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Anesthesia for Combat Casualties on the Basis of Experience in Korea

Medical Science Publication No. 4, Volume 1

ANESTHESIA FOR COMBAT CASUALTIES ON THE BASIS OF EXPERIENCE IN KOREA*

ROBERT D. DRIPPS, M. D.

Because of the type of warfare in Korea during the 18 months preceding the armistice, treatment of the battle casualty was almost ideal. There was prompt evacuation, ample supply of whole blood, rarely were peak loads a problem and personnel, equipment and supplies were adequate generally. The mortality and morbidity figures set in Korea may never be equaled. Valuable lessons were learned, however, and possibilities for improvement in care of the combat casualty still exist. In this paper the Korean experience will be analyzed from the standpoint of anesthesia.

Korea did not turn up new data on the anesthetic management of the wounded. The basic problems involved were merely re-emphasized, and one had the disturbing impression that mankind must relearn hard-won lessons from individual experience rather than build on knowledge previously gained. A few quotations from the British Medical Research Council's Special Report No. 26 entitled "Traumatic Toxemia as a Factor in Shock" (14 March 1919) make this clear. "The surgeon experienced another disappointment. If his measures were sufficient to put the soldier into a state that justified operation, this procedure produced a relapse. A great deal of the bad effects were to be attributed to the anesthetic. Chloroform had long been recognized as dangerous, but it was more evident that ether and other anesthetics were far from harmless. Gas and oxygen was the least noxious and with its wider adoption postoperative shock greatly diminished."

The severely wounded soldier is inordinately susceptible to narcosis regardless of the agent or technic selected. Prior to anesthesia he presents a picture of apathy and depression suggestive of decreased central nervous system function. He appears to be partially narcotized already. In such a patient small amounts of central nervous depressant drugs evoke a response out of proportion to the size of the dose administered. "Normal" dosage regimens will cause death sufficiently frequently to drive this point home to the tyro. The pro-


*Presented 19 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


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longed postoperative sleep of many of these patients tends to support the above. The physiological basis for this susceptibility is not completely understood. It is undoubtedly bound up with the numerous factors responsible for shock and hence has humoral, endocrine, toxic, hemodynamic and psychic aspects, to mention a few.

Experiences in World War I also emphasized the hazard of moving the combat casualty, the necessity for parenteral fluids, the problem of the optimal time after resuscitation for surgical intervention and the question of how much to do at that time. These are the crucial questions which World War II revived and which were again noted in Korea. Unless atomic or hydrogen bombs bring physiologic changes peculiar to them, one can expect future conflicts to pose essentially the same problems.

From the standpoint of "choice of anesthesia" one can set down the following generalities.

Preoperative Medication

The use of morphine to relieve pain, to prepare an individual psychologically for operation and to reduce the amount of additional drugs needed for anesthesia has been traditional. Yet many investigators have recorded the untoward reactions of man to morphine. Its ability to impair the normal compensatory response to circulatory stress is well documented. The prolonged action of a single dose can be shown readily. Such side actions as nausea, vomiting, urinary retention and constriction of smooth muscle in the biliary and respiratory passages are undesirable. Because of tradition, however, it is difficult to eliminate the injection of morphine. Yet morphine has little or no place in the management of the seriously wounded. Men in shock rarely complain of pain. They do complain bitterly of thirst but this is not an indication for morphine. They may be anxious and fearful. These are not indications for morphine. Beecher has suggested barbiturates. I wonder if any drug is needed. The sympathetic attention of corpsmen, doctors and nurses does wonders. If, as anesthesia progresses and resuscitation becomes more established, large amounts of anesthetic drugs appear necessary, the intravenous injection of morphine or meperidine (demerol) may be useful.

The educational campaign outlining the possibilities of harm of morphine must be continued, for although abuse of this drug is now less frequent overdosage is still seen. Aidmen and medical officers must be made to understand the drug better. In the event of overdosage, n-allylnor-morphine appears useful in reversing both the respiratory and circulatory depressant effects. This drug, which is administered intravenously, will return respiratory minute volume towards normal within 60 seconds. Its pressor effect is not as well


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substantiated at the moment but a blood-pressure-raising action has been described.

The belladonna drugs are still used and may be given intravenously as well as intramuscularly. Whether scopolamine is preferable to atropine cannot be stated with finality. The tendency of the former to produce mental aberrations is undesirable.

