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- •Contents
- •Reference
- •Preface
- •The Editors
- •List of Contributors
- •Introduction
- •What Makes Conflict or Disaster Surgery Different?
- •Humanitarian or Conflict Response Categories
- •Laws of Conflict
- •Am I Ready for Deployment Within a Resource-Limited Environment?
- •2. Patterns of Injury
- •Contents
- •Energy Release Processes
- •Bombs
- •Projectile Injury
- •Knives (and Fragments)
- •Blast Effects on the Human Body
- •Echelons and Roles of Medical Support
- •Evacuation Chain Between Roles or Echelons of Care
- •Blast Effects in Vehicles
- •Blunt Impact
- •Burns
- •Deliberate Acts
- •Domestic Explosions
- •Industrial Activity and Explosive Storage
- •The Natural World
- •The Effect of High-Strain Rate on Biological Materials
- •Bone
- •Skin
- •Conclusion
- •Acknowledgements
- •Further Reading
- •3. Damage Control Resuscitation
- •Damage Control Resuscitation (DCR) in Resource-Limited Environment
- •Haemostatic Resuscitation
- •Damage Control Surgery
- •Monitoring
- •Further Reading
- •Haemorrhage
- •Treatment Options in the Prehospital Arena
- •Whole Blood
- •Packed Red Blood Cells
- •Plasma
- •Crystalloids
- •Colloids
- •Tranexamic Acid
- •How Do I Stop Thinking About the Future and Treat the Patient Now?
- •Whenever Shock is Diagnosed, Administer Tranexamic Acid (TXA)
- •Key Points
- •Further Reading
- •5. Point-of-Care Ultrasound
- •Introduction
- •Resource Limitation Concern
- •Brief Review of Material
- •Resource-Limited Environment Pocus
- •E-Fast
- •How to Perform the Exam
- •RUSH (Rapid Ultrasound for Shock)
- •Pump Evaluation
- •Tank Evaluation
- •Pipe Evaluation
- •Optic Nerve Sheath Diameter (ONSD)
- •Other POCUS Range in the Resource-Limited Environment
- •Ten Resource-Limited Environment POCUS Key Points
- •Further Reading
- •6. Thoracic Injury Management
- •Introduction
- •Left Anterolateral Thoracotomy
- •Clamshell Thoracotomy
- •Cardiac Injuries
- •Hilar Injuries
- •Pulmonary Injuries
- •Posterior Mediastinal Injuries
- •Aortic Control
- •Tracheobronchial Injury
- •Oesophageal Injury
- •Combined Tracheobronchial Injuries
- •Clamshell Thoracotomy and Exposure of Arch Vessels
- •Closure and Drains
- •Anterolateral Thoracotomy
- •Clamshell
- •Additional Reading
- •Focal Repairs
- •7. Junctional and Extremity Vascular Trauma
- •Epidemiology
- •Presentation and Initial Workup
- •Pathology
- •Considerations for Vascular Surgery in Austere Conditions
- •Priorities in the Multiply Injured Patient
- •Injury Diagnosis and Imaging
- •Surgical Equipment and Supplies
- •Orthopaedic Injury
- •Vascular Damage Control
- •Vein Injury Management
- •Fasciotomy
- •Postoperative Assessment and Monitoring
- •General Vascular Reconstruction Techniques
- •Vascular Control
- •Injury Exposure
- •Thrombectomy and Anticoagulation
- •Interposition and Bypass Grafts
- •Tissue Coverage
- •Common Vascular Exposures and Reconstructions
- •Upper Extremity
- •Key Points
- •Further Reading
- •Introduction
- •Who Needs Damage Control Surgery?
- •Damage Control Laparotomy
- •The Venue
- •Patient Position
- •The Technique
- •The Incision
- •Once Inside
- •Then What?
