Ukraine/Triaj Blast Injury Protocol Presentation

Now, for, for those of you that are from Ukraine and may not speak English, don't worry about trying to write anything down. We have this translated, the entire presentation translated into Ukraine. So I would just listen, uh, look at some of the, uh, diagrams I'm gonna show you, and then we will make available through these two associations, the presentation that I'm gonna make today. We'll try to get it to you today or tomorrow, um, which would be easier for you. The the the just let me tell them that uh the tea sankyo the team slide the the new kraskuyo uh remote uh the uh now reinskimovioma may my file wisdom. OK, thank you. Well, thank you. No, good, Yuri, that's very good. You, you, you go ahead and bounce in whenever you think it's uh the appropriate time. The The important thing here is that we want to give you the general concept. And I, my name is Martin Eichelberger. I'm a pediatric surgeon at the Children's National Medical Center in Washington DC. I have been there for almost 40 years and uh my expertise is in injuries, injuries to children, burns, and general pediatric surgery. But the one thing I think that's important for you to know is that in general, this is probably one of the most complex injuries to, to, to treat as you go forward. And one of the things you have to do is get used to thinking about the physiology first because you're gonna be distracted by many of the anatomic injuries that these kids sustained. So if you don't forget, if you don't remember anything else, just remember these three things that are critical. One is that you, you want to avoid hypothermia. Two, you wanna make sure that the patient uh doesn't end up in an acidotic state, which is very difficult when you're trying to restrain the amount of fluid that you're giving patients. And then the other problem is you want to avoid hypercoagulation. Those are, that's called the, the, the, uh, death tri triad, the death triad. So you wanna make sure that that doesn't happen. I'm gonna give you examples of these as we go forward here. The other part of this is that the best treatment you have is to stop the bleeding in the patient. Most of the time, you can do this in the field with a tourniquet or your hand, uh, or have the patient themselves hold pressure on whatever is bleeding because that leads to hypothermia, acidosis, and hypocoagulation. The other part of it is remember that as the patient comes into your facility, you're thinking damage control. You're not trying to make everything perfect at the beginning. And it gets Complicated if you try to solve every problem and, and fix every issue that the patient has at that time. I personally try to limit myself to no more than 30 minutes in the operating room uh with these children. So you're gonna be dam doing damage control surgery, and you're gonna hold back on the fluids. You do not want to give these patients too much fluid or hold off as much as you can, Yuri. You wanna say something, Yuri? No, no, don't continue. That's quite understandable even in English, OK, so the other, the other issue that becomes very important is you gotta keep in your mind that the final common pathway of a lot of these injuries is the lung, and things happen during barrel trauma that have a direct impact on the lung, which makes it very difficult for you to actually maintain the patient's physiology. One of the things that these kids have is have a very hard, a large head compared to their uh surface area of their body, very narrow, uh, between the, the belly button and the, and the spine and foreshortened extremities. So those are anatomic areas that have an impact on how you're gonna take care of this child. When you have an explosion or a blast injury, The part of the patient's body that's facing the blast is gonna have the biggest impact. The interesting thing about this is there's some significant injuries without any evidence of an injury, so that you, the barrel trauma, the kinetic energy that's transferred to your body may have no evidence that there is some problem with the head. Now, it's a little different if it has a penetrating injury, because you can see all this debris that gets mobilized, and at the same time, as you go through the, the pressure itself can cause a contracoup injury to the brain with a contusion, uh, or the fact that you're gonna have one of these missiles hit you, or that you're gonna fall and have a blunt injury at the same time. So you have a multitude of different mechanisms of injury. The fascinating thing about the blast injury is that in the initial blast, you have a very high increase in the um The pressure And what that does is it, it, it really collapses everything in your body. If you're standing there, you're, that barrel pressure collapses most of the organs of your body, and then there's an expansion, so it expands. So anything that's got air in