Choice of Anesthesia

The guiding principle for the administration of anesthesia to any patient is use of the least amount of narcotic compatible with the surgical requirements. As already stated, this is essential in the severely wounded. The susceptibility of the serious battle casualty to anesthesia enables one to provide satisfactory working conditions with 50 to 60 percent nitrous oxide in oxygen in many patients. This concentration will not produce even minimal surgical anesthesia in normal individuals, but if satisfactory results can be obtained the shocked patient has been spared the consequences of a more potent depressant. This technic deserves continued application. I used it successfully in Korea, as have others to whom it has been suggested.

It is difficult to divorce the problem of selection of anesthetic agent from a consideration of the background of the anesthetist. Fortunately, the training of physicians in the specialty of anesthesiology has increased greatly during the past decade. Specialists were available in MASH units in Korea and in installations behind these mobile hospitals. Some of these individuals were trained in one approach to the anesthetic management of the substandard patients. Others had had a different indoctrination. Until definitive data are available to prove that one agent or technic is superior to another in the management of the severely wounded it would seem wise to permit anesthetists to apply those methods with which they are most familiar. If the patient's susceptibility is kept foremost in one's thinking, this approach appears reasonable.

Those men trained primarily in the administration of thiopental soon realized that very small doses of this drug suffice. Profound depression may be produced by 25 to 50 mg. If such be the case, it is my opinion that thiopental should be abandoned since nitrous oxide with adequate quantities of oxygen will undoubtedly be all that is necessary. If more thiopental be required but the amounts still do not compare to those used in patients in good physical condition, this fact must constantly be remembered lest overdosage result. Supplementation with nitrous oxide-oxygen is almost invariable.

Beecher has stated that the induction of anesthesia with ether alone is safe in the seriously wounded. Yet I have produced severe hypo-


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tension in battle casualties with this drug in apparently very light planes of anesthesia. According to recent studies the safety of ether so far as the circulation is concerned lies in its ability to mobilize epinephrine and norepinephrine from adrenal medulla and sympathetic nerve endings. If this be prevented totally or in part, ether is a potent circulatory depressant. Probably in certain seriously wounded patients such mobilization is reduced.

Observations by Zweifach and Chambers of the greater tolerance of dogs to blood loss during cyclopropane as compared to ether are corroborated by Crooke's statement during World War II that "the best anesthetic used in our shocked patients was cyclopropane," and the data of Hershey and Rovenstine on the value of cyclopropane in the management of patients with recent severe hemorrhage. I believe that this drug has a place in the anesthetic management of the battle casualty and that it does not deserve the neglect of military planners.

Unless it can be shown that some such technic as the use of a continuous drip of norepinephrine will maintain adequate circulation during spinal anesthesia, this method of pain relief probably has no place in the management of the seriously wounded. The circulatory alterations produced by spinal anesthesia would seem contraindicated for such patients.

For intra-abdominal operations in substandard patients, bilateral intercostal block can provide excellent muscular relaxation in light planes of general anesthesia. The block can be performed after the patient is put to sleep so that the multiple needle sticks are not objectionable. Other forms of regional anesthesia also have a place if dilute solutions are used and overdosage with its threat of hypotension is avoided. An 0.5 percent solution of procaine is adequate for infiltration anesthesia. For nerve block a 1 percent solution should suffice.

The "curare" group of drugs proved of great value in Korea; d-Tubocurarine and succinylcholine were most frequently used. These substances permitted rapid intubation of the trachea, and provided muscular relaxation for varying periods of time when this was essential. Patients in shock tended to react to succinylcholine with an exaggerated degree of muscular fasciculation. Occasionally this motor activity resembled clonic convulsions. It is possible that this represented a diminished amount of plasma cholinesterase. This deserves study as one of the derangements associated with shock.

Illustrations of some of the principles discussed above are presented in figures 1 to 10.


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FIGURE 1. A 21-year-old American soldier with both legs blown off by a mine. On the left side the loss was close to the pelvis; on the right the loss occurred at the junction of the upper and middle third of the femur. Despite heroic transfusion therapy consisting of 14,000 cc. of whole blood in 2 hours and with a preanesthetic blood pressure of 110/70 and a pulse rate of 111, attempts at anesthesia with nitrous oxide-oxygen (60: 40) and attempts to prepare the wounds for débridement brought complete collapse of the circulation. Operation was canceled.

Suggestions for the Future

War in the future may well involve many nations and many geographic areas. Civilian as well as military casualties can be expected. Infants, children and the aged and infirm may require anesthesia. National differences in electric current, terminology, coloring of gas cylinders and the like should be anticipated and efforts at standardization made. Furthermore, the earlier habit of the Armed Forces of limiting anesthetic equipment and supplies should be changed. Anesthesia is now an established science and art. As such it functions


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better if a variety of agents and technics are available. Fortunately, none of these are bulky and space for shipment or storage should not prove a problem.

