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Chapter V

Battle Casualties in Korea, Studies of the Surgical Research Team, Volume I

A Survey of Plasma Electrolyte Changes in the Seriously Injured Battle Casualty*

Captain John M. Howard, MC, USAR
First Lieutenant John P. Frawley, MSC, USAR
and
Lieutenant Colonel Curtis P. Artz, MC, USA

With the Technical Assistance
of
Joe C. Meikrantz

The explosion of a land mine which avulses a leg or the perforation of the leg by a shell fragment does not result in only a local wound. Although tissue destruction is primarily a local wound, the loss of blood and the absorption of bacterial toxins are at least two concomitant injuries which constitute a wound of the entire organism. Since both the leg and the entire organism are injured, it is not surprising that both respond to the injury in the fight for survival. This response to injury includes a response of every organ, every system, and presumably every cell in the body.

The changes in plasma electrolyte concentrations are not in themselves "dynamic" but are reflections of dynamic changes within the myriad of cells of the many organs, the chief of which is the wound. These changes are believed to represent, in part, the injury and resultant cell degeneration and, in part, the response to the injury and the changes in electrolyte concentrations by living cells.

The magnitude of the total changes in sodium and potassium metabolism following massive injuries of combat soldiers has been demonstrated by balance studies.1 A 70-kilogram soldier with a gangrenous limb may have a net cumulative loss of 480 milliequivalents of potassium within the first few days after injury. Since the total plasma potassium constitutes only 12 to 14 mEq. and the total extracellular potassium only 60 to 70 mEq., a net loss of 480 mEq. represents a shift of intracellular potassium of considerable magnitude. Similarly, casualties conserved as much as 970 mEq. of sodium, the equivalent of over 6 liters of normal saline. Plasma concentrations on these patients in the earlier study were determined only at 24-hour


*This paper is currently being published in Archives of Surgery.


81

intervals but occasionally demonstrated striking fluctuations in the early postoperative period. The present study was undertaken to extend the survey of the magnitude of the changes in the immediate period after injury and resuscitation.

In the absence of intestinal obstruction, fistula, or renal failure, most of the serious complications of electrolyte imbalance in the combat casualty will probably be found within the first 24 hours after injury. This hypothesis has not been proved but it is during this period when most of the problems of refractory shock are found, when most of the fatalities occur, and when the most rapid changes in electrolyte concentrations are found. The relationship between refractory shock and electrolyte changes has been strongly suggested by clinical experience2 but requires further study.

Materials and Methods

Twenty-five soldiers wounded in combat were selected for study on the basis of the magnitude of their injuries. Studies were begun at the time of admission to the forward surgical hospital and were continued until the patients were evacuated. An effort was made to obtain blood specimens before and after transfusion, immediately after operation, 3, 6, 9, 12, and 24 hours after operation, and daily thereafter. Deviation from the protocol was frequently unavoidable.

Blood was drawn into a dry syringe (Patients No.1 to 17) or a heparinized syringe (Patients No. 18 to 25) and centrifuged; the serum or plasma was separated and immediately frozen in a sealed, hard glass test tube. Sodium and potassium analyses were performed 2 to 3 weeks later. Magnesium analyses were performed several months later after shipment of the frozen specimens to the Department of Biochemistry at the Army Medical Service Graduate School.

For sodium and potassium analyses, samples were selected at random for analysis in groups of 25 or 50, and arbitrary numbers, unassociated with date of admission, were assigned to each patient. All specimens were analyzed by flame photometry, using an internal lithium standard technic. A dilution of 1:200 with 250 ppm lithium was used for sodium determinations and a dilution of 1:25 with 50 ppm lithium for potassium.

Magnesium analyses were performed on eight casualties by the Clayton Yellow method3 which was reproducible within a range of ±0.l mEq./L. in 15 controlled studies. Six healthy soldiers served as controls.


82

Controls for the sodium and potassium studies consisted of 20 healthy soldiers. Freezing and storage, under the conditions of the experiment, did not affect the concentration.