it, like the intestines, your middle ear, um, your bladder, all of these things have this compression and then expansion. And the problem with that is you can have a perforation of the bowel, and it would be Not evident for the 1st 24 to 48 hours. So what I'd like to do is show you this video, and uh what I want you to focus on here is this truck. Uh, this is an improvised explosive device that was used in Afghanistan. You can see the people sitting here, the car, see the trees, and you can see that what the, what the, these individuals would do was plant the IED and then take a video of it for propaganda purposes, and we got a hold of one of these. So I want you to take a look at this. Um, I can, can you see the motion? Yeah, I want you to keep an eye on this area, this area right here. When that truck gets here, uh, you're gonna see an explosion, and it's really to give you an idea of what the miserable situation is when they come into your hospital or in the field when you have to go to resuscitate them. So, what we've tried to do is to get people to understand what the mechanism of injury, cause then it, it helps explain the different types of injuries that you have to be looking for. So you can see these people right here just getting in and out of a car, and so you can see all of the all of the material there. This is noxious fumes, it's got all kinds of chemicals in it. It's hot, and you can see the amount of blast that goes in one of these IEDs. So, you can break it down into 4 components. Just the barrow trauma itself. Many of the patients have a tympanic membrane perforation, so they came, came in and you're examining them, make sure you look in their ears because they have problems with that. You can see most people out there that are in our combat environments are, are wearing glasses or some kind of a shield. The reason is because the explosion, uh, you can lose, you can have a foreign body get into your eye, so. That's one of the reasons you see that the penetrating injuries with the lacerations and amputation, the blunt injuries, I call your attention to the compartment syndrome. Compartment syndrome is what you see in extremities, and we'll talk a little bit about that going forward. What I also want to do is to try to make a linkage here so that when I give you a demonstration of the of the uh triage 2.1, you'll have an understanding of how we've taken this information and put it on the app itself. And then the other have to, you have to be ready for burns and inhalation injuries. And most people are not comfortable with burns, so there, that has to be addressed as you go forward. Unfortunately, the kids with all the munitions that are all over the Ukraine right now, they use that as a playground. And so what you're gonna end up seeing is kids stepping on landmines, or they're having, they're in the target range of whatever artillery or missile that's coming in. So these things happen without any, any knowledge. The explosion and then the contraction creates a significant amount and every one of these kids have different problems with their age, weight, type of thing. So this child was involved in a, in a blast, and you can see the shrapnel in his face, so he was pretty low, low to the ground, and uh the shrapnel that went off created a burn, as well as a pulmonary injury that required uh the treatment. This youngster was actually stepped on a landmine, and what you end up with a landmine is that every injury that you have comes up from the, from the top, comes up from the bottom. So could you, uh, if somebody's on, could you put yourself on mute? Thank you. So in this kind of a situation, this is a situation where you want to put a tourniquet on this child. You wannaka a second. You want a victor Chibulaka microphon chef of my futureni book Alexia and Blaskayakoyo. Thank you. So when you go to these tourniquets, when you put them on, you can see the amount of shrapnel and the injuries. A lot of times they're open wounds. You want to put it proximal or close, just above the, the place that's, that's really bleeding, and you can see these are specialized tourniquets that the, that the military uses. I, I don't think it's necessary for you to worry too much about that, uh, but you could use a belt, you could use a sheet, a towel, anything with pressure, you could, you could use your hand. Uh, but I think when you transfer the patient with this kind of a Device on, you wanna make sure you immediately you know there's a vascular injury. So when you get into the resuscitation bay, that's when you want to take it off, because then you can get it under control. You can get the vascular control on this. If a lot of people are worried about tourniquets, but if you don't put a tourniquet in, the survival is just, it, it, it's almost, it's zero. If you put the tourniquet on, you can see the survival, uh, goes up significantly. So, don't be worried about using a