- •Total Haemorrhage Control
- •The Retroperitoneum
- •Hollow Viscus Injury
- •Other Important Injuries Not to Miss
- •At the End of Damage Control Surgery Stage I
- •Additional Reading
- •Introduction
- •Pelvic Anatomy and Haemorrhage
- •Damage Control for Pelvic Haemorrhage
- •Technique of Pelvis-Only Extraperitoneal Pelvic Packing
- •Technique of Extraperitoneal Pelvic Packing via the Abdomen
- •Other Strategies
- •Additional Reading
- •10. Abdominal Injuries
- •Resource Limitation Concerns
- •Brief Review of Material
- •How to Do It?
- •Aortic Control
- •Abdominal Compartments
- •Liver
- •Liver Suturing (Deep Suture Repair)
- •Omental Plugging (Packing)
- •Local Haemostatic Agents
- •Hepatic Balloon Tamponade
- •Spleen
- •Mesentery
- •Retroperitoneal Haemorrhage
- •Major Abdominal Vascular Injuries
- •Kidney
- •Diaphragm
- •Pancreas
- •Hollow Viscus Injuries
- •Oesophagus
- •Gastric Injuries
- •Duodenum
- •Small Bowel
- •Colon and Rectum
- •Urinary Tract Injuries
- •Ten Key Points
- •Further Reading
- •11. Acute Care Emergency Surgery
- •Resource Limitation Concerns
- •Acute Appendicitis
- •Procedure
- •Hernia
- •Umbilical and Paraumbilical Hernia Repair
- •Inguinal Hernia Repair
- •Right Hemicolectomy
- •Surgical Considerations
- •Left Hemicolectomy
- •Stoma Formation
- •Perforation of Gastric and Duodenal Ulcers
- •Operative Versus Non-operative Management
- •Further Reading
- •Introduction
- •Anatomical Considerations
- •Physiological Considerations
- •The Initial Assessment
- •Airway
- •Breathing
- •Circulation
- •Vascular Access
- •Fluid Resuscitation
- •Disability
- •Exposure
- •Imaging
- •Assume Every Child Is Sick
- •Tranexamic Acid (TXA)
- •Massive Transfusion
- •In the Operating Room
- •Further Reading
- •Damage Control Principles
- •Resource Limitation Concerns
- •Procedures
- •Wound Incision
- •Wound Excision
- •Amputation
- •Application of Splints and Casts
- •Upper Extremity
- •Lower Extremity
- •Application of Traction
- •Application of Extremity External Fixation
- •Upper Extremity
- •Lower Extremity
- •Application of Pelvic External Fixation
- •Key Points
- •Further Reading
- •Cranial Trauma
- •Introduction
- •Considerations
- •Common Cases and Treatment
- •Blast Injury
- •Ballistics
- •Closed Head Injuries
- •Spinal Trauma
- •Introduction
- •Military Versus Civilian
- •Spinal Column Injury
- •Spinal Cord Injury
- •Key Points
- •Further Reading
- •Resource Limitation Concerns
- •Step-by-Step Procedures
- •Exsanguinating Haemorrhage
- •Airway Provision
- •Step-by-Step Procedure 1: Surgical Cricothyroidotomy
- •Cervical Spine Immobilisation
- •Management of Facial Haemorrhage
- •Step-by-Step Procedure 2: Arresting Facial Bleeding by Nasal and Oral Packing
- •Damage Control Surgery for Penetrating Neck Injury
- •Investigations of Penetrating Neck Injury
- •The Use of Neck Zones
- •Zone 1 Injuries
- •Zone 2 Injuries
- •Zone 3 Injuries
- •Surgical Treatment of Penetrating Cervical Vascular Injury
- •Step-by-Step Procedure 3: Access to the Common Carotid Artery in Neck Zone II
- •Surgical Treatment of Laryngotracheal Injuries
- •Surgical Treatment of Oesophageal Injuries
- •Soft Tissue Facial Trauma
- •Imaging of Facial Fractures
- •Internal Fixation of Facial Fractures
- •External Fixation of Facial Fractures
- •Ten Key Points
- •Further Reading
- •Introduction
- •Recognise That Ocular Pathology is Present
- •History
- •Examination
