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Chapter XIX

Contents

CHAPTER XIX

General Considerations of Shock Therapy

According to Brig. Gen. Elliott C. Cutler (1), the single feature of professional care that contributed most directly to the improvement in morbidity and mortality in World War II was adequate resuscitation of the wounded man. This factor, in his opinion, transcended in importance any single method of therapy, even the administration of blood and plasma, for it comprised the total evaluation and care of battle casualties before surgery, not attention to a single anatomic region or some particular wound. This concept led to the greatly improved management of shock, chiefly by the liberal use of whole blood.

PRINCIPLES OF RESUSCITATION

Role of Surgery

In a report to the Surgeon, NATOUSA (North African Theater of Operations, U.S. Army), on 2 July 1943, Col. Edward D. Churchill, MC, emphasized what was, for all practical purposes, a new principle in military medicine, the role of surgery itself in resuscitation (2, 3).

The establishment of a shock or resuscitation ward, Colonel Churchill pointed out, to which casualties in actual or impending shock could be sent as they were received, was an efficient arrangement and absolutely essential when casualties were received in overwhelming numbers. When this system was used, however, there was one error to be guarded against: Resuscitation might come to be regarded as a subspecialty of military surgery and, as such, as a goal in itself. Though it might seem too obvious for mention, one central fact had to be repeatedly emphasized, that a wounded man was resuscitated not only to deliver him from his immediate peril but also to prepare him for whatever surgery he needed.

With this concept in mind, a number of principles of resuscitation became clear:

1. Any delay in resuscitation prolongs the crucial interval between the time of wounding and surgery; that is, the timelag.

2. Any delay in the reversal of shock increases the deleterious effects of circulatory failure. Prompt restoration of blood volume stands out as the most important advance in the war to date (July 1943).

3. Resuscitation of every casualty being prepared for operation is an integral part of the surgical management of trauma. Operating surgeons must not fail to follow closely the clinical course of patients in the resuscitation wards. They must not wait for the patients to be "served up" to them. They


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must not rely on the judgment of inexperienced medical officers with inadequate training in surgery. To divorce the surgeon from shock is a disquieting outgrowth of war that cannot be too severely condemned.

4. Replacement fluids must be introduced rapidly. The use of a syringe to increase the rate of flow is too infrequent.

5. Delay in the procurement of whole blood must not be interpreted as justification for not using plasma.

6. The resuscitation ward tends to become a routine stopping point to regulate the flow of casualties to the operating room. The delay caused by lack of precision in the selection of casualties for resuscitation is wasteful and intolerable.

Practical Implications

In the months that followed Colonel Churchill's report, a sophisticated and highly efficacious system of resuscitation was developed in the North African theater.1 Out of this development came the implementation of his concept that surgery was indeed the climax and goal of resuscitation and was in itself the most potent of all acts of resuscitation.

The immediate outgrowth of this new concept was the establishment of field hospitals immediately adjacent to clearing stations (4), with the result that surgeons trained and equipped to perform emergency surgery were brought within a short litter-carry of casualties whose wounds did not permit them to be transported to an evacuation hospital to the rear but who, after resuscitation, could be operated on close to where they were wounded.

Concepts of Shock and Its Management

It was extremely important that all medical officers and others responsible for resuscitation should understand that shock is not a fixed state but is dynamic. Once resuscitation was begun (figs. 154, 155, and 156), the casualty had to be observed frequently and carefully, so that surgery could be performed at the peak of improvement. Once that peak had passed, it was usually difficult, and sometimes impossible, to attain again the same degree of response to the measures employed. Delay during periods of pressure might mean a lost opportunity in the selection of the optimum time for operation. Stabilization of the circulatory mechanism was, however, essential before surgery was undertaken. Clinical observations were important. So were such observations as the level of the blood pressure, the pulse rate, the presence or absence of sweating, and the state of the peripheral circulation. Serial determinations (fig. 157) of the pulse and blood pressure were necessary; single observations might be highly misleading. Pulse volume was often more important than pulse rate. Collapsed veins and fluctuations of the blood pres-

1Full details of shock and resuscitation appear in another volume of this historical series, based on observations made in the Mediterranean Theater of Operations, U.S. Army, by Lt. Col. Henry K. Beecher, MC, and others (3).


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FIGURE 154.-Administration of plasma and other intravenous therapy in shock ward, 60th Field Hospital, Dieuze, France, November 1944. Note U.S. plasma bottle hanging by white tape, and, next to it, British transfusion bottle, with filter below it, containing blood collected in the European theater.

sure sounds with respiration indicated that restoration of the blood volume had been inadequate.

No reliable criteria were ever developed for recognition of the degree of hemodynamic instability in shocked patients. Blood pressure readings provided only a rough indication. Often when the pulse rate and blood pressure had been restored to almost normal levels, movement of the patient, however slight, might cause a rapid reversion to the original stage of shock. If the significance of this reversion was not realized and if further resuscitation was not carried out before anesthesia and operation, deep and fatal shock might occur. In some cases, compensation might be so complete that, while there were no objective signs of shock, a slight additional blood loss might induce a rapid fall in the blood pressure. Continued or recurrent hemorrhage was one of the most important considerations in resuscitation. The possibility was always to be suspected in casualties who did not respond to adequate resuscitation, including adequate blood replacement.

In general, the degree of shock was proportional to the amount of blood lost, though there was occasionally a surprising lack of correlation. In wounds


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FIGURE 155.-Transfusion in progress in typical shock ward, 102d Evacuation Hospital, Huy, Belgium, January 1945.

of the spleen or the mesentery, in which 1,000 to 1,500 cc. of blood could be aspirated from the peritoneal cavity, there was sometimes complete hemodynamic compensation. It was a mistake to be content with that status. The safety of these casualties required that they be transfused before operation and that preparations be made to transfuse them rapidly during operation (fig. 158), to compensate for the blood loss during it. Many medical officers shared Dr. Owen H. Wangensteen's opinion that measured blood loss at operation always proved larger than it seemed (5).