Results

The control studies demonstrated an average sodium concentration of 143 mEq./L. with a range of 140 to 155 mEq./L. The average plasma potassium concentration was 4.5 mEq./L. with a range of 4.3 to 4.9 mEq./L. The average magnesium concentration was 1.9 mEq./L. with a range of 1.4 to 2.4 mEq./L.

The results of the individual studies are summarized in Table 1. The most striking changes occurred during the first 24 hours. During this period a pattern, although not always found, appeared to evolve. This pattern consisted not only of the well-known fall in sodium concentration but also a definite, transient rise in potassium concentration. Magnesium concentration in the plasma did not appear to follow a predictable pattern but sometimes fell to rather low levels.

Table 1. The Concentration (mEq./L.) of Electrolytes in the Plasma (or Serum) of 25 Severely Wounded Battle Casualties

Patient

Wound Description

Hrs. Postoperative

Plasma

Na+

K+

Mg.++


No. 1


Penetrating abdominal wound, massive mesenteric damage-15 pts. blood

 


Preop.
18
42
66
90
114
138
162

mEq./L.
144
137
136
144
134
146
127
125

mEq./L.
4.7
5.3
5.4
4.6
3.4
4.1
4.5
4.9

 

No. 2

Multiple shell fragment wounds of face, neck, chest, and all extremities-29 pts. blood

10
16
34
58
82
106
130
154

132
127
139
138
120
136
125
102

4.0
6.2
4.2
4.8
5.1
5.1
4.1
3.6

 

No. 3

Multiple shell fragment wounds of lung, diaphragm, liver, back, both arms

0
16
30
54

135
125
118
120

4.7
4.9
3.7
3.7

 


83

Table 1. The Concentration (mEq./L.) of Electrolytes in the Plasma (or Serum) of 25 Severely Wounded Battle Casualties-Continued

Patient

Wound Description

Hrs. Postoperative

Plasma

Na+

K+

Mg.++


No. 4


Shell fragment wounds of abdomen, liver, hip, and right leg-47 pts. blood

 


Preop.
0
15
39
63
87
110
135
158
182
207
231

mEq./L.
139
144
140
136
137
125
125
134
139
125
132
132

mEq./L.
5.0
3.4
6.2
4.5
4.4
3.8
4.0
4.4
4.5
3.9
3.9
3.6

 

No. 5

Laceration of head, face, penetrating wounds of both thighs and right arm-8 pts. blood

Preop.
0
20
50
94
140
164

137
141
123
130
125
125
132

4.3
5.1
4.8
5.3
4.4
4.9
4.9

 

No. 6

Shell fragment wounds of cheek, chest, both arms, right leg, fracture of left tibia

Preop.
0
9
33
57
80
104
128
152
178
200
223
247

131
124
131
125
133
134
131
134
141
125
127
120
125

4.8
3.9
4.4
---
3.9
4.4
4.0
4.2
4.4
5.2
5.1
5.0
4.7

 

No. 7

Penetrating wound of left hip

Preop.
0
10
34
58

139
141
125
127
116

3.5
4.4
4.4
4.0
3.9

 

No. 8

Shell fragment wounds of chest and countless small penetrating wounds of entire body-14 pts. blood

20
44
68
92
116

139
123
117
97
109

3.7
6.0
7.5
5.6
5.6

 


84

Table 1. The Concentration (mEq./L.) of Electrolytes in the Plasma (or Serum) of 25 Severely Wounded Battle Casualties-Continued

Patient

Wound Description

Hrs. Postoperative

Plasma

Na+

K+

Mg.++


No. 9


Shell fragment wound of abdomen, traumatic amputation left leg, multiple penetrations of back-18 pts. blood

 


Preop.
12
24
48

mEq./L.
144
132
125
125

mEq./L.
5.4
4.6
4.1
3.9

 

No. 10

Penetrating wound of flank, abdomen and diaphragm

Preop.
0
17

151
125
132

4.7
3.9
4.0

 

No. 11

Traumatic amputation of leg, multiple wounds of leg and arm-14 pts. blood

Preop.
0
23
47
71

132
129
113
118
116

4.2
4.4
4.9
4.6
4.6

 

