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Preoperative and Postoperative Care of Battle Casualties

Medical Science Publication No. 4, Volume 1

PREOPERATIVE AND POSTOPERATIVE CARE OF BATTLE CASUALTIES*

MAJOR CURTIS P. ARTZ, MC
CAPTAIN ALVIN W. BRONWELL, MC
AND
CAPTAIN YOSHIO SAKO, MC

In recent years, more and more attention has been focused on the care of patients before and after operation. In the Korean conflict, great emphasis was placed on preoperative and postoperative care.

General Aspects of Preoperative Care

As soon as a casualty is admitted to the hospital all his clothing should be removed. In the preoperative section, it is important for the medical officer to examine the entire body in order that all wounds may be recognized. A brief record should be made of the findings. A review of the emergency medical tag will point out the results of previous examinations. It may be necessary to perform a very cursory examination and immediately begin restorative treatment. A more complete examination can be carried out when the casualty's general condition improves.

A record of the blood pressure and pulse rate should be started immediately upon admission. This record may be maintained by the attending corpsman. It provides the medical officer with information concerning the progress of the injured soldier's condition.

Most wounded men require resuscitative fluids. Replacement therapy should be instituted in accordance with the severity of the injury. Large-bore needles should always be used for infusion. It may be necessary to expose a vein surgically and insert a cannula or to insert a long, polyethylene catheter through a large-bore needle into the femoral vein. Since wounded men are usually restless, the needle or cannula must be fastened securely.


*Presented 20 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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Adequate Airway

Casualties with injuries of the chest, neck or head may have obstrutions of the respiratory passages. An adequate airway must be established as soon as possible. This may be accomplished by aspirating the posterior pharynx and trachea and positioning the casualty on his side and pulling out his tongue. Not infrequently a tracheotomy will be necessary. Tracheotomy should never be delayed or considered as a last-resort measure. It is a simple operative procedure that not only assists in establishing a clear airway but offers a convenient and safe method of maintaining tracheobronchial toilet. Increased secretions or blood in the trachea may lead to anoxia. Oral or nasopharyngeal suction consume time and may be inadequate. After a tracheotomy is performed, it is easy for the corpsman or the nurse to keep the trachea clear. Too frequently tracheotomy is delayed because it is believed to be a procedure that increases nursing care; actually, however, it lessens nursing care.

Control of Hemorrhage

Careful attention should be paid to control of hemorrhage. In the most severely wounded casualties, it may be quite difficult. In the slightly wounded casualty, hemorrhage can usually be controlled by a pressure dressing; however, all areas of injury should be observed and adequate dressings should be applied. Too frequently several small wounds will be neglected and an appreciable amount of blood will ooze from them. In the preoperative section of a forward hospital, careful attention should be paid to the proper application of tourniquets. Patients may be observed who actually have an increase in the amount of blood lost from a limb because of the application of a tourniquet. A tourniquet will control bleeding in most casualties who have wounds of an extremity. Sometimes a tourniquet partially controls arterial bleeding, but actually increases venous oozing. It is necessary to apply a firm, bulky pressure dressing in order to control venous bleeding. In casualties with laceration of a large vessel, hemostatic clamps may be applied if the vessel can be easily located.

Narcotics

Severely wounded soldiers experience little pain but have a great deal of fear and anxiety. It is important that the medical officer, nurse and corpsman attempt to alleviate this fear and anxiety. The patient should be made as comfortable as possible. Such a simple procedure as washing a patient's face may help considerably in contributing to his feeling of well-being. It may be necessary to give some patients a narcotic. For an immediate effect, it should be administered intravenously.


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Prevention of Infection

American soldiers are immunized with tetanus toxoid. A booster dose of toxoid should be given as soon as a casualty is admitted to a forward hospital. Antibiotics should be given to all wounded soldiers to prevent infection. The amount and type of antibiotic therapy may vary according to current practice. At the 46th Surgical Hospital, casualties were given 500,000 units of penicillin and 0.5 gram of streptomycin intravenously as soon as they were admitted. Intravenous antibiotic therapy was continued throughout the early postoperative course. As soon as the injured man's condition was stabilized, 600,000 units of crystalline penicillin and 0.5 gram of streptomycin were given intramuscularly twice a day for the first 5 days. Thereafter, antibiotic therapy was given only on specific indication. In abdominal injuries, some surgeons used 1 gram of terramycin intravenously twice a day.

Abdominal Wounds

An indwelling gastric tube should be placed in all casualties who have abdominal injuries. An attempt should be made to empty the stomach. This is frequently unsuccessful because of the presence of a large amount of undigested food in the stomach at the time of injury.