Limitations of Plasma

Since loss of blood externally or into body cavities was the principal cause of shock, its successful management depended upon the restorations of both red blood cells and blood volume. Plasma alone would not suffice (p. 55). In fact, used beyond a certain point, it might do harm by diluting the remaining blood cells at a time that rising blood pressure, caused by the plasma transfusion, could increase hemorrhage. Also, a false sense of security might be induced when elevation of the systolic pressure was accomplished by plasma alone. A pressure elevated by these means might fall precipitately with induction of anesthesia, operative manipulations, or mere movement of the


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FIGURE 156.-Transfusion in shock ward in U.S. field hospital in Germany. Note suspension of blood bottle (Alsever type) from overhead wire.

patient. Finally, the plan of giving only plasma before operation, with the idea of making up the preoperative blood deficit on the operating table, was poor practice and dangerous besides.

RESUSCITATION

Diagnostic Routine

The plan of resuscitation which evolved in the Mediterranean theater came into general use elsewhere. It began with first aid measures, which frequently included the administration of plasma (figs. 159-162), on the battlefield. They were followed, as soon as the casualty was hospitalized, by rapid, complete examination, with his clothing removed, to appraise his general condition; estimate his state of shock; and determine the factors


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FIGURE 157.-Type of form used for serial observations in shock ward.

which might be contributing to it and which required immediate control, as part of resuscitation. These conditions included cardiorespiratory embarrassment from such causes as painful wounds of the chest wall; sucking wounds; hemothorax, pneumothorax, and tension pneumothorax; cardiac tamponade; blood or mucus or both in the tracheobronchial tree (wet lung); paradoxical respiration; anoxia from any of these causes; inadequately immobilized fractures; large soft-tissue wounds, clostridial myositis; gross peritoneal contamination; and sepsis. Blood loss was the major cause of shock and in most instances it was associated with the conditions just listed. They were, however, able in themselves to produce and maintain shock, and they therefore required separate consideration. The replacement of lost blood was essential, but it could not, in itself, eliminate other factors causing shock.


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FIGURE 158.-Transfusion in operating room of 111th Evacuation Hospital, Ninth U.S. Army, November 1944.

The diagnostic routine also included roentgenologic examination and the performance of certain laboratory tests. These tests were limited to those absolutely necessary; a medical staff that was too energetic might well contribute to the precipitation or aggravation of traumatic shock in a badly wounded casualty.

On the basis of these examinations, casualties were grouped into two categories:

1. Those with minor or slight wounds, in good condition, who needed no special preoperative preparation. They were operated on as soon as possible, with due regard to the more urgent needs of more seriously wounded casualties.

2. Those with severe wounds, who were in shock, and in whom adequate resuscitation might mean the difference between survival and death. The classification of casualties according to their degree of shock has been described elsewhere (p. 39).

Blood Replacement

Casualties admitted in severe shock, with no perceptible blood pressure, were given low-titer group O blood immediately and rapidly, without waiting for grouping and crossmatching of the first liter. The blood was sometimes run into two, three, or even four veins, depending upon the urgency of the patient's state. Blood was obtained at the first venipuncture for grouping and crossmatching in subsequent transfusions.


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FIGURE 159.-Administration of plasma on beach, only few feet from surf, to survivor of landing craft sunk off coast in first days of invasion of Normandy, June 1944.

In cases in which there was time for laboratory examinations, a unit of plasma or albumin could be given while preparations were made for transfusion. After 1,000 to 1,500 cc. of non-type-specific blood had been given to a bled-out casualty, a new sample of his blood was obtained for crossmatching, and the same precaution was repeated after the administration of every additional liter.

When the systolic blood pressure had risen to 80 mm. Hg, the rate of transfusion was reduced while an additional 500 cc. of blood was administered over a 30- to 60-minute period. The rationale of this practice was that the blood pressure often reached an almost normal level before the depleted blood volume had reached a safe level. Transfusions for prophylactic purposes; that is, to guard against a possible fall of blood pressure, were also given slowly.

Ideally, blood replacement was always an individual matter, based on the requirements of the casualty. Since the initial blood pressure was sometimes misleadingly high, the necessity for transfusion was best gaged by the extent and severity of the wound or wounds, the probable amount of blood lost, and the general state of the patient. When Maj. (later Col.) Howard E. Snyder, MC, began to visit hospitals as Consultant to the Surgeon, Fifth U.S. Army (4), he could easily tell, simply by looking at patients after operation,


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FIGURE 160.-Care of wounded, one of whom is receiving plasma, at advance battalion 
aid station, Mortain, France, August 1944.

which ones had not had enough blood before operation; they looked white and bled-out. Generally speaking, each 3- or 4-point deficit on the hematocrit scale or each 0.9-gm. percent deficit in hemoglobin required a transfusion of 500 cc. When there was doubt, it was considered better to give blood than to withhold it.

Blood was sometimes given in larger amounts than was necessary (3). Aside from the waste of a scarce and precious substance, results achieved by this method were no better than those achieved with amounts more consonant with the actual needs. The use of excessive amounts of blood could also be dangerous: If there was no response in the pulse or blood pressure to the transfusion of 2 to 4 pints of blood, it had to be assumed that hemorrhage was continuing or that an overwhelming infection was the cause of the failure of resuscitation. In such cases, immediate operation offered the best chance of life.

Blood was given during operation according to the indications and was also given after operation in large numbers of cases. The correction of nutritional depletion was an essential phase of postoperative care. Many of the wounded had been living for weeks under field conditions, with suboptimum consumption of protein, calories, and vitamins. Loss of blood and plasma at wounding increased the protein and hemoglobin deficits. Postoperative dietary restrictions and exudation into inflamed tissues led to further depletion. These conditions, which retarded wound healing and delayed convalescence,


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FIGURE 161.-Wounded British soldier receiving plasma under care of U.S. and British corpsmen, British-U.S. sector, Holland, October 1944.

responded well to plasma and blood transfusions, continued until the red blood cell count was above 4 million per cubic millimeter and preferably higher. The correction of these deficits was a postoperative objective.