No. 12

Traumatic amputation of foot, penetrating wound of chest, compound fracture of left leg

Preop.
0
18
122
138

146
148
118
128
139

3.6
4.9
4.2
3.0
3.8

 

No. 13

Penetrating wound of back and abdomen

Preop.
0
24
38

144
144
132
131

4.1
4.7
5.1
4.3

 

No. 14

Multiple fragment wounds of both legs, arm, fractures of left hand, right arm-8 pts. blood

11
28
52
76
100

132
132
134
134
133

4.0
4.1
4.2
4.3
4.2

 

No. 15

Multiple wounds of shoulder, back, chest, liver-2 pts. blood

4
10
24
50
74
98
122
146
170

141
141
134
132
134
137
137
137
134

4.3
4.2
4.1
4.1
4.0
3.6
3.5
3.5
4.2

 

No. 16

Bayonet wound of chest, diaphragm and spleen

3
10
27
51
74

135
137
134
137
134

4.0
5.1
4.2
4.6
4.4

 


85

Table 1. The Concentration (mEq./L.) of Electrolytes in the Plasma (or Serum) of 25 Severely Wounded Battle Casualties-Continued

Patient

Wound Description

Hrs. Postoperative

Plasma

Na+

K+

Mg.++


No. 17


Multiple wounds of back (involving pelvis and rectum), shoulders and arms

 


11
18
32
56
80
104
128

mEq./L.
131
132
130
137
134
135
124

mEq./L.
4.0
4.3
4.4
3.9
3.7
3.9
3.5

 

No. 18

Small arms injury to abdomen, kidney, liver, colon-19 pts. blood. Post-traumatic renal insufficiency

Preop.
3
6
9
12
20

---
151
---
141
---
125

3.8
3.0
3.6
4.2
4.8
5.7

---
1.30
1.77
---
---
1.02

No. 19

Traumatic amputation of both legs, multiple wounds of both arms

Preop.
OR
0
3

141
153
144
141

3.0
3.2
3.0
3.5

1.42
2.20
1.54
0.83

No. 20

Traumatic amputation at right thigh, perforation of liver, kidney, buttocks. Post-traumatic renal insufficiency

Preop.
OR
0
4
7
10
13
37

158
141
146
139
171
155
167
136

3.8
3.7
5.4
6.0
6.3
6.6
5.1
6.6

2.22
2.14
1.82
2.11
1.50
1.97
1.08
---

No. 21

Multiple shell fragment wounds, massive destruction of muscles of both legs and back-14 pts. blood

Adm.
Preop.
0
3
6
9
12
33
57
81
105
129
153

146
155
153
145
145
145
148
137
137
130
136
137
140

3.4
4.5
4.6
5.4
5.9
4.6
4.5
4.6
4.7
3.9
4.3
3.9
4.8

1.75
1.35
1.87
1.52
1.81
1.51
1.67
1.35
1.87
1.42
0.85
1.77
1.63


86

Table 1. The Concentration (mEq./L.) of Electrolytes in the Plasma (or Serum) of 25 Severely Wounded Battle Casualties-Continued

Patient

Wound Description

Hrs. Postoperative

Plasma

Na+

K+

Mg.++


No. 22


Shell fragment wound of left shoulder, fragment lodging in myocardium

 


Preop.
0
3
6
9
12
24
53
72
101
125
149
173

mEq./L.
144
141
109
147
144
146
137
137
136
132
120
139
138

mEq./L.
4.4
4.4
3.3
4.4
4.3
4.7
5.0
3.7
3.9
3.9
4.2
4.4
4.9

 


2.03
3.17
2.82
---
1.17
3.07
0.75
2.08
0.53
2.43
0.89
2.08
1.74

No. 23

Small arms injury of abdomen, involving liver, small and large intestine

0
3
6
9
12
24
48
72
96
120
144
166
192
214
238

158
148
153
148
153
139
141
137
134
139
136
139
137
133
120

4.5
5.1
5.4
5.6
5.7
4.4
4.4
3.5
3.4
3.6
3.6
3.6
4.3
4.2
3.8

---
1.27
---
---
1.89
1.89
1.74
1.40
1.45
1.71
1.49
1.36
1.73
---
1.52

No. 24

Traumatic amputation of right leg, compound fractures of legs, multiple wounds of both buttocks, scrotum, and small intestine-22 pts. blood

