or from spates provoked by rainfall or erosion upstream, sometimes very far from the fl ooded area. Generally, fl ood is less of a crisis factor than drought, although this depends on duration, the time of year, the speed of the waters and the available means to confront it and mitigate its effects. In Somalia, fl oods in the Shabelle and Juba River basins usually have serious consequences because they...
+
+=== Chunk 1770 ===
+Source: 0820_002-ebook.pdf
+Length: 427 chars
+
+Hurricanes
+Hurricanes are less frequent than drought and fl oods, and their consequences are usually more short-lived. More frequently, the danger arises from the risk of injury. Nevertheless, hurricane Mitch, combined with torrential rains, has demonstrated the high damage potential of such phenomena; they can push large areas into precariousness, thus increasing the danger of disaster related to any aggravating phenomenon....
+
+=== Chunk 1771 ===
+Source: 0820_002-ebook.pdf
+Length: 995 chars
+
+Predators of production activities
+Man is increasingly his own worst predator; however today some societies and regions still fall prey, for lack of control capacity, to predators that can massively threaten agricultural production, be it in the form of crops or harvest. The well-documented devastating damage of locusts can result in famine. Similarly, some insects and caterpillars can destroy agricultural production, as observed in southern Sudan in 1989 and 1994. Birds are likewise feared, par...
+
+=== Chunk 1772 ===
+Source: 0820_002-ebook.pdf
+Length: 1527 chars
+
+Predators of man
+In the food relations of ecology, man is indeed a formidable predator and destroyer, but he also accommodates predators who threaten to kill him through viral, bacterial or parasitic infection. Illness therefore also plays a major part in triggering nutritional crises. Those of specifi c concern to humanitarian intervention include infectious diseases, owing to their potentially devastating consequences on entire communities. Diarrhoea and infant diseases can cause individual nut...
+
+=== Chunk 1773 ===
+Source: 0820_002-ebook.pdf
+Length: 1998 chars
+
+2.2.4 Geophysical environmental phenomena
+Geophysical environmental phenomena – such as earthquakes, volcanic eruptions and tidal waves – are brutal occurrences that can cause many casualties both human and infrastructural in mere seconds. Governmental and humanitarian response, in terms of nutrition, is usually required and signifi cant for only a very brief period immediately following the catastrophe and until its survivors have recovered from the initial shock. Thereafter, recovery programmes...
+
+=== Chunk 1774 ===
+Source: 0820_002-ebook.pdf
+Length: 1908 chars
+
+2.3 VULNERABILITY
+Vulnerability expresses the susceptibility or weakness of a given entity confronted with aggression, and indicates a defi ciency rather than something tangible. Indeed, for a phenomenon not to constitute an aggression, a system must preclude it from occurring by preventing or destroying it; or it must be evaded while relying either on the means to wait for it to end, or on activities which do not provide it with a hold. As a result, vulnerability that provides a hold for the phe...
+
+=== Chunk 1775 ===
+Source: 0820_002-ebook.pdf
+Length: 798 chars
+
+aggression
+A 100 % vulnerability indicates that the phenomenon will occur, that resilience is negligible, and that the aggression will thus have maximum impact. If resilience is greater than the aggression, vulnerability becomes negative and thus indicates safety with respect to the phenomenon. A 0 % vulnerability indicates either that the phenomenon is unlikely to occur, or that resilience is equal to the aggression. Such an equation is diffi cult to quantify accurately, as is the crisis equatio...
+
+=== Chunk 1776 ===
+Source: 0820_002-ebook.pdf
+Length: 6185 chars
+
+2.3.1 Nutritional vulnerability
+In human nutrition, “vulnerable groups” is a common concept. It encompasses small children, pregnant and lactating women, sick people and the elderly, in the context of nutritional vulnerability. Indeed, within the population, these categories or groups are the most vulnerable to malnutrition, but their vulnerability is universal because its nature is above all physiological.8 However, restricting nutritional vulnerability to physiological vulnerability indicates ...
+
+=== Chunk 1777 ===
+Source: 0820_002-ebook.pdf
+Length: 821 chars
+
+2.3.2 Political vulnerability
+Political vulnerability is related to the risk of confl ict, repression or discrimination, the lack of appropriate measures to arrest the crisis process, and disregard for the provisions of international humanitarian law and other legal instruments aiming at securing acceptable living conditions for man. It also relates to the inadequacy of services which usually depend on the political system functioning properly, such as public transport, and health and education s...
+
+=== Chunk 1778 ===
+Source: 0820_002-ebook.pdf
+Length: 745 chars
+
+2.3.3 Economic vulnerability
+Commonly, economic vulnerability allows phenomena to undermine economic productive activities and their yield. It can be caused by human and natural phenomena, as described above. It can infl uence human groups or entire regions, depending on whether the phenomenon affects geographic zones or specifi c productive activities. This type of vulnerability is inversely proportional to the household’s means of production and resilience. It infl uences the securing of food and...
+
+=== Chunk 1779 ===
+Source: 0820_002-ebook.pdf
+Length: 539 chars
+
+2.3.4 Ecological vulnerability
+Ecological vulnerability is shaped by the environment’s support capacity, and to the danger of environmental hazards. The environment’s support capacity is inversely proportional to the intensity of production activities exploiting it. Environmental hazards such as drought, locusts or endemics like trypanosomiasis weaken the productive capacity as well as the organism. Ecological vulnerability often accompanies economic and physiological vulnerability, and can thus...
+
+=== Chunk 1780 ===
+Source: 0820_002-ebook.pdf
+Length: 988 chars
+
+2.3.5 Social vulnerability
+Social vulnerability generally refers to the weakness of individuals, households or groups, due to ignorance, isolation or behaviour, and diminishes them within a society by, for example, excluding them from solidarity mechanisms and preventing them from countering aggression adequately. However, social vulnerability also arises from dependency on external assistance for survival. This is obviously the case of small children, the sick and the injured, the elderly who h...
+
+=== Chunk 1781 ===
+Source: 0820_002-ebook.pdf
+Length: 1122 chars
+
+2.3.6 Cultural vulnerability
+In cultural vulnerability, inadequacy in responding to phenomena results from economic, educational, legal or political practices inherent in the culture in question, that is, the acquired behaviour specifi c to a society or community. It is, for example, the absence of norms regarding the exploitation of given secondary resources, which can nonetheless become vital in case of diffi culty; behaviour types transmitted through education which can arrest development and c...
+
+=== Chunk 1782 ===
+Source: 0820_002-ebook.pdf
+Length: 1667 chars
+
+2.3.7 Physiological vulnerability
+Physiological vulnerability has been discussed above. With respect to nutrition, it concerns higher than average food needs, and susceptibility to illness, particularly infectious diseases. It is aggravated by inadequate access to healthcare, be it due to lack of resources (economic vulnerability at household level), or because the latter are inappropriate (political vulnerability at society level). The combination of malnutrition and infection increases physiol...
+
+=== Chunk 1783 ===
+Source: 0820_002-ebook.pdf
+Length: 868 chars
+
+2.3.8 Psychological vulnerability
+Psychological vulnerability refers to the quality of the socio-cultural environment and the amount and magnitude of stress. The socio-cultural environment largely determines a group’s resilience and self- confi dence. Stress also plays a major part in determining reactive capacity. At the inception of a stressful event, this capacity can be undermined by the refusal to face reality, just as much as it can be stimulated. On the other hand, if stress is too severe ...
+
+=== Chunk 1784 ===
+Source: 0820_002-ebook.pdf
+Length: 235 chars
+
+2.4 IMPACT
+In view of the large variety of phenomena and types of vulnerability from which they can arise, impacts are relatively easy to understand. Indeed, they manifest themselves very materially with respect to the feeding process....
+
+=== Chunk 1785 ===
+Source: 0820_002-ebook.pdf
+Length: 710 chars
+
+2.4.1 Diffi culties in obtaining food
+9 Low food availability within the society, which often results in a rise in the price
+of essential commodities (additional impact).
+9 Insuffi cient economic production at household level, indicating an inadequate economic performance.
+9 Losses before and after the harvest.
+9 Loss of reserves through excessive sale, consumption or looting.
+9 Impoverishment resulting from the use of reserves to cover essential needs (due to an inadequate economic performance).
+...
+
+=== Chunk 1786 ===
+Source: 0820_002-ebook.pdf
+Length: 575 chars
+
+2.4.2 Problems in food consumption
+9 Insuffi cient food consumption, owing to shortfalls in the obtaining of food, discussed above.
+9 Disturbed eating habits, owing to changes in the availability of food products, the available time for the preparation and sharing of food, and weaning practices.
+9 Lack of means and knowledge regarding the care of dependants, because changing circumstances impose unfamiliar or inapplicable measures.
+9 Exposure to infectious disease and the lack of healthcare due t...
+
+=== Chunk 1787 ===
+Source: 0820_002-ebook.pdf
+Length: 247 chars
+
+2.4.3 Problems in the biological utilization of food
+9 Ineffi cient biological utilization of food, owing to reduced and inadequate food consumption.
+9 Disturbed biological utilization of food, owing to insuffi cient intake and damage to the system....
+
+=== Chunk 1788 ===
+Source: 0820_002-ebook.pdf
+Length: 3678 chars
+
+2.5.1 Diversity and complexity
+Nutritional crises can be diverse and sometimes quite complex in nature, for the following reasons:
+9 the feeding process comprises three distinctive steps, themselves refl ecting a combination of specifi c activities – inadequate performances within the process can therefore be manifold;
+9 the inadequate performance of a given activity can have a trickle-down effect on activities following it in the process, as well as affecting those occurring before;
+9 many differ...
+
+=== Chunk 1789 ===
+Source: 0820_002-ebook.pdf
+Length: 592 chars
+
+2.5.2 Numbers
+In the humanitarian world, referring to victims in numbers is signifi cant in defi ning the crisis itself, because it serves to justify intervention. Indeed, when a crisis affects only a limited number of households or individuals, it is likely that the resources required to address it will be found locally. This is no longer the case where crisis strikes large segments of the population. But the use of numbers is also contingent upon the parameters of the crisis, and is subjective i...
+
+=== Chunk 1790 ===
+Source: 0820_002-ebook.pdf
+Length: 1024 chars
+
+2.5.3 Nutritional crises and malnutrition
+To conclude, the effect of aggression on the food process is sometimes analysed according to the nutritional status of individuals or selected groups, giving an idea of the overall performance of the process. From this angle, nutritional crisis refers to malnutrition – being the last stage before death experienced by victims of dysfunctions in the food process. This approach to nutritional crises through malnutrition ignores the fact that some event has ...
+
+=== Chunk 1791 ===
+Source: 0820_002-ebook.pdf
+Length: 4600 chars
+
+2.6 NUTRITIONAL CRISIS ILLUSTRATED
+The following example illustrates the application of the formulation of the mechanism of a crisis.
+For farmers relying on subsistence agriculture in an area where production alternatives are limited, where agriculture is essentially restricted to a monoculture vulnerable to water shortage, the impact of a major drought will be negative by signifi cantly depleting production. The most probable response will be to resort to resources intended to face the situation...
+
+=== Chunk 1792 ===
+Source: 0820_002-ebook.pdf
+Length: 2061 chars
+
+1.1 INTRODUCTION
+Famine is the most classical type of nutritional crisis. The defi nition of “famine” nevertheless remains hazy. This is no doubt because, although all famines result from a serious and protracted defi ciency in the securing of food, the process resulting in this situation, as well as its severity and prognosis vary considerably. The process is determined by aggressive phenomena and vulnerabilities, resilience and the timeframe set by economic performance. Its severity is determine...
+
+=== Chunk 1793 ===
+Source: 0820_002-ebook.pdf
+Length: 1640 chars
+
+1.2 DEFINITIONS
+As mentioned earlier, the defi nition of famine remains hazy. The commonest defi nitions are:
+9 “Extreme and protracted shortage of food, causing widespread and persistent hunger, emaciation of the affected population, and a substantial increase in the death rate”. (Encyclopaedia Britannica, 2006).
+9 “Extreme scarcity of food”. (Oxford Dictionary, 2000).
+COU
+9 “Extreme food scarcity: a severe shortage of food resulting in widespread hunger”. (Encarta, 2005).
+9 “A regional failure o...
+
+=== Chunk 1794 ===
+Source: 0820_002-ebook.pdf
+Length: 1718 chars
+
+1. Food shortage
+Food shortage is an ambiguous concept: is food lacking in the absolute sense, or rather is it inaccessible to the affected population (because it is unaffordable or for any other reason such as crops are growing in a confl ict/mined area) ? In fact, both are possible, and one does not exclude the other. It is therefore preferable to refer to an insuffi cient access to food, without attempting a more accurate defi nition.
+1 See Part III of this Manual.
+244
+1. Famine
+1.2 Defi nitions
+...
+
+=== Chunk 1795 ===
+Source: 0820_002-ebook.pdf
+Length: 351 chars
+
+3. Widespread mortality
+Widespread mortality may indeed be a major characteristic of famine, distinguishing it from scarcity. But this mortality, however frightful it may be, varies signifi cantly according to the cause of the famine, its duration, its severity, the associated risk of infectious disease, and the resilience of the affected population....
+
+=== Chunk 1796 ===
+Source: 0820_002-ebook.pdf
+Length: 680 chars
+
+4. Famine affects specifi c geographic areas
+Famine is a regional phenomenon. On the other hand, nutritional crisis that affects individuals or households can be explained by inadequate access to food, suffering resulting from hunger, and one or several deaths. As long as the phenomenon is restricted to single individuals or households, it is not famine, even if the affected individuals may consider it to be so. The expression famine refers strictly to the fact that a signifi cant proportion of th...
+
+=== Chunk 1797 ===
+Source: 0820_002-ebook.pdf
+Length: 816 chars
+
+5. Duration
+The process resulting in famine is undoubtedly lengthy. The concept of duration is questionable however, because it is not a precondition for famine. When a famine is said to be protracted, reference is being made to the period during which its victims have been suffering from hunger. Famine may in fact develop rapidly, depending on the severity of the lack of food access. For example, a general strike in the transport sector of a capital city could cause famine within weeks, and res...
+
+=== Chunk 1798 ===
+Source: 0820_002-ebook.pdf
+Length: 258 chars
+
+6. Collective dimension
+Widespread mortality and the regional dimension both suggest that famine affects a signifi cant proportion of the population of a given region. If these two concepts are accepted, then it follows that famine is a collective phenomenon....
+
+=== Chunk 1799 ===
+Source: 0820_002-ebook.pdf
+Length: 195 chars
+
+7. Cause and effect
+Famine results from a chain of causes; but the expression famine suggests the inevitable, and thus encourages fatalism when it would in fact be possible to address its causes....
+
+=== Chunk 1800 ===
+Source: 0820_002-ebook.pdf
+Length: 1445 chars
+
+8. Causes of mortality
+The mortality associated with famine is much discussed: does it really result from malnutrition, or rather from disease? The mortality caused by disease is clearly worse
+2 See Sections 2.2.1. and 2.5. in this Chapter.
+245
+I I I V
+I I I V
+NUTRITION MANUAL Chapter VIII – The pathology of nutritional crisis
+1. Famine
+than usual in famines.3 Similarly, the chaos surrounding many famine situations promotes the spread of infectious diseases such as typhus fever, cholera, tubercu...
+
+=== Chunk 1801 ===
+Source: 0820_002-ebook.pdf
+Length: 634 chars
+
+10. Increasingly desperate behaviour
+Famine has two fundamental characteristics in this respect: it is the culmination of a process (as suggested by “increasingly”), and the economic disorder is eclipsed by the biological problem, which usually aggravates the economic disorder. Desperate behaviour replaces a conduct intended to preserve economic self-sustainability with biological survival refl exes, induced by the suffering related to acute and protracted hunger, and by the absence of alternativ...
+
+=== Chunk 1802 ===
+Source: 0820_002-ebook.pdf
+Length: 2754 chars
+
+11. Abnormal economic and social behaviour
+The previous Chapter has shown that an unusually strong (in duration or magnitude) aggression provokes an insuffi cient or abnormal response. This is no doubt the crux of the famine problem. Abnormal economic and social behaviour suggests the existence of a famine process; urgent action is thus required in order to prevent the otherwise inevitable economic, social, physiological and psychological consequences. Assessment must highlight such abnormal beha...
+
+=== Chunk 1803 ===
+Source: 0820_002-ebook.pdf
+Length: 3766 chars
+
+1.3 THE CAUSES OF FAMINE
+Famine always results from insuffi cient access to food; its direct cause is therefore an insuffi cient performance in the securing of food. This direct cause itself has two underlying causes that may combine:
+9 households cannot afford available commodities;
+9 the availability of food is limited.
+These underlying causes have their own causes (i.e. secondary causes):
+9 household food production is insuffi cient or non-existent;
+9 the hunting, gathering and fi shing activitie...
+
+=== Chunk 1804 ===
+Source: 0820_002-ebook.pdf
+Length: 15182 chars
+
+1.4 THE FAMINE PROCESS
+Some famine processes are obvious, because their causes have rapid and clear consequences. Examples include the sudden displacement of populations who have lost all their belongings and depend entirely on outside assistance, and complete isolation such as that produced by a siege or a suspension of supplies, where food is no longer available, whatever the means to purchase it. In such extreme cases, the cause and effect relation is clear enough, and does not require furthe...
+
+=== Chunk 1805 ===
+Source: 0820_002-ebook.pdf
+Length: 1607 chars
+
+1.5 RESILIENCE TO FAMINE
+Resilience to famine amounts to the ability to overcome aggressive phenomena that threaten the usual means of ensuring economic performance; more briefl y expressed, it is embodied by coping mechanisms, which are activated during the fi rst three phases of the famine process. They consist of the qualitative and quantitative adjustment of production activities, the invoking of social obligations, the utilization of reserves, resorting to credit, the restriction and modifi ca...
+
+=== Chunk 1806 ===
+Source: 0820_002-ebook.pdf
+Length: 571 chars
+
+1.5.1 The adjustment of production activities
+When productivity drops substantially, the fi rst reaction is an attempt to compensate the resulting loss by increasing production in minor sectors, or resorting to production activities that are normally unpopular because of their image or because they are gruelling. In other words, the full exploitation of all available production alternatives in order to maintain a suffi cient economic performance; however, this is not always possible. Where feasibl...
+
+=== Chunk 1807 ===
+Source: 0820_002-ebook.pdf
+Length: 1274 chars
+
+1.5.2 Invoking social obligations
+Social obligations are usually cultural mechanisms intended to assist community members who face economic diffi culties to avoid destitution. Their strength varies according to society and circumstance. They fl ow from rich to poor through the conversion of surplus wealth held by the rich into commodities that are essential to the survival of the poor. Social obligation mechanisms
+253
+I I I V
+I I I V
+NUTRITION MANUAL Chapter VIII – The pathology of nutritional cri...
+
+=== Chunk 1808 ===
+Source: 0820_002-ebook.pdf
+Length: 2757 chars
+
+1.5.3 The utilization of reserves
+Reserves are manifold, as illustrated in Figure 8.2 above. Stocks of consumables primarily include food reserves, whose utilization is particularly sensitive in a famine process that usually involves steep price increases. It is therefore probably preferable to resort to credit when interest rates and local food prices are still reasonable; this enables food to be kept for a time when speculation is favourable, and interest rates refl ect the risk-mitigation effo...
+
+=== Chunk 1809 ===
+Source: 0820_002-ebook.pdf
+Length: 717 chars
+
+1.5.4 Debt
+Credit is a means of extending the household capacity to cope with economic diffi culties. Its cost may however be high, and refund efforts may affect several successive generations. Like social obligations, the sustainability of debt is related to compliance with reciprocal obligations. Resorting to credit is always determined by the cost of debt with respect to the utilization of alternative mechanisms, such as the sale of animals, and by the prospects for improvement or deterioratio...
+
+=== Chunk 1810 ===
+Source: 0820_002-ebook.pdf
+Length: 1407 chars
+
+1.5.5 Dietary restriction and adjustment
+The controlled restriction of consumption is a privileged mechanism in the management of resources, because it enables the preservation of household assets, and the ability to cope with economic diffi culties at a usually acceptable cost (i.e. hunger and weight loss). Intake restriction and weight loss increase physiological vulnerability and may give rise to specifi c defi ciencies that often remain at the sub-clinical stage, but may develop into fatal clin...
+
+=== Chunk 1811 ===
+Source: 0820_002-ebook.pdf
+Length: 409 chars
+
+1.5.6 Restricting the number of household dependants
+An effi cient way of alleviating the pressure of the nutritional need on households is to send children to stay with wealthier relatives and adolescents or young men to work afar, to marry off young girls and, sometimes, to return wives to their own families. Of course, such behaviour contributes to social disintegration and, hence, to the famine process....
+
+=== Chunk 1812 ===
+Source: 0820_002-ebook.pdf
+Length: 3801 chars
+
+1.5.7 Additional remarks regarding resilience
+1. When all the members of a given group share the same coping mechanisms, some will automatically lose effi ciency because of increased competition for the same resources, jobs or social obligation networks. This competition deteriorates the terms of trade and weakens the coveted resources, and this is always to the detriment of the victims of the famine process. For example, if all members of the group must sell cattle to purchase grain, and if grai...
+
+=== Chunk 1813 ===
+Source: 0820_002-ebook.pdf
+Length: 7063 chars
+
+1.6 FAMINE AND WAR
+The previous Chapter presented war as a catalyst of nutritional crises. The relationship between famine and war is not absolute: famine can occur in the absence of war, and vice-versa. Nevertheless, many of the worst famines occur during armed confl ict. The reason for this is simple: the climatic and economic factors conducive to famine notwithstanding, the loss of access to food resources arises primarily from deliberate action. This action usually falls into one of the follo...
+
+=== Chunk 1814 ===
+Source: 0820_002-ebook.pdf
+Length: 2808 chars
+
+1.7.1 Famine prevention
+“In the early 1990s, world production is theoretically suffi cient to feed the 5.3 billion inhabitants of the planet, and it seems possible to meet the food requirements during the fi rst half of the 21st century. An equitable distribution would nevertheless be required, based on an organization enabling the inhabitants of each region to meet their needs independently. This assumes that the international market organization, aid (fi nancial, technological, infrastructural, m...
+
+=== Chunk 1815 ===
+Source: 0820_002-ebook.pdf
+Length: 4143 chars
+
+1.7.2 Early warning
+The suffering and the waste of human life and resources caused by famine are unacceptable in the modern world, and any system devised to avert famine is welcome. Credible early warning might provide a solution but, in spite of numerous attempts at introducing such systems, their effi ciency is disappointing. Even the combination of several such systems does not enable the reliable forecast of nutritional crises.
+Questions related to early warning include: how early need it be?...
+
+=== Chunk 1816 ===
+Source: 0820_002-ebook.pdf
+Length: 448 chars
+
+1.7.3 Famine indicators
+The famine process threatens the household economy well before individuals seriously resort to their physiological resources. The economic analysis of optimum resource utilization provides a fi rst detection level. Indicators relevant to prevention are therefore those that highlight the fact that a given population is reduced to its coping mechanisms in order to survive.
+The common early warning indicators are as follows....
+
+=== Chunk 1817 ===
+Source: 0820_002-ebook.pdf
+Length: 1385 chars
+
+Meteorological and harvest monitoring indicators
+Meteorological data provides invaluable information as to the anticipated reduction in agricultural production and food availability; but it provides no prognosis as to the possible resulting human suffering and its location. Rainfall and other climatic phenomena are erratic in time and space. As a result, rainfall monitoring must be synoptic, that is, performed through many stations widely scattered throughout the area under consideration. The mo...
+
+=== Chunk 1818 ===
+Source: 0820_002-ebook.pdf
+Length: 709 chars
+
+Nutritional anthropometry
+Nutritional anthropometry is considered by many humanitarian agencies and donors as the absolute precondition for early warning. As mentioned above, a deteriorated nutritional status may indicate controlled dietary restriction; however, many humanitarian agencies tend to concentrate on the deterioration caused by the last resort, being the consumption of physiological reserves. Similarly, prime-time media reporting – and, therefore, the widespread alert of the general p...
+
+=== Chunk 1819 ===
+Source: 0820_002-ebook.pdf
+Length: 2803 chars
+
+Economic and social information
+Economic and social data are more basic to predictions than the previous category. A signifi cant, unseasonable, rise in staple prices is a clear indication of a problem regarding access to food, especially if it combines with other economic phenomena or behaviours, such as a drop in the market value of livestock and a rise in the volume of sales. This indicates instability, and signifi cant progression
+260
+1. Famine 2. Nutritional disorder
+1.7 Famine prevention, ea...
+
+=== Chunk 1820 ===
+Source: 0820_002-ebook.pdf
+Length: 2614 chars
+
+2.1 INTRODUCTION
+The general expression “malnutrition” is commonly used in reference to nutrition problems of a physiological nature. This expression covers various ailments that correspond to nutritional disorders. These conditions have many causes – this Manual restricts itself to the discussion of the defi ciency disorders that are most commonly encountered in humanitarian operations, and that pose problems insofar as they may escalate into epidemics and have serious, sometimes fatal, conseque...
+
+=== Chunk 1821 ===
+Source: 0820_002-ebook.pdf
+Length: 158 chars
+
+2.2 CLASSIFICATION
+The classifi cation of nutritional defi ciency disorders follows two criteria: the type of nutrient that is defi cient, and the primary cause....
+
+=== Chunk 1822 ===
+Source: 0820_002-ebook.pdf
+Length: 3709 chars
+
+2.2.1 Classifi cation according to nutrient defi ciency
+Nutritional defi ciency disorders are classifi ed according to the response of the organism to defi ciencies in different nutrients; it translates into a reduced tissue concentration of the nutrient under consideration (i.e. Type I defi ciency), or stunting and weight loss (Type II defi ciency) (Golden, 1988; Golden in Waterlow, 1992). The classifi cation of nutrients according to observed responses in case of defi ciency is provided in Table 8.1, a...
+
+=== Chunk 1823 ===
+Source: 0820_002-ebook.pdf
+Length: 2218 chars
+
+2.2.2 Classifi cation according to primary cause
+The concatenation of the causes of nutritional disorder is illustrated in Figure 8.3 below, which lists causes according to their ranking. The primary causes are of interest here (underlying causes have been discussed in the previous Chapter).
+263
+I I I V
+I I I V
+NUTRITION MANUAL Chapter VIII – The pathology of nutritional crisis
+2. Nutritional disorder
+2.2 Classifi cation
+Figure 8.3 Ranking of the causes of nutritional disorder
+NUTRITIONAL  DISORDE...
+
+=== Chunk 1824 ===
+Source: 0820_002-ebook.pdf
+Length: 1144 chars
+
+2.3 DEFINITIONS
+A distinction is usually made between specifi c vitamin and mineral defi ciencies (i.e. Type I nutrient defi ciency) and protein-energy malnutrition (PEM), which manifests itself through a broad range of signs from kwashiorkor to marasmus, and refers to protein and/or energy defi ciency as the main cause of malnutrition. The expression “specifi c defi ciency” has been in common use for some time, and is accordingly referred to in this Manual also. The expression protein-energy malnutri...
+
+=== Chunk 1825 ===
+Source: 0820_002-ebook.pdf
+Length: 2903 chars
+
+2.4.1 Defi nitions
+Severe malnutrition includes all Type II defi ciencies in addition to carbon defi ciency as a source of energy. Severe malnutrition thus amounts to a multiple defi ciency, and the limiting nutrient may not be obvious except in situations of declared famine. This is in fact unimportant because, as defi ciency develops, all Type II nutrients in excess with respect to the limiting nutrient are lost; as a result, nutritional treatment is the same because it must include all Type II nut...
+
+=== Chunk 1826 ===
+Source: 0820_002-ebook.pdf
+Length: 1101 chars
+
+2.4.2 Classifi cation9
+Clinical manifestations of severe malnutrition result from an evolving process during which malnutrition is initially mild, becomes moderate, and then fi nally severe. Quantifying severe malnutrition requires the application of parameters that distinguish between these three forms and, consequently, enable a quantitative classifi cation of observed individuals, depending on their state of malnutrition.
+As mentioned in Chapter VI, one of the interpretations of nutritional stat...
+
+=== Chunk 1827 ===
+Source: 0820_002-ebook.pdf
+Length: 1200 chars
+
+Table 8.2 The Waterlow classifi cation
+Classifi cation of malnutrition according to Waterlowa Normal nutritional Mild malnutrition Moderate malnutrition Severe malnutrition status Weight-for-height 90 – 120 %b +2 Zc to –1 Z 80 – 89 % < –1 Z to –2 Z 70 – 79 % < –2 Z to –3 Z < 70 % < –3 Z Height-for-age 95 – 110 % +2 Z to –1 Z 90 – 94 % < –1 Z to –2 Z 85 – 89 % < –2 Z to –3 Z < 85 % < –3 Z
+a This classifi cation includes children with bilateral oedema of the lower limbs in severe malnutrition.
+b Perc...
+
+=== Chunk 1828 ===
+Source: 0820_002-ebook.pdf
+Length: 2415 chars
+
+MUAC-for-height
+9 Acceptable nutritional status: > 85 % of the reference median
+9 Moderate malnutrition:
+85–75 % of the reference median
+9 Severe malnutrition:
+< 75 % of the reference median.
+Z-scores may also be applied to MUAC-for-height, with the following thresholds: –2 Z instead of 85 %, and –3 Z instead of 75 %.12 The application of these two thresholds to a reference population reveals roughly the same prevalence of severe malnutrition, but Z-scores provide a somewhat lower prevalence rat...
+
+=== Chunk 1829 ===
+Source: 0820_002-ebook.pdf
+Length: 352 chars
+
+MUAC alone
+9 Acceptable nutritional status: > 13.5 cm
+9 Moderate malnutrition:
+13.5–12.5 cm
+9 Severe malnutrition:
+< 12.5 cm
+Médecins sans Frontières recommend a < 11 cm threshold in selecting severely wasted children for admission to therapeutic feeding centres (MSF, 1995). Thus different thresholds may be applied, depending on the ultimate purpose....
+
+=== Chunk 1830 ===
+Source: 0820_002-ebook.pdf
+Length: 1214 chars
+
+Adolescents
+No weight-for-height reference table in relation to age has been developed for adolescents. One table does provide centiles for the Quételet body mass index (see below), and malnutrition should be diagnosed among adolescents when the Quételet index is lower than the fi fth centile (WHO, 1995). This indicates wasting levels that range between approximately 87% of the weight-for-height index in a 9-year-old child, and 80% in a 20-year-old man. The fi fth centile threshold is thus useful ...
+
+=== Chunk 1831 ===
+Source: 0820_002-ebook.pdf
+Length: 5524 chars
+
+2.4.3 Marasmus
+The aetiology, or cause, of marasmus that occurs in schoolchildren (i.e. above fi ve), adolescents and adults is usually easier to defi ne than that affecting pre-school children and infants, in whom several phenomena may interact to cause malnutrition.
+Marasmus is a condition of wasting resulting from the fact that the organism is reduced to consuming its own reserves (mainly muscle and adipose tissue) in order to satisfy its nutrient requirements – this amounts to self-cannibalism...
+
+=== Chunk 1832 ===
+Source: 0820_002-ebook.pdf
+Length: 504 chars
+
+General appearance
+The classic presentation of marasmus is emaciation, giving the patient a shrunken, wasted appearance due to the loss of subcutaneous fat and muscle. The skin is fl accid, sagging (particularly on the buttocks), and wrinkled, conveying the impression of an “old man’s face” (some authors refer to simian features, or “monkey face”).
+15 See Chapter XV.
+269
+I I I V
+I I I V
+NUTRITION MANUAL Chapter VIII – The pathology of nutritional crisis
+2. Nutritional disorder
+2.4 Severe malnutri...
+
+=== Chunk 1833 ===
+Source: 0820_002-ebook.pdf
+Length: 1161 chars
+
+Appetite
+Primary marasmus usually does not diminish appetite, and patients may even be voracious. Secondary marasmus on the other hand (and the clinical complications associated with primary marasmus) almost always induces anorexia to some degree. However, if the associated disorder is bacterial or a parasite infection (giardiasis or amoebiasis), appropriate treatment quickly stimulates appetite. Appetite is a major indicator of the seriousness of the problem, and the possible presence of underl...
+
+=== Chunk 1834 ===
+Source: 0820_002-ebook.pdf
+Length: 2264 chars
+
+Mood
+Apathy and lethargy are typical of severe malnutrition – and indeed of any disorder causing the exhaustion of the organism. With the exception of the fi nal stage, when ocular disorder prevents the patient from focusing and movements are slow, marasmic patients can remain alert and focused, showing interest in their environment; they may show anxiety in spite of their often sunken eyeballs. This may also be a sign of dehydration. Marasmic children are often moody, but are usually less irrita...
+
+=== Chunk 1835 ===
+Source: 0820_002-ebook.pdf
+Length: 655 chars
+
+Other clinical signs
+Marasmus is often associated with Type I nutrient defi ciencies, and the clinical signs of such defi ciencies may be detected accordingly.16
+16 The clinical signs of specifi c defi ciencies are described in Chapter III, Sections 2.2.5 and 2.2.6, and in this Chapter, Section 2.5.
+270
+2. Nutritional disorder
+2.4 Severe malnutrition
+Kwashiorkor is often associated with Type I nutrient defi ciencies, and the clinical signs of such defi ciencies are thus common.18 It is also usually ac...
+
+=== Chunk 1836 ===
+Source: 0820_002-ebook.pdf
+Length: 10601 chars
+
+Pathophysiological aspects
+Arrested growth and weight loss provide the overall manifestation of severe malnutrition. They result in the third clinical disorder, nutritional dwarfi sm. A reduction in physical activity is another general manifestation owing to muscle loss, but also as an energy preservation mechanism. As discussed above, marasmus is the pathological outcome of wasting, which expresses the ability to adapt to an insuffi cient dietary intake. The physiology of marasmic subjects also e...
+
+=== Chunk 1837 ===
+Source: 0820_002-ebook.pdf
+Length: 450 chars
+
+Energy mobilization and expenditure
+Physical activity drops and subcutaneous fat reserves are used fi rst; amino acids are then increasingly used as a source of energy (particularly alanine for gluconeogenesis). This causes adipose tissue and muscle loss. In parallel, the energy utilization improves, and the vital functions slow down, particularly those associated with the sodium pump and protein synthesis, in order to reduce the basal metabolism....
+
+=== Chunk 1838 ===
+Source: 0820_002-ebook.pdf
+Length: 553 chars
+
+Protein utilization
+Adaptation also enables the preservation of protein, particularly in order to maintain the essential functions that depend on it. Changes in enzyme activity promote the degradation of muscle protein, the synthesis of liver protein, and the mobilization of stored fat. Visceral protein is preserved longer than muscle protein; when the latter is depleted, the loss of visceral protein is fatal. Another indication of adaptation is provided by the fact that the protein half-life in...
+
+=== Chunk 1839 ===
+Source: 0820_002-ebook.pdf
+Length: 1047 chars
+
+Hormone balance
+The hormone balance changes in case of insuffi cient dietary intake, in order to maintain energy homeostasis and determine the mechanisms described above. Hormone mechanisms are complex, and are not further discussed here. It should be noted nevertheless that changes in the hormone balance (that defi nes the general sense of the metabolism towards degradation or synthesis – catabolism or anabolism) do not occur instantly in either direction. When nutritional catch-up begins, hormon...
+
+=== Chunk 1840 ===
+Source: 0820_002-ebook.pdf
+Length: 452 chars
+
+Oxygen requirements
+The loss of lean mass and the reduction in physical activity cause a drop in the tissue oxygen requirements. Red blood cells and the haemoglobin concentration diminish as a result, thus contributing to the saving of amino acids. This no doubt amounts to a form of adaptation, but nutritional catch-up increases the demand for oxygen, and the organism must be provided with iron, folic acid and vitamin B12 in order to avert anaemia....
+
+=== Chunk 1841 ===
+Source: 0820_002-ebook.pdf
+Length: 436 chars
+
+Harmful physiological change
+Adaptation to an insuffi cient dietary intake can extend over a given period of time; beyond a certain point, however, the response no longer amounts to an advantageous adjustment, but entails an increase in the patient’s liability to accidents that may impair his health.
+271
+I I I V
+I I I V
+NUTRITION MANUAL Chapter VIII – The pathology of nutritional crisis
+2. Nutritional disorder
+2.4 Severe malnutrition...
+
+=== Chunk 1842 ===
+Source: 0820_002-ebook.pdf
+Length: 130 chars
+
+Cardio-vascular function
+Reductions in the blood fl ow, the cardiac rhythm, and blood pressure can result in cardiac insuffi ciency....
+
+=== Chunk 1843 ===
+Source: 0820_002-ebook.pdf
+Length: 693 chars
+
+Kidney function
+The kidney function is impaired, and kidney failure may result, particularly in patients whose protein supply abruptly exceeds their maintenance needs. This may occur at the onset of treatment, if the staff is unskilled in the treatment of severe malnutrition. In such cases, patients develop oedemas, not to be confused with those resulting from kwashiorkor, and these may prompt some caretakers to increase protein intake further – such a diet is fatal in most cases. Furthermore, i...
+
+=== Chunk 1844 ===
+Source: 0820_002-ebook.pdf
+Length: 642 chars
+
+Nervous system
+Critical forms of severe malnutrition affect the nervous system, especially during growth, as growth failure corresponds to impaired brain growth. The brain is however much better protected than other organs, and its weight defi cit amounts to growth retardation rather than to an actual loss of substance. However, myelin production is delayed, conduction may slow down, and the density of the nervous synapses may decrease (Waterlow, 1992). The impact of these alterations is not know...
+
+=== Chunk 1845 ===
+Source: 0820_002-ebook.pdf
+Length: 1034 chars
+
+Immune system and response to infection
+Critical forms of severe malnutrition induce a signifi cant depression of the acquired (cellular, but also humoral) and innate immune function. This manifests itself notably in the T lymphocytes (in the form of thymus atrophy) and in the complement, owing to the reduced production of several of its proteins. Antibody production may also be perturbed (e.g. Immunoglobin A – IgA). As a result of these alterations, patients suffering from critical forms of seve...
+
+=== Chunk 1846 ===
+Source: 0820_002-ebook.pdf
+Length: 1363 chars
+
+Water, electrolytes and minerals
+Severe malnutrition may combine with dehydration or over-hydration. Patients must be able to drink, but must not be forced to do so in the absence of clinical evidence of dehydration. Furthermore, the changes in body composition associated with severe malnutrition imply an increase in sodium and a loss in potassium, while other minerals (i.e. copper, magnesium, manganese, and zinc) are lost as metabolic activity diminishes. As a result, the rehydration formula in...
+
+=== Chunk 1847 ===
+Source: 0820_002-ebook.pdf
+Length: 2854 chars
+
+2.4.4 Kwashiorkor
+Kwashiorkor is doubtless the most serious form of critical severe malnutrition, entailing the greatest risk of mortality. Marasmus is caused by famine, acute infection, and improper weaning conditions and early infant feed; kwashiorkor (clearly indicated by bilateral oedema of the lower limbs) results rather from dietary imbalance, belated weaning, chronic infection, and metabolic disorder. It may develop quickly but unobtrusively. Kwashiorkor is much less common than marasmus ...
+
+=== Chunk 1848 ===
+Source: 0820_002-ebook.pdf
+Length: 1955 chars
+
+Oedema
+Oedema is the distinctive feature of kwashiorkor; the absence of bilateral oedema of the lower limbs excludes the kwashiorkor diagnosis. Oedema (from the Greek oidein, to swell) is produced
+273
+I I I V
+I I I V
+NUTRITION MANUAL Chapter VIII – The pathology of nutritional crisis
+2. Nutritional disorder
+2.4 Severe malnutrition
+by an expansion of the extra-cellular fl uid in the tissue, and this results in diffuse and painless swelling. Kwashiorkor causes the swelling to begin in the feet, and...
+
+=== Chunk 1849 ===
+Source: 0820_002-ebook.pdf
+Length: 1425 chars
+
+Facial features
+Before the face itself is affected by oedema, it shows swelling, chubby cheeks, and enlarged lower eyelids. Dark skin grows lighter. The fi rst impression might be that the child is in fact overfed. The miserable demeanour, compounded by the other clinical signs (particularly bilateral oedema of the lower limbs), should quickly dispel any doubts, however.
+Hair
+The effects of kwashiorkor on hair are usually more obvious than in marasmus. Hair discolours and may turn auburn-red, som...
+
+=== Chunk 1850 ===
+Source: 0820_002-ebook.pdf
+Length: 463 chars
+
+Hepatomegaly
+Hepatomegaly (i.e. the enlargement of the liver beyond its normal size), owing to lipid retention, is common. Post-mortem analysis suggests that lipid retention is systematic in kwashiorkor, but it can be more or less signifi cant and may therefore not result in hepatomegaly. The latter may contribute to abdominal swelling, in addition to helminthic (parasite worm) infection and intestinal gases.
+274
+2. Nutritional disorder
+2.4 Severe malnutrition...
+
+=== Chunk 1851 ===
+Source: 0820_002-ebook.pdf
+Length: 264 chars
+
+Wasting
+Wasting can occur to varying extent. Generally speaking, subcutaneous fat is usually preserved and muscle loss unobtrusive. The combined condition called marasmic kwashiorkor discussed below nevertheless presents serious wasting in association with oedema....
+
+=== Chunk 1852 ===
+Source: 0820_002-ebook.pdf
+Length: 603 chars
+
+Marasmic kwashiorkor
+Kwashiorkor oedemas appear at different stages of wasting; when wasting is considerable, however, the problem is called marasmic kwashiorkor. Marasmic kwashiorkor calls for the most pessimistic prognosis, particularly if it combines with septic shock. It usually results from protracted diarrhoea, which could lead to signifi cant potassium defi ciency. Another common disorder, hyponatraemia (i.e. low plasma sodium) indicates signifi cant cell damage; it is the main cause for pro...
+
+=== Chunk 1853 ===
+Source: 0820_002-ebook.pdf
+Length: 911 chars
+
+2.4.5 Nutritional dwarfi sm
+Nutritional dwarfi sm or stunting refers to a grossly insuffi cient height at a given age; it can also be called growth failure. It can usually only be detected by comparing the subject’s height with the reference height for his age group. Individuals who have suffered from arrested growth usually share the same characteristics as other individuals of the same height, and remain healthy. Stunting may therefore be described as the stigma of failed growth, insofar as the l...
+
+=== Chunk 1854 ===
+Source: 0820_002-ebook.pdf
+Length: 1674 chars
+
+Height (cm)
+120  110  100  90  80  70  60  50  40  0  6  12  18  24  30  36  42  48  54  60  Age (months)  REFERENCE CURVE  REAL CURVE
+In the above example, growth retardation at 60 months lies 12% below the standard – this amounts to moderate malnutrition according to the Waterlow classifi cation provided earlier.
+Growth retardation is not irreversible, provided that specifi c conditions are met. These include a healthy diet, the appropriate and timely treatment of ailments and, thus, an appropri...
+
+=== Chunk 1855 ===
+Source: 0820_002-ebook.pdf
+Length: 3485 chars
+
+The validity of anthropometric reference curves
+Nutritional dwarfi sm can only be measured by comparing the subject’s height with the standard provided for the same age group by reference tables. A natural question immediately arises as to the validity of the data contained in these tables, in view of obvious ethnic and regional differences. This leads to the
+278
+2. Nutritional disorder
+2.4 Severe malnutrition
+concept of genetic growth potential and environmental factors. The reference curves tha...
+
+=== Chunk 1856 ===
+Source: 0820_002-ebook.pdf
+Length: 683 chars
+
+The aetiology of nutritional dwarfi sm
+As stated above, reference values only enable the relative detection of nutritional dwarfi sm, and a margin of uncertainty results between rather specifi c anthropometric malnutrition thresholds and a suffi ciently sensitive threshold. The actual causes of growth retardation must then be clarifi ed. Generally speaking, growth retardation can be ascribed to Type II nutrient defi ciencies, hormone disorder, chronic infancy ailments, repeated or protracted infectiou...
+
+=== Chunk 1857 ===
+Source: 0820_002-ebook.pdf
+Length: 1480 chars
+
+The role of Type II nutrients
+Children who suffer from growth failure during primary or secondary malnutrition episodes do so because they lack the nutrients required for their growth in terms of height and weight. In terms of Type II nutrients, growth will occur up to the most limiting nutrient, according to
+19 See also Chapter X, Section 4.4.7.
+279
+I I I V
+I I I V
+NUTRITION MANUAL Chapter VIII – The pathology of nutritional crisis
+2. Nutritional disorder
+2.4 Severe malnutrition
+the necessary b...
+
+=== Chunk 1858 ===
+Source: 0820_002-ebook.pdf
+Length: 981 chars
+
+The role of anorexia
+Anorexia is a loss of appetite that expresses itself in an insuffi cient food intake. It leads to growth retardation if it is protracted or repeated without suffi cient recovery periods between episodes. Anorexia may result from illness, a monotonous diet or one that is defi cient in one or several Type II nutrients, and insuffi cient psycho-social stimulation. Anorexic subjects do not necessarily stop eating entirely, but lose appetite and thus can no longer meet their nutritio...
+
+=== Chunk 1859 ===
+Source: 0820_002-ebook.pdf
+Length: 1672 chars
+
+The role of sickness
+The relation between growth retardation and chronic and metabolic illnesses, and infectious disease seems obvious. The fi rst two types of disorder are essentially individual, and infectious disease is therefore of greater interest to humanitarian action, because it can affect large numbers and develop into epidemics. Waterlow concludes that the relation no doubt exists, but does not explain everything. Indeed, growth retardation always results from the balance of a triple in...
+
+=== Chunk 1860 ===
+Source: 0820_002-ebook.pdf
+Length: 1643 chars
+
+The role of scarcity and famine
+Scarcity and famine cause an overall reduction in food intake; this can lead to marasmus, kwashiorkor, or their combined form. In addition to an inadequate dietary intake of Type I and II nutrients, changes in eating habits, a poor quality or monotonous diet can cause anorexia related to food insuffi ciency and malnutrition. Furthermore, the loss of resistance to infectious disease can increase morbidity, which also causes anorexia and perturbs the metabolism and t...
+
+=== Chunk 1861 ===
+Source: 0820_002-ebook.pdf
+Length: 3720 chars
+
+The implications of nutritional dwarfi sm
+Growth retardation may be associated with the following disabilities, summarized according to Waterlow (Waterlow, 1992).
+The work capacity of adults suffering from growth retardation is inferior, to the point that short individuals fi nd employment with greater diffi culty than taller individuals. In women, a limited height is associated with problems in childbirth and an increase in infant mortality. The immune function of children having suffered from gro...
+
+=== Chunk 1862 ===
+Source: 0820_002-ebook.pdf
+Length: 1431 chars
+
+Operational consequences
+Growth retardation results from inadequate living conditions during growth; the question thus arises as to whether it affects a signifi cant proportion of the population, or isolated individuals. In the fi rst case, the exposed population is signifi cant, and timely protective and preventive measures must be taken accordingly. In the second case, serious growth retardation (< 85% or <–3 Z-scores from the height-for-age standard) probably refl ect extreme vulnerability to the...
+
+=== Chunk 1863 ===
+Source: 0820_002-ebook.pdf
+Length: 547 chars
+
+2.4.6 Severe malnutrition and infection
+The relation between malnutrition and infection is important. Infection can alter the nutritional status by causing secondary malnutrition, whereas primary malnutrition can affect the liability to infection and its invasive process. This may lead to a vicious circle in which infection and malnutrition reinforce one another, entailing high mortality rates. The mechanisms that are involved in the relation between malnutrition and infection are highly complex...
+
+=== Chunk 1864 ===
+Source: 0820_002-ebook.pdf
+Length: 1552 chars
+
+The effects of malnutrition on infection
+The ability of infection to spread in the host organism contributes to the severity of the infection. This capacity is shaped by the means of defence of the host, and by the integrity of its tissue (tissue contributes to the organism’s defence mechanisms). In critical forms of severe malnutrition, the means of defence are seriously impaired, while damaged tissue is prone to infectious invasion. As a result, severe malnutrition increases vulnerability to i...
+
+=== Chunk 1865 ===
+Source: 0820_002-ebook.pdf
+Length: 4002 chars
+
+Vitamin A
+The role of vitamin A in protection against infection is capital: it contributes signifi cantly to the state of mucous membranes (and, hence, resistance to invasion), and to the cell immunity and lysozyme activity.22 Even sub-clinical vitamin A defi ciency increases liability to diarrhoea and respiratory disease; vitamin A supplementation can reduce mortality by approximately one-third (Tomkins, 1989). Vitamin A is especially important in mitigating damage and mortality in measles (Shils...
+
+=== Chunk 1866 ===
+Source: 0820_002-ebook.pdf
+Length: 1997 chars
+
+Iron
+Iron contributes signifi cantly to many functions of the organism, but it is also an indispensable growth factor for most infectious agents. This raises questions as to the possible benefi ts of iron defi ciency in terms of protection against infection, while at the same time depressing immunity and increasing morbidity. Tomkins and Watson have reached the following conclusions regarding this quandary (Tomkins, 1989):
+9 iron defi ciency is associated with:
+q a reduction in cell immunity and bac...
+
+=== Chunk 1867 ===
+Source: 0820_002-ebook.pdf
+Length: 548 chars
+
+Other minerals and vitamins
+Defi ciency in other vitamins and minerals (such as ribofl avin, folic acid, vitamin C, and iodine) is, probably correctly, assumed to play a role in the vulnerability to infection, and in the impact of its spread. But this assumption remains to be demonstrated with certainty. Once again, the emphasis should be on a global approach to the prevention and treatment of malnutrition, with a view to protecting health; this would most probably result in most nutritional facto...
+
+=== Chunk 1868 ===
+Source: 0820_002-ebook.pdf
+Length: 756 chars
+
+Conclusion
+Infectious agents must also satisfy their nutritional needs, and therefore compete with the host organism. This means that, in the early stages of the treatment of severe malnutrition, when the defence of the organism remains weak, the infectious agent will thrive on the nutrients made available; as a result, it may delay recovery or even dominate. Infection must therefore be prevented and treated at the onset of nutritional catch-up, and the administration of iron must be withheld as...
+
+=== Chunk 1869 ===
+Source: 0820_002-ebook.pdf
+Length: 1674 chars
+
+Restricted food consumption
+This restriction is associated primarily with anorexia; it consists of a loss of appetite caused by a mechanism that remains not fully elucidated, but appears to involve cytokines, which are molecules that are produced and released by macrophages in response to infection. Anorexia is the main cause of secondary malnutrition. When it combines with infection, it restricts the appetite for solids more severely than that for liquids (maternal milk is particularly well tol...
+
+=== Chunk 1870 ===
+Source: 0820_002-ebook.pdf
+Length: 456 chars
+
+Malabsorption
+Many infections, be they systemic or local, induce diarrhoea; gastro-intestinal infection usually manifests itself in diarrhoea also. Diarrhoea reduces the absorption of macro-nutrients (i.e. lipids, protein, and glucides) by initially nutritionally healthy individuals by 10 to 20%. Micro-nutrient absorption is likewise impaired, particularly in the case of vitamin A and iron. Malabsorption is worse still in already malnourished patients....
+
+=== Chunk 1871 ===
+Source: 0820_002-ebook.pdf
+Length: 525 chars
+
+Metabolic losses
+The organism responds to infection with fever, by improving the effi ciency of the immune system, which is more active at 39°C than at 37°C. This performance entails a metabolic cost that is estimated to be an increase of the energy spending of around 10 to 15% per degree of body temperature increase. Moreover, infection and wounds induce a negative protein balance as a result of the increased degradation of muscle protein, itself arising partly from an altered utilization of ene...
+
+=== Chunk 1872 ===
+Source: 0820_002-ebook.pdf
+Length: 827 chars
+
+Intestinal losses
+The cell turnover of the intestinal mucous membrane is rapid; discarded cells terminate in the intestine, where they are dismantled. In normal circumstances, their components are well reabsorbed – but not in case of infection. Furthermore, damage to the intestinal mucous membrane increases the disposal of mucous cells into the intestine, thus involving nutrient leakage. In addition, some parasites cause bleeding.
+Some types of infection deserve particular attention here owing t...
+
+=== Chunk 1873 ===
+Source: 0820_002-ebook.pdf
+Length: 2449 chars
+
+Diarrhoea
+Diarrhoea is the commonest illness in children, with a prevalence peak between the end of the fi rst year and the second. This is due to the foreign pathogens found by the child in its diet during weaning, and in its environment. Diarrhoea is also a secondary disorder to many types of infection (e.g. malaria, measles, and otitis). Where poverty prevails, the environment is often highly contaminated, and climatic factors (hot and humid conditions) promote this contamination. Diarrhoea is...
+
+=== Chunk 1874 ===
+Source: 0820_002-ebook.pdf
+Length: 1399 chars
+
+Measles
+Measles is rightly considered to be one of the most frightening childhood illnesses in the tropics. Its seriousness results from the following:
+9 the illness itself puts the organism under considerable stress;
+9 it is often complicated by the infection it causes, such as diarrhoea (persistent or not), and infections of the respiratory tract;
+9 it often results in full-fl edged epidemics of critical severe malnutrition, particularly kwashiorkor;
+9 it depresses immunity for up to several mo...
+
+=== Chunk 1875 ===
+Source: 0820_002-ebook.pdf
+Length: 1857 chars
+
+Tuberculosis
+Tuberculosis is again becoming a major public health problem, affecting the entire world. Cachexia24 associated with tuberculosis is a familiar phenomenon since the disease is a cause of severe malnutrition, and impedes nutritional treatment until the chemical treatment of tuberculosis begins. Untreated adolescent tuberculosis patients in a therapeutic feeding centre on the Angolan Planalto in 1983 were observed to lose weight at the same rate as their food intake increased; only af...
+
+=== Chunk 1876 ===
+Source: 0820_002-ebook.pdf
+Length: 1775 chars
+
+Malaria
+Malaria resulting from Plasmodium falciparum has the most serious consequences on the nutritional status. However, the degree of immunity, or exposure, also contributes signifi cantly. Malaria entails the same type of metabolic reactions as any other systemic infection, particularly nitrogen loss; it induces haemolytic anaemia. It depresses immunity, thus raising the prevalence and severity of infections such as diarrhoea and respiratory disease – this has additional consequences on the n...
+
+=== Chunk 1877 ===
+Source: 0820_002-ebook.pdf
+Length: 1874 chars
+
+Intestinal parasites
+All intestinal parasites have some impact on the nutritional status; they cause growth retardation, mild to moderate wasting, anorexia, anaemia, and diarrhoea. The signifi cance of such symptoms is determined by the spread of the infestation and its duration, and is aggravated by a poor nutritional status. The commonest infection is caused by intestinal roundworm (Ascaris lumbricoides): it results in the greatest accumulation of parasites, to the point of rendering weight-bas...
+
+=== Chunk 1878 ===
+Source: 0820_002-ebook.pdf
+Length: 810 chars
+
+Acquired Immune Defi ciency Syndrome (AIDS)
+Like tuberculosis, AIDS is a cause of critical severe malnutrition: the latter always accompanies the terminal stage of the illness. It results from pronounced anorexia, the eating diffi culties caused by oral lesions, malabsorption related to diarrhoea, and the aggravating effects of associated infections. Usually, the manifestation of recurrent infection suggests the presence of AIDS. Like tuberculosis, AIDS is diffi cult to detect in the situations tha...
+
+=== Chunk 1879 ===
+Source: 0820_002-ebook.pdf
+Length: 2244 chars
+
+The interaction between malnutrition and infection
+In view of the two previous points, the relation between infection and malnutrition implies reciprocal causality; this can give rise to an interaction25 in which infection and malnutrition reinforce their mutual severity in a process that may spiral and is commonly fatal. This interaction, and the main contributing factors, is illustrated in Figure 8.5 below.
+25 The expression “malnutrition-infection complex” is commonly found in the literature....
+
+=== Chunk 1880 ===
+Source: 0820_002-ebook.pdf
+Length: 3976 chars
+
+2.4.7 The prognosis and consequences of severe malnutrition
+The prognosis of critical severe malnutrition episodes is shaped by:
+9 the possibility of treatment;
+COdL
+9 the quality of treatment;
+9 the history and causes of the episode, and the history of the period preceding it;
+9 the quality of the social environment.
+Critical severe malnutrition that is not treated specifi cally, or whose causes have not been addressed comprehensively, is usually fatal. The loss of reserves, the resulting metabo...
+
+=== Chunk 1881 ===
+Source: 0820_002-ebook.pdf
+Length: 4170 chars
+
+Figure 8.6 Possible evolutions of severe malnutrition
+CRITICAL SEVERE MALNUTRITION  DWARFISM WITHOUT OTHER AFTER-EFFECTS  NUTRITIONAL DWARFISM  AGGRAVATION  OTHER AFTER-EFFECTS  INFECTION  RECOVERY  DEATH  ABSENCE OF AFTER-EFFECTS
+The primary consequence of critical severe malnutrition may be growth retardation if the conditions for height recuperation are not met. However, as discussed in Section 2.4.5 above, nutritional dwarfi sm may be associated with a number of disabilities; the most worryin...
+
+=== Chunk 1882 ===
+Source: 0820_002-ebook.pdf
+Length: 2876 chars
+
+2.5 SPECIFIC DEFICIENCY 28
+Specifi c defi ciency relates to Type I nutrients. It manifests itself through a decrease in the reserves of a specifi c nutrient, followed by a reduction in its tissue concentration, and the appearance of clinical signs. The presence of clinical signs indicates that the defi ciency is overt and declared, and physiological damage is usually well advanced. However, sub-clinical defi ciency levels already have serious consequences, and protracted marginal defi ciency is suspec...
+
+=== Chunk 1883 ===
+Source: 0820_002-ebook.pdf
+Length: 1609 chars
+
+2.5.1 Scurvy
+Scurvy is the clinical manifestation of defi ciency in ascorbic acid, or vitamin C. Vitamin C defi ciency is mainly associated with an insuffi cient intake of fresh vegetables and fruit.
+Scurvy was common in Antiquity, but was poorly identifi ed. In the Middle Ages, scurvy was endemic in northern Europe during the winter, when fruit and vegetables all but vanished from the diet. The expression “scurvy” is of Germanic origin. Because of its terrible toll on the crews of maritime expediti...
+
+=== Chunk 1884 ===
+Source: 0820_002-ebook.pdf
+Length: 6691 chars
+
+Vulnerability
+The groups that are particularly vulnerable to scurvy are:
+9 the elderly, alcoholics, heavy smokers, social outcasts, and migrant workers, because their diet is usually poor owing to isolation and/or addiction;
+9 the inmates of institutions such as prisons, orphanages, homes for the elderly, and psychiatric and hospital facilities – the food can be monotonous, insuffi cient and defi cient, large-scale cooking promotes vitamin loss, healthcare may be insuffi cient, and the living condi...
+
+=== Chunk 1885 ===
+Source: 0820_002-ebook.pdf
+Length: 14146 chars
+
+The development of defi ciency and symptoms
+At the stage of declared scurvy, the illness is already well advanced, and death may be imminent. There are, however, intermediate stages of defi ciency that are either temporary because defi ciency is developing, or stable because the diet contains some ascorbic acid, but not enough. A diet that lacks vitamin C entirely causes depletion at a daily rate of 2.6% of existing reserves. Clinical signs appear when reserves drop below 300 mg. Basu & Dickerson d...
+
+=== Chunk 1886 ===
+Source: 0820_002-ebook.pdf
+Length: 8453 chars
+
+Treatment
+Scurvy is easily treated, especially because of the availability of synthetic ascorbic acid that can be administered orally at very high doses without danger of toxicity. The vitamin is highly soluble and easily assimilated by the digestive tract. Usually a 250 mg dose four times a day, administered orally for a week, brings vitamin C reserves back to the highest possible level. The risk of mortality is averted as of the fi rst dose; recovery is usually fast and complete. Except in the ...
+
+=== Chunk 1887 ===
+Source: 0820_002-ebook.pdf
+Length: 12295 chars
+
+Prevention
+Preventive measures consist of immediate dietary improvement; this is done through the provision of fresh fruit and vegetables and, where feasible, the promotion of local fruit and vegetable production and consumption. Horticulture should in this case be encouraged through the provision of seeds, secured access to family gardens (allotments), and the planning of orchards and vegetable cultivation areas, both in towns and in rural environments. If these foods cannot be produced or foun...
+
+=== Chunk 1888 ===
+Source: 0820_002-ebook.pdf
+Length: 1854 chars
+
+2.5.2 Beriberi
+Beriberi is the clinical manifestation of thiamine or vitamin B1 defi ciency. The name comes from the Sinhalese beri, meaning “I cannot”, in reference to the weakness resulting from neuro-motive damage. Defi ciency is usually the result of an excessive dietary dependency on overly refi ned cereals, particularly rice. The abrasion of the outer layers of the grain during processing causes signifi cant loss in various nutrients, especially thiamine.31 Beriberi was endemic for thousands o...
+
+=== Chunk 1889 ===
+Source: 0820_002-ebook.pdf
+Length: 1580 chars
+
+Infantile beriberi
+Infantile beriberi frequently affects breastfed infants between the age of 2 and 8 months; affected infants do not necessarily suffer any other disorder, and usually receive adequate amounts of maternal milk. The problem results from a thiamine defi ciency in the mother’s milk, without her necessarily showing obvious signs of defi ciency. In fact, mothers face mild defi ciency towards the end of their pregnancy. Early signs of infantile beriberi include anorexia, vomiting, pallor...
+
+=== Chunk 1890 ===
+Source: 0820_002-ebook.pdf
+Length: 407 chars
+
+Cardiac form
+Cardiac beriberi is an acute form that usually appears in babies between the age of 2 and 4 months in an abrupt attack. Symptoms appear with a piercing scream, followed by cyanosis, dyspnoea (respiratory disorder), vomiting, tachycardia (accelerated heart rate) and cardiomegaly (enlarged heart muscle). Death usually follows within a few hours after the attack if thiamine is not administered....
+
+=== Chunk 1891 ===
+Source: 0820_002-ebook.pdf
+Length: 487 chars
+
+Aphonic form
+Aphonic beriberi is a sub-acute form that appears between the age of 5 and 7 months, and is less brutal than the cardiac form. Infants produce hoarse and aphonic cries owing to paralysis of the laryngeal nerve. They cannot assimilate food, regurgitate or vomit it; they become anorexic and suffer from diarrhoea. They lose weight and become cachectic as the disorder advances. Oedema may develop; the appearance of convulsions announces imminent death due to cardiac arrest....
+
+=== Chunk 1892 ===
+Source: 0820_002-ebook.pdf
+Length: 607 chars
+
+Pseudo-meningitic form
+This is a chronic form that appears between 8 and 10 months, frequently in combination with the aphonic form. Patients suffer from vomiting, persistent constipation, nystagmus (i.e. involuntary twitching of the eye, especially in lateral sight), uncoordinated movements of the extremities and convulsions. The analysis of the cerebral spinal fl uid (CSF) is normal. Sudden death from cardiac arrest is common.
+Infantile beriberi still remains a major cause of mortality in child...
+
+=== Chunk 1893 ===
+Source: 0820_002-ebook.pdf
+Length: 1398 chars
+
+Wet beriberi and dry beriberi
+These are by far the commonest and best known forms of beriberi. In their early stages, their symptoms are similar: the onset is insidious and may be precipitated by fatigue and/or fever. Initially anorexia appears, and an ill-defi ned discomfort and heaviness of the lower limbs discourage movement. Small oedemas may appear on the legs or face, and patients sometimes complain of palpitations. They
+296
+2. Nutritional disorder
+2.5 Specifi c defi ciency
+frequently feel ti...
+
+=== Chunk 1894 ===
+Source: 0820_002-ebook.pdf
+Length: 4387 chars
+
+Wet beriberi
+Also called cardiac beriberi, wet beriberi implies progressive cardio-vascular disorder, associated with excess pyruvate and lactic acid in the bloodstream (thiamine defi ciency impedes the transformation of pyruvate into acetyl coenzyme A). The accumulation of these metabolites appears to cause the dilatation of peripheral blood vessels, resulting in vasodilatation. At this stage, fl uid is leaking from capillary vessels, resulting in the formation of oedemas. Vasodilatation also cau...
+
+=== Chunk 1895 ===
+Source: 0820_002-ebook.pdf
+Length: 1582 chars
+
+Dry beriberi
+Dry beriberi mainly involves peripheral neuropathy, combined with sometimes severe wasting. The problem here appears to be related to a lack of acetyl coenzyme A, a precursor of the nerve myelin lining, causing a loss of myelin and axon (the long nerve fi bres leading away from the cell body or the neuron) destruction. This causes a symmetrical reduction in motor functions, refl exes and sensitivity, which affects the distal segments (i.e. those directed away from the midline) of the ...
+
+=== Chunk 1896 ===
+Source: 0820_002-ebook.pdf
+Length: 2756 chars
+
+Shoshin beriberi
+This form is similar to wet beriberi, except that it causes fulminant cardiac failure (from a few hours to a few days), but usually no oedemas of the lower limbs. Shoshin is Japanese meaning acute disorder (sho) of the heart (shin). In addition to its rapid development, this form of beriberi is characterized by rapid breathing (because of acute lung oedema and metabolic lactic acidosis), agitation (due to anxiety and acidosis), cyanosis arising from intense peripheral vasoconstr...
+
+=== Chunk 1897 ===
+Source: 0820_002-ebook.pdf
+Length: 2730 chars
+
+Wernicke-Korsakoff syndrome
+In 1881, Wernicke described a form of neurological disorder that affected alcoholics mainly, and was characterized by ophthalmoplegia (i.e. weakness of the eye muscles), which affected patients looking upwards and sideways, in addition to mental confusion and apathy. Nystagmus and ataxia (unsteady and clumsy motion of the limbs or trunk) may also appear. In its most serious form, this disorder also called Wernicke’s encephalopathy, causes coma, resulting in high morta...
+
+=== Chunk 1898 ===
+Source: 0820_002-ebook.pdf
+Length: 2425 chars
+
+2.5.3 Pellagra
+Pellagra is the clinical manifestation of niacin defi ciency. The word “pellagra” comes from the Italian pelle meaning skin, and agra, rough. Pellagra is usually associated with other defi ciencies – primarily in tryptophan, an essential amino-acid, and a precursor of niacin. Tryptophan can contribute substantially to niacin intake, provided it is excessive with respect to protein requirements and the amino-acid homeostasis. Pellagra is usually related to defi ciency in ribofl avin an...
+
+=== Chunk 1899 ===
+Source: 0820_002-ebook.pdf
+Length: 696 chars
+
+Dermatosis
+The fi rst clinical sign of pellagra is dermatosis. It is photosensitive, and appears symmetrically on skin that is exposed to the sun. It is particularly visible around the collar (known as Casal collar), the shoulder blades, the forearms and wrists, the back of the hands and the shinbones. On white skin, it appears as strong sunburn; darker skin initially shows stronger pigmentation, and then dries and cracks. The affected area is rough. Dermatosis evolves towards desquamation, crevi...
+
+=== Chunk 1900 ===
+Source: 0820_002-ebook.pdf
+Length: 939 chars
+
+Dementia
+Advanced niacin defi ciency undermines the nervous system in various ways. The fi rst symptoms include irritability, anxiety, headache, apathy, insomnia, and memory loss. Muscular weakness, loss of sensitivity, and trembling are systematic. The disorder develops towards manic-depressive psychosis or, less usually, dementia. It is not uncommon for the psychic disorders arising from pellagra to be interpreted as resulting from madness, and for patients to be interned in psychiatric faciliti...
+
+=== Chunk 1901 ===
+Source: 0820_002-ebook.pdf
+Length: 1130 chars
+
+Death
+Untreated pellagra is fatal because of the generalized failure of the energy metabolism and the anabolism35 it causes.
+As mentioned earlier, pellagra dermatosis does not develop without exposure to the sun (e.g. during the rainy season, concealing clothes, etc.); atypical gastro-intestinal and digestive tract disorders thus appear fi rst. But they must still be recognized as such, in a timely fashion. In other words, a signifi cant reservoir of sub-clinical defi ciency cases (or clinical defi ...
+
+=== Chunk 1902 ===
+Source: 0820_002-ebook.pdf
+Length: 1719 chars
+
+2.5.4 Vitamin A defi ciency
+The following is adapted from McLaren and Frigg (McLaren & Frigg, 1997).
+Vitamin A defi ciency is the primary cause of blindness in pre-school children, but also affects older children. It furthermore increases the risk of mortality and morbidity in relation to infectious disease. The WHO estimate that 6 to 7 million new cases of xerophthalmia (see below) appear each year, among which one-tenth suffer from corneal lesions. Among these, approximately 60% die within the f...
+
+=== Chunk 1903 ===
+Source: 0820_002-ebook.pdf
+Length: 322 chars
+
+Xerophthalmia
+Xerophthalmia is a pathological dryness of the eye that deprives it of its epithelial protection. However, the expression includes all clinical signs and symptoms of ocular disorder caused by vitamin A defi ciency. Xerophthalmia in principle progresses according to the following stages (except the XF stage):...
+
+=== Chunk 1904 ===
+Source: 0820_002-ebook.pdf
+Length: 193 chars
+
+Night blindness (XN stage)
+Night blindness usually refers to a loss of visual acuity in the dark. It manifests itself through obvious clumsiness, and the inability to recognize familiar people....
+
+=== Chunk 1905 ===
+Source: 0820_002-ebook.pdf
+Length: 297 chars
+
+Conjunctival xerosis (X1A stage)
+Conjunctival dryness38 is the fi rst stage of the alteration of the epithelial protection of the eye. At this stage, the conjunctiva loses its brilliance and its shine, and becomes lacklustre. This dryness is not easy to detect, and is thus an unreliable indicator....
+
+=== Chunk 1906 ===
+Source: 0820_002-ebook.pdf
+Length: 266 chars
+
+Bitot’s spots (X1B stage)
+Bitot’s spots are raised triangular or oval white, foamy lesions. The disorder is bilateral, appearing fi rst on the temporal side of the cornea, and then on the nasal side. Bitot’s spots may be removed if the patient rubs his eyes strongly....
+
+=== Chunk 1907 ===
+Source: 0820_002-ebook.pdf
+Length: 1130 chars
+
+Corneal xerosis (X2 stage)
+Conjunctive dryness extends to the cornea, which becomes milky. As from this stage, ulceration through the softening of the cornea occurs within a matter of days.
+Corneal ulceration or keratomalacia involving less than one-third of the cornea (X3A stage) Corneal ulceration, or keratomalacia, occurs in two stages of severity (X3A and X3B); it results from necrosis of the cornea. If ulceration is not immediately treated, then the cornea perforates and infects, causing th...
+
+=== Chunk 1908 ===
+Source: 0820_002-ebook.pdf
+Length: 1029 chars
+
+Xerophthalmia fundus (XF)
+In the early stages of the defi ciency, examination through an ophthalmoscope may sometimes reveal white spots around the periphery of the fundus oculi (that is, the back of the eye).
+The following fi ve indicators for minimum prevalence are used in order to determine whether xerophthalmia is a public health issue.
+38 The conjunctiva is the mucous membrane that lines the inner surface of the eyelids and extends over the forepart of the eyeball.
+305
+I I I V
+I I I V
+NUTRITI...
+
+=== Chunk 1909 ===
+Source: 0820_002-ebook.pdf
+Length: 4125 chars
+
+Impact on mortality and morbidity
+The risk of mortality has been demonstrated to be signifi cantly higher in children who are objectively affected by xerophthalmia. The reason for this is probably a weakened response to concomitant infectious disease. Studies conducted after the distribution of vitamin A to pre- school children have confi rmed this observation, with mortality drops of the order of 30%. These distributions appear to have a greater effect on mortality related to measles and diarrhoe...
+
+=== Chunk 1910 ===
+Source: 0820_002-ebook.pdf
+Length: 327 chars
+
+Other effects of vitamin A defi ciency
+The other effects of vitamin A defi ciency remain hypothetical and would require confi rmation; they are, however, supported by many converging indications. Vitamin A defi ciency may contribute signifi cantly to growth retardation, a depressed immune response, and insuffi cient haematopoiesis....
+
+=== Chunk 1911 ===
+Source: 0820_002-ebook.pdf
+Length: 2765 chars
+
+2.5.5 Nutritional anaemia
+Anaemia is certainly the most widespread nutritional disorder in the world. It is a major problem,
+but one that often goes unnoticed because it does not cause spectacular symptoms, and is rarely fatal. It arises mainly from an iron defi ciency within the organism, but can also arise from dietary folic acid defi ciency (its second most important cause), or defi ciency in vitamin B12 and protein. Vitamin A, C, E, B6 (pyridoxine), and copper defi ciency also contribute to anae...
+
+=== Chunk 1912 ===
+Source: 0820_002-ebook.pdf
+Length: 1005 chars
+
+Dietary defi ciency
+In adults, the diet is rarely iron defi cient in quantitative terms, but may be in qualitative terms, because the iron contained in foods is in a form that is diffi cult to assimilate. On the other hand, premature and/or low birth weight (< 2.5 kg) infants frequently develop anaemia through dietary defi ciency because their iron status is weak, and cannot be compensated by maternal milk; in parallel, growth requirements are signifi cant (the amount of iron in the organism must dou...
+
+=== Chunk 1913 ===
+Source: 0820_002-ebook.pdf
+Length: 2722 chars
+
+Insuffi cient absorption
+Iron retention by the organism is remarkable, but its absorption is rather poor. Iron from animal sources is generally better absorbed than vegetable iron. Moreover, non-anaemic subjects only absorb approximately 10% of the iron contained in their food, whereas anaemic subjects tend to absorb the double, that is, 20%. Iron from animal sources increases the absorption of vegetable iron – in other words, even low dietary contents of animal origin result in a considerably be...
+
+=== Chunk 1914 ===
+Source: 0820_002-ebook.pdf
+Length: 889 chars
+
+2.5.6 Iodine defi ciency
+Iodine is an essential element because it is integrated into the thyroid hormones thyroxine (T4) and triiodothyronine (T3), which are indispensable to physical growth and mental development. Iodine defi ciency has long been associated with goitre and cretinism; but it has since become clear that it also induces a number of other disorders, and reference is therefore made nowadays rather to disorders arising from iodine defi ciency.
+The origin of most manifestations of iodin...
+
+=== Chunk 1915 ===
+Source: 0820_002-ebook.pdf
+Length: 701 chars
+
+PART THREE HUMANITARIAN ACTION
+The previous Chapters provided an initial approach to nutrition by developing the concepts that are most useful to humanitarian operations. This third part of the Manual discusses fi eld practice. It is worth noting that nutrition is considered here as one discipline among others in this type of action, for which an overall approach can be found in Pierre Perrin’s Handbook on War and Public Health (Perrin, 1996). Chapter IX briefl y introduces humanitarian aid by set...
+
+=== Chunk 1916 ===
+Source: 0820_002-ebook.pdf
+Length: 503 chars
+
+1.2 OBJECTIVE
+The overall objective of humanitarian assistance is twofold: preventing and alleviating human suffering. This consists in preserving or restoring the living standards of victims with a view to reducing their dependency on external assistance, and enabling them to maintain acceptable living conditions in compliance with their cultural standards. This clearly implies an additional responsibility to that of keeping people alive: providing them in some way with prospects for their futu...
+
+=== Chunk 1917 ===
+Source: 0820_002-ebook.pdf
+Length: 524 chars
+
+1.3 STRATEGY
+Humanitarian operations must rest upon a strategy that combines and coordinates all available means. This strategy obeys the following principles.
+1 The latter arise from the victims’ own perception of their needs: this perception is frequently correct, but may be biased by ignorance of what humanitarian agencies can and should do, and by the natural inclination to secure as many resources as possible.
+319
+X I
+X I
+NUTRITION MANUAL Chapter IX – An approach to humanitarian action
+1. I...
+
+=== Chunk 1918 ===
+Source: 0820_002-ebook.pdf
+Length: 3932 chars
+
+1.3.1 Defi ning a balance between the different components of action
+The need for assistance usually arises from neglect or deliberate action, and humanitarian action must therefore combine dialogue and assistance itself. Dialogue aims to put an end to neglect, abuse, and the violation of fundamental rights; it addresses relevant authorities and stakeholders in order to encourage behaviour complying with the rights and principles that provide its basis. Assistance on the other hand expresses itse...
+
+=== Chunk 1919 ===
+Source: 0820_002-ebook.pdf
+Length: 1498 chars
+
+1.3.2 Defi ning priorities for action
+Up until the late 1970s, human lives had to be at immediate risk for humanitarian operations to be launched, and this condition itself shaped the concept of emergency. Food distributions were initiated only when severe malnutrition rates were on the rise or achieved endemic proportions; this frequently resulted in serious mistakes and real disaster.
+It was later recognized on the one hand that responding to a deteriorated health status alone is a late reactio...
+
+=== Chunk 1920 ===
+Source: 0820_002-ebook.pdf
+Length: 1696 chars
+
+1.3.3 Preventive action
+The health pyramid suggests that steps must be taken early to avoid creating demand that overwhelms health services at an already advanced stage of the crisis; it also expresses one of the principles of humanitarian ethics, that is, the need to prevent suffering and not confi ne action to its alleviation. This introduces the concept that prevention is also incumbent upon humanitarian action. Chapter VII discussed the cause and effect relations that shape crisis processes; ...
+
+=== Chunk 1921 ===
+Source: 0820_002-ebook.pdf
+Length: 830 chars
+
+1.3.4 Ensuring multidisciplinary action
+The health pyramid sets operational priorities according to a strategy that enables timely and effi cient action in terms of the danger of morbidity and mortality. This rests upon a multidisciplinary approach that deploys specifi c skills in the fi elds of nutrition, water supply, water and environmental hygiene, habitat, and preventive and curative medicine. This in turn requires a strong compatibility among the members of the agency under scrutiny, but also...
+
+=== Chunk 1922 ===
+Source: 0820_002-ebook.pdf
+Length: 536 chars
+
+1.3.5 Operational tactics
+Strategy rests upon general principles that apply to any type of action. Actual operations must then adapt to specifi c contextual parameters. This practical approach to action is referred to as operational tactics, which are subjected to the overall strategy. They aim at optimizing the use of all available means in order to respond to a specifi c situation. As such, humanitarian action amounts to an adapted response that applies strategic principles to achieve the object...
+
+=== Chunk 1923 ===
+Source: 0820_002-ebook.pdf
+Length: 3361 chars
+
+1.4 HUMANITARIAN ACTION AND EMERGENCY
+Humanitarian aid is often simply referred to as emergency aid, for two main reasons. Firstly, humanitarian aid has long been viewed as a last resort, dictated by the “emergency” of saving lives. Secondly, the expression contrasts humanitarian aid (i.e. emergency aid) and development aid,
+6 See also Chapter VIII regarding the prevention of famine.
+7 See Chapter X.
+322
+1. Introduction
+1.4 Humanitarian action and emergency
+with occasional reference to a continu...
+
+=== Chunk 1924 ===
+Source: 0820_002-ebook.pdf
+Length: 557 chars
+
+1.4.1 Time
+Humanitarian operations must sometimes be quick and comply with exceptional measures, because the situation is exceptional, mainly because the response is belated. But it may also spread over time and allow for the type of crisis – ranging from prevention to rehabilitation – or compensate for the absence or inadequacy of local services. Humanitarian action must, therefore not be limited arbitrarily. It should instead begin at the emergence of a threat, and persist until it has been av...
+
+=== Chunk 1925 ===
+Source: 0820_002-ebook.pdf
+Length: 582 chars
+
+1.4.2 Target
+In crisis, individuals whose life is endangered are usually not a distinct group within their society or culture. They are simply the most vulnerable, and herald the fate of their companions if crisis cannot be averted. The principle of prevention being accepted and encouraged, action must focus on those whose life is already endangered, but extend to those who face the same threat ultimately. This aspect is now understood and accepted by most humanitarian agencies, even if some (ow...
+
+=== Chunk 1926 ===
+Source: 0820_002-ebook.pdf
+Length: 393 chars
+
+1.4.3 Type of action
+The view that humanitarian aid is confi ned to specifi c operations such as food assistance or healthcare is now obsolete. Accordingly, Perrin’s essay adopts a global and multidisciplinary approach: humanitarian and development aid are both linked to social problems, and must ensure that society can live adequately in compliance with its cultural standards (Perrin, 1996)....
+
+=== Chunk 1927 ===
+Source: 0820_002-ebook.pdf
+Length: 713 chars
+
+1.4.4 Cost
+Free donations are less common today; concepts such as cost recovery and compensation funds – or micro-credit – are steadily gaining ground, not to mention “food-for-work” projects that are questionable in many circumstances. In fact, when services default (and not the population’s resources), free donations are probably not the most appropriate. The challenge lies in setting contribution levels that do not exclude the poorest: this may be achieved through differentiated tariffs, or t...
+
+=== Chunk 1928 ===
+Source: 0820_002-ebook.pdf
+Length: 1296 chars
+
+1.4.5 Interaction with local authorities
+Unless humanitarian action combines with military intervention (on the basis of the right to interfere as defi ned by Jean-François Revel, 1979), it has little chance of imposing views on local or national authorities. However, combining efforts with the military is rarely an option in humanitarian action because of the principle of independence. Humanitarian action must therefore convince authorities of the need for their action, especially when neutralit...
+
+=== Chunk 1929 ===
+Source: 0820_002-ebook.pdf
+Length: 1357 chars
+
+1.4.6 Interaction with local organizations
+Humanitarian action is rather imperialistic and, frequently, unacceptably arrogant towards the societies it intends to assist. The same attitude is noted towards local organizations whose resources are limited and sometimes, like some local authorities, attempt to divert assistance for their own profi t. Here again, emergency and political constraints are frequently invoked (rightly or wrongly) to avoid cooperating with such associations. Pragmatism is h...
+
+=== Chunk 1930 ===
+Source: 0820_002-ebook.pdf
+Length: 1857 chars
+
+1.4.7 The concept of emergency
+The expression “emergency” as it is commonly understood should be questioned because it confuses the issue and is counter-productive. When opposing relief and development in terms of a continuum9 where the starting point is emergency relief and the fi nishing point is development, via rehabilitation, the implicit admission is that each expression refers to a type of intervention. In fact, from a semantic perspective, the words development and rehabilitation are comp...
+
+=== Chunk 1931 ===
+Source: 0820_002-ebook.pdf
+Length: 2893 chars
+
+1.5 HUMANITARIAN ACTION IN THE FIELD OF NUTRITION
+In nutrition, humanitarian action is justifi ed to prevent or mitigate crisis, defi ned as a situation in which the performance of the feeding process is insuffi cient, and its victims cannot cope independently. The concept of preserving or restoring living conditions has horizontal implications
+9 A continuum is defi ned as a linear evolution following precise steps towards a clear outcome; in this case, the transition from emergency relief through r...
+
+=== Chunk 1932 ===
+Source: 0820_002-ebook.pdf
+Length: 593 chars
+
+1.5.1 The securing of food
+This is the determining stage of the feeding process, the one that requires most effort and means, and whose infl uence on living conditions and social integration is the greatest. Its success is determined by the household’s overall economic performance, which is in turn shaped by the means of production and their yield. In other words, households must be economically self-suffi cient for their securing of food to be adequate. This leads to the following defi nition of t...
+
+=== Chunk 1933 ===
+Source: 0820_002-ebook.pdf
+Length: 1745 chars
+
+The preservation or restoration of economic self-suffi ciency at household level, in an economic security perspective, through palliative measures that persist until self-suffi ciency is guaranteed.
+Action must therefore revolve around the household economy – mainly the means of production intended to meet the basic economic needs, as determined by physiology, environment, and culture. The adequacy of the means of production in meeting such needs (that is, ensuring a suffi cient economic performanc...
+
+=== Chunk 1934 ===
+Source: 0820_002-ebook.pdf
+Length: 4873 chars
+
+1.5.2 The consumption of food
+If access to basic economic goods and services for households is ensured by survival relief and activities in the fi elds of protection, support, substitution or the rehabilitation of production means, then the food that corresponds to eating habits and the means required for its preparation are, in principle, ensured (vertical preventive dimension, see Figure 9.2). Consequently, action should concern itself with the parameters that determine consumption directly, as...
+
+=== Chunk 1935 ===
+Source: 0820_002-ebook.pdf
+Length: 1082 chars
+
+1.5.3 The biological utilization of food
+Food consumption occurs in a rather private sphere, shaped by cultural determinism. It can only be promoted through indirect operations such as the delivery of food and material assistance earlier in the process, and water and sanitation operations in order to preserve or restore health. The biological utilization of food takes place within the organism, and is shaped by biological determinism – further complicating its direct resolution. Problems that oc...
+
+=== Chunk 1936 ===
+Source: 0820_002-ebook.pdf
+Length: 759 chars
+
+THE COMPONENTS OF ACTION
+Humanitarian action in the fi eld of nutrition may be divided into the following:
+9 action modes that are determined by the timing of the action with respect to the crisis,
+9 programmes that are determined by the operational strategy.
+The model chosen to illustrate humanitarian action modes is the famine process, which also refers to the crisis process (see Figure 9.3 below).
+Figure 9.3 Humanitarian action modes in the crisis process
+CRISIS PROCESS  PRELIMINARY PHASE   AC...
+
+=== Chunk 1937 ===
+Source: 0820_002-ebook.pdf
+Length: 164 chars
+
+2.1 HUMANITARIAN ACTION MODES
+Figure 9.3 above shows the possible humanitarian modes of action in the fi eld of nutrition. Their specifi c content is discussed below....
+
+=== Chunk 1938 ===
+Source: 0820_002-ebook.pdf
+Length: 1141 chars
+
+2.1.1 Protection measures
+Such measures consist in motivating authorities to enforce respect for fundamental rights, thus protecting the conditions necessary for economic self-suffi ciency against abuse or, failing that, enabling the timely adoption of appropriate assistance measures. Protection measures are clearly essential in times of armed confl ict; but they are also necessary in the modern economic environment, in the face of developments such as global economy, structural adjustment program...
+
+=== Chunk 1939 ===
+Source: 0820_002-ebook.pdf
+Length: 537 chars
+
+2.1.2 Economic support
+This mode of action consists in providing a given group with the means to avoid disaster, and to enable it to wait for the crisis to abate. Examples include the distribution of food in order to preserve the resource base and the production capacity, support to the diversifi cation and intensifi cation of production, the provision of employment opportunities, support or strengthening of the local services required for production, and the provision of such services (e.g. veter...
+
+=== Chunk 1940 ===
+Source: 0820_002-ebook.pdf
+Length: 563 chars
+
+2.1.3 Survival relief
+This mode amounts to what is usually referred to as emergency relief; it provides a given group with the goods and services that are essential to its survival when its own production can no longer ensure it independently. As mentioned earlier (see Section 1.4.), the expression “survival” is preferred here to “emergency”. Survival relief includes general food distributions (GFD), non-food distributions, therapeutic feeding, water and sanitation projects, the provision of hea...
+
+=== Chunk 1941 ===
+Source: 0820_002-ebook.pdf
+Length: 473 chars
+
+2.1.4 Economic rehabilitation
+This mode consists in restoring the means of production to the point of ensuring economic self- suffi ciency at household level. Economic rehabilitation clearly only makes sense if the circumstances permit durable rehabilitation, that is, usually during the recovery phase following crisis. Economic rehabilitation should nevertheless be considered earlier also, in order to ensure a timely and comprehensive approach when circumstances permit....
+
+=== Chunk 1942 ===
+Source: 0820_002-ebook.pdf
+Length: 2931 chars
+
+2.1.5 Development
+Development seldom devolves on humanitarian agencies, at least in the sense of mitigating vulnerability to possible crisis. Those who analyse vulnerability must nevertheless inform relevant development agencies in order for the latter to devote the necessary attention to groups that have been affected by crisis. They must also see to it that rehabilitation programmes are followed by development initiatives that consolidate economic security.
+The action modes discussed above occ...
+
+=== Chunk 1943 ===
+Source: 0820_002-ebook.pdf
+Length: 224 chars
+
+2.2 HUMANITARIAN PROGRAMMES IN THE FIELD OF NUTRITION
+Humanitarian action must be multidisciplinary, and its implementation requires specifi c skills: some programmes pertain to nutrition directly, and others complement them....
+
+=== Chunk 1944 ===
+Source: 0820_002-ebook.pdf
+Length: 1161 chars
+
+2.2.1 Nutrition programmes
+Such programmes are traditionally the following:
+9 general food distributions (Chapter XII);
+COdd
+9 therapeutic feeding (Chapter XIII);
+9 supplementary feeding programmes (Chapter XIV);
+9 nutritional and sanitary sensitization/information (Chapter XV).
+However, operational implementation and monitoring require the conduct of assessments. Such assessments do not constitute operational programmes as such, but their contribution is nevertheless essential, and they are dis...
+
+=== Chunk 1945 ===
+Source: 0820_002-ebook.pdf
+Length: 249 chars
+
+2.2.2 Complementary programmes
+“Complementary” does not imply “of less importance” or “unjustifi ed on its own”; in fact, complementary programmes usually contribute signifi cantly to the overall impact of operations on the feeding process and health....
+
+=== Chunk 1946 ===
+Source: 0820_002-ebook.pdf
+Length: 671 chars
+
+Water and habitat
+Water and habitat programmes aim especially at:
+9 ensuring suffi cient access to safe water;
+9 eliminating waste and taking relevant hygiene measures (the construction and rehabilitation
+of latrines and wastewater treatment systems, and waste collection and disposal);
+9 building or renovating essential structures such as hospitals, camps for the displaced or
+refugees, and providing material assistance for housing (building and heating material, and fuel);
+9 protecting the enviro...
+
+=== Chunk 1947 ===
+Source: 0820_002-ebook.pdf
+Length: 502 chars
+
+Health services
+Healthcare programmes aim at providing access to curative and preventive care in compliance with universal quality standards. Healthcare services divide into:
+9 community healthcare for public and primary healthcare programmes;
+9 hospital support, which consists in setting up hospital facilities, and assisting existing ones through the provision of the required materials and personnel;
+9 the rehabilitation of the disabled (amputees, paralytics, and the psychologically traumatized...
+
+=== Chunk 1948 ===
+Source: 0820_002-ebook.pdf
+Length: 574 chars
+
+Non-food relief
+Non-food relief consists in distributing economic commodities (essential household items) that are indispensable to the survival of households, such as clothing, blankets, tarpaulins, mosquito netting, kitchen utensils, candles, toiletries and fuel. Such commodities contribute to survival relief and economic support, and represent a necessary complement to general food distributions, in order to avoid the sale of the latter in order to secure other essential goods. They may also ...
+
+=== Chunk 1949 ===
+Source: 0820_002-ebook.pdf
+Length: 2515 chars
+
+Economic rehabilitation
+Economic rehabilitation consists in restoring production means (that is, livelihoods) and their capacity to ensure the economic self-suffi ciency of households. Humanitarian action must include it in some form to reduce the dependency of victims on external aid, and enable them to preserve their living standards in compliance with their culture. It provides a logical continuation to survival relief programmes. Economic rehabilitation usually involves the provision of the i...
+
+=== Chunk 1950 ===
+Source: 0820_002-ebook.pdf
+Length: 1920 chars
+
+Development
+Development understood broadly departs from rehabilitation mainly because it seeks to generate improved and more secure living conditions by addressing vulnerability factors. Rehabilitation on the other hand is restricted to restoring economic independence, but the factors of vulnerability may remain unchanged in the process. Development that attempts to mitigate vulnerability addresses the three parameters of the crisis process, and aims to:
+9 predict and prevent phenomena;
+9 reduce...
+
+=== Chunk 1951 ===
+Source: 0820_002-ebook.pdf
+Length: 3293 chars
+
+HUMANITARIAN ETHICS
+Humanitarian ethics amount to a code of conduct for action. The philosophical bedrock of humanitarian ethics is expressed in the three fi rst principles of the International Movement of the Red Cross and Red Crescent (Fundamental Principles, 1993):
+“Humanity The Movement, born of a desire to bring assistance without discrimination to the wounded on the battlefi eld, endeavours – in its international and national capacity – to prevent and alleviate human suffering wherever it ma...
+
+=== Chunk 1952 ===
+Source: 0820_002-ebook.pdf
+Length: 154 chars
+
+3.1 THE ETHICS OF OPERATIONAL PRACTICE
+The ethics of operational practice rest mainly on the professionalism of fi eld staff and the respect of procedures....
+
+=== Chunk 1953 ===
+Source: 0820_002-ebook.pdf
+Length: 763 chars
+
+3.1.1 Professionalism
+The professionalism expected of humanitarian staff comprises training and experience in the fi rst place. In addition, considerable tact and sensitivity are essential for these two aspects to be fully exploited in the fi eld. Sensitivity is a quality that combines courtesy and respect for local customs. In humanitarian operations, the concept reaches further: it is an instrument fundamental to establishing dialogue and securing acceptance, understanding problems and, ultimate...
+
+=== Chunk 1954 ===
+Source: 0820_002-ebook.pdf
+Length: 3560 chars
+
+3.1.2 Deontology
+Frequent reference is made in humanitarian affairs to the concept of “good practice”, which is understood broadly as compliance with a set of policies and practices that are required to ensure the promotion and protection of the rights of victims. This Manual prefers the expression “deontology”, which takes the concept further to include not only proper standards of behaviour, but also the principles that provide their basis.
+It should be obvious for humanitarian action to respe...
+
+=== Chunk 1955 ===
+Source: 0820_002-ebook.pdf
+Length: 6746 chars
+
+3.2 ETHICS CONCERNING VICTIMS
+An ethical approach to victims consists mainly in preventing and alleviating suffering. Then local customs must be observed when defi ning the needs and the required assistance. Ethics also require that victims be treated as privileged working partners: participatory practices invite the direct involvement of recipients, and this is the only way of securing their active support. The ethics underlying participatory approaches are those of a real desire to understand d...
+
+=== Chunk 1956 ===
+Source: 0820_002-ebook.pdf
+Length: 390 chars
+
+3.3 ETHICS CONCERNING THE UNAFFECTED POPULATION, LOCAL SERVICES AND ORGANIZATIONS, AND LOCAL AND NATIONAL AUTHORITIES
+The purpose of this section is to raise awareness as to the existence of these entities, to encourage respect for and recognition of them, to draw attention to the fact that they may require assistance themselves, and to invite their involvement without risking diversion....
+
+=== Chunk 1957 ===
+Source: 0820_002-ebook.pdf
+Length: 841 chars
+
+3.3.1 Unaffected population
+The unaffected population frequently accommodates displaced persons (hence the expression “host community”), and the resulting cost may be such as to cause a need for assistance. In such cases, the motivation to assist the host community should clearly be humanitarian ethics and also common sense. Humanitarian agencies that do so thus apply the principle of reciprocity, and preserve the social peace that discrimination would certainly jeopardize. Moreover, if victims ...
+
+=== Chunk 1958 ===
+Source: 0820_002-ebook.pdf
+Length: 2699 chars
+
+3.3.2 Local services and organizations
+In times of humanitarian crisis, local institutions lack the means to satisfy the needs for assistance adequately. This leads to the question as to how other actors should stand in for them, to what extent, and what role they should be given. There is no simple answer to this question. Some local services and organizations are effective and provide reliable partners, while others are closer to petty crime and do not shy away from physical threats to achieve...
+
+=== Chunk 1959 ===
+Source: 0820_002-ebook.pdf
+Length: 3310 chars
+
+3.3.3 Authorities
+Transparency is a must in dealing with host authorities, as is the observance of local and national rules and standards. The latter include regulations that apply to road traffi c, importation practices, and the treatment of contagious disease. Clearly, local traffi c regulations do not warrant further discussion here; but humanitarians may be confronted with health standards that are inappropriate in view of the circumstances of a given crisis. The issue is not to follow regulat...
+
+=== Chunk 1960 ===
+Source: 0820_002-ebook.pdf
+Length: 1421 chars
+
+3.4 ETHICS CONCERNING DONORS
+Ethical behaviour towards donors consists fi rstly in supplying them with the complete information that justifi es action, usually on the basis of preliminary assessments. It then involves operational implementation in compliance with operational ethics as discussed earlier,19 and providing them with the demonstration that the funds they have released have been spent according to the agreed budget plan. Ethics also involves fi rmness in terms of operational principles a...
+
+=== Chunk 1961 ===
+Source: 0820_002-ebook.pdf
+Length: 3462 chars
+
+3.5 ETHICS CONCERNING OTHER HUMANITARIAN AGENCIES
+Humanitarian action has become more professional over the last twenty years or so. Humanitarian agencies have also grown in size and resources. Their agenda may vary according to their mandate, their degree of development, the specifi city of their operations, their relationships with States, and their fi nancial capacity. Prime time media coverage facilitates the securing of the funds that are required to exist, and the “scramble for humanity” is ...
+
+=== Chunk 1962 ===
+Source: 0820_002-ebook.pdf
+Length: 24737 chars
+
+DEFINITIONS AND GENERAL CONSIDERATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348
+Introduction, objectives, and stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350 The objectives of preliminary appraisal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351 General objective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...
+
+=== Chunk 1963 ===
+Source: 0820_002-ebook.pdf
+Length: 6275 chars
+
+1. DEFINITIONS AND GENERAL CONSIDERATIONS
+Assessment consists in the methodical gathering and compilation of information, and concludes with its analysis.
+The counterpart of this defi nition is that assessment teams must have an objective when conducting their work, and at least a theoretical understanding of the fi eld of investigation; they will otherwise be unable to collect the appropriate data in a proper manner, or to interpret it.
+Assessment rests upon a process that aims to establish and u...
+
+=== Chunk 1964 ===
+Source: 0820_002-ebook.pdf
+Length: 1101 chars
+
+THE DIFFERENT TYPES OF ASSESSMENT
+Humanitarian action comprises six types of assessment, which are discussed below.
+1. Preliminary appraisal.
+2. Thorough investigation, which must necessarily follow preliminary appraisal.
+3. Monitoring.
+4. Evaluation.
+1 Plans are understood as a series of steps to be carried out or goals to be achieved according to a pre-set calendar.
+2 See Chapter VII.
+349
+X
+X
+NUTRITION MANUAL Chapter X – Assessment and planning I. Assessment
+2. The different types of assessmen...
+
+=== Chunk 1965 ===
+Source: 0820_002-ebook.pdf
+Length: 3147 chars
+
+2.1.1 Introduction, objectives, and stages
+Preliminary appraisal deserves the most attention here, because it provides the basis for the other types of assessment. It considers a new situation that has attracted attention following a signal of the requirement for assistance, be it observed or anticipated. Its underlying principle is always the same: to determine whether the requirement for assistance is immediate or anticipated. Such requirements arise from an imbalance between the needs that mu...
+
+=== Chunk 1966 ===
+Source: 0820_002-ebook.pdf
+Length: 6579 chars
+
+Specifi c objectives
+1. According to the signals that prompt the preliminary appraisal, to defi ne the existing or anticipated harm caused by the combination of phenomena and vulnerability, and whether the performances of the feeding process are abnormally insuffi cient, or likely to become so.
+2. In the presence of existing or anticipated harm, to defi ne whether it poses a problem and, if so, of what type; this amounts to determining the presence (or anticipated presence) of an abnormal imbalance ...
+
+=== Chunk 1967 ===
+Source: 0820_002-ebook.pdf
+Length: 214 chars
+
+2.1.2 The methodology of preliminary appraisal
+The implementation of a preliminary appraisal follows the seven stages illustrated in Figure 10.2 above, in which each stage has its own justifi cation and methodology....
+
+=== Chunk 1968 ===
+Source: 0820_002-ebook.pdf
+Length: 773 chars
+
+Situation analysis
+Situation analysis consists in conducting a more or less formal pilot assessment, with a twofold objective.
+1. To approach the natural and human environment that provides the setting for assessment; this is achieved thanks to baseline data and a fi rst contact with the fi eld. During this approach, landmarks and benchmarks are located for the future collection of information. This raises the credibility of investigators in the eyes of stakeholders, and is usually appreciated. Ad...
+
+=== Chunk 1969 ===
+Source: 0820_002-ebook.pdf
+Length: 541 chars
+
+Defi ning and testing hypotheses (assessment strategy)
+Hypotheses must be defi ned in order to decide what is sought, where, and how. This defi nition is determined by fi ndings resulting from the preliminary appraisal, and by the scrutiny of the actual warning signal. Two scenarios can arise, and they may combine:
+352
+2. The different types of assessment
+2.1 Preliminary appraisal
+9 the signal amounts to phenomena that are assumed to infl uence the feeding process of a given
+population;
+9 the signal ...
+
+=== Chunk 1970 ===
+Source: 0820_002-ebook.pdf
+Length: 2347 chars
+
+Verifying the possible impact of phenomena
+The underlying hypothesis that phenomena infl uence the feeding process (or may do so) is tested by:
+9 identifying the region where the phenomena occur or have occurred;
+CO
+9 identifying the affected population;
+9 attempting to determine which groups may present vulnerabilities according to existing risk factors;
+9 verifying the existence of such vulnerabilities;
+9 attempting to determine whether such vulnerabilities have given rise to such phenomena in ...
+
+=== Chunk 1971 ===
+Source: 0820_002-ebook.pdf
+Length: 4600 chars
+
+Verifying the existence of harm
+The location and the population that is assumed to suffer the harm indicated by the warning signal are identifi ed; the underlying hypothesis that such harm does indeed exist is then tested. If the harm exists, its causes must be investigated, that is, what phenomena have combined with what vulnerabilities to produce such harm, and the assessment process continues according to the stages described above. If harm does not exist, then the origin of the warning signal...
+
+=== Chunk 1972 ===
+Source: 0820_002-ebook.pdf
+Length: 1183 chars
+
+Identifying existing or anticipated problems
+Following hypothesis testing, existing and anticipated problems must be detected; this consists in demonstrating that the population’s response to harm is or will be insuffi cient and/or dangerous.
+9 In order to demonstrate insuffi ciency, the qualitative and quantitative gap between the available/produced means and the needs must be measured. The more insuffi cient the means are, the more the response to harm will be insuffi cient, and the more serious t...
+
+=== Chunk 1973 ===
+Source: 0820_002-ebook.pdf
+Length: 183 chars
+
+The securing of food
+Problems arise from a reduction in production activities and/or in production options, an absolute or relative drop in yield, and restricted options for exchange....
+
+=== Chunk 1974 ===
+Source: 0820_002-ebook.pdf
+Length: 2602 chars
+
+The gap between means and needs
+The gap between means and needs is not always obvious, unless the famine stage has been reached, marked by a clear deterioration of the nutritional status of the population (this case provides an indirect, but reliable, indication that the gap is signifi cant and has existed for some time). Otherwise, a balance study must compare the unavoidable expenses, the resources produced, and their yield6 which is meant to cover these unavoidable expenses. The proportion of ...
+
+=== Chunk 1975 ===
+Source: 0820_002-ebook.pdf
+Length: 9700 chars
+
+The behavioural gap7
+The behavioural gap amounts to the manner of obtaining and utilizing economic resources at the time of assessment, in comparison with the manner of doing so in normal circumstances (i.e. neither exceptionally good, nor exceptionally bad), as defi ned by local criteria. However, the existence of such a gap alone is not enough; it remains to be seen whether the gap reveals a problem, and whether the latter may worsen over time. Ultimately, the idea is to determine what level of...
+
+=== Chunk 1976 ===
+Source: 0820_002-ebook.pdf
+Length: 85 chars
+
+The consumption of food
+Problems arise from insuffi cient and/or abnormal consumption....
+
+=== Chunk 1977 ===
+Source: 0820_002-ebook.pdf
+Length: 912 chars
+
+The behavioural gap
+The behavioural gap may manifest itself in the following:
+9 the quality and quantity of food consumed at the moment of assessment, in comparison with normality;
+9 the time devoted to the preparation of food;
+COdd
+9 the distribution and attribution of food;
+9 the time devoted to caring for and feeding dependants;
+9 the health status, which infl uences the consumption of food.
+For example, the consumption of cereals that would normally be kept as seeds is not an abnormal consump...
+
+=== Chunk 1978 ===
+Source: 0820_002-ebook.pdf
+Length: 1057 chars
+
+The biological utilization of food
+Problems arise here from an insuffi cient food intake and poor health. Gaps may not be measured directly, because this phase takes place within the organism; however, gaps may be estimated by appraising the nutritional status and the health status, because the standard is defi ned as an absence of debilitating disorder and an acceptable nutritional status.9
+To conclude the identifi cation of problems, it is worth noting that a given phenomenon may have no impact o...
+
+=== Chunk 1979 ===
+Source: 0820_002-ebook.pdf
+Length: 3028 chars
+
+Identifying the causes of problems
+Identifying and demonstrating the causes of problems that may result in crisis amounts to clarifying the interaction of phenomena, vulnerabilities, and impacts. This is necessary in order to defi ne the need for assistance, in both time and content. For example, a drought may threaten to cause famine in a given subsistence agriculture area; this threat is likely to disappear during the following rainy season if the latter is normal. As a result, action should pe...
+
+=== Chunk 1980 ===
+Source: 0820_002-ebook.pdf
+Length: 553 chars
+
+Predicting developments
+Predicting the evolution of a given situation is just as important as identifying the causes of the problem in order to defi ne the need for assistance and to plan operations. Indeed, planning is often determined by this, since the nature of its causes can signifi cantly infl uence the duration of the crisis. Predicting the evolution of the situation also enables the setting of a timeframe for the operation, and enables the anticipation of the evolution of the need for assis...
+
+=== Chunk 1981 ===
+Source: 0820_002-ebook.pdf
+Length: 798 chars
+
+Defi ning the need for assistance, constraints, and opportunities
+The need for assistance is usually simple to defi ne, as it amounts to the gap between available resources and needs, assistance being aimed at bridging this gap. In other words, a performance of the feeding process that cannot be ensured by the usual means and cannot be compensated by coping and survival mechanisms must be balanced through assistance, up to the level of what the population can do for itself without running further ...
+
+=== Chunk 1982 ===
+Source: 0820_002-ebook.pdf
+Length: 131 chars
+
+9 Political:
+q insecurity;
+q inappropriate operation as viewed from a military or political perspective;
+q administrative problems....
+
+=== Chunk 1983 ===
+Source: 0820_002-ebook.pdf
+Length: 123 chars
+
+9 Logistical:
+q inadequate means of transport;
+q inadequate communication means and infrastructure;
+q storage diffi culties....
+
+=== Chunk 1984 ===
+Source: 0820_002-ebook.pdf
+Length: 128 chars
+
+9 Negative side effects:
+q negative impact on the surrounding economy;
+q attraction (or “magnet effect”);
+q exacerbated tension....
+
+=== Chunk 1985 ===
+Source: 0820_002-ebook.pdf
+Length: 599 chars
+
+9 Means:
+q lack of fi nancial and human resources.
+Opportunities include all locally available resources that could contribute to the operation, such as local organizations, competencies, infrastructure, and goods and services. They must be resorted to carefully: will they continue to function beyond the crisis proper?
+The combination of needs for assistance, constraints, and opportunities permits the translation of what should be done into what can be done.
+361
+X
+X
+NUTRITION MANUAL Chapter X – A...
+
+=== Chunk 1986 ===
+Source: 0820_002-ebook.pdf
+Length: 3496 chars
+
+Data to be collected during preliminary appraisal
+The data that should be collected in order to shed light on a given situation and, where appropriate, decide upon an appropriate form of assistance are as follows.
+1. The geographic location of the affected area.
+2. The identifi cation of the groups that react differently to the development of the crisis – differences are determined by exposure and vulnerability to the phenomenon, and by existing harm.
+Then, the following must be determined for ea...
+
+=== Chunk 1987 ===
+Source: 0820_002-ebook.pdf
+Length: 1140 chars
+
+2.1.3 The process of preliminary appraisal
+In practice, assessment takes place according to a process that runs from the collection of information and the defi nition of its stages, to the analysis of the resulting data and the need for assistance, which imply the need for action. The assessment process consists of:
+9 the review of existing information (i.e. secondary data review), which enables the establishment of baseline data before the inception of fi eldwork;
+9 interviews with key informants...
+
+=== Chunk 1988 ===
+Source: 0820_002-ebook.pdf
+Length: 853 chars
+
+ASSESSMENT TOOLS
+BASELINE DATA PRIOR TO FIELDWORK
+REVIEW OF
+EXISTING DATA
+LIBRARIES, INTERNET, MEDIA, RESEARCH INSTITUTES, GOVERNMENTAL RESOURCES
+PRELIMINARY IDENTIFICATION OF THE SITUATION
+INTERVIEWS WITH KEY INFORMANTS
+AND FIELD OVERVIEW
+THOUGHT MODELS AND INTERVIEW TECHNIQUES
+SYSTEMATIC AND COMPREHENSIVE DOCUMENTATION OF THE SITUATION
+THOROUGH FIELD
+INVESTIGATION
+INVESTIGATION
+INVESTIGATION STRATEGIES, EPIDEMIOLOGICAL AND SAMPLING TECHNIQUES, RAPID APPRAISAL AND MEASUREMENT TECHNIQUES
+INFORMA...
+
+=== Chunk 1989 ===
+Source: 0820_002-ebook.pdf
+Length: 1964 chars
+
+2.2 THOROUGH INVESTIGATION
+Preliminary appraisal adopts optimal ignorance10 to save time, and this usually does not promote a thorough understanding of the social fabric. Moreover, according to the severity of the crisis and its evolution, victims eventually behave atypically and the interpretation of behaviour as a refl ection of cultural determinism grows increasingly diffi cult, even dangerous. Therefore, the objectives of preliminary appraisal must be achieved fi rst, without delving into super...
+
+=== Chunk 1990 ===
+Source: 0820_002-ebook.pdf
+Length: 363 chars
+
+The objectives of thorough investigation
+General objective
+The general objective is to adjust action to local reality. This approach allows appropriate corrective measures to be taken early, thanks to an adequate understanding of the situation, the culture, the economy, the stakeholders, the issues, and the prospects as perceived by the stakeholders themselves....
+
+=== Chunk 1991 ===
+Source: 0820_002-ebook.pdf
+Length: 889 chars
+
+2.3 MONITORING
+Monitoring is a continuous, or at least a regular, process; it seeks to detect changes in the nutritional situation of a given population, and to supervise the practical implementation of the operation if relevant. In terms of nutritional monitoring, assessment rests upon pre-defi ned indicators, and takes place according to a plan that allows for events that may affect the different stages of the feeding process. It includes balance studies at regular intervals (or compliant with ...
+
+=== Chunk 1992 ===
+Source: 0820_002-ebook.pdf
+Length: 343 chars
+
+The objectives of monitoring
+General objective
+The general objective is to lead to relevant operational decisions. This is achieved by securing continuous and regular information on the nutritional condition of a given population or individuals, on the factors that infl uence it, and on any others that may affect the conduct of the operation....
+
+=== Chunk 1993 ===
+Source: 0820_002-ebook.pdf
+Length: 858 chars
+
+2.4 EVALUATION
+Evaluation serves to determine whether operational objectives have been achieved. If evaluation only takes place at the end of the operation, it can merely draw lessons from the past. This is only useful if the agency has the means to integrate fi ndings into future action. Evaluation is more relevant if it is continuous or regular (like monitoring), in order to adjust current programmes in a timely fashion. This means that, like monitoring, programme appraisal must be planned ahea...
+
+=== Chunk 1994 ===
+Source: 0820_002-ebook.pdf
+Length: 615 chars
+
+INTERMEDIARY ASSESSMENT
+Intermediary assessment is justifi ed whenever events occur that may infl uence the needs for assistance, by changing the condition of the benefi ciaries of a given operation, or by aggravating the circumstances of the previously unaffected, but monitored, population. The magnitude of the event distinguishes this type of assessment from monitoring because it changes the situation signifi cantly. The principle of intermediary assessment is identical to preliminary appraisal, b...
+
+=== Chunk 1995 ===
+Source: 0820_002-ebook.pdf
+Length: 872 chars
+
+2.6 PILOT STUDY
+Pilot study is important to direct and streamline thorough investigation, when the situation is not self-evident. It enables a quick appraisal of the circumstances, and the verifi cation that they do agree with the assumptions of the assessment. For example, if a perturbing phenomenon is suspected to
+366
+2. The different types of assessment 3. General aspects of assessment methods
+2.6 Pilot study 3.1 A conceptual approach to assessment
+cause a given population diffi culty in securi...
+
+=== Chunk 1996 ===
+Source: 0820_002-ebook.pdf
+Length: 574 chars
+
+GENERAL ASPECTS OF ASSESSMENT METHODS
+Assessment consists in gathering and analysing information in line with the overall objective. Guiding principles are required in this effort, followed by techniques for the collection and analysis of information, information-access tools, and refl ection and presentation tools. This discussion concentrates chiefl y on preliminary appraisal, as these considerations also apply to most other types of assessment (except evaluation, which requires statistical and ...
+
+=== Chunk 1997 ===
+Source: 0820_002-ebook.pdf
+Length: 230 chars
+
+3.1 A CONCEPTUAL APPROACH TO ASSESSMENT
+The three basic concepts underlying data collection in preliminary nutritional assessment are the same as those that have been suggested for rapid rural appraisal or “RRA” (McCracken, 1988)....
+
+=== Chunk 1998 ===
+Source: 0820_002-ebook.pdf
+Length: 3626 chars
+
+3.1.1 Optimal ignorance
+This concept rests upon the idea that only the information that is strictly necessary should be sought, and no more. This concept is simple to grasp, and its application is important, but this is not always easily done. The idea is for preliminary appraisal to enable rapid response in order to avert the deterioration, or the continued deterioration, of a situation. Data to be collected must therefore be limited to the strict minimum required for decision-making. To this e...
+
+=== Chunk 1999 ===
+Source: 0820_002-ebook.pdf
+Length: 1531 chars
+
+3.1.2 Triangulation
+This concept is fundamental to organize data collection, in order to defi ne reality as accurately and quickly as possible. As such, triangulation reinforces the concept of optimal ignorance. Triangulation consists in combining different sources and means to obtain information. Accuracy and the completion of assessment are achieved by resorting to several indicators, each of which requires the use of different sources of information. Reality appears as assessment progresses, b...
+
+=== Chunk 2000 ===
+Source: 0820_002-ebook.pdf
+Length: 1523 chars
+
+3.1.3 Flexibility
+This concept implies the constant adjustment of assessment as it progresses and as the understanding of reality becomes more accurate, according to developments, new avenues to be explored, and changes in direction or method. Flexibility is not an excuse for chaos or scattering. It simply indicates an ability to adjust to circumstances, while pursuing a specifi c objective that cannot be questioned without valid reason. This concept consists in:
+9 proceeding in steps, each of wh...
+
+=== Chunk 2001 ===
+Source: 0820_002-ebook.pdf
+Length: 145 chars
+
+3.2 DATA TO BE COLLECTED DURING ASSESSMENT
+The purpose of assessment is to collect data, which is based on variables that are used as indicators....
+
+=== Chunk 2002 ===
+Source: 0820_002-ebook.pdf
+Length: 760 chars
+
+3.2.1 Data
+Data collected during assessment is quantitative or qualitative – this is not to be confused with qualitative and quantitative variables. Quantitative data is expressed in numbers (e.g. prevalence rates). Qualitative data is collected in a manner that produces information that can only be expressed in words: why the local population believes that a well should not be dug in this specifi c location, explaining the panic following an increase in market prices, quoting a key informant, et...
+
+=== Chunk 2003 ===
+Source: 0820_002-ebook.pdf
+Length: 1808 chars
+
+3.2.2 Variables
+Variables may have different values (e.g. height), different aspects (e.g. habitat), and present or absent features. Each variable may have only one value or state for a given subject at a specifi c moment. Quantitative variables are expressed as a quantity: birth weight, cholesterol level, age of the mother at her fi rst delivery, etc. Qualitative variables on the other hand express a condition: sick or healthy, severely malnourished, nationality, sex, etc.
+12 Participation contri...
+
+=== Chunk 2004 ===
+Source: 0820_002-ebook.pdf
+Length: 582 chars
+
+3.2.3 Indicators
+Variables are meaningless on their own; they must be converted into indicators, for example by combining them in indexes and, above all, by providing them with a meaning with respect to a more complex variable, or a vulnerability or risk factor. For instance, an anthropometric variable (such as weight) is converted into an anthropometric index by referring it to the reference value for the subject’s height. This weight-for-height index is then converted into an indicator of nutr...
+
+=== Chunk 2005 ===
+Source: 0820_002-ebook.pdf
+Length: 2324 chars
+
+Interpreting indicators
+The use of indicators assumes that they have meaning. To be valid, the variability of the indicator must be related mainly to the variability of what the indicator is intended to refl ect; the two must also be connected directly and quantitatively. For example, purchasing power may be taken as an indicator of access to food: in this case, access to food must vary like purchasing power, indicating that the latter is the main means of access to food, independently of the cir...
+
+=== Chunk 2006 ===
+Source: 0820_002-ebook.pdf
+Length: 4257 chars
+
+The quality of indicators
+Clearly, the quality of indicators is determined mainly by their relevance in terms of detecting or documenting the subject of assessment. The quality of indicators is also infl uenced by their ease in use, their variability when handled by different investigators and, sometimes, their acceptability. A major aspect of indicator quality is its validity, which may be expressed mathematically. The validity of an indicator corresponds to its suitability for revealing the obj...
+
+=== Chunk 2007 ===
+Source: 0820_002-ebook.pdf
+Length: 400 chars
+
+The expression of indicators
+Indicators can be expressed qualitatively (such-and-such an aspect does or does not exist) or quantitatively (the average wage is X; X millimetre rainfall measured during the last quarter; X individuals suffer from measles; X individuals express a given opinion, etc.). Quantitative data is often expressed in the form of rates, the commonest of which are provided below....
+
+=== Chunk 2008 ===
+Source: 0820_002-ebook.pdf
+Length: 784 chars
+
+Incidence and relative risk
+The incidence rate can be described as the number of new cases during a specifi ed period of time as a proportion of a specifi c group at risk. For example, the incidence rate of looting during one month is the ratio between the number of cases reported during that month and the total number of houses in the dwelling, multiplied by one hundred to provide a percentage. A more common example is the ratio between infection arising during a given period and the overall popu...
+
+=== Chunk 2009 ===
+Source: 0820_002-ebook.pdf
+Length: 101 chars
+
+number of new cases during a given period
+incidence rate = –––––––––––––––––––––––––––––––––––– × 100...
+
+=== Chunk 2010 ===
+Source: 0820_002-ebook.pdf
+Length: 721 chars
+
+overall number of individuals at risk
+Incidence rates enable the calculation of relative risk, which is the risk faced by subjects who are exposed to a phenomenon (or risk factor) as compared to subjects who are not. Relative risk is expressed as follows:
+incidence rate among exposed subjects
+relative risk = ––––––––––––––––––––––––––––––––––––––– × 100
+incidence rate among unexposed subjects
+372
+3. General aspects of assessment methods
+3.2 Data to be collected during assessment
+Prevalence rates...
+
+=== Chunk 2011 ===
+Source: 0820_002-ebook.pdf
+Length: 643 chars
+
+Prevalence
+The prevalence rate is the number of cases at a given moment as a proportion of a specifi c group at risk. For example, the prevalence rate of malnutrition among children between 1 and 5 years is the ratio between the number of malnourished children between 1 and 5 and the overall number of children between 1 and 5, multiplied by one hundred to provide a percentage. The same reasoning may be applied to the prevalence of a given opinion: in this case, the ratio between the number of ind...
+
+=== Chunk 2012 ===
+Source: 0820_002-ebook.pdf
+Length: 92 chars
+
+number of cases at a given moment
+prevalence rate = –––––––––––––––––––––––––––––––––– × 100...
+
+=== Chunk 2013 ===
+Source: 0820_002-ebook.pdf
+Length: 464 chars
+
+Mortality
+The mortality rate is the number of deaths during a specifi ed period of time as a proportion of the overall population, measured at the middle of that period, expressed in per 1,000, per 10,000, or per 100,000. Mortality rates are commonly calculated for age or sex groups, or in relation to the causes of a specifi c situation. Cause-specifi c mortality rates are useful to determine the severity of a problem, provided that valid comparison points exist....
+
+=== Chunk 2014 ===
+Source: 0820_002-ebook.pdf
+Length: 545 chars
+
+Morbidity
+The morbidity rate refl ects the prevalence of a given illness – it is the number of cases of illness as a proportion of the overall population. It is expressed as follows:
+number of cases at a given moment  morbidity rate    =   ––––––––––––––––––––––––––––––––––   ×  100  overall number of individuals at risk
+The usefulness of indicators
+Indicators are necessary in all types of assessment; this implies that preliminary appraisal must already determine what type of indicators will be u...
+
+=== Chunk 2015 ===
+Source: 0820_002-ebook.pdf
+Length: 754 chars
+
+Types of indicators13
+Indicators can refer to anything that characterizes or infl uences a nutritional situation directly or indirectly. The following types of indicators may therefore be used:
+13 A list of examples is provided in Annex 7.
+373
+X
+X
+NUTRITION MANUAL Chapter X – Assessment and planning I. Assessment
+3. General aspects of assessment methods
+3.2 Data to be collected during assessment 3.3 Data collection
+9 demographic
+GCUGEdY
+9 epidemiological
+9 ecological and environmental
+9 economic
+...
+
+=== Chunk 2016 ===
+Source: 0820_002-ebook.pdf
+Length: 1812 chars
+
+3.3.1 Targeting preliminary appraisal
+Data collection is always targeted. The key to the target is provided by the aggressive phenomena, recognized vulnerabilities and, in the case of preliminary or intermediary assessment, existing harm that corresponds to the warning signals. Preliminary appraisal must defi ne assessment areas and groups that may share the same needs because they face the same problems. Targeting regions and population groups for assessment is derived fi rstly from the warning s...
+
+=== Chunk 2017 ===
+Source: 0820_002-ebook.pdf
+Length: 663 chars
+
+3.3.2 Obtaining data
+There are four ways of obtaining the data required to achieve the objectives of assessment:
+9 the review of existing data
+COC
+9 interviews
+9 observation
+9 measurement
+374
+3. General aspects of assessment methods
+3.3 Data collection
+They resort to different sources of information that must be used with the triangulation concept. Prior to assessment, it is important to reiterate the type of information that is sought, how it may and should be obtained, where, and what resource...
+
+=== Chunk 2018 ===
+Source: 0820_002-ebook.pdf
+Length: 3412 chars
+
+Secondary data review
+This is important, both in preliminary appraisal and thorough investigation. Much data is already available in books, reports and collective memory, and there is therefore no need to waste time seeking it in the fi eld. This review must be performed before and during assessment (possibly afterwards also, in order to document specifi c points more thoroughly).
+Prior to assessment, it serves the following purposes.
+9 To acquire a basic or minimum understanding of the country an...
+
+=== Chunk 2019 ===
+Source: 0820_002-ebook.pdf
+Length: 5021 chars
+
+Interviews
+Except in disaster, when facts speak loudly enough, interviews are the key method for attempting to understand a given situation. They promote dialogue and confi dence. Interviews may involve individuals or small groups (e.g. households), key informants (e.g. the local authorities, organizations, specialists or public servants), or larger groups that represent the community.
+The procedure consists fi rst of all of introducing and briefl y explaining the purpose of the assessment. Interlo...
+
+=== Chunk 2020 ===
+Source: 0820_002-ebook.pdf
+Length: 821 chars
+
+Observation
+Direct observation consists in examining the environment, which is usually the source of invaluable information. The systematic observation of the indicators selected for assessment (such as the condition of crops, the methods of waste disposal, or the water supply) is simple. However, the more permanent, informal observation that amounts to “reading the environment” is a different matter: it is an investigation method in its own right, which may seem self-evident but demands experie...
+
+=== Chunk 2021 ===
+Source: 0820_002-ebook.pdf
+Length: 486 chars
+
+Measurement
+Measurement produces quantitative data, which is useful in determining the seriousness of a given situation and the need for urgent action. In the humanitarian context, only anthropometric measurements are specifi c to nutrition (see below). Many other dimensions can clearly be measured, counted, or weighed in order to document observations or interviews, such cultivated area, the number of food bags in storage and their weight, or the volume and weight of food consumed....
+
+=== Chunk 2022 ===
+Source: 0820_002-ebook.pdf
+Length: 1697 chars
+
+3.3.3 The time required
+Time matters mainly in preliminary appraisal, as it must quickly produce conclusive evidence in order to permit decision. Repeated assessments that relate to monitoring and evaluation are easier to plan, and the resources that they require can be anticipated. Preliminary appraisal therefore
+377
+X
+X
+NUTRITION MANUAL Chapter X – Assessment and planning I. Assessment
+3. General aspects of assessment methods
+3.3 Data collection 3.4 Selecting subjects
+usually resorts to so-cal...
+
+=== Chunk 2023 ===
+Source: 0820_002-ebook.pdf
+Length: 1004 chars
+
+3.4 SELECTING SUBJECTS
+Valid data by defi nition must provide an accurate refl ection of reality, and this accuracy is infl uenced by how it is collected. For example, the average size of agricultural land can hardly be determined on the basis of a single visit to one farm; all the farms in the area of interest must be visited, either that or at least a certain number that is representative of the whole. In this case, strict sampling is required to ensure that selected farms are indeed representati...
+
+=== Chunk 2024 ===
+Source: 0820_002-ebook.pdf
+Length: 1037 chars
+
+Basic principles
+Sampling is a tool for assessment that minimizes the costs and time spent collecting data by selecting a limited number of subjects within the overall population under scrutiny. However, selecting a sample must comply with a number of rules, and this may result in a lengthier process than a comprehensive survey. Here again, it is a matter of adapting to circumstances. The principle of sampling argues that information obtained on the sample should refl ect reality as accurately as...
+
+=== Chunk 2025 ===
+Source: 0820_002-ebook.pdf
+Length: 1619 chars
+
+Group homogeneity
+Sampling consists in selecting individuals from a group (or “population”) so that, by studying the features of this sample, the results may fairly be extrapolated to the group from which the sample was taken; the group must therefore be homogenous with respect to the variable, or characteristic, under consideration and to its affecting factor. For example, it would be absurd to test the hypothesis that displacement affects nutritional status by measuring – within the same sampl...
+
+=== Chunk 2026 ===
+Source: 0820_002-ebook.pdf
+Length: 395 chars
+
+Probability sampling
+All individuals in the group must have equal probabilities of being selected for inclusion in the sample. This requires the use of random selection and a fair understanding of the group (or population) under scrutiny. Selection methods are determined by the sampling method, which is infl uenced by the accuracy of sampling, and by constraints of time, resources, and access....
+
+=== Chunk 2027 ===
+Source: 0820_002-ebook.pdf
+Length: 120 chars
+
+Accuracy
+The accuracy of the result is determined by the size of the sample, which is set mainly by the sampling method....
+
+=== Chunk 2028 ===
+Source: 0820_002-ebook.pdf
+Length: 6019 chars
+
+Simple random sampling
+This is statistically the most orthodox method in terms of random selection. Theoretically, this method requires the availability of lists (e.g. census data) of all numbered subjects (individuals or objects) of the population under consideration, and implies that they are all accessible. The number of subjects amounting to the size of the sample is then randomly chosen. This may be done by resorting to tables (an example is provided in Annex 19), mixing tickets up in a hat...
+
+=== Chunk 2029 ===
+Source: 0820_002-ebook.pdf
+Length: 781 chars
+
+Systematic random sampling
+Systematic sampling consists in selecting subjects at regular intervals (for example, every fi fth individual), starting from the fi rst subject, which is selected randomly. This method implies a comprehensive census and numbering of the population under scrutiny; it also requires a sound understanding of the local geographic or spatial organization in order to, in this case, count all subjects and then select those (in this example, every fi fth) to be included in the sa...
+
+=== Chunk 2030 ===
+Source: 0820_002-ebook.pdf
+Length: 2933 chars
+
+n = the number of subjects in the sample, say 20
+N/n = a = the interval size, in this case 5
+The fi rst subject is selected randomly within the fi rst interval, in this case, between 1 and 5, say 3. Then, the other subjects to be included in the sample are every fi fth subject (because the interval is 5) starting at 3 (the fi rst subject): 8, 13, 18, 23, 28, …, 93, 98.
+381
+X
+X
+NUTRITION MANUAL Chapter X – Assessment and planning I. Assessment
+3. General aspects of assessment methods
+3.4 Selecting su...
+
+=== Chunk 2031 ===
+Source: 0820_002-ebook.pdf
+Length: 1029 chars
+
+Simple method
+Cluster sampling makes things easier when the overall population is large, for example in the case of an entire region. The method involves dividing a geographical area that is homogenous with respect to the variable under consideration into comparable clusters (usually along administrative or geographical lines), sampling some of these clusters randomly, and measuring subjects within the sampled clusters. All the clusters are represented graphically on a map and numbered; then, th...
+
+=== Chunk 2032 ===
+Source: 0820_002-ebook.pdf
+Length: 4429 chars
+
+Systematic method
+A more sophisticated approach, similar to systematic sampling, consists in dividing up a given geographical area into sections, which are not strictly clusters, and obtaining for each section an acceptable estimation of the total number of subjects. The resulting data is then refl ected in a fi ve- column table as follows:
+9 column 1 indicates the section names or numbers;
+CO
+9 column 2 indicates the estimated overall population within the section;
+9 column 3 indicates the aggreg...
+
+=== Chunk 2033 ===
+Source: 0820_002-ebook.pdf
+Length: 1756 chars
+
+Stratifi ed random sampling
+Stratifi ed random sampling consists in defi ning, within a given area, groups (based on sex, age, professional activity, number of children per family, etc.) that are known to share specifi c features with respect to the variable under scrutiny. Each group is then subjected to the sampling method that is most appropriate in the circumstances. This amounts to considering each stratum as a specifi c target for investigation. This method is illustrated in Figure 10.10 below....
+
+=== Chunk 2034 ===
+Source: 0820_002-ebook.pdf
+Length: 2274 chars
+
+The choice of sampling method
+Classical nutritional assessment is all too frequently restricted to the defi nition of malnutrition rates based upon overly detailed sampling. As a result, sampling virtually becomes an end in itself, to the point of obscuring the issue: human beings for whom malnutrition is far more important than spreadsheets and fi gures. In nutritional assessment, sampling is only a tool that must be used carefully, and is by far not the best manner of obtaining information as to...
+
+=== Chunk 2035 ===
+Source: 0820_002-ebook.pdf
+Length: 737 chars
+
+Sample size
+The underlying principle here is that, whatever the issue under investigation, the size of the population from which the sample is taken is infi nite. As a result, the size of the sample is not determined by the size of the population. Exceptions exist, in the case of small groups whose size is well known; in such cases, the sample size may be recalculated (see below). The paradox lies in the
+386
+3. General aspects of assessment methods
+3.4 Selecting subjects
+fact that the total popul...
+
+=== Chunk 2036 ===
+Source: 0820_002-ebook.pdf
+Length: 778 chars
+
+Quantitative variables
+Because of their nature, biological dimensions (such as anthropometric variables, seric rates, and birth weight) usually follow a distribution that corresponds closely to normal law.17 This translates into the fact that even with a limited number of sample values (“n”), the average (“m”) of these “n” values is rather reliable. Reliability is considered to be adequate as of 30 values; hence, in the case of biological quantitative variables, the sample size is suffi cient if ...
+
+=== Chunk 2037 ===
+Source: 0820_002-ebook.pdf
+Length: 540 chars
+
+Qualitative variables
+For qualitative variables, sample size is primarily determined by the sampling method. It is then infl uenced by the sampling error that is considered as acceptable, the determined confi dence interval, the expected prevalence rate (the actual prevalence rate is what is sought), and the total population when it is small. The result of qualitative variable sampling is expressed in prevalence rates “p” subject to the obtained degree of accuracy, which amounts to more or less a ...
+
+=== Chunk 2038 ===
+Source: 0820_002-ebook.pdf
+Length: 953 chars
+
+20 × (100-20)
+n = 1.962 × –––––––––––––––– = 246 52
+If the sampling error is reduced to 1%, then ε equals 2.576 and, consequently, the sample size “n” rises to 425. Similarly, if accuracy is increased to ± 3%, for a 5% sampling error, the sample size rises to 683. Finally, if the prevalence rate cannot be estimated and is therefore arbitrarily set at 50% to minimize the risk of inaccuracy, the sample size for a 5% sampling error and a ± 5% accuracy is 384.
+Generally speaking, the lower the sampl...
+
+=== Chunk 2039 ===
+Source: 0820_002-ebook.pdf
+Length: 330 chars
+
+Correction for small populations
+Population size does not in principle infl uence sample size. However, in small populations, a correction factor may be used. A small population is one in which the sample “n” as calculated above exceeds 10% of the total population “N”. In such cases, the corrected sample is calculated as follows:...
+
+=== Chunk 2040 ===
+Source: 0820_002-ebook.pdf
+Length: 124 chars
+
+corrected n = n / [1 + (n / N)]
+Referring to the above example: n = 246 N = the total population, say 2,000 subjects
+n = 246...
+
+=== Chunk 2041 ===
+Source: 0820_002-ebook.pdf
+Length: 468 chars
+
+corrected n = 246 / [1 + (246 / 2,000)] = 246 / (1 + 0.123) = 219
+In this example, the sample size is reduced by 11%. Had the total population been 1,000 subjects, the corrected sample size would be 197 subjects, that is, a 20% reduction in sample size.
+Sample size for systematic random sampling, and for each unit in stratifi ed sampling, is calculated in the same way as for simple random sampling.
+388
+3. General aspects of assessment methods
+3.4 Selecting subjects...
+
+=== Chunk 2042 ===
+Source: 0820_002-ebook.pdf
+Length: 766 chars
+
+Cluster random sampling
+Sample size is calculated in the same way as simple random sampling, but the greater uncertainty, and the inevitable heterogeneity associated with clusters must be allowed for. The formula is therefore completed with a “c” cluster factor, which increases sample size in order to preserve the degree of accuracy. Experience shows that a factor of 2 (c = 2) is usually suffi cient: doubling the sample size obtained through the simple sampling formula adequately allows for the c...
+
+=== Chunk 2043 ===
+Source: 0820_002-ebook.pdf
+Length: 1946 chars
+
+n = 1.96 × 1.96 × 2 × [(20 × 80) / 52] = 492
+And 492 is twice 246 (because c = 2).
+The number of clusters must then be determined: for example, 10 clusters amount to 49.2 subjects per cluster. The number of subjects per cluster must then be rounded up, preferably upwards to increase accuracy, in this case 50. However, it is also possible to take 20 clusters of 25 subjects each: this still totals 500 subjects. The question therefore is whether it is best to have many clusters, and fewer subjects ...
+
+=== Chunk 2044 ===
+Source: 0820_002-ebook.pdf
+Length: 2258 chars
+
+Correction for accuracy following sampling
+If sampling serves to estimate the prevalence rate of a qualitative variable, sample size is calculated according to intended accuracy and expected prevalence rates mainly as described in Section 3.4.1 under Qualitative variables. Subsequent investigation provides prevalence rates that usually differ somewhat from expected rates; likewise, actual sample size may differ from expectations. As a result, confi dence intervals probably differ slightly from th...
+
+=== Chunk 2045 ===
+Source: 0820_002-ebook.pdf
+Length: 159 chars
+
+accuracy = ± 1.96 × [55.42 / (5 × 4)]1/2 = ± 3.3%
+And the fi nal result is then 30.1 ± 3.3%.
+390
+3. General aspects of assessment methods
+3.4 Selecting subjects...
+
+=== Chunk 2046 ===
+Source: 0820_002-ebook.pdf
+Length: 4335 chars
+
+3.4.2 Complete enumeration
+In some cases, it may be easier and faster to avoid sampling altogether, and observe all subjects within the overall population. This is the case, for example, in anthropometry, especially in using mid-upper arm circumference (MUAC) or MUAC-for-height, which are faster to measure than weight and height. If almost all the subjects in a village or neighbourhood can be gathered in a central location, it is usually possible to measure them all in a matter of hours; samplin...
+
+=== Chunk 2047 ===
+Source: 0820_002-ebook.pdf
+Length: 783 chars
+
+4. ASSESSMENT TOOLS
+The use of appropriate tools improves the quality of assessment results. Some tools, such as analytical grids, mapping and ranking, have two specifi c advantages in addition to serving their direct purpose: their design itself involves thought and analysis, and is a simple and effi cient manner of developing discussion and the exchange of views.
+The use of such tools may be illustrated by referring to the summary of data to be collected during the preliminary appraisal discusse...
+
+=== Chunk 2048 ===
+Source: 0820_002-ebook.pdf
+Length: 1528 chars
+
+Table 10.4 Data to be collected
+Tool Geographic location Maps and transects Differentiated response to crisis Relative vulnerability analysis, functional classifi cation Wealth ranking Functional classifi cation, proportional ranking Economic resource appraisal Proportional ranking, economy models (Figures 6.8, 6.9, 6.10, 6.11, 6.12, 6.13, 6.14, 10.11, 10.12), food consumption analysis, possibly via questionnaires Minimum economic resources Household economy model (Figure 10.11), budget balance mo...
+
+=== Chunk 2049 ===
+Source: 0820_002-ebook.pdf
+Length: 1038 chars
+
+4.1 REFERENCE MODELS
+Nutritional surveys may be compared to gathering mushrooms: excursions to the woods are not the end, they serve a purpose. Locating edible mushrooms involves some knowledge as to toxicity, and of where, when and how they may be found. This cannot be done effectively by a beginner referring continuously to a textbook, because academic research and fi eld investigation are not simultaneous activities. As a result, a certain minimum knowledge or the presence of an expert is requ...