In his May 1944 report to the Surgeon, NATOUSA, Colonel Churchill pointed out that not until the end of 1943 were supplies available in sufficient quantities to permit the establishment of facilities for adequate resuscitation of wounded in forward areas (6). The improvement effected was evident in comparative series: In the first, 200 casualties in Tunisia who were operated on in forward hospitals received 350 plasma infusions and 6 blood transfusions. In the second series, 297 casualties in Italy were admitted to a field hospital, a type of installation which did not exist during the Tunisian campaign. In this series, 285 of the 297 casualties received 1,364 units of plasma and 277 received 511 transfusions. The two series are perhaps not entirely comparable,


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FIGURE 162.-U.S. corpsmen administering care to German civilian who stepped on mine, Würselen, Germany, November 1944. Administration of plasma is part of first aid therapy.

since the first included many less seriously wounded than the second. On the other hand, more than half of the casualties in the first series had wounds serious enough to require immediate operation, and, had facilities and blood been available, there is little doubt that as many of them, proportionately, would have been treated by transfusion as in the second series.

TECHNICAL CONSIDERATIONS

A number of technical improvements and short cuts were developed in all theaters as experience increased. Some of them were as follows:

If blood had to be administered rapidly, an 18-gage needle attached to a 50-cc. syringe was inserted into the tube already in situ, which was clamped off just below the needle. After the syringe had been filled with blood, the clamp was placed above the needle and the blood was pumped in.

When a second transfusion was to be given immediately after the first, the original needle was left in situ and the second transfusion set was connected with it.

If the veins were collapsed, one of the superficial veins about the ankle could be exposed and a cannula inserted, which could be left in place for 24 to 48 hours.

Blood could also be forced in rapidly by the use of a bulb from the blood pressure apparatus attached to the air inlet of the blood bottle. This was an effective method in extreme emergencies but not desirable, for, in careless hands, it could-and did-carry the risk of air embolism.

General Surgical Team No. 25, 2d Auxiliary Surgical Group, which once used 20,000 cc. of type O blood in 4 days, developed the practice of crossmatching three to four bottles


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of blood at once if the casualty seemed exsanguinated (7). This practice had two added advantages, that there was no delay in the transfusions and that recipient sets, which were frequently in short supply at this time, were conserved by the use of the same set for the total amount of blood.

Intrasternal administration of parenteral fluids was discussed at a number of meetings of the Subcommittee on Blood Substitutes and allied groups (8, 9) but, after a vigorous discussion, it was decided not to recommend it, for two reasons: It required a degree of skill unlikely to exist in medical officers of all degrees of training and experience. Also, some fatalities had been reported after it, from puncture of the inner table of the sternum and puncture of the mediastinum.

There was also a vigorous discussion concerning administration of fluids by the femoral vein (8, 9). This technique had been used successfully at Pearl Harbor in burned patients, but it was concluded that it was too dangerous for general use. One reason was that a hypertonic solution such as concentrated human albumin might cause serious damage if it was extravasated.

As early as 1940, Dr. Elmer L. DeGowin and his associates (10) at the State University of Iowa School of Medicine had demonstrated that preserved blood could safely be given without reheating. This practice, which later became routine Army practice, had a number of advantages. It eliminated the frequently costly apparatus and the manpower expended by medical and nursing personnel in the former endeavor to keep parenteral fluids at body temperature during injection. It also saved the time formerly spent in heating blood, and eliminated the risk of hemolysis from the injudicious application of heat.

USE OF BLOOD IN ZONE OF INTERIOR HOSPITALS

In the spring of 1945, Col. B. Noland Carter, MC, Assistant Chief, Surgical Consultants Division, Office of The Surgeon General, was impressed, on his visits to a number of Zone of Interior hospitals, by an apparent tendency to use too little blood in the preoperative, operative, and postoperative management of battle casualties. Part of the explanation was the paucity of surgical personnel trained in the use of whole blood as well as in its storage and processing. Before the war ended, the amounts being used were increased as medical officers who had used blood overseas returned to the United States. At a few hospitals, blood had always been used in adequate quantities. Walter Reed General Hospital, Washington, D.C., as might have been expected, was outstanding in this respect, for the blood for the 250-300 transfusions given there every month was provided by the Blood Research Section, Division of Surgical Physiology, Army Medical School, which conducted most of the research on whole blood carried out before and during the war.

To be certain that difficulty in obtaining blood was not the explanation of its minimum use, Colonel Carter instituted a survey, in April and May 1945, of the hospitals he had recently visited (11). With the end of the war, no action was taken in the matter, but the replies to his questionnaire are worth putting on the record:

Ashford General Hospital, White Sulphur Springs, W. Va., which gave about 20 transfusions a week, obtained the blood from the hospital detachment and civilian personnel. If the necessary refrigerator could be supplied, it was thought that about 50 pints of blood a week could be secured and the number of transfusions per week increased by 10 or 15.


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Thomas M. England General Hospital, Atlantic City, N.J., gave about 20 transfusions a week. It procured the necessary blood from the Philadelphia chapter of the American Red Cross and had adequate facilities for its storage.

Mayo General Hospital, Galesburg, Ill., gave 59 transfusions in January and 60 in March 1945, against an average of 28 in each of the preceding 4 months. The increase was explained by the increase in the number of operations and in their magnitude. Blood was procured from men of the detachment, who were paid $10 for each donation. An informal arrangement had been made with the civilian hospitals in Galesburg, which paid $25 per donation, that no men of the detachment would be permitted to donate blood at any of them until they had first donated at Mayo General Hospital. No man was permitted to donate oftener than every 6 weeks, and 3 months was the preferable interval. The hospital staff saw no particular advantage to establishing a blood bank with such a pool of donors at hand and only a limited amount of surgery being done.

Newton D. Baker General Hospital, Martinsburg, W. Va., reported a strong tendency early in its operation to use plasma in preference to blood because of its ready availability and its ease of administration. Over the past several months, an attempt had been made to use more blood, and an average of three transfusions a week had been given between 1 January and 9 April 1945. Group B and group AB bloods were sometimes in short supply but there had been no shortages in donors of other types. Although the number of transfusions given was small, the use of blood was considered adequate. Paraplegics had sometimes presented compatibility difficulties, possibly because they had already received so many transfusions.

