The ICRC Approach to War Wounds:
Adam L. Kushner
Introduction:
Henry Durant, Gustave Moynier, Louis Appia, Theodore Maunoir and Guillaume-Henri Dufour founded
the International Committee of the Red Cross (ICRC) in 1863. The original name of the organization was the
International Committee for Relief to Wounded Soldiers. The ICRC’s mandate currently covers all victims of
war: the wounded, shipwrecked, prisoners, and civilians. These principles are based on the Geneva
Conventions of 1949 and the 1977 additional protocols. According the Dr. Remi Russbach, former Chief
Medical Officer of the ICRC, “providing direct surgical care for victims of war, whether combatants or civilians,
has occupied an increasingly important place in ICRC activities over recent years.”1 In accomplishing these
tasks, the ICRC has become the premier international organization providing medical facilities and surgical
treatment to vast numbers of combatants and civilians in war torn countries throughout the world. ICRC
delegates do not discriminate between combatants and aim at providing the highest quality care to all in
need. The standards and principles in managing war wounds as developed by the ICRC are important for
all personnel who may be treating victims of war. This paper will highlight the various aspects of war wound
management as developed by the experts of the ICRC.
Under international law, the treatment of war wounded is the responsibility of the warring parties. In many
situations, however, local facilities and capabilities are so significantly overwhelmed and degraded that the
ICRC is frequently compelled to assist with medical supplies, personnel or entire surgical facilities. During
the late 1980’s the increase in number of conflicts and resulting ICRC interventions resulted in the number of
wounded patients admitted to ICRC hospitals increasing from 4,000 in 1987 to 23,000 in 1994.2 Twenty-two
surgical facilities in countries ranging from Cambodia and Afghanistan to Sudan and Gaza have assisted
victims of war. ICRC involvement varies according to the local needs.3 Surgical units may operate entirely
under ICRC authority or ICRC surgical teams may work in government-run hospitals where local services are
provided by the host government.
The basic principles adhered to at all ICRC facilities include: no weapons or political activity in the
hospital, and no discrimination against enemy wounded. ICRC surgical facilities function as self-contained
units, providing first aid as well as definitive care; evacuation or referral is not readily available in these
situations.
Relatively few personnel staff ICRC hospitals. Usually two to four surgical teams consisting of a surgeon,
an anesthetist and theater nurse, and a head nurse, a physiotherapist and a medical administrator work
along with locally recruited personnel. The surgical equipment and medications are standardized. No
sophisticated equipment such as automatic respirators, monitors or ECG machines is used. A laboratory is
present for blood transfusions, hemoglobin, hematocrit, cross matching, screening for hepatitis, HIV, syphilis
and malaria, and urine analysis. Limited radiographic equipment provides for simple x-rays of limbs, thorax
and abdomen. Prosthetic workshops are frequently attached to the hospital.
Studies show that approximately two-thirds of war wounds are to the extremities, including simple or
multiple soft tissue injuries, open fractures or traumatic amputations.3 Transport time to medical treatment is
important in the proportion of differing types of injuries. With longer transport times, fewer patients with
thoracic, abdominal and cranial injuries survive long enough to reach definitive care. The causes of war
wounds vary according to the type of combat. Injuries may be due to fragments from bombing or shelling,
bullets, or anti-personnel landmines. Fragments and shrapnel usually account for a majority of injuries.
According to the ICRC medical division, the central issue for the doctor faced with the victim of a mine, a
bullet or a metallic fragment injury is the wound: what to do about it and how to treat it.1
Overview Issues:
First Aid and Triage:
The treatment of war wound depends upon the effectiveness of first aid, the speed of evacuation, the
availability of staff and equipment and the competence of the surgeon. Triage is the principle of achieving
the “best for the most.”4 Decisions must be made to assess patients according to their wounds and then
group them into priorities for treatment.
It is important to establish a triage area close to the hospital entrance but accessible to radiology and the
operating theater. Equipment must be available to assist with determining the severity of wounds and for
initiating first aid and resuscitation efforts. One person must be in charge of triage and in ICRC hospitals, the
head nurse usually undertakes this. Difficult decisions on priorities for treatment necessitate that all
personnel are mentally prepared and aware that the most severely wounded may not be their top priority.
All patients need to be clearly marked with ( I ) for highest priority, ( II ) for lowest priority and ( III ) safe to
wait for surgery. “ A patient with a hopeless prognosis uses valuable time, energy and skill in the operating
theatre, while another case for whom surgery could be life saving has to wait and may lose the chance.”5
The process of sorting and prioritizing must continually be reevaluated as some patients initially felt to be
inoperable may improve, while other felt to be stable may deteriorate. The importance of having a triage
plan can not be underestimated.
To begin the initial assessment all of the victim’s clothing should be removed and vital signs (blood
pressure, heart and respiratory rate) recorded. Level of consciousness, surgical emphysema in the neck
and chest, abdominal distension and tenderness need to be noted. The fundamental principles of airway,
breathing and circulation need to be strictly adhered to with maintaining a patent airway, arresting
hemorrhage and replacing lost intravascular volume with fluid. The administration of penicillin and anti-
tetanus prophylaxis should be given routinely.
