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Chapter IX

Contents

CHAPTER IX

Resuscitation and Preoperative Preparation

Lyman A. Brewer III, M.D.

GENERAL CONSIDERATIONS

Adequate resuscitation of the wounded man before initial surgery was the policy that most clearly distinguished professional care in World War II from that of World War I. It was probably also the single factor that contributed most directly to the improved salvage rate. Essentially, it was based on the surgeon's appreciation of the entire status of the patient as well as of the nature and severity of his regional wound or wounds. For all battle casualties, regardless of the type of wound sustained, this led to the better management of shock. For the thoracic casualty, it led to consideration of his disturbed cardiorespiratory physiology not as an entity separate from shock but as a condition precipitating it or aggravating it.

About 2 percent of all casualties admitted to field hospitals were either dead on arrival or were in such poor condition that intensive resuscitation failed to improve them sufficiently to permit operation. Under no circumstances, however, was the condition of a patient who was admitted alive considered so hopeless that resuscitation was not attempted. This policy paid rich dividends. Many a casualty received without obtainable pulse or blood pressure responded to resuscitation and recovered after surgery.

Surgical Timing

In military practice, casualties with wounds of the abdomen were operated on as soon as their general condition permitted because continuing intraperitoneal hemorrhage or infection was always a serious possibility. Casualties with injuries confined to the thorax, on the other hand, ran their chief risks from altered cardiorespiratory mechanisms. Even if the timelag was prolonged, infection was not the serious possibility that it was in all abdominal injuries. It was imperative to correct the altered cardiorespiratory mechanism as promptly as possible; but it was seldom necessary to operate immediately in the absence of intra-abdominal injuries (thoracoabdominal or associated abdominal), traumatic amputations, or continuing hemorrhage within the chest or elsewhere.

It was the general opinion, founded on sound evidence and experience, that a casualty with a severe wound of the chest was in better condition for opera-


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tion, and convalesced more rapidly afterward, if time were taken before operation for his blood pressure, pulse, and respiration to be restored to satisfactory levels. In such conditions as extensive pulmonary contusion from blast (vol. II, ch. I) or myocardial contusion (vol. II, ch. II), it was best to allow from 24 to 48 hours, or longer, to elapse before even minor surgery was undertaken. In blast injuries and contusions, in particular, it was a major, and often fatal, error to operate too promptly. Casualties who were held at the clearing station or field hospital for replacement therapy, oxygen, and other resuscitative measures, and who were held until full recovery from primary shock, were always received in better condition at an evacuation hospital than if they were rushed through without such care.

Resuscitation was not an end in itself, simply a means to an end. The end was corrective and restorative surgery. When the patient had reached an optimum stage of recovery, which in thoracic casualties was after cardiorespiratory stabilization, it was essential to operate without delay, for the status of a wounded man was never static, and deterioration was the rule if surgery was too long deferred.

The initial treatment of all thoracic casualties was always resuscitation, whether they required immediate operation in the field hospital or could be evacuated farther to the rear for surgery. No decision was made for or against emergency surgery until adequate resuscitative measures had been instituted (fig. 30). After they had been, emergency surgery in the field hospital that originally had seemed inevitable, often proved unnecessary. Even when the indication for emergency surgery was unquestionable, as it was when the injury was a large traumatic thoracotomy or an obvious thoracoabdominal wound, operation was never carried out without adequate resuscitation and preoperative preparation.

As far as the time element was concerned, it was important to shorten to the minimum the interval in which diminished oxygenation of the blood could produce cerebral damage. Once normal oxygenation of the tissues had been reestablished, the time interval from that point to surgery was not of major importance.

Personnel of Shock Ward

The medical officer who cared for casualties in the shock ward and prepared them for operation was a vital link in the successful management of chest injuries. Early in the war, there was an inclination to delegate the duties in this ward to anybody who happened not to have more pressing duties at the time. The fallacy of this policy was soon learned, and at a heavy price. It took experience and sound judgment to resuscitate a thoracic casualty intelligently and successfully. It took expert judgment to determine the optimum time for operation. A patient who was permitted to slip back into shock because advantage had not been taken of the optimum recovery to be expected was far


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FIGURE 30.-Resuscitation of casualty with chest wound in shock ward of field hospital.

more difficult to resuscitate a second time and represented a far poorer surgical risk.

The evaluation of one special category of casualties could be quite misleading unless it was remembered that the combination of anoxia and excessive carbon dioxide could result in an elevation of the blood pressure, even when blood loss had occurred. If such a patient were taken to the operating room without any preparation at all, in the belief that he did not need it, surgery might prove fatal. Surgeons with an experience of combat-incurred chest injuries were aware of these cases, but an inexperienced medical officer was likely to feel a false sense of security about them. Such a patient might show a fall in blood pressure when the proper shock therapy was instituted.

The duties in a shock ward were best carried out by medical officers who were well grounded in the physiology of the cardiorespiratory system. As a rule, a well-trained internist was a better shock officer than a surgeon, however technically brilliant, who was poorly trained in physiology. Members of shock teams of auxiliary surgical groups proved ideal for this purpose. There was no single reliable guide to the status of shock in thoracic or other casualties, but the clinical impressions of an experienced medical officer were generally more useful than the measurement and numerical record of any body function.


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Case Histories

The two case histories that follow illustrate the improvement that occurred in concepts and practices of resuscitation as the war progressed. The first patient was treated during the northern Tunisian campaign in the spring of 1943 and the second a year later, on the Cassino-Minturno sector, just before the drive on Rome.

Case 1-This patient received a severe penetrating gunshot wound of the right posterior chest on 29 April 1943 at 0600 hours. He was admitted to a forward evacuation hospital, in severe shock, 10 hours later. Preoperative measures consisted of the administration of 500 cc. of plasma and 1,000 cc. of glucose solution by vein. Thoracotomy was performed at 1845 hours. The procedure consisted of removal of 1,000 cc. of blood from the right pleural cavity; segmental resection of the lower portion of the lower lobe of the right lung, which was badly lacerated; repair of a laceration of the diaphragm; crushing of the right phrenic nerve; and wound closure. Although a laceration of the loin was present, subcostal drainage was not provided. The patient was given 500 cc. of plasma and 1,000 cc. of glucose by vein. He did not react after operation and died at 0700 hours on 30 April, 25 hours after wounding.