tourniquet, uh, in the field, especially most of the military, uh, at least in the US military, they carry tourniquets in their pocket. So that they can put it on each other when the when the blast injury occurs, so we can really save a lot of lives. The other thing is, let me, let me comment on that. We have actually been really, really good, uh, in this situation, uh, and the medics and the army has been really, really good in teaching the soldiers to put the tourniquets on each other, and it's been saving lives of our soldiers. And we actually have really good tourniquets, so most of them we bought from the west, but um it's, it's actually been, it's, it's true for us too. Well, that's excellent. That's excellent, cause that, that's a simple thing that you can do to avoid that triad that we talked about, the acidosis, hypothermia, and hypercoagulation. Those maneuvers are very, very important, and they have evolved, uh, because many people did not use tourniquets before, during the beginning of the Afghan war, and now, it's a, it's a standard practice. So, don't be afraid to use it. Thank you very much, Yuri. Uh, the other part of this is be careful on, on the amount of fluid that you give these patients. And what you really wanna do, I, I, I personally, uh, think that we, you do a 1 to 1 to 1, uh, resuscitation cause I like the idea of putting fresh frozen plasma and platelets in as well as packed red blood cells. Whole blood is really good. The problem is it's hard to get, and secondly, it's hard to get right to the point where you need it. So, If you don't remember anything else I tell you, don't give him too much fluid. Be really careful with the amount of fluid that you're giving it, because that fluid is going directly into the lung because of the barrel trauma. The other way, the other thing that's really important is the fact that if you have a blast injury, it's very important to intubate the patient and probably do bronchoscopy. The bronchoscopy will give you an opportunity to clean out the area or to decide that there's alveolitis in the region or what level of injury that you have starting right off the bat because it's gonna change over the next 24 hours. If you don't have a bronchoscope, then intubate the patient and be very gentle when you're doing the suction. And avoid a tracheostomy. A tracheostomy is a problem because you, it's very difficult to manage in a child, actually with any patient, and the other part of it is you're gonna manipulate the, the pulmonary airway multiple times. The other thing is, if you have a child that comes in after a blast injury and he happened to be 100 yards away or 200 yards away, don't send that child home. Because what happens is that these injuries take 24, 48 hours to evolve. So you might want to keep them, watch them, because of the fact that their respiratory rate goes up, and all of a sudden now after 24 hours, uh, they have to be intubated. So, they look normal at the beginning, but it, when you have the barrel trauma, it injures all the cells of the body, not just one, everything. And so they tend, especially as you start to get more fluid to the patient, all that stuff tends to expand. And now you have a reactive edema that you now have in the lung where you can't ventilate for the child, so be very cautious about that. The other part of this is, uh, we've gotten to the point now where if you listen to the patient's chest and you, you have no air, you have no breath sounds, put a chest tube in. Do not get a chest X-ray. Do not send them to the, to the CT scan. Just put the chest tube in and do it on both sides. And this is, these are, these are the kinds of things that save lives. You can always take the chest tube out. The problem is if you take that child to X-ray and they have a pneumothorax, and they end up having a, a, uh, uh, tension pneumothorax, they're gonna die. So don't do a chest X-ray, don't do anything, just put the chest tubes in. And that will help, uh, if, especially like if you have a decrease in the blood pressure, you, you don't, you don't see any bleeding, and there's a decrease in the blood pressure. Think about listening to the chest, chest, and put the chest tube of the uh chest tubes on both sides that will expand the lung, and all of a sudden your blood pressure comes back. These are the problems you have in, in a combat or open injuries is that there's a lot of exposure of the patients. You can see with the intestines being operated on here, it's very easy to drop their temperature. So you have to have somebody, usually an anesthesiologist or a resident or a nurse, making sure they're keeping track of what the temperature is on, on the child. OK, so, one of the things we did with the triage app that hopefully I'll show you is to try to put this information so that you can have it immediately. It's hard to remember all this information, but we've created a checklist that you can