+
+=== Chunk 2050 ===
+Source: 0820_002-ebook.pdf
+Length: 1444 chars
+
+4.1.1 Simplifi ed household economy model
+The simplifi ed household economy model uses relevant variables; it defi nes the conditions for household self-suffi ciency, and the level of the crisis process that has been reached accordingly. Figure 10.11 below presents this model for the example of an agricultural household.
+Quantifying the importance of relevant variables and the relative market value of commodities permits the defi nition of the household economic situation, from which the need for ass...
+
+=== Chunk 2051 ===
+Source: 0820_002-ebook.pdf
+Length: 1371 chars
+
+4.1.2 Budget balance model
+This model complements the previous model, which provides its basis. It has been designed by ICRC economist, G. Carbonnier. The model rests upon the two groups of variables that shape the household budget balance. Figure 10.12 below illustrates this concept.
+Figure 10.12 Variables infl uencing budget balance
+IMPOVERISHMENT /
+ECONOMIC SECURITY
+CAPITAL LOSS  EXPENSES  REVENUE   FOOD  HOME FOOD PRODUCTION:  NON-FOOD:  – AGRICULTURE  – HOUSING & FURNITURE  – STOCK-BREEDING ...
+
+=== Chunk 2052 ===
+Source: 0820_002-ebook.pdf
+Length: 2496 chars
+
+4.2 APPRAISING THE RESOURCES TO SECURE FOOD
+Graphic illustration helps to appraise the gap between the resources available to secure food and household needs. The fi gure below refl ects food availability within the household, in terms of needs and for an identical production and consumption frequency. The abscissa (or x-axis) indicates food production and the food reserves available for consumption expressed in calories; the ordinate (or y-axis) refl ects the purchasing power available to secure f...
+
+=== Chunk 2053 ===
+Source: 0820_002-ebook.pdf
+Length: 1672 chars
+
+4.3 APPRAISING FOOD CONSUMPTION
+The examination of food consumption permits the quantitative and qualitative defi nition of what people eat. It provides information as to dietary adequacy and food sources. As is done for production activities, what is normally eaten must be established fi rst, and how it is usually prepared. Qualitatively, this amounts to eating habits. Then the situation at the moment of assessment must be defi ned for the sake of comparison. It is usually not possible to observe ...
+
+=== Chunk 2054 ===
+Source: 0820_002-ebook.pdf
+Length: 2768 chars
+
+4.4 NUTRITIONAL ANTHROPOMETRY
+Nutritional anthropometry consists in measuring the physical dimensions of the human body in order to appraise its nutritional status. It provides information as to ponderal growth (i.e. the weight achieved for a given height) and statural growth (the height achieved for a given age). It also facilitates the understanding of nutritional compartments, such as lean mass and adipose tissue, for example through the measurement of mid-upper arm circumference and skin fol...
+
+=== Chunk 2055 ===
+Source: 0820_002-ebook.pdf
+Length: 2114 chars
+
+4.4.1 Anthropometric variables and their measurement
+The commonest anthropometric variables are age, weight, height, and mid-upper arm circumference (MUAC, or brachial circumference). This section also discusses the detection of oedema, which is not an anthropometric variable, but is usually investigated together with nutritional anthropometry.
+Age
+The age of small children is a necessary parameter in evaluating statural growth and, to a certain extent, ponderal growth.
+396
+4. Assessment tools
+4...
+
+=== Chunk 2056 ===
+Source: 0820_002-ebook.pdf
+Length: 3741 chars
+
+Weight
+Weight must be established to evaluate ponderal growth and corpulence.
+The measurement of weight provides an approximation of nutritional reserves; but the measurement of weight involves measuring the entire organism, including:
+9 intestinal parasites, which may be likened to antimatter because they are counted as nutritional reserves when they, in fact, consume part of the food and nutritional reserves; the burden of intestinal worms can exceed 1 kg;
+9 sub-clinical oedema, which is an ac...
+
+=== Chunk 2057 ===
+Source: 0820_002-ebook.pdf
+Length: 1291 chars
+
+Height
+Height must be established in order to measure statural growth and corpulence.
+Children under 2 years old are placed horizontally on their backs, barefoot, on an accurately graduated height board, whose “0” value extremity is fi tted with a fi xed perpendicular head board. The child’s head is held fi rmly against this board, its buttocks must rest fully on the table, and the legs are held extended by pressing on the knees. The measurement cursor lies perpendicular to the table, and is then s...
+
+=== Chunk 2058 ===
+Source: 0820_002-ebook.pdf
+Length: 1140 chars
+
+Arm circumference (AC)
+Arm circumference, also called mid-upper arm circumference (MUAC) or brachial circumference, is used to estimate lean mass and adipose tissue, being the two compartments of nutritional reserves. In this respect, it is therefore more accurate than weight.
+MUAC is measured on the left arm, which must hang relaxed or be held against the torso if the subject is struggling. The value is measured at the mid-point between the tip of the shoulder
+398
+4. Assessment tools
+4.4 Nutrit...
+
+=== Chunk 2059 ===
+Source: 0820_002-ebook.pdf
+Length: 995 chars
+
+4.4.2 Measurement standardization or normalization
+It is best to practice before each measurement session or assessment in order to ensure that measurements are properly made, reproducible, and are similar. A dozen volunteers should be selected and measurements should be made by fi eld workers, under the supervision of an experienced operator. The latter records results and the mistakes that he or she observes; the operator then measures each subject him or herself, and records results as the ref...
+
+=== Chunk 2060 ===
+Source: 0820_002-ebook.pdf
+Length: 1898 chars
+
+4.4.3 Anthropometric indexes and measurement units
+Mid-upper arm circumference can provide an indication of the nutritional status for children between 1 and 5 years old on its own, and oedema for all age groups. No other anthropometric variable can provide indications of nutritional status on their own: they must be combined with another variable to provide an index. Moreover, all anthropometric indexes must be compared with reference values that are defi ned from a population of healthy subject...
+
+=== Chunk 2061 ===
+Source: 0820_002-ebook.pdf
+Length: 132 chars
+
+Percentage of the median
+Results are expressed as a percentage of the median in the reference population, and the formula is simple:...
+
+=== Chunk 2062 ===
+Source: 0820_002-ebook.pdf
+Length: 83 chars
+
+observed value of the dependent variable
+–––––––––––––––––––––––––––––––––––– × 100...
+
+=== Chunk 2063 ===
+Source: 0820_002-ebook.pdf
+Length: 539 chars
+
+median reference value
+The disadvantage of this unit is the fact that it does not have the same malnutrition meaning for all points of the independent variable because standard deviation varies according to points. For example, 80% of the weight-for-height median in boys corresponds to –2.2 standard deviations for an 80 cm height, and to –2.3 standard deviations for a 130 cm height.
+In the example used earlier, an 80 cm boy weighs 8 kg, and the median of the reference weight for his height is 11...
+
+=== Chunk 2064 ===
+Source: 0820_002-ebook.pdf
+Length: 929 chars
+
+Reference population centiles
+Centile numbers refl ect a position within a total of 100. Centile 50 corresponds to the median of the reference population: precisely half of this population shows values that exceed the median, and the other half shows lower values. For example, a measured value corresponding to the tenth centile indicates that the subject’s value is equal to or greater than 10% of the individuals within the reference population. However, there is by defi nition no value below the t...
+
+=== Chunk 2065 ===
+Source: 0820_002-ebook.pdf
+Length: 609 chars
+
+Standard deviation from the median
+Standard deviation26 is also called Z-score. Its use is spreading, because it is the best index to compare populations (and, thus, surveys) and individuals. Variables that are characteristic of a reference population usually follow a normal distribution of 2 standard deviations around the median, and this includes approximately 95% of the reference population. In biology and medical science, values lying outside this bracket are considered as abnormal or pathol...
+
+=== Chunk 2066 ===
+Source: 0820_002-ebook.pdf
+Length: 99 chars
+
+standard deviation
+In the above example the standard deviation below the median is 1 kg, therefore:...
+
+=== Chunk 2067 ===
+Source: 0820_002-ebook.pdf
+Length: 225 chars
+
+(8–11) / 1 = –3 standard deviations or –3 Z-scores
+All the above calculations require the use of reference tables indicating the median, standard deviations, and centiles or anthropometric data processing computer programmes....
+
+=== Chunk 2068 ===
+Source: 0820_002-ebook.pdf
+Length: 617 chars
+
+Weight-for-age or Gomez index
+Advantages: a good basic indicator that combines ponderal and statural growth and is useful in the monitoring of programme performance; sensitive to slight variations (although many variables can account for weight changes).
+Drawbacks: does not distinguish wasting from growth retardation (stunting), because a tall, lean child may refl ect the same weight-for-age ratio as a short, stout child; it requires accuracy in setting age, which is usually diffi cult to ensure; ...
+
+=== Chunk 2069 ===
+Source: 0820_002-ebook.pdf
+Length: 1468 chars
+
+Conventional cut-off points and classifi cation:
+9 > 90%:
+normal nutritional status
+9 90 to 75%: mild malnutrition (fi rst degree)
+9 < 75 to 61%: moderate malnutrition (second degree)
+9 < 60%:
+severe malnutrition (third degree).
+26 Standard deviation measures statistical dispersion, or the average distance of values from the mean if the values are normally distributed (see Annex 8).
+401
+X
+X
+NUTRITION MANUAL Chapter X – Assessment and planning I. Assessment
+4. Assessment tools
+4.4 Nutritional anthr...
+
+=== Chunk 2070 ===
+Source: 0820_002-ebook.pdf
+Length: 600 chars
+
+Height-for-age
+Advantages: a good indicator of past nutritional and health disorders that result in growth retardation.
+Drawbacks: of little use for programme monitoring, because height progresses slowly in humans; the method requires two different techniques: reclining position for children below 2 years old and standing position for older children, when the two categories must be measured simultaneously (which is usually the case); height is not easy to measure accurately; it requires the part...
+
+=== Chunk 2071 ===
+Source: 0820_002-ebook.pdf
+Length: 400 chars
+
+Conventional cut-off points and Waterlow classifi cation:
+9 > 95% or
+> –1 Z-score:
+adequate growth severe growth retardation.
+=> 295% or 2-1 Z-score:
+9 94 to 90% or
+< –1 Z-score to –2 Z-scores: mild growth retardation
+=> 94to090% or <-1Z-score to-2 Z-scores:
+9 89 to 85% or
+< –2 Z-scores to –3 Z-scores: moderate growth retardation
+=> 89 to 85% or <2 Z-scores to -3 Z-scores:
+9 < 85% or < –3 Z-scores:...
+
+=== Chunk 2072 ===
+Source: 0820_002-ebook.pdf
+Length: 1002 chars
+
+Weight-for-height
+Advantages: a good indicator of wasting, regardless of age.
+Drawbacks: weight is infl uenced by variables that may alter the interpretation of results; weight is not always easily measured (see above, weight-for-age); it requires that two measurements be accurately recorded, which is not easy, and the participation of two persons; measurements are time- consuming, as is data processing (unless results are entered into a specifi c computer programme such as EPINUT, which is also t...
+
+=== Chunk 2073 ===
+Source: 0820_002-ebook.pdf
+Length: 218 chars
+
+Conventional cut-off points and classifi cation
+> –2 Z-scores:28 –2 Z-scores to –3 Z-scores: moderate malnutrition < –3 Z-scores: severe malnutrition.
+9 > 85% or
+satisfactory nutritional status
+9 85 to 75% or
+9 < 75% or...
+
+=== Chunk 2074 ===
+Source: 0820_002-ebook.pdf
+Length: 386 chars
+
+MUAC
+Mid-upper arm circumference changes little in children aged 1 to 5 years. As a result, it may not need to be combined with another measurement in order to be compared to reference values.
+Advantages: a good indicator of wasting; it requires a single, simple measurement and is thus fast; age need not be specifi ed.
+Drawbacks: the method is less accurate than the QUAC Stick method....
+
+=== Chunk 2075 ===
+Source: 0820_002-ebook.pdf
+Length: 259 chars
+
+4.4.5 Anthropometry in adults
+The index that is most commonly used for adults is the Body Mass Index (BMI) or Quételet index. This method reveals wasting; the BMI is calculated by dividing weight expressed in kilograms by height (expressed in metres) squared:...
+
+=== Chunk 2076 ===
+Source: 0820_002-ebook.pdf
+Length: 33 chars
+
+weight (kg)
+BMI = –––––––––––––––...
+
+=== Chunk 2077 ===
+Source: 0820_002-ebook.pdf
+Length: 2710 chars
+
+height2 (m)
+BMI is independent of height: if the index is identical for subjects of different heights, then the nutritional reserves of the organism are comparable. Variables that infl uence the interpretation of weight measurements are far less signifi cant in adults than in children.
+Table 10.5 Body mass index classifi cation (Quételet index)
+Classifi cation of the adult nutritional status according to BMI
+Obesity Normal nutritional Moderate malnutrition Severe malnutrition status Women > 28.6 23....
+
+=== Chunk 2078 ===
+Source: 0820_002-ebook.pdf
+Length: 457 chars
+
+4.4.6 Anthropometry in adolescents
+Weight-for-height expressed as a percentage of the median is the best method for adolescents, using the combined table provided in Annex 4.4, and the cut-off points suggested by Waterlow (see above, weight-for-height). BMI-for-age is used to distinguish malnourished adolescents from healthy individuals, the cut-off point being the 5th centile. This method is however of little practical relevance to humanitarian action....
+
+=== Chunk 2079 ===
+Source: 0820_002-ebook.pdf
+Length: 3500 chars
+
+4.4.7 Reference populations29
+In order to defi ne nutritional status, measurements must be compared with standards or reference points taken from a reference population. The choice of the reference is a controversial issue; however this is not critical so long as the choice is an informed one. Anthropometric reference is established through the greatest possible number of measurements of supposedly healthy individuals (200 per measurement). Available reference tables relate to white European and ...
+
+=== Chunk 2080 ===
+Source: 0820_002-ebook.pdf
+Length: 2398 chars
+
+4.4.8 The value of anthropometric indicators in refl ecting nutritional status
+Measuring nutritional status usually consists implicitly in appraising the prevalence of malnutrition based on a given classifi cation (the use of cut-off points), for a given index. What reasoning, then, leads to the conclusion that prevalence measured below a given cut-off point actually refl ects pathological disorder?
+The following example sheds some light on the issue. In June 1985, approximately 40% of the children...
+
+=== Chunk 2081 ===
+Source: 0820_002-ebook.pdf
+Length: 647 chars
+
+The choice of index
+Anthropometry nevertheless remains essential in many circumstances. The points discussed here are intended to facilitate the selection of an index that is relevant to the dimension under investigation. The cut-off points discussed earlier are commonly used, but their meaning requires some attention. It goes without saying that the choice of index and cut-off points is determined by the overall purpose in doing so. However, choices are still all too often dictated by imitation...
+
+=== Chunk 2082 ===
+Source: 0820_002-ebook.pdf
+Length: 3574 chars
+
+Indicator of wasting
+As mentioned earlier, anthropometric indexes provide an estimate of nutritional status, and not a proper refl ection of a dysfunction. All the more so because the extreme form of wasting (marasmus) that results from a metabolic adjustment to an insuffi cient dietary intake, is not
+406
+4. Assessment tools
+4.4 Nutritional anthropometry
+necessarily pathological in itself, as frequently confi rmed in famine: individuals may be very thin without actually being sick. Thresholds must ...
+
+=== Chunk 2083 ===
+Source: 0820_002-ebook.pdf
+Length: 148 chars
+
+Indicator of mortality
+MUAC, related or not to age or height, provides the best indicator of mortality (Chen, 1980; Trowbridge, 1981; Briend, 1987)....
+
+=== Chunk 2084 ===
+Source: 0820_002-ebook.pdf
+Length: 160 chars
+
+Indicator of growth
+Height-for-age is the best indicator by far. Weight-for-age is sometimes used, and may provide an idea of the growth of pre-school children....
+
+=== Chunk 2085 ===
+Source: 0820_002-ebook.pdf
+Length: 595 chars
+
+Indicator of change
+This implies the longitudinal study (i.e. over time) of individuals or groups. Weight, MUAC and height may also be used independently, without reference to age or height. Weight is most appropriate for individual monitoring, and MUAC for group monitoring. Clearly, if operators change in the
+407
+X
+X
+NUTRITION MANUAL Chapter X – Assessment and planning I. Assessment
+4. Assessment tools
+4.4 Nutritional anthropometry 4.5 Market analysis
+course of the monitoring, the method used i...
+
+=== Chunk 2086 ===
+Source: 0820_002-ebook.pdf
+Length: 382 chars
+
+Indicator of reference point
+It may be best to set reference points, especially in preliminary appraisal. Indicator selection is determined by:
+9 the purpose of the measurement: growth and/or tissue mass;
+COU
+9 available resources;
+9 available time;
+9 the sampling method;
+9 existing data where available.
+MUAC, alone or related to height, is more suitable than weight measurements....
+
+=== Chunk 2087 ===
+Source: 0820_002-ebook.pdf
+Length: 267 chars
+
+Screening indicator
+MUAC-for-height provides the most accurate indication of wasting, but MUAC alone is quite acceptable, and is faster. Depending on the purpose of screening and available resources, thresholds may be set that differ from conventional cut-off points....
+
+=== Chunk 2088 ===
+Source: 0820_002-ebook.pdf
+Length: 1170 chars
+
+4.4.9 Magnitude of the malnutrition problem according to its prevalence
+The measured nutritional status of a given population must be adequately interpreted. However, the magnitude of malnutrition is not to be confused with the seriousness of the nutritional situation. For example, a serious primary wasting rate of 30% indicates a serious malnutrition problem, but if this rate is registered shortly before the harvest, which is anticipated to be exceptionally good, this does not justify alarm as ...
+
+=== Chunk 2089 ===
+Source: 0820_002-ebook.pdf
+Length: 1549 chars
+
+4.5 MARKET ANALYSIS
+The fi eld study of local markets is fundamental, because it provides a good idea of the local economy. Market analysis enables the defi nition of the relative value of commodities and its evolution, the evolution of prices, and their value in terms of purchasing power. It shows who is buying what, cash
+408
+4. Assessment tools
+4.5 Market analysis 4.6 Functional classifi cation
+and commodity fl ows, supply and demand related to basic commodities (that is, commodities the demand fo...
+
+=== Chunk 2090 ===
+Source: 0820_002-ebook.pdf
+Length: 2678 chars
+
+4.6 FUNCTIONAL CLASSIFICATION
+Functional classifi cation is an approach developed by Payne (Pacey & Payne, 1985); in humanitarian action, it consists in defi ning homogenous population groups with respect to their living conditions. It involves the defi nition of administrative regions, followed by the defi nition of ecological sub- regions and/or those affected by the phenomenon that has prompted action. In each sub-region, population groups are defi ned according to their livelihoods and/or social ...
+
+=== Chunk 2091 ===
+Source: 0820_002-ebook.pdf
+Length: 4387 chars
+
+4.7 RELATIVE VULNERABILITY ANALYSIS
+The following is adapted from F. Grunewald (Grunewald, 1997).
+Victims of a crisis do not all suffer identically because their vulnerabilities differ. In other words, the need for assistance is not equally signifi cant and urgent for all, and those that face the greatest risk must be identifi ed accordingly. To this end, hypotheses are formulated as to the relative vulnerability of different groups with respect to a given phenomenon (e.g. drought); population cat...
+
+=== Chunk 2092 ===
+Source: 0820_002-ebook.pdf
+Length: 3191 chars
+
+4.8 STAKEHOLDER ANALYSIS
+The following is adapted from Serge Ghinet (Ghinet, 1997).
+Humanitarian action evolves in a diverse human context in terms of vulnerability to crisis factors, but also in terms of social and functional dimensions, and diverging interests and issues at stake. These diversifi cation factors permit the defi nition of the different stakeholders involved in a given environment.
+The general objective of stakeholder analysis is to ensure that operations will run in the best possi...
+
+=== Chunk 2093 ===
+Source: 0820_002-ebook.pdf
+Length: 3060 chars
+
+4.9 PROPORTIONAL PILING
+Proportional piling is a simple tool that refl ects preferences, which can then be expressed quantitatively. It involves the participation of those concerned, because they must defi ne the actual proportionality. Specifi c variables are defi ned fi rst: for example, time, food, population. Boxes are then drawn up, each corresponding to an object in relation to which the variable must be examined. Informants are then requested to place a number of tokens, such as beans or stone...
+
+=== Chunk 2094 ===
+Source: 0820_002-ebook.pdf
+Length: 1583 chars
+
+4.10 PAIRED RANKING
+Ranking is a participatory method that permits the defi nition of priorities (or relative importance). For example, several informants may be asked to indicate their problems or needs by order of priority, and investigators can then verify the consistency of answers. Alternatively, wealth categories can be defi ned and described in terms of means and occupation, while differences between very poor, poor, average, and rich households are established. Proportional piling may then...
+
+=== Chunk 2095 ===
+Source: 0820_002-ebook.pdf
+Length: 671 chars
+
+Table 10.9 Paired ranking – example of food sources
+Food source Production Purchase Gathering Gift Production Production Production Production Purchase Gathering Purchase Gathering Gathering Gift
+In the above example, totals are as follows:
+9 production was found to be more important three times: 3
+9 gathering was said to be more important twice: 2
+9 purchase was said to be more important once: 1
+9 and gift was not once said to be more important than another source.
+In other words, the most impo...
+
+=== Chunk 2096 ===
+Source: 0820_002-ebook.pdf
+Length: 1297 chars
+
+4.11 SWOC ANALYSIS
+This tool permits the analysis of the Strengths, Weaknesses, Opportunities and Constraints (SWOC) of a given programme. To do so, a four-box matrix is used, each box corresponding to one trait; Table 10.8 below provides an example for a general food distribution.
+Table 10.10 SWOC analysis matrix – example of a GFD
+STRENGTHS WEAKNESSES – Distributions regular; – Ration monotonous, discourages the appetite of small – Ration adequate; children; – Appropriate distribution method; ...
+
+=== Chunk 2097 ===
+Source: 0820_002-ebook.pdf
+Length: 447 chars
+
+4.12 GRAPHIC ILLUSTRATION
+This method is a useful way of presenting information visually, making it easier to understand, provided that it is supported by some form of explanation. All types of graphic illustration require interpretation, and thus imply analysis and thought. As such, they are also sometimes useful in preparing a survey. The different forms of graphic illustration described below are all useful in presenting and analysing data....
+
+=== Chunk 2098 ===
+Source: 0820_002-ebook.pdf
+Length: 1475 chars
+
+4.12.1 Graphs
+Graphs are widely used in humanitarian action; they are useful mainly to represent distributions, the evolution of a given characteristic with respect to another parameter (malnutrition, the price of basic food commodities, etc.), and the relationship between two varying characteristics. They commonly comprise a horizontal axis (x-axis, or abscissa), which usually refl ects the independent variable, and a vertical axis (y-axis, or ordinate), which refl ects the dependent variable. Tw...
+
+=== Chunk 2099 ===
+Source: 0820_002-ebook.pdf
+Length: 1632 chars
+
+4.12.2 Maps and transects
+Maps and transects refl ect space and its occupation in order to facilitate orientation within this space and reach chosen destinations more easily. Like graphs, maps are in common use in humanitarian action, and usually show physical features such as overland routes, dwellings, administrative boundaries, infrastructure, waterways (hydrography) and relief. It is best to simplify them as much as possible for fi eld use, and restrict them to their necessary aspects (in acco...
+
+=== Chunk 2100 ===
+Source: 0820_002-ebook.pdf
+Length: 2443 chars
+
+4.12.3 Seasonal calendars
+Seasonal calendars are useful in rural environments where production varies throughout the year. They can refl ect all signifi cant events occurring during the year. Seasonal calendars should ideally be established for a period of 18 months, in order to refl ect seasonal cross-over periods. Calendar design is usually based on a normal year, thus facilitating the subsequent deduction of deviances observed during assessment. Whatever the ultimate approach, calendars must ind...
+
+=== Chunk 2101 ===
+Source: 0820_002-ebook.pdf
+Length: 1021 chars
+
+4.12.4 Flow charts
+Flow charts are the most frequently used tool in this Manual. They show the connections and relationships between the variables of a given feature, and their direction and sense. Flow charts are an invaluable tool for analysing how variables relate, and to qualify them as dependent or independent; this also permits the defi nition of cause and effect relations. Flow charts usually provide the basis for thought models and conceptual illustration. Figure 10.18 below provides an e...
+
+=== Chunk 2102 ===
+Source: 0820_002-ebook.pdf
+Length: 555 chars
+
+4.12.5 Decision trees
+Decision trees illustrate the different stages of decision-making according to circumstances. They are used to design a plan to achieve an objective. They also serve as models for decision-making, for example in a surveillance system, and to defi ne diagnoses. As such, they are designed to facilitate decision-making. Figure 10.19 below provides an example of a decision tree.
+419
+X
+X
+NUTRITION MANUAL Chapter X – Assessment and planning I. Assessment
+4. Assessment tools
+4.12 G...
+
+=== Chunk 2103 ===
+Source: 0820_002-ebook.pdf
+Length: 194 chars
+
+Figure 10.19 Decision tree
+MALNUTRITION  < 10% SEVERE  > 10% SEVERE  PRIMARY  SECONDARY  PRIMARY  SECONDARY  PASSIVE  SURVEILLANCE  HEALTH   SERVICE   SENSITIZATION  MONITORING  MEDICAL   ACTION...
+
+=== Chunk 2104 ===
+Source: 0820_002-ebook.pdf
+Length: 779 chars
+
+4.13 CHECKLISTS
+Checklists are good reminders of all the different aspects that must not be omitted in an assessment. It is therefore useful to consult them while preparing the assessment, in order not to forget anything, but also after each survey, or data collection exercise, to confi rm that all their points have indeed been covered, or explore avenues related to points that were previously not included in the lists. This being said, it is best not to consult them during assessment proper, as ...
+
+=== Chunk 2105 ===
+Source: 0820_002-ebook.pdf
+Length: 971 chars
+
+4.14 QUESTIONNAIRES
+Questionnaires permit the systematic collection of information. Like checklists, their use ensures that no aspect is forgotten, and they permit the systematization of the information provided by different sources. However, inexperienced staff risks being closed into restrictive thinking, without the necessary latitude to explore unexpected aspects and adapting their understanding to the progress of the assessment. To improve the usefulness of questionnaires, they should be co...
+
+=== Chunk 2106 ===
+Source: 0820_002-ebook.pdf
+Length: 1571 chars
+
+4.15 ASSESSMENT REPORTS
+Assessment reports are an essential tool for analysis and synthesis. As such, they also serve as basic reference documents for the subsequent conduct of operations (monitoring and evaluation), and “assessment archives”. Finally, they provide the basis for operational planning.
+Assessment reports must contain the following:
+9 reference details:
+q reference numbers and fi ling codes;
+q the name of their authors;
+q the dates of the assessment;
+9 a one-page summary (executive ...
+
+=== Chunk 2107 ===
+Source: 0820_002-ebook.pdf
+Length: 470 chars
+
+1. DEFINITION
+Planning usually follows preliminary appraisal, or should do so. It consists in the thorough examination of assessment fi ndings, in order to formulate realistic operational proposals, their priorities, and their objectives. These proposals translate the need for assistance, constraints, and opportunities into an operational strategy that combines the different programmes in the most effi cient manner in terms of achieving general operational objectives....
+
+=== Chunk 2108 ===
+Source: 0820_002-ebook.pdf
+Length: 194 chars
+
+2.1 MAIN OBJECTIVE
+The main objective is to plan an operation within a logical framework and according to a set calendar based upon the needs for assistance as revealed by preliminary appraisal....
+
+=== Chunk 2109 ===
+Source: 0820_002-ebook.pdf
+Length: 899 chars
+
+2.2 SPECIFIC OBJECTIVES
+1. Setting priorities.
+2. Setting operational objectives.
+3. Planning the activities and resources necessary to achieve operational objectives.
+4. Planning the mobilization of resources.
+FNAME
+5. Planning the implementation of specifi c operational and monitoring activities.
+6. Planning operational evaluation.
+7. Allowing for operational adjustments, if relevant.
+8. Planning withdrawal.
+The specifi c objectives of planning interrelate in a cycle as illustrated in Figure 10....
+
+=== Chunk 2110 ===
+Source: 0820_002-ebook.pdf
+Length: 3321 chars
+
+3.1 SETTING PRIORITIES
+Crisis results in many different needs for assistance, which are usually not equally urgent, and may not always have an immediate, comprehensive answer.32 Setting operational priorities is therefore essential, and the urgency to act must be viewed as the primary criterion. However, as discussed earlier in this Chapter, the concept of emergency itself is ambiguous: the primary emergency that relates to saving lives is in opposition with the more strategic emergency of avoid...
+
+=== Chunk 2111 ===
+Source: 0820_002-ebook.pdf
+Length: 5310 chars
+
+3.2 SETTING OBJECTIVES
+Setting objectives amounts to stating clearly what is to be done in order to cover the need for assistance. This consists of the practical translation of general operational objectives: the prevention and alleviation of suffering. Objectives are defi ned in reference to the following points:
+9 the nature of the objective; this includes stating the problem;
+COREY
+9 the benefi ciaries of the operation;
+9 the number of benefi ciaries;
+9 the location of the operation;
+9 the expec...
+
+=== Chunk 2112 ===
+Source: 0820_002-ebook.pdf
+Length: 922 chars
+
+3.3 PLANNING ACTIVITIES AND RESOURCES
+Planning consists in defi ning what activities must be implemented, their precise combinations, in order to achieve specifi c objectives; it also sets their timing. This effort amounts to operational tactics, which must not be confused with the overall strategy. The strategy sets the combination and coordination of the different operational measures in order to achieve an overall objective; the tactics on the other hand are subjected to the strategy and permit...
+
+=== Chunk 2113 ===
+Source: 0820_002-ebook.pdf
+Length: 558 chars
+
+3.4 PLANNING RESOURCE MOBILIZATION
+Planning the mobilization of resources consists of determining appropriate:
+9 headhunting: how to fi nd and employ skilled staff;
+9 procurement: how to secure the necessary material and logistical resources;
+9 donor relations: how to select and approach donors in order to secure funding and in-kind donations;
+9 timing: the best timeframe for the availability and use of resources.
+426
+3. Planning stages 3.5 Planning implementation and monitoring
+3.6 Planning eval...
+
+=== Chunk 2114 ===
+Source: 0820_002-ebook.pdf
+Length: 661 chars
+
+3.5 PLANNING IMPLEMENTATION AND MONITORING
+Implementation planning consists in determining:
+9 the roles and responsibilities of staff members;
+COdL
+9 the logistics chain;
+9 the activity calendar or timeframe;
+9 administrative aspects (staff accommodation,
+labour regulations, codes of conduct and security guidelines);
+9 the operational methodology;
+9 coordination with other stakeholders.
+Monitoring planning consists in determining:
+9 situation (or context) tracking methods;
+9 indicators in relati...
+
+=== Chunk 2115 ===
+Source: 0820_002-ebook.pdf
+Length: 350 chars
+
+3.6 PLANNING EVALUATION
+Planning the evaluation in the operation consists in developing procedures that must include:
+9 methods and indicators to appraise the impact
+of the operation;
+9 the calendar of evaluation surveys;
+9 the external contributors (individuals and/or agencies) who will lead the exercise;
+9 reporting lines, methods, and deadlines....
+
+=== Chunk 2116 ===
+Source: 0820_002-ebook.pdf
+Length: 610 chars
+
+3.7 ALLOWING FOR ADJUSTMENT
+It may seem strange to allow for adjustment; this aspect, in spite of being the corollary of monitoring and evaluation, is frequently overlooked because of routine and/or because the history of past experiences is lost, and adapting an operation usually entails costs in terms of resources and additional effort. Adjustment or adaptation is therefore often resisted wrongly. Allowing for adjustments is however essential, and simply consists in the regular and timely revi...
+
+=== Chunk 2117 ===
+Source: 0820_002-ebook.pdf
+Length: 1650 chars
+
+3.8 PLANNING WITHDRAWAL
+Anticipating withdrawal is just as important as defi ning objectives and implementation proper. It consists in determining the criteria for and modalities for pulling out. It is all the more important in view of the uncertainty surrounding the actual success of the operation, because of precarious security among others.
+427
+X
+X
+NUTRITION MANUAL Chapter X – Assessment and planning II. Planning
+3. Planning stages
+3.8 Planning withdrawal
+A number of circumstances may prompt w...
+
+=== Chunk 2118 ===
+Source: 0820_002-ebook.pdf
+Length: 1097 chars
+
+1. POSITION IN HUMANITARIAN ACTION
+When the inobservance of rights and/or abusive behaviour causes or contributes to the development of crisis, putting a halt to them is a constant priority in humanitarian action, from the beginning to the end of the crisis process. Figure 11.1 below provides an illustration of this approach.
+1 The term “rights” also engulfs the duties of States and authorities towards the population under their control, such populations having the right that these duties be obs...
+
+=== Chunk 2119 ===
+Source: 0820_002-ebook.pdf
+Length: 844 chars
+
+2. RIGHTS RELATING TO NUTRITION
+The rights that, if unobserved, affect nutrition and that may be invoked accordingly are:
+9 those contained in the United Nations International Bill of Human Rights, the Universal Declaration of Human Rights, and the International Covenant on Economic, Social, and Cultural Rights (ICESCR), which apply at all times;
+9 those contained in international humanitarian law (IHL), which applies in armed confl ict;
+9 those contained in customary law, which contribute substa...
+
+=== Chunk 2120 ===
+Source: 0820_002-ebook.pdf
+Length: 507 chars
+
+Article 22
+“Everyone, as a member of society, has the right to social security and is entitled to realization, through national effort and international cooperation and in accordance with the organization and resources of each State, of the economic, social and cultural rights indispensable for his dignity and the free development of his personality.”
+432
+2. Rights relating to nutrition 2.1 The universal declaration of human rights
+2.2 The international covenant on economic, social, and cultural...
+
+=== Chunk 2121 ===
+Source: 0820_002-ebook.pdf
+Length: 554 chars
+
+Article 23
+“1. Everyone has the right to work, to free choice of employment, to just and favourable conditions of work and to protection against unemployment.
+2. Everyone, without any discrimination, has the right to equal pay for equal work.
+3. Everyone who works has the right to just and favourable remuneration ensuring for himself and his family an existence worthy of human dignity, and supplemented, if necessary, by other means of social protection.
+4. Everyone has the right to form and to j...
+
+=== Chunk 2122 ===
+Source: 0820_002-ebook.pdf
+Length: 616 chars
+
+Article 25
+“1. Everyone has the right to a standard of living adequate for the health and wellbeing of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”
+It is worth noting that, following the 1996 World Food Summit held in Rome, the inclusion of the right to adequate food in hu...
+
+=== Chunk 2123 ===
+Source: 0820_002-ebook.pdf
+Length: 571 chars
+
+Article 7
+“The States Parties to the present Covenant recognize the right of everyone to the enjoyment of just and favourable conditions of work, which ensure, in particular:
+a) remuneration which provides all workers, as a minimum, with:
+i) fair wages and equal remuneration for work of equal value without distinction of any kind, in particular women being guaranteed conditions of work not inferior to those enjoyed by men, with equal pay for equal work;
+ii) a decent living for themselves and the...
+
+=== Chunk 2124 ===
+Source: 0820_002-ebook.pdf
+Length: 1384 chars
+
+Article 11
+“1. The States Parties to the present Covenant recognize the right of everyone to an adequate standard of living for himself and his family, including adequate food, clothing and housing, and to the continuous improvement of living conditions. The States Parties will take appropriate steps to ensure the realization of this right, recognizing to this effect the essential importance of international cooperation based on free consent.
+2. The States Parties to the present Covenant, recogn...
+
+=== Chunk 2125 ===
+Source: 0820_002-ebook.pdf
+Length: 395 chars
+
+2.3 OTHER LEGAL INSTRUMENTS GOVERNING HUMAN RIGHTS
+Many legal provisions forbid all form of discrimination based on race, employment, occupation, pay and sex (United Nations, 2002). The many other international human rights instruments should, in combination with those discussed above and provided they are observed and applied, avert or at least mitigate nutritional crisis arising from abuse....
+
+=== Chunk 2126 ===
+Source: 0820_002-ebook.pdf
+Length: 6897 chars
+
+INTERNATIONAL HUMANITARIAN LAW
+9 Article 14 of Protocol II of 1977 Additional to the Geneva Conventions of 1949 states: “Starvation of civilians as a method of combat is prohibited.” (see also article 54, paragraph 1, of Protocol I of 1977 Additional to the Geneva Conventions of 1949);
+9 Article 54, paragraph 2 of Protocol I states: “It is prohibited to attack, destroy, remove or render useless objects indispensable to the survival of the civilian population, such as foodstuffs, agricultural are...
+
+=== Chunk 2127 ===
+Source: 0820_002-ebook.pdf
+Length: 3207 chars
+
+3. A PRACTICAL APPROACH TO THE PROTECTION OF RIGHTS
+The above discussion shows that legal instruments do exist to protect the feeding system, both in peace and in times of armed confl ict. The major challenge lies in their application and enforcement, and can be addressed through three main approaches that can combine:
+9 one extreme approach involves the enforcement of law by force;
+9 an intermediary approach consists of reminders or reprimands in the hope that the alleged authors of abuse will c...
+
+=== Chunk 2128 ===
+Source: 0820_002-ebook.pdf
+Length: 1099 chars
+
+1.2 GFD IN HUMANITARIAN ACTION
+In humanitarian action, GFD relates both to economic support and to survival relief, and can contribute to economic rehabilitation and, consequently, can serve different purposes, as discussed later. Figure 12.1 below shows the different levels at which GFD fi ts into the crisis process.
+Figure 12.1 General food distribution within humanitarian action
+CRISIS PROCESS  PRELIMINARY PHASE  OVERT PHASE  OR CRISIS  RECOVERY PHASE  PROTECTION MEASURES  GENERAL FOOD  DISTRI...
+
+=== Chunk 2129 ===
+Source: 0820_002-ebook.pdf
+Length: 537 chars
+
+1.3 THE OBJECTIVES OF GFD
+In the framework of humanitarian action, the objective of GFD is usually understood as mitigating hunger. Hunger in this sense refers to classic situations of famine, which deprive groups of their access to food because of extreme destitution and/or insuffi cient food availability (whatever the group’s resources to secure it); the expression also applies to situations in which displaced persons or refugees depend exclusively on external assistance. In such cases, GFD amo...
+
+=== Chunk 2130 ===
+Source: 0820_002-ebook.pdf
+Length: 1117 chars
+
+ensuring adequate food access, through the provision of food where the primary role of that food is to provide nutrients.
+Such action is expected to preserve or improve the nutritional status, that is, to protect or restore the functional capacity of household members. This implies that food rations be adapted to circumstances, and distributed regularly according to plan.
+In earlier stages of the famine process, during recovery from it, and in the case of groups that have remained in their usual...
+
+=== Chunk 2131 ===
+Source: 0820_002-ebook.pdf
+Length: 991 chars
+
+preserving the activities and resources required for the survival of the household.
+To this end, it may pursue the following specifi c objectives:
+1. avoiding premature (i.e. untimely) harvesting and, thus, mitigate the effects of the forthcoming hunger season;
+2. avoiding consumption of seed grains in cases of food scarcity;
+3. protecting the workforce by sparing recipients the search for scarce food;
+4. preserving the time required for essential activities, such as infant care;
+AYP
+5.
+limiting ...
+
+=== Chunk 2132 ===
+Source: 0820_002-ebook.pdf
+Length: 4191 chars
+
+1.4 OPERATIONAL PRIORITY
+In a nutritional crisis, GFD is usually an operational priority as (provided that it meets the criteria below) one of the only available means to humanitarian agencies to improve the economic system of crisis victims in a polyvalent way. By preventing impoverishment, capital loss, and starvation,
+442
+1. General considerations
+1.4 Operational priority 1.5 Criteria for intervention
+GFD therefore usually takes precedence over other “nutritional” measures such as supplementa...
+
+=== Chunk 2133 ===
+Source: 0820_002-ebook.pdf
+Length: 2464 chars
+
+1.5 CRITERIA FOR INTERVENTION
+Since food is an economic resource, the criteria for GFD rest less on the nutritional status of the proposed recipients than on their ability to secure food, and at what cost. Their nutritional status is simply an additional variable that improves accuracy as to the level of the famine process that has been reached; it however also provides indications as to the possible impact of infectious disease.
+With reference to the crisis process,3 the causes of famine, and c...
+
+=== Chunk 2134 ===
+Source: 0820_002-ebook.pdf
+Length: 550 chars
+
+1.6 THE BROADER ROLE OF FOOD
+GFD should provide nutrients, and caloric nutrients provide the quantitative reference. Therefore, GFD rations are usually defi ned according to the energy requirements of the target group. Beyond the diffi culty of setting the calorie level of rations on a nutritional basis, the fact that food represents more than just nutrients and calories must also be considered. Indeed, its fundamental nutritional role provides it with social, economic and political dimensions tha...
+
+=== Chunk 2135 ===
+Source: 0820_002-ebook.pdf
+Length: 1052 chars
+
+1.6.1 The social dimension of food
+Food must be consumed daily in order to meet the nutritional need of humans. In primitive societies, most production activities are related to the securing of food, which thus plays a central role. This role has been preserved in all societies up to now, and food is no doubt the most fundamental commodity and symbol of social exchange. The banquets of Antiquity, ritual mediaeval meetings or reconciliation feasts, modern day business lunches, and hospitality eti...
+
+=== Chunk 2136 ===
+Source: 0820_002-ebook.pdf
+Length: 1915 chars
+
+1.6.2 The economic dimension of food
+Food must be acquired on a regular basis, be it produced, gathered, hunted, fi shed, or purchased with a means for exchange. As man began to choose particular areas of activity and specialize in them instead of being a self-suffi cient all-rounder, food acquired an economic dimension.
+At the same time, as discussed in Chapter VI, man increases the range of non-food commodities that he needs for cultural integration. That is, he creates essential material needs ...
+
+=== Chunk 2137 ===
+Source: 0820_002-ebook.pdf
+Length: 904 chars
+
+1.6.3 The political dimension of food
+Food is a basic commodity that is sometimes diffi cult to secure and, as such, is a major instrument for exchange, confl ict, and power. As a result, food production, stocks and exchanges are often political issues that must be identifi ed and controlled, especially in armed confl ict. The political dimension of food is one of the major constraints of humanitarian assistance. It gives rise to problems of neutrality, power balances, ethics, and security. The only...
+
+=== Chunk 2138 ===
+Source: 0820_002-ebook.pdf
+Length: 4685 chars
+
+1.7 NEGATIVE AND SIDE EFFECTS OF GFD
+GFD induces side effects that are a direct consequence of the crucial role of food. The commonest side effects are the use of food as a convertible commodity in an attempt to optimize the use of available resources, changes in market prices, and changes in the economic recovery behaviour of recipients, which seek to maximize the impact of the GFD in terms of recovering their economic self-suffi ciency. Side effects are negative if they are harmful. For example...
+
+=== Chunk 2139 ===
+Source: 0820_002-ebook.pdf
+Length: 1607 chars
+
+Food assistance fuels crisis
+If, in armed confl ict, authorities and armed groups divert humanitarian aid to their profi t, humanitarian agencies are accused of fuelling the crisis. Should humanitarian assistance be questioned as a result? And what about humanitarian ethics? Clearly, in such circumstances, the victims have little choice, if any. They are penalized by their own authorities and the armed groups that violate their most basic rights. As such, they deserve to be protected via represent...
+
+=== Chunk 2140 ===
+Source: 0820_002-ebook.pdf
+Length: 1134 chars
+
+The assistance syndrome
+A common opinion holds that GFD, at best, runs counter to motivating its recipients to self-help or, at worst, encourages them to sit back and wait for assistance. Indeed, recipients include GFD in their survival and economic recovery strategies, and not always as anticipated. This does not necessarily indicate the development of an assistance syndrome. The author has in fact never observed such a development – on the contrary, people who need GFD rations for survival and...
+
+=== Chunk 2141 ===
+Source: 0820_002-ebook.pdf
+Length: 2510 chars
+
+The sale of rations
+Another commonly quoted negative effect is the use of food to other ends than those intended, and the deduction by observers that rations exceed actual needs. This may indeed be the case – rations can be overly abundant or unbalanced, and their recipients may in such cases sell the surplus. This indicates mistakes in the defi nition of rations, and amounts to a negative side effect. Usually, however, the sale or exchange of food indicates an optimized utilization of resources ...
+
+=== Chunk 2142 ===
+Source: 0820_002-ebook.pdf
+Length: 798 chars
+
+2. PLANNING GFD
+Planning GFD consists in converting the need for aid as observed during preliminary assessment into practical dimensions documenting the following topics:
+9 compendium of the need for and relevance of a GFD;
+COUGEIGEY
+9 GFD feasibility;
+9 inclusion of the GFD in the overall operational strategy;
+9 GFD recipient selection;
+9 GFD objective(s);
+9 required type of GFD ration in order to achieve objectives and satisfy the need for aid;
+9 distribution methods;
+9 GFD termination criteri...
+
+=== Chunk 2143 ===
+Source: 0820_002-ebook.pdf
+Length: 856 chars
+
+2.1 COMPENDIUM OF NEED AND RELEVANCE
+Planning GFD must rest upon a convincing demonstration of the need for the operation. This demonstration must be summarized in the planning document. It must follow assessment (usually preliminary assessment, but possibly also ad hoc monitoring depending on developments that may have occurred after preliminary assessment). Planning rests on a sound understanding of the economic problems and living conditions faced by the affected population and the resulting ...
+
+=== Chunk 2144 ===
+Source: 0820_002-ebook.pdf
+Length: 283 chars
+
+9 Target population:
+q geographic location;
+q habitat (urban, rural, camp accommodation, etc.);
+q climate;
+q estimated numbers;
+q status (resident, displaced, refugee, or returnee);
+q cultural parameters (ethnic, religious, etc.);
+q social position by age group, sex, and occupation....
+
+=== Chunk 2145 ===
+Source: 0820_002-ebook.pdf
+Length: 647 chars
+
+9 Economic and nutritional aspects:
+q access to food, according to cultural standards;
+q eating habits;
+q pre-crisis stability, according to cultural standards;
+q normal variability of the factors affecting access to food;
+q usual cultural coping mechanisms to address this variability;
+q critical thresholds that indicate that variations exceed the norm;
+7 See Chapter X, Section I.
+448
+2. Planning GFD 2.1 Compendium of need and relevance
+2.2 Feasibility 2.3 Integration into the operational strate...
+
+=== Chunk 2146 ===
+Source: 0820_002-ebook.pdf
+Length: 856 chars
+
+9 Situation at the time of assessment:
+q main disruptive factors regarding access to food;
+q effects of such factors on regional food availability, and the access of households to it;
+q crisis process level reached at the time of assessment, in terms of normality or abnormality of the observed response of the population to its problems;
+q status of the relative value of commodities (terms of trade) and self-suffi ciency levels;
+q food consumption;
+q access to essential non-food goods and services...
+
+=== Chunk 2147 ===
+Source: 0820_002-ebook.pdf
+Length: 5093 chars
+
+2.2 FEASIBILITY
+The feasibility of a GFD is determined by access to the target population, the danger of negative side effects, prevailing security conditions, and available means. Access to the target population is in turn determined by the endorsement of the GFD on the part of relevant authorities and, in case of armed confl ict, by all parties involved. This endorsement is an operational imperative, because GFD involves heavy logistics and high visibility; as such, it is highly vulnerable to m...
+
+=== Chunk 2148 ===
+Source: 0820_002-ebook.pdf
+Length: 2278 chars
+
+INTEGRATION INTO THE OPERATIONAL STRATEGY
+General distribution is seldom an isolated operation because it usually contributes to a general goal. As such, it enhances the overall consistency of an operation in the fi elds of economics, representation for the respect of rights, water and habitat, and access to healthcare. This comment underscores the close connection between the different measures required in a crisis. In a famine, for example, a
+449
+I I X
+I I X
+NUTRITION MANUAL Chapter XII – Gener...
+
+=== Chunk 2149 ===
+Source: 0820_002-ebook.pdf
+Length: 449 chars
+
+2.4 BENEFICIARY SELECTION
+In principle, benefi ciaries are selected in the course of preliminary assessment, when populations requiring assistance are identifi ed. However, all households may not need to be included in a GFD; targeting individual households is not always possible, either because cut-off points are diffi cult to set or because targeting is not acceptable or tolerated. The issue of targeting is discussed further in Section 3.3 below....
+
+=== Chunk 2150 ===
+Source: 0820_002-ebook.pdf
+Length: 412 chars
+
+2.5 OBJECTIVES AND EXPECTED IMPACT
+As discussed in Section 1.3 above, a GFD may serve different purposes separately or in parallel; planning must specify this or these objectives clearly. This encourages planners to examine the relevance of the GFD closely (thus enabling the anticipation and prevention of possible negative effects), and to identify indicators required for monitoring and evaluation beforehand....
+
+=== Chunk 2151 ===
+Source: 0820_002-ebook.pdf
+Length: 1838 chars
+
+2.6 SETTING RATIONS TO ACHIEVE OBJECTIVES AND MEET THE NEED FOR AID
+The composition of food rations depends on the ultimate objective, according to the two roles ascribed to food: nutritional and economic (in terms of exchange commodity). It is useful to reiterate here that food should only be distributed as an exchange commodity if the necessary essential goods and services cannot be provided directly. In terms of the nutritional role of a GFD, ration composition is determined by whether they o...
+
+=== Chunk 2152 ===
+Source: 0820_002-ebook.pdf
+Length: 2201 chars
+
+2.7 DISTRIBUTION METHODS
+Direct distributions involve the delivery of rations to their ultimate recipients by the operating agency itself; in indirect distributions, rations are handed over to the community, which then distributes them to its members. Direct distribution is always best, especially in armed confl ict, in order to ensure that the food does indeed reach its intended benefi ciaries. Misuse and corruption are all too common in the case of indirect distribution, and they are impossible ...
+
+=== Chunk 2153 ===
+Source: 0820_002-ebook.pdf
+Length: 1526 chars
+
+2.8 TERMINATION CRITERIA
+It is usually accepted that the termination criteria of a GFD must be set at its planning stage, because that implies a complete overview. They are also necessary for the mobilization of resources and fundraising. Clearly, there are no universal criteria for the termination of a GFD. On the other hand, they are by defi nition set at the outset of the operation, because they are determined by:
+9 the operational and GFD objectives;
+9 the implementation criteria (i.e. those ...
+
+=== Chunk 2154 ===
+Source: 0820_002-ebook.pdf
+Length: 410 chars
+
+2.9 RESOURCE MOBILIZATION
+The author is not an expert in the mobilization of resources, and the issue reaches beyond the scope of this Manual; as such, it is discussed only briefl y here. Resource mobilization involves the collection of means in cash and kind, the logistics set-up (food transport, storage, and distribution), the purchase and hire of goods and services, and the recruitment of competent staff....
+
+=== Chunk 2155 ===
+Source: 0820_002-ebook.pdf
+Length: 929 chars
+
+2.9.1 Obtaining means
+For donors to commit the necessary means for a GFD, they must be convinced of its relevance and approve the chosen approach. Persuasion is rather simple, provided that reliable and documented data is available to support the operation, that the justifi cation for the operation rests on its underlying humanitarian principles, that reporting is context-specifi c, and that donors deal with competent staff. In this respect, donors like to engage directly with fi eld staff in charg...
+
+=== Chunk 2156 ===
+Source: 0820_002-ebook.pdf
+Length: 2279 chars
+
+2.9.2 Setting up logistics
+The three criteria for good logistics are the fi nal delivery of quality material, as fast as possible, and at the lowest possible cost. However, these three criteria are not necessarily compatible. Fast delivery and quality are not usually cheap, and emergency may impose compromises. Consequently, logistics staff must be informed of criteria ranking as early as possible in order to clarify their operational constraints. Furthermore, “cheaper” may not necessarily mean “...
+
+=== Chunk 2157 ===
+Source: 0820_002-ebook.pdf
+Length: 1335 chars
+
+2.9.3 Purchasing and hiring goods and services
+Logistical services must purchase and hire goods and services, and this demands professional expertise. Standard procedures exist, especially for foodstuffs:
+452
+2. Planning GFD 3. GFD implementation
+2.9 Resource mobilization 3.1 Operational organization 3.2 Setting rations
+9 calling for several tenders in each case from known and reliable suppliers;
+9 setting quality specifi cations, in compliance with the FAO Codex Alimentarius or the European Comm...
+
+=== Chunk 2158 ===
+Source: 0820_002-ebook.pdf
+Length: 883 chars
+
+2.9.4 Recruiting competent staff
+Operational success is determined by the quality of fi eld staff and its professional expertise, which is in turn shaped by its training, experience, and common sense. GFD is not particularly complicated to run in terms of the actual distribution of commodities. On the other hand, fi eld staff must be close to the recipients, open to their concerns, and able to detect attempts at abuse. It must have some knowledge of nutrition in order to comprehend the factors tha...
+
+=== Chunk 2159 ===
+Source: 0820_002-ebook.pdf
+Length: 953 chars
+
+3.1 OPERATIONAL ORGANIZATION
+Before discussing the practical aspects of GFD as such, it is worth repeating that its success depends on organization. The staff in charge must be available, have the means to operate (i.e. accommodation, vehicles, and material), and tasks must be clearly defi ned and attributed. Of particular importance is the establishment of an operational centre, which ensures liaison with logistics staff and a reporting system to record the conduct of the operation (for instance...
+
+=== Chunk 2160 ===
+Source: 0820_002-ebook.pdf
+Length: 1555 chars
+
+3.2 SETTING RATIONS
+A GFD targets households or family groups, and not individuals. This is important in order to reinforce family and social cohesion, which is frequently undermined in a nutritional crisis. Besides, a GFD cannot allow for individual nutritional needs; even if it could, the effort would be pointless as the
+453
+I I X
+I I X
+NUTRITION MANUAL Chapter XII – General food distribution
+3. GFD implementation
+3.2 Setting rations
+several rations would in any case end up in the communal coo...
+
+=== Chunk 2161 ===
+Source: 0820_002-ebook.pdf
+Length: 1479 chars
+
+3.2.1 Full rations
+In view of the above, the assumption of the complete absence of food in the given environment on the one hand, and that distributed food will not be sold or exchanged on the other leads to a rather theoretical approach. Such an assumption is anyway seldom completely true, except in institutions (such as homes for the elderly, asylums, hospitals, and orphanages).8
+The exercise is useful nevertheless for two main reasons.
+1. It involves the review of the main factors that must b...
+
+=== Chunk 2162 ===
+Source: 0820_002-ebook.pdf
+Length: 2850 chars
+
+Eating habits
+Eating habits must be respected for two main reasons. The fi rst relates to ethics in rejection of the pretext that “anything goes” in the face of starvation. The second is physiological: small children especially would rather eat less than consume unfamiliar food. This rejection is stronger still in psychologically traumatized children suffering from anorexia due to illness and malnutrition. Chapter V indicated that, in most cultures whose food is supplied by agriculture rather tha...
+
+=== Chunk 2163 ===
+Source: 0820_002-ebook.pdf
+Length: 756 chars
+
+Qualitative aspects
+Food rations must supply enough energy and protein, and energy requirements take precedence over all others. Rations must satisfy these requirements fi rst, or severe malnutrition may develop rapidly. The staples that contribute to the ration are therefore usually the following:
+9 a main source of energy, usually cereals which also supplies a substantial amount of protein and micro-nutrients;
+9 a concentrated source of protein, usually legumes, which provides both energy and m...
+
+=== Chunk 2164 ===
+Source: 0820_002-ebook.pdf
+Length: 1246 chars
+
+The lipid energy/overall energy ratio
+According to different recommended intakes, the contribution of lipids should represent 10 to 20% of the overall calorie supply; only de Ville de Goyet recommends 20–40% (de Ville de Goyet, 1978). Oil is included in food rations because it is a concentrated source of energy and is essential in some cooking methods; it also enhances fl avour. This concentrated source of energy contributes especially to increasing the energy density of the diet of infants, and ...
+
+=== Chunk 2165 ===
+Source: 0820_002-ebook.pdf
+Length: 420 chars
+
+The protein/energy ratio
+In the discussion on nutritional needs, Chapter III demonstrated that diets that supply enough energy usually supply enough protein also. This is noted especially in the case of food rations that combine cereals and legumes. The proportion between protein and energy is expressed as a percentage of the energy value11 of the protein and the overall energy supply: this is the “P/E%” ratio below....
+
+=== Chunk 2166 ===
+Source: 0820_002-ebook.pdf
+Length: 440 chars
+
+G × Kp
+P/E% = –––––––––––––– × 100
+Kr
+Where:
+G = the protein weight in the ration
+K = the calorie value
+Kp = the calorie value of the protein contained in the ration (kcal/gram, or kJ/gram) Kr = the overall calorie value of the ration (kcal or kJ)
+For example, a ration that supplies 2,400 kcal (10,032 kJ) in total, with 70 g of protein, translates into the following P/E% ratio:
+70 g × 4 kcal/g P/E% = ––––––––––––––––––––– × 100 = 11.7 %...
+
+=== Chunk 2167 ===
+Source: 0820_002-ebook.pdf
+Length: 2426 chars
+
+2,400 kcal
+A P/E% ratio of 10 to 13% is usually adequate to satisfy protein requirements, provided that energy requirements are met. The P/E% ratio of cereals is approximately 11%, that of legumes at least 23%. Practically then, a ration that supplies 65% of its energy in cereals, 20% in oil, and 15% in legumes amounts to a P/E% of 11.5%. If the ration supplies 20% of its energy in the form of oil, and the remainder in cereals only (i.e. to the exclusion of legumes), the P/E% drops to 9% or belo...
+
+=== Chunk 2168 ===
+Source: 0820_002-ebook.pdf
+Length: 410 chars
+
+Quantitative aspects
+The amount of food that makes up the ration is determined by the average energy requirement. In the case of a nutritionally healthy population at the onset, the average requirement is calculated based upon:
+9 the demographic composition of the population under scrutiny;
+COdd
+9 the average weight per age and sex groups;
+9 the level of physical activity;
+9 the average ambient temperature....
+
+=== Chunk 2169 ===
+Source: 0820_002-ebook.pdf
+Length: 417 chars
+
+Demographic composition
+Clearly, the demographic composition of each population is specifi c to itself. An average composition that is representative of all groups living in a given situation must therefore be defi ned. This defi nition results in two profi les: one applies to economically developed countries, and the other to underdeveloped or developing countries. These two profi les are provided in Table 12.2 below....
+
+=== Chunk 2170 ===
+Source: 0820_002-ebook.pdf
+Length: 742 chars
+
+Average weight per age and sex group
+The population must be divided into age and sex groups, because these groups correspond to different average weights, and because basal metabolisms differ according to weight and sex. What matters here is the average weight per group or stratum, and it may differ signifi cantly between populations of adolescents and adults. In Table 12.2, adult men included in the WHO 1 population weigh 65 kg on average, and women 55 kg. In the WHO 2 population, men weigh 60 k...
+
+=== Chunk 2171 ===
+Source: 0820_002-ebook.pdf
+Length: 994 chars
+
+Physical activity
+The level of physical activity infl uences energy expenditures (and, hence, energy requirements) signifi cantly. The basal metabolism is multiplied to calculate energy requirements according to the level of physical activity. WHO proposes the use of the following multiplication factors for calculating average daily energy requirements according to physical activity (WHO, 1985):
+Light activity Moderate activity Heavy activity 1.55 1.78 2.1 1.56 1.64 1.82
+Men
+Men
+Women
+In practice,...
+
+=== Chunk 2172 ===
+Source: 0820_002-ebook.pdf
+Length: 1795 chars
+
+Ambient temperature
+Ambient temperature infl uences energy requirements14 substantially. The lower the temperature, the higher the energy cost of thermo-genesis. It goes without saying that rations should not be automatically increased in harsh climatic conditions: habitat material must be supplied fi rst in order to protect their recipients against the cold (shelter against rain or snow and wind, heating material, etc.), and clothing and blankets for thermal comfort. Such measures against the col...
+
+=== Chunk 2173 ===
+Source: 0820_002-ebook.pdf
+Length: 1391 chars
+
+Calorie content
+The above parameters being set, the calorie content of food rations must be defi ned in order to satisfy all the energy requirements of the target population. In terms of temperature, specifi c recommendations exist, provided that the necessary complementary measures relating to habitat and thermal comfort are taken. The average weight per age and sex groups, the level of physical activity and the demographic profi le are defi ned by direct observation and measurements in each indivi...
+
+=== Chunk 2174 ===
+Source: 0820_002-ebook.pdf
+Length: 9857 chars
+
+Table 12.2 Daily calorie values for humanitarian aid rations
+WHO 1 WHO 2 WHO 3 Age (years) %a Energy requirements (kcal) ((kJ)) Age (years) % Energy requirements (kcal) ((kJ)) Age (years) % Energy requirements (kcal) ((kJ)) 0 – 1 3 820 (3,290) 0 – 4 12.37 1,290 (5,390) 0 – 4 6.16 1,290 (5,390) 2 – 3 9 1,360 (5,680) 5 – 9 11.69 1,860 (7,770) 5 – 9 6.67 1,880 (7,860) 4 – 6 8.7 1,830 (7,650) 10 – 14 10.53 2,210 (9,240) 10 – 14 6.81 2,220 (9,280) 7 – 9 8.5 2,190 (9,150) 15 – 19 9.54 2,420 (10,120) 1...
+
+=== Chunk 2175 ===
+Source: 0820_002-ebook.pdf
+Length: 1631 chars
+
+Micro-nutrient requirements
+Full rations should supply all essential micro-nutrients (i.e. vitamins and essential minerals), in line with recommended intakes.16 There are 35 essential micro-nutrients, some of which are “Type II” micro-nutrients, meaning that they must be supplied in a stoechiometric17 relation. The micro-nutrient requirements of groups that rely entirely on food aid are certainly most diffi cult to satisfy. The challenge lies in including all the foodstuffs required for a full ra...
+
+=== Chunk 2176 ===
+Source: 0820_002-ebook.pdf
+Length: 1308 chars
+
+Supplying foods to complete staple foods
+This is no doubt the best way by far of providing all essential nutrients, because complements enhance fl avour and dietary variety. Its major drawback relates to the fact that such complements are fresh foods (such as vegetables, fruits, and animal products), which spoil quickly. This implies that they must be found locally or suffi ciently close to ensure that they are still fresh enough at the time of distribution. Furthermore, they must be distributed s...
+
+=== Chunk 2177 ===
+Source: 0820_002-ebook.pdf
+Length: 471 chars
+
+Supplying rations that contain all essential nutrients
+This type includes survival biscuits and rations that supply concentrated foods; it is useful in the short term. It draws its appeal from its simplicity: it limits distribution to a single type of commodity that requires no specifi c preparation. Its disadvantage lies in its cost, its lack of acceptability in some circumstances, its monotony, and the fact that armed groups fi nd such products especially attractive....
+
+=== Chunk 2178 ===
+Source: 0820_002-ebook.pdf
+Length: 2915 chars
+
+Supplying specifi cally fortifi ed foods
+The distribution of fortifi ed foods is the best way of preventing specifi c defi ciencies, and is the most widely recommended accordingly. Biscuits, fl our, blended foods, groundnut paste, seasoning cubes or pastes can all be fortifi ed in micro-nutrients, according to the amounts required to complete basic rations. The best-known are corn soy blend (CSB) and Unimix, which combine cereal and legume fl ours, and are enriched in vitamins and minerals.
+100 g of CSB...
+
+=== Chunk 2179 ===
+Source: 0820_002-ebook.pdf
+Length: 705 chars
+
+Supplying tablets or powders
+In some circumstances, it may be necessary to supply micro-nutrient tablets or powders to be added to meals after their cooking. Tablets must be distributed regularly and frequently (i.e. at least once a week) because vitamin C and B group vitamins are not stored in the organism. As a result, the distribution of tablets demands signifi cant investment in terms of logistics and work. By the same token, their recipients usually tire of them and tend to take them less an...
+
+=== Chunk 2180 ===
+Source: 0820_002-ebook.pdf
+Length: 1339 chars
+
+Supplying basic rations that permit their exchange for complementary foods
+This approach is the most practical for humanitarian agencies, which thereby transfer the search for complementary foods to recipients. However it provides no guarantee that recipients will indeed satisfy their micro-nutrient requirements. Economic priorities usually take precedence over nutritional concerns when the amount of food is more or less suffi cient to satiate hunger. In the absence of nutritional knowledge, spec...
+
+=== Chunk 2181 ===
+Source: 0820_002-ebook.pdf
+Length: 1157 chars
+
+Supporting the agricultural production of complementary foods
+Such an approach is useful especially when target groups are accustomed to cultivating most of their food, and provided that agricultural land and water (e.g. rain, rivers, and recycled waste water) are available. Garden or backyard cultivation may also be encouraged for the production of vegetables and aromatic herbs in the case of groups that are unfamiliar with such practices. In all cases, the resulting production must begin to be...
+
+=== Chunk 2182 ===
+Source: 0820_002-ebook.pdf
+Length: 552 chars
+
+Refraining from supplying complements where they are available
+This option can only be chosen if the population is clearly used to securing complementary foods by producing or gathering them. The understanding of gathering practices requires sound knowledge of eating habits, and natural resources and their potential. Here again, much certainly remains to be investigated by examining all traditional methods that contribute to a varied diet and account for micro-nutrient supplies. Some such method...
+
+=== Chunk 2183 ===
+Source: 0820_002-ebook.pdf
+Length: 400 chars
+
+Setting priorities
+On principle, all essential micro-nutrients should be included in full rations, in conformity with recommended intakes. However, some specifi c defi ciencies must be avoided at all costs as their health consequences are especially serious.18 The corresponding micro-nutrients are: vitamin A, vitamin C, folic acid, niacin, thiamine, iron, and iodine (these are all Type I nutrients)....
+
+=== Chunk 2184 ===
+Source: 0820_002-ebook.pdf
+Length: 1445 chars
+
+Vitamin C
+Vitamin C poses the greatest challenge as it is only found in fresh (and thus perishable) products, or in enriched foods that risk considerable loss through oxidation during storage and cooking. Consequently, apart from the distribution of tablets as discussed earlier, vitamin C can only be supplied in the form of specifi cally fortifi ed foods or biscuits. This method is however only effective
+18 Chapter III describes the different types of defi ciencies.
+19 Prevention recommendations in...
+
+=== Chunk 2185 ===
+Source: 0820_002-ebook.pdf
+Length: 330 chars
+
+Iron and folic acid
+Here again, iron and folic acid can only be distributed in the form of tablets or fortifi ed foods and biscuits in order to ensure their adequate intake.
+Given that the SFP ration must be fortifi ed according to recommendations in Annex 16, medicinal iron and folic acid should not be distributed in SFP centres....
+
+=== Chunk 2186 ===
+Source: 0820_002-ebook.pdf
+Length: 365 chars
+
+Thiamine and niacin
+In principle, there should be no thiamine or niacin defi ciency if basic rations that supply macro- nutrients are properly defi ned. Proper rations include legumes that complete cereals in the proportions indicated above, and cereals that are milled with the lowest possible extraction rate. If rice is the cereal supplied, it should be parboiled....
+
+=== Chunk 2187 ===
+Source: 0820_002-ebook.pdf
+Length: 1391 chars
+
+Summary
+The above shows that there is no single solution to the supply of essential micro-nutrients in the case of groups that rely exclusively on humanitarian aid. On the other hand, combining the above methods usually provides a satisfactory answer to all situations. In addition, time-scales must be allowed for. In the early stages of food aid, the most comprehensive ration is usually best; later, adjustments must be made to accommodate local resources. This requires considerable monitoring.
+T...
+
+=== Chunk 2188 ===
+Source: 0820_002-ebook.pdf
+Length: 1752 chars
+
+Flavour
+Besides the fact that they are seldom comprehensive, humanitarian food rations are usually quite monotonous – to the point, in fact, that it is fair to question the view that food aid leads to dependency in its recipients and a disinclination to overcome the crisis. Full rations, especially if they are distributed over a signifi cant period, however must include ingredients that enhance their fl avour. Besides pertaining to humanitarian ethics, this method also encourages consumption, espe...
+
+=== Chunk 2189 ===
+Source: 0820_002-ebook.pdf
+Length: 791 chars
+
+Other factors justifying ration increase
+The basic factors that must be taken into account when setting full rations are:
+9 the demographic profi le of the group under consideration;
+9 the real or desired average weight per age and sex group;
+9 the average level of physical activity;
+9 the average ambient temperature.
+The defi nition of standard conditions facilitates the defi nition of reference rations for planning purposes, as described earlier. Rations may need to be adjusted to the above facto...
+
+=== Chunk 2190 ===
+Source: 0820_002-ebook.pdf
+Length: 3665 chars
+
+Nutritional catch-up
+Nutritional catch-up is costly. Weight gain of 1 g of tissue that contains an average of 16% of protein and 25% of lipids involves in the process a consumption of approximately 5 kcal (21 kJ) (WHO, 1985 and Waterlow, 1982). Thus, desired nutritional catch-up rates may be planned. In prisons for example, intakes can sometimes be easily controlled, and fi eld workers can set deadlines for the BMI of inmates to reach an acceptable level; the results are then observed and compare...
+
+=== Chunk 2191 ===
+Source: 0820_002-ebook.pdf
+Length: 4590 chars
+
+Post-distribution losses
+GFD benefi ciaries can suffer commodity losses, for example in the course of cereal milling (if it is distributed in grains), and despoiling.
+In the case of milling, loss is determined by the type of milling itself and the cost involved. According to the type of mill and local eating habits, milling itself causes 10 to 20% losses or more, and also involves substantial vitamin, protein, and mineral loss.23 The cost of milling on the other hand is determined by supply and d...
+
+=== Chunk 2192 ===
+Source: 0820_002-ebook.pdf
+Length: 2833 chars
+
+Composition
+In short, foodstuffs used in full GFD rations usually include the following items.
+1. A basic food, usually cereals, supplied whole, milled or manufactured (e.g. pasta). Family parcels may include wheat fl our, pasta and rice; if wheat fl our is included for bread production, yeast must be available or supplied also.
+2. A concentrated source of energy in the form of fat or oil, which is compatible with local eating habits and enriched in vitamin A if possible. Palm oil contains much pr...
+
+=== Chunk 2193 ===
+Source: 0820_002-ebook.pdf
+Length: 9526 chars
+
+Examples of food rations
+A number of examples of full rations are provided below. It is worth reiterating here that breastfeeding must be encouraged, restored and protected actively in all circumstances as the best method of infant feeding, and an invaluable nutritional and emotional complement during weaning.
+Full rations must be designed on the basis of simple and easily found foods and ingredients. Table 12.3 below suggests a list of such foodstuffs, indicating their average protein and energ...
+
+=== Chunk 2194 ===
+Source: 0820_002-ebook.pdf
+Length: 6590 chars
+
+3.2.2 Complementary rations
+Complementary rations are used when the target group cannot secure enough food and/or when doing so is dangerous. As a result, if a given group clearly still has access to food, but insuffi ciently so or in a way that exposes it to risks, complementary rations supply the food commodities that the group cannot secure, or replace what the group obtains or consumes in a way that threatens its survival.
+The concept is rather simple; however its implementation is usually mo...
+
+=== Chunk 2195 ===
+Source: 0820_002-ebook.pdf
+Length: 2101 chars
+
+The problem
+It must be clear from the outset that food aid should not serve as a currency. This is a waste of resources and effort, not to mention that its relative value is then usually lower than if cash were distributed instead. This is especially true when many recipients sell the same commodity in order to purchase scarce goods. Humanitarian aid must strive to meet all needs for aid involving economic goods and services necessary for survival, in order to prevent the use of food to other en...
+
+=== Chunk 2196 ===
+Source: 0820_002-ebook.pdf
+Length: 2148 chars
+
+Practical aspects
+The distribution of food rations is seldom intended to supply an exchange commodity only; in principle it usually aims at two objectives, whose relative importances vary according to circumstances.
+1. The nutritional objective: the approach is identical to that applied in setting full or complementary rations. Readers are therefore referred to Sections 3.2.1 and 3.2.2 above.
+2. The economic objective: the approach consists in supplying a complement that should permit its exchan...
+
+=== Chunk 2197 ===
+Source: 0820_002-ebook.pdf
+Length: 1467 chars
+
+3.3 TARGETING GROUPS
+The decision to target specifi c groups within a given population for GFD aims at limiting the waste of resources committed by donors, and at excluding those that do not really require assistance.
+Targeting involves three levels of identifi cation.
+1. The geographic identifi cation of areas and populations that are affected by adverse phenomena.
+2. The identifi cation within such populations27 of communities that face crisis because of their functional or cultural features.
+3. T...
+
+=== Chunk 2198 ===
+Source: 0820_002-ebook.pdf
+Length: 4206 chars
+
+3.3.1 The need to target only the most needy within communities
+Three types of justifi cation exist for this level of identifi cation.
+1. Socio-economic discrepancies internal to the community are such as to result in some of its members needing aid, and others not.
+2. GFD could demotivate the community from fi nding its own solutions to the problem.
+3. Available resources are insuffi cient to assist all households, even if they all more or less require support.
+27 The expression “population” is und...
+
+=== Chunk 2199 ===
+Source: 0820_002-ebook.pdf
+Length: 5054 chars
+
+3.3.2 Feasibility
+It may be diffi cult to single out specifi c households within a given community. The exercise entails two major challenges. The fi rst relates to the targeting itself, which may not be acceptable to the community and/or their leaders. Some cultures require that assistance be shared among all members of the community, and targeting specifi c households is pointless in this case. Such cultures usually rest upon strong social obligations, and the redistribution of wealth to the poor ...
+
+=== Chunk 2200 ===
+Source: 0820_002-ebook.pdf
+Length: 5220 chars
+
+3.4 ATTENDING TO GROUPS
+A GFD involves taking responsibility for its benefi ciaries. This responsibility is informal, consisting of relations of trust with the population and its traditional leaders as from preliminary assessment. Once the decision has been made to engage in GFD, its benefi ciaries must be counted and registered, and they must receive cards that grant them access to the GFD. GFD modalities
+478
+3. GFD implementation
+3.4 Attending to groups
+must also be discussed with them in terms ...
+
+=== Chunk 2201 ===
+Source: 0820_002-ebook.pdf
+Length: 4474 chars
+
+3.4.1 Individual census and registration
+This approach consists in gathering the population in one or more locations, and registering all its members on the same day, if possible at the same time in order to avoid people registering twice in different locations. All able persons, young and old, must report. Exceptionally, sick, helpless, or absent individuals may be registered provisionally, provided that the reasons are valid (for example, persons who have had to remain in the village or neighb...
+
+=== Chunk 2202 ===
+Source: 0820_002-ebook.pdf
+Length: 1402 chars
+
+3.4.2 Census and registration according to residence
+This method consists in identifying dwellings and their occupants in order to list them. All members of all family units of a given dwelling or defi ned group of dwellings (i.e. clusters) must be present. This method is useful in urban settings, provided that enough teams are working in parallel in order to discourage attempts at abuse. This approach involves three steps.
+1. A perimeter is set to include dwellings or clusters within an overall ...
+
+=== Chunk 2203 ===
+Source: 0820_002-ebook.pdf
+Length: 3894 chars
+
+N1/14/c
+Where “N1” is neighbourhood number 1, 14 the fourteenth house registered in this neighbourhood, and “c” indicates that three families live under the same roof in house number 14.
+2. Subsequently or simultaneously to coding (depending on circumstances), benefi ciary lists are established, which involves the registration according to family units of all individuals living in each dwelling or cluster. Persons who are absent or do not return home every night are not included. The data that is...
+
+=== Chunk 2204 ===
+Source: 0820_002-ebook.pdf
+Length: 1783 chars
+
+3.4.3 Distribution cards
+GFD cards acquire crucial importance in crisis settings. For the operating agency, they contribute substantially to the monitoring of benefi ciaries; for the benefi ciaries, they give access to the GFD. As such, they are of considerable value. The end justifying the means, the creative ingenuity shown in forging or tampering with cards knows no limits. Consequently, the thorough checking of cards is of crucial importance.
+Distribution cards indicate a number, which corresp...
+
+=== Chunk 2205 ===
+Source: 0820_002-ebook.pdf
+Length: 2986 chars
+
+Figure 12.2 Distribution card – example
+DISTRIBUTION CARD No  1 2 3 4 5 /10001  NGO  X  Name : _________________________________  Alphaland / Gamma region  Info   : _________________________________  31  21  22  23  24  25  26  27  28  29  30  11  12  13  14  15  16  17  18  19  20  1  2  3  4  5  6  7  8  9  10  DISTRIBUTION  CODE FOR THE NUMBER  MARKING  OF FAMILY MEMBERS
+DISTRIBUTION
+POINT CODE
+POPULATION
+GROUP CODE
+Distribution rounds may be marked in the second and third row, for example, w...
+
+=== Chunk 2206 ===
+Source: 0820_002-ebook.pdf
+Length: 791 chars
+
+3.5 DISTRIBUTION MODALITIES
+Food may be distributed directly to its recipients, or indirectly through their local or traditional leaders. However, indirect distribution requires the application of means to control its quality; it should only be resorted to in the absence of alternative, as it usually results in lapses that are diffi cult to correct subsequently. Direct distribution involves the provision of take-away rations or food to be eaten on the spot. Food is supplied in take-away form if i...
+
+=== Chunk 2207 ===
+Source: 0820_002-ebook.pdf
+Length: 2904 chars
+
+3.5.1 Take-away rations
+The distribution of take-away food rations must ensure the regular and suffi cient food consumption of its recipients. It must be organized in a way that complies with a set frequency, involving the intended amounts and timeframes, and avoids interruptions at all costs. This implies that the logistics supply chain can indeed run smoothly, and that its staff is informed in time of the required amounts to be delivered to specifi c distribution points. Recipients must be invol...
+
+=== Chunk 2208 ===
+Source: 0820_002-ebook.pdf
+Length: 441 chars
+
+Informing the population
+Distribution dates
+The population must be informed of the fi rst distribution round suffi ciently in advance, so that it may organize itself, especially if it must travel long distances to reach distribution points. Provided that frequency is regular and plans are adhered to, simple confi rmation should suffi ce thereafter. If plans must be modifi ed on the other hand, timely information must be delivered accordingly....
+
+=== Chunk 2209 ===
+Source: 0820_002-ebook.pdf
+Length: 1572 chars
+
+Location
+There must be no possible confusion as to where the distribution will take place.
+Distribution must be planned in a large, central location, which enables recipients to move around unhindered within its boundaries in an organized fl ow from the entry to the exit points. To this end, the chosen location must at least be cordoned off and guarded by organization staff and benefi ciaries; the latter have a serious interest in avoiding chaos and excluding agitators who, for their part, have ev...
+
+=== Chunk 2210 ===
+Source: 0820_002-ebook.pdf
+Length: 756 chars
+
+Attendance
+In some cases, it may be best that all benefi ciaries attend, and assistance only be delivered to persons who are present accordingly (especially if attempts at abuse have been noted). Distributing agencies may on the other hand choose to meet only cardholders accompanied by a limited number of their relatives who are there to help the cardholder transport the distributed goods.34 The extent of required attendance is also determined by the other types of activity that may be conducted ...
+
+=== Chunk 2211 ===
+Source: 0820_002-ebook.pdf
+Length: 387 chars
+
+Material required of benefi ciaries
+In principle, distributing agencies do not supply the material required for carrying assistance items away. Recipients must therefore be told clearly what type of material they must bring to the distribution; however, distributing agencies must always keep some packing material for the completely destitute, but this must however remain the exception....
+
+=== Chunk 2212 ===
+Source: 0820_002-ebook.pdf
+Length: 114 chars
+
+Ration type and size
+Recipients must understand their entitlements, in order for them to organize their transport....
+
+=== Chunk 2213 ===
+Source: 0820_002-ebook.pdf
+Length: 292 chars
+
+Distribution modalities
+Recipients must be aware of distribution modalities, what other activities will be taking place at the same time where relevant, and what they are expected to do; this saves considerable time and effort at the beginning of the distribution itself, and limits disorder....
+
+=== Chunk 2214 ===
+Source: 0820_002-ebook.pdf
+Length: 1588 chars
+
+Work plans
+Distribution follows a plan, according to distribution points and benefi ciary groups. Available means must permit distribution rounds to be carried out as planned, and be fl exible enough to allow for unexpected delays (uncertainty is practically the rule in humanitarian action). For example, the use
+34 In such cases, only able-bodied relatives should be admitted; on the other hand, mothers must frequently report accompanied by their smaller children as they cannot leave them unattende...
+
+=== Chunk 2215 ===
+Source: 0820_002-ebook.pdf
+Length: 1919 chars
+
+Recipient units
+Food can be distributed according to a set number of members per family, a set number of individuals belonging to different grouped families, or on an individual basis. The set number of members per family refl ects average family size, as observed during registration. If the average family size turns out to be four individuals, for example, then four individual rations will be distributed to each family, regardless of its actual size. The set number of individuals per group of fa...
+
+=== Chunk 2216 ===
+Source: 0820_002-ebook.pdf
+Length: 1824 chars
+
+Crowd control
+Benefi ciaries should enter at one end of the distribution location, and exit at the other. Intersection of queues and backtracking must be avoided at all costs. The population gathers and splits into families at the entry point; each family is then referred to a specifi c queue according to how many members it comprises. Each queue is channelled by ropes, and leads to the card verifi cation desk (see below). The population then reports to the other attention points (where relevant, f...
+
+=== Chunk 2217 ===
+Source: 0820_002-ebook.pdf
+Length: 1778 chars
+
+Food distribution
+The distribution of individual parcels or survival rations is usually simple, as the number of parcels should amount to the number of cards. Distribution from bulk consignments (or “scooping”, for example the distribution of fl our out of bags) is usually more quickly and often more accurately done according to volume rather than weight. This involves the use of calibrated containers to ensure the
+487
+I
+I
+X
+I I X
+NUTRITION MANUAL Chapter XII – General food distribution
+3. GFD im...
+
+=== Chunk 2218 ===
+Source: 0820_002-ebook.pdf
+Length: 682 chars
+
+Card verifi cation
+Cards must be verifi ed at each distribution round in order to limit both claims and attempts at abuse. The verifi cation process takes place at the queue, before recipients proceed to the different attention points. Verifi cation includes the checking of distribution location codes, and those indicating the group due to receive assistance on that specifi c date. Cards that do not indicate the correct distribution location are withheld, their holders’ identity is verifi ed, and the ...
+
+=== Chunk 2219 ===
+Source: 0820_002-ebook.pdf
+Length: 649 chars
+
+Notifi cation to offi cials
+Local authorities must be informed of the distribution due to take place, as they must also ensure that third parties are prevented from taking over. This does not suggest that police or army forces should ensure order at the actual distribution points; this duty devolves upon the distributing agency. However, they must be informed and accept that they cannot take advantage of the distribution to make political speeches, exercise control over the population, recruit or ...
+
+=== Chunk 2220 ===
+Source: 0820_002-ebook.pdf
+Length: 1045 chars
+
+The role of staff in charge of distribution
+The staff in charge of the distribution has two main and equally essential roles. The fi rst is to ensure the smooth conduct of the distribution itself. The second involves the understanding of the following parameters in their broadest sense:
+9 the population, its reactions, and its needs for assistance;
+9 the impact and effects of the GFD, as well as possible associated or resulting problems arising from organizational issues;
+9 new developments in th...
+
+=== Chunk 2221 ===
+Source: 0820_002-ebook.pdf
+Length: 770 chars
+
+3.5.2 Rations to be consumed on the spot
+Food can be distributed in the form of meals to be consumed on the spot in two types of circumstances.
+1. In institutions (such as prisons, homes, asylums, hospitals, nutritional centres, and canteens for the elderly). As such, this approach does not amount to a GFD proper. Its practical implementation aspects are similar to those of soup kitchens (which are discussed below); however, the decision to provide meals in institutions is routine, and should no...
+
+=== Chunk 2222 ===
+Source: 0820_002-ebook.pdf
+Length: 3470 chars
+
+Situations where soup kitchens are appropriate
+In principle, soup kitchens are not recommended for the feeding of large populations. They are usually culturally inappropriate (even offensive), they are time-consuming for their benefi ciaries, and may complicate the carrying-out of production activities that are essential to economic recovery. Food hygiene is diffi cult to ensure in the framework of soup kitchens, and the diet they provide is often monotonous. They upset the food consumption of sma...
+
+=== Chunk 2223 ===
+Source: 0820_002-ebook.pdf
+Length: 1376 chars
+
+Soup kitchen rations
+Rations are set according to the same parameters as those discussed earlier in Section 3.2, based on Tables 12.5 and 12.6. Both full and complementary rations require that the food supplied to the kitchens ensures an adequate daily food intake. In the case of full rations, the minimum objective is to avoid deterioration in the nutritional status of their recipients and, if possible, to permit those who are already malnourished to recover. Thus, kitchen rations must cover at ...
+
+=== Chunk 2224 ===
+Source: 0820_002-ebook.pdf
+Length: 383 chars
+
+Planning
+Soup kitchens must be well planned – this is made easier by the fact that they operate on a daily routine. If the programme supplies only the strict minimum for survival, and especially if clinical malnutrition is the criterion for admission, organization is even more important in order to avoid confusion and perhaps riots. Good organization involves the following points....
+
+=== Chunk 2225 ===
+Source: 0820_002-ebook.pdf
+Length: 616 chars
+
+Standard organization
+All kitchens involved in the programme must observe the same:
+9 benefi ciary admission criteria;
+CORRVGGTEIUE
+9 benefi ciary registration methods;
+9 benefi ciary control methods;
+9 management;
+9 supply;
+9 meal times;
+9 operational supervision;
+9 operational evaluation;
+9 staff compensation procedures;
+9 ration amounts and quality;
+9 benefi ciary contribution procedures where applicable (such as the supply of fi rewood and water, support to assistants, the provision of edible fol...
+
+=== Chunk 2226 ===
+Source: 0820_002-ebook.pdf
+Length: 326 chars
+
+Continuity
+Once the programme has begun, interruptions must be avoided at all costs, especially in the case of malnourished subjects because their metabolism cannot easily adapt to interruptions early in the resumption of feeding – such interruptions can in fact be fatal.
+490
+3. GFD implementation
+3.5 Distribution modalities...
+
+=== Chunk 2227 ===
+Source: 0820_002-ebook.pdf
+Length: 307 chars
+
+Comprehensive coverage
+The number of kitchens must be adequate, and they must be properly located in order to maximize their effi ciency and coverage. All subjects who meet the admission criteria must clearly have access to a kitchen, and discrimination is a major cause of protest in conditions of survival....
+
+=== Chunk 2228 ===
+Source: 0820_002-ebook.pdf
+Length: 249 chars
+
+Suffi cient dietary intake
+In order to reduce mortality signifi cantly, full rations must supply at least 1,900 kcal (7,940 kJ) per person per day. Failing that, the exercise is a useless waste of resources and, worse, contradicts humanitarian ethics....
+
+=== Chunk 2229 ===
+Source: 0820_002-ebook.pdf
+Length: 3232 chars
+
+Benefi ciaries
+It is possible to admit all individuals who report spontaneously to soup kitchens, especially in the case of passive targeting. However, this usually entails a number of complications: complete disorder at mealtimes, upsetting logistics plans, and the risk of lapses in proportion to the magnitude of needs. It is therefore best to set criteria for admission from the outset, and these can be combined: obvious clinical malnutrition, age groups, lists of destitute families produced in ...
+
+=== Chunk 2230 ===
+Source: 0820_002-ebook.pdf
+Length: 6420 chars
+
+Management
+Kitchens must be managed systematically, and the following aspects deserve specifi c attention in this respect.
+1. Kitchens must have easy and suffi cient access to clean water. Options include piped supply, transport (e.g. water-trucking), catchments or wells located within the kitchen compound or in its close vicinity. In all cases, one or more tanks must be available to ensure water self-suffi ciency, and these must at least cover supply during foreseeable breakdowns; rainwater can al...
+
+=== Chunk 2231 ===
+Source: 0820_002-ebook.pdf
+Length: 3656 chars
+
+Meals
+Full rations must be supplied in the form of two meals a day at least, preferably three, and obviously at set times, which must be observed by all kitchens involved in the programme (for example, 10:00 am and 3:00 pm, or 09:00 am, 1:00 pm and 5:00 pm). Kitchens must operate every day of the week.
+Meals must imperatively be eaten on site, so as to ensure that the food is actually consumed by the benefi ciaries, and in order to help small children and the sick with their meal.
+The food must b...
+
+=== Chunk 2232 ===
+Source: 0820_002-ebook.pdf
+Length: 1699 chars
+
+Important associated activities
+Even if food distribution is the only planned activity, one must ensure that vaccination against measles has been done or is planned. It is in any case essential and compulsory.
+Soup kitchens provide the ideal setting for:
+9 the detection of sickness and severely malnourished subjects, and their referral to hospitals and therapeutic feeding centres;
+9 the conduct of healthcare activities such as vaccination, vitamin A supplementation, parasite treatment, ambulator...
+
+=== Chunk 2233 ===
+Source: 0820_002-ebook.pdf
+Length: 1334 chars
+
+3.6 MONITORING AND EVALUATION
+Any GFD programme must be combined with monitoring and evaluation in order to determine:
+9 that it is running according to plan and, if not, why not;
+COU
+9 that it is achieving its objectives and has the intended impact and, if not, why not;
+9 its side effects and negative effects, and their reasons;
+9 the necessary corrective measures resulting from the three previous points;
+9 developments in the situation in general, and that of the nutritional situation in parti...
+
+=== Chunk 2234 ===
+Source: 0820_002-ebook.pdf
+Length: 568 chars
+
+3.7 GFD TERMINATION
+The two criteria for the termination of a GFD are set during its planning phase: its objectives must have been achieved, and the implementation criteria must no longer apply (as demonstrated in monitoring and evaluation fi ndings). In some circumstances however, GFD must be terminated earlier because unexpected negative effects have appeared, because security conditions no longer permit its continuation, or because monitoring and evaluation have revealed new parameters that re...
+
+=== Chunk 2235 ===
+Source: 0820_002-ebook.pdf
+Length: 2741 chars
+
+3.8 FOOD STORAGE
+Food storage is an important aspect of GFD in order to ensure food quality and appropriate management.
+9 The storage space or warehouse must be sheltered from the elements, and must therefore be structurally sound. In particular, its roofi ng must be adequate, its fl oor must be high enough to limit the risk of fl ooding, it must be well-ventilated and offer the least possible refuge to rodents and other pests. It must be cleaned daily if it operates permanently, and cleaning must ...
+
+=== Chunk 2236 ===
+Source: 0820_002-ebook.pdf
+Length: 209 chars
+
+4.7 TREATING ADOLESCENTS AND ADULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 550
+499
+Chapter XIII – Therapeutic feeding
+1. General considerations
+1.1 Defi nition...
+
+=== Chunk 2237 ===
+Source: 0820_002-ebook.pdf
+Length: 913 chars
+
+1.2 THERAPEUTIC FEEDING IN HUMANITARIAN ACTION
+Within the framework of humanitarian action in crisis, therapeutic feeding is part of survival relief3 efforts and represents the last safety net before death (see Figure 13.1 below).
+Figure 13.1 Therapeutic feeding within humanitarian action
+CRISIS PROCESS  PRELIMINARY PHASE  OVERT PHASE  OR CRISIS  RECOVERY PHASE  PROTECTION MEASURES  THERAPEUTIC FEEDING  ECONOMIC SUPPORT  SURVIVAL RELIEF  WARNING  ECONOMIC REHABILITATION  SIGNALS  DEVELOPMENT  AD...
+
+=== Chunk 2238 ===
+Source: 0820_002-ebook.pdf
+Length: 94 chars
+
+1.3 THE OBJECTIVE OF THERAPEUTIC FEEDING
+The objective of therapeutic feeding is quite simple:...
+
+=== Chunk 2239 ===
+Source: 0820_002-ebook.pdf
+Length: 307 chars
+
+avoiding the death of severely malnourished individuals and restoring their nutritional status up to satisfactory levels.
+A satisfactory level permits survival in a natural environment, provided that living conditions are adequate; the latter are usually the object of other types of humanitarian attention....
+
+=== Chunk 2240 ===
+Source: 0820_002-ebook.pdf
+Length: 1324 chars
+
+2. PLANNING THERAPEUTIC FEEDING
+Figure 13.3 below illustrates the planning process for the treatment of severe malnutrition and its implementation parameters.
+Figure 13.3 Logical sequence for the treatment of severe malnutrition in a TFC
+PLANNING  IMPLEMENTATION  INITIAL ASSESSMENT  – THERAPEUTIC FEEDING CENTRE (TFC)  DEMONSTRATION OF A SEVERE  MALNUTRITION PROBLEM  DEMONSTRATION OF THE  – CRITERIA FOR ADMISSION AND DISCHARGE  FEASIBILITY OF A THERAPEUTIC  FEEDING PROGRAMME  – OPERATIONAL PROCED...
+
+=== Chunk 2241 ===
+Source: 0820_002-ebook.pdf
+Length: 740 chars
+
+2.1 UNDERSTANDING THE PROBLEM AND THE SITUATION
+Therapeutic feeding programmes must be based on a convincing demonstration that they respond to a need in terms of the magnitude of the problem (the size of the affected population), its seriousness (severe malnutrition rates), the prognosis (rising, falling, or stable rates), and its causes (e.g. food insuffi ciency, inadequate care, and sickness). This understanding is gained through assessment, which not only sheds light on the types of problems ...
+
+=== Chunk 2242 ===
+Source: 0820_002-ebook.pdf
+Length: 3235 chars
+
+2.4 TERMINATION CRITERIA
+It may seem paradoxical to set criteria for the termination of a programme before it has even begun. This aspect nevertheless pertains to good planning, because it encourages decision-makers to consider the programme in its overall context.
+The termination of a therapeutic feeding programme, and the closure of a TFC, is called for when the number of patients no longer justifi es its maintenance. This is the major practical criterion, provided that the reduction in admissi...
+
+=== Chunk 2243 ===
+Source: 0820_002-ebook.pdf
+Length: 406 chars
+
+3. IMPLEMENTING THERAPEUTIC FEEDING PROGRAMMES FOR THE TREATMENT OF SEVERE MALNUTRITION
+The implementation of therapeutic feeding programmes requires the following elements to be
+established:
+9 the therapeutic feeding centre (TFC) (Section 3.1);
+9 the criteria for admission and discharge (Section 3.2);
+9 TFC operational procedures (Section 3.3);
+9 TFC operational monitoring and evaluation (Section 3.4)....
+
+=== Chunk 2244 ===
+Source: 0820_002-ebook.pdf
+Length: 3843 chars
+
+3.1 THERAPEUTIC FEEDING CENTRES
+Therapeutic feeding programmes are run through therapeutic feeding centres (TFC). Such centres are organized so as to provide the indispensable services required to treat patients suffering from severe malnutrition. They must be located in the close vicinity of the benefi ciary population, and of some healthcare facility to which patients that require special medical attention may be referred. The chosen location must be protected from the general risks prevailing,...
+
+=== Chunk 2245 ===
+Source: 0820_002-ebook.pdf
+Length: 4593 chars
+
+3.1.1 Facilities
+A standard TFC includes the following facilities.
+9 Shelter for the watchmen, located next to the gates and inside the compound, which enables the supervision of the entrance and its immediate vicinity.
+9 A room or offi ce for registration, admissions, nutritional surveillance, and discharges. Depending on the size of the TFC, it may be best to separate the surveillance room and the admission room, in order to perform admissions, discharges, and surveillance on a daily basis.
+9 A...
+
+=== Chunk 2246 ===
+Source: 0820_002-ebook.pdf
+Length: 4249 chars
+
+3.1.2 Water and sanitation
+Access to water
+Preliminary remarks
+The setting up of water supply systems (especially for drinking water) requires technical skills that are often beyond those of the health staff running a TFC; this is particularly true because access to water varies signifi cantly from location to location. The general rule is that all matters pertaining to water and sanitation in a TFC should be addressed by water and environmental engineers or technicians.
+Beyond that, the major po...
+
+=== Chunk 2247 ===
+Source: 0820_002-ebook.pdf
+Length: 2104 chars
+
+Sanitation
+Hygiene is very important in a TFC. The equipment must permit ablutions, the cleaning of material, and the disposal of garbage and waste water, and this with as little pollution as possible.
+This equipment includes the following items and facilities.
+9 Cleaning and disinfection material specifi c to each unit (for example, the material used to clean the intensive care unit must not be used to clean the kitchens or the latrines); adequate reserves of such material must also be kept.
+9 L...
+
+=== Chunk 2248 ===
+Source: 0820_002-ebook.pdf
+Length: 604 chars
+
+3.1.3 Operational equipment
+This material comprises the following items and item categories (Annex 13 provides detailed item lists for TFC, and Annex 18 provides them for Supplementary Feeding Programme):
+9 furniture;
+COgtCIgTeVy
+9 surveillance and monitoring equipment;
+9 stationery and offi ce material;
+9 medical material;
+9 stocks of medicine, food, fuel, and consumables;
+9 kitchen utensils and material, crockery and cutlery;
+9 cleaning and disinfection material;
+9 maintenance and construction ...
+
+=== Chunk 2249 ===
+Source: 0820_002-ebook.pdf
+Length: 2519 chars
+
+3.1.4 Human resources
+The centre must be suffi ciently staffed, and personnel must be properly paid, be aware of roles and responsibilities, and be appropriately trained. Each function within the centre must be supervised by specifi c staff members: security, cleaning, kitchens, surveillance, etc. The necessary number of persons is determined by the workload, which is itself defi ned by the number of benefi ciaries, the level of care, and follow-up. Centres that include an intensive care unit that o...
+
+=== Chunk 2250 ===
+Source: 0820_002-ebook.pdf
+Length: 2207 chars
+
+Table 13.1 TFC overview matrix
+Tasks Facilities Material Staffa Admission Admission room, which may Offi ce furniture and 1 nurse also be the examination equipment, nutritional 3 assistants room; sheltered waiting measurement material. rooms. Accommodation Room(s) for benefi ciaries who Beds, mattresses, mats, 1 supervisor require 24-hour attention; mosquito nets, blankets, 3 assistants per 20 children, water and hygiene points, clothing, and soap; access 24-hours. latrines, water stocks; to water...
+
+=== Chunk 2251 ===
+Source: 0820_002-ebook.pdf
+Length: 1541 chars
+
+3.2.1 Admission criteria
+Logically, a TFC should only admit individuals who will have adequate access to food and living conditions after their discharge. This leads once again to the remark that nutritional feeding programmes must fi t into a broader range of measures for the prevention of malnutrition – failing that, the TFC operation is useless and ethically unacceptable.
+TFC are often restricted to children under 5 for practical and also cultural reasons:
+9 this age group is the fi rst to show...
+
+=== Chunk 2252 ===
+Source: 0820_002-ebook.pdf
+Length: 4492 chars
+
+Screening
+Patients admitted to a TFC must be identifi ed in some way. This can be done in the following ways:
+9 during registration ahead of GFD, or during GFD itself, when all benefi ciaries are present;4
+CO
+9 through systematic home visits;
+9 through broad publicity asking the population to refer children to screening points (this is not advisable if the nutritional situation is already very bad, as this would soon saturate entry points and possibly the centres themselves);
+4 See Chapter XII.
+51...
+
+=== Chunk 2253 ===
+Source: 0820_002-ebook.pdf
+Length: 385 chars
+
+Carers
+Children under 6 years of age must be accompanied, preferably by their mother. If it is necessary to accommodate carers near the centre (because their home is too distant or owing to insecurity), then mothers must be accommodated together with their other children, even if they are not malnourished. Carers must be included in the general food distribution set-up if necessary....
+
+=== Chunk 2254 ===
+Source: 0820_002-ebook.pdf
+Length: 630 chars
+
+Special cases
+If AIDS, tuberculosis or an incurable sickness are suspected, the patient must not be admitted to the TFC. Such cases must be referred to appropriate healthcare facilities, or be sent home to die, provided that they are properly taken care of, or resort to social services and other specialized entities. If such cases are numerous, a specifi c attention point must be set up to ensure that they receive minimum healthcare and adequate feeding, and die in decent conditions.
+Sugar and al...
+
+=== Chunk 2255 ===
+Source: 0820_002-ebook.pdf
+Length: 892 chars
+
+Admitting adolescents and adults
+Adolescents and adults should only be admitted to a TFC that caters for children if they are very seriously malnourished and sick, provided that their illness can be treated in the TFC. Admission criteria should be a weight-for-height index inferior to 70%, in compliance with the table included in Annex 4.4 for adolescents, and a BMI6 inferior to 14 for adults. Kwashiorkor cases are only admitted if they are marasmic, in compliance with the above criteria. A TFC ...
+
+=== Chunk 2256 ===
+Source: 0820_002-ebook.pdf
+Length: 702 chars
+
+Discharge following nutritional catch-up
+For children, the criterion for discharge is the stabilization of their weight for two weeks at the level defi ned for their resumption of a normal diet. The anthropometric threshold for this shift can vary, as explained in Section 4.2.5 below. In addition, the child must be healthy, and it must have recovered its appetite. In some cases, the mother must also have acquired the knowledge to feed and take care of the child properly. This last criterion only ...
+
+=== Chunk 2257 ===
+Source: 0820_002-ebook.pdf
+Length: 1206 chars
+
+Exclusion due to absenteeism or misconduct
+Absences that exceed three days in a row, or fi ve days spread over a fortnight without good reason, in spite of three warnings, leads to the exclusion of the patient from the programme. TFC operators must
+6 BMI: body mass index = weight (kg)/height (m squared). See Chapter VIII.
+7 See Section 4.7 in this Chapter.
+515
+I I I X
+I I I X
+NUTRITION MANUAL Chapter XIII – Therapeutic feeding
+3. Implementing therapeutic feeding programmes for the treatment of se...
+
+=== Chunk 2258 ===
+Source: 0820_002-ebook.pdf
+Length: 221 chars
+
+3.3 OPERATIONAL PROCEDURES
+A minimum set of procedures is necessary to run a TFC properly; the application of such procedures calls for common sense, allowing for the circumstantial characteristics of each individual TFC....
+
+=== Chunk 2259 ===
+Source: 0820_002-ebook.pdf
+Length: 394 chars
+
+3.3.1 Registration and admission
+The registration of patients immediately follows their selection, unless selection is performed during home visits when appointments are set. Registration consists in recording the information required for individual monitoring and for the evaluation of the operation proper; patients are then issued with an identifi cation bracelet, and admitted to the centre....
+
+=== Chunk 2260 ===
+Source: 0820_002-ebook.pdf
+Length: 1215 chars
+
+Collecting and recording personal data
+Data collection consists of the following steps.
+1. Registering the patient in a ledger (Annex 14 provides an example). The same row indicates the personal identifi cation number (attributed by order of admission), the admission date, the name, age, sex, address of the patient, and the name of the carer. The following row contains the personal data of the next patient, and so on.
+2. Performing anthropometric measurements and physical examination in order to ...
+
+=== Chunk 2261 ===
+Source: 0820_002-ebook.pdf
+Length: 329 chars
+
+Identifi cation bracelets
+All patients must wear bracelets that indicate their personal identifi cation numbers, codes that correspond to the centre they are assigned to, and the code or logo of the operating agency; this information also limits abuse. Bracelets can be colour-coded according to the phase of nutritional treatment....
+
+=== Chunk 2262 ===
+Source: 0820_002-ebook.pdf
+Length: 549 chars
+
+Admission
+Benefi ciaries and their carers are admitted and receive routine attention accordingly (see Section 4.6.1 below), together with the medical treatment required by their condition, where applicable;
+516
+3. Implementing therapeutic feeding programmes for the treatment of severe malnutrition
+3.3 Operational procedures
+the process also includes providing information as to operational procedures and the layout of the centre. They should then be able to wash and receive clothes, blankets and s...
+
+=== Chunk 2263 ===
+Source: 0820_002-ebook.pdf
+Length: 271 chars
+
+3.3.2 Monitoring
+The surveillance process is useful to monitor benefi ciaries, and at the same time provides the indications required to evaluate the operation proper. The monitoring of the condition of the benefi ciary is separate from that of attendance (or absenteeism)....
+
+=== Chunk 2264 ===
+Source: 0820_002-ebook.pdf
+Length: 750 chars
+
+Monitoring benefi ciary condition and progress
+The nutritional status of benefi ciaries is measured at regular intervals, usually on the basis of rotations. Patients need not be measured daily, even during initial treatment; bi-weekly weighing is suffi cient to monitor progress. Results must be compared immediately with the previous entry in order to detect possible complications and take appropriate measures. In addition, the assistants in charge of meals must permanently observe the condition of ...
+
+=== Chunk 2265 ===
+Source: 0820_002-ebook.pdf
+Length: 436 chars
+
+Monitoring attendance
+It is essential for attendance to be regular in order to ensure adequate feeding and care. Attendance is monitored at each meal, and recorded in a special ledger that indicates the bracelet number and the name of the patient under consideration. Benefi ciaries and their carers must be informed of the rules governing their presence at mealtimes and medical treatment sessions, and the consequences of absenteeism.8...
+
+=== Chunk 2266 ===
+Source: 0820_002-ebook.pdf
+Length: 998 chars
+
+3.3.3 Discharge
+The criteria for discharge have been discussed earlier. In principle, patients should remain in the centre until their nutritional status has stabilized at the anthropometric discharge criteria for two weeks. However, a signifi cant prevalence rate of severe malnutrition can impose faster rotations, and may lead to the reduction, or even the complete waiving of this safety period. In any case, TFC operators must ensure that discharged patients have followed the routine termination...
+
+=== Chunk 2267 ===
+Source: 0820_002-ebook.pdf
+Length: 1600 chars
+
+3.3.4 Food preparation
+The preparation of food must follow clear, illustrated protocols and fi gures, which must be posted visibly in the kitchen, alongside the compulsory schedules. Kitchens operate essentially in strict compliance with schedules that defi ne the activities for each meal:
+9 attendance monitoring, and the resulting acquisition and
+preparation of resources (fuel, water, and food), that is, as required by the number of benefi ciaries and no more;
+9 lighting up the stoves;
+9 bringing ...
+
+=== Chunk 2268 ===
+Source: 0820_002-ebook.pdf
+Length: 1860 chars
+
+3.3.5 Food distribution
+The benefi ciaries, their carers, and the staff must all know and observe mealtime schedules. During initial treatment, assistants can deliver the food directly to the patients in the intensive care unit, especially if the latter operates 24 hours per day. Otherwise, the benefi ciaries and carers collect the food. They are asked to queue in an orderly way; their presence is recorded at each meal. They then wash their hands and proceed to the canteen; at its entrance, they r...
+
+=== Chunk 2269 ===
+Source: 0820_002-ebook.pdf
+Length: 5652 chars
+
+3.3.6 Feeding
+Feeding is the most important activity in a TFC – that is its justifi cation. It is however also initially the most complicated, because severely malnourished subjects are apathetic and irritable, lack appetite, and are generally diffi cult to feed.
+Success in this endeavour is determined by the observance of a number of rules.
+1. Feeding bottles are strictly prohibited: they are diffi cult to clean and, above all, their use is harmful for breastfeeding.
+2. Oral feeding is to be attem...
+
+=== Chunk 2270 ===
+Source: 0820_002-ebook.pdf
+Length: 972 chars
+
+3.3.7 Healthcare
+Healthcare must be systematic,11 and consist of medical examination and individual care. Medical examination is performed every time and as soon as patients present problems of a medical nature. It is performed daily for patients undergoing treatment (including rehydration), and at each weighing session during initial treatment and the fi rst week of rehabilitation. Individual care is delivered to subjects whose medical disorder requires treatment. Except for the type of care tha...
+
+=== Chunk 2271 ===
+Source: 0820_002-ebook.pdf
+Length: 309 chars
+
+3.3.8 Administration, management and maintenance
+TFC require strict administration and management. This should not be seen as an excessive attention to detail: rigorous management ensures the detection of problems that may otherwise be overlooked, and sets an example to discourage slackness and misbehaviour....
+
+=== Chunk 2272 ===
+Source: 0820_002-ebook.pdf
+Length: 1137 chars
+
+Staff
+Staff must be recruited according to what it is expected to do: each position and its corresponding schedule must be clearly set out. Respective responsibilities, reporting lines and compensation scales must be well defi ned. It may be diffi cult to secure a comprehensive set-up of qualifi ed staff from the outset; in such cases, training schemes must be designed, and individual progress must be tracked and documented. The TFC manager or deputy must monitor all TFC activities regularly and wi...
+
+=== Chunk 2273 ===
+Source: 0820_002-ebook.pdf
+Length: 291 chars
+
+Stocks
+Although food stocks are discussed here, the following comments apply equally to medical and material stocks. The anticipation of needs, the rigorous monitoring of commodity movements, inventories and stock maintenance are all necessary in order to limit complications and temptation....
+
+=== Chunk 2274 ===
+Source: 0820_002-ebook.pdf
+Length: 514 chars
+
+Anticipation of needs
+Needs are anticipated according to weekly or monthly consumption patterns; this type of management allows for buffer stocks according to potential breakdowns in the logistics chain, and implies that orders be placed on time, according to usual delivery delays. While buffer stocks are necessary to allow for possible supply breakdowns, they must nevertheless be kept to a minimum to discourage looting. Storage conditions (heat and humidity) may also preclude the maintenance of...
+
+=== Chunk 2275 ===
+Source: 0820_002-ebook.pdf
+Length: 158 chars
+
+Stock-fl ow monitoring
+The systematic recording of the incoming and outgoing commodity fl ow provides an accurate overview of stock positions at any one moment....
+
+=== Chunk 2276 ===
+Source: 0820_002-ebook.pdf
+Length: 275 chars
+
+Physical inventories
+Inventories are performed at least fortnightly, and involve the physical counting of all commodities that are present in the warehouse. Resulting totals are compared with stock card entries, permitting the application of corrective measures if necessary....
+
+=== Chunk 2277 ===
+Source: 0820_002-ebook.pdf
+Length: 611 chars
+
+Stock maintenance
+Proper stock maintenance consists in rotating commodities on the “fi rst in/fi rst out” principle, and according to expiry dates. Warehouses should be cleaned daily. Commodities should be stacked on pallets, and be slightly removed from walls to allow air to circulate. The contents of damaged bags and packaging must be repacked, and contaminated foodstuffs (or those damaged beyond repair) must be disposed of. According to the size of stocks, vermin eradication measures (such as f...
+
+=== Chunk 2278 ===
+Source: 0820_002-ebook.pdf
+Length: 1036 chars
+
+Internal communication
+If kitchens are to operate properly and produce adequate amounts of food, their staff must be informed every day of the attendance expected for the following day; the same comment applies to warehouse staff. TFC admission and discharge ledgers provide the necessary information for determining expected attendance. One staff member should be specifi cally entrusted with this task, and record this information in a special ledger, and impart it verbally to the colleagues concer...
+
+=== Chunk 2279 ===
+Source: 0820_002-ebook.pdf
+Length: 320 chars
+
+Equipment management
+The material equipment and tools used in a TFC are valuable; they must be tracked through inventories and checked, and renewable items such as cleaning materials must be replaced in good time. The staff that uses them is held accountable, and sanctions for loss or misuse must be clearly understood....
+
+=== Chunk 2280 ===
+Source: 0820_002-ebook.pdf
+Length: 453 chars
+
+Hygiene
+The population of a TFC constantly changes. As a result, newcomers and their personal belongings must be treated against external parasites upon admission. Thereafter, bedding and clothing must be regularly disinfected, and TFC residents must wash and keep up the best possible personal hygiene. Taking part in sanitation information sessions and maintenance and cleaning chores are key aspects of raising awareness of issues related to hygiene....
+
+=== Chunk 2281 ===
+Source: 0820_002-ebook.pdf
+Length: 428 chars
+
+TFC condition
+The sheer magnitude of the task at hand can easily eclipse some supervision aspects. Here again however, unrelenting thoroughness is essential: the cleanliness of facilities and latrines, the condition of water supply and disposal systems, the infrastructural condition, and the general appearance of the TFC, all contribute to making the centre more welcoming. Repairs and replacements must be done without delay....
+
+=== Chunk 2282 ===
+Source: 0820_002-ebook.pdf
+Length: 330 chars
+
+Data processing
+Data processing is tedious; it is nevertheless essential in order to evaluate operational progress and impact, and for corrective measures to be taken if necessary. Data must be processed regularly enough to correct dysfunctions, but not so frequently as to disrupt operations; weekly analysis is usually adequate....
+
+=== Chunk 2283 ===
+Source: 0820_002-ebook.pdf
+Length: 1128 chars
+
+3.3.9 Other activities
+Activities that complement food distributions can be conducted within a TFC. Depending on available staff, its training and motivation, and available time, nutritional information sessions may be held in line with the recommendations made in Chapter XV. The substance of information sessions must be adapted to local circumstances and customs, and should include concrete examples, demonstrations, and the active involvement of benefi ciaries and carers alike; this approach lim...
+
+=== Chunk 2284 ===
+Source: 0820_002-ebook.pdf
+Length: 298 chars
+
+3.4 MONITORING AND EVALUATION
+The monitoring of activities is useful to appraise the TFC’s operation, and to understand how the situation is developing; evaluation on the other hand provides the opportunity to confi rm that the operation is in fact achieving its objectives with the expected impact....
+
+=== Chunk 2285 ===
+Source: 0820_002-ebook.pdf
+Length: 1690 chars
+
+3.4.1 Monitoring
+Monitoring serves to confi rm that planned activities are being implemented according to set standards; it also permits the analysis of admissions and discharges, and of attendance at mealtimes and treatment sessions.
+Monitoring should also provide information as to developments in the living conditions outside the TFC, and as to the factors that infl uence them.
+9 The quality of the operation must remain stable and satisfactory, and comply with set standards. This type of monitor...
+
+=== Chunk 2286 ===
+Source: 0820_002-ebook.pdf
+Length: 1320 chars
+
+3.4.2 Evaluation
+Evaluation consists in verifying nutritional catch-up rates, the duration of TFC residence (which is related to the catch-up rate), the recovery rate from sickness, and the rate of discharges due to recovery (objective achieved) and of exit through death, abandon, expulsion or referral to other therapeutic feeding or hospital facilities.
+9 The nutritional catch-up rate should be 15 g/kg/day on average if rations are enriched in vitamins and minerals as per the formula provided i...
+
+=== Chunk 2287 ===
+Source: 0820_002-ebook.pdf
+Length: 4046 chars
+
+TREATING SEVERE MALNUTRITION
+The treatment of severe malnutrition is based on strict procedures that constitute the heart of therapeutic feeding; they must be strictly applied. Arrangements can be found in terms of the infrastructure, organization and functioning of a TFC and there is room for some fl exibility; however, there is no lee-way regarding the treatment of patients.
+The following treatment protocols are adapted from those provided in the WHO manual (WHO, 1999). The WHO manual was mostl...
+
+=== Chunk 2288 ===
+Source: 0820_002-ebook.pdf
+Length: 1375 chars
+
+4.1 INITIAL TREATMENT
+Children are admitted to therapeutic feeding facilities because their lives are threatened. This threat arises from the fact that their nutritional metabolism is at its limit, and additional complications may occur, such as water and electrolyte imbalance, infection and, less commonly, functional disorder caused by specifi c defi ciencies. Initial treatment aims at treating and preventing the direct causes of mortality in time.
+Practically, the following tasks are involved (r...
+
+=== Chunk 2289 ===
+Source: 0820_002-ebook.pdf
+Length: 197 chars
+
+4.1.1 Hypoglycaemia and hypothermia
+Hypoglycaemia and hypothermia often combine, and the fi rst precipitates the second. Both are major causes of mortality during the fi rst days following admission....
+
+=== Chunk 2290 ===
+Source: 0820_002-ebook.pdf
+Length: 1258 chars
+
+Hypoglycaemia
+Hypoglycaemia is caused by an interval of more than 4 to 6 hours between meals after the inception of initial treatment, and by severe systemic infection. Its prevention clearly consists of feeding patients at an adequate frequency and/or the administration of broad-spectrum antibiotics.15 If manifestations of hypothermia, lethargy and mental disorder appear to indicate hypoglycaemia, immediate action is required in the form of oral administration of:
+15 See Section 4.1.5 in this C...
+
+=== Chunk 2291 ===
+Source: 0820_002-ebook.pdf
+Length: 1643 chars
+
+Hypothermia
+Hypothermia is proportional to the seriousness of severe malnutrition. On the one hand, body temperature is sub-standard because the basal metabolism diminishes with malnutrition; on the other, the lower critical temperature17 is higher, whereas the capacity for thermo-genesis of the organism diminishes with ambient temperature (among other things, malnourished children are unable to shiver). As a result, mortality peaks among famished, unsheltered groups occur at dawn and in rainy c...
+
+=== Chunk 2292 ===
+Source: 0820_002-ebook.pdf
+Length: 882 chars
+
+4.1.2 Dehydration and electrolyte and mineral imbalance
+Dehydration is a very serious complication of severe malnutrition. As such, it must be detected and treated rapidly. Dehydration occurs in the following stages (Gentilini, 1986):
+16 See Section 4.1.4 in this Chapter.
+17 See Chapter III, Section 1.1.4.
+526
+4. Treating severe malnutrition
+4.1 Initial treatment
+9 mild dehydration: its clinical signs are thirst and agitation – fl uid loss is roughly 40 to 50 ml/kg;
+9 moderate dehydration: its cl...
+
+=== Chunk 2293 ===
+Source: 0820_002-ebook.pdf
+Length: 672 chars
+
+Causes of dehydration
+Dehydration frequently results from recent and profuse episodes of watery diarrhoea; diarrhoea is thus a good indicator in explaining substantial fl uid loss. If dehydration is suspected, the patient’s recent history of diarrhoea episodes must therefore be systematically documented. In a TFC in famine settings however, dehydration may also result from non-pathological losses that are not compensated by adequate fl uid intake. This is commonly noted during admission, in patien...
+
+=== Chunk 2294 ===
+Source: 0820_002-ebook.pdf
+Length: 354 chars
+
+Preventing dehydration
+The prevention of dehydration during initial treatment consists in administering rehydration solutions in order to compensate excessive loss due to diarrhoea and sometimes vomiting. In the absence of these two symptoms, patients must be made to drink regularly, through breastfeeding, fl uid reanimation feeding, and drinking water....
+
+=== Chunk 2295 ===
+Source: 0820_002-ebook.pdf
+Length: 5945 chars
+
+Treating dehydration
+Diarrhoea that combines with severe malnutrition causes substantial electrolyte and mineral imbalance; its treatment is therefore different from that recommended for diarrhoea that is unrelated to malnutrition.
+1. In case of marasmus, the sodium pump activity slows down. This results in excess sodium and potassium defi ciency in the cell, and potassium is excreted. This logically causes hyponatraemia.
+2. In case of kwashiorkor, the sodium pump activity is faster than in healt...
+
+=== Chunk 2296 ===
+Source: 0820_002-ebook.pdf
+Length: 2928 chars
+
+Differentiated diagnosis of dehydration and septic shock
+Dehydration is easily confused (or associated) with septic shock. However, experience with severely malnourished subjects in famines shows that septic shock is much less common than dehydration. Nevertheless, every case of severe dehydration should suggest septic shock. The disorder must hence be identifi ed, but the differentiated diagnosis poses a sensitive problem:
+9 the signs of shock overlap signifi cantly with those of dehydration;
+9 t...
+
+=== Chunk 2297 ===
+Source: 0820_002-ebook.pdf
+Length: 3083 chars
+
+4.1.3 Incipient or developed septic shock21
+As a complication of severe malnutrition, septic shock is rare when malnutrition is mainly primary, and prevailing hygiene conditions and access to water remain adequate. It is however common when malnutrition is secondary, associated with seasonal climatic variations and particular individual vulnerability.
+Septic shock results from serious infection of the digestive, respiratory and urinary tracts, where the toxins released by bacteria stimulate the ...
+
+=== Chunk 2298 ===
+Source: 0820_002-ebook.pdf
+Length: 533 chars
+
+4.1.4 Nutritional treatment of severe malnutrition
+The treatment of severe malnutrition extends from initial treatment through rehabilitation to the resumption of a normal diet. The protocol follows a graded scale from fl uids (highly diluted foods with low protein and energy contents) to solids that should be as similar as possible to those the child will be given following discharge from the TFC. As a reminder, severely malnourished children are usually anorexic; great patience is therefore req...
+
+=== Chunk 2299 ===
+Source: 0820_002-ebook.pdf
+Length: 4614 chars
+
+Feeding on admission
+During initial treatment, the diet is fl uid and consists of highly diluted foods with low protein and energy contents. Severe malnutrition upsets all metabolic functions; this results in the functional incapacity of vital organs (such as the kidneys, heart, and liver) to manage signifi cant and/or unbalanced dietary intakes. Moreover, digestion is usually substantially impaired, further aggravating the overall ability of the organism to cope with excessive and/or unbalanced i...
+
+=== Chunk 2300 ===
+Source: 0820_002-ebook.pdf
+Length: 350 chars
+
+1. Improvised F-75 Formula
+F-75 Formula can easily be improvised in compliance with Table 13.5 above, from powdered milk, sugar, oil, cereal fl our, and special vitamin and mineral complements.26 The difference lies in the use of cereal fl our instead of cereal starch – this increases the protein concentration, raising the P/E% to approximately 6.5%....
+
+=== Chunk 2301 ===
+Source: 0820_002-ebook.pdf
+Length: 2184 chars
+
+2. ReSoMal adjunction
+In the absence of vitamin and mineral complements, ReSoMal may be used to produce a formula that is similar to F-75 (see Table 13.6 below); this alternative however lacks vitamins, which can be supplied in the form of tablets. On the other hand, in the absence of declared vitamin defi ciency, minerals (especially zinc) are more important at this stage.
+24 The protein-energy ratio (P/E%) is the percentage of the protein contribution to the overall energy of the diet. As a rem...
+
+=== Chunk 2302 ===
+Source: 0820_002-ebook.pdf
+Length: 1323 chars
+
+3. Formula without ReSoMal
+In the absence of both vitamin and mineral complements and ReSoMal, a formula similar to F-75 may nevertheless be prepared; it however lacks the amounts of vitamins and minerals that are necessary for the optimal treatment of severe malnutrition. The amount of sugar is increased to compensate for the absence of ReSoMal. This formula has nevertheless proven effi cient in initial treatment, and is presented in Table 13.7 below.
+Recipe for an alternative formula without Re...
+
+=== Chunk 2303 ===
+Source: 0820_002-ebook.pdf
+Length: 917 chars
+
+Daily intake
+Care must be taken to avoid overloading digestion, while preventing a further deterioration of the nutritional status. Therefore, maintenance requirements must be met with respect to actual body weight. Daily intake is determined by body weight, whereas requirements per kg of body weight vary according to age. Table 13.8 below indicates F-5 Formula intake for different age groups; no distinction is made according to sex, as this would be illusory in a TFC. For more safety, intakes a...
+
+=== Chunk 2304 ===
+Source: 0820_002-ebook.pdf
+Length: 904 chars
+
+Intake frequency
+Ideally, F-75 Formula should be administered continuously using a pump, as is commonly done in hospitals. This is usually impossible in humanitarian operations; it is therefore best to observe a high feeding frequency, in order to supply small amounts at a time. The purpose is to avoid hypoglycaemia/hypothermia resulting from excessive intervals between meals, and an overload of the digestive system. The usual recommendation for initial treatment in a TFC involves 24-hour
+535
+I ...
+
+=== Chunk 2305 ===
+Source: 0820_002-ebook.pdf
+Length: 751 chars
+
+Food utilization
+In order to avoid unnecessary repetitions, the utilization of food is discussed in Section 4.2.3 below, in the section on nutritional rehabilitation; fi eld workers must be familiar with its contents.
+The transition to rehabilitation
+Initial treatment is completed when the patient’s digestion is restored and medical complications have been treated and are receding accordingly – this is demonstrated by renewed appetite. The process takes 2 to 3 days at least, and 1 week at most af...
+
+=== Chunk 2306 ===
+Source: 0820_002-ebook.pdf
+Length: 506 chars
+
+4.1.5 Preventing and treating infection
+Infection is a common complication of severe malnutrition. Several types of infection can coincide, as may hypoglycaemia and hypothermia. The typical signs of infection can be quite unobtrusive (even non-existent) in the severely malnourished, thus complicating their detection. Infection is therefore a serious danger and a major cause of mortality during initial treatment. As a result, preventive and curative measures to address infection are essential in ...
+
+=== Chunk 2307 ===
+Source: 0820_002-ebook.pdf
+Length: 3555 chars
+
+Bacterial infections
+The number of children suffering from respiratory, urinary, and systemic infection upon admission can be very high. This poses a problem insofar as diagnosis upon admission is complicated – hence the question as to whether treatment should simply be systematic. The WHO and MSF are rather in favour of this option (WHO, 1999; MSF, 1995); experience however shows that the answer should vary according to circumstances. In famines, where severe malnutrition is mainly primary and ...
+
+=== Chunk 2308 ===
+Source: 0820_002-ebook.pdf
+Length: 1454 chars
+
+Eye infections
+Eye infections must be treated with penicillin or tetracycline ointments. However, the traditional method of applying a few drops of maternal milk to each eye three times daily for a few days is quite effective. Maternal milk contains the specifi c antibodies necessary to counter germs in the environment; its antiseptic properties are therefore well-adapted to the pathogens that children are exposed to.
+Intestinal infections
+Intestinal infections usually manifest themselves through...
+
+=== Chunk 2309 ===
+Source: 0820_002-ebook.pdf
+Length: 1334 chars
+
+Viral infections
+The worst viral infection in a TFC is measles. All children must be vaccinated against measles upon admission, and again upon their discharge (when their health and nutritional status is restored). In view of the mortality resulting from measles combined with malnutrition, the author recommends that all children between 9 months and 8 years be vaccinated. Children under 9 months are also vaccinated upon admission, bearing in mind that they must be vaccinated again when they reac...
+
+=== Chunk 2310 ===
+Source: 0820_002-ebook.pdf
+Length: 89 chars
+
+Parasite infections
+Protozoa and nematodes account for most parasite infections in a TFC....
+
+=== Chunk 2311 ===
+Source: 0820_002-ebook.pdf
+Length: 941 chars
+
+Protozoa
+The commonest protozoa infections are amoebiasis (Entamoeba Hystolitica) and giardiasis (or lambliasis, Giardia Lamblia). In the absence of laboratory facilities to analyse stool and if dysentery persists in spite of antibiotic treatment, amoebiasis or giardiasis should be suspected – both are treated orally with metronidazole, as per the posology provided in Table 13.9 below.
+Table 13.9 Metronidazole posology for the treatment of amoebiasis and giardiasis
+Age 2 – 12 months 1 – 5 years ...
+
+=== Chunk 2312 ===
+Source: 0820_002-ebook.pdf
+Length: 476 chars
+
+Nematodes
+Nematodes include intestinal roundworms (ascaris, Ascaris Lumbricoides), hookworms (ankylostomes, Ancylostoma Duodenale or Necator Americanus), and pinworms (oxyures, Enterobius Vermicularis). Nematode infection is so common that it should be treated systematically. However, the treatment is too brutal to be administered during initial treatment; it should only be administered once patients have progressed into rehabilitation, usually one week after admission.32...
+
+=== Chunk 2313 ===
+Source: 0820_002-ebook.pdf
+Length: 750 chars
+
+Scabies
+Scabies is a parasite skin infection that causes rashes and intense itching. It spreads rapidly under crowded conditions where there is frequent skin-to-skin contact, and by contact with the clothing or bedding of infected persons. Treatment consists of cleaning the sores with a 2% copper sulphate lotion, and applying a 20–25% benzyl-benzoate solution twice at a 2-day interval to the infected area (preferably the entire body). Patients must be washed on the third day; clothing and beddin...
+
+=== Chunk 2314 ===
+Source: 0820_002-ebook.pdf
+Length: 998 chars
+
+Specifi c defi ciencies
+These can affect the entire population, and usually do not require treatment in a TFC, unlike severe malnutrition. Treatment and prevention protocols therefore apply both inside and outside a TFC. Moreover, if specifi c defi ciencies are substantial within a TFC, the problem is likely to be equally serious outside, requiring action accordingly. Ideally, the population outside the TFC should be provided with adequate feeding, and this is not always possible by far. Usually, th...
+
+=== Chunk 2315 ===
+Source: 0820_002-ebook.pdf
+Length: 444 chars
+
+Congestive heart failure
+Heart failure can result from over-hydration when standard ORS solution is given, or from severe anaemia. It is indicated mainly by fast breathing (40 breaths per minute or more in children between 2 and 12 months, and 30 breaths per minute in children between 1 and 5 years). Feeding and fl uid intake must be stopped immediately until breathing slows down substantially – this can take between half a day and two days....
+
+=== Chunk 2316 ===
+Source: 0820_002-ebook.pdf
+Length: 587 chars
+
+Kwashiorkor dermatosis
+This is characterized by pigment loss (hypo-pigmentation) of the skin, shedding of the skin in fl akes or scales, and skin ulceration. Provided that feeding follows the protocols indicated above, dermatosis recedes and heals quickly (within 2 to 3 days), mainly because of the zinc contained in the diet. Because kwashiorkor cases must in any case be subjected to antibiotic treatment upon admission, the risk of infection is controlled. Lesions may also be bathed daily with 1%...
+
+=== Chunk 2317 ===
+Source: 0820_002-ebook.pdf
+Length: 601 chars
+
+4.2 NUTRITIONAL REHABILITATION
+Resumed appetite and an improved general health status are the main criteria for the initiation of nutritional rehabilitation following initial treatment. During rehabilitation, medical treatment is completed, and patients are brought back to a satisfactory nutritional status. In the case of kwashiorkor, the disappearance of oedema terminates initial treatment; if oedema does not disappear within one week however, the diet should nevertheless be more concentrated t...
+
+=== Chunk 2318 ===
+Source: 0820_002-ebook.pdf
+Length: 5484 chars
+
+4.2.1 The nutritional aspects of rehabilitation
+During nutritional rehabilitation, the amount of food should cover maintenance and nutritional catch-up requirements. This permits patients to gain weight quickly, and to promote the metabolic shift towards anabolism, that is, tissue synthesis. This change occurs through a modifi ed balance and hormone control, and is not quickly reversible towards catabolism, which should nevertheless occur when energy requirements for maintenance exceed available ...
+
+=== Chunk 2319 ===
+Source: 0820_002-ebook.pdf
+Length: 1295 chars
+
+4.2.2 Feeding during rehabilitation
+During rehabilitation, the density and quantity of nutrients must be increased, and the diet must begin to diversify in order to re-accustom patients to a normal diet. In principle, the process begins with high-energy milk, subsequently alternates milk with porridge, and ends with normal meals that should be as similar as possible to the patient’s after discharge. The progression of the diet is determined by staff resources, the overall workload, and the catch...
+
+=== Chunk 2320 ===
+Source: 0820_002-ebook.pdf
+Length: 635 chars
+
+F-100 Formula
+F-100 Formula differs from F-75 Formula35 in macro-nutrients and not micro-nutrients. The composition that supplies macro-nutrients is 80 g of skimmed dried milk, 50 g of sugar, and 60 g of oil for the preparation of 1 litre of formula. F-100 Formula supplies 100 kcal (418 kJ) and 2.8 g of protein for 100 ml, for a P/E ratio of 11.2%. Commercial ready-made preparations already contain vitamin and mineral supplements, and they are simply diluted in previously boiled water in complia...
+
+=== Chunk 2321 ===
+Source: 0820_002-ebook.pdf
+Length: 1346 chars
+
+Improvised F-100 Formula
+F-100 Formula can easily be improvised in compliance with the above indications, and by adding the vitamin-mineral preparation used for F-75 Formula.36 If only whole dried milk (and not skimmed dried milk) is available, the composition is 120 g of whole dried milk, 30 g of oil, and 40 g of sugar, plus the vitamin-mineral complement to prepare 1 litre of formula – this supplies approximately 100 kcal (418 kJ) and 3 g of protein for 100 ml, with a P/E ratio of 11.6%. If th...
+
+=== Chunk 2322 ===
+Source: 0820_002-ebook.pdf
+Length: 1483 chars
+
+Basic F-100 Formula
+Before the introduction of F-100 and F-75 Formulae, therapeutic feeding was more basic; its results were less spectacular, but effi cient nevertheless. Should the formula be improvised in the absence of modern formulae and adequate measurement material, the previous recipe may be used; it is based on volumes as follows:
+9 pre-mix:
+q 6 volumes of dried skimmed milk;
+q 2 volumes of oil;
+q 1 volume of sugar;
+9 the milk is reconstituted thus:
+q 1 volume of pre-mix is dissolved in
+...
+
+=== Chunk 2323 ===
+Source: 0820_002-ebook.pdf
+Length: 1350 chars
+
+Porridge
+Commercial products also exist for the preparation of nutritional rehabilitation porridge; like F-100 Formula, they contain all the necessary nutrients in adequate amounts (for example, ThP. 450 or ThP. 380 produced by Nutriset). This porridge supplies between 100 and 130 kcal (418 and 543 kJ)/ml, with a P/E ratio of 10%. If commercial formulae are not available, a basic alternative can be produced from basic ingredients and, if possible, adapted vitamin and mineral complements.
+The fol...
+
+=== Chunk 2324 ===
+Source: 0820_002-ebook.pdf
+Length: 892 chars
+
+Other foods
+Other foods may also be supplied, for example to be taken home or eaten on site with or between meals. Such foods include high-energy biscuits (whose composition should be as close as possible to that of F-100 Formula), special peanut paste that is equivalent to one F-100 Formula meal (e.g. Plumpy’nut produced by Nutriset) that supplies 500 kcal (2,090 kJ) for one 92 g sachet, and fruit. Such products derive their appeal from the fact that they require no preparation or cooking. They...
+
+=== Chunk 2325 ===
+Source: 0820_002-ebook.pdf
+Length: 508 chars
+
+Normal meals
+After 1 week of rehabilitation, 1 porridge meal should be replaced with a normal meal. Such meals must be prepared with local products or GFD foods (if the latter accounts for most of the food supply). Like porridge, meals must supply between 100 and 150 kcal (420 and 630 kJ) for 100 ml, with a P/E ratio of 11 to 12%, and account for at least 1/5 of the daily food intake.
+37 Annex 16 provides its composition and utilization.
+544
+4. Treating severe malnutrition
+4.2 Nutritional rehabi...
+
+=== Chunk 2326 ===
+Source: 0820_002-ebook.pdf
+Length: 1304 chars
+
+4.2.3 Handling of food
+Milk must be consumed immediately after its preparation, because milk contaminated by pathogens quickly becomes toxic. This is due to the following:
+9 its composition: it contains basic free nutrients that can be directly absorbed by microbes;
+9 its liquid state: the Brownian motion38 quickly scatters contaminating bacteria, not to mention the shaking of containers by preparers and consumers;
+9 its consumption temperature for a long period corresponds to the optimum temper...
+
+=== Chunk 2327 ===
+Source: 0820_002-ebook.pdf
+Length: 2294 chars
+
+4.2.4 Serving meals
+During the fi rst week, children should continue to consume 8 meals daily at 3 hour intervals, especially those who show complications in the course of treatment. Practically speaking, if intake is set at 200 kcal (840 kJ)/kg/day with F-100 Formula, then 8 rations of 25 ml each of F-100 Formula/kg/day must be supplied. Circumstances may prevent this, especially in case of night-time security problems or curfews, and if the TFC cannot include a camp for the permanent accommodat...
+
+=== Chunk 2328 ===
+Source: 0820_002-ebook.pdf
+Length: 1279 chars
+
+4.2.5 Criteria for the transition to a normal diet
+In principle, nutritional rehabilitation is achieved when the patient’s nutritional status meets the following criteria:
+9 weight-for-height index equal to or greater than –1 Z-score or 90%; or
+9 MUAC-for-height index equal to or greater than –2 Z-scores or 85%.
+At this stage, most children will have substantially reduced their food intake, as their catch-up capacity is saturated. However, depending on the urgency resulting from the potential nu...
+
+=== Chunk 2329 ===
+Source: 0820_002-ebook.pdf
+Length: 470 chars
+
+4.3.1 Breastfeeding
+Breastfeeding is an absolute priority in the treatment of severe malnutrition, and every effort must be made to encourage or restore it.40 The importance of breastfeeding is even greater in a TFC because maternal milk is the best possible infant food: it protects against infection (which is often rampant in a TFC), and plays a fundamental role in the emotional balance of infants, which is usually upset by their living conditions and malnutrition....
+
+=== Chunk 2330 ===
+Source: 0820_002-ebook.pdf
+Length: 851 chars
+
+4.3.2 Infant diet in a TFC
+If a wet nurse cannot be found, orphans who have lost their mother cannot breastfeed. In such circumstances, readers are referred to the recommendations made in Chapter XV, Section 6.2.1 regarding alternatives to breastfeeding. Should the child be severely malnourished, the recommended amounts for each meal should simply be increased by 25 to 30%; if the child cannot ingest such amounts, feeding should be more frequent, involve smaller amounts, and be spread as evenly ...
+
+=== Chunk 2331 ===
+Source: 0820_002-ebook.pdf
+Length: 1044 chars
+
+4.3.3 Psychological support
+When children in a TFC begin to smile, they are in principle saved.