Comment -This case history illustrates a complete failure to apply the principles that should govern the initial management of all intrathoracic injuries. Although the patient was in severe shock, he was not adequately resuscitated before operation. He received no blood either before or during operation, though he had lost at least 1,000 cc. into the pleural cavity. The fluids he received must have resulted in dangerous hemodilution. He was submitted to major surgery while still in a state of shock. It is no wonder that he never reacted from it.

Case 2-This patient was wounded at 0830 hours on 2 May 1944. He received multiple penetrating shell-fragment wounds, including a wound of the left chest and another of the left thigh, with a compound fracture of the left femur. When he was admitted to a platoon of a field hospital at 1200 hours, his blood pressure was 70/40 mm. Hg. He was moderately dyspneic and had a wet cough. The abdomen was diffusely tender and rigid in both upper quadrants.

As soon as the patient had received 500 cc. of low titer O blood, and 1,200 cc. of bright red blood had been aspirated from the left chest, his breathing became quieter, and his color improved. The aspirated blood was discarded, as the abdominal findings made its contamination likely. Intercostal nerve block on the left side was followed by prompt relief of pain in the chest wall, which was followed, in turn, by effective coughing and obvious clearing of the tracheobronchial tree.

After a second 500 cc. of blood had been given, the blood pressure was 105/60 mm. Hg, and the patient's general condition was greatly improved. Roentgenograms of the chest, abdomen, and left thigh in two planes showed a foreign body in the left upper abdominal quadrant and a complete fracture of the middle third of the shaft of the left femur.

Operation was performed at 1445 hours, after another transfusion of 500 cc. of low titer O blood. The occlusive dressing placed over the chest wound was not removed until an endotracheal tube was introduced. The sucking wound, 2.5 cm. in diameter, found in the fourth intercostal space in the midaxillary line was thoroughly debrided, and the pleuromuscular layers were closed.

A posterolateral thoracotomy incision was then made, with resection of the ninth rib. Approximately 500 cc. of blood was removed from the pleural cavity. A laceration of the left lower lobe was sutured with fine silk.

A 2-cm. laceration was found in the left hemidiaphragm and was extended. Exploration revealed a fractured spleen and a perforation of the splenic flexure with fecal spillage. The foreign body visualized by roentgenogram was found free in the peritoneal cavity. The spleen was removed. Spur colostomy was done after mobilization of the splenic flexure,


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and the bowel was brought out through an incision in the left lower quadrant of the abdomen. After lavage of the peritoneal cavity with physiologic salt solution, 25,000 units of penicillin was instilled into it. The diaphragm was closed with silk. After copious lavage of the thoracic cavity, 25,000 units of penicillin was instilled into it. The lung was expanded and the chest wall closed.

The wound in the thigh was debrided, the fracture reduced, and a plaster spica applied.

As the final step in the procedure, the trachea and bronchi were thoroughly aspirated. During the operation, 1,500 cc. of blood was given, bringing the total amount administered to 3,000 cc.

At the end of the operation, the blood pressure was 110/75 mm. Hg and the patient was in excellent condition. Penicillin was given intramuscularly for 5 days after operation. Recovery was entirely uncomplicated.

Comment.-The management of this patient represents the mature application of modern resuscitative practices. The initial appraisal was careful and accurate. Resuscitation was prompt and expert. Cardiorespiratory physiology was brought back to almost normal. Whole blood was administered judiciously. In short, this was careful, expert preparation for major surgery, and the results were gratifying.

ROUTINE OF RESUSCITATION

The resuscitation of the soldier with a thoracic wound comprised five principal components:

1. The treatment of shock, which was usually hemorrhagic in origin, by adequate blood replacement.

2. Correction of the impaired cardiorespiratory physiology.

3. The relief of pain.

4. Restoration of the fluid balance.

5. Measures to prevent infection.

Although these procedures are discussed separately as a matter of convenience, in reality, they were carried out simultaneously and were all interrelated, just as the pathologic conditions which required correction were interrelated.

Treatment of Shock

The problems of resuscitative therapy in World War II were greatly simplified once there was general acceptance of the concept that the cause of the deterioration of the status of any seriously wounded man, regardless of the site of his wound or wounds, was a reduction in the circulating blood volume caused by loss of blood. These problems were still further simplified when the additional concept won general acceptance that, except for processes leading to dehydration, fluid loss from the circulation could be explained by local losses of fluid at the site of injury.

Concepts-In thoracic casualties, the concept of shock had to be somewhat modified. The patient's condition was related, just as in wounds of any other area, to such factors as blood loss, tissue trauma, exposure, the timelag between wounding and medical care, and his status before he was injured. Although external blood loss might occur, bleeding was more often internal, into the pleural cavity, in which blood was not only lost to the circulating blood volume


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but in which it interfered mechanically with the cardiorespiratory function by preventing expansion of the lung. The principal causes of shock in thoracic casualties included, in addition to the loss of blood just described, painful wounds of the chest wall; sucking wounds; pneumothorax and tension pneumothorax; paradoxical respiration; cardiac tamponade; the accumulation of blood, mucus, or both in the tracheobronchial tree; and anoxia from any of these causes.

The most frequent cause of anoxia in thoracic injuries was the presence of blood, air, or both, in the pleural cavity, with a corresponding reduction of the functioning pulmonary tissue to a degree insufficient to maintain adequate oxygenation of the blood. Amounts of blood or air that would be of little consequence in the normal individual were of grave significance in the wounded man. They were superimposed upon the burden he was already bearing because of loss of blood, tissue trauma, and concomitant wounds. Combined dyspnea and anoxia in a thoracic casualty might result in a sharp decrease in vital capacity that might prove fatal unless vigorous resuscitative measures were instituted without delay. When anoxia was profound, there was also some fluid loss because of the general increase in capillary permeability associated with it.

The principal difference between a thoracic casualty and a casualty with any other type of injury was that the thoracic casualty, in addition to his actual chest wound and associated wounds, also had the all-important handicap of a disturbed cardiorespiratory physiology, and that this imbalance was likely to be the dominating factor in his condition. All attempts at resuscitation, including all measures to treat shock, would inevitably prove futile unless they included correction of the cardiorespiratory imbalance.

In thoracoabdominal wounds, another factor entered the picture. There might be spillage, sometimes massive, of fecal matter into the peritoneum or into the peritoneum through the transdiaphragmatic wounds or into both cavities. Shock arising from abdominal injuries and from other associated injuries compounded, and was itself compounded by, the shock caused by thoracic injuries.

