Document text
Hans Husum
Swee Chai Ang
Erik Fosse
Third World Network
08677 ]
Cover photo
The boy has a comminuted AK47-bullet fracture of the humerus
with radial nerve injury and "drop hand" - a classic injury. The
: pe plaster cast.drains his debrided wound.
War Surgery
Field Manual
COMMUNITY HEALTH CELL
Library and Information Centre
No. 367, Srinivasa Nilaya, Jakkasandra,
I Main, I Block, Koramangala, Bangalore - 560 034.
THIS BOOK MUST BE RETURNED BY
THE DATE LAST STAMPED
lis ublished by
are ee of organizations and individuals involved in
ira Wo ’
Third World and development issues.
Copyright © Hans Husum and Third World Network, 1995
oduction of any part of this publication is
ermitted and encouraged, on the condition that the source of reference is
eed Husum, H et al: War Surgery, field manual. TWN, Penang. 1995.
All illustrations, except 7. 14, 7.15 and 7.16, by Hans Husum.
Non-commercial use and repr
For information, address to Third World Network, 228 Macalister Road,
10400 Penang, Malaysia. Tel: 604-2293511 Fax: 604-2298106
Notice
Although War Surgery, field manual encourages non- graduate health workers
to engage in war casualty management, the manual cannot replace
practical instruction by qualified experts. Neither the publisher nor the
authors of this volume are responsible for damage done by unqualified
implementation of the described procedures.
Library of Congress Cataloging in Publication Data
Hans Husum, Swee Chai Ang, Erik Fosse.
War Surgery, field manual.
Includes glossary and index.
ISBN 983-9747-12-6 Pb, 983-9747-14-2 Hb
1. Wounds and injuries. I. Husum, Hans
II. Ang, Swee Chai. Ill. Fosse, Erik
Text illustrations: Hans Husum
Design and cover: Hans Husum
Typography and co ition:
tas by mposition: AK Grafisk, 9710 Indre Billefjord, Norway
Phoenix Printers
sno rinters Sdn. Bhd., 6, Lebuh Gereja, 10200 Penang,
a
(\ “ (? ' ‘a by
Foreword — why this book
War Surgery, field manual is written for health workers and doctors in the
front line, as a how-to-do-it-yourself, and also as a training manual. It is on
life- and limb-saving procedures, and on organizing war medical services in the
field. We also hope it is useful to the experienced surgeon faced with mass
casualties under difficult conditions with few resources.
There are other books on war surgery, mainly written for well-equipped armies
and hospitals. This manual looks at surgery from a different angle — from the
standpoint of deprived Third World communities caught in wars they did not
ask for. As surgeons working with Afghan peasants, the Palestinians in refugee
camps, guerrillas in rural areas in South East Asia — people caught in wars they
did not start and are unable to stop — we should be truly depressed by the
injustice of the situation: Poorly equipped local medical services in poverty-
stricken areas and paramedics with little formal education are made to cope
with injuries from the most advanced weapons of modern warfare. Logic
would say that when a village or refugee camp is "blanket" bombed to satura-
tion level, the people being injured there would stand no chance of survival.
But the reverse is true. We learn from our fellow health workers a whole new
way of looking at problems. We should not simply look at the wounded in the
way surgical textbooks have taught us — dividing the patient into systems.
Because resources are so scarce, we have to look at the enormous healing
capacity of the human body as our best pauy, — and look at surgery as a total
supportive strategy to assist that healing capacity. And we should look at the
injured person as someone who is not a passive recipient of medical attention.
The patient is actively trying to help himself, and so are his family and friends.
The patient and his community therefore become part of the medical team, as
operation assistants, blood donors, nurses and physiotherapists. They also teach
us how to use local food resources for nutrition, and how to improvise and
"pirate" equipment which would otherwise be beyond their reach.
The wounded starts dying at the time of injury, and can only survive if he re-
ceives life support and surgery immediately. In the war zones of the Third
World, who are the surgeons? We ourselves have to come to terms with the
traditional hang-up that only qualified surgeons can do life-saving operations.
FT
One of us had an Afghan peasant as a fellow surgeon, and the other a nurse as
chief orthopedic resident surgeon. And it is our belief that if the "copyright
and patent” on surgical knowledge are broken, then many more talented
people will come forward.
With an experience drawn from 15 years working in various war fronts, and
always under the constant teaching of the people we work with, we feel ready
to synthesize what we learnt in the field, teaching materials from training
courses we conducted, and our scientific medical background into this manual.
Our book is written for and about the "little man" struggling under enormous
odds, with very little to fall back upon. We can only admire his strength. His
survival proves the effectiveness of his methods.
This manual is dedicated to him.
Hans Husum, 1994
How to use the book
War Surgery, field manual may be used in several ways
¢ Asa bed-side surgical manual for specific injuries
¢ As a manual in anesthesiology
¢ To plan and organize wartime clinics
¢ To run training courses for medical staff
¢ For self-study
For non-graduates
All health workers managing war casualties — paramedics, surgeons and organ-
izers — should know the basics of war surgery: how bullets act, how the body
responds, and how we basically can assist the body to overcome the damage
done by the weapon. This is the content of Section 2 which we recommend
everybody to study as a beginning. Do not let medical and technical terms
scare you. They are all explained in the glossary, p. 721. Knowing the more
common terms, you are able to analyze, discuss and communicate medical
matters in a more exact way.
Points to note
Non-graduates should study the inlet points at the head of each chapter.
They list the most important features of the topic concerned. Proce-
dures not listed as "Points to note" are more difficult; you need more
,
surgical experience and theoretical knowledge to perform them.
A manual in surgery
Use the black-edged pages: Table 1 on p. 37 (forward field management)
and Table 2 on p. 41 (clinic management) form the manual index. The tables
list ways of managing specific regional injuries, whether you work with few
resources (in a light forward clinic) or are better equipped (in a heavy forward
clinic). The tables give references to pages of Chapter 7 and Section 4 where
the management procedures are discussed in detail.
eon i Page Heavy FC
Type of injury Light FC g
Closed fracture Peritoneal lavage? 109
Sling compression 478
Traction 499
475 External fixation apparatus 478
Plaster spica
Complications to pelvic injury
= pelvic abscess
Exploratory Japarotomy: Drain 356
_ buttock abscess Exploration 480
_ organ failure Management 588-596
Eo 11 109
Penetrating injury Peritoneal lavage asi
a Exploratory Japarotomy’ 307, 396
Spinal fracture
— stable Debridement 312
_ unstable Two-step surgery:
— 1 Debridement
Transport cast
Evacuation ey fos | 308, 316
= Exploration
seer
|mmobilization
Spinal cord injury Transport cast
ame Evacuation > Exploration
Decompressive Jaminectomy? 09
Dura graft? a ae 313
——
Complications to spinal injury
— spinal hematoma Exploration 313
Control bleeding 317 Decompressive Jaminectomy?