- •Inspect the Eyes
- •Closed Globe Injury
- •Orbital Compartment Syndrome
- •Visual Acuity Is Tested as Follows
- •Pupils Are Tested as Follows
- •Chemical Injury
- •Orbital Compartment Syndrome
- •Open Globe Injury
- •Hyphaemia
- •Retinal Detachment and Dialysis
- •Closed Globe Injuries After Refractive Surgery
- •Understand How to Safely Temporise and Package Serious Ocular Pathology
- •Chemical Injury
- •Orbital compartment syndrome
- •Open Globe Injuries
- •Closed Globe Injuries
- •Retinal Detachments
- •Closed Globe Injuries After Refractive Surgery
- •Understand Some of the Issues Around Prolonged Care of Eye Injuries, Including the Effect of Delay and the Risk of Sympathetic Ophthalmia
- •Further Reading
- •Introduction
- •Tissue Response to Injury
- •Debridement
- •Extension Lines
- •Fasciotomy of the Extremities
- •Overview
- •Resource Limitation Concerns
- •Diagnosis
- •Surgical Technique
- •Foot
- •Thigh
- •Hand
- •Dorsal
- •Palmar
- •Digital
- •Forearm
- •Burns
- •Overview
- •Resource Limitation Concerns
- •Acute Management
- •Airway
- •Breathing
- •Circulation
- •Disability
- •Exposure
- •Fluids
- •Adjunctive Measures
- •Dressings
- •Burn Excision
- •Electrical Burns
- •Chemical Burns
- •Peripheral Cold Injury
- •Overview
- •Resource Limitation Concerns
- •Clinical Presentation
- •Assessment
- •Management
- •Plastic Surgery Reconstructive Elevator
- •Principles
- •Skin Grafts
- •Types
- •Local Flaps
- •Vascularity
- •Composition
- •Method of Movement
- •Procedure and Equipment Details for Local Skin Flaps
- •Suggested Reading
- •Resource Limitation Concerns
- •Limitations of Diagnosis
- •Limitations of Treatment
- •Bone Conducting Hearing Systems
- •Knowledge Update (Brief Review of Material)
- •Key Concepts
- •Further Reading
- •Introduction
- •Haemorrhage
- •Management
- •Hypertensive disorders
- •Sepsis
- •Abortion
- •Obstructed Labour
- •Caesarean Section
- •Indications
- •Techniques
- •Postoperative Care
- •Caesarian Section for Breech Delivery
- •Types and Definitions
- •Key points:
- •Further Reading
- •Index


Fundamentals of Frontline
Surgery


Fundamentals of
Frontline Surgery
Edited by
Professor Mansoor Khan
Consultant Oesophagogastric, General and Trauma Surgeon, Honorary
Clinical Professor of Trauma Surgery, Brighton and Sussex University
Hospital, Brighton, UK
Surgeon Commander Royal Navy (Retired)
and
Professor David Nott
Professor of Humanitarian Surgery, Imperial College London
Consultant Vascular, General and Trauma Surgeon. St Mary’s Hospital,
Paddington, London, UK

First edition published 2021
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742
and by CRC Press
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
© 2021 Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, LLC
This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been
made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or
liability for any errors or omissions that may be made. The publishers wish to make clear that any views or opinions expressed
in this book by individual editors, authors, or contributors are personal to them and do not necessarily reflect the views/
opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific, or
health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their
knowledge of the patient’s medical history, relevant manufacturer’s instructions, and the appropriate best practice guidelines.