use, and it will take you through the processes and the judgments that you need to make right at the beginning. So this is the type of patient that you're gonna end up with. You got a patient who's now got a head injury and you can't see very well, but he's got, uh, ocular injuries. He's got, he, he required a midline laparotomy for for an exploration. He's got shrapnel wounds, and which is important. See, all these little shrapnel wounds suggest that there may be penetration of the abdomen, and if you, I personally, I'm very aggressive. If I really think. And he's got tenderness, then I usually go ahead and operate on him to make sure in this kind of an environment now, an explosion injury environment. You can see he stepped on a landmine and lost his extremity here, and he's got a fracture in this leg, and it's very, you gotta be careful with wrapping this up too tight and making it look too good, because what happens is they develop compartment syndrome. Uh, my guess is he's probably got a tibial fracture, and that's even worse. So you've got to be thinking about the fact that the pressure is gonna increase in all components or all compartments of the body. So if you have a head injury, and I'm gonna just quickly go through this, I can give you some more information, uh, through some of the, we have a very good presentation on head injuries, uh, for children, but the biggest pitfall that you have is the delay in swelling, and when you do get a CT scan, it generally is uh, it doesn't show how serious the injury really is. It, it, the first CT scan is, is gonna look better than it does in 2 days. Yeah, go ahead, Yuri. Uh, before going to the head, I'm just having a question. If you have lack of resources, no CT scans and all of that, and, uh, let's say there's sharp, shrapnel, and, and they're not acute situation, you know, 24, 48 hours later, you think of abdominal perforation. Have you tried using, uh, laparoscopy or you just go open? Personally, in a, in this kind of an environment, I go open. I think it's too much trouble to set everything up. If you have that equipment, fine, you know, but in most, most combat environments, you don't have that kind of equipment. I mean if you already in the hospital 24 or 48 hours later, right, after the onset of acute period, I, I think, I think that's your choice. I mean, I, if you're in a hospital and the, and the patient looks like you could use the, you could use it, the only problem I don't like about it is the amount of inflating pressure you have on the lungs, and if you have an injured lung, it makes it even worse. So yeah, that's what I'm asking you on the inflating. That's why I'm asking. I, I personally would operate on the patient. I wouldn't use laparoscopy. Uh, I, I, you know, that, that's something you can do if you're used to doing it every day, but if you're not doing it every day, do what you know. That's the simplest and the best, because as, as a, a patient who has surgery, if you're doing that kind of surgery every day, that's one thing. So it depends on you as an individual. I'm not saying absolutely don't do laparoscopy. I'm not saying that. I'm saying if you feel comfortable, you can do it. The problem I have with that is that with you shrapnel injuries, you don't know where the injury is gonna be, you know, it's like a gunshot wound. Um, so, you, you have, you have one chance to do it correctly. And remember, it's not about the abdomen, it's about the entire physiology of the patient. And generally, the focus is on the head and on the chest. That's where you have your, your problem. And if you happen to have a neurosurgeon, that simplifies some of the, some of the problems, uh, but I'm gonna get into that here in a second, uh, as to what you wanna do. So the reality of it is that you wanna maintain their, their cerebral, uh, profusion pressure. You wanna maintain around 60 tor, uh, and that's hard to do. So you gotta maintain the blood pressure and the ICP pressure. So you want, you want the ICP pressure at a normal range, uh, usually, you know, less than 20 something like that. And then the surgery, once, once you've taken this patient and you think that you've done everything you can do, I mean, doing some simple things like just putting the um sedation of the patient, maintaining their, their pain, um, getting their head elevated about 45 degrees off of the, off of the uh horizon, um, keeping them normal thermic, not letting them get cold. Uh, ventilating them, and then, um, you know, making sure that their sodium and their, their, uh, hematocrit are in reasonable range. You can hyperventilate them, but I don't think you should do too much of that. Uh, the other is to paralyze the patient. If the patient's intubated and you have the capacity to paralyze them, I think that's a critical thing. Elevate the head, paralyze them, and, uh, give them some pain medication cause that will bring down the ICP. And