The typical manifestations of shock were usually present in thoracic injuries, including a systolic blood pressure below 100 mm. Hg and frequently much lower; a rapid, frequently irregular pulse; rapid, shallow respirations; a lowered skin temperature; sweating; and pallor or cyanosis. In addition, the thoracic casualty was likely to be dyspneic. He also presented the extreme restlessness and apprehension characteristic of hypoxia and indicative of impending cerebral anoxia.

Posture-Thoracic casualties who were hypotensive but who were not cyanotic or dyspneic were placed in the Trendelenburg position. In the absence of shock, the sitting position was ideal, since vital capacity was greater and coughing more effective when it was used. The semirecumbent position, however, was usually better tolerated by freshly wounded men, and it was therefore more generally used both for transportation and during resuscita-


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tion. In this position, the patient lay on his back, with his head and chest slightly elevated, to permit the diaphragm to function more efficiently. A patient not in shock was sometimes more comfortable recumbent than semi-recumbent or sitting, and he was permitted to assume whatever position made respiration easier for him.

It was possible to perform an effective and complete thoracentesis without requiring the patient to change his position, no matter how he was lying or sitting.

Replacement therapy is considered later, under a separate heading (p. 253).

Correction of Cardiorespiratory Imbalance

Measures to correct the cardiorespiratory imbalance in thoracic injuries included oxygen therapy; the relief of pain; evacuation of the tracheobronchial tree; stabilization of the thoracic cage; thoracentesis for hemothorax, pneumothorax, or hemopneumothorax; management of sucking wounds; and management of tension pneumothorax. These measures are discussed separately, as a matter of convenience, and the order of presentation is no indication of their relative importance, which depended upon the special conditions present in each patient. As a matter of fact, the success of one of these measures was likely to depend upon the institution of one or more of the other measures. Oxygen therapy was urgently necessary in cyanosis, for instance, but it was not effective unless the airway was open.

Oxygen Therapy

The general appearance of the thoracic casualty furnished a useful guide to his need for certain therapeutic measures. The presence of cyanosis, which is an indication of comparatively advanced anoxia, was a warning that vigorous measures must be instituted, and instituted promptly, to correct the cardiorespiratory imbalance. Other signs of cerebral anoxia, such as unconsciousness or maniacal manifestations, made the correction of the decreased blood oxygenation even more urgent.

The efficacy of oxygen in the management of shock was a frequent source of discussion during the war, but there was never any argument over the indication for its use in all thoracic injuries associated with any degree of respiratory difficulty. All casualties diverted to a field hospital were admitted to the shock ward (fig. 30) immediately upon their arrival, regardless of the nature and severity of their wounds, and here the shock officer practically always instituted oxygen therapy for those with thoracic injuries. Specifically, it was used promptly and freely for any patient who was restless or dyspneic or whose pulse remained elevated (over 110). It was even better to administer it before cyanosis and restlessness developed. A patient could readily pass from a state of simple restlessness into a manic state that was frequently the immediate precursor of death.


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Once normal oxygenation of the tissues had been restored, the timelag to surgery became of less importance. The essential consideration was to shorten to a minimum the period in which a diminution of the blood oxygen supply could produce cerebral damage.

The most efficient way to administer oxygen was by the Boothby-Lovelace-Bulbulian mask, but it was also perfectly satisfactory to administer it by an intranasal catheter. The minimum rate of flow was 7 liters per minute. Administration was continued until cyanosis, dyspnea, and tachycardia were relieved.

Relief of Pain

As pointed out elsewhere (p. 231), pain was an almost constant accompaniment of any wound of the chest. The clue to its correct management was the realization of the fact that painful stimuli originate in the thoracic wall and not in the lung itself. The relief of pain had a vital bearing on hastening recovery from shock. Until it had been accomplished, the patient was unwilling to breathe deeply or cough, because of the discomfort which followed both acts, and fluid substances therefore accumulated in the tracheobronchial tree, which led to wet lung (vol. II, ch. V).

Administration of morphine.-When a casualty was seen at the clearing station or field hospital, he had usually had an injection of morphine, given by the company aidman when he reached him on the battlefield. The standard Army syrette contained gr. , and this was usually the size of the dose the casualty had received. It would have been better if the standard syrette had contained only gr. . The smaller dose has practically the same pain-abolishing power as the large dose, without its depressant effects, but, in spite of much discussion on the subject, gr. remained the standard dose throughout the war.1

A dose of this size was not harmful to many patients, but it was distinctly harmful to casualties who were already in severe shock and suffering from impending or actual anoxia. It was therefore the policy, after management of chest injuries had been standardized, not to give morphine in clearing stations or field hospitals to patients suffering from hypoxia, particularly if restlessness indicated that cerebral anoxia was impending.

Even a small dose of morphine dulls the sensorium, decreases respiratory efficacy and increases cerebral anoxia, all undesirable effects in casualties with chest injuries. Another serious effect was that the patient as he became less sensitive, also became less aware of the accumulation of secretions in the tracheobronchial tree and made no effort to remove them.

The use of morphine also presented other problems. Some wounded men had had two, or even three, injections before they reached the field hospital.

1As a matter of fact, although the desirability of a smaller dose of morphine in the standard syrettes was called to the attention of the Medical Research and Development Board in June 1943, on the basis of the work of Dr. Henry K. Beecher at the Massachusetts General Hospital, official action was not taken until August 1954. At that time, the amount of morphine in the syrette was reduced to gr. .


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Casualties were frequently heavy, and the medical officer in the battalion aid station, the collecting station, or the clearing station often had no time to appraise the individual patient's symptoms and to determine whether his complaints were really caused by pain or were of some other origin. Cerebral anoxia was frequently accompanied by restlessness that at times seemed maniacal. In this sort of rushed atmosphere, particularly before the risks of oversedation were realized, it was easy to consider that the patient was writhing in pain and natural to give him an injection of morphine. The patient who deteriorated under this policy was the one who was already in rather marked shock, with hypotension and poor peripheral circulation. The first morphine administered, therefore, was not picked up by the lagging circulation, particularly if the environment was chilly or cold. As a result, more was given, and it too was not picked up. When, however, the patient was brought into a warm environment and measures to correct his shock were instituted, the circulation improved, and all of the morphine in the subcutaneous tissues was picked up. The result was a cumulative effect which might result in morphine poisoning.