FIGURE 2. The soldier discussed in figure 1 was re-anesthetized 48 hours after the first attempt. He had received a total of 19,000 cc. of whole blood, had a blood pressure of 124/70 and a pulse rate of 126. High bilateral amputation of both thighs was successfully completed under extremely light anesthesia with small amounts of pentothal and nitrous oxide-oxygen.

1. Equipment

The Table of Supplies should he broadened to include equipment recognized to be of value in anesthesia. Kits should be provided which would contain several types of laryngoscope blades, oral and nasotracheal tubes of various sizes including those for infants and children, oral and nasal airways, syringes and needles for regional anesthesia, connectors and small parts for anesthesia machines. The


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machines should be standardized so that cylinders from various countries can be interchanged. Portable operating tables should be standardized so that voltage differences in different countries will not be an obstacle. Suction equipment not requiring electricity should be provided.

FIGURE 3. A 23-year-old white male who was pale, "tired" and thirsty despite 2,500 cc. of whole blood. His right leg had been blown off below the knee by a mine. Blood pressure was 144/90 and pulse rate 154. The relatively high blood pressure suggested maximal efforts at compensatory vasoconstriction, and warned of hypotension with induction of anesthesia. This occurred as pentothal (200 mg.) was administered slowly over a 10-minute period. A more seriously ill casualty might have had an even greater fall in blood pressure. Note the reduction in pulse pressure following anesthesia.

A field anesthesia record should be provided which will fit into the EMT jacket and accompany the casualty. This record should have sufficient blank space to permit recording of essential data.


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FIGURE 4. A 24-year-old white male with multiple penetrating wounds of the abdomen. The pre-anesthetic pulse rate of 148 and the high diastolic pressure should have warned of circulatory instability. Induction of anesthesia was followed by a sharp decrease in blood pressure and a narrowing of the pulse pressure. The addition of ethyl ether vapor at 4 p. m. brought a further reduction in arterial pressure. Five thousand cc. of fluid was administered during the operation. A pressor drug, neosynephrine, appeared of value.

2. Supplies

Drugs should be increased in scope. Various "curare" drugs, pressor agents such as norepinephrine, adrenolytic or ganglionic blocking drugs, and various local anesthetics should be provided. Cyclopropane should be available. All gas cylinders should conform to the international color code to avoid the confusion and dangers noted during World War II when, for example, a green American cylinder contained oxygen and a green British cylinder contained carbon dioxide.


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FIGURE 5. A 26-year-old white male with penetrating wounds of the right side of chest, right hand and arm and left thigh. This soldier did not appear to be seriously wounded. The hypotension which followed the onset of anesthesia was related to a gross overdosage of pentothal. A technician anesthetist administered 1.5 gm. of this drug in 15 minutes in an effort to facilitate tracheal intubation. One cannot blame the drug in this instance so much as the way in which it was administered. It was fortunate that a fatality was averted.

3. Organization

Much more would have been learned in Korea had mature, experienced anesthetists been assigned to FECOM and the 8th Army as consultants. The recent provision of a senior consultant in anesthesia in the Office of The Surgeon General has been a valuable step. In future wars consultants for field units should be made available. These men should be urged to administer anesthesia in forward units such as the surgical hospitals so as to have first-hand knowledge of the problems involved, and thus to be able to advise and train others more authoritatively.


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FIGURE 6. A 24-year-old white male who was not in shock prior to anesthesia. After 2 hours of a perfectly satisfactory pentothal-nitrous oxide-oxygen anesthesia this patient began to hiccup. The anesthetist failed to realize that pentothal can accumulate in the body as anesthesia progresses. Its rate of destruction (about 15 percent per hour) is slower than many recognize. Injection of 125 mg. of pentothal, a dose which was well tolerated at 6 p. m., caused profound respiratory and circulatory depression at 7:50 p. m.

As Tovell has pointed out in "The History of Anesthesiology in the European Theater of Operations" and as I stated in my report to The Surgeon General in December of 1952, the greatest need for thoroughly qualified physician anesthetists is in forward medical installations. Decisions requiring judgment and experience are required in these units. If improperly made, the casualty will suffer.

