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Medical Science Publication No. 4, Volume 1



Resuscitation, which actually means the act of reviving or restoring, is a term frequently used to describe the procedures involved in the initial management of a severely wounded man. Since the wound is a continuing injury and its effects on the entire body are dynamic ones, resuscitation may be considered as those procedures which are carried out to counteract the effect of the wound. Therefore, resuscitation is a process of continuing treatment. Since the effect of the wound starts as soon as the man is injured, resuscitation should start as soon as the man is seen. One of the effects of the wound is the loss of blood; hence resuscitation includes the administration of blood. Since tissue is damaged, resuscitation means excision of this devitalized tissue. If an airway is blocked, one of the important procedures of resuscitation is the performance of a tracheotomy in order to establish an adequate airway.

The aim of resuscitation is to restore the wounded man in order that he may withstand evacuation to the nearest surgical installation and then to further restore him so that he may safely undergo anesthesia and surgery. Some casualties with head injuries and massive chest injuries have vital organ damage incompatible with life. Others may have very serious wounds but, with judicious care, they can be evacuated to a surgical hospital where a successful repair can be carried out.

Resuscitation at Division Level

The primary aims of the battalion surgeon are to arrest hemorrhage, to prevent deterioration of the casualty's condition and to prepare him for transportation. Corpsmen are taught methods of arresting hemorrhage and of positioning for transportation; and also the value of early replacement of a deficit of blood volume with a plasma expander. Early in the Korean conflict the company aidman learned to carry small bottles of albumin for administration during litter-carry to an aid station. Later, early administration of dextran became

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


popular. Dextran in plastic bags had the advantage that the company aidman could carry three or four of these units on patrol. Battalion surgeons emphasized the importance of the administration of a plasma expander as soon as a casualty was seen. Although severe blood loss may not be evident immediately after injury, a blood-volume deficiency will always occur after wounding; and therefore it is logical that immediate restoration be started.

As soon as a casualty arrives at a battalion aid station, it is the responsibility of the medical officer to make a cursory examination and to correct obvious defects. This includes the control of hemorrhage, together with closure of sucking wounds of the chest, and clearance of the airway. Simultaneously replacement therapy should be started.

Tourniquets should be used judiciously. Too frequently a tourniquet is used when a large, properly applied pressure dressing would better control hemorrhage. Application of a tourniquet often increases venous bleeding. In massive arterial bleeding and in crushed or mangled extremities, a tourniquet may be lifesaving. If necessary, tourniquets may be permitted to remain in place for 11/2 hours or longer; but they may be loosened at shorter intervals if the casualty's condition will not become more critical because of risk of added blood loss. Not infrequently, a tourniquet may be used as an emergency procedure; and, after further evaluation, bleeding may be controlled by a pressure dressing. Since venous bleeding persists in spite of a tourniquet, it is always wise to put a. firm pressure dressing over the wound at the same time the tourniquet is applied.

A free airway must be maintained, or hypoxia will lead to rapid deterioration. Frequently, positioning of the patient on his side and pulling out his tongue is sufficient to establish an adequate airway. In severe maxillofacial wounds, neck wounds, or wounds of the head and chest, it may be necessary to do a tracheotomy in an aid station.

Fractures must be splinted properly before transportation. An unsplinted fracture increases damage to muscle and thereby promotes further blood loss. Pain, associated with movement in all unsplinted fracture, aggravates the casualty's poor condition.

Since wounds break the barrier against bacteria, early antibiotic therapy is indicated. Whenever possible, large doses of penicillin should be given intravenously. When procaine penicillin is used, 300,000 units should be given in three or four different deposits for more rapid absorption.

The battalion surgeon is not merely a first aid man but a most important member of the resuscitative team. The care that he gives is of an emergency type, but he must also take time to institute initial procedures which will best prepare the wounded soldier for transpor-


tation. A severely wounded casualty's chance of survival during transportation can be greatly enhanced by the infusion of 2 or 3 units of a plasma expander. Hurried evacuation may lead to undue deterioration during transportation. The importance of a short time lag between injury and admission to a forward hospital is well recognized; but the battalion surgeon must weigh the advantages of a slightly prolonged evacuation time against the ability of the casualty to withstand transportation.

The most common mistakes made in division units are inadequate control of hemorrhage, inadequate splinting, overdosing with morphine, and hasty evacuation not allowing time for proper preparation of a casualty for transport. It is recognized that, in a rapidly moving type of warfare at the battalion level, the heavy flow of casualties may prohibit a medical officer from administering ideal care. At all times, however, his aim should be to put a casualty in the best possible condition for transportation in the shortest period of time.

Resuscitation at a Forward Surgical Hospital

Resuscitation at a forward surgical hospital may be divided into three phases: preoperative, operative and postoperative.