_ infection Exploration. Drain 318 Decompressive laminectomy? 309
— pressure wounds Preventive measures 318
_ bladder contracture 319
Upper limb in general Evaluation of major injuries 238, 484
Exploration of the main bones, vessels and nerves
— shoulder 487
—arm 490
— elbow 495
_ forearm, wrist and hand 504
Upper limb soft tissue injury
— minor
Debridement. Drain 178, 180
Fasciotomy
— major
: nay 491
_ forearm 502
Skin flaps 955
Muscle flaps 200
How to use the book
Oa mm
See table on the opposite page,
copied from p. 46.
Textbooks for further studies: p. 71 3.
Eg, the primary management of a patient with a deep bullet wound at the back
¢ The bullet or fracture fragments may have entered the abdominal cavity. Con-
sider peritoneal lavage to find out. Peritoneal lavage should be done also in
light clinics, the reasons for diagnostic lavage are discussed on p. 109.
¢ The spinal wound must be debrided. The debridement of penetrating spinal
injuries is illustrated on p. 312.
° If the fracture is unstable with risk of secondary cord injury, it should be
stabilized with plaster cast at the light clinic, p. 311, and the patient evacu-
ated to a better equipped clinic for exploration and fixation p. 313 and 317.
° If the clinical examination and primary debridement reveal spinal cord injury,
the case may be evacuated for complete exploration. How to repair dural tears
and reasons for decompressive laminectomy are discussed on p. 313 and 309.
A manual in anesthesiology
With the anesthesia methods in Section 6, proper surgery can be done on all
types of regional injuries. The equipment needed is simple and light, and all
methods can be done in the field. But nobody should give anesthesia, not even
simple procedures, without thorough knowledge, equipment, drugs, and
practical training as detailed in basic life support, Chapter 7.
Ether anesthesia with EMO apparatus is a valuable supplement to the methods
in Section 4, specially for major stationary clinics. Study M.B.Dobson: Anaes-
thesia at the district hospital.
Use the book to plan and organize wartime clinics
Chapter 1 evaluates several models of forward war surgical networks already
tested in recent wars under different conditions. Although you cannot use
them as blueprints, you can apply to your local setting the guidelines and the
check list on p. 31.
Chapter 2 presents two levels of equipment for a forward wartime clinic.
Table 4 on p. 57 lists a minimum alternative with which you can manage at
least 80% of all cases (light forward clinic), and a better but more expensive
alternative (heavy forward clinic). Table 8 on p. 68 lists the approximate
consumption of medical materials at a forward clinic, foodstuffs excluded.
Chapter 42 lists food materials available in Third World countries, and discusses
how to organize production of post-operative nutrients based on local foodstuffs.
Use the book to run training courses for medical staff
War Surgery, field manual is based on teaching material developed for train-
ing courses in war casualty management conducted in several Third World
areas of conflict. There is, of course, no standard program on how such train-
ing should be run. The type of weapons used, the level of experience and
theoretical knowledge among the local staff must be considered. Such is the
framework of the author’s training programs:
Programs for quality assessment:
p. 697.
Levels of equipment, and consump-
tion of medical materials: p. 57 and
68.
How to improvise: p- 70.
Train medical staff at three levels:
p: 3h
Session one is our paramedic training
program.
Use "Points to note" ahead of each
chapter to guide the students’ home-
work. Also devise tests and exams
based on "Points to note".
Practical training is done on animals
; > |
and in the operating room.
10
ts examine the local setting
* Collect local facts on the types of weapons and warfare, the distribution of
the mean time-lag from injury to the first medical support, the death
rate (within one hour, one day, and one week after injury), the rate of com-
mon complications (post-operative wound infections, gram-negative pneu-
monia, septicemia). Assess roughly the quality of forward casualty manage-
ment based on these facts.
e Examine the general level of nutrition, and rates of common endemic
diseases among the local population.
¢ Examine the experience of the local staff in basic life support: How many
cases they have done, how they did them in detail, what kind of problems
thev faced. Formal education is no guarantee for quality —a surgeon's skill
can only be checked at the operating table, and by the results and rates of
complications his clinic has.
¢ Examine the technical resources and logistic capacity: The training must fit
the medical network at hand. The students must learn how to carry out
diagnosis, life support and surgery with the equipment available.
First — let the studen
injuries,
Second — define the target of the actual training together with the
students
¢ Training paramedics: Agree ona list of exactly defined basic life support proce-
dures which the students should learn during the training. Our proposal: TaeS Fe
* Training surgeons: We recommend concentrating the training on basic life-
saving surgery. On p. 32. we list the minimum procedures a wartime surgeon
should know in order to properly manage 80% of all casualties and run a
forward surgical clinic.
Third — the training course
* Session one — basic life support:
¢ The injury, and the response to injury: Chapter 3 — weapon physics;
Chapter 4 — basic physiology; Chapter 41 — complications to injury and
surgery; Chapter 42 — metabolism after injury and surgery; Chapter 20 —
endemic diseases complicating the injury.
* The practical procedures for basic life support: Chapter 5 — the exami-
nation; Chapter 6 — the sorting of injuries; Chapters 7, 8 and 9 — the
technical procedures.
* Some case studies are described in the book, but more should be included
in the training course. Evaluate in detail patients managed by the local
clinics; arrange student exams based on realistic case studies.
* Session two — basic war surgery: Chapters 10-1 6 — management strategy for
the main types of tissue injury; Chapter 44 — prevention and management of
infections.
* Session three — field anesthesia: Chapters 45-48; repeat Chapter 7 — basic life
support.
* Session four — regional surgery: Chapters 26, 36 and 7 — emergency
abdominal surgery; Chapters 38 and 39 — limb injuries; Chapter 21 — open
skull fractures; and Chapter 40 — burns.
For self-study
The fundamental strategy of the authors — basic life-saving surgery — is discuss-
ed in Chapter 7. Here we argue why a model of very forward surgical support
should be implemented. Let that be your entry to War Surgery, field
manual, together with Chapter 3 — what is actually modern warfare.
To health workers from rich countries in the North going to work in Third
World areas with few technical facilities: Study Chapter 2 — how proper
management can be done with simple equipment; Chapter 41 — how post-
operative monitoring can be done without much laboratory equipment,
Chapter 42 — how advanced nutrition can be drawn from local resources;
Chapter 20 — how local endemic diseases can interfere with surgery.
We want feedback from our readers
To make the next edition of War Surgery, field manual a better tool in health
worker education, we ask you to kindly forward your comments, criticism and
proposals about
* new items and procedures you recommend us to change or include in the
manual
e technical information, new weapons, the injuries they cause, and how to
respond with surgery
* your experience with this manual in training of staff
* your experience and proposals for organizing forward field clinics
¢ distribution, making the manual better available for those who need it most.
Forward your comments to
Third World Network, 228 Macalister Road, 10400 Penang, Malaysia.