Adm.
Preop.
0
3
6
9
12
32
56
80
104
128
152
176

132
139
144
141
136
148
127
114
114
116
130
127
137
103

3.7
3.5
4.0
4.8
4.8
4.7
5.1
4.1
3.2
3.3
3.2
3.5
3.6
3.3

1.17
1.75
0.56
1.67
1.34
1.39
1.34
0.82
1.95
1.82
1.52
1.95
---
---


87

Table 1. The Concentration (mEq./L.) of Electrolytes in the Plasma (or Serum) of 25 Severely Wounded Battle Casualties-Continued

Patient

Wound Description

Hrs. Postoperative

Plasma

NA+

K+

Mg.++


No. 25


Penetrating wound of abdomen, both thighs, compound fracture of right femur-13 pts. blood

 


Preop.
0
3
6
9
12
21
45
69
93
118
142
166

mEq./L.
144
132
127
141
134
120
125
123
111
123
123
132
132

mEq./L.
4.7
4.9
4.5
4.9
4.2
4.2
4.6
4.2
3.6
4.3
3.6
4.0
4.0

 


2.08
2.86
2.12
2.66
1.12
2.40
2.92
2.90
2.63
---
2.08
1.35
2.03

Sodium concentrations fluctuated tremendously during the period of operation and transfusion. Occasionally transfusion was marked by a rise in the sodium concentration but, as a generalization, the fall in concentration was marked and progressive. Patient No. 7 demonstrated a fall from 141 to 125 mEq./L. during the first 10 hours after operation and Patient No. 8 revealed a fall from 139 to 97 mEq./L. within the first 4 days of convalescence although he had no unusual, apparent extra renal loss.

Table 2, demonstrating the average plasma sodium concentration, indicates that the maximal depression was reached on the third day after injury.

The potassium concentration often demonstrated a striking rise during the first 24 hours (Figs. 1 to 6), sometimes increasing by almost 100 per cent (Patient No. 4). This period of maximal elevation did not coincide with the period of rapid transfusion and characteristically was associated with no simultaneous potassium intake.

Discussion

The falling sodium concentration coincided with a period of sodium retention by the kidneys1 and often coincided with a period in which the fluid infusion consisted of normal saline solution, blood (Table 3),


88

Table 2. Average Plasma Sodium Levels From 25 Patients at Intervals From Admission to 6 Days Postoperative

 

Adm. And Preop.

0-12 Hours Postop.

12-24 Hours Postop.

1 Day Postop.

2 Days Postop.

3 Days Postop.

4 Days Postop.

5 Days Postop.

6 Days Postop.

mEq./L. Na (average)

141

141

133

129

129

125

131

131

133

Number of observations

18

46

22

20

16

13

12

13

10

Per cent of observations below 130 mEq./L.

0%

11%

45%

45%

44%

46%

25%

46%

20%


89

FIGURE 1.
Depicting the rising curve of plasma potassium concentration on the day of injury. Note that the elevation
is transient and would have been overlooked had the studies been made at 24-hour intervals only. The plasma
sodium concentration fell from 158 mEq./L. to 139 mEq./L. on the day of injury.
The urinary output remained high throughout the period of study.

FIGURE 2.
As in Figure 1, the increasing potassium concentration in the plasma is noted on the day of injury. Within a
period of 32 hours after operation, the plasma sodium concentration fell from 144 mEq./L. to 114 mEq./L.


90

FIGURE 3.
Within a period of 6 hours, the plasma potassium concentration increased by 50 per cent.

FIGURE 4.
This patient with massive wounds and requiring massive transfusions demonstrated an increase
in plasma potassium concentration of almost 100 per cent during the first 15 hours after the completion of operation.


91

FIGURE 5.
The plasma potassium concentration rose steadily from
the time of admission to the sixth hour after injury.