In view of all these considerations, there was seldom any indication for the administration of additional morphine to the thoracic casualty in a clearing station or field hospital. If it was indicated, the intravenous route was preferred because the effects are more predictable and can be immediately assessed.

A small group of thoracic casualties, who had received morphine, presented a clinical picture for which no explanation was ever adduced. They were observed more often in the late fall and winter months, after they had lain out in the cold and wet for many hours, than when the weather was more moderate. They presented the typical picture of morphine overdosage; that is, they had pinpoint pupils, their respiratory rate was slow, and they were difficult to arouse. Yet their records only occasionally showed that they had had more than a single injection of morphine, which sometimes was gr. and not gr. . If the records could be accepted, these patients were not suffering from morphine poisoning, which had been the original assumption.

It is of course possible that in some of these cases the records were inaccurate. On the other hand, the same clinical picture was seen too often to accept possible recording error as the universal explanation. This condition was a well-proved clinical entity. No definite proof for the theory was ever produced, but it was postulated that these patients presented another manifestation of relative anoxia. Almost invariably, they were severely wounded; they had frequently suffered from exposure; and they were cyanotic unless they were given oxygen.

Strapping-In civilian practice, adhesive strapping is rather widely used for the immobilization of fractured ribs and to relieve the pain caused by them. This method was used to some extent early in World War II, but it frequently accomplished neither of the desired purposes, and the patients complained of the discomfort caused by the adhesive.

The chief contraindication to this method was that it is unphysiologic. Many patients with fractured ribs showed varying degrees of wet lung (vol. II,


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ch. V), with increased bronchial secretions, blood, transudates, and sometimes intrapleural bleeding. When the lungs were compressed and expansion of the chest restricted by adhesive strapping, the secretions became more difficult to raise. Therefore, as the war progressed, it became the policy to reserve this method for the stabilization of a flail chest associated with paradoxical motion (p. 248).

Nerve block-Instead of morphine, which depressed respirations, or strapping, which mechanically limited respirations, the policy was to block the painful impulses near their origin, which proved to be far more effective. This was accomplished by procaine hydrochloride injection of the intercostal nerves supplying the wounded area.

Regional block was employed in preference to local infiltration at the injured site because the probable contamination of all wounds made injections close to the injured area undesirable. Regional block was a simple, efficacious procedure which could be accomplished in 5 or 10 minutes (vol. II, ch. V) and which produced lasting results. In the usual case, it was not necessary to block the sympathetic chain, nor was there any evidence that this technique produced any better results than those obtained by simpler intercostal injection. Any sympathetic block probably also anesthetized the contiguous intercostal nerve roots. Furthermore, injection of the intercostal nerves usually anesthetized the sympathetic nerve fibers accompanying the intercostal vessels.

Unless one had observed the results of nerve block, it was hard to conceive the immediate relief of pain and the improvement in the casualty's condition that usually followed this procedure. A patient who had been unable to cough, or who would not attempt to cough because of pain, now coughed without difficulty. Clearing the tracheobronchial tree of blood and other secretions by vigorous coughing rapidly changed a hypotensive, cyanotic, dyspneic casualty to one with deep, unhurried respirations; good color; and a prompt return of blood pressure to more normal levels. A single injection usually gave relief from pain for at least 24 hours, and frequently only a single injection was necessary. The relief of pain for periods of 24 hours or more, far longer than the pharmocologic effect of procaine, was a surprise to frontline surgeons who observed this phenomenon for the first time. The exact mechanism was not known. The most plausible explanation was that the blocking of the sympathetic nerve fibers of the intercostal vessels, mentioned previously, improved the blood supply to the chest wall and pleura sufficiently to prevent arteriospasm and ischemic pain.

Transportation of casualties with chest injuries was so frequently facilitated following nerve block that this method was sometimes employed in forward installations on this indication alone.

Evacuation of the Tracheobronchial Tree

Concept of wet lung-The management of the condition that came to be known as wet lung and that is described in detail elsewhere (vol. II, ch. V) was


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so important a part of the resuscitative routine that certain details concerning it must be repeated here.

In any kind of chest injury, including fractured ribs, blast injuries, and both parietal and intrathoracic wounds, there were two pathologic factors, (1) abnormal fluids in the tracheobronchial tree, and (2) the patient's inability to expel them adequately. The pulmonary tissue, following chest trauma, reacted by producing more than the normal amount of interstitial and intraalveolar fluid. Increased mucous secretions and intrapulmonary and intrabronchial hemorrhage further compounded the difficulty.

Inadequate evacuation of tracheobronchial fluid and blood was observed in the majority of casualties with serious chest wounds, sometimes within a few hours after injury, sometimes not until 6 or 7 days had elapsed. The accumulation of fluid in the chest interfered with adequate blood oxygenation because it impaired the absorptive functions of the alveoli. It greatly increased the surgical risk if operation was performed without its recognition or before it was corrected. It was a serious complication in the postoperative period, and, before its importance was realized, it was responsible for a considerable number of deaths.

Clinical picture-The most common symptoms and signs of wet lung were oral wheezing; rhonchi heard constantly over one or both sides of the chest; and a frequent, painful, ineffectual, wet cough. Only small amounts of sputum were raised, and the bubbling character of the respirations persisted after the secretions had been coughed up. Tenacious mucus and blood constituted the bulk of the fluid, but an occasional purulent exudate was present, signifying a preexistent bronchitis. Wet lung was an entirely different entity from massive collapse of the lung (atelectasis), which was the result of obstruction of the main bronchus. This latter complication was very infrequent in the Mediterranean theater, probably because of the attention paid to the diagnosis and management of wet lung.

Management-The aim of treatment in wet lung was to improve bronchopulmonary drainage. Sedative cough mixtures were contraindicated. Morphine was withheld unless incontrovertible indications for its use were present; then it was given in very small amounts and always intravenously. If the secretions were frothy and fine rales were heard, some surgeons used atropine (gr. 1/100), but no evidence existed that it was really useful in clearing the tracheobronchial tree, and there was some evidence that it was harmful.

Two adjunct measures were helpful, (1) the administration of oxygen (vol. II, ch. V), and (2) the relief of thoracic pain by nerve block (vol. II, ch. V), after which the patient was willing to cough. Vigorous coughing was the simplest and most effective method of clearing the chest of obstructing secretions. If he was alert enough to understand the situation, the necessity was explained to the patient in detail. Personnel in the shock tent were instructed to help him cough effectively by holding the chest or supporting the abdomen if the act caused pain or discomfort in either location.


