Wound Complications from the Tsunami Disaster: A Reminder of Indications for Delayed Closure

Abstract

Objectives: To illustrate the character, clinical course and late complications of wounds caused by high energy with severe contamination during a natural disaster, as a basis for designing principles for primary treatment under these conditions.

Patients and methods: This paper presents case reports from complicated wounds treated at a specialized unit for wound management in a hospital receiving patients after transfer from primary to definitive treatment.

Results: Of the Swedish citizens evacuated from the disaster zone in Thailand after the tsunami disaster in 2004, 174 of those arriving at Stockholm Airport were referred to the Karolinska Hospital for treatment, of whom 75 were admitted. Forty of the patients admitted were seen by the surgeons at the Department of Plastic and Reconstructive Surgery because of complicated wounds requiring special treatment. Fifteen of these could be treated as ambulatory patients and 25 required hospitalization for a mean time of 10.5 days (range 1-48). The majority had multiple injuries, 93% on the lower limbs and 47% on the upper limbs. The majority had been primarily closed at primary treatment. Treatment strategies included removal of all sutures, wound excision, secondary healing (38/40, 95%), delayed primary closure (40/40, 100%), vacuum-assisted closure (VAC) (3/40, 8%), splitthickness skin grafts (23/40, 58%), pedicled perforator flap (1/40, 2%) and free flap (1/40, 2%). Amputation was requested in two cases. Aside from long-lasting psychological sequelae and varying degrees of physical disability, unusual late infections occurred with progressing and migrating abscesses. Cultures and skin biopsies from these revealed both mycobacteria and pigmented fungal hyphae.

Conclusions: The patterns of injury and clinical courses in these patients illustrate the risk of complications in wounds caused by high energy, with severe contamination and which arrive late for primary treatment by staff who are not fully aware of the risk of secondary complications under these conditions. Recommendations for primary treatment should include extensive cleaning, excision of dead tissue and delayed primary closure, according to the well-established principles of management of war wounds, where the conditions are similar.

Keywords: Flap; Mycobacteria; Plastic and reconstructive surgery; Skin graft; Trauma.