Or, Dr. Hans Husum, 9710 Indre Billefjord, Norway.
Contents
Foreword — why Ghats PI ois ei cessneosssseeonccuensenecnct se cnt OnRE MRR aspen Tea emrnss oo 2r
Paw to Use thre WOGi pre oseeee cere eec cee see reeeesnante cn a ieemmnnnnnnr ttre
Section 1: The war medical organization
1 The war medical network... sce crenennnaennnnn tennant
Examples from recent regional SAS ee on nvcncduucceee nee COE EEE Ree ramos Varennes
Training CoP TH CCUC AN ERE cccas vs cesnceccoes Gnateooess creer delpe aD emmmteNr Pens =>
The forward Clie (EC)... amyens--eroo-e-nierstentsecmenitsanremmtertneerenseesse
Organization of forward basic life support (BLS) «0...
Tee TALS tea eee rage en eee Bro osceneoet am Dente
Management Pe ali ok en taper rk a
Organization of the forward climic (FC) ........::sssccseserssssssenessnennnensssnscennsennen
Standard medical and technical equipment...
Light and heavy BLS ye eee eo ee
Tae OTe TELAT TIO OUR rccrs ce conse. -c onan soonrer bonne aaa ammmnnggaesetson soe
Consumption OP erCMICAL TAterials ...c..........-cssccccseneasannemnasennnntassneessenseenenscortee
Cleaning and maintenance of INStrUMENts .........ccccceeccseseeeeeseseeeeneeseeenteentenentess
pS Cop Sak Pee tes 90)'2 hh aR Rr a
Section 2: Basics of war surgery
3 Physics Peco =) 1 Sahn Em aa |
Weapon GOCE crete ar caesescossceesseseeecssceeventonn aan
PY WOUiTICL CRE nr rare s cans cneceseeceonensensennnsshtt TA an aR .
Blast injuries 0.0...
Mine injuries ..........:00e
Modern arms and ammunition
———S
4 Physiology of thie imp umyagiee ne teeione essere ovens 93
The tissue response to Trl (lig 0 a 94
The body response to Te Rc 96
5 The clinical POP ii) 5 aR 103
Assess vital functions — pain and anxiety ........---+---sseecenenenneesssseseeceeseneenennen 104
Assess vital functions — airways and breathing ..........-:-.-seeeese erect 105
Assess vital functions — CHYESRARAENIREL <cccsscisssccoss-eecosovesoeesnsnsananmnanoaannscanmiantanmentae 107
Examine the regional i) a haan oa a 109
Abdominal and pelvic imjury «---.seseccssccessess--sevesreenatenantineneunnrsntsastis 110
Beco rn fuay.scecsectene amit ihhen onsen none a a a 114
Bfedd and neck injury sssssstercpetsesgrcsseesscecceceeesseseneeesenesanunseetaas aon 115
Spinal Tg Pe i
Fracture and joint injury cevssscsccssescesseeesssssssceceesssseeneeecssenannnnnnanamnanensseeg 118
Fee tig A ae i119
6 Triage — sorting Peers (i) 0 mere a 123
The principles Of $riB GE creapvergeaepeierscrseeneeesesreneeeeeeenereceneresunanntnnnnnaauntbarsentne 124
Triage in mass aS (SPS | EEE 127
7 BLS: Basic life support and basic life-saving surgery .........-.00+ 129
Fundamentals of basic life-saving SUrQeTY ..........--..--:::e eee eeess reer esses tetteeette 130
FRCS ALE WAY ..-.ssssersececsennubeniaieentemnesrveestsocecceceversnsssssnscnsseseneeaeittaniaaaaaaeTeT 135
Support the breathing. Chest draimage ...........:::s:ssssssessssseesecsenneneenennsecsnneess 140
Manage circulatory RE ner 143
Manage pain eal Feeae e ov swnccon scncuceusesnvussoavenseuetn ental ais 150
Early carbohydrate nutrition .........----ssesececsssseeesccsssseeeeeetennnncennnnnscennnnnnssenennenn 152
Procedures of basic life-saving SUTQery ..............:-:.-ss.esseeeeesetesteeneeeseecentsntecs 153
Prevent heat loss — start early rewarming .............-:-: sees 153
Emergency thoracotomy and aortic Clamping ..............--::sseseseseeeeeenee 154
Emergency laparotomy ...........::ssssssseseseesssseesessseeeennnneensnnnsecnnnnessnnnnassacee 155
Liver emergencies .......crvssscssvsssecsnsseenieeccssesssssessssesennesesnnsennnsacnnnsaqanasceussenstess 158
Injury to the spleen .........sccsssessessssssnnecessseessesesssssesssnesesnnsennnasennnansanasennnasnetyes 158
Duodenal and stomach emergencies ..............:::.essesessreteese tees eeeeteeteesieee 158
Pancreatic Emergencies .........sesssessssessnessseeesneesneessseessecensenseensnsennnennnnennseneesen 159
Kidney emergencies ccicpratessccess roses tithe oss0es-ssosssserseeesnsyeotasnnni anes 160
Limb emergencies ssssurscanencorcrsessens cit vessseessosesoeeseureeonnetner stage RRS 160
Ue ieyiigce@e heck: | Oe Seer ce 161
Srsurgical technic ue aig ees estes soe seo een scarce 163
Nfontraumatic techni vac...-..-...ncsee nn 164
Minict of incision 165
Dissection and retraction (——_—_- ~ ee: 165
Control of bleeding eo ES ll 166
Surgery bn bone... a Sip. .onn..0.cac 168
Sutures and surgical knots — ee 169
9 Fasciotomy, debridement and drainage 0.0.0.0... eee “7S
Plan your SUPQETY ..scacgigleeeaasertactescsshss<hs-ssie\..c+--s+..4es0< eh eel 176
Fasciotomy — when anid: HOW iiciscsccccs-cetsesescsessuss0er1 cosas ae ay
Contents
ee SEE
The debridement in detail: iid... sess ee eesesesseseenenensnaanananmndaneasnnese 178
Methods for drainage si. ctiscicscsscsesdsecsnsssseessssssssteesecceseeesonstnannaanaaantgasatonanearts 180
Section 3: General procedures
10
11
12
13
14
15
Injuries to arteries amd VEINS «ee er nett 185
Types of vascular injury ...tsccctessesscssssceenstssseteesesernerenetennarnnnesnneszeneanes 186
Primary amputation, ligature OF FECONStFUCTION? ...........e cece eseeteeeteeeereeees 187
separate eee Resse sence 189
Deceit ACEO ny: 00 nee eo vee vcs onsen essen ene ecens seen ee le eR 191
Complications of vascular SUIQETY ...sessesseessseeeessssseeceeeeeeeeenteenennnannnannnnannenss 193
re TT eto MRI cars Lc Jp ante ct 7
Types Bit fractures: :2iikvgiReW Reece etlacesecesctyessssseeessesecesvossunsarsosnrnteri aan 198
Biealarip tot fractures che cement sence ice 199
SeoFeneainsyne lapis <2i.ca ope seeks cee cena cen 200
Poti pro te ctl ota ts226 00) BRIE reece cnces is enn etc eenecetensecennttr IE 202