Lovell General Hospital, Ayer, Mass., which operated its own blood bank, gave an average of 30 transfusions a week. Blood was obtained without difficulty from the medical and Women's Army Corps detachments and civilian employees and was supplemented by blood from the Worcester Blood Bank and the Boston Red Cross Chapter, which provided as many as 20 bottles a week and could furnish more if necessary.

DeWitt General Hospital, Auburn, Calif., which gave an average of 12 transfusions a week, obtained blood from civilian and military members of the hospital staff. Local Red Cross representatives had informed the commanding officer of the hospital that about 100 Auburn civilians, who periodically gave blood for the plasma program, would be glad to contribute to the hospital if the need should arise.

Halloran General Hospital, Staten Island, N.Y., which operated its own blood bank, gave about 40 transfusions per week. Group O blood was secured from duty personnel, and A, B, and AB blood from the Army Whole Blood Procurement Service, which procured it from the New York chapter of the American Red Cross.

Billings General Hospital, Indianapolis, Ind., which operated its own blood bank, gave 559 transfusions between 27 March and 27 April 1945. The blood was secured from individuals confined in the U.S. Disciplinary Barracks on the post and was collected at regular intervals. The bleeding of prisoners was always on an entirely voluntary basis.

Brooke General Hospital, San Antonio, Tex., which gave about 40 transfusions per week, was not permitted to operate a blood bank because the liquid plasma center operated at the 4th Army Laboratory at Fort Sam Houston could supply all the blood needed. The hospital, however, had set up a transfusion section which prepared and issued all intravenous sets, typed all patients requiring transfusion, crossmatched all bloods, drew all bloods collected in the hospital, and investigated reactions. The transfusion section kept 6 pints of O blood on hand at all times for emergency use, replacing within 24 hours all blood used.

The bulk of the blood collected locally came from the medical detachment. Donors were paid at the usual rate. Civilian donations amounted to about 15 per week.

Walter Reed General Hospital

Late in 1943, the Division of Surgical Physiology, Army Medical School, undertook to supply blood for all routine transfusions at Walter Reed General


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Hospital. A strict record was kept of the first 3,000 transfusions given under the new system, and a continuing effort was made to see that recipient sets were properly prepared. With this precaution, the reaction rate, as already noted, was reduced from 22 percent to approximately 0.5 percent.

Only O blood was supplied. At first, the bloods were not tested for agglutinin titer, and no effort was made to avoid giving A, B, or AB recipients transfusions of high-titer blood. During this period, there was only one instance in which it was suspected that an A recipient might have suffered from some hemolysis of her own cells. The reaction was mild, perhaps because the blood had been collected in Alsever's solution and the amount of agglutinin was therefore diluted and was taken into the bloodstream more slowly than if the amount of solution transfused had been 500 or 600 cc.

In January 1945, a number of high-titer bloods were deliberately given to A and B recipients. No clinical reactions were observed until bloods with titers of 1:1024 or higher were administered. Then, the patients had chills, fever, vomiting, and other symptoms, and an increase in the serum bilirubin was observed.

Since these observations suggested that high-titer O bloods might cause reactions in non-group O recipients, all O bloods handled at the hospital in the future were separated on the basis of their agglutinin content. The titration technique which was adopted separated approximately 25 percent of O bloods with the highest titers of anti-A or anti-B agglutinins, or both. High-titer bloods were given only to O recipients, and low-titer bloods were reserved for A, B, and AB recipients.

Maj. Leslie H. Tisdall, MC, Coordinator, Army Whole Blood Procurement Service, with his associates, made a study of the effects of high-titer O blood on incompatible recipients (12) (p. 259), and further studies in the Zone of Interior were being planned when the war ended.

PLASMA THERAPY

Indications

While too much credit was given to plasma early in World War II, it remained until the end of the war an extremely useful emergency agent. This has been indicated in so many discussions earlier in this volume that any repetition is unnecessary here.

There were certain injuries and conditions in which plasma was of greater value than blood or was needed in addition to blood. These included:

1. Head injuries. Limitation of fluids was desirable, and plasma was given only in sufficient quantities to control shock and restore blood volume.

2. Crushing injuries, in which hemoconcentration was frequent. The tremendous swelling which developed in the limbs of these victims after they were removed from beneath the stones and masonry which had crushed them often was associated with very high hematocrit values. The management of these injuries was also complicated by the development of pigment nephropathy and anuria, which might be enhanced by blood transfusions.


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3. Fulminating clostridial myositis, particularly of the wet type. Loss of plasma through the wound or into the affected muscles was best combated with large plasma infusions. These same patients, however, tended to present severe anemia, and they required whole blood as well as plasma.

4. Severe wounds associated with hypoproteinemia; abdominal wounds which required prolonged nasogastric suction; and bedsores, particularly in paraplegics. Amino acid solutions for intravenous use were never generally available in World War II and were not available at all until late in the war. Plasma proved to be an excellent substitute.

5. Burns, which furnished perhaps the most clear-cut indication of all for the use of plasma. When Elkinton (13), in 1939, reported four cases treated by this method, he pointed out:

a. That hemoconcentration or diminution of the plasma volume, as measured by serial hematocrit determinations, was evident in all four patients, who also all exhibited a decrease in the plasma protein concentration, a decrease which, because of the hemoconcentration also present, was even more marked than the figures indicated.

b. That plasma infusions, to replace the lost plasma and protein, was the most rational therapy. Whole blood would supply the necessary elements, but to add red cells to a circulation already relatively overloaded with them, was not logical.

The onset of shock in severe burns is remarkably rapid and may occur within an hour after injury. Immediately after injury, however, the need for plasma is not yet reflected in the hematocrit, and larger amounts are needed than its current level indicates.

The tragic experience of the fire at the Cocoanut Grove in Boston in November 1942 provided an instructive experience in the management of shock in burns (14). The mass disaster bore a real resemblance to the situation that might be encountered in military experience. An instructive comparison was also furnished between the use of plasma at Massachusetts General Hospital, where all the patients were treated uniformly, under the direction of Dr. Churchill, and its use at the Boston City Hospital, where the patients were treated on five separate services.

