Table IV.

Surgical care

Surgical care	Facility level
	PH C	First- level	Referr al	Tertia ry
External hemorrhage control with direct pressure	E	E	E	E
Appropriate tourniquet application and time keeping	E	E	E	E
Vessel ligation	I	E	E	E
Vascular anastomosis	I	D	E	E
Damage control shunting*	I	E	E	E
Fasciotomy (all sites)*	I	E	E	E
Debridement of mangled extremity	I	E	E	E
Local debridement of ulcer	D	E	E	E
Exposure and operative management of peripheral vascular Injuries*	I	E	E	E
Exposure and operative management of central vascular injuries	I	D	E	E
Damage control amputation (e.g., Guillotine, through joint)	I	E	E	E
Digital amputation	I	E	E	E
Ray amputation	I	D	E	E
Trans-metatarsal amputation	I	D	E	E
Below-knee amputation*	I	E	E	E
Above-knee amputation*	I	E	E	E
Non-damage control upper-extremity amputation	I	D	E	E
Visceral or peripheral thromboembolectomy*	I	E	E	E
Visceral or peripheral endarterectomy	I	I	D	E
Vein harvest and grafting*	I	E	E	E
Peripheral bypass	I	I	D	E
Carotid endarterectomy	I	I	I	E
Surgical management of varicose veins and chronic venous insufficiency	I	I	D	E
Elective abdominal aortic aneurysm repair	I	I	I	D
Arteriovenous fistula or graft for vascular access	I	I	D	D
Peritoneal dialysis catheter placement	I	I	D	E
Staged subcutaneous excision underneath flaps	I	I	D	D
Subcutaneous excision and SSTG resurfacing for chronic lymphedema	I	I	D	D
Central venous catheterization	I	D	E	E
Arterial pressure monitoring	I	I	D	D
Negative pressure wound management	I	D	E	E

PHC – primary health center; SSTG – split-thickness skin graft; PHC – outpatient clinics, staffed by non-physicians; First-level hospital – typically staffed by general practitioners, may or may not provide surgical services; Referral hospital – typically staffed by specialists, usually including a general surgeon; Tertiary hospital – offer a wider range of specialists, and laboratory and imaging capabilities; Resource designation at a particular level: E – essential; D – desirable; I – irrelevant (i.e. resource not considered to be available at the particular level even with full resource availability);

^*Procedure requires moderate skill and should be considered essential only at well-functioning first-level hospitals (and higher levels) where a surgeon or at least a very experienced non-surgeon is available.