+Severely malnourished children are also emotionally harmed, and malnutrition itself impairs mental development. This impairment is partly caused by the child’s restricted interaction with its physical and social environment resulting from its apathy, irritability, and reduced mobility. Consequently, the treatment of severely malnourished children involves emotional stimulation: this includes showing t...
+
+=== Chunk 2332 ===
+Source: 0820_002-ebook.pdf
+Length: 157 chars
+
+4.3.4 The use of locally produced foods
+Gardening and poultry breeding are strongly recommended in a TFC in order to enrich meals with the resulting produce....
+
+=== Chunk 2333 ===
+Source: 0820_002-ebook.pdf
+Length: 352 chars
+
+4.3.5 Failure to respond to treatment
+Patients who do not gain weight at the minimum expected rate are not eating enough. They must be monitored closely in order to determine the reason for this as quickly as possible, and take corrective action. Often, failure to respond results from illness; however, four main reasons exist to explain this failure....
+
+=== Chunk 2334 ===
+Source: 0820_002-ebook.pdf
+Length: 386 chars
+
+Absenteeism
+The supervisor in charge of monitoring should be informed of unjustifi ed absences without delay, in order for corrective measures to be taken. Absenteeism must under no circumstances be punished by exclusion, as this can amount to a death sentence. If carers cannot remain permanently with the child under their responsibility, someone must be found within the TFC to do so....
+
+=== Chunk 2335 ===
+Source: 0820_002-ebook.pdf
+Length: 1357 chars
+
+Illness
+Healthy patients can develop infections that are not immediately detected; others can be admitted sick without their condition being detected owing to their state of malnutrition, or suffer from severe disorders such as tuberculosis or AIDS. These illnesses can manifest themselves in anorexia, vomiting, diarrhoea, malabsorption and an insuffi cient biological utilization of food. In addition, pathogens thrive on the feeding of patients. Meal supervisors and carers must report any dietary ...
+
+=== Chunk 2336 ===
+Source: 0820_002-ebook.pdf
+Length: 1003 chars
+
+TFC or staff dysfunctions
+The TFC may be badly organized or managed, mistakes may be made in the kitchens or in healthcare, staff may be incompetent or discriminate against some patients, or the general atmosphere prevailing in the TFC may be poor. TFC staff should detect such problems and inform the TFC manager; however, it may be reluctant or unwilling to do so. Consequently, the TFC manager must monitor operations systematically and comprehensively, including the quality of surveillance and t...
+
+=== Chunk 2337 ===
+Source: 0820_002-ebook.pdf
+Length: 577 chars
+
+Epidemics
+Severe epidemics such as measles can be avoided; other, less harmful epidemics such as infl uenza or common cold cannot, and can affect a large number of patients quite abruptly. They are often associated with the climate, and their effects can be underestimated. Whoever has visited a TFC will remember the persistent sound of coughs and sobs, which grow familiar to the point of masking a relapse. The latter nevertheless indicate such epidemics, which impair nutritional catch-up signifi c...
+
+=== Chunk 2338 ===
+Source: 0820_002-ebook.pdf
+Length: 1070 chars
+
+4.4 THE RESUMPTION OF A NORMAL DIET
+Following their nutritional rehabilitation, patients must be prepared for the diet that will be theirs upon their discharge from the TFC. This phase usually lasts 2 weeks during which at least 75% of the diet must be identical to the patient’s normal diet, the nutritional status must remain stable, and possible health problems must have been resolved. During the fi rst week of this preparation for discharge, meals are reduced to four per day, two of which are n...
+
+=== Chunk 2339 ===
+Source: 0820_002-ebook.pdf
+Length: 381 chars
+
+4.5 FOLLOW-UP
+After discharge, children should preferably be monitored by measuring their nutritional status and developments in their health status. Discharged children should be visited 1 week, 2 weeks, 1 month, 3 months, and 6 months after their return home. This frequency facilitates action in case of relapse.
+548
+4. Treating severe malnutrition
+4.6 Routine medical treatment...
+
+=== Chunk 2340 ===
+Source: 0820_002-ebook.pdf
+Length: 114 chars
+
+4.6 ROUTINE MEDICAL TREATMENT
+Routine treatments must be performed in a TFC in order to prevent or treat problems....
+
+=== Chunk 2341 ===
+Source: 0820_002-ebook.pdf
+Length: 393 chars
+
+4.6.1 Routine treatment upon admission
+Measles vaccination
+Measles is highly virulent and is frequently fatal in malnourished children. It can spread very fast in a TFC. All children should be vaccinated upon admission, except those that have clearly been vaccinated already (as registered in a vaccination card). Their sojourn in the TFC provides the opportunity to update their vaccinations....
+
+=== Chunk 2342 ===
+Source: 0820_002-ebook.pdf
+Length: 205 chars
+
+Antibiotic treatment
+All kwashiorkor cases must receive broad-spectrum antibiotic treatment, as described in Section 4.1.3 above. Section 4.1.5 discusses the extension of the treatment to all TFC patients....
+
+=== Chunk 2343 ===
+Source: 0820_002-ebook.pdf
+Length: 592 chars
+
+External parasites
+Fleas and lice are haematophagic dipterans (blood-sucking parasites) whose bite is often infl ammatory and pruriginous, and causes dermatosis and itching. The insects multiply and transmit quickly and spread infection. Lice transmit exanthematic typhus and cosmopolitan recurrent fever; fl eas transmit murine typhus, the plague, and two types of tenia. Patients must therefore be treated against these parasites upon admission to the TFC with pyrethroid insecticide (0.5% permethrin...
+
+=== Chunk 2344 ===
+Source: 0820_002-ebook.pdf
+Length: 229 chars
+
+4.6.2 Routine treatment during rehabilitation
+One week after admission, when diarrhoea and vomiting should in principle have stopped and infection is either fully or partially under control, the following treatment must be given:...
+
+=== Chunk 2345 ===
+Source: 0820_002-ebook.pdf
+Length: 291 chars
+
+Anaemia treatment
+All severely malnourished children suffer from anaemia to some extent. After 15 days, when infection should in principle be controlled, all patients should therefore be given 1 mg of folic acid and 100 mg of ferrous sulphate daily for the duration of their stay in the TFC....
+
+=== Chunk 2346 ===
+Source: 0820_002-ebook.pdf
+Length: 255 chars
+
+4.6.3 Routine treatment upon discharge
+Immunization
+All children should have been vaccinated against measles upon their admission, and be vaccinated again before their discharge. Moreover, all children should be immunized according to national guidelines....
+
+=== Chunk 2347 ===
+Source: 0820_002-ebook.pdf
+Length: 2788 chars
+
+4.7 TREATING ADOLESCENTS AND ADULTS
+As discussed in Section 3.2 in relation to admission criteria, only very severely malnourished and sick adolescents and adults should be admitted to a TFC (which is normally reserved for children), provided that their sickness can be cured within the TFC. However, if large numbers of adolescents and adults are severely malnourished (as can be the case in famines), it is best to establish special facilities for them, in the form of a highly simplifi ed TFC. Adol...
+
+=== Chunk 2348 ===
+Source: 0820_002-ebook.pdf
+Length: 1281 chars
+
+1.2 POSITION IN HUMANITARIAN INTERVENTION
+SFPs play a double role in humanitarian intervention: they provide both economic support and survival relief. They can also complement economic rehabilitation programmes. Figure 14.1 below illustrates the possible levels of SPF implementation within the crisis process.
+Like any other programme, SFPs must be integrated consistently into the overall intervention strategy.4 While they can be necessary to complete other programmes, their peripheral role mean...
+
+=== Chunk 2349 ===
+Source: 0820_002-ebook.pdf
+Length: 3758 chars
+
+1.3 BACKGROUND TO SFPS
+SFPs have evolved within the public health programmes of developing countries to address stable situations. They were initially intended to promote the nutritional recovery of moderately and slightly malnourished children, as well as preventing a deterioration of the nutritional status in specifi c circumstances: poverty, weaning, or an unfavourable environment, conducive to infectious disease – whose possible impact on the nutritional status has been discussed above.5 Resu...
+
+=== Chunk 2350 ===
+Source: 0820_002-ebook.pdf
+Length: 3444 chars
+
+1.4 THE OBJECTIVE OF SUPPLEMENTARY FEEDING PROGRAMMES
+Supplementary feeding programmes concentrate on the following:
+9 an existing nutritional defi ciency (slight and moderate malnutrition according to the Waterlow classifi cation,10 in children under 5 years of age);
+9 an increased susceptibility to nutritional deprivation (under 5, and sick people);
+9 an increased need of nutrients (pregnant and breastfeeding women, individuals suffering from specifi c medical problems, particularly the wounded o...
+
+=== Chunk 2351 ===
+Source: 0820_002-ebook.pdf
+Length: 755 chars
+
+1.5 PRIORITY IN THE INTERVENTION STRATEGY
+In view of the above, SFPs are the last choice but one in the intervention strategy. On the other hand, agencies specializing in SFPs can consider them as a priority intervention from a tactical perspective, and in an attempt to mitigate damage until more effective, but also more time- consuming and complex, measures are fully operational. This can be the case provided that they are not implemented in isolation, and that they contribute to the implementa...
+
+=== Chunk 2352 ===
+Source: 0820_002-ebook.pdf
+Length: 1093 chars
+
+INTERVENTION CRITERIA
+Usually in a nutritional crisis, SFPs should be curative; as a result, the criterion triggering their implementation is moderate malnutrition. It should also be possible to address this malnutrition effi ciently, that is, the programme should aim at reducing moderate malnutrition rates rapidly, providing safety nets or a relay for therapeutic feeding once all necessary measures previously taken have proven ineffective. These circumstances are indeed those in which SFPs have ...
+
+=== Chunk 2353 ===
+Source: 0820_002-ebook.pdf
+Length: 6110 chars
+
+1.7 THE RISK OF NEGATIVE SIDE EFFECTS
+Where SFPs aim at temporarily containing the effects of an acute or developing crisis – owing to the fact that preventive measures are inadequate – the risk of negative side effects is greatest. All the more so because some humanitarian agencies view SFPs as an almost standard response to inadequate basic rations, which translate into more or less serious malnutrition. Thus the rationale for SFPs in crisis is usually observed malnutrition rates and insuffi ci...
+
+=== Chunk 2354 ===
+Source: 0820_002-ebook.pdf
+Length: 1283 chars
+
+1.8 PROGRAMME EXIT CRITERIA
+As in any other humanitarian intervention, defi ning programme modifi cation and exit criteria from the outset is essential.
+Where it targets groups most prone to malnutrition (i.e. a preventive approach), the SFP’s exit criterion is the implementation of more effi cient preventive measures (such as GFDs, sanitation, and access to healthcare), or crisis resolution. The programme can then be adapted to address existing moderate malnutrition more speedily, or to act as a s...
+
+=== Chunk 2355 ===
+Source: 0820_002-ebook.pdf
+Length: 854 chars
+
+INTERVENTION MODES ACCORDING TO SFP OBJECTIVES
+SFPs can pursue the following objectives in crisis situations:
+9 temporarily containing malnutrition, morbidity and mortality;
+9 contributing to a more effective response to moderate malnutrition;
+9 providing a safety net;
+9 providing a relay for therapeutic feeding.
+The following recommendations relate to targeting, admission criteria according to targeting, and distribution modes for each scenario.
+It is to be noted moreover that an SFP also calls...
+
+=== Chunk 2356 ===
+Source: 0820_002-ebook.pdf
+Length: 514 chars
+
+2.1.1 Temporarily containing malnutrition, morbidity and mortality
+Where this is the SFP’s objective, it indicates a deteriorating or acute crisis, and signals that the main problem is inadequate access to food. Two targeting options result. The fi rst concerns individuals depending on specifi c criteria. This is the only realistic modality,13 and is incidentally by far the most frequent. The second, sometimes found in transition phases, targets the entire group that is likely to suffer nutritiona...
+
+=== Chunk 2357 ===
+Source: 0820_002-ebook.pdf
+Length: 1087 chars
+
+A. Targeting individuals
+In this approach, individuals are chosen according to:
+9 their existing confi rmed nutritional defi cit (moderate malnutrition);
+9 their increased probability of developing severe malnutrition;
+9 their high exposure to the development of a synergy between malnutrition and infection.
+At the inception of a crisis, such individuals usually belong to the group of children under 5 years of age; this instantly provides programme admission criteria, together with an idea of malnu...
+
+=== Chunk 2358 ===
+Source: 0820_002-ebook.pdf
+Length: 2367 chars
+
+Criteria for admission: moderate malnutrition
+Moderately malnourished children under 5 years of age are priority candidates. If their age is unknown, the criterion can be set as a height inferior to 110 cms. Moderate malnutrition can be assessed through mid-upper arm circumference (MUAC), MUAC-for-height, or weight-for-height. As noted by Briend, mid-upper arm circumference provides a better indicator of mortality risk than weight-for-height (Briend, 1995).14 Mid-upper arm circumference can be u...
+
+=== Chunk 2359 ===
+Source: 0820_002-ebook.pdf
+Length: 1004 chars
+
+Criteria for discharge
+For individuals to be discharged, their medical treatment must have been completed, and their nutritional status must have remained stable during the past fortnight and be equal or superior to the following thresholds:
+9 mid-upper arm circumference (MUAC): 13.5 cm;
+CORD
+9 MUAC-for-height expressed as a percentage of the median: 80%;
+9 MUAC-for-height expressed in Z-scores: –2 Z-scores;
+9 weight-for-height expressed as a percentage of the median: 80%;
+9 weight-for-height ex...
+
+=== Chunk 2360 ===
+Source: 0820_002-ebook.pdf
+Length: 1415 chars
+
+Ration distribution methods
+In targeting individuals suffering from a confi rmed nutritional defi cit it must be possible to monitor impact and provide the required healthcare. As a result, benefi ciaries must be admitted to an SFP centre where they eat their meals and benefi t from medical care (these centres are described in Section 2.2 below). Demanding of benefi ciaries that they be present on a daily basis may seem extreme, but nevertheless derives from two imperatives combined to counter the ne...
+
+=== Chunk 2361 ===
+Source: 0820_002-ebook.pdf
+Length: 1304 chars
+
+Benefi ciary selection
+This should occur at the entry point of and outside the centre, after having explained the latter’s existence and objectives to the population. Measuring the brachial circumference facilitates the selection of benefi ciaries, who are then admitted into the centre for registration. At the beginning of the programme, the number of admissions should not exceed the centre’s daily capacity; it is useless to admit children who cannot receive adequate medical and nutritional care u...
+
+=== Chunk 2362 ===
+Source: 0820_002-ebook.pdf
+Length: 695 chars
+
+Warning
+When the purpose of an SFP is to contain malnutrition, morbidity and mortality temporarily until an adequate GFD is set up, a pitfall to be avoided at all costs would be to condition benefi ciary admission on the distribution of a food ration to the rest of their family. It would appear that all needy families would thus be targeted; however, in practically all cases, this results in a large number of families depriving one of their children in order to gain access to the distribution. Be...
+
+=== Chunk 2363 ===
+Source: 0820_002-ebook.pdf
+Length: 1703 chars
+
+B. Targeting groups most exposed to malnutrition
+When a supplementary feeding programme is anticipated to interrupt the development of malnutrition – for example, in a transition situation – and the available resources are adequate to target an entire group, it is possible to distribute food supplements to all children under 5 years of age (or whose height is inferior to 110 cm). The sick can possibly be included. On the other hand, specifi cally selecting pregnant and breastfeeding women is stro...
+
+=== Chunk 2364 ===
+Source: 0820_002-ebook.pdf
+Length: 877 chars
+
+2.1.2 Contributing to a more effective response to moderate malnutrition
+Once preventive measures are in place, SFPs can prove useful in accelerating the reduction of moderate malnutrition. This scenario illustrates what has been discussed in Section 2.1.1.A above, where the same criteria – children under 5 or whose height is inferior to 110 cm, suffering from moderate malnutrition – apply to admission and discharge. Feeding also takes place in an SFP centre, where benefi ciaries have access to a...
+
+=== Chunk 2365 ===
+Source: 0820_002-ebook.pdf
+Length: 1205 chars
+
+2.1.3 Providing safety nets
+An SFP intending to provide a safety net relates to two different situations. In the fi rst, measures are taken to counter malnutrition, especially in terms of guaranteeing regular access to adequate basic food rations. The purpose is then to complement the GFD once moderate malnutrition rates have fallen, but new cases continue to appear owing to new arrivals and/or persistently harsh living conditions (incapacity to deliver adequate healthcare, poor climatic conditio...
+
+=== Chunk 2366 ===
+Source: 0820_002-ebook.pdf
+Length: 672 chars
+
+2.1.4 Providing a relay for therapeutic feeding
+When therapeutic feeding centres (TFC) are overstretched, it may be preferable to complete the nutritional treatment in an SFP centre, linked to the TFC. Children must be transferred as soon as they are no longer severely malnourished. Implementation modalities are those described in Section 2.1.1.A above. When SFPs provide a relay for therapeutic feeding, it is crucial that the entire population have adequate access to food (GFD or adequate indivi...
+
+=== Chunk 2367 ===
+Source: 0820_002-ebook.pdf
+Length: 1355 chars
+
+2.2 SUPPLEMENTARY FEEDING PROGRAMME CENTRES
+Supplementary feeding programmes (SFP) translate into practice in centres which can moreover be linked to therapeutic feeding centres and health centres, unless they provide healthcare themselves. Two types of SFP centres exist, where the ration is to be either eaten on the spot or taken home. It is tempting to prefer take-away rations owing to their following advantages:
+9 their organization is simpler;
+COURUTY
+9 they demand less resources;
+9 more ben...
+
+=== Chunk 2368 ===
+Source: 0820_002-ebook.pdf
+Length: 421 chars
+
+2.2.1 Activities in an SFP centre
+In centres where food rations are eaten on a daily basis, the range of activities is wider than in a centre supplying take-away rations, where it consists of the registration and discharge of benefi ciaries, monitoring their nutritional and health status, and the distribution of food. Activities pertaining to both set-ups are nevertheless discussed here together, for simplicity’s sake....
+
+=== Chunk 2369 ===
+Source: 0820_002-ebook.pdf
+Length: 245 chars
+
+Registration and admission of benefi ciaries
+These aspects are virtually identical to those of a therapeutic feeding centre’s (TFC). Characteristics specifi c to SFPs are indicated below; the remaining are discussed in Chapter XIII, Section 3.3.1....
+
+=== Chunk 2370 ===
+Source: 0820_002-ebook.pdf
+Length: 785 chars
+
+Identifi cation through bracelets
+In SFP centres, the use of bracelets not only facilitates identifi cation, it also avoids the use of distribution cards to accompanying relatives or the benefi ciary himself – distribution cards are always a source of problems and abuse. This practice applies both to centres distributing meals to be eaten on the spot and those providing take-away rations. Bracelets indicate the benefi ciary’s number, the identifi cation code of the registration centre, and the code o...
+
+=== Chunk 2371 ===
+Source: 0820_002-ebook.pdf
+Length: 174 chars
+
+Supervision
+Supervision permits the monitoring of benefi ciaries and their attendance at the centre, which also provides the data required to appraise the centre’s effi ciency....
+
+=== Chunk 2372 ===
+Source: 0820_002-ebook.pdf
+Length: 1911 chars
+
+Monitoring benefi ciary status and progress
+The nutritional status of benefi ciaries is measured at regular intervals (usually once a week), often on a rotating basis or during distribution in the case of take-away rations. Benefi ciaries and accompanying relatives must be informed of the date set for the check-up, and of the fact that the procedure takes time. In principle, an SFP targeting the moderately malnourished should lead to nutritional recovery, but – unlike therapeutic feeding centres – ...
+
+=== Chunk 2373 ===
+Source: 0820_002-ebook.pdf
+Length: 1112 chars
+
+Attendance monitoring
+This monitoring is of utmost importance in ensuring appropriate benefi ciary feeding. When meals are eaten within the centre, it is done during each meal, in a register indicating bracelet number and benefi ciary name. The latter and accompanying relatives must be informed of meal, distribution and healthcare attendance rules. Absences on more than three consecutive occasions, or more than fi ve days in two weeks, without proper reason, will exclude the benefi ciary from the pr...
+
+=== Chunk 2374 ===
+Source: 0820_002-ebook.pdf
+Length: 961 chars
+
+Discharge of benefi ciaries
+The criteria for discharge have been discussed above. In principle, the benefi ciary’s nutritional status should have remained stable, equal to or above discharge thresholds, for a fortnight. However, depending on the severity of the situation, it may be necessary to accelerate the rotation of benefi ciaries and, therefore, reduce or even waive this safety period. Furthermore, it is necessary to expel absentees and cases of bad behaviour (theft, refusal to abide by the r...
+
+=== Chunk 2375 ===
+Source: 0820_002-ebook.pdf
+Length: 269 chars
+
+Food preparation
+Recommendations for food preparation are identical for an SFP centre and a TFC, apart from the organization required in a therapeutic feeding centre (TFC) to prepare different ration types. Readers are therefore referred to Chapter XIII, Section 3.3.4....
+
+=== Chunk 2376 ===
+Source: 0820_002-ebook.pdf
+Length: 1040 chars
+
+Distribution of food rations
+Take-away rations
+In the case of take-away rations, benefi ciaries and accompanying relatives must be aware that it is their responsability to provide containers, which should not preclude the storage of bags to assist those who have forgotten theirs or do not have any. Distribution should not be more frequent than once a week, nor less frequent than once a fortnight. In principle, four to fi ve days per week should be devoted to distribution, with one day for stock re...
+
+=== Chunk 2377 ===
+Source: 0820_002-ebook.pdf
+Length: 655 chars
+
+Meals to be eaten on the spot
+In the case of rations to be eaten on the spot, distribution schedules must be known and respected both by benefi ciaries and centre staff – the latter have their own constraints, but so do the benefi ciaries and, above all, their accompanying relatives (especially time constraints). Furthermore, distributing snacks to accompanying relatives can prove extremely helpful when the crisis deteriorates and the basic ration at home is insuffi cient. The other features of mea...
+
+=== Chunk 2378 ===
+Source: 0820_002-ebook.pdf
+Length: 354 chars
+
+Provision of healthcare
+Healthcare is, in principle, provided within the SFP centre, unless a health centre is located close by and intended also for this purpose. Nevertheless, an SFP centre should always be equipped to dispense basic care. A centre delivering weekly rations cannot provide healthcare. Systematic care is different from individual care....
+
+=== Chunk 2379 ===
+Source: 0820_002-ebook.pdf
+Length: 570 chars
+
+Measles vaccinations
+Measles is a particularly virulent disease, often fatal for malnourished children. It can propagate extremely fast in a feeding centre. It is therefore indispensable, systematically upon admission, to vaccinate children previously not vaccinated, doubtful cases and those without vaccination cards. Their presence in the centre provides the opportunity to update vaccinations.
+567
+V I X
+V I X
+NUTRITION MANUAL Chapter XIV – Supplementary feeding programmes
+2. Implementing supple...
+
+=== Chunk 2380 ===
+Source: 0820_002-ebook.pdf
+Length: 589 chars
+
+Vitamin A distribution
+The importance of vitamin A has been discussed in Chapters III and VIII. Malnourished children often suffer from sub-clinical vitamin A defi ciency. Administering a prophylactic dose upon admission, as per the Figure provided in Chapter XIII, Section 4.6.1, is therefore essential. The administering of vitamin A should be repeated according to the same Figure upon discharge from the programme. Protracted SFPs targeting entire vulnerable groups require the quarterly repetitio...
+
+=== Chunk 2381 ===
+Source: 0820_002-ebook.pdf
+Length: 272 chars
+
+Parasite treatment
+Infestation by intestinal worms such as roundworm, hookworm and pinworm is so frequent that the general rule in an SFP centre is to treat all patients above the age of 1 systematically, upon admission, with mebendazole. Posology is a 500 mg single dose....
+
+=== Chunk 2382 ===
+Source: 0820_002-ebook.pdf
+Length: 253 chars
+
+Individual care
+Individual care mainly addresses infections calling for antibiotic treatment, and the attention required in case of diarrhoea and dehydration, for which skilled nursing staff is necessary. Treatment outlines are provided in Chapter XIII....
+
+=== Chunk 2383 ===
+Source: 0820_002-ebook.pdf
+Length: 190 chars
+
+Management of the centre
+These features are the same for supplementary feeding programme (SFP) and therapeutic feeding centres (TFC). They have been discussed in Chapter XIII, Section 3.3.8....
+
+=== Chunk 2384 ===
+Source: 0820_002-ebook.pdf
+Length: 320 chars
+
+Other activities
+SFP centres delivering rations to be eaten on the spot offer the opportunity for other activities than meal distribution, healthcare and recovery monitoring – which must, nevertheless, remain the centre’s central tasks. Such additional activities are described in Chapter XIII, Sections 3.3.9 and 4.3.3....
+
+=== Chunk 2385 ===
+Source: 0820_002-ebook.pdf
+Length: 1637 chars
+
+2.2.2 SFP centre structure, equipment and human resources
+With a simplifi ed structure and services, centres providing meals to be eaten on the spot are similar to the therapeutic feeding centres (TFC) discussed in Chapter XIII; readers should refer to Sections 3.1, 3.1.1, 3.1.2 and 3.1.3, and use common sense to adapt the recommendations they contain. Therefore, only aspects specifi c to SFP centres are discussed here.
+In a centre restricted to the distribution of take-away rations, activities ar...
+
+=== Chunk 2386 ===
+Source: 0820_002-ebook.pdf
+Length: 1215 chars
+
+Human resources
+The centre must be staffed with suffi cient resources, properly paid, aware of their role and responsibilities, and trained to perform their tasks. Each task within the centre must be assigned to a person in charge: caretaking, cleaning, cooking, verifi cation, etc.
+For an SFP centre, the following positions are required.
+9 1 person in charge, usually a nurse, assisted by a deputy.
+9 1 assistant in charge of general supervision and providing back-up for the person in charge of the ...
+
+=== Chunk 2387 ===
+Source: 0820_002-ebook.pdf
+Length: 1584 chars
+
+2.3 FOOD RATIONS
+Whether the SFP aims to contain a crisis, contribute to the rapid eradication of moderate malnutrition, provide a safety net or a relay for therapeutic feeding, it will anyway involve substantial rations. When the objective is to contain a crisis, the child clearly does not receive enough food at home and, in view of the fact that it might face discrimination owing to its inclusion in a feeding programme, it should receive at least half its daily requirements, without expecting ...
+
+=== Chunk 2388 ===
+Source: 0820_002-ebook.pdf
+Length: 2648 chars
+
+2.3.1. Rations to be eaten on the spot
+The ration should provide at least 500 kcal (2,090 kJ) per day, if possible 700 kcal (2,930 kJ), even 1,000 kcal (4,180 kJ), circumstances permitting. The protein contribution of these three levels of ration should then be 15 g, 21 g, and 30 g respectively, calculated on a 12% protein/energy ration (P/E ratio).
+The ration can be composed of the following preparations.
+9 A porridge made with commercial formula containing all necessary nutrients (for example,...
+
+=== Chunk 2389 ===
+Source: 0820_002-ebook.pdf
+Length: 971 chars
+
+2.3.2 Take-away rations
+For take-away rations, pre-mix is desirable. This can be either commercial or locally prepared (as described in Section 2.3.1 above) for mothers, properly trained, to cook at home. This is the safest way of ensuring that the child will eat most of its ration. Individual ingredients or biscuits should not be distributed, as they would likely be eaten by others. However, sharing with other family members
+16 Corn Soy Blend, see Chapter XII.
+570
+2. Implementing supplementary ...
+
+=== Chunk 2390 ===
+Source: 0820_002-ebook.pdf
+Length: 243 chars
+
+2.4 SUPERVISION AND ASSESSMENT
+Supervising the activities of the centre facilitates the overall assessment of its performance and of developments in the circumstances, while assessment allows the verifi cation that set objectives are being met....
+
+=== Chunk 2391 ===
+Source: 0820_002-ebook.pdf
+Length: 473 chars
+
+2.4.1 Supervision
+In terms of supervision, comments are the same as those found in Chapter XIII, Section 3.4.1, except for meal attendance. In an SFP centre, a higher than 90% meal attendance is considered satisfactory. A lower rate usually indicates problems external to the centre rather than doubts about the quality of the services it provides. Understanding the reasons for lower than expected attendance rates is therefore necessary for appropriate steps to be taken....
+
+=== Chunk 2392 ===
+Source: 0820_002-ebook.pdf
+Length: 1193 chars
+
+2.4.2 Assessment
+This consists in verifying the rate of nutritional recovery, the duration of stay (related to the recovery rate), the speed of recovery from sickness and the discharge or exit rate versus recovery (objective met), death, drop-out, absenteeism, and transfer to therapeutic feeding centres or hospitals. In other words:
+9 the nutritional recovery rate should be at least 5 g/kg/day, provided the ration is enriched in vitamins and minerals as described in Annex 16;
+9 the duration of s...
+
+=== Chunk 2393 ===
+Source: 0820_002-ebook.pdf
+Length: 9831 chars
+
+THE THEMES OF NUTRITIONAL INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580
+Food storage and preservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582 Choosing foodstuffs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582 Protecting foodstuffs . . . . . . . . . . . . . . . . . . . . . . . . ...
+
+=== Chunk 2394 ===
+Source: 0820_002-ebook.pdf
+Length: 4454 chars
+
+THE LIMITS OF NUTRITIONAL INFORMATION
+Gillespie and Mason have analysed common and chronic nutritional problems that relate mainly to structural and cultural issues (Gillespie & Mason, 1991); this approach provides a useful illustration of the foregoing, and facilitates the positioning of nutritional information within humanitarian action. The fi rst signal is inadequate food security at household level (which in this Manual corresponds to economic insecurity). The second signal is the associatio...
+
+=== Chunk 2395 ===
+Source: 0820_002-ebook.pdf
+Length: 1797 chars
+
+2. KEY STAGE OF NUTRITIONAL INFORMATION WITHIN THE FEEDING PROCESS
+In a crisis, the only stage of the feeding process that may be addressed by nutritional information is the food consumption stage. At that level, poor practice resulting from a lack of knowledge and motivation always gives rise to health problems. The main objective of nutritional information is then to improve the health of target groups by reducing the prevalence, incidence, and seriousness of such disorders. In developing coun...
+
+=== Chunk 2396 ===
+Source: 0820_002-ebook.pdf
+Length: 2641 chars
+
+THE OBJECTIVE AND PREMISE OF NUTRITIONAL INFORMATION
+Within the framework of humanitarian action, nutritional information aims at replacing poor practices with others that are more appropriate. To this end, preliminary assessment must fi rst demonstrate that:
+9 observed nutritional problems arise from poor practice;
+9 such poor practice results mainly from lack of knowledge and/or motivation, and not from the inadequacy of basic resources (time or material means) or other priorities taking preced...
+
+=== Chunk 2397 ===
+Source: 0820_002-ebook.pdf
+Length: 1318 chars
+
+4.1 DEMONSTRATING THE RELEVANCE OF NUTRITIONAL INFORMATION
+In a crisis especially, nutritional information programmes must be supported by survey data that clearly demonstrates their relevance and pertinence. This may be achieved in two ways. A causal model can be designed from all cases that present a given pathology, by backtracking to the causes of this pathology, and demonstrating that they can be resolved through information. Alternatively, local nutritional and care practices can be compar...
+
+=== Chunk 2398 ===
+Source: 0820_002-ebook.pdf
+Length: 226 chars
+
+4.2 TRAINING COMPONENTS
+Field staff must have the means (time and resources) to engage in dialogue with target groups; it should avoid restricting training sessions to academic lectures that in fact do little for the audience....
+
+=== Chunk 2399 ===
+Source: 0820_002-ebook.pdf
+Length: 1738 chars
+
+4.2.1 Basic principles
+The following are basic pre-conditions for success.
+9 Target communities should be involved in the operational planning, implementation, and
+evaluation processes.
+9 Proposed changes should be simple, context-specifi c, and be expected to improve health substantially; they should comply with cultural standards and not upset them.
+9 Proposed changes should refer to positive deviants5 as examples in order to avoid becoming
+excessively theoretical.
+9 Key messages should be kept...
+
+=== Chunk 2400 ===
+Source: 0820_002-ebook.pdf
+Length: 1738 chars
+
+Planning and organizing sessions
+Once the problems and key messages have been determined, the programme is planned in a sequence of sessions that address one problem at a time, proceeding from the simplest to the more complex.
+Sessions should be scheduled in such a way as to disrupt essential community activities as little as possible; a weekly frequency is usually adequate. The location chosen for sessions should be welcoming, and be sheltered from the elements. The audience should be limited t...
+
+=== Chunk 2401 ===
+Source: 0820_002-ebook.pdf
+Length: 775 chars
+
+Content of sessions
+Trainers should:
+9 begin the session with a brief description of the problem under consideration;
+ODY
+9 invite participants to provide their views on the problem and its causes;
+9 compare such views with the behaviour of positive deviants, and describe the approach that averts the problem;
+9 describe best behaviour in a discussion with the audience;
+9 proceed to the demonstration and experimentation stage if relevant, by involving one or more
+participants as assistants;
+9 sum...
+
+=== Chunk 2402 ===
+Source: 0820_002-ebook.pdf
+Length: 980 chars
+
+THE THEMES OF NUTRITIONAL INFORMATION
+At the level of food consumption, the commonest health disorders arise in relation to the following aspects – these provide the themes of nutritional information:
+9 food hygiene, which is of capital importance in infant and child feeding;
+9 infant and child feeding;
+9 diet.
+Training sessions, based on the observation of poor practice, may revolve around one or more of the above themes. Good practice is indicated here in rather abstract terms and for ideal co...
+
+=== Chunk 2403 ===
+Source: 0820_002-ebook.pdf
+Length: 3789 chars
+
+5.1 FOOD HYGIENE
+A signifi cant proportion of infectious disease results from poor food hygiene, and is the main cause of infant morbidity and mortality. Foodstuffs can contain intestinal parasites from the
+580
+5. The themes of nutritional information
+5.1 Food hygiene
+beginning, but they can also be contaminated later by microbes that cause gastro-intestinal and respiratory infection, in addition to hepatitis, tuberculosis, poliomyelitis, and typhoid fever. Some of these microbes also produce tox...
+
+=== Chunk 2404 ===
+Source: 0820_002-ebook.pdf
+Length: 689 chars
+
+5.1.1 Poor practice resulting in food contamination
+The risk of consuming contaminated food is associated with the following behaviours:
+9 the use of visibly contaminated foods;
+9 the premature preparation of food: it increases the risk of contamination before consumption, and harmful bacteria that have resisted the preparation process have more time to multiply;
+9 insuffi cient cooking, which spares parasites and harmful bacteria;
+9 contamination through contact (contaminated workbenches, utensi...
+
+=== Chunk 2405 ===
+Source: 0820_002-ebook.pdf
+Length: 1574 chars
+
+Food storage and preservation
+Quality food storage is the fi rst stage of hygiene. Foodstuffs must be sheltered from rodents, birds, and insects; these can contaminate them directly, and/or open the way for additional contamination through the damage they cause. Foodstuffs must be sheltered from humidity, heat, and dust in order to avoid the spread of mould and bacteria, but also from light, which can likewise cause degradation. Storage space must be clean, closed but ventilated, easy to clean, a...
+
+=== Chunk 2406 ===
+Source: 0820_002-ebook.pdf
+Length: 1265 chars
+
+Choosing foodstuffs
+Only quality foodstuffs must be selected according to the following criteria.
+9 The wrapping of deep-frozen foods must be intact, and the expiry date must not be past. Deep-frozen foods must be thawed in their intact wrapping, sheltered from contamination (especially from fl ies). Thawed foods must not be refrozen.
+9 The odour and appearance of fresh foods must be pleasant; they must be devoid of bruises, mould and traces of predators. They must not be overripe or withered.
+9 ...
+
+=== Chunk 2407 ===
+Source: 0820_002-ebook.pdf
+Length: 238 chars
+
+Protecting foodstuffs
+No food must be left uncovered in kitchens, even briefl y; fl ies need mere seconds to fl y from latrines to kitchens, and the dust in the air carries germs.
+582
+5. The themes of nutritional information
+5.1 Food hygiene...
+
+=== Chunk 2408 ===
+Source: 0820_002-ebook.pdf
+Length: 219 chars
+
+Contact between foodstuffs
+Foodstuffs that are not prepared together, especially cooked and raw foods, should be kept separate; indirect transmission through kitchen utensils, linen and workbenches must also be avoided....
+
+=== Chunk 2409 ===
+Source: 0820_002-ebook.pdf
+Length: 473 chars
+
+Preparing foodstuffs
+Foodstuffs should only be prepared for immediate consumption. Foods that are eaten raw should be washed carefully with clean water, or peeled. They may be soaked in salted or chlorinated water. Fresh foods are in principle prepared the same day in the absence of refrigerators; even refrigerated meat, fi sh, and milk can usually only be kept for two days at most. Food that is ready for consumption must be sheltered from dust, splashes, and predators....
+
+=== Chunk 2410 ===
+Source: 0820_002-ebook.pdf
+Length: 169 chars
+
+Cooking foodstuffs
+Food should be cooked through, especially animal products that must be brought to a temperature of 70°C at least; milk, in particular, must be boiled....
+
+=== Chunk 2411 ===
+Source: 0820_002-ebook.pdf
+Length: 230 chars
+
+Consuming foodstuffs
+Prepared and cooked food must be consumed immediately in order to avoid the proliferation of pathogens that may have resisted cooking, or have contaminated the food after cooking (for example through contact)....
+
+=== Chunk 2412 ===
+Source: 0820_002-ebook.pdf
+Length: 367 chars
+
+Keeping prepared foodstuffs
+In principle, cooked food should not be kept after the meal, unless this can be done at a temperature above 60°C or below 5°C. Neither option is practical (especially the sudden cooling to 5°C), and both can only be done in very small quantities. In any case, infants must never be fed items that have not been prepared immediately before....
+
+=== Chunk 2413 ===
+Source: 0820_002-ebook.pdf
+Length: 177 chars
+
+Reheating cooked food
+The reuse of cooked food implies that it be reheated throughout at a temperature of at least 70°C. Such foods are nevertheless also unsuitable for infants....
+
+=== Chunk 2414 ===
+Source: 0820_002-ebook.pdf
+Length: 1403 chars
+
+Kitchen cleanliness
+Together with sanitary facilities, the kitchen should be the cleanest location in any home. It must be cleaned regularly and equipped with the specifi c material and cleaning linen for each task: cloths that are used to clean kitchen utensils are not the same as those used to clean workbenches, fl oors, or hands. Cleaning material must itself be cleaned regularly: cloths that are in contact with food and kitchen utensils and hand towels must be changed several times a week (ide...
+
+=== Chunk 2415 ===
+Source: 0820_002-ebook.pdf
+Length: 915 chars
+
+Personal hygiene
+In terms of personal hygiene, hands must be washed with water and soap, and dried with an immaculate towel or else air-dried. A soiled soap or towel can easily turn into a culture medium. Soap should be rinsed and drained after each use. Hands should be washed before handling food or sitting down at the meal table, following each interruption of kitchen chores – especially in order to visit sanitary facilities or change diapers, and between chores (for example, after handling ra...
+
+=== Chunk 2416 ===
+Source: 0820_002-ebook.pdf
+Length: 931 chars
+
+Water used for food preparation and washing
+The water used for the preparation and washing of food is usually the same as drinking water, and is a common source of contamination and infection. In case of doubt, it should be boiled for at least 10 minutes. The securing of safe drinking water is one of the greatest hygiene problems in poor countries and in a crisis. Access to water, and to the fuel required to boil it, is often complicated. Generally speaking, water must be collected and kept in a...
+
+=== Chunk 2417 ===
+Source: 0820_002-ebook.pdf
+Length: 486 chars
+
+5.2 FEEDING INFANTS AND SMALL CHILDREN
+The diet of infants and small children is crucial for their development and health. Breastfeeding and weaning practices play a major role in this framework. Feeding follows three phases: 0 to 4–6 months, 4–6 months until the completion of weaning (whose duration varies), and weaned infant feeding.6
+6 Chapter VI discusses the general aspects of food consumption.
+584
+5. The themes of nutritional information
+5.2 Feeding infants and small children...
+
+=== Chunk 2418 ===
+Source: 0820_002-ebook.pdf
+Length: 3052 chars
+
+Poor practice
+Infants between 0 and 4–6 months should be exclusively breastfed. In the industrialized West however, breastfeeding is often replaced by bottle feeding with milk reconstituted from special powdered formulae. Clearly, the quality of such milk does not match maternal milk, and the use of bottles does not provide the same emotional bond between mother and child as breastfeeding does. The process itself does not entail immediate danger however, provided that it is properly followed; at...
+
+=== Chunk 2419 ===
+Source: 0820_002-ebook.pdf
+Length: 2159 chars
+
+General information regarding breastfeeding
+Breastfeeding is the best and most natural way to feed infants. In most cases, breastfeeding alone is enough from birth up to 4 to 6 months because maternal milk is a complete and balanced food whose composition evolves over time and also with the child’s own development. The volume of
+7 Annex 3 discusses the utilization of maternal milk substitutes in humanitarian operations.
+585
+V X
+V X
+NUTRITION MANUAL Chapter XV – Nutritional information
+5. The the...
+
+=== Chunk 2420 ===
+Source: 0820_002-ebook.pdf
+Length: 4050 chars
+
+The advantages of breastfeeding
+Besides containing all necessary nutrients (provided that the mother does not suffer from defi ciencies in vitamins and minerals), maternal milk has other advantages that cannot be matched by any other method of infant feeding.
+9 Maternal milk protects against environmental bacterial and viral infection because it contains the defences that the mother herself secretes against the infectious agents to which she is exposed. It contains protection factors such as:
+q l...
+
+=== Chunk 2421 ===
+Source: 0820_002-ebook.pdf
+Length: 4347 chars
+
+The implementation of breastfeeding
+The pre-conditions for successful breastfeeding are the following.
+1. The mother must feel capable of breastfeeding, and be at ease in doing so. This attitude can be encouraged by the mother’s family and healthcare staff. In societies where breastfeeding is traditional and the use of substitutes and bottles is practically unknown, breastfeeding in principle involves no problems. In societies that are familiar with artifi cial infant feeding, it is common to fi n...
+
+=== Chunk 2422 ===
+Source: 0820_002-ebook.pdf
+Length: 2175 chars
+
+Substituting maternal milk
+In some cases, breastfeeding is not possible (sick or deceased mother, or insuffi cient milk secretion10), and a wet-nurse cannot be found; in such cases, the child must be fed maternal milk substitutes, or baby milk formulae. In the industrialized West and among the more affl uent groups in the developing world, this is usually no problem. Artifi cial feeding is in fact sometimes a deliberate choice on the part of the mother who can usually afford it. On the other hand, ...
+
+=== Chunk 2423 ===
+Source: 0820_002-ebook.pdf
+Length: 540 chars
+
+The use of substitution formulae (according to Cameron & Hofvander, 1983)
+The total volume for children up to 6 months of age is 150 ml of substitution formula per kg of body weight per day, to be spread out over 5 meals per day, that is, 30 ml per kg of body weight per meal. Meals should be spaced out according to 3 to 4 hour intervals, and children should be fed on demand (as for breastfeeding). Because of the constraints of formula preparation however, it is best to observe a set schedule, as...
+
+=== Chunk 2424 ===
+Source: 0820_002-ebook.pdf
+Length: 420 chars
+
+The use of cow’s milk
+Cow’s milk should be boiled in order to destroy potentially pathogenic microbes and improve the digestibility of its protein; boiled water and sugar should then be added in the following proportions:
+9 125 ml of boiled milk;
+9 75 ml of boiled water;
+9 15 g of sugar.
+This procedure produces approximately 200 ml of milk preparation, supplying roughly 70 kcal (290 kJ) and 2 g of protein per 100 ml....
+
+=== Chunk 2425 ===
+Source: 0820_002-ebook.pdf
+Length: 561 chars
+
+The use of dried whole milk
+In order to achieve the same concentration as with the previous recipe using cow’s milk, whole dried milk should be reconstituted with one weight unit of milk for 11 weight units of water (or one volume unit of milk for 5 volume units of water). The water should be previously boiled and allowed to cool off completely; sugar should be added. In other words:
+9 15 g of milk powder;
+9 170 ml of boiled and cooled water;
+9 15 g of sugar.
+This procedure produces 200 ml of mi...
+
+=== Chunk 2426 ===
+Source: 0820_002-ebook.pdf
+Length: 793 chars
+
+The use of dried skimmed milk
+Dried skimmed milk should not be used as a substitute for maternal milk; in a crisis however, this option can sometimes not be avoided. In such cases, it should be reconstituted according to the same proportions as for dried whole milk, and sugar and oil must be added as follows:
+9 10 g of milk powder;
+9 170 ml of boiled and cooled water;
+9 15 g of sugar;
+9 5 g of oil.
+This procedure produces 200 ml of milk, supplying 70 kcal (290 kJ) and 1.8 g of protein per 100 ml...
+
+=== Chunk 2427 ===
+Source: 0820_002-ebook.pdf
+Length: 968 chars
+
+The use of special maternal milk substitution formulae
+Commercially-available substitution formulae must be reconstituted with previously boiled water, in compliance with the manufacturer’s instructions, and without further addition.
+The three formulae provided above do not contain enough minerals or vitamins to cover neonatal requirements; consequently, it is best to supply fl uid pharmaceutical mineral and vitamin supplements intended for this specifi c use. Unfortunately, it is precisely in cri...
+
+=== Chunk 2428 ===
+Source: 0820_002-ebook.pdf
+Length: 645 chars
+
+Formula preparation
+Formulae must be prepared with previously boiled water and utensils that have been sterilized in boiling water for 5 to 10 minutes. It may not be possible to sterilize utensils after each meal; in such cases, they must be sterilized at least once or twice daily. If sterilization is impossible altogether, utensils must at the very least be washed in hot water and detergent, and be rinsed in clean drinking water or salted water, and left to dry in the sun if possible. If basic ...
+
+=== Chunk 2429 ===
+Source: 0820_002-ebook.pdf
+Length: 1019 chars
+
+Formula administration
+In most crisis settings, the use of bottles and teats is highly dangerous, because their proper cleaning and sterilizing is virtually impossible to guarantee. It is therefore best to use spoons, even if this option initially requires patience and time. The use of bottles and teats is strongly advised against here, because children can be spoon-fed from day one, provided that they are gently and patiently coaxed into the method. The use of bottles also suggests that such ut...
+
+=== Chunk 2430 ===
+Source: 0820_002-ebook.pdf
+Length: 299 chars
+
+Medical care
+Children that are not breastfed run greater risks of developing infections. Special attention must therefore be devoted to any suspicion of health disorders, especially diarrhoea and loss of appetite. In case of problems, the child must be referred to a healthcare facility immediately....
+
+=== Chunk 2431 ===
+Source: 0820_002-ebook.pdf
+Length: 4810 chars
+
+Mother-to-child HIV infection
+In the last thirty years, the promotion of breastfeeding has been viewed as a priority in limiting infant morbidity and mortality. Signifi cant progress has resulted, both in terms of breastfeeding trends and of commercial and humanitarian practice. Today however, the HIV/AIDS pandemic is a serious
+590
+5. The themes of nutritional information
+5.2 Feeding infants and small children
+threat to past efforts and achievements because HIV infection (especially HIV-1) can be...
+
+=== Chunk 2432 ===
+Source: 0820_002-ebook.pdf
+Length: 1515 chars
+
+5.2.2 Weaning
+In relation to food consumption, Chapter VI discusses weaning as the crucial stage in the survival and development of infants. Poor practice during this phase can have disastrous consequences.
+Poor practice
+The mortality associated with weaning can be very high, owing to the following factors:
+9 local habits can involve abrupt weaning that causes emotional shock in the child, and serious health risks if its food is inadequate and contaminated by infectious agents;
+9 varied and high...
+
+=== Chunk 2433 ===
+Source: 0820_002-ebook.pdf
+Length: 1252 chars
+
+The transition between breastfeeding and weaning
+In smooth breastfeeding conditions, the weaning process should begin at 4 months at the earliest, 6 months at the latest. Some societies begin it during the second month already. Moreover, occupational constraints and changing living conditions can cause mothers to adopt weaning practices that are not cultural but rather result from forced adaptation to new parameters. This subject must be understood properly before advising mothers.
+Breastfeeding...
+
+=== Chunk 2434 ===
+Source: 0820_002-ebook.pdf
+Length: 1183 chars
+
+Introducing weaning foods
+Semi-solid foods are introduced fi rst in the form of porridges or stews that are easy to chew and swallow; they are administered in small portions initially, in order for breastfeeding to predominate. It is best to supply them after breastfeeding, beginning with a single type of food and waiting for a few days for the child to grow used to it before introducing another fl avour. The fi rst food can be cereal porridge, mashed boiled tubers, or fruit stew (ripe banana is a ...
+
+=== Chunk 2435 ===
+Source: 0820_002-ebook.pdf
+Length: 2438 chars
+
+The energy density of weaning foods
+The energy density of weaning foods is of little importance early in the process; this importance however increases as the child grows and breastfeeding diminishes. This progression results from the substantial energy requirements per kilogram in infants, considering that their stomach is small and that they can only be fed small amounts at a time (150 ml between 6 and 12 months old, and 200 to 300 ml between 2 and 3 years). The energy density of weaning foods...
+
+=== Chunk 2436 ===
+Source: 0820_002-ebook.pdf
+Length: 2286 chars
+
+Variety
+As breastfeeding diminishes, the child needs more varied foods in order to satisfy its nutritional requirements.
+The principle is rather simple: breastfeeding should be complemented with four types of foods, as follows.
+1. One basic food, preferably a cereal.
+2. One protein food (legumes or animal products) that also supplies vitamins and minerals. Legumes are not easily digested (especially by infants) and cause fl atulence. They should therefore be soaked, shelled, and fully cooked unti...
+
+=== Chunk 2437 ===
+Source: 0820_002-ebook.pdf
+Length: 1226 chars
+
+Food hygiene
+The strict observance of basic hygiene rules is essential for infant health during the weaning process, when breastfeeding provides less and less protection against environmental pathogens – this moment unfortunately coincides with a substantial increase in the exposure to such germs.
+The following is a brief reminder of hygiene rules that are specifi c to the weaning process:
+9 only impeccable, washed, and freshly prepared foodstuffs should be used, and they should be peeled if nece...
+
+=== Chunk 2438 ===
+Source: 0820_002-ebook.pdf
+Length: 2174 chars
+
+Quality attention and healthcare
+During the weaning process, infants need much attention and require appropriate care quickly if infections appear. Furthermore, they should be regularly treated for parasites and vaccinated against infant diseases; these especially include measles and whooping cough, but also other dangerous infections such as poliomyelitis, diphtheria, and tetanus. Attention and healthcare are the two complements of feeding. Children suffering from infection must continue to be ...
+
+=== Chunk 2439 ===
+Source: 0820_002-ebook.pdf
+Length: 884 chars
+
+5.2.3 Feeding children up to 6 years old
+There is no nutritional information that is specifi c to the age bracket between 2 and 6 years. However, from the completion of weaning up until 5 to 6 years, children remain particularly vulnerable to infectious disease such as infant sicknesses, microbial and viral intestinal infections, respiratory infections and parasite infections. As their independence grows, they also receive less continuous attention, and their exposure to infection rises. The birt...
+
+=== Chunk 2440 ===
+Source: 0820_002-ebook.pdf
+Length: 1730 chars
+
+5.3 DIETS
+Human diets vary substantially, and are determined mainly by the following:
+9 what the natural environment produces;
+9 culture, according to:
+q the degree of economic development;
+q eating habits, which determine overall preferences, tastes, beliefs, and taboos;
+9 individual households, according to:
+q food access possibilities;
+q personal preferences.
+In nutritional crises, most food consumption problems result primarily from an inadequate access to food; this type of problem cannot b...
+
+=== Chunk 2441 ===
+Source: 0820_002-ebook.pdf
+Length: 1608 chars
+
+5.3.1 Nutrient balance
+The balance between different nutrients is determined mainly by recommended intakes. However, energy may equally be supplied in the form of lipids or glucides (simple or complex, see below) as in the form of protein. In order to limit statistical health risks,14 the necessary balance between macro- nutrients in order to satisfy energy requirements are summarized below.
+The contribution of lipids to the overall energy intake
+Lipids should account for 15 to 30% of the overal...
+
+=== Chunk 2442 ===
+Source: 0820_002-ebook.pdf
+Length: 802 chars
+
+The contribution of complex glucides to the overall energy intake
+Subtracting the lipid and protein contribution from the overall energy intake indicates that complex glucides should account for between 55 and 75% of the overall energy intake. This recommendation does not allow for the possible intake of alcohol and simple glucides, whose harmful effects on health require no further demonstration.
+14 Statistical health statistics risks are those revealed by epidemiological surveys and are expres...
+
+=== Chunk 2443 ===
+Source: 0820_002-ebook.pdf
+Length: 734 chars
+
+Fibre
+The dietary contribution of fi bre cannot be deduced from the overall energy intake because fi bre does not contribute to the coverage of the nutritional need. Fibre is nevertheless important, because it promotes digestion, helps to eliminate cholesterol, and contributes to the prevention of intestinal disorders. It is found in vegetables, fruits, cereals, and legumes; the recommended intake is approximately 20 g of fi bre per person, per day (WHO, 2003). The fi bre content of foods is diffi cu...
+
+=== Chunk 2444 ===
+Source: 0820_002-ebook.pdf
+Length: 2011 chars
+
+5.3.2 Food group balance
+Chapter V discusses the different food groups consumed by man; as a general rule, diets should comprise fi ve types of food.
+1. One basic food (or “staple food”, cereal or tuber). In crises, this type must be consumed in suffi cient amounts in order to avoid the development of severe malnutrition.
+2. One protein food (legumes, oilseeds, meat, fi sh, dairy products, eggs). This type also prevents the development of severe malnutrition and of specifi c defi ciencies, notably pe...
+
+=== Chunk 2445 ===
+Source: 0820_002-ebook.pdf
+Length: 2675 chars
+
+Staple foods
+Several possibilities exist: the staple food is cereals or tubers (or a combination of the two), or a combination of foodstuffs pertaining to different food groups. It is important for the cases where the staple food is mainly cereals or tubers to be discussed here, as it must in such cases be complemented with an adequate protein supplement. In the case of cereal as discussed in Chapter V, it must be
+15 Vegetable oil is preferred to animal fat, which increases the risk of cardiac c...
+
+=== Chunk 2446 ===
+Source: 0820_002-ebook.pdf
+Length: 2845 chars
+
+Protein
+The protein complement in the form of legumes should be approximately 60 to 200 g (200 to 680 kcal (840 to 2 840 kJ)), according to whether the staple is in the form of cereal or a protein-poor tuber. It may be supplied by way of other protein-rich foodstuffs – what then matters is to ensure the protein equivalent of what the legumes supply, that is, approximately 15 g of protein if the latter complement cereals, or 45 g if they complement the abovementioned tubers. In both cases, correc...
+
+=== Chunk 2447 ===
+Source: 0820_002-ebook.pdf
+Length: 1030 chars
+
+Energy
+The energy complement should account for 15 to 30% of the overall energy intake; in terms of a 2,400 kcal (10,000 kJ) ration, this converts roughly into the following:
+9 40 to 80 g of oil;
+COREY
+9 50 to 100 g of butter;
+9 60 g of sugar with 15 to 55 g of oil;
+9 65 to 130 g of dried peanuts;
+9 60 to 120 g of nuts;
+9 70 to 140 g of oilseeds.
+In dietary terms, the population of wealthy countries whose physical activity is light should observe the lower values provided above for oil, butter, ...
+
+=== Chunk 2448 ===
+Source: 0820_002-ebook.pdf
+Length: 124 chars
+
+Sugar
+As mentioned earlier, sugar should not account for more than 10% of the overall energy intake (WHO, 2003; WHO, 1988b)....
+
+=== Chunk 2449 ===
+Source: 0820_002-ebook.pdf
+Length: 705 chars
+
+Alcohol
+Rather than ignoring alcohol deliberately because of its harmfulness in many respects, and in view of its widespread consumption in the world, this Manual prefers to set the upper limit for its consumption, which is identical to that for sugar. Alcohol should not account for more than 10% (ideally less, even not at all) of the average required overall energy intake of nutritionally healthy adults. With respect to an overall energy requirement of 2,400 kcal (10,000 kJ), being that of a li...
+
+=== Chunk 2450 ===
+Source: 0820_002-ebook.pdf
+Length: 272 chars
+
+Application
+The above principles provide a general framework for a dietetic approach to diets. Table 15.1 below illustrates their practical application, by suggesting family diets built upon the eating habits of different regions; it is adapted from Latham (Latham, 1997)....
+
+=== Chunk 2451 ===
+Source: 0820_002-ebook.pdf
+Length: 2341 chars
+
+Table 15.1 Examples of diets
+Region Rural Philippines Uganda Mexico Masai Santiago de India Mozambique Country Chile Foodstuffs: Staple Millet Rice Plantain 1 kg Maize tortilla Milk Bread 400 g Rice 500 g 400 g 500 g Sweet potato 500 g 2 l Rice Cassava 200 g 100 g 200 g Protein Curdled milk Fish Meat Meat Blood Eggs Fish complement 150 ml 100 g 50 g 50 g 100 ml 30 g 100 g Peanuts Beans Beans Beans Meat Lentils 50 g 150 g 150 g 150 g 100 g 150 g Milk 60 ml Energy Bambara nuta Oil Oil Oil Maize Bu...
+
+=== Chunk 2452 ===
+Source: 0820_002-ebook.pdf
+Length: 129 chars
+
+ANNEX 1
+ENERGY COST OF SPECIFIC OCCUPATIONS: EXAMPLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 606...
+
+=== Chunk 2453 ===
+Source: 0820_002-ebook.pdf
+Length: 126 chars
+
+ANNEX 2
+FOOD GROUPS CONTAINING THE FOUR MAJOR VITAMINS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 608...
+
+=== Chunk 2454 ===
+Source: 0820_002-ebook.pdf
+Length: 141 chars
+
+ANNEX 3
+THE USE OF ARTIFICIAL MILKS IN RELIEF ACTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 609...
+
+=== Chunk 2455 ===
+Source: 0820_002-ebook.pdf
+Length: 154 chars
+
+ANNEX 4.1
+WEIGHT-FOR-HEIGHT TABLES (WHO, 1983) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614...
+
+=== Chunk 2456 ===
+Source: 0820_002-ebook.pdf
+Length: 162 chars
+
+ANNEX 4.2
+HEIGHT-FOR-AGE TABLES (WHO 1983) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623...
+
+=== Chunk 2457 ===
+Source: 0820_002-ebook.pdf
+Length: 182 chars
+
+ANNEX 4.3
+MID-UPPER ARM CIRCUMFERENCE (CM) FOR AGE AND HEIGHT BETWEEN 6 AND 60 MONTHS (BOTH SEXES) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627...
+
+=== Chunk 2458 ===
+Source: 0820_002-ebook.pdf
+Length: 115 chars
+
+ANNEX 4.4
+WEIGHT-FOR-AGE AND WEIGHT-FOR-HEIGHT OF ADOLESCENTS . . . . . . . . . . . . . . . . . . . . . . . . . 629...
+
+=== Chunk 2459 ===
+Source: 0820_002-ebook.pdf
+Length: 177 chars
+
+ANNEX 5
+THE CODE OF CONDUCT FOR THE INTERNATIONAL RED CROSS AND RED CRESCENT MOVEMENT AND NGOs IN DISASTER RELIEF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 636...
+
+=== Chunk 2460 ===
+Source: 0820_002-ebook.pdf
+Length: 161 chars
+
+ANNEX 6
+RED CROSS POLICY ON NUTRITION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 641...
+
+=== Chunk 2461 ===
+Source: 0820_002-ebook.pdf
+Length: 1488 chars
+
+ANNEX 7
+NUTRITIONAL SURVEY INDICATORS: EXAMPLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 650
+604
+TABLE OF CONTENTS
+ANNEX 8 NORMAL DISTRIBUTION (SCHWARTZ, 1963) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 651 ANNEX 9 THE QUAC STICK ANTHROPOMETRIC METHOD (FROM DE VILLE DE GOYET, 1978) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ....
+
+=== Chunk 2462 ===
+Source: 0820_002-ebook.pdf
+Length: 137 chars
+
+ANNEX 17
+SUPPLEMENTARY FEEDING PROGRAMME LAYOUT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 668...
+
+=== Chunk 2463 ===
+Source: 0820_002-ebook.pdf
+Length: 146 chars
+
+ANNEX 18
+SPECIAL FEEDING PROGRAMME EQUIPMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 669...
+
+=== Chunk 2464 ===
+Source: 0820_002-ebook.pdf
+Length: 176 chars
+
+ANNEX 19
+RANDOM NUMBER TABLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673...
+
+=== Chunk 2465 ===
+Source: 0820_002-ebook.pdf
+Length: 166 chars
+
+ANNEX 20
+ENERGY AND PROTEIN CONTENT OF COMMON FOODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674
+605
+NUTRITION MANUAL ANNEXES
+Annex 1...
+
+=== Chunk 2466 ===
+Source: 0820_002-ebook.pdf
+Length: 149 chars
+
+ANNEX 1 ENERGY COST OF SPECIFIC OCCUPATIONS: EXAMPLES
+The cost is expressed as a multiple of the basal metabolism (BM). Adapted from WHO (WHO, 1985)....
+
+=== Chunk 2467 ===
+Source: 0820_002-ebook.pdf
+Length: 2235 chars
+
+Table A.1 Energy cost of male occupations
+Light activity: 1 – 2.5 × BM Moderate activity: 2.6 – 4 × BM Sleep: 1.0 Sweeping: 2.7 Seated clerical work: 1.3 Industrial machine work: 3.1 Calm standing position: 1.4 Walking: 3.2 Kneeling position (e.g. sorting): 1.6 Bamboo cutting: 3.2 Domestic kitchen chores: 1. 8 Masonry work: 3.3 Printing work: 2.0 Hunting: 3.5 Seated weaving work: 2.1 Harvesting sweet potato: 3.5 Tractor driving: 2.1 Walking with a 10-kg load: 3.5 Line fi shing: 2.1 Motor engine m...
+
+=== Chunk 2468 ===
+Source: 0820_002-ebook.pdf
+Length: 1938 chars
+
+Table A.2 Vitamin content
+Vitamin C Thiamine (B1) Niacin Vitamin A mg/100 g mg/100 g mg/100 g mg/100 g and (IU) PRIa: 45 mg PRI: 0.4 mg/1,000 kcal PRI: 6.7 mg/1,000 kcal PRI: 0.7 mg (2,330) 200 – 101 > 1 – 0.6 20 – 11 15 – 2 (50,000 – 6,700) Cabbage, guava, parsley, Dried peanuts, black-eyed Dried peanuts (17), dried Poultry and livestock liver, chilli pepper. peas, dried peas, soybeans, larvae. palm oil. cashew nuts, sesame and sunfl ower seeds, lean pork. 100 – 50 0.5 – 0.3 10 – 4 1 – 0.3 (3,30...
+
+=== Chunk 2469 ===
+Source: 0820_002-ebook.pdf
+Length: 363 chars
+
+ANNEX 3 THE USE OF ARTIFICIAL MILKS IN RELIEF ACTIONS
+This paper is an annex to the International Red Cross and Red Crescent Movement’s policy on nutrition.
+1. Introduction
+NAR ONE
+2. Policy
+3. The value of milk
+4. Problems associated with using artifi cial milk in relief actions
+5. Mixed diet
+6. The safe usage of artificial milk in relief actions
+7. Conclusions...
+
+=== Chunk 2470 ===
+Source: 0820_002-ebook.pdf
+Length: 324 chars
+
+1. INTRODUCTION
+In times of disaster, artifi cial milks1 are frequently requested or donated for distribution to the victims. This almost inevitable response has arisen because such products have become readily available in recent years and because there is a widespread belief in the particular properties of milk as a food....
+
+=== Chunk 2471 ===
+Source: 0820_002-ebook.pdf
+Length: 1443 chars
+
+2. POLICY
+Because there have been problems associated with the indiscriminate distribution of milk, the International Red Cross has found it necessary to draw up the following policy for its distribution in relief actions.
+2.1 In relief actions the International Red Cross will only distribute artifi cial milks to those populations who traditionally use milk in their diets and only then under strictly controlled and hygienic conditions.
+2.2 The International Red Cross will not use artifi cial milk ...
+
+=== Chunk 2472 ===
+Source: 0820_002-ebook.pdf
+Length: 1910 chars
+
+3. THE VALUE OF MILK
+Milk is a versatile food. It is a rich source of essential proteins. Being liquid it can be consumed by the very young, the very weak and the sick. It can be eaten soured, as cream, as yoghurt, as cheese or as an ingredient with other foods.
+3.1 Human breast milk is the perfect balanced food for the human baby. Breast milk alone will provide all the nutrients a baby needs for at least the fi rst 4 months of life. If breast milk is not available for the small baby, alternative...
+
+=== Chunk 2473 ===
+Source: 0820_002-ebook.pdf
+Length: 4075 chars
+
+4. PROBLEMS ASSOCIATED WITH USING ARTIFICIAL MILK IN RELIEF ACTIONS
+4.1. General: the indiscriminate distribution of artifi cial milk in relief actions instils or perpetuates the belief that milk is an essential food and threatens to change long established food habits and to create unnecessary economic pressures.
+4.2. Management of supplies: as with any other food with high water content, liquid or semi-liquid milks should not be transported or distributed since the high costs involved cannot be...
+
+=== Chunk 2474 ===
+Source: 0820_002-ebook.pdf
+Length: 1672 chars
+
+5. MIXED DIET
+5.1 It is now recognized that to prevent malnutrition it is necessary to get enough energy (calories). If a person can eat enough of a mixed diet to satisfy his energy requirements he will automatically be satisfying his protein requirements. This is true for growing children as well as for adults. Milk being a liquid (nearly 90% water) is a very dilute source of energy and a baby after the fi rst 4–6 months of life cannot satisfy his energy requirements from milk alone, but needs s...
+
+=== Chunk 2475 ===
+Source: 0820_002-ebook.pdf
+Length: 1096 chars
+
+THE SAFE USAGE OF ARTIFICIAL MILK IN RELIEF ACTIONS
+Where people traditionally use milk in their diets it is acceptable to provide artifi cial milks under controlled and hygienic conditions (usually from special feeding centres).
+6.1 Milk powder used as an ingredient: the safest way to use milk powder is to add it to a cooked porridge or soup for “on the spot” feeding. The milk will then be a useful, easily absorbed and safe source of protein and of limited quantities of minerals and vitamins.
+6....
+
+=== Chunk 2476 ===
+Source: 0820_002-ebook.pdf
+Length: 591 chars
+
+7. CONCLUSIONS
+The understanding and cooperation of National Societies is being sought in order to regularize the use of artifi cial milks in relief actions.
+Since such products are potentially hazardous if improperly used, National Societies are being asked to give careful consideration before requesting, donating or accepting consignments.
+Where a National Society sees a real need for artifi cial milk and appeals for such through the International Red Cross, they must be prepared to take respons...
+
+=== Chunk 2477 ===
+Source: 0820_002-ebook.pdf
+Length: 10445 chars
+
+ANNEX 4.1 WEIGHT-FOR-HEIGHT TABLES (WHO, 1983)1
+Table A.4.1.1 Weight-for-height of boys between 49 and 138 cm (up to 9 years)
+Height (cm) Median –1 Z-score –2 Z-scores –3 Z-scores 49 3.1 2.8 2.5 2.1 49.5 3.2 2.9 2.5 2.1 50 3.3 2.9 2.5 2.2 50.5 3.4 3.0 2.6 2.2 51 3.5 3.1 2.6 2.2 51.5 3.6 3.1 2.7 2.3 52 3.7 3.2 2.8 2.3 52.5 3.8 3.3 2.8 2.4 53 3.9 3.4 2.9 2.4 53.5 4.0 3.5 3.0 2.5 54 4.1 3.6 3.1 2.6 54.5 4.2 3.7 3.2 2.6 55 4.3 3.8 3.3 2.7 55.5 4.5 3.9 3.3 2.8 56 4.6 4.0 3.5 2.9 56.5 4.7 4.1 3.6 3.0 ...
+
+=== Chunk 2478 ===
+Source: 0820_002-ebook.pdf
+Length: 7739 chars
+
+ANNEX 4.2 HEIGHT-FOR-AGE TABLES (WHO 1983)1
+Table A.4.2.1 Height-for-age of boys between 0 and 59 months
+Age (months) –3 Z-scores –2 Z-scores –1 Z-score Median + 1 Z-score + 2 Z-scores 0 43.6 45.9 48.2 50.5 52.8 55.1 1 47.2 49.7 52.1 54.6 57.0 59.5 2 50.4 52.9 55.5 58.1 60.7 63.2 3 53.2 55.8 58.5 61.1 63.7 66.4 4 55.6 58.3 61.0 63.7 66.4 69.1 5 57.8 60.5 63.2 65.9 68.6 71.3 6 59.8 62.4 65.1 67.8 70.5 73.2 7 61.5 64.1 66.8 69.5 72.2 74.8 8 63.0 65.7 68.3 71.0 73.6 76.3 9 64.4 67.0 69.7 72.3 75.0 ...
+
+=== Chunk 2479 ===
+Source: 0820_002-ebook.pdf
+Length: 7119 chars
+
+ANNEX 4.4 WEIGHT-FOR-AGE AND WEIGHT-FOR-HEIGHT OF ADOLESCENTS1
+In humanitarian operations, the indicator of nutritional status that must be measured is usually corpulence. Unfortunately, there are no weight-for-height tables that apply to adolescents. This Manual therefore combines existing tables for height for age and weight for age for girls and boys aged between 2 and 18 years (WHO, 1983). Results are provided within one centimetre, rounded up to the closest category as an approximate where ...
+
+=== Chunk 2480 ===
+Source: 0820_002-ebook.pdf
+Length: 933 chars
+
+Purpose
+This Code of Conduct seeks to guard our standards of behaviour. It is not about operational details, such as how one should calculate food rations or set up a refugee camp. Rather, it seeks to maintain the high standards of independence, effectiveness and impact to which disaster response NGOs and the International Red Cross and Red Crescent Movement aspire. It is a voluntary code, enforced by the will of the organization accepting it, to maintain the standards laid down in the Code.
+In ...
+
+=== Chunk 2481 ===
+Source: 0820_002-ebook.pdf
+Length: 1003 chars
+
+Defi nitions
+NGOs: NGOs (Non-Governmental Organizations) refers here to organizations, both national and international, which are constituted separately from the government of the country in which they are founded.
+NGHAs: For the purposes of this text, the term Non-Governmental Humanitarian Agencies (NGHAs) has been coined to encompass the components of the International Red Cross and Red Crescent Movement – The International Committee of the Red Cross, The International Federation of Red Cross a...
+
+=== Chunk 2482 ===
+Source: 0820_002-ebook.pdf
+Length: 141 chars
+
+The Code of Conduct
+Principles of Conduct for the International Red Cross and Red Crescent Movement and NGOs in Disaster Response Programmes....
+
+=== Chunk 2483 ===
+Source: 0820_002-ebook.pdf
+Length: 3498 chars
+
+1. The humanitarian imperative comes fi rst
+The right to receive humanitarian assistance, and to offer it, is a fundamental humanitarian principle which should be enjoyed by all citizens of all countries. As members of the international community, we recognize our obligation to provide humanitarian assistance wherever it is needed. Hence the need for unimpeded access to affected populations is of fundamental importance in exercising that responsibility. The prime motivation of our response to dis...
+
+=== Chunk 2484 ===
+Source: 0820_002-ebook.pdf
+Length: 155 chars
+
+5. We shall respect culture and custom
+We will endeavour to respect the culture, structures and customs of the communities and countries we are working in....
+
+=== Chunk 2485 ===
+Source: 0820_002-ebook.pdf
+Length: 1202 chars
+
+6. We shall attempt to build disaster response on local capacities
+All people and communities – even in disaster – possess capacities as well as vulnerabilities. Where possible, we will strengthen these capacities by employing local staff, purchasing local materials and trading with local companies. Where possible, we will work through local NGHAs as partners in planning and implementation, and cooperate with local government
+637
+Annex 5
+NUTRITION MANUAL ANNEXES
+structures where appropriate. We ...
+
+=== Chunk 2486 ===
+Source: 0820_002-ebook.pdf
+Length: 741 chars
+
+8. Relief aid must strive to reduce future vulnerabilities to disaster as well as meeting basic needs
+All relief actions affect the prospects for long-term development, either in a positive or a negative fashion. Recognizing this, we will strive to implement relief programmes which actively reduce the benefi ciaries’ vulnerability to future disasters and help create sustainable lifestyles. We will pay particular attention to environmental concerns in the design and management of relief programmes...
+
+=== Chunk 2487 ===
+Source: 0820_002-ebook.pdf
+Length: 1754 chars
+
+accept resources
+We often act as an institutional link in the partnership between those who wish to assist and those who need assistance during disasters. We therefore hold ourselves accountable to both constituencies. All our dealings with donors and benefi ciaries shall refl ect an attitude of openness and transparency. We recognize the need to report on our activities, both from a fi nancial perspective and the perspective of effectiveness. We recognize the obligation to ensure appropriate monit...
+
+=== Chunk 2488 ===
+Source: 0820_002-ebook.pdf
+Length: 4210 chars
+
+The working environment
+Having agreed unilaterally to strive to abide by the Code laid out above, we present below some indicative guidelines which describe the working environment we would like to see created by donor governments, host governments and the inter-governmental organizations – principally the agencies of the United Nations – in order to facilitate the effective participation of NGHAs in disaster response.
+These guidelines are presented for guidance. They are not legally binding, no...
+
+=== Chunk 2489 ===
+Source: 0820_002-ebook.pdf
+Length: 1158 chars
+
+Annex II: Recommendations to donor governments
+1. Donor governments should recognize and respect the independent, humanitarian and impartial actions of NGHAs: NGHAs are independent bodies whose independence and impartiality should be respected by donor governments. Donor governments should not use NGHAs to further any political or ideological aim.
+5. Donor governments should provide funding with a guarantee of operational independence: NGHAs accept funding and material assistance from donor gove...
+
+=== Chunk 2490 ===
+Source: 0820_002-ebook.pdf
+Length: 1787 chars
+
+Annex III : Recommendations to inter-governmental organizations
+1. IGOs should recognize NGHAs, local and foreign, as valuable partners: NGHAs are willing to work with UN and other inter-governmental agencies to effect better disaster response. They do so in a spirit of partnership which respects the integrity and independence of all partners. Inter-governmental agencies must respect the independence and impartiality of the NGHAs. NGHAs should be consulted by UN agencies in the preparation of re...
+
+=== Chunk 2491 ===
+Source: 0820_002-ebook.pdf
+Length: 201 chars
+
+ANNEX 6 RED CROSS POLICY ON NUTRITION1
+TWENTY-FIFTH INTERNATIONAL CONFERENCE OF THE RED CROSS Geneva, October 1986
+Geneva, October 1986
+ICRC/LEAGUE2 POLICIES IN EMERGENCY SITUATIONS: NUTRITION POLICIES...
+
+=== Chunk 2492 ===
+Source: 0820_002-ebook.pdf
+Length: 2986 chars
+
+INTRODUCTION TO NUTRITION POLICIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 642
+2.1 THE RED CROSS POLICY ON THE NUTRITIONAL ASPECTS
+i Initial assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 643 ii Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...
+
+=== Chunk 2493 ===
+Source: 0820_002-ebook.pdf
+Length: 765 chars
+
+2.3 DRAFT RESOLUTION ON NUTRITION AND FOOD DONATION POLICY IN RED CROSS EMERGENCY SITUATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 649
+1 This policy is somewhat dated with regard to recent developments in humanitarian interventions. However , most of the basic principles it presents are still valid today. Furthermore, this policy is important for the Red Cross because it was approved by the entire International Red Cross and Red Crescent Movement and by the governments which ...
+
+=== Chunk 2494 ===
+Source: 0820_002-ebook.pdf
+Length: 1416 chars
+
+INTRODUCTION TO NUTRITION POLICIES
+A satisfactory level of health depends on some basic needs being met. The most important of these are water, food and a safe environment. When these needs are not met and when conditions exist which threaten people’s health status, it is essential that the actions taken in response to the identifi ed problems are appropriate and effective. Nutrition is an essential component of health and requires specifi c consideration within the comprehensive approach to the p...
+
+=== Chunk 2495 ===
+Source: 0820_002-ebook.pdf
+Length: 2320 chars
+
+2.1 THE RED CROSS POLICY ON THE NUTRITIONAL ASPECTS OF RELIEF OPERATIONS
+The Red Cross3 recognizes that the causes of “nutritional emergencies” and the problems arising from them are many and complex. A large number of factors have to be taken into consideration in responding to such emergencies and the aim of any action must always be to restore or maintain the self-suffi ciency of the affected population.
+Although these policies deal only with the nutritional aspects of relief operations, it is...
+
+=== Chunk 2496 ===
+Source: 0820_002-ebook.pdf
+Length: 1456 chars
+
+A) Disaster preparedness and prevention
+i The Red Cross should establish through its network of National Societies, contacts with other institutions and agencies involved in the collection of data, which provide an early warning of developing nutritional emergencies. Such information will be used to supplement and assist with the interpretation of subsequent surveys in the area, and will help to ensure an effective, appropriate and above all, timely response.
+ii The Red Cross/Crescent will use s...
+
+=== Chunk 2497 ===
+Source: 0820_002-ebook.pdf
+Length: 382 chars
+
+B) Emergency relief
+i Initial assessment
+A Red Cross programme in response to nutritional emergencies must be based on comprehensive surveys organized by the National Society affected using experienced personnel. The initial survey must assess the level of malnutrition, analyse the causes and indicate what resources are either available or are required to deal with the emergency....
+
+=== Chunk 2498 ===
+Source: 0820_002-ebook.pdf
+Length: 511 chars
+
+ii Planning
+After consideration of the information resulting from the initial survey the decision to intervene or not will be made. If intervention is to be made a comprehensive plan of action must be drawn up covering the requirements for supplies, personnel, funding and giving indications of the type of programme to be established, given the constraints of the situation and the activities of other agencies. The initial planning should take into consideration the long-term needs of the affected...
+
+=== Chunk 2499 ===
+Source: 0820_002-ebook.pdf
+Length: 451 chars
+
+iii Intervention
+Recognizing that vulnerability is greatly increased if a population migrates from their normal environment, early intervention is recommended, with emphasis placed on support to the family unit. Priority should be given to the provision of adequate supplies of water and food, the prevention of measles, Vitamin A defi ciency and diarrhoeal diseases and attention to other priority health problems.
+643
+Annex 6
+NUTRITION MANUAL ANNEXES...
+
+=== Chunk 2500 ===
+Source: 0820_002-ebook.pdf
+Length: 166 chars
+
+iv Food supplies
+Food donated or bought for the purposes of relief distribution must be subject to the conditions and principles outlined in the food donation policy....
+
+=== Chunk 2501 ===
+Source: 0820_002-ebook.pdf
+Length: 801 chars
+
+a) Provision of basic rations
+When food is needed, an adequate basic ration must be assured either by the Red Cross complementing the available food, or when necessary, by taking the responsibility for the full ration.
+Whether wholly or partly responsible for the basic ration, the Red Cross must ensure that there is an adequate basic ration for all family members. This basic ration must take into consideration the many factors, which may affect the nutritional requirements of different communiti...
+
+=== Chunk 2502 ===
+Source: 0820_002-ebook.pdf
+Length: 479 chars
+
+b) The care of the malnourished
+Every effort must be made to assist these groups through the basic ration distribution rather than by setting up separate programmes: given suffi cient quantities of appropriate food and adequate support, mothers are the best people to rehabilitate mildly or moderately malnourished children. The initiation of a therapeutic feeding programme should depend on the place which severe malnutrition takes in the overall hierarchy of health priorities....
+
+=== Chunk 2503 ===
+Source: 0820_002-ebook.pdf
+Length: 367 chars
+
+c) Community health workers
+The training and supervision of community health workers is an essential part of any nutritional intervention programme. They will ensure early “case fi nding”, follow-up of malnourished individuals, nutrition education and surveillance. Community health workers will also be fundamental to the development of primary healthcare activities....
+
+=== Chunk 2504 ===
+Source: 0820_002-ebook.pdf
+Length: 571 chars
+
+vi Surveillance and evaluation
+The effectiveness of nutritional interventions must be monitored regularly using standard methods. The results should be compared with the objectives outlined in the original plan of action and programmes should be modifi ed in response to this information.
+Phasing out of nutritional interventions should be considered when the criteria established in the original plan of action have been met. At this stage, it will be essential to further strengthen development acti...
+
+=== Chunk 2505 ===
+Source: 0820_002-ebook.pdf
+Length: 246 chars
+
+vii Development of National Societies
+During all phases of responding to nutritional emergencies every opportunity should be taken to increase the National Societies’ capacity to plan, implement monitor and evaluate relief operations.
+644
+Annex 6...
+
+=== Chunk 2506 ===
+Source: 0820_002-ebook.pdf
+Length: 1439 chars
+
+A) Introduction
+Food supplies are frequently part of Red Cross response to emergencies. However, it is essential in each situation to fi rst establish that food supply is a correct response and then that the composition is defi ned and described after an adequate comprehensive survey. In every instance it is necessary to ensure that food donations are culturally and nutritionally appropriate for the affected population and that the costs of their purchase, transportation, storage and distribution ...
+
+=== Chunk 2507 ===
+Source: 0820_002-ebook.pdf
+Length: 4186 chars
+
+B) General principles
+1. Foods should be appropriate to the benefi ciaries to:
+q meet nutritional needs;
+q maintain traditional food habits;
+q avoid waste and large scale sale on black markets;
+q economize on scarce fuel;
+q avoid creation of new tastes;
+q avoid dependency on external food resources;
+q avoid disruption of local markets.
+2. Local knowledge on each emergency situation will be the basis for the establishment of the food ration.
+Together with the National Society, a comprehensive surv...
+
+=== Chunk 2508 ===
+Source: 0820_002-ebook.pdf
+Length: 6227 chars
+
+C) Recommendations
+Food in unmilled form especially cereals is Food in umilled form usually has longer shelf life, preferable. higher nutritional value, more identifi able taste and lower cost. Donors of whole grains should ascertain that local Whole grain must be milled to release full food value. milling facilities are available. Displaced persons and Some traditional methods retain more nutrients and refugees need special consideration. should therefore be encouraged and supported. Protein req...
+
+=== Chunk 2509 ===
+Source: 0820_002-ebook.pdf
+Length: 3623 chars
+
+Nutrition and food donation policy in Red Cross emergency operations
+The 25th International Conference of the Red Cross
+q aware that the physical and mental health of victims is affected during any emergency,
+q recalling that during health assessment of damage caused by any emergency, nutritional problems often represent the major component,
+q recognizing that due to the complexity of nutritional problems which cannot always be solved by food distribution alone, a professional approach is of utm...
+
+=== Chunk 2510 ===
+Source: 0820_002-ebook.pdf
+Length: 828 chars
+
+ANNEX 8 NORMAL DISTRIBUTION (SCHWARTZ, 1963)
+The normal distribution or law (also called Gaussian distribution) is a probability law that applies to quantitative, continuous, and non-limited variables. The equation of normal distribution is provided in Figure A.8.1 below.
+Figure A.8.1 Probability density function
+1  (x-μ)2  y =   σ 2π  e  2σ2
+Where
+μ is the average σ is the standard deviation e is the base of natural logarithms (approx. 2.718…) x is the variable under scrutiny
+The standard devia...
+
+=== Chunk 2511 ===
+Source: 0820_002-ebook.pdf
+Length: 157 chars
+
+Figure A.8.2 Normal distribution
+y  σ1  σ2  μ1  μ2
+x
+651
+NUTRITION MANUAL ANNEXES
+ANNEX 9 THE QUAC STICK ANTHROPOMETRIC METHOD (FROM DE VILLE DE GOYET, 1978)...
+
+=== Chunk 2512 ===
+Source: 0820_002-ebook.pdf
+Length: 1008 chars
+
+1. MAKING A QUAC STICK OR HEIGHT SCALE (FIGURE A.9)
+1.1 Find a 150 cm (height) by 10 cm (width) board.
+1.2 Sandpaper one of its sides in order to draw gradients or fasten a ready-made adhesive tape (see below) on it.
+1.3 Down the middle of the length of the board, mark each centimetre (0 at ground level) up to 115 cm, indicating 1/2 cm; alternatively, a measuring tape may be fastened down the middle of the board.
+1.4 On the left hand side, mark the mid-upper arm circumference corresponding to –2...
+
+=== Chunk 2513 ===
+Source: 0820_002-ebook.pdf
+Length: 204 chars
+
+Figure A.9 The QUAC stick – example
+–2sd
+–3sd
+cm _90_ ___ 13.6 _89_ ___ _88_ ___ _87_ ___ _86_ 12.2 ___ 13.4 _85_ ___ _84_ 13.4 ___ 12.1 _83_ ___ _82_ ___ _81_ ___ 12.0 13.2 _80_
+Ground = 0 cm
+652
+Annex 9...
+
+=== Chunk 2514 ===
+Source: 0820_002-ebook.pdf
+Length: 2525 chars
+
+2. CHOOSING THE REFERENCE AND THRESHOLDS
+The data usually used to make QUAC sticks are those provided by de Ville de Goyet (de Ville de Goyet, 1978), as indicated in Table A.9.1 below. Moderate malnutrition is indicated by a mid-upper arm circumference (MUAC) of less than 85% of the median, and severe malnutrition by one lower than 75% of the median. The 85% cut-off point is usually considered to be overly sensitive, whereas the 75% cut-off point is neither too sensitive nor too specifi c in orde...
+
+=== Chunk 2515 ===
+Source: 0820_002-ebook.pdf
+Length: 353 chars
+
+Table A.9.2 Data for QUAC sticks according to Annex 4.3
+Height Mid-upper arm Height Mid-upper arm (cm) circumference (cm). –2 (cm) circumference (cm). –3 Z-scores Z-scores 74 12.8 74 11.6 76.5 13.0 77.5 11.8 80 13.2 80.5 12.0 85 13.5 83.5 12.1 89 13.6 86 12.2 93 13.7 92 12.3 96.5 13.8 96.5 12.4 101.5 14.0 100 12.5 104 14.1 103.5 12.6 109 14.2 110 12.7...
+
+=== Chunk 2516 ===
+Source: 0820_002-ebook.pdf
+Length: 1689 chars
+
+3. USING THE QUAC STICK
+1. Ensure that the height scale is held fi rmly vertical on a plane surface.
+2. Select all children between 74 and 109 cm in height (i.e. roughly between 1 and 5 years old) for measurement.
+2. Measure mid-upper arm circumference as described in Chapter X, Section 4.4.1.
+3. Stand the child upright with its back fl at against the height scale.
+ae
+4. Observations may be interpreted in two ways; they lead to the same result, but may cause confusion.
+q The child’s actual mid-upp...
+
+=== Chunk 2517 ===
+Source: 0820_002-ebook.pdf
+Length: 604 chars
+
+1. ASSESSMENT REFERENCE DATA
+9 Assessment date(s)/Name of the assessor(s).
+Cogeggcgugauey
+9 Name and type of location visited (hill W, camp X, village Y, suburb B of town Z, etc.).
+9 District/province.
+9 Local population (individuals).
+9 Roadmap and/or GPS coordinates.
+9 Closest location indicated on the map, and distance to assessed location (km).
+9 Authorities met, and names of offi cials and counterparts.
+9 Local administration (type, key counterparts, staff).
+9 Reasons for the assessment.
+9 H...
+
+=== Chunk 2518 ===
+Source: 0820_002-ebook.pdf
+Length: 1511 chars
+
+2. DEMOGRAPHIC AND BASIC DATA
+9 Population type (residents/displaced/detainees, etc.).
+9 Information regarding displaced persons: date of arrival in their present location, origin, reason for the movement, duration of the journey and its conditions, sustained losses and damage, anticipated return (i.e. necessary conditions), anticipated date of return, belongings that could be taken along.
+9 Population breakdown according to age and sex, and population density.
+COdd
+9 Population movements, dates...
+
+=== Chunk 2519 ===
+Source: 0820_002-ebook.pdf
+Length: 746 chars
+
+9 Feeding system of the observed population
+q Production:
+q contribution of the agricultural and pastoral production to the overall economy in normal conditions and at the time of the assessment;
+q access to land and production inputs (seeds, fertilizer, pesticides, irrigation, veterinary services, animal feed);
+q crop and herd types;
+q seasonal calendar;
+q cultivated surface, herd size, and possible yield;
+q presence of pests and diseases affecting crops and/or herds;
+q possible and anticipated...
+
+=== Chunk 2520 ===
+Source: 0820_002-ebook.pdf
+Length: 618 chars
+
+q Purchase:
+q contribution of income-generating activities to the economy in normal conditions and at the time of the assessment;
+q access to income-generating activities;
+q type of income-generating activities;
+q yield of income-generating activities;
+q relative purchasing power for essential goods and services (market survey in terms of goods, services, and labour and their evolution, status of supply and demand for essential goods and services);
+q contribution of purchasing power to the econo...
+
+=== Chunk 2521 ===
+Source: 0820_002-ebook.pdf
+Length: 1857 chars
+
+q Gathering:
+q contribution of gathering activities to the economy in normal conditions and at the time of the assessment;
+q type and yield of gathering activities;
+q contribution of gathering activities to the economy, and anticipated evolution of this contribution;
+q existing compensation systems for inadequacies in gathering activities.
+q Social obligations:
+q contribution of social obligations to the economy in normal conditions and at the time of the assessment;
+q type of existing social ob...
+
+=== Chunk 2522 ===
+Source: 0820_002-ebook.pdf
+Length: 906 chars
+
+IMPORTANT COMPLEMENTARY ISSUES
+9 The overall health situation, condition of existing healthcare facilities (infrastructure, staff, equipment, supply), and their ability to cope with the present situation, the cost of healthcare and medicine.
+9 Water and habitat (access to water, water quality, water access for herds, the risk of contamination of drinking water sources, existing waterborne disease, runoff, human waste and garbage disposal, problems related to this disposal, personal hygiene, vect...
+
+=== Chunk 2523 ===
+Source: 0820_002-ebook.pdf
+Length: 702 chars
+
+5. PRELIMINARY ON-SITE CONCLUSIONS
+9 The comments and appraisals of key stakeholders should be included.
+Cog COdd
+9 Compendium of hypothesis testing.
+9 Compendium of the assessment objectives.
+9 Adjustment of chosen methodologies and tools to reality.
+9 Appraisal of existing problems and their cause (i.e. “what”, “because of what”).
+9 Appraisal of the need for assistance (i.e. “what”, “why”, “for whom”, “how much”, “for how long”).
+9 Priority ranking.
+9 Appraisal of opportunities and constraints...
+
+=== Chunk 2524 ===
+Source: 0820_002-ebook.pdf
+Length: 442 chars
+
+ANNEX 11 THERAPEUTIC FEEDING CENTRE LAYOUT
+Figure A.11 Therapeutic feeding centre
+GATE
+WATCHMEN’S  CANTEEN INITIAL  SHELTER  TREATMENT  KITCHEN  STORAGE  PHASE  SLOPE  ADMISSION/  SURVEILLANCE  RECREATION  AREA  WATER  CANTEEN  REHABILITATION  PHASE  ACCOMMODATION  MEDICAL  CARE  PHARMACY  PREVAILING WIND  DIRECTION  ADMISSION  FOLLOW-UP  DOWN  WASTE  WATER  LAUNDRY  SHOWER  GARDEN  LATRINES  INCINERATOR  GARBAGE PIT
+658
+Annex 11
+Annex 12...
+
+=== Chunk 2525 ===
+Source: 0820_002-ebook.pdf
+Length: 5926 chars
+
+ANNEX 12 IMPROVING WATER QUALITY IN A THERAPEUTIC FEEDING CENTRE
+Both the quality and the quantity of the water supply must be adequate in a therapeutic feeding centre (TFC) in order to ensure appropriate care and feeding. The recommended amount of water is usually 30 l per patient and per day; 10 litres are the absolute minimum. This amount applies to the type of TFC that is common in disasters in developing countries; it may however be much greater in modern facilities equipped with fl ush toil...
+
+=== Chunk 2526 ===
+Source: 0820_002-ebook.pdf
+Length: 721 chars
+
+1. NUTRITIONAL EQUIPMENT
+Oxfam kits provide the basis of nutritional equipment. Should they not be available, the following lists detail the necessary materials, which can usually be found locally and more cheaply than actual kits. The use of kits on the other hand saves time, they are complete and easily transported. MSF also provide kits that are similar to Oxfam kits.
+Oxfam kits provide the basis of nutritional equipment. Should they not be available, the following lists detail the necessary ...
+
+=== Chunk 2527 ===
+Source: 0820_002-ebook.pdf
+Length: 1316 chars
+
+1.1 KIT 1: ANTHROPOMETRY
+9 Suspended scales (Salter type), 25 kg, 100 g graduation, with 3 slings, 1 suspension bar 2 9 MUAC strips 50 9 Notebooks 4 9 Calculator 1 9 Manual counters, metal 2 9 Rope (10 m x 6 mm), roll 1 9 Pencils 12 9 Clipboards, A4 4 9 Assessment forms 40 9 Evaluation forms 2 9 Plastic A4 folders, open on two sides 10 9 Erasers 5 9 Permanent markers, broad, black 4 9 Notes on revised Oxfam kits (English) 1 9 Notes on revised Oxfam kits (French) 1 9 Scissors, 17cm 1 9 Graphic mi...
+
+=== Chunk 2528 ===
+Source: 0820_002-ebook.pdf
+Length: 1673 chars
+
+1.2. KIT 4: THERAPEUTIC FEEDING
+9 Kitchen scales, 5 kg 1 9 Suspended scales, 50 kg, 200 g graduation 1 9 Washbasins, 20 l 4 9 Jerrycans, plastic, collapsible, with tap 10 9 Bowls, 500 ml 200 9 Candles, box 1 9 Scrubbing brushes 4 9 Calculator 1 9 Milk cards 500 9 Teaspoons, 5 ml, metal 50 9 Teaspoons, 5 ml, plastic 250 9 Spoons, metal, 30 cm handle 2 9 Whisks, metal, 76 cm handle 3 9 Mugs, 500 ml 200 9 Petrol lamps 4 9 Ladles, metal, 43 cm handle, 250 ml volume 4 9 Cauldron, 100 l 1 9 Cauldrons,...
+
+=== Chunk 2529 ===
+Source: 0820_002-ebook.pdf
+Length: 802 chars
+
+1.3 KIT 4/2: REGISTRATION FOR THERAPEUTIC FEEDING
+9 Notebook, bound, A4
+1 9 Filing box for A4 forms 1 9 Alphabetical cards A–Z, A4, series 1 9 Identifi cation bracelets, red 400 9 Milk cards 500 9 Monitoring cards A4 500 9 Erasers 4 9 Notes on revised Oxfam kits (English) 1 9 Notes on revised Oxfam kits (French) 1 9 Graphic millimetre paper, A4, pad 1 9 Ballpoint pens, black 10 9 Permanent markers, broad, black 2 9 Permanent markers, broad, red 2 9 Pencils 10 9 Pencil sharpeners, metal 4 9 Ledger...
+
+=== Chunk 2530 ===
+Source: 0820_002-ebook.pdf
+Length: 1249 chars
+
+2. MEDICAL EQUIPMENT
+Medical equipment should be provided in kits (dispensary/paediatric), and be renewed in time. The TFC pharmacy should contain the following:
+9 Ampicillin/amoxicillin
+CUOGGCEeGeguveggegyy
+9 Gentamicin
+9 Cotrimoxazole
+9 Chloramphenicol
+9 Tetracycline ointment
+9 Metronidazole
+9 Mebendazole
+9 Chloroquine
+9 Quinine
+9 ReSoMal or ORS
+9 Paracetamol
+9 Vitamin A
+9 Iron and folic acid
+9 Gentian violet
+9 Permethrin
+9 Benzyl benzoate
+663
+NUTRITION MANUAL ANNEXES
+Annex 13
+It should also c...
+
+=== Chunk 2531 ===
+Source: 0820_002-ebook.pdf
+Length: 774 chars
+
+TOOLS AND MISCELLANEOUS EQUIPMENT
+9 Wheelbarrows 9 Shovels 9 Pickaxe 9 Padlocks for gates and doors 9 Padlocks for cupboards 9 Axe 9 Wood saw 9 Hoes 9 Machetes 9 Strong knives 9 Hammer 9 Wire, rolls 9 Wire-cutter (cutting pliers) 9 Screwdriver, slotted 9 Screwdriver, cross-point 9 Screws, box 9 Nails, box 9 Rope, 5 mm section, 10 m rolls 9 String, rolls 9 Adhesive tape, rolls 9 Paraffi n lamps 9 Paraffi n, litres 9 Matches (boxes of) and/or lighters 9 Tarpaulin, sheets 9 Barrels 2 2 1 4 8 1 1 2 2 ...
+
+=== Chunk 2532 ===
+Source: 0820_002-ebook.pdf
+Length: 280 chars
+
+STATIONERY AND OFFICE EQUIPMENT
+In addition to such material included in Oxfam kits, it is best to allow for equipment that is especially allocated to offi ce work, such as perforators, envelopes, notepads, staplers, scissors, pens, pencils, erasers, rulers, and pencil sharpeners....
+
+=== Chunk 2533 ===
+Source: 0820_002-ebook.pdf
+Length: 336 chars
+
+5. CLEANING MATERIAL
+In addition to Oxfam kits, the following items should also be provided: detergent (soap, laundry powder, dishwashing liquid), sponges, kitchen towels, fl oor cloths, brooms, buckets that are only used for cleaning purposes, water chlorination kits, and used engine oil and quicklime for the disinfection of latrines....
+
+=== Chunk 2534 ===
+Source: 0820_002-ebook.pdf
+Length: 174 chars
+
+6. FURNITURE
+9 Benches
+5 9 Chairs 20 9 Tables 5 9 Cupboards and padlocks 2 9 Pharmacy shelves 9 One warehouse wall should be equipped with shelves 9 Medical examination bed 1...
+
+=== Chunk 2535 ===
+Source: 0820_002-ebook.pdf
+Length: 131 chars
+
+7. BEDDING
+9 Mattresses/mats, corresponding to the number of benefi ciaries
+9 Blankets, corresponding to the number of benefi ciaries...
+
+=== Chunk 2536 ===
+Source: 0820_002-ebook.pdf
+Length: 2048 chars
+
+8. WATER AND SANITATION
+Provided that the water supply system is reliable 24 hours per day, there is no need for high-capacity water tanks. Otherwise, the TFC must have a reserve capacity of at least 100,000 l (500 children × 30 l /day × 7 days = 105,000 l), and a dozen 100 l tanks equipped with taps or gravity water distribution ramps connected to the main tank.
+An incinerator must be combined with the latrines and garbage pit; incinerators are easily made from an empty standard 200 l oil barre...
+
+=== Chunk 2537 ===
+Source: 0820_002-ebook.pdf
+Length: 879 chars
+
+ANNEX 15 VITAMIN AND MINERAL FORMULA FOR THERAPEUTIC FEEDING
+This formula is based on the recommendations of Briend and Golden (Briend & Golden, 1993). The commonest commercial form is manufactured by Nutriset (therapeutic vitamin and mineral complex, CMV); 6.35 g of this powder (i.e. one dose) must be added to 2 litres of previously boiled milk for nutritional catch-up (see Chapter XIII, recipes). This process produces the equivalent of F-100 ou F-75 Formula.
+6.35 g of therapeutic CMV contain:
+...
+
+=== Chunk 2538 ===
+Source: 0820_002-ebook.pdf
+Length: 876 chars
+
+ANNEX 16 VITAMIN AND MINERAL FORMULA FOR SUPPLEMENTARY FEEDING
+This formula is based on the recommendations of Golden et al. (Golden et al., 1995) for fl our preparations used in therapeutic and supplementary feeding. The commonest commercial form is manufactured by Nutriset (supplementary vitamin and mineral complex, CMV); 24 g of this powder (i.e. 4 doses of 6 g each) are added to each kilogram of fl our after cooking.
+6 g of supplementary CMV contain:
+Vitamins: vit. A (2,560 IU), vit. D (360 IU...
+
+=== Chunk 2539 ===
+Source: 0820_002-ebook.pdf
+Length: 735 chars
+
+ANNEX 17 SUPPLEMENTARY FEEDING PROGRAMME LAYOUT
+Figure A.17.1 Supplementary feeding programme centre, rations consumed on site
+GATE  WATCHMEN’S SHELTER  KITCHEN  STORAGE  WATER  SLOPE  ADMISSION/  EXAMINATION  RECREATION  AREA  C  A  N  MEDICAL  CARE  T  E  E  L  A  T  N  R  PHARMACY  I  N  POST-  ADMISSION  FOLLOW-UP  WASTE  WATER  E  S  DOWN  GARDEN  INCINERATOR  GARBAGE PIT  PREVAILING WIND DIRECTION
+Figure A.17.2 Supplementary feeding programme centre, take-away rations
+GATE  BENEFICIARY ENT...
+
+=== Chunk 2540 ===
+Source: 0820_002-ebook.pdf
+Length: 1322 chars
+
+1.1 ANTHROPOMETRY KIT (12 BOLD)
+9 Suspended scales (Salter type), 25 kg, 100 g graduation, with 3 slings, 1 suspension bar 2 9 MUAC strips 50 9 Notebooks 4 9 Calculator 1 9 Manual counters, metal 2 9 Rope (10 m x 6 mm), roll 1 9 Pencils 12 9 Clipboards, A4 4 9 Assessment forms 40 9 Evaluation forms 2 9 Plastic A4 folders, open on two sides 10 9 Erasers 5 9 Permanent markers, broad, black 4 9 Notes on revised Oxfam kits (English) 1 9 Notes on revised Oxfam kits (French) 1 9 Scissors, 17cm 1 9 Gra...
+
+=== Chunk 2541 ===
+Source: 0820_002-ebook.pdf
+Length: 1010 chars
+
+1.2 KIT 2: SUPPLEMENTARY FEEDING (RATIONS TO BE CONSUMED ON SITE)
+9 Kitchen scales, 5 kg 1 9 Suspended scales, 50 kg, 200 g graduation 1 9 Washbasins, 20 l 4 9 Jerrycans, plastic, collapsible, with tap 10 9 Bowls, 500 ml 300 9 Scrubbing brushes 4 9 Calculator 1 9 Teaspoons, 5 ml, metal 10 9 Teaspoons, 5 ml, plastic 400 9 Spoons, metal, 30 cm handle 2 9 Attendance sheets, 50-sheet pads, numbered 1–500 2 9 Whisks, metal, 76 cm handle 3 9 Mugs, 500 ml 400 9 Ladles, metal, 43 cm handle, 250 ml volum...
+
+=== Chunk 2542 ===
+Source: 0820_002-ebook.pdf
+Length: 871 chars
+
+1.3 KIT 2/2: REGISTRATION FOR SUPPLEMENTARY FEEDING (ON-SITE CONSUMPTION)
+9 Attendance sheets, 50-sheet pads, numbered 1–500
+9 Notebook, bound, A4 1 9 Filing boxes for A4 forms 2 9 Alphabetical cards A-Z, A4, series 2 9 Identifi cation bracelets, blue 600 9 Monitoring cards A4 600 9 Erasers 4 9 Notes on revised Oxfam kits (English) 1 9 Notes on revised Oxfam kits (French) 1 9 Graphic millimetre paper, A4, pad 1 9 Ballpoint pens, black 10 9 Permanent markers, broad, black 2 9 Permanent markers, br...
+
+=== Chunk 2543 ===
+Source: 0820_002-ebook.pdf
+Length: 715 chars
+
+1.4 KIT 3: SUPPLEMENTARY FEEDING (TAKE-AWAY RATIONS)
+9 Kitchen scales, 5 kg
+1 9 Suspended scales, 50 kg, 200 g graduation 1 9 Calculator 1 9 Rope (10 m x 5 mm), roll 1 9 Attendance sheets, 50-sheet pads, numbered 1–500 2 9 Graduated measures, transparent plastic, 2 l 4 9 Notes on revised Oxfam kits (English) 1 9 Notes on revised Oxfam kits (French) 1 9 Plastic containers, volume 100 to 120 l 1 9 Plastic bags, volume 4 to 5 l 1,000 9 Soap (box of 24 bars @ 100/200g) 1 9 Buckets, plastic, graduate...
+
+=== Chunk 2544 ===
+Source: 0820_002-ebook.pdf
+Length: 891 chars
+
+1.5 KIT 3/2: REGISTRATION FOR SUPPLEMENTARY FEEDING (TAKE-AWAY RATIONS)
+9 Attendance sheets, 50-sheet pads, numbered 1–500
+9 Notebook, bound, A4 1 9 Filing boxes for A4 forms 4 9 Alphabetical cards A-Z, A4, series 2 9 Identifi cation bracelets, white 1,000 9 Monitoring cards A5 1,000 9 Erasers 4 9 Notes on revised Oxfam kits (English) 1 9 Notes on revised Oxfam kits (French) 1 9 Graphic millimetre paper, A4, pad 1 9 Ballpoint pens, black 10 9 Permanent markers, broad, black 4 9 Permanent markers,...
+
+=== Chunk 2545 ===
+Source: 0820_002-ebook.pdf
+Length: 251 chars
+
+2. OTHER EQUIPMENT
+The remaining equipment needed in an SFP centre is the same as for a TFC. Readers are therefore referred to Annex 13 for the selection of additional items according to planned activities and working modalities.
+672
+Annex 18
+Annex 19...
+
+=== Chunk 2546 ===
+Source: 0820_002-ebook.pdf
+Length: 2747 chars
+
+ANNEX 19 RANDOM NUMBER TABLE
+The random numbers indicated in the Table below have been generated by a Hewlett-Packard 15C calculator.1
+Table A.19
+Random number table
+92523 04766 06117 90764 57694 90696 38358 94068 76013 07183 55985 31214 22132 87810 40114 23712 96073 07465 80955 92412 34079 41959 49241 08671 53800 78973 19340 30848 70246 75081 52278 67173 31589 08752 50692 78236 61012 97449 94773 49014 44174 39913 83779 34280 26724 53218 42672 40793 90088 09867 50862 71185 69610 32725 91918 0337...
+
+=== Chunk 2547 ===
+Source: 0820_002-ebook.pdf
+Length: 198 chars
+
+ANNEX 20 ENERGY AND PROTEIN CONTENT OF COMMON FOODS
+Readers are referred to Chapter V, Annex 2, and the food composition tables provided by Platt, 1962; Randoin et al., 1982; and Souci et al., 1989....
+
+=== Chunk 2548 ===
+Source: 0820_002-ebook.pdf
+Length: 1594 chars
+
+Table A.20 Energy and protein content of common foods: edible portion of 100 g of raw food
+Foodstuff Energy Protein Foodstuff Energy Protein (kcal(kJ)) (g) (kcal(kJ)) (g) Rough cereal Oilseeds Oats 388 (1,622) 12 Nutsb 650 (2,717) 14 Wheat 344 (1,438) 11.5 Seedsc 550 (2,300) 23 Maize 363 (1,517) 10 Millet 355 (1,484) 10 Barley 339 (1,417) 12 Purifi ed fats 900 (3,762) Brown rice 360 (1,505) 7.5 Rye 350 (1,463) 8 Sorghum 355 (1,484) 10.4 Meat 266 (112) 17 Teff 345 (1,442) 8.5 Beef (sirloin) 225 (9...
+
+=== Chunk 2549 ===
+Source: 0820_002-ebook.pdf
+Length: 19511 chars
+
+BIBLIOGRAPHY
+Alwnick, D. (1986). Personal communication.
+Ashworth, A. & Millward, D.J. (1986). Catch-up growth in children. Nutrition Reviews 44: 157–163.
+Aykroyd, W. & Doughty, J. (1982). Legumes in human nutrition. FAO Food and Nutrition Paper No. 20. FAO.
+Azoulay, G. & Dillon, J.-C. (1993). La sécurité alimentaire en Afrique. Manuel d’analyse et d’élaboration des stratégies. Karthala.
+Basu, T. & Dickerson, J. (1996). Vitamins in Human Health and Disease. CAB International.
+Bailey, K. (1963). ...
+
+=== Chunk 2550 ===
+Source: 0820_002-ebook.pdf
+Length: 2615 chars
+
+A
+Abdomen, distension of, 270
+Access to goods and services, 179, 180 Action, humanitarian, see Humanitarian action Activities, behavioural, 163 Activities, economic, 161–164 Authorities, 167 Community, 165 Enforcement, 167 Function, 165 Legitimacy, 166 –167 Necessary means, 164 Norm, 166 Organization and determinism, 165 Respect for the norm and crisis situations, 167 Structure, 165 Sustainability, 190 and War, 222 Yield parameters/factors, 174 Activities, productive, 154 –156 Productivity input...
+
+=== Chunk 2551 ===
+Source: 0820_002-ebook.pdf
+Length: 2128 chars
+
+INDEX
+Including acronyms
+Indexes and Indicators, 370–371
+Interpretation of results, 408
+Measurement units, 399 Measurement standardization, 399 Oedema, 399 Percentage of the median, 400 QUAC stick, 403, 652 References, 278, 405 References, international, 279, 405 References, local, 279, 405 References, validity, 278, 405 and SFPs, 562 standard deviation (or Z-score), 400 Tables, 614 – 635 Variables, 396 Z-scores, 401 Antibiotics, in TFC, 537 Appetite, 200, 202, 270 Appraisal, preliminary, see Pr...
+
+=== Chunk 2552 ===
+Source: 0820_002-ebook.pdf
+Length: 6269 chars
+
+B
+Baby bottles, and Maternal milk substitution, 590 and Therapeutic feeding, 519 Banana, ripe, 125 see also Plantain Barley, 107 and Beer, 108 and Whisky, 108 Barter, 157, 162 Bases, 17 Beans, 113, see also Legumes Beer, 134 Beet, sugar, 133 Behaviour, Abnormal economic, 246, 251 Changes, 355 of Crisis victims, 336 and Essential needs, 170 and Food, see Behaviour, food Gap and Assessment, 356, 359 and Nutritional information, 578 Behaviour, food, 200 Hazards, 473 Infl uencing factors, 200 Benzyl-...
+
+=== Chunk 2553 ===
+Source: 0820_002-ebook.pdf
+Length: 5753 chars
+
+D
+Quantitative, 369
+Data collection, 367, 374 –377
+Basic concepts, 367–369
+Complete enumeration, 391
+Comprehensive, 378, 391
+Convergence, 378
+Direct observation, 377
+Flexibility, 369
+Interviews, 376
+Measurement, 377
+Optimal ignorance, 367
+685
+INDEX C-D
+Sampling, 378
+Secondary data review, 375
+Targeting, 374 Time required, 377–378 Triangulation, 368 Databases, food composition, 135 Debt, 251, 254 Decision trees, 419 Declaration of Human Rights, universal, 432 Defi ciencies, major specifi c, 291 Ber...
+
+=== Chunk 2554 ===
+Source: 0820_002-ebook.pdf
+Length: 4951 chars
+
+F
+F-75 (Formula F-75), 494, 532–536 F-100 (Formula F-100), 543 Factor, intrinsic, 56 Factors, risk, 353 Famine, 5–6, 29, 108, 186, 243–260 Causes, 247–248 Characteristics, 244 –245 Defi nition, 244 –247 Early warning, 259 and GFD, 442 Indicators, 260–261 and Infectious disease, 245–246, 251 and Mortality, 245–246, 251 and Norm, respect for, 166 –167 Predictability, 248 Prevention, 258–260, 261 Prevention failure, 258–259 Process, 248–253, see also Process, famine Prohibition in warfare, 257, 434 ...
+
+=== Chunk 2555 ===
+Source: 0820_002-ebook.pdf
+Length: 1138 chars
+
+G
+Monitoring, 494
+Negative effects, 445
+NUTRITION MANUAL
+Nutritional catch-up, 466
+Objectives, 442
+Organization, 453 Planning, 448 Priorities, 442– 443 Quality control, 453 Rations, 447, 450, 453– 476 Registration, 478 Remedies for negative effects, 445 Role of food, 444 – 445 Sale of rations, 447 Side effects, 445 Soup kitchens, 489 Specifi c defi ciencies, 462– 465 Storage, 495 Survival supplies, 442 Take-away rations, 484 – 488 Target, 441 Targeting, 476 Withdrawal criteria, 451, 495 Geneticall...
+
+=== Chunk 2556 ===
+Source: 0820_002-ebook.pdf
+Length: 2969 chars
+
+H
+Habitat, 330 Habits, eating, 199, 200 and GFD, 454 – 455 Malnutrition and infection, 287–288 Respect for, 454 Taboos, 199 Haemorrhage, Internal, 293 of Newborn babies, 63 Harm, 354 Hazelnut, 123 HCN, see Hydrogen cyanide Health, Mental, 203
+Physical, 202
+Statistical risks, 597 Health condition/status, 174, 328 Health pyramid, 321 Health services, 332 Access to, 330 and Weaning, 596 Healthcare, Access to, 330 Quality, 595 SFPs, 567 Therapeutic feeding, 512, 516, 517, 520 Heart, Energy consumpti...
+
+=== Chunk 2557 ===
+Source: 0820_002-ebook.pdf
+Length: 2768 chars
+
+I
+Ignorance, 328, 575 Optimal, 367 IHL, see International humanitarian law ILO, see International Labour Organization
+IMF, see International
+Monetary Fund
+Immune system and malnutrition, 272 Immunity, 282–283 and Malaria, 287 and Measles, 286 Impacts, 217, 218, 233 Verifi cation, 353 Impartiality, 334, 339 Impoverishment, 185, 193, 250 Incidence rates, 372 and Relative risk, 372 Indexes, 370 Anthropometric, see Anthropometry, indexes BMI (Quételet), 267, 404, 405, 461 Gomez, 401 Height-for-age, 2...
+
+=== Chunk 2558 ===
+Source: 0820_002-ebook.pdf
+Length: 52 chars
+
+J
+J (Joule), 13
+Jam, 133
+Joule, 13
+689
+INDEX I-J-K-L...
+
+=== Chunk 2559 ===
+Source: 0820_002-ebook.pdf
+Length: 928 chars
+
+K
+Kcal (Kilocalorie), 13
+Keshan disease, 73 Kidney, energy consumption, 39 Kilocalorie (Kcal.), 13 Kilojoule (kJ), 13 Kitchen, Hygiene, 583–584 SFP, 567, see also 518 Soup, see Soup kitchens TFC, 518 Kj (Kilojoule), 13 Kwashiorkor, 45, 273–277 Aetiology, 273 Afl atoxins, 275, 277 Anorexia, 274 Antibiotic treatment in TFC, 549 Appetite, 274 Associated defi ciencies, 275 and Cassava consumption, 45, 111, 276 Clinical aspects, 273–275 Dermatosis, 274, 540 Diarrhoea, 275 Dietary, 111, 277 Facial featu...
+
+=== Chunk 2560 ===
+Source: 0820_002-ebook.pdf
+Length: 1020 chars
+
+L
+Lactose, intolerance, 130, 536 Larvae, 128 Lathyrism, 121 Law, Engel’s, 157 Law, see International humanitarian Law, normal or distribution, 651 Lead, 73 Lectin, 120 Legumes, 113 Adverse factors, 120 –121 and Beriberi, 299 Combined with cereals, 114 –117 Combined with starchy plants, 117 Families of , 113 and GFD, 455 Nutritional value, 113 and Pellagra, 303 Preparation, 122 Problems, 119 –121 Protein complement, 114 –116
+and Relief supplies, 117
+NUTRITION MANUAL
+Sprouting, 117, 122
+Toxicity, ...
+
+=== Chunk 2561 ===
+Source: 0820_002-ebook.pdf
+Length: 5134 chars
+
+M
+Macro-nutrients and GFD, 455– 461
+Magenta, 50 Magnesium, 68 Defi ciency, 68 Recommended intake, 91 Toxicity, 68 Maintenance requirements, 31 Maize, 105 and Afl atoxins, 105, 106 and Beriberi, 106, 455 Combined with legumes, 106 Nutritional value, 105 and Pellagra, 106, 455 Malabsorption, 285 and HIV/AIDS, 287 Malaria, 269, 283, 287, 309, 310 Treatment, 540 Malnutrition, 261 Effects of infection, 284 Effects on infection, 282 and Infection, 282–288, 536–539, see also Infections and malnutrition P...
+
+=== Chunk 2562 ===
+Source: 0820_002-ebook.pdf
+Length: 3022 chars
+
+N
+Nasogastric feeding, 519–520
+Need, energy, see Energy need Need, protein, see Protein need Needs, aid, 337, 350, 351 Defi ning, 361 and Requests, 337 Needs, basic, 148 Needs, cultural, 148 Increase in, 156 Response, 148 Needs, essential, 149, 155, 156 Activities and resources to cover them, 191 Behaviour, 170 Cultural variability, 169 Economic, 156, 168 Evaluation, 170 Magnitude, 169 Minimum, 170 Ranking, 170 Needs, nutritional, 6 Average, 454 Components, 10 and GFD, 455– 465 Intake level, 80 M...
+
+=== Chunk 2563 ===
+Source: 0820_002-ebook.pdf
+Length: 955 chars
+
+O
+Oats, 108 Obesity, 129, 133, 134 Objectives, 424 – 426 SMART rule, 425 Obligations, social, 163 and Culture, 185 and Security mechanisms, 185, 188, 251 Observations, direct, 377 Oedema, Bilateral, 266, 273 Checking for, 399 and Intestinal parasites, 287 and Kwashiorkor, 273 Origin, 275 Pitting, 274 Offal, 126 Nutritional value, 127 Offi ce of the United Nations High Commissioner for Refugees (UNHCR), 458 Oil, 123–124, 455, 532, 533, 534, 543, 544, 570 Coconut, 124 Ghee (butter), 131 Olive, 124 ...
+
+=== Chunk 2564 ===
+Source: 0820_002-ebook.pdf
+Length: 4974 chars
+
+P
+Paddy, 104 Paired ranking, 414 Pantothenic acid (Vitamin B5), 51 Defi ciency, 52 Recommended intake, 87 Paraparesia, spastic, 111 and Kwashiorkor, 111 Parasites, external, treatment in TFC, 549
+Parasites, internal, 270
+and Anaemia, 287
+and Anorexia, 287 and Diarrhoea, 287 and Malnutrition, 287 and Nutritional dwarfi sm, 280 and Weight, 270, 397 Treatment of, in TFC, 549 Parasitosis, intestinal, 205, 269 Participatory approach, and Nutritional information, 578 and Risks of negative side effects, ...
+
+=== Chunk 2565 ===
+Source: 0820_002-ebook.pdf
+Length: 267 chars
+
+Q
+QUAC Stick (Quaker arm circumference), 403, 652 Quaker arm circumference, see QUAC Quality, Control, 452 Criteria/specifi cations, of food, 138, 453 Criteria in SFPs, 571 Criteria in TFC, 523 Questionnaires, 420 Limits of use, 420 Quételet (BMI) index, 268, 404, 461...
+
+=== Chunk 2566 ===
+Source: 0820_002-ebook.pdf
+Length: 3525 chars
+
+R
+Radicals, free, 275–276, 283 Hormonal response, 275 Random numbers table, 673 Ranking, paired, 414 Rapid rural appraisal, 367, 378 Rates, extraction, 103 Ratios, Glucids/overall energy, 597 Lipid energy/overall energy, 455, 597 Lipids, types of/overall energy, 597 Protein/energy (P/E%), 456, 597 Rations, complementary, 473 Complications, 474 Criteria for setting, 473 Foodstuffs used, 474 Rations, distribution of take-away, 484 – 488 Rations, eaten on the spot, 489 Rations, as exchange commodit...
+
+=== Chunk 2567 ===
+Source: 0820_002-ebook.pdf
+Length: 12369 chars
+
+S
+Sago, 113
+Salt, 134 –135 and High blood pressure, 65 Iodine enriched, 71, 314 SAM (severe acute malnutrition), see Malnutrition, severe Sample, size of, 386 Cluster random samples, size of, 389 Cluster random sampling, 389 Confi dence interval, 387 Correction for small populations, 388 Error, 387 Qualitative variables, 387 Quantitative variables, 387 Prevalence rate, 387 Simple random sampling, 387 Sampling, 378–390 Accuracy, 379 Simple random, 379 Choice of method, 386 Cluster, random, 383, 38...
+
+=== Chunk 2568 ===
+Source: 0820_002-ebook.pdf
+Length: 1741 chars
+
+W
+War, 222 Acts of, 257 and Economic activities, 222 and Famine, 256–258 and Famine, liability to, 256 and Feeding process, 222 and Humanitarian action/ intervention, 257 and IHL, 257 Warning, early, 259, 360 and Security mechanisms, 188 Water, 16, 41 Access, 321, 330 Filtration, 659 Hygiene, 584 Iodine levels, 312 Purifi cation, 659 Quality, improvement of, in TFC, 659 Sedimentation, 659 and Therapeutic feeding, 509–511 Water and habitat, 332 Waterlow classifi cation, 266 Weaning, 129, 197, 592–5...
+
+=== Chunk 2569 ===
+Source: 0820_002-ebook.pdf
+Length: 112 chars
+
+X
+Xerophtalmia fundus, 305 as Public health indicator, 305–306 Stages, 305 Xerosis, 305, 306
+697
+INDEX V-W-X-Y-Z...
+
+=== Chunk 2570 ===
+Source: 0820_002-ebook.pdf
+Length: 103 chars
+
+Y
+Yam, 112 Yield, 155, 161, see also Productivity and Activities, productive Yield parameters, 173 –175...
+
+=== Chunk 2571 ===
+Source: 0820_002-ebook.pdf
+Length: 201 chars
+
+Z
+Zinc, 71
+Defi ciency, 71–72 and Infection, 284 and Nutritional catch-up, 72 Recommended intake, 93 and Refi ned cereals, 71 Toxicity, 72 Z-score (standard deviation), 401
+NUTRITION MANUAL
+698
+699
+NOTES...
+
+=== Chunk 2572 ===
+Source: 0820_002-ebook.pdf
+Length: 675 chars
+
+MISSION
+The International Committee of the Red Cross (ICRC) is an impartial, neutral and independent organization whose exclusively humanitarian mission is to protect the lives and dignity of victims of war and internal violence and to provide them with assistance. It directs and coordinates the international relief activities conducted by the Movement in situations of conflict. It also endeavours to prevent suffering by promoting and strengthening humanitarian law and universal humanitarian pri...
+
+=== Chunk 2573 ===
+Source: ijfae-2688-gholeh.pdf
+Length: 205 chars
+
+Untitled Section
+Gholeh, I. (2024). First Aid in Conflict: A view from the occupied Palestinian Territories. International Journal of First Aid Education, 7(1), 1–3. https://doi.org/10.25894/ijfae.7.1.2688...
+
+=== Chunk 2574 ===
+Source: ijfae-2688-gholeh.pdf
+Length: 3446 chars
+
+Ibrahim Gholeh
+Introduction from the Editor:
+The horrific and devastating conflict in many parts of the world poses significant challenges to first aid, humanitarian, and medical responders as they struggle to provide care with limited resources and often while under attack. The IJFAE seeks a systematic understanding of the gaps, and how emerging norms are developed in these conflicts in order to reduce suffering and promote healing at all levels. Our View from the Field articles offer individua...
+
+=== Chunk 2575 ===
+Source: ijfae-2688-gholeh.pdf
+Length: 446 chars
+
+EXAMPLES OF ACTIVITY AT MEDICAL
+POSTS
+The PRCS worked to set up a triage center at the Episcopal Al-Ahli Arab Hospital as it was the only functioning hospital in the Gaza Strip at the end of 2023. Since then, damage by an air strike and subsequent shelling has forced the hospital to close. Despite this, the PRCS uses this medical point to continue to help patients with light to medium wounds providing a minimum level of care to those in need....
+
+=== Chunk 2576 ===
+Source: ijfae-2688-gholeh.pdf
+Length: 2097 chars
+
+CONFLICT ESCALATION ACTIVITY
+Under continued Israeli occupation, EMS providers face significant risks. Between 2000 and 2022, 22 PRCS medics and volunteers lost their lives while on duty in the Palestinian Territories. The current war on Gaza (since 7th October 2023) has significantly intensified tensions, complexity and danger in what was already a protracted crisis situation with a further 21 PRCS medics losing their lives. Tens of thousands of civilians have been killed and wounded, and thous...
+
+=== Chunk 2577 ===
+Source: ijfae-2688-gholeh.pdf
+Length: 848 chars
+
+WHAT NEXT?
+This View from the Field highlights the extreme challenges of providing first aid and emergency medical services in conflict-affected areas, offering important lessons for first aid educators and practitioners worldwide. These experiences highlight the critical need for specialized first aid training and protocols tailored to extreme conflict
+2
+Gholeh International Journal of First Aid Education DOI: 10.25894/ijfae.7.1.2688
+situations (working under fire, working under threat, low or ...
+
+=== Chunk 2578 ===
+Source: ijfae-2688-gholeh.pdf
+Length: 327 chars
+
+RESEARCH QUESTIONS FOR FIRST AID
+EDUCATION
+4. What strategies, policies, or enforcement of law can be developed to protect first aiders and facilities in conflict areas while maintaining operational capacity?
+1. How can the sustainability and efficiency of emergency medical posts be improved in conflict zones by first
+aiders?...
+
+=== Chunk 2579 ===
+Source: ijfae-2688-gholeh.pdf
+Length: 308 chars
+
+COMPETING INTERESTS
+The author has no competing interests to declare.
+2. What training makes sense during a conflict? What specific training, equipment, logistics, and standard operating procedures are needed for first aiders in these high-risk environments? What alternatives are there if these don’t exist?...
+
+=== Chunk 2580 ===
+Source: 4105_002-ebook.pdf
+Length: 140 chars
+
+Untitled Section
+WAR SURGERY WORKING WITH LIMITED RESOURCES IN ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE
+VOLUME 2
+SECOND EDITION, 2021...
+
+=== Chunk 2581 ===
+Source: 4105_002-ebook.pdf
+Length: 206 chars
+
+C. GIANNOU M. BALDAN Å. MOLDE
+E C N E R E F E R
+ICRC
+WAR SURGERY WORKING WITH LIMITED RESOURCES IN ARMED CONFLICT AND OTHER SITUATIONS OF VIOLENCE
+VOLUME 2
+SECOND EDITION, 2021
+C. GIANNOU M. BALDAN Å. MOLDE...
+
+=== Chunk 2582 ===
+Source: 4105_002-ebook.pdf
+Length: 2426 chars
+
+PREFACE
+It is with great pleasure that I welcome the completion of Volume 2 of War Surgery: Working with Limited Resources in Armed Conflict and Other Situations of Violence. This second volume benefited from numerous remarkable professional collaborations and scientific contributions under the joint authorship and review of Drs Christos Giannou, Marco Baldan and Åsa Molde. I feel certain that it will provide a new point of reference for health professionals engaged in providing lifesaving servi...
+
+=== Chunk 2583 ===
+Source: 4105_002-ebook.pdf
+Length: 6187 chars
+
+TABLE OF CONTENTS
+BLAST PHENOMENA A.1 Short history of the weapons of war and armed conflict A.2 Munition composition A.3 Open-air bomb explosion A.4 Effects due to the environment A.5 Specific explosive devices EXPLOSIONS AND PRIMARY BLAST INJURIES 19.1 Introduction 19.2 The single bombing incident 19.3 Epidemiology 19.4 Pathogenesis and pathophysiology 19.5 Clinical presentations and management 19.6 The ear and ruptured tympanum 19.7 Blast lung 19.8 Air embolism 19.9 Visceral injury 19.10 Eye ...
+
+=== Chunk 2584 ===
+Source: 4105_002-ebook.pdf
+Length: 4175 chars
+
+Part D TORSO
+D.1
+Introduction
+D.2
+Epidemiology
+D.3
+Thoraco-abdominal wounds
+D.4
+Injuries to the diaphragm
+D.5 Transaxial injuries
+D.6 Junctional trauma
+D.7
+The general surgeon and the chest: the psychological partition
+360
+361
+363
+363
+367
+369
+369
+370
+372
+373
+373
+374
+9
+10
+THORACIC INJURIES 31.1 Introduction 31.2 Wound ballistics 31.3 Epidemiology 31.4 Clinical presentation 31.5 Emergency room management 31.6 Intercostal chest tube drainage 31.7 Thoracotomy 31.8 Exploration of the chest cavity 31....
+
+=== Chunk 2585 ===
+Source: 4105_002-ebook.pdf
+Length: 5617 chars
+
+INTRODUCTION TO VOLUME 2
+Volume 1 of this manual has been well received by its target audience: surgeons of the Red Cross/Red Crescent Movement and other humanitarian agencies, and civilian and military colleagues working in austere, constrained and at times hostile environments. While Volume 1 dealt with general themes and topics, the challenge of Volume 2 lies in applying the same logic to the management of actual wounds in specific organ systems.
+Different socio-economic and tactical contexts...
+
+=== Chunk 2586 ===
+Source: 4105_002-ebook.pdf
+Length: 20979 chars
+
+Please note:
+Two annexes have been added to Part F to facilitate the reading of this Volume. They include a short summary of wound ballistics and the Red Cross Wound Score. Including them in Volume 2 allows for a quick reference. For detailed explanations, the reader should refer to the relevant chapters in Volume 1.
+The manual, a film on the treatment of anti-personnel landmine injuries, and ICRC physical rehabilitation guidelines are available on the ICRC website at https://icrc. scenari.eu/pu...
+
+=== Chunk 2587 ===
+Source: 4105_002-ebook.pdf
+Length: 3747 chars
+
+Acknowledgements
+Volume 2 concludes the updating of Surgery for Victims of War, first published by the ICRC in 1988. In addition, several chapters have made extensive use of the ICRC brochures by Robin Coupland, Amputations for War Wounds (1992), and David I. Rowley, Professor of Orthopaedic and Trauma Surgery, University of Dundee, War Wounds with Fractures: A Guide to Surgical Management (1996).
+The authors of the present manual and all ICRC surgeons owe a debt of gratitude to the pioneering w...
+
+=== Chunk 2588 ===
+Source: 4105_002-ebook.pdf
+Length: 2737 chars
+
+Permissions and assistance
+Apart from ICRC surgeons, a number of colleagues have made photographs available for this manual. The authors wish to thank Takashi Shiroko and Masaharu Nakade of
+INTRODUCTION TO VOLUME 2
+the Japanese Red Cross Society; Franco Plani at the Chris Hani Baragwanath Hospital, Soweto, South Africa; Gamini Goonetilleke, Sri Jayewardenapura General Hospital, and Past President of the College of Surgeons of Sri Lanka; K.N. Joshi, Lumbini Zonal Hospital, Nepal; Dan Deckelbaum, ...
+
+=== Chunk 2589 ===
+Source: 4105_002-ebook.pdf
+Length: 1691 chars
+
+Note to the Second Edition
+The authors have endeavoured to bring a number of sections of this volume up to date while still adhering to its basic philosophy: appropriate protocols and procedures using appropriate technology when working under the constraints of limited resources in precarious conditions. We do not attempt to offer “cutting-edge” developments, which are largely irrelevant to the everyday work of the great majority of readers of this manual. Nonetheless, we have attempted to be as...
+
+=== Chunk 2590 ===
+Source: 4105_002-ebook.pdf
+Length: 578 chars
+
+Part A BLAST PHENOMENA
+19
+WAR SURGERY
+20
+A. BLAST PHENOMENA
+A.1 A.2 A.3 A.3.1 A.3.2 A.3.3 A.4 A.5 A.5.1 A.5.2 A.5.3 A.5.4 A.5.5 Short history of the weapons of war and armed conflict Munition composition Open-air bomb explosion Positive-pressure shock wave Negative-pressure suction wave Blast wind Effects due to the environment Specific explosive devices Thermobaric (fuel-air) weapons Shaped-charge explosives Improvised explosive devices (IED) Dense inert metal explosives (DIME) Landmines and un...
+
+=== Chunk 2591 ===
+Source: 4105_002-ebook.pdf
+Length: 17516 chars
+
+Basic principles
+Weapons systems can act at an ever greater distance from the victim.
+Explosive devices have become the major weapons deployed in contemporary warfare.
+Fragments from explosive devices have become the most common mechanism of wounding.
+An open-air bomb explosion consists of three phases: positive-pressure shock wave; negative- pressure suction wave; and blast wind.
+A single explosion can produce many victims suffering a variety of injuries.
+A single victim may present all four ty...
+
+=== Chunk 2592 ===
+Source: 4105_002-ebook.pdf
+Length: 2634 chars
+
+A.1 Short history of the weapons of war and armed conflict
+From traditional face-to-face combat using bare fists, sticks and stones, knives, swords and spears, other “hand-energized” weapons that struck at a distance came into being: the sling-shot, javelin and bow and arrow. The invention and propagation of gunpowder triggered off a revolution in warfare with the development of weapons that act at an even greater distance: explosive devices and the rifle.
+The evolution of warfare has in certain...
+
+=== Chunk 2593 ===
+Source: 4105_002-ebook.pdf
+Length: 23 chars
+
+Figure A.2
+C
+IcRC
+R
+C
+I...
+
+=== Chunk 2594 ===
+Source: 4105_002-ebook.pdf
+Length: 59 chars
+
+Figure A.3
+Irregular fragment removed from a victim’s body....
+
+=== Chunk 2595 ===
+Source: 4105_002-ebook.pdf
+Length: 633 chars
+
+Figure A.4
+Friedlander curve: pressure-time relationship of a blast wave in open air without obstacles in its path. The area under the curve is the total impulse per unit area.
+Positive-pressure shock wave: a pulse of peak overpressure that travels through the ambient medium – air, water or the ground. Only high-order explosives cause an overpressure shock wave.
+Negative pressure or rarefaction phase: a suction wave, again only occurring with high-order explosives.
+Blast wind: phase of dynamic o...
+
+=== Chunk 2596 ===
+Source: 4105_002-ebook.pdf
+Length: 1805 chars
+
+A.2 Munition composition
+Explosives are described as either high- or low-order and provoke different patterns of injury. Low-order explosives include gunpowder, small bombs such as pipe bombs, and “Molotov cocktails” (petroleum based). High-order explosives can either be improvised using simple substances available commercially, such as fertilizer and diesel fuel, or specifically manufactured. The latter can be for civilian use, for example quarrying, building dams and other large civil engineer...
+
+=== Chunk 2597 ===
+Source: 4105_002-ebook.pdf
+Length: 1366 chars
+
+A.3 Open-air bomb explosion
+The detonation of an explosive is an exothermic4 chemical process that converts the explosive charge into high-pressure gases in an extremely short time, measured in microseconds.5
+In an open-air bomb explosion, part of the energy from the gases produced ruptures the casing, imparting high kinetic energy to the resulting fragments; their initial velocity may be up to 2,000 m/s. Another part produces heat in the form of a fireball, as well as sound, light and smoke. Th...
+
+=== Chunk 2598 ===
+Source: 4105_002-ebook.pdf
+Length: 868 chars
+
+A.3.1 Positive-pressure shock wave
+The positive-pressure shock wave is a moving peak of high pressure and density travelling at supersonic speed at first, as high as 3,000 – 9,000 m/s, but decreasing very quickly with distance. It is of very short duration – in the order of milliseconds – but of very rapid onset, and reaches its maximum pressure load almost instantaneously. This high-pressure peak, in the order of hundreds of bars,6 also decreases rapidly as the wave moves away from the source o...
+
+=== Chunk 2599 ===
+Source: 4105_002-ebook.pdf
+Length: 354 chars
+
+A.3.2 Negative-pressure suction wave
+The passage of the positive component is followed by a negative pressure trough, a relative vacuum, which sucks in air and debris. The pressure differential is much less than the positive phase, but can last three to ten times as long, and during its first phase it has more destructive energy than the positive peak....
+
+=== Chunk 2600 ===
+Source: 4105_002-ebook.pdf
+Length: 545 chars
+
+A.3.3 Blast wind
+The rapidly expanding gases from the explosion displace an equal volume of air and, together, produce a blast wind. This mass movement of air creates a “dynamic overpressure” that travels immediately behind the shock wave, but at a much lower speed. Nonetheless, it can reach several hundred km/h (approximately 100 m/s). It is of lower amplitude than the shock wave, but lasts much longer and travels much further. This dynamic overpressure knocks over or scatters any object shatte...
+
+=== Chunk 2601 ===
+Source: 4105_002-ebook.pdf
+Length: 2201 chars
+
+A.4 Effects due to the environment
+The propagation of the blast wave can become very complicated in the presence of obstacles or when channelled along streets, corridors, or through pipes and tunnels. Like sound waves, a blast shock wave flows over and around an obstacle and will affect someone sheltering behind. On the other hand, obstacles can also create blast wave turbulence immediately behind them with the formation of relatively safe areas, which is why sometimes people close to explosions...
+
+=== Chunk 2602 ===
+Source: 4105_002-ebook.pdf
+Length: 160 chars
+
+Figure A.5
+Explosive detonation. Note the blast front indicated by the arrow.7
+Blast overpressure  Positive pressure phase  Atmospheric  pressure  Time
+Pressure...
+
+=== Chunk 2603 ===
+Source: 4105_002-ebook.pdf
+Length: 151 chars
+
+Figure A.6
+Typical pressure – time relationship of a blast in an enclosed space.
