Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXVIII: Wounds and Injuries of the Chest
United States Department of Defense
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The combat surgeon must not expect to find available the same spectrum of resources as are found in the civilian surgical intensive care ward. Nevertheless, survival of at least 90% of the chest casualties evacuated from the battlefield is to be expected. In the postoperative period, careful attention should be paid to the maintenance of adequate pulmonary ventilation and the removal of tracheobronchial. secretions by coughing and suctioning. These interventions have been instrumental in lessening the incidence of the pulmonary edema-like syndrome known as "wet lung," which was so common in World War II casualties. Analgesia, preferably given by intercostal block, may lessen the need for suction. However, the surgeon must not delay in resorting to suctioning or even bronchoscopic aspiration for the removal of secretions. Patients who cannot ventilate adequately will require the assistance of a volume cycled respirator. Surgeons should be aware that arterial blood gas determinations may not be available for guiding the management of such patients. Furthermore, reliance on clinical judgment rather than invasive monitoring will be necessary to minimize the possibility of fluid overload during the early postoperative period. Diuretic agents may be necessary to decrease pulmonary extravascular water. In a recent Israeli experience, as many as 25% of severely wounded casualties were inadvertently volume overloaded and needed diuretics or even phlebotomy. It is unwise to attempt to evacuate casualties who still require ventilatory support from the combat zone. Patients should not be evacuated by air until at least three days have elapsed following removal of chest tubes. In one series, about 20% of the Vietnam chest casualties evacuated by air developed a recurrent pneumothorax, and arterial hypoxia was a common finding.
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