then the hypertonic solution uh allows you to put fewer cc's of, of uh liquid into the patient, and it's very effective. And then the final option that you have, I mean, I'm assuming now that you, you can have, you have a device that you can measure the endocranial pressure. If you don't, then you just have to do it clinically. I mean, I wouldn't worry, I wouldn't worry too much about it if you don't have it. I mean, the best you can do is to treat the patient clinically and examine the patient. Um, and you can tell by looking at their, their eyes and, and profusion as to whether or not you're doing well. They start to, I don't think, I don't think, I don't think any hospital in Ukraine has the ICP monitors. I, I've never seen them. OK. Well, I, I think that that's, that makes it, you know, using the, the simple observation is an important thing. I mean, I, I personally like that more than I do the ICP numbers. Um, I'd rather examine the patient and make sure that, uh, I keep track of it. So that means you gotta examine the patient multiple times. Do you agree with that, Yuri? Yeah, I, I think a good care is always important. Yeah, exactly, exactly. So I'm, I'm trying to, I'm trying to be basic about this. I'm not trying to be sophisticated cause the hospitals that I, I've been in hospitals where they're, they're not adequate, uh, equipment for caring for the patient, and that's just the way it is, and the key is that you gotta do the best you can cause you've gotten to the point where there's so much monitoring your device, you forget to examine the patient. So I think you really need to spend time by the bedside if you've got a patient that's got this kind of an injury, um. So, let's go. So I told you about the hypertonic saline, the mannitol. Uh, if you're increased, your pressures are going so high and you can't control the patient, one of the things you can do is a craniectomy, uh, which has been It's been used in multiple situations. This youngster, uh, is pre-op, uh, and you can see it looks like his, he has some upper, uh, injury here. He's also got pulmonary injury and he's got an injury to his head. So this youngster, unfortunately, had a penetrating injury. You can see over here on this side, uh, this is his nose up here, but he had a penetrating injury, uh, that looks, doesn't look too bad. The problem is the pressure is high, so he was taken, you can see there's no bone between here and here. You have this big open area, so this, which was the first CT went to this, and so you can see by taking this off, it relieves the pressure on this. And you have to just make sure that you cover this, uh, if you can do this. Do they have neurosurgeons, uh, Yuri, one or two neurosurgeons in, uh. Yeah, yeah, each hospital, each hospital has neurosurgeons, adult and pediatric. It's, it's a, it's a good service right now. Well, that's good. So the craniectomy, I, I've like that. I've, I've seen several patients say, uh, when we thought that the patient was gonna die because we did the craniectomy. And when you do it, this is the, this is the cranium, uh, you can see the dura right here. The dura has to be open widely. You don't wanna open it, drain the blood, and then put this back without opening up the dura, because they're gonna increase and they're gonna expand, and that's what you're looking for. You want the expansion of the brain because it will contract back over a period of time. So the others, let's talk about the lung here real quick. Um, you, I've, I've talked a lot about the fact that you got a lot of hemorrhage and, and edema, as well as the fact that you get pulmonary contusions because of the barrel trauma. So, generally speaking, using Keep sedation, uh, keeping the title volumes, uh, you know, at a normal rate using neuro muscular blockade. It's almost like treating the helm, the head. Hold on, hold on, hold on a second. turn your legs out yours now you got from your microphone. Thank you. The other thing that's, that's sometimes is useful is the oscillation, oscillator to cut, cut down on the pressure, um, because of the, uh, hemorrhaging through the lung or it can, it can increase the pressure, uh, to stop some of the bleeding without too much, uh, too much damage to the lung. So here's a youngster who was involved in a blast, and you can see that the youngster had a chest injury, has a mark over the abdomen. When the patient first came in, this is the way the chest X-ray looks. This is the left side. This is the right side. You can see that the heart has shifted way over. Uh, the esophagus is bowed out, and you have a big tension pneumothorax. So this child would not have done well sending him to, to X-ray. You just put a chest tube in. You have to believe in yourself and your physical findings. And when you do that, it straightens everything up. The heart goes back to normal, the, the esophagus back in the midline, and you can see the diaphragms