+23
+t
+h
+g
+i
+r
+y
+p
+o
+C
+n
+i
+w
+o
+r
+C
+C
+IcRC
+R
+C
+I
+C
+IcRC
+R
+C
+I
+WAR SURGERY...
+
+=== Chunk 2604 ===
+Source: 4105_002-ebook.pdf
+Length: 70 chars
+
+Figure A.7
+Disc incorporated into an explosively-formed projectile.
+24...
+
+=== Chunk 2605 ===
+Source: 4105_002-ebook.pdf
+Length: 166 chars
+
+A.5 Specific explosive devices
+A number of variations on basic ordnance have been developed to fulfil specific military demands. A short, non-exhaustive list follows....
+
+=== Chunk 2606 ===
+Source: 4105_002-ebook.pdf
+Length: 807 chars
+
+A.5.1 Thermobaric (fuel-air) weapons
+With these weapons, a first small detonation spreads out explosive material as a fine aerosol that mixes with atmospheric oxygen, which is then triggered to produce a second explosion. The disseminated explosive aerosol creates a much larger area of propagation of the shock wave and the initial overpressure lasts longer and reaches further than in an ordinary explosion. In addition, the consumption of atmospheric oxygen in the explosion causes death by asphyx...
+
+=== Chunk 2607 ===
+Source: 4105_002-ebook.pdf
+Length: 964 chars
+
+A.5.2 Shaped-charge explosives
+In these weapons, the explosive device is constructed in such a way as to amplify the blast overpressure and brisance effect and to channel it into a tight trajectory. The blast wave thus extends as a cone rather than as a sphere starting from a point. The blast overpressure has a devastating effect within the cone, but very little damage is caused outside it. One type of anti-tank mine (ATM) is equipped with a shaped charge.
+An explosively-formed projectile is a p...
+
+=== Chunk 2608 ===
+Source: 4105_002-ebook.pdf
+Length: 544 chars
+
+A.5.3 Improvised explosive devices (IED)
+As the name implies, these are home-made bombs. The explosive material may be military munitions (mortar or artillery shells, or landmines) or commercially available products, such as ammonium nitrate (fertiliser) and petrol. IED are used by insurgent groups and non-State actors and factions, and include a great diversity of types, small and large, and are more-or-less efficient: pipe bombs, car bombs, roadside bombs, booby-traps, etc. If activated by the...
+
+=== Chunk 2609 ===
+Source: 4105_002-ebook.pdf
+Length: 1169 chars
+
+A.5.4 Dense inert metal explosives (DIME)
+This device mixes tiny particles of an inert heavy metal, such as tungsten, together with the explosive; thus the fragments are incorporated into the explosive itself rather than derived from the casing, which is made of a material with little fragmentation effect. The result is the creation of a shower of “microfragments” on detonation producing an increased brisance from a relatively low initial blast yield. These microfragments are highly lethal at cl...
+
+=== Chunk 2610 ===
+Source: 4105_002-ebook.pdf
+Length: 2988 chars
+
+A.5.5 Landmines and unexploded ordnance (UXO)
+A landmine constitutes a particular explosive device that is legally defined by the method of activation. Whether industrially-manufactured or improvised, a mine is activated by the victim. An anti-tank or anti-vehicle mine is “designed to be detonated or exploded by the presence, proximity or contact … of a vehicle”.9 An anti-personnel mine is defined as “designed to be exploded by the presence, proximity or contact of a person”.
+Anti-personnel mine...
+
+=== Chunk 2611 ===
+Source: 4105_002-ebook.pdf
+Length: 1079 chars
+
+EXPLOSIONS AND PRIMARY BLAST INJURIES
+27
+WAR SURGERY
+28
+19. EXPLOSIONS AND PRIMARY BLAST INJURIES
+19.1 Introduction 19.2 The single bombing incident 19.3 Epidemiology 19.3.1 Mortality 19.3.2 Survivors 19.4 Pathogenesis and pathophysiology 19.4.1 Primary blast injury: barotrauma 19.4.2 Secondary blast injury: fragment wounds 19.4.3 Tertiary blast injury: blast wind 19.4.4 Quaternary or miscellaneous blast injury 19.5 Clinical presentations and management 19.5.1 General concussion syndrome: resist...
+
+=== Chunk 2612 ===
+Source: 4105_002-ebook.pdf
+Length: 1734 chars
+
+19.1 Introduction
+Explosions can be caused by various events.
+• Physical-mechanical: exploding pressure cooker.
+• Exothermic chemical: conventional military-type explosion transforming a chemical compound – solid or liquid – into a large quantity of gas in an exothermic reaction, as seen in bombs, shells, mines and incendiary bombs (napalm, white phosphorus).
+• Nuclear: fission or fusion device, atomic and hydrogen bombs.
+Non-conventional chemical weapons may or may not involve a conventional de...
+
+=== Chunk 2613 ===
+Source: 4105_002-ebook.pdf
+Length: 657 chars
+
+19.2 The single bombing incident
+The great difference between the individually-held assault rifle and an explosive device is in the number of victims that can be produced by a single combatant during a single incident. The range of scenarios using explosive devices during armed conflict is thus far more varied than with simple firearms, and injuries due to the different blast effects of explosions have become more common in modern warfare. However, few single bomb explosions have a preponderance...
+
+=== Chunk 2614 ===
+Source: 4105_002-ebook.pdf
+Length: 72 chars
+
+Figure 19.1
+Fireball and plume of dust and smoke arising from a bombing....
+
+=== Chunk 2615 ===
+Source: 4105_002-ebook.pdf
+Length: 2338 chars
+
+Figure 19.2
+Building collapse: the frequent result of a bombing.
+30
+In wartime, most medical services and facilities – whatever the level of resources – are prepared and expect the arrival of large numbers of casualties, which they deal with to the best of their capabilities. Even the civilian population learns to take certain protective measures when violence is expected. However, the single bombing incident in an urban environment, as an isolated act of terrorism, takes the system by surprise ...
+
+=== Chunk 2616 ===
+Source: 4105_002-ebook.pdf
+Length: 2362 chars
+
+19.3 Epidemiology
+The general epidemiology of armed conflict as described in Chapter 5 applies. Most war wounds are the result of fragments from some sort of explosive device, but most wounded survivors have been injured beyond the radius of the primary blast effect. Indeed, within this radius the density of primary and secondary fragments is so great that lethal injuries are caused by both primary blast effect and fragments. However, many different tactical situations exist. This section descri...
+
+=== Chunk 2617 ===
+Source: 4105_002-ebook.pdf
+Length: 187 chars
+
+19.3.1 Mortality
+“La mort était due à la grande et prompte dilation [sic] d’air.”  (Death was caused by the great and immediate expansion   of air.)  Pierre Jars 2 1758
+Pierre Jars 2 1758...
+
+=== Chunk 2618 ===
+Source: 4105_002-ebook.pdf
+Length: 5544 chars
+
+Figure 19.3
+Casualties may suffer total body disruption or fireball carbonization. Some bodies may show no recognizable external sign of penetrating or blunt injury – there are many
+Total body carbonization of a mother and two children following a bomb explosion.
+1 People who are partially submerged in water when subjected to a blast explosion, for example, suffer very different injuries to the under-water and above-water body parts.
+2 French physiologist who was the first to correctly determine...
+
+=== Chunk 2619 ===
+Source: 4105_002-ebook.pdf
+Length: 2843 chars
+
+19.3.2 Survivors
+Many patients suffer multiple injuries caused by a wide variety of blast effects, covering a whole spectrum of trauma. Representative of this are the injuries recorded following the bomb attacks against the Madrid trains in 2005, which took place within a closed space; only 512 patients among more than 2,000 casualties were deemed seriously injured enough to be recorded in this study (Table 19.2).
+Body region Patients wounded Injuries Head, neck and face 340 Brain and skull 41 N...
+
+=== Chunk 2620 ===
+Source: 4105_002-ebook.pdf
+Length: 143 chars
+
+19.4 Pathogenesis and pathophysiology
+Although four different categories of blast injury are described, they often coexist in a single patient....
+
+=== Chunk 2621 ===
+Source: 4105_002-ebook.pdf
+Length: 2723 chars
+
+19.4.1 Primary blast injury: barotrauma
+Primary blast injuries are due to the direct effects of over- and under-pressure caused by the shock wave: i.e. barotrauma. These injuries are usually confined to a relatively small area around the point of explosion, since the wounding potential is inversely related to the third power of the distance between the victim and the explosion.8
+The peak overpressure induces surface compression and deformation waves upon hitting the body and interacts with the t...
+
+=== Chunk 2622 ===
+Source: 4105_002-ebook.pdf
+Length: 1070 chars
+
+Ear
+Rupture of the tympanic membrane is the most common injury, but does not depend only on the absolute blast overpressure. The orientation of the head, i.e. the external auditory canal acting as a corridor for the passage of blast pressure, is an important consideration. Transitory sensorineural deafness (neurapraxia of the receptor organs) is very frequent. Degloving of the cartilage of the external ear may also occur.
+Cave KM, Cornish EM, Chandler DW. Blast injury of the ear: clinical update...
+
+=== Chunk 2623 ===
+Source: 4105_002-ebook.pdf
+Length: 1641 chars
+
+Lung
+Lung injuries carry the highest morbidity and mortality. The alveolar-capillary septum is the typical air-fluid interface where spalling may occur. Alveolar air is compressed by the positive pressure wave and, with the negative phase, the alveoli burst. Inertial shearing occurs at the attachments of the tracheobronchial tree.
+The disruption of peripheral alveoli may lead to the formation of subpleural cysts and tearing of the visceral pleura. Pneumothorax, haemopneumothorax, pneumomediastin...
+
+=== Chunk 2624 ===
+Source: 4105_002-ebook.pdf
+Length: 1221 chars
+
+Figure 19.4
+Alternating phases for lung haemorrhage and vascular air emboli.
+Normally, the intravascular fluid pressure is greater than the air pressure in the alveoli. This intravascular pressure reacts less to the changes due to blast than the alveolar air.
+With peak pressure, the alveolar-capillary membrane ruptures and intravascular fluid enters the alveolar space: fluid to gas phase causing “forced” haemorrhage and oedema.
+With negative pressure, intra-alveolar air is pressed into the capil...
+
+=== Chunk 2625 ===
+Source: 4105_002-ebook.pdf
+Length: 974 chars
+
+Hollow viscera
+Any perforation due to the direct effect of the pressure wave is usually immediate and most commonly affects the ileo-caecal region or colon.
+Less common are delayed perforations that develop insidiously in stages owing to a process of intramural haemorrhage and/or mesenteric ischaemia, both leading to infarction, necrosis and gangrene of the affected site. Pathological studies on rats have shown the injury to begin in the mucosa and then migrate toward the serosa.10 Necrosis begi...
+
+=== Chunk 2626 ===
+Source: 4105_002-ebook.pdf
+Length: 310 chars
+
+Figure 19.5
+Traumatic amputation of the lower legs through the tibia.
+Figure 19.6 X-ray showing glass shards in the tissues.
+36
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+R
+C
+I
+/
+e
+r
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+.
+M
+any serosal injury due to primary blast seen at operation indicates that the entire intestinal wall is involved and requires debridement and repair....
+
+=== Chunk 2627 ===
+Source: 4105_002-ebook.pdf
+Length: 139 chars
+
+Solid organs
+Ischaemia, infarction or haemorrhage often occur; complete rupture of the liver, spleen or kidney is rarely seen in survivors....
+
+=== Chunk 2628 ===
+Source: 4105_002-ebook.pdf
+Length: 351 chars
+
+Musculoskeletal system
+Brisance can fracture long bones; the blast wind that follows the shock wave then strips away the soft tissues. One possible result in victims close to the blast epicentre is traumatic amputation, which usually occurs at the upper third of the tibia. Abdominal evisceration is also seen. Massive soft-tissue wounds are frequent....
+
+=== Chunk 2629 ===
+Source: 4105_002-ebook.pdf
+Length: 81 chars
+
+Eye
+Rupture of the eye globe and open fracture of the orbital ridge are possible....
+
+=== Chunk 2630 ===
+Source: 4105_002-ebook.pdf
+Length: 729 chars
+
+Head and central nervous system
+Direct blast overpressure causes diffuse axonal injury, and coup-counter-coup injury as well as fractures of the skull. Petechial haemorrhages with brain oedema are seen. Cerebral vasospasm that can last for up to a month may occur and some authors have reported pseudoaneurysms of the cerebral vessels following the vasospasm.
+Pathological changes of secondary neurodegenerative effects at the molecular and cellular levels may continue for hours or even days after e...
+
+=== Chunk 2631 ===
+Source: 4105_002-ebook.pdf
+Length: 610 chars
+
+Autonomic nervous system
+The blast wave can stimulate the pulmonary C-fibre receptors of the vagus nerve located in the alveolar septa, thus activating the “pulmonary defensive reflex” of a pronounced vagal state: a triad of apnoea, bradycardia and hypotension. The result is the paradoxical condition of profound shock with bradycardia, rather than compensatory tachycardia, as well as the absence of compensatory peripheral vasoconstriction. A loss of skeletal muscle tone is also a feature of this...
+
+=== Chunk 2632 ===
+Source: 4105_002-ebook.pdf
+Length: 528 chars
+
+19.4.2 Secondary blast injury: fragment wounds
+Projectiles may be primary fragments, derived from the casing or bomb contents, or secondary missiles: objects mobilized by the blast wind or arising from environmental debris (glass shards from shattered windows, wood splinters, soil and stones).
+Fragment wounds within the radius of the primary blast effect result in more severe injuries; the formation of a temporary cavity described for projectiles is compounded by blast-driven debris and delayed ...
+
+=== Chunk 2633 ===
+Source: 4105_002-ebook.pdf
+Length: 1110 chars
+
+19.4.3 Tertiary blast injury: blast wind
+The blast wind can displace people, throwing them against objects, or mobilize large objects in the environment which then strike people, causing blunt trauma. Brisance and the blast wind can cause building collapse with subsequent entrapment and crush injuries as well as head trauma, traumatic asphyxia, fractures and spinal injury.
+Cernak I, Savis J, Ignatovic D, Jevtic M: Blast injury from explosive munitions. J Trauma 1999; 47: 96 – 104.
+12 Cernak I, S...
+
+=== Chunk 2634 ===
+Source: 4105_002-ebook.pdf
+Length: 1174 chars
+
+19.4.4 Quaternary or miscellaneous blast injury
+The fireball of the explosion may reach 3,000° C causing flash burns; it may also set fire to the environment, as when a building goes up in flames. Most affected are the face and hands because clothing offers some protection, although it often also catches fire. The combination of blast effect and a burn injury affecting more than 30 % body surface area is usually fatal.
+The blast can let off toxic gases, including carbon monoxide, leading to asph...
+
+=== Chunk 2635 ===
+Source: 4105_002-ebook.pdf
+Length: 526 chars
+
+19.5 Clinical presentations and management
+Previously, it was thought that rupture of the tympanum indicated the probability of more severe injury elsewhere. This has been shown to be false. More accurately, skull and facial fractures, penetrating head and torso wounds, and burns covering over 10 % of the total body surface area are better indicators.16 The best indicator is pharyngo-laryngeal blast injury diagnosed by laryngeal nasendoscopy, although this procedure is not readily available wher...
+
+=== Chunk 2636 ===
+Source: 4105_002-ebook.pdf
+Length: 979 chars
+
+19.5.1 General concussion syndrome: resistance to resuscitation
+Russian surgeons in Afghanistan and, more recently, US surgeons in Iraq and Afghanistan have described patients with mixed patterns of blast injury, largely due to anti-tank and anti-personnel landmines in the first case and improvised explosive devices in the latter. Separated by over twenty years, the clinical descriptions are eerily similar.
+The condition manifests itself clinically as haemorrhagic shock that is resistant to aggr...
+
+=== Chunk 2637 ===
+Source: 4105_002-ebook.pdf
+Length: 1271 chars
+
+19.5.2 “Shell shock” and the “bewildered” walking wounded
+Survivors of the sudden flash, sonic boom and neural barotrauma of an explosion can experience what was once called “shell shock”. Wind of shot, vent du boulet, divine madness, soldier’s heart, combat fatigue, reflex paralysis, air concussion, shell
+16 Almogy G, Mintz Y, Zamir G, Bdolah-Abram T, Elazary R, Dotan L, Faruga M, Rivkind AI. Suicide bombing attacks: can external signs predict internal injuries? Ann Surg 2006; 243: 541 – 546.
+1...
+
+=== Chunk 2638 ===
+Source: 4105_002-ebook.pdf
+Length: 2178 chars
+
+Figure 19.7
+20 Bryusov PG, Shapovalov VM, Artemyev AA, Dulayev AK, Gololobov VG. Combat Injuries of Extremities. Moscow: Military Medical Academy, GEOTAR; 1996. [Translation by ICRC Delegation Moscow]
+The walking wounded: dazed, disoriented, and frightened.
+37
+C
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+WAR SURGERY
+38
+concussion, blast concussion,21 are all terms that were used in the past to describe similar conditions – if these symptoms persist, nowadays they would be classified as PTSD.
+The patien...
+
+=== Chunk 2639 ===
+Source: 4105_002-ebook.pdf
+Length: 1047 chars
+
+19.6 The ear and ruptured tympanum
+Almost all persons closely exposed to a significant blast suffer functional perceptive deafness and some dizziness at the time of the explosion; the inner ear can suffer damage at a pressure insufficient to rupture the tympanum. Most recover rapidly with a return to normal hearing within a matter of minutes or hours. Some suffer permanent hearing loss at high frequencies.
+Apart from transient sensorineural deafness and dizziness, perforation of the tympanic mem...
+
+=== Chunk 2640 ===
+Source: 4105_002-ebook.pdf
+Length: 390 chars
+
+19.6.1 Management
+Dazed but stable patients with a ruptured eardrum do not require a chest X-ray, providing there are no respiratory symptoms or other clinically significant injuries. They should however be observed for four to six hours in a quiet environment.22
+Initial treatment of a ruptured tympanic membrane is conservative (see Chapter 28). Up to 75 % of patients heal spontaneously....
+
+=== Chunk 2641 ===
+Source: 4105_002-ebook.pdf
+Length: 338 chars
+
+19.7 Blast lung
+The lungs are the second most commonly injured organ following exposure to primary blast, but the leading cause of late blast mortality. The diagnosis of blast lung injury (BLI) is made on a clinical basis and confirmed by chest X-ray. In the absence of mechanical ventilation, the management of severe cases is difficult....
+
+=== Chunk 2642 ===
+Source: 4105_002-ebook.pdf
+Length: 2875 chars
+
+19.7.1 Clinical presentations
+There are three major clinical presentations of respiratory insufficiency in blast victims.
+1. Severe respiratory distress with bloody, frothy sputum and rapidly deteriorating level of consciousness, bradycardia and hypotension, shortly after exposure, often within minutes.
+The condition is immediately life-threatening and the prognosis grave whatever the treatment. In a mass casualty situation where resources are limited, these patients are classed as “expectant” (...
+
+=== Chunk 2643 ===
+Source: 4105_002-ebook.pdf
+Length: 1013 chars
+
+19.7.2 Chest X-ray and pulse oximetry
+Any patient subjected to explosive blast and suffering the slightest respiratory sign or symptom, should have a radiograph taken of the chest and be held under observation for 4 – 6 hours, including pulse oximetry.
+The first X-ray may be clear because clinical symptoms appear before radiological signs. Patients with a normal X-ray, but still showing clinical signs or symptoms of pulmonary effects after 6 hours, should have a repeat X-ray performed and remain...
+
+=== Chunk 2644 ===
+Source: 4105_002-ebook.pdf
+Length: 165 chars
+
+Figure 19.9
+Bilateral “butterfly” pulmonary infiltrates : central consolidation, compatible with lung contusion is seen in the chest X-ray.
+2
+,
+.
+l
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+
+=== Chunk 2645 ===
+Source: 4105_002-ebook.pdf
+Length: 1438 chars
+
+19.7.3 Assessment of patients with suspected lung injury
+Of the three clinical presentations mentioned above, immediate respiratory distress and ARDS are self-evident. The diagnostic problem lies with the insidious development of BLI and, therefore, begs the question of how long to keep patients under observation.
+The real world scenario of actual time elapsed since exposure to the blast resembles the following picture.
+1. Casualties of an explosion are transported to the hospital, and reach it ...
+
+=== Chunk 2646 ===
+Source: 4105_002-ebook.pdf
+Length: 3193 chars
+
+19.7.4 Patient management
+Not all patients suffering from BLI require intubation and mechanical ventilation; only severe cases presenting respiratory distress or those with progressing insufficiency with hypoxaemia do. Treatment of severe blast lung is challenging even with the aid of mechanical ventilation; high ventilation pressures increase the risk of air embolism or tension pneumothorax and should be avoided. If mechanical ventilation is available, the simplest recommended protocol is permi...
+
+=== Chunk 2647 ===
+Source: 4105_002-ebook.pdf
+Length: 1291 chars
+
+19.8 Air embolism
+Air may be shunted from ruptured alveoli to the pulmonary circulation. Air is trapped in the right atrium, causing hypotension, tachycardia and distension of the jugular veins. There is sudden, severe respiratory distress with tachypnoea and a “cogwheel” murmur, continuous throughout the heart cycle. Systemic air emboli to the brain or myocardium causing infarction are rapidly fatal and may occur especially at the initiation of positive pressure ventilation, whether manual or m...
+
+=== Chunk 2648 ===
+Source: 4105_002-ebook.pdf
+Length: 1720 chars
+
+19.9 Visceral injury
+Rupture of solid organs (liver, spleen or kidney, testicles) from primary blast injury is rarely seen in surviving patients. Far more common presentations are secondary (projectile) or tertiary (blunt and crush) blast injuries. Injury is more common in a closed-space explosion or under water.
+Children are more susceptible to abdominal blast injury than adults. Not only is the abdominal wall smaller and thinner, offering less protection, but the liver and spleen are proportio...
+
+=== Chunk 2649 ===
+Source: 4105_002-ebook.pdf
+Length: 675 chars
+
+19.10 Eye and maxillo-facial injuries
+Rupture of the eye globe, serous retinitis, retinal detachment, and hyphaemia have all been reported, as well as air embolism to the central artery of the retina. Fractures of the orbit, with possible injury to the optic nerve, as well as to the frontal and maxillary paranasal sinuses are possible. Secondary injury of the eyes and eyelids from shattered glass is far more common.
+Treatment follows standard ophthalmology protocols according to the lesion (see ...
+
+=== Chunk 2650 ===
+Source: 4105_002-ebook.pdf
+Length: 645 chars
+
+19.11 Limb injuries
+Primary blast can produce a fracture, typically at the tibial tuberosity. The blast wind then avulses the distal tibia producing a traumatic amputation. These injuries are most often seen when an explosion occurs in an enclosed space, and only 1–2 % survive to hospital.
+The vast majority of limb injuries, however, are due to fragments. Fragment wounds suffered within the radius of primary blast result in extensive tissue devitalization and contamination, which may not be evid...
+
+=== Chunk 2651 ===
+Source: 4105_002-ebook.pdf
+Length: 598 chars
+
+19.12 Other injuries
+Burns incurred in combination with primary blast effects are much more serious and have a worse prognosis than those without. Patients suffering burns affecting more than 30 % body surface area and primary blast injury rarely survive, even in specialized centres that commonly deal with even more serious burn injuries. Circumferential burns may require a full fasciotomy and not just escharotomy (see Section 15.6.1).
+Combined blast and fragment wounds are more liable to sepsis...
+
+=== Chunk 2652 ===
+Source: 4105_002-ebook.pdf
+Length: 3799 chars
+
+19.13 Removal of retained unexploded ordnance
+An exceedingly rare but disconcerting case is the patient presenting with a retained live munition. A projectile has hit and penetrated the body, but not exploded. The cases reported in the literature usually deal with mortar or RPG grenades with the tip in the body and the rest of the munition protruding out. The patient may be moribund or not – the projectile may not have struck a vital organ.
+It is obvious that only explosive ordnance disposal qua...
+
+=== Chunk 2653 ===
+Source: 4105_002-ebook.pdf
+Length: 410 chars
+
+INJURIES DUE TO ANTI-TANK MINES
+47
+™
+WAR SURGERY
+48
+20. INJURIES DUE TO ANTI-TANK MINES
+20.1 Introduction 20.2 Epidemiology 20.3 ATM effects on an armoured vehicle 20.3.1 Non-penetration of the armour 20.3.2 Penetration of armour 20.4 Clinical presentations 20.4.1 Injuries without penetration of the armour 20.4.2 Injuries with penetration of the armour 49 49 50 50 51 51 51 52
+INJURIES DUE TO ANTI-TANK MINES...
+
+=== Chunk 2654 ===
+Source: 4105_002-ebook.pdf
+Length: 652 chars
+
+20.1 Introduction
+An anti-tank mine contains a large amount of explosive, 7 kg and more, and requires a larger weight (110 – 350 kg) to set off the explosion than an anti-personnel mine. If the fuse is damaged the pressure required may be less. Some are manufactured purposefully to penetrate armour as described in Part A.5.2.
+Unlike the deployment of anti-personnel mines, the use of anti-tank landmines is not prohibited, but is nonetheless constrained by treaty.1
+e
+k
+z 3 g
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+...
+
+=== Chunk 2655 ===
+Source: 4105_002-ebook.pdf
+Length: 1087 chars
+
+20.2 Epidemiology
+Most epidemiological studies do not differentiate between anti-tank and anti- personnel mines when referring to “injured by mines”. In addition, reports dealing with the major tank battles of history do not, and probably cannot, discriminate between the casualties seen when armoured vehicles were hit by an anti-tank mine, a cannon shell, rocket-propelled grenade (RPG) or “Molotov cocktail”.
+One of the very few reports that do make the distinction between ATM and APM comes from ...
+
+=== Chunk 2656 ===
+Source: 4105_002-ebook.pdf
+Length: 490 chars
+
+Figure 20.3
+Blast impulse and vehicle acceleration causing injuries within a vehicle striking an anti-tank mine.
+a. Deformation of the floor of the vehicle.
+b. Parts of the body submitted to the direct transmission of the blast impulse and axial load to the bones of the skeleton ( ).
+c. Parts of the body that strike the interior of the passenger compartment upon acceleration of the vehicle – acceleration-deceleration effects that are similar to what occurs in a motor vehicle crash ( )....
+
+=== Chunk 2657 ===
+Source: 4105_002-ebook.pdf
+Length: 213 chars
+
+Figure 20.4
+Acceleration of the vehicle may cause passengers to be flung against the top or sides of the compartment and any passengers riding on top or in an open entry hatch may be thrown out onto the ground.
+50...
+
+=== Chunk 2658 ===
+Source: 4105_002-ebook.pdf
+Length: 833 chars
+
+20.3 ATM effects on an armoured vehicle
+An armoured vehicle is constructed with thick, reinforced sides and undercarriage. A tank is the prime example. Armoured personnel carriers have less armour protection, and even the metal body of a civilian vehicle can be regarded as a type of “armour”, although a weak one. When a vehicle runs over an ATM, which is usually buried, or is struck by a roadside bomb or an improvised explosive device (IED), which usually results in a directed open-air explosion...
+
+=== Chunk 2659 ===
+Source: 4105_002-ebook.pdf
+Length: 1217 chars
+
+20.3.1 Non-penetration of the armour
+The shock wave of an ATM explosion does not enter the passenger cabin, it simply reflects off the armour or at the soil-air interface of the buried explosion. The detonation does result in two distinct physical phenomena that both transmit kinetic energy to the vehicle. The rapid expansion of the explosion gases imparts an impulse to the vehicle that can deform or even rupture the floor or result in the destruction of the various parts of the vehicle. The exp...
+
+=== Chunk 2660 ===
+Source: 4105_002-ebook.pdf
+Length: 924 chars
+
+20.3.2 Penetration of armour
+Armour undoubtedly confers a great deal of protection. However, when it is penetrated, the results are more complex. Besides all the effects described under non-penetration, primary fragments from the mine and secondary fragments from the armour itself turn into projectiles and the rupture of the armour allows hot gases to penetrate the passenger compartment. The effects are compounded by possible ignition and explosion of the ammunition carried by the vehicle. Howev...
+
+=== Chunk 2661 ===
+Source: 4105_002-ebook.pdf
+Length: 262 chars
+
+Figure 20.5
+Penetration of the armour: the same effects result from a rocket-propelled grenade or a shaped-charge anti-tank mine breaching the armour: fragments from the armour and weapon, residual jet material from the weapon. The difference is one of degree.
+C...
+
+=== Chunk 2662 ===
+Source: 4105_002-ebook.pdf
+Length: 213 chars
+
+20.4 Clinical presentations
+Tertiary blast effects predominate with non-penetration of the armour. Only penetration of the armour by an ATM can cause all four types of blast injuries to a greater or lesser extent....
+
+=== Chunk 2663 ===
+Source: 4105_002-ebook.pdf
+Length: 539 chars
+
+20.4.1 Injuries without penetration of the armour
+Victims inside a vehicle that has not been penetrated are exposed to very high acceleration, projecting them against the sides and roof of the interior, and suffer particularly from closed and open fractures of the lower limbs, skull and spine (vertical axial injury).
+Fractures of the limbs present a wide spectrum of severity: about half are closed and half open, and one-third are bilateral. Of particular note is the classically-described
+51
+WAR ...
+
+=== Chunk 2664 ===
+Source: 4105_002-ebook.pdf
+Length: 1291 chars
+
+Figure 20.6
+Pathogenesis of “pied de mine” injury.
+zones of primary direct impulse transfer and axial load.
+zones of indirect shearing of bone.
+52
+“pied de mine”: the foot is transformed into an intact bag of skin containing the shattered bones of the foot.3 These injuries tend to primarily affect the calcaneus.
+Although these injuries are usually described in relation to military vehicles, they have also been seen in a civilian context. For instance, among the 57 passengers travelling in pick-u...
+
+=== Chunk 2665 ===
+Source: 4105_002-ebook.pdf
+Length: 820 chars
+
+Civilian vehicles also hit anti-tank mines.
+In a military context, in addition to various limb injuries, the impulse transfer may deform the armoured vehicle floor, which forces flexion of the hips, rotation of the pelvis and flexion of the lumbar spine. The upward acceleration causes an axial spinal load resulting in thoracolumbar burst fractures and wedge-compression fractures, with or without paraplegia.6
+Nonetheless, the upward acceleration is such that the majority of fatalities result from...
+
+=== Chunk 2666 ===
+Source: 4105_002-ebook.pdf
+Length: 1640 chars
+
+Injuries with penetration of the armour
+Penetration of tank armour is frequently lethal because the resulting ignition of ammunition and fuel carbonizes the bodies of the occupants. This is especially the case with an armour-piercing munition and the resultant high temperature “jet flow”. Otherwise, primary- and secondary-fragment injuries predominate.
+Summary of blast effects in an armoured vehicle hitting an anti-tank mine
+• Without penetration of the armour, the main cause of injury is impuls...
+
+=== Chunk 2667 ===
+Source: 4105_002-ebook.pdf
+Length: 1601 chars
+
+Chapter 21 INJURIES DUE TO ANTI-PERSONNEL MINES
+55
+WAR SURGERY
+56
+21. INJURIES DUE TO ANTI-PERSONNEL MINES 21.1 Introduction: the humanitarian challenge 21.2 Mechanism of injury 21.2.1 Blast mines 21.2.2 Fragmentation mines 21.3 Clinico-pathological patterns of injury 21.3.1 Pattern 1 injury 21.3.2 Pattern 2 injury 21.3.3 Pattern 3 injury 21.4 Epidemiology 21.4.1 Definitions, classifications and data collection 21.4.2 Consequences of the tactical use of landmines 21.4.3 Effects on civilians post...
+
+=== Chunk 2668 ===
+Source: 4105_002-ebook.pdf
+Length: 2638 chars
+
+Introduction: the humanitarian challenge
+“The worldwide epidemic of landmine injuries is a classic example of a pathology that is not simply biological in scope; like all epidemics, in their causes and consequences, it is a social, economic, health, and political event, which particularly targets the innocent, the weakest, and the least prepared.”1
+Anti-personnel mines (APM) are a distinct subset of explosive devices and are amongst the most noxious of weapons systems. The wounds they cause are ...
+
+=== Chunk 2669 ===
+Source: 4105_002-ebook.pdf
+Length: 305 chars
+
+Figure 21.3.1
+Fragmentation stake mine in field with tripwire detonation mechanism.
+58
+in this regard and many of the challenges of the humanitarian consequences of APM remain. The humanitarian repercussions of landmines are detailed in Annex 21.A.
+This chapter is a detailed elaboration of Section 3.1.3....
+
+=== Chunk 2670 ===
+Source: 4105_002-ebook.pdf
+Length: 420 chars
+
+21.2 Mechanism of injury
+An anti-personnel mine is a small bomb, containing between 8 and 500 g of explosive and, by definition, is set off by the victim. It is conceived as an “anti person” weapon and comes in two main types: blast and fragmentation. The main mechanisms of injury are the primary blast effect, penetrating fragments, and the thermal reaction; exactly what can be expected from a small explosive device....
+
+=== Chunk 2671 ===
+Source: 4105_002-ebook.pdf
+Length: 662 chars
+
+21.2.1 Blast mines
+Blast mines are usually buried or laid on the surface of the ground and are activated by contact with a pressure plate. The casing is plastic, metal or wood. Blast APM are designed so that their detonation causes at least a foot injury in an infantryman wearing a combat boot or bursts the tyre of a vehicle. The great majority are industrially manufactured; some armed groups have produced improvised or “home-made” mines. Injury is caused by what amounts to a miniature and extre...
+
+=== Chunk 2672 ===
+Source: 4105_002-ebook.pdf
+Length: 845 chars
+
+21.2.2 Fragmentation mines
+These mines scatter metal fragments on detonation. They are set off by the victim hitting a tripwire or fuse. Different types have different modes of operation: held on a stake just above the ground; bounding up into the air 1 m before exploding; or spewing out fragments over a defined arc in a chosen direction, i.e. directional mines of the “Claymore”-type. With the first two, multiple metallic fragments derived from the outer casing or the contents are projected at 3...
+
+=== Chunk 2673 ===
+Source: 4105_002-ebook.pdf
+Length: 154 chars
+
+Figure 21.3.2
+Activation of a fragmentation mine by hitting a tripwire.
+Figure 21.3.3 Directional fragmentation mine.
+INJURIES DUE TO ANTI-PERSONNEL MINES...
+
+=== Chunk 2674 ===
+Source: 4105_002-ebook.pdf
+Length: 944 chars
+
+21.3 Clinico-pathological patterns of injury
+As a subset of blast injuries, the same general factors affect the pathological patterns and severity of injury:
+• type of mine;
+• amount and type of explosive material;
+• distance from or contact with the device and position of the victim at the moment of explosion;
+• the environment, in this case any means of protection worn by the victim (special boots, flak jacket, etc.).
+As described in Section 3.1.3, ICRC surgeons have defined three different cl...
+
+=== Chunk 2675 ===
+Source: 4105_002-ebook.pdf
+Length: 821 chars
+
+21.3.1 Pattern 1 injury
+The victim steps on the pressure plate of a blast mine: the foot or leg is blown away causing a traumatic amputation, with varying degrees of penetrating injuries and burns to the contralateral leg, perineum and buttocks, abdomen, chest or arm.
+The severity of the injury, as well as the level of traumatic amputation, is a function of the amount of explosive material relative to the body mass of the victim and the position of the foot at the moment of contact. If the explo...
+
+=== Chunk 2676 ===
+Source: 4105_002-ebook.pdf
+Length: 772 chars
+
+21.3.2 Pattern 2 injury
+The victim detonates a fragmentation mine by hitting a tripwire or fuse and the resulting explosion scatters metal fragments in the same manner as any explosive device. In another instance, someone may be injured by fragments when standing near a person or an animal, such as a cow taken out to pasture, who steps on a blast or fragmentation mine. The fragments may hit any part of the body and their penetration can be superficial or deep depending on the distance of the vic...
+
+=== Chunk 2677 ===
+Source: 4105_002-ebook.pdf
+Length: 886 chars
+
+21.3.3 Pattern 3 injury
+Manipulation of a mine causing its detonation may injure combatants laying mines, mine-clearance personnel, peasants touching a mine while planting rice in a paddy field, or curious children playing with a mine, especially the small and fascinating “butterfly” mine (Figure 3.3.3).
+Victims suffer amputation of the fingers or hand, with varying degrees of penetrating injury and burns to the face, neck and chest; many are blinded. The presence of face burns affecting the air...
+
+=== Chunk 2678 ===
+Source: 4105_002-ebook.pdf
+Length: 116 chars
+
+Figure 21.7.2
+The victim is blind and has suffered amputation of both hands.
+60
+INJURIES DUE TO ANTI-PERSONNEL MINES...
+
+=== Chunk 2679 ===
+Source: 4105_002-ebook.pdf
+Length: 240 chars
+
+21.4 Epidemiology
+Epidemiological studies on the use of landmines are by and large divided into two categories; the first deals with the general public health and socio-economic consequences; the second with the more purely medical aspects....
+
+=== Chunk 2680 ===
+Source: 4105_002-ebook.pdf
+Length: 1362 chars
+
+21.4.1 Definitions, classifications and data collection
+Data on landmines are confusing because of the problem of definitions. Whether industrially-manufactured or improvised, a mine is activated by the victim. Devices activated by an individual are classed as anti-personnel mines, while those that require the weight of a vehicle are considered anti-tank or anti-vehicle mines. The various explosive remnants of war – unexploded ordnance, especially cluster- bomb submunitions – cause injuries in a...
+
+=== Chunk 2681 ===
+Source: 4105_002-ebook.pdf
+Length: 2825 chars
+
+21.4.2 Consequences of the tactical use of landmines
+The pattern of landmine use in international wars, local wars, and guerrilla wars differs. The armies of States tend to place them along borders or front lines; guerrilla warfare knows no such limitations: there are no front lines and landmines are often placed more randomly.4 However State armed forces can also deploy mines and cluster munitions by aircraft and artillery which can result in widespread lethal contamination beyond border areas ...
+
+=== Chunk 2682 ===
+Source: 4105_002-ebook.pdf
+Length: 326 chars
+
+Figure 21.8
+ICRC Peshawar Hospital study 1992 – 93: activities of mine victims (N = 600).7
+62
+(3.53 %); 611 (21.8 %) were civilians and 120 (4.3 %) were of unknown status.6 The most malicious aspect of mine warfare, however, is that after a conflict is over most casualties are civilians and people involved in mine clearance....
+
+=== Chunk 2683 ===
+Source: 4105_002-ebook.pdf
+Length: 3872 chars
+
+21.4.3 Effects on civilians post-ceasefire and post-conflict
+Several studies undertaken by ICRC staff demonstrate this particularly pernicious consequence of the widespread use of APM on the civilian population. The ICRC Sarajevo Database shows that after the Dayton Agreement was signed in December 1995, there was a dramatic change in the kind of victim injured by No answer Combat 2% landmines. Of the 1,055 people listed as killed or injured between 15 December 1995 13% and 31 December 1998, 822...
+
+=== Chunk 2684 ===
+Source: 4105_002-ebook.pdf
+Length: 3476 chars
+
+21.4.4 Mortality
+The tactical use of APM has serious and long-lasting effects. The use of mines over wide regions of rural countryside, far from urban centres and communications, means that a large number of casualties are alone when they suffer injury. If they happen to be accompanied, their companions must be exceedingly careful when rushing to the rescue, for they too will be entering the minefield and risk being killed or injured. The number of people who die in isolated rural areas is seldo...
+
+=== Chunk 2685 ===
+Source: 4105_002-ebook.pdf
+Length: 250 chars
+
+Figure 21.9
+Distribution of patterns of APM-injury, Mongkol Borei Hospital, Cambodia, January – August 1991: N = 319.
+Pattern 1: traumatic amputation of lower limb.
+Pattern 2: dispersed fragment wounds.
+Pattern 3: traumatic amputation of the hand.
+64...
+
+=== Chunk 2686 ===
+Source: 4105_002-ebook.pdf
+Length: 1297 chars
+
+21.4.5 Survivors
+Patients surviving both the injury and delays in transport arrive with a large variety of wounds presenting one of the three clinical patterns. Figure 21.9 shows the distribution for 319 patients treated by an ICRC team at the Mongkol Borei Hospital, Cambodia, during the first 8 months of 1991.
+These different patterns of injury explain the enormous variety of wounds seen (Table 21.2). Out of the pattern 1 group of lower-limb traumatic amputations, 72 % had transtibial amputatio...
+
+=== Chunk 2687 ===
+Source: 4105_002-ebook.pdf
+Length: 1343 chars
+
+21.4.6 Hospital resources and workload
+Landmine victims require a disproportionate amount of hospital resources. In the ICRC’s experience, the average stay in hospital for a patient with a bullet or shrapnel injury is two weeks; for all mine-injured patients three weeks, and for a mine amputee it rises to almost five weeks. This means a much heavier workload for the nursing staff and demands more time and effort on the part of physiotherapists.
+As demonstrated in Table 5.22 and Figure 5.8, perso...
+
+=== Chunk 2688 ===
+Source: 4105_002-ebook.pdf
+Length: 1879 chars
+
+21.5 Blast mine injury: pathogenesis and clinical implications
+The pathology of traumatic amputation due to anti- personnel blast mines is unique.
+The most common are pattern 1 injuries at the level of the tibia and this is used as the prime example for the discussion in this section.
+INJURIES DUE TO ANTI-PERSONNEL MINES
+It is the close contact with a body part at the time of explosion that makes blast mine injury so particular. These wounds are the “perfect” example of the dirty and contaminate...
+
+=== Chunk 2689 ===
+Source: 4105_002-ebook.pdf
+Length: 232 chars
+
+Figure 21.10.1
+Typical pattern 1 injury with large amount of explosive. Note the “umbrella” effect of the skin and muscles being pushed up and out. The deeper tissue planes suffer greater damage than the more superficial ones.
+C
+.
+R...
+
+=== Chunk 2690 ===
+Source: 4105_002-ebook.pdf
+Length: 188 chars
+
+Figure 21.10.2
+Traumatic amputation of the left leg with injury to the other leg: note the proper application of a pneumatic tourniquet.
+C
+IcRc
+R
+C
+I
+65
+WAR SURGERY
+C
+Coupland / ICRC
+C
+.
+R...
+
+=== Chunk 2691 ===
+Source: 4105_002-ebook.pdf
+Length: 454 chars
+
+Figure 21.11.1
+Pattern 1 injury, small amount of explosive. Note that the calcaneus is completely shattered while the forefoot and attachment of the Achilles tendon are intact. The damage to the deep tissues around the end of the tibia rises proximally beyond the level of damage to more superficial tissues.
+C
+Coupland /ICRC
+C
+.
+R
+Figure 21.12.1
+Radiograph showing multiple foreign body fragments and air driven up along the fascial planes.
+C
+IcRC
+R
+C
+I...
+
+=== Chunk 2692 ===
+Source: 4105_002-ebook.pdf
+Length: 393 chars
+
+Figure 21.12.2
+Blast effect propagated along fascial planes: far-reaching contamination and contusion of the tissues.
+66
+The same umbrella effect is seen in the foot setting off a mine containing a small amount of explosive; the dorsum and heel are often spared, while the sole is severely damaged.
+C
+Icrc
+R
+C
+I
+C
+ICRC
+R
+C
+I
+Figure 21.11.2 Pattern 1 injury completely destroying the calcaneus....
+
+=== Chunk 2693 ===
+Source: 4105_002-ebook.pdf
+Length: 1319 chars
+
+Figure 21.11.2
+Figure 21.11.3
+Radiograph showing complete destruction of the calcaneus and closed transverse fracture of the other leg.
+The final open wound takes the circular form of the limb, with only skin tags and tendon ends dangling below. The spared structures that were pushed up and away have fallen back down, covering over and masking the extensively damaged deeper tissues. The deepest penetration of the blast wind takes place along the “weak” spaces of the limb: areolar tissue around n...
+
+=== Chunk 2694 ===
+Source: 4105_002-ebook.pdf
+Length: 1645 chars
+
+21.5.1 The effect of body size and footwear
+Many surgeons have witnessed the difference in severity of injuries seen in various patients who have detonated the same type of mine. This can be explained by considering that the extent of tissue destruction depends on the distance or gap between the explosion and the core mass of the body and on the quality of the footwear.
+Russian surgeons have performed laboratory studies comparing the results of different sized feet – therefore different body hei...
+
+=== Chunk 2695 ===
+Source: 4105_002-ebook.pdf
+Length: 1105 chars
+
+21.5.2 More proximal lesions
+The more proximal parts of the limb (the blast wave can cross the joints) suffer an irregular zone of tissue contusion and cellular concussion whose limits are difficult to determine. During the first three days after injury, tissue oedema becomes marked and may lead to proximal compartment syndrome.
+Blast wave effect: microscopic tissue   Level IV   disturbance and circulatory disorders.  rupture in vessel walls  with thrombotic   Level III  phenomena.  Brisance eff...
+
+=== Chunk 2696 ===
+Source: 4105_002-ebook.pdf
+Length: 96 chars
+
+Figure 21.13.1
+Levels of injury after a traumatic amputation.
+.
+l
+a
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+Nechaev et
+e
+v
+e
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+N...
+
+=== Chunk 2697 ===
+Source: 4105_002-ebook.pdf
+Length: 1653 chars
+
+Figure 21.13.2
+The blast effect has caused a traumatic amputation of the right foot and splitting of the skin on the proximal lower leg.
+C
+R
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+The stress waves propagated through the column of blood in the vessels of the limb can provoke variable levels of fissuring of the tunicae intima and media, leading to thrombosis, as well as contusion of the muscles with subsequent compartment syndrome.
+9 Trimble K, Clasper J. Anti-personnel mine injury; mechanism and medical management. J R Army Med Co...
+
+=== Chunk 2698 ===
+Source: 4105_002-ebook.pdf
+Length: 15075 chars
+
+ICRC EXPERIENCE
+ICRC surgeons and colleagues from Russia, Sri Lanka and Iraq have reported anecdotal incidences of sudden death hours or one to two days following resuscitation and surgery for a traumatic amputation due to APM. No presence of airway or torso injury was observed in these patients.
+Some surgeons have presumed that fat or thrombotic emboli lead to the sudden death. There is no conclusive evidence-based reason for the occurrence; however, this might be an example of what has been de...
+
+=== Chunk 2699 ===
+Source: 4105_002-ebook.pdf
+Length: 210 chars
+
+21.6 Clinical presentation and management
+The management of APM injuries poses a challenge to the entire chain of casualty care, from pre-hospital first aid through to physical and psychological rehabilitation....
+
+=== Chunk 2700 ===
+Source: 4105_002-ebook.pdf
+Length: 2219 chars
+
+21.6.1 First aid
+Pre-hospital care in cases of APM injury is often rendered difficult and dangerous by the prevailing circumstances: the patient is in the middle of a minefield! It is important for first aiders to understand that the last thing to do is to rush to the assistance of the wounded, thus putting themselves in danger. Someone should go for specialized help to assist with the extraction of the injured person.11
+However, the first aider can do much to assist the victim in situ. The casu...
+
+=== Chunk 2701 ===
+Source: 4105_002-ebook.pdf
+Length: 181 chars
+
+Figure 21.15
+Inappropriate tourniquet applied at the knee for a traumatic amputation of the foot and left on for more than 12 hours. The patient subsequently developed gas gangrene....
+
+=== Chunk 2702 ===
+Source: 4105_002-ebook.pdf
+Length: 747 chars
+
+Examination
+As with all trauma patients, the initial examination and resuscitation are based on the ABCDE algorithm (see Chapter 8). It is important to recognize the aforesaid patterns of APM injury to avoid missing any hidden injuries. Pattern 3 is most likely to produce injuries that affect the airway and breathing (Figure 21.7.1).
+As with all fragment injuries, close examination for small penetrating wounds is mandatory. This is particularly the case in pattern 1 where meticulous examination ...
+
+=== Chunk 2703 ===
+Source: 4105_002-ebook.pdf
+Length: 580 chars
+
+Resuscitation
+Patients suffering APM wounds frequently are injured in remote rural areas with exceedingly long evacuation times. Dehydration and tissue oedema compound the effects of any original haemorrhage and require adequate resuscitation prior to surgery. In addition, the proximity of the blast may induce “resistance to resuscitation” (see Section 19.5.1). Furthermore, the extremely contaminated nature of these wounds means that sepsis is a constant danger. Antibiotics should be administere...
+
+=== Chunk 2704 ===
+Source: 4105_002-ebook.pdf
+Length: 300 chars
+
+Figure 21.16
+Pattern 1 injury with burns and wounds in the perineum and penetration of the abdomen.
+The surgeon must take into account the pattern of injury and any associated injuries to determine management strategies.
+69
+Coupland / ICRC
+C
+.
+R
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+.
+E
+WAR SURGERY...
+
+=== Chunk 2705 ===
+Source: 4105_002-ebook.pdf
+Length: 61 chars
+
+Figure 21.17
+Scrubbing of a highly contaminated APM wound.
+70...
+
+=== Chunk 2706 ===
+Source: 4105_002-ebook.pdf
+Length: 692 chars
+
+21.7 Surgical management of pattern 1 traumatic amputations12
+It is the traumatic amputation of patterns 1 and 3 due to blast mines that poses the greatest technical challenge to the inexperienced surgeon and where war surgery differs most from civilian trauma and even from the rest of war trauma. An understanding of the pathology is essential.
+The general topic and operative surgical details of amputations and disarticulations are dealt with in Chapter 23. This section deals with the specificit...
+
+=== Chunk 2707 ===
+Source: 4105_002-ebook.pdf
+Length: 253 chars
+
+21.7.1 Preparation of the patient
+Given the highly contaminated nature of these wounds, the affected limbs should be thoroughly scrubbed with soap and water and a brush after induction of anaesthesia.
+Scrub the limb clean and use a pneumatic tourniquet....
+
+=== Chunk 2708 ===
+Source: 4105_002-ebook.pdf
+Length: 1747 chars
+
+21.7.2 Level of amputation and surgical technique
+Surgery involves performing a formal amputation above the irregular and soiled traumatic amputation stump, transforming it into a clean, properly-moulded surgical one.
+The surgical amputation must excise all dead and contaminated tissue.
+The surgeon must remember the pathology of the “umbrella” effect: deeper muscle layers suffer greater damage than more superficial ones and distal skin is still viable. Thus, an amputation level based on civilian...
+
+=== Chunk 2709 ===
+Source: 4105_002-ebook.pdf
+Length: 907 chars
+
+21.7.3 Classical approach to amputation
+The surgeon removes all dead, devitalized and contaminated tissue and amputates “as distal as possible through viable tissue” using techniques resembling civilian amputations, while taking the specific pathology into consideration.
+Skin flaps are raised and then pulled back once more to expose the damage to the deep muscles, all of which are cut across obliquely proximal to this level. This is particularly important in the anterolateral compartment of the ...
+
+=== Chunk 2710 ===
+Source: 4105_002-ebook.pdf
+Length: 1983 chars
+
+21.7.4 “Umbrella effect” and myoplasty or myodesis amputations
+The principle of a myoplasty or myodesis amputation involves leaving the muscle intact rather than cutting across its fibres. The whole muscle is dissected out; only the distal tendon attachment is sectioned. The umbrella effect that spares the superficial muscles makes these amputations particularly suitable for APM injuries.
+The intact muscle and overlying skin form a myoepithelial   flap: particularly useful after the umbrella eff...
+
+=== Chunk 2711 ===
+Source: 4105_002-ebook.pdf
+Length: 98 chars
+
+Figures 21.20.1 and 21.20.2
+Complex mine-blast injury to the foot without traumatic amputation.
+72...
+
+=== Chunk 2712 ===
+Source: 4105_002-ebook.pdf
+Length: 984 chars
+
+21.7.5 Other operative considerations and DPC
+The standard operative protocol applies: removal of the tourniquet and definitive haemostasis; copious irrigation; leaving the wound wide open; and application of a large, bulky dressing. After 4 – 5 days, the dressings are removed in the operating theatre and the wound inspected under anaesthesia.
+Leave the stump open for DPC.
+Once the wound is clean, the surgeon can proceed to delayed primary closure. However, mine-induced amputations are notorious...
+
+=== Chunk 2713 ===
+Source: 4105_002-ebook.pdf
+Length: 776 chars
+
+21.7.6 Other pattern 1 injuries
+The contralateral limb is often injured in pattern 1 injuries. Some wounds may be large, others small. Unlike small soft-tissue wounds due to ordinary fragments, which often do not require debridement because the body’s defence mechanisms are capable of dealing with the damage and contamination (see Section 10.8.1), all blast-mine fragment wounds should be debrided. Soil, mud, leaves or other contaminants are habitually found in these wounds.
+In the case of trauma...
+
+=== Chunk 2714 ===
+Source: 4105_002-ebook.pdf
+Length: 1623 chars
+
+21.8 Special features of mine-blast injury to the foot
+Certain anti-personnel mine injuries to the foot do not result in complete traumatic amputation because of the very small quantity of explosive material. Instead, there is wide and deep soft-tissue injury to the sole of the foot, a mini-umbrella effect and perhaps loss of one or several toes.
+C
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+Meticulous serial debridements every 2 – 3 days are often necessary if there is to be any hope of saving the foot. Dissection under tourniquet ...
+
+=== Chunk 2715 ===
+Source: 4105_002-ebook.pdf
+Length: 867 chars
+
+21.9 Special features of mine-blast injury to the hand: pattern 3
+Some patients will suffer complete traumatic amputation of the hand, others of one or several fingers. The primary blast effects described previously also pertain here.
+In the hand, it is even more imperative to retain important anatomical structures if any function is to be preserved. Again, meticulous and conservative serial debridements are carried out and only grossly necrotic tissues excised bit by bit. Decompression by carpa...
+
+=== Chunk 2716 ===
+Source: 4105_002-ebook.pdf
+Length: 430 chars
+
+21.10 Surgical management of pattern 2 injuries
+The management of pattern 2 injuries due to fragments follows the same rules and procedures as for those caused by other fragmentation devices. As mentioned previously, these wounds tend to be more severe if sustained within the radius of any primary blast effect. The management of fragment wounds in the various parts of the body is the topic of the other chapters in this volume....
+
+=== Chunk 2717 ===
+Source: 4105_002-ebook.pdf
+Length: 403 chars
+
+Figures 21.22.1 and 21.22.2
+Pattern 2 injury and some of the fragments removed during wound excision.
+C
+ICRC
+R
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+Icrc
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+13 Tajsic NB, Husum H. Reconstructive surgery including free flap transfers can be performed in low-resource settings: experience from a wartime scenario. J Trauma 2008; 65: 1463 – 1467.
+73
+WAR SURGERY
+Figures 21.23.1 and 21.23.2 Mine-injury survivors at play and at work.
+74...
+
+=== Chunk 2718 ===
+Source: 4105_002-ebook.pdf
+Length: 1317 chars
+
+21.11 Physical and psychological rehabilitation
+Successful surgical treatment of mine victims is only one step; then come the problems of the physical and psychological rehabilitation and social and economic reintegration of amputees. Although the immediate effects of draining hospital resources are considerable, the long-term consequences of rehabilitation costs and replacement of prostheses, loss of income and socio-economic dependency are debilitating to the individual, the family, and societ...
+
+=== Chunk 2719 ===
+Source: 4105_002-ebook.pdf
+Length: 1239 chars
+
+21.12 Conclusion: the humanitarian challenge
+At the beginning of this chapter mention was made of the worldwide epidemic of landmine injuries. Political, social, economic and healthcare initiatives are necessary to overcome the humanitarian effects of anti-personnel mines and the other explosive remnants of war. The international treaties banning APM and cluster munitions contain initiatives to address these issues.
+Four levels of a public health approach to meet the challenges of APM
+1. Primary...
+
+=== Chunk 2720 ===
+Source: 4105_002-ebook.pdf
+Length: 1285 chars
+
+ANNEX 21. A Humanitarian repercussions of landmines15
+The general effects of anti-personnel landmines are direct, indirect and widespread and remain long after a conflict has ended: disabled individuals, handicapped families, and mutilated societies. The humanitarian effects described apply to all lethal remnants of war: anti-tank mines, unexploded and abandoned ordnance and cluster munitions, as well as to anti-personnel mines.
+Landmines infesting agricultural land and water sources result in a...
+
+=== Chunk 2721 ===
+Source: 4105_002-ebook.pdf
+Length: 612 chars
+
+Figure 21.A.1
+Figure 21.A.2 Village near Prilep, Kosovo.
+These socio-economic repercussions can destabilize the fragile economies of post-war societies and, thus, after a civil conflict, exacerbate political tensions when the aim is to achieve national reconciliation.
+The response to these humanitarian effects must comprise preventive, curative, and rehabilitative measures. These must include mine clearance, marking of mined areas and mine-risk education to warn populations at high risk of the p...
+
+=== Chunk 2722 ===
+Source: 4105_002-ebook.pdf
+Length: 2175 chars
+
+Figures 21.A.3 and 21.A.4
+Marking of mined areas and mine clearance are essential.
+e
+a
+L
+.
+W
+M
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+T
+Figure 21.A.3
+Minefield near Kabalo, Katanga province, Democratic Republic of the Congo.
+Figure 21.A.4 Mine clearance near Angkot village, Battambang province, Cambodia.
+Figure 21.A.4
+Assistance begins with access to the wounded, evacuation and transportation of patients, and proper first aid. It involves correct surgery, physiotherapy, psychological support, and the fitting of an artificial limb w...
+
+=== Chunk 2723 ===
+Source: 4105_002-ebook.pdf
+Length: 196 chars
+
+1. Mortality and morbidity:
+• number of killed and wounded;
+• amputees – according to type of mine; need for artificial limbs and long-term investment in physical and psychological rehabilitation....
+
+=== Chunk 2724 ===
+Source: 4105_002-ebook.pdf
+Length: 263 chars
+
+2. Capacity of the health system to deal with the needs:
+• access to the wounded, first aid, transportation;
+• hospital infrastructure, qualified personnel, adequate medical supplies;
+• physiotherapy, prostheses, rehabilitation, social and economic reintegration....
+
+=== Chunk 2725 ===
+Source: 4105_002-ebook.pdf
+Length: 610 chars
+
+3. Civilian mined areas:
+• land use of affected areas – residential, agricultural, industrial;
+• booby-trapped neighbourhoods and outskirts of cities and villages;
+• percentage of farming or pastoral lands mined compared to those still available for economic activity; livestock lost; water sources infested, riverbanks rendered inaccessible;
+• regions containing mineral resources; electric projects and pylons.
+4. Percentage of civilian population affected in socio-economic terms:
+• loss of income...
+
+=== Chunk 2726 ===
+Source: 4105_002-ebook.pdf
+Length: 388 chars
+
+5. Public or community programmes disrupted because of mines:
+• repatriation of displaced persons or refugees;
+• rural immunization campaigns;
+• access to schools.
+6. Population density compared to density of mines laid.
+16 See: Hobbs L, McDonough S, O’Callaghan A. Life after Injury: A rehabilitation manual for the injured and their helpers. Penang, Malaysia: Third World Network; 2002....
+
+=== Chunk 2727 ===
+Source: 4105_002-ebook.pdf
+Length: 167 chars
+
+7. Transportation infrastructure affected:
+• roads, airstrips, ports;
+• transport of relief supplies and operational consequences;
+• resumption of commercial activity....
+
+=== Chunk 2728 ===
+Source: 4105_002-ebook.pdf
+Length: 143 chars
+
+9. Security concerns:
+• ongoing conflict or post-conflict situation;
+• new mines being laid;
+• banditry, which can disrupt mine-clearance work....
+
+=== Chunk 2729 ===
+Source: 4105_002-ebook.pdf
+Length: 278 chars
+
+10. Method of laying mines:
+• by irregular forces or conventionally trained army;
+• minefields marked and fenced off or not;
+• existence of maps indicating mined areas;
+• remotely delivered mines (cannon, helicopter, etc.) or hand placed.
+INJURIES DUE TO ANTI-PERSONNEL MINES
+77...
+
+=== Chunk 2730 ===
+Source: 4105_002-ebook.pdf
+Length: 1874 chars
+
+Part B LIMBS
+79
+WAR SURGERY
+80
+B. LIMBS B.1 Introduction B.2 Wound ballistics B.3 Epidemiology B.3.1 Mortality B.3.2 Incidence B.3.3 Combined bone and vascular injuries B.3.4 Classification systems B.4 Emergency room care B.4.1 Initial examination B.4.2 Complete clinical examination B.4.3 X-ray evaluation B.5 Surgical decision-making B.5.1 Limb salvage versus amputation B.5.2 Damage control for limb injuries B.6 Patient preparation B.6.1 Theatre use of a tourniquet B.7 Surgical treatment B.7.1 I...
+
+=== Chunk 2731 ===
+Source: 4105_002-ebook.pdf
+Length: 263 chars
+
+b.1 introduction
+The management of war wounds of the extremities, more than in any other body system, requires a change in the mindset of the surgeon when working with limited resources. This is often difficult, especially for the trained orthopaedic surgeon.
+T z...
+
+=== Chunk 2732 ===
+Source: 4105_002-ebook.pdf
+Length: 1314 chars
+
+Figure B.1
+This patient has a fracture but that is not his primary problem.
+C
+IcRC
+R
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+I
+Limited resources usually mean “operating theatres of doubtful sterility and lack of adequate equipment and human resources making operative treatment of fractures impossible in many … health care facilities”. Often this is further complicated by the inappropriate training received by doctors from low-income countries in hospitals in wealthier parts of the world where “only casual reference to conservative f...
+
+=== Chunk 2733 ===
+Source: 4105_002-ebook.pdf
+Length: 2167 chars
+
+b.2 Wound ballistics
+It is in the limbs that all the classical phenomena of wound ballistics described in Chapter 3 are fully encountered. Specific ballistic effects affecting bones, blood vessels and nerves are discussed in separate chapters.
+The commonest wounding agent in most modern combat is the fragment, whose non-aerodynamic irregular shape causes ballistic instability, with an early transfer of kinetic energy. All fragment injuries have the same wounding profile: a cone of tissue destruc...
+
+=== Chunk 2734 ===
+Source: 4105_002-ebook.pdf
+Length: 611 chars
+
+b.3 Epidemiology
+As in all epidemiological studies on war surgery, the problem of definitions surfaces when dealing with wounds in the extremities, multiple wounds, wounds of the limbs and soft tissues: all these terms have been used. The full definition of anatomic regions and descriptive pathological categories is not standardized, although attempts have been made in the surgical literature (see Section 5.6.2).
+Any study specific to wounds of the limbs or bony pelvic girdle can be described in...
+
+=== Chunk 2735 ===
+Source: 4105_002-ebook.pdf
+Length: 1319 chars
+
+b.3.1 mortality
+Historically, open fractures and major soft-tissue war wounds of the limbs were accompanied by a high mortality rate from sepsis. In a previous era, amputation was considered the treatment of choice for war wounds with fractures. Times have changed and gangrene, tetanus and invasive haemolytic streptococcal infection are no longer the perils they once were, although they are still encountered in patients suffering from neglected and mismanaged wounds (see Chapter 12).
+ICRC studie...
+
+=== Chunk 2736 ===
+Source: 4105_002-ebook.pdf
+Length: 3021 chars
+
+b.3.2 incidence
+Wounds of the limbs account for 50 – 75 % of all injured patients presenting at hospital (Table 5.6). This percentage increases where body armour covering the torso is worn by soldiers, anti-personnel mines are widely deployed, and long evacuation times “triage out” the most severely injured. Although no longer a major cause of mortality, limb injuries constitute the greatest burden on surgical workload because of their sheer volume (Tables 5.8 – 5.11). They also are the most sig...
+
+=== Chunk 2737 ===
+Source: 4105_002-ebook.pdf
+Length: 956 chars
+
+b.3.3 Combined bone and vascular injuries
+One-quarter to one-half of projectile wounds in the extremities involve open fractures and the major arteries are injured in up to 6 % of patients, even more if anti- personnel landmines or IEDs are widely used. Many limb wounds with fractures and severe soft-tissue damage, with and without arterial injury, can be complicated by compartment syndrome.
+Combined injuries of bone and vasculature are notorious for resulting in loss of limb. During World War I...
+
+=== Chunk 2738 ===
+Source: 4105_002-ebook.pdf
+Length: 1246 chars
+
+b.3.4 Classification systems
+The severity of limb wounds is determined by a combination of factors: extent of soft-tissue injury; gravity of bone comminution; presence of major arterial injury; and certain physiological parameters. Assessment of the severity has given rise to a number of classification systems.
+The Gustilo-Anderson classification endeavours to define guidelines for the treatment of open fractures by taking into account the soft-tissue injury and adequacy of soft- tissue coverage...
+
+=== Chunk 2739 ===
+Source: 4105_002-ebook.pdf
+Length: 448 chars
+
+Red Cross Wound Score
+It is for war wounds in the extremities that the RCWS has proven to be of greatest prognostic value (see Sections 4.5, 5.10.4 and 5.10.5). The entry, exit, cavity and fracture parameters offer a good estimate of the effective transfer of kinetic energy in terms of tissue damage. In the case of the extremities, the Vital = Haemorrhage parameter is more of a physiological one, putting the life or limb of the patient at risk....
+
+=== Chunk 2740 ===
+Source: 4105_002-ebook.pdf
+Length: 2405 chars
+
+b.4.1 initial examination
+Priority goes to the life-threatening conditions of the C-ABCDE paradigm: the pertinent parameter in the limbs is peripheral haemorrhage due to a lesion in a major blood vessel. Control of peripheral haemorrhage is an emergency and requires immediate intervention by means of a compressive bandage, tamponade, proximal digital pressure or a pneumatic tourniquet.
+5 DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II: an analysis of 2,471 cases. Ann Surg...
+
+=== Chunk 2741 ===
+Source: 4105_002-ebook.pdf
+Length: 125 chars
+
+Figure B.3
+Primarily sutured wound: fever, oedema, and the telltale signs of gas gangrene. All sutured wounds must be opened....
+
+=== Chunk 2742 ===
+Source: 4105_002-ebook.pdf
+Length: 1023 chars
+
+b.4.2 Complete clinical examination
+The surgeon should look for entry and exit wounds (front, flanks and back), any swelling – haematoma, oedema – and fractures, and check and document the distal vascular and neurological status in order to note any later change. It is important to keep in mind that:
+• small entry and exit wounds can co-exist with extensive internal injury;
+• compartment syndrome is an ever-present possibility and danger;
+• a wound in the groin or axilla may constitute a junctio...
+
+=== Chunk 2743 ===
+Source: 4105_002-ebook.pdf
+Length: 1050 chars
+
+Figure B.2.1
+Figure B.2.2 Kramer wire-splint with padding.
+85
+C
+Barrand/ ICRC
+.
+K
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+/
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+.
+T
+WAR SURGERY
+86
+Junctional trauma is discussed in Part D. The anatomic site does not allow for the placement of a tourniquet, making bleeding control problematic.
+Clinical diagnosis of injuries to the joints is based on the anatomic location of the wound, loss of function, and aspiration of intra-articular blood. A reverse arthrocentesis test may be helpful: under full aseptic preca...
+
+=== Chunk 2744 ===
+Source: 4105_002-ebook.pdf
+Length: 1104 chars
+
+b.4.3 X-ray evaluation
+X-rays are not required as a routine and judgement is necessary to determine which patients really need them; an important consideration when resources are scarce. If radiography is readily available, then all patients with limb wounds should be X-rayed after initial stabilization, except for cases with through-and-through soft-tissue wounds. The joints above and below any fracture site should be included and two views taken. For injuries in junctional areas, the proximal ...
+
+=== Chunk 2745 ===
+Source: 4105_002-ebook.pdf
+Length: 1881 chars
+
+b.5 surgical decision-making
+Many authors contrast “civilian” with “military” or “combat” projectile wounds, including those writing this manual. The differences involve context and working conditions as well as wound pathology. It is more appropriate, and a better use of ballistics knowledge, to speak of energy-transfer wounds. Low-energy transfer wounds are found in both situations and the conservative approach developed by civilian surgeons is probably the most appropriate for many patients. ...
+
+=== Chunk 2746 ===
+Source: 4105_002-ebook.pdf
+Length: 1476 chars
+
+Low-energy transfer wounds
+Wound excision is not required for punctate superficial soft-tissue wounds due to fragments (see Figures 10.15.1 and 10.15.2). These injuries can be described as Grade 1 soft-tissue wounds according to the RCWS. Neither is debridement necessary for wounds with uncomplicated fractures without displaced bone fragments and with an entry and exit wound less than 2 cm wide: Grade 1, Type F1 wounds. Projectiles lodged in the bone or in the fracture haematoma of such wounds d...
+
+=== Chunk 2747 ===
+Source: 4105_002-ebook.pdf
+Length: 357 chars
+
+Medium- and high-energy transfer wounds
+Larger RCWS Grade 1 wounds (greater than 2 cm entry or exit) and Grades 2 and 3 require surgical exploration and consideration for the management of the entire limb since soft-tissue injury is usually extensive, the neurovascular bundle is at greater risk, and fractures tend to be more comminuted.
+C
+V.Sasin / ICRC
+V...
+
+=== Chunk 2748 ===
+Source: 4105_002-ebook.pdf
+Length: 165 chars
+
+Figures B.4.1 and B.4.2
+Through-and-through low-energy wound with clinically insignificant fracture of the acromion and no evidence of haematoma or oedema formation....
+
+=== Chunk 2749 ===
+Source: 4105_002-ebook.pdf
+Length: 74 chars
+
+Figure B.5
+Medium-energy wound of the right gluteal region.
+87
+WAR SURGERY...
+
+=== Chunk 2750 ===
+Source: 4105_002-ebook.pdf
+Length: 125 chars
+
+Figure B.6
+High-energy multiple gunshot wounds of the left leg. Salvage of the limb can be problematic, if not impossible.
+88...
+
+=== Chunk 2751 ===
+Source: 4105_002-ebook.pdf
+Length: 1869 chars
+
+Limb salvage versus amputation
+Whether to try to save a limb or proceed with amputation is one of the most difficult decisions in orthopaedic trauma.
+Certain wounds in the extremities are near-traumatic amputations in their own right: extensive loss of soft tissue, severely comminuted bone, and section of the neurovascular bundle. There is little room for discussion when faced with such an injury.
+There are, on the other hand, less extensive injuries that nonetheless put the limb in danger and p...
+
+=== Chunk 2752 ===
+Source: 4105_002-ebook.pdf
+Length: 1702 chars
+
+b.5.2 Damage control for limb injuries
+When faced with a patient suffering the lethal triad of hypothermia, acidosis and coagulopathy, abbreviated operations should be the rule. It must be kept in mind that “damage control is a principle, a treatment mode applied to severely-injured trauma patients with deranged physiology, to restore the physiology rather than the anatomy …it is all about physiology”.7
+Although usually employed for life-threatening abdominal or thoracic injury, several examples...
+
+=== Chunk 2753 ===
+Source: 4105_002-ebook.pdf
+Length: 806 chars
+
+b.6 Patient preparation
+First, and foremost, is patient hygiene. Except for those with catastrophic bleeding, all patients should be showered before entering the operating theatre. Then, under anaesthesia in the OT, the affected limb should be scrubbed clean with soap and water, and excessive hair shaved if necessary. The wound is copiously irrigated to remove any loose contaminants.
+Wash the patient; wash the wound, with soap and water and a brush.
+Positioning of the patient on the operating ta...
+
+=== Chunk 2754 ===
+Source: 4105_002-ebook.pdf
+Length: 2009 chars
+
+b.6.1 Theatre use of a tourniquet
+Apart from minor injuries, limb wounds can best be debrided under a tourniquet to provide a bloodless field and minimize blood loss. However, the proper use of a tourniquet cuts off all blood supply to a limb causing tissue anoxia; it makes it difficult to assess tissue viability, and adds to any pre-existing ischaemic injury. Its use in general should be as short as possible and, especially in vascular trauma, limited to the time necessary for proximal and dist...
+
+=== Chunk 2755 ===
+Source: 4105_002-ebook.pdf
+Length: 129 chars
+
+Figure B.7.2
+The skin and deep fascia are widely incised to decompress the tissues and gain access to the depths of the wound.
+90...
+
+=== Chunk 2756 ===
+Source: 4105_002-ebook.pdf
+Length: 252 chars
+
+b.7 surgical treatment
+The key principles of wound excision and delayed primary closure, as described in Chapter 10, take soft-tissue and skeletal wounds of the limbs as their basis. This Section only aims to emphasize a few essential practical points....
+
+=== Chunk 2757 ===
+Source: 4105_002-ebook.pdf
+Length: 1040 chars
+
+b.7.1 initial wound excision
+Wound excision is best performed in a systematic sequence, layer by anatomic layer, from the skin through the soft tissues down to the periosteum and bone.
+1. Debridement of the skin wounds themselves should be conservative. Access to the wound track is through generous skin incisions in the long axis of the extremity, with deviation in the usual manner if the incision crosses a flexion crease. Deep fascia must be divided throughout the length of the incision to allo...
+
+=== Chunk 2758 ===
+Source: 4105_002-ebook.pdf
+Length: 2915 chars
+
+Figure B.7.3
+The exposed wound cavity.
+3. Muscles are debrided in the routine manner and all foreign material removed. The volume of damaged muscle in the permanent wound channel after all temporary effects have subsided is difficult to judge. Inexperience on the part of the surgeon leads either to inadequate surgery, infection and repeated debridements or to an overestimation of the amount of non-viable muscle and over-excision of the wound.
+4. Fragments of cortical bone without any attachment ...
+
+=== Chunk 2759 ===
+Source: 4105_002-ebook.pdf
+Length: 182 chars
+
+Figure B.7.4
+Unattached fragments of cortical bone are removed.
+91
+C
+2
+R
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+N
+.
+H
+WAR SURGERY...
+
+=== Chunk 2760 ===
+Source: 4105_002-ebook.pdf
+Length: 97 chars
+
+Figure B.7.5
+The wound is left open without any suturing and covered with a large bulky dressing....
+
+=== Chunk 2761 ===
+Source: 4105_002-ebook.pdf
+Length: 618 chars
+
+Figure B.8.1
+Wound dressing at DPC showing dried blood and serum and giving off the “good bad odour” of a clean wound.
+92
+11. The wound should afterwards be left open to drain, not sutured primarily or packed tightly. It is finally dressed with a layer of fine mesh gauze in contact with the raw surface and a bulky non-occlusive dressing of loose, fluffed dry gauze and absorbent cotton wool held in place with an elastic bandage providing gentle compression.
+12. Even in the absence of a fracture, ...
+
+=== Chunk 2762 ===
+Source: 4105_002-ebook.pdf
+Length: 898 chars
+
+b.7.2 initial post-operative care
+The limb is kept elevated and physiotherapy commenced the day after wound debridement.
+Constant vigilance must be maintained to make sure the onset of vascular complication or infection is quickly detected. Severe increasing pain that is out of proportion with what can be expected requires immediate intervention. Pain on passive flexion or extension of the fingers or toes is the single most sensitive sign of compartment syndrome requiring re-operation. Signs of ...
+
+=== Chunk 2763 ===
+Source: 4105_002-ebook.pdf
+Length: 1070 chars
+
+b.7.3 second operation: delayed primary closure
+Soft-tissue oedema should have more or less settled within 5 days following debridement: the optimum time for delayed primary closure. A clean wound ready for DPC presents a final gauze compress sticking to the fibrin of the raw surface. Upon its removal, the muscle contracts and bleeds.
+C
+H.Nasteddine / ICRC
+H
+Figure B.8.2 Clean wound ready for DPC.
+Limbs
+Many wounds and open amputation stumps often have a particular ammoniacal odour that can lead...
+
+=== Chunk 2764 ===
+Source: 4105_002-ebook.pdf
+Length: 2463 chars
+
+Old lesson for new surgeons
+The surgeon must learn the difference between the “good bad odour” of a clean wound and the “bad bad odour” of an infected one.
+It is usually sufficient to close the skin alone with large, widely-spaced interrupted sutures; the deeper tissues collapse into place. A drain may have to be placed if there is any dead space. If the wound cannot be sutured without tension, skin grafting and/ or a local rotation skin flap should be used. It may be possible to partially sutur...
+
+=== Chunk 2765 ===
+Source: 4105_002-ebook.pdf
+Length: 1445 chars
+
+b.7.4 Definitive post-operative care
+Nursing care and physiotherapy continue, as well as observation for any signs of infection. The patient should be mobilized with crutches unless on skeletal traction. Exercises to maintain muscle mass and joint mobility are important. Proper nutrition and patient hygiene must never be neglected.
+Drains should be removed as soon as possible, usually within 24 – 48 hours. A clean, dry wound requires no change of dressing until removal of sutures as per routine....
+
+=== Chunk 2766 ===
+Source: 4105_002-ebook.pdf
+Length: 2719 chars
+
+Topical negative pressure and vacuum dressing
+Topical negative pressure has been used since the 1940s as a method of wound management. Experimental studies show that there exists a different metabolic environment for tissues under a vacuum and this apparently has a positive effect on wound healing by stimulating angiogenesis and formation of granulation tissue; in addition it causes physical shrinking of the soft-tissue wound. The technique was originally designed for chronic wounds, but it has ...
+
+=== Chunk 2767 ===
+Source: 4105_002-ebook.pdf
+Length: 1851 chars
+
+Crush injury of the limbs: rhabdomyolysis
+Crush injury results from persistent excessive pressure to a body part, usually the legs but the arms and trunk can also be the site of injury. It is most often seen in persons caught in the wreckage after a motor vehicle crash and after natural catastrophes such as earthquakes when people are trapped under rubble and debris. Bombardment leading to the structural collapse of a building is the wartime equivalent.
+“A crush injury is a direct injury resulti...
+
+=== Chunk 2768 ===
+Source: 4105_002-ebook.pdf
+Length: 1057 chars
+
+Extended tourniquet use: pseudo-crush syndrome
+Similar pathological changes to crush injury occur if an improvised occlusive tourniquet is left on for more than six hours. Release of the tourniquet may result in ischaemia-reperfusion injury. Close clinical examination of the limb is necessary to determine if the occlusion has been complete, unfortunately all too often the case. In this instance serial incisions are made to inspect the muscles for viability; they are usually necrotic and amputati...
+
+=== Chunk 2769 ===
+Source: 4105_002-ebook.pdf
+Length: 1321 chars
+
+b.10 Compartment syndrome and fasciotomy
+Compartment syndrome is most often seen in the lower leg, but can also affect any other closed anatomic space or body cavity. In a limb, if neglected or inadequately treated, it can lead to similar systemic effects as with crush syndrome as the muscles undergo necrosis. Severe shock with massive crystalloid resuscitation can lead to a secondary “poly- compartment syndrome” affecting the brain, thorax, abdomen and limbs, usually seen
+13 The 1948 Universal ...
+
+=== Chunk 2770 ===
+Source: 4105_002-ebook.pdf
+Length: 1133 chars
+
+Aetiology
+Compartment syndrome of a limb can result from a number of causes.
+Trauma:
+• multiple fractures in a single limb – more commonly in closed, but also possible after an open fracture – especially of the tibia
+• anti-personnel blast mine injury
+• multiple small fragments provoking a large intramuscular haematoma plus primary blast effects
+• any delay in limb reperfusion after vascular injury
+• crush injury
+• prolonged forced position on a hard surface or too tense binding of the limbs, un...
+
+=== Chunk 2771 ===
+Source: 4105_002-ebook.pdf
+Length: 811 chars
+
+Pathogenesis
+A vicious cycle sets in: tissue oedema in a tight closed space causes a rise in compartment pressure gradually leading to a compromise of the microcirculation with consequent tissue hypoxia. The hypoxia and by-products of cell death cause further oedema. When the compartmental pressure rises high enough, occlusion of the macro-circulation supervenes. The resultant ischaemia affects all vital structures in the compartment, including muscles, nerves, blood vessels and lymph channels. ...
+
+=== Chunk 2772 ===
+Source: 4105_002-ebook.pdf
+Length: 623 chars
+
+Clinical picture
+By far the most common occurrence of compartment syndrome is in the lower leg. The muscles of the affected compartment become tense, swollen and hard. The earliest and most important clinical symptom is excessive pain out of proportion with the injury, especially on passive extension or flexion of the toes or fingers. Other signs of ischaemia appear, including pallor, paraesthesia and paresis. The pulse may remain normal for some time. Early diagnosis is the key, with a high deg...
+
+=== Chunk 2773 ===
+Source: 4105_002-ebook.pdf
+Length: 1021 chars
+
+Surgical decision-making
+During armed conflict most wounds are due to projectiles, although blunt injury occurs as well. After a natural disaster such as an earthquake, this proportion is reversed. Both open and closed wounds are susceptible to compartment syndrome. Nonetheless, open wounds are dirty and contaminated and the skin as a protective barrier against infection has been breached.
+a
+F.Plani /C.H. Baragwanath, Africa
+c
+i
+r
+f
+A
+.
+S
+,
+h
+t
+a
+n
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+w
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+a
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+B
+.
+H
+.
+C
+/
+i
+n
+a
+l
+P
+.
+F
+Limbs
+Sev...
+
+=== Chunk 2774 ===
+Source: 4105_002-ebook.pdf
+Length: 2295 chars
+
+Figure B.10.3
+Compartment syndrome of the forearm with viable muscles.
+Necrotic muscles following compartment syndrome of the forearm.
+2. A patient presents with an open or closed injury and established compartment syndrome and gangrene. Wet (infective) gangrene calls for urgent amputation. Dry (ischaemic) gangrene can wait until a line of demarcation forms before proceeding to amputation.
+3. A patient with an open wound presents with signs and symptoms of incipient or established compartment sy...
+
+=== Chunk 2775 ===
+Source: 4105_002-ebook.pdf
+Length: 436 chars
+
+Surgical treatment
+If fasciotomy is performed, the limb should always be slightly elevated afterwards and splinted in the functional position. Delayed primary closure after subsidence of oedema and re-establishment of normal circulation is standard procedure. Infection is common after projectile wounds and crush injury and amputation is often the final result.
+The fasciotomy incisions should be left open for delayed primary closure....
+
+=== Chunk 2776 ===
+Source: 4105_002-ebook.pdf
+Length: 783 chars
+
+b.10.1 Fasciotomy of the foot
+The four compartments of the foot are decompressed through three dorsal incisions. The medial incision follows the lower border of the first metatarsal and extends up to the medial malleolus; it goes through the tough and thick plantar fascia. This decompresses the medial compartment and, by dissection, the central plantar space.
+The lateral incision is made between the fourth and fifth metatarsals, decompressing the central dorsal space and, by lateral extension th...
+
+=== Chunk 2777 ===
+Source: 4105_002-ebook.pdf
+Length: 1598 chars
+
+b.10.2 Fasciotomy of the lower leg
+Adequate decompression involves all four compartments of the lower leg through two generous skin incisions. The fascial incisions should include the entire length of the respective fascia. The greatest error lies in making incisions that are too short.
+The posterior compartments are best approached through a single incision extending from the knee to the medial malleolus, 2 cm posterior to the palpable postero-medial edge of the tibia. The deep fascia is incise...
+
+=== Chunk 2778 ===
+Source: 4105_002-ebook.pdf
+Length: 274 chars
+
+Figure B.12.4
+Decompression of the lateral and superficial posterior compartments.
+After opening the lateral compartment, the skin flap can be rotated to gain access to the anterior compartment. The deep posterior compartment is accessed through the superficial compartment....
+
+=== Chunk 2779 ===
+Source: 4105_002-ebook.pdf
+Length: 614 chars
+
+b.10.3 Fasciotomy of the thigh
+There are three compartments to decompress in the thigh – anterior, posterior, and the adductor – requiring two incisions. A lateral incision beginning at the greater trochanter and extending to the lateral condyle of the femur is carried down to split the fascia lata, allowing entrance into the anterior compartment. subcutaneous dissection downwards allows for an incision just behind the fascia lata and the lateral fascial septum, affording entry into the posterio...
+
+=== Chunk 2780 ===
+Source: 4105_002-ebook.pdf
+Length: 622 chars
+
+b.10.4 Fasciotomy of the buttocks
+Compartment syndrome of the buttocks is rare. All three gluteal compartments (maximus, medius and minimus) must be decompressed. With the patient lying on the opposite side, the Kocher-Langenbeck incision begins at the posterior superior iliac spine and curves down over the greater trochanter and down the shaft of the proximal femur to expose the gluteus maximus, ilio-tibial tract and tensor fascio lata, which are incised. This exposes the gluteus medius, which ...
+
+=== Chunk 2781 ===
+Source: 4105_002-ebook.pdf
+Length: 280 chars
+
+b.10.5 Fasciotomy of the arm
+The arm contains three compartments: the anterior compartment (biceps, brachialis and coracobrachialis); the posterior compartment (three heads of the triceps); and the deltoid (not a real compartment, but the muscle is covered by a thick fascia). The...
+
+=== Chunk 2782 ===
+Source: 4105_002-ebook.pdf
+Length: 110 chars
+
+Figure B.12.2
+Anterolateral fasciotomy incision.
+99
+WAR SURGERY
+Figure B.13.1 Volar fasciotomy of the forearm....
+
+=== Chunk 2783 ===
+Source: 4105_002-ebook.pdf
+Length: 833 chars
+
+Figure B.13.2
+Decompression of the dorsal aspect of the forearm and hand.
+100
+lateral approach begins at the insertion of the deltoid muscle and continues down between the mass of the biceps and triceps to the lateral epicondyle. The dissection is deepened to the lateral intermuscular septum and the fascia is then split to enter the anterior and posterior compartments. A medial approach is also possible as a proximal continuation of a forearm fasciotomy, and also allows for exposure of the brach...
+
+=== Chunk 2784 ===
+Source: 4105_002-ebook.pdf
+Length: 184 chars
+
+b.10.6 Fasciotomy of the forearm
+There are two aspects to fasciotomy in the forearm: the volar and the dorsal.
+a
+c
+i
+&
+r
+f
+A
+.
+S
+,
+:
+h
+t
+a
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+a
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+g
+2 &
+a
+r
+a
+B
+.
+H
+.
+C
+S
+/
+i
+n
+a
+l
+P
+.
+F...
+
+=== Chunk 2785 ===
+Source: 4105_002-ebook.pdf
+Length: 892 chars
+
+Volar compartments of the forearm
+A curving s-incision is made from the medial epicondyle of the humerus across to the radial flexors and back to the ulnar end of the flexor crease. This is then carried across to the mid-palm immediately to the ulnar side of the thenar crease. Proximally, the bicipital aponeurosis (lacertus fibrosis) is incised, the incision continued through the fascia over the flexor carpi ulnaris, and the muscle retracted medially. Then the superficial flexor muscles are retr...
+
+=== Chunk 2786 ===
+Source: 4105_002-ebook.pdf
+Length: 244 chars
+
+Dorsal compartment of the forearm
+A dorsal midline incision from the elbow to the wrist is carried down through the deep fascia to expose the extensor compartment. Each muscle has its own fascial sheath, which requires individual decompression....
+
+=== Chunk 2787 ===
+Source: 4105_002-ebook.pdf
+Length: 394 chars
+
+b.10.7 Fasciotomy of the hand
+Two dorsal incisions of the hand between the second and third and fourth and fifth metacarpals are deepened to release the interossei, lumbricals and adductor pollicis.
+Limbs
+On the palmar aspect, the thenar and hypothenar eminences are decompressed through longitudinal incisions along their radial and ulnar borders; the thenar may include separate compartments....
+
+=== Chunk 2788 ===
+Source: 4105_002-ebook.pdf
+Length: 1132 chars
+
+b.10.8 Closure of fasciotomy incisions
+The closure of a fasciotomy incision involves only the skin, leaving the fascia open. Closure of a forearm fasciotomy after 4 – 5 days and subsidence of oedema is usually not difficult. The same can be said for “prophylactic” fasciotomy of the lower leg during vascular repair.
+There are many examples in the lower leg where such delayed primary closure is difficult, if not impossible, because it results in undue tension with subsequent necrosis of the skin e...
+
+=== Chunk 2789 ===
+Source: 4105_002-ebook.pdf
+Length: 3205 chars
+
+b.11 Reconstructive surgery of the limbs
+War wounds, like other major trauma, often require major reconstructive surgery to obtain a reasonable functional result. Lack of surgical expertise, adequate facilities and time often limit the extent to which this type of surgery can be performed.
+Nevertheless, there are occasions when appropriate reconstructive surgery is indicated and can be performed effectively, even where resources are limited. A certain number of basic techniques of reconstructive...
+
+=== Chunk 2790 ===
+Source: 4105_002-ebook.pdf
+Length: 3246 chars
+
+ANNEX b.1 Pneumatic tourniquet
+A pneumatic tourniquet should be treated with as much respect as any surgical instrument; jarring, blows and shocks will damage the aneroid gauge. All parts should be inspected before use for leaks or loose connections. Regular calibration of the aneroid pressure gauge can be accomplished by hooking it up to the mercury column gauge of an ordinary sphygmomanometer. The pressure in the tourniquet is raised to 100 mm Hg on the aneroid gauge and then released into the...
+
+=== Chunk 2791 ===
+Source: 4105_002-ebook.pdf
+Length: 333 chars
+
+ANNEX b.2 Crush injury
+Crush injury is most often seen after natural disasters such as earthquakes. It also occurs during armed conflict when buildings collapse on the occupants after bombardment. The extraction of the surviving victims may easily be delayed, bringing all the consequences of dehydration and hypothermia in its wake....
+
+=== Chunk 2792 ===
+Source: 4105_002-ebook.pdf
+Length: 1252 chars
+
+b.2.a Pathology and pathophysiology
+Continuous pressure on a body part for at least four hours or severe compression for as little as one hour causes physical disruption of the muscle fibres: acute traumatic rhabdomyolysis; and this occurs independently from any ischaemia. Although the pathology is muscular in origin, the trauma may also have caused fractures and crushing of bone.
+The breakdown of a large muscle mass liberates enormous amounts of myoglobin, uric acid, potassium and other product...
+
+=== Chunk 2793 ===
+Source: 4105_002-ebook.pdf
+Length: 1853 chars
+
+b.2.b Pre-hospital presentation and care
+Depending on the time spent under compression and any other injuries, hypothermia and dehydration are often prominent. Typically the victim appears generally well, often without complaint of pain until after extraction, and then suddenly decompensates after release of the compression. This is due to reperfusion hyperkalaemia and hypovolaemia. A strong analgesic or ketamine just prior to extraction is indicated; the pain can be excruciating.
+Precautions to...
+
+=== Chunk 2794 ===
+Source: 4105_002-ebook.pdf
+Length: 945 chars
+
+b.2.c Clinical picture and emergency room care
+Persons crushed under rubble often suffer multiple injuries. Initial examination follows the standard ABCDE paradigm and the usual resuscitation measures should be instituted.
+The crushed limb itself may suffer closed injury, present an open wound, or be frankly mangled. In the first two cases the condition may mimic flaccid paralysis with a mosaic pattern of sensory loss and the condition misdiagnosed as spinal injury.
+The limb is greatly swollen a...
+
+=== Chunk 2795 ===
+Source: 4105_002-ebook.pdf
+Length: 4812 chars
+
+b.2.d medical treatment of crush injury
+Patients suffering crush injury should be cared for in an intensive care unit with access to a proper laboratory, rarely available in the field. Optimum fluid therapy requires measurement of the central venous pressure and a full complement of laboratory analyses.18 An intensive nursing unit with a minimum of laboratory analyses, preferably including serum electrolytes, is usually all that can be organized where resources are limited (see Part F).
+The spec...
+
+=== Chunk 2796 ===
+Source: 4105_002-ebook.pdf
+Length: 2854 chars
+
+b.2.e surgical management
+Surgical treatment is limited and fraught with problems and complications.21 22
+If the crush injury has an open wound:
+• A severely mangled extremity or infection endangering the life of the patient calls for immediate amputation through healthy tissue without releasing a tourniquet if it has been applied.
+• If the limb is salvageable, the surgeon should proceed with debridement and fasciotomy.
+19 Adapted from Sever MS, Vanholder R, Lameire N. Management of crush-relate...
+
+=== Chunk 2797 ===
+Source: 4105_002-ebook.pdf
+Length: 631 chars
+
+b.2.f Further care
+Elevation of the limbs is apparently not well tolerated and results in increased pain. Furthermore, such elevation does not appear to assist in the resorption of oedema. The patient is best left with the legs straight and flat. In addition, physiotherapy for the limbs should focus only on maintenance of muscle mass and tone, since passive movement of the joints is very painful. After 10 – 14 days the pain subsides and passive and active movements can be commenced.
+Extreme caut...
+
+=== Chunk 2798 ===
+Source: 4105_002-ebook.pdf
+Length: 2500 chars
+
+Chapter 22 INJURIES TO BONES AND JOINTS1
+1 Large parts of this chapter are based on the brochure by David I. Rowley, Professor of Orthopaedic and Trauma Surgery, University of Dundee: War Wounds with Fractures: A Guide to Surgical Management. Geneva: ICRC; 1996.
+109
+WAR SURGERY
+110
+22. INJURIES TO BONES AND JOINTS
+22.1 Introduction 22.2 Wound ballistics 22.2.1 Kinetic energy 22.2.2 Bone-projectile interface 22.2.3 Joints 22.3 Epidemiology 22.3.1 Anatomic distribution 22.3.2 Type of fracture 22.3...
+
+=== Chunk 2799 ===
+Source: 4105_002-ebook.pdf
+Length: 334 chars
+
+22.1 introduction
+Limb injuries constitute the bulk of surgical work during armed conflict and fractures are present in a large number of them. It is thus essential that the general surgeon have a good knowledge of basic fracture management.
+A fracture is often best described as a soft-tissue injury complicated by a break in a bone....
+
+=== Chunk 2800 ===
+Source: 4105_002-ebook.pdf
+Length: 748 chars
+
+22.2 Wound ballistics
+The basics of wound ballistics with respect to bone are dealt with in Section 3.4.5. Bone tissue is significantly denser and harder than soft tissue and less elastic; it does not simply deform, it breaks. Within the shooting channel, the exact point where the missile hits the bone is of overriding importance. During the narrow, phase 1 channel, an FMJ bullet simply punches a hole in the bone. During temporary cavity formation, severe comminution results.
+“The surgeon is con...
+
+=== Chunk 2801 ===
+Source: 4105_002-ebook.pdf
+Length: 1125 chars
+
+22.2.1 Kinetic energy
+The key element determining the amount of tissue damage is the effective transfer of kinetic energy, which depends on several factors: the total energy available; the composition of the bone; and the duration of contact between projectile and bone, which is inversely proportional to the projectile’s velocity. Thus a slow travelling FMJ bullet in stable flight may cause more damage than one with a much greater velocity because its contact with the bone lasts longer allowing ...
+
+=== Chunk 2802 ===
+Source: 4105_002-ebook.pdf
+Length: 550 chars
+
+Figure 22.1
+The effect of increased hydraulic pressure in the bone marrow of a long bone: bone fragments are dispersed in all directions.
+112
+matter. High-energy transfer wounds are characterized by the vacuum created by temporary cavity formation with severe bacterial and foreign body (clothing, dirt, etc.) contamination, and present massive soft-tissue injury. As is often the case the very worst are the wounds caused by anti-personnel mines where the energy of the local blast effect is added t...
+
+=== Chunk 2803 ===
+Source: 4105_002-ebook.pdf
+Length: 746 chars
+
+22.2.2 bone-projectile interface
+Projectiles must reach a threshold velocity that leads to sufficient energy density in order to penetrate tissue; otherwise, they simply bounce off the body. For bone, this is approximately 40 – 60 m/s. The penetration depth of a projectile in bone and the effective transfer of kinetic energy depend on the degree of projectile retardation by the tissues: the “push” of the bullet versus the resistance of the bone. The main factors influencing the resistance are th...
+
+=== Chunk 2804 ===
+Source: 4105_002-ebook.pdf
+Length: 2959 chars
+
+Long bones
+Long bones of the limbs are heterogeneous. The diaphysis has a relatively thick wall that is dense and brittle and may be compared to a fluid-filled rigid-walled tube: bone marrow surrounded by cortical bone. Therefore, the boundary effect comes into play if the diaphysis is affected by the temporary cavity (see Section 3.4.3). Cavity formation generates an increase of the hydraulic pressure in the marrow that spreads in all directions and fractures the bone, thus propelling bone frag...
+
+=== Chunk 2805 ===
+Source: 4105_002-ebook.pdf
+Length: 1473 chars
+
+Figure 22.3
+Drill-hole fracture in the cortical bone of the lower tibia and fibula.
+Divot fracture: the entire thickness of only one cortex is fractured. A small piece of bone is broken off from the main shaft, occasionally accompanied by a non-displaced fracture extending from the divot.
+C
+R
+C
+I
+/
+i
+n
+a
+C
+Papas /ICRC
+l
+P
+.
+F
+P
+.
+N
+Figure 22.4.1 Fracture of the tibial shaft with a butterfly fragment.
+Figure 22.4.1
+Figure 22.4.2 Fracture with double butterfly fragments.
+Spongy and porous metaphys...
+
+=== Chunk 2806 ===
+Source: 4105_002-ebook.pdf
+Length: 404 chars
+
+Figure 22.5
+Drill-hole fracture through metaphyseal bone hit during the narrow phase 1 channel. The entry is usually the same size or slightly less than the diameter of the bullet and the edges of the exit are funnelled outwards. The diaphysis of a long bone reacts in the same way (see Figure 22.2.).
+Figures 22.6.1 and 22.6.2 Intra-articular metallic fragment.
+114
+C
+Papas / ICRC
+P
+.
+Entry
+Entry
+Exit
+N...
+
+=== Chunk 2807 ===
+Source: 4105_002-ebook.pdf
+Length: 435 chars
+
+Flat bones
+Flat bones include the scapulae, sternum, iliac fossae and the skull. They are mostly diploe cancellous bone with an absence of marrow and therefore suffer no hydraulic pressure effect; a bullet creates a hole with a little fissuration fracture. Injury is due only to direct crush by the projectile. A bullet entry wound is more or less circular, depending on the angle of impact. Its exit is usually a funnel-shaped defect....
+
+=== Chunk 2808 ===
+Source: 4105_002-ebook.pdf
+Length: 701 chars
+
+22.2.3 Joints
+A projectile passing into a joint can damage bone, cartilage, ligaments and menisci, largely through direct crush or laceration. Infection can easily cause chondrolysis and destruction of the joint.
+Lead fragments in soft tissue are rapidly isolated by avascular scar tissue. In synovial fluid, lead dissolves and can cause plumbism: generalized lead poisoning (see Section 14.3). Lead is also well known for causing a strong chemical arthritis.
+C
+R
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+.
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+Furthermore, any...
+
+=== Chunk 2809 ===
+Source: 4105_002-ebook.pdf
+Length: 1043 chars
+
+22.3.1 Anatomic distribution
+Although much has been written about the anatomic distribution of war wounds, there have been only a few studies on the distribution of fractures among the different bones in the limbs. Fractures occur in one-quarter to one-third of all limb wounds and the lower limb is injured about twice as often as the upper. However, the incidence of fractures in the upper and lower limbs is relatively equal. This is probably due to the smaller volume and more exposed position of...
+
+=== Chunk 2810 ===
+Source: 4105_002-ebook.pdf
+Length: 1099 chars
+
+22.3.2 Type of fracture
+The great majority of fractures are open, as is to be expected. Closed fractures in combat are usually due to tertiary blast effect and anti-tank landmines. Vehicle collisions and other accidents are also common non-combat causes.
+Fracture Closed Open Total Percentage open fractures Clavicle 6 7 13 53 % Scapula 4 28 32 87 % Humerus 16 106 122 86 % Forearm 23 107 130 82 % Hand 20 144 164 87 % Total upper limb 69 392 461 85 % Femur 16 107 123 86 % Lower leg 45 173 218 79 % ...
+
+=== Chunk 2811 ===
+Source: 4105_002-ebook.pdf
+Length: 635 chars
+
+22.3.3 Joints
+Even fewer reports deal specifically with injuries to the major joints. One such study, from the war in the former Yugoslavia, gives an incidence of 18.2 % joint injuries (339 patients) out of a total of 1,860 casualties with limb wounds treated in a large military hospital. The knee and elbow were the most common joints injured and also the most common sites of associated neurovascular injury.
+Joint injured Percentage distribution of total joint injuries Knee 46.6 % Elbow 20.1 % H...
+
+=== Chunk 2812 ===
+Source: 4105_002-ebook.pdf
+Length: 598 chars
+
+22.3.4 Red Cross Wound score
+The Red Cross Wound Score takes into account the soft-tissue injury as well as the fracture. The degree of bone damage in the version described in Chapter 4 makes a distinction between a simple fracture, hole, or clinically insignificant comminution (F = 1) and severe, clinically significant comminution (F = 2). Basically, these scores correspond to either two bone fragments or more as seen at wound debridement. However, the F parameter does not apply to the bone def...
+
+=== Chunk 2813 ===
+Source: 4105_002-ebook.pdf
+Length: 321 chars
+
+Defect A: small and circumferentially incomplete bone defects
+These drill-hole type, divot or chip-fracture defects heal well after correct debridement. If the soft-tissue injury is minimal, a conservative non-operative approach may be considered.
+C
+¥
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+.
+.
+D
+D
+Figure 22.7.1...
+
+=== Chunk 2814 ===
+Source: 4105_002-ebook.pdf
+Length: 477 chars
+
+Figure 22.7.2
+An F1 Type A fracture of the tibia without bone defect. Once the soft-tissue wound around the fracture has been excised, healing usually progresses smoothly.
+An F1 fracture in a child’s tibia with Type A defect. There is overall continuity of the bone despite the defect.
+5 Nikolić D, Jovanović Z, Popović Z, Vulović R, Mladenović M. Primary surgical treatment of war injuries of major joints of the limbs. Injury 1999; 30: 129 – 134.
+iNJURiEs TO bONEs AND JOiNTs...
+
+=== Chunk 2815 ===
+Source: 4105_002-ebook.pdf
+Length: 297 chars
+
+Defect B: small and circumferentially complete bone defect (<3 cm)
+In these cases, the defect may be retained as it is, or the limb permitted to shorten; the patient usually adapts to slight shortening. The extent of soft-tissue injury usually requires debridement.
+C
+Rowley /ICRC
+R
+.
+D
+IcRc
+tliy¢...
+
+=== Chunk 2816 ===
+Source: 4105_002-ebook.pdf
+Length: 202 chars
+
+Figures 22.8.1 and 22.8.2
+A bullet has produced circumferential bone loss (F2), but the defect is small: Type B. All the periosteum is usually present in such wounds and must be retained during surgery....
+
+=== Chunk 2817 ===
+Source: 4105_002-ebook.pdf
+Length: 337 chars
+
+Defect C: large and circumferentially complete bone defect (>3 cm)
+Remaining periosteum may ensure some callus formation. If progress is slow as revealed by serial X-rays, a bone graft may be considered later. The associated soft- tissue damage is significant, and wound debridement will clearly have been required.
+C
+R
+C
+D. Rowley /ICRC...
+
+=== Chunk 2818 ===
+Source: 4105_002-ebook.pdf
+Length: 682 chars
+
+Figures 22.9.1 and 22.9.2
+There is gross comminution and bone loss that will lead to a Type C defect. Many of the fragments will be found to be loose, but some will still have good periosteal attachment and should be retained.
+I
+Defect D: large defect associated with circumferential loss of bone and periosteum The capacity for bone regeneration in such fractures is limited. Even after a bone graft, healing may take months or years. Management options depend on which bone is injured – and the ult...
+
+=== Chunk 2819 ===
+Source: 4105_002-ebook.pdf
+Length: 258 chars
+
+Figures 22.10.1 and 22.10.2
+Two examples of a Type D defect: in this case, the soft-tissue loss is considerable and the extent of bony tissue loss such that the osteogenic potential is very small, even with bone grafting.
+C
+Icrc
+R
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+=
+117
+WAR SURGERY
+118...
+
+=== Chunk 2820 ===
+Source: 4105_002-ebook.pdf
+Length: 1538 chars
+
+22.4 management of war wounds with fractures
+The image of the fracture as seen on an X-ray is only one aspect of the wound complex. “Treat the wound, not the weapon” is a well-known aphorism in war surgery (see Section 3.2.1). One may well add: “treat the wound, not the X-ray”. The first and essential step to bone healing and the recovery of function is correct treatment of the soft-tissue wound. Furthermore, “cure” is not dependent on the radiological appearance of consolidating bone. The patie...
+
+=== Chunk 2821 ===
+Source: 4105_002-ebook.pdf
+Length: 1406 chars
+
+22.4.1 Primary wound debridement
+The surgeon’s essential concern should focus on wound excision, not on the method of fracture immobilization. The extent of soft-tissue excision should not be influenced by the risk of exposing bone; dead muscle and fat do not protect underlying bone and do not preserve function.
+As mentioned repeatedly in this manual, all unattached cortical bone fragments should be removed no matter how large. These are all avascular and retaining them in the wound will only re...
+
+=== Chunk 2822 ===
+Source: 4105_002-ebook.pdf
+Length: 2367 chars
+
+Figure 22.11.2
+Cortical bone fragments without periosteal attachment removed at wound debridement.
+C
+Rowley /ICRC
+C
+Rowley /ICRC
+R
+R
+.
+.
+D
+D
+Figure 22.11.3
+Figure 22.11.4
+After wound excision, the skeletal traction over- distracted the bone ends. This was corrected by adjusting the weight.
+Five weeks after wound excision, bone healing has occurred from the intact periosteum and callus is visible.
+As much periosteum as possible should be retained, since it is the periosteum that generates new bon...
+
+=== Chunk 2823 ===
+Source: 4105_002-ebook.pdf
+Length: 1096 chars
+
+22.4.2 Delayed primary closure
+A clean wound is closed by direct suture or skin grafting. Small wounds with a deep cavity, in which direct suture would create tension, may be left to heal by granulation and secondary intention. In some cases, a rotation flap or another reconstructive procedure may be necessary (see Section B.11). If skin closure proves impossible, the fracture may still be covered by nearby muscle at the second operation. This applies particularly to the tibia.
+At second operati...
+
+=== Chunk 2824 ===
+Source: 4105_002-ebook.pdf
+Length: 4210 chars
+
+22.5 methods of bone immobilization: surgical decision-making
+Factors to consider for good bone immobilization:  • functional result, not X-ray result;  • choice of method with lowest risk of complications;  • simplicity of technique, taking into account surgical skill and experience;  • simplicity of nursing care;  • reduction of hospitalization time, i.e. early discharge;  • expense.
+iNJURiEs TO bONEs AND JOiNTs
+There is no single and ideal method of fracture immobilization that fits all situa...
+
+=== Chunk 2825 ===
+Source: 4105_002-ebook.pdf
+Length: 1694 chars
+
+22.5.1 Plaster-of-Paris
+The use of plaster-of-Paris is a simple non-invasive technique for constructing a moulded support for a limb. The effective use of POP, in whatever form, is a manual skill that must be learnt and practised. A previous generation of general and orthopaedic surgeons was well versed in its use. Today, this is often no longer the case. The basic techniques include the making of a back slab or posterior splint and a complete cylindrical cast and its variations.
+The indications...
+
+=== Chunk 2826 ===
+Source: 4105_002-ebook.pdf
+Length: 1212 chars
+
+22.5.2 Traction
+Traction can be applied to a limb by various means:
+• the weight of the body part itself;
+• adhesive taping applied to the skin; or
+• a pin through a bone.
+It is the optimal method for managing most femoral and humeral fractures, especially in the hands of the non-specialized surgeon. The technique is simple and safe with few complications, provided it is carefully supervised by the surgeon or a well-trained physiotherapist. The minimal invasiveness of traction permits resorting ...
+
+=== Chunk 2827 ===
+Source: 4105_002-ebook.pdf
+Length: 751 chars
+
+Figure 22.14.1
+Frame for unilateral skin traction of the femur made out of locally-available materials.
+Figure 22.14.2 Gallows traction from a beam.
+Skeletal traction is the best choice for:
+• initial immobilization of most femoral and some tibial and humeral fractures;
+• definitive immobilization of fractures of the femur;
+• definitive immobilization of particularly difficult fractures of the tibia near the knee and of the humerus near the elbow.
+Skeletal traction is the most suitable method of...
+
+=== Chunk 2828 ===
+Source: 4105_002-ebook.pdf
+Length: 528 chars
+
+Figure 22.15
+Traction for a femur fracture is applied through a tibial pin with the knee in almost full extension, which acts as a focus for the force applied by a weight. The position of the pin is such that the force is applied in a uniform direction along the axis of the limb irrespective of the position of the leg and is not affected by the position of the knee. The knee can therefore be flexed through 90° by removing the horizontal support under the leg while still in traction (see Figure 2...
+
+=== Chunk 2829 ===
+Source: 4105_002-ebook.pdf
+Length: 663 chars
+
+Figures 22.16.1 and 22.16.2
+Two patients undergoing treatment by skeletal traction with manufactured and improvised frames.
+124
+C
+2
+R
+C
+I
+/
+n
+i
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+a
+Stedmon / ICRC
+S
+.
+V
+.
+J
+The principal disadvantage of skeletal traction is prolonged confinement of the patient in bed, and the demands put on nursing care and physiotherapy. The main advantage is the rapidity of fracture consolidation.
+Application of the different traction techniques is described in Annex 22.B and in Plaster of Paris and Other Frac...
+
+=== Chunk 2830 ===
+Source: 4105_002-ebook.pdf
+Length: 720 chars
+
+22.5.3 External fixation
+The concept of external fixation is deceptively simple: a rigid frame mounted across the fracture site and attached to the bone with pins. However, it is a specialist technique and presents a number of practical difficulties and complications, especially delayed union or non-union and increased risk of infection. Many surgeons have improvised external fixators by using transfixion Steinmann pins embedded in a POP cast or bamboo external bars.
+In a resource-poor context, ...
+
+=== Chunk 2831 ===
+Source: 4105_002-ebook.pdf
+Length: 1602 chars
+
+At initial wound debridement
+In ICRC practice, the indications for application of an external fixator at initial wound debridement are restrictive and fall into several categories.
+Fixation due to significant soft-tissue injury.
+• Protection of an arterial anastomosis with an unstable fracture (e.g. fractured femur with concomitant injury of the femoral artery).
+• Fractures with extensive burns.
+2. Fixation due to the bony injury.
+• Extensive and unstable bone comminution, usually resulting in a...
+
+=== Chunk 2832 ===
+Source: 4105_002-ebook.pdf
+Length: 1014 chars
+
+At attempted DPC
+If wound closure by suture cannot be performed owing to an extensive injury that necessitates further surgical care, a posterior POP-slab or skeletal traction can be usefully replaced by an external fixator. Important examples are wounds that require:
+• skin grafting or a reconstructive flap for closure;
+• serial debridements in an effort to save the limb (see Section 10.8.2);
+• repeated debridements and sequestrectomies for an infected and unstable fracture, usually the case wi...
+
+=== Chunk 2833 ===
+Source: 4105_002-ebook.pdf
+Length: 191 chars
+
+Figure 22.17
+Patient with external fixation to allow for skin grafting of the wound.
+u
+o
+6
+C
+.
+R
+Remove the external fixator as soon as access to the soft tissue wound is no longer necessary....
+
+=== Chunk 2834 ===
+Source: 4105_002-ebook.pdf
+Length: 1105 chars
+
+Late indications
+Late indications for the application of external fixation are mostly limited to factors concerning the bone:
+• failure of conservative treatment (e.g. interposition of soft tissue at the fracture site of a femur in traction, a rare occurrence in ballistic wounds);
+• reduction and positioning for bone grafting;
+• operative arthrodesis;
+• limb lengthening – a very specialized technique.
+The application of an external fixator can be difficult and can lead to many complications when...
+
+=== Chunk 2835 ===
+Source: 4105_002-ebook.pdf
+Length: 1464 chars
+
+22.5.4 Damage-control orthopaedics
+In addition to the pathophysiological changes typically seen in patients treated by a damage-control approach, recent studies have shown that severe soft-tissue injury initiates its own deleterious systemic inflammatory response, especially in the presence of blood loss, ischaemia, necrosis and/or infection, and prolonged fracture manipulation. Consequently, in order to manage major fractures with extensive soft- tissue trauma, a “multi-stage” approach has been...
+
+=== Chunk 2836 ===
+Source: 4105_002-ebook.pdf
+Length: 685 chars
+
+22.5.5 internal fixation: osteosynthesis
+Internal fixation should never be used for initial bone immobilization in war wounds. Wherever resources are scarce and working conditions precarious, it should not be considered at any stage, because of the high risk of dangerous bone infection.7
+Several reports from the US army in Viet Nam and the Soviet army in Afghanistan demonstrated the very high infection rate (50 – 80 %) when internal fixation was used as a means of primary treatment. Its use was ...
+
+=== Chunk 2837 ===
+Source: 4105_002-ebook.pdf
+Length: 1272 chars
+
+Figure 22.18.1
+Figure 22.18.2
+Pus pours out of the wound; the plate and screws should be removed.
+Infected plate-and-screw fixation of a war wound replaced by external fixation during wound redebridement.
+In selected patients – whose wounds have healed fully without any occurrence of infection, who have been evacuated to a specialized centre with experienced surgeons and where the proper equipment and operative facilities and excellent nursing care are available – internal fixation for war wound...
+
+=== Chunk 2838 ===
+Source: 4105_002-ebook.pdf
+Length: 701 chars
+
+22.6 Wounds involving joints
+The knee and elbow are the most frequently injured major joints, after the hands and feet. Associated injury to the neurovascular bundle is often seen in the shoulder, elbow, hip and knee.
+Articular cartilage has no direct blood supply; its nutrition comes from the synovial fluid. An intact and well vascularized synovium is therefore essential for the survival of damaged cartilage.
+A GSW of a joint is usually obvious, while injury by small fragments can be difficult ...
+
+=== Chunk 2839 ===
+Source: 4105_002-ebook.pdf
+Length: 1847 chars
+
+22.6.1 Joint debridement
+The same principles of bone excision apply to penetrating joint injuries, with one exception: removal of the projectile is an essential part of the debridement. Small, unattached bone and cartilage fragments should also be removed while no effort should be spared to preserve the synovium, just as important as the periosteum in the case of long bones. It is best to operate on joints using a pneumatic tourniquet and with the limb draped in a way that permits mobilization o...
+
+=== Chunk 2840 ===
+Source: 4105_002-ebook.pdf
+Length: 1151 chars
+
+22.6.2 Wound closure
+In relatively minor injuries, a small entry hole and/or incision in the synovium should be sutured with an absorbable stitch, with or without the placement of a drain, preferably of the closed suction type. If this is not available, a closed system consisting of a catheter and sterile urine bag may be used. The drain should be removed within 24 hours. The joint capsule, ligaments and skin must be left open for DPC.
+If the synovium cannot be closed directly, the capsule or mu...
+
+=== Chunk 2841 ===
+Source: 4105_002-ebook.pdf
+Length: 648 chars
+
+22.6.3 Joint immobilization
+After initial debridement, most joints can be immobilized in the position of function using a well-fitting posterior-slab. Some injuries in the knee and most injuries in the hip require skeletal traction.
+At the second operation, if immobilization with POP is continued – whether a slab or a split cast – the joint should be mobilized cautiously, both passively and actively, after a week. Certain cases may best be treated by external fixation bridging the joint, or by a...
+
+=== Chunk 2842 ===
+Source: 4105_002-ebook.pdf
+Length: 727 chars
+
+22.6.4 infected joints
+If infection ensues, the joint must be re-operated. Dead tissue and debris are removed and the joint copiously irrigated and left open for drainage. The antibiotic coverage should be reviewed and, since cartilage imbibes the synovial fluid, the local instillation of antibiotics may prove useful, but not in the form of continuous irrigation. Old and neglected wounds of a joint with established infection should be treated in the same way. Control of infection can be difficul...
+
+=== Chunk 2843 ===
+Source: 4105_002-ebook.pdf
+Length: 396 chars
+
+22.6.5 Pelvi-abdominal injuries and the hip joint
+These injuries may involve the hip joint and cause contamination with intestinal contents or urine. After laparotomy, exploration of the joint through an anterior approach arthrotomy is called for. The joint is irrigated, debrided and drained, and skeletal traction applied. Attention must be paid to the vascular supply of the head of the femur....
+
+=== Chunk 2844 ===
+Source: 4105_002-ebook.pdf
+Length: 1172 chars
+
+22.6.6 Arthrodesis
+Normal limb function might be irretrievable following a serious wound of a joint because of instability or severe pain; surgical fusion is an effective way of countering both. The decision to perform arthrodesis is made only after complete healing of the
+128
+iNJURiEs TO bONEs AND JOiNTs
+soft tissues and consolidation of the remaining bone so that the full extent of tissue loss can be determined.
+The joint must be opened and any remaining cartilage cleaved off with an osteotome...
+
+=== Chunk 2845 ===
+Source: 4105_002-ebook.pdf
+Length: 746 chars
+
+22.6.7 Pseudo-arthrosis arthroplasty
+Once any infection has been controlled, and with proper facilities and expertise, a destroyed joint can be replaced with a prosthetic implant. Without such resources, the best that can be hoped for is a pseudo- arthrosis arthroplasty: a false joint that affords some movement. The entire joint is excised – bone and any excess cartilage – and raw bone ends opposed. No external fixation or traction is applied. Mobilization is started early so that a false joint ...
+
+=== Chunk 2846 ===
+Source: 4105_002-ebook.pdf
+Length: 457 chars
+
+22.7 Hand and foot injuries
+Hand and foot surgery is a subspecialty of orthopaedic surgery and many of the usual techniques are not relevant to war injuries treated by a general surgeon. Nonetheless, patience and time taken for meticulous debridement frequently give good functional results, better than is often expected. Wounds of the feet caused by anti-personnel mines in particular can be very difficult to manage; amputation must often be resorted to....
+
+=== Chunk 2847 ===
+Source: 4105_002-ebook.pdf
+Length: 613 chars
+
+22.7.1 Examination
+Injuries to the hands and feet are common in cases of multiple wounds but are often the last to receive attention; other conditions threatening the life of the patient or major fractures take precedence.
+When the time comes for dealing with the hand or foot, examination should not be hurried. Proper assessment of the many complex structures demands patience. Thorough examination should be performed for finger or toe movement and sensation. The presence of soft-tissue damage, i...
+
+=== Chunk 2848 ===
+Source: 4105_002-ebook.pdf
+Length: 1107 chars
+
+22.7.2 surgical exploration and debridement
+Wound exploration should be performed under adequate anaesthesia, with tourniquet control, and only in the theatre; a minor-looking wound can hide damage to important deep-seated structures. The wound should be thoroughly scrubbed with soap and water and a brush to remove in-driven dirt and debris and then irrigated with saline to clear the operative field.
+Figure 22.20.1
+Gunshot wound of the hand with near total destruction of the second metacarpal.
+S...
+
+=== Chunk 2849 ===
+Source: 4105_002-ebook.pdf
+Length: 3039 chars
+
+Figure 22.20.3
+Clean and granulating wound; however, the index finger is non-functional due to loss of bone (see-through hole) and the tendons.
+130
+and return the patient to theatre after 48 hours (see Section 10.8.2). The attempt to preserve delicate structures and function requires time and therefore depends on the hospital workload. A massive influx of casualties does not allow for such individualized and time-consuming treatment.
+The hands and feet contain relatively little soft tissue but t...
+
+=== Chunk 2850 ===
+Source: 4105_002-ebook.pdf
+Length: 534 chars
+
+22.7.3 immobilization
+The hand or foot should be kept elevated and the joints splinted with a POP slab. The ankle should be maintained at 90° of dorsiflexion.
+The presence of open wounds in the hand does not prevent immobilization in the “safe position” and a bulky dressing fitted into the palm can help maintain it (see Figure 15.13). Unaffected digits should be left free to move, unless used to “buddy- splint” an isolated injured finger. The tips of all the digits must be left exposed to monito...
+
+=== Chunk 2851 ===
+Source: 4105_002-ebook.pdf
+Length: 388 chars
+
+22.7.4 Delayed primary closure
+Delayed primary closure of wounds in the feet is performed after 5 days, but for the hands already after 3 – 4 days. Often, the extent of skin loss is such that skin grafting is required. To reduce the disability of graft contraction, a full thickness skin graft or fascio-cutaneous pedicle should be used on palmar and plantar surfaces.
+C
+R
+C
+I
+/
+i
+t
+t
+i
+c...
+
+=== Chunk 2852 ===
+Source: 4105_002-ebook.pdf
+Length: 487 chars
+
+Figures 22.21.1 and 22.21.2
+Reconstruction of the soft tissues of the hand using a fascio-cutaneous pedicle from the abdominal wall.
+a
+P
+.
+C
+The hand and foot are the exceptions to the rule concerning internal fixation: Kirschner wires should be used for immobilization of the metacarpals, metatarsals or phalanges at debridement, or to bridge a gap while awaiting bone grafting. The hand should be supported in a cock-up splint or cast for 2 weeks and then vigorous physiotherapy begun....
+
+=== Chunk 2853 ===
+Source: 4105_002-ebook.pdf
+Length: 1100 chars
+
+22.8 Problematic cases
+When working in resource-poor settings, surgeons are often faced with wounds that are weeks or even months old. As a result, complications are common. The major problems encountered are malunion, non-union, chronically exposed bone and osteomyelitis.
+Many of the techniques required to deal with these problems belong to specialized areas of orthopaedic and reconstructive surgery and even sophisticated and specialist procedures often fail and result in a worse situation. Onl...
+
+=== Chunk 2854 ===
+Source: 4105_002-ebook.pdf
+Length: 192 chars
+
+Figure 22.22
+Tibio-fibular synostosis following a gunshot wound of the tibia. The fibula blocks any movement at the site of the non-union of the tibia. The functional result is acceptable.
+132...
+
+=== Chunk 2855 ===
+Source: 4105_002-ebook.pdf
+Length: 468 chars
+
+22.8.1 malunion
+Most cases of malunion can be prevented by correct reduction of the fracture, whatever method of bone holding is chosen. Some old fractures present with well- established malunion. The question is whether to accept the degree of deformity present or to attempt a correction.
+Correction of a malunion involves refracturing of the bone and sometimes requires a bone graft as well. External fixation may be needed for proper alignment of the new fracture....
+
+=== Chunk 2856 ===
+Source: 4105_002-ebook.pdf
+Length: 225 chars
+
+22.8.2 Non-union
+Non-union of fractures is common. Infection is a major cause, resulting from inadequate surgery or neglect as seen in old untreated wounds, and must be brought under control before anything else is attempted....
+
+=== Chunk 2857 ===
+Source: 4105_002-ebook.pdf
+Length: 502 chars
+
+Preventable causes
+Soft-tissue interposition may occur between fracture ends; in fresh cases, the wound should be explored and the fracture reduced.
+Traction may have been too strong and the bone ends distracted; this should have been prevented by proper monitoring and correction of the traction weight.
+External fixation is often very rigid and, as a result, delayed union and non-union are common. Conversion to a POP cast with weight-bearing mobilization is a simple and often successful techniqu...
+
+=== Chunk 2858 ===
+Source: 4105_002-ebook.pdf
+Length: 308 chars
+
+Non-preventable causes
+Extensive bone defect due to the original injury and debridement is the major non- preventable cause. Large bone gaps can fill in if a sufficient periosteal sleeve remains and the patient is well fed; malnutrition is common in patients with old, neglected wounds and must be corrected....
+
+=== Chunk 2859 ===
+Source: 4105_002-ebook.pdf
+Length: 685 chars
+
+Management
+No radiological evidence of union after three months in the lower limb and two months in the upper, or less than 50 % union after six months all qualify as delayed union and call for freshening of the fracture site and insertion of a bone graft.
+In most cases, external fixation is required to maintain alignment for bone grafting. To give the graft the best chance of “taking”, the wound should be clean with a good local blood supply, and free of haematoma accumulation. In ideal circums...
+
+=== Chunk 2860 ===
+Source: 4105_002-ebook.pdf
+Length: 715 chars
+
+22.8.3 Chronically exposed bone
+The bone often remains exposed in war wounds, particularly if infection supervenes. The most common and problematic example involves the tibia; common because of its subcutaneous nature and problematic because of its vascular supply and the frequent loss of a considerable surface area of periosteum. The patient usually presents with an unhealed fracture and a draining wound; or an exposed dry bone with necrotic periosteum and sequestra.
+First and foremost, it is t...
+
+=== Chunk 2861 ===
+Source: 4105_002-ebook.pdf
+Length: 2117 chars
+
+22.9 bone infection
+Bone infection complicating fractures is a common problem. War wounds with fractures become infected because they present late, are mismanaged, or because inadequate surgery leaves dead bone in the wound after debridement. Basic principles apply, especially concerning the use of antibiotics. The general topic of neglected or mismanaged wounds and the role of biofilm in chronic infection are dealt with in Chapter 12. The difficulty of controlling chronic post-traumatic infecti...
+
+=== Chunk 2862 ===
+Source: 4105_002-ebook.pdf
+Length: 893 chars
+
+22.9.1 Definitions and surgical decision-making
+The definition of surgical infection has always been ambiguous, especially in the case of bone. While pus, wound breakdown, a fistula and sinus are obvious, consensus on the spectrum of the infective process has been difficult to reach.12 Bone culture alone does not help.13 The surgeon must also consider local and systemic signs (redness, swelling, local temperature and fever), laboratory markers of infection (ESR, WBC and CRP), and radiographic si...
+
+=== Chunk 2863 ===
+Source: 4105_002-ebook.pdf
+Length: 922 chars
+
+22.9.2 Wound management
+Surgery is essential to remove all foreign material and dead tissue, including devascularized bone, and to disrupt the biofilm of chronic infection. Antibiotics alone do not eradicate bone infection. Recurrence of infection after initial surgery usually means the presence of a sequestrum. In addition, immobilization is important. External fixation is often the best choice as it allows access for repeated sequestrectomies and wound care.
+Patients who present with infected ...
+
+=== Chunk 2864 ===
+Source: 4105_002-ebook.pdf
+Length: 977 chars
+
+22.9.3 surgical treatment
+As mentioned, this manual makes a distinction between two clinical presentations.
+• Early bone infection in neglected or mismanaged wounds or following the failure of initial debridement for which the patient must undergo several re-excisions is dealt with in Section 12.3.
+• Chronic bone infection may present weeks, months or even years after injury and often even after apparently successful treatment: i.e. true chronic osteomyelitis. This usually presents as consolidat...
+
+=== Chunk 2865 ===
+Source: 4105_002-ebook.pdf
+Length: 109 chars
+
+Figure 22.23
+Old GSW of the tibia; a chronic sinus has opened and closed and is now “pointing”.
+i
+n
+a
+l
+P
+.
+F...
+
+=== Chunk 2866 ===
+Source: 4105_002-ebook.pdf
+Length: 534 chars
+
+22.9.4 Preparing the patient
+In low-income countries, patients with a chronically discharging sinus are often malnourished. The haemoglobin must be checked and the nutritional status corrected. An antihelminthic may be indicated in addition to a high protein diet and iron and vitamin supplements. Patient hygiene is important and the burden of potentially pathogenic commensal organisms should be reduced: besides general showering, the skin of the affected limb should also be scrubbed clean with c...
+
+=== Chunk 2867 ===
+Source: 4105_002-ebook.pdf
+Length: 334 chars
+
+22.9.5 Radiography
+Appropriate X-rays of the affected bone in two planes are essential; stereotactic localization employing radio-opaque markers is very useful in the absence of sophisticated radiography (see Section 14.4). A sinugram helps outline the cavity that contains the sequestrum properly. The sinus can be surprisingly long....
+
+=== Chunk 2868 ===
+Source: 4105_002-ebook.pdf
+Length: 284 chars
+
+Performing a sinugram
+The surgeon must perform the sinugram in person and in cooperation with the X-ray technician. The equipment is simple: standard X-ray cassettes and lead aprons; 50 % diluted solution of urological contrast medium; a Foley catheter (CH 8 or 10); and two syringes....
+
+=== Chunk 2869 ===
+Source: 4105_002-ebook.pdf
+Length: 1165 chars
+
+Figure 22.24
+Patient X: a sinugram showed that the sinus was associated with a cavity containing a sequestrum.
+1. The patient and X-ray cassette are positioned and the radiographer sets the exposure appropriately. Once the contrast medium is injected, there may not be time to make adjustments.
+2. The surgeon wipes the wound clean and inserts the Foley catheter into the sinus for a few centimetres. The balloon is inflated slightly in the tight confines of the sinus to prevent back-flow of contras...
+
+=== Chunk 2870 ===
+Source: 4105_002-ebook.pdf
+Length: 404 chars
+
+22.9.6 Excision of the sinus
+Sequestrectomy cannot be achieved by simply scraping the sinus with a curette. The piece of dead bone in the depths must be found and removed; the operation should be planned according to the sinugram. The sinus is often very small; to explore the wound properly may involve making a partially healed wound bigger. A secondary
+135
+C
+&
+R
+C
+I
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+y
+zB 3
+e
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+.
+D
+WAR SURGERY...
+
+=== Chunk 2871 ===
+Source: 4105_002-ebook.pdf
+Length: 956 chars
+
+Figures 22.25.1 and 22.25.2
+Patient Y: methylene blue has been injected into a sinus and has stained the target sequestrum in the metatarsal.
+136
+incision through healthy tissue may be necessary to reach and remove all the sequestra. The procedure may have to be repeated until all dead bone is removed.
+The operation is best performed under a pneumatic tourniquet. The injection of methylene blue into the sinus assists in the identification of the tract and the surgeon should make a mental note of...
+
+=== Chunk 2872 ===
+Source: 4105_002-ebook.pdf
+Length: 333 chars
+
+Figure 22.25.3
+Figure 22.25.4
+Patient X: the sinus tract has been excised and the bone fragment removed.
+Patient X: resolution of the infection and consolidation of the fracture has followed.
+The wound should be left open to granulate and subsequently accept a skin graft, or be allowed to close spontaneously by secondary intention....
+
+=== Chunk 2873 ===
+Source: 4105_002-ebook.pdf
+Length: 828 chars
+
+22.9.7 Dressing the wound and follow-up
+The ideal ward dressing for a deep cavity left after excision of a sinus is cheap, non-toxic, antibacterial and easy to apply. A daily sugar dressing after rinsing with saline fulfils these criteria; honey is even better, but more expensive and not always available. This method effectively cleans wounds and promotes the formation of granulation tissue.
+iNJURiEs TO bONEs AND JOiNTs
+When the exudate has stopped, a simple dry dressing changed every 3 – 4 days...
+
+=== Chunk 2874 ===
+Source: 4105_002-ebook.pdf
+Length: 232 chars
+
+22.10 bone grafting
+As with soft-tissue reconstruction, there are simple basic techniques for bone grafting that are well within the competency of a general surgeon, and other more specialized ones that should be left to the expert....
+
+=== Chunk 2875 ===
+Source: 4105_002-ebook.pdf
+Length: 1614 chars
+
+22.10.1 indications for bone grafting
+1. Non-union and primary bone defects.
+Some Type C and most Type D bone defects, according to the RCWS, require a graft. This is just as true for the metacarpals as for the tibia or femur, in order to regain as good a function as possible.
+Timing is important. For Type D defects, the requirement for a bone graft is usually obvious from the very beginning and can be performed as soon as the soft-tissue wound is well healed. In cases of non-union, the need for...
+
+=== Chunk 2876 ===
+Source: 4105_002-ebook.pdf
+Length: 787 chars
+
+22.10.2 Donor site and types of bone graft
+The donor site from which cancellous bone chips are harvested will usually be the iliac crest on the same side as the injured bone. Cancellous bone stimulates bone formation: it is both osteo-conductive (the acellular matrix serves as a scaffold for new bone deposition) and osteo-inductive (cells and substrates carry and produce chemicals such as growth factors that stimulate bone formation). Cortical bone does not have the same properties.
+Cortical gra...
+
+=== Chunk 2877 ===
+Source: 4105_002-ebook.pdf
+Length: 797 chars
+
+22.10.3 Follow-up of bone grafting
+Once the graft has been placed, the patient should be gradually mobilized with increasing weight-bearing to stimulate callus formation.
+An X-ray taken soon after grafting gives a better baseline of bone radiodensity than pre-operative films. A successful “take” of the graft shows no radiographic change for the first two weeks; it then becomes increasingly dense. Resorption or infection of the graft, on the contrary, is revealed by loss of radiodensity.
+The time...
+
+=== Chunk 2878 ===
+Source: 4105_002-ebook.pdf
+Length: 612 chars
+
+22.10.4 Complications of bone grafting
+There are a number of complications related to bone grafting; infection is the most common. When pure cancellous bone grafts become infected, they simply dissolve. Cortical bone grafts, on the other hand, can become the nidus of later infection and require active removal.
+If donor site infection is suspected, the surgeon should not hesitate to open the wound, wash it thoroughly and leave it open to heal by granulation. Haemorrhage and haematoma formation at...
+
+=== Chunk 2879 ===
+Source: 4105_002-ebook.pdf
+Length: 798 chars
+
+ANNEX 22. A Plaster-of-Paris
+Plaster-of-Paris is calcium-sulphate hemihydrate, produced by heating gypsum, the common name for sulphate of lime. Bone immobilization techniques using plaster-of- Paris are simple, effective, inexpensive and versatile. Certain basic rules and conditions must be respected and, like all manual techniques, require practice and close attention to detail. POP is particularly suited to surgeons working where resources are scarce.
+The reader is referred to standard textbo...
+
+=== Chunk 2880 ===
+Source: 4105_002-ebook.pdf
+Length: 1428 chars
+
+General principles
+In general, a POP splint or cast should include the joints above and below the fracture site, which should be immobilized in their functional position. For the lower limb, the knee is flexed to 15° and the ankle kept at 90°. In the arm, the elbow is kept at slightly more than 90° of flexion and the hand should be immobilized in the safe (functional) position. The unaffected fingers and toes should be kept free to allow a full range of movement of metatarso-phalangeal, metacarp...
+
+=== Chunk 2881 ===
+Source: 4105_002-ebook.pdf
+Length: 863 chars
+
+22.A.a Equipment
+The basic materials and tools needed to perform satisfactory POP techniques are simple, easily acquired, and undemanding to maintain.
+T.Gassmann /ICRC
+T.Gassmann /ICRC
+T
+T
+Figure 22.A.1 Plaster shears.
+Figure 22.A.2 Cast spreader.
+T.Gassmann /ICRC
+T.Gassmann /ICRC
+T
+T
+Figure 22.A.3 Figure 22.A.4 Cast breaker. Oscillating saw.
+Cast breaker.
+1. Plaster-of-Paris bandages come in several standard widths: 2.5, 10, 15 and 20 cm. They should be kept in airtight containers because plast...
+
+=== Chunk 2882 ===
+Source: 4105_002-ebook.pdf
+Length: 1986 chars
+
+Figure 22.A.5
+Materials: four 15 cm rolls of plaster; stockinet or cotton padding; and gauze or elastic bandages. Two slabs – each eight layers of plaster thick – are prepared. The length of the slabs is measured on the patient’s good limb, from the tip of the toes to just below the greater trochanter.
+140
+3. Plaster wool, also known as cellulose padding, or unbleached cotton wool (10 and 15 cm widths).
+4. Adhesive and non-adhesive orthopaedic felt.
+5. Kramer wire splints or strips of wood or me...
+
+=== Chunk 2883 ===
+Source: 4105_002-ebook.pdf
+Length: 1104 chars
+
+22.A.b initial temporary immobilization
+A POP splint is most useful as the initial temporary holding method after wound excision. In the upper limb, it can be applied for fractures of the forearm and hand and, when combined with a sling, for some cases of the humerus. In the lower limb, it can be used for the tibia and the foot. The only long bone not suitable for plaster splinting is the femur.
+The application of a POP posterior splint for the tibia is described here; the same principles and ba...
+
+=== Chunk 2884 ===
+Source: 4105_002-ebook.pdf
+Length: 271 chars
+
+Figure 22.A.8
+The first wetted plaster slab is applied so that it encloses the fifth toe and lateral border of the foot, passes posteriorly over the heel and is moulded over the calf. It continues behind the knee to end on the medial aspect of the thigh.
+Rowley /ICRC
+.
+D...
+
+=== Chunk 2885 ===
+Source: 4105_002-ebook.pdf
+Length: 392 chars
+
+Figure 22.A.10
+The second slab is applied in the same fashion, but starting over the first toe and medial border of the foot, crossing over the first slab in the popliteal fossa, and finishing on the lateral aspect of the thigh. The figure- of-eight or X-crossing of the two slabs in the popliteal fossa is the key to giving this lightweight posterior splint its strength.
+Rowley / ICRC
+R
+.
+D...
+
+=== Chunk 2886 ===
+Source: 4105_002-ebook.pdf
+Length: 193 chars
+
+Figure 22.A.12
+Gauze or elastic bandage is gently but firmly applied to keep the slabs in position; it should not be too restrictive.
+iNJURiEs TO bONEs AND JOiNTs
+Rowley / ICRC
+it a : F a
+R
+.
+D...
+
+=== Chunk 2887 ===
+Source: 4105_002-ebook.pdf
+Length: 410 chars
+
+Figure 22.A.7
+Padding is applied over the stockinet to pressure points at risk: the malleoli, heel, patella and head of the fibula.
+C
+D.Rowley/ ICRC
+R
+C
+I
+/
+y
+e
+l
+w
+o
+R
+.
+D
+Figure 22.A.9 The slab should take the configuration shown.
+Rowley / ICRC
+R
+.
+D
+Figure 22.A.11
+Any excess plaster is trimmed; simply folding it back results in an uncomfortable, lumpy cast.