A monthly report of the anesthetics administered, the physical condition of the anesthetized subjects, and the results obtained should be required from each medical installation. It is a platitude to state that war is wasteful. Yet in reviewing the medical opportunities


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FIGURE 7. A 24-year-old white male with gas gangrene in a right thigh amputation stump. Inadequate fluid therapy was partially responsible for the severe hypotension noted. Ether anesthesia, however, although only mid-first plane according to clinical signs, appeared to contribute to the profound circulatory collapse.

presented by combat-whatever the field of interest-one is impressed with how much is lost, unrecorded and unappraised. How important, for example, it would be to have data on deaths related to anesthesia; to have records of different methods of management of various types of casualties; to know the course of the soldier who ultimately develped post-traumatic renal failure, i. e., how long did hypotension exist, what kind of blood was administered; what were the incidence and sequelae of vomiting during anesthesia of the soldier with a full stomach. These and dozens of other problems demand solutions. All personnel should be indoctrinated in the necessity of collecting data. Anesthetists should be stimulated to observe, record and make sugges-


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FIGURE 8. A 23-year-old white male who did well during secondary closure of 35 penetrating wounds of the head and extremities. Operation, which required almost 3 hours, was performed under dilute procaine 0.5 percent. The total volume of solution was high, but it must be remembered that this amount was given over a long period of time.

tions based on their experience. Such an approach should increase interest among anesthetists but must be initiated at top levels.

Under "Organization" should also be listed the provision of facilities for photography, wherever possible in color. This can preserve experiences which otherwise are lost.

Finally, on the basis of World War II and Korean experience, facilities for research should be planned in advance. The Surgical Research Team in Korea justified itself beyond expectation.

4. Education and Training

Manuals and training films for military anesthetists should be prepared now rather than waiting for an outbreak of hostilities. The


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FIGURE 9. A 23-year-old white male with a large gaping wound of the face and multiple penetrating wounds of the thighs. On admission this individual was pale, thirsty and had a blood pressure of 90/70. After what appeared to be successful resuscitation with parenteral fluids, the patient was moved about 60 feet for X-ray examinations. Blood pressure promptly fell from 130/86 to 80/60 (The adverse effect of motion on the blood pressure was commonly seen.) After additonal efforts at resuscitation, induction of anesthesia was also followed by a decline of blood pressure from 112/72 to 60/45.

Subcommittee on Anesthesia of the National Research Council might be given this responsibility in consultation with experts who have served in World War II and in Korea. A sufficient amount of knowledge has now accumulated to make such manuals and films of value. Basic aspects of resuscitation, pharmacology and physiology should be included.

5. Projects for Research in Civilian and Military Centers

A number of problems bearing on the anesthetic management of battle casualties require investigation. These include the effects of anes-


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FIGURE 10. A critically injured 29-year-old Negro with penetrating wounds of the abdomen, skull and lower extremities. Onset of anesthesia was followed by profound hypotension. Neosynephrine was of no value, but norepinephrine by constant intravenous infusion restored blood pressure to normal limits. Each time that the drip of this drug was slowed hypotension occurred.

thetic agents and technics on the adrenal cortex and medulla; the effects of anesthetic agents on blood flow to various tissues and organs; the value of adrenolytic or ganglionic blocking drugs in the management of hemorrhagic or wound shock; the role of vasoconstrictor drugs such as norepinephrine in the management of patients in shock of varying types; the utility of hypothermia as an adjunct to anesthesia; the value of intra-arterial transfusion; the etiology and therapy of uncontrolled oozing during operation; the physiologic alterations in the circulation related to motion and change of position.

In addition, one must anticipate whether such future possibilities as atomic or hydrogen bomb warfare, combat in the Arctic, or use of


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chemical warfare agents will pose specific problems for the anesthetist.

Finally, clinical evaluation of such new technics as transtracheal injection of topical anesthetics, continuous drip of pentothal, continuous drip of succinylcholine and the use of trichlorethylene is needed. This should be done by a number of competent individuals with subsequent discussion and analysis of results by a group. Again the Subcommittee on Anesthesia of the National Research Council is suggested as an advisory body.

One is uncertain as to whether to recommend pharyngeal irritation to produce vomiting in casualties who face anesthesia and who have full stomachs. This deserves exploration.

The severe, shaking chills seen during the immediate postoperative period appear undesirable. Their cause and prevention should be considered. These may be related to the effects of narcotics on temperature regulation, to the administration of a large volume of cold blood or to exposure during operation.

The establishing of tests to assist in the selection of the ideal time for initial surgical intervention merits thought. As a rule this decision involves the art of anesthesia and surgery at the moment rather than the science of these branches of medicine.

It is no exaggeration to say that World War II provided great impetus for the growth of the specialty of anesthesiology. There are now many trained individuals available and more are being trained each year. Research work in anesthesia is progressing in a number of laboratories. The Armed Forces should benefit from this growth and development in any future conflict. But maximal benefit will come only if plans are made in advance.