Twenty-one-year experience with land mine injuries

Land mines produce devastating injuries which are usually fatal. In Guantanamo Bay, there have been no survivors from close range, functioning antipersonnel mines of the M-16 series. All 15 antipersonnel mine fatalities suffered extremity amputation. Seven of the 15 patients suffered immediately fatal head, neck, or truncal injuries (Type I injury). The three patients who underwent hospital resuscitation had extremity amputation but were spared major head, neck, or truncal injury. It is in this group of injured that potentially salvageable patients can be identified; for them aggressive rescue and resuscitation must be performed. Those with Type II injuries are the highest priority in any triage plan. In a mass casualty or combat casualty scenario, Type II patients, in particular those with high bilateral above-the-knee amputations, may be reassigned to an expectant treatment category so as to allow the main focus on more salvageable patients. The prehospital management plan emphasizes rapid assessment and triage of patients, use of tourniquets to control extremity hemorrhage, supplemental oxygen or endotracheal intubation if possible, neck immobilization, use of the extremity section of the pneumatic antishock garment if applicable, and rapid transport to a hospital. Hospital management of these patients emphasizes aggressive resuscitation, early endotracheal intubation, and rapid volume replacement with simultaneous balanced salt solution and blood. Operative debridement with broad-spectrum antibiotic coverage and tetanus prophylaxis is performed; wounds are managed in an open fashion and frequently examined at subsequent dates in the operating room.