nicely now without any pressure on them. So, the problem that what you really have is when the patient comes in with all these little pun punctate wounds. There's, there's debris in there. So, the question is, did any of these penetrate? Because if they did, it can create vascular injury, bowel injuries, uh, that type of thing. So you have to clean this up. And then decide whether you think it has penetrated it. Generally, the, you know, the diaphragm goes way down here, so it may be they have a the pneumothorax is because of this penetration of the shrapnel. So, We also have to be concerned about the fact that the smoke and the noxious chemicals that you saw, you can imagine inhaling that material, and so if people come in with soot on their on their mouth, or they're spitting up um debris that looks black. And those are the ones that you really definitely have to take, take the operating room and make sure that you do a bronchoscopy to clean all that out, because you know it's hurt, number one, it's burned, it's like a, a, a carbon monoxide injury, and this only gets worse if you give him too much fluid. So you have to hold back on the fluid. You want to keep the urine output in these kids, generally speaking, around 1 cc per kilo. I would be OK with a 0.5 cc per kilo, and then, and then slowly base it on what kind of injury you're seeing. Uh, and then the other is that you get, everybody sees the patient that's got a blood pressure that's very low, and they start putting a lot of fluids into them because they wanna get the, the, uh, the hematocrit count back up. Uh, you gotta be careful with that. And so what you really want. to do is you want to be very, very gender, uh, allow the patient's hemoglobin to be, you know, in the, in the 7 to 9 range. Uh, I'm OK with a very low hemoglobin, uh, and so consequently, you don't want, you, you're not looking for perfection here. You're looking for just adequate to keep them going. Cause if you don't, here's the patient's heart right here. This is the left side, this is the right side, the patient's looking up, here's the sternum. What happens is, this is all pulmonary contusion here. And you can compare it to the normal lung over here. So this child is not for using this lung at all on this side. And so one of the things that happens is that you don't want air going into the poor side of it. So one of the things that you can do is you can actually take a tube that's got a Special tube here to, to really actually ventilate only one lung. And I've actually seen It almost looks like a Foley catheter, doesn't it? Uh, you can actually put a Foley catheter down here if you don't have one, if you don't have one of these tubes, and blow it up slowly, and then you can do bronchoscopy or you can ventilate the patient. So, I saw one of these when I was in Sri Lanka, and it was a young surgeon who said, that's all I had, and I knew that things were really bad, and the he saved the patient's life. This is what, this is a thoracotomy. This is a chest incision here. Uh, the patient's head is up here to the top part, feet are down here. He's facing, uh, this way, and you can see the way the lung looks. This lung is really, really damaged. It's really hurt. You can see the normal lung down here and the contrast. There's a lot of blood in this, so you can't ventilate them. You can't get the oxygen into that portion of the lung, so that's why you want to bypass it if you can. This is the way it looks. If you're looking at a microscope, you got all this blood, you can see the bronchioles and the alveoli are all obstructed, uh, so, you, you have a real problem, uh, with these kids. The other thing is that sometimes you ventilate the patient, over ventilate them. You can see the patient's abdomen is distended here. So what you want to do here, and I'm gonna show you a photo in a second, but I usually make an incision halfway between the belly button and the, and the xiphoid. I make a little longitudinal incision, and I put a chest tube in. I just put a chest tube in, and then I put it to water seal, because generally speaking, it's because the peep is so high that they're dissecting this through the mediastinum into the abdomen, and you get this big dilatation that then creates this problem. You can see the diaphragm up here, and here, this happens to be the liver, believe it or not, so that you've got this compression from below, making it so you can't ventilate the patient. It's a simple step, you know, the problem is you put a needle in there. You're gonna have to go back several times to do it. Just put the chest tube in there, put it to water seal, and you're done, and it works like a charm. I don't know how many, I don't know how many ICU doctors have called me and said, come in here and just put this chest tube in, will you please? They never saw it until I did it once. And you can see here, here's the, the heart. This is the spine. This