Battlefield management .......-t..ssccsssssssceeceeteenseseeeeereneeeeetnnennnnnntaeeennene eee 202
oN es ce a 203
The Trueta plaster metic ete. LG iin... sees 208
Peete rmal fixation ....2:emllemRibee sc ste sec- tae cesies.--.-0.--s00 sas 9 208
ceo aT A einen en 211
Delayed healing and infected FraCtUres ooo... cccccesesessesseseeneeeenesanenmenennensenease 214
Wetet eats car es 0c penne ne 2V7
Evaluation of joint function ....cecesssssssssescccesese tenses eee 218
The soft tissue problem’. ree einccesecee esses ieteee sores aR GSE 219
Fracture through joints 0). .2 iscsi eesssseeeenceeensssieemnaasaannnae nea 221
Pihectedd joints .......(2ls. RUDE ReaNimemrtemmet rt ts ates een nnnecne sere tora 222
Persdony injuries 21s Lecigpmene eee noone 225
Primary manager mers twee B Ices ree ences n seen eeeteesensnse RES 226
Secondary reconstruction eseesssesccssesteneesssseetentttter ens nee ee 228
ersten Nt Lg Cocca oe cncacaacs aaa a es SEN 231
Diagnosis ain explora tit tier 6 LER no-sense te RRR ES 232
Secondary nerve Pe a ene i 233
Amputations ee rm Ree 237
Evaluation of extensive limb injuries «0.0... esr 238
Types of emergency acPYigS QUUREUTES Yn. feb sennseeeeess serene RRR 239
Amputation theory — the elective amputation... 242
Early prosthesis ee: Se ONES anna ec 244
ilperricl Closures is. WRl APIs cones Beg n ee eeee eee cece 249
te eee ce tin | i. . s a Masta 2 RMRRSSESSS DSSS aaa esa 250
Closure by spontaneous granulation . re oaaniviN a eS 250
Delayed primary suture ) .) —— , ita ae hy |
i —>———™
16
ce. a ) ail : : :
Skin Flaps tensile tecnica aS SP"
17 Injuries to children and old people... 259
Basic life support and surgery in Children ...::c+:ncuiMnmieemeerssctoreeeroeensesesees 260
Basic life support and surgery in old people .......-.sseceeeeseeeeeeesenrettteee 263
18 Emergency blood tramsfusion ............:-:..::csssessessnmeeseennnntseenneenseeneententeee 267
Reasons for blood transfusion ..............-ss--s-sssseresersssmanannannaantncrnssanennnserereeeeeseee 268
Emergency blood trAaNISAUASIOM ...........-.-.-sss-cseesensecneennnansmannnparcerersecenseennersencenssss 268
AnrtotransfUsionn samme Deco... --s-.---c00e-cenronssssenenenntsnanammmanaempnnimnenasscnrsenesterserst 270
Complications of blood tramsfusion .........::+::s::ssessesssseneensesrsenseneenseenenerentensenses fay
19 Hypothermia and hyperthermia ee lS 275
Management of hypothermia .........--.css-ssssseesenssneennsscensnnnnnerenennnesrinsersse 276
Management of hyperthermia .............c---ecsssessenseeesnnsseeesnnseensnnntrennennerss 278
20 Diseases interfering With SUTQENY oo... eeeecsseeeseeseceeessnneencentennnteteecesentensaes 281
Types of amemmia jascssisctsttithsiesssssscssneceeseneeeenseeessnersnnnaraannanagnnnanaanrenseenensoe 282
Malabsorption and vitamin deficiencies ............::scssssescsseseeneneeseteteesetesseetiees 284
Schistosomiasis .cc.cstsssssisctbeveessesssesecessececessesssesensenonabenasnassdanenenunasensnsneneneesenssessoces 286
Ascar isis 2: cee utet Laci ss... -.esssseessceonsonnnasoniin amiapinapmEsemensndnevascenseieaee 286
Amebiasis. ... crreeien MINERAL. ...-.......0.........c0ksnetesenanyaanganEEIEgieaneaevennrcnenensene 287
elie eee. oh nneceene ce co ween eae 288
Typhoid fever siscccscsssssssssstsssesssesssssssssssssssssnesssssssensenseesensanannnannnnnnnannonssnssasaceesesentee 289
SINE GLO 2 - eee ee 290
Section 4: Specific injuries
21 Injury to the head amd meck 0.0.0... cesses esssneeeseeseeeestessnnnennneeennees 293
Surgical amavOmyr Gee Aasriiee ss. cssesscssescseeseeserosseenesenneenanattiacnaneversnsernesessereneeseess 294
Preparations for surgery. Anesthesia. ...............::cvsessssrsescosesnserssesesessnessssennses 295
Scalp inv} vir ype rena once sessenenesnnanstnaemnsnaneenenenatenesanntnerasavee ene 296
Operas SUCRE aa isaac ssn. nnnspns nn a Cos 296
Control bleesiarge armament |........:....:..csscesdasgieaneaementedneeionersereieee stone 298
Skull hematoma after closed skull injury ..............cccscsseseesseeeteeseeseeeeestennes 299
Com plicatioriayiimmemmemeMebOy «<4. ..0.serss0s1ey0eto en AREER Forno rnae se eene st 301
Mama gern erat ein emai ti 065500050. chseuse0ien see RRR uses 303
22 lan} cary 00 ste ecco css eco:ssvenensS eM erect och 307
Surgical anatomy. Types of spinal IN JULY. ...:cr secon ae Reet ato cee ees- 308
Evacuation ics me erent «5. ..0..00<.c\seos, viuascncene eam ley er assicces 310
Preparations #OmmungenygAmesthesia |. r...cons:ca:ncas ee eRe rcp eee en eos os. 311
Open spiral aiip Git teers eccs. coc... 050.21 snp ae o12
Spinal fractunresiieyameeemeen 0%. ...-.<c.cs.. 0: nee, Ace cc deees 314
Complications‘of inyaryamd’ surgery ....:..j,!%......ngmemmmretee rater cere 317
Rehabilitation after SUA AIAFOT Yo. iss eg nce 318
Contents
eee
23
24
25
26
27
28
Injury to the BO rec reer ni ct AM Oe Gatarecadngsos sms noneraessswoeeid bre aaneee 321
Surgical Bramtermmrnysanctis Leisici0 cetera memantine ss snnroneeneeeeceneeneneneniaiaa o22
Fiancrersen Ur Pe er eee cao... scotananlmpveettngenennrepeeneee ener eeveennennenennnnenen inte 323
Preparations for surgery. A restheSia seitiecccccteccesvccrsssceveesenbessosussnsavnenencnaangnae 323
Soft, GiSMeMMOIULIVr 3. 000hb-- ss esses sanbnigmpenenncntencseronenesscnseeeneeeetenneescereaa aaa 324
Qypeie Praemties Serbs. 68a asc crermenrtecceesectereeticessoeeeneeta ct 325
MCE ULIEES ccccccuecscscscsscenscscsersnecoMeMMMetenniscnrsvansicenderseseevesoversosnneshi nama 327
Upper Perce AC TUT OS 12.0621 thts eestor ceaetncnsrn ss seesoeseesseeneere cose cnenes aria 328
Innjenrrysteltie GY 1.6.01. Fh scene areeeeee cee cern 331