FIGURE 6.
This patient had less tissue destruction but was in profound hemorrhagic shock on admission.
He was not studied intensively during the first 24 hours but thereafter demonstrated a marked and
progressive rise in potassium and fall in sodium concentration.

or dextran, each of which had a sodium concentration approximating that normally found in the plasma. Dilution by infusion was, therefore, not the explanation. The third day post-injury marked not only the maximal average depression in plasma sodium concentration but also marked the time of greatest depression in the serum albumin concentration.4


92

Table 3. Plasma Electrolyte Concentration (mEq./L.) of Bank Blood Administered to Patients on Day of Injury

Patient

Bottle No.

Na

K

Mg

No. 21

1

148

17.6

1.92

2

153

18.0

---

3

148

18.0

1.78

4

153

17.4

1.10

5

156

14.8

1.33

6

171

24.0

0.88

7

149

13.8

0.38

8

149

18.4

0.95

9

146

23.8

---

10

153

18.8

2.03

11

153

16.0

2.24

12

149

15.4

1.50

13

153

18.8

0.67

14

145

18.8

0.75

 


Average

 


152

 


18.1

 


1.29

No. 24

1

149

18.8

2.14

2

147

18.0

1.23

3

149

16.8

1.09

4

153

15.6

1.33

5

141

14.0

1.22

6

153

13.6

1.60

7

151

13.6

1.22

8

148

14.0

1.31

9

160

19.2

2.42

10

153

19.6

0.70

11

137

12.8

---

12

---

---

---

13

144

15.6

0.32

14

144

20.4

1.57

15

141

13.2

1.22

16

144

15.6

1.34

17

146

20.0

1.48

18

148

14.0

1.13

19

144

23.2

2.49

20

151

17.6

0.91

21

146

14.4

1.15

22

144

18.8

1.33

 


Average

 


147

 


16.6

 


1.36


93

A few sudden changes deserve special mention. Patient No. 20 showed a rise of plasma sodium from 139 to 171 mEq./L. within a 3-hour period during noradrenalin therapy. His level remained elevated from 155 to 167 mEq./L. during 6 additional hours of a slow, continuous noradrenalin infusion. After discontinuing the drug, his concentration dropped to 136 mEq./L.

Another sudden change was noted in Patient No. 22 who received 1,000 cc. of dextran (in normal saline) during the first 3 hours following the removal of a shell fragment from his myocardium. During the 3-hour period his plasma sodium concentration fell from 141 to 109 mEq./L. Within another 3 hours it returned to the original level.

No interpretation of these marked changes can, as yet, be made.

The rising potassium concentration often found during the first 24 hours after injury and operation coincided with the period of potassium diuresis.1 Only 2 of the 25 patients studied (Patients No. 18 and 20) demonstrated clinically the complication of post-traumatic renal insufficiency. Patient No. 18 showed a rise in potassium concentration from 3.8 to 5.7 mEq./L. within 20 hours after operation (Fig. 7-A) and Patient No. 20 from 3.8 to 6.6 mEq./L. within a period of 10 hours after operation (Fig. 8). As has been clearly demonstrated, many critically injured soldiers, although they maintain their urinary output at a high level, revealed all stages of subclinical renal insufficiency.5, 6 Patients with such a subclinical renal failure, although their glomerular and tubular clearances remain low, selectively excrete potassium (Fig. 9).7 Their blood urea or nonprotein nitrogen continues to rise for several days; its curve not paralleling the transient rise in plasma potassium depicted in this study (Fig. 10). Patient No. 8 (Fig. 6), although his urinary output remained over a liter per day, demonstrated a more prolonged elevation in potassium concentration, a curve more suggestive of renal insufficiency.

The bank blood used in Korea ranged from 14 to 21 days old. The plasma potassium concentration of this blood was elevated (Table 3) at the time of infusion. Occasionally patients in profound circulatory collapse demonstrated a marked elevation in their plasma potassium concentration as blood was pumped in through several portals, but this was not demonstrated in this survey.