+C
+R
+§
+C
+I
+/
+y
+= é
+e
+l
+w
+o
+R
+\\\ Ati i\) i x
+.
+D...
+
+=== Chunk 2888 ===
+Source: 4105_002-ebook.pdf
+Length: 613 chars
+
+Figure 22.A.13
+The back slab is held until the plaster has set with the knee flexed to 15° to prevent rotation: the easiest way to ensure this is by placing a one-litre plastic bag of i.v. fluid under the knee. The ankle joint is immobilized in the neutral position: 90° to the axis of the tibia to avoid plantar flexion. The finished edges should be smooth and not dig into the skin. The limb and finished back slab are raised on a pillow. A POP-calendar is written on the bandaging with a felt mark...
+
+=== Chunk 2889 ===
+Source: 4105_002-ebook.pdf
+Length: 198 chars
+
+Initial splinting of specific fractures
+Similar slabs are employed for other bones. The reader is referred to standard orthopaedic texts for the details.
+C
+g
+R
+C
+I
+/
+n
+o
+m
+d
+2
+e
+t
+S
+.
+J
+C
+ICRC
+R
+C
+I...
+
+=== Chunk 2890 ===
+Source: 4105_002-ebook.pdf
+Length: 465 chars
+
+Figure 22.A.15
+Long arm slab for fractures around the elbow joint or of both bones of the forearm: elbow in slightly greater than 90° flexion, forearm in neutral pronation-supination, wrist flexed depending on level of fracture.
+Forearm slab for fractures of one bone in the forearm, or for the wrist or hand. Injured fingers should be included in the splint in the “safe position” (Figure 15.13). Unaffected fingers are left free to allow a full range of movement....
+
+=== Chunk 2891 ===
+Source: 4105_002-ebook.pdf
+Length: 1499 chars
+
+22.A.c Definitive immobilization
+After DPC, the limb can continue to be immobilized with a POP splint if oedema is still present or visual inspection of the wound is required. If the splint is retained, it can be taken down after 10 days for suture removal and replaced with a cylindrical cast.
+The use of POP for definitive fracture stabilization entails the use of a cylindrical cast, bridge cast, or spica. This definitive cast requires no more padding than absolutely necessary, namely to protect...
+
+=== Chunk 2892 ===
+Source: 4105_002-ebook.pdf
+Length: 1423 chars
+
+Methods of definitive POP immobilization
+A complete cylindrical cast or spica (not always easy to make) can be applied to both the upper and lower limbs. Other modifications can also be usefully employed.
+• Foot: boot-cast.
+• Tibia: full-length leg cast from the gluteal crease to the toes.
+• Tibia: Sarmiento patella-tendon-bearing (PTB) cast – a special type of walking cast.
+• Femur: “Chinese splints” (two non-overlapping POP slabs held in place by an elastic bandage) or a functional brace with ...
+
+=== Chunk 2893 ===
+Source: 4105_002-ebook.pdf
+Length: 234 chars
+
+Figure 22.A.16
+• Hand or the forearm: especially if only one bone is fractured.
+Shoulder or thoraco-brachial spica: shoulder in abduction, flexion and slight external rotation; elbow in 90° flexion; forearm in full supination.
+C
+R
+C
+I...
+
+=== Chunk 2894 ===
+Source: 4105_002-ebook.pdf
+Length: 369 chars
+
+Figure 22.A.17
+Application of a hip spica on a locally-made table using a bicycle seat and aluminium tubing.
+C
+2
+R
+C
+I
+/
+a
+5S 8g
+t
+o
+g
+N
+o
+b
+m
+a
+i
+h
+3
+d
+O
+2 &
+s 8 5S 2 8g 5 3 6 a
+D. Odhiambo Ngota / ICRC
+.
+D
+Figure 22.A.18 Locally-made spica table.
+Figures 22.A.19 and 22.A.20
+Hip spica: hip in 30° flexion, 10° abduction and 10° external rotation; knee in 15° flexion....
+
+=== Chunk 2895 ===
+Source: 4105_002-ebook.pdf
+Length: 599 chars
+
+22.A.d Tibia: sarmiento tibial cast 15
+Casting of the tibia is by means of either a long leg cast, from the groin to the toes, or the Sarmiento patella-tendon-bearing cast. Rather than the immediate application of a Sarmiento PTB-cast, a long-leg cast can be applied for the first two weeks and then replaced with a Sarmiento cast, which is preferred because it permits knee movement.
+The Sarmiento PTB-cast is moulded around the patellar tendon, distal patella and upper third of the tibia, where it...
+
+=== Chunk 2896 ===
+Source: 4105_002-ebook.pdf
+Length: 394 chars
+
+Figure 22.A.21
+Materials: five 15 or 20 cm and two 10 cm plaster bandages; two rolls of padding and stockinet.
+15 Dr Augusto Sarmiento, orthopaedic surgeon at the University of Miami School of Medicine, has specialized in fracture healing by non-operative methods and functional fracture bracing.
+143
+C
+Nasreddine / ICRC
+N
+.
+H
+C
+e
+R
+C
+I
+/
+n
+n
+a
+m
+s
+s
+a
+8
+G
+.
+T
+WAR SURGERY
+C
+Rowley / ICRC
+R
+.
+D...
+
+=== Chunk 2897 ===
+Source: 4105_002-ebook.pdf
+Length: 274 chars
+
+Figure 22.A.22
+The patient sits on the end of the bed with the leg hanging vertically, the foot not touching the floor, thus allowing gravity to align the bones and relaxing the quadriceps muscle. Stockinet is put on from the toes to 15 cm above the knee.
+C
+Rowley /ICRC
+.
+D...
+
+=== Chunk 2898 ===
+Source: 4105_002-ebook.pdf
+Length: 296 chars
+
+Figure 22.A.25
+The upper third of the central part is moulded around the tibia in front and indented by both thumbs into both sides of the patellar tendon. It is flattened at the back in the popliteal fossa.
+Figure 22.A.28 The plaster is allowed to set.
+144
+C
+Rowley / ICRC
+R
+.
+D
+D. Rowley / ICRC...
+
+=== Chunk 2899 ===
+Source: 4105_002-ebook.pdf
+Length: 268 chars
+
+Figure 22.A.24
+The stockinet is covered with padding, paying special attention to the vulnerable bony pressure points.
+The central part of the cast over the tibia is fashioned first by applying two 15 or 20 cm plaster bandages.
+C
+Rowley / ICRC
+R
+C
+Rowley /ICRC
+.
+.
+D
+D...
+
+=== Chunk 2900 ===
+Source: 4105_002-ebook.pdf
+Length: 703 chars
+
+Figure 22.A.27
+The cast is left to set enough to retain the moulded shape with the ankle kept at 90° flexion. The two 10 cm plaster bandages are then applied up to the superior pole of the patella and moulded over it.
+While the plaster is still wet, the stockinet is turned down so the patella remains covered. The plaster in the popliteal fossa is trimmed to two finger- breadths below the level of the popliteal flexion crease, low enough to allow 90° of knee flexion without the edge of the cast r...
+
+=== Chunk 2901 ===
+Source: 4105_002-ebook.pdf
+Length: 223 chars
+
+Figure 22.A.31
+The sole is reinforced; a rubber walking-heel may be added.
+The finished Sarmiento PTB-cast seen from the front.
+The finished cast seen from the side. The knee should flex to 90° and fully extend.
+Papas /ICRC...
+
+=== Chunk 2902 ===
+Source: 4105_002-ebook.pdf
+Length: 158 chars
+
+Figure 22.A.32
+Principle of the Sarmiento PTB short leg cast: the knee can be fully flexed and extended while the cast provides good support to the tibia.
+.
+N...
+
+=== Chunk 2903 ===
+Source: 4105_002-ebook.pdf
+Length: 343 chars
+
+22.A.e Post-traction support of the femur
+Many patients who have undergone skeletal traction as a definitive holding method for fracture of the femur require no further support once they are out of bed and moving on crutches. Some, however, do better with the physical and psychological support provided by “Chinese splints” or a hinged brace....
+
+=== Chunk 2904 ===
+Source: 4105_002-ebook.pdf
+Length: 613 chars
+
+“Chinese splints”
+‘‘Chinese splints’’ – named after traditional bamboo splints – offer the simplest method (Figures 22.A.33 and 22.A.34). Two straightforward plaster shells which do not overlap are held onto the leg by bandages. The circumferential hydrostatic pressure provides comfort and soft-tissue support, and a small degree of positional control. They also give useful proprioceptive feedback to the contracting muscles during exercise, thus making physiotherapy more effective. The “Chinese s...
+
+=== Chunk 2905 ===
+Source: 4105_002-ebook.pdf
+Length: 330 chars
+
+Figure 22.A.33
+Two simple slabs are moulded to the thigh while the plaster is setting.
+146
+aX
+C
+Rowley /ICRC
+R
+C
+R
+C
+I
+/
+a
+t
+o
+g
+2 8
+N
+o
+b
+m
+a
+j
+h
+d
+6
+O
+.
+.
+D
+D
+Figure 22.A.34 The slabs are held in place by bandaging.
+Figure 22.A.35
+Locally-made knee hinges join a simple below-knee POP cylinder to a thigh cylinder. See Appendix....
+
+=== Chunk 2906 ===
+Source: 4105_002-ebook.pdf
+Length: 748 chars
+
+Femoral hinged brace
+The alternative is a femoral cast brace with hinges at the knee. The bi-pivotal hinge permits normal movement of the knee, controls rotation and angulation of the fracture, and provides vertical support.
+There are two components to a femoral brace: 2 circular casts and 2 hinges. A standard below-knee walking cast and a well-moulded plaster thigh piece are fashioned and then connected by means of hinges, medially and laterally. The moulding of the plaster to the soft tissues ...
+
+=== Chunk 2907 ===
+Source: 4105_002-ebook.pdf
+Length: 1023 chars
+
+22.A.f Definitive immobilization with an open wound
+A complete cylindrical cast may be applied before the wound has fully healed. For small wounds some surgeons cut a window in the POP to allow for dressings (Figure 22.A.36). However, the soft tissues tend to bulge out and rub on the edges of the window creating “window oedema”. To prevent this, it is best to overdress the wound under the cast so it bulges out above the level of the rest of the cast, then cut the window so that it is tangential,...
+
+=== Chunk 2908 ===
+Source: 4105_002-ebook.pdf
+Length: 182 chars
+
+Figure 22.A.36
+A below-knee cast with windows cut out so that wounds can be dressed. Note the “window oedema”. The size of the wounds does not justify the creation of a window.
+R
+.
+D...
+
+=== Chunk 2909 ===
+Source: 4105_002-ebook.pdf
+Length: 869 chars
+
+Tibia bridge-cast
+A variation of a cylindrical cast is a bridge-cast, which allows access to the wound while maintaining bone immobilization: a low-technology alternative to external fixation for the tibia. It is most useful for the tibia, but can also be used for the humerus or elbow joint.
+1. One circular plaster cast is applied to the lightly-padded thigh, knee and leg to just above the wound with the knee at 15° of flexion.
+2. A second circular cast is applied from just below the wound down ...
+
+=== Chunk 2910 ===
+Source: 4105_002-ebook.pdf
+Length: 425 chars
+
+Figure 22.A.37
+C
+Papas/ ICRC
+P
+b
+Constructing a bridge-cast: a. upper cast placed first; b. lower cast placed second.
+.
+N
+An ICRC physiotherapist, Fernando Vega, developed a sliding-sleeve mechanism as a bridging piece that can be manufactured locally. The sliding sleeve allows for distraction or compression or slight alteration of the fracture site and is locked in place with a simple nut and bolt.
+C
+IcRC
+R
+C
+I — — ——=,....
+
+=== Chunk 2911 ===
+Source: 4105_002-ebook.pdf
+Length: 95 chars
+
+Figure 22.A.38
+A Vega bridge-piece can be manufactured locally. See Appendix.
+I
+147
+WAR SURGERY...
+
+=== Chunk 2912 ===
+Source: 4105_002-ebook.pdf
+Length: 326 chars
+
+Figures 22.A.39 and 22.A.40
+Bridge-cast applied to the leg with a wound that still requires change of dressings and skin grafting.
+148
+C
+R
+C
+¥
+R
+C
+I
+/
+g
+e
+n
+o
+m
+i
+S
+8
+e
+D
+C
+I
+.
+F
+C
+Irmay / ICRC
+C
+I
+R
+.
+F
+C
+I
+Figure 22.A.41 Patient walking with a Vega bridge-cast.
+Figure 22.A.42 Radiograph showing a Vega bridge-cast in place....
+
+=== Chunk 2913 ===
+Source: 4105_002-ebook.pdf
+Length: 2241 chars
+
+22.A.g managing patients in POP
+Initially, any limb immobilized in POP should be elevated when the patient is sitting or lying down and the state of the limb carefully monitored to detect compromise of the distal circulation that might lead to compartment syndrome and ischaemia (see Section B.10). Even a dressing stiff with dried blood may be sufficient to restrict the circulation. Any complaint of pain or numbness should be taken seriously and any suspicion of circulatory problems requires imme...
+
+=== Chunk 2914 ===
+Source: 4105_002-ebook.pdf
+Length: 362 chars
+
+‘‘Plaster disease’’
+The application of a plaster cast with the joints immobilized invariably results in joint stiffness, muscle wasting and osteoporosis. Isometric exercises while wearing the cast, early weight-bearing and the use of functional braces, and post-removal physiotherapy reduce these phenomena to a minimum and promote a rapid retrieval of function....
+
+=== Chunk 2915 ===
+Source: 4105_002-ebook.pdf
+Length: 519 chars
+
+Malunion and non-union
+Whatever the treatment, some incidence of malunion and non-union invariably occurs because of the type of fracture, or host factors (smoking, medication, infection, etc.). Apart from that, they never result from the proper use of a POP cast but can be due to poor technique. Malunion is caused by inadequate reduction of the fracture. Non- union is due to excessive movement at the fracture site because of too much padding, an insufficient quantity of plaster bandages, or poo...
+
+=== Chunk 2916 ===
+Source: 4105_002-ebook.pdf
+Length: 1226 chars
+
+Skin problems
+Patient hygiene is an important consideration and the presence of a splint or cast prevents washing. The skin under the plaster becomes dry and scaly since shed epithelium cannot be washed off and may become a focus for dermatitis, maceration of the skin, rash and infection. Thorough washing of the limb prior to wound excision and again before application of a cast can diminish if not entirely prevent skin problems. Patients discharged wearing a cast and managed on an outpatient ba...
+
+=== Chunk 2917 ===
+Source: 4105_002-ebook.pdf
+Length: 1732 chars
+
+APPENDIX
+These items may be manufactured locally or ordered from an ICRC operational delegation in a country which is the scene of an armed conflict.
+m  c     2  2 cm  2.5 cm  A  6 cm  1.5 cm  m  c     3  40°  140°  5.5 cm  6 cm  All measurements remain the same except for A, which may be 4, 6, 8 or 10 cm,   depending on the height of the patient.
+C
+R
+C
+I
+/
+a
+t
+o
+g
+N
+o
+b
+m
+a
+i
+h
+d
+O
+.
+D
+Figure 22.A.43
+Polycentric joint for a knee hinge.
+2 cm  m  m     0  1  5 mm  m  c     2  50°  130°  2 cm  10 ...
+
+=== Chunk 2918 ===
+Source: 4105_002-ebook.pdf
+Length: 617 chars
+
+ANNEX 22. b Traction
+Traction is an ancient technique: a simple sling has been used for fractures of the humerus since time immemorial. Skin traction by means of a Thomas splint was the standard care for fractures of the femur during World War I. Skeletal traction proved to be the safest and simplest method for mass treatment of femur fractures in World War II. A noted advantage was that the technique was readily mastered by the extra-medical personnel recruited to serve and who had had no previ...
+
+=== Chunk 2919 ===
+Source: 4105_002-ebook.pdf
+Length: 382 chars
+
+22.b.a biomechanical principles of traction
+The basis for traction treatment lies in the concept of ligamentotaxis. The limb can be visualized as a cylinder of soft tissues pulled and elongated by the traction force, which then pulls and moulds the bone fragments into place until callus has formed and is sticky enough to maintain length.
+n
+Gosselin.
+i
+l
+e
+s
+s
+o
+G
+ZRWRD
+Tt fl \l ¥...
+
+=== Chunk 2920 ===
+Source: 4105_002-ebook.pdf
+Length: 636 chars
+
+Figure 22.B.1
+Ligamentotaxis: the leg can be compared to a balloon with solid fragments in it. Pulling the balloon by traction moulds the fragments into place.
+.
+R
+Ligamentotaxis: traction applies a force to the soft tissue of the limb, not to the bone.
+The elongating force opposes the tone in the muscles surrounding the fracture site, thus enabling the bone fragments to be slowly pulled into alignment as the muscle tone is overcome. The elongating force may be applied either via a physiological...
+
+=== Chunk 2921 ===
+Source: 4105_002-ebook.pdf
+Length: 982 chars
+
+Physiological traction
+Physiological traction is used for the clavicle or humerus and relies on gravity to reduce and immobilize the bone within its soft-tissue sleeve. For the clavicle a simple triangular or figure-of-eight bandage is sufficient. For the humerus, the arm is kept suspended in a narrow wrist cuff-and-collar sling that does not support the elbow. A very light POP U-slab may be added for extra protection and weight. This hanging cast may cause distraction at the fracture site and n...
+
+=== Chunk 2922 ===
+Source: 4105_002-ebook.pdf
+Length: 1445 chars
+
+Skin traction
+Skin traction is indicated for fractures of the femur in infants and children and frail elderly patients requiring a small amount of traction. Application of adhesive strapping requires proper degreasing of the skin with tincture of benzoin or ether. Both initial and definitive immobilization can be ensured.
+For infants below 12 – 15 kg of body weight (usually less than three to four years of age), it is applied in the form of “gallows traction” on both legs, which are hung up abov...
+
+=== Chunk 2923 ===
+Source: 4105_002-ebook.pdf
+Length: 817 chars
+
+Skeletal traction
+A pin is placed in the bone to act as a focal point for the application of traction.
+Skeletal traction is used for:
+• fractures of the femur;
+• some fractures of the distal humerus around the elbow;
+• fractures of the tibia, particularly around the knee joint or in the distal third.
+Skeletal traction is the most common method of fixation used for the femur when working with limited resources, both as initial and as definitive bone holding. The leg is supported by means of a Bra...
+
+=== Chunk 2924 ===
+Source: 4105_002-ebook.pdf
+Length: 2675 chars
+
+22.b.c Pin placement
+The limb should be washed, prepped and draped as for any operation. Local anaesthesia can be used to place the pin or, if a debridement is to take place at the same time, general anaesthesia.
+The pin should always be placed from the side most at risk, dissecting out the neurovascular bundle to protect it. This means the lateral aspect for the tibia, and the medial for the femur, calcaneus and olecranon.
+For the femur, the best site is the upper tibia, 2.5 cm distal to and 2....
+
+=== Chunk 2925 ===
+Source: 4105_002-ebook.pdf
+Length: 1041 chars
+
+Figure 22.B.12
+Traction pin placed in the femoral metaphysis and an empty vial used as a pin guard.
+Figures 22.B.13 – 22.B.15
+Classical and modified Braun-Böhler traction frame; improvisation by ICRC physiotherapists.
+154
+7. A pin guard fashioned from a cork or an empty medicine vial – the pointed tip pushed through the rubber diaphragm – is placed to protect both patient and staff from injury. Dry gauze is placed over the pin sites and covered with a bandage to prevent the patient from fiddling...
+
+=== Chunk 2926 ===
+Source: 4105_002-ebook.pdf
+Length: 1311 chars
+
+22.b.d managing traction of the femur
+In war wounds reduction of the femur fracture is relatively easy because the damaged muscles around the fracture site have been excised resulting in a loss of soft-tissue volume. The pulling effect of the muscles on the proximal and distal bone fragments is therefore decreased and there is rarely any interposition of muscle between the bone fragments as frequently occurs after blunt trauma. Also unlike blunt trauma where the femur is often stripped of perios...
+
+=== Chunk 2927 ===
+Source: 4105_002-ebook.pdf
+Length: 2066 chars
+
+Position of the leg in traction
+In any fracture, different forces are at work on the proximal and distal bone ends. The proximal fragment takes up a position determined by the balance of forces of the muscles that remain attached to it. The distal fragment takes up a position determined by gravity if not held in check. For traction to succeed, the distal fragment must be aligned with the proximal fragment and then the two held in this position.
+A Braun-Böhler frame is most suitable for fractures...
+
+=== Chunk 2928 ===
+Source: 4105_002-ebook.pdf
+Length: 303 chars
+
+Figure 22.B.18
+A modified traction frame with a series of pulleys to treat a high femoral fracture. The hip is flexed 90° permitting the alignment of the distal fragment with the flexed proximal fragment. The position of the knee, flexed to 90°, allows the joint to be fully exercised.
+D
+155
+WAR SURGERY...
+
+=== Chunk 2929 ===
+Source: 4105_002-ebook.pdf
+Length: 277 chars
+
+Figure 22.B.19
+Alternative method to a Braun-Böhler frame for a proximal femur fracture.
+Figure 22.B.20 Traction ward in an ICRC hospital.
+rs Bae d
+C
+Macala / ICRC
+M
+.
+I
+Figure 22.B.21 Controlling the traction and position of the patient.
+Figure 22.B.21
+156
+C
+Cooke/ ICRC
+C
+.
+D...
+
+=== Chunk 2930 ===
+Source: 4105_002-ebook.pdf
+Length: 2460 chars
+
+Monitoring of the patient and nursing care
+Management of a patient in traction is an active process. Dedicated nursing and physiotherapy staff are important; understanding what traction can achieve is essential for its successful management.
+A special “traction ward” can be created and is usual practice in ICRC hospitals. Ideally, a mobile X-ray machine is available. If not, a bed on which wheels and a traction system can be fixed is of great assistance in moving patients about and bringing them...
+
+=== Chunk 2931 ===
+Source: 4105_002-ebook.pdf
+Length: 392 chars
+
+Mobilization of joints
+Early exercises to maintain muscle tone and movement of joints are important. Movement of the joints by temporarily removing the weight should be encouraged as soon as patient comfort permits, usually after one week. However, if the soft-tissue wound is large, active physiotherapy can be painful and may hinder wound healing.
+Good analgesia assists good physiotherapy....
+
+=== Chunk 2932 ===
+Source: 4105_002-ebook.pdf
+Length: 84 chars
+
+Figure 22.B.24
+Mobilization of the joints of a patient in skeletal traction.
+C
+R
+C
+I...
+
+=== Chunk 2933 ===
+Source: 4105_002-ebook.pdf
+Length: 691 chars
+
+Mobilization of the patient in bed
+The patient must be monitored for the development of bedsores and kept mobile while bedridden; at the same time the alignment of the limb must be maintained. The foot of the bed should be kept raised on blocks to avoid the shearing force of the patient sliding down the bed and the bed linen should be kept as wrinkle-free as possible.
+An overhead ring or bar or sling attached to the foot of the bed helps patients lift themselves up off the bed, assists in the us...
+
+=== Chunk 2934 ===
+Source: 4105_002-ebook.pdf
+Length: 286 chars
+
+Removal of traction and mobilization out of bed
+Radiological consolidation always follows clinical consolidation and should not be a determining factor.
+There is no need to wait for full radiographic continuity before mobilizing a patient out of bed.
+157
+WAR SURGERY
+C
+D.Rowley / ICRC
+D...
+
+=== Chunk 2935 ===
+Source: 4105_002-ebook.pdf
+Length: 103 chars
+
+Figure 22.B.25
+GSW to the thigh. X-ray on admission, before debridement. Note the loose bone fragments....
+
+=== Chunk 2936 ===
+Source: 4105_002-ebook.pdf
+Length: 2429 chars
+
+Figures 22.B.28 and 22.B.29
+Calcaneal pin and traction of a tibial fracture with the level of the pulley ensuring that the line of pull is along the axis of the limb.
+158
+Removal of traction and mobilization of the patient out of bed can start as soon as the fracture is ‘‘sticky’’, usually after four to five weeks; it is not necessary to wait for clinical union. The decision to withdraw traction should be made solely on clinical grounds, and only confirmed by X-ray evidence of progressive callus...
+
+=== Chunk 2937 ===
+Source: 4105_002-ebook.pdf
+Length: 589 chars
+
+22.b.e skeletal traction of the tibia
+A 3 mm threaded Steinmann pin is inserted through the calcaneus, the entry site lying 2.5 cm below the medial malleolus. The soft tissues are carefully and bluntly dissected with a haemostat to avoid injury to the posterior tibial artery. Strict adherence to the protocol for pin insertion is particularly important since infection in the calcaneus is difficult to eradicate. The traction weight is 0.5 kg per 10 kg body weight. Patient management continues as f...
+
+=== Chunk 2938 ===
+Source: 4105_002-ebook.pdf
+Length: 704 chars
+
+22.b.f skeletal traction of the humerus
+Some fractures of the humerus, particularly around the elbow, are difficult to reduce and hold by physiological traction through a cuff-and-collar sling. Skeletal traction is an alternative to external fixation for these patients. A thin Steinmann pin or Kirschner wire is introduced into the olecranon from the medial side, using blunt dissection with a haemostat to protect the ulnar nerve. Traction weight should begin with 2 kg in an adult and reduction ch...
+
+=== Chunk 2939 ===
+Source: 4105_002-ebook.pdf
+Length: 236 chars
+
+22.b.g Complications of traction
+Poor results associated with skeletal traction itself, rather than due to the severity of the original wound, are the result of poor technique and failure of proper supervision or adequate physiotherapy....
+
+=== Chunk 2940 ===
+Source: 4105_002-ebook.pdf
+Length: 2201 chars
+
+Delayed union and non-union
+There is no simple answer regarding when a femoral fracture is “united” and estimations are always approximations. A fracture is usually ‘‘sticky’’ after 4 weeks and clinically united at 7 – 8 weeks. Full radiological union before 10 weeks is unusual. In penetrating injury these timeframes are usually shorter than the ones the surgeon sees in blunt trauma; this is largely due to the difference in the extent of periosteal stripping.
+The monthly radiographs usually show...
+
+=== Chunk 2941 ===
+Source: 4105_002-ebook.pdf
+Length: 739 chars
+
+Malunion
+Fractures of the upper third and lower third of the femur are the most common sites for malunion while under traction treatment. In the proximal third, flexion exerted by the psoas muscle has usually not been overcome, although this is more common with closed fractures than with war wounds. In the case of the lower third, the fracture sags into the traction frame creating a posterior angulation because of the pull from the gastrocnemii; this can be lessened by knee flexion and padding.
+...
+
+=== Chunk 2942 ===
+Source: 4105_002-ebook.pdf
+Length: 1274 chars
+
+Pin track infection
+Pain around the pin often indicates deep infection; it should be taken seriously. By contrast, inflamed skin around a firm and painless pin is only a superficial infection.
+If the pin is firm but the skin red, tender and adherent, the pin site should be opened with a knife and forceps to provide for drainage and irrigated daily with a dilute antiseptic solution. The pin must be kept free from the skin. Antibiotics are only necessary if there is a spreading cellulitis.
+If the ...
+
+=== Chunk 2943 ===
+Source: 4105_002-ebook.pdf
+Length: 569 chars
+
+Muscle wasting and bedsores
+As with “plaster disease”, lean body mass is lost during the immobility in bed imposed by skeletal traction. Exercises help maintain muscle mass and attention should always be paid to nutrition.
+Bedsores are caused by prolonged immobility coupled with shearing forces between bone and the overlying skin and subcutaneous fat, and exacerbated by loss of body mass. The patient must be kept mobile while in bed and taught to raise the body frequently. The development of bed...
+
+=== Chunk 2944 ===
+Source: 4105_002-ebook.pdf
+Length: 187 chars
+
+Depression
+Psychological support of the patient is also essential. Many people, especially the young, do not easily tolerate bed confinement for weeks on end.
+iNJURiEs TO bONEs AND JOiNTs...
+
+=== Chunk 2945 ===
+Source: 4105_002-ebook.pdf
+Length: 797 chars
+
+ANNEX 22. C External fixation
+The concept of an external fixator is relatively simple and straightforward. Screws or pins are placed into the bone proximal and distal to the fracture site, which are then joined together to create a metallic “exoskeleton” that bridges the fracture and maintains the length and position of the bone.
+External fixation is a specialist’s technique, although it is implemented by general surgeons in ICRC practice. The technique requires considerable skill and experience...
+
+=== Chunk 2946 ===
+Source: 4105_002-ebook.pdf
+Length: 562 chars
+
+22.C.a Equipment
+A number of commercial systems of different sizes are available. Many surgeons have incorporated Steinmann pins in a plaster cast; others have improvised simple systems using wood, bamboo or metal components joined with plaster bandages or bone cement. The easiest system to apply for the non-specialist is one that allows free placing of the pins, the positions not being determined by the frame.
+Many other elements exist for the specialist surgeon.
+C
+T.Gassmann /ICRC
+R
+C
+I
+/
+n
+n
+...
+
+=== Chunk 2947 ===
+Source: 4105_002-ebook.pdf
+Length: 385 chars
+
+Figure 22.C.2
+Schanz screws or Steinmann pins, all commonly referred to as “pins”: either self-drilling (pictured here) or requiring pre-drilling by a smaller-sized bit.
+External tubes or bars, the length depending on the bone to be held.
+T.Gassmann / ICRC
+T.Gassmann / ICRC
+T
+T
+Figure 22.C.3 Pin-to-tube clamps.
+Figure 22.C.4 Tube-to-tube clamps.
+T.Gassmann /ICRC
+T.Gassmann /ICRC
+T
+T...
+
+=== Chunk 2948 ===
+Source: 4105_002-ebook.pdf
+Length: 160 chars
+
+Figure 22.C.5
+Instruments needed to place the screws or pins: soft-tissue guard.
+Figure 22.C.6 Hand chuck.
+V.Sasin / ICRC
+V
+C
+R
+C
+I
+iNJURiEs TO bONEs AND JOiNTs...
+
+=== Chunk 2949 ===
+Source: 4105_002-ebook.pdf
+Length: 651 chars
+
+22.C.b Pin placement and insertion
+The wound should be carefully studied beforehand to decide on the sites for placement of the pins in order to obtain both axial and rotational alignment of the fracture. The tibia, humerus and bones of the forearm require at least two pins proximal and two distal to the fracture site; the femur requires three and three.
+Pins should be inserted at right angles to the long axis of the bone and should not pierce muscle or tendons. They should not be inserted into ...
+
+=== Chunk 2950 ===
+Source: 4105_002-ebook.pdf
+Length: 976 chars
+
+Figure 22.C.9
+Incorrect placement of pins using an improvised fixator; the skin is under tension and the pin is going through the wound.
+C
+R
+C
+I
+Each pin must traverse both cortices of the bone to ensure the stability of the fixator. However, the distal cortex must only just be perforated; if pins penetrate too far beyond they may cause muscle tethering, damage to nerves, or even injury to an artery.
+The placement of external fixation pins follows a similar protocol to that for a traction pin. F...
+
+=== Chunk 2951 ===
+Source: 4105_002-ebook.pdf
+Length: 144 chars
+
+Figure 22.C.12
+Modular technique: two pins are placed in each major fragment and the pins joined with short tubes creating two separate modules....
+
+=== Chunk 2952 ===
+Source: 4105_002-ebook.pdf
+Length: 571 chars
+
+Figure 22.C.15
+Mono-axial side-tube method: the four Schanz screws are well-aligned in a row.
+164
+4. The procedure is repeated for each Schanz screw. Any skin tension around the pins must be released by extending the incision.
+5. The Schanz screws are joined to side tubes by pin-to-tube clamps. The tube frame should be close to the skin but allow sufficient room for access to the wound.
+6. The pin sites are covered with separate gauze compresses. The “dead space” between the skin and tubes is fi...
+
+=== Chunk 2953 ===
+Source: 4105_002-ebook.pdf
+Length: 142 chars
+
+22.C.c Construction of the frame
+Two possible constructs of an external fixation frame are possible depending on the expertise of the surgeon....
+
+=== Chunk 2954 ===
+Source: 4105_002-ebook.pdf
+Length: 813 chars
+
+Modular technique
+Two pins joined by a tube are placed in each major bone fragment creating two separate modules. The two tubes are then joined by a third cross-tube, loosely held. The two modules are manoeuvred, the tubes serving as handles, to reduce the fracture and the cross-tube tightened in position. A second long tube may be added between at least the most proximal and most distal pins to assure greater rigidity of the device; sometimes three or all four of the pins can be held by the sec...
+
+=== Chunk 2955 ===
+Source: 4105_002-ebook.pdf
+Length: 973 chars
+
+Mono-axial side-tube method
+The pins are placed well aligned in a row and all the pins held by a single long tube. This method requires experience on the part of the surgeon.
+The tube is prepared with four pin-to-tube clamps. The first Schanz screw is inserted into the main bone fragment, 2 – 3 cm from the proximal joint, and then passed through a pin-to-tube clamp. A second screw is similarly placed through a clamp into the second main fragment, also 2 – 3 cm from the distal joint. Slight tract...
+
+=== Chunk 2956 ===
+Source: 4105_002-ebook.pdf
+Length: 810 chars
+
+External fixator applied to the tibia
+Being a subcutaneous bone the tibia is readily accessible and application of a fixator is relatively uncomplicated. At least four pins are required: two above the fracture site and two below. A single pin on one side cannot provide adequate stability; if there is not room for two, a pin may be placed in the tarsus and/or calcaneus, or an alternative method of bone holding should be chosen.
+The anterior crest of the tibia is the ideal site for pin placement a...
+
+=== Chunk 2957 ===
+Source: 4105_002-ebook.pdf
+Length: 370 chars
+
+External fixator applied to the femur
+The femur is surrounded by a voluminous muscle mass and dissection down to the bone for pin placement is far more difficult than for the tibia. Proper posterolateral placement of the pins is important to avoid tethering any muscles and impeding joint movement. Three pins are required proximal to the fracture site and three distal....
+
+=== Chunk 2958 ===
+Source: 4105_002-ebook.pdf
+Length: 160 chars
+
+Figure 22.C.16
+Incorrect and correct engagement of the pin in the anterior crest of the tibia.
+C
+C.Giannou/ ICRC
+V. intermedius
+V. lateralis
+Plane of dissection...
+
+=== Chunk 2959 ===
+Source: 4105_002-ebook.pdf
+Length: 225 chars
+
+Figure 22.C.17
+Correct plane of dissection for the placement of pins in the femur.
+C
+C
+¥
+R
+C
+I
+/
+d
+=
+n
+a
+l
+p
+u
+o
+C
+Coupland / ICRC
+Figures 22.C.18 and 22.C.19 Correct pin placement postero-laterally.
+C
+C
+.
+.
+R
+R
+C
+Sasin/ ICRC...
+
+=== Chunk 2960 ===
+Source: 4105_002-ebook.pdf
+Length: 144 chars
+
+Figure 22.C.20
+Incorrect pin placement tethering the quadratus femoris muscle.
+S
+.
+V
+165
+C
+C.Giannou/ ICRC
+C
+WAR SURGERY
+C
+Nareddine/ ICRC
+N
+.
+H...
+
+=== Chunk 2961 ===
+Source: 4105_002-ebook.pdf
+Length: 85 chars
+
+Figure 22.C.21
+Gunshot wound of the humerus: X-ray on admission prior to debridement....
+
+=== Chunk 2962 ===
+Source: 4105_002-ebook.pdf
+Length: 80 chars
+
+Figures 22.C.24 and 22.C.25
+Application of external fixation to the humerus.
+166...
+
+=== Chunk 2963 ===
+Source: 4105_002-ebook.pdf
+Length: 407 chars
+
+External fixator applied to the humerus
+The humerus is readily accessible in the lateral groove between the biceps and triceps muscles. Two pins are required proximal and two distal to the fracture site. Care must be taken not to injure the radial nerve that passes around the bone or go too far beyond the second medial cortex where the brachial artery lies.
+C
+Nareddine/ ICRC
+C
+Nareddine/ ICRC
+N
+N
+.
+.
+H
+H...
+
+=== Chunk 2964 ===
+Source: 4105_002-ebook.pdf
+Length: 329 chars
+
+Figure 22.C.23
+Post-debridement radiograph; the fracture was held in a POP back slab and cuff-and-collar sling.
+Correction of the alignment by means of external fixation; healing in progress.
+C
+Nareddine / ICRC
+C
+Nareddine / ICRC
+N
+N
+.
+.
+H
+H
+Figure 22.C.24 Functional result: extension.
+Figure 22.C.25 Functional result: flexion....
+
+=== Chunk 2965 ===
+Source: 4105_002-ebook.pdf
+Length: 1407 chars
+
+22.C.d management of the patient in external fixation
+After application of an external fixator the limb should be elevated.
+A control X-ray is taken as soon as possible to confirm bone alignment. Malunion can be avoided by early adjustment of the construct under light anaesthesia, if necessary. Adhesions around the fracture site and oedema render late adjustment much less effective. Accepting poor alignment defeats much of the purpose of applying an external fixator.
+The pin sites should be care...
+
+=== Chunk 2966 ===
+Source: 4105_002-ebook.pdf
+Length: 154 chars
+
+22.C.e Complications
+As with any invasive technique using specialist technology, complications are many. The more serious and frequent are described here....
+
+=== Chunk 2967 ===
+Source: 4105_002-ebook.pdf
+Length: 1342 chars
+
+Infection of pin tracks and pin loosening
+Most early infections of pin tracks are secondary to residual contamination or infection in the wound itself. Lymphatic drainage from the area of the wound often adversely affects the proximal pins. The other major cause is poor technique of pin insertion leading to damage to the bone and surrounding soft tissue. Meticulous technique and pin site care are essential. Infection leads to loosening of the pin, and is revealed by discharge and pain at the pin...
+
+=== Chunk 2968 ===
+Source: 4105_002-ebook.pdf
+Length: 425 chars
+
+Injury to nearby structures
+Proper placement of the pins involves a good knowledge of the anatomy of the limb. Proper technique will avoid injury to major nerves and blood vessels. A pseudoaneurysm, presenting late, is one well-known complication.
+Tethering of tendons and muscles by the pins prevents joint movement, thus defeating one of the main advantages of external fixation.
+167
+C
+R
+C
+I
+/
+y
+e
+i
+l
+w
+o
+R
+.
+D
+WAR SURGERY...
+
+=== Chunk 2969 ===
+Source: 4105_002-ebook.pdf
+Length: 81 chars
+
+Figure 22.C.27
+Correct positioning of the pins and complete flexion of the knees....
+
+=== Chunk 2970 ===
+Source: 4105_002-ebook.pdf
+Length: 142 chars
+
+Figure 22.C.28
+Incomplete flexion of the knee: incorrect positioning of the Schanz screws.
+168
+C
+Coupland / ICRC
+C
+.
+R
+C
+Coupland / ICRC
+C
+.
+R...
+
+=== Chunk 2971 ===
+Source: 4105_002-ebook.pdf
+Length: 230 chars
+
+Mechanical problems with the device
+As with any apparatus consisting of numerous elements, with time and use some components may no longer function properly. These should be discarded and replaced; often a very expensive exercise....
+
+=== Chunk 2972 ===
+Source: 4105_002-ebook.pdf
+Length: 938 chars
+
+ANNEX 22. D iCRC chronic osteomyelitis study16
+In the province of South Kivu in the Democratic Republic of Congo, after many years of warfare, ICRC delegates noticed the presence of hundreds of patients suffering from chronic osteomyelitis; most of them had old war wounds. The majority had languished for months and years in hospitals or at home, receiving various antibiotic cocktails and dressings; some underwent surgical operations from time to time, whenever they could afford treatment. Neglec...
+
+=== Chunk 2973 ===
+Source: 4105_002-ebook.pdf
+Length: 638 chars
+
+Material and methods
+Between March 2007 and December 2008, an ICRC surgical team treated 168 patients suffering from either haematogenous or post-traumatic osteomyelitis according to a standard protocol based on a previous ICRC study and publication.17 Inclusion criteria included symptoms for more than three consecutive months, active purulent discharge or abscess collection in an extremity, and X-ray changes compatible with chronic osteomyelitis (sequestration, cavitation, presence of a foreign...
+
+=== Chunk 2974 ===
+Source: 4105_002-ebook.pdf
+Length: 1326 chars
+
+Surgical protocol
+The aim of surgical debridement was to remove all necrotic bone and saucerization down to bleeding bone (“paprika sign”) when required, but not necessarily with a 5 mm margin of healthy bone, in an attempt to minimize bone destabilization. Special attention was paid to removing all biofilm by curettage and irrigation of the wound with saline solution under moderate pressure.
+Pr tiles & oshfow
+C
+Simone / ICRC
+D
+C
+2
+R
+C
+I
+/
+e
+n
+o
+m
+i
+S
+e
+8
+D
+.
+F
+.
+F
+Figure 22.D.1 Pus pouring out ...
+
+=== Chunk 2975 ===
+Source: 4105_002-ebook.pdf
+Length: 1152 chars
+
+Dressing protocol
+The operative dressing was removed on post-operative day 2. The wound was dressed using generous amounts of granulated brown sugar and dry compresses. Sugar dressings were repeated on a daily basis after thorough rinsing of the wound with normal saline to remove the previous day’s sugar. This routine was continued until the wound healed by secondary intention or a split-thickness skin graft was applied.
+C
+De Simone / ICRC
+C
+De Simone / ICRC
+D
+D
+.
+F
+.
+F
+Figure 22.D.3 Granulated ...
+
+=== Chunk 2976 ===
+Source: 4105_002-ebook.pdf
+Length: 995 chars
+
+Antibiotic protocol
+Intra-operative cultures of superficial and deep tissues and also of sequestra if present were routinely obtained. The initial antibiotic protocol consisted of parenteral gentamycin and cloxacillin for 24 hours, followed by 4 weeks of oral cloxacillin. Culture results showed a high level of multiple-resistance, so the protocol was simplified to a 24-hour course of parenteral benzyl penicillin and metronidazole aimed only at controlling any bacteraemia related to the surgical ...
+
+=== Chunk 2977 ===
+Source: 4105_002-ebook.pdf
+Length: 276 chars
+
+Post-operative care
+Early physiotherapy sessions were established for all patients, to maintain or increase joint mobility and muscle tone and progressively load the affected limb. Patients were fed a calorie- and protein-rich diet, for the first time in months in many cases....
+
+=== Chunk 2978 ===
+Source: 4105_002-ebook.pdf
+Length: 1218 chars
+
+Follow-up results
+Average length of hospital stay was 12 weeks (range 1 – 48 weeks) and no patient was discharged with active infection. Mean follow-up was 13.7 months (range 5 – 28 months) for the 71 patients who could be traced. Isolated geography and security constraints made follow-up of more patients impossible.
+Forty-six patients (63.4 %) had excellent to good results in terms of clinical cure of their infection at follow-up. Thirty-six (50.7 %) had excellent to good overall results with r...
+
+=== Chunk 2979 ===
+Source: 4105_002-ebook.pdf
+Length: 504 chars
+
+ANNEX 22. E bone grafting
+The iliac crest is used as a donor site because a generous amount of cancellous bone can be harvested and it is easily accessible. The exact site depends on how much bone graft is required. For defects smaller than 4 cm, the anterior iliac crest may be used. Where larger quantities are needed the posterior iliac crest is preferred. And, for a very large quantity, both sides of the pelvis can be used. Each cancellous bone chip should be about the size of a fingernail, 1 ...
+
+=== Chunk 2980 ===
+Source: 4105_002-ebook.pdf
+Length: 1705 chars
+
+22.E.a Harvesting the graft
+The patient is placed in a lateral or prone position.
+1. For a small graft, the incision goes backwards from 2 cm posterior to the anterior superior iliac spine for 6 – 8 cm. For larger grafts, the incision begins at the posterior iliac spine and proceeds forwards along the crest for 8 – 10 cm.
+2. The muscles on the external surface of the crest are cut by knife. With a periosteal elevator, 1 cm of muscle is gently scraped from the bone.
+3. A sharp osteotome is insert...
+
+=== Chunk 2981 ===
+Source: 4105_002-ebook.pdf
+Length: 1111 chars
+
+22.E.b Placing the graft: closed wounds
+The patient’s position is re-arranged and a pneumatic tourniquet placed on the limb and inflated.
+It is preferable to approach the fracture site through a new incision away from the original wound; this carries less chance of infection and avoids the fibrous tissue of wound healing. Once the fracture is exposed, the bone ends are freshened by excision of adherent fibrous tissue and nibbling by a rongeur. Care is taken not to remove periosteum. The bone fra...
+
+=== Chunk 2982 ===
+Source: 4105_002-ebook.pdf
+Length: 1089 chars
+
+22.E.c Placing the graft: open wounds
+The same techniques are used for harvesting and applying the graft, but in an open wound. This method is most relevant to grafting the tibia.
+The graft site may be covered by a muscle or skin-and-fascia flap if available, by far the preferred technique. Otherwise the limb is encased in a complete cylindrical cast, without a window, and kept away from prying fingers and eyes (Orr-Trueta technique, see Section 22.8.3). Under the cast, the graft site remains mo...
+
+=== Chunk 2983 ===
+Source: 4105_002-ebook.pdf
+Length: 411 chars
+
+22.E.d bone immobilization
+Whether an open or a closed technique is used, the grafted fracture must be held by an appropriate method for at least four weeks. This is an important indication for external fixation. Depending on which bone is grafted, the Orr-Trueta method of encasing the limb in a complete cast can also be of benefit.
+C
+R
+C
+I
+C
+E
+R
+C
+I
+/
+E
+e
+n
+o
+m
+i
+S
+e
+g
+D
+C
+Simone / ICRC
+D
+.
+F
+.
+F
+Chapter 23...
+
+=== Chunk 2984 ===
+Source: 4105_002-ebook.pdf
+Length: 2020 chars
+
+AMPUTATIONS AND DISARTICULATIONS1
+1 This Chapter should be read in conjunction with the relevant sections of Chapter 21 on anti-personnel landmine injuries. Parts are based on: Coupland RM. Amputations for War Wounds. Geneva: ICRC; 1992.
+177
+WAR SURGERY
+178
+23. AMPUTATIONS AND DISARTICULATIONS 23.1 Introduction 23.2 Epidemiology 23.3 Surgical decision-making 23.3.1 Permission to surgically amputate 23.3.2 Indications for amputation 23.3.3 Clinico-pathological types of “vascular injury and severe...
+
+=== Chunk 2985 ===
+Source: 4105_002-ebook.pdf
+Length: 3501 chars
+
+23.1 introduction
+The surgeon must take into consideration a number of factors when deciding whether to amputate and at what level the amputation should be performed. Local rehabilitation services may offer only a small variety of prostheses; limited availability of intensive nursing care may dictate earlier amputation so as to save life; imperfect surgical experience and lack of proper suture material and vascular instruments may make vascular repair ill-advised. In some cultures, amputation wi...
+
+=== Chunk 2986 ===
+Source: 4105_002-ebook.pdf
+Length: 2127 chars
+
+23.2 Epidemiology
+The incidence and frequency of amputation for war wounds varies greatly and is dependent on a number of factors.
+• Widespread use of anti-personnel mines (numerous patients suffer pattern 1 and pattern 3 injuries) or improvised explosive devices: the incidence of multiple traumatic amputations has increased with the use of APM and IED, from 2 % in World War I to 18 % in the American war in Viet Nam, and up to 30 % in Afghanistan and Iraq.2
+• Long delay in evacuation of casualti...
+
+=== Chunk 2987 ===
+Source: 4105_002-ebook.pdf
+Length: 426 chars
+
+23.3.1 Permission to surgically amputate
+Different societies take differing views of body integrity and the image of the self. Patients may prefer to keep a useless limb or even to die from their wounds rather than suffer amputation. In some cultures the patient alone does not decide on operation. As mentioned, the extended family or clan must be consulted and the amputation, and even the stump length, discussed with them....
+
+=== Chunk 2988 ===
+Source: 4105_002-ebook.pdf
+Length: 2263 chars
+
+23.3.2 indications for amputation
+In a number of patients, the pathology and decision are obvious: traumatic amputation. These are more frequent during conflicts where weapons that combine blast and projectile effects, such as anti-personnel mines and sophisticated improvised explosive devices, are widespread.
+Other cases call for surgical judgement regarding whether or not to amputate. The following indications are based on the experience of ICRC surgeons and only offer guidance. The surgeon’s ...
+
+=== Chunk 2989 ===
+Source: 4105_002-ebook.pdf
+Length: 1562 chars
+
+23.3.3 Clinico-pathological types of “vascular injury and severe tissue damage”
+The expression “vascular injury in addition to severe tissue damage” above is very general and ambiguous, as is a “mangled, grossly contaminated wound”. All war wounds are contaminated and many can be described as mangled, but not all are candidates for amputation in modern surgery.
+The scheme below provides a guideline to aid decision-making, based on a clinico- pathological description of various war wounds using t...
+
+=== Chunk 2990 ===
+Source: 4105_002-ebook.pdf
+Length: 609 chars
+
+23.3.4 Damage-control procedures
+In patients with multiple severe injuries the setting of correct priorities for the various operations is essential. The precarious physiological state of the patient may require a damage-control approach. This may involve disarticulation through the knee joint rather than a transfemoral amputation; abbreviated laparotomy and washing and dressing only of a traumatic amputation stump after ligature of the major vessels pending proper debridement after stabilizatio...
+
+=== Chunk 2991 ===
+Source: 4105_002-ebook.pdf
+Length: 1840 chars
+
+23.3.5 Level of amputation
+Length in an amputation stump is most important in the lower limb: the longer the bone stump, the less effort is required when walking. Energy expenditure and oxygen consumption increase as the level of amputation rises in the limb.
+The most severe soft-tissue injury, not the bone injury, usually dictates the level of amputation, which should be at the lowest possible level of viable tissue compatible with good and durable prosthetic fitting. Although the longest stump...
+
+=== Chunk 2992 ===
+Source: 4105_002-ebook.pdf
+Length: 446 chars
+
+23.4 Classical surgical procedure: initial operation
+The aim at the initial amputation is to excise all dead and contaminated tissue in preparation for DPC. Some mangled extremities require several debridements, often because of infection; this is especially the case after APM injury. Two surgical approaches are possible: the classical procedure as described in this Section, and myoplasty and myodesis amputations as described in Section 23.6....
+
+=== Chunk 2993 ===
+Source: 4105_002-ebook.pdf
+Length: 648 chars
+
+23.4.1 Preparation of the patient
+Ketamine is the preferred anaesthetic. Spinal anaesthesia may be used in a haemodynamically stable patient. In extremis, amputations can be performed under infiltration of a local anaesthetic.
+The initial amputation should be performed under a tourniquet. However, muscle retracts back in relation to the skin and bone after removal of the tourniquet and this should be kept in mind when deciding on the level of bone section. It should be released prior to the end ...
+
+=== Chunk 2994 ===
+Source: 4105_002-ebook.pdf
+Length: 682 chars
+
+23.4.2 soft tissues
+The surgeon must usually resort to “flaps of opportunity” as determined by the injury rather than standard amputation flaps; no attempt should be made to define formal flaps at the initial operation. This entails excision of all damaged soft tissues first and then planning the bone section as distal as feasible. To allow as much leeway as possible to accomplish DPC and fashion a sturdy and painless stump fit for a prosthesis, the surgeon should save all viable skin and muscle...
+
+=== Chunk 2995 ===
+Source: 4105_002-ebook.pdf
+Length: 147 chars
+
+Figures 23.2.1 and 23.2.2
+The injury often determines the anatomy of the skin flaps.
+.
+.
+R
+R
+183
+C
+IcRc
+R
+C
+I
+WAR SURGERY
+C
+Nasreddine / ICRC
+N
+.
+H...
+
+=== Chunk 2996 ===
+Source: 4105_002-ebook.pdf
+Length: 243 chars
+
+Figure 23.3
+The skin flap has been raised and excess subcutaneous fat is being trimmed.
+C
+&
+R
+C
+I
+/
+i
+n
+a
+l
+P
+.
+F
+Figure 23.4
+The surgeon is filing down the edge of the cut bone. Note that the muscles have been cut obliquely across the fibres....
+
+=== Chunk 2997 ===
+Source: 4105_002-ebook.pdf
+Length: 485 chars
+
+Figure 23.5
+The major vessels are separated out and ligated individually.
+184
+Do not attempt to fashion definitive flaps at the first operation.
+Salvage as much viable tissue as possible; any excess can be removed at DPC.
+The skin flaps are raised and the edges and subcutaneous fat trimmed. Muscles are cut back obliquely across their fibres. If a specific muscle can be retained in its entirety, this is preferable and the muscle should be detached at its distal tendinous insertion....
+
+=== Chunk 2998 ===
+Source: 4105_002-ebook.pdf
+Length: 1206 chars
+
+23.4.3 bone
+Bone section is planned as distal as possible after excision of the damaged soft tissues and should be compatible with the remaining quantity of viable muscle to cover the bone end after the 4 – 7 day delay to DPC. At the end of the operation, the skin and muscle should approximate easily, without tension, over the bone end.
+Bone is cleared of muscular and fascial attachments and periosteum up to 1 cm proximal to the level of transection. The bone is sectioned preferably with a Gigli...
+
+=== Chunk 2999 ===
+Source: 4105_002-ebook.pdf
+Length: 183 chars
+
+23.4.4 blood vessels
+Named vessels are transfixed and doubly ligated and the artery and vein ligated separately.
+C
+&
+R
+C
+I
+/
+e
+n
+i
+d
+d
+z
+e
+r
+s
+a
+N
+.
+H
+AmPUTATiONs AND DisARTiCULATiONs...
+
+=== Chunk 3000 ===
+Source: 4105_002-ebook.pdf
+Length: 941 chars
+
+23.4.5 Nerves
+The technique of “traction neurectomy” is applied to all named nerves and to any obviously visible cutaneous nerves. To reduce the risk of a painful neuroma, gentle traction is applied to the nerve, which is divided as high up as possible with a fresh scalpel blade. The end is then buried in a muscle so situated that it is not subjected to pressure from the prosthetic socket.
+Nerves should be neither crushed, nor ligated, nor injected; the surgical trauma is more likely to favour t...
+
+=== Chunk 3001 ===
+Source: 4105_002-ebook.pdf
+Length: 399 chars
+
+23.4.6 Haemostasis, irrigation, dressing
+The tourniquet is removed and haemostasis assured. The wound is irrigated with copious amounts of normal saline or potable water under the simple pressure of squeezing an i.v. bag, or gravity-flow by hanging up the bag. The stump is then dressed as usual with a bulky absorbent dressing to soak up the exudate. Bandaging should be firm, but non-constricting....
+
+=== Chunk 3002 ===
+Source: 4105_002-ebook.pdf
+Length: 357 chars
+
+Figure 23.6
+Copious irrigation of the amputation stump.
+C
+R
+C
+I
+It is not advisable to insert a few tension sutures to hold a large compressive tamponade between the flaps to prevent retraction of the skin. This only impedes drainage and promotes strangulation of muscle and skin that will always become oedematous.
+The stump should not be closed primarily....
+
+=== Chunk 3003 ===
+Source: 4105_002-ebook.pdf
+Length: 976 chars
+
+23.4.7 Post-operative care
+The limb should be kept elevated in bed to reduce oedema and the stump kept in a position to prevent joint contractures (see Section 23.9). Great attention should be paid to post-operative pain and adequate analgesia administered. This helps initiate appropriate physiotherapy to maintain muscle tone and keep remaining joints mobile, which should be commenced immediately, before delayed primary closure. Good pain relief leads to faster rehabilitation, better psychologic...
+
+=== Chunk 3004 ===
+Source: 4105_002-ebook.pdf
+Length: 80 chars
+
+Figure 23.8
+Delayed primary closure by skin grafting of an amputation stump.
+186...
+
+=== Chunk 3005 ===
+Source: 4105_002-ebook.pdf
+Length: 3063 chars
+
+23.5 Delayed primary closure
+Attempted DPC takes place on the fifth post-operative day, as per routine. A good amputation wound presents a healthy, bleeding muscle surface that contracts as the last compress is removed.
+The aim of DPC is not merely to close the wound but also, and especially, to fashion a suitable stump with a sufficient padding of muscular soft tissue. Although the surgeon may be constrained by whatever soft tissues remain and have to make do with “flaps of opportunity”, long p...
+
+=== Chunk 3006 ===
+Source: 4105_002-ebook.pdf
+Length: 1638 chars
+
+23.6 myoplasty and myodesis amputations
+As mentioned, muscle that has been cut across its fibres swells greatly before DPC. This is especially the case in young men with bulky muscle groups. An intact muscle belly is relatively unaffected by oedema and swells little, if at all; it is soft and pliable and readily holds sutures. The muscle is dissected out in its entirety and the distal tendinous insertion cut. If mobilized along with its fascio-cutaneous covering, the result is a myoepithelial fl...
+
+=== Chunk 3007 ===
+Source: 4105_002-ebook.pdf
+Length: 508 chars
+
+Figure 23.9.3
+Equal anterior and posterior skin flaps have been raised. The muscles of the anterolateral compartment were contused (the dark muscle held in the forceps). The muscle section was made proximal to this.
+The tibia section in process, a little below the level of muscle section. Note the cutting angle of the Gigli wire saw to produce bevelling of the anterior edge, which was then filed smooth. The fibula was cut 2 cm shorter, again with a wire saw.
+C
+Coupland /ICRC
+C
+Coupland /ICRC
+C
+C...
+
+=== Chunk 3008 ===
+Source: 4105_002-ebook.pdf
+Length: 302 chars
+
+Figure 23.9.5
+The amputation at the end of primary surgery. The intact soleus was the only muscle remaining distal to the tibial section.
+The soft tissues approximated easily at the end of initial surgery, but were not sutured closed.
+C
+&
+R
+C
+I
+z
+/
+d
+n
+a
+l
+p
+u
+o
+C
+.
+R
+C
+&
+R
+C
+I
+/
+3
+d
+n
+a
+l
+p
+u
+o
+C
+.
+R...
+
+=== Chunk 3009 ===
+Source: 4105_002-ebook.pdf
+Length: 302 chars
+
+Figure 23.9.6
+A bulky gauze and cotton wool dressing was applied.
+Figure 23.9.8
+The stump was clean and ready for DPC and the soleus myoplasty was sutured to the periosteum of the anterior tibial edge.
+C
+&
+R
+C
+I
+z
+/
+d
+n
+a
+l
+p
+u
+o
+C
+.
+R
+C
+&
+R
+C
+I
+/
+3
+d
+n
+a
+l
+p
+u
+o
+C
+.
+R
+AmPUTATiONs AND DisARTiCULATiONs...
+
+=== Chunk 3010 ===
+Source: 4105_002-ebook.pdf
+Length: 106 chars
+
+Figure 23.9.7
+The original operative dressing during removal showing the gauze with dried exudative serum....
+
+=== Chunk 3011 ===
+Source: 4105_002-ebook.pdf
+Length: 167 chars
+
+Figure 23.9.9
+The skin flaps were closed independently. A bulky dry dressing was applied over the closed stump. The sutures were removed after 12 days.
+189
+WAR SURGERY...
+
+=== Chunk 3012 ===
+Source: 4105_002-ebook.pdf
+Length: 217 chars
+
+Figures 23.10.1 – 23.10.11
+Medial gastrocnemius myodesis amputation.
+190
+C
+Coupland / ICRC
+C
+.
+R
+Figure 23.10.1
+A patient with an APM traumatic amputation of the left leg.
+C
+Coupland /ICRC
+C
+Coupland /ICRC
+C
+C
+.
+.
+R
+R...
+
+=== Chunk 3013 ===
+Source: 4105_002-ebook.pdf
+Length: 1025 chars
+
+Figure 23.10.3
+The medial gastrocnemius was intact and undamaged (indicated by the surgeon’s left index finger bluntly dissecting the muscle free). The soleus and muscles of the anterolateral compartment were contused.
+The tibia and fibula were sectioned by Gigli wire saw, bevelled and filed smooth.
+C
+&
+R
+C
+I
+/
+d
+n
+a
+l
+p
+u
+o
+C
+Coupland /ICRC
+C
+C
+.
+.
+R
+R
+Figure 23.10.4
+Figure 23.10.5
+The soleus and anterolateral muscles were divided just above the level of the bone section and separated from the ...
+
+=== Chunk 3014 ===
+Source: 4105_002-ebook.pdf
+Length: 151 chars
+
+Figure 23.10.7
+At DPC the gauze dressing adhered to the fibrin coagulum on the surface of the muscle, which contracted and bled.
+C
+Coupland /ICRC
+C
+.
+R...
+
+=== Chunk 3015 ===
+Source: 4105_002-ebook.pdf
+Length: 439 chars
+
+Figure 23.10.9
+The gastrocnemius myoplasty easily covered the tibial section from medial to lateral. It was sutured to the anterolateral periosteum.
+C
+2
+R
+C
+I
+/
+d
+n
+a
+l
+p
+u
+o
+C
+.
+R
+Figure 23.10.11
+The fascial undersurface of the muscle may be scored if necessary to allow for its elongation and to release any tension.
+191
+Figures 23.11.1 – 23.11.9 Vastus medialis myoplastic amputation.
+192
+C
+Coupland / ICRC
+C
+Coupland / ICRC
+C
+C
+.
+.
+R
+R...
+
+=== Chunk 3016 ===
+Source: 4105_002-ebook.pdf
+Length: 587 chars
+
+Figure 23.11.2
+A patient with traumatic amputation of the left leg (field dressing) and a mangled right limb from an APM explosion.
+Damage to the mangled limb was so severe that an above-knee amputation was decided in addition to the amputation of the left leg. Standard equal “fish-mouth” skin incisions were made commencing at the upper border of the patella. Care was taken not to extend the incision into the vastus medialis muscle.
+C
+Coupland /ICRC
+C
+.
+R
+Figure 23.11.3
+Dissection reveals the ro...
+
+=== Chunk 3017 ===
+Source: 4105_002-ebook.pdf
+Length: 375 chars
+
+Figure 23.11.5
+The V. medialis was separated from its insertion into the quadriceps tendon by reflecting down the distal skin. The surgeon’s left index finger is shown here deep to this muscle.
+The intact V. medialis has been reflected up, the other muscles having been cut slightly below the proposed level of bone section.
+AmPUTATiONs AND DisARTiCULATiONs
+C
+Coupland / ICRC...
+
+=== Chunk 3018 ===
+Source: 4105_002-ebook.pdf
+Length: 470 chars
+
+Figure 23.11.6
+The femur was sectioned by Gigli wire saw where the shaft begins to flare into the condyles, while the assistant kept the soft tissues clear of the saw.
+C
+.
+R
+The femoral vessels were clamped and transfixed individually and the sciatic nerve gently pulled and cut with a fresh blade. The intercompartmental fat around the sciatic nerve and vessels was excised because it contained contaminants.
+C
+Coupland /ICRC
+C
+Coupland /ICRC
+C
+C
+.
+.
+R
+R
+Figure 23.11.7...
+
+=== Chunk 3019 ===
+Source: 4105_002-ebook.pdf
+Length: 366 chars
+
+Figure 23.11.8
+The tourniquet was released and haemostasis achieved. The intact V. medialis easily covered the bone section. The open stump was irrigated with saline and dressed.
+The patient returned to theatre after five days for DPC. Some exudate had reached the dressing surface but was dry by this time. The stump was clean and ready for closure.
+C
+R
+C
+I
+/
+d
+n
+a...
+
+=== Chunk 3020 ===
+Source: 4105_002-ebook.pdf
+Length: 371 chars
+
+Figure 23.11.9
+The vastus medialis myoplasty was sutured to the lateral thigh muscles and fascia in both limbs. It could also have been sutured to the periosteum. The skin flaps were sutured closed. The dressings were changed after six days and the skin sutures removed after 12 days.
+l
+p
+u
+o
+C
+.
+R
+193
+WAR SURGERY
+Figure 23.12 Oedematous guillotine amputation stump.
+194...
+
+=== Chunk 3021 ===
+Source: 4105_002-ebook.pdf
+Length: 1341 chars
+
+23.7 Guillotine amputation
+Guillotine amputation for a severely mangled limb or prolonged crush is only indicated as a last resort and in extreme situations such as emergency extraction of a victim under rubble or in a vehicle wreck, or for widespread gas gangrene. In a critically ill patient, where appropriate, disarticulation is preferable as a more rapid and less bloody damage-control procedure.
+Guillotine amputation should not be performed as a routine operation.
+The skin, fascia and muscle ...
+
+=== Chunk 3022 ===
+Source: 4105_002-ebook.pdf
+Length: 987 chars
+
+23.7.1 management of an open guillotine stump
+If, for whatever reason, the surgeon is faced with an open guillotine stump, further management will depend on timing and the state of the wound.
+1. If received within 48 hours, a clean stump should be re-amputated at the correct level, salvaging all viable soft tissue. The stump is left open, and DPC performed 5 days later.
+2.
+If later than 48 hours and still clean, the stump should be left as it is. Dressings are performed every 2 – 3 days and the ...
+
+=== Chunk 3023 ===
+Source: 4105_002-ebook.pdf
+Length: 304 chars
+
+23.8 specific amputations and disarticulations
+For the technical operative details of different amputation levels the reader is referred to standard textbooks of orthopaedic surgery. The following Section deals only with those aspects relevant to the management of war wounds where resources are limited....
+
+=== Chunk 3024 ===
+Source: 4105_002-ebook.pdf
+Length: 214 chars
+
+23.8.1 Foot amputations
+A few patients suffer trauma limited to the forefoot, the calcaneus and its soft-tissue covering being preserved. Several levels of amputation-disarticulation are described.
+C
+Papas / ICRC
+P...
+
+=== Chunk 3025 ===
+Source: 4105_002-ebook.pdf
+Length: 212 chars
+
+Figure 23.13.1
+Partial foot amputations.
+a. Amputation across the metatarsal shafts.
+b. Tarso-metatarsal disarticulation.
+c. Tarso-talar disarticulation (Chopart amputation).
+.
+N
+C
+Icrc
+R
+C
+I
+C
+Papas / ICRC
+P
+.
+N...
+
+=== Chunk 3026 ===
+Source: 4105_002-ebook.pdf
+Length: 804 chars
+
+Figure 23.13.3
+Partial foot amputation and some common problems: skin trauma and calcaneus tilt due to muscle imbalance.
+Possible solution for correction of the calcaneus tilt: arthrodesis of the ankle by means of screws or Steinmann pins.
+In communities where many people still go barefoot or farmers work in muddy fields and rice paddies, a Syme amputation, which is an end-bearing stump, is often much preferred by the patient. Amputation at a higher level involves the use of footwear or crutches...
+
+=== Chunk 3027 ===
+Source: 4105_002-ebook.pdf
+Length: 95 chars
+
+Figures 23.14.2 and 23.14.3
+Syme’s amputation and a simple improvised repair of the prosthesis....
+
+=== Chunk 3028 ===
+Source: 4105_002-ebook.pdf
+Length: 93 chars
+
+Figure 23.15.1
+From the prosthetist’s point of view, these are overly-long and -short stumps....
+
+=== Chunk 3029 ===
+Source: 4105_002-ebook.pdf
+Length: 110 chars
+
+Figure 23.15.2
+The ideal stump length: somewhere in the middle third.
+196
+C
+Sasin / ICRC
+S
+.
+V
+V. Sasin / ICRC...
+
+=== Chunk 3030 ===
+Source: 4105_002-ebook.pdf
+Length: 1963 chars
+
+23.8.2 Transtibial amputation
+Transtibial amputation is by far the most common amputation performed for war trauma. With a good but simple prosthesis, it allows the patient a high degree of physiological function.
+The level of bone section is very important for the proper biomechanics of walking: 12 – 14 cm below the tibial tuberosity, with a minimum of 5 cm, is the classically defined level. In reality, this equates to 2.5 cm of bone length for every 30 cm of body height. Most transtibial amput...
+
+=== Chunk 3031 ===
+Source: 4105_002-ebook.pdf
+Length: 716 chars
+
+Very short tibial stump
+In some patients with an amputation high through the upper third of the tibia the remaining tissues are inadequate to cover the stump properly. In addition, the short fibular stump is no longer held in place by the interosseous membrane attaching it to the tibia and the strong pull of the lateral collateral ligament tilts the fibular head, which sticks out in abduction. ICRC prosthetists advise removing the head of the fibula in such cases. Removal of the head solves this...
+
+=== Chunk 3032 ===
+Source: 4105_002-ebook.pdf
+Length: 1235 chars
+
+Post-operative positioning and physiotherapy
+After a transtibial amputation, the normal tendency is to flex the knee; measures must be undertaken to prevent the development of a flexion contracture. The limb should be kept elevated on a pillow or Braun-Böhler frame to decrease oedema, but with no flexion of the knee. A POP back slab may assist in achieving this in the immediate post- operative period if a Braun-Böhler frame is not used and may then be applied only at night later on, if necessary...
+
+=== Chunk 3033 ===
+Source: 4105_002-ebook.pdf
+Length: 736 chars
+
+23.8.3 Knee disarticulation
+Primary knee disarticulation can be performed at the initial operation as a damage- control procedure, to minimize surgical trauma and blood loss in haemodynamically unstable patients. It can be performed quickly and without any sectioning of bone and be converted to a transfemoral amputation at a second operation.
+Whether a knee disarticulation should be a permanent and definitive procedure depends almost exclusively on the prosthetic expertise and technology availab...
+
+=== Chunk 3034 ===
+Source: 4105_002-ebook.pdf
+Length: 636 chars
+
+Advantages and disadvantages
+Much controversy surrounds the recourse to disarticulation where there are no adequate prosthetic services. If such services are available, then the through-knee disarticulation offers a better functional outcome compared to an amputation. On the other hand, cosmetic concerns may arise – and they are common – given the resulting prominence of the femoral condyles and the different height of the centre of the knee in the intact limb when compared to the artificial one...
+
+=== Chunk 3035 ===
+Source: 4105_002-ebook.pdf
+Length: 1000 chars
+
+Figure 23.16
+Operative technique for knee disarticulation. a. Outlining the anterior and posterior flaps.
+b. The anterior flap has been raised exposing the patellar tendon, which is cut through.
+c. The cruciate ligaments have been sectioned.
+d. The patellar tendon has been sutured to the remainder of the cruciate ligaments; the menisci have been removed.
+e. Anterior and medial view of the stump.
+f. The stump has been closed and a drain put in place.
+Figures 23.17.1 and 23.17.2 Typical knee disar...
+
+=== Chunk 3036 ===
+Source: 4105_002-ebook.pdf
+Length: 2693 chars
+
+Operative technique
+Various techniques have been described for the through-knee disarticulation. They all cause a certain extent of surgical trauma.
+d
+King Volume 2 adapted
+10 cm  5 cm  a  b  c  d  e  f
+10 cm
+5 cm
+a
+b
+c
+.
+M
+d
+e
+f
+It is not necessary to remove the articular cartilage.
+The ICRC experience of both surgeons and prosthetists suggests using the simplest technique. If the wound allows for it, an anterior skin flap is raised, providing stronger skin than that of the popliteal fossa. The...
+
+=== Chunk 3037 ===
+Source: 4105_002-ebook.pdf
+Length: 772 chars
+
+23.8.4 Transfemoral amputation
+The loss of the knee results in much more effort and expenditure of energy and oxygen consumption in walking because the prosthesis bears the weight in the groin instead of the stump. The femoral stump should be kept as long as possible, with a minimum of 10 cm from the greater trochanter. Managing a very short stump requires close consultation with the prosthetist.
+cm  0  60°  Abduction pronounced due to insufficient adductor brevis  20  70°  Moderate abduction an...
+
+=== Chunk 3038 ===
+Source: 4105_002-ebook.pdf
+Length: 654 chars
+
+Figure 23.18.1
+The longer the transfemoral stump, the better the functional result.
+The shorter the stump, the greater the abduction force and the energy required for walking.
+Where possible, a myodesis of the adductors – attached to the bone through drill holes – on the lateral side of the femoral stump helps prevent abduction contractures.
+C
+ICRC
+R
+C
+I
+Oedematous swelling of the transected muscles can be considerable. As many intact muscles should be retained as the trauma permits, especially ...
+
+=== Chunk 3039 ===
+Source: 4105_002-ebook.pdf
+Length: 596 chars
+
+Figure 23.18.2
+Good left stump, poor right stump: not enough soft tissue covering.
+C
+ICRC
+R
+C
+I
+In amputations of the proximal third of the femur, the surgeon must attempt to salvage whatever can be kept of the antagonistic muscle groups and try to create a residual limb dynamically balanced between adductors and abductors. There might not be sufficient muscular mass to achieve this. The surgeon should aim at least for a good, firm soft-tissue padding of the bone end.
+As mentioned in the case of...
+
+=== Chunk 3040 ===
+Source: 4105_002-ebook.pdf
+Length: 537 chars
+
+23.8.5 Hip disarticulation and hemipelvectomy
+These mutilating operations are fortunately rarely encountered in war trauma. Associated injury to the pelvis and abdomen is usually so severe that most patients succumb. If it does need to be performed, usually because of severely infected and unsuccessfully managed more distal amputations, sufficient soft-tissue cover is required and as much of the pelvic bone structure retained as possible.
+E. Dykes / ICRC
+z g
+é
+Figures 23.19.1 and 23.19.2
+Hip dis...
+
+=== Chunk 3041 ===
+Source: 4105_002-ebook.pdf
+Length: 671 chars
+
+23.8.6 Arm amputations
+The general rule is to keep the upper-limb stump as long as possible, to provide the longest possible “paddle” that is stable and painless. A short below-elbow amputation is better than an above-elbow stump. The radius and ulna are sectioned at the same level and antagonistic muscle groups sutured together. Of greatest importance is the functional position of the remaining part of the limb: 90° flexion of the elbow and supination of the forearm to enable whatever manipulat...
+
+=== Chunk 3042 ===
+Source: 4105_002-ebook.pdf
+Length: 133 chars
+
+Figure 23.20
+The Krukenberg procedure: rehabilitation exercises are a first step towards socio-economic reintegration of the patient....
+
+=== Chunk 3043 ===
+Source: 4105_002-ebook.pdf
+Length: 308 chars
+
+23.9 Post-operative care
+Overly constrictive bandaging of amputation stumps can easily compromise the blood supply to the skin over the anterior surface of the tibia. Gentle but firm compression helps control oedema and decreases pain.
+C
+R
+C
+I
+/
+s
+a
+p
+a
+P
+.
+N
+a  b  c  d  e  f  g  h  i  j
+a
+b
+c
+d
+e
+f
+g
+h
+i
+j...
+
+=== Chunk 3044 ===
+Source: 4105_002-ebook.pdf
+Length: 1423 chars
+
+Figures 23.21.1 and 23.21.2
+Figure-of-eight elastic bandaging of amputation stumps.
+The size of the elastic bandage should be adapted to the stump: for a transtibial stump 8 – 10 cm wide, and for transfemoral 10 – 15 cm wide.
+The bandage should be wrapped from the tip of the stump to always end at the lymph nodes proximal to the oedema (popliteal fossa or groin) and pressure should be greater distal than proximal.
+The layers should overlap about half of the bandage width at each turn, with the b...
+
+=== Chunk 3045 ===
+Source: 4105_002-ebook.pdf
+Length: 587 chars
+
+23.10 Patient rehabilitation
+Treatment of the patient is not over until rehabilitation is complete. This may entail reconstructive surgery involving specialist techniques, which are beyond the scope of this publication; physiotherapy continuing long after surgery; the fitting of a prosthesis; and subsequent vocational training to help the patient regain as active and independent a role as possible in the community.
+Treatment is not complete until the patient is fitted with a prosthesis and achie...
+
+=== Chunk 3046 ===
+Source: 4105_002-ebook.pdf
+Length: 5054 chars
+
+Figure 23.22
+The importance of physical rehabilitation: mine victim at the Cúcuta prosthetic limb-fitting centre (Colombia).
+202
+Once healing has been established, firm bandaging helps decrease oedema and maintain the shape of the stump. The physiotherapist is the person closest to the patient and best placed to determine if the stump is ready for fitting. This was usually considered to be after three months, but fitting of a prosthesis can be performed much earlier (6 – 8 weeks after skin closu...
+
+=== Chunk 3047 ===
+Source: 4105_002-ebook.pdf
+Length: 1710 chars
+
+23.11 Complications and stump revision
+Many patients suffer from a number of complications, early and late, from minor skin irritation to wound infection and necrosis. The most common include a painful neuroma, phantom and residual pain, redundant soft tissue, bone spurs and heterotopic ossification; and later the occurrence of low-back pain and degenerative joint disease due to faulty gait.
+Patients should be examined by the surgeon together with the prosthetist and physiotherapist. What might ...
+
+=== Chunk 3048 ===
+Source: 4105_002-ebook.pdf
+Length: 1057 chars
+
+Figures 23.23.1 – 23.23.8
+Examples of some common complications.
+C
+Nasreddine / ICRC
+N
+C
+Nasreddine / ICRC
+N
+C
+H.Tarakhchyan / ICRC
+.
+.
+H
+H
+H
+Figure 23.23.1 Infection of the wound.
+Figure 23.23.2 Globular stump and “dog ears” of the scar.
+Figure 23.23.3 Invagination of the scar.
+C
+H.Tarakhchyan / ICRC
+C
+R
+:
+C
+H.Tarakhchyan / ICRC
+H
+C
+I
+H
+Figure 23.23.4 Adherent scar.
+Figure 23.23.5 Very short stump.
+Figure 23.23.6 Non-bevelling of the anterior crest of the tibia.
+C
+IcRC
+R
+C
+C
+ICRC
+R
+C
+I
+I
+Figure...
+
+=== Chunk 3049 ===
+Source: 4105_002-ebook.pdf
+Length: 879 chars
+
+23.11.1 Painful neuroma
+A painful neuroma is probably the most common surgical complication after amputation; it is entirely organic in origin. The patient complains of a sharp, clearly localized pain, like an electric shock, caused by pressure at a specific point of the stump. On gentle palpation a hard, mobile swelling is identified, at times the size of an olive. Palpation of the swelling exacerbates the pain, which is described as the one the patient feels with the prosthesis.
+The treatment:...
+
+=== Chunk 3050 ===
+Source: 4105_002-ebook.pdf
+Length: 1888 chars
+
+23.11.2 Phantom limb sensation and pain
+The loss of a limb radically changes the psychological self-image of the patient, but a great deal of the physiological and anatomic image remains intact, so much so that the patient perceives the continued presence of the amputated limb. The person maintains a complete “body map” imprinted in the higher brain centres. Many phantom sensations are not painful and their occurrence should be explained to the amputee as a normal reaction post-injury. Persons w...
+
+=== Chunk 3051 ===
+Source: 4105_002-ebook.pdf
+Length: 79 chars
+
+Figure 23.24.1
+The amputee lies in bed and places a mirror between his legs.
+as...
+
+=== Chunk 3052 ===
+Source: 4105_002-ebook.pdf
+Length: 1573 chars
+
+Figure 23.24.2
+While looking at the mirror image, the patient exercises his foot: plantar flexion.
+Recently, ICRC physiotherapists have introduced “mirror therapy”, based on visual feedback.7 It had been observed that an amputee looking at the reflection of an intact limb in a mirror helped induce sensations of movement in the phantom limb. The illusion of two intact limbs may reverse the pathological changes in the somatotopic organization of the motor and sensory cortex and in neuron excitabil...
+
+=== Chunk 3053 ===
+Source: 4105_002-ebook.pdf
+Length: 1407 chars
+
+Chapter 24 VASCULAR INJURIES
+207
+WAR SURGERY
+208
+24. VASCULAR INJURIES 24.1 Introduction 24.2 Wound ballistics and types of arterial injury 24.3 Epidemiology 24.3.1 Relative incidence of peripheral vascular injuries 24.3.2 Combined arterially-associated injuries 24.3.3 Amputation rate after vascular injuries 24.3.4 Amputation versus limb salvage 24.3.5 Missile emboli 24.3.6 Red Cross Wound Score 24.4 Emergency room care 24.4.1 Pneumatic tourniquet 24.4.2 Paraclinical investigations 24.5 Diagnosi...
+
+=== Chunk 3054 ===
+Source: 4105_002-ebook.pdf
+Length: 579 chars
+
+24.1 introduction
+Exsanguination from wounds in the limbs is the most frequent cause of preventable death on the modern battlefield. Although this primarily concerns the pre-hospital first-aid phase, its importance in hospital surgical care cannot be underestimated. Major vascular procedures in the limbs have become commonplace in modern surgical practice; however, when faced with an influx of mass casualties, vascular repair may consume an inordinate amount of theatre time. Simple ligation and ...
+
+=== Chunk 3055 ===
+Source: 4105_002-ebook.pdf
+Length: 483 chars
+
+24.2 Wound ballistics and types of arterial injury
+In most cases, the elongated elastic structure of arteries causes them to “flee” a projectile. It is not uncommon for the surgeon to find that the only intact structures traversing a large wound cavity are the neurovascular bundle and/or tendons.
+Ballistic effects create several different types of arterial injury (Figure 24.1).        a  d  b  f  C  R  e  C  I     /     u  o  n  n  c  a  i  G     .  C
+C
+R
+C
+I
+/
+u
+o
+n
+n
+a
+i
+G
+.
+C...
+
+=== Chunk 3056 ===
+Source: 4105_002-ebook.pdf
+Length: 465 chars
+
+Figure 24.1
+Types of arterial trauma.
+a. Section of the artery with spasm of the cut ends.
+b. Lateral punctate laceration: the lesion remains open.
+c. Lateral laceration with rupture of the entire arterial wall: pulsating haematoma leading to a pseudoaneurysm.
+d. Contusion, intimal damage and spasm leading to thrombosis.
+e. Contusion and rupture of the media causing a true aneurysm.
+f. Combined arterial and venous injury: arterio-venous fistula.
+209
+WAR SURGERY...
+
+=== Chunk 3057 ===
+Source: 4105_002-ebook.pdf
+Length: 367 chars
+
+Figure 24.2
+Artery in proximity to the wound channel of a fragmenting FMJ high-kinetic energy bullet.
+a. Vessel close to straight narrow channel: no lesion, the vessel “flees” the bullet.
+b. Involvement in the temporary cavity: arterial avulsion or contusion depending on the distance from the centre of the cavity.
+c. Laceration of the artery by bullet fragment.
+210...
+
+=== Chunk 3058 ===
+Source: 4105_002-ebook.pdf
+Length: 1403 chars
+
+Complete transection or avulsion
+Most injuries to blood vessels are due to direct contact with the projectile: i.e. laceration, whether by a low- or high-kinetic energy missile. In addition, a near-miss by a high- energy projectile at the point of temporary cavity formation in the shooting channel may cause the artery to be avulsed by the severe stretch to which it is subjected.
+A complete transection or avulsion of the artery is accompanied by loss of tissue and microscopic damage to all layers...
+
+=== Chunk 3059 ===
+Source: 4105_002-ebook.pdf
+Length: 815 chars
+
+Lateral laceration or punctate wound
+After lateral laceration or punctate wound, vessel continuity remains intact but a portion of the wall is torn open. A small shrapnel fragment, a piece of a fragmented bullet, or a spicule of bone may occasionally puncture and remain stuck in the vessel wall, thereby creating a tamponade effect. In most cases, a lateral laceration stays open: there is no retraction and no spasm and immediate haemorrhage occurs, which may result in a pulsating haematoma and, a...
+
+=== Chunk 3060 ===
+Source: 4105_002-ebook.pdf
+Length: 1411 chars
+
+Arterial contusion and intimal detachment
+The temporary cavity can cause arterial contusion when the vessel is at a distance from the track of a high-energy missile, in contrast to the near-miss. The artery is stretched and compressed against the wall of the cavity causing adventitial haemorrhage first, then breaks in the tunica media, and finally disruption of the intima with or without the prolapse of an intimal flap. Microscopic changes have been described up to 2 cm in both directions into a...
+
+=== Chunk 3061 ===
+Source: 4105_002-ebook.pdf
+Length: 966 chars
+
+Arterial spasm
+Arterial spasm, a reflex contraction of the vessel wall, may result from projectile- induced cavity formation or a blunt injury. The diagnosis can only be made on angiography or surgical exploration to exclude contusion, or on an arteriotomy to exclude a significant intimal flap. A high degree of suspicion is necessary and the surgeon should not be content with “spasm” as an explanation for ischaemia.
+VAsCULAR iNJURiEs
+It is very dangerous to diagnose arterial spasm on simple clin...
+
+=== Chunk 3062 ===
+Source: 4105_002-ebook.pdf
+Length: 351 chars
+
+24.3 Epidemiology
+Hospital mortality after vascular injuries frequently depends on associated trauma to other body regions, hence the maxim: “sacrifice a limb to save a life”. By the time the life-saving laparotomy has been completed, the viability of a limb may have been compromised beyond recuperation by the cumulative time of shock and ischaemia....
+
+=== Chunk 3063 ===
+Source: 4105_002-ebook.pdf
+Length: 1330 chars
+
+24.3.1 Relative incidence of peripheral vascular injuries
+Although 50 – 75 % of major war wounds involve the limbs, only 1 – 2 % include injury to major vessels. This figure rises to 9 % and more where modern body armour is used, as it offers greater protection to the torso, and in conflicts where anti-personnel mines are widely deployed; about one-half undergo repair and the other half ligation. One ICRC surgical team working on the Cambodian-Thai border in 1988 during a conflict that witnessed...
+
+=== Chunk 3064 ===
+Source: 4105_002-ebook.pdf
+Length: 2265 chars
+
+24.3.2 Combined arterially-associated injuries
+The anatomy of certain regions lends itself more readily to combined injuries to the artery and vein and concomitant fracture of the bone. This is particularly the case for the popliteal artery and vein, the axillary artery and brachial plexus, and the femoral vessels and femur.
+Vein (%) Nerve (%) Bone (%) Artery Lebanon N = 550 USA Viet Nam N = 936 USSR Afghanistan N = 194 USA Afghanistan / Iraq N = 585 USA Viet Nam USSR Afghanistan USA Viet Nam US...
+
+=== Chunk 3065 ===
+Source: 4105_002-ebook.pdf
+Length: 1772 chars
+
+24.3.3 Amputation rate after vascular injuries
+Several classic studies of vascular wounds in World War II, Korea and Viet Nam, have set the modern standard. Until the Korean War, ligation of a severed artery was the primary treatment, although a few surgeons had already tried to practise vascular repair. The most often quoted statistic is taken from the well-known World War II study by DeBakey and Simeone.3 Out of 2,471 vascular injuries, only 81 (3 %) were repaired primarily, with an amputation...
+
+=== Chunk 3066 ===
+Source: 4105_002-ebook.pdf
+Length: 3669 chars
+
+24.3.4 Amputation versus limb salvage
+Shock, the state of the patient’s collateral circulation, and concomitant fracture play important roles in determining the outcome: amputation or limb salvage. Among the most frequent operations for vascular injury are amputation and fasciotomy.
+Major clinical reasons for an amputation in patients with vascular injury include:
+• delay in diagnosis and revascularization;
+• inability to perform vascular repair due to extensive soft-tissue damage;
+• infection;
+...
+
+=== Chunk 3067 ===
+Source: 4105_002-ebook.pdf
+Length: 913 chars
+
+24.3.5 missile emboli
+As discussed in Chapter 14, missile embolism is an exceedingly rare phenomenon that is only ever reported for individual cases. More cases have been described following civilian violence than in the military literature. The Vietnam Vascular Registry recorded only 22 such cases among approximately 7,500 casualties with vascular lesions, representing an incidence of only 0.3 %. All but three of these 22 cases had been wounded by small fragments from anti-personnel landmines, ...
+
+=== Chunk 3068 ===
+Source: 4105_002-ebook.pdf
+Length: 729 chars
+
+24.3.6 Red Cross Wound score
+Peripheral vascular injury proximal to the knee and elbow can result in life-threatening haemorrhage. Thus, in the RCWS a lesion in one of these vessels is scored V = H.
+The results of an ICRC study on 73 patients with lesions in the femoral or popliteal arteries, with and without a concomitant fracture, are shown in Figure 24.4. Although the numbers do not allow for a statistically significant result, the tendency is obvious and stands to reason. Arterial lesions in...
+
+=== Chunk 3069 ===
+Source: 4105_002-ebook.pdf
+Length: 290 chars
+
+Figure 24.4
+ICRC study of mortality and amputation by wound Type and Grade. Lesions of the femoral or popliteal vessels qualify as a Type H wound. The presence of a clinically significant fracture = Type F wound. Grades are 1, 2 and 3 according to the size of the wound.
+213
+WAR SURGERY
+214...
+
+=== Chunk 3070 ===
+Source: 4105_002-ebook.pdf
+Length: 1566 chars
+
+24.4 Emergency room care
+Catastrophic external haemorrhage from peripheral vessels is the first C in the C-ABCDE paradigm and, in the best circumstances, should have been dealt with by first aid in the pre-hospital setting (see Section 7.4.3). If pre-hospital measures have been taken and are effective, they should not be removed until the patient is in the operating theatre. If there is ongoing bleeding, a proximal pneumatic tourniquet can be applied. Re-bleeding from a poorly applied tourniquet...
+
+=== Chunk 3071 ===
+Source: 4105_002-ebook.pdf
+Length: 362 chars
+
+24.4.1 Pneumatic tourniquet
+The use of a pneumatic tourniquet is of great value until proximal and distal control can be obtained in theatre. However, it should not be used for a wound with a self- contained haematoma or isolated signs of ischaemia as it cuts off the collateral circulation that may be the only thing maintaining viability of the distal tissues....
+
+=== Chunk 3072 ===
+Source: 4105_002-ebook.pdf
+Length: 2020 chars
+
+24.4.2 Paraclinical investigations
+If available, arteriography may be performed in a stable patient where the signs of ischaemia are inconclusive. This is best undertaken by the surgeon. If the proper X-ray equipment (mobile machine, C-arm fluoroscopy) is not available in theatre, then the surgeon must go with the patient to the X-ray department and make certain that there is no delay. The common femoral artery can be cannulated percutaneously away from the injury with a fine 18-gauge needle whi...
+
+=== Chunk 3073 ===
+Source: 4105_002-ebook.pdf
+Length: 3172 chars
+
+24.5 Diagnosis and surgical decision-making
+Major arterial lesions can be difficult to diagnose in the presence of shock, large fragment blast wounds with severe soft tissue and bony involvement, or multiple injuries. However, some “hard signs” of arterial injury are evident:
+• active, pulsatile haemorrhage;
+• large, expanding haematoma;
+• pulsatile haematoma with a bruit or thrill (pseudoaneurysm);
+• “machinery” murmur (arteriovenous fistula);
+• signs of acute distal ischaemia, especially absen...
+
+=== Chunk 3074 ===
+Source: 4105_002-ebook.pdf
+Length: 308 chars
+
+Figure 24.5
+Ecchymosis in association with a bullet track close to the popliteal artery.
+Figure 24.6
+Obvious vascular injury: frank ischaemic gangrene following GSW.
+Figure 24.7
+Always compare both limbs for signs of ischaemia.
+215
+C
+IcRC
+R
+C
+I
+C
+F.Hekert / ICRC
+F
+C
+R
+C
+I
+WAR SURGERY
+C
+Coupland / ICRC
+C
+.
+R...
+
+=== Chunk 3075 ===
+Source: 4105_002-ebook.pdf
+Length: 2550 chars
+
+Figure 24.8
+The muscles of more than two compartments were found to be necrotic.
+C
+&
+R
+C
+I
+/
+n
+n
+a
+m
+s
+s
+a
+S
+G
+.
+T
+Figure 24.9 Vascular clamps.
+216
+Partial ischaemia with some collateral blood flow and developing compartment syndrome can be difficult, if not impossible, to differentiate from complete ischaemia. The clinical evaluation of irreversible ischaemic muscle and nerve damage is usually not possible, except where there has been much delay. In ambiguous presentations fasciotomy should be ...
+
+=== Chunk 3076 ===
+Source: 4105_002-ebook.pdf
+Length: 106 chars
+
+24.6 surgical management
+The most effective procedure to stop haemorrhage is a ligature around the vessel....
+
+=== Chunk 3077 ===
+Source: 4105_002-ebook.pdf
+Length: 362 chars
+
+24.6.1 Preparation of the non-specialist
+Vascular surgery takes time. The general surgeon who does not perform vascular surgery on a regular basis must prepare for it with a thorough revision of vascular anatomy and the incisions for exposure of major vessels. The basic techniques of arterial suture are straightforward, as are simple damage-control procedures....
+
+=== Chunk 3078 ===
+Source: 4105_002-ebook.pdf
+Length: 1001 chars
+
+24.6.2 Preparation of the operating theatre
+Vascular instruments are special and specific: DeBakey, Blalock and Satinsky vascular and bulldog clamps, etc. They can be improvised to a certain extent: non-crushing intestinal clamps or ordinary haemostatic forceps with plastic intravenous-giving lines placed over the blades can be used. Vascular sutures are monofilament, very fine, and inserted on a non-traumatic eyeless needle. If vascular monofilament suture is not available, fine braided silk pa...
+
+=== Chunk 3079 ===
+Source: 4105_002-ebook.pdf
+Length: 703 chars
+
+24.6.3 Preparation of the patient
+The positioning and draping of the patient for proper vascular exposure is important; proximal control may require opening the chest or abdomen for “junctional zone” injuries (see Section D. 6). The skin of the uninjured leg should be prepared at the same time for the harvesting of a vein interposition graft if necessary.
+Anaesthesia is as usual. The patient must first have been properly resuscitated: vascular surgery is time-consuming and the patient must not b...
+
+=== Chunk 3080 ===
+Source: 4105_002-ebook.pdf
+Length: 463 chars
+
+24.6.4 surgical techniques for arterial trauma
+Major arteries should be repaired whenever possible. The basic principles comprise:
+• control of haemorrhage;
+• exposure and control of the vessels, proximally and distally;
+• maintenance of the patency of the vascular tree;
+• preparation of the vessel;
+• repair or reconstruction of the artery;
+• covering the artery with appropriate soft tissue;
+• wound debridement and stabilization of any fracture;
+• fasciotomy....
+
+=== Chunk 3081 ===
+Source: 4105_002-ebook.pdf
+Length: 174 chars
+
+Figures 24.10.1 and 24.10.2
+Rummel tourniquet: a tape is passed through a rubber tube or catheter.
+217
+WAR SURGERY
+Figure 24.11
+Generous incision for exposure of the vessels....
+
+=== Chunk 3082 ===
+Source: 4105_002-ebook.pdf
+Length: 3892 chars
+
+Figure 24.12
+Proximal and distal control of the vessel using vascular clamps and improvised Rummel tourniquets using Penrose drains.
+218
+1. Control haemorrhage.
+The pneumatic tourniquet is inflated. It may be applied even without overt haemorrhage, but should not be inflated until the very moment it is needed. Remote proximal control can be obtained by groin cutdown to access the femoral vessels and Rummel tourniquets applied.
+2. Expose the vessel.
+Proximal exposure of the major vessels is accom...
+
+=== Chunk 3083 ===
+Source: 4105_002-ebook.pdf
+Length: 202 chars
+
+Figure 24.13
+The sectioned ends are held in bulldog clamps.
+—_— ~*
+Figure 24.14 Thrombus removed from the damaged vessel.
+219
+C.Pacitti / ICRC
+WAR SURGERY
+Figure 24.15.1 Lateral laceration of an artery....
+
+=== Chunk 3084 ===
+Source: 4105_002-ebook.pdf
+Length: 165 chars
+
+Figure 24.15.2
+Repair of lateral arterial laceration with a vein patch graft. Two stay sutures may be placed at both ends first for better control of the vessel.
+220...
+
+=== Chunk 3085 ===
+Source: 4105_002-ebook.pdf
+Length: 611 chars
+
+Lateral laceration
+Direct repair by suture is possible only for small, clean-cut lacerations of large arteries, except if there is a risk of stenosis. Sutures should be inserted 1 mm apart and about 1 mm from the wound edge using continuous 5/0 – 6/0 synthetic vascular suture. Lacerations of significant small- or medium-sized arteries or cases where direct suture of a debrided artery would result in stenosis are better repaired with a venous patch graft. Some surgeons prefer resection of the inj...
+
+=== Chunk 3086 ===
+Source: 4105_002-ebook.pdf
+Length: 193 chars
+
+Arterial contusion
+Intimal damage is usually too extensive to allow for resection and anastomosis. Resection back to healthy tissue and replacement with a vein graft is the operation of choice....
+
+=== Chunk 3087 ===
+Source: 4105_002-ebook.pdf
+Length: 623 chars
+
+Arterial anastomosis
+The ends of the artery should be cut slightly obliquely (spatulation) but not as much as for the ureter. A continuous suture of very fine monofilament synthetic material (5/0 or 6/0) is best for the anastomosis. Two or three interrupted lateral stay-sutures may be used to control the proximal and distal ends. Interrupted sutures should be used for smaller calibre arteries such as the radial, ulnar or tibial or in children. There should be no tension on the arterial anastomos...
+
+=== Chunk 3088 ===
+Source: 4105_002-ebook.pdf
+Length: 1240 chars
+
+Interposition vein graft
+More extensive damage requires replacement by an interposition saphenous vein graft taken from the opposite limb so as not to compromise venous return in the injured extremity. Most arterial damage associated with missile wounds affects a large segment. Even after proximal and distal dissection, the cut ends still cannot be sufficiently approximated without tension and therefore a vein graft is necessary.
+The saphenous vein graft should be harvested from the uninjured li...
+
+=== Chunk 3089 ===
+Source: 4105_002-ebook.pdf
+Length: 268 chars
+
+Figure 24.16.2
+Excision of traumatized arterial segment with end-to-end anastomosis. Note the spatulation of the arterial ends.
+221
+WAR SURGERY
+C
+g
+R
+C
+I
+/
+i
+z &
+t
+t
+i
+c
+a
+P
+.
+C
+C
+P.Zylstra /ICRC
+a   a   a   v  v  v
+a
+a
+a
+v
+v
+v
+Figure 24.17.1 Interposition vein graft....
+
+=== Chunk 3090 ===
+Source: 4105_002-ebook.pdf
+Length: 685 chars
+
+Figure 24.17.2
+End-to-end vein graft anastomosis after resection of the segment of injured artery and spatulation of the ends: a = artery; v = vein graft.
+For interposition grafts some surgeons use a synthetic prosthesis. ICRC surgeons believe that in contaminated war wounds it is best to avoid a graft of synthetic material, which in any case is seldom available when working with limited resources. An autogenous vein graft is best.
+Please note:
+Children grow and so will their blood vessels: it i...
+
+=== Chunk 3091 ===
+Source: 4105_002-ebook.pdf
+Length: 643 chars
+
+The final stitch
+Before completing the last stitch of the repair, the distal clamp is removed momentarily to fill the segment with blood and remove any air. Once the final stitch is tied, the distal clamp is released first (lower pressure), then the proximal.
+In any arterial anastomosis, bleeding through the suture line after release of the clamps often occurs and should be controlled by gentle pressure packing for up to 10 minutes if necessary.10 Additional sutures usually only result in more b...
+
+=== Chunk 3092 ===
+Source: 4105_002-ebook.pdf
+Length: 335 chars
+
+Debride the wound
+After arterial repair or vein grafting, the wound is debrided and irrigated as usual and left open for delayed primary closure. During debridement, additional vascular and neural injuries should be looked for in the vicinity, especially if the primary damage has been inflicted by fragments which tend to be numerous....
+
+=== Chunk 3093 ===
+Source: 4105_002-ebook.pdf
+Length: 826 chars
+
+Provide soft-tissue coverage
+The repaired vessel should be covered with soft tissue: fascia or a muscle rotation flap if necessary (see Section B.11). The latissimus dorsi can cover the axillary and brachial vessels, and the gracilis muscle, among others, can be used for the femoral vessels. The gastrocnemius is suitable for the popliteal. However, to prevent thrombosis excessive compression of the vessel should be avoided. As mentioned, failure of soft- tissue coverage leads to failure: either ...
+
+=== Chunk 3094 ===
+Source: 4105_002-ebook.pdf
+Length: 452 chars
+
+Fasciotomy
+The following are particular indications for fasciotomy:11
+• delay of more than 4 hours between injury and restoration of flow;
+• prolonged period of hypotension or shock;
+• obvious oedema pre-operatively or developing during or after the surgical
+procedure;
+• combined venous and arterial injury in major vessels;
+• massive associated soft-tissue injury;
+• arterial ligation or obvious failure of the repair;
+• isolated major venous injury....
+
+=== Chunk 3095 ===
+Source: 4105_002-ebook.pdf
+Length: 420 chars
+
+Control the repair
+Distal perfusion of the limb – pulses and capillary filling – should be checked before the surgeon leaves the operating theatre. Re-exploration and confirmation of the patency of the anastomosis is best performed now rather than hours later. If the facilities are available and a pre-operative on-table arteriogram has been performed, it may be repeated immediately upon completion of primary surgery....
+
+=== Chunk 3096 ===
+Source: 4105_002-ebook.pdf
+Length: 671 chars
+
+24.7 Post-operative care
+Circulation peripheral to the vascular repair must be checked regularly. Close observation is necessary for any signs of haemorrhage or ischaemia (denoting thrombosis of the anastomosis), infection, or compartment syndrome if fasciotomy was not performed primarily.
+The limb should be splinted and maintained slightly elevated to improve venous drainage. Active isometric muscle exercises should begin on the first day after operation, whilst immobilization in bed is require...
+
+=== Chunk 3097 ===
+Source: 4105_002-ebook.pdf
+Length: 799 chars
+
+24.8 Damage control and temporary shunt
+In the past, the standard technique for dealing with an exsanguinating patient was simple ligation of the artery. This is still a possibility for an inexperienced surgeon and the safest haemostatic procedure in extremis.
+Modern trauma surgery makes wide use of a technique that was the basis for the first attempts at arterial anastomosis at the beginning of the 20th century and is very useful for the general surgeon operating with limited resources: a tempo...
+
+=== Chunk 3098 ===
+Source: 4105_002-ebook.pdf
+Length: 1266 chars
+
+Indications for a temporary shunt
+Rather than performing an arterial anastomosis or vein graft, some situations call for a temporary shunt as a damage-control approach:
+• a haemodynamically unstable patient with multiple injuries;
+• a large soft-tissue wound where the anatomy renders debridement difficult owing to the position of the neurovascular bundle;
+• a wound with a major fracture (see below);
+• multiple patients requiring repair and arriving at the same time;
+• a surgeon who is simply not...
+
+=== Chunk 3099 ===
+Source: 4105_002-ebook.pdf
+Length: 2100 chars
+
+Technique
+Distal and proximal embolectomy with a Fogarty catheter, instillation of heparinized saline into the vascular tree, and fasciotomy should all be performed beforehand.
+To construct a temporary shunt, a sufficiently long piece of i.v. line or other appropriate calibre of material (suction catheter, naso-gastric tube, paediatric feeding tube, T-tube, etc.), which does not injure the intima, is cut and filled with heparinized saline. This shunt is passed into the distal end first, then the...
+
+=== Chunk 3100 ===
+Source: 4105_002-ebook.pdf
+Length: 2017 chars
+
+24.9 Complex limb injuries: concomitant arterial lesion and fracture
+Arterial injury combined with a severe fracture presents a therapeutic challenge and leads to a relatively high rate of amputation. Appropriate priorities for surgical treatment must be decided: reperfusion comes before fracture immobilization. In theory, a vascular anastomosis may be disrupted by orthopaedic manipulation and, therefore, the argument has been made to stabilize the bone first. This is a theoretical danger more t...
+
+=== Chunk 3101 ===
+Source: 4105_002-ebook.pdf
+Length: 82 chars
+
+24.10 specific arteries
+Junctional trauma is of special concern (see Section D.6)....
+
+=== Chunk 3102 ===
+Source: 4105_002-ebook.pdf
+Length: 761 chars
+
+24.10.1 Arteries of the arm
+For the axillary artery, the arm is abducted and an incision made along the deltopectoral groove, from the middle of the clavicle to the distal edge of the pectoralis major. The dissection is continued between the deltoid and pectoralis major to expose the clavipectoral fascia and pectoralis minor, which are divided to access the axillary vessels and nervous plexus. The brachial artery is exposed by an incision in the medial groove between the biceps and triceps. The ...
+
+=== Chunk 3103 ===
+Source: 4105_002-ebook.pdf
+Length: 65 chars
+
+Figure 24.19
+Inverted Y-repair at the femoral artery bifurcation....
+
+=== Chunk 3104 ===
+Source: 4105_002-ebook.pdf
+Length: 126 chars
+
+Figure 24.20
+Medial incision for access to the popliteal fossa. The dotted red line is the medial fasciotomy continuation.
+226...
+
+=== Chunk 3105 ===
+Source: 4105_002-ebook.pdf
+Length: 1286 chars
+
+24.10.2 Femoral arteries
+Rapid laparotomy and clamping of the retroperitoneal external iliac artery assure proximal control in the groin. This can also be accomplished by a straightforward vertical incision placed halfway between the anterior superior iliac spine and the pubic tubercle and cutting through the inguinal ligament. Distal control of the femoral vessels does not always stop back-bleeding because of the position of the deep femoral artery. The intact distal femoral artery should be di...
+
+=== Chunk 3106 ===
+Source: 4105_002-ebook.pdf
+Length: 1169 chars
+
+24.10.3 Popliteal artery
+The popliteal artery is probably the most difficult to access and repair – and the results of repair the worst. Poor collateral circulation and a cramped anatomy combine to make popliteal injuries the most prone to result in amputation. A fasciotomy should always be performed even as a first step and can be a part of surgical exposure.
+To gain access to the popliteal vessels, two incisions are commonly used: medial and direct posterior. In the first, the knee is flexed 3...
+
+=== Chunk 3107 ===
+Source: 4105_002-ebook.pdf
+Length: 1509 chars
+
+24.11 Venous injury
+Major veins should be repaired rather than ligated whenever possible. An inadequate venous return increases the peripheral pooling of blood, which results in venous
+VAsCULAR iNJURiEs
+hypertension and greater blood loss. In addition, oedema formation and compartment pressure are increased, which in turn readily lead to compartment syndrome.
+Seventy-two hours appears to be the critical period for maintaining venous return flow in a major vein; a venous shunt is a useful adjunct...
+
+=== Chunk 3108 ===
+Source: 4105_002-ebook.pdf
+Length: 919 chars
+
+24.11.1 specific veins
+Certain major veins are particularly prone to complications after ligation: the popliteal in particular, where amputation may prove necessary even after successful arterial repair. The veins of the lower leg below the popliteal, and the forearm, however, may be ligated with impunity.
+In veins proximal to the profunda femoris (common femoral, external iliac and common iliac) ligation may lead to acute venous insufficiency with massive oedema and the risk of venous gangrene,...
+
+=== Chunk 3109 ===
+Source: 4105_002-ebook.pdf
+Length: 717 chars
+
+24.11.2 Combined arterial and venous injuries
+The vein should be repaired or shunted first to allow for free return when arterial flow is re-established. Otherwise there is the danger of venous pooling and stasis with subsequent thrombosis in the capillary bed. The exception is the carotid artery, which can be considered a central artery (see Section 30.8.3).
+In combined injuries, repair the vein before the artery.
+After repair of a vein and artery, a flap of muscle should be placed between the ...
+
+=== Chunk 3110 ===
+Source: 4105_002-ebook.pdf
+Length: 269 chars
+
+24.12 Arterio-venous fistula and pseudoaneurysm
+An arterio-venous fistula or pseudoaneurysm may occur acutely, but are more frequently seen in patients presenting late or in cases of missed diagnosis. They tend to occur more often with low-energy small fragment wounds....
+
+=== Chunk 3111 ===
+Source: 4105_002-ebook.pdf
+Length: 296 chars
+
+Figure 24.21
+Repair of an arterio-venous fistula using double interposition vein grafts.
+227
+C
+Papas /ICRC
+P
+.
+N
+C
+R
+C
+I
+/
+y
+2
+a
+m
+r
+I
+.
+F
+WAR SURGERY
+Figure 24.22
+Peri-operative angiogram of the left thigh showing a pseudoaneurysm of the superficial femoral artery and an arterio-venous fistula....
+
+=== Chunk 3112 ===
+Source: 4105_002-ebook.pdf
+Length: 84 chars
+
+Figure 24.23
+Pseudoaneurysm of the brachial artery just above the cubital fossa.
+228...
+
+=== Chunk 3113 ===
+Source: 4105_002-ebook.pdf
+Length: 1189 chars
+
+Arterio-venous fistula
+If an A-V fistula is encountered, it should be excluded or repaired, although there is a place for conservative non-operative management, depending on the condition of the patient and the experience of the surgeon. Should the limb be viable and show no signs of ischaemia, an A-V fistula may be allowed to “mature”, rendering the surgical approach easier and giving time for the full development of collateral circulation; or allowing for referral to a skilled vascular surgeon...
+
+=== Chunk 3114 ===
+Source: 4105_002-ebook.pdf
+Length: 1083 chars
+
+Pseudoaneurysm
+A lateral arterial laceration in a confined space may result in bleeding that is contained by the clot, which then becomes organized and transformed into a pseudoaneurysm; the patient presents with a pulsating haematoma.
+a
+b
+a
+b
+2
+A
+s
+i
+d
+d
+=
+A
+l
+a
+t
+i
+p
+s
+o
+H
+y
+m
+r
+A
+=
+l
+a
+r
+e
+n
+e
+G
+g 3
+/
+u
+d
+l
+e
+W
+.
+A
+As always, vascular control above and below the aneurysm must be secured. After clamping the vessel, the aneurysm is opened and the hole in the lumen identified.
+• If the hole is s...
+
+=== Chunk 3115 ===
+Source: 4105_002-ebook.pdf
+Length: 298 chars
+
+24.13 Complications
+The ultimate complications are infection with secondary haemorrhage or thrombosis of the repair leading to ischaemia and amputation. The significance of iatrogenic complications – damage to nerves during overzealous fasciotomies or blind clamping – should not be underestimated....
+
+=== Chunk 3116 ===
+Source: 4105_002-ebook.pdf
+Length: 546 chars
+
+24.13.1 infection
+Infection of the wound is the most common complication and often leads to the breakdown of an arterial repair and haemorrhage or thrombosis. Additional repair should not be performed in the infected site; proximal and distal ligation and resection of the infected arterial segment is mandatory. Occasionally it may be possible to reconstruct the arterial supply in an extra-anatomic location of healthy soft tissue to maintain viability of the limb; otherwise amputation is all too ...
+
+=== Chunk 3117 ===
+Source: 4105_002-ebook.pdf
+Length: 1252 chars
+
+24.13.2 Thrombosis
+Thrombosis of an anastomotic suture line can be due to infection but is usually due to a technical error that should have been identified before ending the primary operation. Such errors include:
+• inadequate arterial debridement;
+• residual distal arterial thrombus;
+• severe stenosis at the suture line;
+• loss of soft tissue cover over an arterial repair;
+• twisting, kinking, or external compression of a vein graft.
+The corrective is to re-operate and perform a new repair.
+A ...
+
+=== Chunk 3118 ===
+Source: 4105_002-ebook.pdf
+Length: 108 chars
+
+Figure 24.24
+Extra-anatomic repair after excision of an infected repair.
+229
+C
+Papas / ICRC
+P
+.
+N
+Chapter 25...
+
+=== Chunk 3119 ===
+Source: 4105_002-ebook.pdf
+Length: 615 chars
+
+INJURY TO PERIPHERAL NERVES
+231
+WAR SURGERY
+232
+25. INJURY TO PERIPHERAL NERVES
+25.1 Introduction 25.2 Wound ballistics 25.3 Pathophysiology 25.4 Epidemiology 25.4.1 Red Cross Wound Score 25.5 Clinical picture 25.6 Surgical management 25.6.1 Primary surgery 25.6.2 Delayed primary suture of a transected nerve 25.6.3 Surgical decision-making: delayed operation or not 25.7 Surgical technique of nerve suture 25.8 Post-operative care 25.8.1 Splinting for nerve palsies 25.9 Post-trauma sequelae 25.9.1...
+
+=== Chunk 3120 ===
+Source: 4105_002-ebook.pdf
+Length: 355 chars
+
+25.1 introduction
+Injuries to peripheral nerves occur more often than is commonly realized. Although not life-threatening, they are a major cause of long-term disability. In a low-income country, this will have a particularly adverse socio-economic impact on a person’s life. The results of nerve repair are mediocre and few cases are amenable to surgery....
+
+=== Chunk 3121 ===
+Source: 4105_002-ebook.pdf
+Length: 1181 chars
+
+25.2 Wound ballistics
+Nerves are less fragile than most structures and, like arteries and tendons, tend to “flee” a passing projectile. They are lacerated if struck directly, more frequently by a jagged fragment than by a bullet. It is not uncommon to find a small fragment embedded in a nerve trunk and causing a partial section. However, most lacerations of peripheral nerves in war wounds are caused by the jagged bone ends of fractures.
+The effects of the creation of a temporary cavity, on the o...
+
+=== Chunk 3122 ===
+Source: 4105_002-ebook.pdf
+Length: 110 chars
+
+25.3 Pathophysiology
+Projectiles can produce any of the three classical categories of peripheral nerve injury....
+
+=== Chunk 3123 ===
+Source: 4105_002-ebook.pdf
+Length: 308 chars
+
+Neurapraxia (nerve concussion or conduction block)
+Some demyelination may occur, but the axons remain intact. There is a transient functional loss – physiological paralysis – with spontaneous full recovery. When recovery of nervous conduction takes place, motor and sensory functions return at the same time....
+
+=== Chunk 3124 ===
+Source: 4105_002-ebook.pdf
+Length: 1046 chars
+
+Axonotmesis (intrathecal rupture of axons)
+The nerve sheath remains intact but the axons and their myelin sheath are damaged. Wallerian degeneration of the axons distal to the injury occurs, as well as intraneural fibrosis at the sites of axonal rupture. After an initial period of about ten days, the damaged proximal axons proliferate and grow down into the distal tubules at a very slow rate: approximately 1 – 2 mm per day. Proliferating axons and intraneural fibrosis create a fusiform neuroma-i...
+
+=== Chunk 3125 ===
+Source: 4105_002-ebook.pdf
+Length: 1310 chars
+
+Neurotmesis (anatomical division of the nerve)
+Division of the nerve trunk may be partial or complete, but all layers – sheath and axons – are affected. The nerve sheath also suffers longitudinal tears extending from the site of division. As with axonotmesis, proliferation of new fibres occurs in the proximal cut end while Wallerian degeneration occurs distally. In addition, the Schwann cells of the distal end proliferate forming a slight bulb. The severed ends retract like those of an artery, w...
+
+=== Chunk 3126 ===
+Source: 4105_002-ebook.pdf
+Length: 592 chars
+
+Recovery and nerve regeneration after repair
+Recovery after nerve repair or grafting is less satisfactory than with axonotmesis; some intraneural fibrosis takes place in the suture line no matter how accurate the surgery, and is increased by any suture-line tension, local inflammation or sepsis. In addition, proliferation of axons into the distal segment is never perfect and creates misallocation between axons and end organs, particularly noticeable in mixed motor- sensory nerves. The rate of ne...
+
+=== Chunk 3127 ===
+Source: 4105_002-ebook.pdf
+Length: 304 chars
+
+Perineural fibrosis
+A projectile coming to lie next to a nerve may provoke post-traumatic perineural fibrosis that causes nerve entrapment and compression leading to chronic neurological problems. Entrapment of the nerve in a callus can result in the same conditions. Both may require surgery for relief....
+
+=== Chunk 3128 ===
+Source: 4105_002-ebook.pdf
+Length: 1497 chars
+
+25.4 Epidemiology
+Peripheral nerve injuries commonly occur in projectile trauma to the limbs, but do not always involve major trunks. They are rarely isolated but more often found in conjunction with vascular injury and fractures, and more frequently in the upper than the lower limb.
+Except when concomitant with vascular injury, the incidence of nerve injuries is poorly documented and the frequency of neurapraxia is usually not recorded. Indeed, a large majority of patients demonstrate “lesions-...
+
+=== Chunk 3129 ===
+Source: 4105_002-ebook.pdf
+Length: 544 chars
+
+25.4.1 Red Cross Wound score
+The RCWS does not include a category for lesions of peripheral nerves. The Wound Score attempts to correlate ballistic effects with the extent of permanent tissue damage, rather than with physiological parameters.
+Nonetheless, one study was carried out on post-operative peripheral nerve recovery following war injuries using the Abbreviated Injury Scale (AIS) and the RCWS. A statistically significant relation was obtained between the functional nerve recovery, the AIS...
+
+=== Chunk 3130 ===
+Source: 4105_002-ebook.pdf
+Length: 1228 chars
+
+25.5 Clinical picture
+When facing a patient in a life-threatening condition, peripheral nerve injury is of the lowest priority and diagnosis is often missed. The arrival of large numbers of wounded patients and limited personnel, the inability to communicate with a patient in a coma, in shock or in pain and distressed, a lack of reliable diagnostic means, and poor clinical routine are among the other factors leading to a missed diagnosis.
+The complete examination of the limb involves a neurologi...
+
+=== Chunk 3131 ===
+Source: 4105_002-ebook.pdf
+Length: 732 chars
+
+Symptomatizing extraneural lesions
+Volume-occupying lesions such as a pseudoaneurysm or A-V fistula may lead to pressure on or stretching of a nerve resulting in severe pain and progressive loss of neurological function. This is especially the case when they occur in a confined space such as the popliteal fossa or anterior compartment of the lower leg, the axilla, elbow, or volar compartment of the forearm. Similarly, a compartment syndrome creates pressure on a nerve causing local ischaemic cha...
+
+=== Chunk 3132 ===
+Source: 4105_002-ebook.pdf
+Length: 125 chars
+
+Figure 25.1
+Complete division of the radial nerve. Only a thin strand of epineurium remains to join the two severed ends.
+236...
+
+=== Chunk 3133 ===
+Source: 4105_002-ebook.pdf
+Length: 228 chars
+
+25.6 surgical management
+Different scenarios must be discussed when dealing with injuries to peripheral nerves: the acute primary surgery stage and the delayed stages, where careful patient selection is of the utmost importance....
+
+=== Chunk 3134 ===
+Source: 4105_002-ebook.pdf
+Length: 397 chars
+
+25.6.1 Primary surgery
+Nerve injuries are usually noted incidentally during wound excision. If injury has been diagnosed pre-operatively, an attempt should be made to inspect the appropriate nerve during operation, without however dissecting through healthy tissues. The degree of damage should be recorded.
+One of two situations will be revealed: either the identified nerve is transected or not....
+
+=== Chunk 3135 ===
+Source: 4105_002-ebook.pdf
+Length: 2155 chars
+
+Transection of the nerve: neurotmesis
+If there has been complete division of the nerve, the ends are identified but not resected. They should be tacked down with non-absorbable monofilament sutures to separate but adjacent areas of healthy soft tissue at different levels while maintaining the correct rotation as much as possible. Tacking the severed ends prevents fibrotic retraction of the nerve, thereby maintaining the proper length for eventual repair; and placing them away from injured soft t...
+
+=== Chunk 3136 ===
+Source: 4105_002-ebook.pdf
+Length: 258 chars
+
+Non-transection of the nerve: lesion-in-continuity
+A contused nerve may exhibit neurapraxia or axonotmesis, which cannot readily be distinguished by observation at operation. A conservative approach is warranted and any decision to repair should be deferred....
+
+=== Chunk 3137 ===
+Source: 4105_002-ebook.pdf
+Length: 1118 chars
+
+Post-debridement and DPC
+Routine follow-up examination of any limb injury after wound debridement should include an assessment of the circulatory and neurological state of the extremity. An injury may have been missed during wound excision. While a vascular lesion may require immediate re-exploration, there is no rush with a missed nerve injury.
+Whether or not a nerve lesion was recognized during debridement, a careful examination should be made and the exact sensory, motor, and reflex status re...
+
+=== Chunk 3138 ===
+Source: 4105_002-ebook.pdf
+Length: 895 chars
+
+25.6.2 Delayed primary suture of a transected nerve
+A nerve known to be transected should be repaired when the wound is healthy and clean and once acute inflammation has subsided, but before irreparable damage has occurred to the motor end plate. Optimally, this is between 3 and 6 weeks post- DPC. However, surgery can wait for up to 3 months, provided certain nursing and physiotherapy protocols are respected.
+During this period, the extremity should be kept warm and covered with padding to prote...
+
+=== Chunk 3139 ===
+Source: 4105_002-ebook.pdf
+Length: 1084 chars
+
+25.6.3 surgical decision-making: delayed operation or not
+Most patients with nerve injuries have suffered a lesion-in-continuity: it is best to wait before deciding on surgical intervention because the majority will recover spontaneously. Some show no improvement at all. Many patients will present with old and healed wounds with a persisting neurological deficit: few cases, however, are amenable to surgery. To a large degree prognosis is determined by the status of the supplied tissues pending n...
+
+=== Chunk 3140 ===
+Source: 4105_002-ebook.pdf
+Length: 1880 chars
+
+Restoration of function
+Neurapraxia is common and axonotmesis will heal with time. In the latter case, the expected interval before recovery can be estimated by measuring the distance from the likely site of injury to the first muscle group innervated by the nerve: regeneration rate is about 1 mm a day, and the subsequent reactivation of the muscle end plate takes 3 weeks. If no improvement occurs within 6 – 12 weeks with expectant treatment, operative treatment should be considered.
+The most wi...
+
+=== Chunk 3141 ===
+Source: 4105_002-ebook.pdf
+Length: 562 chars
+
+Post-injury pain relief
+Surgery may be required to alleviate neuropathic pain. Conditions amenable to simple
+surgery include:
+• release of a nerve entrapped in fibrous tissue or a fracture callus
+• removal of a bone or projectile fragment lodged in a nerve trunk;
+• resection of a painful neuroma, especially in an amputation stump.
+Pain may also be iatrogenic, the result of inadvertent nerve ligature or badly applied external fixation.
+More complex chronic pain syndromes are initially treated wit...
+
+=== Chunk 3142 ===
+Source: 4105_002-ebook.pdf
+Length: 1510 chars
+
+25.7 surgical technique of nerve suture
+Nerve repair is properly a specialist technique requiring equipment and materials that are not usually available in resource-poor settings. Whether for primary or secondary repair, it is best to use an operating microscope, loupe or magnifying glasses; sometimes the latter can be improvised. Intra-operative electrophysiological measurements of function – standard in modern neurosurgery – are not often available either. Monofilament nylon suture produces th...
+
+=== Chunk 3143 ===
+Source: 4105_002-ebook.pdf
+Length: 157 chars
+
+Figure 25.2
+Regional anaesthesia and the use of a tourniquet facilitate the operation.
+Direct suture of a sectioned nerve after mobilization of the two ends....
+
+=== Chunk 3144 ===
+Source: 4105_002-ebook.pdf
+Length: 146 chars
+
+Figure 25.3.2
+Successive sections of the neuroma are sliced off until healthy nerve fibrils are reached.
+C
+C.Giannou/ ICRC
+R
+C
+I
+/
+u
+o
+n
+n
+a
+i
+G
+....
+
+=== Chunk 3145 ===
+Source: 4105_002-ebook.pdf
+Length: 133 chars
+
+Figure 25.4
+Stay sutures should pick up the epineurium only.
+C
+239
+C
+IcRc
+R
+C
+I
+C
+Papas / ICRC
+P
+.
+N
+C
+Papas / ICRC
+P
+.
+N
+WAR SURGERY...
+
+=== Chunk 3146 ===
+Source: 4105_002-ebook.pdf
+Length: 1383 chars
+
+Figure 25.5
+Repair is accomplished with fine sutures taking up the epineurium only.
+Figure 25.6 Loop-repair of lateral neuroma.
+N. Papas/ ICRC
+Nerve  Tendon
+Figure 25.7
+Differentiating a sectioned nerve from a tendon.
+240
+4. The repair is then completed with the finest sutures available picking up the epineurium only. The number of stitches should be kept to a minimum (3 to 6) as long as the apposition of the nerve ends is accurate.
+C.Giannou / ICRC
+eS
+5. If a lateral neuroma is encountered, onl...
+
+=== Chunk 3147 ===
+Source: 4105_002-ebook.pdf
+Length: 1989 chars
+
+25.8 Post-operative care
+Many long-term pathological changes occur after nerve injuries that influence the management and clinical outcome. The limb must be protected against these changes for nerve regeneration to be successful after the spontaneous recovery from axonotmesis or the repair of neurotmesis. Paralytic disuse of the limb impairs the distal circulation causing the skin to become blue, cold and thin, and the nails brittle. It also results in the formation of peri-articular adhesions a...
+
+=== Chunk 3148 ===
+Source: 4105_002-ebook.pdf
+Length: 986 chars
+
+25.8.1 splinting for nerve palsies
+Splints to prevent contractures and deformity from nerve palsies can be applied in many situations: when external fixation or traction is used after primary surgery; while awaiting nerve suture or recuperation after repair; and as a palliative measure for irremediable injury.
+Splints should be simple:
+• a well-padded POP-slab to prevent wrist-drop for radial nerve palsy;
+• small improvised aluminium finger-splints to prevent clawing of the fingers in ulnar nerv...
+
+=== Chunk 3149 ===
+Source: 4105_002-ebook.pdf
+Length: 924 chars
+
+25.9 Post-trauma sequelae
+Irremediable neurological deficit is the all too frequent outcome of nerve injuries. Nonetheless, partial compensation often occurs by adjacent muscle groups taking on some of the lost motor function so that the ultimate functional result is better than might be expected. Resorting to nerve grafting is often disappointing: it is a difficult specialist procedure with uncertain results. Tendon transfer operation may be considered in selected patients in case of hand or fo...
+
+=== Chunk 3150 ===
+Source: 4105_002-ebook.pdf
+Length: 1935 chars
+
+25.9.1 Post-injury pain syndromes
+Various chronic pain syndromes are frequent after missile trauma to peripheral nerves; more so in mixed nerves than in purely motor ones. Their treatment differs according to cause and type of pain: medication, nerve block, physiotherapy, or surgery. Painful neuromas and phantom limb pain are dealt with in Section 23.11.2. Some forms of neuropathic pain are usually amenable to simple surgery (see Section 25.6.3).
+A number of chronic complex pain syndromes can on...
+
+=== Chunk 3151 ===
+Source: 4105_002-ebook.pdf
+Length: 144 chars
+
+Part C HEAD, FACE, AND NECK
+245
+WAR SURGERY
+246
+C. HEAD, FACE, AND NECK
+The general surgeon and the head, face and neck
+248
+HEAD, FACE, AND NECK...
+
+=== Chunk 3152 ===
+Source: 4105_002-ebook.pdf
+Length: 1284 chars
+
+The general surgeon and the head, face and neck
+The general surgeon will usually have only a passing knowledge of the techniques and procedures of neurosurgery, maxillo-facial surgery, ophthalmology, and otorhinolaryngology.3 Nonetheless, the same solid scientific principles that underlie the treatment of war wounds in general can also be applied to projectile injuries of this region and are well within the competency of the general surgeon. The surgeon should note that wounds of the head, face ...
+
+=== Chunk 3153 ===
+Source: 4105_002-ebook.pdf
+Length: 2015 chars
+
+Chapter 26 CRANIO-CEREBRAL INJURIES
+251
+WAR SURGERY
+252
+26.
+CRANIO-CEREBRAL INJURIES
+26.1 Introduction 26.1.1 The general surgeon and neurotraumatology 26.2 Mechanisms of injury and wound ballistics 26.2.1 Behaviour of the bone 26.2.2 Behaviour of the brain 26.2.3 Wearing a protective helmet 26.3 Epidemiology 26.3.1 Incidence 26.3.2 Mechanism of injury and survivability 26.3.3 Prognosis 26.3.4 Red Cross Wound Score 26.4 Pathophysiology 26.4.1 Primary and secondary brain injury 26.4.2 Cerebral pe...
+
+=== Chunk 3154 ===
+Source: 4105_002-ebook.pdf
+Length: 1121 chars
+
+26.1 Introduction
+Head trauma in times of war may be penetrating or closed. Closed head injuries can result from blunt trauma, as seen in civilian life, and after exposure to explosive blast, which is much more common than previously realized (see Sections 19.4 and 19.5). Projectile wounds to the head produce direct localized brain injury along the missile tract; by contrast, an equivalent release of energy from a blunt blow would provoke diffuse and widespread neuronal injury. Many patients suf...
+
+=== Chunk 3155 ===
+Source: 4105_002-ebook.pdf
+Length: 2572 chars
+
+26.1.1 The general surgeon and neurotraumatology
+All too often the blood-brain barrier is not only an anatomic and physiological one in the body of the patient, but also a psychological one in the mind of the surgeon. However, neurotraumatology is not the same as neurosurgery. The general surgeon with limited resources should not despair or take a fatalistic approach (“The patient has a brain injury and there is not much I can do”). There is nothing sacred or magical about the brain, although it...
+
+=== Chunk 3156 ===
+Source: 4105_002-ebook.pdf
+Length: 1017 chars
+
+26.2 Mechanisms of injury and wound ballistics
+Ballistic research related to cranio-cerebral wounds is particularly difficult because of the lack of an adequate experimental model. Both the skull and the face are constituted of a mixture of heterogeneous bony structures and soft tissues. The juxtaposition of these very diverse tissues means that the same projectile, following different trajectories only millimetres apart, can create lesions that vary greatly.
+Survivable injuries are usually caus...
+
+=== Chunk 3157 ===
+Source: 4105_002-ebook.pdf
+Length: 3191 chars
+
+26.2.1 Behaviour of the bone
+The skull is a closed box whose walls comprise a vault and a base. The vault is a bony envelope whose thickness varies with site, age, and the individual. The base of the skull has a complex structure with many foramina and air sinuses; in some areas the bone is very thin and delicate and in others very thick and dense.
+Different outcomes are possible when a projectile strikes the skull, according to the angle of impact and the bone’s elastic reaction.
+1. Bone remain...
+
+=== Chunk 3158 ===
+Source: 4105_002-ebook.pdf
+Length: 508 chars
+
+Figure 26.1.8
+Unilateral hemispheric transit caused by high kinetic energy bullet: the injury is entirely due to a narrow phase 1 shooting channel, cavity formation begins at the exit.
+Bitemporal through-and-through injury: the thin temporal bone offers little resistance to the bullet.
+6. Penetrating wounds of the base of the skull.
+These occur either by a direct hit or by the irradiation of a fracture from an entry wound to the vault. Direct injuries often implicate the upper vertebral column a...
+
+=== Chunk 3159 ===
+Source: 4105_002-ebook.pdf
+Length: 1396 chars
+
+26.2.2 Behaviour of the brain
+The most important prognostic factor is injury to the vital centres, even the smallest lesion of which will bring about rapid death. The cranium can be compared to a closed bony envelope containing a homogeneous fluid medium that does not accommodate the formation of any sizeable cavity. An expansion of the cerebral volume quickly reaches a limit because the elastic displacement of brain tissue is constrained by the rigid skull. When stretched beyond bearing, and ow...
+
+=== Chunk 3160 ===
+Source: 4105_002-ebook.pdf
+Length: 496 chars
+
+26.2.3 Wearing a protective helmet
+A military helmet, even if made of Kevlar®, protects only against low-energy projectiles; high-energy bullets will traverse the helmet, become destabilized, and cause more severe injury. Even without penetration, kinetic energy is still propagated into the head and brain as a powerful jolt, like hitting the helmet with a hammer. This is a form of blunt trauma and may cause injury and even death. A helmet provides no protection against primary blast effects....
+
+=== Chunk 3161 ===
+Source: 4105_002-ebook.pdf
+Length: 846 chars
+
+26.3 Epidemiology
+Almost half of all those killed in times of armed conflict have devastating injuries to the head that are incompatible with life. Many, however, have penetrating injuries that are survivable if the airway can be maintained and infectious complications avoided. These wounds require simple procedures and, therefore, the surgeon should first of all focus on these particular cases where a good outcome can be expected with relatively simple measures.
+The most common closed injury is...
+
+=== Chunk 3162 ===
+Source: 4105_002-ebook.pdf
+Length: 774 chars
+
+26.3.1 Incidence
+The formula for body surface area exposed to combat trauma gives a figure of 12 % for the head and neck, while the historical overall average of head and neck wounds is about 15 %, ranging from 4 to 24 % (see Tables 5.5 and 5.6). The use of protective head and torso armour by soldiers tends to modify these figures. This is not the case for unprotected civilians and irregular combatants.
+In reports from military studies, injuries to the vault vastly exceed those to the base of
+th...
+
+=== Chunk 3163 ===
+Source: 4105_002-ebook.pdf
+Length: 2423 chars
+
+26.3.2 Mechanism of injury and survivability
+Historically, the lethality of penetrating head wounds is close to 80 %. Between one- half and three-quarters of those who will die do so within the first 24 hours after injury. However, great progress has been made in reducing post-operative mortality, reflecting improvements in field triage and evacuation, resuscitation and post- operative intensive care as much as operative effectiveness. Hospital mortality rates have fallen from 70 % during the Cr...
+
+=== Chunk 3164 ===
+Source: 4105_002-ebook.pdf
+Length: 2165 chars
+
+26.3.3 Prognosis
+The lethal potential of any penetrating injury to the brain is obvious. Nonetheless, certain factors are attended by a worse prognosis as attested by numerous epidemiological studies. These factors can be either general with respect to all brain General factors include hypoxia, hypotension, hypoglycaemia, hypo- and hyperthermia, age, other injuries, complications and comorbidities, and delay to surgical treatment.9
+Factors more specific to projectile wounds include the following...
+
+=== Chunk 3165 ===
+Source: 4105_002-ebook.pdf
+Length: 896 chars
+
+Post-resuscitation GCS
+The pre-hospital GCS score is useful to monitor the adequacy of first aid and the evolution of the patient, but it is the GCS score post-resuscitation that is truly prognostic. Poor outcomes are associated with:
+1. total score ≤ 8
+2. motor score < 3
+wk wn
+3. eye opening < 2
+4. verbal response < 2
+5. pupils: dilated or abnormal response to light
+The relevance of the prognostic value of GCS after full resuscitation is given in Table 26.2 based on civilian gunshot injuries in...
+
+=== Chunk 3166 ===
+Source: 4105_002-ebook.pdf
+Length: 534 chars
+
+26.3.4 Red Cross Wound Score
+Penetration of the meninges is considered a vital wound putting into jeopardy the patient’s life. The notation in the RCWS is V = N. Fracture of the skull is also noted in the F score. Of course, blunt trauma and blast injury too can be life-threatening, but the RCWS is only applicable to penetrating wounds.
+C
+¥
+R
+C
+I
+/
+d
+=
+n
+a
+l
+p
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+o
+8
+C
+C
+¥
+R
+C
+I
+/
+d
+=
+n
+a
+l
+p
+u
+o
+8
+C
+C
+Coupland / ICRC
+C
+.
+.
+.
+R
+R
+R
+Figures 26.2.1 – 26.2.3
+Example of the RCWS applied to a penetrat...
+
+=== Chunk 3167 ===
+Source: 4105_002-ebook.pdf
+Length: 1105 chars
+
+26.4.1 Primary and secondary brain injury
+Traumatic injury to the brain is described as being primary or secondary. Primary injury is due to organ damage and can be direct in the case of blunt or penetrating trauma, or indirect when due to acceleration, deceleration, and rotational forces causing brain impacts (counter-coup) on the inner surface of the skull. Both play a part in ballistic
+10 Adapted from Semple PL, Domingo Z. Craniocerebral gunshot injuries in South Africa – a suggested manageme...
+
+=== Chunk 3168 ===
+Source: 4105_002-ebook.pdf
+Length: 1304 chars
+
+26.4.2 Cerebral perfusion and oxygenation
+The brain is a soft jelly contained within a solid, closed box. There is a normal physiological balance between contents of the cranial cavity (brain, blood, and cerebrospinal fluid) and the general circulation. Constant blood flow to the brain resulting in good perfusion and oxygenation is critical to life, and is a function of this balance.
+Cerebral blood flow =
+Cerebral perfusion pressure
+Cerebral peripheral resistance
+Cerebral perfusion pressure = Me...
+
+=== Chunk 3169 ===
+Source: 4105_002-ebook.pdf
+Length: 737 chars
+
+Intracranial pressure and cerebral oedema
+Oedema is the normal reaction of the brain to injury of any sort. Increased intracranial pressure is usually associated with closed head trauma; it is rare with penetrating injury, except for wounds with a very small opening.
+Significant brain oedema only begins after 6 hours in penetrating wounds. Furthermore, the cranium with an open wound no longer represents a closed box and damaged brain is often extruded, thus decreasing cerebral volume.
+A large op...
+
+=== Chunk 3170 ===
+Source: 4105_002-ebook.pdf
+Length: 1273 chars
+
+26.5 Clinical examination
+“And in addition to the appearances in the bone, which you can detect by sight, you should make inquiry as to all these particulars (for they are symptoms of a greater or less injury), whether the wounded person was stunned, and whether darkness was diffused over his eyes, and whether he had vertigo, and fell to the ground.”
+Hippocrates
+In the absence of sophisticated diagnostic and monitoring technology, a thorough and systematic clinical examination is essential and r...
+
+=== Chunk 3171 ===
+Source: 4105_002-ebook.pdf
+Length: 802 chars
+
+26.5.1 Glasgow Coma Scale
+The Glasgow Coma Scale (see Table 8.4) was originally established for patients with closed head injury, yet it has proven a useful clinical tool for penetrating trauma as well.11 Although several studies have shown that the inter-rater reliability is poor, the GCS is nonetheless particularly useful for monitoring the evolution of the patient’s condition, especially if it is repeated by the same doctor or nurse. It is the post-resuscitation GCS that should serve as the b...