Because of the rapid advances in medical science, any information or advice on dosages, procedures, or diagnoses should be
independently verified. The reader is strongly urged to consult the relevant national drug formulary and the drug companies’
device or material manufacturers’ printed instructions and their websites, before administering or utilising any of the drugs,
devices, or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or
suitable for a particular individual. Ultimately, it is the sole responsibility of the medical professional to make his or her own
judgments, so as to advise and treat patients appropriately. The authors and publishers have also attempted to trace the
copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in
this form has not been obtained. If any copyright material has not been acknowledged, please write and let us know so we may
rectify in any future reprint.
Except as permitted under US Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in
any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying,
microfilming, and recording, or in any information storage or retrieval system, without written permission from the
publishers.
For permission to photocopy or use material electronically from this work, access www.copyright.com or contact the
Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. For works that are not
available on CCC please contact mpkbookspermissions@tandf.co.uk
Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for
identification and explanation without intent to infringe.
Library of Congress Cataloging‑in‑Publication Data
Names: Khan, Mansoor, 1977- editor. | Nott, David (David M.), editor.
Title: Fundamentals of frontline surgery / edited by Professor Mansoor Khan and David Nott.
Description: First edition. | Boca Raton : CRC Press, 2021. | Includes bibliographical references and index. |
Summary: “Fundamentals of Frontline Surgery is an easy to read text, written by world class faculty, that provides clinicians
with succinct and didactic information about what to do in high intensity, resource limited situations. With global conflicts
and humanitarian emergencies on the rise, there has been a dramatic uptake in the number of volunteers for both military and
humanitarian operations. This manual aids best practice and fast decision making in the field”‐‐ Provided by publisher.
Identifiers: LCCN 2020035126 (print) | LCCN 2020035127 (ebook) | ISBN 9780367435592 (paperback) | ISBN
9780367437497 (hardback) | ISBN 9781003005469 (ebook)
Subjects: MESH: Surgical Procedures, Operative | Wounds and Injuries‐‐surgery | Armed Conflicts | Disasters | Developing
Countries | Health Resources
Classification: LCC RD31 (print) | LCC RD31 (ebook) | NLM WO 500 | DDC 617.‐‐dc23
LC record available at https://lccn.loc.gov/2020035126
LC ebook record available at https://lccn.loc.gov/2020035127
ISBN: 978-0-367-43749-7 (hbk)
ISBN: 978-0-367-43559-2 (pbk)
ISBN: 978-1-003-00546-9 (ebk)
Typeset in Sabon
by MPS Limited, Dehradun

‘Ut alii vivant’
(So others may live)


Contents
Forewords ix
Preface xi
Editors xiii
Contributors xv
1 The Resource-Limited Environment 1
Mansoor Khan and David Nott
2 Patterns of Injury 7
Danyal Magnus, Katherine A. Brown, Mansoor Khan, and William Proud
3 Damage Control Resuscitation 25
Mark Midwinter
4 No Blood . . . What to Do? 31
Avi Benov, Roy Nadler, Avishai M. Tsur, Ori Yaslowitz, Andrew P. Cap,
Mark H. Yazer, and Elon Glassberg
5 Point-of-Care Ultrasound 37
Carlos Augusto M. Menegozzo and Bruno M. Pereira
6 Thoracic Injury Management 45
David R. King and James V. O’Connor
7 Junctional and Extremity Vascular Trauma 63
David S. Kauvar and Mohammed Mar’ae Asieri
8 Trauma Laparotomy and Damage Control Laparotomy 83
Carrie Valdez and David Nott
9 Damage Control for Severe Pelvic Haemorrhage in Trauma 91
Kristin Hummel and John H. Armstrong
10 Abdominal Injuries 99
Viktor Reva and Boris Kessel
11 Acute Care Emergency Surgery 119
Marcelo A.F. Ribeiro and Mansoor Khan

viii Contents
12 Frontline Consideration for Paediatric Emergency and Trauma Surgery 131
Nicholas Alexander
13 RLE Orthopaedic Injury Management 137
Jowan Penn-Barwell and Daniel Christopher Allison
14 Neurotrauma in the Field 151
Kevin Tsang
15 Management of Ballistic Face and Neck Trauma in an Austere Setting 163
Johno Breeze
16 Management of Ophthalmic Injuries by the Forward Surgical Team 175
Richard J. Blanch, Johno Breeze, and William G. Gensheimer
17 Resource-Limited Environment Plastic Surgery 187
Johann A. Jeevaratnam, Charles Anton Fries, Dimitrios Kanakopoulos,
Paul J.H. Drake, and Lorraine Harry
18 Acute Acoustic Trauma and Blast-Related Hearing Loss 213
Jameel Muzaffar, Christopher Coulson, Jonathan D.E. Lee, and Linda E. Orr
19 Obstetrics in Limited-Resource Settings 223
Carlos Pilasi Menichetti and Rebekka Troller
Index 235

Forewords to Fundamentals of
Frontline Surgery
Victims of armed conflict deserve the best trauma care
possible. They already endure too much misery.