Surgical anatomy. The Gxammination ..Betececcteccee-ceseeececeeeeneesesennnantdenmenagzene fe
Preparations for surgery. Arnesthe Sia MMe ctsctyeeccn-cncoentes nesses senaeserssntiseanaanal & fe fe)
Fiyechicliimrjrimgrsey. coc. c00..0:08 5008. AE ccmammmererincerten tenses ot a a 334
Penetrating eyesimjury sis: sesseeeeeBRMeceennctceerestiesseeessecernereenenan ae 336
Complications of injury amdSUN Gey Bi eeresncestetesnsensensceeeeesesetereseeenn aan 337
Injury to the i rn. ene 339
Surgicalramabomay el. ci.158h668 Bi tea escretnetnttes oer cence 340
Types OF wartimeichest injury +... dpe cereeseececeeessseeeeeeeercennenenaeineeanaaaaaa 341
Preparations for surgery. AtreStheSia Bie cc ersccencccecewseseseecesescnees-soneenneieenaaam 342
ee erie lo Geen) os aaa 344
Exploration of the chest — standard thoracotomy .........-..:-:-: ess 345
th ce 347
Emergency Phoraco tommy? \.jicth Lies mmecenesceeceeteecenenseeeeeeeeteeett nena RRS 348
Complications of imjurry ard SUT gery... Be aennnneceeeeeeeesseeeeesrennnsereer ern 349
Abdominal injuries in general eee 353
Priotitiesstotsur gery c%..1.5isj4cd.sovsnsaenneimmpscrerterssnencneessrsreessoneistte GS 354
Preparations for surgery. An@sthesia tiie scsesecessee esses ereenn svn enneneh ani 357
A tpdevmnr cat wall itnjur'y ........c.:..-.1lcceeccaeemmmmateeetetenconemvenseve-vessmorno 7g eit,
The midline incision. The exploration i... ere eres 360
Methods to control bleeding .......c.cccc.eipecrssstsessseccereeeerneensseneteneesnn 365
Decompression — drainage — alec iigcl. See eeeeeeeereneen occ 368
Emergency laparotomy ee ere 370
Injury to Paeadrvte sti ©: iil bebe ncceet er rere ere oh 375
Surgical Ee Co a 376
The general procedure in missile imjury so... esses eerste teers 377
Two-step management in ETE GETICIESIR faeasn nes scsnennnseesneeseesenstes sree 379
Injury to see Serva | dima teste yds wap meen neno ent ieee teeeee een 381
Injury to AT er a: ee 383
Enjurry. tothe rectum ii.ssnsesteersssntneegmecernetsernsee eee IT 387
Reconstruction after enterostoMy «...... a.
Injury to the liver and biliary tract ..........-- | ; nee
Surgical AMATO iscesncecesseesssessecessnsenenseeeatttggesssee 392
Liver Htaguarry oi cots. spss este coe ensene een RB oe 393
Complications of liver injury and surgery 395
395
Injury to the biliary rant disncdiwhu
—_—"——
29 Injury to the stomach anid GuGdemiaM ...........------o-nseeererensnteenerssnereees
Surgical anatomy Se ee an
Stomach injury .....-:iiseteeteedilchessesteestesvaeersses he
Injury to the duodenum and proximal jefUmU eeeeeeeeeeceeeeeeeetet ae
Emergency procedures ee 8 ME.........-.----naghamenanes one snaelaaaenene seers?
Complications of injury amd SUTQery ....e.-oec eee essssteeceettnnetenntnneennnntt 405
30 Injury to thie spleen 1:20pegee ries inecptee enone snsenntnrneratacinnenneroe 409
Surgical aa COTY. «ax: ssn RRIMtieginensegigeco--ss+--n>+o+nimmetceaamese se 410
Removal of the spleen — splemectOmy ....-.------c--essssseeeeeeteteensseetteeeennentnnine 411
Complications of injury arid SUIQETY ....cceec-csesecceceeeecesseneeennennsennannnnannnnnannnnnnsty 412
31 Injury to the pancreatic sctesnsene cons seeeseenss-sonseseeesesianhannnnnnnarnnarnsinets 415
Surgical amabOmny ii! HREM Neale cermeneee-eeeensesseeseeaneenenentnnannaneannaaneet 416
Pancreatic injury. ..:.i0iecs:igyiltiatecesnescbennsnatamhessssesesceeeeeeeeeeeneeesnnnntaaaanangnnnarnanagnte7 9% 417
Complications of injury arn SUTQELY -.csecsessesseeseeeesssssseeneenennnnnnnnnnnnssnnnnnnteee 418
32 Injury to the kiGmeys ...cccscssssssessetsessseeteessseeeneseeeeeceenennnnnanccentnnnnnnnnnnsasaagnnee 421
Surgical AMACOMY .sais.-snsadblatenensceesecencececpangorssssesssssscsseceseconnnnsnnnnangnnngnnmnamaaansonn 422
Injury to the kidney ..i.:sisstiiicsececscesssesssessceneteeesssscsesssssseeseeccennnssnannsnnnnnnnenannnnnnansans 423
Injury to the ureter hii eerste MIB «oon 0e os -ssocessnaninnpsiioalla QeRapeelnebe na penh == 425
Complications of injury and SUIQETY .ccs...--ecesssseeeeessseeeeesesssnnneennnnnnnnsennnnnnnsscen 427
33 Injury to the urinary bladder and urethra 431
Surgical AMALOMY ....sseissessbbescnedccnsnncesenseceengenesssessseessssnessnneccnnsengnasannunauamnesansnananass 432
Types of injury ..........csssssssveseseseesnnsssecesesevsnaacsssssssescsssssnesesessannassnnnannannascnnnaneagngty 433
Injury to the Netter be: 8: de. erie. << vena 435
Injury to the urethra .......ccccceccsescsseeseeesteessseeceseesesessnscennastannenannanncnnecsansceness 436
Complications of injury QING SUTIETY rina sesesnscsenseseneeescnnenennssnatiadnannesennvernnes 438
34 Injury to the male Organs 0.0... .cscsesceescee ee eee eeeeeeeeenneetettntnnenitee 441
35 Injury to the female Organs on... Doce... sees essecesecenenseenstenpeaensareannenan? 445
Surgical anatomy and physiology ei SE 446
Anesthesia to the PTCGMAE WOTISIA cies... assessersenqnssuaneangennetenpaaEnSran 449
IN jUry tothe pregriant wemsennnt iss tos cage c-~-......-......:0u0hhepsokes eran Een 449
injury to the nOn-prepriaiiemeepeAN ..re.................0...0025drnansha ener 453
Complications of injury and 4 Oe) ieee eo 455
36 Complications of abdominal surgery ...........0.....0000::cceess tees 457
Post-operative TT ORI COU RII eerie oI =n. 458
The management of common complications 2.0.0.0... cece eeteteeeeeeee 461
37 Pelvic injury eee ee er 467
Surgical anatomy’ .4.: jae Me cccselles-0..:-+ssvenuey ea 468
Freparations for surgeiryyammemenesin tite... ovi.s:s0:s.s..00s eee 471
Penetrating pelvic el gg 5. i ee nner a a 472
Hip joint EEA ULTY «cS... nsdoveege 473
Exploration of the maim sebbemhes so... 2 80 ceccsoscoscccs.. 477
Pelvic fractures ..ccccccsscssteleieeetesee tistics 477
~
——.