In cases of burn shock not complicated by wounds, in which the reduced blood volume was due almost entirely to loss of plasma, the most common error of management in World War II was failure to administer plasma rapidly enough and in large enough amounts. The best results were secured when it was given into two veins, or with positive pressure, until the hematocrit became approximately normal. Then, administration was continued at a rate just sufficient to maintain this level. As much as 4,000 to 6,000 cc. of plasma might be necessary in the first 24 to 36 hours in extensive burns. After this period, secondary anemia tended to develop rapidly, and whole blood replaced plasma in the management of the injury.

The special experience of the 77th Field Hospital in the European theater, commanded by Maj. Henry Metz, MC, with the use of plasma in true protein depletion, in which it was more valuable than whole blood, is described elsewhere (p. 570).

Dosage and Administration

The dosage of plasma, as of blood, was an individual matter. The blood pressure level was the simplest method of determining the need for it and the response to it, but not necessarily the most accurate method.

The degree of hemoconcentration was another method of determining the amount of plasma to be used; 50 cc. was given for every point that the concentration exceeded the normal 100 percent. It was also estimated that 100 cc. of plasma was required for every point that the hematocrit determination exceeded the normal of 45.


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When the hematocrit was low, patients treated with plasma sometimes had a rapid pulse for days, even though the blood pressure was well sustained.

It was realized very early in the war that 250 cc. of plasma was never an adequate dose; if plasma was needed at all, at least 500 cc. was necessary, and, many times, a good deal more (15, 16). As time passed, the initial dose tended to become larger, up to 1,000 cc., and some hospitals, such as the 33d Field Hospital in November 1943, reported using as much as 5,000 cc. for resuscitation (6).

The first 500 cc. of plasma was given rapidly, and rapid administration was continued until the blood pressure became approximately normal. If the patient was evacuated to the rear, additional plasma was given before he was put in the ambulance. This method was very useful in the Tunisian campaign, when, field hospitals not yet being in use in their later conventional manner, undesirably long evacuations were often necessary. Plasma was also given during transportation, particularly to patients with abdominal injuries and fractures of the femur. Later, of course, patients with such injuries were resuscitated and operated on in forward hospitals.

Isotonic plasma was recommended by the Subcommittee on Blood Substitutes (15). Its members did not look with favor on the use of concentrated plasma (p. 275).

Other Proposed Uses

The suggestion that dried plasma be used as a menstruum for the local application of penicillin to wounds did not get beyond the experimental stage. The same was true of a study at the University of Chicago on filling the pleural space with plasma after lung resection, to compensate for the protein loss that occurs after such operations.

Attempts to treat decompression sickness with plasma, on the ground that some patients presented decreases in specific gravity, came to no more than the suggestion. A similar fate befell the suggestion that concentrated dried plasma be used in the treatment of acute nephritis.

The proposal that plasma be administered by hypodermoclysis in deeply shocked casualties was discouraged for the reason that if the veins were collapsed and difficult to locate, there was all the more reason for injecting plasma intravenously as promptly as possible to restore an effective circulating blood volume.

Technique of Administration

The standard Army-Navy package of dried plasma contained two sealed cans and a printed questionnaire. Filling out the questionnaire was the final step of administration of plasma and was particularly important in the early days of the program, when the Blood Research Section, Army Medical School, urgently needed the data thus secured to determine further steps in procedure.

The detailed technique of plasma administration is described in figure 163.


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SERUM ALBUMIN THERAPY

The Army, in contrast to the Navy, used very little serum albumin because of its satisfaction with plasma and for other reasons (p. 347). Clinically, except for the need for supplying fluids when serum albumin was used in dehydrated patients, there was little to choose between the two agents. At times, however, the compact size of the serum albumin package was a distinct advantage. One medical officer, for instance, related how he and some of his corpsmen, after they had lost all their plasma when their landing boat was sunk off the Normandy beaches, filled their pockets with packages of serum albumin and administered it to many seriously wounded men, most of whom lived to be taken aboard ships on which they could receive definitive care.

As albumin was put up for the Armed Forces, its high concentration made its physiologic effect dependent upon the rapidity with which it mobilized interstitial fluid. In a well-hydrated patient, this was no problem; the circu-

FIGURE 163.-Reconstitution of standard Army-Navy package of normal human dried plasma. A. Unopened waterproof cardboard box sealed with waterproof tape. B. Removal of tape from box. C. Opened box, showing contained cans, which are removed by pulling on the draw cord. D. Cans removed from box. E. View of can showing spot-welded key on top.


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FIGURE 163.-Continued. F. Opening of can with spot-welded key. G. Removal of contents of cans. The plasma can, packaged under vacuum, contains a double-ended needle, intravenous needle, and bottle of dried plasma. The water can, packaged under nitrogen to protect the rubber tubing, contains an intravenous set, an airway assembly, and a bottle of distilled water. H. Contents of cans assembled for demonstration. I. Insertion of double-ended needle into water bottle, for transfer of water to dried plasma bottle. J. Insertion of other end of double-ended needle into plasma bottle after preliminary inversion of water bottle and painting of stopper of plasma bottle with antiseptic solution. K. Insertion of airway needle into water bottle if vacuum is not sufficient to pull all water into plasma bottle. After the water is transferred, the airway needle is withdrawn from the water bottle and inserted into the plasma bottle.


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FIGURE 163.-Continued. L. Direct transfer of water to plasma bottle when standard techniques just described (J, K) have failed. Plasma reconstituted by this technique must be used immediately. M. Shaking (or rotation) of plasma bottle while water is being added, to expedite solution, which normally takes 1-2 minutes. N. Airway inserted into stopper of plasma bottle, after it has been painted with antiseptic solution. O. Giving needle inserted into stopper of plasma bottle. The plasma is now ready for administration by the usual intravenous technique. Note the turbidity of the reconstituted plasma, which has no effect on its usefulness. P. Attachment of intravenous needle, still covered by glass tube (and up to this point by a cellophane wrapper), to Luer tip of glass observation tube. Q. Final step in administration of plasma, filling out questionnaire in package, to be returned to the Blood Research Section, Division of Surgical Physiology, Army Medical School.


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lating blood volume was promptly increased, and the intravascular discrepancy characteristic of shock was promptly overcome. In the dehydrated casualty, the problem was different. Since the majority of wounded soldiers, under the rigorous conditions of combat, were dehydrated, isotonic fluids usually had to be administered along with the serum albumin. This was no problem for the Navy but made the use of albumin by the Army far less practical and convenient.