By placing a catheter in the bladder, output of urine can be measured and information can be obtained concerning injury to the genitourinary tract. If there has been damage to the urinary system, the urine will show gross blood. The rate of flow of urine will indicate the adequacy of resuscitation.

Whenever a wound of the rectum is suspected, a rectal examination should be made. If injury cannot be determined by digital examination, a proctoscopic examination should be performed. Most surgeons insert the proctoscope on the operating table immediately after the induction of anesthesia.

Roentgenograms are of value in determining the presence of shell fragments, free air or retroperitoneal hemorrhage. It is difficult to localize fragments in the abdomen accurately, especially if they lie near the spine, in the pelvis, or near the parietal peritoneum. Free air under the diaphragm indicates a perforated viscus, and absence of a psoas shadow usually denotes obliteration by hemorrhage.

In the preoperative preparation of casualties with abdominal injuries, it is important to determine immediately the presence of gross intra-abdominal hemorrhage. If a wounded man does not respond readily to a rapid infusion of blood and if he has a rapidly expanding abdomen, it may be assumed that a large abdominal vessel has been injured. In such instances, blood should be infused rapidly and


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immediate operation should be performed without further preparation.

The surgeon who is to accept the responsibility of operation should go over the casualty's entire history, record of examination and x-rays. Not infrequently certain injuries are missed by the operating surgeon unless he makes a thorough review of the findings. The surgeon should discuss the proposed operative procedure and resuscitative measures with the anesthesiologist.

Immediately after operation, an accurate chart should be kept of blood pressure, pulse rate and hourly output of urine. This will indicate the progress of the casualty and aid in determining the amount of resuscitative fluids required. A hematocrit may be of some value in determining the need for further blood. A hypotensive casualty with a low hematocrit usually requires additional blood. However, most soldiers who have abdominal injuries have a hematocrit that may rise for the first 24 or 48 hours after operation. This is believed to be caused by loss of plasma into the lumen of the bowel, into the bowel wall and into the peritoneal cavity.

Intragastric suction should be continued. A great deal of care may be required to keep the tube functioning. Frequent irrigation of the tube is essential. In casualties with an intranasal gastric tube who are also receiving oxygen by nasal catheter, it is important to be certain that the oxygen cylinder is not inadvertently connected to the gastric tube. When this occurs, tremendous gastric dilation follows and the casualty's condition may deteriorate rapidly. Acute gastric distention may occur in the presence of a non-functioning intragastric tube when oxygen is administered by nasal catheter.

In the immediate postoperative period, frequent examination of the casualty should be made. Since atelectasis is one of the more common complications following abdominal injuries, the patient should be urged to take deep breaths and to cough. A good method of maintaining tracheal toilet is aspiration of the trachea through the nasopharynx at frequent intervals. When heavy, thick secretions block the bronchial tract, bronchoscopy may be necessary.

As soon as the blood volume has been restored, electrolyte solutions and water should be given. Most casualties have been without water for many hours. Some of these soldiers may have been on patrol prior to injury. Casualties who have abdominal wounds require it least 3,000 cc. of fluids by vein daily; 1,000 cc. or more of glucose in saline and 2,000 cc. of glucose in water. When intragastric suction is continued for several days, the casualty may require potassium.

Most young soldiers who sustain abdominal wounds can be ambulated on the day following the operation. On the second or third postoperative day, an abdominal wound should be examined. The


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wire stay sutures may require loosening because of edema of the wound edges. Before a casualty is evacuated, a careful examination should be made of all his wounds.

Thoracic Wounds

Many thoracic wounds do not require operation and are therefore treated in the preoperative section of the hospital. Hemothorax or pneumothorax should be diagnosed as early as possible and can usually be managed by thoracentesis. Tension pneumothorax requires immediate decompression. If a wounded soldier has an injury to the chest and if he has a great deal of respiratory difficulty, it is unnecessary to wait for roentgenograms. Exploratory thoracentesis may be carried out to aspirate air or blood. Sucking wounds of the chest should be closed by a large occlusion dressing. In preoperative preparation of a casualty with a thoracic injury, it is the surgeon's aim to restore the respiratory physiology as nearly as possible to normal. This may require a tracheotomy in order to clear the respiratory tract of excessive secretions and blood. An intercostal nerve block relieves pain and permits increase in respiratory excursion.

In casualties that require multiple, frequent thoracenteses, a tube thoracotomy may be performed. When a tube is inserted and water-seal drainage is used, particular attention must be paid to the mechanics of the system in order that water will not flow into the pleural space. The tube should be removed before the casualty is evacuated. In the Korean conflict, several wounded soldiers were evacuated with tube thoracotomies in place and subsequently empyema developed.

