Emergency War Surgery NATO Handbook: Part II: Response of the Body to Wounding: Chapter IX: Shock and Resuscitation
United States Department of Defense
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Early in the evaluation and resuscitation phase of the unstable casualty, extremity dressings should not be removed, as the ensuing bleeding will only serve to further deplete circulating volume and will impede therapy by diverting attention away from the business at hand. Direct pressure will adequately control most external hemorrhage. Blind clamping in deep wounds is usually time consuming and frustrating, and in general should be avoided. Tourniquets should be used only after other methods of control have failed. If indicated, the properly applied tourniquet can save the life, but endangers the limb. A common mistake with tourniquets is inadequate compression, which occludes the veins but fails to occlude the artery, resulting in all increased rate of blood loss. The tourniquet should be placed as distally as possible on the extremity, just proximal to the wound. Once in place and adequately controlling hemorrhage, it should not be released until the casualty reaches the operating room. When applied in the field or enroute, the time of tourniquet application should be recorded on the field medical card.
Expedient evacuation of the shock casualty to a definitive facility should not be delayed by application of military antishock trouser (MAST). Some controversy still surrounds their use. MAST trousers can produce ischemia and compartment syndromes if improperly used. A recent combat casualty with abdominal wounds and no lower extremity wounds was treated with MAST trousers in addition to fluid resuscitation and operation. Instability was such that the trousers were left inflated for 18 hours. This casualty subsequently required bilateral above knee amputations. The trousers should never be inflated beyond 100 mm Hg. If there has not been a hemodynamic response within 30 minutes, the inflation pressure should be reduced as the resuscitation continues.
Operation in the resuscitation area of the hospital is rarely necessary; however, the casualty that arrives with penetrating or perforating chest wounds and very recent loss of vital signs is an exception. Salvage may be attempted by immediately opening the unprepped chest of the unanesthetized casualty in an attempt to temporarily control hemorrhage, as fluids are pumped in and the casualty is ventilated via endotracheal tube. An occasional young man will be salvaged in this manner. If some degree of stability is achieved, the casualty is moved to the operating room for definitive repair and closure.
Autotransfusion devices may be available in future wars. There are basically two types of such devices. Both add small amounts of anticoagulant to the collected blood. One simply collects the blood, filters it and reinfuses it. The other type collects the shed blood. washes and centrifugally separates out the red blood cells, and then reinfuses them. These devices may be practical in the resuscitation area for casualties with substantial and ongoing hemothorax. In the operating room, these devices may be applicable in extremity wounds or in cases of uncontaminated hemoperitoneum.
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