Contents
ee eee
38
39
Complications of injury and surgery ....-:...:+:-:s nett 479
Upper hima injury. 05sec tenets ener ctr erttcerennennnnnnenees 483
Preparations for sureriy, Lali cessepeecns I eee teeeeeeeeee eee enema tear 484
Shoulder and arm injury: eet ceeeancgeneeessscereessssseeeceecssssesssrennennnnaansaaaeamnaatass 485
UE TCaDATAtOTI Yc en ncgpenc ercomsecdmmmpens fee eeeenee centr bean tet 486
Exploration of shoulder injury: ......----:es-s-ssese reenter teere erences 487
BE GUleY ETACCULES ...c/-scssaperctooescnrceeeMponsnevsserseececcussesesensenneuereqaainantnneananes 489
Extensive shoulder injury ........c-s-sesccesses cesses sseeeeeneeresssesennnasecnnnnnaaaasanstenees 490
Exploration of arm injury ......c--csceseeessesse ts scseseeeeentretnereecneesnccetnees 490
Open arm PraCtUres oo ee ae cdacsscaticoecvsesannoe>s tree = 49]
Beda 110 U0 cece one- css ete MMR cce nee eeneer ener 493
Sturgical. amatorrny. ...-ccsscssrsncamsettecnesensseerscsneroreecerntte: te IRR 493
Exploration of elbow injury cc. esse eect erences 495
Tel bscrr bra Ct ures. aocss<pissesesescrtece cee Daanepeteneeseeeeeeeensarenpsseses77neae anes aa 496
Extensive elbow injury. .s..iccccccsctecceeesssssccseeseceeeeeesesneeenessanecaeennnnnnnennnnennnnsats 497
Forearm aind hand injury... tseesssereesenseeseeseeteceeeceeneennnnmnnnnnnnaaanaasasaeeses 499
Suirgical amatorny: ...ncuccsgpeee iene reer nr =a 499
Exploration of forearm and hand injury .......--..::.: ee eet reece tees 503
Fractures of the forearm and Hard ...............s.ccceecceessessseeennecennennanennnanantens 505
Extensive hand injury .-.:.crcccccccseresntscenneennseessestsssssnsssssesanasn ty rasan 507
Amputations at the forearm and hand ..............cccccecseeseesesseeeneenecteeneeneenenns 508
Complications of injury and SUrge©ry «cece cssteenentettnnteresesaan 510
Bosver limab injury. iss 20 Wasser tenner 513
Preparations For: Sur Be ly imapeetaenge-teossencencenseesreetseesteee eee 514
. STOLE ig ge Tce 516
Sturgical anatomy nan nsapeeeentnteneneetee senescent EES S17
Fasciotomy and exploratOU, cateeeeteetsserscesteectes-s-e--srnth hia a 522
Fracture management... pececcctnesscseesiteeeesesscsenteeesceeeeeseaen te ES 524
os CALA tg ge Cs 527
PPfigh armiputathonis ...cscessrnrcsensrirenrccreesnesese resets GS 528
Injury to the distal thigh AV BEC fesce ee cncves ences oe soesssernerensso evn 529
Guarpiical anatosny < .sisdsteisedlctepeneitcentrn senescent GT ES 529
Preparations for Surgery etbetaba cen neers con 532
Exploration for missile imjUry. cvwssscesesectesseecceseeeenee sesh 532
Open joint fractures sconces ee eS 534
Amputations at thre Acree hBME es ires scents et eeonscerseeroeeees sn etetnt a 537
PVE Vege BUY sn scnctavntenerntrnr sc sttenvnccersseeenresee tS 538
Surgical BTACOTY, acecseasesneigigtemernte eirecrevncseessevensoeesorss a 538
Preparations POT SUIEY, coupiereeeestert sere es-cresseeesoeoreore ar a 542
Exploration ATicl feaSCHOMUOTADY eee ceturonent fees ssvevesssssesssosoventsentcinanh Rr SS 543
Fracture mamagemennt .....-..secseecs recesses eset SS 544
Types of amputation... Z 548
550
Complications of limb injury and surgery
19
a 555
40 Burns ........ miei: | ame sie
Physiology of burn injury ...-cneeemmeen sso
Examination and Classification’ Of Dine tntigeces.....--.+-<-----s-eesessererenretrechanennatags 557
Co. a 559
SAR a 560
Triage Be narertirrie. DUrInS cyseii-o eienmemmmreenssneesntevsseneencensoreennesssmernnanmanaat 561
EOC eenncegsseqeese tamara enero 563
Management of the burn WOU seccssesoodibbesscsesseesesssssestneerensseneenevsennnmennnaagtin 568
High-voltage electrical burns <oescecsensstMtbernesssessoserseersennsannvecsesessueshenenensannnne 572
Ae) Ce 572
Complications OF Urns csecesssteisieelbee rest cat enusvvecneneeeessoesessnneanntnnanestethainnnnas 573
Section 5: Treatment after surgery
41 Monitoring and complications after SUEQETY ..........c eee S77
Monitor the war WOuUNG .......csse::ccsscsecsesnsanarsesecsessseeeseeseeseesseessesscsnsanenannanceuanaanns 578
Monitor vital functions .........::cssccsesecssceeneneessecsesessessseeneseerssestseensasenenensananennananen® 582
Respiratory ee ee 588
Circulatory faihure .........-cccscecsssecssssssssssnnammnnenscssssseseeesescesecsnnossnesnasusscssssasonnnanentn 590
0 A | enero 591
Coagulation system COMPpLicatiOMs .......--.eecse sess ees eeeeeseeeenneeetnenennenennetten ne
Multi-organ failure ............-ccsssssssssssssssssessneesessssseseceeeceeeensessesnensnnesnsanssacnnnsenngne 595
42 Nutrition after injury and surgery ................::.-.0 eee eee 599
Why enteral feeding — why Bree ICTS. ................00.ccesssenenens 600
Metabolic response to injury ATI SUP GERY nnn es nese one eeecseeeessnseensnsennamvenannnas 601
Malnutrition complicates surgery .........::.c:1escssces sess ees esses eee eeeeeteeennetnecneteess 604
Planning post-operative nutrition 2... cesses esses eeeeeeeeeeteentnennneee 607
PERE PIIOL IG TYUITTICION. <...<;<csc-vnsc set tev cce vines es een creecveensenn ne 611
BARONE soo sesc.susasenscaslo seni RERR Erbe seerseeeeeeeooeeeeoneeeosentna kn 612
PRE Pe|Sding procedure .....:ccslicsccssanesseegMenceeten sees eece eee esonesnenssnsnomneseain teen 615
Common foodstuffs and their nutrient value o.....00000.00.00.cceceeeeeeeeteeteteees 616