+
+=== Chunk 3172 ===
+Source: 4105_002-ebook.pdf
+Length: 674 chars
+
+Categorization of head injury severity12
+• Minimal: GCS = 15, with no loss of consciousness or amnesia (Alert).
+• Mild: GCS = 13 or 15 with either brief loss of consciousness or impaired alertness or memory (Alert).
+• Moderate: GCS = 9 – 12, or loss of consciousness greater than 5 minutes, or focal neurological deficit (responsive to Voice).
+• Severe: GCS = 5 – 8 (responsive to Pain).
+• Critical: GCS = 3 – 4 (Unresponsive).
+It is the patient who presents a post-resuscitation mild or moderate sev...
+
+=== Chunk 3173 ===
+Source: 4105_002-ebook.pdf
+Length: 1479 chars
+
+26.5.2 Paraclinical investigations
+Radiographs should be taken of the head and include antero-posterior and lateral views. A CT-scan is rarely available where resources are limited.
+When examining entry wounds, the inner table of the skull always appears more fractured than the outer table, while the opposite is the case for exit wounds. Fractures irradiating from the wounds are a sign of severe injury. However, X-rays give little information about intracranial lesions and fractures of the base ...
+
+=== Chunk 3174 ===
+Source: 4105_002-ebook.pdf
+Length: 3108 chars
+
+26.6 Emergency room management
+The aim is to minimize secondary brain injury through standard principles of resuscitation. Most of the mortality from head injury, apart from direct immediate organ destruction, is associated with secondary injury resulting from hypoxia and hypotension.
+More initial survivors die from secondary brain injury than from primary tissue damage. Many of these deaths are avoidable.
+Severely-injured patients (GCS ≤ 8) require intubation or even a surgical airway; those wi...
+
+=== Chunk 3175 ===
+Source: 4105_002-ebook.pdf
+Length: 2119 chars
+
+26.7 Decision to operate
+Priority for surgery is given to other life-threatening lesions involving the airway, breathing or circulation. Life-threatening neurological lesions requiring immediate surgery are few – for example a rapidly expanding intracranial haematoma with tentorial herniation – and most frequently seen with blunt rather than penetrating trauma.
+More than one injury: control haemorrhage elsewhere first!
+As for the management of the penetrating head injury itself, this should be d...
+
+=== Chunk 3176 ===
+Source: 4105_002-ebook.pdf
+Length: 513 chars
+
+Figure 26.5
+The head of the patient has been shaved and is being washed with soap and water before application of povidone iodine.
+264
+The surgeon should focus on patients with GCS of 9 – 13.
+An open head wound is often awe-inspiring, but might be much less severe than thought at first. Post-resuscitation GCS is particularly important in setting priorities during triage of mass casualties. Most survivable wounds are classed Category II: they require surgery but can wait, provided a good airway i...
+
+=== Chunk 3177 ===
+Source: 4105_002-ebook.pdf
+Length: 809 chars
+
+26.8.1 Patient positioning and preparation
+The head should be entirely shaved and draped in such a fashion as to allow extension of the scalp incision and manipulation of the head by the surgeon or anaesthetist.
+For wounds of the parietal or temporal regions, the patient should be put in the lateral position; for the occipital region and posterior fossa, lying on the face. Patients can be placed supine; however, excessive tilting or lateral rotation of the head should be avoided so as not to imp...
+
+=== Chunk 3178 ===
+Source: 4105_002-ebook.pdf
+Length: 1455 chars
+
+26.8.2 Anaesthesia
+Except in the most minor and superficial of wounds, it is best to intubate the patient if anaesthesia resources allow. With intubation the anaesthetist must at all times control the patient’s ventilation and oxygenation by gentle “bagging”. Controlled ventilation prevents coughing, retching and respiratory effort, all of which raise the ICP.
+Hyperventilation should be avoided except when visible signs of brain herniation or severe oedema during operation develop. Short-term mi...
+
+=== Chunk 3179 ===
+Source: 4105_002-ebook.pdf
+Length: 739 chars
+
+26.8.3 Theatre equipment and instruments
+A few simple pieces of equipment are of great assistance: an operating table with a head that can be tilted up and down manually; low-power suction, electric if available or otherwise a large syringe (60 – 100 ml); diathermy is “nice to have”.
+When dealing with open head injuries, the only essential specific instrument is the bone nibbler.
+CRANIO-CEREBRAL INJURIES
+C
+T.Gassman ICRC
+R
+C
+I
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+n
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+m
+s
+s
+a
+G
+.
+T
+A simple set of essential instruments for neurotr...
+
+=== Chunk 3180 ===
+Source: 4105_002-ebook.pdf
+Length: 1630 chars
+
+26.8.4 Basic surgical management
+The discussion on wound ballistics demonstrates the wide variety of projectile wounds to the brain. However, the fundamental surgical techniques are relatively limited and basically the same for all: trepanation, debridement of the scalp, cranium and brain, and primary closure.
+“The same principles of débridement utilized so   successfully for wounds elsewhere have in their essentials   been adapted to wounds involving the brain.”  Harvey W. Cushing 15
+Harvey W. ...
+
+=== Chunk 3181 ===
+Source: 4105_002-ebook.pdf
+Length: 300 chars
+
+26.9 Cranio-cerebral debridement: “burr-hole” wound
+The prognosis for many such wounds is good. The patient often remains lucid and, depending on the exact location of the cerebral lesion, may even walk into the emergency room. Surgical intervention should always be contemplated.
+C
+Papas/ ICRC
+P
+.
+N...
+
+=== Chunk 3182 ===
+Source: 4105_002-ebook.pdf
+Length: 1169 chars
+
+26.9.1 Wound pathology
+The ballistic profile is similar to that of a fragment, or deforming or destabilized bullet but with low-kinetic energy. The entry wound is much larger than the diameter of the projectile and the lesion in the skull has the appearance of a punched out burr-hole, hence the descriptive name. There is a “cone” of tissue destruction comprising pulped brain and haematoma, hair and the skin of the scalp and bone fragments. Protrusion of the brain outside the skull is often seen:...
+
+=== Chunk 3183 ===
+Source: 4105_002-ebook.pdf
+Length: 116 chars
+
+26.9.2 Operative technique
+The operative procedure unfolds layer by anatomic layer: scalp, bone, dura, brain tissue....
+
+=== Chunk 3184 ===
+Source: 4105_002-ebook.pdf
+Length: 558 chars
+
+Scalp incision
+Inspection of the damaged brain requires a wide exposure and two different incisions are described: the inferiorly-based horseshoe flap or “U”-incision with the wound at its centre or the “S”-extension incision going through the wound. Both have advantages and disadvantages. In the practice of ICRC surgeons, the horseshoe incision is usually preferred for large wounds; and the “S”-incision chosen for small wounds and trepanation. The site of the scalp incision can be infiltrated w...
+
+=== Chunk 3185 ===
+Source: 4105_002-ebook.pdf
+Length: 470 chars
+
+Figures 26.8.1 and 26.8.2
+Horseshoe flap or “U”-incision: the incision is carried down through all the layers of the scalp. The wound itself is excised at the end of the operation. The small horizontal cut at one end of the flap is a release incision and permits a slight rotation in order to close the incision without tension. Dilute adrenaline solution may be injected into incision.
+C
+Papas / ICRC
+P
+.
+N
+C
+IcRC
+R
+C
+I
+C
+Papas /ICRC
+P
+.
+N
+V. Sasin /ICRC
+V. Sasin /ICRC...
+
+=== Chunk 3186 ===
+Source: 4105_002-ebook.pdf
+Length: 788 chars
+
+Figures 26.9.1 – 26.9.3
+“S”-extension incision: all the layers of the wound are debrided first, to prevent further soiling of the brain from the scalp. The wound is then extended in an “S” fashion and the edges widely undermined.
+266
+CRANIO-CEREBRAL INJURIES
+The surgeon now sees a gaping hole in the skull, filled with a pulped mass: haematoma and tissue debris. Sometimes, simply bringing down the skin flap is sufficient to release the tension and cause the damaged tissue to “plop” out as a blood...
+
+=== Chunk 3187 ===
+Source: 4105_002-ebook.pdf
+Length: 574 chars
+
+Bone
+The dura is carefully separated from the bone with a dural elevator, since it has often become adherent to the bone edges. Using a bone-nibbling forceps (rongeur), the defect in the skull is carefully enlarged by biting away the damaged bone edges piece by piece until dura is visible all around the circumference of the wound. Any bleeding from the diploe is best dealt with using a crushed muscle patch dipped in the dilute adrenaline solution, and is preferable to bone wax which, being a for...
+
+=== Chunk 3188 ===
+Source: 4105_002-ebook.pdf
+Length: 185 chars
+
+Meninges
+The ragged edges of the dura should be trimmed. Dural tears may extend for some distance and care should be taken not to extend them further. They will need to be closed later....
+
+=== Chunk 3189 ===
+Source: 4105_002-ebook.pdf
+Length: 612 chars
+
+Brain
+Pulped, dead brain has the consistency of yoghurt or porridge; it does not bleed, and does not “beat” in time with the pulse. Living brain is jelly-like; it bleeds and pulsates with the heartbeat.
+Dead brain is like yoghurt; living brain is like jelly.
+Debridement is performed by sucking out pulped brain and haematoma with mechanical low-pressure suction; a large syringe with a soft Foley catheter attached is an alternative – the technique originally used by Harvey Cushing. The wound cavit...
+
+=== Chunk 3190 ===
+Source: 4105_002-ebook.pdf
+Length: 1044 chars
+
+Figures 26.11.1 and 26.11.2
+A rongeur is used to nibble away the bone edges to expose dura all around the circumference of the bone defect.
+267
+C
+ICRC
+R
+C
+I
+C
+N.Papas/ ICRC
+R
+C
+I
+/
+s
+a
+p
+a
+P
+.
+N
+WAR SURGERY
+Figure 26.12.1 Irrigation using a syringe.
+Figure 26.13
+A tenting suture tacks the dura up to the pericranium to control bleeding.
+268
+C
+R
+C
+I
+/
+n
+i
+s
+a
+S
+.
+V
+Figure 26.12.2
+After irrigation, the wound cavity is then aspirated using low-power suction.
+Loose bone fragments, which are always to...
+
+=== Chunk 3191 ===
+Source: 4105_002-ebook.pdf
+Length: 1256 chars
+
+Haemostasis
+Haemostasis must be meticulous. For the surface of the cerebral tissue itself, which may present capillary ooze, bipolar cautery is best, if available. Because of the folds of the cerebral cortex, cauterization is usually easy at the top of the gyri, and very difficult in the base of the sulci. Otherwise, gauze pledgets soaked in the dilute adrenaline solution or warm saline are placed within the wound cavity and kept there for several minutes under gentle digital pressure. Upon remo...
+
+=== Chunk 3192 ===
+Source: 4105_002-ebook.pdf
+Length: 894 chars
+
+Closure of the dura
+The clean and dry wound cavity is now ready for closure. Direct suture of the dural edges is rarely possible, except in very small wounds and for dural tears. A patch graft is usually necessary and can be taken from the pericranium, temporalis or occipitalis fascia, galea aponeurotica or from the fascia lata if a very large patch is necessary.
+The graft patch is fixed to the surrounding dura with a continuous interlocking suture aiming at a watertight closure and using 3/0 sy...
+
+=== Chunk 3193 ===
+Source: 4105_002-ebook.pdf
+Length: 1058 chars
+
+Scalp closure
+Cranio-cerebral wounds are one of the exceptions to the rule of delayed primary closure. At the end of the operation, the scalp wound is excised and sutured. The loss of substance due to the wound debridement may render closure of the scalp incision difficult. A release incision at the base of the horseshoe flap helps to rotate the skin for closure. Further extension and undermining of the “S”-incision to create a rotation flap serves the same purpose. The flap should be raised ben...
+
+=== Chunk 3194 ===
+Source: 4105_002-ebook.pdf
+Length: 122 chars
+
+26.10 Tangential wounds
+This is a relatively common projectile wound seen by the surgeon, testifying to its survivability....
+
+=== Chunk 3195 ===
+Source: 4105_002-ebook.pdf
+Length: 575 chars
+
+26.10.1 Pathology
+The projectile may fracture the bone or not. The fracture may be depressed and have produced a “V-shaped gutter” that has filled with a pulsating haematoma causing the surgeon to think there has been penetration of the dura. Bone splinters may have been driven deep into the brain (Figure 26.1.2), but the external appearance of the wound does not indicate the degree of splintering. Injury to dural vessels can create an extradural or subdural haematoma.
+Figure 26.15 Scalp closure...
+
+=== Chunk 3196 ===
+Source: 4105_002-ebook.pdf
+Length: 924 chars
+
+Figure 26.16.1
+Figure 26.16.2
+Tangential gunshot injury: the forceps has been passed through the entry and exit wounds. Note the horseshoe flap incision that includes both wounds.
+The tip of the forceps points out the gutter deformity of the bone: no penetration into the brain.
+C
+R
+C
+Icrc
+I
+Figures 26.17.1 – 26.17.3
+Gunshot causing a gutter wound with penetration into the brain.
+The most severe tangential injury is a gaping wound, a punched-out defect with comminution of the bone resembling a si...
+
+=== Chunk 3197 ===
+Source: 4105_002-ebook.pdf
+Length: 89 chars
+
+26.10.2 Indications for surgery
+Indications for surgery include the following conditions....
+
+=== Chunk 3198 ===
+Source: 4105_002-ebook.pdf
+Length: 580 chars
+
+Depressed fracture with focalizing signs
+Focal signs of compression are an absolute indication to operate. Many surgeons prefer to trephine all such injuries because of the high incidence of bone splinters driven into the cerebral cortex. Others prefer to observe and operate only if focal signs appear or if there is no improvement over several days.
+Figure 26.18 Patient A: depressed fragment of the cranium.
+270
+CRANIO-CEREBRAL INJURIES
+J. Stedmon /ICRC
+J. Stedmon /ICRC
+Figures 26.19.1 and 26.19....
+
+=== Chunk 3199 ===
+Source: 4105_002-ebook.pdf
+Length: 157 chars
+
+Focal signs of a space-occupying haematoma
+Trepanation and evacuation of the clot are essential, whether the haematoma is extra- or subdural, or subcortical....
+
+=== Chunk 3200 ===
+Source: 4105_002-ebook.pdf
+Length: 197 chars
+
+Epileptic seizures
+Seizures may follow damage to the meninges by bone splinters; their removal does not guarantee long-term relief, but is sometimes able to prevent evolution to status epilepticus....
+
+=== Chunk 3201 ===
+Source: 4105_002-ebook.pdf
+Length: 133 chars
+
+Single entry-exit, punched-out defect with laceration of the brain
+This open wound of the brain requires debridement.
+C
+R
+C
+I
+/
+s
+e
+k...
+
+=== Chunk 3202 ===
+Source: 4105_002-ebook.pdf
+Length: 93 chars
+
+Figures 26.20.1 and 26.20.2
+Two examples of tangential penetration: one entry-exit.
+y
+D
+.
+E
+=...
+
+=== Chunk 3203 ===
+Source: 4105_002-ebook.pdf
+Length: 937 chars
+
+26.10.3 Operative management
+Without an indication for operation, apart from debridement of any scalp wound, conservative treatment as for a closed head injury should be adopted. Recovery is often spontaneous, although slow.
+If trepanation is undertaken, it must be performed next to the gutter or depressed fracture; the bone fragments are elevated and the dura inspected. It may be intact or lacerated.
+• An intact dura overlying contused brain without actual cortical liquefaction may be left as i...
+
+=== Chunk 3204 ===
+Source: 4105_002-ebook.pdf
+Length: 97 chars
+
+Figures 26.22.1 and 26.22.2
+X-ray and CT scan showing multiple fragments in the frontal lobe.
+272...
+
+=== Chunk 3205 ===
+Source: 4105_002-ebook.pdf
+Length: 163 chars
+
+26.11 Other penetrating wounds
+Small fragment wounds are relatively common; transfixing wounds are rare, as the patient usually does not survive to reach hospital....
+
+=== Chunk 3206 ===
+Source: 4105_002-ebook.pdf
+Length: 281 chars
+
+26.11.1 Small Grade 1 fragment wounds
+Fragments with just enough kinetic energy to pierce the vault of the skull and enter the brain cause relatively little local tissue damage. They constitute a Grade 1 wound according to the Red Cross Wound Score. Several scenarios are possible....
+
+=== Chunk 3207 ===
+Source: 4105_002-ebook.pdf
+Length: 768 chars
+
+Single or limited number of fragments
+Given that vital centres are not touched, the prognosis is good and the patient is usually quite lucid, often walking into the emergency admissions. Since oedema and haematoma formation are usually limited, most surgeons adopt a conservative non- operative approach apart from local toilet and suture of the scalp wound.
+Icrc
+ICRC
+The patient must remain under strict observation, however, and any indication of increased intracranial pressure, focalizing signs ...
+
+=== Chunk 3208 ===
+Source: 4105_002-ebook.pdf
+Length: 683 chars
+
+Large number of fragments
+With multiple fragments there is a cumulative effect of oedema and haematoma formation, particularly if accompanied by primary blast injury. The level of consciousness is usually decreased; even frank coma may ensue. This type more closely resembles a severe closed head injury.
+2
+8 2
+$
+3 2 =
+Nablus
+M. Yacoub / Rafidia Hospi
+If the GCS is > 8 and there is no deterioration of the patient’s condition, a conservative approach may be adopted. In the face of a rapidly deterio...
+
+=== Chunk 3209 ===
+Source: 4105_002-ebook.pdf
+Length: 309 chars
+
+26.11.2 Transfixing through-and-through wounds
+These are very serious injuries and often fatal; cavity formation is quickly lethal. The projectile also often traverses the lateral ventricle. Haematoma, bone fragments, and oedema are found irregularly throughout the whole wound track.
+CRANIO-CEREBRAL INJURIES...
+
+=== Chunk 3210 ===
+Source: 4105_002-ebook.pdf
+Length: 828 chars
+
+Unilateral hemispheric transfixation
+The entry and exit wounds involve only one cerebral hemisphere (Figure 26.1.5). Given the poor prognosis, only a few patients with lesions relatively high in the vault and an acceptable GCS score proceed to surgery.
+s
+u
+l
+b
+a
+N
+l
+a
+t
+i
+p
+s
+o
+=
+H
+a
+i
+d
+fi
+é
+a
+R
+/
+b
+u
+o
+c
+C
+IcRC
+R
+C
+I
+IcRC
+a
+£
+Y
+.
+M
+Figures 26.23.1 and 26.23.2 GSW of the head: the entry was frontal and the exit parietal.
+The entry and exit wounds are debrided as usual. The long narrow track is ...
+
+=== Chunk 3211 ===
+Source: 4105_002-ebook.pdf
+Length: 626 chars
+
+Bilateral hemispheric transfixation
+The projectile crosses the midline, involving both cerebral hemispheres (Figure 26.1.6). These injuries are rarely seen in hospital, and those that do present are usually high in the vault and involve the frontal lobes and sinuses.
+C
+C.Giannou /ICRC
+R
+C
+I
+/
+u
+o
+n
+n
+a
+i
+G
+.
+C
+Except in the case of bifrontal wounds, a simplified and abbreviated version of the previous procedure is performed. Conservative supportive treatment is usually the best that can be offer...
+
+=== Chunk 3212 ===
+Source: 4105_002-ebook.pdf
+Length: 87 chars
+
+Figures 26.24.1 and 26.24.2
+Retained projectile after traversing the entire hemisphere....
+
+=== Chunk 3213 ===
+Source: 4105_002-ebook.pdf
+Length: 97 chars
+
+Figure 26.25
+The forceps indicate the entry and exit wounds high up in the vault.
+273
+WAR SURGERY...
+
+=== Chunk 3214 ===
+Source: 4105_002-ebook.pdf
+Length: 641 chars
+
+26.12 Trepanation
+The main indication for trepanation is blunt trauma with an intracranial haematoma or a closed depressed fracture with signs of lateralization; but it is also required for some tangential wounds or those due to small fragments.
+Please note:
+As mentioned, tangential wounds and primary blast injuries can also cause a closed intracranial haematoma.
+Burr-hole trepanation is an operation well within the competency of the general surgeon and should be included in the standard armamen...
+
+=== Chunk 3215 ===
+Source: 4105_002-ebook.pdf
+Length: 162 chars
+
+26.13 Difficult situations
+A number of difficult presentations of penetrating head injury exist. Some require the presence of a neurosurgeon for proper treatment....
+
+=== Chunk 3216 ===
+Source: 4105_002-ebook.pdf
+Length: 1074 chars
+
+Falling bullets
+In many societies, it is customary to celebrate a military victory, birth or marriage by firing rifles into the air; even more so if the country is the scene of armed conflict. It is not rare for the falling bullets to injure or kill bystanders. Some falling bullets have enough energy to perforate the skull and penetrate the brain for several centimetres: a mini-burr hole wound. The surgical management follows the same criteria as the wounds discussed previously.
+In a certain num...
+
+=== Chunk 3217 ===
+Source: 4105_002-ebook.pdf
+Length: 447 chars
+
+Loss of a large amount of scalp cover
+A sufficient rotation flap is fashioned, based on the arterial supply reaching the scalp from below; the flap may involve over half the scalp. Any bare area of pericranium is covered immediately with a split-skin graft.
+R, Coupland / ICRC
+R, Coupland / ICRC
+Figures 26.26.1 and 26.26.2
+Large rotation skin flap of the scalp: a split skin graft covers the bare area of pericranium.
+274
+CRANIO-CEREBRAL INJURIES...
+
+=== Chunk 3218 ===
+Source: 4105_002-ebook.pdf
+Length: 799 chars
+
+Loss of a large amount of skull
+Various synthetic materials now exist to replace large bone defects. Cranioplasty, however, is a specialized procedure and is beyond the scope of this manual. In some cases, the general surgeon may be able to save large pieces of the skull and replace them later. Any dirtied edges of bone should be nibbled away. The bone should then be washed in a saline-antibiotic solution and kept in the blood bank refrigerator, to be retrieved and replaced once the patient is f...
+
+=== Chunk 3219 ===
+Source: 4105_002-ebook.pdf
+Length: 284 chars
+
+Injury to the base of the skull
+Local debridement of the wound is the only surgical procedure to undertake. The patient should be nursed in a semi-sitting position. If otorrhoea occurs, the ear should not be packed, but simply covered with an absorbent dressing bandaged over the ear....
+
+=== Chunk 3220 ===
+Source: 4105_002-ebook.pdf
+Length: 487 chars
+
+Injury to a deep-seated major blood vessel
+This injury is usually rapidly fatal. There may be times when the surgical evacuation of pulped brain, haematoma and bone fragments uncovers and releases such an injury, with ensuing heavy haemorrhage. The condition is usually beyond the competency of the general surgeon, who may choose to take a simple damage-control approach and pack the cavity in an attempt to stop the bleeding and re-operate 24 hours later if the patient is still alive....
+
+=== Chunk 3221 ===
+Source: 4105_002-ebook.pdf
+Length: 870 chars
+
+Traumatic aneurysm or arterio-venous fistula
+These lesions are usually due to a fragment; a bullet tends to push blood vessels aside or transect them completely with a rapidly fatal issue. Severe primary blast injury to the brain may also lead to the formation of a pseudoaneurysm. In survivors, it is usually the distal and more superficial branches of the cerebral circulation that are concerned. Diagnosis is difficult without sophisticated technology.
+When a pseudoaneurysm or arterio-venous (A-V...
+
+=== Chunk 3222 ===
+Source: 4105_002-ebook.pdf
+Length: 867 chars
+
+26.13.1 Superior sagittal sinus injury
+The superior sagittal sinus is triangular in cross-section and lies between the two layers of the falx cerebri with each angle tethered. The venous sinuses of the brain are not compressible, unlike other major veins in the body, and are permanently held open by fibrous dura mater. With the head above the level of the heart, they drain into the jugular veins by siphonage (when the head bends forward, the superior sagittal sinus flows upwards from the forehea...
+
+=== Chunk 3223 ===
+Source: 4105_002-ebook.pdf
+Length: 829 chars
+
+Figure 26.27
+Anatomy of the superior sagittal sinus.
+275
+WAR SURGERY
+276
+The venous sinuses of the cranial cavity have no valves and ultimately drain into the right auricle with only one valve at the inferior bulb in the internal jugular to stop backflow of blood during auricular systole. Thus, the venous pressure in the right atrium is reflected in the sagittal sinus when the patient is in the decubitus position, and raising the head above the level of the heart decreases pressure in the sinus....
+
+=== Chunk 3224 ===
+Source: 4105_002-ebook.pdf
+Length: 2847 chars
+
+Surgical management
+Good coordination between the surgeon and the anaesthetist is essential in manoeuvring the patient’s head and body position.
+1. A scalp flap is fashioned in preference to an “S”-incision to allow for adequate exposure, whether for a falling bullet wound or for a depressed fracture of the vertex.
+2. One or two burr holes are drilled and the opening enlarged with bone-nibbling forceps to reveal the projectile or bone splinter. In other cases, it is discovered during brain debri...
+
+=== Chunk 3225 ===
+Source: 4105_002-ebook.pdf
+Length: 944 chars
+
+26.13.2 Frontal sinus injury
+A projectile may pass through the frontal sinus and then enter the frontal lobe of the brain. The orbit may also be implicated. It is simplest to perform a brain debridement
+CRANIO-CEREBRAL INJURIES
+directly through the shattered sinus, although a horseshoe flap centred on the supra- orbital artery is preferred.
+At the end of the brain debridement, every attempt must be made to close the dura, using whatever graft is necessary in order to prevent ascending infection....
+
+=== Chunk 3226 ===
+Source: 4105_002-ebook.pdf
+Length: 826 chars
+
+26.13.3 Damage-control neurotraumatology
+The practice of damage control in head trauma was first described in 1901. Difficult- to-control bleeding may be temporarily controlled by tamponade packing and the operation revised several days later (see Annex 26.B). It may be successfully practised in remote areas with the possibility of patient transfer after evacuation of a haematoma or abbreviated debridement of open brain trauma.
+In a patient with multiple injuries, the surgeon may have to perform...
+
+=== Chunk 3227 ===
+Source: 4105_002-ebook.pdf
+Length: 139 chars
+
+Figure 26.28.1
+A frontal flap has been taken down revealing damage to the sinus and exposure of the dura covering the frontal lobe (arrow)....
+
+=== Chunk 3228 ===
+Source: 4105_002-ebook.pdf
+Length: 105 chars
+
+Figure 26.28.2
+The dura has been closed by means of a fascial flap stitched in place.
+277
+WAR SURGERY
+278...
+
+=== Chunk 3229 ===
+Source: 4105_002-ebook.pdf
+Length: 4165 chars
+
+26.14 Post-operative and conservative management
+Post-operative care: more “heroic” than the surgery.
+Whether they are comatose or lucid, post-operative monitoring and nursing care of patients suffering severe head injury are onerous and a great drain on time, effort, and personnel – as is the conservative treatment of the comatose patient. The compensation comes with seeing the recovery of many patients. The importance of post-operative care is often underestimated. In patients with severe neur...
+
+=== Chunk 3230 ===
+Source: 4105_002-ebook.pdf
+Length: 1978 chars
+
+26.14.1 Prophylaxis of epileptic seizures
+The development of epilepsy varies among clinical studies: up to 50 % incidence after 15 years follow-up. Early seizures occurring within 7 days are more common than late onset. Current knowledge suggests that early prophylaxis does not prevent late seizures.
+The occurrence of epileptic seizures very early in the convalescent period causes a radical and rapid deterioration of the patient’s condition due to secondary brain injury. The immediate treatment ...
+
+=== Chunk 3231 ===
+Source: 4105_002-ebook.pdf
+Length: 650 chars
+
+26.15 Increased intracranial pressure
+Any increase in ICP should be diagnosed early and treated aggressively. It is much rarer in open wounds than in closed head trauma.
+The first priority for the head-injured patient is complete and rapid physiologic resuscitation. During resuscitation, and where sophisticated means of patient monitoring are not available, no specific treatment should be directed at preventing a rise in ICP.
+All treatment modalities for ICP (for example, the use of osmotic diur...
+
+=== Chunk 3232 ===
+Source: 4105_002-ebook.pdf
+Length: 1656 chars
+
+26.15.1 Management
+Treatment should begin with simple measures: supplemental oxygen, elevation of the head, sedation, rapid control of fever, and avoidance of hypotension and of over- hydration; glucose in water is to be excluded entirely.
+In the absence of mechanical ventilation, the capacity to paralyse the patient and proceed with manual ventilation depends on the staff available in the hospital. Mild, controlled hyperventilation is rapidly effective, but should only be practised for a very s...
+
+=== Chunk 3233 ===
+Source: 4105_002-ebook.pdf
+Length: 1596 chars
+
+26.16 Cerebrospinal fluid fistula
+A leak of CSF may be acute or delayed; 70 % present within two weeks of injury. Only about half the leaks occur at the wound site; a post-operative CSF fistula in the vault is usually caused by failure to close the dura. The others are mostly due to the extension of fractures and dural tears, particularly with fractures of the base of the skull; the patient then presents with otorrhoea or rhinorrhoea. In doubtful cases, gentle compression of both jugular veins f...
+
+=== Chunk 3234 ===
+Source: 4105_002-ebook.pdf
+Length: 535 chars
+
+26.17 Infection
+Two different clinical presentations are seen. The first is in patients who have survived the initial wounding but arrive late to hospital; the second is a complication of hospital treatment. It should be noted that many clinical studies have demonstrated no relationship between the bacteria contaminating the wound and the post-operative infective organisms. Furthermore, it would appear that bone and metal are not as important in causing infection when compared to skin and hair a...
+
+=== Chunk 3235 ===
+Source: 4105_002-ebook.pdf
+Length: 1453 chars
+
+26.17.1 Neglected wounds
+In low-income countries with difficult lines of transportation it is uncommon but not rare to have patients present with a neglected cerebral fungus forming an open, draining abscess. The open, gaping wound – usually a burr-hole type – prevents a fatal increase of ICP. The abscess is walled off by glial tissue (the equivalent of fibrous tissue in the central nervous system) and the pus pours out.
+Treatment follows the same standard principles for all neglected wounds and...
+
+=== Chunk 3236 ===
+Source: 4105_002-ebook.pdf
+Length: 1527 chars
+
+26.17.2 Post-operative infectious complications
+Whether the patient has been treated conservatively or operatively, infection is always a potentially lethal complication in open head wounds, with a mortality rate greater than 50 %; historically, it was the great killer after organ destruction. Infection rates of 10 – 15 % are not uncommon in modern practice and even higher if there is delay in treatment. Scalp wound dehiscence increases the risk of infection, as well as CSF leakage. Bone fragmen...
+
+=== Chunk 3237 ===
+Source: 4105_002-ebook.pdf
+Length: 1404 chars
+
+26.18 Primary blast neurotrauma
+As described in Sections 19.4.1 and 19.5, primary blast injury to the central and autonomic nervous systems has several pathophysiological mechanisms of injury, some of which resemble blunt trauma – such as biochemical damage at the cellular level and severe cerebral oedema – others not. The positive pressure wave is transmitted through the skull and also probably “tunnelled” through the skull openings: orbits, nasal cavity and foramen magnum.
+The clinical present...
+
+=== Chunk 3238 ===
+Source: 4105_002-ebook.pdf
+Length: 835 chars
+
+26.19 Post-trauma rehabilitation
+The ultimate outcome of patients suffering severe brain injury is more important than simple mortality figures. Many surviving patients go on to lead full, independent, and productive lives. Active and prolonged rehabilitation is necessary, however, and the means may be limited.
+Post-operative rehabilitation is a “creative cooperative effort by the health care team, patient, and family that is aimed at optimizing mental, social, and vocational
+aptitudes”.18
+Many ...
+
+=== Chunk 3239 ===
+Source: 4105_002-ebook.pdf
+Length: 1536 chars
+
+26.19.1 Patient outcome
+Given such a dire outcome for many patients with severe head injury, and the possibility of a wide spectrum of post-trauma disabilities, mortality is not the only parameter to take into account when judging the results of treatment. A widely-used system is the Glasgow Outcome Scale (GOS).19 The patient’s status is assessed upon discharge and again later, after a certain follow-up period lasting months or even years, to determine the evolution of his or her condition.
+The ...
+
+=== Chunk 3240 ===
+Source: 4105_002-ebook.pdf
+Length: 268 chars
+
+ANNEX 26. A Trepanation
+The trepanation of the skull is one of the oldest known surgical operations, practised in ancient Mesopotamia and Pharaonic Egypt. Herein follows a simple presentation. For greater detail the surgeon should refer to standard surgical textbooks....
+
+=== Chunk 3241 ===
+Source: 4105_002-ebook.pdf
+Length: 84 chars
+
+26.A.a Clinical picture and indications for surgery
+F  P  T
+F
+P
+T
+Papas / ICRC
+P
+.
+N...
+
+=== Chunk 3242 ===
+Source: 4105_002-ebook.pdf
+Length: 1553 chars
+
+Figure 26.A.1
+Position of blind burr holes for intracranial haematoma.
+In blunt injuries, the most common intracranial bleeding is an acute subdural haematoma from rupture of small veins bridging the space between the cortex and the dura. An acute extradural haematoma usually arises from a rupture of the middle meningeal artery after a fracture of the temporal bone and gives rise to the classic phenomenon described as the “lucid interval”.
+Closed head injuries must be closely and repeatedly asse...
+
+=== Chunk 3243 ===
+Source: 4105_002-ebook.pdf
+Length: 534 chars
+
+Figures 26.A.2 and 26.A.3
+Depressed cranial fracture after a blast injury with focalizing signs.
+C
+IcRc
+R
+C
+Icrc
+I
+In cases of a tangential wound, the haematoma is most likely to underlie the fracture and the trepanation should be placed next to the fracture or the “gutter”. In some patients, a direct approach to the fracture may be possible. Large projectiles, including falling bullets, that have penetrated the skull but remain superficial in the cerebral cortex are also readily removed by trep...
+
+=== Chunk 3244 ===
+Source: 4105_002-ebook.pdf
+Length: 231 chars
+
+Figure 26.A.5
+Direct access to a depressed fracture and elevation by means of a dural elevator.
+Burr hole access to a depressed fracture; the depressed fragment can then be raised by a lateral approach.
+284
+CRANIO-CEREBRAL INJURIES...
+
+=== Chunk 3245 ===
+Source: 4105_002-ebook.pdf
+Length: 2427 chars
+
+26.A.b Operative technique of burr-hole trepanation
+Preparation of the patient and anaesthesia are described in Section 26.9. The basic technique of burr-hole trepanation is the same for closed head injuries, tangential wounds or small fragment lesions.
+C
+e
+R
+C
+I
+/
+n
+n
+a
+m
+s
+s
+a
+8
+G
+.
+T
+Perforators
+Perforators
+Trephine
+Conical and spherical burrs
+1. The site is infiltrated with a dilute solution of adrenaline from the skin down to the pericranium. The first blind burr hole should be temporal.
+2....
+
+=== Chunk 3246 ===
+Source: 4105_002-ebook.pdf
+Length: 221 chars
+
+26.A.c Further surgical management
+The burr-hole or holes having been accomplished, the surgeon must deal with the intracranial pathology: extradural, subdural or subcortical haematoma, or lacerated dura and brain cortex....
+
+=== Chunk 3247 ===
+Source: 4105_002-ebook.pdf
+Length: 2134 chars
+
+Clot evacuation
+• Once through the inner table, an extradural haematoma instantly presents itself. A catheter is introduced immediately and the clot aspirated; the opening is then enlarged as necessary. The haematoma is very localized and can be totally missed if the burr hole is off by 1 – 2 cm; it is usually to be found strictly underneath a fracture.
+• If the dura is bulging and deep purple in colour, it should be incised by an “X”-incision and the subdural clot evacuated before enlarging the...
+
+=== Chunk 3248 ===
+Source: 4105_002-ebook.pdf
+Length: 220 chars
+
+Dural closure
+The dura should be closed at the completion of the procedure. Drains should not be used beneath the dura, but a drain may be placed after evacuation of an extradural haematoma, to be removed 24 hours later....
+
+=== Chunk 3249 ===
+Source: 4105_002-ebook.pdf
+Length: 1203 chars
+
+ANNEX 26. B Damage control neurotraumatology
+The practice of damage control in head trauma follows the same principles as damage control surgery elsewhere, a function of physiology: preventing hypothermia, coagulopathy, and acidosis (see Chapter 18). However, in most individual cases, it is the difficulty in controlling haemorrhage, and not the physiology, that is the determining factor.
+Simple techniques have been used since the 19th century and, like many cases of difficult bleeding, rely on d...
+
+=== Chunk 3250 ===
+Source: 4105_002-ebook.pdf
+Length: 878 chars
+
+Surgical technique
+A local haemostatic and cotton balls and gauze are applied to the bleeding area and packed in. Manual pressure is applied for several minutes. If bleeding has stopped, the pack is carefully removed. If bleeding reoccurs, the pack is reapplied. This may be repeated several times.
+Recurrence of bleeding every time the pack is removed calls for leaving the pack in place. The dura is left open and the galea aponeurotica stitched closed. The skin edges are loosely approximated with...
+
+=== Chunk 3251 ===
+Source: 4105_002-ebook.pdf
+Length: 1014 chars
+
+Chapter 27 MAXILLO-FACIAL INJURIES
+289
+WAR SURGERY
+290
+27.
+MAXILLO-FACIAL INJURIES
+27.1 Introduction 27.2 Wound ballistics 27.3 Epidemiology 27.4 Clinical examination and emergency room care 27.4.1 Complete maxillo-facial examination 27.4.2 Establishment of an adequate airway 27.5 Decision to operate 27.5.1 Preparation of the patient 27.6 Haemostasis and debridement 27.6.1 Control of haemorrhage 27.6.2 Debridement and mucosal suture 27.7 Mandibular fractures 27.7.1 Vertical sling bandage 27.7.2 ...
+
+=== Chunk 3252 ===
+Source: 4105_002-ebook.pdf
+Length: 1368 chars
+
+27.1 Introduction
+The face is an exquisitely distinct anatomic area – characteristic of each person’s presentation to others and deformity, therefore, is a fundamental issue. Even more important than aesthetic concerns are the essential functions of breathing, seeing, chewing, swallowing, and talking.
+The maxillo-facial region is composed of very heterogeneous bony and soft-tissue structures. The bones vary in density and thickness, and contain air sinuses that are colonized by a specific bacter...
+
+=== Chunk 3253 ===
+Source: 4105_002-ebook.pdf
+Length: 170 chars
+
+Figure 27.2.1
+Through-and-through trajectory of an FMJ bullet passing through the thin bone of the maxillary sinuses. Note that there is no destabilization of the bullet....
+
+=== Chunk 3254 ===
+Source: 4105_002-ebook.pdf
+Length: 197 chars
+
+Figure 27.3
+A low-energy bullet has been destabilized by the right ascending ramus of the mandible and tumbles in the mass of the tongue causing major comminution of the left ramus at the exit.
+292...
+
+=== Chunk 3255 ===
+Source: 4105_002-ebook.pdf
+Length: 1040 chars
+
+27.2 Wound ballistics
+While small in volume, the delicate structures of the face can suffer extensive local ballistic damage affecting a large percentage of their bulk. It is the destruction and dislocation of these delicate elements that gives maxillo-facial wounds their “explosive” character on first inspection. In addition, the maxillo-facial region is not limited by bony structures, thus allowing spectacular accumulations of oedema and haematoma. The injury usually looks far more serious tha...
+
+=== Chunk 3256 ===
+Source: 4105_002-ebook.pdf
+Length: 1160 chars
+
+Figure 27.2.2
+Bullet injury through the maxillary arch: multiple bone fragments projected outwards.
+The effects of cavity formation are minimal with a stable high-energy FMJ bullet because the length of the trajectory in the face is insufficiently long. A temporary cavity will form upon entry by a fragment or destabilized bullet. A low-kinetic energy bullet may be destabilized by striking bone and easily tumble in the muscular body of the tongue.
+C
+Papas / ICRC
+P
+.
+N
+A fracture of the mandible d...
+
+=== Chunk 3257 ===
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+Length: 4754 chars
+
+27.3 Epidemiology
+Historical epidemiological studies that differentiate the various head, face, and neck wounds are rare, and more recently an attempt has been made to rectify this (Tables C.1 and C.2). The clinically important points to note from various military studies are the increased incidence of facial injuries in soldiers wearing body armour and the large number of patients with relatively superficial wounds not requiring hospitalization. Additionally, there is a high incidence of wound ...
+
+=== Chunk 3258 ===
+Source: 4105_002-ebook.pdf
+Length: 1049 chars
+
+27.4 Clinical examination and emergency room care
+The initial examination and emergency care follow the standard ABCDE algorithm. The mechanism of injury determines the need to control the cervical spine. With penetrating projectile wounds, this is not as important as with blunt trauma (see Sections 7.7.2 and 36.5).
+The priority is obviously to secure and maintain an open airway. Maxillo-facial injuries are often associated with intracranial wounds and/or injuries to the neck, both of which can ...
+
+=== Chunk 3259 ===
+Source: 4105_002-ebook.pdf
+Length: 1489 chars
+
+27.4.1 Complete maxillo-facial examination
+Important specific points to note in the detailed examination of the maxillo-facial region itself include the following.
+• The injury is often “spectacular”, but the tissue damage usually less severe than it appears at first inspection.
+• Direct inspection of the mouth and pharynx must be carried out, to look for any loose or broken teeth or bone fragments, or continuing bleeding. This is necessary even in a conscious patient.
+• Attention must be paid t...
+
+=== Chunk 3260 ===
+Source: 4105_002-ebook.pdf
+Length: 1429 chars
+
+27.4.2 Establishment of an adequate airway
+Asphyxia resulting from airway obstruction is the major cause of death in facial injuries. The portals for air entry can be obstructed by displacement and excessive mobility of the bony skeleton, oedema and haematoma, vomitus, blood, and “foreign” bodies (bone fragments, broken teeth and dentures). Missile injuries of the mandible usually involve the floor of the mouth and base of the tongue, causing loss of skeletal support to the airway and important ...
+
+=== Chunk 3261 ===
+Source: 4105_002-ebook.pdf
+Length: 423 chars
+
+Figure 27.5
+Major injuries of the mandible almost always require a tracheostomy.
+296
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+Icrc
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+Important emergency clinical points  • Control the AIRWAY.  • Control bleeding from disrupted soft tissues.  • Look for and remove bone fragments or broken teeth or dentures.  • Observe for delayed oedema formation.
+• Control the AIRWAY.
+• Control bleeding from disrupted soft tissues.
+• Observe for delayed oedema formation....
+
+=== Chunk 3262 ===
+Source: 4105_002-ebook.pdf
+Length: 2736 chars
+
+27.5 Decision to operate
+The majority of projectile wounds to the maxillo-facial area are simple and isolated lacerations that are easily cleaned and closed primarily: one of the exceptions to the rule of delayed primary closure. Many others require simple maxillo-mandibular fixation as well. The recommended procedure is to deal with both soft-tissue and bone injuries at the time of initial debridement.
+However, there is a great difference between the management of an isolated maxillo- facial wo...
+
+=== Chunk 3263 ===
+Source: 4105_002-ebook.pdf
+Length: 98 chars
+
+Figures 27.6.1 – 27.6.5
+Blast injury of the face managed with staged operations.
+C
+Dykes /ICRC
+.
+E...
+
+=== Chunk 3264 ===
+Source: 4105_002-ebook.pdf
+Length: 247 chars
+
+Figures 27.7.1 – 27.7.5
+The patient arrived several days after suffering a gunshot wound. A staged approach resulted in a reasonably satisfactory outcome.
+297
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+e
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+WAR SURGERY
+Figure 27.8 Anterior nasal phase of oro-nasal packing.
+298...
+
+=== Chunk 3265 ===
+Source: 4105_002-ebook.pdf
+Length: 1128 chars
+
+27.5.1 Preparation of the patient
+Operating on maxillo-facial injuries requires a secure airway. Nasotracheal intubation or tracheostomy is indispensable if maxillo-mandibular fixation is to be employed. In all cases, the pharynx should be packed to absorb blood and saliva. Severe injuries always require a tracheostomy for post-operative care.
+A gastric tube is passed to empty the stomach of swallowed blood, and ocular ointment instilled into the conjunctiva. The patient’s head is draped in a wa...
+
+=== Chunk 3266 ===
+Source: 4105_002-ebook.pdf
+Length: 266 chars
+
+27.6 Haemostasis and debridement
+The airway now under control, operative priority goes to achieving haemostasis, which may be difficult given the disorganization of the injured tissues and the anatomic constraints of the confined area of the oral cavity and midface....
+
+=== Chunk 3267 ===
+Source: 4105_002-ebook.pdf
+Length: 1473 chars
+
+27.6.1 Control of haemorrhage
+The source of bleeding may be peripheral (facial, temporal or lingual arteries) or central (maxillary artery). The management proceeds in progressive steps.
+1. Direct pressure and elevation of the head to control peripheral bleeding.
+2. Ligation of bleeding points that do not stop with the above measures. Accurate and targeted control of bleeding vessels is essential to avoid clamping of important structures.
+3. Tamponade by means of gauze packs and a large Foley ca...
+
+=== Chunk 3268 ===
+Source: 4105_002-ebook.pdf
+Length: 723 chars
+
+Figure 27.9.3
+Removal of the bandage revealed an avulsion injury of the face.
+Haemorrhage was finally controlled by suture of the soft tissues over anterior and posterior packing.
+5. Ligation of one or both external carotid arteries is a last resort. This is usually not necessary if anterior and posterior packing is possible and can be properly done. The risk of bilateral ligation is ischaemic necrosis of the tip of the nose or the floor of the mouth. It should be noted that the midface is suppl...
+
+=== Chunk 3269 ===
+Source: 4105_002-ebook.pdf
+Length: 130 chars
+
+Figure 27.9.1
+Patient arrival in the ER. A compressive bandage was placed in the field.
+299
+WAR SURGERY
+an
+Nasreddine / ICRC
+N
+.
+H...
+
+=== Chunk 3270 ===
+Source: 4105_002-ebook.pdf
+Length: 139 chars
+
+Figure 27.10.1
+All loose teeth and bone fragments must be removed.
+C
+ICRC
+R
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+Figures 27.10.2 Attached bone fragments should be retained....
+
+=== Chunk 3271 ===
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+Length: 148 chars
+
+Figure 27.11
+Closure of the oral mucosa; in this case a continuous suture reinforced by interrupted sutures to avoid tension on the suture line.
+300...
+
+=== Chunk 3272 ===
+Source: 4105_002-ebook.pdf
+Length: 2473 chars
+
+27.6.2 Debridement and mucosal suture
+The remaining skin is scrubbed with a hard brush to remove any superficial particles causing “tattooing”. The wound edges are excised very conservatively. Soft-tissue tags that are not clearly necrotic should be preserved. The blood supply to the face is generous and adequate for nearly all tissue, no matter how contused or small the remaining pedicle, which allows a minimalist approach.
+Debridement of the well-vascularized soft and bony tissues of the face ...
+
+=== Chunk 3273 ===
+Source: 4105_002-ebook.pdf
+Length: 830 chars
+
+27.7 Mandibular fractures
+The management of maxillo-facial fractures can in many ways be considered “facial orthopaedics”.6 The same general principles apply, particularly the attention that must be paid to associated soft-tissue damage in what are grossly contaminated wounds. The presence of saliva means that every fracture situated in the toothed part of the mandible, even if the fracture site is not open to the skin, must be approached like an open fracture.
+There are a number of methods avai...
+
+=== Chunk 3274 ===
+Source: 4105_002-ebook.pdf
+Length: 345 chars
+
+27.7.1 Vertical sling bandage
+The simplest and most rapid method of immobilization is to use an elastic bandage slung under the jaw and wrapped over the vertex of the skull. This is excellent for temporary immobilization, non-dislocated fractures, or for mandibular fractures that cannot otherwise be immobilized (see Figures 27.22.1 – 27.22.5)....
+
+=== Chunk 3275 ===
+Source: 4105_002-ebook.pdf
+Length: 697 chars
+
+27.7.2 Maxillo-mandibular fixation
+Maxillo-mandibular fixation, also called intermaxillary fixation, is the standard method for mandibular fracture immobilization and allows for osseous healing within six weeks, four in adolescents and young adults. The principle of MMF is to use the teeth to indirectly immobilize the bone fragments in their proper relation.
+After closure of the mucosa, reduction of the fracture is obtained manually by restoring normal occlusion between the upper and lower teeth...
+
+=== Chunk 3276 ===
+Source: 4105_002-ebook.pdf
+Length: 1823 chars
+
+Maxillo-mandibular wiring
+This is the simplest method of MMF and is to be preferred in simple fractures provided there are enough opposing teeth in both jaws for accurate occlusion, and when more sophisticated methods are not available. The procedure involves fixing the two jaws together with flexible non-corrosive soft wire that has been pre-stretched.
+Maxillo-mandibular wiring requires soft steel wire strong enough to hold the bone fragments with stability, yet thin enough to pass through the ...
+
+=== Chunk 3277 ===
+Source: 4105_002-ebook.pdf
+Length: 160 chars
+
+Figure 27.13.5
+Intermediate tie wires of a thinner gauge (Ø 0.25 mm) or rubber bands join the upper and lower eyelets accomplishing intermaxillary fixation.
+302...
+
+=== Chunk 3278 ===
+Source: 4105_002-ebook.pdf
+Length: 477 chars
+
+Ivy ligature
+Eyelets of stainless steel wire are fashioned on the labial aspect of the gums and anchored to adjacent teeth of the upper and lower jaws; tie wires or rubber-band loops are then passed through them to provide splinting. Two or several eyelets are placed on each jaw according to the fracture site, degree of bone comminution, and number of remaining teeth: a useful technique if there has been loss of teeth.
+r
+Richter
+e
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+Richter
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+ie
+.
+.
+M
+M...
+
+=== Chunk 3279 ===
+Source: 4105_002-ebook.pdf
+Length: 283 chars
+
+Figure 27.13.2
+A loop of wire (Ø 0.25 or 0.40 mm) is passed between two teeth, from lingual to labial side.
+One free end is passed around the neck of one tooth and brought forward. It is then passed through the loop.
+r
+Richter
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+Richter
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+.
+.
+M
+M
+Figure 27.13.3...
+
+=== Chunk 3280 ===
+Source: 4105_002-ebook.pdf
+Length: 334 chars
+
+Figure 27.13.4
+The other free end is passed around the other tooth and brought forward.
+The free ends are twisted together to entrap the adjacent teeth. The eyelet is formed by twisting the loop around a dental burr or the tip of a haemostat. All twists for eyelets should be in the same clockwise direction.
+r
+Richter
+e
+t
+h
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+.
+M...
+
+=== Chunk 3281 ===
+Source: 4105_002-ebook.pdf
+Length: 323 chars
+
+Multiple interdental eyelets
+If enough teeth are present, a more stable fixation is provided by multiple Ivy ligatures. This technique is excellent if arch bars are not available and in the event of a major unilateral loss of mandibular substance.
+MAXILLO-FACIAL INJURIES
+r
+Richter
+e
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+r
+Richter
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+.
+.
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+M...
+
+=== Chunk 3282 ===
+Source: 4105_002-ebook.pdf
+Length: 297 chars
+
+Figure 27.14.2
+Interdental passing wires of a thin calibre (Ø 0.25 mm) are used to help pass the thicker and sturdier fixation wires between the teeth.
+Interdental passing wires have been removed. One loose end of the fixation wire is passed through the interdental loops, as for the Ivy ligature....
+
+=== Chunk 3283 ===
+Source: 4105_002-ebook.pdf
+Length: 246 chars
+
+Ernst ligature
+These rapidly fashioned ligatures are appropriate as a temporary holding measure to prevent displacement and relieve pain until more definitive immobilization can be accomplished.
+r
+Richter
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+.
+.
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+M...
+
+=== Chunk 3284 ===
+Source: 4105_002-ebook.pdf
+Length: 423 chars
+
+Figure 27.15.2
+Ernst ligature: there is no interdental loop. One large loop encloses two adjacent teeth on the labial side and the two free ends are brought out between the teeth from the lingual to the labial aspect, one passing above and the other below the transverse wire and then twisted together.
+The mandibular and maxillary wires are kept long enough to be twisted together avoiding the need for separate tie wires....
+
+=== Chunk 3285 ===
+Source: 4105_002-ebook.pdf
+Length: 1008 chars
+
+Arch bars for maxillo-mandibular fixation
+A more sophisticated version of MMF is provided by commercially available arch bars made of malleable metal, available in pre-cut lengths (Erich, Dautrey, Schuchardt, etc.): a much preferred technique if the components are available. One arch bar is placed on the upper jaw and one on the lower and they are then firmly fixed with stainless steel wire to each remaining tooth; intermediate tie wires or rubber bands then join the two bars. This technique is ...
+
+=== Chunk 3286 ===
+Source: 4105_002-ebook.pdf
+Length: 264 chars
+
+Figure 27.14.3
+Multiple eyelets are formed by twisting the loops, all in a clockwise direction. Again as for Ivy ligature, intermediate tie wires of a thinner gauge (Ø 0.25 mm) or rubber bands join the upper and lower eyelets accomplishing intermaxillary fixation....
+
+=== Chunk 3287 ===
+Source: 4105_002-ebook.pdf
+Length: 857 chars
+
+Figure 27.16
+Malleable prefabricated Dautrey arch bar with hooks.
+303
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+.
+M
+WAR SURGERY
+The bar is ligated to each tooth with stainless steel wire (Ø 0.40 mm) passing around the neck of the tooth, from labial to lingual side and then back through on the opposite side of the tooth. One end of the wire is above the bar and the other below. By twisting the two ends of wire together, the bar is tightly fixed around the neck of the tooth. To facilitate the adjustment of the cut twisted ...
+
+=== Chunk 3288 ===
+Source: 4105_002-ebook.pdf
+Length: 937 chars
+
+Figure 27.18
+Intermaxillary fixation with upper arch bar and lower dental eyelets.
+A tracheostomy is mandatory if there is any risk of compromise to the airway, especially if it is due to oedema or in a comatose patient.
+With MMF, if an emergency such as vomiting occurs and the mouth has to be opened quickly, the intermediate tie wires or rubber bands can easily be cut with a wire-cutter or scissors, which should always be kept at the patient’s bedside. Both the patient and the attendant nursing...
+
+=== Chunk 3289 ===
+Source: 4105_002-ebook.pdf
+Length: 246 chars
+
+27.7.3 External fixation
+Mini-external fixators are a very effective method for immobilizing fractures of the mandible with extensive soft-tissue damage and bone defect. It is the only fixation method that allows mandibular movement and function....
+
+=== Chunk 3290 ===
+Source: 4105_002-ebook.pdf
+Length: 906 chars
+
+Figure 27.19
+Mini-external fixator. Stabilization of the fractured mandible.
+C
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+/
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+M
+304
+MAXILLO-FACIAL INJURIES
+After mucosal closure, the fracture is reduced and temporarily immobilized with maxillo-mandibular wiring, of the kind used for the Ernst ligature, in order to assure correct occlusion. The muscles and skin are closed and then the pins are placed. This is the only immobilization method where the soft tissues of the face should be closed first, in order to preve...
+
+=== Chunk 3291 ===
+Source: 4105_002-ebook.pdf
+Length: 344 chars
+
+Figure 27.20.2
+X-ray of a patient treated with mini-external fixation without prior temporary MMF: excellent consolidation of the bone.
+After removal of the external fixator, the patient is unable to eat because of a major impediment to occlusion of the upper and lower jaws, which resulted from not using temporary maxillo-mandibular fixation....
+
+=== Chunk 3292 ===
+Source: 4105_002-ebook.pdf
+Length: 192 chars
+
+Alternatives
+If mini-external fixators are not available, improvisation with standard fixators and small Steinmann pins or Schanz screws can be resorted to.
+C
+&
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+A...
+
+=== Chunk 3293 ===
+Source: 4105_002-ebook.pdf
+Length: 581 chars
+
+27.7.4 Bone defect or non-union of the mandible
+Repair of bone defects may be contemplated at a later date. However, reconstruction of mandibular defects is a challenge, often requiring specialist techniques. Non-union of the mandible due to a bone defect is unusual if the periosteum has been preserved, as demonstrated in the patient in Figures 27.22.1 – 27.22.5 and 27.23.1 – 27.23.2. A conservative approach can prove fruitful and, just as with limb orthopaedics, there should be no hurry to proc...
+
+=== Chunk 3294 ===
+Source: 4105_002-ebook.pdf
+Length: 94 chars
+
+Figures 27.21.1 and 27.21.2
+Maxillo-facial immobilization using standard external fixator.
+305...
+
+=== Chunk 3295 ===
+Source: 4105_002-ebook.pdf
+Length: 114 chars
+
+Figure 27.22.1
+Patient pre-operative: extensive injury to the mandible and soft tissues of the floor of the mouth....
+
+=== Chunk 3296 ===
+Source: 4105_002-ebook.pdf
+Length: 78 chars
+
+Figure 27.22.2
+Pre-operative X-ray showing severe comminution of the mandible....
+
+=== Chunk 3297 ===
+Source: 4105_002-ebook.pdf
+Length: 142 chars
+
+Figure 27.22.3
+Patient post-operative. Closure of the mucosa and skin has been achieved. Immobilization was ensured by a simple sling bandage....
+
+=== Chunk 3298 ===
+Source: 4105_002-ebook.pdf
+Length: 254 chars
+
+Figure 27.22.4
+Post-operative X-ray showing complete loss of the horizontal rami and symphysis menti.
+306
+C
+R
+C
+I
+/
+d
+n
+a
+l
+p
+u
+o
+C
+.
+R
+C
+Coupland /ICRC
+C
+.
+R
+C
+Coupland / ICRC
+C
+.
+R
+C
+R
+C
+I
+/
+d
+n
+a
+l
+p
+u
+o
+C
+.
+R
+MAXILLO-FACIAL INJURIES
+C
+Coupland / ICRC...
+
+=== Chunk 3299 ===
+Source: 4105_002-ebook.pdf
+Length: 770 chars
+
+Figure 27.22.5
+Patient three weeks post-operative enjoying a semi-solid meal
+C
+.
+R
+C
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+n
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+p
+u
+u
+o
+C
+o
+C
+.
+.
+R
+R
+Figure 27.23.1
+Figure 27.23.2
+Same patient on a return visit after a second war X-ray on follow-up visit: osteogenesis from the remaining periosteum has completely replaced the trauma, 24 months later. missing bone.
+When grafting is necessary, a graft from the iliac crest as a combined cortico-cancellous block provides good shape, bulk, and rigidity. Maxi...
+
+=== Chunk 3300 ===
+Source: 4105_002-ebook.pdf
+Length: 628 chars
+
+27.8 Midface fractures
+There is a great variety of midface fractures yet, with projectile injuries they are often not as complex as they seem or as occurs with blunt trauma. Patency of the airway and control of haemorrhage are, as always, the essential emergency concerns. Many useful tamponade techniques to control bleeding have been described. In a shattered maxillary sinus, simple straightforward packing is best, removed or replaced after 48 hours. There are few projectile fractures of the max...
+
+=== Chunk 3301 ===
+Source: 4105_002-ebook.pdf
+Length: 121 chars
+
+Figure 27.24
+Projectile wounds are often not as complex as injuries due to blunt trauma, but are challenging nonetheless....
+
+=== Chunk 3302 ===
+Source: 4105_002-ebook.pdf
+Length: 161 chars
+
+Figures 27.25.1 and 27.25.2
+Caldwell-Luc approach. A 2.5 cm incision in the oral mucosa of the bucco-labial sulcus is centred above the root of the canine tooth....
+
+=== Chunk 3303 ===
+Source: 4105_002-ebook.pdf
+Length: 175 chars
+
+Figures 27.25.3 and 27.25.4
+The muco-periosteum is elevated. The antrum of the sinus is then entered with a gouge chisel and the opening enlarged with a bone nibbling forceps....
+
+=== Chunk 3304 ===
+Source: 4105_002-ebook.pdf
+Length: 195 chars
+
+Figures 27.25.5 and 27.25.6
+An antrostomy through the nose is performed to allow rinsing of the sinus with exit of the fluid through the Caldwell-Luc orifice into the mouth.
+308
+C
+Dykes/ ICRC
+.
+E...
+
+=== Chunk 3305 ===
+Source: 4105_002-ebook.pdf
+Length: 1949 chars
+
+27.8.1 Injuries of the maxillary sinus
+Transfixing through-and-through bullet wounds result in relatively little soft-tissue or bone damage. Entry and any exit wounds should be conservatively debrided and closed, leaving the simple hole in the bone as it is. However, blood often accumulates in the sinus and becomes infected if not properly drained. Drainage of the maxillary sinus is best accomplished through an intra-oral approach in the upper bucco-labial sulcus as is done for drainage of chron...
+
+=== Chunk 3306 ===
+Source: 4105_002-ebook.pdf
+Length: 2317 chars
+
+27.8.2 Fractures involving the orbit
+The various components of the bony orbit may be damaged individually or as a whole and should be debrided in the usual manner. Significant injuries usually involve disorganization of the eye globe leading to enucleation (see Section 29.11.2). Note must be made of any extension of the injury into the cranium and brain. Major wounds often involve the superior orbital ridge and frontal sinus; again, any extension into the cranium must be dealt with as a priority...
+
+=== Chunk 3307 ===
+Source: 4105_002-ebook.pdf
+Length: 1861 chars
+
+27.9 Skin closure
+Aesthetic considerations are important in the face. The teeth should be occluded and any fractures immobilized before making an attempt to close the skin. This permits a more accurate approximation of the soft tissues.
+Immediate primary closure of the skin is acceptable in uncomplicated maxillo-facial injuries: an exception to the rule of delayed primary closure.
+Immediate primary closure of the skin, without undue tension, should be attempted. Even in seemingly massive injurie...
+
+=== Chunk 3308 ===
+Source: 4105_002-ebook.pdf
+Length: 1092 chars
+
+27.9.1 Specific sites
+The skin-vermilion junction of the lip should be realigned accurately. The mucosa, muscle and skin are then closed in separate layers. Penetrating wounds of the cheek should also be closed in layers.
+Wounds of the tongue may bleed a great deal and may require ligature of the lingual artery. Deep lacerations should be repaired with synthetic absorbable sutures. Partial tongue flaps can be used to cover a defect in the mucosa of the floor of the mouth.
+The parotid duct should...
+
+=== Chunk 3309 ===
+Source: 4105_002-ebook.pdf
+Length: 2501 chars
+
+27.10 Post-operative management
+Antibiotic cover and anti-tetanus prophylaxis should be administered according to protocol and analgesia given as necessary.
+Continued attention must be paid to the airway. In major injuries, particularly those with large soft-tissue wounds and extensive oedema or fracture of the mandible with loss of substance, the patient requires a tracheostomy for a considerable period of time, whatever the method of immobilization, until the upper airway is sufficiently free....
+
+=== Chunk 3310 ===
+Source: 4105_002-ebook.pdf
+Length: 92 chars
+
+27.11 Complications
+Complications may be early or late and concern the soft tissues or bone....
+
+=== Chunk 3311 ===
+Source: 4105_002-ebook.pdf
+Length: 1289 chars
+
+27.11.1 Soft tissues
+The most common and important early complication is a salivary fistula causing infection, which can provoke secondary haemorrhage. The mucosal repair must then be revised and the skin wound laid open. This is followed by copious irrigation of the soft tissues of the floor of the mouth and neck, removal of any foreign bodies, and close inspection made of remaining fragments of bone that may have become sequestrated. The wound is left open and packed with iodoform gauze and re...
+
+=== Chunk 3312 ===
+Source: 4105_002-ebook.pdf
+Length: 915 chars
+
+27.11.2 Osteomyelitis of the mandible
+Mandibular osteomyelitis is the most dreadful complication to deal with and occurs relatively often, usually in conjunction with a salivary fistula. The principles of treatment are the same as for post-traumatic osteomyelitis of any bone: removal of sequestra; wide, open drainage; prevention of further contamination; judicious use of antibiotics; and maintenance of the general and nutritional status of the patient.
+After opening the wound and removing necrot...
+
+=== Chunk 3313 ===
+Source: 4105_002-ebook.pdf
+Length: 517 chars
+
+27.11.3 Limitation of mouth opening
+Inability to open the mouth widely is a frequent complication. Severe cases may be due to soft-tissue contractures requiring excision and reconstructive surgery, or to problems with the mandible necessitating special operations. The best method of management in such cases will depend on the availability of transfer to specialized care on the one hand, and on the technical competency of the surgeon on the other.
+Three major forms are recognized, from simple to ...
+
+=== Chunk 3314 ===
+Source: 4105_002-ebook.pdf
+Length: 418 chars
+
+Trismus
+Trismus is a reversible limitation of mouth opening due to a lack of muscle relaxation (temporal and/or pterygo-masseter). It is the consequence of direct trauma, chronic inflammation, and/or infection or simply of a long period of maxillo-mandibular immobilization.8 Intensive jaw-opening exercises using wooden tongue blades and chewing gum are generally sufficient to allow a return to normal mouth opening....
+
+=== Chunk 3315 ===
+Source: 4105_002-ebook.pdf
+Length: 539 chars
+
+Ankylosis and coronoid process hyperplasia
+This limitation of mouth opening results from a progressive fibrotic change and, later, bony transformation of the tendon of the temporalis muscle. A patient with coronoid hyperplasia or fibrous ankylosis is able to open the mouth only about 10 to 15 mm, as measured between upper and lower anterior teeth, and to move the mandible laterally. Removal of the coronoid process (coronoidectomy) is the treatment of choice but not easy to achieve owing to the s...
+
+=== Chunk 3316 ===
+Source: 4105_002-ebook.pdf
+Length: 801 chars
+
+Ankylosis of the temporo-mandibular joint
+Ankylosis of the joint is a fusion of the condylar head with the glenoid fossa of the temporal bone. This osseous bridge is usually the consequence of fractures that involved the condyle and that were immobilized during too long a period of time. The patient is no longer able to open the mouth even 10 to 15 mm. Excision of the mandibular condyle gives poor results, because of the high incidence of relapse with a larger ankylosis. To prevent its developme...
+
+=== Chunk 3317 ===
+Source: 4105_002-ebook.pdf
+Length: 252 chars
+
+Chapter 28 INJURIES TO THE EAR
+315
+WAR SURGERY
+316
+28. INJURIES TO THE EAR 28.1 Epidemiology and mechanism of wounding 28.2 External ear 28.3 Middle ear 28.3.1 Management of a ruptured tympanum 28.4 Inner ear 315 317 317 318 318 319
+INJURIES TO THE EAR...
+
+=== Chunk 3318 ===
+Source: 4105_002-ebook.pdf
+Length: 1796 chars
+
+28.1 Epidemiology and mechanism of wounding
+The ear is divided into three parts: the external, the middle, and the inner ear, all exposed to injury from the various weapons of war. There are four functions related to the ear: hearing, balance, cosmetic appearance and facial expression mediated through the facial nerve. Missiles and explosive blast injury can affect all four functions.
+The different parts of the ear may be injured directly by projectiles, but this occurrence is relatively rare. O...
+
+=== Chunk 3319 ===
+Source: 4105_002-ebook.pdf
+Length: 1844 chars
+
+28.2 External ear
+Trauma to the pinna and external auditory canal is usually due to projectiles and should be managed like other soft-tissue injuries; unless treated correctly it may well result in considerable deformity.
+A haematoma of the pinna is treated by aspiration or evacuated under strict aseptic conditions and the ear protected with a firm sterile dressing. The dressing is removed at least every 48 hours and the wound inspected for recurrence of the haematoma.
+317
+WAR SURGERY
+318
+In sim...
+
+=== Chunk 3320 ===
+Source: 4105_002-ebook.pdf
+Length: 1067 chars
+
+28.3 Middle ear
+Injury to the tympanic membrane is caused most frequently by primary blast. It may also be the result of direct penetration by a projectile hitting the base of the skull or extension of a fracture of the base of the skull involving the tympanic ring.
+Blast injury produces a spectrum of insults from hyperaemia and intra-tympanic haemorrhage, to one or several perforations, or even complete loss of the eardrum. Perforations may be smooth, punched out, or have ragged inverted or eve...
+
+=== Chunk 3321 ===
+Source: 4105_002-ebook.pdf
+Length: 1854 chars
+
+28.3.1 Management of a ruptured tympanum
+Diminished hearing or outright deafness, tinnitus, otalgia, and bleeding from the ear are the obvious signs. Small perforations, less than 1/3 of the eardrum (about 80 % of cases), usually heal spontaneously within a few weeks. Severe injuries, infection and Eustachian tube dysfunction affect spontaneous healing and will require the services of a specialist ENT surgeon.
+The basis of treatment is conservative. In general, nothing should be introduced into ...
+
+=== Chunk 3322 ===
+Source: 4105_002-ebook.pdf
+Length: 1586 chars
+
+28.4 Inner ear
+Trauma to the inner ear may occur in combination with the above injuries or in isolation injury and may be accompanied by total hearing loss, severe vertigo, high- pitched tinnitus, or facial nerve palsy.
+Many victims of blast suffer from a temporary shift of their hearing threshold and tinnitus. The hearing loss usually resolves in a few hours when the patient is placed in a quiet environment. In some patients, it may persist and even become permanent, most commonly in the high t...
+
+=== Chunk 3323 ===
+Source: 4105_002-ebook.pdf
+Length: 598 chars
+
+Clinical features of primary blast injury of the ear
+• Loss of hearing and tinnitus are frequent, but usually resolve spontaneously.
+• Otalgia is usually temporary, but may last for several weeks.
+• Vertigo occurs, but is uncommon.
+• Bleeding from the external auditory meatus is due to perforation of the tympanum.
+• The status of the tympanum does not indicate the presence or absence of lung injury.
+• Tympanic membrane perforation usually heals spontaneously.
+• Mucopurulent discharge is a sign o...
+
+=== Chunk 3324 ===
+Source: 4105_002-ebook.pdf
+Length: 1183 chars
+
+Chapter 29 INJURIES TO THE EYE
+321
+WAR SURGERY
+322
+29.
+INJURIES TO THE EYE
+29.1 Introduction 29.2 Wounding mechanisms and ballistics 29.3 Epidemiology 29.4 First aid and emergency care 29.5 Clinical picture and examination 29.5.1 Basic principles of ocular examination 29.5.2 Complete ocular examination 29.6 Primary management 29.7 Assessment of injury and decision to operate 29.8 Anaesthesia 29.9 Minor procedures 29.9.1 Conjunctival foreign bodies and lacerations 29.9.2 Corneal foreign body and/...
+
+=== Chunk 3325 ===
+Source: 4105_002-ebook.pdf
+Length: 2211 chars
+
+29.1 Introduction
+The most common wounds of the eye incurred during armed conflict are inflicted by projectiles; primary blast and blunt trauma also occur. Chemical and laser weapons cause distinct pathologies. Although these weapons systems have been prohibited by international treaty, they are still available.1 2 Fortunately, scenes such as that depicted in Figure 2.6 with long lines of blinded soldiers have not recurred in contemporary armed conflict, with rare exceptions. This Chapter deals ...
+
+=== Chunk 3326 ===
+Source: 4105_002-ebook.pdf
+Length: 345 chars
+
+29.2 Wounding mechanisms and ballistics
+A simple classification of eye injuries is given in Figure 29.2, adapted from the Birmingham Eye Trauma Terminology System. Injuries are either closed globe, where no full-thickness wound of the sclera or cornea has occurred; or open globe.
+ZONE  I  ZONE  II  ZONE  III  ZONE  I  5 mm  ZONE  II  ZONE  III...
+
+=== Chunk 3327 ===
+Source: 4105_002-ebook.pdf
+Length: 802 chars
+
+Open globe injuries
+Zone 1: injuries confined to cornea and limbus Zone 2: injuries involving anterior 5 mm of the sclera
+Most ocular injuries in contemporary warfare are open globe and due to small fragments and debris from explosions, in particular shattered glass, grit or small stones. Much of the debris is so small and has so little kinetic energy that it does not penetrate clothing or the skin, but can nonetheless pierce the eye and be retained as an intra-ocular foreign body (IOFB). The pr...
+
+=== Chunk 3328 ===
+Source: 4105_002-ebook.pdf
+Length: 3035 chars
+
+Closed globe injuries
+Zone 1: injuries to external surface only (conjunctiva, sclera, cornea) Zone 2: injuries to anterior segment Zone 3: injuries to posterior segment (posterior to posterior lens capsule)
+Contusion: primary blast or blunt trauma Partial thickness laceration: primary blast, blunt trauma, or small foreign body External injuries of cornea, conjunctiva: fragments, debris
+If carrying enough kinetic energy, the projectile passes through the eye in a transfixing wound; this is often ...
+
+=== Chunk 3329 ===
+Source: 4105_002-ebook.pdf
+Length: 1170 chars
+
+29.3 Epidemiology
+Although the eye represents only 0.27 % of the anterior body surface area and 4 % of the face, about 5 – 10 % of all casualties suffer an ocular injury; up to 25 % in one-off explosions. Most are isolated injuries, but many are associated with wounds to the brain, face or neck, or tympanic rupture. The wearing of body armour and especially eye protection tends to modify the relative frequency of the anatomic distribution of wounds. Penetrating wounds of the globe constitute 20 ...
+
+=== Chunk 3330 ===
+Source: 4105_002-ebook.pdf
+Length: 109 chars
+
+Figures 29.3.1 and 29.3.2
+Bullet cartridge lodged in the orbit causing complete disorganization of the globe....
+
+=== Chunk 3331 ===
+Source: 4105_002-ebook.pdf
+Length: 1790 chars
+
+Figure 29.4
+Acute retrobulbar haemorrhage with extreme proptosis and subconjunctival haemorrhage resulting from penetration by an artillery shell fragment.
+325
+WAR SURGERY
+326
+probably mostly due to landmines. Pattern 3 mine injuries often involve the eyes (see Section 21.3.3). Initial treatment began shortly after injury but, for tactical and geographic reasons, only 10 % of patients received specialist care within 10 days. Total rupture of the globe occurred in 255 cases, and 412 enucleations ...
+
+=== Chunk 3332 ===
+Source: 4105_002-ebook.pdf
+Length: 1557 chars
+
+29.4 First aid and emergency care
+Although the main reason for examining the pupils is the “D” of the C-ABCDE paradigm to assess any neurological deficit, this also allows a quick examination to ensure the presence and integrity of the eyes and any sight-threatening lesion. A bulging proptotic hard eye globe is indicative of retrobulbar haematoma and constitutes a true surgical emergency.
+A lacerated lid should be gently closed to protect the cornea. A protruding foreign body should be left in s...
+
+=== Chunk 3333 ===
+Source: 4105_002-ebook.pdf
+Length: 1432 chars
+
+29.5 Clinical picture and examination
+Until proven otherwise, it should be assumed that all injuries around the eye involve an open globe. There is a wide spectrum of clinical presentations. The eyeball may be grossly disrupted or suffer only a minute penetrating wound. Blast injuries in particular may be accompanied by minimal symptoms while concealing major lesions. Common signs and symptoms include irritation and discomfort, or frank pain; sensation of a foreign body; diminished vision or ent...
+
+=== Chunk 3334 ===
+Source: 4105_002-ebook.pdf
+Length: 247 chars
+
+Figure 29.9
+Retraction of the eyelid without exerting any pressure on the globe. Note the ecchymosis of the eyelids and subconjunctival injection. There is a fragment entry wound just lateral to the orbit.
+328
+C
+F.Plani / ICRC
+F
+C
+Baldan/ ICRC
+.
+M...
+
+=== Chunk 3335 ===
+Source: 4105_002-ebook.pdf
+Length: 204 chars
+
+Figure 29.8
+GSW penetrating the orbit and extending into the frontal sinus and frontal lobe.
+GSW involving the maxilla and orbit causing traumatic loss of the eye globe and shattering of the orbital bone....
+
+=== Chunk 3336 ===
+Source: 4105_002-ebook.pdf
+Length: 1126 chars
+
+29.5.1 Basic principles of ocular examination
+An open globe injury should be suspected in every wound around the eye.
+The preliminary examination should be performed with the lids retracted. Voluntary opening of the eyelids is difficult in case of injury and topical anaesthesia should be used (oxybuprocaine 0.4 % or lidocaine 2 %) and general analgesia administered. Gentle separation using a lid retractor is preferable. In its absence, the tips of the fingers should be braced against the bony ri...
+
+=== Chunk 3337 ===
+Source: 4105_002-ebook.pdf
+Length: 1203 chars
+
+29.5.2 Complete ocular examination
+After confirmation of the presence of both eyes and their overall integrity, as well as that of the bony orbit, a thorough ocular examination should follow. A slit-lamp is preferred for proper examination but is rarely available in the absence of an ophthalmologist.
+The complete examination includes:
+• eyelids and lashes;
+• conjunctiva, cornea and sclera;
+• reaction of the pupils;
+• ocular motility;
+• visual acuity of both eyes.
+Visual acuity is the single most...
+
+=== Chunk 3338 ===
+Source: 4105_002-ebook.pdf
+Length: 1551 chars
+
+29.6 Primary management
+Ideally, all eye injuries should be treated primarily by an ophthalmologist, even if this means several days’ delay.
+Where no specialist is available, the following measures should be undertaken.
+Topical anaesthetic having been applied, the conjunctival sac is washed out with copious saline or water and any loose foreign material gently picked out. Embedded foreign bodies are left in situ at first.
+Measures aimed at prevention of post-traumatic endophthalmitis should be i...
+
+=== Chunk 3339 ===
+Source: 4105_002-ebook.pdf
+Length: 3509 chars
+
+29.7 Assessment of injury and decision to operate
+If the patient can be referred to an ophthalmologist, no eye surgery should be performed. The exception is the one true ophthalmic surgical emergency: retrobulbar haemorrhage and acute orbital compartment syndrome calling for immediate sectioning of the lateral canthal ligament (lateral canthotomy and cantholysis: see Section 29.12).
+If the patient cannot be referred, the general surgeon should be able to repair simple injuries to the eyelid, cor...
+
+=== Chunk 3340 ===
+Source: 4105_002-ebook.pdf
+Length: 1138 chars
+
+29.8 Anaesthesia
+Minor procedures and ocular irrigation can be performed using anaesthetic eye drops. Although it is theoretically possible to operate on the eye under local or regional block anaesthesia, with or without i.v. thiopentone sedation, general anaesthesia is preferred for significant procedures, especially in the hands of the non-specialist surgeon. In case of open globe injury, muscle relaxation is mandatory to prevent any retching or spasm that may raise intra-ocular pressure and c...
+
+=== Chunk 3341 ===
+Source: 4105_002-ebook.pdf
+Length: 188 chars
+
+29.9 Minor procedures
+Most minor procedures can usually be performed under local anaesthesia. In the distraught and uncooperative patient, general anaesthesia or sedation may be necessary....
+
+=== Chunk 3342 ===
+Source: 4105_002-ebook.pdf
+Length: 419 chars
+
+29.9.1 Conjunctival foreign bodies and lacerations
+The conjunctival sac is irrigated by syringe with copious quantities of sterile saline or water, and any loose foreign material picked out with forceps or a cotton-wool bud on a stick. Non-penetrating conjunctival lacerations heal spontaneously. Chloramphenicol eye drops should be instilled into the conjunctival sac 4 times daily for a week. No dressing is required....
+
+=== Chunk 3343 ===
+Source: 4105_002-ebook.pdf
+Length: 909 chars
+
+29.9.2 Corneal foreign body and/or corneal abrasion
+As mentioned in Annex 29. A, fluorescein helps visualize a corneal abrasion, but is usually only available with the presence of an ophthalmologist. A good magnifying glass is of great help.
+A foreign body lying on the surface of the cornea can be removed with the tip of a large sterile hypodermic needle after instillation of a local anaesthetic, the shaft of the instrument approaching the cornea at a tangent. Any rust in the ulcer crater that i...
+
+=== Chunk 3344 ===
+Source: 4105_002-ebook.pdf
+Length: 539 chars
+
+Iris and ciliary body injury: hyphaema
+Hyphaema occurs with non-penetrating injuries more commonly than with penetrating wounds. The danger lies in the tendency to have a second bleed on the third to fifth day after injury, which is often worse than the primary haemorrhage, and leads to secondary glaucoma and corneal staining with blood. Patients should be tested for sickle-cell anaemia or other blood dyscrasias where this is relevant. A re-bleed and consequent increase in intra-ocular pressure ...
+
+=== Chunk 3345 ===
+Source: 4105_002-ebook.pdf
+Length: 1318 chars
+
+Figure 29.10
+Insertion of the initial stay suture between the lash line and the grey line.
+332
+• complete bed rest for a week with the head elevated to 30°, followed by another week of reduced activity;
+• cycloplegic drops, such as 1 % atropine or homatropine TID, to prevent the pupil moving;
+• chloramphenicol eye drops TID;
+• steroid eye drops TID;
+• a pad on both eyes.
+Aspirin and non-steroidal anti-inflammatory medications should not be taken as they promote bleeding. Paracetamol and oral tra...
+
+=== Chunk 3346 ===
+Source: 4105_002-ebook.pdf
+Length: 2109 chars
+
+29.9.4 Lacerations of the eyebrows and eyelids
+An eyebrow should never be shaved, as it may not regrow. Sutures should be avoided
+if possible; adhesive skin tape or skin closure strips (Steri-Strips ®) are usually sufficient.
+A laceration of the eyelid calls for irrigation of the eye first. It is then infiltrated using 1 % lidocaine with adrenaline. Minimalist excision of any dead tissue is sufficient if at all necessary; the eyelids are highly vascular and even necrotic-looking tissue can often...
+
+=== Chunk 3347 ===
+Source: 4105_002-ebook.pdf
+Length: 542 chars
+
+29.9.5 Orbital blow-out fracture
+Primary blast may cause a blow-out fracture of the maxillary sinus affecting the floor of the orbit. The orbital contents may herniate into the sinus. Reduction of the contents followed by tamponade packing of the sinus is required (see Section 27.8.2).
+If the eye is not affected, management of an orbital blow-out fracture is conservative: it should simply be kept under observation for two weeks. The patient is instructed not to blow the nose and vasoconstrictor ...
+
+=== Chunk 3348 ===
+Source: 4105_002-ebook.pdf
+Length: 256 chars
+
+29.10 Intermediate injuries
+Repair should be attempted only if fine instruments and suture material are available. It is preferable that open globe injuries be repaired within 24 hours. A few basic principles of plastic surgery techniques must be observed....
+
+=== Chunk 3349 ===
+Source: 4105_002-ebook.pdf
+Length: 107 chars
+
+29.10.1 Wounds of the cornea and sclera
+Corneal wounds should be sutured and the anterior chamber reformed....
+
+=== Chunk 3350 ===
+Source: 4105_002-ebook.pdf
+Length: 906 chars
+
+Corneal wounds
+Magnification of any type is of great assistance. It should first be determined if the lesion is full or only partial thickness. A partial thickness wound of the cornea should be repaired if materials are available; otherwise a conservative approach may be taken. A full thickness wound should be repaired with whatever materials are available.
+The finest silk, monofilament nylon, or synthetic absorbable suture material available (6/0 – 8/0) and the finest available instruments shou...
+
+=== Chunk 3351 ===
+Source: 4105_002-ebook.pdf
+Length: 102 chars
+
+Figures 29.11.1 and 29.11.2
+“Degloving” injury of the eyelid. The grey line is intact.
+333
+WAR SURGERY...
+
+=== Chunk 3352 ===
+Source: 4105_002-ebook.pdf
+Length: 95 chars
+
+Figure 29.12
+Midstromal suture of the cornea using non- coloured or absorbable suture material....
+
+=== Chunk 3353 ===
+Source: 4105_002-ebook.pdf
+Length: 141 chars
+
+Figure 29.13
+Suture of combined scleral and corneal laceration: a stay suture is placed at the limbus and the corneal wound is sutured first....
+
+=== Chunk 3354 ===
+Source: 4105_002-ebook.pdf
+Length: 1225 chars
+
+Figures 29.14.1 and 29.14.2
+Conjunctival flap to cover a gaping wound of the cornea. The area up to the dotted line denotes the extent of undermining of the conjunctiva.
+334
+and taken to mid-stromal depth from where it is directed horizontally to the edge of the wound. The needle should then penetrate the opposing edge of the wound at mid-stromal depth and come out of the cornea 2 mm from the wound edge. The interrupted sutures are placed every 2 mm. The suture is then rotated so that the knot i...
+
+=== Chunk 3355 ===
+Source: 4105_002-ebook.pdf
+Length: 493 chars
+
+Scleral wounds
+As with the cornea, a partial thickness lesion of the sclera may be treated conservatively if materials are not available and is the treatment of choice for very posterior wounds. Full-thickness wounds should be closed in a similar fashion as those of the cornea, using non-coloured sutures. Gaping scleral wounds that cannot be closed should also be protected by a conjunctival flap.
+Local antibiotic eye drops or ointment should be applied for 1 – 2 weeks.
+INJURIES TO THE EYE...
+
+=== Chunk 3356 ===
+Source: 4105_002-ebook.pdf
+Length: 885 chars
+
+29.10.2 Uveal tract, vitreous body and lens capsule
+After reflection of the conjunctiva, any prolapse of the contents of the globe is excised using sharp scissors and the cornea or sclera closed as described above. Intra-ocular tissue must never be left incarcerated in a wound. Systemic and local antibiotic cover is essential.
+C
+&
+R
+C
+I
+/
+i
+n
+a
+l
+P
+.
+F
+With all penetrating wounds, the possibility of a retained foreign body should be kept in mind. If the presence of an IOFB is confirmed, local st...
+
+=== Chunk 3357 ===
+Source: 4105_002-ebook.pdf
+Length: 567 chars
+
+29.11 Excision of the eye
+Excision of the eye is indicated for:
+• complete disorganization of the globe,
+• painful, blind eye,
+• endophthalmitis resistant to therapy, or
+• sympathetic ophthalmia.
+If excision of the eye is indicated, complete evisceration of the contents is preferred to enucleation, in order to prevent ascending meningitis. As with all mutilating surgery, proper consent and advice to the patient are essential. The correct fitting of an artificial eye is a specialist technique, bu...
+
+=== Chunk 3358 ===
+Source: 4105_002-ebook.pdf
+Length: 79 chars
+
+Figure 29.15
+Extrusion of the iris through a corneal wound.
+335
+WAR SURGERY
+336...
+
+=== Chunk 3359 ===
+Source: 4105_002-ebook.pdf
+Length: 766 chars
+
+29.11.1 Evisceration of the eye
+The posterior half of the globe should be retained, with the attachments of the extrinsic eye muscles intact. This is the best technique for fitting a prosthesis at a later date.
+1. The eyelids are kept retracted by an ophthalmic speculum or fine retractors.
+2. An incision is made in the sclera fairly close to its junction with the cornea and is carried through its full thickness and around the whole circumference, thus removing the cornea.
+3. All the contents of ...
+
+=== Chunk 3360 ===
+Source: 4105_002-ebook.pdf
+Length: 255 chars
+
+29.11.2 Enucleation of the eyeball
+In some cases, the destruction of the globe is so great that its entire removal is inevitable. Enucleation provides less risk of ascending infection.
+C
+R
+&
+C
+I
+/
+s
+a
+C
+R
+&
+C
+I
+/
+s
+a
+p
+p
+a
+a
+P
+z
+.
+N
+P
+z
+.
+N
+Figure 29.16.1...
+
+=== Chunk 3361 ===
+Source: 4105_002-ebook.pdf
+Length: 277 chars
+
+Figure 29.16.2
+After retraction of the eyelids, whatever remains of the conjunctiva is picked up and incised as close as possible to the remaining cornea.
+The space adjacent to the globe (Tenon’s capsule) is entered by blunt dissection with curved scissors.
+C
+Papas /ICRC
+P
+.
+N...
+
+=== Chunk 3362 ===
+Source: 4105_002-ebook.pdf
+Length: 207 chars
+
+Figure 29.16.3
+The eye muscles are successively clamped and cut as close to the sclera as possible. The severed muscle is ligated or a stitch passed through and the end left long.
+INJURIES TO THE EYE
+C
+R
+C
+I...
+
+=== Chunk 3363 ===
+Source: 4105_002-ebook.pdf
+Length: 310 chars
+
+Figure 29.16.4
+The remains of the globe, freed from the muscle attachments, are then grasped with Kocher forceps and pulled upward until the optic nerve is isolated.
+C
+R
+C
+ICRC
+I
+Figures 29.16.5 and 29.16.6
+The nerve is cut and the globe removed, any strands of connecting tissue are severed.
+C
+Papas/ ICRC
+.
+N...
+
+=== Chunk 3364 ===
+Source: 4105_002-ebook.pdf
+Length: 317 chars
+
+Figure 29.16.7
+A compress with hot saline or dilute adrenaline solution is inserted into the empty socket and pressure applied for a few minutes for haemostasis.
+The loose ligatures of the muscles are tied together to fill the residual cavity and the conjunctiva sutured closed.
+A firm dressing is applied for 2 days....
+
+=== Chunk 3365 ===
+Source: 4105_002-ebook.pdf
+Length: 740 chars
+
+29.12 Retrobulbar haemorrhage
+As mentioned, retrobulbar haemorrhage with the advent of an acute orbital compartment syndrome constitutes a true surgical emergency and treatment must be instituted within two hours if the eye is to be saved. Severe burns on the face may also result in an orbital compartment syndrome.
+The eye presents with severe pain, tense proptosis that is hard to the touch, loss of pupillary reactions to light, ocular paralysis and rapidly progressing loss of vision.
+Superior b...
+
+=== Chunk 3366 ===
+Source: 4105_002-ebook.pdf
+Length: 135 chars
+
+Figure 29.17.2
+Incision of the lateral canthus: the eyelids are retracted back and the skin cut for one centimetre.
+C
+Papas/ ICRC
+P
+.
+N...
+
+=== Chunk 3367 ===
+Source: 4105_002-ebook.pdf
+Length: 1547 chars
+
+Figure 29.17.3
+The skin is cut through to expose the inferior branch of the lateral canthal ligament, which is then sectioned.
+338
+Decompression of the orbit by a lateral canthotomy with sectioning of the lateral canthal ligament is a relatively simple procedure that can be performed quickly and easily repaired later.
+1. Local anaesthesia with adrenaline is infiltrated into the conjunctiva of the lateral canthus, the lateral canthal ligament and for two centimetres into the skin.
+2. The lids are...
+
+=== Chunk 3368 ===
+Source: 4105_002-ebook.pdf
+Length: 1075 chars
+
+29.13 Treatment of complications
+One entirely preventable complication is exposure keratitis. Injuries and burns of the eyelids or injury affecting the orbicularis oculis muscle can directly expose the cornea, which should be protected by eye ointment or a conjunctival flap. Far more common occurrences, however, are seen in comatose patients with no ocular involvement whatsoever or an alert patient with a facial nerve injury. Proper eye hygiene of the comatose patient involves daily swabbing wit...
+
+=== Chunk 3369 ===
+Source: 4105_002-ebook.pdf
+Length: 1125 chars
+
+29.13.1 Endophthalmitis
+Intra-ocular infection, either bacterial or fungal, is always a risk with penetrating wounds especially after landmine injuries with organic intra-ocular foreign bodies. Endophthalmitis constitutes a medical emergency.
+Headache and local pain are usually prominent, photophobia and visual loss acute, and the patient may have a fever. The eye is “fiery” red, the conjunctiva and lids greatly swollen and purulent discharge abundant. Examination of the anterior chamber frequen...
+
+=== Chunk 3370 ===
+Source: 4105_002-ebook.pdf
+Length: 2247 chars
+
+29.13.2 Sympathetic ophthalmia
+Although the condition has been known since the time of Hippocrates, and much feared, it is a rare occurrence and its incidence has probably been exaggerated. In modern wars its estimated incidence is lower than 0.2 % of all ocular injuries.
+This auto-immune granulomatous uveitis begins in the injured “exciting” eye and goes on to involve the uninjured “sympathizing” eye later on. The pathological changes are the same in both eyes and the condition leads to loss of...
+
+=== Chunk 3371 ===
+Source: 4105_002-ebook.pdf
+Length: 596 chars
+
+29.14 Burns of the eyelids and eye
+Burns in the region of the eye should not be treated with drying agents, as this invariably results in extensive ectropion from scar contraction leading to exposure keratitis, frequently followed by blindness or loss of the eye.
+C
+R
+C
+I
+The burnt area of the lid should be thoroughly cleaned with saline, any blister opened and an antibiotic cream applied over the raw area. This should be covered by vaseline gauze dressing and a pad under a firm bandage. The pad ...
+
+=== Chunk 3372 ===
+Source: 4105_002-ebook.pdf
+Length: 1173 chars
+
+Figures 29.18.1 and 29.18.2
+Pattern 3 blast mine injury: second degree burns and small superficial fragment wounds to the face, eyelids and cornea. The patient also suffered injuries to the hands, arm and leg.
+339
+WAR SURGERY
+340
+For open exposure treatment of burns around the eyes, the area is irrigated with saline and chloramphenicol eye ointment applied every four hours, and 1 % homatropine drops instilled twice daily.
+Whole thickness skin burns of the eyelid should be excised and grafted at ...
+
+=== Chunk 3373 ===
+Source: 4105_002-ebook.pdf
+Length: 426 chars
+
+ANNEX 29. A Complete ocular examination
+A full and proper examination of the eyes should be performed using a slit-lamp, which is rarely available in the absence of an ophthalmologist. Nonetheless, a systematic approach using the means at hand is quite adequate when working with limited resources. A pen torch, ophthalmoscope and simple eye chart are sufficient. The reader should refer to standard textbooks for more detail....
+
+=== Chunk 3374 ===
+Source: 4105_002-ebook.pdf
+Length: 618 chars
+
+Inspection of the eyelids and lashes
+A flattened upper eyelid may indicate a disrupted globe. If a disrupted globe is suspected, the eyelids should not be everted, but rather retracted apart.
+Even a small laceration of the eyelid may hide serious damage underneath and be the entry point of a projectile that has penetrated the globe and even the brain. A high degree of suspicion is necessary.
+The depth of any laceration should be noted, whether superficial or full-thickness. In addition, any loss...
+
+=== Chunk 3375 ===
+Source: 4105_002-ebook.pdf
+Length: 1418 chars
+
+Inspection of the conjunctiva, cornea, and sclera with a torch
+Gross contamination of the conjunctiva by dirt and debris is frequent. Once a disrupted globe is excluded, the upper eyelid should be everted and a few drops of local anaesthetic instilled (0.4 % oxybuprocaine or, if not available, 2 % lidocaine). Foreign bodies on the tarsal surface can be removed by irrigation or by picking them out with a fine forceps or a cotton-wool bud on a stick.
+Any abrasion of the cornea should be sought out...
+
+=== Chunk 3376 ===
+Source: 4105_002-ebook.pdf
+Length: 1304 chars
+
+3. Pupillary reactivity
+The size, shape, symmetry and reaction of the pupils to light should be noted, as well as any opacity of the lens. Pupillary irregularity and blood within the anterior chamber (hyphaema), or even collapse of the anterior chamber, denote anterior segment trauma with loss of aqueous humour causing the iris to come into contact with the posterior surface of the cornea. There may be prolapse of the iris through a wound.
+The pupillary red reflex is tested by direct ophthalmosc...
+
+=== Chunk 3377 ===
+Source: 4105_002-ebook.pdf
+Length: 215 chars
+
+Figure 29.A.1
+Normal eyes: bilateral myosis. Shining a light in one eye results in its constriction = direct response. The other pupil also exhibits myosis = consensual response.
+roe nb Wa iG = wis SY is us ya a <a?...
+
+=== Chunk 3378 ===
+Source: 4105_002-ebook.pdf
+Length: 232 chars
+
+Figure 29.A.2
+If the left optic nerve is damaged, neither pupil constricts when the left eye is stimulated (neither direct nor consensual response). When a light is shone in the right eye, both pupils constrict.
+A DISTR Sep 7 Waa we...
+
+=== Chunk 3379 ===
+Source: 4105_002-ebook.pdf
+Length: 318 chars
+
+Figure 29.A.3
+If the left oculomotor nerve is damaged, the direct response of myosis is lost but not the consensual: the right pupil constricts. When a light is shone in the right eye, only the direct response of constriction is maintained.
+341
+C
+Papas / ICRC
+P
+.
+N
+C
+Papas / ICRC
+P
+.
+N
+C
+Papas /ICRC
+P
+.
+N
+WAR SURGERY...
+
+=== Chunk 3380 ===
+Source: 4105_002-ebook.pdf
+Length: 71 chars
+
+Figure 29.A.4
+The nine positions of gaze, including straight ahead.
+342...
+
+=== Chunk 3381 ===
+Source: 4105_002-ebook.pdf
+Length: 243 chars
+
+4. Ocular motility
+The full range of eye movements tests the integrity of cranial nerves III (oculomotor), IV (trochlear) and VI (abducent) and can only be elicited in a conscious and cooperative patient. All nine positions of gaze are tested....
+
+=== Chunk 3382 ===
+Source: 4105_002-ebook.pdf
+Length: 504 chars
+
+5. Visual acuity of both eyes
+This is the most important parameter in diagnosing the seriousness of an eye injury, but requires a conscious and cooperative patient. It should be recorded in five grades:
+1. reads print;
+2. counts fingers;
+3. perceives hand movements;
+4. perceives light;
+5. does not perceive light.
+In evaluating perception of light, it is important to pass a very bright light in front of the eye whilst completely shielding the other eye from the light and possible heat from the to...
+
+=== Chunk 3383 ===
+Source: 4105_002-ebook.pdf
+Length: 1194 chars
+
+Chapter 30 INJURIES TO THE NECK
+345
+WAR SURGERY
+346
+30. INJURIES TO THE NECK 30.1 Introduction 30.2 Surgical anatomy 30.3 Wound ballistics 30.4 Epidemiology 30.4.1 Red Cross Wound Score 30.5 Clinical presentations and emergency room care 30.5.1 C-ABCDE: Catastrophic haemorrhage 30.5.2 Airway 30.5.3 Breathing and Circulation 30.5.4 Disability 30.5.5 Œsophagus and visceral wounds 30.5.6 Investigations 30.6 Decision to operate 30.7 Patient preparation 30.8 Surgical management of vascular injuries 3...
+
+=== Chunk 3384 ===
+Source: 4105_002-ebook.pdf
+Length: 717 chars
+
+30.1 Introduction
+The most common causes of death from projectile wounds in the neck are exsanguination, cervical spine injury and asphyxia. Direct blunt trauma to the neck, such as being struck with the cross or butt of a rifle, also occurs during combat. Delayed causes include sepsis, most commonly following an oesophageal fistula.
+The cervical spine requires special care during examination and treatment if the patient has suffered the more common forms of blunt trauma and deceleration injury ...
+
+=== Chunk 3385 ===
+Source: 4105_002-ebook.pdf
+Length: 642 chars
+
+30.2 Surgical anatomy
+In classical anatomy textbooks, the neck is usually described as comprising anterior and posterior triangles with their various subdivisions. Although useful, this classification is not totally relevant to penetrating injuries and a division into Zones, specifically pertinent to vascular injuries, is preferable. Zone I extends from the sternal notch and clavicle to the cricoid cartilage; Zone II from the cricoid cartilage to the angle of the mandible; and Zone III from the ...
+
+=== Chunk 3386 ===
+Source: 4105_002-ebook.pdf
+Length: 1188 chars
+
+Figures 30.1.1 and 30.1.2
+Zones of the neck.
+Zone I: great vessels of the thoracic outlet; lung apices and trachea; oesophagus, thyroid, and thoracic duct; cervical spine and cervical nerve trunks. Access to the major vessels of Zone I may require resection of part of the clavicle or a sternotomy.
+Zone II: jugular-carotid vascular bundle and vertebral vessels; larynx, pharynx, and cervical spine. The vasculature of Zone II is easy to access.
+Zone III: distal internal carotid and vertebral arteri...
+
+=== Chunk 3387 ===
+Source: 4105_002-ebook.pdf
+Length: 96 chars
+
+Figure 30.2
+Aero-digestive tract in the neck.
+Figure 30.3 Major vessels of the root of the neck....
+
+=== Chunk 3388 ===
+Source: 4105_002-ebook.pdf
+Length: 1620 chars
+
+Figure 30.4
+Fascial layers and compartments of the neck.
+348
+C
+Papas / ICRC
+Nasopharynx  C2  Oropharynx  Hypopharynx / laryngopharynx  Cricoid cartilage  Oesophagus  Trachea
+Nasopharynx
+C2
+Oropharynx
+Hypopharynx / laryngopharynx
+Cricoid cartilage
+Oesophagus
+Trachea
+P
+.
+N
+C
+Papas /ICRC
+Left common carotid           Scalenus anterior        Right jugular v.      Left jugular v.        Left subclavian a.  Right subclavian a.               Right subclavian v.   Left subclavian v.     Left brachiocep...
+
+=== Chunk 3389 ===
+Source: 4105_002-ebook.pdf
+Length: 2561 chars
+
+30.3 Wound ballistics
+The neck is an intersection of soft organs lying against the cervical vertebral column and surrounded by an inelastic fascial enclosure. In terms of wound ballistics, three regions can be described. Posteriorly, the nape comprises muscles and fascia surrounding the cervical spine – a uniquely mobile bony axis. Laterally, the posterior triangles contain relatively few vital structures. The anterior triangles contain the great vessels and the hollow organs of the aero-digesti...
+
+=== Chunk 3390 ===
+Source: 4105_002-ebook.pdf
+Length: 710 chars
+
+30.4 Epidemiology
+Like the head, the neck receives a disproportionate percentage of injury. The surface area of the neck represents only 1 % – 2 % of the body, yet accounts for 5 – 15 % of wounds amongst survivors. Table 30.1 shows statistics for neck injuries among US armed forces during World War II, in Korea and in Viet Nam.
+Killed in action Died of wounds Wounded survivors 9 % 6 % 9 % 10 % 7 % 11 % 8 % 8 % 17 %
+Conflict
+World War II
+Korea
+Viet Nam
+Neck wounds among US casualties during World...
+
+=== Chunk 3391 ===
+Source: 4105_002-ebook.pdf
+Length: 3167 chars
+
+Figure 30.5
+Low-kinetic energy fragment involving the carotid and resulting in a haematoma in the closed fascial compartment leading to compression of the airway.
+349
+C
+Papas /ICRC
+P
+.
+N
+EZ
+WAR SURGERY
+350
+More recent studies show the difference in lethality between GSW of the neck (47 – 78 %) and fragment wounds (37 – 41 %). Haemorrhage is the commonest cause of death, followed by trauma to the spinal cord.3
+In general, Zone II injuries tend to be the most common (about 50 %) with the highest m...
+
+=== Chunk 3392 ===
+Source: 4105_002-ebook.pdf
+Length: 353 chars
+
+30.4.1 Red Cross Wound Score
+Injuries to major structures are considered vital wounds. Wounds of the major vessels, carotid artery and internal jugular vein, qualify as V = H, given that exsanguination is possible with both. Lesions of the airway from the larynx down through the trachea constitutes a V = T wound. Injury to the cervical spine is V = N....
+
+=== Chunk 3393 ===
+Source: 4105_002-ebook.pdf
+Length: 408 chars
+
+30.5 Clinical presentations and emergency room care
+C-ABCDE sequence for the neck
+Catastrophic haemorrhage = open bleeding from major vessel.
+Airway = larynx + trachea.
+Breathing = apex of lungs.
+Circulation = contained bleeding from thoracic outlet, carotid, jugular, or vertebral vessels.
+Disability = cervical spine + cranial nerves + cervical and brachial plexus + internal carotid artery.
+E = Œsophagus....
+
+=== Chunk 3394 ===
+Source: 4105_002-ebook.pdf
+Length: 1138 chars
+
+30.5.1 C-ABCDE: Catastrophic haemorrhage
+Catastrophic open haemorrhage from a major vessel is rarely seen in emergency reception unless the patient has been injured close to the hospital or if pre-hospital care has controlled the bleeding by digital pressure and the evacuation time is relatively short. First aiders should be questioned about any loss of blood in the field.
+If direct digital pressure keeps the haemorrhage under control, it should be maintained up to the operating theatre where th...
+
+=== Chunk 3395 ===
+Source: 4105_002-ebook.pdf
+Length: 103 chars
+
+Figure 30.6
+Tamponade of a vascular lesion in the neck by means of two Foley catheters.
+351
+WAR SURGERY...
+
+=== Chunk 3396 ===
+Source: 4105_002-ebook.pdf
+Length: 306 chars
+
+Figures 30.7.1 and 30.7.2
+This patient suffered a GSW to the neck. The trachea has been intubated.
+352
+If a Foley catheter tamponade is used, the airway should be secured even if it is not immediately threatened. Failure to intubate leads to asphyxiation as the haematoma expands and presses on the airway....
+
+=== Chunk 3397 ===
+Source: 4105_002-ebook.pdf
+Length: 3201 chars
+
+30.5.2 Airway
+The next important life-threatening condition is a compromised airway, which may be due to direct injury or compression by a haematoma, whether immediate or delayed.
+Most penetrating airway injuries are obvious on presentation. The signs and symptoms include stridor, hoarseness, or even loss of voice; dyspnoea and haemoptysis; laryngeal instability; tracheal deviation; and tenderness on palpation. There may be “bubbling” of blood in the wound or subcutaneous emphysema. Because of t...
+
+=== Chunk 3398 ===
+Source: 4105_002-ebook.pdf
+Length: 1171 chars
+
+30.5.3 Breathing and Circulation
+Injury to the apices of the lungs or vascular lesions in Zone I may lead to tension pneumothorax or haemothorax requiring a chest tube.
+Less than catastrophic bleeding may show active external haemorrhage or “bubbling” of blood at an entry wound. A tracheo-vascular fistula may present as haemoptysis and an oesophago-vascular fistula as haematemesis. An expanding or pulsatile haematoma may be seen and felt on gentle palpation. In the event of a pseudoaneurysm or A...
+
+=== Chunk 3399 ===
+Source: 4105_002-ebook.pdf
+Length: 1282 chars
+
+30.5.4 Disability
+Disability presents as tetraplegia, cranial nerve injury and/or brachial plexus injury. Sensation and movement and the cranial nerves should be tested; the patient must be conscious and cooperative.
+Injury to the carotid or vertebral arteries may show signs of cerebrovascular ischaemia: hemiparesis or hemiplegia, aphasia, or decreased level of consciousness not relative to blood loss. Such central neurological manifestations may occur with spasm of the carotid artery owing to a...
+
+=== Chunk 3400 ===
+Source: 4105_002-ebook.pdf
+Length: 389 chars
+
+30.5.5 Œsophagus and visceral wounds
+Injury to the hypopharynx or oesophagus may present as dysphagia, haematemesis, or pain on swallowing (odynophagia). Such lesions are often asymptomatic at first but serious injury may nonetheless have occurred. Many cases are associated with lesions of the larynx or trachea, and a high degree of suspicion is warranted when faced with
+353
+WAR SURGERY...
+
+=== Chunk 3401 ===
+Source: 4105_002-ebook.pdf
+Length: 285 chars
+
+Figures 30.8.1 and 30.8.2
+GSW to the front of the neck resulting in an oesophageal fistula. The patient’s neck was tilted back when hit with the resultant ragged double exit wound. No haematoma, no airway problems and no infection. The patient is under i.v. antibiotics preoperatively....
+
+=== Chunk 3402 ===
+Source: 4105_002-ebook.pdf
+Length: 573 chars
+
+Figures 30.9.1 and 30.9.2
+Late-presentation oesophageal fistula; the airway was intact. Fluids escape from the orifice in the patient’s neck when drinking. X-ray showing a retained fragment.
+354
+wounds in the airway. Late presentation is frequently complicated by fistula formation and infection that may extend into the mediastinum. Blind insertion of a nasogastric tube should not be attempted.
+g g
+g
+g g
+g
+a
+a
+F. Irmay / ICRC
+A clear or milky discharge from a left-sided wound indicates injury to ...
+
+=== Chunk 3403 ===
+Source: 4105_002-ebook.pdf
+Length: 638 chars
+
+30.5.6 Investigations
+The haemodynamic stability of the patient determines the extent of paraclinical investigations. Plain X-rays of the neck (antero-posterior and lateral) and chest should be taken as a minimum, with radio-opaque markers placed on entry and any exit wounds. Radiography may show tracheal deviation or subcutaneous emphysema, soft-tissue swelling denoting a haematoma, or a haemo- or pneumothorax, as well as a lesion of the vertebral column or a retained projectile. Retropharyngea...
+
+=== Chunk 3404 ===
+Source: 4105_002-ebook.pdf
+Length: 3050 chars
+
+30.6 Decision to operate
+Superficial wounds down to the platysma require only a debridement, thorough irrigation and immediate primary closure; this is one of the exceptions to delayed primary closure.
+Traditionally, all wounds penetrating the platysma underwent surgical exploration, even in asymptomatic patients; this practice was largely based on military experience. The high percentage of negative explorations has given rise to a more conservative approach in recent practice.
+However, this se...
+
+=== Chunk 3405 ===
+Source: 4105_002-ebook.pdf
+Length: 257 chars
+
+30.7 Patient preparation
+A naso-gastric tube is gently placed only when in the operating theatre and after the patient has been intubated or a cricothyroidotomy or tracheostomy performed, under local anaesthesia if necessary.
+Isaza-Restrepo A, et al., 2020....
+
+=== Chunk 3406 ===
+Source: 4105_002-ebook.pdf
+Length: 1230 chars
+
+Figure 30.10
+Superficial wound of the neck – entry and exit – with no symptoms of airway distress or haemorrhage: simple wound debridement and primary closure are sufficient.
+355
+C
+&
+R
+C
+I
+2 2
+/
+e
+r
+r
+o
+T
+a
+l
+3
+l
+e
+D
+.
+M
+WAR SURGERY
+356
+The patient is placed in a supine position, both arms tucked in at the sides with a small roll under the shoulders to extend the neck. The head is held in a ring-shaped or “doughnut” pillow and rotated to the contralateral side. In addition, the table should be p...
+
+=== Chunk 3407 ===
+Source: 4105_002-ebook.pdf
+Length: 2480 chars
+
+30.8.1 Basic principles
+As mentioned in Section 24.6, if repair of a vessel is not possible, ligation is the simplest and surest method to stop bleeding. The neck is a good example of two extremes of any resultant ischaemia: the external carotid artery can be ligated with impunity, the brachiocephalic trunk never.
+Two extremes: the external carotid artery can always be ligated, the brachiocephalic trunk never.
+As with all vascular surgery, gaining proper access proximal and distal to the lesion ...
+
+=== Chunk 3408 ===
+Source: 4105_002-ebook.pdf
+Length: 716 chars
+
+30.8.2 Zone I access and injuries
+Vascular access is the challenge with these injuries, more so than the actual repair or ligation. A wound to a Zone I vessel may bleed locally (external, haematoma, pseudoaneurysm or A-V fistula) or into the chest. The neck thus constitutes a “junctional” area between the chest and the head (see Section D.6).
+Most injuries to the brachiocephalic trunk, subclavian or axillary vessels can be repaired directly or with a venous graft. The subclavian and axillary art...
+
+=== Chunk 3409 ===
+Source: 4105_002-ebook.pdf
+Length: 798 chars
+
+Axillary vessels or second or third parts of the subclavian
+Proximal control of wounds in the second or third parts of the subclavian or axillary vessels can be achieved through a supraclavicular incision while the arm is kept tucked in at the side. The SCM and anterior scalenus muscles are divided at their insertion to the clavicle, with preservation of the phrenic nerve lying on the scalenus. The middle third of the clavicle may be sectioned or resected subperiosteally if necessary. The collat...
+
+=== Chunk 3410 ===
+Source: 4105_002-ebook.pdf
+Length: 819 chars
+
+First part of the subclavian vessels and brachiocephalic trunk
+The brachiocephalic trunk and first part of the subclavian vessels require proximal control in the chest. The preferred approach is a median sternotomy that is extended into the neck as an SCM incision for the right brachiocephalic trunk or left carotid, or as a supraclavicular incision for the first part of the subclavian vessels. The arm is abducted 30°. The median sternotomy is described in Annex 31. C.
+C
+Papas / ICRC
+P
+.
+N
+Once t...
+
+=== Chunk 3411 ===
+Source: 4105_002-ebook.pdf
+Length: 259 chars
+
+Figure 30.11
+Left supraclavicular incision and median sternotomy extended into a right SCM incision (see Figure 30.13.1).
+357
+WAR SURGERY
+358
+the neck and/or supraclavicular fossa in order to gain control of the proximal internal jugular and subclavian veins....
+
+=== Chunk 3412 ===
+Source: 4105_002-ebook.pdf
+Length: 693 chars
+
+Neck wound with exsanguinating haemothorax
+In the event of an exsanguinating haemothorax from a neck wound, it is best to perform an anterior thoracotomy through the fourth intercostal space of the injured side and push up a pack of gauze compresses into the apex of the thorax to act as a tampon. This is handed over to the assistant who applies manual pressure to the compresses from within the chest. Manual pressure by the assistant’s other hand is applied over the supraclavicular fossa or a lar...
+
+=== Chunk 3413 ===
+Source: 4105_002-ebook.pdf
+Length: 764 chars
+
+30.8.3 Zone II access and injuries
+Most injuries occur in Zone II, which is also fortunately the easiest to access. An incision along the anterior border of the SCM offers excellent access to the carotid sheath, hypopharynx and oesophagus, and the lateral and posterior wall of the trachea. The SCM is retracted laterally or may be sectioned at its sternoclavicular insertion and pulled back for better exposure. Bilateral SCM incisions connected by a transverse extension create a large superior pla...
+
+=== Chunk 3414 ===
+Source: 4105_002-ebook.pdf
+Length: 457 chars
+
+Internal jugular vein
+In the case of injury to the internal jugular vein, the patient’s head should be kept lower than the heart to lessen the possibility of air embolism. The vein should be repaired if possible, but no great efforts should be deployed to do so; it can be simply ligated with a transfixing suture. For bilateral injuries, however, an attempt to repair at least one should be made. Bilateral ligation has significant morbidity and mortality....
+
+=== Chunk 3415 ===
+Source: 4105_002-ebook.pdf
+Length: 116 chars
+
+External carotid artery
+The external carotid artery and its branches may be ligated with impunity, even bilaterally....
+
+=== Chunk 3416 ===
+Source: 4105_002-ebook.pdf
+Length: 1536 chars
+
+Common and internal carotid arteries
+For the common and internal carotid arteries, repair should be performed if the patient is neurologically intact. Repair or ligation is possible, but repair should be attempted if the patient suffers a mild deficit lasting less than 24 hours and there is retrograde flow from the artery. A temporary shunt can be considered to observe the neurological evolution. In the absence of retrograde flow, it is probably too late with respect to cerebral ischaemia and be...
+
+=== Chunk 3417 ===
+Source: 4105_002-ebook.pdf
+Length: 929 chars
+
+30.8.4 Zone III access and injuries
+The anterior SCM incision is carried up as far as possible and curved posteriorly over the mastoid process to avoid the mandibular branch of the facial nerve. Exposure of the distal internal carotid at the base of the skull is aided by dislocation of the temporo-mandibular joint or section of the mandible just below the condyle, allowing a pseudo-arthrosis to form later. In addition the mastoid insertion of the SCM can be sectioned.
+In most cases, ligation of ...
+
+=== Chunk 3418 ===
+Source: 4105_002-ebook.pdf
+Length: 599 chars
+
+30.8.5 Posterior triangle: vertebral artery
+Seldom injured, the vertebral artery in the posterior triangle is very difficult to access, especially in the foramina of the upper 6 vertebral transverse processes. Tamponade with a compress and skin closure, removed after 48 hours, is probably the procedure of choice in the acute condition. Most cases undergo thrombosis. Should bleeding recur, the hole in the transverse process should be stopped up with a piece of crushed muscle or bone wax, and pres...
+
+=== Chunk 3419 ===
+Source: 4105_002-ebook.pdf
+Length: 136 chars
+
+Figure 30.13
+A lesion at the bifurcation of the carotid has been repaired.
+359
+WAR SURGERY
+Figure 30.14 Repair of a laryngeal wound.
+360...
+
+=== Chunk 3420 ===
+Source: 4105_002-ebook.pdf
+Length: 253 chars
+
+30.9 Surgical management of laryngo-tracheal injuries
+Up to 50 % of laryngo-tracheal wounds are complicated by injury to the pharynx or oesophagus; any airway lesion requires an appropriate exploration. A tracheo- oesophageal fistula should be repaired....
+
+=== Chunk 3421 ===
+Source: 4105_002-ebook.pdf
+Length: 297 chars
+
+30.9.1 Surgical access
+A midline incision should be used only for very small and uncomplicated injuries. Otherwise, access to the larynx and trachea is easily accomplished through bilateral SCM incisions with a transverse connexion. The distal trachea usually requires a partial median sternotomy....
+
+=== Chunk 3422 ===
+Source: 4105_002-ebook.pdf
+Length: 803 chars
+
+30.9.2 Laryngeal wounds
+A distal tracheostomy is mandatory. Small wounds are debrided and the mucosa and cartilage closed with absorbable sutures; the knot is placed external to the laryngeal cavity. For an injury to the cricoid cartilage, the tissues around the first tracheal ring should be mobilized to close the defect. A stent such as an endotracheal tube should be used to prevent stenosis of the larynx and kept in place for 14 days.
+C
+IcRc
+R
+C
+I
+Severe damage to the laryngeal skeleton or par...
+
+=== Chunk 3423 ===
+Source: 4105_002-ebook.pdf
+Length: 1477 chars
+
+30.9.3 Tracheal wounds
+If the wound is very small and anteriorly placed it can be transformed into a formal tracheostomy and cannulated with a tube until oedema resolves. The tube is then removed and the opening allowed to close spontaneously.
+A tracheal wound less than 40 % of the circumference can be directly repaired. The edges of the mucosa and cartilage are conservatively debrided. The mucosa is closed with interrupted absorbable sutures, with the knot placed outside the airway cavity. The ...
+
+=== Chunk 3424 ===
+Source: 4105_002-ebook.pdf
+Length: 588 chars
+
+30.9.4 Blunt injuries
+A sharp blow to the throat with the butt of a rifle, for example, may cause a laryngeal or soft-tissue haematoma, or a dislocation-fracture of the laryngeal cartilages. Immediate laryngeal obstruction may not occur but the risk is always present. Careful observation is important and needle cricothyroidotomy may be required as an emergency procedure if surgical emphysema impedes identifying the cricothyroid membrane, followed by a tracheostomy. If such close observation is n...
+
+=== Chunk 3425 ===
+Source: 4105_002-ebook.pdf
+Length: 236 chars
+
+30.9.5 Other viscera and soft tissues, etc.
+Injury to the thyroid gland requires minimal debridement and closure of the capsule. Attention must be paid to the parathyroid glands and recurrent laryngeal nerve as with all thyroid surgery....
+
+=== Chunk 3426 ===
+Source: 4105_002-ebook.pdf
+Length: 371 chars
+
+30.10 Surgical management of pharyngo-oesophageal injuries
+Wounds involving the pharynx or cervical oesophagus tend to cause gross contamination of the tissue planes of the neck with saliva. The subsequent infection may cause a retropharyngeal abscess or track downwards and cause fatal mediastinitis. Every attempt should be made to prevent such spreading contamination....
+
+=== Chunk 3427 ===
+Source: 4105_002-ebook.pdf
+Length: 401 chars
+
+30.10.1 Access and operative diagnosis
+In some cases a left SCM incision is sufficient; in others, with significant injury, careful and wide exposure through bilateral SCM incisions with a transverse connexion is necessary to get at the depths of the wound. A Foley catheter or Penrose drain passed around the oesophagus allows it to be rotated to permit better inspection of its entire circumference....
+
+=== Chunk 3428 ===
+Source: 4105_002-ebook.pdf
+Length: 83 chars
+
+Figure 30.15
+Direct intubation of a tracheal wound prior to repair.
+361
+WAR SURGERY...
+
+=== Chunk 3429 ===
+Source: 4105_002-ebook.pdf
+Length: 1169 chars
+
+Figure 30.16
+Surgical access to the cervical oesophagus.
+362
+C
+Papas / ICRC
+Strap muscle  Pretracheal fascia  Thyroid  Sternocleidomastoid  Omohyoid muscle  Trachea  Carotid sheath  Oesophagus
+Strap muscle
+Pretracheal fascia
+Thyroid
+Sternocleidomastoid
+Omohyoid muscle
+Trachea
+Carotid sheath
+Oesophagus
+P
+.
+N
+Lesions of the pharynx or oesophagus may not be obvious, the clinical signs minimal or absent. Often, the only evidence is a small haematoma in the para-oesophageal tissues. The complications...
+
+=== Chunk 3430 ===
+Source: 4105_002-ebook.pdf
+Length: 2916 chars
+
+30.10.2 Repair
+The edges of the injured pharynx or oesophagus are carefully trimmed. Surrounding dead and contaminated tissues are debrided.
+Primary repair of the hypopharynx should be done if practicable. Otherwise a defunctioning pharyngo-cutaneous mucosal fistula and closure of the oesophagus with an absorbable suture or cervical oesophagostomy should be performed.
+Small oesophageal lacerations should be sutured directly. Larger injuries may require some mobilization of the oesophagus to perm...
+
+=== Chunk 3431 ===
+Source: 4105_002-ebook.pdf
+Length: 855 chars
+
+30.11 Post-operative care
+The patient should be nursed in a semi-sitting position. Close monitoring of the tracheostomy and signs of complications specific to neck injuries is essential:
+• haemorrhage;
+• compression of the airway by an enclosed haematoma;
+• pneumothorax;
+• missed oesophageal injury with a salivary fistula;
+• infection;
+• thoracic duct injury with chylothorax or a lymphatic fistula.
+Antibiotic coverage should be administered, according to protocol: if the airway or digestive trac...
+
+=== Chunk 3432 ===
+Source: 4105_002-ebook.pdf
+Length: 936 chars
+
+30.12 Tracheostomy
+Mention is often made of tracheostomy in this manual. It is a very useful procedure when working with limited resources and its importance easily underestimated. A tracheostomy removes about 150 ml of dead space from the airway, thus making respiration more efficient in terms of oxygen delivery and removal of carbon dioxide with less effort on the part of the patient. It is a good adjunct to the treatment of a patient with severe head or lung injury or tetanus, and is essentia...
+
+=== Chunk 3433 ===
+Source: 4105_002-ebook.pdf
+Length: 1943 chars
+
+30.12.1 Tracheostomy care
+Adequate nursing care is the key if the patient is to receive full benefit of the treatment and complications avoided.
+• The skin around the tracheostomy should be kept clean of any dried secretions; gentle swabbing with a moist compress is usually sufficient.
+• A special filter to breathe through should be used, if available. Otherwise, a gauze compress kept moist with normal saline should cover the opening.
+364
+INJURIES TO THE NECK
+• Any oxygen delivery should be humi...
+
+=== Chunk 3434 ===
+Source: 4105_002-ebook.pdf
+Length: 817 chars
+
+D.1 Introduction
+The torso comprises the chest, abdomen, and pelvis, including the buttocks. Penetrating missile wounds to the torso can easily involve more than one body cavity, and commonly do. The extent of the thorax differs considerably during inspiration and expiration with excursion of the diaphragm. Thus, an entry wound in the “thorax” can easily affect the abdomen as well, and vice versa. Any penetrating wound from the nipple line to the groin and upper thighs must raise suspicion of an...
+
+=== Chunk 3435 ===
+Source: 4105_002-ebook.pdf
+Length: 129 chars
+
+Figure D.1
+Figure D.1 Multiple fragment wounds often pose a problem of clinical diagnosis.
+Figure D.2 And do not forget the back!...
+
+=== Chunk 3436 ===
+Source: 4105_002-ebook.pdf
+Length: 421 chars
+
+D.2 Epidemiology
+In most series from the past, both the thorax and the abdomen are the site of 6 to 15 % of the injuries (see Table 5.6). Up to 40 % of thoracic injuries are thoraco-abdominal. Table D.1 shows some examples from various modern conflicts where the wearing of body armour was not standard.
+After severe brain trauma, haemorrhage in the torso is the leading cause of death in combat injuries.
+369
+WAR SURGERY...
+
+=== Chunk 3437 ===
+Source: 4105_002-ebook.pdf
+Length: 1155 chars
+
+Figure D.3
+A good example of what should not be done: the laparotomy incision is paramedian rather than midline and is continued on in a low anterior thoracotomy. This incision is of very little use in trauma surgery. Note the infection around the drains that have been left in too long.
+370
+Conflict / Source Intrathoracic injuries (N = number of patients) Thoraco-abdominal wounds Other associated injuries* USA – Viet Nam (1968 – 69) McNamara et al., 1970. 547 34 % 85 % UK – Iraq, Afghanistan (20...
+
+=== Chunk 3438 ===
+Source: 4105_002-ebook.pdf
+Length: 4016 chars
+
+Thoraco-abdominal wounds
+A chest tube should be inserted routinely in all thoraco- abdominal wounds, and before the laparotomy.
+Patients with thoraco-abdominal injuries have thoracic wounds that can usually be managed by closed chest tube drainage, and abdominal wounds that require laparotomy. Mortality in war trauma comes not from a negative laparotomy, but from a missed abdominal injury. It has been said that the most common operation for chest trauma, after intercostal tube drainage, is a lap...
+
+=== Chunk 3439 ===
+Source: 4105_002-ebook.pdf
+Length: 137 chars
+
+Figure D.4
+Thoraco-abdominal wound with air under both cupolas of the diaphragm.
+Figure D.5 Repair of a perforation of the diaphragm.
+372...
+
+=== Chunk 3440 ===
+Source: 4105_002-ebook.pdf
+Length: 1546 chars
+
+D.4 Injuries to the diaphragm
+C
+ICRC
+R
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+I
+A single projectile wounding both the thorax and the abdomen must perforce injure the diaphragm. If the defect is large enough, an abdominal viscus may herniate into the chest, although this is more common with blunt trauma. More importantly, intestinal contents from a perforated bowel may pass into the chest, demanding appropriate toilet and washing out of the pleural cavity after adequate control of the abdominal injuries. It is essential to remember ...
+
+=== Chunk 3441 ===
+Source: 4105_002-ebook.pdf
+Length: 2253 chars
+
+D.5 Transaxial injuries
+Transaxial injuries present entry and exit wounds on opposite sides of the torso, or a retained bullet on the opposite side of the entry, as diagnosed either by X-ray or intra- operatively. Such a projectile trajectory obviously has a great chance of hitting a vital structure in either the thorax or the abdomen, or both. Automatic, natural triage comes into play and few casualties survive to reach hospital. The shorter the evacuation time, the more serious the injuries en...
+
+=== Chunk 3442 ===
+Source: 4105_002-ebook.pdf
+Length: 1415 chars
+
+D.6 Junctional trauma
+The torso forms a “junction” with the upper extremities at the axilla, with the lower limbs at the groin, and with the root of the neck at the thoracic outlet. Trauma at these sites, with major vascular bundles, puts life and limb at risk. Proximal control of haemorrhage must be performed in a body cavity and distal control in the limb or the neck. The general surgeon is thus faced with an especially complicated task.
+A good analysis of the challenges is presented in Table ...
+
+=== Chunk 3443 ===
+Source: 4105_002-ebook.pdf
+Length: 126 chars
+
+Figure D.6
+Shotgun injury to the thorax with pellets traversing the mediastinum.
+373
+C
+2
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+/
+y
+= £
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+.
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+WAR SURGERY...
+
+=== Chunk 3444 ===
+Source: 4105_002-ebook.pdf
+Length: 673 chars
+
+Figure D.7
+Direct pressure to control a case of junctional haemorrhage; there is no space to apply a tourniquet.
+374
+Proximal control of the vascular bundle at the root of the neck (Zone 1) is dealt with in Section 30.8.2 and covers the junction between thorax and neck on the one hand, and between the thorax and upper limb on the other. The vascular bundle at the junction between the abdomen and the lower limb is most rapidly and best controlled proximally by laparotomy to expose the iliac vesse...
+
+=== Chunk 3445 ===
+Source: 4105_002-ebook.pdf
+Length: 1995 chars
+
+D.7 The general surgeon and the chest: the psychological partition
+The diaphragm not only constitutes an anatomic partition between the thorax and the abdomen, but also a psychological barrier in the mind of many general surgeons. The general surgeon must familiarize himself with thoracic anatomy in order to operate with confidence – and gather courage. Most general surgeons lack experience in operating in the chest and approach a thoracotomy with trepidation. This is probably due to the presenc...
+
+=== Chunk 3446 ===
+Source: 4105_002-ebook.pdf
+Length: 2522 chars
+
+Chapter 31 THORACIC INJURIES
+377
+WAR SURGERY
+378
+31.
+THORACIC INJURIES
+31.1 Introduction 31.2 Wound ballistics 31.2.1 Reaction of bone 31.2.2 Reaction of the lung 31.2.3 Reaction of other organs 31.2.4 Reaction of the diaphragm 31.3 Epidemiology 31.3.1 Mortality 31.3.2 Distribution of thoracic organ injuries 31.3.3 Thoracotomy rate 31.3.4 Associated injuries 31.3.5 Red Cross Wound Score 31.4 Clinical presentation 31.4.1 Initial examination 31.4.2 Complete examination 31.4.3 Haemothorax and pneum...
+
+=== Chunk 3447 ===
+Source: 4105_002-ebook.pdf
+Length: 1518 chars
+
+31.1 Introduction
+“Bleeding from the parenchyma of the lung in wounds of the thorax may be massive, but is slow and seldom requires hemostasis. On the other hand, free bleeding from the heart, great vessels, internal mammary or intercostal arteries is fast and profuse. Rapidly progressive shock is present early and death may quickly ensue unless hemorrhage is checked.”
+R. Arnold Griswold and Charles H. Maguire 1
+Blunt, blast, and penetrating trauma to the chest all occur during armed conflict. M...
+
+=== Chunk 3448 ===
+Source: 4105_002-ebook.pdf
+Length: 125 chars
+
+Figure 31.1
+Transfixing wound of the lung entirely within the narrow phase 1 shooting channel with no cavity formation.
+P
+.
+N...
+
+=== Chunk 3449 ===
+Source: 4105_002-ebook.pdf
+Length: 822 chars
+
+31.2 Wound ballistics
+The chest is composed of a set of heterogeneous organs with widely differing ballistic characteristics. The trajectory and particularly the length of the wounding channel are of crucial importance for the production of a temporary cavity. A particularly stable bullet traversing the antero-posterior diameter of the chest may create only a narrow shooting channel with little permanent tissue damage (Figure 31.1); if cavity formation occurs at the exit point, it will result in...
+
+=== Chunk 3450 ===
+Source: 4105_002-ebook.pdf
+Length: 266 chars
+
+Figure 31.2
+1 Griswold RA, Maguire CH. Penetrating wounds of heart and pericardium. Surg Gynecol Obstet 1942; 74: 406 – 418.
+Antero-posterior transfixing FMJ bullet: cavity formation beginning at the exit and resulting in an open sucking chest wound.
+379
+WAR SURGERY...
+
+=== Chunk 3451 ===
+Source: 4105_002-ebook.pdf
+Length: 123 chars
+
+Figure 31.3
+Tangential wound of the chest wall with underlying pulmonary contusion. The bullet has become destabilized.
+380...
+
+=== Chunk 3452 ===
+Source: 4105_002-ebook.pdf
+Length: 1140 chars
+
+31.2.1 reaction of bone
+A stable bullet punches a hole through a rib or the sternum, but a fragment or destabilized bullet can drive bits of bone into the underlying lung or mediastinum. The point of entry of an unstable projectile can create a large hole resulting in the open pneumothorax of a sucking chest wound.
+The flexibility and curvature of the ribs can cause a bullet arriving at a low impact angle to inflict a tangential wound. The impulse provokes a serious contusion of the underlying l...
+
+=== Chunk 3453 ===
+Source: 4105_002-ebook.pdf
+Length: 1192 chars
+
+31.2.2 reaction of the lung
+The lung parenchyma is highly elastic and can easily withstand stretch deformation; however, it is readily lacerated. Thus a high-energy stable rifle bullet can cause less permanent damage than a slower and heavier handgun bullet that causes little cavity formation but crushes a greater volume of tissue. Larger lacerations are the result of bony fragments projected into the lungs. Significant cavity formation from a high- kinetic energy bullet may nonetheless provoke ...
+
+=== Chunk 3454 ===
+Source: 4105_002-ebook.pdf
+Length: 821 chars
+
+31.2.3 reaction of other organs
+The heart and great vessels are essentially fluid-filled organs that do not tolerate stretch at all: the formation of a cavity causes explosive rupture. The trachea and oesophagus react like hollow organs and are minimally affected by stretch. The close proximity of all these vital structures in the mediastinum makes isolated injuries uncommon and most major wounds are quickly fatal.
+In survivors, however, injuries from low-kinetic energy projectiles – small fragm...
+
+=== Chunk 3455 ===
+Source: 4105_002-ebook.pdf
+Length: 564 chars
+
+31.2.4 reaction of the diaphragm
+Cavity formation close to the diaphragm causes very serious lesions to this muscle. A large laceration of the left cupola may result in herniation of abdominal organs into the chest; wounds in the right cupola invariably lead to severe injury to the liver or major vessels. More frequently, simple projectile perforation and small radial tears of the diaphragm are seen; the effects of cavity formation may be observed further along the wounding channel, either in th...
+
+=== Chunk 3456 ===
+Source: 4105_002-ebook.pdf
+Length: 1327 chars
+
+31.3.1 Mortality
+Penetrating chest wounds account for about 10 % of the wounded and approximately 25 % of those killed in action. The mortality of a thoracic wound is about 70 % and depends greatly on the type of weapon: it is much higher with high-energy bullets and close-up primary blast than with small fragments. Body armour protects against projectile penetration but not against primary blast effects. This has been noted in recent conflicts in Iraq and Afghanistan.2 3
+The main causes of deat...
+
+=== Chunk 3457 ===
+Source: 4105_002-ebook.pdf
+Length: 1696 chars
+
+31.3.2 Distribution of thoracic organ injuries
+Pulmonary lesions are present in 98 – 100 % of all series. Injury to certain intrathoracic organs such as the trachea and oesophagus, on the other hand, are rarely observed in survivors; their anatomic relationship to the major vasculature explains the dearth of such lesions. Table 31.1 shows the distribution of injuries to intrathoracic organs, other than the lungs, found during thoracotomy in several series from past conflicts.
+2 Keneally R, Szpis...
+
+=== Chunk 3458 ===
+Source: 4105_002-ebook.pdf
+Length: 2815 chars
+
+31.3.3 Thoracotomy rate
+Chest tube drainage is sufficient surgical treatment in the great majority of patients reaching hospital; the experience of ICRC surgeons puts this figure over 95 %. Some patients, particularly with a very small haemo- or pneumothorax, do not require drainage at all.
+The great historical controversy concerns the criteria for performing a thoracotomy. Certain circumstances have encouraged surgeons to take a more aggressive approach, and this explains the great variability ...
+
+=== Chunk 3459 ===
+Source: 4105_002-ebook.pdf
+Length: 627 chars
+
+31.3.4 Associated injuries
+The incidence of concomitant abdominal injuries ranges between 10 % and 40 % (Table D.1). Penetrating thoracic injuries below the T4 level (nipple line) have a high probability of involving abdominal structures. Apart from wound excision and insertion of chest tubes, overall the most common operation in projectile or blast chest injury is laparotomy. Other associated injuries are also common, varying from 12 to 90 % in reported series, but depend largely on the woundin...
+
+=== Chunk 3460 ===
+Source: 4105_002-ebook.pdf
+Length: 104 chars
+
+Figures 31.4.1 and 31.4.2
+Combined abdominal and thoracic gunshot wound: small entry and large exit.
+.
+H...
+
+=== Chunk 3461 ===
+Source: 4105_002-ebook.pdf
+Length: 529 chars
+
+31.3.5 red Cross Wound score
+Many studies note a large proportion of superficial wounds to the thorax; anywhere between 45 and 65 % of chest injuries. It is interesting to note that this phenomenon occurs in urban conflict with short evacuation times as well as during rural guerrilla warfare with delayed evacuation. As mentioned in Sections 4.5 and 5.6.2, not all studies make this distinction between superficial and penetrating wounds, but it is an essential one.
+C  R  C  I     /     e  r  r  o ...
+
+=== Chunk 3462 ===
+Source: 4105_002-ebook.pdf
+Length: 450 chars
+
+Figures 31.5.1 and 31.5.2
+Small and large wounds of the chest wall, without penetration of the pleural cavity.
+xz 2 s &
+C
+R
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+e
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+.
+M
+6 Edens JW, et al., 2009.
+7 Morrison JJ, et al., 2013.
+383
+384
+In the Red Cross Wound Score and Classification System penetration of the pleura counts as a vital wound: V = T. A lesion of the thoracic trachea also qualifies as V = T, even without penetration of the pleura, although this is rare....
+
+=== Chunk 3463 ===
+Source: 4105_002-ebook.pdf
+Length: 201 chars
+
+31.4 Clinical presentation
+The standard procedure of immediate examination according to the ABCDE sequence of trauma resuscitation should be carried out and followed by a complete physical examination....
