Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XIV: War Surgery Within the Division
United States Department of Defense
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Emergency life-saving interventions are described in the appropriate sections of this manual. Relevant skills consist of the ability to create a surgical airway in the casualty with a severe facial wound, the insertion of an intercostal tube in the casualty with a hemo- or pneumothorax, the occlusion of a sucking chest wound, the ability to tamponade bleeding from major extremity arteries, and the infusion of therapeutic volumes of resuscitation fluids in those in shock.
Cricothyroidotomy, as shown in Figure 23, is an expeditious way to create a surgical airway. It is performed by palpating upward in the neck with the tip of the index finger to identify the cricoid cartilage Place the tip of the index finger into the cricothyroid dimple just superior to the cricoid cartilage. By grasping the thyroid cartilage which lies just superior to the dimple, maintain the thumb and middle finger in place to steady the larynx. Stab the cricothyroid fibro-cartilaginous membrane with a #20 blade. The stab wound must be extended slightly to either side to accommodate an appropriately-sized tube.
Five to ten percent of battle deaths result from extremity exsanguination in which first aid could have controlled bleeding. Death due to hemorrhage from an extremity wound is preventable by simple direct compression. Medics must be taught to arrest high-grade hemorrhage by pressing the hand or dressing at the source until other means of control are established. A pressure bandage accomplishes this ideally when applied as a broad band of uniform tightness. If the tails of the battle dressing are tied too tightly, arterial flow may be occluded. Once immediate control of the hemorrhage has been accomplished and prior to the application of the pressure dressing, distal pulses should be assessed. Use of pressure points is a temporary measure to control severe bleeding while the pressure dressing is applied. Only two pressure points are of practical value for field use: the femoral artery in the groin and the axillary artery against the humerus. If the first dressing becomes soaked, a second dressing should be applied over the first applying greater pressure Increased pressure is provided by tying the knot over a wad of material directly on top of the wound. One attempts, when possible, to preserve the distal pulse. The medical officer should bear in mind that the standard individual field dressing; when completely soaked, holds less than 250 cc of blood.
When pressure dressings fail to control the hemorrhage and the bleeding vessel is visible, a hemostat may be applied and incorporated into the dressing. Blind clamping is almost always futile. A tourniquet may be required to control hemorrhage, especially for the casualty with a traumatic amputation. A properly applied tourniquet, while endangering the limb, can save the life. An improperly applied tourniquet threatens both life and limb. A common mistake is inadequate compression which fails to occlude the artery but does occlude venous return. This results in an increased rate of blood loss. The tourniquet should be placed as distally as possible, just proximal to the wound. Once in place and adequately controlling hemorrhage, it should not be released until the casualty reaches a definitive care facility. The time and site of tourniquet application should be recorded clearly on the field medical card, and evacuation should be accelerated.
Intra-abdominal and intrathoracic hemorrhages require surgical intervention. When the intrathoracic bleeding is from the pulmonary circulation, it will usually be significantly diminished by tube thoracostomy and reinflation of the lung. Intra-abdominal bleeding may be diminished by application of a pneumatic antishock garment and inflation of both the extremity and abdominal compartments to at least 40mm Hg. Higher pressures have been employed, but there is no good evidence that they are advantageous and may in fact be deleterious if utilized for prolonged periods. The therapeutic effectiveness of the antishock garment is still very much open to question.
In the context of combat casualty care, there is very little hope for the exsanguinated, pulseless casualty. The salvage rate of traumatic cardiac arrest in the field approaches zero. Under these circumstances, the casualty that arrests after initial volume restoration and ventilation should be considered dead.
The civilian emergency medical doctrine which dictates that all trauma victims with possible injury to the cervical spine should have neck immobilization performed prior to transportation is not necessarily applicable to combat casualties. The overwhelming majority of combat casualties with penetrating wounds involving the head, neck, or upper chest who survive long enough to be treated do not have spinal cord injury or spinal injury which might predispose to a cord injury. There is likely to be little potential benefit from field immobilization of the combat casualty who does not have frank evidence of neurologic impairment. Bearing in mind the lethality of the battlefield with the resultant very substantial risk of performing time-consuming field medical procedures, medical personnel need to be selective in deciding which casualties need neck immobilization prior to evacuation from the battlefield.
Most often the medical officer's combat surgical practice does not involve managing acute lifethreatening problems, but rather the splinting of extremity fractures and the dressing of soft tissue wounds. The earliest possible parenteral administration of antibiotics is mandatory in all casualties with penetrating abdominal injuries, open comminuted fractures of extremity bones, and extensive soft tissue wounds. Cefoxitin, 2gm IM or (preferably) IV is an appropriate antibiotic in such circumstances.
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