Repeated roentgenograms may be necessary in order to follow the course of the pulmonary changes. Thoracotomies should be drained postoperatively with water-seal drainage in nearly all patients. The water trap bottle should be clearly labeled and corpsmen should be instructed to pay particular attention to the apparatus.

Since atelectasis is a frequent complication of chest operations, every effort should be made to encourage the patient to breathe deeply and to cough frequently. Intercostal nerve block helps the patient to breathe more comfortably and to cough. Whenever atelectasis occurs, a bronchoscopy should be performed.

Care should be taken not to overtransfuse casualties who have sustained injuries to the chest. Frequent auscultation is required to evaluate the chest findings.

A roentgenogram should be taken immediately following a chest operation and at regular intervals thereafter. Narcotics should be used sparingly. Most pain can be controlled by intercostal nerve block.


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Extremity Wounds

In wounds of the extremities, careful records should be made of nerve, vascular and bone injury. It may be necessary to refer to these findings later.

When a fracture is present, the extremity must be immobilized. Motion in an unsplinted extremity causes considerable pain, further tissue damage and bleeding. Roentgenograms should be made in all extremity wounds in order to determine the site and extent of bone injury and the location and size of retained fragments. When several wounds have been débrided and left open, considerable oozing may occur. Postoperatively, frequent examinations of wounds should be made in order to detect any further bleeding. The extremity enclosed in a cast should be examined for edema and evidence of circulatory impairment. Although all casts have a segment resected to permit expansion when edema occurs, the surgeon must make sure that undue pressure is not being exerted on any part of the injured extremity.

In extremity wounds, it is extremely important to explain the extent of injury to the casualty. In many instances, an injured soldier is fearful that his injury may lead to amputation or permanent disability. In casualties on whom amputations have been performed, great care must be taken to explain that every effort was made to save the extremity. A soldier will usually accept this new situation better if an explanation is made at the forward hospital, rather than later. Chaplains and nurses are of assistance to the surgeon in helping an injured soldier overcome his problems of adjustment.

Casualties who have minor wounds of the extremities may be evacuated on the day following injury. When casualties are held longer than 24 hours, however, wounds should be examined and redressed prior to evacuation. This gives the surgeon an opportunity to determine the adequacy of the débridement and to make sure that the wounds are properly dressed before evacuation. It is difficult to do a complete débridement in very large wounds of the buttocks and upper thigh; hence further excision of devitalized tissue is usually necessary. This should be carried out before the casualty is evacuated.

Wounds of the Neck and Face

The usual preoperative procedures of blood replacement and roentgenographic examination are carried out in casualties who have wounds of the neck. If profuse bleeding occurs inside the mouth, it may be necessary to do a tracheotomy and pack the mouth in order to control hemorrhage. In wounds of the neck, a tracheotomy may be


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required for the establishment of an airway or for tracheobronchial toilet.

Improvement of Preoperative and Postoperative Care

In any type of medical care, it is important to maintain a record of experiences. Only by reviewing casualties' records can information be ascertained about the mortality, morbidity, complications and efficacy of treatment. Since evacuation, tactical situations and types of injury differ from war to war-even from campaign to campaign-it is imperative in forward surgical units to keep careful records and analyze them frequently.

Routine records are necessarily brief because of time limitations. These records are usually placed in in envelope and they accompany the casualty as he is evacuated. Unless a separate record is kept at the forward hospital, the medical officers in forward units do not have an opportunity to review their experiences. To depend upon each surgeon to maintain a record of his own experiences will not provide uniform data. Therefore, it is necessary to furnish some type of standardized data sheet for use in forward areas. The data from these sheets should be thoroughly studied each month in order that the medical officers may obtain a summary of their experiences and be guided accordingly if changes in technics and practices are indicated. Unless some satisfactory procedure is established for summarizing current experiences, it is difficult to determine the problems that require further study and to ascertain the areas in which improvements must be made.

During the final few months of the Korean conflict, a statistical data sheet was used at the 46th Surgical Hospital. This form was placed in the wounded soldier's envelope and accompanied him through the preoperative section, operating room and recovery section. The initial information on resuscitative fluids and time intervals was completed during the operative procedure by the anesthesiologist. The remainder of the sheet was completed by the surgeon. These sheets were retained at the hospital and summarized monthly. All surgeons then had an opportunity to observe the results of their work.

A tremendous amount of valuable information might be gained in a theater of combat if these data sheets were completed on every casualty seen in a forward surgical hospital. At the end of each month, summaries of the information on these forms could be sent to the surgical consultant in the theater, and he, in turn, could correlate the information and obtain all overall view of the professional care being administered throughout the theater. Without some type of statistical summary it is impossible to obtain the much needed information on surgical experiences and care.