+
+=== Chunk 3464 ===
+Source: 4105_002-ebook.pdf
+Length: 4144 chars
+
+31.4.1 Initial examination
+It is important to remember that the chest is directly involved in problems of the airway (intrathoracic trachea), breathing (lung parenchyma, chest wall defect), and circulation (lung, heart and great vessels), as well as neurological deficit through thoracic spinal injury.
+Since 90 % or more projectile chest wounds can be treated by intercostal tube drainage, the early diagnosis of the other 10 % is of extreme importance. These are life-threatening injuries, some of ...
+
+=== Chunk 3465 ===
+Source: 4105_002-ebook.pdf
+Length: 1357 chars
+
+31.4.2 Complete examination
+As always, proper exposure of the patient for the shortest period possible and complete examination – front and back – are necessary, while protecting the patient from hypothermia. The location of all wounds should be noted. It may be difficult to see a small opening in the folds and body hair of the axilla. Concomitant injury to the abdomen, neck, or an anatomic juncture should be sought out. It should also be remembered that the anterior mediastinal space immediatel...
+
+=== Chunk 3466 ===
+Source: 4105_002-ebook.pdf
+Length: 239 chars
+
+Figures 31.6.1 and 31.6.2
+Multiple fragment wounds from shelling resulting in a thoraco-abdominal injury: the penetrating wound was in the back.
+385
+C
+R
+C
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+y
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+I
+.
+F
+Figure 31.8
+Barium swallow demonstrating injury to the oesophagus....
+
+=== Chunk 3467 ===
+Source: 4105_002-ebook.pdf
+Length: 558 chars
+
+Figure 31.9
+The patient suffered multiple gunshot wounds to the chest, abdomen and left elbow six hours previously. The BP was 140/90 and the pulse 80. The right hemithorax presented one penetrating wound and was hyper-resonant on percussion. The left side showed two penetrating wounds, was bulging, and demonstrated subcutaneous emphysema and a dull note on percussion. A clinical diagnosis of right pneumothorax and left haemothorax was made and was sufficient for placing bilateral chest tubes. T...
+
+=== Chunk 3468 ===
+Source: 4105_002-ebook.pdf
+Length: 1045 chars
+
+Figure 31.7
+The patient was wounded by two bullets at close range as noted by the tattooing around the entry wounds. The bullets ricocheted off the ribs without penetration of the thoracic cavity. The surgeon demonstrates the superficial character of the wounds. Bilateral chest tubes have been placed prior to proper examination.
+Fractures of the ribs, sternum, scapula, or clavicle occur in up to 70 % of cases. Slight pressure with both hands on the lateral sides of the rib cage and in the antero...
+
+=== Chunk 3469 ===
+Source: 4105_002-ebook.pdf
+Length: 2040 chars
+
+31.4.3 Haemothorax and pneumothorax
+Technically, all wounds penetrating the pleura create a mixed pneumo-haemothorax; clinically, one predominates. Haemothorax or pneumothorax is present in almost all patients with intrathoracic war injuries.
+C
+R
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+I
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+d
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+.
+H
+THorACIC INJUrIEs
+Bleeding usually comes from the low-pressure pulmonary system, less often from an intercostal or internal mammary vessel. Lesions to the great vessels or heart are usually fatal before the patient arrives ...
+
+=== Chunk 3470 ===
+Source: 4105_002-ebook.pdf
+Length: 1020 chars
+
+31.4.4 Paraclinical investigations
+X-rays should be taken in the antero-posterior and lateral planes, but should neither delay treatment for a clinically obvious acute condition nor hinder resuscitation. A proper chest X-ray should be taken in the sitting position; up to 1,000 ml of fluid may be present in the pleural cavity and appear only as a haze, especially if the film is taken while the patient is supine. Superposition of a projectile on the normal radio-opaque heart shadow may make diagno...
+
+=== Chunk 3471 ===
+Source: 4105_002-ebook.pdf
+Length: 5512 chars
+
+Figures 31.11.1 and 31.11.2
+Difficult diagnosis: the radio-opaque shadow of the bullet is not easily distinguishable in the A-P view when superimposed on the heart shadow.
+387
+y
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+3 zs
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+M
+WAR SURGERY
+C
+2
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+d
+2 2
+e
+r
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+N
+.
+H
+Figure 31.12 Diagnostic thoracocentesis.
+388
+In some countries, the widespread prevalence of pulmonary disease prior to injury can cause confusion on reading the X-ray. The pleural cavity can be oblit...
+
+=== Chunk 3472 ===
+Source: 4105_002-ebook.pdf
+Length: 938 chars
+
+31.6 Intercostal chest tube drainage
+The equipment necessary for chest tube placement is rather simple. Ready-made manufactured items are usually available; alternatives can readily be improvised.
+T.Gassmann/ ICRC
+T.Gassmann/ ICRC
+T
+T
+Figure 31.13.1
+Figure 31.13.2
+Essential equipment: commercially manufactured chest drainage system.
+Essential equipment: improvised chest tube using a Foley catheter and re-sterilizeable plastic bottle with underwater seal of sterile normal saline.
+a
+i
+p
+g
+o
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+t
+...
+
+=== Chunk 3473 ===
+Source: 4105_002-ebook.pdf
+Length: 2686 chars
+
+31.6.1 Indications and basic principles
+Indications for intercostal chest tube drainage:  • all detected haemothoraces;  • tension pneumothorax;  • simple pneumothorax greater than 2 cm on X-ray;  • any pneumothorax where the patient requires intubation and ventilation;  • bronchopleural fistula;  • blast lung: bilateral chest tubes;  • signs of chest penetration in a patient during a mass casualty situation when   adequate examination or X-ray is not possible;  • as part of thoracic operation; ...
+
+=== Chunk 3474 ===
+Source: 4105_002-ebook.pdf
+Length: 659 chars
+
+31.6.2 Chest tube drainage and autotransfusion
+Blood in the thoracic cavity rarely clots unless the haemothorax is so large that the lung is completely collapsed and thus unable to defibrinogenate the blood by its movements.
+If the clinical picture of the patient points to a massive haemothorax with shock, autotransfusion of the shed blood should be resorted to. Rather than “remove and waste” the blood coming through the chest tube, it should be recuperated. Therefore, normal saline should be pu...
+
+=== Chunk 3475 ===
+Source: 4105_002-ebook.pdf
+Length: 1045 chars
+
+31.6.3 Post-operative care of chest tube drainage
+Elementary measures for all patients with thoracic injury
+• The head of the bed is raised and the patient placed semi-sitting.
+• Supplemental oxygen must be humidified.
+• Pain is relieved by repeated intercostal nerve blocks and strong analgesics that do not depress respiration (e.g. tramadol).
+• Physiotherapy is essential: deep-breathing exercises, voluntary coughing, inflating a balloon, or blowing through a straw into a bottle of water. A trai...
+
+=== Chunk 3476 ===
+Source: 4105_002-ebook.pdf
+Length: 953 chars
+
+Functioning of the chest tube
+The functioning of a chest tube must be checked immediately. The bloody discharge inside the drain and the fluid level in the underwater seal tubing should swing with each breath. If this is not the case, the tube should be inspected to confirm that there has been no dislodgement from the chest wall exposing a side-hole. Or, if the drain is blocked, it can be flushed with 50 ml of normal saline. If this does not work, the chest tube should be withdrawn and replaced....
+
+=== Chunk 3477 ===
+Source: 4105_002-ebook.pdf
+Length: 848 chars
+
+Figure 31.16
+Patient X: kinking of the chest tube compromising function.
+Figure 31.17 Patient Y: kinked chest tube, but functioning well.
+Figure 31.17
+If these criteria are not fulfilled, further measures are necessary.
+1. The drain should be changed or repositioned – however, if the drain is functioning correctly, its exact position on X-ray is of little consequence.
+2. The efficiency of suction should be checked if this is being used.
+3. A second apical chest drain may be required, especially ...
+
+=== Chunk 3478 ===
+Source: 4105_002-ebook.pdf
+Length: 751 chars
+
+Observations
+The tubing connections and fixation and clinical condition of the patient should be checked hourly after first placement of the chest drain and then every four hours once the patient’s condition has stabilized.
+Observations should include:
+• the functioning of the drain;
+• any bubbling of air;
+• amount and nature of the drainage discharge;
+• respiratory rate, pulse and blood pressure;
+• O2 saturation by pulse oximetry.
+A subjective assessment should also be recorded of the patient’s...
+
+=== Chunk 3479 ===
+Source: 4105_002-ebook.pdf
+Length: 635 chars
+
+Care of the chest bottle
+When the patient is moved or mobilized, care must be taken to make sure the drainage system remains below the level of the chest tube. If it is absolutely necessary to raise it above this level, the tubing should be clamped very briefly. Similarly, clamping is necessary when changing an overfull chest bottle. If after clamping the patient becomes dyspnoeic the clamp should immediately be removed. The plastic tubing should not be clasped directly by the clamp, but rather ...
+
+=== Chunk 3480 ===
+Source: 4105_002-ebook.pdf
+Length: 844 chars
+
+Antibiotics
+It used to be the practice of ICRC surgical teams to continue the administration of oral antibiotics for 48 hours after drain removal to cover any residual collection or intrapulmonary haematoma. This usually resulted in a total antibiotic administration of 4 – 5 days. The updated ICRC protocol is to administer antibiotics to all patients for a standard five days, in order to simplify nursing care.
+Abdominal trauma carries a high risk of infection, particularly associated with increa...
+
+=== Chunk 3481 ===
+Source: 4105_002-ebook.pdf
+Length: 714 chars
+
+Removal of a chest tube
+A chest tube should be removed once it has accomplished its task: i.e. the lung has re-expanded and there is no active haemorrhage or air leak. In the vast majority of patients with a haemothorax this means two to three days. An air leak that slowly decreases and does not require a thoracotomy takes about a week to close.
+A common occurrence with a chest tube in place after a couple of days is the discharge of clear serous fluid. This is a foreign body reaction to the pre...
+
+=== Chunk 3482 ===
+Source: 4105_002-ebook.pdf
+Length: 1129 chars
+
+31.6.4 Complications
+Although a “relatively simple and minor” operation, especially when compared to a thoracotomy, chest tube drainage like any other surgical procedure is not entirely free of complications. These may be of several different sorts.
+• Insertional, i.e. faulty insertion technique leading to:
+– laceration of the lung or other organ;
+– haemorrhage due to injury of the intercostal vessels;
+– exposed side-holes;
+– extrapleural placement in the subcutaneous tissues.
+• Positional:
+– ki...
+
+=== Chunk 3483 ===
+Source: 4105_002-ebook.pdf
+Length: 1545 chars
+
+31.7 Thoracotomy
+In a civilian health system exposed to armed conflict, transport and security constraints surrounding casualty evacuation usually mean that thoracotomy is required for less than 5 – 10 % of patients because “natural triage” has already occurred. While urban warfare may allow rapid transport of severely injured patients and therefore lead to a higher rate of thoracotomy, the principles of mass casualty triage frequently intervene as well, often limiting this possibility. Nonethel...
+
+=== Chunk 3484 ===
+Source: 4105_002-ebook.pdf
+Length: 983 chars
+
+31.7.1 Emergency room thoracotomy
+Emergency room thoracotomy (ERT) is a desperate resuscitative procedure for patients in extremis owing to exsanguinating haemorrhage or suspected cardiac tamponade resulting in cardiac arrest. The practice of a thoracotomy in the ER rather than the OT may be considered in a referral trauma centre – although even there the results are generally poor.
+For the general surgeon working with limited resources, thoracotomy in the ER is a futile exercise. Better to brin...
+
+=== Chunk 3485 ===
+Source: 4105_002-ebook.pdf
+Length: 2543 chars
+
+Indications for urgent thoracotomy
+Indications for urgent thoracotomy in the operating theatre  1.  Open pneumothorax of a sucking chest wound.  2.  Exsanguinating haemorrhage: cross-clamping of aorta or lung hilum.  3.  Haemopericardium with cardiac tamponade.  4.  Massive air leak: cross-clamping of hilum.  5.  Open cardiac massage.
+A sucking chest wound can be brought under control in the emergency department, even if only with a large wet dressing, and the patient taken to theatre immediatel...
+
+=== Chunk 3486 ===
+Source: 4105_002-ebook.pdf
+Length: 500 chars
+
+Indications for early thoracotomy
+Indications for early thoracotomy  1.  Continued bleeding.  2.  Persistent significant air leak.  3.  Massive or increasing intrapulmonary haematoma.  4.  Mediastinal injury: oesophagus, trachea and great vessels.  5.  Foreign body: large and in a “delicate” location.
+The indications for early thoracotomy, less than 24 – 48 hours after injury, are more commonly met. Most often encountered is continuing haemorrhage, followed by persistent significant air leakage....
+
+=== Chunk 3487 ===
+Source: 4105_002-ebook.pdf
+Length: 2185 chars
+
+Continued bleeding
+In the practice of ICRC surgeons this applies to cases arriving shortly after injury, with more than 1,500 ml blood discharge at the time of insertion of the chest drain,
+• and 500 ml in the first hour;
+• or 200 – 300 ml/hour for 2 – 3 hours afterwards.8
+Autotransfusion of the haemothorax gives the patient a chance of haemodynamic stabilization and readily permits this period of observation.
+This bleeding must indeed be coming from a thoracic wound and not from the abdomen thr...
+
+=== Chunk 3488 ===
+Source: 4105_002-ebook.pdf
+Length: 187 chars
+
+Persistent pleural air leak
+Thoracotomy should only be considered in the presence of continuing and significant leakage of air over a period of 24 – 48 hours, with no sign of diminishing....
+
+=== Chunk 3489 ===
+Source: 4105_002-ebook.pdf
+Length: 415 chars
+
+Intrapulmonary haematoma
+Clinical evidence of respiratory distress with an intrapulmonary haematoma larger than 5 cm in diameter on X-ray or increasing in size on serial X-rays is an indication for thoracotomy. Given the additional risk of infection in a large haematoma, a thoracotomy is justified. In the event of a lung abscess, however, massive antibiotic therapy without thoracotomy is the treatment of choice....
+
+=== Chunk 3490 ===
+Source: 4105_002-ebook.pdf
+Length: 911 chars
+
+Mediastinal injury
+Injury to mediastinal structures is often problematic, especially with a transaxial wound of the chest. In a haemodynamically stable patient, the presence of dyspnoea, surgical emphysema or mediastinal air on X-ray calls for investigation of the oesophagus and trachea. The patient can usually withstand a few hours delay for proper resuscitation and diagnosis.
+Most patients with injury to the great vessels who arrive at the hospital alive have come through “natural, automatic t...
+
+=== Chunk 3491 ===
+Source: 4105_002-ebook.pdf
+Length: 637 chars
+
+Foreign body
+A very large and especially jagged fragment retained in the pleural cavity, lung parenchyma or lying on a great vessel in the mediastinum, or exceptionally a projectile embolus in the heart, carries extraordinary risks. The possibility of infection or erosion of a vessel provoking haemorrhage or embolization may be great enough to warrant a thoracotomy to remove the projectile.
+The criteria, medical on the one hand and related to the surgeon on the other, have been discussed in Chap...
+
+=== Chunk 3492 ===
+Source: 4105_002-ebook.pdf
+Length: 152 chars
+
+31.7.4 Indications for late thoracotomy
+Thoracotomy is also indicated in the following cases
+1. Clotted haemothorax/clot retention.
+2. Empyema thoracis....
+
+=== Chunk 3493 ===
+Source: 4105_002-ebook.pdf
+Length: 253 chars
+
+Clotted haemothorax
+Only the very small retained haemothorax reaching less than the 7th rib on an upright X-ray may be treated conservatively. If greater than this, a thoracotomy for evacuation of the retained clot should be performed within 5 – 7 days....
+
+=== Chunk 3494 ===
+Source: 4105_002-ebook.pdf
+Length: 670 chars
+
+Empyema
+Infection is a complication that should not occur, but all too often does. It is most frequently seen in neglected injuries with long evacuation times, but also occurs following inadequate analgesia and physiotherapy with subsequent failure to fully expand the lung and drain a haemothorax.
+Carrillo EH, Barkoe DJ, Sanchez R, Lee SK, Rosenthal A, Pepe A, Nardiello D. Open thoracic window: a useful alternative for retained infected pleural collections in critically ill trauma patients. Am S...
+
+=== Chunk 3495 ===
+Source: 4105_002-ebook.pdf
+Length: 1706 chars
+
+31.7.5 Patient preparation, positioning, and anaesthesia
+For an exploratory thoracotomy, the patient is placed in the supine position with both arms abducted. In urgent cases a strict minimum of preparation is sufficient:
+THorACIC INJUrIEs
+quick swabbing of the chest with disinfectant. Otherwise, the area from the neck to the symphysis pubis is prepared in case a laparotomy is required. For more planned procedures, such as oesophageal and/or tracheal injuries, clotted haemothorax and empyema, th...
+
+=== Chunk 3496 ===
+Source: 4105_002-ebook.pdf
+Length: 1697 chars
+
+31.7.6 Choice of incision
+A correct choice of incision is necessary for a successful thoracotomy. In an exploratory emergency thoracotomy, the quickest and easiest is an anterolateral incision on the injured side in the fourth or fifth intercostal space, going as far posteriorly as possible with the patient in the supine position.
+Internal  mammary   artery line  Midaxillary line
+Internal
+mammary
+artery line
+Papas / ICRC
+Midaxillary line
+P
+Papas/ ICRC
+Midaxillary line
+Midaxillary line
+.
+.
+N
+N
+Fi...
+
+=== Chunk 3497 ===
+Source: 4105_002-ebook.pdf
+Length: 353 chars
+
+Figure 31.25
+Exploration of the chest cavity: visualization of the mediastinum.
+398
+easier to perform than the median sternotomy and is particularly useful for the exploration of a transfixing mediastinal injury in an unstable patient. However, most patients require mechanical ventilation afterwards.
+C
+N.Papas/ ICRC
+R
+C
+I
+/
+s
+a
+p
+a
+P
+.
+N
+N.Papas/ ICRC...
+
+=== Chunk 3498 ===
+Source: 4105_002-ebook.pdf
+Length: 330 chars
+
+Figure 31.23
+Median sternotomy with possible extension as a laparotomy, into the neck as an SCM incision, or as a supraclavicular incision.
+Clamshell incision: bilateral anterolateral incisions joined across the sternum.
+The operative details of the different incisions available for thoracic trauma are to be found in Annex 31.C....
+
+=== Chunk 3499 ===
+Source: 4105_002-ebook.pdf
+Length: 1219 chars
+
+31.8 Exploration of the chest cavity
+Once the chest cavity has been entered a Finochietto rib retractor is inserted; two wide and long laparotomy retractors can be used if a Finochietto is not available. The inflated and moving lung makes exploration difficult. The anaesthetist can cease ventilation momentarily; or the surgeon can help guide the endotracheal tube into the contralateral bronchus thus achieving selective ventilation without the use of a double-lumen tube.
+To visualize the mediasti...
+
+=== Chunk 3500 ===
+Source: 4105_002-ebook.pdf
+Length: 2091 chars
+
+31.9 Wounds of the chest wall
+Entrance and exit wounds should be excised removing all devitalized tissue.
+Intercostal vascular bleeding should be handled by ligation. Occasionally, a vessel may be difficult to access and a new incision may be necessary to gain control. A cut intercostal artery can retract into the muscles and require a figure-of-eight haemostatic suture: the needle is passed parallel to the ribs, not perpendicular, as there is not enough room to manoeuvre in the intercostal spac...
+
+=== Chunk 3501 ===
+Source: 4105_002-ebook.pdf
+Length: 467 chars
+
+31.10.1 Haemostasis of the lung parenchyma
+It is best if the anaesthetist momentarily stops ventilation, or the surgeon manipulates the endotracheal tube into the contralateral bronchus, allowing the lung to be deflated while the surgeon deals with the damage. The aims are haemostasis, stopping any air leakage, and debridement of any devitalized tissue. There are several methods of surgical haemostasis of the injured lung depending on the extent of tissue damage....
+
+=== Chunk 3502 ===
+Source: 4105_002-ebook.pdf
+Length: 148 chars
+
+Direct suture
+Small lesions of the margins of the lung may be directly oversewn with hepatic-type mattress sutures: pneumonorrhaphy.
+399
+WAR SURGERY...
+
+=== Chunk 3503 ===
+Source: 4105_002-ebook.pdf
+Length: 52 chars
+
+Figure 31.26
+Suture of a pulmonary laceration.
+r
+.
+A...
+
+=== Chunk 3504 ===
+Source: 4105_002-ebook.pdf
+Length: 2075 chars
+
+Non-anatomic wedge resection
+Larger wounds are best clamped with Duval lung clamps, large vascular clamps, or non-crushing intestinal clamps and the isolated wedge resected in a “V” fashion. The edges are then oversewn with a 3/0 continuous synthetic absorbable suture.
+Figure 31.27
+Wedge-resection and suture of the lung.
+l
+a
+t
+i
+p
+s
+o
+H
+.  U     l  l  i  G  c  M     /     m  u  a  b  l  e  k  c  e  M     .  D  C  R  C  I  Figure 31.28  The lung tissue between the entry and exit   wounds has been...
+
+=== Chunk 3505 ===
+Source: 4105_002-ebook.pdf
+Length: 1830 chars
+
+Damage control and lobectomy or pneumonectomy
+A lobectomy, or even pneumonectomy, may be necessary if there is massive bleeding, damage requiring extensive debridement of lung tissue, or air leakage from a non- repairable lobar bronchus. It is best to perform a “thoracic Pringle manoeuvre” first to stop haemorrhage and prevent air embolism. The anaesthetist should stop ventilation momentarily; the inferior pulmonary ligament is divided and, approaching from above, the fingers pinch the hilum. A ...
+
+=== Chunk 3506 ===
+Source: 4105_002-ebook.pdf
+Length: 2866 chars
+
+31.10.2 Intrapulmonary haematoma, blast lung, lung contusion and flail chest
+Most intrapulmonary haematomas from penetrating projectiles are small and self- contained and usually resolve by draining into a haemothorax, haemoptysis, or slow absorption. Only an intrapulmonary haematoma larger than 5 cm in diameter on X-ray or increasing in size on serial X-rays should be treated by thoracotomy and evacuation.
+Pulmonary contusion following blunt trauma or blast lung usually progresses for 2 – 3 day...
+
+=== Chunk 3507 ===
+Source: 4105_002-ebook.pdf
+Length: 222 chars
+
+31.10.3 Tracheobronchial injury
+Half the trachea is in the neck and half in the thorax and always intimately related to the oesophagus and major vessels; isolated injury is therefore rare.
+2 =
+3
+2 &B 2 2 2
+3
+2 &B 2 2 2
+B
+B...
+
+=== Chunk 3508 ===
+Source: 4105_002-ebook.pdf
+Length: 1881 chars
+
+Figure 31.32.1
+Figure 31.32.2
+Midline gunshot wound to the juncture of the neck and chest: tension pneumothorax was diagnosed and a chest tube placed (white circle).
+It was possible to intubate the patient in order to splint the injured trachea.
+A small broncho-pleural fistula is more common than a massive air leak. Bleeding stops but air continues to bubble through the water seal in the chest bottle with every breath. Many small fistulae close spontaneously with time. A conservative approach is...
+
+=== Chunk 3509 ===
+Source: 4105_002-ebook.pdf
+Length: 1506 chars
+
+31.11 Great vessels, heart and pericardium
+A patient with a massive haemothorax requiring thoracotomy and who arrives alive to hospital will usually have suffered injury to the internal mammary or intercostal arteries. These can be safely ligated. A lesion in the aorta or another great vessel is not commonly encountered, unless an inadvertent injury is caused iatrogenically, i.e. intra-operatively.
+The surgeon for whom this manual is intended is more likely to see a pseudoaneurysm or arterio-ven...
+
+=== Chunk 3510 ===
+Source: 4105_002-ebook.pdf
+Length: 67 chars
+
+Figure 31.35
+Opening in the pericardial-diaphragmatic triangle.
+404...
+
+=== Chunk 3511 ===
+Source: 4105_002-ebook.pdf
+Length: 1879 chars
+
+31.11.1 Pericardial tamponade
+Among the patients with cardiac injury who reach hospital alive the majority will have a small wound with self-limiting haemorrhage resulting in a pericardial tamponade. The patient has an automatic permissive hypotension of less than 90 mm Hg; the constrained heart is not capable of filling and pumping at a higher pressure. Efforts to raise the blood pressure by i.v. fluids should be avoided: the shock is cardiogenic, not hypovolaemic. A high degree of diagnostic s...
+
+=== Chunk 3512 ===
+Source: 4105_002-ebook.pdf
+Length: 1118 chars
+
+31.11.2 subxyphoid pericardial window
+The patient lies supine with a pillow under the lumbar spine to accentuate the lumbar lordosis. The operation can be performed under local anaesthesia and proper sedation. The incision begins to the left of the xyphoid and then down for 5 – 6 cm in the midline of the abdomen, through the linea alba but not penetrating the peritoneum. If necessary the xyphoid process is excised. The sternum is then retracted upward to reveal the preperitoneal fat.
+Blunt finge...
+
+=== Chunk 3513 ===
+Source: 4105_002-ebook.pdf
+Length: 931 chars
+
+31.11.3 Anterior thoracotomy and injuries to the heart
+The approach is through an anterolateral thoracotomy or median sternotomy. Great care must be taken to identify and avoid injury to the phrenic nerve as the pericardium is opened in a cranio-caudal direction.
+THorACIC INJUrIEs
+Head  Phrenic n.
+Head
+d
+Sangthong /Songkla Hospital, Thailand
+Phrenic n.
+S
+.
+B
+Once the pericardium is opened, the clot is evacuated and a finger placed to plug any hole in the myocardium. Alternatively, a small Foley ...
+
+=== Chunk 3514 ===
+Source: 4105_002-ebook.pdf
+Length: 384 chars
+
+31.11.4 Pericardial window during laparotomy
+If a patient remains in shock without obvious blood loss during laparotomy and tamponade is suspected, the central tendon of the diaphragm can be incised directly into the pericardial sac. The operation then continues either as a median sternotomy or left thoracotomy.
+10 If the balloon does not deflate, it can be punctured with a needle....
+
+=== Chunk 3515 ===
+Source: 4105_002-ebook.pdf
+Length: 282 chars
+
+Figure 31.36
+Opening the pericardium away from the phrenic nerve.
+me -/
+r
+Taha / American Beirut Medical Center
+T
+.
+A
+Figure 31.38
+Foley catheter tamponade of the lacerations in the heart.
+405
+WAR SURGERY
+Figures 31.39.1 and 31.39.2 Myocardial mattress suture through a pledget.
+406...
+
+=== Chunk 3516 ===
+Source: 4105_002-ebook.pdf
+Length: 2369 chars
+
+31.11.5 Myocardial suture
+Repair differs according to the heart chamber injured. The atria are akin to a large vein and a Satinsky side-biting clamp can usually be placed and repair performed using a typical continuous vascular suture. It is best to commence the suture in intact healthy tissue and proceed into the lesion. In the case of a very small lesion, a purse-string suture can be used.
+When suturing the thicker parts of the myocardium it is important to use a large non- cutting needle and ...
+
+=== Chunk 3517 ===
+Source: 4105_002-ebook.pdf
+Length: 445 chars
+
+31.11.6 Azygous venous system
+In the rare instances when an injury to the azygous veins is encountered during an emergency thoracotomy, an anterior incision is unsatisfactory for proper visualization. The patient must be repositioned to perform a formal posterior thoracotomy and enter the posterior mediastinum where the bleeding vessels can be ligated.
+11 This is a basic principle of Einstein’s theory of special relativity.
+THorACIC INJUrIEs...
+
+=== Chunk 3518 ===
+Source: 4105_002-ebook.pdf
+Length: 2108 chars
+
+31.12 oesophageal injuries
+Oesophageal injury is rare and all untreated patients die of mediastinitis and septic shock. Even with treatment, which is difficult, results are often poor. Occasionally, the patient is diagnosed and operated on in the first 12 hours, but it is unusual for the patient to be sufficiently haemodynamically stable to allow for primary repair as can be performed for the cervical oesophagus. Thus, a damage-control approach is justified in most cases, especially in non-exper...
+
+=== Chunk 3519 ===
+Source: 4105_002-ebook.pdf
+Length: 234 chars
+
+Figure 31.40
+Primary repair with oesophageal exclusion: proximal oesophagostomy and mucous fistula with distal gastrostomy. The repair should be covered with a flap of pleura or intercostal muscle.
+407
+C
+Papas / ICRC
+P
+.
+N
+WAR SURGERY...
+
+=== Chunk 3520 ===
+Source: 4105_002-ebook.pdf
+Length: 391 chars
+
+Figures 31.41.1 and 31.41.2
+Mobilization of a flap from the diaphragm.
+408
+N. Papas/ ICRC
+N. Papas/ ICRC
+In all instances, the patient is kept NPO and antibiotics given (ampicillin, metronidazole, and gentamycin) for at least a week. Nutritional support through the feeding stoma is essential. Mediastinitis due to oesophageal leakage is invariably fatal when working with limited resources....
+
+=== Chunk 3521 ===
+Source: 4105_002-ebook.pdf
+Length: 768 chars
+
+31.13.1 Thoracic duct
+Injury to the thoracic duct presents as chylothorax: yellow and fatty discharge through a chest tube. Initial management is conservative with prolonged chest tube drainage and a non-fat diet. However, the condition usually requires right posterior thoracotomy and perhaps a left supraclavicular incision, depending on the exact site of the lesion, and ligation of the fistula – the thoracic duct ascends on the right side of the vertebral bodies before passing behind the oesoph...
+
+=== Chunk 3522 ===
+Source: 4105_002-ebook.pdf
+Length: 347 chars
+
+31.13.2 Thymus
+In children, the thymus may be very large and quite susceptible to injury. Its importance in developing the immune response means that every attempt should be made to preserve as much of it as possible. Debridement and oversewing of the cut edges are usually all that are required. A mediastinal drain is left in place for 24 hours....
+
+=== Chunk 3523 ===
+Source: 4105_002-ebook.pdf
+Length: 859 chars
+
+31.13.3 Diaphragm
+Diaphragmatic rupture due to a projectile is not an indication for thoracotomy. Injury to the diaphragm indicates a thoraco-abdominal wound and repair is preferable via a laparotomy. If the injury is noted during a thoracotomy, it should be repaired directly. The diaphragm can bleed profusely because of its good vascularity. Lavage of the pleural cavity for any contamination is usually possible through the diaphragm without having to resort to a separate thoracotomy incision. A...
+
+=== Chunk 3524 ===
+Source: 4105_002-ebook.pdf
+Length: 1836 chars
+
+31.14 Thoracic damage control
+Emergency room thoracotomy may be considered a damage-control procedure. Its limitations have already been discussed. Most descriptions of thoracic damage control are not really mere temporizing measures but rather definitive repairs that are rapid and relatively simple. The goal of abbreviated thoracotomy is to stop bleeding and restore a survivable physiology; contamination is not usually a problem.
+As with the abdomen, an “open” thorax during thoracotomy results ...
+
+=== Chunk 3525 ===
+Source: 4105_002-ebook.pdf
+Length: 385 chars
+
+31.15 Post-operative care after thoracotomy
+The principles of care for a chest tube also apply to the post-thoracotomy patient, only more so. The patient is in a more critical clinical state and requires close observation and monitoring. A ward designated as an “intensive nursing ward” is best for this purpose, with a high ratio of nursing staff to number of patients (see Part F.3)....
+
+=== Chunk 3526 ===
+Source: 4105_002-ebook.pdf
+Length: 59 chars
+
+Figure 31.42
+A large hole in the diaphragm.
+409
+WAR SURGERY...
+
+=== Chunk 3527 ===
+Source: 4105_002-ebook.pdf
+Length: 1018 chars
+
+Figure 31.43
+Chest physiotherapy in the intensive nursing ward of the ICRC Lokichokio Hospital, northern Kenya.
+410
+C
+Icrc
+R
+C
+I
+In the absence of mechanical ventilation, some patients are better off with a tracheostomy to better secure the airway, decrease the effort of breathing, and achieve tracheal toilet. There are relatively few specific indications for ventilation. One particularly useful procedure is to alternate short periods of manual ventilation by Ambu® bag with spontaneous breathing...
+
+=== Chunk 3528 ===
+Source: 4105_002-ebook.pdf
+Length: 1837 chars
+
+31.16 retained haemothorax
+Apart from late evacuation of patients, the principal cause of empyema is failure to achieve complete evacuation of a haemothorax and re-expansion of the lung. If these are not achieved, antibiotics and other measures will seldom be enough to prevent infection. A retained haemothorax clots and then becomes organized into a thick and dense fibrinous collection of protein-rich fluid, which becomes infected and/or fibrotic, forming adhesions to the lung and pleura. Serial...
+
+=== Chunk 3529 ===
+Source: 4105_002-ebook.pdf
+Length: 2667 chars
+
+31.17 Empyema
+If empyema occurs, or if the patient presents late with frank infection, closed chest tube drainage should be attempted at first. If this fails, as is often the case, it can be followed by the well-established technique of chest fenestration: segmental resection of one or two ribs posteriorly and open thoracostomy drainage. This can be accomplished under local anaesthesia with minimal operative risk, in what is often a septic and malnourished patient. Good hydration and extra feedi...
+
+=== Chunk 3530 ===
+Source: 4105_002-ebook.pdf
+Length: 2624 chars
+
+31.17.1 Decortication of empyema
+Failure of resolution after 20 days of open treatment is an indication for thoracotomy and decortication; the empyema has now “matured”. However, patients suffering empyema are often critically ill and malnourished and not usually candidates for major surgery, such as a decortication: a difficult operation with much blood loss and a high risk for the septic patient. First, the nutritional status of the patient must be improved and the anaemia corrected. Only if t...
+
+=== Chunk 3531 ===
+Source: 4105_002-ebook.pdf
+Length: 106 chars
+
+Figure 31.A.2
+Angling of the syringe to reach the neurovascular bundle at the lower border of the rib.
+414...
+
+=== Chunk 3532 ===
+Source: 4105_002-ebook.pdf
+Length: 1808 chars
+
+ANNEX 31. A Intercostal nerve block
+Intercostal nerve blocks are useful methods of analgesia for all kinds of chest wall pain. Lidocaine 1 % or 2 % with adrenaline is normally used; it is effective for two to three hours. Maximum dose for an adult is 6 mg/kg with adrenaline, and 3 mg/kg without. Bupivacaine 0.5 % with adrenaline is an alternative; maximum dose for an adult is 2 mg/kg and is effective for six to twelve hours. Bupivacaine has a much longer duration of action than lidocaine, but is...
+
+=== Chunk 3533 ===
+Source: 4105_002-ebook.pdf
+Length: 284 chars
+
+Intra-operative nerve block
+At the end of a thoracotomy and before closure of the chest wall, an injection of bupivacaine around the intercostal nerve posteriorly in the incision space as well as the intercostal spaces above and below the incision is a good adjunct.
+THorACIC INJUrIEs...
+
+=== Chunk 3534 ===
+Source: 4105_002-ebook.pdf
+Length: 1176 chars
+
+Insertion of midaxillary (basal) chest tube
+The “safe area” of the chest wall for chest tube insertion is located between the lateral border of the pectoralis major muscle, avoiding the tail of the breast in women, and the mid-axillary line, in the 4th or 5th intercostal space horizontal to the nipple line. A simple rule of thumb, particularly useful in a stressful situation and with obese adults, is to place the hand horizontally in the apex of the axilla: the safe area is to be found just belo...
+
+=== Chunk 3535 ===
+Source: 4105_002-ebook.pdf
+Length: 187 chars
+
+Figure 31.B.2
+Preparing the chest bottle: normal saline should be used and not ordinary water in case autotransfusion is to be employed. Ordinary water is hypotonic and causes haemolysis....
+
+=== Chunk 3536 ===
+Source: 4105_002-ebook.pdf
+Length: 2762 chars
+
+Figures 31.B.3 – 31.B.19
+A patient suffered multiple gunshot wounds with a right pneumothorax and left haemothorax; his condition was stable.
+Figure 31.B.3
+415
+WAR SURGERY
+Figure 31.B.4
+Figures 31.B.5 and 31.B.6
+Figures 31.B.7 and 31.B.8
+416
+2. A horizontal skin incision large enough to admit a finger is made just anterior to the mid-axillary line at the fourth or fifth intercostal space.
+C
+Nasreddine / ICRC
+N
+.
+H
+3. Using a curved haemostat, blunt dissection is continued through the intercostal...
+
+=== Chunk 3537 ===
+Source: 4105_002-ebook.pdf
+Length: 446 chars
+
+31.B.b Insertion of midclavicular (apical) chest tube
+A size 20 F or 24 F tube (16 F in children) is inserted through the second intercostal space (using the angle of Louis as an anatomic landmark) in the mid-clavicular line anteriorly, using the same technique as for a mid-axillary tube. The tube is advanced upwards to the apex of the pleural space. This site is preferred to the basal one in children < 12 years due to their higher diaphragm....
+
+=== Chunk 3538 ===
+Source: 4105_002-ebook.pdf
+Length: 527 chars
+
+31.B.c Management of chest tubes13
+When moving a patient the chest drain and tubing should be made secure and kept below the level of the chest by an accompanying nurse. A chest drain should only be clamped when:
+• the tubing and underwater seal bottle need to be changed;
+• doing a clamping “trial” for pneumothorax;
+• reconnecting an accidentally disconnected tubing.
+If a drain is clamped, it should be released as soon as possible and by the same individual who placed it, to avoid an overlooked ...
+
+=== Chunk 3539 ===
+Source: 4105_002-ebook.pdf
+Length: 2563 chars
+
+31.B.d removal of chest tubes
+The removal of a chest tube is based on a number of factors.
+1. Auscultation, percussion and an absence of air leakage confirm that the lung has re-expanded and there is no evidence of respiratory compromise;
+2. AND there is no active bleeding (bloody/blood-tinged drainage < 100 ml/24 hours) or chylothorax;
+3. AND drainage consists only of serous fluid of less than 250 ml/24 hours, which is simply a foreign body reaction to the presence of the tube;
+4. AND the fluid...
+
+=== Chunk 3540 ===
+Source: 4105_002-ebook.pdf
+Length: 152 chars
+
+ANNEX 31. C Thoracic incisions
+Several thoracotomy incisions are possible depending on the objective of the operation and the experience of the surgeon....
+
+=== Chunk 3541 ===
+Source: 4105_002-ebook.pdf
+Length: 1857 chars
+
+31.C.a Antero- and posterolateral incisions
+The operative technique in both the anterior and posterior incisions is similar; only the position of the patient is different to allow greater posterior access.
+For the anterolateral approach, which is the quickest and most practical incision, the patient is supine with the hemi-thorax slightly raised on a pillow or sandbag and the arms abducted 90° (Figure 31.C.1). The anterior incision begins lateral to the sternum in the 4th intercostal space and f...
+
+=== Chunk 3542 ===
+Source: 4105_002-ebook.pdf
+Length: 1490 chars
+
+Figure 31.C.1
+Anterior thoracotomy incision.
+Left: access to heart, left lung and hilum, and descending aorta (for cross-clamping).
+Right: access to right lung and hilum, azygos veins, right bronchus, and superior and inferior vena cava.
+421
+WAR SURGERY
+N. Papas /ICRC
+F.Plani / CH. Baragwanath, S. Africa
+F.Plani / CH. Baragwanath, S. Africa
+Figures 31.C.2 - 31.C.4
+Posterolateral thoracotomy incision.
+Left: access to left lung and hilum, lower oesophagus, descending aorta, distal left bronchus, l...
+
+=== Chunk 3543 ===
+Source: 4105_002-ebook.pdf
+Length: 485 chars
+
+Figures 31.C.5 and 31.C.6
+Basic essential equipment: Finochietto rib retractor, top view and underside.
+C
+T.Gassmann / ICRC
+\ Sy © Rann
+C
+T.Gassmann / ICRC
+T
+T
+a
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+S
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+H
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+C
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+3 =
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+C
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+P
+.
+F
+.
+F
+Figures 31.C.7 and 31.C.8
+Finochietto retractor in use during an anterolateral thoracotomy. The cranking mechanism is placed lower down, below the retractor flanges.
+422
+THorACIC INJUrIEs...
+
+=== Chunk 3544 ===
+Source: 4105_002-ebook.pdf
+Length: 1403 chars
+
+Closure of anterior and posterior incisions
+At the end of the operation, pleural toilet involves washing out the cavity with warm saline, removal of any clots and foreign bodies, and the placement of a chest tube under direct vision in the 7th or 8th intercostal space, a different intercostal space from the one chosen for the initial incision. The internal mammary vessels should be identified before closure and preserved; but if sectioned, they should be ligated.
+Three or four vertical mattress ...
+
+=== Chunk 3545 ===
+Source: 4105_002-ebook.pdf
+Length: 426 chars
+
+31.C.b Median sternotomy
+The patient should be placed supine with a pillow or roll placed between the scapulae. The incision extends from the suprasternal notch down to just beyond the xyphoid process, going all the way through to the periosteum of the manubrium and sternum. Bleeding from the periosteum is controlled by gauze compress pressure and cauterization or bone wax.
+C
+Papas / ICRC
+© as ) oo 09 97> i \ / \e XN
+P
+.
+N...
+
+=== Chunk 3546 ===
+Source: 4105_002-ebook.pdf
+Length: 171 chars
+
+Figures 31.C.9 and 31.C.10
+Mattress sutures are passed through the spaces above and below the incision, going around the ribs, but not tied until all sutures are in place....
+
+=== Chunk 3547 ===
+Source: 4105_002-ebook.pdf
+Length: 524 chars
+
+Figure 31.C.11
+Median sternotomy incision gives wide access to the mediastinum and is extendable: the dotted lines depict possible extension for a laparotomy, into the neck as an SCM incision, or as a supraclavicular incision.
+423
+C
+N.Papas/ ICRC
+R
+C
+I
+/
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+N
+WAR SURGERY
+Small connecting veins crossing the sternal notch and the xyphoid are clamped and ligated. The sternoclavicular ligament is carefully incised; the brachio-cephalic trunk lies just under the joint. Distally, the xyphoid ...
+
+=== Chunk 3548 ===
+Source: 4105_002-ebook.pdf
+Length: 1400 chars
+
+Figure 31.C.12
+Clamping and dividing the connecting veins crossing the sternal notch.
+a
+Plani / Baragwanath, Africa
+P
+.
+F
+Finger dissection separates the soft tissue from the under-surface of the sternum. A long curved abdominal or pelvic haemostat is passed under the sternum and a Gigli wire pulled through; the bone is then cut using the protective metal strip that comes with the kit. Alternatively, a hammer and bone chisel or Lebsche knife can be used to split the sternum. If available, a spec...
+
+=== Chunk 3549 ===
+Source: 4105_002-ebook.pdf
+Length: 802 chars
+
+Closure of median sternotomy
+The pillow is removed from between the scapulae. Closure of the cut bone is accomplished with large-gauge stainless steel wire; two stitches for the manubrium and three or more for the rest of the sternum. Holes are drilled one centimetre from the cut edge of the bone and the wires passed through, crossed, and twisted. Great care should be taken when passing the wires and/or needles through the sternum to avoid damage to underlying structures; a sterilized dessert sp...
+
+=== Chunk 3550 ===
+Source: 4105_002-ebook.pdf
+Length: 141 chars
+
+Figure 31.C.15
+Sternotomy for exposure and repair of the trachea.
+Figures 31.C.16 and 31.C.17 Closure of median sternotomy: mattress sutures....
+
+=== Chunk 3551 ===
+Source: 4105_002-ebook.pdf
+Length: 505 chars
+
+Figures 31.C.18 and 31.C.19
+Peristernal stitch: avoid putting the knot in the intercostal space.
+425
+C  R  C  I     /     s  a  p  a  P     .  N
+WAR SURGERY
+Figures 31.C.20 and 31.C.21 Pericostal stitch.
+C
+P
+.
+N
+Before tightening the wires and closing the incision, chest tube drains are placed in the mediastinum and brought out through the epigastrium, and the internal mammary vessels on each side are inspected; any injury to them is treated by ligation.
+Sternal infection is a dangerous complica...
+
+=== Chunk 3552 ===
+Source: 4105_002-ebook.pdf
+Length: 1774 chars
+
+31.C.c “Clamshell” incision
+Although a seemingly “radical” approach, this incision can be performed very quickly and safely by the general surgeon for a patient in extremis. While not often necessary, it is useful in transaxial injuries or if there is difficulty in controlling haemorrhage. It consists of bilateral anterior thoracotomies joined by a division of the sternum.14 The patient is supine with the arms abducted and a small pillow placed under the lower thoracic spine. Two incisions are m...
+
+=== Chunk 3553 ===
+Source: 4105_002-ebook.pdf
+Length: 2995 chars
+
+Chapter 32 INJURIES TO THE ABDOMEN
+429
+WAR SURGERY
+430
+32.
+INJURIES TO THE ABDOMEN
+32.1 Introduction 32.2 Wound ballistics 32.2.1 Hollow viscera 32.2.2 Solid parenchymatous organs and major blood vessels 32.2.3 Retroperitoneal muscles 32.2.4 Pelvis and buttocks 32.2.5 Extraperitoneal bullet trajectory, intraperitoneal damage 32.2.6 Primary blast injury 32.3 Epidemiology 32.3.1 Incidence of abdominal injuries 32.3.2 Mortality 32.3.3 Mortality risk factors 32.3.4 Frequency of organ injuries 32.3.5...
+
+=== Chunk 3554 ===
+Source: 4105_002-ebook.pdf
+Length: 1164 chars
+
+32.1 Introduction
+Abdominal war wounds have the strangest history of all injuries suffered in times of armed conflict. Leaving behind the long-held belief and fatalistic approach that all such wounds were inevitably lethal and that operative intervention was fruitless, surgeons have moved on to a modern aggressive approach of damage control and staged multiple-operation surgery. Of all major life-threatening injuries, wounds in the abdomen are the most amenable to surgical intervention likely to...
+
+=== Chunk 3555 ===
+Source: 4105_002-ebook.pdf
+Length: 516 chars
+
+32.2 Wound ballistics
+When considering wounds in the abdomen, the patient’s individual anatomy is important. Given enough tissue substance, a stable high-energy FMJ bullet tumbles and demonstrates all three phases of the shooting channel. Thus, a bullet striking a thin individual whose lateral diameter of the abdomen is barely 30 cm and antero- posterior diameter 20 cm will not have the same effect as a bullet hitting an obese individual with an 80 cm lateral and 50 cm antero-posterior diameter....
+
+=== Chunk 3556 ===
+Source: 4105_002-ebook.pdf
+Length: 1137 chars
+
+Figure 32.1.1
+The entry wound is located in the right flank: the liver is affected by the initial narrow channel with crush and laceration only. Temporary cavity formation occurs within the general peritoneal cavity amongst loops of intestine that can better absorb the stretch.
+432
+High-energy fragments can cause large defects in the abdominal wall with considerable intraperitoneal damage. On the other hand, small fragments with just enough energy to pierce the abdominal wall may cause little in...
+
+=== Chunk 3557 ===
+Source: 4105_002-ebook.pdf
+Length: 1283 chars
+
+32.2.1 Hollow viscera
+Hollow organs may suffer direct crush and laceration resulting in a small punctate wound with a very narrow zone of contusion around it. A single projectile may hit several loops of intestine causing multiple perforations, or strike parallel to and along the length of the bowel creating a large laceration.
+The effects of temporary cavity formation on hollow organs depend on whether the organ is empty or full. Section 3.4.3 describes the “boundary effect” of the wall of the ...
+
+=== Chunk 3558 ===
+Source: 4105_002-ebook.pdf
+Length: 698 chars
+
+32.2.2 solid parenchymatous organs and major blood vessels
+Solid organs contained within a strong connective tissue capsule, such as the liver, spleen, kidney, or pancreas have the same specific gravity as muscle but are not elastic and do not tolerate cavity formation; they are also subject to boundary effect within their capsule. The slightest cavity effect destroys their cellular and connective tissue matrix and tends to shatter them.
+The trajectory of a missile is thus very important: two ex...
+
+=== Chunk 3559 ===
+Source: 4105_002-ebook.pdf
+Length: 598 chars
+
+Figure 32.1.2
+The entry wound is anterior and para-umbilical with the exit in the right flank: cavity formation occurs within the liver, thus producing a shattering effect.
+N
+Damage from a fragment or destabilized ricochet bullet is greatest at the entry and then tapers off as it penetrates.
+Major vessels are usually injured by direct hits. The fixed retroperitoneal vessels are at greater risk from cavity formation than those in the mesos: violent lateral displacement of the fixed aorta and vena...
+
+=== Chunk 3560 ===
+Source: 4105_002-ebook.pdf
+Length: 785 chars
+
+32.2.3 retroperitoneal muscles
+The retroperitoneal muscles react like all muscles and ballistic damage can be minimal or severe. As with skeletal muscles, small punctate wounds caused by low-energy fragments do not require debridement, while large and ragged wounds do. Projectiles traversing the colon can theoretically carry contaminants with them, injecting bacteria into the retroperitoneal tissues. Apparently not much contamination occurs with small fragments; studies have shown that the bacte...
+
+=== Chunk 3561 ===
+Source: 4105_002-ebook.pdf
+Length: 736 chars
+
+32.2.4 Pelvis and buttocks
+The pelvis and buttocks include a bony enclosure (including the proximal part of the femur), large muscle masses, and an important region of extraperitoneal areolar tissue containing blood vessels and nerves and hollow viscera such as the bladder and ano- rectum. The gravid uterus reacts like a muscular mass or hollow organ depending on the gestational age and the quantity of amniotic fluid, which determine the extent of cavity formation effects and resistance to stret...
+
+=== Chunk 3562 ===
+Source: 4105_002-ebook.pdf
+Length: 205 chars
+
+Figure 32.2.2
+Major GSW of the buttocks, but involving the soft tissues only.
+Schematic diagram of abdomino-pelvic wound. Cavity formation occurs at the sacral exit with devastating damage.
+433
+WAR SURGERY...
+
+=== Chunk 3563 ===
+Source: 4105_002-ebook.pdf
+Length: 83 chars
+
+Figure 32.3
+Thoraco-abdominal evisceration due to bomb blast: survival is rare.
+434...
+
+=== Chunk 3564 ===
+Source: 4105_002-ebook.pdf
+Length: 1835 chars
+
+32.2.5 Extraperitoneal bullet trajectory, intraperitoneal damage
+A bullet with sufficient velocity and a tangential trajectory, passing entirely within the muscles of the abdominal wall for a long enough distance, can create a temporary cavity. It is this cavity formation that can affect intraperitoneal organs. More often, in what remains a relatively rare occurrence, the stretch of the mesentery provokes an area of ischaemia in a small segment of the bowel, which then proceeds to necrosis and p...
+
+=== Chunk 3565 ===
+Source: 4105_002-ebook.pdf
+Length: 1794 chars
+
+32.2.6 Primary blast injury
+As described in Section 19.4.1, primary blast affecting a solid organ is rarely seen in survivors; most die of exsanguination shortly after injury. On the other hand, injury to a hollow viscus is well documented and seen especially after explosions occurring under water or in an enclosed space. Rupture of the testes has also been described. Most abdominal injuries, however, are due to the secondary blast mechanism of fragments.
+d
+i z 2 £
+n
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+
+=== Chunk 3566 ===
+Source: 4105_002-ebook.pdf
+Length: 506 chars
+
+32.3.1 Incidence of abdominal injuries
+Given the large surface area of the abdomen, it comes as no surprise that about 20 % of battlefield-injured patients suffer abdominal wounds. The immediate lethality of projectile abdominal wounds – about half the wounded die shortly after injury – means that about 10 % of the patients brought to a hospital alive have wounds in the abdomen (see Table 5.6). The percentage may be much smaller where transfer to hospital is lengthy or where soldiers wear body a...
+
+=== Chunk 3567 ===
+Source: 4105_002-ebook.pdf
+Length: 3613 chars
+
+32.3.2 Mortality
+Mortality figures for abdominal wounds in the surgical literature suffer from all the problems of methodology, definition, and data collection described in Chapter 5: superficial injuries and negative laparotomies included or not, for example. Data collection is certainly neither uniform nor standardized.
+Nonetheless, a broad and clear trend has emerged, thanks to improved evacuation and medical care and a more aggressive surgical approach, including damage control surgery. Gene...
+
+=== Chunk 3568 ===
+Source: 4105_002-ebook.pdf
+Length: 1442 chars
+
+32.3.3 Mortality risk factors
+Mortality depends on a large number of factors which inevitably make an amalgamation of “abdominal wounds” inconsistent. Besides purely aetiological and medical factors, there are always those associated with poverty and limited resources: malnutrition, lack of blood, inadequate pre-hospital care and evacuation, and precarious working circumstances.
+• Mechanism of injury: high-energy projectiles are often rapidly fatal. The majority of patients with abdominal lesion...
+
+=== Chunk 3569 ===
+Source: 4105_002-ebook.pdf
+Length: 4359 chars
+
+32.3.4 Frequency of organ injuries
+As mentioned, there are two major syndromes associated with abdominal injury: haemorrhagic and peritoneal. There is a remarkable difference in the relative frequency of these presentations between civilian studies in industrialized countries and statistics from the battlefield, where delay in evacuation is more common. This is also evident in studies of armed conflict where first aid and transport are very efficient, especially during urban conflict or with for...
+
+=== Chunk 3570 ===
+Source: 4105_002-ebook.pdf
+Length: 1640 chars
+
+32.3.5 Negative and non-therapeutic laparotomy
+A negative laparotomy refers to patients who undergo a laparotomy on the suspicion of intraperitoneal injury, and in whom there are no significant findings. Usually, the trajectory of the projectile is tangential and no penetration of the peritoneum has occurred. More rarely, the bullet or piece of shrapnel penetrates and is found floating free in the peritoneal cavity without having injured any organ.
+A non-therapeutic laparotomy is different: whil...
+
+=== Chunk 3571 ===
+Source: 4105_002-ebook.pdf
+Length: 3906 chars
+
+32.3.6 role of the wounding mechanism
+The lethality of the various wounding agents has often been described (see Section 5.7.4). Numerous studies show that, for patients treated in the same hospital and thus all other factors being equal, the mortality rate for abdominal wounds is three to four times higher with high-kinetic energy bullets than with low-energy bullets and fragments. Comparison with primary blast injury must also be taken into consideration, but is rendered more difficult because...
+
+=== Chunk 3572 ===
+Source: 4105_002-ebook.pdf
+Length: 1125 chars
+
+32.3.7 scoring systems
+Several scoring systems have been devised in an attempt to quantify the severity of abdominal trauma: abbreviated injury scale (AIS), the penetrating abdominal trauma index (PATI), etc. These can be rather complicated and require good administrative clerical support, which is not readily available where resources are limited.
+In the Red Cross Wound Score system, V = A if there is peritoneal penetration. The RCWS attempts to relate tissue damage to the effective transfer of...
+
+=== Chunk 3573 ===
+Source: 4105_002-ebook.pdf
+Length: 624 chars
+
+Figure 32.4
+Difficulty in diagnosis: a patient suffered fragment injuries to the thigh, foot, forearm and hand from a bomb blast. In addition, there was a small wound in the epigastrium; however, the abdomen was soft, not tender, and bowel sounds were present. The patient was not cooperative and it was decided to explore. During the laparotomy incision, the surgeon noticed a small nodule in the subcutaneous tissue. The scissors have been passed through the fragment track and the tip of the force...
+
+=== Chunk 3574 ===
+Source: 4105_002-ebook.pdf
+Length: 985 chars
+
+32.4.1 Diagnosis
+The important issue is not to determine pre-operatively the exact extent of intra- abdominal injury, but rather to decide whether or not surgery is warranted.
+Abdominal diagnosis in war surgery: the decision to operate, or not to operate.
+Meticulous clinical examination is essential but can be difficult in the presence of a depressed level of consciousness due to severe shock, an associated head injury, or intoxication. Moreover, extraperitoneal injuries can cause diagnostic amb...
+
+=== Chunk 3575 ===
+Source: 4105_002-ebook.pdf
+Length: 1208 chars
+
+32.4.2 Presenting syndromes
+As demonstrated in the discussion of epidemiology, there are two large cohorts of patients: those presenting with a haemorrhagic syndrome and those with a peritoneal syndrome. Many patients have injuries to both parenchymatous and hollow viscera, but one syndrome usually predominates. It should be noted that a small amount of blood can also provoke a response of peritoneal irritation – peritonism – but this is usually overshadowed by the symptoms due to the haemorrhag...
+
+=== Chunk 3576 ===
+Source: 4105_002-ebook.pdf
+Length: 898 chars
+
+32.4.3 Clinical examination
+The complete examination of the abdomen must include the following elements.
+1. Careful examination of the front and back of the abdomen, chest, perineum, buttocks and upper thighs. Projectile injury between the nipple line, the groins and pubis, and the posterior axillary lines should be treated as an abdominal injury until proven otherwise. Retro- and intraperitoneal injuries can result from wounds occurring between the tip of the scapulae to the coccyx.
+2. Recordin...
+
+=== Chunk 3577 ===
+Source: 4105_002-ebook.pdf
+Length: 379 chars
+
+Figure 32.6
+Figures 32.7.1 and 32.7.2
+Non-penetrating fragment wound in the right hypochondrium.
+Penetrating thoraco-abdominal gunshot wound.
+4. Consideration of the possibility of a closed abdominal injury, caused by primary blast injury or blunt trauma if the patient was blown over by an explosion.
+d
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+i
+c
+n
+i
+&
+v
+o
+r
+P
+i
+n
+i
+2
+t
+t
+a
+P
+/
+h...
+
+=== Chunk 3578 ===
+Source: 4105_002-ebook.pdf
+Length: 582 chars
+
+Figure 32.8
+Blunt injury to the flank: tertiary blast effect after a bomb explosion.
+a
+e
+l
+a
+S
+.
+R
+Observation, palpation, percussion and auscultation are essential. Digital rectal examination should be conducted to identify a defect in the rectal wall, a lack of sphincter tone, bony spicules, or bleeding (blood on the examining finger).
+A urinary catheter should be placed, with the standard precautions for urethral injury in the event of any perineal haematoma, and the urine checked for gross h...
+
+=== Chunk 3579 ===
+Source: 4105_002-ebook.pdf
+Length: 1210 chars
+
+32.4.4 Paraclinical investigations
+Haemodynamically unstable patients require only a minimum of pre-operative tests: haemoglobin, blood grouping, and urine pregnancy test for women. Performing these should not delay surgical treatment.
+In the stable patient, erect and lateral decubitus plain X-rays of the abdomen and pelvis, with radio-opaque markers on any wounds, should be taken to look for projectiles and intraperitoneal free air. An erect X-ray of the chest should be taken as well. An intrav...
+
+=== Chunk 3580 ===
+Source: 4105_002-ebook.pdf
+Length: 1232 chars
+
+Figure 32.9
+GSW of the abdomen: intraperitoneal free air under both cupolae of the diaphragm.
+443
+C
+R
+C
+I
+C
+R
+8
+C
+I
+/
+y
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+.
+F
+WAR SURGERY
+Figure 32.10
+Disrupted bullet indicating a large transfer of kinetic energy and severe damage to the tissues.
+444
+Focused Assessment Sonography in Trauma (FAST) is a non-invasive screening tool; it has proven better for haemopericardium than for haemoperitoneum in which it has been found unreliable. Diagnostic peritoneal lavage (DPL) is of value in blu...
+
+=== Chunk 3581 ===
+Source: 4105_002-ebook.pdf
+Length: 225 chars
+
+32.5 Emergency room management
+The most important aspect of emergency room care for abdominal injuries is resuscitation and early disposition of the patient; the choice of strategy depends on the general physiological status....
+
+=== Chunk 3582 ===
+Source: 4105_002-ebook.pdf
+Length: 1664 chars
+
+32.5.1 resuscitation
+The haemorrhaging group comprises the patients who have bled significantly or are still actively bleeding. Death from haemorrhage depends to a large degree on the rate of blood loss. The therapeutic possibilities are limited for those with uncontrolled major bleeding and whose systolic blood pressure is less than 90 mm Hg; they require urgent surgery for resuscitation to succeed. The availability of blood for transfusion is essential and this may pose problems in a resource-...
+
+=== Chunk 3583 ===
+Source: 4105_002-ebook.pdf
+Length: 312 chars
+
+32.5.2 Evisceration
+Some patients may present with a small piece of omentum or loops of intestine protruding from the wound. Any extruded organs should be covered with a large moist compress or sterile towel; no attempt should be made to put them back into the abdominal cavity.
+Plani / Baragwanath, Africa
+P
+.
+F...
+
+=== Chunk 3584 ===
+Source: 4105_002-ebook.pdf
+Length: 735 chars
+
+32.5.3 Impalement
+A patient may present with a projectile, a knife, bayonet, or other object impaled in the abdomen. The foreign body should not be removed and no force should be placed upon it. It must be immobilized in situ until the patient is taken to theatre. The distal pulses should be checked.
+Immobilization of the object can be accomplished by surrounding it with bulky bandages (laparotomy packs or dressings used for amputation stumps) and then protecting these with a scaffold made of a ...
+
+=== Chunk 3585 ===
+Source: 4105_002-ebook.pdf
+Length: 87 chars
+
+Figure 32.11
+Severe case of evisceration with strangulation and ischaemia of the bowel....
+
+=== Chunk 3586 ===
+Source: 4105_002-ebook.pdf
+Length: 94 chars
+
+Figure 32.12
+Cardboard box scaffolding to immobilize a penetrating object.
+445
+WAR SURGERY
+446...
+
+=== Chunk 3587 ===
+Source: 4105_002-ebook.pdf
+Length: 467 chars
+
+32.6 Decision to operate
+“Penetrating injuries below the nipples, above the symphysis pubis, and between the posterior axillary lines must be treated as injuries to the abdomen and mandate exploratory laparotomy.”
+D.E. Lounsbury et al. 7
+The general approach to abdominal war wounds has become mandatory exploration. The common-sense exception is the patient who reaches hospital several hours or even days after injury and who is and remains clinically asymptomatic....
+
+=== Chunk 3588 ===
+Source: 4105_002-ebook.pdf
+Length: 1051 chars
+
+32.6.1 Criteria for consideration
+In addition to frank presentations of haemorrhagic shock or peritonitis, certain conditions calling for a laparotomy are clear-cut:
+• the presence of free air in the peritoneal cavity on plain X-ray;
+• difficulty in performing proper abdominal examination: thoraco-abdominal injury with compromised breathing, an associated spinal cord or head injury, etc.
+In a mass-casualty triage situation, the stable patient with an abdominal wound should be placed in Category ...
+
+=== Chunk 3589 ===
+Source: 4105_002-ebook.pdf
+Length: 1952 chars
+
+32.7 Preparation of the patient and anaesthesia
+A laparotomy is a major operation requiring the full range of OT staff. The anaesthetist may require an “extra pair of hands”, especially if autotransfusion is to be performed. The surgeon may not only require one “extra pair of hands”, but perhaps two if extended retraction of the abdominal wall is to be accomplished.
+1. The patient is placed supine with both arms abducted. The operation site is prepared so that the incision can be extended upward...
+
+=== Chunk 3590 ===
+Source: 4105_002-ebook.pdf
+Length: 244 chars
+
+Figures 32.13.1 – 32.13.4
+Tangential wound with evisceration: the laparotomy was performed through an extension of the wound because a midline incision would have compromised the vascularity of the intervening segment of the abdominal wall.
+448...
+
+=== Chunk 3591 ===
+Source: 4105_002-ebook.pdf
+Length: 289 chars
+
+32.8 General plan of surgery
+Whether the surgeon is performing a “routine” laparotomy or one in extremis, a certain number of basic operative gestures should be carried out. This Section deals with general principles. The treatment of individual organs is discussed in subsequent Sections....
+
+=== Chunk 3592 ===
+Source: 4105_002-ebook.pdf
+Length: 488 chars
+
+32.8.1 Incision
+A midline xyphoid to pubis incision is best. This is rapidly performed and provides excellent access. An extension of the abdominal wound itself is used only in the case of a large defect where the midline incision would compromise the vascularity of the intervening tissues. Separate abdominal and thoracic incisions are preferred to a thoraco-abdominal incision. Transverse incisions are preferable in infants.
+2 S
+2
+z &
+2 S
+2
+z &
+P. Andersson / ICRC
+P. Andersson / ICRC...
+
+=== Chunk 3593 ===
+Source: 4105_002-ebook.pdf
+Length: 1058 chars
+
+32.8.2 Exploration
+The surgeon should follow a routine for the proper exploration of the contents of the abdomen to inspect all intraperitoneal and retroperitoneal organs. Missed injuries can prove fatal for the patient. Obvious haemorrhage must be controlled first. If there is no overt bleeding, the surgeon should pass a hand quickly over the liver, spleen and, pulling the intestines first towards him and then away, inspect the retroperitoneum. Attention then turns to any contamination by a met...
+
+=== Chunk 3594 ===
+Source: 4105_002-ebook.pdf
+Length: 177 chars
+
+Haemorrhagic syndrome
+Stop the bleeding, by direct ligation or by damage-control procedures if necessary. Then inspect the liver, spleen, retroperitoneum and mesenteric vessels....
+
+=== Chunk 3595 ===
+Source: 4105_002-ebook.pdf
+Length: 187 chars
+
+Peritoneal syndrome
+Meticulously inspect – centimetre by centimetre – the entire gastro-intestinal tract, including the retroperitoneal duodenum, colon and rectum.
+INJUrIEs To THE ABDoMEN...
+
+=== Chunk 3596 ===
+Source: 4105_002-ebook.pdf
+Length: 1119 chars
+
+32.8.3 Massive haemorrhage
+The efficacy of resuscitation depends on stopping the haemorrhage. The haemodynamically unstable patient with massive bleeding that is difficult to control except with temporary measures is the prime candidate for the damage-control approach of an abbreviated laparotomy. A left anterolateral thoracotomy with clamping of the aorta in the chest may be necessary to control haemorrhage in the abdomen (see Section 31.7.2).
+Massive intraperitoneal haemorrhage may occur from ...
+
+=== Chunk 3597 ===
+Source: 4105_002-ebook.pdf
+Length: 357 chars
+
+Figure 32.14.1
+Figure 32.14.2
+The patient suffered a GSW to the right flank five hours before admission, at which point the BP was 110/70 and the pulse 78. The abdomen was soft and the bowel sounds present.
+On opening the abdomen, a large retroperitoneal haematoma was seen in the infracolic area.
+C
+R
+C
+I
+/
+e
+n
+i
+d
+d
+e
+r
+s
+a
+C
+Nasreddine / ICRC
+N
+N
+.
+.
+H
+H...
+
+=== Chunk 3598 ===
+Source: 4105_002-ebook.pdf
+Length: 2657 chars
+
+Figure 32.14.3
+Figure 32.14.4
+Manipulation resulted in decompression of the haematoma and brisk bleeding from the inferior mesenteric vessels.
+Apart from the large haematoma in the root of the mesentery, shown in this photograph, there was a small perforation of the jejunum.
+Even so, this is difficult surgery and many patients die of exsanguination “on table”. Large quantities of readily available blood for transfusion are necessary for any surgery to prove successful.
+In a mass casualty situati...
+
+=== Chunk 3599 ===
+Source: 4105_002-ebook.pdf
+Length: 472 chars
+
+32.8.4 Mild to moderate haemorrhage
+Most wounded patients who have survived transport to a hospital do not have life- threatening haemorrhage and the approach should be quick but systematic. The most common source is from a vessel in the small bowel mesentery or mesocolon, and ligation suffices. The next most common sources are the liver, spleen and the major divisions of the great vessels. Simple surgical measures for haemostasis are discussed in subsequent Sections....
+
+=== Chunk 3600 ===
+Source: 4105_002-ebook.pdf
+Length: 2488 chars
+
+32.8.5 Controlling contamination
+On opening the abdomen the surgeon must make a mental note of any free intestinal contents in the peritoneal cavity and any faecal odour.
+All viscera must be meticulously inspected. Any perforation, however small, can be fatal.
+The entire alimentary tract must be carefully inspected from the abdominal oesophagus to the anal canal. The surgeon must find and treat all perforations.
+INJUrIEs To THE ABDoMEN
+They may be very small and in unexpected places, but all are...
+
+=== Chunk 3601 ===
+Source: 4105_002-ebook.pdf
+Length: 237 chars
+
+Figure 32.16
+Blood and bile staining in the triangle between the liver, the colon and the duodenum suggest a retroperitoneal pancreatic and/or duodenal lesion. Surgical emphysema may indicate a retroperitoneal colonic or duodenal injury....
+
+=== Chunk 3602 ===
+Source: 4105_002-ebook.pdf
+Length: 1006 chars
+
+Figure 32.17
+Kocher manoeuvre: the second part of the duodenum is mobilized via an incision in the peritoneum lateral to the duodenum. The duodenum is reflected medially so that the posterior surface can be inspected. The manoeuvre can be facilitated by first mobilizing the hepatic flexure of the colon (dotted red line).
+451
+WAR SURGERY
+452
+A faecal smell may be the only indication of a colonic injury.
+Finally, the uterus, rectum and urinary bladder should be examined. An extraperitoneal injury ...
+
+=== Chunk 3603 ===
+Source: 4105_002-ebook.pdf
+Length: 1239 chars
+
+32.8.6 Finishing and closure
+At the end of the operation, the abdominal cavity is cleaned by thorough and copious irrigation with warm normal saline and the subhepatic and splenic spaces and pouch of Douglas sucked dry. Drains are placed as necessary.
+Old lesson for new surgeons   No time should be wasted looking for projectiles!
+The abdominal wall is closed preferably by a continuous mass suture including peritoneum and fascia. It is safe to close the skin if there has been minimal or no intest...
+
+=== Chunk 3604 ===
+Source: 4105_002-ebook.pdf
+Length: 5240 chars
+
+32.9 Damage control: abbreviated laparotomy
+Section 18.3 discusses damage control surgery in general terms. The basic idea is to abbreviate the initial laparotomy to prevent and overcome hypothermia, acidosis and coagulopathy. Continued resuscitation and aggressive correction of this “lethal triad” are undertaken in the ICU to restore the physiology. The length of this stage depends on the correction of the physiological parameters and can last 12 to 48 hours. The patient is then returned to the...
+
+=== Chunk 3605 ===
+Source: 4105_002-ebook.pdf
+Length: 3411 chars
+
+32.9.1 Temporary abdominal closure
+The abbreviated laparotomy is an incomplete operation; the abdomen will be re-opened shortly for definitive repair. Consequently, a simple and easily reversible technique for closure of the abdominal wall is sufficient. One possibility is a continuous suture of the skin only, with thick monofilament nylon. An alternative is to use a series of surgical towel clips, taking up the skin only. In either case, the fascia is not included but left open for later defini...
+
+=== Chunk 3606 ===
+Source: 4105_002-ebook.pdf
+Length: 2259 chars
+
+32.10 “Frontline laparotomy” and late-presenting patients
+Vacpac sandwich technique as taught in Definitive Surgical Trauma Care © International Association for Trauma Surgery and Intensive Care.
+ICRC surgeons have on numerous occasions received patients who had been operated “somewhere in the field” and arrived in a septic state with obvious intestinal or urinary leakage, missed injuries, or retained surgical compresses. These patients invariably die, even after a “second look” operation by a c...
+
+=== Chunk 3607 ===
+Source: 4105_002-ebook.pdf
+Length: 810 chars
+
+Figure 32.19
+Patient was received three days after a field laparotomy; the abdomen was distended, no bowel sounds present, and obviously septic. At re-exploration, a jejunal anastomosis and ileostomy were observed and the caecum was found to be necrotic. An extended right hemicolectomy was performed. There is no record of the result.
+C  R  C  I  Zone I  pulsatile or expanding.  Zone II  Zone II  exploration.  Zone III  managed expectantly.  C  R  C  I  Figure 32.20 The three vascular   zones of ...
+
+=== Chunk 3608 ===
+Source: 4105_002-ebook.pdf
+Length: 1070 chars
+
+32.11 Midline great vessels
+Injury to the midline vessels usually presents at operation as a contained retroperitoneal haematoma; free-flowing haemorrhage is rapidly fatal. A pulsatile or expanding retroperitoneal haematoma in any Zone requires immediate exploration; depending on the Zone, some that are stable also require immediate exploration. Some small and stable haematomata may be treated conservatively.
+Observe if the retroperitoneal haematoma is stable, pulsatile or expanding.
+A pulsatile...
+
+=== Chunk 3609 ===
+Source: 4105_002-ebook.pdf
+Length: 952 chars
+
+Figure 32.20 The three vascular zones of the abdomen
+Zone I: aorta, IVC, coeliac trunk, SMA, and IMA; approached by left medial visceral rotation. For IVC, right medial rotation.
+Even with injury to a major vessel, the basic principles of vascular surgery apply: adequate exposure with proximal and distal control; minimal debridement of the vessel wall; irrigation with a heparin-saline solution; and meticulous repair with a monofilament vascular suture, avoiding stenosis of the vessel. Certain ve...
+
+=== Chunk 3610 ===
+Source: 4105_002-ebook.pdf
+Length: 657 chars
+
+32.11.1 Access to the aorta: left medial visceral rotation (Mattox manoeuvre)
+For access to the proximal aorta and its major anterior branches, the left colon is mobilized as for a left colectomy by cutting through the white line of Toldt in the paracolic gutter. The colon and small bowel together with the spleen and pancreas are then all pulled medially: medial visceral rotation. The left kidney can be included to fully expose the aorta or left in place if its vascular pedicle is the intended g...
+
+=== Chunk 3611 ===
+Source: 4105_002-ebook.pdf
+Length: 1162 chars
+
+Figure 32.21
+Left medial visceral rotation.
+a. Incision along the white line of Toldt in the paracolic gutter extending up to the spleen.
+b. Line of cleavage behind the spleen and in front of the left kidney for access to the aorta; behind the kidney to access directly the renal artery. The dissection is facilitated by the presence of the haematoma which opens up the plane.
+c. The colon, small intestines, spleen, pancreas and stomach are all swept to the patient’s right exposing the aorta.
+To fa...
+
+=== Chunk 3612 ===
+Source: 4105_002-ebook.pdf
+Length: 770 chars
+
+32.11.2 Access to the inferior vena cava: right medial visceral rotation
+For access to the infrahepatic vena cava, right kidney and renal pedicle, the same dissection is performed through the right paracolic white line of Toldt as for a right- hemicolectomy, and continued on around the duodenum via a Kocher manœuvre (Figure 32.17). The caecum and right colon, duodenum and head of the pancreas, along with the small bowel are swung to the patient’s left. The incision can be extended around the cae...
+
+=== Chunk 3613 ===
+Source: 4105_002-ebook.pdf
+Length: 631 chars
+
+Figure 32.23.3
+Right medial visceral rotation.
+a. Kocher manœuvre: incision lateral to the duodenum.
+Extended Kocher manoeuvre: the duodenum and colon are retracted toward the patient’s left, the liver to the right.
+Cattell-Braasch manœuvre: the caecum, transverse colon and small intestines are mobilized up and to the patient’s left exposing the entirety of the inferior vena cava.
+b. Extended Kocher manœuvre: the incision is continued into the paracolic gutter along the white line of Toldt.
+c. C...
+
+=== Chunk 3614 ===
+Source: 4105_002-ebook.pdf
+Length: 346 chars
+
+32.11.3 Management of arterial injuries
+For incomplete lesions of the aorta, a partial occluding vascular clamp is applied (side-clamping), which allows for suture, resection or patching. The aorta requires minimal trimming of the edges and a transverse continuous repair with 3/0 or 4/0 non-absorbable monofilament suture.
+ER
+C
+Papas/ ICRC
+P
+.
+N...
+
+=== Chunk 3615 ===
+Source: 4105_002-ebook.pdf
+Length: 2583 chars
+
+Figure 32.24
+Repair of the aorta.
+a. Small wound: digital pressure to control bleeding and suture of the aorta as the fingers are removed.
+b. Alternatively, a side-clamp is applied.
+c. Larger wounds: total occlusion of the aorta by proximal and distal vascular clamps.
+14 Cattell RB, Braasch JW. A technique for exposure of the duodenum. Surg Gynecol Obstet 1960; 133: 378 – 379.
+458
+INJUrIEs To THE ABDoMEN
+The coeliac trunk, left gastric, inferior mesenteric and splenic arteries can be ligated; th...
+
+=== Chunk 3616 ===
+Source: 4105_002-ebook.pdf
+Length: 789 chars
+
+32.11.4 Management of venous injuries
+Access and repair of the inferior vena cava (IVC) are difficult and the surgeon may have to revert to packing for temporary control. Control of the IVC is best achieved by direct digital pressure followed by clamping with vascular or sponge forceps proximal and distal to the injury. Alternatively, Foley catheters inserted proximally and distally and then inflated can provide temporary intraluminal control of haemorrhage, which allows for the proper placement...
+
+=== Chunk 3617 ===
+Source: 4105_002-ebook.pdf
+Length: 562 chars
+
+Figure 32.25
+Suture technique for the IVC: Babcock clamps hold the edges of the laceration. The suture begins in the intact vein.
+460
+Ligation of the suprarenal vena cava provokes renal failure and therefore injuries must be repaired or shunted. The infrarenal vena cava can be ligated if repair proves impossible; the ligature is placed outside the clamp on the collapsed vein and not on the engorged part. After ligation, distal fasciotomies are performed, the legs are elevated and the patient sho...
+
+=== Chunk 3618 ===
+Source: 4105_002-ebook.pdf
+Length: 1452 chars
+
+Repair of the inferior vena cava
+Repair is accomplished by minimal trimming of the edges followed by direct suture or a vein patch to overcome any defect, and fashioned from an autologous vein. In the midst of welling blood, the wall of the IVC can be difficult to see and suture without creating a larger tear. A simple technique after applying proximal and distal pressure involves grasping the edges of the laceration with Allis or Babcock clamps and then running a suture from the intact vein thr...
+
+=== Chunk 3619 ===
+Source: 4105_002-ebook.pdf
+Length: 130 chars
+
+32.12 Liver and biliary tract
+Haemorrhage from the liver can be arterial, venous, coagulopathic, or a combination of any of these....
+
+=== Chunk 3620 ===
+Source: 4105_002-ebook.pdf
+Length: 1583 chars
+
+32.12.1 severity of injury
+Hepatic injuries vary in severity from superficial lacerations to a shattered liver. Liver tissue is particularly susceptible to temporary cavity formation. Several classification systems have been used to describe the severity of hepatic damage, but they tend to be complicated and more readily applicable post-operatively to better define the injury
+16 Louis Riddez, Associate Professor of Surgery, Karolinska Institute University Hospital and senior Red Cross surgeon.
+I...
+
+=== Chunk 3621 ===
+Source: 4105_002-ebook.pdf
+Length: 1163 chars
+
+32.12.2 Management of simple liver lacerations
+A small laceration that has stopped bleeding on opening the abdomen should be left as is. Any manipulation will disrupt the natural haemostatic process and cause bleeding to start again. However, this applies only if the patient is normotensive.
+Capsular bleeding can be controlled by:
+• direct compression for a few minutes;
+• cauterization with electric diathermy;
+• local pressure and simple suture;
+• application of a topical haemostatic (Gelfoam® o...
+
+=== Chunk 3622 ===
+Source: 4105_002-ebook.pdf
+Length: 176 chars
+
+Figures 32.26.1 and 32.26.2
+Hepatic haemostatic mattress sutures: “liver suture”. The first mattress sutures overlap and the edges are brought together with horizontal sutures....
+
+=== Chunk 3623 ===
+Source: 4105_002-ebook.pdf
+Length: 267 chars
+
+Figures 32.27.1 and 32.27.2
+If the hepatic needle is not long enough, or is not available, one can be improvised by threading a thick suture through a spinal needle held in place by crimping the needle. The plastic end is then snapped off and removed.
+461
+WAR SURGERY...
+
+=== Chunk 3624 ===
+Source: 4105_002-ebook.pdf
+Length: 437 chars
+
+Figure 32.28
+Pringle manoeuvre: the porta hepatis is compressed with the fingers in the free edge of the lesser omentum. If this succeeds in stopping the haemorrhage, a hole is punched through a nonvascular part of the lesser omentum and the fingers replaced by a vascular clamp or a non- crushing intestinal clamp. The maximum period of occlusion is not known with exactitude, but it should not be prolonged beyond 30 minutes at a time....
+
+=== Chunk 3625 ===
+Source: 4105_002-ebook.pdf
+Length: 142 chars
+
+Figure 32.29
+Partial resection of the liver: haemostatic hepatic mattress sutures and individual ligation of vessels and biliary radicles.
+462...
+
+=== Chunk 3626 ===
+Source: 4105_002-ebook.pdf
+Length: 846 chars
+
+32.12.3 Management of larger wounds of the liver
+Larger, actively bleeding wounds may require the application of the Pringle manoeuvre to temporarily control haemorrhage first. The Pringle manoeuvre occludes circulatory inflow to the liver and controls haemorrhage originating from the intrahepatic branches of the portal vein and hepatic artery. Failure to control massive haemorrhage indicates injury to the retrohepatic vena cava or hepatic veins.
+C
+Papas/ ICRC
+P
+.
+N
+Large lacerations near the ed...
+
+=== Chunk 3627 ===
+Source: 4105_002-ebook.pdf
+Length: 684 chars
+
+Finger-fracture dissection17
+The normal capsule is incised or cut through by diathermy and the parenchyma broken down by squeezing it between the thumb and index finger. When a strong resistant “thread” is felt instead of the crumbling parenchyma, the surgeon has come upon a lobar portal triad: the biliary radicles and intrahepatic branches of the portal vein and the hepatic artery. The triad is selectively clamped, divided, and suture-ligated. Any large raw surface can be covered by omentum sti...
+
+=== Chunk 3628 ===
+Source: 4105_002-ebook.pdf
+Length: 2311 chars
+
+32.12.4 Through-and-through wounds of the liver
+Some through-and-through wounds of the liver have stopped bleeding by the time the abdomen is entered. In this case, the liver should be compressed between two hands and then released to see if active bleeding recommences. If not, the entry and exit wounds should not be sutured closed. This can create an intrahepatic haematoma and bile leakage with the possibility of abscess formation or haemobilia; instead a simple drain should be placed.
+If bleed...
+
+=== Chunk 3629 ===
+Source: 4105_002-ebook.pdf
+Length: 1427 chars
+
+32.12.5 Management of complex liver injuries
+These are the few severe hepatic injuries that present massive bleeding on opening the abdomen. The surgeon should immediately think of a damage-control approach. The availability of blood and autotransfusion is often crucial.
+First, the active haemorrhage must be stopped as quickly as possible. This is best accomplished by having the assistant apply external two-handed compression on the liver downwards and backwards to bring the shattered tissues to...
+
+=== Chunk 3630 ===
+Source: 4105_002-ebook.pdf
+Length: 175 chars
+
+Figure 32.31.1
+Stellate lesion of the liver: bleeding has stopped and the lesion is covered with fibrin – often the case with those patients who survive to reach hospital.
+464...
+
+=== Chunk 3631 ===
+Source: 4105_002-ebook.pdf
+Length: 1617 chars
+
+Perihepatic compression packing
+Packing must always be “around” the liver, never into the laceration, which simply keeps the bleeding wound open. Proper packing involves placing folded laparotomy pads above and below the liver, laterally, and between the liver and the anterior chest and abdominal wall. The aim is to wrap the liver in such a way as to restore the normal liver form and outline, thus compressing the torn tissues together.
+Overuse of laparotomy pads causes an increase in intra-abdom...
+
+=== Chunk 3632 ===
+Source: 4105_002-ebook.pdf
+Length: 618 chars
+
+Stellate fracture or shattered liver
+A
+A large stellate fracture or shattered liver with blood welling up from the depths, but controlled by the Pringle manoeuvre, indicates bleeding from branches of the portal vein or hepatic artery. Definitive surgical control involves finger-fracture into the depths of the cavity, releasing the Pringle to identify the bleeding points, and then ligation or suture repair of the vessels depending on their size.
+d
+n
+a
+l
+i
+a
+h
+e
+T
+,
+l
+a
+t
+i
+p
+g
+s
+o
+H
+.
+U
+a
+l
+3 & >...
+
+=== Chunk 3633 ===
+Source: 4105_002-ebook.pdf
+Length: 1671 chars
+
+Figure 32.31.3
+Stellate laceration of the right lobe: a vascular clamp has replaced the surgeon’s fingers to maintain the Pringle manoeuvre. Finger- fracture of the hepatic parenchyma reveals blood vessels and bile ducts.
+Devitalized tissue has been excised, portal triads ligated and hepatic mattress sutures inserted. Omentum from the stomach and transverse colon has been mobilized, maintaining a pedicle on the patient’s right.
+If the bleeders cannot be found and the blood is bright red, individ...
+
+=== Chunk 3634 ===
+Source: 4105_002-ebook.pdf
+Length: 157 chars
+
+Figure 32.31.4
+The liver laceration has been plugged by a mobilized omental pedicle and deep horizontal sutures inserted to hold it in place.
+465
+WAR SURGERY...
+
+=== Chunk 3635 ===
+Source: 4105_002-ebook.pdf
+Length: 90 chars
+
+Figure 32.32
+Shattered liver: the patient rarely survives.
+466
+e
+k
+e
+l
+l
+i
+t
+e
+n
+o
+o
+G
+.
+G...
+
+=== Chunk 3636 ===
+Source: 4105_002-ebook.pdf
+Length: 2171 chars
+
+Retrohepatic vena cava and hepatic veins
+Haemorrhage from the depths of a cavity not controlled by the Pringle manoeuvre, or welling up from behind the liver, indicates injury to the retrohepatic vena cava or hepatic veins. It is usually best to adopt a damage-control approach.
+The retrohepatic haematoma must not be explored and the liver must not be mobilized; instead the right coronary and triangular ligaments should be left intact to provide a proper scaffold for the tamponade to be effective...
+
+=== Chunk 3637 ===
+Source: 4105_002-ebook.pdf
+Length: 1708 chars
+
+Porta hepatis injury
+Injury to both the portal vein and hepatic artery is rarely encountered in survivors. Direct injury to vessels within the porta hepatis usually involves the major bile ducts as well.
+INJUrIEs To THE ABDoMEN
+a
+& 2
+c
+i
+r
+f
+A
+.
+S
+,
+h
+t
+a
+n
+a
+w
+g
+2
+a
+r
+a
+B
+.
+H
+.
+C
+x
+/
+i
+n
+a
+l
+P
+.
+F
+First, a Pringle manoeuvre is performed and a vascular clamp placed distally close to the liver, then the porta hepatis dissected to identify the lesion. Every effort should be made to restore portal ...
+
+=== Chunk 3638 ===
+Source: 4105_002-ebook.pdf
+Length: 560 chars
+
+32.12.6 Drains
+Blood and bile oozing from a raw surface rapidly subside and are decreased by covering with a patch of omentum. Insofar as possible, drains should be a closed system, not an open Penrose or corrugated rubber drain. A Nelaton catheter can be brought out posteriorly through the right flank and attached to a sterile urine collection bag. Most drains can be withdrawn after 24 – 48 hours. T-tube drainage of the common bile duct is indicated only if the biliary tree is injured. It is no...
+
+=== Chunk 3639 ===
+Source: 4105_002-ebook.pdf
+Length: 614 chars
+
+32.12.7 Complications
+Complications of liver injuries include secondary haemorrhage; subphrenic, intrahepatic or subhepatic abscess; and biliary fistula. They are usually caused by inadequate excision of devitalized parenchyma or unrecognized associated injuries to other surrounding structures such as the biliary ducts, duodenum, the pancreas and, especially, the colon. Infectious complications are also common after perihepatic packing as a damage-control technique. When a major liver resection ...
+
+=== Chunk 3640 ===
+Source: 4105_002-ebook.pdf
+Length: 57 chars
+
+Figure 32.33
+Injury to the porta hepatis.
+467
+WAR SURGERY...
+
+=== Chunk 3641 ===
+Source: 4105_002-ebook.pdf
+Length: 999 chars
+
+32.12.8 Extrahepatic biliary tract
+Injury to the extrahepatic biliary tract is uncommon and never occurs in isolation.
+A lesion of the gallbladder requires cholecystectomy.
+Injury to the common bile duct with minor loss of tissue is closed over a T-tube using 4/0 absorbable sutures, as practised following exploration for gallstones. Major loss of tissue invariably requires a staged procedure: primary temporary drainage followed by reconstruction.
+For injuries below the cystic duct two choices fo...
+
+=== Chunk 3642 ===
+Source: 4105_002-ebook.pdf
+Length: 756 chars
+
+Figure 32.34
+Possible reconstructive procedures.
+a. Direct cholecysto-jejunostomy with entero-anastomosis.
+b. Roux-en-Y cholecysto-jejunostomy.
+c. Roux-en-Y choledocho-jejunostomy stented by a T-tube.
+For injuries above the cystic duct, choledochostomy followed by a Roux-en-Y choledocho-jejunostomy with an internal stent as a definitive repair is the procedure of choice.
+Injury to the right or left hepatic ducts is even more difficult and complicated to deal with. If only one duct is damaged, it...
+
+=== Chunk 3643 ===
+Source: 4105_002-ebook.pdf
+Length: 1486 chars
+
+32.13 Pancreas, duodenum and spleen
+Treating the pancreas as a single organ makes little sense in trauma surgery. Injuries to the tail or head of the pancreas differ greatly in their inherent problems and appropriate surgical approach. It is best to consider the duodenum-head-of-the-pancreas complex to the right of the mesenteric vessels as a single surgical unit. Similarly, the distal pancreas to the left of the vessels should be taken together with the spleen.
+468
+INJUrIEs To THE ABDoMEN
+Major...
+
+=== Chunk 3644 ===
+Source: 4105_002-ebook.pdf
+Length: 1784 chars
+
+32.13.1 Injuries to the head of the pancreas
+Recognizing an injury to the pancreas or duodenum may be difficult; often a simple haematoma may hide a severe lesion. Retroperitoneal bile staining is pathognomonic. A missed injury results in a septic patient due to the action of various enzymes. Proper exposure of the pancreas involves going through the gastro-colic omentum to enter the lesser sac and opening the peritoneum over it to reveal the nature of the haematoma and the depth of the lesion. ...
+
+=== Chunk 3645 ===
+Source: 4105_002-ebook.pdf
+Length: 78 chars
+
+Figure 32.35.1
+Simple laceration, intact pancreatic duct: suture and drainage....
+
+=== Chunk 3646 ===
+Source: 4105_002-ebook.pdf
+Length: 116 chars
+
+Figure 32.35.2
+Deep injury with possibility of injury to the pancreatic duct: drainage is the mainstay of treatment....
+
+=== Chunk 3647 ===
+Source: 4105_002-ebook.pdf
+Length: 466 chars
+
+Figures 32.36.1 and 32.36.2
+Sump drainage: a large chest tube with multiple perforations at the distal end is placed close to the injured pancreas. A naso-gastric tube is inserted through the chest tube without extending beyond its end and is then fixed to it. The chest tube is sutured to the patient’s skin. If the naso-gastric tube becomes obstructed it can easily be replaced, leaving the outer tube in situ.
+469
+Papas / ICRC
+P
+.
+N
+Papas / ICRC
+P
+.
+N
+WAR SURGERY...
+
+=== Chunk 3648 ===
+Source: 4105_002-ebook.pdf
+Length: 112 chars
+
+Figure 32.37.1
+Large haematoma overlying the head of the pancreas.
+Figure 32.37.2 Verifying the pancreatic duct....
+
+=== Chunk 3649 ===
+Source: 4105_002-ebook.pdf
+Length: 600 chars
+
+Figure 32.37.3
+Debridement of the wound and control of the duodenum and pancreatic duct.
+470
+a
+F.Plani / Baragwanath, Africa
+F
+a
+c
+i
+r
+& = @
+f
+A
+.
+S
+,
+h
+t
+a
+n
+a
+w
+g
+2 &
+a
+r
+a
+B
+.
+H
+.
+C
+S
+/
+i
+n
+a
+l
+P
+.
+F
+a
+F.Plani / Baragwanath, Africa
+c
+i
+r
+f
+A
+.
+S
+,
+h
+t
+a
+n
+a
+w
+g
+a
+r
+a
+B
+.
+H
+.
+C
+/
+i
+n
+a
+l
+P
+.
+F
+More severe injuries including the duodenum are extremely difficult to treat and are usually accompanied by severe haemorrhage. A damage control approach by packing tamponade and drainage is best. Pancre...
+
+=== Chunk 3650 ===
+Source: 4105_002-ebook.pdf
+Length: 471 chars
+
+Complications
+Complications are multiple and include a fistula, pancreatitis, pseudocyst, and abscess formation. Mild pancreatitis occurs in up to a fifth of patients post-operatively; conservative management is usually sufficient. Careful observation is important and, if the patient’s condition deteriorates, re-operation to remove necrotic tissue and control pancreatic duct leakage may be necessary. Drainage, again, is the basis of treatment.
+INJUrIEs To THE ABDoMEN...
+
+=== Chunk 3651 ===
+Source: 4105_002-ebook.pdf
+Length: 1761 chars
+
+32.13.2 Injuries to the duodenum
+There are two categories of injuries that the surgeon encounters: simple ones that lend themselves to direct repair and complex ones involving several nearby organs, usually in a haemodynamically unstable patient. Beware the septic patient with a missed diagnosis.
+Most wounds are minor, involving less than 40 % of the circumference. They can be closed by suturing transversely to the duodenal axis to avoid stenosis. The suture line should be reinforced by a jejuna...
+
+=== Chunk 3652 ===
+Source: 4105_002-ebook.pdf
+Length: 154 chars
+
+Figures 32.38.1 and 32.38.2
+Simple laceration of the duodenum sutured transversely.
+Figures 32.38.3 and 32.38.4 The repair is covered with a jejunal loop....
+
+=== Chunk 3653 ===
+Source: 4105_002-ebook.pdf
+Length: 152 chars
+
+Figures 32.39.1 and 32.39.2
+Pyloric exclusion: the pylorus is exteriorized through a gastrostomy and closed with a purse- string suture.
+471
+WAR SURGERY...
+
+=== Chunk 3654 ===
+Source: 4105_002-ebook.pdf
+Length: 201 chars
+
+Figure 32.40
+Alternative procedures for decompression of the duodenum and protection of the anastomotic line:
+a. tube duodenostomy.
+b. gastrostomy.
+c. decompressive jejunostomy.
+d. feeding jejunostomy....
+
+=== Chunk 3655 ===
+Source: 4105_002-ebook.pdf
+Length: 400 chars
+
+Figure 32.41
+Large wounds leaving a defect not amenable to direct suture or anastomosis can be closed with a jejunal loop patch. The serosa exposed to the duodenal contents is eventually resurfaced by mucosa. The duodenum should be decompressed by gastro-jejunostomy and tube gastrostomy. Both anastomoses are retrocolic. Any injury to the head of the pancreas is treated by haemostasis and drainage....
+
+=== Chunk 3656 ===
+Source: 4105_002-ebook.pdf
+Length: 1900 chars
+
+Figure 32.42
+An alternative for a severe lesion is resection of the damaged part and repair using a jejunal end-to-end Roux-en-Y duodeno-jejunostomy. Pyloric exclusion and gastrostomy are good adjuncts to protect the suture lines. A feeding jejunostomy tube should be threaded distal to the last anastomosis either through the loop or beyond depending on the patient’s anatomy.
+472
+C
+N.Papas/ ICRC
+R
+C
+I
+/
+s
+a
+p
+a
+P
+.
+N
+a  b  c  d
+a
+b
+c
+d
+For complex injuries in an unstable patient, a damage-control...
+
+=== Chunk 3657 ===
+Source: 4105_002-ebook.pdf
+Length: 1066 chars
+
+32.13.3 Treatment of injuries to the body and distal pancreas
+Minor injuries, with an intact pancreatic duct, are adequately treated with minimal debridement and haemostasis and dependent drainage through the posterior flank via a wide-bore drain or two.
+In major injuries to the pancreatic body or tail involving the duct, distal pancreatic resection and splenectomy should be performed. The spleen is mobilized and the plane of cleavage continued behind the pancreas to bring the entire block out o...
+
+=== Chunk 3658 ===
+Source: 4105_002-ebook.pdf
+Length: 387 chars
+
+Figures 32.43.1 and 32.43.2
+Extensive injury to the first or second part of the duodenum and/or pylorus may require a diverticulization of the duodenum and Billroth II antrectomy with gastro-jejunostomy and vagotomy. There are alternative procedures for decompression of the duodenal stump: lateral- or end-tube duodenostomy.
+Figure 32.44 Duodenal fistula showing bile-stained discharge....
+
+=== Chunk 3659 ===
+Source: 4105_002-ebook.pdf
+Length: 140 chars
+
+Figures 32.45.1 and 32.45.2
+Major injury to the pancreatic tail: distal resection of the pancreas with ligature of the duct and splenectomy....
+
+=== Chunk 3660 ===
+Source: 4105_002-ebook.pdf
+Length: 595 chars
+
+Figures 32.45.3 and 32.45.4
+Injury to the tail and spleen: distal resection and splenectomy.
+473
+C
+2
+R
+C
+I
+/
+n
+a
+3 &
+d
+l
+a
+B
+.
+M
+C
+IcRC
+R
+C
+I
+C
+IcRc
+R
+C
+I
+C
+Icrc
+R
+C
+I
+WAR SURGERY
+Injuries involving the body and tail of the pancreas and with suspected or direct evidence of pancreatic duct disruption require distal pancreatectomy and splenectomy.
+The damage-control approach in a haemodynamically unstable patient is to tamponade the lesser sac by packing it and to place one or more drains to conve...
+
+=== Chunk 3661 ===
+Source: 4105_002-ebook.pdf
+Length: 1679 chars
+
+32.13.4 Treatment of injuries to the spleen
+In war surgery, injuries to the spleen should be treated by splenectomy.
+In war surgery, the management of an injury to the spleen or splenic pedicle is by splenectomy. This is the only safe approach. Various techniques for splenic repair are described, but they are inappropriate for a surgeon not specially trained in the procedure and working in a hospital where post-operative care is limited. In some infants with a minor injury, it might be judicious...
+
+=== Chunk 3662 ===
+Source: 4105_002-ebook.pdf
+Length: 2997 chars
+
+32.13.5 Post-splenectomy prophylaxis of infection
+Infants and children are far more susceptible to infections after splenectomy than adults, except for those suffering immune depression (HIV/AIDS in particular). Reportedly, a syndrome of overwhelming post-splenectomy infection (OPSI) can occur any time from the immediate post-operative period up to decades post-splenectomy, although direct evidence is inconclusive. The true incidence of OPSI after traumatic splenectomy is not known. It usually p...
+
+=== Chunk 3663 ===
+Source: 4105_002-ebook.pdf
+Length: 2391 chars
+
+32.14 stomach
+The stomach provides a large surface susceptible to injury. Whether the stomach is empty or full is of great consequence as described previously; the same projectile may create a small puncture wound or a large laceration with widespread dissemination of the full stomach’s contents. The contaminating contents of the stomach are important: the pH of fasting gastric juice is bactericidal; conversely, during digestion the pH is neutralized and bacteria then flourish. Therefore, fastin...
+
+=== Chunk 3664 ===
+Source: 4105_002-ebook.pdf
+Length: 2371 chars
+
+32.15 small bowel
+The small intestines occupy a large volume of the peritoneal cavity and are consequently the most common site of injury. Occasionally, perforations may be small and sealed off by protruding mucous membrane or, if old, covered by fibrin and adhesive omentum. The only evidence of perforation at laparotomy may be a small amount of blood without intestinal content. On the other hand, some lesions may be large lacerations with manifest contamination of the peritoneal cavity. The pre...
+
+=== Chunk 3665 ===
+Source: 4105_002-ebook.pdf
+Length: 154 chars
+
+Figure 32.49
+Even number of perforations.
+Figures 32.50.1 – 32.50.3 Mesenteric haematoma adjacent to bowel wall.
+477
+C
+2
+R
+C
+I
+/
+n
+i
+s
+a
+S
+.
+V
+WAR SURGERY...
+
+=== Chunk 3666 ===
+Source: 4105_002-ebook.pdf
+Length: 779 chars
+
+Figure 32.51
+Resection of a long segment of intestine with multiple perforations.
+478
+The technique of small bowel anastomosis – one layer or two – depends on the surgeon’s training and experience, and the use of a stapling device on its availability.
+Primary blast injury to the small intestines begins in the mucosa, as mentioned previously. Consequently, any serosal lesion indicates damage to the full thickness of the intestinal wall and requires excision.
+Damage-control techniques for the smal...
+
+=== Chunk 3667 ===
+Source: 4105_002-ebook.pdf
+Length: 1337 chars
+
+32.16 Colon
+Given its large volume, the colon is the most frequently injured organ in war trauma along with the small bowel. Injuries to additional structures are common and greatly influence the management and prognosis. Besides catastrophic haemorrhage, colonic injury – because of its potential for sepsis – is the main factor that determines morbidity and mortality, which is seldom less than 15 % in contemporary war surgery.
+Upon opening the abdomen, injury to the visible colon is obvious, but...
+
+=== Chunk 3668 ===
+Source: 4105_002-ebook.pdf
+Length: 2131 chars
+
+32.16.1 General principles of treatment
+During World War II, surgical dogma decreed that any injury to the colon required a colostomy. There was good reason for this given the high mortality following colonic lesions in an era of limited antibiotics and resuscitation. Subsequently, civilian surgeons faced with increasing numbers of low-energy handgun wounds, and benefiting from the time and relative comfort of working in specialized centres, called this dogma into question – again with good reas...
+
+=== Chunk 3669 ===
+Source: 4105_002-ebook.pdf
+Length: 253 chars
+
+Figure 32.52.1
+Very small perforation near the splenic flexure of the colon with slight faecal contamination present: a low-energy transfer wound. The odour on opening the abdomen gives away the presence of the wound, which may not otherwise be obvious....
+
+=== Chunk 3670 ===
+Source: 4105_002-ebook.pdf
+Length: 4169 chars
+
+Figure 32.52.2
+Larger hole in the splenic flexure of the colon.
+Figure 32.52.3 Large bloody laceration of the splenic flexure.
+479
+WAR SURGERY
+C.Pacitti / ICRC
+C
+&
+R
+C
+I
+/
+i
+n
+a
+l
+P
+.
+F
+Figures 32.53.1 and 32.53.2 Well-fashioned colostomy.
+480
+• Mechanism of injury: small fragment, bullet with cavity formation, or blast causing indeterminate thrombotic phenomena in the adjacent colonic tissues.
+• Extent of local damage to the surrounding extracolonic tissues, perhaps indicating a high-energy les...
+
+=== Chunk 3671 ===
+Source: 4105_002-ebook.pdf
+Length: 934 chars
+
+32.16.2 right colon
+The right colon is easily mobilized and, in many respects, resembles the small intestine.
+1. Under optimal conditions simple wounds of the right colon can be treated with primary suture; wounds of the ileo-caecal junction by ileo-caecectomy and anastomosis.
+2. In more problematic cases, any repair or suture line can be protected by a decompressive caecostomy. A wide-bore de Pezzer or Foley catheter is placed through the site of the appendix and held in place by a purse-string...
+
+=== Chunk 3672 ===
+Source: 4105_002-ebook.pdf
+Length: 766 chars
+
+32.16.3 Transverse colon
+The transverse colon is the most accessible and mobile part of the organ, but part of it is “hidden” under the omentum.
+1. Small lesions under optimal conditions can be treated by primary suture, with or without a caecostomy.
+2. Large lacerations of the hepatic flexure or proximal third of the transverse colon may be treated by extended right-hemicolectomy and primary ileo-transverse colostomy.
+3. Extensive injuries of the central or distal third of the transverse colon ...
+
+=== Chunk 3673 ===
+Source: 4105_002-ebook.pdf
+Length: 1957 chars
+
+32.16.4 Left colon and intraperitoneal rectum
+The choice between primary repair and diversion is most problematic when dealing with lesions of the sigmoid colon and rectum. The left colon can easily be exteriorized, but adequate mobilization is mandatory to prevent stoma retraction.
+1. Small lesions of the left colon may be sutured or undergo primary resection- anastomosis, but again only under optimal conditions. Otherwise, a protective transverse colostomy or caecostomy is advisable.
+2. In ext...
+
+=== Chunk 3674 ===
+Source: 4105_002-ebook.pdf
+Length: 996 chars
+
+32.16.5 retroperitoneal missile tract
+Any projectile passing through the colon and then into the retroperitoneal soft tissues is bound to carry some contamination with it. The degree of contamination is related to the energy of the missile; a low-energy fragment carries bacteria only into the first centimetre of the track. Like all other low-energy fragment wounds to soft tissue the retroperitoneal track does not require debridement. Antibiotics and the body’s natural defence mechanisms are capa...
+
+=== Chunk 3675 ===
+Source: 4105_002-ebook.pdf
+Length: 863 chars
+
+32.16.6 Complications
+Morbidity is particularly high with combat injuries of the colon. The most frequent and serious causes are infectious in origin, while others involve primarily the diversionary colostomy. They include:
+• leak of an anastomosis or repair leading to faecal fistula and possibly an intra-
+abdominal abscess or diffuse peritonitis;
+• bleeding from an anastomosis;
+• wound infection and dehiscence;
+• peristomal bleeding;
+• retraction of a colostomy stoma;
+• prolapse of a stoma;
+• i...
+
+=== Chunk 3676 ===
+Source: 4105_002-ebook.pdf
+Length: 2218 chars
+
+32.16.7 Colostomy care
+Even a temporary colostomy is psychologically difficult for the patient to accept and, for cultural and social reasons, in some societies even more so. Muslim practice, for example, requires washing (ablutions) before the five daily prayers. Many practitioners worry that the presence of the stoma compromises their cleanliness. “The consensus opinion from Islamic scholars is that [stoma patients] can pray normally, attend mosque and perform the Hajj pilgrimage. Stoma patien...
+
+=== Chunk 3677 ===
+Source: 4105_002-ebook.pdf
+Length: 68 chars
+
+Figure 32.56
+Repair of a perineal wound extending into the anus.
+484...
+
+=== Chunk 3678 ===
+Source: 4105_002-ebook.pdf
+Length: 1458 chars
+
+32.16.8 Colostomy closure
+Traditionally, closure of a colostomy is performed after three months once the patient has fully recovered. Recently, this practice has been called into question. Patients with a double-barrelled or loop colostomy or ileostomy and a relatively minor burden of injury and an uncomplicated recovery can undergo colostomy closure after two to three weeks. Closure before discharge is particularly important in certain contexts of armed conflict where patients may easily be los...
+
+=== Chunk 3679 ===
+Source: 4105_002-ebook.pdf
+Length: 1281 chars
+
+32.17 Pelvis
+Wounds of the pelvis may involve the bony girdle or soft tissues. The important sources of haemorrhage, often fatal, are the iliac vessels and their branches and the presacral venous plexus. Contamination from the gastro-intestinal and urogenital tracts requires diversion and drainage. Wounds of the extraperitoneal viscera are associated with high morbidity because of the frequency of unrecognized injury and the commonly associated vascular damage in a small, enclosed space. Further...
+
+=== Chunk 3680 ===
+Source: 4105_002-ebook.pdf
+Length: 1718 chars
+
+32.17.1 Pelvic fractures
+After projectile injury, unlike after blunt trauma, unstable fractures are quite rare and displacement of the fragments seldom needs reduction. A stable fracture of the pelvic ring requires immobilization for three to four weeks. Occasionally, an unstable fracture may result from primary blast; the posterior sacro-iliac ligaments are torn. Temporary measures include a pelvic binder (a surgical drape is more solid than a bedsheet) centred on the greater trochanters, with ...
+
+=== Chunk 3681 ===
+Source: 4105_002-ebook.pdf
+Length: 816 chars
+
+Figure 32.58
+Extraperitoneal packing: the first pack is placed below the sacro-iliac joint; the second at the middle of the pelvic brim; and the third in the retropubic space just lateral to the bladder. The packing is repeated on the other side.
+P
+.
+N
+485
+WAR SURGERY
+486
+Particular attention should be paid to any injury to the nearby hip joint in conjunction with an abdominal visceral injury. The joint should be considered contaminated and must be explored and treated as an open joint injury an...
+
+=== Chunk 3682 ===
+Source: 4105_002-ebook.pdf
+Length: 1032 chars
+
+32.17.2 Injury to the iliac vessels
+The internal iliac vessels can be ligated. Bleeding from the distal branches can be difficult to control since there is an abundant collateral system; packing may be the only recourse.
+In some patients the source of bleeding may be outside the bony pelvis, and blood flows into the pelvis along the projectile track. Foley catheter tamponade is often successful; otherwise, packing may be the only alternative.
+The common and external iliac arteries should be repa...
+
+=== Chunk 3683 ===
+Source: 4105_002-ebook.pdf
+Length: 2122 chars
+
+32.17.3 sacral venous injury
+Profuse bleeding from the venous plexus subsequent to fracture of the sacrum is very difficult to control: the sectioned veins tend to retract under the bony surface; there are numerous communicating channels; and the pelvis is a confined space. The haemorrhage can be exsanguinating.
+During laparotomy, if the surgeon observes a large and expanding pelvic haematoma and if trauma to the iliac vessels, rectum or urogenital tract is diagnosed or cannot be excluded, then ...
+
+=== Chunk 3684 ===
+Source: 4105_002-ebook.pdf
+Length: 1573 chars
+
+32.17.4 Extraperitoneal rectum and anus
+Wounds of the extraperitoneal rectum and anus are accompanied by a very high rate of concomitant injuries to nearby structures. The resulting faecal contamination of the pelvic areolar tissues may lead to severe infection that can prove fatal. One consequence has been that operative management has long advocated the classic “4D’s”: divert, drain, direct repair, and distal washout.
+As with injuries to the colon, some of these principles have recently been c...
+
+=== Chunk 3685 ===
+Source: 4105_002-ebook.pdf
+Length: 171 chars
+
+Diversion
+A proximal loop or double-barrelled sigmoidostomy is considered to be the most critical part of management. Closure of the distal end ensures complete diversion....
+
+=== Chunk 3686 ===
+Source: 4105_002-ebook.pdf
+Length: 336 chars
+
+Direct repair
+Access to the extraperitoneal rectum within the bony confines of the pelvis is difficult and does not lend itself to reliable repair. Exposure may be easier via the anus, especially for a very low lesion. Repair of a rectal wound should be attempted if at all possible. Unrepaired small wounds heal by secondary intention....
+
+=== Chunk 3687 ===
+Source: 4105_002-ebook.pdf
+Length: 782 chars
+
+Distal washout
+Manual faecal evacuation through the anus followed by irrigation of the bowel distal to the colostomy is appropriate only insofar as it helps to identify and repair the injury. Washing the distal rectum lessens the bacterial burden, but it may also force contaminants into the tissue planes. Therefore, mild pressure such as that from a running intravenous line is best. A large rectal tube may be left in place after anal dilatation, with or without distal washout, to assist in the s...
+
+=== Chunk 3688 ===
+Source: 4105_002-ebook.pdf
+Length: 296 chars
+
+Drainage
+Extensive faecal contamination of the perirectal tissues requires dependent drainage. An incision between the anus and coccyx permits drainage of the presacral space. A debrided perineal wound may be sufficient for adequate drainage. Presacral
+487
+C
+&
+R
+C
+I
+/
+t
+r
+e
+k
+e
+H
+.
+F
+WAR SURGERY...
+
+=== Chunk 3689 ===
+Source: 4105_002-ebook.pdf
+Length: 1173 chars
+
+Figures 32.60.1 and 32.60.2
+Presacral drainage of an extraperitoneal rectal lesion via a transverse incision posterior to the anus. removal of the coccyx may be helpful, depending on the patient’s anatomy.
+Figure 32.61 Some patients require multiple drains.
+488
+drainage may have to be replaced by temporary packing in cases where the venous plexus has been injured.
+N.Papas / ICRC
+N.Papas / ICRC
+Serial debridements of anal and perineal wounds may be necessary; especially if, as is often the case, ...
+
+=== Chunk 3690 ===
+Source: 4105_002-ebook.pdf
+Length: 2195 chars
+
+32.18 Abdominal drains
+The placing of intra-abdominal drains is a contentious topic. A generation ago, surgeons used to implement four-quadrant drainage after most major laparotomies: subhepatic, subsplenic, right paracolic gutter and Douglas pouch. The idea was to prevent the accumulation of any fluids that might lead to a peritoneal abscess. A better understanding of pathophysiology has shown that the presence of a drain, on the contrary, is more likely to result in infection. A drain is a for...
+
+=== Chunk 3691 ===
+Source: 4105_002-ebook.pdf
+Length: 253 chars
+
+Analgesia
+Adequate control of pain is important after major surgery to help combat shock and assist in physiotherapy and ambulation, as well as for the patient’s comfort. Limited resources and combat trauma should not be an excuse for patient suffering....
+
+=== Chunk 3692 ===
+Source: 4105_002-ebook.pdf
+Length: 2598 chars
+
+Physiotherapy
+Physiotherapy and early mobilization of the patient are essential to avoid pulmonary complications, stiffness of joints, wasting of muscles, and deep vein thrombosis. Getting the patient out of bed, and deep breathing and coughing exercises are essential.
+In low-income and some medium-income countries, physiotherapists are far less numerous than nursing staff, if at all present. Furthermore, doctors and nursing staff are often poorly trained in basic patient physiotherapy. Skilled ...
+
+=== Chunk 3693 ===
+Source: 4105_002-ebook.pdf
+Length: 1151 chars
+
+Nutrition
+As a general rule, naso-gastric tubes should be removed as soon as possible and intake of fluids and food by mouth started early. Normal peristalsis of the small intestine occurs within 12 – 24 hours, of the stomach within 24 – 48 hours and of the colon in 3 – 5 days. However, there is no need to wait for full peristaltic activity and the passage of flatus as traditionally taught. A change in the colour of naso-gastric aspirate from green to clear, denoting an absence of bile reflux in...
+
+=== Chunk 3694 ===
+Source: 4105_002-ebook.pdf
+Length: 361 chars
+
+Urinary catheter
+A urinary catheter for monitoring the patient’s fluid balance should be removed as soon as possible to avoid ascending urinary infection, in most cases within 24 hours. In severely injured or dehydrated patients, however, it is wise to keep the catheter longer. After bladder injuries, the catheter should be kept for a week (see Section 33.7)....
+
+=== Chunk 3695 ===
+Source: 4105_002-ebook.pdf
+Length: 416 chars
+
+Incisions and wounds
+Dry dressings of the sutured laparotomy incision need not be changed until removal of sutures. If dressings have become soaked with blood or pus, the wound must be opened and thoroughly inspected. Dressings of excised wounds in the abdominal wall, like all soft-tissue wounds, should be left undisturbed until delayed primary closure.
+489
+WAR SURGERY
+Figure 32.62 Post-operative peritonitis.
+490...
+
+=== Chunk 3696 ===
+Source: 4105_002-ebook.pdf
+Length: 1410 chars
+
+32.20 Post-operative complications
+Complications occur in anywhere between 20 % and 60 % of the patients who have suffered abdominal trauma, depending on the severity of injury and general condition of the patient. The most important life-threatening conditions include continuing or recurrent haemorrhage, missed injuries giving rise to peritonitis or enteric fistulae, and multiple organ system failure and acute respiratory distress syndrome (ARDS).
+Abdominal complications are numerous and many a...
+
+=== Chunk 3697 ===
+Source: 4105_002-ebook.pdf
+Length: 867 chars
+
+Figure 32.63
+Necrotizing fasciitis of the abdominal wall.
+H
+Some complications require immediate surgical intervention; others may be amenable to conservative treatment, such as enteric fistulae. Re-laparotomy for peritonitis is usually the result of a missed injury and carries a high risk of mortality unless performed very early.
+C
+R
+C
+ICRC
+I
+Figures 32.64.1 – 32.64.3
+Mismanaged and neglected patient injured by a bomb explosion three days prior to admission. Multiple superficial lacerations wer...
+
+=== Chunk 3698 ===
+Source: 4105_002-ebook.pdf
+Length: 512 chars
+
+Post-operative fever
+Fever can result from well-known intra- and extra-abdominal causes, such as urinary tract infection, atelectasis or pneumonia, deep vein thrombosis, and sepsis. In countries where malaria is endemic, it is not unusual for the patient to have an acute attack 48 hours post-operatively after severe trauma. Even if a first malaria smear is negative, it may be wise to start malaria treatment preventively. Other endemic diseases such as typhoid fever must also be kept in mind.
+491...
+
+=== Chunk 3699 ===
+Source: 4105_002-ebook.pdf
+Length: 192 chars
+
+Figure 32.A.1
+Oedematous bowel: all too often the result of overzealous resuscitation with crystalloids.
+492
+a
+c
+i
+r
+=
+f
+A
+.
+S
+,
+l
+a
+t
+i
+p
+s
+o
+H
+h
+t
+a
+n
+a
+w
+g
+&
+a
+r
+a
+B
+.
+H
+.
+C
+/
+i
+n
+a
+l
+P
+.
+F...
+
+=== Chunk 3700 ===
+Source: 4105_002-ebook.pdf
+Length: 2935 chars
+
+ANNEX 32. A Abdominal compartment syndrome
+A compartment syndrome may affect any compartment of the body. It especially affects the abdomen after aggressive resuscitation with i.v. crystalloid fluids, which may be unavoidable when faced with a lack of blood for transfusion, and after major manipulation of the tissues, both leading to oedema of the viscera. An additional factor can be the presence of voluminous abdominal packs for tamponade of bleeding. Abdominal compartment syndrome has also bee...
+
+=== Chunk 3701 ===
+Source: 4105_002-ebook.pdf
+Length: 203 chars
+
+Figure 32.A.2
+Measurement of intra-abdominal pressure via the intravesical pressure: indirect method. Height of column of saline from meniscus to symphysis pubis equals bladder pressure in cm of H2O.
+493...
+
+=== Chunk 3702 ===
+Source: 4105_002-ebook.pdf
+Length: 1231 chars
+
+Chapter 33 UROGENITAL TRACT INJURIES
+495
+WAR SURGERY
+496
+33. UROGENITAL TRACT INJURIES 33.1 Introduction 33.2 Wound ballistics 33.3 Epidemiology 33.4 Examination and diagnosis 33.5 Kidneys 33.5.1 Severity of injury 33.5.2 Surgical decision-making 33.5.3 Non-surgical management 33.5.4 Patient preparation, incision, and access 33.5.5 Surgical treatment 33.5.6 Nephrostomy 33.5.7 Nephrectomy 33.5.8 Partial nephrectomy and renorrhaphy 33.5.9 Bilateral renal injuries 33.6 Ureters 33.6.1 Diagnosis 33.6...
+
+=== Chunk 3703 ===
+Source: 4105_002-ebook.pdf
+Length: 273 chars
+
+33.1 Introduction
+The urogenital tract (UGT) is part of the abdomen and pelvis and the examination of the patient for wounds of the UGT is part and parcel of the general abdominal examination. Exploration of the great majority of UGT injuries is by the standard laparotomy....
+
+=== Chunk 3704 ===
+Source: 4105_002-ebook.pdf
+Length: 1348 chars
+
+33.2 Wound ballistics
+The kidney, like all other solid organs, is not elastic and will shatter if subjected to the formation of a temporary cavity. Exposure to an explosion can result in contusion or laceration of the renal parenchyma, the pathology resembling that of blunt trauma. It is usually relatively minor and self-limiting in survivors.
+The urinary bladder, like other hollow organs, reacts differently to a projectile depending on whether it is full or empty. A projectile will simply perfo...
+
+=== Chunk 3705 ===
+Source: 4105_002-ebook.pdf
+Length: 1033 chars
+
+33.3 Epidemiology
+Combat wounds of the urogenital tract are found in only 2 – 4 % of all the wounded and constitute 10 – 15 % of abdominal organ injuries (Table 32.2). Injuries to the kidneys are far more common than those to other parts of the UGT. The wearing of modern body armour, however, decreases the relative incidence of injury to the kidneys and ureters, but increases that of wounds to the lower urinary tract.
+Projectile injuries to the urinary tract are rarely isolated: 75 – 90 % of the...
+
+=== Chunk 3706 ===
+Source: 4105_002-ebook.pdf
+Length: 2663 chars
+
+33.4 Examination and diagnosis
+The abdominal examination as described in Section 32.4.3 includes all the elements of the urogenital tract. Small projectile wounds in the skin folds of the perineum may not be obvious at first glance. Complete examination and ER care of the patient include a rectal and vaginal examination and the placement of a urinary catheter. Proper care in the insertion of the latter is warranted in case of injury to the genitalia and is contraindicated if blood is present at ...
+
+=== Chunk 3707 ===
+Source: 4105_002-ebook.pdf
+Length: 350 chars
+
+33.5 Kidneys
+The main objectives in the management of renal injury are to control bleeding and preserve as much renal tissue as possible, as long as preservation of renal function is compatible with the need to deal with other life-threatening injuries. The preservation of at least 25 % of the renal parenchymal mass is necessary to avoid dialysis.3...
+
+=== Chunk 3708 ===
+Source: 4105_002-ebook.pdf
+Length: 613 chars
+
+33.5.1 severity of injury
+Severe projectile injury to the kidney is manifested by shock that requires immediate abdominal exploration. Most injuries present with a retroperitoneal haematoma and may be classified according to their severity. A simple grading system adapted to ballistic injuries is presented in Figure 33.1. More sophisticated grading systems exist, but are more pertinent to blunt trauma.
+3 Carroll PR, McAninch JW. Operative indications in penetrating renal trauma. J Trauma 1985; 2...
+
+=== Chunk 3709 ===
+Source: 4105_002-ebook.pdf
+Length: 81 chars
+
+Grade A
+Parenchymal contusion or laceration alone without extravasation of urine....
+
+=== Chunk 3710 ===
+Source: 4105_002-ebook.pdf
+Length: 214 chars
+
+Grade B
+Deep laceration involving the calyceal system with extravasation of urine.
+Grade C
+Complete rupture of the kidney.
+Grade D
+Shattered kidney.
+Grade E
+Injury to the vascular pedicle.
+UroGENITAL TrACT INJUrIEs...
+
+=== Chunk 3711 ===
+Source: 4105_002-ebook.pdf
+Length: 103 chars
+
+Figures 33.1.1 – 33.1.5
+Schematic drawings of renal injuries according to severity.
+499
+WAR SURGERY
+500...
+
+=== Chunk 3712 ===
+Source: 4105_002-ebook.pdf
+Length: 1721 chars
+
+33.5.2 surgical decision-making
+Haemorrhage from projectile wounds to the kidney can present in four different ways:4
+• free bleeding into the peritoneal cavity following disruption of Gerota’s fascia;
+• expanding perirenal haematoma;
+• exsanguination into the renal collecting system presenting as haematuria and even with clots in the bladder;
+• stable retroperitoneal haematoma.
+The extent of renal damage is obvious only in the case of a shattered kidney, vascular lesion, or exsanguinating haema...
+
+=== Chunk 3713 ===
+Source: 4105_002-ebook.pdf
+Length: 975 chars
+
+33.5.3 Non-surgical management
+Some patients may suffer small low-energy fragment wounds to the flank or back and present with haematuria and/or a tender renal angle on palpation, but remain in a stable condition without other signs of abdominal injury. IVP generally confirms the isolated and limited renal injury, usually with no extravasation of urine. These injuries are more like stab wounds of the parenchyma and can be treated expectantly.
+Kidney damage must always be suspected after explosiv...
+
+=== Chunk 3714 ===
+Source: 4105_002-ebook.pdf
+Length: 1633 chars
+
+33.5.4 Patient preparation, incision, and access
+The patient should be prepared as for any laparotomy and the standard midline incision employed. The flank incision of elective urological procedures has no place in the emergency treatment of the war trauma patient since intraperitoneal injury cannot be ruled out.
+4 Adapted from Schecter SC, Schecter WP, McAninch JW. Penetrating bilateral renal injuries: principles of management. J Trauma 2009; 67: E25 – E28.
+UroGENITAL TrACT INJUrIEs
+Access to t...
+
+=== Chunk 3715 ===
+Source: 4105_002-ebook.pdf
+Length: 1672 chars
+
+33.5.5 surgical treatment
+Grade A: superficial parenchymal laceration without extravasation of urine A perinephric haematoma of variable size has developed. If the haematoma is small and stable it should be left as it is without opening Gerota’s fascia. Extraperitoneal drainage of the renal area should be established. Later, in the post-operative recovery period, an IVP can be performed.
+Grade B: deep laceration involving calyx/pelvis with extravasation of urine A small to moderate sized haemato...
+
+=== Chunk 3716 ===
+Source: 4105_002-ebook.pdf
+Length: 287 chars
+
+Grade C: complete rupture of the kidney
+This lesion usually presents with a large and expanding haematoma. These injuries may be salvageable by partial nephrectomy, but only if the laceration occurs near a pole of the kidney. Partial nephrectomy and renorrhaphy are specialist techniques...
+
+=== Chunk 3717 ===
+Source: 4105_002-ebook.pdf
+Length: 114 chars
+
+Figure 33.2
+Exposure of the renal vessels medial to the inferior mesenteric vein and anterior to the aorta.
+WW ‘yt...
+
+=== Chunk 3718 ===
+Source: 4105_002-ebook.pdf
+Length: 166 chars
+
+Figure 33.3
+Minor calyceal lesion debrided and repaired by a continuous watertight suture and haemostatic mattress sutures placed over peritoneal or fascial pledgets....
+
+=== Chunk 3719 ===
+Source: 4105_002-ebook.pdf
+Length: 140 chars
+
+Figure 33.4
+Nephrostomy through the renal wound itself; sometimes the only option.
+501
+C
+Papas / ICRC
+P
+.
+N
+C
+Papas / ICRC
+P
+.
+N
+WAR SURGERY...
+
+=== Chunk 3720 ===
+Source: 4105_002-ebook.pdf
+Length: 670 chars
+
+Figure 33.5
+GSW causing complete section of the inferior pole of the left kidney.
+Figure 33.6 The shattered kidney has been removed.
+C
+Papas / ICRC
+P
+.
+N
+Figure 33.7
+Nephrostomy: Cabot’s method through a pyelotomy.
+502
+and hardly ever work out well in the hands of the general surgeon. Most of the time, nephrectomy is the rule. The exceptions are a patient with a single functioning kidney or one suffering bilateral renal injuries (see Section 33.5.9).
+l
+Meckelbaum McGill University Hospital
+a
+t
+i...
+
+=== Chunk 3721 ===
+Source: 4105_002-ebook.pdf
+Length: 401 chars
+
+Grade E: injury to the vascular pedicle
+A pulsatile and expanding haematoma denotes vascular injury. Repair of the vessels can seldom be performed; nephrectomy is usually the outcome, although a temporary shunt may prove useful if the patient does not die of exsanguination first. Only the left renal vein can be ligated with impunity since venous drainage is assured by the gonadal and adrenal veins....
+
+=== Chunk 3722 ===
+Source: 4105_002-ebook.pdf
+Length: 768 chars
+
+33.5.6 Nephrostomy
+Percutaneous nephrostomy is rarely available when working with limited resources and the surgeon must resort to an open nephrostomy.
+Nephrostomy is best performed through the renal pelvis to keep damage to the cortex to a minimum. An incision is made into the pelvis and a finger inserted into the lowest calyx. The renal cortex is then incised over the finger in the bloodless line of Brodel, lying 5 mm behind and parallel to the convex border. An appropriate catheter (Malecot, ...
+
+=== Chunk 3723 ===
+Source: 4105_002-ebook.pdf
+Length: 1379 chars
+
+33.5.7 Nephrectomy
+Nephrectomy is necessary for uncontrollable haemorrhage from a shattered kidney or irretrievable damage to the vascular pedicle. The surgeon must always ensure, by intra-abdominal palpation, the existence of a second kidney that “feels normal”.
+If the patient’s condition permits and the facilities are available, an intra-operative single-dose IVP or i.v. injection of an excretable dye such as methylene blue is of great assistance in determining the status of the other kidney. ...
+
+=== Chunk 3724 ===
+Source: 4105_002-ebook.pdf
+Length: 895 chars
+
+33.5.8 Partial nephrectomy and renorrhaphy
+Partial nephrectomy or renorrhaphy is not a simple operation and has a significant rate of complications such as urinary fistula and infection, often leading to delayed nephrectomy. If the patient is haemodynamically unstable, or the surgeon lacks the experience, it is best to proceed directly with nephrectomy, a technically easier procedure. The exceptions are the patient whose contralateral kidney is absent or where the renal function may be inadequat...
+
+=== Chunk 3725 ===
+Source: 4105_002-ebook.pdf
+Length: 468 chars
+
+Figure 33.8.2
+The sectoral artery to the damaged part of the kidney is clamped and divided. The main vascular pedicle is controlled by a vascular clamp or Rummel tourniquet.
+Debridement-resection is performed by finger- fracture. Meticulous haemostasis is assured by figure-of-eight suture-ligature with 4/0 absorbable suture. The pelvis and calyces should be closed watertight by a continuous 4/0 absorbable suture.
+C
+R
+C
+I
+/
+s
+a
+p
+C
+R
+C
+I
+/
+s
+a
+p
+a
+P
+z
+.
+N
+a
+P
+z
+.
+N...
+
+=== Chunk 3726 ===
+Source: 4105_002-ebook.pdf
+Length: 851 chars
+
+Figure 33.8.4
+The resected surface is compressed with mattress sutures over pledgets.
+The raw surface is covered with any remaining renal capsule or an omental pedicle flap or free peritoneal graft. The urinary flow is drained by means of nephrostomy. Dependent drainage of the kidney bed is instituted extraperitoneally and should not be removed until drainage has ceased.
+503
+WAR SURGERY
+504
+According to some surgeons, Gerota’s fascia should not be opened before the renal vessels have been expose...
+
+=== Chunk 3727 ===
+Source: 4105_002-ebook.pdf
+Length: 1710 chars
+
+33.5.9 Bilateral renal injuries
+Injury to both kidneys is a dilemma and challenge even under the best of circumstances. As mentioned, at least 25 % of the renal parenchymal mass is necessary to avoid dialysis, which is seldom available in low-income countries. Every effort must therefore be expended to preserve at least one-half of one kidney. In a stable patient, an on-table one-shot IVP can prove invaluable, if available. If a damage-control approach is adopted, both kidneys are packed and an ...
+
+=== Chunk 3728 ===
+Source: 4105_002-ebook.pdf
+Length: 2160 chars
+
+33.6.1 Diagnosis
+Injury to the ureters is almost always associated with lesions to other intra-abdominal organs, which are more obvious and take precedence over the ureteric injury. Haematuria is often absent with ureteric injury, whether transection or contusion, and when present is usually microscopic.
+Except in the rare instance of a pre-operative IVP revealing a transected ureter, the diagnosis is never made before exploration. In fact, the diagnosis of a ureteric injury is often missed duri...
+
+=== Chunk 3729 ===
+Source: 4105_002-ebook.pdf
+Length: 939 chars
+
+Figure 33.9
+Direct inspection reveals a small laceration of the ureter surrounded by haematoma.
+It should be noted that significant devascularization of the ureter can also be caused by iatrogenic crush from a haemostatic clamp or ischaemic injury from excessive dissection during hurried exploration of a haematoma.
+If the haematoma precludes good visualization of the ureter an injection of methylene blue or indigo carmine, either intravenous or directly into the pelvis of the kidney through a fi...
+
+=== Chunk 3730 ===
+Source: 4105_002-ebook.pdf
+Length: 1081 chars
+
+33.6.2 surgical decision-making
+The method of repair or diversion for the ureter depends on the haemodynamic stability of the patient since the urgency of the associated injuries usually predominates over the ureteric lesion. Transection and contusion of the ureter necessitate different approaches, as does the level of injury.
+Transection of a ureter requires some form of repair or urinary diversion. Successful methods for ureteric repair are based on the level of the injury.
+• Proximal third: u...
+
+=== Chunk 3731 ===
+Source: 4105_002-ebook.pdf
+Length: 1922 chars
+
+Proximal or middle third: abdominal ureter
+Resection-anastomosis of the damaged segment (uretero-ureterostomy) is the preferred option for repair of injuries to the proximal and middle third of the ureter. Partial lacerations of the ureter have been treated with direct suture repair over a ureteric stent. However, the rate of stenosis is high and it is preferable to transform the partial laceration into a full transection through healthy tissue and perform a formal anastomosis.
+1. Any mobilizati...
+
+=== Chunk 3732 ===
+Source: 4105_002-ebook.pdf
+Length: 1487 chars
+
+Figure 33.12
+Catheter stenting of ureteric repair. The catheter is passed out through a cystostomy. Dependent external drainage of the site has been instituted.
+—_
+T-tube ureteric drainage through a ureterostomy in healthy ureteric tissue.
+UroGENITAL TrACT INJUrIEs
+In cases of extensive damage and tissue loss precluding a direct anastomosis, the available options include:
+• liberation of the kidney from Gerota’s fascia to mobilize it distally in order to gain several extra centimetres, nephropex...
+
+=== Chunk 3733 ===
+Source: 4105_002-ebook.pdf
+Length: 766 chars
+
+Distal third: pelvic ureter
+Uretero-ureterostomy deep in the confined limits of the pelvis is technically challenging. Therefore, a distal lesion is best treated by re-implantation of the ureter into the bladder over a stent: uretero-neocystostomy.
+The distal end of the sectioned ureter is ligated and the proximal end is debrided and spatulated. A cystostomy is performed in the anterior wall and, working from inside the bladder, the proximal ureter is then pulled through a submucosal tunnel in t...
+
+=== Chunk 3734 ===
+Source: 4105_002-ebook.pdf
+Length: 291 chars
+
+Figure 33.14.2
+A horizontal incision is made 4 cm below the highest point of the bladder.
+A tunnel is created in the detrusor muscle and submucosa of the posterior wall.
+C
+Papas /ICRC
+P
+.
+N
+Figure 33.14.3 The ureter is pulled through the tunnel.
+Figure 33.13 Transverse uretero-ureterostomy....
+
+=== Chunk 3735 ===
+Source: 4105_002-ebook.pdf
+Length: 229 chars
+
+Figures 33.14.1 – 33.14.5
+Uretero-neocystostomy: re-implantation of the ureter in the bladder.
+507
+C
+Papas /ICRC
+P
+.
+N
+WAR SURGERY
+Figures 33.15.1 – 33.15.4 Cysto-ureteroplasty: Boari flap.
+508
+C
+Papas /ICRC
+C
+Papas /ICRC
+.
+.
+N
+N...
+
+=== Chunk 3736 ===
+Source: 4105_002-ebook.pdf
+Length: 1183 chars
+
+Figure 33.14.5
+Working from inside the bladder, the spatulated ureteric end is sutured to the bladder mucosa over a stent with 4/0 interrupted absorbable sutures, with the knots excluded from the mucosal surface. From the outside, the ureter is also sutured to the bladder wall.
+The cystostomy is closed at right angles to the incision and the ureteric stent externalized through it or through a separate incision. The top of the bladder is stitched to the psoas muscle. Division of the contralateral...
+
+=== Chunk 3737 ===
+Source: 4105_002-ebook.pdf
+Length: 320 chars
+
+Figure 33.15.1
+The end of the ureter has been debrided and a stent inserted. A long flap is mobilized from the anterior bladder wall with its base on the same side as the injured ureter.
+Figure 33.15.2 The mobilized flap is pulled up to the ureter.
+C
+Papas /ICRC
+R
+C
+I
+/
+s
+a
+p
+a
+P
+C
+Papas /ICRC
+R
+C
+I
+/
+s
+a
+p
+a
+P
+.
+.
+N
+N...
+
+=== Chunk 3738 ===
+Source: 4105_002-ebook.pdf
+Length: 822 chars
+
+Figure 33.15.4
+The ureter is pulled through a submucosal tunnel and anastomosed to the bladder mucosa over the stent.
+The incision is closed with a continuous suture and the stent brought out either through it, or through a separate incision to the bladder. The Boari flap has been pulled up above the common iliac vessels and sutured to the psoas muscle: psoas hitch.
+UroGENITAL TrACT INJUrIEs
+If neither of the above options is possible then the injured ureter should be implanted in the contralate...
+
+=== Chunk 3739 ===
+Source: 4105_002-ebook.pdf
+Length: 1466 chars
+
+33.6.4 surgical treatment of contused ureter
+Several approaches are proposed in the case of contusion of the ureter, depending on the extent and mechanism of injury. Untreated contusions often lead to complications such as delayed necrosis and urinary fistula or ureteric stricture, particularly after high- energy missile wounds.
+1. Careful and expectant observation of very mild contusion: the area around the ureter is simply drained, and perhaps wrapped in a sleeve of omentum or peritoneum. The ...
+
+=== Chunk 3740 ===
+Source: 4105_002-ebook.pdf
+Length: 1790 chars
+
+33.6.5 Delayed diagnosis and complications
+Missed diagnosis of ureteric injury is usually the result of an overlooked transection that presents with a urine leak immediately in the post-operative period. Otherwise, delay in clinical presentation is due to a complication. This may reveal itself relatively early after a leak of a primary anastomosis. On the other hand, a urine leak or ureteric stricture may present after several days or even weeks in the event of devascularization of a ureteric se...
+
+=== Chunk 3741 ===
+Source: 4105_002-ebook.pdf
+Length: 160 chars
+
+33.7 Urinary bladder
+Wounds of the bladder may be intra- or extraperitoneal and are commonly associated with lesions of other pelvic and intraperitoneal organs....