At the 2 June 1944 meeting of the Subcommittee on Blood Substitutes (17), the principal discussion concerned the possibility of resuscitation in airplanes. It was decided that if this procedure should be attempted, serum albumin would be the best agent to use. There were numerous problems, including limitation of space, thermal stability, and the effect of turbulence. No further action was taken, chiefly because D-day was 4 days after this meeting and the Army Air Forces were fully occupied with other, more urgent matters.

At the end of the war, the clinical indications and contraindications for the use of serum albumin were quite clear:

1. It could be used in shock and in hypoproteinemic states almost interchangeably with plasma. It had to be borne in mind, however, that albumin is purified protein and contains no complement, prothrombin, or other components of plasma.

2. Serum albumin was of special value in edematous patients, particularly in burned patients, because it could be administered without a significant amount of fluid. On the other hand, if it was given to a dehydrated patient the parenteral administration of fluid was necessary simultaneously or immediately after the serum was injected.

3. Serum albumin was useful in patients with cranial injuries, in which fluids were generally contraindicated.

4. The fact that albumin is hypertonic and remains in the vascular system longer than hypertonic crystalloid solutions made it necessary to use it with great care. It was not useful in older patients if any myocardial weakness was evident; the rapid elevation of the blood pressure could cause pulmonary edema. It was also contraindicated in concealed arterial bleeding and in uncontrolled or recurrent hemorrhage because of the rapid rise in blood pressure which it produced.

Technique of Administration

The standard Army-Navy package for concentrated serum albumin (fig. 164A and B) contained three cans (fig. 164C), each of which contained:

A double-ended glass container, sealed at each end with rubber stoppers, and containing 100 cc. of 25-percent solution of serum albumin (25 gm.).

An airway.

Equipment for intravenous administration.

Tape for suspension of the albumin bottle.


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Etched on the metal can were the following instructions for the administration of the serum albumin (fig. 164):

1. Open metal can with attached key.

2. Remove air filter needle, intravenous set, and intravenous needle.

3. Remove container of albumin.

4. Apply alcohol or iodine to both rubber stoppers.

5. Holding container in upright position, insert air filter needle through top of rubber stopper.

6. Insert short needle of intravenous set through rubber stopper at opposite end.

7. Attach intravenous needle to observation tube.

8. Allow tubing to fill with albumin solution.

9. Insert intravenous needle into vein. If venipuncture is difficult, cut down on vein.

10. Suspend container about 3 ft. above patient..

11. Except in severe shock, do not let rate of administration exceed 5 cc. per minute.

MANAGEMENT OF SPECIAL TYPES OF WOUNDS

Wounds of the Extremities

Patients with multiple wounds of the extremities, particularly those produced by landmines, traumatic amputations, and fractures of the femur, required large amounts of blood. A common mistake in the management of femoral fractures in the early experience of the Mediterranean theater was failure to restore the blood volume promptly. Penicillin was brought to the theater by Maj. Champ Lyons, MC, in the late winter of 1943, and he and Maj. (later Lt. Col.) Oscar P. Hampton, Jr., MC, introduced an extremely successful three-point program of blood, penicillin, and surgery (18). In all their instruction, they emphasized that even as potent an agent as penicillin would be less potent without the liberal use of whole blood and that surgery would be much less successful-and sometimes impossible-without it.

Blood was given in preparation for operation, during operation, and postoperatively in the forward hospital, and was also given later, before reparative surgery, in the base hospital.

Secondary anemia, often of a considerable degree, was evident in casualties admitted to base hospitals, even when they had received large amounts of blood in forward hospitals. These anemias would undoubtedly have corrected themselves spontaneously in time if adequate diets had been supplied and had been supplemented by iron therapy. There was, however, an urgent need to get on rapidly with reparative surgery, not only because the military situation required the rapid turnover of hospital beds but, even more impellingly, in the patient's own best interests. Wound closure with low hematocrit levels would have introduced a completely preventable surgical risk (19, 20).

Three series of fractures of the long bones illustrate these points (18):

1. At the 16th Evacuation Hospital, 28 of 100 casualties with fractures of the femur required between 1,500 and 2,000 cc. of blood before and during operation, and only 9 patients in the series required no blood at all. In contrast, only 3 of 100 patients with compound fractures of the radius, ulna, or long bones required blood in such quantities, and


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FIGURE 164.-Administration of serum albumin. A. Standard box containing three bottles of albumin. B. Removal of sealing tape. C. Opened box with contents. D. Can with spot-welded key.

63 required no blood at all. Casualties with compound fractures of the humerus, tibia, fibula, or both bones of the leg constituted an intermediate group.

2. At the 23d General Hospital, 33 patients with fractures of the long bones had hematocrit values under 30; 80 others had values between 31 and 40; and only 25 (18 percent) had values of 40 or higher, the desirable level for reparative operation. Only 2 of 38 patients with fractures of the femur fell into the latter category.

3. At the 21st General Hospital, the proportions were substantially the same in 166 patients with fractures of the long bones; 37 had hematocrit readings under 30, and only 31 (19 percent) were regarded as safe for operation without further blood replacement.

While no absolute proof can be adduced to show that such intensive blood replacement was necessary for good results, there is a great deal of indirect proof. The program of reparative surgery in compound fractures, the use of penicillin, and liberal whole blood replacement therapy came into existence in the Mediterranean theater at about the same time. It is naturally impossible to attribute the improved results that promptly followed their introduction to any single one of these factors. It was the general impression, however, that the anesthetic risk was far less in patients whose secondary anemia had been corrected, that wound healing was prompter, and that convalescence was less


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FIGURE 164.-Continued. E. Opening of can with key. F. Bottle, airway, and giving set being removed from can. G. Double-ended albumin bottle, double-ended airway, giving set, and needle. H. Albumin and equipment set up and ready for use. Airway has been inserted in one end of bottle and intravenous needle in other. Set will be suspended by cloth scrap attached to bottle.

complicated. It was also the impression that those who had received liberal transfusions were less likely to present chronic infections.