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Suction was necessary for patients who could not clear the trachea and bronchi by the simple methods described. The introduction of a catheter, as demonstrated by Haight (1)in 1938, was then carried out without delay. The irritation caused by its introduction and presence stimulated all but unconscious and almost moribund patients to cough and thus rid themselves of much more secretion than could be removed by aspiration of the catheter alone. Catheter aspiration was a particularly useful measure in comatose or semi-comatose patients or patients who had been heavily sedated, none of whom could cough voluntarily and effectively.

Usually only one or two aspirations were necessary, but the procedure could be repeated as often as necessary. When aspiration had to be repeated frequently, it was best to introduce a Magill intratracheal tube and aspirate the trachea through it by inserting the catheter at regular intervals. When a catheter was left indwelling, oxygen was administered through it between aspirations.

If catheter aspiration was not promptly effective, bronchoscopy (vol. II, ch. V) was resorted to without delay and was repeated as necessary. Experience showed that it could be performed twice a day without any ill effects, although one bronchoscopic aspiration was all that was usually needed. Catheter aspiration was most often effected after bronchoscopy.

Occasionally, continued bleeding prevented successful clearance of the tracheobronchial tree. In such cases, further delay was considered unwarranted. The patient was removed at once to the operating tent, for rapid induction of anesthesia with endotracheal intubation, which permitted more complete tracheobronchial suction. It was the general experience that the necessary surgery could be proceeded with, without further delay, as soon as the airway had been completely cleared.

When the retained transudates, secretions, and blood in the lung were controlled by this plan, tracheotomy was seldom necessary as an emergency measure. In some instances, however, either the patient was not in condition to withstand a thoracotomy, or a thoracotomy was not the answer to his problem. In these circumstances, tracheotomy was performed.

The continued extravasation of fluid transudates into the alveoli and from trauma of the bronchi resulted in a type of pulmonary edema which clinically was similar to that seen in other conditions. Mechanical aspiration of fluid was ineffectual in correcting it, and excess fluid continued to be formed in the alveoli. The intermittent administration of positive pressure oxygen (vol. II, ch. V) was found to be highly effectual in decreasing fluid production and ultimately drying up the lungs. This mode of therapy was sometimes lifesaving in preparing casualties for surgery, though those in irreversible shock were likely to prove refractory to it.

Stabilization of the Thoracic Cage

Flail chest, caused by multiple rib fractures, is discussed in more detail elsewhere. It was always serious, and, if the paradoxically moving seg-


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ment of the chest wall was large, it could endanger life. Localized flail chest could be controlled by regional nerve block, sometimes stabilized by a pressure dressing held in place by an elastic binder. Lying with the affected side down was sometimes useful, as was the use of small sandbags. When the affected area was larger and paradoxical motion was excessive, mechanical means of stabilization had to be employed. Occasionally it was necessary to insert a sterile towel clip, under aseptic precautions, around the central rib of the affected segment. This was followed by the use of light traction, obtained by a cord attached to a weight, usually of about 3 to 5 pounds, suspended over a pulley attached to an overhead frame. Stabilization was sometimes accomplished in 4 or 5 days, but it might be necessary to maintain traction for from 7 to 14 days.

In severe flail chest, with extreme paradoxical respiration, management of the wet lung syndrome might be extremely difficult. In these circumstances, strapping of the chest or the use of a firm binder was occasionally necessary to prevent ballooning out of the chest wall. The method was never officially forbidden, but, with very occasional exceptions, its use was avoided, since strapping simply increased the anoxia by limiting the motion of the chest wall. In addition, it served as an actual handicap to the propulsive mechanism of the act of coughing. In fact, it was frequently observed that patients who had been strapped improved considerably as soon as the strapping was removed.

Management of Sucking Wounds

Any injury to the chest wall which produced an open wound into the pleural cavity caused profound disturbances in the intrathoracic physiology, chiefly because of the exchange of air in the pleural cavity and the outside atmosphere. As a result, the normally negative intrapleural pressure was replaced by atmospheric pressure. The type and size of the wound were generally correlated with the effects of these alterations on the cardiorespiratory physiology.

In every so-called sucking wound, there was usually a decrease in the vital capacity immediately after the injury was sustained. The decrease was progressive and, if it was not interrupted, led to mediastinal flutter; interference with the right side of the heart; and increasing anoxia resulting from pendulum respiration.

A patient with a properly treated sucking wound-as all wounds of the chest eventually came to be managed-arrived at the field hospital with an occluding dressing over it. The preliminary inspection was to make certain that it had not been disarranged during evacuation. If it had been, it was at once replaced.

Before an ineffectual dressing was replaced, it was sometimes useful to evacuate a portion of the air or blood that had collected in the pleural cavity, particularly if the injury were of the valvular type. This was easily accomplished by placing the patient in such a position that the wound was roughly dependent. Its edges were held open during forced expiration and coughing


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and were approximated during inspiration. Several hundred cubic centimeters of air and fluid could often be rapidly removed by this simple method.

When this procedure was completed, another dressing was applied, twice as large as the wound and thickly impregnated with petrolatum. It was applied across the wound and covered with a large gauze dressing held firmly in place with adhesive strips. This dressing was left in situ until the patient was on the operating table. It should be stressed again, however, that the original dressings were not disturbed if they were occluding the wound satisfactorily and the pleural opening was airtight when they were first inspected.

If there was a pulmonary, bronchial, or tracheal tear of any moment, then a tension pneumothorax, with collapse of the lung, might develop after the integrity of the pleural cavity had been reestablished by an occluding petrolatum-impregnated gauze pack. In these circumstances, a needle, or preferably a catheter, as used in tension pneumothorax, was placed in the second interspace parasternally to provide for the escape of air. This was an essential precaution if leakage of air into the pleural cavity continued.

Experience early in the war showed that any wound that was not of the sucking or blowing type while the casualty lay in one position, might readily become one with a change of position of the body or even of the arms. It was, therefore, the rule that the chest wound should be closed with the type of dressing just described in all patients who were to be transported farther to the rear without surgery in the field hospital.

The original practice of dusting the wound with sulfanilamide powder was generally, though not universally, discontinued in the summer of 1944.

Sucking wounds are discussed in greater detail under that heading (vol. II, ch. I).