is the abdomen. You can see all this perforation of the stomach caused this particular injury. You can't even get a, you can't get the nasal gastric tube down. So when you start to put it in and it doesn't go, don't push it. All right. The abdomen itself, uh, in general, we talked a little bit about that with, um, I don't know whether you use fast or not, but I use my hand, uh, when I, when I'm trying to do an examination of the patient. Um, if If you're in the operating room for 30 minutes only doing damage control, you wanna do a colostomy. If there's any question in your mind, do a colostomy and be very careful fixing any enterotomies because the barrel trauma and the pressure, they tend to, it tends to be worse than you think. So don't try to fix it and then exclude the duodenum as best you can, uh, which is a, a, a, a challenge with plenty of drainage. So this patient here had a midline incision. You can see he had a significant injury here to this portion of the wall, and we put, I know a lot of you guys, a lot of you do not have access to the um commercial VAC system, but with 30 minutes only in the operating room, you wanna put a vacC in here and you want to get out. Uh, as soon as you stop the bleeding, even if you have to pack it, pack the quadrants. And make sure that the patient has got hemostasis as best you can, then get out. And then I, I, there, by the way, there's a video I'm gonna show you, uh, that has a way to just use whatever you've got in the operating room. Um, I mean, that's the way I think about it now because sometimes you don't even have it, have the commercial available in the operating room to make that happen. So, this patient had the vac placed, um, and this happened to be one we had. You can see that all the petechia here, and he's got a colostomy now, and he's, and the rest of it is just just stapled over the top and just dropped it in to leave it there. Cause remember, you got 30 seconds, I mean 30, uh, 30 minutes. The extremities, this is the other problem you're gonna see that's gonna distract you because they're horrible-looking wounds. Just remember, put a tourniquet on it. That's just start with that. And then you can figure out whether or not, uh, the patient needs, uh, anything done. And, and the key here is when you've got a vascular injury in the femoral area, don't let the orthopedic surgeon talk you into allowing him to go first to fix the bones. Fix the arterial injury with a shunt. Don't spend half an hour, take 5 minutes to put a shunt in, and those shunts really work well, and then you go back 6 to 8 hours later and do the vascular repair. So don't spend a half hour doing the, the fracture, allowing the compartment to swell up, which by the way, if any patient comes in with a blast injury, having had any kind of injury to the extremities, make sure you're thinking compartment syndrome right off the bat. This is a youngster that stepped on a landmine, and you can see, uh, that's his belly button, that's his scrotum, his legs are going up on both sides. He's got this huge injury because this blast came up from below, very common in kids, because they're going to step on landmines that people planted those, you know, that shouldn't be there. So, the way I like to deal with this is I like to put the vac on it. I generally do debridement of the wound. I use a warm saline. I just debride it conservatively. I don't try to take everything off. I just try to get, get it down to some superficial bleeding, but not much. And then I put the vac on, and you can make a vac out of just about anything. If you've got sponges in the operating room, just pull the sponge off of whatever the, the brush side of it, and just collect a lot of those, put them on top of it, put er form or some, some Vaseline type material, and then put the suction device on there and leave it for 2 or 3 days, then go back to the operating room and take it off. It works great. It really does, and it contracts this wound down, and then you put a skin graft on top of that. This is the other type of injury you're gonna see. Um, so what's the first thing you're gonna think about with this kid? Blood loss and compartment syndrome. So, this looks like a horrible wound. This is not a time to be fixing all this. This is a time to stop the bleeding, debride this wound. If they can put up an external fixator, that's fine. If they don't, just put it in a splint, but don't wrap it very tight, because what you wanna do is be able to know that there's a, there's a pulse in the distal portion of the extremity, and then you can daily go by. If that pulse goes away, to be honest with you, I think this patient is probably gonna need a four-compartment, um, fasciotomy and decompress it. And the other option you have is to do an amputation, and most people don't like to do this because they think that they can save the extremity. Uh, so, I personally, I tend to wait a little bit, but