Preoperative Resuscitation

As soon as a wounded soldier arrives at the hospital, the surgeon must perform the same examination as was carried out at the battalion aid station. He should determine that hemorrhage is controlled and that there is an adequate airway. He should immediately start transfusion of blood if indicated. Nasal oxygen is of value if cyanosis is present, if there is a depressed respiration, a chest wound or massive blood loss. Blood should be started through a 15- or 17-gauge needle; it may be necessary to use two or three transfusions simultaneously. If a large amount of blood replacement is anticipated, it is wise to expose an accessible vein surgically and tie in a cannula. When it is difficult to find a suitable vein, a 13-gauge needle may be inserted into the femoral vein and a long segment of plastic tubing threaded into the inferior vena cava. The needle can be removed immediately allowing the plastic tubing to remain in place. This tubing should be removed after 24 hours or clots may form, giving rise to pulmonary embolism.

The rate of administration of blood is most important. Blood volume deficiency should be replaced as rapidly as possible. In severely wounded patients who are admitted with a blood pressure too low to be obtained by the usual cuff method, it may be necessary to start blood in three or four veins and give it at a rate of 100 cc. or


more per minute. As soon as the blood pressure has risen to 80 systolic, the rate of administration may be retarded.

It is difficult to determine the real value of intra-arterial transfusion. It is generally accepted that the value of this type of transfusion is the increased rapidity with which blood can be administered. A review of the experiences with casualties who had marked blood volume deficiency at the 46th Surgical Hospital showed that the average rate of administration by the intra-arterial route was 88 cc. per minute. In a comparable group of wounded soldiers, the rate by vein was 70 cc. per minute. No attempt was made by the observers to achieve an absolute maximum rate of infusion by either method. No definite conclusions could be drawn from this very limited experience. However, the impressions gained were that blood by the intra-arterial route was of no more value in the resuscitation of patients in deep oligemic shock than was blood by the intravenous route, provided it was given at the same rate by both methods. It was observed that the blood replacement in the small series of similarly wounded soldiers was accomplished as rapidly by multiple intravenous route as it was by the intra-arterial route. Further data and controlled experience must be obtained before the real value of intra-arterial transfusion can be ascertained.

Regardless of route of administration, many transfusions given in a forward hospital must be infused under pressure. Pumping air into the bottle of blood is the presently accepted method. Air embolism is a grave inherent danger in this procedure. In Korea, during 1952 and 1953, five deaths were reported from this procedure as a result of air embolism.

Transfusion must be continued until the casualty is ready for operation. It is most difficult to decide when a casualty's blood volume has been replaced to the extent that he can best tolerate anesthesia and surgery. Unless continued hemorrhage is present and operation is necessary to control this hemorrhage, a wounded soldier should be in the best condition possible before being subjected to the operative procedure. The value of adequate preparation of a patient has frequently been emphasized in elective civilian surgery. Likewise in the surgery of trauma, the casualty withstands the operative procedure better if he is properly restored before the operation. This means that his blood volume deficiency must be replaced to near normal levels. It is common to underestimate the amount of blood that has been lost. Redressing is done in the chain of evacuation by nurses and corpsmen; hence the surgeon does not see the large quantities of blood that may have exuded from the wound. His guides to adequacy of restoration consist of blood pressure, pulse rate and output of urine. If sufficient blood has been provided to permit good periph-


eral circulation, it will be indicated by the blood pressure. The adequacy of visceral blood flow can be estimated by the flow of urine. In severely wounded soldiers, a catheter should be inserted in the bladder in order to observe the output of urine. If a casualty excretes urine at the rate of 30 to 40 cc. per hour, adequate replacement can be assumed. Normal blood pressure does not always mean adequate replacement. A wounded soldier usually requires one to two units of blood after his systolic blood pressure has risen to 100.

Surgeons with experience in forward areas are able to judge blood requirements by the size and character of the wound and the adequacy of restoration by general appearance and color of the conjunctiva. In the absence of hemo- or pneumothorax, injury to the central nervous system, or anoxia from blockage of the respiratory passages, hypotension usually means deficiency in blood volume. Replacement should be completed as rapidly as possible; however, it may require a few hours. Sometimes a surgeon observes that hemorrhage is occurring as rapidly as blood is being replaced. Blood should then be started through two or three veins and the casualty should be placed on the operating table immediately.

In some patients with extensive wounds, slow blood loss will continue throughout the preoperative period and the blood pressure will rise very slowly. There may be a tendency to hold these patients in the preoperative section too long. It is useless to continue to replace blood endlessly when it is being lost almost as rapidly as it is being infused.

In the presence of slow, continuous hemorrhage, it is usually possible to infuse 3 or 4 units of blood rapidly, and then start the operation. If the delay is too great prior to operation, the patient may require 8 or 10 pints of blood before operation. He then will require about 10 pints of blood during the operative procedure and the total amount of blood administered will exceed 20 pints. In casualties who have received 18 or 20 pints of stored blood, a deficiency in the clotting mechanism may occur and fatal oozing from all wound surfaces may result.