The elevations in the current study were found following the completion of operation and during the period when the plasma hemoglobin was being cleared from the circulation.8 One patient who received only dextran and fresh type-specific blood (1 to 5 hours old) demonstrated a similar rise in potassium concentration (Fig. 11).1

The infusion of potassium in the plasma of stored blood is therefore not the explanation for the increments in plasma potassium demon-


94

FIGURE 7.
A. During the first few hours after injury, as post-traumatic renal insufficiency
developed, the plasma potassium and sodium concentrations revealed marked inverse changes.
B and C. Demonstrating the transient rise in potassium concentration in the absence of detectable renal failure.

FIGURE 8.
During the first few hours after operation, the plasma potassium
concentration increased almost 100 per cent.


95

FIGURE 9.
The patient with bilateral traumatic amputations of the legs, requiring massive transfusion, developed a subclinical
degree of renal insufficiency yet selectively excreted potassium and retained sodium, as indicated by the sharp
fall in urinary Na/K ratio. His urinary output was never less than 1,000 ml. per 24 hours and his
urinary potassium concentration was maintained at 100 to 125 mEq./L.

FIGURE 10.
In spite of the potassium diuresis depicted in Figure 9, the patient developed
a transient rise in his plasma potassium concentration. This elevation, however,
did not parallel the rising B. U. N. concentration.


96

FIGURE 11.
This patient with a traumatic amputation of a foot and multiple soft tissue wounds was resuscitated with dextran, 2,500 cc., and fresh type-specific blood (1 to 5 hours old), 1,500 cc. Nevertheless, the plasma potassium concentration rose over 50 per cent, indicating that the bank blood, routinely used, was not necessarily the cause of the rising potassium concentration.

strated in these casualties. A secondary, in vivo breakdown of red blood cells, with the release of potassium may contribute to the elevation but a more tenable hypothesis is that the increment represents the release of intracellular potassium from the wounded tissues or from cells with altered permeability throughout the body.

Summary

A survey of the plasma sodium and potassium concentrations of 25 severely injured soldiers has been made, including intervals from admission to 10 days postoperative. The potassium concentration of the oliguric patient rises quite rapidly; the non-oliguric patient often demonstrating a transient and less marked elevation. The plasma sodium concentration falls following operation, reaching its lowest level about the third day. Plasma magnesium levels, studied on eight patients, revealed no definite pattern.

References

1. Howard, J. M., Olney, J. M., Frawley, J. P., Peterson, R. E., and Guerra, S.: Adrenal Function in the Combat Casualty. Surgery. (In press.)

2. Strawitz, J. G., Howard, J. M., and Artz, C. P.: Clinical Observations of the Effect of Intravenous Calcium Gluconate on Post-transfusion Hypotension. Final Report to the Army Medical Service Graduate School, Washington, D. C. (August), 1954.


97

3. Heagy, F. C.: The Use of Polyvinyl Alcohol in the Colorimetric Determination of Magnesium in Plasma or Serum by Means of Titan Yellow. Can. J. Research 26 E: 295-298, 1948.

4. Frawley, J. P., Howard, J. M., and Artz, C. P.: Changes in Plasma Proteins Following Injury. Report to the Army Medical Service Graduate School, Washington, D. C. (August), 1954.

5. Ladd, M.: Renal Sequelae of War Wounds in Man. Functional Patterns of Shock and Convalescence. Final Report to the Army Medical Service Graduate School, Washington, D. C. (August), 1954. (Chap. 11 in Vol. IV of this series.)

6. Howard, J. M.: Experiences with Shock in the Korean Theater. Shock and Circulatory Homeostasis. Transactions of the 3rd Conference (September), 1953, The Josiah Macy, Jr. Foundation, New York.

7. Howard, J. M.: Preliminary Reports to the Army Medical Servive Graduate School, Washington, D. C.

8. Crosby, W. H., and Howard, J. M.: The Hematologic Response to Wounding and to Resuscitation Accomplished by Large Transfusions of Stored Blood. A Study of Battle Casualties in Korea. Blood 9: 439, 1954. (Chap. 6 in Vol. II of this series.)