Wound Classification:
The ICRC developed a classification of war wounds based upon features of the wound and not the
weapon.6 The system scores wounds based upon the size of the entry (E) and exit (X), whether there is a
cavity (C), a fracture (F), or a vital structure injured (V), and the presence or absence of metallic foreign
bodies (M). This scoring system provides data that is useful for wound assessments, establishing a scientific
basis to war surgery, surgical audits and for facilitating wound data collection from the field.
An Epidemiological Approach to Wound Management:
Dr. Robin Coupland of the ICRC in Geneva wrote of an epidemiological approach to war wounds.7 His
approach is based upon lessons he learned from the field, including:
(1) Many patients even with severe injuries do not necessarily require surgery to survive many days or even
weeks.
(2) Appropriate surgical skill and equipment are difficult to import and may not be usable under difficult or
dangerous conditions.
(3) Inadequate surgery is worse than nothing.
(4) A basic level of nursing care could achieve much.
By seeing that many patients with severe injuries had to wait many days for surgery and that only those with
massive multiple wounds died he learned that:
(1) Intravenous fluids and antibiotics buy time for most patients.
(2) Patients with severe life threatening injuries die despite treatment unless resources, the number of
nursing staff, and the organization of the hospital infrastructure are adequate.
(3) When the hospital infrastructure is disrupted, surgical resources are easily wasted by operating on
patients whose prognosis is hopeless-underlining the importance of realistic triage for treatment-and the
death rate is unacceptably high among those who should survive.
Coupland noted that many patients are admitted to ICRC hospitals days or even weeks after wounding and
that spontaneous healing of large wounds is common. Providing an airway, fluid resuscitation, arresting
hemorrhage and tube thoracostomy, may prevent early deaths. Later deaths may be avoided by preventing
infective complications by the use of antibiotics, wound excision, correct amputation or laparotomy for
perforation alone. “A surgical facility is expensive, requires an enormous input of staff relative to the number
who benefit from it, and is a form of aid that must be delivered on an individual basis...[W]hen there is limited
resources or difficulty of access to a conflict zone, a surgical action alone might be inappropriate because
many more lives are saved by providing clean drinking water, food, and shelter or by merely protecting the
population’s access to health services that would otherwise be denied.”7 This approach to victim
assistance allows for the greatest proportion of the wounded to benefit from the limited resources and
surgical care available in most conflict situations.
Specific Management Issues:
According to the ICRC, “the work of the doctor is to arrest hemorrhage, repair vital structures, or restore
vital function, and in all cases to prevent infective complications. War wounds are produced by fragments of
metal, bullets or blast from mines. All are contaminated to a variable degree by bacteria from clothing, skin,
and the environment. There is no uniform wound; the volume of dead and contaminated tissue varies. This
tissue is a potential culture medium. It is the removal of this variable volume of dead and damaged tissue,
involving different structures and in different locations, which is difficult and new for the doctor unused to
dealing with such cases.”8 The next sections will highlight some of the major ICRC principle of managing war
wounds.1,8,9,10
Wound Excision:
War wounds are often multiple and involve varying amounts of soft tissue. The treatment of these soft
tissue injuries requires a two step procedure: wound excision and delayed primary closures. Wound excision
involves completely cutting away dead and damaged soft tissue that may be contaminated with bacteria and
other debris. It is imperative to leave only health tissue with a good blood supply. Incisions to expose wound
should be generous and facial compartment may need to be decompressed by a fasciotomy. All dead
muscle, which is not health and red, which does not contract or bleed must be excised.
The edges of the wound should be retracted and dirt, debris, clot and missile fragments removed. The
wounds need to be irrigated and explored. Metallic fragments may be let in place, however, all fragments of
clothing, dirt and vegetation must be removed. Simple through and through wounds of the extremities in
which there is minimal soft tissue damage do not require exploration, unless there is significant damage to
major vessels.
All wounds should be left open with the following exceptions:
(1) Face, neck, scalp and genitals. May close primarily.
(2) Soft tissues of chest wall. The skin is left open.
(3) Head. Close dura if possible.
(4) Hand. Left open for delayed primary closure. Tendons and nerves must be covered.
(5) Joints. Synovial membranes should be closed.
(6) Blood vessels. Vessels repaired or vein grafts should be covered by viable muscle.
After a wound has been adequately excised, a dry dressing is used to cover it. The wound should not be
packed tightly, as this will inhibit the outflow of fluid. These dressings should not be removed until the patient
is again in the operating theater for delayed primary closure. Only if patient appears toxic or the wound
appears grossly infected and further excision is required should the dressing be removed early.
Delayed Primary Closure:
If an adequate wound excision has been performed then simple approximation of the deep structures and
skin can be safely undertaken. This procedure, delayed primary closure (DPC) is done within seven days of
injury. There must be no evidence of residual infection or contamination. If significant tissue loss does not
allow for a tension free closure, then DPC can not be achieved and skin grafts or musculocutaneous flaps
may be required.