Abdominal Injuries

Casualties with abdominal injuries required replacement therapy by the usual routine (3). In such injuries, however, it was important to observe the response carefully. If it was not what could be expected with the amount of blood used, prompt surgery was indicated, on the ground that hemorrhage might be continuing or that a fulminating chemical peritonitis might be present.

Plasma was often used liberally in the first few days after closure of a colostomy, to reduce edema of the suture line, and to prevent narrowing of the anastomotic orifice.

Chest Injuries

Both plasma and blood had to be given with great caution in chest injuries (21). Decompensation was always a possibility if edema were per-


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mitted to develop. The same precautions concerning the risk of overloading the circulation held in thoracoabdominal wounds. Sometimes the need for correction of cardiorespiratory pathophysiology, which indicated limitation of fluids, had to be balanced against the need for liberal amounts of blood because of hemorrhage from associated injuries. Theoretically, if red blood cells had been available, their use might have solved the problem of the need for blood and the risk of overloading the circulation in chest injuries.

Before blood was available in liberal quantities in the Mediterranean theater, blood aspirated from the chest was sometimes used for transfusion. Surgeons differed as to the periods within which they considered it safe to use such blood; most were conservative, limiting the time to no more than 6 hours. The blood was never used, of course, if there was the smallest suspicion that a thoracoabdominal wound was present.

ADMINISTRATIVE CONSIDERATIONS

Preparation of Manual On Shock

At the first meeting of the NRC (National Research Council) Committee on Transfusions on 31 May 1940 (19), Dr. Alfred Blalock was appointed to prepare a small pamphlet on shock and allied subjects, for distribution to the Army and the Navy. His choice as principal author was wise, for few people had done more than he to develop the concept of hemorrhage as the basic cause of shock.

It is of interest, therefore, and indicative of how completely shock therapy was revolutionized during the war, to find in this pamphlet (22):

1. A full discussion of isotonic salt and glucose solution in the prevention of shock.

2. A statement of the limitations of blood banks in wartime because of the cumbersome cooling unit necessary, and the limited shelf life of blood. It was pointed out, however, that one of the greatest advantages of preserved blood was that larger quantities could be given than were ordinarily used.

3. A discussion of plasma (twice as long as the space devoted to blood), in which the concept was presented that the loss of red blood corpuscles would be tolerated quite well if the lost plasma were replaced. One of the advantages of plasma was said to be that it did not add to the concentration of red blood corpuscles, hemoconcentration being the usual finding in shock. The intravenous injection of adequate quantities of plasma was considered "probably the single most effective and valuable and practical method for the prevention and treatment of shock, with the possible exception of methods of hemostasis."

All of these statements were correct in the light of 1940 knowledge.

Shock Teams

The blood banks in the Mediterranean and European theaters had a single function, to provide blood for wounded casualties. The U.S. Army blood service personnel, unlike the British Army Transfusion Service personnel, had nothing to do with the administration of the blood. British personnel were trained in the processing and care of preserved blood and also in its


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administration. U.S. personnel were trained only in its procurement and processing.

As shock was handled in the Mediterranean theater during World War II, it was the shock teams assigned from auxiliary surgical group personnel and not organic personnel of field hospitals who carried the major responsibility for treating casualties and determined the efficiency of their care in these hospitals (3). The supervision of shocked casualties by hospital personnel was the responsibility of the anesthesiologist, whose hands were full with his own duties, supervision of his helpers, and supervision of replacement therapy in the operating room.

This situation was almost inevitable. In contradistinction to other areas of medicine and surgery, there was no pool of civilian medical personnel trained in the mass treatment of shock. Almost any civilian physician could treat single patients adequately in peacetime practice, and that was how shocked patients were usually encountered, as individuals. In warfare, there were few occasions on which it was not necessary to treat several casualties at the same time, and it was often necessary to treat overwhelming numbers of seriously wounded casualties simultaneously. Few medical officers possessed this knowledge and ability when they entered the Army and they had to be trained afterward (p. 87).

Shock Wards

Shock wards were promptly set up in hospitals in combat areas in all theaters. The ward described by Col. Douglas B. Kendrick, MC, in October 1945 (figs. 165 and 166) brings together the best features of all such wards as they evolved with experience (23):

Facilities.-While facilities must conform to available terrain, shock wards, whenever possible, should be located in proximity to the triage tent and as close as possible to the surgical tent. If terrain permits, it is best to have all of these tents, plus the radiology tent, joined. With such an arrangement, service is more efficient, and mud, heavy rains, and blackout regulations are less hampering.

The tentage should be sufficient to accommodate 40 patients at the same time (fig. 165). Two squad tents, attached to each other laterally, with the adjoining sidewalls raised, will provide adequate space for 25, and a third tent, joined to one or the other, can care for an additional 15 casualties. Shock wards should not be divided. When they are, additional personnel and equipment are necessary, and comparative surgical priorities are more difficult to establish.

Equipment-Good light is essential for examination, venipuncture, and laboratory work. If electrical fixtures are limited, bulbs attached to long drop cords provide adequate lighting.

Also needed are:

1. Wooden horses (80), half 25 and half 29 inches high, so that litters can be placed in either the Fowler or the Trendelenburg position.


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FIGURE 165.-Interior of shock ward, showing litter on sawhorses. Wire, strung above litter, suspends charts, identification cards, and blood, plasma, and other intravenous fluids.

2. Overhanging wires (fig. 165), strung about 7 feet high and so distributed that a wire passes over each litter. These wires are used for intravenous fluids, individual records, and, for rapid identification, cards with each patient's number.

3. Tourniquets.

4. A refrigerator.

5. A large sterilizer or two small sterilizers.

6. Wash basins, kidney basins, sponge cups, and drinking cups.

7. Levin tubes, urinals, bedpans, and enema bags.

8. Oxygen tanks, reducing valves, and oxygen masks.

9. Syringes, 5-, 10-, 30-, and 50-cc., 100 of each.

10. Hypodermic needles, from 25- to 15-gage.

11. Sternal needles.

12. Intravenous cannulas.

13. Clinical thermometers.

14. Bandages, Carlisle dressings, large and small gauze squares, petrolatum gauze (for sucking wounds of chest), and adhesive tape.