Management of Tension Pneumothorax

Air entered the pleural cavity in all wounds of the chest wall. If the amount that entered was inconsequential, or if it gave rise to no clinical signs and symptoms, the intrapleural air was termed a pneumothorax. If the pneumothorax was of sufficient volume to cause respiratory embarrassment, the contained air was termed a tension or pressure pneumothorax. In other words, the difference between a pneumothorax and a tension pneumothorax was not in kind but in degree.

In spite of its infrequency, tension pneumothorax was a constant threat in combat-incurred chest wounds, and preventive measures had to be employed in every case in which it was a possibility.

The clinical picture included extreme dyspnea, which was the most prominent feature, eventual cyanosis, fullness of the neck veins, hyperresonance of the involved hemithorax with absence of breath sounds, and a shift of the heart and mediastinum to the opposite side.

Management-When tension pneumothorax was present, immediate treatment was required, though thoracotomy was not indicated unless there was reason to suspect a wound of the trachea or of one of the large bronchi.


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Oxygen was given by nasal catheter for cyanosis, persisting rapid pulse, and restlessness caused by anoxia. As an emergency measure, a large-bore needle (16-18) was inserted into an upper (preferably the second) anterior intercostal space, strapped in place, and connected to a water-seal bottle. If tension still persisted after several hours, a catheter (16-18 F.) was substituted for the needle and was connected to a water-seal bottle (fig. 31).

FIGURE 31.-Water-seal catheter management of tension pneumothorax. If necessary, additional suction could be produced.

The response to the measures described was usually prompt and striking. Dyspnea and cyanosis disappeared. As decompression was accomplished, palpation demonstrated that the trachea had resumed its normal midline position and was no longer displaced to the opposite side. In the occasional case in which air continued to leak into the pleural cavity in spite of these measures, thoracotomy was undertaken, but usually only after a period of observation of from 18 to 24 hours. In occasional instances, a large laceration of the trachea or bronchus required earlier operation.

If a patient with a tension pneumothorax had to be transported before decompression was accomplished, because of the tactical situation or for other reasons, a needle still in situ was replaced by a catheter, and a flutter valve replaced the water-seal bottle. A condom or the split finger of a rubber


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glove permitted the escape of fluid and air (fig. 32). Water-seal drainage during evacuation was neither convenient nor safe.

Tension pneumothorax is discussed in greater detail under that heading (vol. II, ch. IV).

FIGURE 32.-Management of tension pneumothorax. Needle introduced through second interspace anteriorly, through cork, with finger cot flutter valve in situ.

THORACENTESIS

Since a large hemothorax or hemopneumothorax could reduce the vital capacity to dangerously low levels, thoracentesis was an important part of resuscitation of the thoracic casualty. It was performed whenever any appreciable amount of blood or air was present, appreciable amount being defined as an amount which could be detected at the dome of the diaphragm on physical examination. With the intrapleural cavity emptied, the lung could reexpand, and an immediate improvement occurred in the vital capacity. The military experience did not bear out the anxiety felt in some quarters before the war that thoracentesis immediately after wounding might cause a resumption of bleeding from the injured pulmonary parenchyma (vol. II, ch. VI).

The amount of blood obtained gave some indication of the severity of the intrathoracic damage and aided in an appraisal of the structures injured and in the decision concerning the best method of treatment. It was also a sound guide to the amount to be replaced by transfusion. If the injury had occurred less than 12 hours earlier, and the blood was considered to be uncontaminated, it was occasionally aspirated directly into a sterile Baxter donor bottle and returned to the patient as an autotransfusion (p. 256). This practice was contraindicated on even the suspicion of a thoracoabdominal injury.

Sterile aspiration sets were eventually standard equipment in all shock tents. A 17-gage needle was used, preferably with a short, beveled point


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rather than a sharp point, to avoid damaging the lung. The needle was connected with a vacuum bottle or with a syringe with a 3-way valve to prevent air from entering the chest while the blood was being aspirated. An assistant clamped the tubing when the syringe was removed to be emptied. The vacuum bottle was placed lower than the patient, usually on the floor. If standard equipment was not available, a short piece of rubber tubing, with appropriate adapters, could be used.

If the needle was introduced low in the axilla, it was possible to remove almost all of the fluid from the chest without making any change in the position of the patient. The site of preference for its insertion was the sixth or seventh interspace in the posterior axillary line or the second anterior interspace in the midclavicular line.

In an uncomplicated hemothorax, no serious attempt was made to empty the pleural cavity completely as part of the resuscitative regimen. At this time, the purpose of the procedure was simply to expand the lung and relieve pressure on the mediastinum. No rule could be laid down concerning the amount of blood to be removed at any single aspiration, but it was seldom necessary to discontinue the procedure because of the amount per se. From 1,200 to 1,500 cc. could usually be removed with impunity. The most reliable guide was the status of the patient and the appearance of symptoms due to too rapid attempts to expand the lung. If he complained of a tight feeling and pain in the chest, dyspnea, or dizziness, aspiration was temporarily discontinued and resumed later.

Hemothorax is discussed in greater detail under that heading (vol. II, ch. VI).

REPLACEMENT THERAPY

Special Considerations in Thoracic Wounds

Replacement therapy was an essential component of resuscitation in chest wounds, but its use was hedged about by a number of qualifications and precautions which did not have to be considered in other types of wounds.

As in all other injuries, the clinical estimation of the need for fluid replacement was based upon the nature of the wound; the known loss of blood; the condition of the patient, including the blood pressure and the pulse and respiratory rates; and the surgery which would be necessary. Facilities for hemoglobin and red blood cell determinations were always available, and later in the war, the copper sulfate method for determination of the hematocrit and plasma protein levels was introduced and proved very useful in regulating fluid replacement.

In chest injuries, however, these observation could not be accepted without qualification. Other circumstances had to be taken into consideration:

1. Deficient oxygenation, whether caused by an obstructed airway, pulmonary compression or contusion, or a cardiac wound, could, in itself, without an excessive loss of blood, produce the typical clinical picture of shock with a


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low or unrecordable blood pressure and a rapid, feeble, irregular pulse. Faced with this picture, the inexperienced medical officer was apt to institute rapid blood replacement, a procedure that could be fatal to a casualty with an already unbalanced cardiorespiratory system.