All dead space within the wound must be closed and absorbable sutures can be used to approximate
deep structures. Tension on the wound that will result in local ischemia must be avoided as this may lead to
a wound infection and non-healing. Drains are to be avoided if possible or else removed within 24 hours. All
doctors working with war wounded patients should be comfortable with techniques of skin grafting including
split thickness and full thickness grafts. After the wounds are closed, a dry dressing should cover them until
it is time to remove the sutures.
Infection
All war wound are considered contaminated with will become infected unless surgical wound excision is
accomplished quickly. Delay in treatment allows for invasive infections and increases the likelihood of
complications. The major bacterial contaminants in war wounds are:
(1) Gram-positive cocci: Staphylococcal and streptococcal infections.
(2) Gram-negative bacilli: E. coli, Proteus, Klebsiella, Pseudomonas and Bacteroides.
(3) Gram-positive bacilli: Clostridia species. (gas gangrene)
Penicillin is the drug of choice and the major efforts are directed at preventing gas gangrene.
Prophylaxis is recommended for 5 days with the patient taking oral doses as quickly as possible. It must be
remembered, however, that despite the value of antibiotics, they are not a substitute for sound surgical
principles such as adequate excision, fecal diversion or drainage.
All war wounded are at risk for tetanus; however, the risk is reduced by early and adequate excision of
devitalized tissue and by leaving the wound open. All patients should receive a tetanus toxoid vaccine and
with injuries presenting after a delay, anti-tetanus immunoglobulin should be administered.
A high index of suspicion must taken for gas gangrene. Delays in treatment are the major factors in war
wounds. The sudden onset of pain, edema and drainage from the wound, along with marked tachycardia
without severe pyrexia and the patient’s clinical deterioration, must be recognized and treatment started
immediately. Treatment involves the urgent surgical excision of all dead and devitalized tissue and the use
of penicillin.
Neglected and Mismanaged Wounds:
Long delays before treatment and mismanagement of wounds are frequent in war situations. In a study
of war wounds in Afghanistan, “the team saw results of suturing war wounds and field laparatomies along with
catheter tubing in penetrating chest wounds, chicken skin dressings, and the parenteral administration of
steroid, vitamin and antibiotic cocktails.”9 Proper management entails surgical wound excision and removal
of all sutures no matter the appearance. Surgical excision is more difficult in these cases with the distinction
between viable and on-viable tissue being blurred. All non-viable tissue must be removed. Wounds should
be dressed and antibiotics administered, as for any other wound; however, these cases have a higher
incidence of wound infection and the need for repeat excisions. Most of these wounds heal by secondary
intention, as delayed primary closure is usually unsuitable.
Conclusions:
The vast experience of ICRC surgeons with many missions in war-torn countries has led to the development
of surgical principles for the care of wounded victims of war. These principles represent the collective
knowledge and experience of many dedicated professionals. Aside from the technical ability and resources
to properly care for the victims of war, their care involved many people working within a system. Teamwork
and cooperation are essential. The ultimate aims of war surgery are to save life and limb, avoid infectious
complications and minimize residual disability. These aims can be attained only by strictly following the basic
principles of wound management: complete wound excision, delayed primary closure, antibiotics and anti-
tetanus vaccine.
The proper equipment, staffing and security are essential components to undertaking successful
management. The ICRC highlights three qualities particularly need by personnel working in their hospitals:
professionalism, sound judgement, and adaptability.8
1. Gray R, War Wounds: Basic Surgical Management, International Committee of the Red Cross, 1994.
2. Russbach R, Gray RC, Coupland RM, ICRC Surgical Activities, www.icrc.org, 13 September 1998.
3. Mulli JC, Surgical Activities in War Zones: The experience of the International Committee of the Red
Cross (ICRC), www.icrc.org, 13 September 1998.
4. Gray R, Surgery of War and Disaster, Tropical Doctor, 1991, 21 (suppl 1) 56-60.
5. Coupland RM, Parker PJ, Gray RC, Triage of War Wounded: The Experience of the International
Committee of the Red Cross, Injury, 1992; 23 (8): 507-10.
6. Coupland, RM, The Red Cross Classification of War Wounds: The E.X.C.F.V.M. Scoring System, World J
Surg, 1992; 16: 910-17.
7. Coupland RM, Epidemiological approach to Surgical Management of the Casualties of War, BMJ, 1994;
308:1693-7.
8. Dufour D, Kroman Jensen S, Owen-Smith M, Salmela J, Stening GF, Zetterstroem B, Surgery for Victims
of War, International Committee of the Red Cross, 1998.
9. Coupland RM, Howell PR, An Experience of War Surgery ad Wounds Presenting after 3 days on the
Border in Afghanistan, Injury, 1988; 19: 259-262.
10. Coupland RM, Techical Aspects of War Wound Excision, Br J Surg, 1989, 76: 663-667.