A casualty is usually ready for operation when his systolic blood pressure reaches 110 and his pulse rate has fallen to 120. Frequently it is difficult to select the optimum time for operation. When the systolic blood pressure reaches 100 or 110, he may be moved to X-ray. If he is properly resuscitated, the movement will not cause a fall in blood pressure. On the other hand, if the casualty has an appreciable blood volume deficiency, a fall in blood pressure will occur when he is moved. This appears to be an additional criterion by which a surgeon can judge the adequacy of preparation for operation.


A simple tilt table was devised by the Surgical Research Team in Korea. The table was made of wood with a platform of a size convenient for holding a litter. The platform was suspended in such a manner as to have a fulcrum in the center, thereby enabling adjustment of the degree of tilt. By tilting the casualty's head up 30 degrees and observing his condition and blood pressure, the surgeon could obtain some indication as to the adequacy of restoration. If, by sufficient transfusion, a casualty was properly prepared for surgery, he could withstand a tilt of his head up 30 degrees for 10 minutes. If his condition deteriorated and his blood pressure fell, however, it was a good indication that additional blood was required. By general observation, surgeons experienced in resuscitation of the severely wounded can usually tell when a patient is ready for surgery. In questionable cases, on the other hand, the tilt table helps to determine the adequacy of the circulation.

Control of hemmorrage is a real problem in severely wounded casualties. In vascular injuries of appreciable extent, it may be possible to cut down on the vessel under local anesthesia above the site of injury and then apply an artery clamp. If there is generalized oozing, an improved pressure dressing may suffice. Concealed hemorrhage in a casualty's abdomen or chest may be the cause of failure of response. When there is a wound in that area, careful attention should be given to the size of the abdomen. A rapidly expanding abdomen may mean serious intra-abdominal hemorrhage.

A thorough search must be made for respiratory complications. Severe hypotension may be due to air or blood in the chest or to cardiac tamponade.

Resuscitation During Operation

During the operative procedure the surgeon must constantly estimate the amount of blood the patient is losing and make sure that it is replaced. Patients who have large wounds, particularly of the abdomen, chest or arteries, should have two large needles or cannulas well anchored in the veins in order that blood can be given rapidly under pressure through multiple portals. When several areas are injured there is constant oozing until the initial surgery is carried out. To minimize blood loss the operative procedure should be performed as expeditiously as possible. When feasible, in casualties who have multiple wounds two surgical teams may work in different areas to lessen the time of anesthesia and operation.

The surgeon should always be near the patient during the induction of anesthesia because of the possibility of cardiac arrest. During the last 6 months of the Korean war 14 cases of cardiac arrest were


reported in forward hospitals and all but 2 of these casualties died. After the removal of the endotracheal tube at the termination of operation, it is important to clear the airway.

Resuscitation During the Postoperative Period

Continued restoration and careful observation is an important part of resuscitation during the postoperative period. Too frequently the surgeon feels that he has restored a casualty's blood volume, through adequate procedure, and then he expects an uneventful recovery without further therapy. However, in patients with multiple severe wounds complications are common. It is imperative that the patient be examined frequently for continued blood loss, atelectasis and collection of blood in the chest. Careful recording of the blood pressure and hourly measurement of the output of urine are essential guides to therapy. A patient who is hypotensive after operation and does not excrete urine probably has a blood volume deficiency which requires further replacement. Among 138 severely wounded soldiers, 18 of the 61 requiring a total of 5 to 10 pints of blood in their first 24 hours after surgery were given more than a pint of blood postoperatively. Of those needing 10 to 35 pints of blood, in a more severely wounded group, over half were given more than 2 pints of blood in the immediate postoperative period.

Most casualties who are hypotensive after surgery require additional blood. On the other hand, there are some few whose compensatory mechanisms have been damaged by anesthesia and they will not respond to further resuscitative fluid therapy. Such wounded soldiers may be supported by norepinephrine. However, the most important and most frequent cause of postoperative hypotension in injured soldiers is an insufficient amount of circulating blood volume. Transfusion after operation should be performed with caution. Frequent auscultation of the chest is essential for signs of pulmonary edema. As long as a casualty's blood pressure is below 80 systolic and he is not excreting urine, he has need for additional blood; therefore, overtransfusion is unlikely.

Continued oozing may occur in patients who have had from 18 to 20 pints of stored blood. No one knows what deficiency in stored blood prevents natural clotting. Sometimes such a deficiency may be replaced by fresh blood. Severe oozing occurred in one casualty who received 39 units of stored blood. This oozing did not cease until after 6 pints of fresh type O blood had been administered.

As soon as a casualty's blood volume is restored to near normal levels, electrolyte solutions and water should be administered.



Since the wound is a continuing insult to the body, resuscitation must be a continuing process. Restoration should begin as soon as the patient is seen and continue throughout the preoperative, operative and postoperative phases of the patient's care.