Traditionally, humanitarian assistance has not excelled
in the quality of care delivered. Good intentions are not
good enough. Austere environments do not justify
assistance with limited resources or poor skills. If a
deployment for assistance is undertaken, there should
be a well-prepared team, with the necessary skills, and
the equipment as required.
Currently, there is a clear picture of the minimum
requirements for emergency medical teams in disasters
and conflicts. The (regrettable) experience of our
military medical colleagues in recent conflicts has
changed the concept of trauma care. Over the past
10 years, there have been good examples of sharing this
military medical experience with humanitarian actors.
The WHO Emergency Medical Team project, with
professional input from humanitarian, military, and
academic colleagues, has now defined these
minimum requirements, and is in the process of
verifying that emergency medical teams meet these
standards. Patients with injuries from armed conflict
and natural disasters do require a different approach
as compared to trauma management ‘at home’.
Additional training of the surgical teams is
required. The book in front of you, Fundamentals
of Frontline Surgery, will be an important tool for
colleagues who would embark on humanitarian
assistance or on military deployments. Extensive
field experience of the international faculty is
shared in this book, and thus, you will be able to
identify your skill gaps, and act on it, before going on
a mission.
On behalf of your future patients, I hereby thank
you for your efforts in making good preparations for
a mission, and optimising the assistance you will
deliver. The victims deserve it!
Harald Veen, FRCSEd
Humanitarian and Conflict Surgeon
The end of the combat operations in Iraq and
Afghanistan provided a sense of relief to all who
bore the burden of those wars. However, the return
to a period of relative peace can have the insidious
effect of eroding the knowledge base and
operational skills needed to manage the first
casualties of the next war. This has been referred
to as the peacetime effect.
surgical currency for future casualty care, there is an
abundant need for proficiency in managing those
who are ill or injured around the world as a result of
political unrest, cross-border conflicts, natural
disasters, poverty or a combination of these
situations.
In this context, the editors of Fundamentals of
Frontline Surgery have assembled a comprehensive
set of exceptionally informative chapters that
represents a weighty contribution to mitigating the
peacetime effect. Professors Khan and Nott have
combined decades of their own patient care
experiences in resource-limited settings with their
international prominence to provide a timely
resource that is practical and straightforward to
read, and that is addressed to all levels of training
and experience. The range of topics explored in the
textbook stretches from managing common injury
patterns, to treatment of non-traumatic lifethreatening conditions, to tips on the use of basic
diagnostic tools and simple lifesaving maneuvers.
The opening chapter, entitled ‘The Resource
Limited Environment’, is written by the editors and
provides a strong foundation for the remainder of
the book’s content. In their opening, Professors
Khan and Nott ready the reader with an overview
of the utility of various echelons of care, the
categories of humanitarian response and the laws
of conflict. The subsequent chapters, written by
seasoned, international experts, build upon the
book’s opening to provide a resource that is a
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