2. Restitution of cardiorespiratory physiology reduced the amount of fluid replacement necessary in thoracic wounds, but this improvement did not mean that replacement therapy could be arbitrarily reduced in amount or omitted entirely. At least a quarter of all thoracic injuries were thoracoabdominal, and half or more were associated with wounds in other parts of the body. Thus shock that was not of thoracic origin or not wholly of thoracic origin was a compelling entity in a large number of thoracic wounds. In such cases, it was augmented and complicated by disturbances in cardiorespiratory physiology, but even after they were corrected, it persisted and was an indication for replacement therapy.

With the correction of reversible pleuropulmonary changes, the resultant increase in the pulmonary capillary area permitted more vigorous replacement therapy, with a reduced degree of risk. It was still necessary, however, to follow a precise resuscitative regimen in which the risk of pulmonary edema was nicely balanced against the need for whole blood. Sound judgment was required to insure that the casualty received the blood that he needed but at-the same time did not receive so much that his precarious, recently restored, cardiorespiratory balance was endangered.

Large transfusions, rapidly administered, were not well tolerated by casualties with damaged lungs and secondary cardiac disturbances:

1. They were particularly poorly tolerated when the injuries were the result of blast. Flooding of these patients with large amounts of blood or plasma could produce acute pulmonary edema, which might be an important factor in the fatal outcome.

2. Casualties with partial or complete pneumothorax, who were suffering from hypoxia caused by reduction in the vital capacity from such mechanical causes as hemothorax and pneumothorax, might also develop pulmonary edema by sudden overloading of the decreased pulmonary vascular tree.

3. The vascular bed in chest injuries was already reduced by partial collapse of the lung, and it could be further reduced by the extensive hematoma of the pulmonary parenchyma present in some cases. The rapid introduction of blood in such cases, with no time allowed for compensation, produced a further, abrupt reduction in the vascular bed.

There was never an indication for rapid transfusion in thoracic casualties unless continued bleeding from a large vessel was occurring or there was knowledge of serious blood loss earlier. As has been pointed out several times, the surgical time factor, after correction of the cardiorespiratory imbalance, was not a matter of extreme importance in chest wounds.

Generally speaking, unless the casualty was obviously bled out, it was best not to start any sort of intravenous therapy on a patient who was coughing and whose chest showed gross rhonchi. After the airway had been cleared by


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aspiration, thoracentesis performed, and pain relieved, so that normal respirations were possible, hypoxia promptly improved. Then the pulmonary vascular bed could better tolerate intravenous fluids in the necessary amounts. It was a mistake to administer blood, especially in quantity, until failure to respond to these measures made it clear that blood loss was playing a major role in the casualty's state of shock. The level of the blood pressure did not furnish the absolute guidance in chest injuries that it did in other wounds, since cardiorespiratory imbalance might be more at fault than actual blood loss.

Plasma Transfusion

Plasma was sometimes administered to thoracic casualties before they reached the clearing station, and in many instances it was lifesaving, particularly in Tunisia, where ambulance hauls were often long and trying. In a report to the Surgeon, II Corps, after this campaign, Maj. Francis M. Findlay, MC, and Capt. (later Maj.) Marion E. Black, MC, noted that it was impractical to give plasma in U.S. Army ambulances, a serious defect him view of these circumstances. Some surgeons believed that if a patient needed plasma, he should not be transported until it had been administered. Another suggested that when long ambulance hauls were necessary, a halfway station should be established, in charge of a medical officer whose function it would be to check the status of each casualty and remove from transit those in need of plasma. The different circumstances in the campaigns in Sicily and Italy made these expedients unnecessary.

A tendency to give too much plasma in the aid and collecting stations was sometimes noted, particularly early in the war, before the limitations of this agent were understood. The administration of excessive amounts placed an extra burden on the already impaired circulatory system of thoracic casualties and sometimes resulted in decompensation, as well as in the development of the wet lung syndrome. The overgenerous use of plasma in installations ahead of the field hospital also made it difficult to give the necessary amounts of blood when the field hospital was reached.

Techniques of Transfusion

Unless the patient was obviously exsanguinated, the most practical plan was to introduce 500 cc. of blood at a moderately rapid rate and then slow the rate of administration. How much more blood was necessary could then be checked by laboratory determinations, though an experienced shock officer or chest surgeon usually could settle the matter without this aid. If 1,500 or 2,000 cc. had to be given, the transfusion was allowed to run over a period of hours.

Since most casualties with chest injuries had to be placed on the operating table on one side or the other, much time was saved, as well as much stress for the patient, if transfusion was started in one of the veins of the leg. This also


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simplified the procedure when a patient with multiple wounds had to be turned to expose them. The needle could usually be introduced at the ankle, without a cannula. If a cannula had to be used the site of preference was the saphenous vein, just above the internal malleolus.

A needle in the antecubital fossa was likely to become dislodged as the patient was moved. Then the anesthesiologist had to turn his attention from the anesthesia to replacing the needle and restarting the blood. The use of a leg vein was practical from another standpoint, that rapid administration of blood might become necessary in the course of the operation.

Patients with chest wounds associated with multiple wounds of the extremities frequently needed prolonged intravenous replacement therapy and had no available avenues of administration. Then other techniques were used, such as sternal puncture or administration of the blood through the external jugular vein or the corpus cavernosum of the penis.

Autotransfusion-Early in the war, before the blood bank was established at Naples, it was a frequent practice, as already noted, to use for autotransfusion the blood which had been aspirated from the pleural cavity. This practice was not followed in thoracoabdominal wounds, even if only the diaphragm had been injured.

While autotransfusion was frequently employed after the blood had been in the chest up to 12 hours, most surgeons believed that from 4 to 6 hours was a much safer limit. Severe reactions (chills, fever, and toxic manifestations) could follow the use of blood aspirated from the chest, partly because of the hemolysis of the red blood cells it contained and partly because of the presence in it of pleural transudates high in protein; blood is an irritant to the pleura, and its presence gives rise to a rapidly developing serous effusion with a high protein content. Autotransfusion was seldom employed late in the war.

Blood secured from the chest was collected into a transfusion bottle or flask, through several thicknesses of fine-mesh gauze. If the autotransfusion was not to be performed immediately, which was the best plan, sodium citrate was added to the blood. If the blood was used at once, it was administered through the recipient tubing set with the stainless steel mesh filter incorporated in the package containing the flask.

Intravenous Crystalloid Solutions

Intravenous crystalloid solutions were practically never employed in chest injuries. There was no indication for their use except in the occasional case in which dehydration was so extreme that it required immediate correction.