+
+=== Chunk 3742 ===
+Source: 4105_002-ebook.pdf
+Length: 1430 chars
+
+33.7.1 Diagnosis
+A high degree of suspicion is warranted when a projectile trajectory involves the pelvis, buttocks or perineum. Like for any wound of the abdomen and pelvis, rectal and vaginal examinations should be performed. In males, special note is taken of the position and integrity of the prostate.
+Bladder injury should be suspected, but is not proven, if the passage of a catheter does not produce urine. Other possibilities include a patient who is oliguric or anuric or has a rupture of t...
+
+=== Chunk 3743 ===
+Source: 4105_002-ebook.pdf
+Length: 1994 chars
+
+33.7.2 surgical treatment
+Minor extraperitoneal lesions that are difficult to reach can be treated with an in-dwelling catheter and drainage of the prevesical retropubic space for a period of one week to ten days.
+All other bladder wounds should be excised judiciously and sutured in two layers with an absorbable suture: a first running suture with minimal bites of the mucosa and generous bites of the submucosa; a second interrupted layer of the detrusor muscle, which should include the peritoneu...
+
+=== Chunk 3744 ===
+Source: 4105_002-ebook.pdf
+Length: 466 chars
+
+33.8 Prostate and posterior urethra
+Projectile wounds of the prostate invariably involve the posterior urethra. Surgically, it is therefore best to consider them together, and separate from the anterior urethra and penis. Injury may involve the prostatic urethra at the bladder neck or the membranous urethra at the urogenital diaphragm. Blunt injury to the prostate and urethra is much more common than missile wounds, especially following a fracture of the pelvis....
+
+=== Chunk 3745 ===
+Source: 4105_002-ebook.pdf
+Length: 991 chars
+
+33.8.1 Diagnosis and Er care
+Injury to the prostate and urethra in itself is never life- threatening; associated pelvic or abdominal injuries, however, can be.
+Suspicious signs of injury include an inability to pass urine, bleeding at the external meatus, and a nearby projectile trajectory. A rectal examination often shows nothing more than a swelling due to haematoma and oedema. Sometimes a floating prostate can be palpated high in the pelvis: always an indication for immediate surgical interve...
+
+=== Chunk 3746 ===
+Source: 4105_002-ebook.pdf
+Length: 1040 chars
+
+33.8.2 surgical treatment
+The best approach to the prostate and posterior urethra is through the bladder. A missile wound at the bladder neck requires debridement of the prostate and urethra and an in-dwelling catheter.
+Injury to the membranous urethra at the urogenital diaphragm typically mimics the shearing injury of blunt trauma following a fracture of the pelvis. The urethra is sectioned and the bladder and prostate float upwards; continuity of the urinary tract is disrupted. Following debri...
+
+=== Chunk 3747 ===
+Source: 4105_002-ebook.pdf
+Length: 187 chars
+
+Figures 33.16.1 – 33.16.4
+Steps illustrating the “railroading” (chemin-de- fer) procedure utilized for repair of a lesion of the posterior urethra.
+512
+C
+Papas /ICRC
+C
+Papas /ICRC
+.
+.
+N
+N...
+
+=== Chunk 3748 ===
+Source: 4105_002-ebook.pdf
+Length: 375 chars
+
+Figure 33.16.2
+A urinary catheter (CH 16 – 18) is inserted through the penis. A second catheter (CH 20 – 24) is passed through a suprapubic cystostomy into the urethral orifice in the bladder.
+Both catheters are retrieved in the prevesical space and their tips are secured together with a ligature passed through the drainage openings.
+C
+Papas /ICRC
+t +
+C
+Papas /ICRC
+.
+.
+N
+N...
+
+=== Chunk 3749 ===
+Source: 4105_002-ebook.pdf
+Length: 1599 chars
+
+Figure 33.16.4
+Traction is exerted on the bladder catheter to guide the penile catheter into the bladder and the balloon is inflated. A stout non-absorbable thread is tied to its tip and brought out through the abdominal wall. If the catheter slips out or gets blocked the thread can be used to guide a new catheter into the bladder past the site of the lesion.
+The bladder catheter is inflated and brought out as a suprapubic cystostomy. A drain is placed in the prevesical space.
+Suture of the sect...
+
+=== Chunk 3750 ===
+Source: 4105_002-ebook.pdf
+Length: 828 chars
+
+33.8.3 sequelae and complications
+The most important complications are infection and anastomotic stricture, the latter requiring dilatation and perhaps further reconstructive surgery. Extension of an infection follows any injured fascial planes and can involve the perineum and medial thighs, or up into the abdomen and chest. Infection may result in urethro-cutaneous fistulae or peri-urethral diverticulae and, more rarely but dangerously, necrotizing fasciitis (Fournier’s gangrene; see Section 13...
+
+=== Chunk 3751 ===
+Source: 4105_002-ebook.pdf
+Length: 177 chars
+
+33.9 Male external genitalia and anterior urethra
+Male genital injuries are not life-threatening but can create long-term sexual and psychological damage and altered self-image....
+
+=== Chunk 3752 ===
+Source: 4105_002-ebook.pdf
+Length: 816 chars
+
+33.9.1 Diagnosis
+Lesions of the external genitalia are usually obvious. However, adequate physical examination may be difficult because of swelling and/or pain, especially in penile wounds where blood and urine may extravasate along fascial plains into the scrotum, perineum, or up into the pubic area. On the other hand, even a small projectile perforation of the scrotum may overlie complete disorganization of the testes. Primary blast injury with ruptured testes is a recognized entity. Pattern 1...
+
+=== Chunk 3753 ===
+Source: 4105_002-ebook.pdf
+Length: 423 chars
+
+33.9.2 surgical treatment
+Most wounds of the scrotum and penis may be closed primarily after debridement; one of the exceptions to the rule. A dependent drain is indicated because of the likelihood of haematoma collection and should be removed after 24 – 48 hours. Injuries due to anti-personnel blast mines and IED should always be left open for delayed primary closure, usually 48 hours in this case, no matter how minor....
+
+=== Chunk 3754 ===
+Source: 4105_002-ebook.pdf
+Length: 578 chars
+
+Anterior urethra
+Treatment of wounds in the anterior urethra depends on the patient’s general condition and on the extent of tissue loss. In a haemodynamically stable patient, immediate treatment can be undertaken. If a damage-control approach is chosen because of associated injuries, delayed primary operation is undertaken later when oedema and inflammation have subsided sufficiently. Deferred treatment usually consists of reconstructive surgery three months later.
+C
+2
+R
+C
+I
+/
+e
+n
+i
+d
+d
+e
+r
+s
+a...
+
+=== Chunk 3755 ===
+Source: 4105_002-ebook.pdf
+Length: 3012 chars
+
+Figure 33.17.1
+The patient suffered a GSW to the scrotum and penis. The bullet was a ricochet and fragmented but had already lost most of its kinetic energy.
+Figure 33.17.2 X-ray showing the presence of the deformed bullet.
+Figure 33.17.3
+Urethrogram demonstrating a partial laceration of the anterior penile urethra.
+513
+513
+C
+2
+R
+C
+I
+/
+3 6
+a
+t
+i
+k
+O
+.
+K
+2 é 2
+/
+a
+t
+h
+a
+B
+i
+e
+k
+e
+T
+.
+A
+WAR SURGERY
+Figures 33.18.1 - 33.18.4
+Figure 33.18.1
+Marsupialization of the injured segment with suture of the ...
+
+=== Chunk 3756 ===
+Source: 4105_002-ebook.pdf
+Length: 156 chars
+
+Figures 33.19.1 – 33.19.5
+Repair of a lesion to the bulb of the penile urethra.
+C.Pacitti / ICRC
+C.Pacitti / ICRC
+C
+R
+C
+I
+/
+i
+t
+t
+i
+c
+a
+P
+.
+C
+Figure 33.19.1...
+
+=== Chunk 3757 ===
+Source: 4105_002-ebook.pdf
+Length: 321 chars
+
+Figure 33.19.2
+Figure 33.19.3
+GSW to the bulb of the penile urethra approached through the perineum.
+Control of the proximal (indicated by the tip of the urinary catheter) and distal segments.
+The two segments can be approximated without tension.
+C
+2
+R
+C
+I
+/
+i
+z
+t
+t
+i
+c
+a
+P
+.
+C
+C.Pacitti ICRC
+R
+C
+I
+/
+i
+t
+t
+i
+c
+a
+P
+.
+C
+C...
+
+=== Chunk 3758 ===
+Source: 4105_002-ebook.pdf
+Length: 134 chars
+
+Figure 33.19.4
+The repaired urethra will be covered with a tag from the bulbocavernosus.
+Figure 33.19.5 Closure of the perineal wound....
+
+=== Chunk 3759 ===
+Source: 4105_002-ebook.pdf
+Length: 909 chars
+
+Penis
+Concomitant urethral injury usually overshadows wounds in the penis. Debridement of the urethral and penile wound involves exploration and repair of the corpora cavernosa and corpus spongiosum. These structures can be repaired primarily after minimal debridement because of their excellent blood supply. The tunica albuginea of the corpora cavernosa in the flaccid state is 2 mm thick and easily holds sutures (interrupted 3/0 synthetic absorbable). The aim is to re-establish the anatomy as mu...
+
+=== Chunk 3760 ===
+Source: 4105_002-ebook.pdf
+Length: 745 chars
+
+Scrotum and its contents
+Wounds of the scrotum require exploration. A severely disorganized testis requires orchidectomy. Incomplete lesions are debrided conservatively: extruded or necrotic seminiferous tubules are excised and the testis irrigated copiously. The tunica albuginea must always be closed carefully with a running 4/0 absorbable suture to prevent the development of a fistula. Bilateral lesions are common: in up to 33 % of the patients with testicular injuries in the experience of ICR...
+
+=== Chunk 3761 ===
+Source: 4105_002-ebook.pdf
+Length: 1142 chars
+
+Figure 33.20.2
+GSW to the scrotum. The patient arrived several days after injury.
+One testicle was totally disorganized and required orchidectomy. The wound was left open owing to the late presentation of the patient.
+C
+&
+R
+C
+I
+/
+e
+n
+i
+d
+d
+z
+e
+r
+s
+a
+C
+Nasreddine/ ICRC
+R
+C
+I
+/
+e
+n
+i
+d
+d
+e
+r
+s
+a
+N
+N
+.
+.
+H
+H
+Figure 33.20.3 The wound at DPC.
+Figure 33.20.4 Closure of the skin over a corrugated rubber drain.
+Injuries to the epididymis or vas deferens are debrided and the structures ligated; and the c...
+
+=== Chunk 3762 ===
+Source: 4105_002-ebook.pdf
+Length: 339 chars
+
+33.10 Female genitalia and urethra
+Projectile lesions of the female genitalia may involve any of the other pelvic structures. The external genitalia are well vascularized and considerable haemorrhage may ensue after trauma. However, as with the male genitalia, other more serious injuries usually take precedence.
+UroGENITAL TrACT INJUrIEs...
+
+=== Chunk 3763 ===
+Source: 4105_002-ebook.pdf
+Length: 580 chars
+
+33.10.1 Diagnosis
+Injuries may involve the vulva or vagina. Vaginal lesions may be simple or complex and implicate the urethra, bladder, ano-rectum, or urogenital diaphragm.
+Meticulous vaginal examination using a speculum should be performed whenever blood or haematoma is noted in the vagina. This should not be confused with menstruation or overlooked because it is thought to be menstrual in origin. Often, vaginal examination is only possible under general anaesthesia. A rectal examination is al...
+
+=== Chunk 3764 ===
+Source: 4105_002-ebook.pdf
+Length: 1762 chars
+
+33.10.2 surgical treatment
+Large GSW wound of the perineum involving the vagina and anus.
+The non-pregnant uterus is a simple but very dense muscle amenable to suturing. A large disruptive laceration may require hysterectomy, subtotal if the cervix is not injured. Minor injuries to the ovaries or fallopian tubes may be sutured; otherwise, oophorectomy or ligature is performed.
+Debridement of simple injuries of the vulva and vagina should be conservative and immediate primary closure may be pract...
+
+=== Chunk 3765 ===
+Source: 4105_002-ebook.pdf
+Length: 622 chars
+
+33.11 Perineum
+Anti-personnel blast mines and improvised explosive devices involve significant blast effects that often affect the perineal soft tissues as well as the nearby organs. Once life-threatening injuries have been taken care of, meticulous debridement of the soft tissues is imperative but may have to wait for resuscitation and stabilization of the patient: a damage control approach. Later reconstruction of the soft tissue loss, often massive, can be a challenge and commonly requires th...
+
+=== Chunk 3766 ===
+Source: 4105_002-ebook.pdf
+Length: 638 chars
+
+33.12 Post-operative care
+Analgesia and antibiotics are given according to protocol. Usually the associated abdominal or pelvic injuries determine the rest of post-operative care.
+The protocol for the management of an in-dwelling urinary catheter – whether urethral or vesical – after repair of some part of the urinary tract is similar to that for spinal cord injury patients (see Section 36.9.1). A urine flow of at least 1,000 ml per 24 hours is required to prevent catheter encrustation and infec...
+
+=== Chunk 3767 ===
+Source: 4105_002-ebook.pdf
+Length: 425 chars
+
+Chapter 34 AUTOTRANSFUSION
+519
+WAR SURGERY
+520
+34. AUTOTRANSFUSION
+34.1 Rationale of autotransfusion 34.2 Methodology of autotransfusion 34.3 Pathophysiological changes 34.4 Indications 34.5 Practical autotransfusion methods 34.5.1 Thorax 34.5.2 Abdomen and limbs 34.5.3 Enteric contamination 34.5.4 Filters 34.5.5 Use of anticoagulants 34.6 Complications and risks 521 522 523 524 525 525 527 528 529 529 529
+AUToTrANsFUsIoN...
+
+=== Chunk 3768 ===
+Source: 4105_002-ebook.pdf
+Length: 2733 chars
+
+34.1 rationale of autotransfusion
+The idea of replacing lost blood has been present in medical thinking for centuries. In the pre-modern era, attempts were made to transfuse blood from animals to humans and from humans to humans, usually with disastrous results. Autotransfusion itself is an old idea, invented and used successfully for the first time in 1818 by James Blundell.1
+“All too often one sees several pints of blood thrown away from the body cavity of patients who are bleeding to death. I...
+
+=== Chunk 3769 ===
+Source: 4105_002-ebook.pdf
+Length: 221 chars
+
+Figure 34.1
+Autotransfusion has been “rediscovered” on many occasions by surgeons working in resource-poor settings: Dr Ahmed Mohamed Ahmed “Tajir”, head surgeon, Keysaney Hospital, Somali Red Crescent Society, Mogadishu....
+
+=== Chunk 3770 ===
+Source: 4105_002-ebook.pdf
+Length: 978 chars
+
+Figure 34.2
+Process and methodology for autotransfusion.
+522
+For surgeons involved in the care of people wounded in armed conflict with its constraints and precarious circumstances, simple procedures for autotransfusion can help save lives. Many simple methods of recuperating and using unprocessed shed blood when dealing with trauma and obstetric patients have been described by various authors and used by ICRC surgical teams.
+As frequently mentioned in this manual, working with limited resources...
+
+=== Chunk 3771 ===
+Source: 4105_002-ebook.pdf
+Length: 1399 chars
+
+34.2 Methodology of autotransfusion
+Various methods and devices have been described for performing autotransfusion, from very simple and improvised to highly-sophisticated commercial ones. They all have certain points in common, nonetheless, and the process is a standard one. Figure 34.2 describes the generic methodology.
+Blood collection  Open  system  Closed system  Without device  With device  Filter  Reservoir with/without  anticoagulant  Unprocessed blood  Processed blood  washed & centrifu...
+
+=== Chunk 3772 ===
+Source: 4105_002-ebook.pdf
+Length: 1150 chars
+
+Figure 34.3.2
+Closed suction method of blood collection. Gauze compress is wrapped around the suction nozzle as a first filtration.
+Unprocessed blood is crude shed blood. Processed blood is aspirated by the suction machine into a special apparatus that adds an anticoagulant, then filters, washes and centrifuges the blood, creating a concentrate of red blood cells with a haematocrit of 50 % to 70 %. Almost all plasma proteins, including clotting factors and platelets are removed in the washing pr...
+
+=== Chunk 3773 ===
+Source: 4105_002-ebook.pdf
+Length: 2530 chars
+
+34.3 Pathophysiological changes
+Shed blood differs in composition from circulating intravascular blood. The act of collection also alters its composition.
+The vast majority of studies of the pathophysiological changes in autotransfused blood concern processed blood. It is not always possible to determine which changes are due to the autotransfusion itself and which to the process of washing and suspension. Some may be common to all forms of autotransfusion; others may depend on which technique i...
+
+=== Chunk 3774 ===
+Source: 4105_002-ebook.pdf
+Length: 3842 chars
+
+34.4 Indications
+Autotransfusion must be placed in the context of a correct surgical approach to the haemorrhaging patient, which includes early control of bleeding and meticulous haemostasis. The first and foremost indication is the need for an emergency source of blood in acute and massive haemorrhage that is clinically diagnosed pre-operatively. This usually concerns a body cavity, either the thorax or the abdomen. A haematocrit value of less than 35 % on admission and expected crystalloid re...
+
+=== Chunk 3775 ===
+Source: 4105_002-ebook.pdf
+Length: 493 chars
+
+34.5 Practical autotransfusion methods
+The best apparatus for conditions of limited resources should be simple, safe and inexpensive, not require a power supply, and demand minimal personnel. This manual will therefore only describe the elementary methods that do not require cell-salvage technology. The efficiency of autotransfusion greatly depends on the ability to recover blood quickly in a useable form. The necessary materials must therefore be prepared beforehand and be ready for use....
+
+=== Chunk 3776 ===
+Source: 4105_002-ebook.pdf
+Length: 809 chars
+
+34.5.1 Thorax
+The most obvious and most common example of an autotransfusion system is an intercostal chest tube connected to some sort of collecting device.
+In extreme cases of massive haemothorax (more than 2,000 ml) no time should be lost. The simplest method is the chest-bottle inversion technique. A sterile chest bottle containing 100 ml of normal saline collects the blood and is then disconnected and inverted to become the administration set. It is replaced by another chest bottle to colle...
+
+=== Chunk 3777 ===
+Source: 4105_002-ebook.pdf
+Length: 85 chars
+
+Figure 34.4
+Collection of blood through a chest tube using a syringe.
+525
+WAR SURGERY...
+
+=== Chunk 3778 ===
+Source: 4105_002-ebook.pdf
+Length: 125 chars
+
+Figure 34.5
+Collection and filtration of blood from pleural cavity into a sterile glass bottle for immediate autotransfusion....
+
+=== Chunk 3779 ===
+Source: 4105_002-ebook.pdf
+Length: 569 chars
+
+Figure 34.6
+Filtration of blood and collection in a transfusion blood bag: an alternative system in the absence of appropriate bottles.5
+526
+With less urgency and under conditions more amenable to preparation, a double filtration system is preferable. The blood is first filtered through 6 – 8 layers of sterile gauze lining a sterilized metal funnel and collected directly from the chest drain into a sterile plastic or glass bottle. After the bottle is filled, the rubber stopper is inserted and th...
+
+=== Chunk 3780 ===
+Source: 4105_002-ebook.pdf
+Length: 2330 chars
+
+34.5.2 Abdomen and limbs
+Contrary to the chest where one filtration of collected blood is sufficient in extreme situations because most of the blood is fluid and micro-particulate matter is at a minimum, shed blood from the abdomen or limbs must be filtered twice.
+The open method of scooping up blood into a basin or kidney dish with a soup ladle is simple, can easily be improvised, and causes little haemolysis. However, it is inefficient, time-consuming and awkward. When faced with an abdomen fu...
+
+=== Chunk 3781 ===
+Source: 4105_002-ebook.pdf
+Length: 396 chars
+
+Figures 34.7.1 – 34.7.4
+Collection by sterile soup ladle and filtration into a glass bottle through several layers of gauze compress.
+527
+WAR SURGERY
+528
+l
+KN. Joshi -K.B, Shrestha /Lumbini Zonal Hospital, Nepal
+a
+p
+e
+N
+,
+l
+a
+t
+i
+p
+s
+o
+H
+l
+a
+n
+o
+Z
+i
+n
+i
+b
+m
+u
+L
+/
+a
+h
+t
+s
+e
+r
+h
+S
+.
+B
+.
+K
+–
+i
+h
+s
+o
+l
+a
+p
+e
+N
+,
+l
+a
+t
+i
+p
+s
+/Lumbini Zonal Hos
+/
+a
+h
+t
+s
+e
+r
+h
+S
+.
+B
+.
+K
+–
+i
+h
+s
+o
+J
+J
+.
+.
+N
+N
+.
+.
+K
+K...
+
+=== Chunk 3782 ===
+Source: 4105_002-ebook.pdf
+Length: 349 chars
+
+Figure 34.8.1
+The necessary kit for an alternative method of blood filtration and collection.
+Figure 34.8.2 Collection of blood using a gallipot.
+l
+a
+p
+e
+N
+,
+l
+a
+t
+i
+p
+s
+o
+H
+l
+a
+n
+o
+Z
+N
+i
+n
+i
+b
+m
+u
+L
+/
+a
+£ &
+h
+t
+s
+e
+r
+h
+S
+.
+B
+.
+K
+–
+i
+h
+s
+8
+o
+J
+l
+a
+p
+e
+N
+,
+l
+a
+t
+i
+p
+s
+o
+H
+l
+a
+n
+o
+Z
+i
+n
+i
+b
+m
+u
+L
+/
+a
+h
+t
+s
+e
+r
+h
+S
+.
+B
+.
+K
+–
+i
+h
+s
+o
+J
+.
+.
+N
+N
+.
+.
+K
+K...
+
+=== Chunk 3783 ===
+Source: 4105_002-ebook.pdf
+Length: 414 chars
+
+Figure 34.8.3
+Figure 34.8.4
+Filtration of blood through layers of gauze compress and its recuperation by means of a large syringe.
+Filtered blood being packed into ordinary transfusion bags.
+For the limbs, the basin or kidney dish is held in such a way as to recuperate as much blood as possible. The blood is then poured through a sterile metal funnel lined with 6 – 8 layers of sterile gauze into a glass bottle....
+
+=== Chunk 3784 ===
+Source: 4105_002-ebook.pdf
+Length: 1631 chars
+
+34.5.3 Enteric contamination
+These methods of blood recuperation from the abdomen are simple enough when only parenchymatous organs are injured; the amount of bile in shed blood has proven to be of little consequence. The question of the suitability of autotransfusion arises in cases of contamination with enteric contents: gastric juice, chyme or faeces. The gross particulate matter of undigested food and faeces must obviously be removed, but also micro-particulates since it is apparently they t...
+
+=== Chunk 3785 ===
+Source: 4105_002-ebook.pdf
+Length: 359 chars
+
+34.5.4 Filters
+The simplest method is to use several layers of sterile surgical compresses followed by the in-line 150 – 200 μm filter that is incorporated in a standard blood transfusion set. It has proved to be sufficient in most settings. The use of a special 20 or 40 micron filter has not proved necessary and it probably removes any remaining platelets....
+
+=== Chunk 3786 ===
+Source: 4105_002-ebook.pdf
+Length: 677 chars
+
+34.5.5 Use of anticoagulants
+The different manufactured devices that process blood obligatorily use various anticoagulants, which are then removed during the washing process. The need for anticoagulants when using non-processed blood has given rise to controversy. This is largely due to the anecdotal evidence concerning their use, which contrasts considerably with the controlled studies of cell-salvage technology.
+It is generally conceded that for blood recuperated from a haemothorax anticoagula...
+
+=== Chunk 3787 ===
+Source: 4105_002-ebook.pdf
+Length: 291 chars
+
+34.6 Complications and risks
+As in all surgical procedures there are possible complications when using autotransfusion. Many are related to the quantity of blood re-infused and are more prevalent with processed blood; they also exist with the transfusion of large quantities of banked blood....
+
+=== Chunk 3788 ===
+Source: 4105_002-ebook.pdf
+Length: 416 chars
+
+Febrile reaction
+About half the patients undergoing autotransfusion suffer a transient febrile reaction in the first days post-operatively. Apart from the normal reaction seen in trauma patients with absorption of haemolysed blood from their wounds, there may be an activation of the complement system and induction of an inflammatory state. This is self-limiting and, clinically, has proved to be of no consequence....
+
+=== Chunk 3789 ===
+Source: 4105_002-ebook.pdf
+Length: 931 chars
+
+Coagulopathy
+Theoretically, a combination of consumptive coagulopathy, fibrinolysis, and platelet dysfunction is the greatest danger when resorting to autotransfusion. In addition, the re-infusion of the activated by-products of the coagulation cascade along with micro-particulate matter may trigger the development of disseminated intravascular coagulation, just as with the re-infusion of trophoblastic by-products.
+529
+WAR SURGERY
+530
+However, as discussed in Chapter 18, there are many factors i...
+
+=== Chunk 3790 ===
+Source: 4105_002-ebook.pdf
+Length: 640 chars
+
+Sepsis
+War wounds, as is known, are contaminated and dirty and therefore the administration of antibiotics should be routine practice. The wound cannot be sterilized by the surgeon, nor can the blood, but the body has its own defence mechanisms. Studies have shown that processed cell-salvaged blood is not sterile even in the absence of enteric contamination, and yet this has not resulted in an increase in infectious complications. Clinically, infection after autotransfusion of unprocessed blood ...
+
+=== Chunk 3791 ===
+Source: 4105_002-ebook.pdf
+Length: 907 chars
+
+Renal failure
+Increased haemolysis liberates large quantities of free haemoglobin with haemoglobinuria. This is especially a risk with the autotransfusion of blood more than six hours old and grossly haemolysed blood. However, there is no proof of clinically relevant complications and the haemoglobinuria usually clears within a few hours.
+Blood collected from the abdomen may be contaminated with activated pancreatic enzymes in the case of combined injury to the pancreas and intestine or a duoden...
+
+=== Chunk 3792 ===
+Source: 4105_002-ebook.pdf
+Length: 460 chars
+
+Pulmonary hypertension and ARDS
+Theoretically, the possibility of microemboli of platelet aggregates and particulate debris is greatest with blood recuperated from the abdomen and the limbs. In the latter, fractures may also liberate fat globules. However, microaggregates also exist in banked blood – the older the blood, the more there are – and there is no supporting evidence for the occurrence of fat embolism syndrome from the process of autotransfusion....
+
+=== Chunk 3793 ===
+Source: 4105_002-ebook.pdf
+Length: 659 chars
+
+Multiple organ failure
+With greater knowledge of the mediators and intermediary products of the inflammatory cascade has come greater awareness of the possible complications that lead to multiple organ failure. These considerations are highly theoretical apart from specific subsets of patients who suffer not only severe trauma but are treated with massive transfusion protocols of blood components and large quantities of i.v. crystalloids. In the setting of the patient suffering massive haemorrha...
+
+=== Chunk 3794 ===
+Source: 4105_002-ebook.pdf
+Length: 1307 chars
+
+WAR WOUNDS IN PREGNANT WOMEN
+533
+WAR SURGERY
+534
+35. WAR WOUNDS IN PREGNANT WOMEN
+35.1 Introduction 35.2 Wound ballistics 35.3 Epidemiology and international humanitarian law 35.3.1 Women facing war and international humanitarian law 35.4 Clinical picture and emergency room care of the mother 35.4.1 The differences of pregnancy 35.4.2 Airway 35.4.3 Breathing 35.4.4 Circulation 35.4.5 Further examination and investigations 35.5 Examination of the foetus 35.6 Surgical decision-making 35.6.1 Extra-...
+
+=== Chunk 3795 ===
+Source: 4105_002-ebook.pdf
+Length: 593 chars
+
+35.1 Introduction
+When presented with a pregnant woman suffering from trauma the attending physician faces two patients: the woman and the foetus. The basic principles of patient management still apply, but the anatomic and physiological changes of pregnancy must be taken into consideration. In addition, foetal monitoring complicates observation of the mother. Resuscitation of the mother takes priority; this is also best for the foetus. Pregnancy, nonetheless, creates particular diagnostic and e...
+
+=== Chunk 3796 ===
+Source: 4105_002-ebook.pdf
+Length: 1411 chars
+
+35.2 Wound ballistics
+The non-gravid uterus is a very dense muscle enclosing a very thin, even virtual, cavity and reacts to projectile injury as any muscle. Alone amongst the organs of the body, the gravid uterus changes in ballistic character over time; the myometrium becomes thinner and the uterus fills with amniotic fluid, the foetus and placenta. The increased size of the full-term uterus fills the abdominal cavity, thus permitting the full effect of wound channel cavity formation to be exp...
+
+=== Chunk 3797 ===
+Source: 4105_002-ebook.pdf
+Length: 3288 chars
+
+35.3 Epidemiology and international humanitarian law
+Although the number of civilian victims of contemporary warfare since World War II has increased, exceedingly little epidemiological information exists on the incidence of the wounding of pregnant women during armed conflict.
+While in most traditional societies women continue working in the fields right up to the moment of childbirth, the tendency in general and especially in urbanized societies is to progressively limit women’s mobility as th...
+
+=== Chunk 3798 ===
+Source: 4105_002-ebook.pdf
+Length: 2064 chars
+
+35.3.1 Women facing war and international humanitarian law
+Projectile and blast trauma are not the only dangers that women face during armed conflict. In many wars throughout history women have often been the targets and victims of sexual violence; i.e. rape as a method of warfare waged against an entire society. For some combatants, the insemination of women is an “aim” of war. In certain modern conflicts, rape has reached epidemic proportions.
+The ICRC and others have studied the implications ...
+
+=== Chunk 3799 ===
+Source: 4105_002-ebook.pdf
+Length: 575 chars
+
+35.4 Clinical picture and emergency room care of the mother
+Every female patient of childbearing age should be considered as possibly pregnant until proven otherwise. It is important to recognize the existence of a pregnancy and its significance for trauma management:
+• same priorities for the mother as for all trauma patients according to the ABCDE paradigm;
+• differences from other trauma patients, according to the physiologic changes due to pregnancy;
+• assessment of the clinical condition of...
+
+=== Chunk 3800 ===
+Source: 4105_002-ebook.pdf
+Length: 121 chars
+
+Figure 35.1
+A pregnant women may suffer any injury. The same priorities apply as for all trauma patients.
+a
+l
+a
+l
+e
+D
+.
+M...
+
+=== Chunk 3801 ===
+Source: 4105_002-ebook.pdf
+Length: 1159 chars
+
+35.4.1 The differences of pregnancy
+Pregnancy produces profound anatomic and physiologic changes; virtually every organ system is affected. The reader should refer to standard textbooks for a full discussion of these changes. Only a short résumé of a few clinically relevant points is given here.
+The anatomic changes in pregnancy, apart from the large mass present in the peritoneal cavity and the displacement upwards of the intestines and diaphragm, include a greatly increased utero-pelvic blood ...
+
+=== Chunk 3802 ===
+Source: 4105_002-ebook.pdf
+Length: 462 chars
+
+35.4.2 Airway
+Here, there are relatively few changes with pregnancy, except for an increased risk of regurgitation and aspiration due to the decrease in the tone of the oesophageal sphincter and delayed gastric emptying due to the increased abdominal volume. It has been noted that endotracheal intubation has a much higher failure rate in late pregnancy owing to oedema of the larynx, with a significant risk of regurgitation and inhalation.
+537
+WAR SURGERY
+538...
+
+=== Chunk 3803 ===
+Source: 4105_002-ebook.pdf
+Length: 556 chars
+
+35.4.3 Breathing
+The respiratory rate remains unchanged in pregnancy, but physiological hyperventilation occurs because of an increase in tidal volume of 40 %. This results in a slight respiratory alkalosis. In late pregnancy, there is diminished chest amplitude due to the rising of the diaphragm with increased intra-abdominal volume. Clinically, great care must be taken in placing a chest tube. Supplemental oxygen is important to avoid hypoxia, particularly deleterious to the foetus.
+Take great...
+
+=== Chunk 3804 ===
+Source: 4105_002-ebook.pdf
+Length: 1563 chars
+
+35.4.4 Circulation
+The patient’s circulation probably shows the greatest physiological changes. Up to a gestational age of 34 weeks there is a steady increase in blood volume with more plasma relative to red blood cells, leading to the physiologic anaemia of pregnancy (haematocrit 31 – 35 %). Cardiac output is increased by 30 % during the first trimester by a slight tachycardia of 10 – 15 beats/minute. This is important in the evaluation of the haemodynamic status of the wounded patient.
+Young, ...
+
+=== Chunk 3805 ===
+Source: 4105_002-ebook.pdf
+Length: 1531 chars
+
+35.4.5 Further examination and investigations
+The full obstetric history of the patient must be taken.
+Increased uterine activity is common following trauma, but can also be a sign of premature labour or abruptio placentae. Its occurrence a few days after the injury may also indicate infection. Any uterine contractions or tenderness, abdominal pain or cramping should be sought.
+Vaginal examination assesses the state of the cervix and the presence of blood or amniotic fluid; combined with abdomin...
+
+=== Chunk 3806 ===
+Source: 4105_002-ebook.pdf
+Length: 632 chars
+
+Figures 35.2.1 and 35.2.2
+X-rays showing an intra-abdominal but extra-uterine bullet.
+A naso-gastric tube and urinary catheter are placed in preparation for any surgery. Routine laboratory examinations are performed.
+Also of particular importance is the mother’s blood group if she is Rh-negative and the foetus Rh-positive. The problem of iso-immunization is not specific to trauma patients, but trauma may theoretically increase the possibility if the foetus is injured. In this case, the mother sh...
+
+=== Chunk 3807 ===
+Source: 4105_002-ebook.pdf
+Length: 1840 chars
+
+35.5 Examination of the foetus
+Once life-threatening injuries in the mother have been addressed, the condition of the foetus and maturity of the pregnancy must be properly dealt with. This includes determining the foetus’ age and its chances of extra-uterine survival and, therefore, the opportune moment for performing a Caesarean section should it prove necessary.
+All patients with a viable foetus should be monitored for six hours after all diagnostic and initial therapeutic procedures have been...
+
+=== Chunk 3808 ===
+Source: 4105_002-ebook.pdf
+Length: 232 chars
+
+35.6 surgical decision-making
+Survival of the mother has priority because she may have other dependent children and, of course, the potential for future pregnancies.
+Survival of the mother has priority over survival of   the foetus....
+
+=== Chunk 3809 ===
+Source: 4105_002-ebook.pdf
+Length: 247 chars
+
+35.6.1 Extra-abdominal wounds
+In a pregnant patient these injuries should be managed as for a non-pregnant patient, taking into proper consideration the physiological changes of pregnancy and the adverse effects of shock and hypoxia on the foetus....
+
+=== Chunk 3810 ===
+Source: 4105_002-ebook.pdf
+Length: 1109 chars
+
+35.6.2 Abdominal injuries
+There are definite indications for surgery in pregnant patients as for others suffering penetrating wounds of the abdomen. Obvious internal haemorrhage or peritoneal irritation and wounds above the level of the uterine fundus call for laparotomy. However, if the entrance wound is below the level of the uterine fundus and there are no clinical signs warranting laparotomy or significant pelvic injury, the patient may be observed and managed non-surgically, especially if t...
+
+=== Chunk 3811 ===
+Source: 4105_002-ebook.pdf
+Length: 1318 chars
+
+Indications for emergency Caesarean section
+Normal labour often occurs shortly after surgery for other injuries if the patient is at term. While even minor maternal trauma increases the rate of spontaneous abortion and stillbirth, early pregnancy often continues unaltered.
+WAr WoUNDs IN PrEGNANT WoMEN
+A dead or injured foetus is not an indication for Caesarean section; the foetus will usually abort spontaneously within a few days. If specialized obstetrical care is available, delivery can be has...
+
+=== Chunk 3812 ===
+Source: 4105_002-ebook.pdf
+Length: 396 chars
+
+Perimortem Caesarean section
+A pregnant woman in the throes of death from abdominal or extra-abdominal trauma should be prepared for Caesarean section if the foetus is still viable and close to term. The operation should be performed preferably before death or at least within 5 minutes of death. Exceptionally, short open cardiac massage can be employed if necessary until delivery of the child....
+
+=== Chunk 3813 ===
+Source: 4105_002-ebook.pdf
+Length: 368 chars
+
+35.7 surgery of the abdomen
+To explore the abdomen the surgeon may retract or pull and push or pack away the uterus without risk to the foetus or placenta. The one manoeuvre to be avoided is the rotation of the uterus on its axis, which may compromise its circulation by distorting the uterine vessels and can injure the low uterine segment during the third trimester....
+
+=== Chunk 3814 ===
+Source: 4105_002-ebook.pdf
+Length: 1336 chars
+
+35.7.1 Injury to the uterus itself
+Small wounds of the uterus that do not themselves compromise the possibility of subsequent vaginal delivery may be debrided and sutured primarily. As with all hollow organs, inspection for an exit wound is warranted, although in most low-kinetic energy lesions the projectile is retained within the uterus.
+Large wounds should be debrided and sutured in layers as with a CS. The extent of the wound, the penetration or not of the amniotic pouch, and the gestational...
+
+=== Chunk 3815 ===
+Source: 4105_002-ebook.pdf
+Length: 487 chars
+
+35.7.2 Injury to other organs
+In most cases, injuries will be to the intestines that have been pushed up into the upper abdomen. Surgical treatment proceeds as usual. Problems may arise with surgical access to injured structures deep in the pelvis. Terminating the pregnancy by Caesarean section, or even in extreme cases emergency hysterectomy, may be necessary to gain adequate exposure, especially if the mother’s life is in danger from exsanguinating haemorrhage.
+541
+WAR SURGERY
+542...
+
+=== Chunk 3816 ===
+Source: 4105_002-ebook.pdf
+Length: 643 chars
+
+35.7.3 Abdominal closure
+Closure of the abdomen is standard. There are damage-control situations, however, where packing has been utilized for temporary control of bleeding or where zealous resuscitation has resulted in oedema of the intestines to such an extent that closure is not possible while maintaining an intact pregnancy. Temporary abdominal closure of the skin only may be accomplished without compromising normal labour and vaginal delivery, even if subsequently the patient is not able to...
+
+=== Chunk 3817 ===
+Source: 4105_002-ebook.pdf
+Length: 642 chars
+
+35.7.4 The foetus
+Caesarean section increases blood loss and causes a uterine scar that greatly augments the risk of rupture during a subsequent pregnancy. Thus, vaginal delivery is preferable, even within a few hours of laparotomy and always when the foetus is dead, providing there are no maternal indications for a CS.
+As mentioned, injury to the uterus does not prevent vaginal delivery of a healthy infant. For a dead foetus, delivery may await the onset of spontaneous labour or it may be induc...
+
+=== Chunk 3818 ===
+Source: 4105_002-ebook.pdf
+Length: 420 chars
+
+35.8 Post-operative care
+There is an increased risk of both deep venous thrombosis and pulmonary embolism during pregnancy. Passive or active means of prevention should be instituted in compliance with local practice. The highest risk is during the immediate post-partum period.
+The rest of post-operative or post-partum nursing care and physiotherapy are the same as for other abdominal injuries and Caesarean sections....
+
+=== Chunk 3819 ===
+Source: 4105_002-ebook.pdf
+Length: 47 chars
+
+Part E SPINE
+545
+WAR SURGERY
+546
+E. SPINE
+SPINE...
+
+=== Chunk 3820 ===
+Source: 4105_002-ebook.pdf
+Length: 1421 chars
+
+Figure E.1
+Rehabilitation of spinal-injury patients.
+548
+N
+Constantine MOTIVATION
+O
+I
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+A
+V
+I
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+O
+M
+/
+e
+n
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+a
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+o
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+.
+D
+The patient and family must assume responsibility for the nursing and physiotherapy tasks involved as early as possible in-hospital and continue to do so on a long-term basis. Patient hygiene is a central concern. This includes washing of the body, care of the genitalia and bowel, and clean and dry bedclothes. Maintenance of nutrition, prevention of infectious complicat...
+
+=== Chunk 3821 ===
+Source: 4105_002-ebook.pdf
+Length: 1711 chars
+
+Home-care team
+In some countries, specialized centres for SCI patients exist and even vocational training workshops and micro-credit programmes. Few low-income societies, however, have fully-fledged programmes for training and social reintegration. These then depend on local initiative at district or village level. Hospital staff are usually well-respected in the community and, therefore, have an important role to play in instigating these initiatives, including the organization of a home-care t...
+
+=== Chunk 3822 ===
+Source: 4105_002-ebook.pdf
+Length: 1694 chars
+
+36.1 Wound ballistics
+The cervical spine is located deep in the tissues, just about in the centre of the neck, which has a rather small diameter in any direction. Its primary characteristic is its mobility, which allows a reaction to any temporary cavity formation. The thoracic spine is more superficial and more stable owing to the rigidity of the rib cage. The lumbar spine has less mobility than the cervical but more than the thoracic and is located deep within the tissues but, since the spinal...
+
+=== Chunk 3823 ===
+Source: 4105_002-ebook.pdf
+Length: 160 chars
+
+Figure 36.3
+The vertebral body is hit and a strong impulse is propagated to the spinal cord.
+Anterior    Middle    Posterior column  column  column
+C
+IcRC
+R
+C
+I...
+
+=== Chunk 3824 ===
+Source: 4105_002-ebook.pdf
+Length: 2878 chars
+
+Figure 36.4
+Mechanical stability of the vertebral column: 3-column theory (Denis )2
+Anterior column = anterior longitudinal ligament, anterior ½ vertebral body, anterior annulus fibrosus
+Middle column = posterior ½ vertebral body, posterior annulus fibrosus, posterior longitudinal ligament
+Posterior column = neural arch, supraspinous ligament, interspinous ligament, ligamentum flavum, facet capsule
+Instability requires damage to all 3 columns or to 2 columns plus rotation causing joint dislocati...
+
+=== Chunk 3825 ===
+Source: 4105_002-ebook.pdf
+Length: 2394 chars
+
+36.2 Epidemiology
+Reports of war wounds to the vertebral column and spinal cord are relatively rare because most cases are included under injuries to the head and neck, thorax or abdomen. A review of 11 military studies totalling 782 patients with spinal injuries found the cervical spine was the site of injury in 23 % of patients, the thoracic in 41 %, and the lumbo-sacral in 36 %.3 Fifty percent suffered complete spinal injury.
+One study comes from a specialized centre in Croatia that admitted ...
+
+=== Chunk 3826 ===
+Source: 4105_002-ebook.pdf
+Length: 3148 chars
+
+36.3 Pathophysiology
+As with all trauma, hypoxia is the major cause of deterioration in the patient’s condition, especially of the CNS. Tissue hypoxia of the spinal cord may result from general hypoxia, injury to the vessels of the cord (including microvascular damage due to blast), or compression by oedema.
+Lesions to the spinal cord may be anatomic (laceration or crush, which may be complete or incomplete and cause permanent damage) or physiological: a form of concussion neurapraxia, which is ...
+
+=== Chunk 3827 ===
+Source: 4105_002-ebook.pdf
+Length: 1100 chars
+
+36.3.1 “Spinal shock”
+“Spinal shock” is that period of usually 48 – 72 hours, and rarely up to two weeks, when there is complete absence of any cord function below the level of injury. It ceases when the cord resumes some function. It is a neurological phenomenon and not a “true” shock in the haemodynamic sense and should be distinguished from neurogenic shock, which does affect the circulation.
+Spinal shock: a neurological event characterized by areflexia, flaccidity, anaesthesia, and autonomic...
+
+=== Chunk 3828 ===
+Source: 4105_002-ebook.pdf
+Length: 1299 chars
+
+36.3.2 Neurogenic shock: autonomic nervous system dysfunction
+A lesion of the cervical cord causes sympathetic denervation (traumatic sympathectomy): sympathetic control of the cardiovascular system is lost while the parasympathetic is maintained. Thus there is an initial haemodynamic neurogenic shock due to the loss of peripheral vasoconstriction leading to pooling of blood in the peripheral veins. The parasympathetic predominance results in bradycardia, rather than the tachycardia of haemorrha...
+
+=== Chunk 3829 ===
+Source: 4105_002-ebook.pdf
+Length: 689 chars
+
+36.4 Clinical picture and examination
+Myotome spinal level Muscle activity C3 – C4 Diaphragm C5 Elbow flexion C6 Wrist extension C7 Elbow extension C8 Finger flexion (middle finger) T1 Abduction of fifth finger T6 – T12 Abdominal muscles L2 Hip flexion L3 Knee extension
+INJURIES OF THE VERTEBRAL COLUMN AND SPINAL CORD
+Myotome spinal level  Muscle activity  L4  Ankle dorsiflexion  L5  Dorsiflexion great toe  S1  Ankle plantar flexion  S4 – S5  Voluntary anal sphincter contraction
+Table 36.1 Key s...
+
+=== Chunk 3830 ===
+Source: 4105_002-ebook.pdf
+Length: 2490 chars
+
+Figure 36.5
+Dermatome spinal sensory levels.
+Between 50 and 60 % of the patients suffering spinal cord injury also have important lesions in other vital organs of the neck, thorax, and/or abdomen. Injury to the vertebral artery is always a risk in cases of trauma to the cervical spine. The picture can be complicated, however, by a high spinal injury causing neurogenic shock in addition to haemorrhagic shock. The priorities remain airway, breathing, and circulation.
+All patients require examinati...
+
+=== Chunk 3831 ===
+Source: 4105_002-ebook.pdf
+Length: 1590 chars
+
+36.4.1 Complete examination
+A complete examination includes not only the observation of entry and exit wounds but also a careful palpation of the spinous processes for any swelling and induration, localized pain and tenderness, crepitus, bruising or haematoma over the vertebral column. Induration is easier to feel than deformity of the spine. Bilateral sensory and motor functions and the testing of reflexes must be complete and repeated and noted in the patient’s file.
+A thorough neurological ex...
+
+=== Chunk 3832 ===
+Source: 4105_002-ebook.pdf
+Length: 2017 chars
+
+36.4.2 Prognosis and re-examination
+The outcome of spinal injury is closely related to the initial neurological deficit. Concussion of the cord is temporary. With a complete lesion, often no improvement can be expected. With an incomplete lesion, the end result is unpredictable. There is always a certain degree of spinal shock with conduction block and localized oedema immediately after injury and time should be allowed for this to resolve. Thus, even a complete lesion may clinically “improve” b...
+
+=== Chunk 3833 ===
+Source: 4105_002-ebook.pdf
+Length: 302 chars
+
+36.4.3 Radiographic investigation
+X-ray investigation shows any bony pathology and any retained projectiles. A standard series of radiographs includes two views of the injured section of the spine. The lateral cervical shot should show the top of vertebral body T1.
+C
+2
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+
+=== Chunk 3834 ===
+Source: 4105_002-ebook.pdf
+Length: 117 chars
+
+Figures 36.7.1 and 36.7.2
+Projectile injury results in definitive but limited spinal cord damage.
+.
+F
+559
+WAR SURGERY...
+
+=== Chunk 3835 ===
+Source: 4105_002-ebook.pdf
+Length: 568 chars
+
+Figures 36.8.1 and 36.8.2
+Multiple fragments and a difficult radiological diagnosis. Clinically the patient is paraplegic.
+Figures 36.9.1 and 36.9.2
+Another difficult radiological diagnosis in a clinically paraplegic patient.
+560
+It is not only difficult to obtain these views properly, but they can be difficult to interpret. The surgeon must rely on clinical findings primarily; X-rays only help to confirm the diagnosis and define the pathology. Violation of the vertebral canal with impingement o...
+
+=== Chunk 3836 ===
+Source: 4105_002-ebook.pdf
+Length: 3169 chars
+
+36.5 Emergency room management
+Paralysed patients are often low on the evacuation priority list and will frequently reach hospital later than the average. They are also low on the hospital priority list during triage of mass casualties. Priority goes to diagnosing any life-threatening injuries implicating the airway, breathing or circulation, which may cause the surgeon to overlook injury to the spinal cord.
+“Do no (further) harm”: handle the patient carefully. However, with projectile spinal in...
+
+=== Chunk 3837 ===
+Source: 4105_002-ebook.pdf
+Length: 1998 chars
+
+36.5.1 Stabilization of the vertebral column
+Projectile wounds rarely cause instability of the vertebral architecture. Nevertheless, while adequate and relevant immobilization procedures should be undertaken when handling the patient, the rigidity of immobilization required after blunt injury, where the possibility of further damage to an incomplete lesion of the cord exists, is not truly relevant or necessary. Especially with cervical injuries, the “over-use” of cervical collars has sometimes b...
+
+=== Chunk 3838 ===
+Source: 4105_002-ebook.pdf
+Length: 1179 chars
+
+36.6 Surgical decision-making
+There is much controversy concerning decompressive laminectomy and its indications in the acute phase for the management of penetrating spinal cord injury. In specialist centres with well-trained staff the results are contradictory in terms of any improvement, even in the case of incomplete spinal lesions. For the general surgeon working with limited resources and with little or no experience of spinal surgery, this pathology calls for conservative treatment: soft t...
+
+=== Chunk 3839 ===
+Source: 4105_002-ebook.pdf
+Length: 2307 chars
+
+36.6.1 Indications for surgery
+Nonetheless, there are several indications for surgery that require less than a full laminectomy, and are within the capacities of the general surgeon.
+1. A large wound leaking CSF requires debridement, removal of obvious and accessible missile and bone fragments, irrigation, and closure of the spinal dura, with a fascial graft if necessary. The exposed cord is handled as little as possible. The soft tissues are left open for delayed primary closure.
+2. A transperi...
+
+=== Chunk 3840 ===
+Source: 4105_002-ebook.pdf
+Length: 369 chars
+
+36.6.2 Medical care
+Whichever treatment modality is decided, conservative or operative, antibiotics should be administered as per protocol for at least 10 days. This is especially important for patients with abdominal injuries where the projectile has passed through the colon. Vertebral injuries can be quite painful and adequate attention should be paid to analgesia....
+
+=== Chunk 3841 ===
+Source: 4105_002-ebook.pdf
+Length: 740 chars
+
+36.7 Organization of further management
+Whether surgery is performed or not, the general management of the spinal cord patient goes through several phases:
+• acute stage of spinal shock;
+• medium-term hospital care; and
+• long-term home care.
+The basis for further management is good nursing, physiotherapy, and support of the patient’s morale. The quality and sophistication of care to be continued at home upon discharge depend on the availability and dedication of hospital staff and a home-care t...
+
+=== Chunk 3842 ===
+Source: 4105_002-ebook.pdf
+Length: 1085 chars
+
+Figure 36.10
+The implementation of certain basic measures (prevention of bedsores, bladder care, etc.) must begin immediately on admission during the phase of acute spinal shock. Various adaptations are then implemented in the mid- to longer-term care of the patient depending on the facilities available.
+Maintaining patient morale is of the utmost importance.
+Long-term home care must be planned from the outset. In situations where no specialized centre is available, the patient, family and frien...
+
+=== Chunk 3843 ===
+Source: 4105_002-ebook.pdf
+Length: 329 chars
+
+36.8 Skin care
+The most immediate concern in patient care is pressure ischaemia of the skin due to the weight of the body. The anaesthetized skin feels no discomfort and the patient
+9 King M, ed. Primary Surgery, Volume Two: Trauma. Oxford: Oxford University Press; 1987.
+563
+C
+¥
+R
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+I
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+n
+n
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+£ g 2
+m
+l
+e
+s
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+a
+H
+.
+V
+WAR SURGERY...
+
+=== Chunk 3844 ===
+Source: 4105_002-ebook.pdf
+Length: 854 chars
+
+Figures 36.11.1 and 36.11.2
+Twelve-year old paraplegic patient whose pressure sores were improving upon discharge. She returned to hospital after two weeks owing to lack of family home care.
+564
+does not move or shift the body to relieve pressure points. The ischaemia develops rapidly into necrosis; the skin breaks down and ulcerates, creating a bedsore.
+The prevention of decubitus ulcers begins at admission and entails preparation of a special bed and frequent change of position of the patient....
+
+=== Chunk 3845 ===
+Source: 4105_002-ebook.pdf
+Length: 1803 chars
+
+36.8.1 Change of position
+The patient’s position must be changed every two hours. A simple notice to this effect should be placed over the patient’s bed, mentioning the new position: front, back, left side, right side. At least two persons are required to change the patient’s position properly; with an unstable vertebral column three are necessary. With time, the patient is able to help in this procedure.
+Pressure sores can be avoided by vigilant nursing care. The patient must be repositioned ev...
+
+=== Chunk 3846 ===
+Source: 4105_002-ebook.pdf
+Length: 186 chars
+
+Figures 36.12.2 – 36.12.5
+Most common areas affected by pressure sores: sacrum and back, trochanter, patella, malleoli and heels.
+V
+M
+C
+V.Hasselmann / ICRC
+ono /ek
+C
+\V.Hasselmann / ICRC...
+
+=== Chunk 3847 ===
+Source: 4105_002-ebook.pdf
+Length: 868 chars
+
+36.9 Care of the bladder
+After decubitus ulcers, the greatest problem facing the patient with spinal cord injury is bladder training and the prevention of urinary tract infection: renal failure is a big killer of SCI patients.
+Several measures definitely decrease the incidence of infection and deterioration of renal function: fluid input of at least three litres a day; keeping the urine bag below the level of the bladder; and keeping a closed drainage system closed by using a disposable bag and ...
+
+=== Chunk 3848 ===
+Source: 4105_002-ebook.pdf
+Length: 616 chars
+
+36.9.1 In-dwelling urinary catheter
+There are no bladder contractions while the patient is still in a stage of spinal shock. The most common procedure is to employ an in-dwelling urinary catheter during this entire period. The best and least irritant are silicone catheters; if not available then the latex catheter should be changed every 7 days. The catheter is passed using sterile precautions. Secretions at the urethral meatus are gently cleaned with soap and water on a daily basis. Early remov...
+
+=== Chunk 3849 ===
+Source: 4105_002-ebook.pdf
+Length: 1285 chars
+
+36.9.2 Intermittent catheterization
+Alternatively, a better but more labour-intensive approach is to perform regular intermittent catheterization (IC) from the beginning, once resuscitation has ended. The preferred method is sterile intermittent catheterization (SIC) using disposable Nelaton-type catheters. If sufficient quantities are not available, the catheter can be resterilized by boiling before each use, i.e. clean intermittent catheterization (CIC), which has apparently more or less the s...
+
+=== Chunk 3850 ===
+Source: 4105_002-ebook.pdf
+Length: 1165 chars
+
+36.9.3 Spastic or flaccid bladder?
+Once the spinal shock has worn off, the anatomic level and nature of the neurogenic bladder – spastic or flaccid – determines further patient management. This applies to the medium-term in hospital, as well as to long-term home care. A suitable routine must be instituted and learnt by patient and family for an appropriate length of time in hospital, before patient discharge.
+A suprasacral injury results in spontaneous bladder contractions (spastic bladder) and ...
+
+=== Chunk 3851 ===
+Source: 4105_002-ebook.pdf
+Length: 238 chars
+
+36.9.4 Testing bladder tone
+Three simple tests can be used to establish bladder tone: spastic or flaccid. They do not require any sophisticated apparatus and provide useful information as to the best way to stimulate the bladder to empty....
+
+=== Chunk 3852 ===
+Source: 4105_002-ebook.pdf
+Length: 571 chars
+
+1. Anal tonus
+The external anal sphincter has the same nerve roots (S2 – S4) as the external bladder sphincter. Response to stimulation of the anal sphincter suggests that the bladder sphincter has some function. In a flaccid bladder, there is no sphincter function and the anal and bulbocavernosus reflexes are absent.
+On PR, a contraction of the anal sphincter indicates some degree of bladder sphincter function and most probably a spastic bladder. In a flaccid bladder, the sphincter is patulous ...
+
+=== Chunk 3853 ===
+Source: 4105_002-ebook.pdf
+Length: 635 chars
+
+2. Ice water test
+Introduction of 100 ml of sterile water at 4° C into the bladder with the catheter balloon deflated gives some indication of detrusor muscle function. Expulsion of the catheter by detrusor contraction in response to the cold water indicates a spastic bladder. If the catheter remains inside, the patient has a flaccid bladder.
+INJURIES OF THE VERTEBRAL COLUMN AND SPINAL CORD
+One hundred ml of sterile water at 4° C is introduced into the bladder and the catheter is left with the b...
+
+=== Chunk 3854 ===
+Source: 4105_002-ebook.pdf
+Length: 922 chars
+
+3. Cysto-manometry
+This test measures intravesical pressure changes in response to stimuli to determine the most effective way to empty the bladder; for example, suprapubic (Credé manoeuvre) or diaphragmatic pressure (Valsalva manoeuvre). Cysto-manometry is described in Annex 36.A.
+This is a test to measure intravesical pressure changes in response to increased filling of the bladder. The response helps differentiate a spastic from a flaccid bladder and then used to determine the most effective ...
+
+=== Chunk 3855 ===
+Source: 4105_002-ebook.pdf
+Length: 596 chars
+
+36.9.5 Medium to long-term bladder management
+When the diagnosis of spastic or flaccid bladder has been established, the patient and the family are consulted about the various methods of continuing urine drainage. There is no single “perfect” regime for long-term care and various compromises must be made. Whichever method is most relevant and acceptable to the context of the patient and family depends on their cooperation and understanding of what is required. The agreed method is instituted whi...
+
+=== Chunk 3856 ===
+Source: 4105_002-ebook.pdf
+Length: 389 chars
+
+Flaccid bladder
+There are several options.
+1. Clean intermittent catheterization, which is the preferred method.
+2. Credé or Valsalva manoeuvre in addition to a local micturition reflex, which is however often inadequate to fully empty the bladder.
+In-dwelling urethral catheter, which is open to infectious complications.
+3.
+4. Suprapubic catheterization; the most prone to complications....
+
+=== Chunk 3857 ===
+Source: 4105_002-ebook.pdf
+Length: 1054 chars
+
+Spastic bladder
+In a patient with a spastic bladder some degree of detrusor contractions occurs. They may be spontaneous or provoked by stimulation of the inner thigh or the genitals. The contractions are usually insufficient, however, to fully evacuate the bladder and the patient must perform an added manoeuvre, either Credé or Valsalva. Detrusor- sphincter dyssynergia may require surgical sphincterotomy to remove the resistance to outflow.
+There are also several options available.
+1. Reflex au...
+
+=== Chunk 3858 ===
+Source: 4105_002-ebook.pdf
+Length: 485 chars
+
+36.9.6 Positioning of a catheter
+To help prevent a urethral fistula in men, the penis should be attached to the patient’s abdomen by a gauze bandage, thus avoiding internal pressure on the peno-scrotal angle. This is especially important during long-term bladder management. In women, the catheter should be strapped to the thigh so that it lies in a direct line from the bladder outwards.
+567
+C
+&
+R
+C
+I
+2
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+e
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+o
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+D
+.
+F
+WAR SURGERY
+568
+C
+Papas /ICRC
+C
+Papas /ICRC
+P
+P
+.
+.
+N
+N...
+
+=== Chunk 3859 ===
+Source: 4105_002-ebook.pdf
+Length: 156 chars
+
+Figure 36.14.1
+Figure 36.14.2
+Proper positioning of catheter and urine bag and fixation of the penis.
+Proper positioning of the urinary catheter in a woman....
+
+=== Chunk 3860 ===
+Source: 4105_002-ebook.pdf
+Length: 1822 chars
+
+36.10 Nutrition and care of the bowels
+As mentioned, an extreme catabolic state intervenes and the patient loses a disproportionate amount of body mass after spinal injury. Once the patient begins oral feeding, nutrition must be kept up and the patient weighed and the haemoglobin checked regularly. Patient depression is an important instigating and complicating factor that affects the wish to feed oneself adequately, defeating efforts to establish a proper nutritional status.
+An H2-receptor anta...
+
+=== Chunk 3861 ===
+Source: 4105_002-ebook.pdf
+Length: 1022 chars
+
+36.11 Physiotherapy and mobilization
+Physiotherapy should commence immediately and is an intrinsic part of nursing care. Each change of position of the patient in the acute phase should involve breathing exercises and passive movement of the major joints through the full range of flexion and extension. The objectives are to prevent respiratory complications and flexion contractures. Basic physiotherapy helps prevent atelectasis and hypostatic pneumonia and improves peripheral circulation. It is ...
+
+=== Chunk 3862 ===
+Source: 4105_002-ebook.pdf
+Length: 395 chars
+
+Figure 36.15
+Importance of training: exercising to over- develop the torso and upper limbs is essential.
+.
+V
+Once consolidation of the vertebral fracture and better bladder control have been achieved, the patient may be mobilized to the standing position using posterior plaster-of-Paris splints, followed by gait training with parallel bars, a walking frame, crutches, or simple brace orthoses....
+
+=== Chunk 3863 ===
+Source: 4105_002-ebook.pdf
+Length: 924 chars
+
+Figure 36.16
+Fitting polypropylene posterior walking splints.
+C
+2
+R
+C
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+V.Hasselmann / ICRC
+V.Hasselmann / ICRC
+Figures 36.17.1 and 36.17.2 Gait training with parallel bars and a walking frame.
+V
+569
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+R
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+C
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+e
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+o
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+e
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+.
+F
+WAR SURGERY
+Some patients remain confined to a wheelchair. Measures must be implemented here as well to prevent pressure sores. The patient should begin using the wheelchair only one or two hours a day, then gradually increase the time in the chair, and be taught to...
+
+=== Chunk 3864 ===
+Source: 4105_002-ebook.pdf
+Length: 743 chars
+
+36.12 Complications
+The SCI patient is prone to multiple complications over time. These include:
+• atelectasis and pneumonia;
+• decubitus ulcers;
+• urinary tract infection and calculi;
+• malnourishment and chronic constipation;
+• osteoporosis and fractures, and heterotopic ossification: the deposition of bone in
+joints causing stiffness and fusion;
+• autonomic hyperreflexia, which constitutes a medical emergency;
+• spasticity of the muscles, often painful;
+• deep vein thrombosis.
+Prevention by r...
+
+=== Chunk 3865 ===
+Source: 4105_002-ebook.pdf
+Length: 2608 chars
+
+36.12.1 Treatment of established decubitus ulcer
+An established decubitus ulcer gives off a foul-smelling discharge, which is highly irritant to the intact skin surrounding the ulcer. The patient’s morale is essential and a stinking sore does nothing to help.
+The treatment of established pressure sores includes:
+• avoiding local pressure on the sore;
+• adapting the patient’s position in bed accordingly;
+• no sheepskin contact because of the danger of infection;
+• use of a mattress with suitably ...
+
+=== Chunk 3866 ===
+Source: 4105_002-ebook.pdf
+Length: 1448 chars
+
+Further surgery
+Large pressure ulcers may require appropriate rotational flaps for closure. No flap should be fashioned before the wound area is clean; this may include removing any necrotic bone. For pressure sores over the ischiatic prominences, typical of the SCI patient spending long hours in the sitting position, a useful tip to prevent recurrence is to surgically flatten the bony prominences.
+The atrophy of the gluteal muscles usually provides a large amount of loose skin that can be mobil...
+
+=== Chunk 3867 ===
+Source: 4105_002-ebook.pdf
+Length: 1109 chars
+
+36.12.2 Urinary tract infection
+In industrialized societies the causes of mortality in patients with spinal cord injury have begun to mirror those of the general population thanks to a steady improvement in nursing care and physiotherapy. In middle to low-income countries, septicaemia and renal failure remain the main causes of death. Kidney failure usually results from a combination of ascending urinary tract infection (UTI) and pressure atrophy of the kidneys due to increased renal pelvis pres...
+
+=== Chunk 3868 ===
+Source: 4105_002-ebook.pdf
+Length: 2866 chars
+
+36.12.3 Autonomic dysreflexia/hyperreflexia
+Autonomic dysreflexia is a complication that occurs in patients with spinal cord injury above T6; occasionally, patients with injury from T6 to T10 may be susceptible. It is generally brought on by what would have been a noxious stimulus before the injury and is an abnormal autonomic nervous system response.
+The irritating stimulus occurs below the level of the spinal cord lesion. A paradoxical disconnection takes place between peripheral and central m...
+
+=== Chunk 3869 ===
+Source: 4105_002-ebook.pdf
+Length: 998 chars
+
+36.A.a Preparation of the bed
+Simple measures can be taken to prepare a proper bed in-hospital and, later, at home. An air mattress, such as the kind used at the beach, is best, although seldom available. Otherwise, a door can be placed on a hospital bed and covered with a thick foam mattress protected by some sort of waterproof covering. A sheepskin or pieces of cotton wool can then be placed where the buttocks and heels usually lie when the patient is lying on his back. The mattress should hav...
+
+=== Chunk 3870 ===
+Source: 4105_002-ebook.pdf
+Length: 308 chars
+
+Figure 36.A.1
+Bedding and frame for the prevention of pressure sores.
+P
+.
+N
+Once the SCI patient’s spine is stable enough to sit up, a special bed with a “Balkan beam” and handle can be constructed from locally available materials. This will allow the patient to change position frequently and independently....
+
+=== Chunk 3871 ===
+Source: 4105_002-ebook.pdf
+Length: 120 chars
+
+Figure 36.A.2
+Bed organized to make the SCI patient’s life as comfortable as possible.
+C
+Papas /ICRC
+.
+N
+573
+WAR SURGERY...
+
+=== Chunk 3872 ===
+Source: 4105_002-ebook.pdf
+Length: 318 chars
+
+Figure 36.A.3
+Procedure for cysto-manometry:
+1. The bladder is slowly filled over 5 minutes with 250 ml of sterile water at 37°C, allowing time for the detrusor muscle to relax.
+2. The infusion tube is then clamped.
+3. The pressure inside the bladder is read on the measuring tape as centimetres of water and recorded....
+
+=== Chunk 3873 ===
+Source: 4105_002-ebook.pdf
+Length: 77 chars
+
+Figure 36.A.4
+Examples of recordings for a spastic and a flaccid bladder.
+574...
+
+=== Chunk 3874 ===
+Source: 4105_002-ebook.pdf
+Length: 241 chars
+
+36.A.b Testing bladder tone
+Two of three simple clinical tests for ascertaining whether an SCI patient has a spastic or flaccid bladder are described in Section 36.9. The mid- to long-term management of the patient depends on this diagnosis....
+
+=== Chunk 3875 ===
+Source: 4105_002-ebook.pdf
+Length: 261 chars
+
+36.A.c Medium to long-term bladder management
+The procedures differ for a flaccid or spastic bladder and the patient and family must be instructed in the advantages and disadvantages of each so that the most appropriate method is chosen to be continued at home....
+
+=== Chunk 3876 ===
+Source: 4105_002-ebook.pdf
+Length: 1799 chars
+
+For the flaccid bladder there are several options.
+1. With clean intermittent catheterization a Nelaton-type catheter is passed every 6 – 8 hours and the bladder emptied as much as possible by suprapubic pressure until withdrawal of the catheter.
+After use, the catheter is washed with soap and water and the lumen rinsed with force from the water tap or by a syringe. The catheter is then either air-dried and kept in a paper bag or put into a savlon solution (chlorhexidine 1.5 % and cetrimide 15 %...
+
+=== Chunk 3877 ===
+Source: 4105_002-ebook.pdf
+Length: 1529 chars
+
+For the spastic bladder several options exist as well.
+1. Reflex automatic bladder following some sort of stimulus. A urinary condom is used in men for collecting the urine. If ready-made urinary condoms are not available, an ordinary condom can be adapted to serve the purpose; for women, incontinence pads or baby diapers may be used.
+The patient should be taught suprapubic tapping while in the sitting position as soon as possible.
+• The suprapubic area is tapped with the tips of the fingers unt...
+
+=== Chunk 3878 ===
+Source: 4105_002-ebook.pdf
+Length: 770 chars
+
+Reflex micturition and residual urine
+If a reflex micturition technique is employed the amount of residual urine should be checked by home-care team follow-up every two weeks in both spastic and flaccid bladders. The bladder is emptied by sterile catheterization and the patient drinks 4 glasses of water. The patient then urinates by whatever method is used and a catheter is passed again to measure the residual urine. The amount of residual urine should be less than 75 ml; if greater, the test is...
+
+=== Chunk 3879 ===
+Source: 4105_002-ebook.pdf
+Length: 484 chars
+
+36.A.d Urinary tract infection
+Several important factors increase the risk of infection and/or overpressure in a neurogenic bladder:
+• incomplete emptying of the bladder with residual urine;
+• increased intravesical pressure from overfilling of the bladder due to a flaccid detrusor muscle followed by vesico-ureteric reflux of urine;
+• increased intravesical pressure due to detrusor-external sphincter dyssynergia, also causing vesico-ureteric backflow; and
+• any use of a catheter....
+
+=== Chunk 3880 ===
+Source: 4105_002-ebook.pdf
+Length: 1240 chars
+
+Signs and symptoms
+Repeated urinary tract infection is very common in SCI patients. The classic symptoms of urinary tract infection (UTI), however, are often absent in a neurogenic bladder. Asymptomatic bacteriuria does not require antibiotics, which should only be used in the presence of frank symptoms. It is all too easy to misuse antibiotics in the attempt to prevent infection and thus cause the development of resistant organisms.
+The most common symptoms of local urinary tract infection are:...
+
+=== Chunk 3881 ===
+Source: 4105_002-ebook.pdf
+Length: 1577 chars
+
+Treatment
+The occurrence of UTI may be treated on an out-patient or in-patient basis, depending on the severity of the infection, the compliance and cooperation of patient and family, and the social context.
+In minor infections:
+• the urinary catheter is changed and a specimen sent for bacteriological culture and sensitivity if available;
+• the quantity of oral fluids is increased to a minimum of 3 – 4 litres per day;
+• the pH of the urine is changed by appropriate oral medication (ammonium chlo...
+
+=== Chunk 3882 ===
+Source: 4105_002-ebook.pdf
+Length: 389 chars
+
+36.A.e Epididymitis
+Epididymitis is a common complication resulting mainly from a prolonged ventral position of the male patient and/or delayed removal of the urinary catheter. Prevention is best accomplished by fashioning a mattress so that the penis and testicles are free from pressure when the patient is in the prone position. Treatment follows the same regime as ascending infection....
+
+=== Chunk 3883 ===
+Source: 4105_002-ebook.pdf
+Length: 838 chars
+
+36.A.f Incidence of urinary tract infection
+Whatever method of bladder training and passage of urine is used, the great danger to the patient is UTI and pressure atrophy of the kidneys. Much effort has been expended to determine the “safest” methods. One study reviews the incidence of urinary tract infection according to the method of bladder voiding (Table 36.A.1).
+Method Incidence of UTI In-dwelling catheter 10 Clean intermittent catheterization 1.5 Male condoms 1.3 Suprapubic stimulation in f...
+
+=== Chunk 3884 ===
+Source: 4105_002-ebook.pdf
+Length: 1290 chars
+
+Patients with spinal cord injury managed by the ICRC in Afghanistan
+The ICRC has been active in Afghanistan for over 30 years and one of its most important activities there is physical rehabilitation services for amputees and paraplegics/tetraplegics. More than 5,800 spinal cord injury patients have been recorded by the ICRC, with about 550 new cases per year in recent years. About 1,500 patients are followed regularly by ICRC teams and another 3,500 estimated to be present in off-limit areas an...
+
+=== Chunk 3885 ===
+Source: 4105_002-ebook.pdf
+Length: 704 chars
+
+In-dwelling catheterization costs
+Latex balloon catheters are the most widely available and used, but, as latex is porous, they cannot be left in place for prolonged periods. The ICRC provides silicone-coated latex catheters, changed on a weekly basis.
+Silicone Foley catheters have a smoother surface and are much less irritant to the urethral mucosa; they can stay in place longer, 6 weeks or more. On the negative side, the balloon tends to deflate with time (possible dislocation of the catheter)...
+
+=== Chunk 3886 ===
+Source: 4105_002-ebook.pdf
+Length: 1101 chars
+
+Clean intermittent catheterization costs
+The re-utilization of Nelaton-silicone catheters for CIC in selected patients can be very inexpensive and quite affordable in low-income countries. A study of 28 spinal cord injury patients in Thailand analysed the outcome of CIC with reused silicone catheters.13
+The results appear quite promising for situations where disposable catheters are not affordable and the only alternative is the in-dwelling catheter with its various complications. These patients...
+
+=== Chunk 3887 ===
+Source: 4105_002-ebook.pdf
+Length: 1033 chars
+
+HOSPITAL MANAGEMENT AND PATIENT CARE
+581
+WAR SURGERY
+582
+F. HOSPITAL MANAGEMENT AND PATIENT CARE
+F.1 Hospital management F.2 Post-operative care F.3 Critical care in low-income countries F.4 Improvisation F.5 Final remarks ANNEX F. 1 Ballistics ANNEX F. 2 Red Cross Wound Score and Classification System 583 584 588 590 592 593 596
+HOSPITAL MANAGEMENT AND PATIENT CARE
+Basic principles Managing a hospital is always a challenge – even more so where resources are limited. The responsibilities of the ...
+
+=== Chunk 3888 ===
+Source: 4105_002-ebook.pdf
+Length: 2522 chars
+
+F.1 Hospital management
+In many resource-poor settings the surgeon is often also the director of the local hospital. Although not optimal, all too frequently this cannot be avoided. Section 6.2.4 explains briefly the major elements in the functioning of a hospital and Annex 6.A is a checklist for the initial assessment of a surgical hospital treating war wounded patients.
+“Perhaps the most important ‘support service’ … for the hospital as a whole, is a functioning administrative structure with s...
+
+=== Chunk 3889 ===
+Source: 4105_002-ebook.pdf
+Length: 613 chars
+
+Figure F.1
+An accompanying family member assists in basic patient care: a common occurrence in many societies.
+584
+C
+R
+C
+I
+Every hospital in the world, no matter how well run, has bottlenecks in its systems for the circulation of patients and distribution of supplies. The cleaning staff, porters and maintenance personnel usually understand the “bowels” of the hospital best, but their knowledge is frequently underestimated or entirely overlooked. Another lesson drawn from ICRC field experience is...
+
+=== Chunk 3890 ===
+Source: 4105_002-ebook.pdf
+Length: 1794 chars
+
+F.2 Post-operative care
+Surgery is a multidisciplinary task and post-operative care is teamwork. Nursing, physiotherapy, radiology and laboratory work, not to mention patient nutrition and hygiene, all contribute towards determining the outcome of patient treatment. The comatose or spinal trauma patient and the amputee best exemplify the absolute necessity of this teamwork.
+In many countries with limited resources the level of education of doctors far exceeds that of nurses, as does their social...
+
+=== Chunk 3891 ===
+Source: 4105_002-ebook.pdf
+Length: 1523 chars
+
+Post-operative rounds
+The surgeon must understand that the treatment of the patient does not end at the door of the operating theatre. The post-operative round is as much an inherent part of surgical practice as the pre-operative examination and the work in the OT. Rounds should be undertaken as a multidisciplinary team with the anaesthetist, ward nurses and the physiotherapist. Checking the dressings, tubing and drains and their connections, and the stability of fracture fixation are not tasks ...
+
+=== Chunk 3892 ===
+Source: 4105_002-ebook.pdf
+Length: 650 chars
+
+Case studies and staff continuing education
+It is very helpful that the surgical team meet to discuss the care of specific patients, preferably on a regular basis. Such sessions can be educational for everybody involved and help establish hospital treatment protocols; they frequently have a significant impact on the outcome of patient management. As mentioned, the surgeon’s extra knowledge of anatomy, physiology and pathology carries an added responsibility of providing instruction for others. M...
+
+=== Chunk 3893 ===
+Source: 4105_002-ebook.pdf
+Length: 910 chars
+
+Hygiene
+Patient hygiene is mentioned several times in this manual. The ICRC practice, apart from a general showering of all patients on admission, is to scrub the affected limb or torso with copious amounts of soap and water and a brush under anaesthesia and just prior to operation, with the obvious exception of patients suffering from immediate life-threatening injuries. This scrubbing may have to be repeated at DPC.
+Patient hygiene includes post-operative body cleanliness and a family member i...
+
+=== Chunk 3894 ===
+Source: 4105_002-ebook.pdf
+Length: 3789 chars
+
+Nutrition protocols3
+Malnutrition in low-income countries is widespread and is exacerbated by situations of armed conflict. Malnourished patients and those who lose weight post-operatively show poor healing of wounds and intestinal anastomoses and greater susceptibility to infection. ICRC supported hospitals have a routine policy that on admission all patients are given iron and vitamin supplements, in addition to an anthelminthic where necessary. Families are often involved in patient feeding a...
+
+=== Chunk 3895 ===
+Source: 4105_002-ebook.pdf
+Length: 1537 chars
+
+Deep vein thrombosis
+Deep vein thrombosis (DVT) and pulmonary embolism (PE) are almost unheard of in ICRC practice of surgery for the war-wounded. They are a rare occurrence in rural societies where people maintain a traditional diet rich in natural fibres and a physically active life-style and do not present other risk factors typical of urban industrialized societies. This is changing in many societies, however, as people adopt a different lifestyle with many more non-communicable diseases bec...
+
+=== Chunk 3896 ===
+Source: 4105_002-ebook.pdf
+Length: 53 chars
+
+Figure F.4
+ICRC physiotherapists applying a POP cast....
+
+=== Chunk 3897 ===
+Source: 4105_002-ebook.pdf
+Length: 249 chars
+
+Figure F.5
+Traction ward in the ICRC Lokichokio Hospital in northern Kenya, under the primary supervision of physiotherapists.
+588
+T.Shiroko / Japanese Red Cross Society
+T
+y
+z 3
+t
+e
+i
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+o
+S
+s
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+2 8 3
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+n
+a
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+o
+k
+o
+r
+i
+h
+S
+2
+.
+T...
+
+=== Chunk 3898 ===
+Source: 4105_002-ebook.pdf
+Length: 431 chars
+
+Discharge
+The hospital should have a clear and simple discharge card. In the rural areas of low- income countries, patients often return home to places where there are no doctors. The card should give clear and simply written information on what has been done and what to do in case of commonly occurring problems. It should also include instructions on how to contact the hospital and whom to contact if any complication develops....
+
+=== Chunk 3899 ===
+Source: 4105_002-ebook.pdf
+Length: 511 chars
+
+Critical care in low-income countries
+“All hospitals have critically ill patients.” D.A.K. Watters et al. 5
+The absence of a sophisticated intensive care unit equipped with mechanical ventilation, advanced high-level patient monitors and resuscitation equipment does not prevent organizing the care of critically ill patients. Good critical care through intensive nursing can do much to help the patient with an open brain injury, a laparotomy, a haemothorax requiring chest tube drainage, tetanus or...
+
+=== Chunk 3900 ===
+Source: 4105_002-ebook.pdf
+Length: 665 chars
+
+Organization of a critical care ward
+Intensive therapy requires a chosen space to segregate critically ill patients kept under constant observation and to concentrate available equipment and specialized nursing staff. The patient to nurse ratio – usually 20 or 30:1 or more in the general wards in settings of limited resources – should be much lower. A 4:1 ratio is the standard in ICRC practice.
+5 Watters DAK, Wilson IH, Leaver RJ, Bagshawe A. Care of the Critically Ill Patient in the Tropics and...
+
+=== Chunk 3901 ===
+Source: 4105_002-ebook.pdf
+Length: 1464 chars
+
+Figure F.6
+Figure F.7 Intensive nursing ward in Lokichokio Hospital.
+Equipment should include at a minimum a suction device, pulse oxymeter, oxygen supply of some sort and humidifier system, as well as the standard stethoscope and sphygmomanometer. Usually lacking in resource-poor settings are mechanical ventilation, a cardiac monitor, an infusion pump, the capacity for inotropic support, dialysis, and central venous lines. These all need trained biomedical technicians for maintenance and repair...
+
+=== Chunk 3902 ===
+Source: 4105_002-ebook.pdf
+Length: 1737 chars
+
+Admission criteria
+The criteria for admission to a critical care ward should apply the same logic as that of triage of mass casualties “to avoid futile efforts [and] to identify potential survivors”.6 There is a great deal of difference between an acute pathology in an otherwise relatively healthy individual – particularly the case with the victims of trauma – and an acute exacerbation of multiple chronic pathologies. The emphasis should be on patients with reversible conditions and a reasonable...
+
+=== Chunk 3903 ===
+Source: 4105_002-ebook.pdf
+Length: 857 chars
+
+Routines and protocols
+Regular patient rounds by the multidisciplinary team are essential for timely recognition of deterioration in the patient’s condition and prompt intervention. An appropriate monitoring system of important physiological parameters should be adopted. Several systems have been developed for use in low-resource settings that record the systolic BP, pulse, respiratory rate, temperature, oxygen saturation, urine output and AVPU score.
+A holistic approach by the team is key to pr...
+
+=== Chunk 3904 ===
+Source: 4105_002-ebook.pdf
+Length: 1250 chars
+
+Assisted ventilation
+The absolute number of patients actually requiring assisted ventilation is rather small. Manually “bagging” a specific patient, and for how long, depends on hospital staffing. Volunteers can be engaged and trained, according to the circumstances.
+Although mechanical ventilation is not an absolute necessity for the treatment of many acutely ill patients, if one is to be used it should consist of an appropriate technology. Annex 1.A defines the ICRC criteria for introducing a ...
+
+=== Chunk 3905 ===
+Source: 4105_002-ebook.pdf
+Length: 2507 chars
+
+F.4 Improvisation
+This manual often speaks of the need to improvise certain pieces of equipment or clinical protocols. Doctors and nurses who have worked in resource poor areas of the world have regularly published articles describing their inventions. A short summary of some of the most useful in conditions of extreme destitution might include the following.
+7 Professor Jean-Louis Vincent, Intensive Care Service, Erasmus University Hospital, Brussels, Belgium.
+HOSPITAL MANAGEMENT AND PATIENT CA...
+
+=== Chunk 3906 ===
+Source: 4105_002-ebook.pdf
+Length: 166 chars
+
+Figure F.9
+Using a cardboard box to maintain patient temperature for prevention and treatment of hypothermia.
+• Modified “pizza-cutter” for meshing split skin grafts....
+
+=== Chunk 3907 ===
+Source: 4105_002-ebook.pdf
+Length: 317 chars
+
+Figure F.10
+• Rectal tap water fluid therapy. An adult patient having had abdominal surgery is given 500 ml of tap water per rectum every 6 hours until capable of taking oral
+Meshing a split-skin graft with a “pizza-cutter” whose edge has been serrated.
+591
+C
+Beveridge /ICRC
+R
+C
+I
+/
+e
+g
+d
+i
+r
+e
+v
+e
+B
+.
+M
+WAR SURGERY...
+
+=== Chunk 3908 ===
+Source: 4105_002-ebook.pdf
+Length: 570 chars
+
+Figures F.11.1 and F.11.2
+Distillator, recyclable glass bottles and autoclave for the local production of i.v. fluids.
+592
+fluids. Sodium chloride (15 gm) and potassium chloride (5 gm) can be added to each 5-litre batch. An intravenous infusion is maintained as well for the first 12 hours post-operatively.
+• Production of i.v. fluids (normal saline, dextrose 5 % in water, Ringer’s lactate) by distillation of water, recyclable glass jars, and autoclaving as done in many isolated missionary hospit...
+
+=== Chunk 3909 ===
+Source: 4105_002-ebook.pdf
+Length: 1978 chars
+
+F.5 Final remarks
+The running of a hospital when resources are scarce is a challenging task. Equipment is limited, medicines and consumables in short supply, trained staff lacking, and support from a far distant ministry often inadequate. Poverty, bureaucratic obstacles, disorganization due to the prevailing violence, and corruption all too often complicate the work of health professionals. Even with adequate support, the management of war-wounded is frequently an overwhelming additional burden ...
+
+=== Chunk 3910 ===
+Source: 4105_002-ebook.pdf
+Length: 1299 chars
+
+ANNEX F. 1 Ballistics
+A detailed description of wound ballistics is to be found in Chapter 3 of Volume 1. This Annex gives a brief summary of some important points.
+Many factors are involved in determining the extent of injury due to projectiles. Ultimately, the most important ones are the effective transfer of kinetic energy to the tissues and the reaction of the specific tissue concerned. Projectiles cause tissue trauma by crush and laceration and by the effects of temporary cavity formation: ...
+
+=== Chunk 3911 ===
+Source: 4105_002-ebook.pdf
+Length: 643 chars
+
+F.1.a Stable high-energy FMJ military rifle bullet travelling at more than 600 m/sec
+The wound channel of the AK-47 bullet is used as an example. The bullet first follows a straight line creating the phase 1 straight narrow channel. It then tumbles and causes the creation of the phase 2 temporary cavity whose diameter can be 25 times that of the bullet. The bullet then carries on more or less in a straight line producing the phase 3 narrow channel.
+l
+Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+K
+Phase 1:   Phase 2:...
+
+=== Chunk 3912 ===
+Source: 4105_002-ebook.pdf
+Length: 472 chars
+
+Figure F.1.1
+Profile of an AK-47 bullet in soap: stable bullet with high-kinetic energy.
+.
+B
+For all three phases to be apparent in the body, the length of the bullet’s trajectory must be long enough. Otherwise, an exit wound occurs at an earlier stage and the characteristics of this wound – large or small – correspond to that particular phase of the profile. Different bullets create different profiles with specific distances for the onset of phase 2 cavity formation....
+
+=== Chunk 3913 ===
+Source: 4105_002-ebook.pdf
+Length: 313 chars
+
+F.1.b Stable low-energy FMJ handgun bullet
+With the bullet from a handgun no tumbling of the bullet occurs and it follows a simple straightforward path. An FMJ rifle bullet hitting the body at less than 600 m/ sec tends to create the same sort of profile as a handgun bullet.
+l
+Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+40 cm
+40 cm...
+
+=== Chunk 3914 ===
+Source: 4105_002-ebook.pdf
+Length: 267 chars
+
+Figure F.1.2
+Profile of a low-kinetic energy stable FMJ bullet in soap.
+K
+.
+B
+593
+WAR SURGERY
+Figure F.1.3 Profile of a deforming SJ rifle bullet in soap.
+Figure F.1.4 Profile of a deforming handgun bullet in soap.
+Figure F.1.5 Shooting profile of a fragment in soap....
+
+=== Chunk 3915 ===
+Source: 4105_002-ebook.pdf
+Length: 229 chars
+
+Figure F.1.6
+Two fragments with the same kinetic energy – note the difference in energy deposition along the track, demonstrated by the difference in the cavities:
+a. lightweight and fast fragment;
+b. heavy and slow fragment.
+594...
+
+=== Chunk 3916 ===
+Source: 4105_002-ebook.pdf
+Length: 471 chars
+
+F.1.c High-energy SJ hunting rifle bullet travelling at more than 600 m/sec
+The bullet deforms – mushrooms – immediately on impact with the body causing an abrupt reduction in velocity and great transfer of kinetic energy, which results in an immediate and large temporary cavity with much tissue damage. These bullets are colloquially known as “dum-dum” bullets and their use in combat is prohibited by international treaties.
+l
+Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+K
+40 cm
+40 cm
+.
+B...
+
+=== Chunk 3917 ===
+Source: 4105_002-ebook.pdf
+Length: 250 chars
+
+F.1.d Deforming low-energy SJ handgun bullet
+The same mushrooming of the bullet occurs, thus presenting a large cross section to the tissues, but the width of the temporary cavity is proportionally smaller.
+l
+Kneubuehl
+h
+e
+u
+b
+u
+e
+n
+40 cm
+40 cm
+K
+.
+B...
+
+=== Chunk 3918 ===
+Source: 4105_002-ebook.pdf
+Length: 407 chars
+
+F.1.e Fragments
+In the case of a fragment – a non-aerodynamic projectile – the major transfer of kinetic energy always occurs at the entry point. This creates a profile that resembles a “cone”. The entry is always larger than the diameter of the fragment and always larger than any exit.
+l
+Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+K
+.
+B
+l
+Kneubueh!
+h
+e
+u
+b
+u
+e
+n
+40 cm
+40 cm
+a.  b.
+K
+.
+B
+HOSPITAL MANAGEMENT AND PATIENT CARE...
+
+=== Chunk 3919 ===
+Source: 4105_002-ebook.pdf
+Length: 393 chars
+
+F.1.f Ricochet bullets
+A ricochet bullet striking some object that destabilizes it before it hits the target creates a profile that resembles that of an SJ bullet or even a fragment, giving off a large part of its kinetic energy soon after impact. The existence of ricochet wounds has often caused combatants to accuse the adversary of using “illegal dum-dum” bullets.
+40 cm
+40 cm
+B. Kneubueh!...
+
+=== Chunk 3920 ===
+Source: 4105_002-ebook.pdf
+Length: 292 chars
+
+Figure F.1.7
+FMJ rifle bullet after ricochet effect in soap. The large impact angle after ricochet destabilizes the bullet, which tumbles easily and early in the shooting channel. Note that the temporary cavity occurs almost immediately on impact, similar to an SJ bullet.
+595
+WAR SURGERY
+596...
+
+=== Chunk 3921 ===
+Source: 4105_002-ebook.pdf
+Length: 1875 chars
+
+ANNEX F. 2 Red Cross Wound Score and Classification System
+Chapter 4 in Volume 1 gives a full description of the Red Cross Wound Score and Classification System.
+The RCWS pertains only to penetrating wounds caused by projectiles. It is an attempt to correlate in a simple manner the effective transfer of kinetic energy as described by wound ballistics to the lesions that the surgeon actually sees. It is based on the features of the wound itself, and not on the weaponry or the presumed velocity or...
+
+=== Chunk 3922 ===
+Source: 4105_002-ebook.pdf
+Length: 86 chars
+
+Grade 1
+E + X is less than 10 cm with Scores C 0 and F 0 or F 1.
+(Low energy transfer)...
+
+=== Chunk 3923 ===
+Source: 4105_002-ebook.pdf
+Length: 79 chars
+
+Grade 2
+E + X is less than 10 cm with Scores C 1 or F 2.
+(High energy transfer)...
+
+=== Chunk 3924 ===
+Source: 4105_002-ebook.pdf
+Length: 424 chars
+
+Grade 3
+E + X is 10 cm or more, invariably with Scores C 1 or F 2.
+(Massive energy transfer)
+These increasing Grades of severity represent the outcome of a simple clinical assessment that corresponds to the effective transfer of kinetic energy of projectiles to body tissues. Plainly put, large wounds are more serious and require greater resources for their management, and this is particularly true of wounds to the limbs....
+
+=== Chunk 3925 ===
+Source: 4105_002-ebook.pdf
+Length: 40 chars
+
+Type ST
+Soft-tissue wounds: F 0 and V 0....
+
+=== Chunk 3926 ===
+Source: 4105_002-ebook.pdf
+Length: 50 chars
+
+Type F
+Wounds with fractures: F 1 or F 2, and V 0....
+
+=== Chunk 3927 ===
+Source: 4105_002-ebook.pdf
+Length: 81 chars
+
+Type V
+Vital wounds putting the patient’s life at risk: V = N, T, A or H and F 0....
+
+=== Chunk 3928 ===
+Source: 4105_002-ebook.pdf
+Length: 123 chars
+
+Type VF
+Wounds with fractures and involving vital structures putting life or limb at risk: F 1 or F 2 and V = N, T, A or H....
+
+=== Chunk 3929 ===
+Source: 4105_002-ebook.pdf
+Length: 642 chars
+
+F.2.c Wound classification
+Combining Grades and Types gives rise to a classification system divided into 12 categories.
+Grade 1 Grade 2 Grade 3 1 ST Small, simple wound 2 ST Medium soft-tissue wound 3 ST Large soft-tissue wound 1 F 2 F 3 F Simple fracture Important fracture Massive comminution threatening limb 1 V 2 V 3 V Small wound threatening life Medium wound threatening Large wound threatening life life 1 VF 2 VF 3 VF Small wound threatening limb Important wound threatening Large wound thre...
+
+=== Chunk 3930 ===
+Source: 4105_002-ebook.pdf
+Length: 2387 chars
+
+ACRONYMS
+ABI Ankle-brachial index
+AIS Abbreviated injury scale
+APM Anti-personnel mine
+ARDS Acute respiratory distress syndrome
+ASIA American Spinal Injury Association
+ATM Anti-tank mine
+A-V BID BLI CH or F CIC CNS CPD-A CS CSF CT scan CVP DIC DIME DOA DPC 2, 3-DPG DPL DVT eFAST EMG Arterio-venous Bis in die; twice a day Blast lung injury Charrière or French gauge system used in sizing catheters (1 CH = 0.333 mm) Clean intermittent catheterization Central nervous system Citrate phosphate dextros...
+
+=== Chunk 3931 ===
+Source: 4105_002-ebook.pdf
+Length: 279 chars
+
+SELECTED BIBLIOGRAPHY
+Many references in Volume 1 have served in the writing of this Volume; they are not referred to here unless mentioned as a source in a table. For the sake of brevity, full references cited in footnotes in the main text are not repeated in this Bibliography....
+
+=== Chunk 3932 ===
+Source: 4105_002-ebook.pdf
+Length: 1264 chars
+
+Additional general references
+Bashir MO, Abu-Zidan FM, Lennquist S. Will the damage-control concept influence the principles for setting priorities for severely traumatized patients in disaster situations? Int J Disaster Med 2003; 1: 97 – 102.
+Hollifield M. Taking measure of war trauma. Lancet 2005; 365 (9467): 1283 – 1284.
+Ivatury RR, Cayten CG, eds. The Textbook of Penetrating Trauma. Media, PA: Williams & Wilkins; 1996.
+Mahoney PF, Ryan JM, Brooks AJ, Schwab CW eds. Ballistic Trauma: A Practi...
+
+=== Chunk 3933 ===
+Source: 4105_002-ebook.pdf
+Length: 2399 chars
+
+Introduction
+Baskin TW, Holcomb JB. Bombs, mines, blast, fragmentation, and thermobaric mechanisms of injury. In: Mahoney PF, Ryan JM, Brooks AJ, Schwab CW eds. Ballistic Trauma: A Practical Guide, 2nd ed. London: Springer-Verlag; 2005: 45 – 66.
+Champion HR, Holcomb JB, Young LA. Injuries from explosions: physics, biophysics, pathology, and required research focus. J Trauma 2009; 66: 1468 – 1477.
+Cullis IG. Blast waves and how they interact with structures. J R Army Med Corps 2001;
+147: 16 – 26....
+
+=== Chunk 3934 ===
+Source: 4105_002-ebook.pdf
+Length: 17800 chars
+
+General references
+Almogy G, Mintz Y, Zamir G, Bdolah-Abram T, Elazary R, Dotan L, Faruga M, Rivkind AI. Suicide bombing attacks: can external signs predict internal injuries. Ann Surg 2006; 243: 541 – 546.
+Arnold JL, Halperin P, Tsai MC, Smithline H. Mass casualty terrorist bombings: a comparison of outcomes by bombing type. Ann Emerg Med 2004; 43: 263 – 273.
+Horrocks CL. Blast injuries: biophysics, pathophysiology and management principles. J R Army Med Corps 2001; 147: 28 – 40.
+International ...
+
+=== Chunk 3935 ===
+Source: 4105_002-ebook.pdf
+Length: 2099 chars
+
+Epidemiology
+Aylwin C, König TC, Brennan RW, Shirley PJ, Davies G, Walsh MS, Brohi K. Reduction in critical mortality in urban mass casualty incidents: analysis of triage, surge, and resource use after the London bombings on July 7, 2005. Lancet 2006; 368: 2219 – 2225.
+Brismar B, Bergenwald L. The terrorist bomb explosion in Bologna, Italy, 1980: an analysis of the effects and injuries sustained. J Trauma 1982; 22: 216 – 220.
+Frykberg ER, Tepas JJ, Alexander RH. The 1983 Beirut airport terrorist...
+
+=== Chunk 3936 ===
+Source: 4105_002-ebook.pdf
+Length: 1113 chars
+
+Cardiovascular and pulmonary barotrauma
+Abu-Zidan FM, Aman S. Underwater explosion lung injury. J Trauma 2001; 50: 169.
+Avidan V, Hersch M, Armon Y, Spira R, Aharoni D, Reissman P, Schecter WP. Blast lung injury: clinical manifestations, treatment, and outcome. Am J Surg 2005; 190: 945 – 950.
+Bala M, Shussman N, Rivkind AI, Izhar U, Almogy G. The pattern of thoracic trauma after suicide terrorist bombing attacks. J Trauma 2010; 69: 1022 – 1029.
+Chavco M, Prusaczyk WK, McCarron RM. Lung injury an...
+
+=== Chunk 3937 ===
+Source: 4105_002-ebook.pdf
+Length: 1492 chars
+
+Neurotrauma
+Armonda RA, Bell RS, Vo AH, Ling G, DeGraba TJ, Crandall B, Ecklund J, Cambell WW. Wartime traumatic cerebral vasospasm: recent review of combat casualties. Neurosurg 2006; 59: 1215 – 1225.
+Bhattacharjee Y. Shell shock revisited: solving the puzzle of blast trauma. Science 2008; 319: 406 – 408.
+605
+WAR SURGERY
+606
+Desmoulin GT, Dionne J-P. Blast-induced neurotrauma: surrogate use, loading mechanisms, and cellular responses. J Trauma 2009; 67: 1113 – 1122.
+Hicks RR, Fertig SJ, Desroch...
+
+=== Chunk 3938 ===
+Source: 4105_002-ebook.pdf
+Length: 817 chars
+
+Gastro-intestinal tract
+Cripps NPJ, Cooper GJ. Risk of late perforation in intestinal contusions caused by explosive blast. Br J Surg 1997; 84: 1298 – 1303.
+Huller T, Bazini Y. Blast injuries of the chest and abdomen. Arch Surg 1970; 100: 24 – 30.
+Owers C, Morgan JL, Garner JP. Abdominal trauma in primary blast injury. Br J Surg 2011; 98: 168 – 179.
+Paran H, Neufeld D, Schwartz I, Kidron D, Susmallian S, Mayo A, Dayan K, Vider I, Sivak G, Freund U. Perforation of the terminal ileum induced by bl...
+
+=== Chunk 3939 ===
+Source: 4105_002-ebook.pdf
+Length: 624 chars
+
+Extremities
+Hull JB, Bowyer GW, Cooper GJ, Crane J. Pattern of injury in those dying from traumatic amputation caused by bomb blast. Br J Surg 1994; 81: 1132 – 1135.
+Ramasamy A, Hill AM, Masouros S, Gibb I, Bull AMJ, Clasper JC. Blast-related fracture patterns: a forensic biomechanical approach. J R Soc Interface 2011; 8: 689 – 698. [doi: 10.1098/rsif.2010.0476]
+Ramasamy A, Masouros SD, Newell N, Hill AM, Proud WG, Brown KA, Bull AMJ, Clasper JC. In-vehicle extremity injuries from improvised exp...
+
+=== Chunk 3940 ===
+Source: 4105_002-ebook.pdf
+Length: 914 chars
+
+Biological foreign bodies
+Braverman I, Wexler D, Oren M. A novel mode of infection with hepatitis B: penetrating bone fragments due to the explosion of a suicide bomber. IMAJ 2002; 4: 528 – 529.
+Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Blast Injuries: Post-Exposure Prophylaxis for Bloodborne Pathogens. Available at https://www.acep.org/imports/clinical-and-practice-management/resources/ems- and-disaster-preparedness/disaster-preparedness-grant-pro...
+
+=== Chunk 3941 ===
+Source: 4105_002-ebook.pdf
+Length: 480 chars
+
+Tungsten toxicity
+Jonas W, van der Voet GB, Todorov TI, Centeno JA, Ives J, Mullick FG. Metals and health: a clinical toxicological perspective on tungsten and review of the literature. Mil Med 2007; 172: 1002 – 1005.
+Machado BI, Murr LE, Suro RM, Gaytan SM, Ramirez DA, Garza KM, Schuster BE. Characterization and cytotoxic assessment of ballistic aerosol particulates for tungsten alloy penetrators into steel target plates. Int J Environ Res Public Health 2010; 7: 3313 – 3331....
+
+=== Chunk 3942 ===
+Source: 4105_002-ebook.pdf
+Length: 871 chars
+
+Chapter 20
+Balazs GC, Polfer EM, Brelin AM, Gordon WT. High seas to high explosives: the evolution of calcaneus fracture management in the military. Mil Med 2014; 179: 1228 – 1235.
+Jacobs LGH. The landmine foot: its description and management. Injury 1991; 22: 463 – 466.
+Ragel BT, Allred CD, Brevard S, Davis RT, Frank EH. Fractures of the thoracolumbar spine sustained by soldiers in vehicles attacked by improvised explosive devices. Spine 2009; 34: 2400 – 2405.
+Ramasamy A, Hill AM, Hepper AE, Bu...
+
+=== Chunk 3943 ===
+Source: 4105_002-ebook.pdf
+Length: 1945 chars
+
+Epidemiology and socio-economic repercussions
+Andersson N, Palha da Sousa C, Paredes S. Social cost of land mines in four countries: Afghanistan, Bosnia, Cambodia, and Mozambique. BMJ 1995; 311: 718 – 721.
+Ascherio A, Biellik R, Epstein A, Snetro G, Gloyd S, Ayotte B, Epstein PR. Deaths and injuries caused by land mines in Mozambique. Lancet 1995; 346: 721 – 724.
+Bilukha OO, Brennan M, Woodruff B. Death and injury from landmines and unexploded ordnance in Afghanistan. JAMA 2003; 290: 650 – 653.
+...
+
+=== Chunk 3944 ===
+Source: 4105_002-ebook.pdf
+Length: 2548 chars
+
+Clinical studies
+Arnson Y, Bar-Dayan Y. Reducing landmine mortality rates in Iran using public medical education and rural rescue teams. What can be learned from landmine casualties, and how can the situation be improved? Prehosp Disast Med 2009; 24: 130 – 132.
+Coupland RM. Amputation for antipersonnel mine injuries of the leg: preservation of the tibial stump using a medial gastrocnemius myoplasty. Ann R Coll Surg Engl 1989; 71: 405 – 408.
+De Wind CM. Antipersonnel mine injuries in Somaliland: ...
+
+=== Chunk 3945 ===
+Source: 4105_002-ebook.pdf
+Length: 374 chars
+
+Essential websites
+E-mine: The electronic Mine Information Network (United Nations) https://www. mineaction.org
+Geneva International Center for Humanitarian Demining https://www.gichd.org
+International Campaign to Ban Landmines http://www.icbl.org/en-gb/home.aspx
+International Committee of the Red Cross https://www.icrc.org/en/war-and-law/ weapons/anti-personnel-landmines...
+
+=== Chunk 3946 ===
+Source: 4105_002-ebook.pdf
+Length: 1334 chars
+
+Limb salvage
+Akula M, Gella S, Shaw CJ, McShane P, Mohsen AM. A meta-analysis of amputation versus limb salvage in mangled lower limb injuriess – the patient perspective. Injury 2011; 42: 1194 – 1197.
+Brown KV, Ramasamy A, McLeod J, Stapley S, Clasper JC. Predicting the need for early amputation in ballistic mangled extremity injuries. J Trauma 2009; 66 (Suppl.): S93 – S98.
+Brown KV, Henman P, Stapley S, Clasper JC. Limb salvage of severely injured extremities after military wounds. J R Army Med...
+
+=== Chunk 3947 ===
+Source: 4105_002-ebook.pdf
+Length: 202 chars
+
+Damage-control orthopaedics
+Andersen RC, Ursua VA, Valosen JM, Shawen SB, Davila JN, Baechler MF, Keeling JJ. Damage control orthopaedics: an in-theatre perspective. J Surg Orthop Adv 2010; 19: 13 – 17....
+
+=== Chunk 3948 ===
+Source: 4105_002-ebook.pdf
+Length: 2008 chars
+
+Wound irrigation and dressings
+Anglen JO, Gainor BJ, Simpson WA, Christensen G. The use of detergent irrigation for musculoskeletal wounds. Int Orthop 2003; 27: 40 – 46.
+Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lower limb fracture wounds: prospective, randomized study. J Bone Joint Surg Am 2005; 87: 1415 – 1422.
+Brown PW. Simplified wound lavage. Tech Orthop 1995; 10: 154.
+Chirife J, Scarmato G, Herszage L. Scientific basis for the use of granulated sugar in the t...
+
+=== Chunk 3949 ===
+Source: 4105_002-ebook.pdf
+Length: 1022 chars
+
+Crush injury
+Bartels SA, VanRooyen MJ. Medical complications associated with earthquakes. Lancet 2012; 379: 748 – 757.
+Bowley DMG, Buchan C, Khulu L; Boffard KD. Acute renal failure after punishment beatings. J R Soc Med 2002; 95: 300 – 301.
+Hiss J, Kahana T, Kugel C. Beaten to death: why do they die? J Trauma 1996; 40: 27 – 30.
+Knottenbelt JD. Traumatic rhabdomyolysis from severe beating – experience of volume diuresis in 200 patients. J Trauma 1994; 37: 214 – 219.
+Malik GH, Reshi AR, Najar MS....
+
+=== Chunk 3950 ===
+Source: 4105_002-ebook.pdf
+Length: 1119 chars
+
+Compartment syndrome and fasciotomy
+Balogh ZJ, Butcher NE. Compartment syndromes from head to toe. Crit Care Med 2010; 38 (Suppl.): S445 – S451.
+Clasper JC, Standley D, Heppell S, Jeffrey S, Parker PJ. Limb compartment syndrome and fasciotomy. J R Army Med Corps 2009; 155: 298 – 301.
+Finkelstein JA, Hunter GA, Hu RW. Lower limb compartment syndrome: course after delayed fasciotomy. J Trauma 1996; 40: 342 – 344.
+Gordon WT, Talbot M, Shero JC, Osier CJ, Johnson AE, Balsamo LH, Stockinger ZT. Acute...
+
+=== Chunk 3951 ===
+Source: 4105_002-ebook.pdf
+Length: 2307 chars
+
+Ballistics
+Clasper JC, Hill PF, Watkins PE. Contamination of ballistic fractures: an in vitro model. Injury 2002; 33: 157 – 160.
+Dougherty PJ, Sherman D, Dau N, Bir C. Ballistic fractures: indirect fracture to bone. J Trauma 2011; 71: 1381 – 1384.
+Ben-Menachem Y. Intra-abdominal injuries in nonpenetrating gunshot wounds of the abdominal wall: two unusual cases. J Trauma 1979; 19: 207 – 210.
+Edwards J, Gaspard DJ. Visceral injury due to extraperitoneal gunshot wounds. Arch Surg 1974; 108: 865 – 8...
+
+=== Chunk 3952 ===
+Source: 4105_002-ebook.pdf
+Length: 943 chars
+
+Plaster-of-Paris
+Anderson LD, Hutchins WC, Wright PE, Disney JM. Fractures of the tibia and fibula treated by casts and transfixing pins. Clin Orthop Relat Res 1974; 105: 179 – 191.
+Brown PW. The early weight-bearing treatment of tibial shaft fractures. Clin Orthop Relat Res 1974; 105: 167 – 178.
+Dehne E; Metz CW; Deffer PA, Hall RM. Nonoperative treatment of the fractured tibia by immediate weight bearing. J Trauma 1961; 1: 514 – 535.
+Dehne E. Ambulatory treatment of the fractured tibia. Clin O...
+
+=== Chunk 3953 ===
+Source: 4105_002-ebook.pdf
+Length: 584 chars
+
+Traction
+Althausen PL, Hak DJ. Lower extremity traction pins: indications, technique, and complications. Am J Orthop 2002; 31: 43 – 47.
+Boyd MC, Mountain AJC, Clasper JC. Improvised skeletal traction in the management of ballistic femoral fractures. J R Army Med Corps 2009; 155: 194 – 196.
+Clasper JC, Rowley DI. Outcome, following significant delays in initial surgery, of ballistic femoral fractures managed without internal or external fixation. J Bone Joint Surg Br 2009; 91: 97 – 101.
+Rungee JL...
+
+=== Chunk 3954 ===
+Source: 4105_002-ebook.pdf
+Length: 1472 chars
+
+External fixation
+Camuso MR. Far-forward fracture stabilization: external fixation versus splinting. J Am Acad Orthop Surg 2006; 14 (Suppl.): S118 – S123.
+Clasper JC, Phillips SL. Early failure of external fixation in the management of war injuries. J R Army Med Corps 2005; 151: 81 – 86.
+Coupland RM. War wounds of bones and external fixation. Injury 1994; 25: 211 – 217.
+Dubravko H, Žarko R, Tomislav T, Dragutin K, Vjenceslav N. External fixation in war trauma management of the extremities – expe...
+
+=== Chunk 3955 ===
+Source: 4105_002-ebook.pdf
+Length: 1294 chars
+
+Internal fixation
+Beech Z, Parker P. Internal fixation on deployment: never, ever, clever? J R Army Med Corps 2012. 158; 4 – 5.
+Bušić Ž, Lovrć Z, Amć E, Bušić V, Lovrc L, Markovc I. War injuries of the extremities: twelve-year follow-up data. Mil Med 2006; 171: 55 – 57.
+Clasper JC, Stapley SA, Bowley DMG, Kenward CE, Taylor V, Watkins PE. Spread of infection, in an animal model, after intramedullary nailing of an infected external fixator pin track. J Orthop Res 2001; 19: 155 – 159.
+Dougherty PJ...
+
+=== Chunk 3956 ===
+Source: 4105_002-ebook.pdf
+Length: 524 chars
+
+Hands and feet
+Bluman EM, Ficke JR, Covey DC. War wounds of the foot and ankle: causes, characteristics, and initial management. Foot Ankle Clin 2010; 15: 1 – 21.
+Brown PW. War wounds of the hand revisited. J Hand Surg Am 1995; 20 (Part 2): S61 – S67.
+Burkhalter WE. Care of war injuries of the hand and upper extremity. Report of the War Injury Committee. J Hand Surg Am 1983; 8: 810 – 813.
+Nikolić D, Jovanović Z, Vulović R, Mladenović M. Primary surgical treatment of war injuries of the foot. Inj...
+
+=== Chunk 3957 ===
+Source: 4105_002-ebook.pdf
+Length: 453 chars
+
+Bone reconstruction
+Coupland RM. A management algorithm for chronically exposed war wounds of bone.
+Injury 1990; 21: 101 – 103.
+Goulet JA, Senunas LE, DeSilva GL, Freenfield M-L VH. Autogenous iliac crest bone graft. complications and functional assessment. Clin Orthop Relat Res 1997; 339: 76−81.
+Ley P, Gosselin RA, Villar R. The Masquelet induced-membrane technique: an option for a tertiary-referral conflict setting. J Surg Case Rep 2019; 6: 1 – 4....
+
+=== Chunk 3958 ===
+Source: 4105_002-ebook.pdf
+Length: 2801 chars
+
+Chapter 23
+Amputation Surgery Education Center. General Principles of Amputation Surgery. Available at https://orthop.washington.edu/patient-care/limb-loss/general-principles- of-amputation-surgery.html.
+Coupland MR. Amputation for antipersonnel mine injuries of the leg: preservation of the tibial stump using a medial gastrocnemius myoplasty. Ann R Coll Surg Engl 1989; 17: 405.
+Doucet JJ, Galarneau MR, Potenza BM, Bansal V, Lee JG, Schwartz AK, Dougherty AL, Dye J, Hollingsworth-Fridlund P, Fort...
+
+=== Chunk 3959 ===
+Source: 4105_002-ebook.pdf
+Length: 4717 chars
+
+Chapter 24
+Amato JJ, Rich NM, Billy LJ, Gruber RP, Lawson NS. High-velocity arterial injury: a study of the mechanism of injury. J Trauma 1971; 11: 412 – 416.
+Stewart BT, Gyedu A, Giannou C, Mishra B, Rich N, Wren SM, Mock C, Kushner AL. Essential Vascular Care Guidelines Study Group. Consensus recommendations for essential vascular care in low- and middle-income countries. J Vasc Surg 2016; 64: 1770 – 1779.
+Dajani OM, Haddad FF, Hajj HA, Sfeir RE, Khoury GS. Injury to the femoral vessels – the ...
+
+=== Chunk 3960 ===
+Source: 4105_002-ebook.pdf
+Length: 1059 chars
+
+Temporary vascular shunt
+Borut J, Acosta JA, Tadlock M, Dye JL, Galarneau M, Elshire D. The use of temporary vascular shunts in military extremity wounds: a preliminary outcome analysis with 2-year follow-up. J Trauma 2010; 69: 174 – 178.
+Ding W, Wu X, Li J. Temporary intravascular shunts used as a damage control surgery adjunct in complex vascular injury: collective review. Injury 2008; 39: 970 – 977.
+Gifford SM, Aidinian G, Clouse WD, Fox CJ, Porras CA, Jones WT, Zarzabal L-A, Michalek JE, Pro...
+
+=== Chunk 3961 ===
+Source: 4105_002-ebook.pdf
+Length: 1226 chars
+
+Chapter 25
+Friedman AH. An eclectic review of the history of peripheral nerve surgery. Neurosurgery 2009; 65 (Suppl. 4): A3 – A8.
+Gousheh J. The treatment of war injuries of the brachial plexus. J Hand Surg Amer 1995; 20 (Suppl.): S68 – S76.
+Hamdan TA. Missed injuries in casualties from the Iraqi-Iranian war: a study of 35 cases. Injury 1987; 18: 15 – 17.
+Jebara VA, Sadde B. Causalgia: A war time experience – report of twenty treated cases. J Trauma 1987; 27: 519 – 524.
+Roganovic Z, Mandic-Gajic...
+
+=== Chunk 3962 ===
+Source: 4105_002-ebook.pdf
+Length: 807 chars
+
+Working with limited resources
+Coupland RM, Pesonen PE. Craniocerebral war wounds: non-specialist management. Injury 1992; 23: 21 – 24.
+Coutts A. Chewing gum for extradural haemorrhage. BMJ 1998; 317: 1687.
+Kanyi JK, Ogada TV, Oloo MJ, Parker RK. Burr-hole craniostomy for chronic subdural hematomas by general surgeons in rural Kenya. World J Surg 2018; 42: 40 – 45.
+Newcombe R, Merry G. The management of acute neurotrauma in rural and remote locations: a set of guidelines for the care of head and...
+
+=== Chunk 3963 ===
+Source: 4105_002-ebook.pdf
+Length: 1005 chars
+
+Infection
+Aarabi B. Causes of infections in penetrating head wounds in the Iran – Iraq war. Neurosurgery 1989; 25: 923 – 926.
+Aarabi B, Taghipour M, Alibaii E, Kamgarpour A. Central nervous system infections after military missile head wounds. Neurosurgery 1998; 42: 500 – 509.
+Gönül E, Baysefer A, Kahraman S, Çiklatekerlioğlu Ö, Gezen F, Yayla O, Seber N. Causes of infections and management results in penetrating craniocerebral injuries. Neurosurg Rev 1997; 20: 177 – 181.
+Splavski B, Šišljagić V...
+
+=== Chunk 3964 ===
+Source: 4105_002-ebook.pdf
+Length: 284 chars
+
+CSF fistulas
+Management of cerebrospinal fluid leaks. Guidelines. J Trauma 2001; 51 (Suppl.): S29 – S33.
+Meirowsky AM, Caveness WF, Dillon JD, Rish BL, Mohr JP, Kistler JP, Weiss GH. Cerebrospinal fluid fistulas complicating missile wounds of the brain. J Neurosurg 1981; 54: 44 – 48....
+
+=== Chunk 3965 ===
+Source: 4105_002-ebook.pdf
+Length: 845 chars
+
+Epilepsy
+Aarabi B, Taghipour M, Gahdar AH, Farokhi M, Mobley L. Prognostic factors in the occur- rence of posttraumatic epilepsy after penetrating head injury suffered during military service. Neurosurg Focus 2000; 8 (1): 1 – 6. Available at: http://thejns.org/doi/10.3171/ foc.2000.8.1.155?mc_phishing_protection_id=28048-c7q17hv0s0veqd2nm5dg.
+Eftekhar B, Sahraian MA, Nouralishahi B, Khaji A, Vahabi Z, Ghodsi M, Araghizadeh H, Soroush MR, Karbalaei Esmaeili S, Masoumi M. Prognostic factors in the...
+
+=== Chunk 3966 ===
+Source: 4105_002-ebook.pdf
+Length: 3543 chars
+
+Chapter 27
+Adeyemo WL, Iwegbu IO, Bello SA, Okoturo E, Olaitan AA, Ladeinde AL, Ogunlewe MO, Adepoju AA, Taiwo OA. Management of mandibular fractures in a developing country: a review of 314 cases from two urban centers in Nigeria. World J Surg 2008; 32: 2631 – 2635.
+Akhlaghi F, Aframian-Farnad F. Management of maxillofacial injuries in the Iran-Iraq war. J Oral Maxillofac Surg 1997; 55: 927 – 930.
+Breeze J, Monaghan AM, Williams MD, Clark RNW, Gibbons AJ. Five months of surgery in the Multinati...
+
+=== Chunk 3967 ===
+Source: 4105_002-ebook.pdf
+Length: 834 chars
+
+Chapter 28
+Ballivet de Régloix S, Crambert A, Maurin O, Lisan Q, Marty S, Pons Y. Blast injury of the ear by massive explosion: a review of 41 cases. J R Army Med Corps 2016. [doi:10.1136/ jramc-2016-000733]
+Garth RJN. Blast injury of the ear: an overview and guide to management. Injury 1995; 26: 363 – 366.
+Kluger Y, Peleg K, Daniel-Aharonson L, Mayo A, Israeli Trauma Group. The special injury pattern in terrorist bombings. J Am Coll Surg 2004; 199: 875 – 879.
+Okpala N. Management of blast ear i...
+
+=== Chunk 3968 ===
+Source: 4105_002-ebook.pdf
+Length: 2552 chars
+
+Chapter 29
+Albert DM, Diaz-Rohena R. A historical review of sympathetic ophthalmia and its epidemiology. Surv Ophthalmol 1989: 34: 1 – 14.
+Ansell MJ, Breeze J, McAlister VC, Williams MD. Management of devastating ocular trauma – experience of maxillofacial surgeons deployed to a forward field hospital. J R Army Med Corps 2010; 156: 106 – 109.
+Biehl J, Biehl JW, Valdez J, et al. Penetrating eye injury in war. Mil Med 1999; 164: 780 – 784.
+Cho RI, Bakken HE, Reynolds ME, Schlifka BA, Powers DB. Co...
+
+=== Chunk 3969 ===
+Source: 4105_002-ebook.pdf
+Length: 3024 chars
+
+Chapter 30
+Asensio JA, Chahwan S, Forno W, et al. Penetrating oesophageal injuries: mulitcenter study of the American Association for the Surgery of Trauma. J Trauma 2001; 50: 289 – 296.
+Breeze J, Gibbons AJ, Shieff C, Banfield G, Bryant DG, Midwinter MJ. Combat-related craniofacial and cervical injuries: a 5-year review from the British military. J Trauma 2011; 71: 108 – 113.
+Breeze J, Allanson-Bailey LS, Hunt NC, Delaney RS, Hepper AE, Clasper J. Mortality and morbidity from combat neck injury...
+
+=== Chunk 3970 ===
+Source: 4105_002-ebook.pdf
+Length: 769 chars
+
+Chest tube drainage
+Aylwin CJ, Brohi K, Davies GD, Walsh MS. Pre-hospital and in-hospital thoracostomy: indications and complications. Ann R Coll Surg Engl 2008; 90: 54 – 57.
+Fitzgerald M, Mackenzie CF, Marasco S, Hoyle R, Kossmann T. Pleural decompression and drainage during trauma reception and resuscitation. Injury 2008; 39: 9 – 20.
+Griffiths JR, Roberts N. Do junior doctors know where to insert chest drains safely? Postgrad Med J 2005; 81: 456 – 458.
+Mattox KL, Allen MK. Symposium Paper: Sys...
+
+=== Chunk 3971 ===
+Source: 4105_002-ebook.pdf
+Length: 989 chars
+
+Thoracotomy
+MacFarlane C. Emergency thoracotomy and the military surgeon. ANZ J Surg 2004; 74: 280 – 284.
+Morrison JJ, Poon H, Rasmussen TE, Khan MA, Midwinter MJ, Blackbourne LH, Garner JP. Resuscitative thoracotomy following wartime injury. J Trauma Acute Care Surg 2013; 74: 825 – 829.
+Mattox KL, Pickard LR, Allen MK. Emergency thoracotomy for injury. Injury 1986; 17: 327 – 331.
+Phelan HA, Patterson SG, Hassan MO, Gonzalez RP, Rodning CB. Thoracic damage- control operation: principles, techniq...
+
+=== Chunk 3972 ===
+Source: 4105_002-ebook.pdf
+Length: 821 chars
+
+Tension pneumothorax
+Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure. Injury 1996; 27: 321 – 322.
+Inaba K, Branco BC, Eckstein M, Shatz DV, Martin MJ, Green DJ, Noguchi TT, Demetriades D. Optimal positioning for emergent needle thoracostomy: a cadaver- based study. J Trauma 2011; 71: 1099 – 1103.
+Leigh-Smith S, Davies G. Indications for thoracic needle decompression. J Trauma 2007; 63: 1403 – 1404.
+McPherson JJ, Fei...
+
+=== Chunk 3973 ===
+Source: 4105_002-ebook.pdf
+Length: 375 chars
+
+Oesophagus
+Ilic N, Petricevic A, Mimica Z, Tanfara S, Frleta Ilic N. War injuries to the thoracic esophagus. Eur J Cardiothorac Surg 1998; 14: 572 – 574.
+Popovsky J. Perforations of the esophagus from gunshot wounds. J Trauma 1984; 24: 337 – 339.
+Wu JT, Mattox KL, Wall MJ Jr. Esophageal perforations: new perspectives and treatment paradigms. J Trauma 2007; 63: 1173 – 1184....
+
+=== Chunk 3974 ===
+Source: 4105_002-ebook.pdf
+Length: 2448 chars
+
+Diagnosis, operative or selective non-operative management
+Beekley AC, Blackbourne LH, Sebesta JA, McMullin N, Mullenix PS, Holcomb JB, Members of 31st Combat Support Hospital Research Group. Selective nonoperative management of penetrating torso injury from combat fragmentation wounds. J Trauma 2008; 64 (Suppl.): S108 – S117.
+Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR, Tandoh MA, Ivatury RR, Scalea TM. Practice management guidelines for selective nonoperative management of penetrating ab...
+
+=== Chunk 3975 ===
+Source: 4105_002-ebook.pdf
+Length: 1080 chars
+
+Damagecontrol laparotomy (further references)
+Ball CG, Wyrzykowski AD, Nicholas JM, Rozycki GS, Feliciano DV. A decade’s experience with balloon catheter tamponade for the emergency control of hemorrhage. J Trauma 2011; 70: 330 – 333.
+627
+WAR SURGERY
+628
+Faulconer ER, Davidson AJ, Bowley D, Galante J. Negative pressure temporary abdominal closure without continuous suction: a solution for damage control surgery in austere and far-forward settings. J R Army Med Corps 2018; 0: 1 – 4. [doi:10.1136/...
+
+=== Chunk 3976 ===
+Source: 4105_002-ebook.pdf
+Length: 2382 chars
+
+Abdominal compartment syndrome and the open abdomen
+An G, West MA. Abdominal compartment syndrome: a concise clinical review. Crit Care Med 2008; 36: 1304 – 1310.
+Arul GS, Sonka BJ, Lundy JB, Rickard RF, Jeffery SLA. Management of complex abdominal wall defects associated with penetrating abdominal trauma. J R Army Med Corps 2015; 161: 46 – 52.
+Basu A. A low-cost technique for measuring the intraabdominal pressure in non- industrialised countries. Ann R Coll Surg Engl 2007; 89: 434 – 435.
+Burlew...
+
+=== Chunk 3977 ===
+Source: 4105_002-ebook.pdf
+Length: 1493 chars
+
+Great vessels
+Asensio JA, Petrone P, Garcia-Nuñez L, Healy M, Martin M, Kuncir E. Superior mesenteric venous injuries: to ligate or to repair remains the question. J Trauma 2007; 62: 668 – 675.
+SELECTED BIBLIOGRAPHY
+Balachandran G, Bharathy KGS, Sikora SS. Penetrating injuries of the inferior vena cava. Injury 2020; 51: 2379 – 2389.
+Feliciano DV, Moore EE, Biffl WL. Western Trauma Association critical decisions in trauma: management of abdominal vascular trauma. J Trauma Acute Care Surg 2015; 79...
+
+=== Chunk 3978 ===
+Source: 4105_002-ebook.pdf
+Length: 903 chars
+
+Liver
+Demetriades D. Balloon tamponade for bleeding control in penetrating liver injuries. J Trauma 1998; 44: 538 – 539.
+Feliciano DV, Mattox KL, Burch JM, Bitondo CG, Jordan GL Jr. Packing for control of hepatic hemorrhage. J Trauma 1986; 26: 738 – 743.
+Ivatury RR, Nallathambi M, Gunduz Y, Constable R, Rohman M, Stahl WM. Liver packing for uncontrolled hemorrhage: a reappraisal. J Trauma 1986; 26: 744 – 751.
+Discussion of the previous two papers: J Trauma 1986; 26: 751 – 753.
+Morrison JJ, Braml...
+
+=== Chunk 3979 ===
+Source: 4105_002-ebook.pdf
+Length: 403 chars
+
+Extrahepatic biliary tract
+Bade PG, Thomson SR, Hirshberg A, Robbs JV. Surgical options in traumatic injury to the extrahepatic biliary tract. Br J Surg 1989; 76: 256 – 258.
+Posner MC, Moore EE. Extrahepatic biliary tract injury: operative management plan. J Trauma 1985; 25: 833 – 837.
+Sheldon GF, Lim RC, Yee ES, Petersen SR. Management of injuries to the porta hepatis. Ann Surg 1985; 202; 539 – 545....
+
+=== Chunk 3980 ===
+Source: 4105_002-ebook.pdf
+Length: 224 chars
+
+Spleen
+Di Sabatino A, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet 2011; 378: 86 – 97.
+Pisters PWT, Pachter HL. Autologous splenic transplantation for splenic trauma. Ann Surg 1994; 219: 225 – 235....
+
+=== Chunk 3981 ===
+Source: 4105_002-ebook.pdf
+Length: 1419 chars
+
+Pancreas and duodenum
+Boffard KD, Brooks AJ. Pancreatic trauma – injuries to the pancreas and pancreatic duct. Eur J Surg 2000; 166: 4 –12.
+Degiannis E, Levy RD, Potokar T, Lennox H, Rowse A, Saddia R. Distal pancreatectomy for gunshot injuries of the distal pancreas. Br J Surg 1995; 82: 1240 – 1242.
+629
+WAR SURGERY
+630
+Degiannis E, Levy RD, Velmahos GC, Potokar T, Florizoone MGC, Saadia R. Gunshot injuries of the head of the pancreas: conservative approach. World J Surg 1996; 20: 68 – 71.
+Degia...
+
+=== Chunk 3982 ===
+Source: 4105_002-ebook.pdf
+Length: 151 chars
+
+Stomach and small bowel
+Guarino J, Hassett JM Jr, Luchette FA. Small bowel injuries: mechanisms, patterns, and outcome. J Trauma 1995; 39: 1076 – 1080....
+
+=== Chunk 3983 ===
+Source: 4105_002-ebook.pdf
+Length: 3655 chars
+
+Colon and rectum
+Angelici AM, Montesano G, Nasti AG, Palumbo P, Vietri F. Treatment of gunshot wounds to the colon: experience in a rural hospital during the civil war in Somalia. Ann Ital Chir 2004; 75: 461 – 464.
+Armstrong RG, Schmitt HJ Jr, Patterson LT. Combat wounds of the extraperitoneal rectum. Surg 1973; 74: 570 – 583.
+Bortolin M, Baldari L, Sabbadini MG, Roy N. Primary repair or fecal diversion for colorectal injuries after blast: a medical review. Prehosp Disast Med 2014; 29: 317 – 319...
+
+=== Chunk 3984 ===
+Source: 4105_002-ebook.pdf
+Length: 3071 chars
+
+Pelvis
+Adams SA. Pelvic ring injuries in the military environment. J R Army Med Corps 2009; 155: 293 – 296.
+Arthurs Z, Kjorstad R, Mullenix P, Rush RM Jr, Sebesta J, Beekley A. The use of damage- control principles for penetrating pelvic battlefield trauma. Am J Surg 2006; 191: 604 – 609.
+Ball CG, Hameed M, Navsaria P, Edu S, Kirkpatrick AW, Nicol AJ. Successful damage control of complex vascular and urological gunshot injuries. Can J Surg 2006; 49; 437 – 438.
+Celentano V, Ausobsky JR, Vowden P....
+
+=== Chunk 3985 ===
+Source: 4105_002-ebook.pdf
+Length: 694 chars
+
+Post-operative care and complications
+Hamp T, Fridrich P, Mauritz W, Hamid L, Pelinka LE. Cholecystitis after trauma. J Trauma 2009; 66: 400 – 406.
+Lindberg EF, Grinnan GLB, Smith L. Acalculous cholecystitis in Viet Nam casualties. Ann Surg 1970; 171: 152 – 157.
+Nastro P, Knowles CH, McGrath A, Heyman B, Porrett TRC, Lunniss PJ. Complications of intestinal stomas. Br J Surg 2010; 97: 1885 – 1889.
+Schein M. To drain or not to drain? The role of drainage in the contaminated and infected abdomen: a...
+
+=== Chunk 3986 ===
+Source: 4105_002-ebook.pdf
+Length: 1186 chars
+
+Kidney
+Karademir K, Gunhan M, Can C. Effects of blast injury on kidneys in abdominal gunshot wounds. Urology 2006; 68: 1160 – 1163.
+Kuveždić H, Tucak A, Grahovac B. War injuries of the kidney. Injury 1996; 27: 557 – 559.
+Master VA, McAninch JW. Operative management of renal injuries: parenchymal and vascular. Urol Clin North Am 2006; 33: 21 – 31, v – vi.
+Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, McAninch JW, Nash P, Schmidlin F. Consensus on genitourinary trauma. Evaluation and m...
+
+=== Chunk 3987 ===
+Source: 4105_002-ebook.pdf
+Length: 1531 chars
+
+Ureter
+Abid AF, Hashem HL. Ureteral injuries from gunshots and shells of explosive devices. Urol Ann 2010; 2: 17 – 20. [doi: 10.4103/0974-7796.62920]
+Al-Ali M, Haddad LF. The late treatment of 63 overlooked or complicated ureteral missile injuries: the promise of nephrostomy and role of autotransplantation. J Urol 1996; 156: 1918 – 1921.
+Azimuddin K, Milanesa D, Ivatury R, Porter J, Ehrenpreis M, Allman DB. Penetrating ureteric injuries. Injury 1998; 29: 363 – 367.
+Brandes S, Coburn M, Armenaksa...
+
+=== Chunk 3988 ===
+Source: 4105_002-ebook.pdf
+Length: 454 chars
+
+Urinary bladder
+Gomez RG, Ceballos L, Coburn M, Corriere JN Jr, Dixon CM, Lobels B, McAninch J. Consensus on genitourinary trauma. Consensus statement on bladder injuries. BJU Int 2004; 94: 27 – 32. [doi:10.1111/j.1464-410X.2004.04896.x]
+Petros FG, Santucci RA, Al-Saigh NK. The incidence, management, and outcome of penetrating bladder injuries in civilians resultant from armed conflict in Baghdad 2005 – 2006. Adv Urol 2009. [doi: 10.1155/2009/275634]...
+
+=== Chunk 3989 ===
+Source: 4105_002-ebook.pdf
+Length: 1210 chars
+
+Genitalia and urethra
+Chapple C, Barbagli G, Jordan G, Mundy AR, Rodrigues-Netto N, Pansadoros V, McAninch JW. Consensus on genitourinary trauma. Consensus statement on urethral trauma. BJU Int 2004; 93: 1195 – 1202. [doi:10.1111/j.1464-410X.2004.04805.x]
+Cline KJ, Mata JA, Venable DD, Eastham JA. Penetrating trauma to the male external genitalia. J Trauma 1998; 44: 492 – 494.
+Goldman HB, Idom CB Jr, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with ur...
+
+=== Chunk 3990 ===
+Source: 4105_002-ebook.pdf
+Length: 2772 chars
+
+Chapter 34
+Ahmed AM, Sabrye MH, Baldan M. Autotransfusion in penetrating chest war trauma with haemothorax: the Keysaney Hospital experience. East Cent Afr J Surg 2003; 8: 51 – 54.
+Baldan M, Giannou C, Rizzardi G, Irmay F, Sasin V. Autotransfusion from haemothorax after penetrating chest trauma: a simple life-saving procedure. Trop Doct 2006; 36: 21 – 22.
+Brown CVR, Foulkrod KH, Sadler HT, Richards EK, Biggan DP, Czysz C, Manuel T. Autologous blood transfusion during emergency trauma operations....
+
+=== Chunk 3991 ===
+Source: 4105_002-ebook.pdf
+Length: 1374 chars
+
+Enteric contamination
+Bowley DM, Barker P, Boffard KD. Intraoperative blood salvage in penetrating abdominal trauma: a randomised, controlled trial. World J Surg 2006; 30: 1074 – 1080.
+Due TL, Johnson JM, Wood M, Hale HW Jr. Intraoperative autotransfusion in the management of massive hemorrhage. Am J Surg 1975; 130: 652 – 658.
+GIover JL, Smith R, Yaw PB, Radigan LR, Bendick P, Plawecki R. Autotransfusion of blood contaminated by intestinal contents. J Am Coll Emerg Phys (Ann Emerg Med) 1978; 7: ...
+
+=== Chunk 3992 ===
+Source: 4105_002-ebook.pdf
+Length: 1577 chars
+
+Chapter 35
+Andersson P, Muhrbeck M, Veen H, Osman Z, von Schreeb J. Hospital workload for weapon-wounded females treated by the International Committee of the Red Cross: more work needed than for males. World J Surg 2018; 42: 93 – 98.
+Buchsbaum HJ. Diagnosis and management of abdominal gunshot wounds during pregnancy. J Trauma 1975; 15: 425 – 430.
+635
+WAR SURGERY
+636
+Grabo DJ, Schwab CW. Trauma in Pregnant Women. In: Peitzman AB, Schwab CW, Yealy DM, Rhodes M, Fabian TC, eds. The Trauma Manual: ...
+
+=== Chunk 3993 ===
+Source: 4105_002-ebook.pdf
+Length: 2385 chars
+
+International humanitarian law
+Customary International Humanitarian Law. Chapter 39, Rule 134. Women: The specific protection, health and assistance needs of women affected by armed conflict must be respected. Available at: https://ihl-databases.icrc.org/customary-ihl/eng/docs/ v1_cha_chapter39_rule134.
+Durham H. Women, armed conflict and international law. International Review of the Red Cross; 2002: 84 (847): 655 – 660. [doi: S1560775500090416]
+Gardam JG. Femmes, droits de l’homme et droit int...
+
+=== Chunk 3994 ===
+Source: 4105_002-ebook.pdf
+Length: 3053 chars
+
+Chapter 36
+Aarabi B, Alibaii E, Taghipur M, Kamgarpur A. Comparative study of functional recovery for surgically explored and conservatively managed spinal cord missile injuries. Neurosurgery 1996; 39: 1133 – 1140.
+Alaca R, Yilmaz B, Goktepe AS, Yazicioglu K, Gunduz S. Military gunshot wound-induced spinal cord injuries. Mil Med 2002; 167: 926 – 928.
+Comstock S, Pannell D, Talbot M, Compton L, Withers N, Tien HC. Spinal injuries after improvised explosive device incidents: implications for Tacti...
+
+=== Chunk 3995 ===
+Source: 4105_002-ebook.pdf
+Length: 1735 chars
+
+Spinal immobilization (additional references)
+Cornwell EE, Chang DC, Bonar JP, Campbell KA, Phillips J, Lipsett P, Scalea T, Bass R. Thoracolumbar immobilization for trauma patients with torso gunshot wounds: Is it necessary? Arch Surg 2001; 136: 324 – 327.
+Haut ER, Kalish BT, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE, Chang DC. Spine immobilization in penetrating trauma: more harm than good? J Trauma 2010; 68: 115 – 121.
+Inaba K, Barmparas G, Ibrahim D, Branco BC, Gruen P, Redd...
+
+=== Chunk 3996 ===
+Source: 4105_002-ebook.pdf
+Length: 2040 chars
+
+Management of spinal cord patients
+American Spinal Injury Association. Dedicated website; for learning materials see: https://asia-spinalinjury.org/learning/.
+Burgdörfer H, Heidler H, Madersbacher H, Kutzenberger J, Palmtag H, Pannek J, Sauerwein D, Stöhrer M. Manual Neuro-Urology and Spinal Cord Lesion. Guidelines for Urological Care of Spinal Cord Injury Patients 4th edition. Cologne: German Working Party on Urological Rehabilitation of Spinal Cord Injury Patients; 2007.
+Consortium for Spinal ...
+
+=== Chunk 3997 ===
+Source: 4105_002-ebook.pdf
+Length: 4860 chars
+
+Part F
+Adler D, Mgalula K, Price D, Taylor O. Introduction of a portable ultrasound unit into the health services of the Lugufu refugee camp, Kigoma District, Tanzania. Int J Emerg Med 2008; 1: 261 – 266. [doi 10.1007/s12245-008-0074-7]
+American Thoracic Society. Fair allocation of intensive care unit resources. Am J Respir Crit Care Med 1997; 156: 1282 – 1301.
+Dünser MW, Baelani I, Ganbold L. A review and analysis of intensive care medicine in the least developed countries. Crit Care Med 2006; ...
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