Food processing and the viscosity problem ...............-..::-:::::ssesieeeneeenees 618
Homemade diets for: enteral feecin et ..:....-....... se csenssvensennenneen genet 620
Common high-energy diets for oral feeding 2.0... 624
Field standards of volume and SARS 625
43 Exercises and physical rehabilitation 2.0.0.0... eeeeeens 627
Draw up a rehabilitation pope 0 Es 628
Respiratory Bupport and GXGr cine want NAS, .6cc....... snes 630
Basic Grarniny tTheTaDy osc sasc ge eM orate tenses snie cong 631
Training after limb Ug ge 634
Ambulation and ap ltaistarits(]ee SRE cc 636
Rehabilitation after head and spinal injury a 638
Rehabilitation of MUuIti-injlry PATO wee esac. cv crcecseionvieeisnen 639
44 Microbiology and infeCtORs: 2.1 eee escicesesis svesceedonr en 641
What is: bacteria ..........s..::s:ssarer hens ce scale sep.setlr 642
SUE i eeteatels Bi: 5 ese 0 ene 642
Guidelines for treatment 2.0.0... ccc eeeeeeesessnnenesnnenmeanerenasennensanenenansneneneeess 643
Septic ic ae, nr eee 645
Bacteria important HT) SUZ ETY neces ssaeetesssseeeesbesseecenmnannsnncentanaaannennaaneatnnersssen 645
Common infections and common antibiotics 0.0.0... 648
Resistance to anti biOties sete cseeccvesccsesesesesesccecssoresssvunnrnnmhsapuMaumasabeneaeasmannnnanedoesas 656
Disinfection and sterilization ............cccceceeseeseseseeeeesenenenenenenernatsesnsesseneneneneness 656
Section 6: Field anesthesia
45 Wartime anesthesia complications ee. ae 663
Airway Par eatlastc Gee eee 664
Circulatory ere) Elec) 2 ce ca 665
Sympathetic Wry Peractivaty os accscceeeessseessssssensnnetcesnnennaneaatanmsaaaentemsararnnersaec 666
Side effects of general SAREE SEIGELICS oc c.o+csccceetevsss.n voce One a Re Sa 667
Side effects of local anesthetics <.....::.c..ccccssseecssssnesneensennenneannennctareseneenernes 667
AG “Local amestleesta ieee ececescoecen ences ee -ceseee sss sen carna rn nee een eran 671
Tnfiltration anesthesia pegem etc ctucsr-ssess-snes0n9Bt -dr+astteanystmaanaa mR Meneses crores 275 672
Intercostal nerve block. Pleural analgesia ..........-..: eee erties 672
Brachial plexus nerve ‘i Qe ee ee 674
Axillary nerve Se | 0 ie MRE nc 675
Nerve block of the: Hanis gcccco0t.g.0si.<.csve+++20+0s:ssnsbe cai aa mnumeree net =A==S® 676
Femoral nerve blGGk aye ete seaess-<cosenrase+++* seen" A 678
Nerve block Of the fot tt oi. d cis ie.s..-..068----+-+.neeel foeegiraee sm ne mcrae ge?" Ee 678
Regional ‘ntTAaveniOUs-aMesthnesia .....dcacss.c..... chore .+ Heiman danaRseeeMmaRne eaten cnee Hs 679
47 Spinal PO PMS a 683
The anesthetics o.com tmemewethes. i seen sss--ssnshssneaetonnee etn i le 684
The procedure Se 685
48 Intermittent ketamine ATVEStHESIA. .......--2.0--cs-nssneenestnmeeeereetnnenssuonencneess 691
Appendices
1 Management quality Die ee 697
2 Blood-grouping, cross-matching, and blood-banking ..........-..- 705
3 Microscopic examination of bacteria. The gram-stain procedure aw 709
A Books recommended for Further studies ........:::cssssereeceecneeseeneenseteneeneee 713
Acknowledgements ...:cscccccssssecssecsse nese tess nent EET 719
FBO BAT Yo. csissn cto mtapieee tienes ceceencen enone RSE SS 721
3 ee eee 737
N
N
Section |
The war
medical
organization
Points to note — Chapter 1
The forward clinic should be mobile and light
* study the Afghan models: p. R29
* the one-man mobile clinic: p. 66
* equipment for forward clinics: p. 56-63
* clinic production of foodstuffs: p. 600, 618-624
There is no fixed standard on how to organize
* examine the local conditions carefully: p. 30 and 31
Continuous training of staff is necessary
* train the clinic staff at three levels: p. 31
* control the quality of clinic management: p. 697
¢ how to use this manual in staff training: p. 10
1 The war medical
network
Examples from recent regional se Be OS, eT
Training HEAT Te 11 MERRION on ee
——_——S——
1 The wat medical network
Examples from recent regional wars
The strategy of this manual is early and forward primary management of
casualties. That means basic life support and primary surgery should be done
within a few hours after the injury, within four hours at best. The basic model
of organization is to locate the surgeon and the forward clinic close to the fight-
ing fields. However, the design of this model in real life depends upon several
factors, such as the actual military setting, the local popular support, the type
of injuries encountered, and the skills and resources of your staff. The organi-
zation of the medical network is a main concern to the war surgeon and should
not be left for military administrators to decide. You may draw some ideas
from the examples listed below.
Two different basic models
1 The traditional model — the medical echelon: The standard model for
casualty management in conventional armies consists of a rather rigid echelon.
There is little or no medical support in the battlefield area. The first line hospi-
tal is not mobile and located far from the fighting grounds. Depending upon
transport facilities there is a delay of hours from the time of injury till primary
surgery. The first line hospital does general surgery only; many regional injuries
(eye, head, chest) are not given primary surgery at the first line, but evacuated
further to remote second line hospitals for specialized but delayed surgical ser-
vice. Limbs and lives are unnecessarily lost due to hours of transport.