Banked Blood

During the African and Sicilian campaigns, large quantities of fresh whole blood were made available from what amounted to a living blood bank of service troops. The men were classified as to blood type, and each donor on the list


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was replaced by another as soon as he had given blood. Donors were secured from the same source during the early fighting in Italy. In February 1944, a blood bank was set up in Naples, and thereafter adequate supplies of fresh whole blood were available from this source. Provision for blood was part of the preparation of the Seventh U.S. Army for the invasion of southern France in August 1944.

Blood flown from the United States was never sent to the Mediterranean theater. The problem therefore did not arise, as it did in the European and Pacific theaters, concerning the use of blood diluted with Alsever's fluid in chest casualties. Fresh blood was desirable for thoracic casualties because of the deterioration of red blood cells in the excessive fluid in blood preserved by this method. This was a particularly important consideration when multiple transfusions were likely to be necessary.

EMPTYING OF THE STOMACH

Correct preoperative preparation included emptying of the stomach before anesthesia, to avoid the risk of aspiration of gastric contents, which could lead to serious pulmonary consequences (p. 292). This measure was desirable in all wounded men and urgently necessary if food had been taken after wounding or as recently as 2 hours or less before wounding. As a matter of fact, the length of time since the patient had taken food was not a sound criterion of the amount of material likely to be in the stomach. A large residue was often present many hours after ingestion of food, possibly as the result of pylorospasm or of lessened gastric motility because of the nervous tension of combat.

An additional reason for inserting a Levin tube before operation in all chest injuries was that in some cases, gastric dilatation was great enough to enhance the respiratory difficulties already present.

RESUSCITATION IN THORACOABDOMINAL WOUNDS

In thoracoabdominal wounds, speed of resuscitation was essential because speed of surgery was essential, just as in any abdominal wound. In these injuries there was always the possibility, if not the probability, that contamination of the peritoneum, as well as of the pleural cavity, was occurring and that continued hemorrhage might threaten life. There was therefore no reason for temporizing and delay after cardiorespiratory imbalance had been corrected, replacement therapy begun, and the diagnosis established with reasonable certainty. Even when the response to adequate resuscitative measures was not entirely satisfactory, delay in the shock tent did not, ideally, exceed 1 to 3 hours at the maximum. In all thoracoabdominal wounds, the operation was itself an essential part of the regimen of resuscitation.

Thoracoabdominal wounds are discussed in greater detail under that heading (vol. II, ch. III).


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RESPONSE TO RESUSCITATION

Criteria of adequate resuscitation included:

1. Spontaneous cessation of hemorrhage or its control.

2. Establishment of a patent airway.

3. Stabilization of the chest wall and restoration of its integrity.

4. Effective cough.

5. Control of shock.

6. Establishment of an adequate cardiorespiratory balance.

7. Clearance of blood and air from the pleural space.

8. Reexpansion of the lung.

After adequate resuscitation, the patient's status was reevaluated in the light of these criteria. Not all of them were met in all cases, but, as a rule, enough of them had been to make surgery safe. It was not necessary that completely normal conditions be reestablished before it was undertaken. When the cardiorespiratory balance had been restored by correction of hemothorax, pneumothorax, and stabilization of the chest wall, the systolic blood pressure was likely to have reached 80 mm. Hg and to be tending upward, and surgery could safely be undertaken.

If resuscitation had been adequate but the patient's status was still poor, certain other possibilities had to be borne in mind in the patient whose shock was obviously not irreversible:

1. Leakage of air in large amounts from the trachea or bronchus.

2. Soiling of the pleura with esophageal or reflux gastric contents.

3. Continuing hemorrhage from an intercostal or mammary vessel, which was not frequent (vol. II, ch. IV).

4. Cardiac tamponade, which was not common in military surgery (vol. II, ch. II).

5. Intraperitoneal or intrapleural contamination from spillage of the contents of a hollow viscus. Gross contamination of the left pleural cavity by large bowel contents produced as profound shock as was seen during the course of the war. In such injuries, a response to resuscitative measures could be expected only after the cause of the shock-producing mechanism had been eliminated.

6. Intraperitoneal hemorrhage. Early surgical intervention was necessary when, for instance, the spleen lay shattered in the left pleural cavity or the right lobe of the liver continued to bleed. If the site of the wound of entry in the chest, the location of retained metallic fragments, and the lack of response to shock therapy pointed to continuing hemorrhage, with or without other intra-abdominal injuries, then the surgeon had to weigh the possibilities and proceed with surgery in spite of the patient's continued shock. If fecal contamination of the peritoneum or pleura had also occurred, the response to resuscitation was slower than if only hemorrhage was a factor. If contamination had been serious and of long duration and if there had also been a massive loss of blood, then the patient might not react at all.


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Any of these conditions served as a sound indication for thoracotomy or thoracolaparotomy. A satisfactory response to resuscitation could not be expected while they remained uncorrected.

Priority of surgery-The combined effect of multiple injuries also seriously influenced the response to resuscitation. Furthermore, the frequency with which other wounds of varying severity complicated intrathoracic wounds often made the decision as to regional priority of management extremely important. There was general unanimity on this point: When wounds of the thorax presented indications for early thoracotomy, this operation was always done before other surgery. The single exception, which was not usual, was severe intra-abdominal hemorrhage. Total equilibration of the cardiorespiratory mechanism enabled combined procedures of surprising magnitude to be done safely.

PSYCHOLOGIC CONSIDERATIONS

Often during the stress of combat, when a hospital was filled to overflowing with battle casualties, there was a tendency, quite understandable under the circumstances, to forget the casualty as an individual and consider him only in terms of his injury. This was a particularly serious error in the management of patients with chest injuries. They were often apprehensive, and the knowledge that they might be harboring foreign bodies in the chest often caused them a great deal of concern. Ideal management, therefore, required that they receive the maximum reassurance possible. Relief of pain and improvement in respiration were probably the two factors that did most to improve the mental attitude of the severely wounded. Morale was high in the forward hospitals of the Mediterranean theater because of the skill and esprit de corps of the surgical staffs and because it was common knowledge among the fighting men in the forward echelons that if they lived to reach a forward hospital, they were almost certain to recover.

Reference

1. Haight, C.: Intratracheal Suction in the Management of Postoperative Pulmonary Complications. Ann. Surg. 107: 218-228, February 1938.

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