at the same time, you don't want the compartment syndrome to get you to the point where the patient is not going to survive. So, in this day and age, you've got a child who's got an amputation. There's a lot of technology now where these kids can actually walk very, very well, and I've seen that, which is just fabulous. I mean, I, I have a couple of patients that actually played various sports, uh, who, who had bilateral amputations. One kid played, played football. The other thing is the burns. Uh, I'm not gonna go through this, this with you, uh, but you, you, you, I use the Parkland formula. I, I like it because it's controllable. Uh, I like Ringer's lactate because it doesn't create a problem for you. Other people like other systems. But the most important thing in the, in the Parkland formula is that you're gonna take the weight times the percent burn, and it's, most of these people, this usually shows up as 4 cc's on this. I tend to compute it out at 2 cc's when I've got a, a, a blast injury or any injury where I'm concerned about putting too much fluid on board. So, you can always put more on, you know, if you have a, a child who, uh, you put, use 2 ccs per kilo in this equation, and they need more, you can add it. But if you start at 4 cc's, it's hard to get it off, uh, because the kidneys are not perfusing generally well, you know, the Lasix that you use sometimes doesn't work, so. This is a youngster who was involved in stepping on a landmine. You can see the, the, the, the scar. Uh, you can see we've already done a fasciotomy on both sides of these kids, and this is just through the skin. Uh, but you can see, she didn't even need to be intubated at this point. Uh, but she underwent because she basically, there's no sensation, uh, when you have a full thickness burn. So a lot of these things can be done. I usually like to use the electric cautery so they cut down some of the superficial bleeding that goes on. And if you have a burn in the back, I use the vac. Um, I, I put the, I just clean it up and then put the vac on it with some er form, wait a day or two, go back, and then put the graft on after that, whenever I think the wound looks the best. And remembering a lot of this is gonna be fluid problems at the beginning, so you want to do as little as you can, uh, to keep that under control. So, it's important to do a rapid resuscitation on the, the patient, uh. Your blood pressure, everybody keeps worried about the blood pressure. Keep it low, so that you don't give them a lot of fluids. Remember, you, you can always take, you, you can't take the fluid back, you can do it a little bit at a time, so do it incrementally, don't do it all at the same time. It means you gotta watch the patient, you gotta be there, you gotta examine the patient. So if you got a patient with this kind of injury, you gotta be by the bedside. This is not something you can be on the phone talking to a resid, um. The other is you wanna, you wanna debride it, irrigate all the wounds, you wanna explore aggressively. That's why if it looks to me like this kid has had barrel trauma, and he's got tender abdomen, I'm gonna operate on him. Um, because I gotta make sure that there's not something there, and remembering that 24 hours afterwards, 24 to 48 hours, is when an ischemic small bowel will perforate. So Just because they don't have it on day one, doesn't mean they're not gonna have it on day 3. So you have to be very, very careful about that. The other thing I like to do, if I'm really, I think the child's really in bad shape, the anesthesiologist is having trouble controlling the child, the temperature's down, they're not peeing. I just pack everything, pack all the quadrants, pack the pelvis. There's a video, by the way, on the app about uh pelvic fractures and and packing the pelvis, it works great. So, those are the techniques that I would, that I would use. And As soon as somebody says there's a, there's a patient with a blast injury coming in, or you're out there in the field, remember these things, the airway edema, the amount of the acute respiratory distress, distress syndrome. Sometimes you have nothing in the abdomen. The abdomen swells up and, and gives you a compartment syndrome. So that's the kind of patient that you either wanna put the chest tube in or put a, uh, a vac on, which I would probably do, cause you can always go back, OK? And the other is the, the compartment syndrome to make sure that you've, you've thought about that whole approach. So, with all of this, this is a very complicated patient, uh, what I wanted to do was to just give you an idea of what the triage app will do for you. Uh, it will take this 6 year old who's 21 kg, who's had a blast injury, and it auto-populates their care from resuscitation all the way through discharge. And what it does is it tells you all the details under each one of these verticals as to how to take care of the patient.