15. Blankets.

16. Portable Van Slyke copper sulfate specific gravity sets and a centrifuge for determining hematocrit and plasma protein values.

17. Phlebotomy sets and chest aspirating sets.

18. Morphine solution in 100-cc. bottles, procaine hydrochloride solution, sodium amytal, and aspirin.

19. Penicillin.


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FIGURE 166.-Setup of shock ward. A. Utility table. B. Oxygen tank. C. Sterilizer. D. Refrigerator. E. Washbowls. F. Entrance from triage ward. G. Exit to surgery. In retrospect, it would have been more efficient to place the refrigerator in the center of the ward.

20. Whole blood, plasma, isotonic sodium chloride solution, and 5-percent dextrose solution in distilled water.

21. Forms for recording transfusions and other intravenous medication.

22. A bulletin board for posting lists of casualties under treatment for shock, with recommended surgical priorities.

A center table, with multiple shelves, placed in the center of the ward makes all equipment and supplies readily accessible. Glassware is washed and prepared on a small table near the sterilizer.

Staffing.-Shock wards must operate fully staffed 24 hours a day. The minimum personnel to handle 30 patients in shock is two officers and four enlisted men, so assigned as to provide efficient coverage in the circumstances.


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Enlisted men should be well trained in aseptic techniques and in the preparation and administration of blood and other intravenous fluids.

Because of the volume of work on a shock ward, it is desirable to utilize personnel from other services. After adequate instruction, dental officers prove very useful, and personnel from the medical services can also help, especially early in a combat operation, when, as a rule, there are few medical admissions.

Assignment of duties-The duties of medical officers on a shock ward are to make an initial examination; control hemorrhage; close sucking wounds of the chest; aspirate hemothoraces; relieve tension pneumothorax; perform intercostal nerve block; take blood for hematocrit and plasma protein determinations; maintain a check on the blood pressure; order replacement therapy and assist in giving it; outline the therapeutic measures to be employed; supervise the setting up and maintenance of records; record all therapy; follow the results of treatment; correlate them with the shock process; determine transportability; and, in conference with the chief of surgery, establish operative priorities, with due regard to relative possibilities of survival.

The medical officer in charge of the ward also organizes the duty roster of officers and enlisted men on shock teams and assigns them to specific tasks.

The duties of enlisted men are to administer morphine, penicillin, blood, plasma, and other therapy as directed by the medical officers; maintain adequate supplies; attend to the care and operation of the sterilizer; clean glassware; record all procedures carried out on patients; provide ordinary nursing care, such as taking temperatures; removing bloody blankets and clothing; cleanse patients, at least superficially; and supply coffee, water, and other fluids if the patients are able to take them.

Experience proved that the methods just outlined provided a simple and efficient routine for the management of shocked casualties.

References

1. Administrative and Logistical History of the Medical Service, Communications Zone, European Theater of Operations, vol. 13, chapter 14, Professional Aspects of the Medical Service. [Official record.]

2. Report of Consultant Surgeon to the Surgeon, NATOUSA, 2 July 1943.

3. Medical Department, United States Army. Surgery in World War II. General Surgery. Volume II. Washington: U.S. Government Printing Office, 1955.

4. Snyder, Howard E.: Fifth U.S. Army. In Medical Department, United States Army. Surgery in World War II. Activities of Surgical Consultants. Volume I. Washington: U.S. Government Printing Office, 1962.

5. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 24 Sept. 1943.

6. Report of Consultant Surgeon to the Surgeon, NATOUSA, 31 May 1944.

7. Hurt, Maj. Lawrence E.: General Surgical Team No. 25, 8 Aug. 1944.

8. Minutes, Conference on Albumin, Division of Medical Sciences, NRC, 5 Jan. 1942.

9. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 23 June 1942.

10. DeGowin, E. L., Hardin, R. C., and Swanson, L. W.: Studies on Preserved Human Blood. IV. Transfusions of Cold Blood Into Man. J.A.M.A. 114: 859-861. 9 Mar. 1940.


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11. Use of Whole Blood in Zone of Interior Hospitals. Survey, Col. B. N. Carter, MC, April-May 1945

12. Tisdall, L. H., Garland, D. M., Szanto, P. B., Hand, A. M., and Barnett, J. C.: The Effects of the Transfusion of Group O Blood of High Iso-Titer Into Recipients of Other Blood Groups. Am. J. Clin. Path. 16: 193-206, March 1946.

13. Elkinton, J. R.: The Systemic Disturbances in Severe Burns and Their Treatment. Bull. Ayer Clin. Lab., Pennsylvania Hosp. 3: 279-291, December 1939.

14. Memorandum, Lt. Col. D. B. Kendrick, MC, to Director, Army Medical School, 15 Dec. 1942, subject: A Preliminary Report on the Cocoanut Grove Disaster From the Massachusetts General Hospital, 6 December 1942.

15. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 23 May 1941.

16. Robinson, G. C.: American Red Cross Blood Donor Service During World War II. Its Organization and Operation. Washington: The American Red Cross, 1 July 1946.

17. Minutes, meeting of Subcommittee on Blood Substitutes, Division of Medical Sciences, NRC, 2 June 1944.

18. Medical Department, United States Army. Surgery in World War II. Orthopedic Surgery in the European Theater of Operations. Washington: U.S. Government Printing Office, 1956.

19. Minutes, meeting of Committee on Transfusions, Division of Medical Sciences, NRC, 31 May 1940.

20. Churchill, E. D.: The Surgical Management of the Wounded in the Mediterranean Theater at the Time of the Fall of Rome. Ann. Surg. 120: 269-283, September 1944.

21. Medical Department, United States Army. Surgery in World War II. Thoracic Surgery, Volume I. Washington: U.S. Government Printing Office, 1963.

22. Shock, Prevention and Treatment. A manual prepared for the Medical Corps of the Army and Navy, under the direction of the Medical Division of the National Research Council, by Alfred Blalock, Nashville, Tenn.

23. Kendrick, Lt. Col. Douglas B.: Organization of a Shock Service in a Combat Area Hospital. J. Mil. Med. Pacific 1: 14-21, October 1945.

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