2 Our basic model — the medical network: The enemy controls the air,
partly the ground and has vast technical resources. Our response must be high-
quality medical management as close to the fighting grounds as possible, and a
flexible and mobile network for casualty management and evacuation. Parame-
dics stabilize the casualties and even provide some life-saving surgery in the
combat area and continuously during the evacuation. Our transport service is
poor and the forward clinic (FC) is located close to the fighting grounds. It has
to be mobile or semi-mobile for reasons of security. The FC should be able to
provide definitive surgery for at least 80% of casualties with a minimum of
delay from the time of injury. When patients are in a stable state after surgery
(1-3 days) they are evacuated home or to villages for rehabilitation. Or to a
non-mobile second line clinic (SLC) for secondary surgery.
Major permanent clinics — hospital infections >
increased mortality
Death due to septic complications accounts for 10-20% of the war-
hospital mortality. The risk of wound infections increases with long
hospital stay. In major permanent wartime clinics one third of major
wounds are infected with gram-negative strains within ten days after
admission. In particular problems are caused by strains of pseudomonas
and proteus resistant to most available antibiotics.
There is only one reason to centralize war surgery in major clinics: By
tradition it is there you find the surgeon. Better apply a model of mobile
The one-man mobile clinic: p. 66. surgery, decentralized clinics and early evacuation to rehabilitation cen-
ters. The surgeon is more mobile than a severe war casualty.
Applications of the network model
In an actual war scene the military events force you to improvise. In the Falk-
lands/ Malvinas war between Britain and Argentina in 1982 some British doc-
tors in a small forward clinic found themselves trapped for several days without
helicopter service; casualties could not be evacuated to the experienced sur-
geons at the second line clinic. So they had no choice but to do definitive sur-
gery on all casualties admitted. After the war they published their surprise at
the positive results of this forward surgery. You should not allow yourself to be
trapped by the circumstances. Geography and climate, the military forces and
positions on both sides, local popular support, actual supplies of water, food
and energy — these are all factors that should be closely examined before you
design a military medical network. Here are some examples from late regional
wars:
Afghanistan 1985 — village area in the countryside
The conflict: Afghan resistance fighters against Soviet army and Soviet suppor-
ted government forces. Soviet forces: total air control, bombs, air-to-ground
rockets and aircraft gunfire against military and civilian targets. Heavy artillery
at random against village areas. Ground control of main roads, mining of minor
roads. Resistance Afghan forces: light weapons and mines only. Communica-
tion and transport by horse and bicycle. The geography: plains without woods
or other cover against planes. Densely populated village area with mud houses.
Some agricultural production. Extensive popular support with minimal enemy
infiltration. Evacuation time to a second line hospital is three days.
ee 3 Mobile light forward clinic (FC): Central depot (CD) with surgical
equipment is stored underground. District depot (DD), each district had one
paramedic responsible for forward medical management. He kept the district
mae depot and joined the FC staff for training when the FC was working inside
Ww
his district.
t
Need | op |-- site J FC equipment
a W eback:
Total weight is 40 kg, carried on bicycles or hors
¢ General surgical instruments for four major debridements; instruments for
e: abdominal surgery, external fixation of fractures, amputations, skull trephina-
tion, and vascular surgery
DD ¢ Pedal suction and intubation set
(oo) ¢ 10 000 ml Ringer infusion
Fa * Drugs: antibiotics, analgesics, ketamine, diazepam, atropine, drugs for local
and spinal anaesthesia
* Bandages and plaster
* One big kettle and primus heater for sterilization
~
——_————™
1 The war medical network
° Headlights y
This equipment enabled the FC to provide definitive surgery to any casualty.
For mass casualties or planned secondary surgery, supplies were collected from
the CD.
The central depot
It is a surgical unit of total weight 200 kg, available for the FC on horseback
with twelve hours' delay. The surgical unit contained
¢ Surgical instruments for another four major debridements
¢ Ether gas apparatus
¢ 50 000 ml infusion
¢ Electric generator and X-ray apparatus
* Blood-typing equipment
In case of planned attacks on Soviet posts, the FC was set up close to the fight-
ing area. In unexpected Soviet attacks, the FC was called by courier. Surgery
was done in village houses, mostly during the night due to enemy air-sur veil-
lance. After surgery patients were distributed in neighboring villages and
monitored by the district paramedic every day and by the FC team every 3-5
days. The results proved this model to be efficient: 75 surgical operations were
performed within two months, all patients given definitive treatment and
secondary surgery at the FC. The mortality among cases admitted for surgery
was less than 10%, the rate of post-operative infections was 10%. The main
strengths of this model were its flexibility, its military security, the low rate of
wound infections and low costs. The drawbacks were the delay in surgery
due to problems of communication, transport, and limited capacity in a mass
casualty situation.
The Jalalabad front, Afghanistan 1989-93
The conflict: Afghan resistance fighters holding Soviet-backed government
army under siege inside the city of Jalalabad (city population 200 000).
4 VU y ee Pro-Soviet forces: close- and far-range fighting. Any type of ground- and air-to-
gf = ground weapons were used against the siege forces and villagers of the area, in-
oe cluding delayed explosion bombs, anti-personnel cluster bombs and minefields,
BOS modern HE fragmentation shells and mortar bombs (p. 86). Air-surveillance
(OR = ‘ pul SS eare Afghan resistance forces: hand weapons, mines, light mortars
AIFS. % aie ie oo eG. ee and meaeliecs= e
: sation by wireless between the FCs, the ambulances an militar
Ne wi — AS units. The geography: plains with some woods. Village area with low agri- :
7 cultural output. The population was small with considerable Soviet infiltration.
VA The time of evacuation from FCs to second line hospitals was 3-8 hours.
4 "Mujahed Medical Center" at Jalalabad: Ambulances manned with
ey aa a ie doctors and paramedics that did life-saving surgery and stabilized the serious
cases before evacuation to the FC — a mobile truck operation theater for
maximum of three cases at a time. The FC took supplies and staff from the
central depot — with surgical service for mass casualties, store for instruments,
infusions and drugs. Across the border were second line clinics and hospitals
run by the resistance forces and international relief organizations.
28
Afghanistan
Each ambulance carried a basic life support (BLS) kit:
* Stethoscope, airways, face masks, suction unit, intubation set
* Bag and connections for ventilation, chest tube unit, naso-gastric tubes
¢ Instruments for venous cut-down, NaCl infusion 10 000 ml, plasma expander
Standard BLS kit: p. 64. 2000 ml, large gauze packs and elastic bandages
¢ Drugs: Ketamine, analgesics, local anesthesia, diazepam, atropine, antibiotics
¢ Others: Splints, headlights
The FC truck carried three beds, three BLS kits; surgical instruments for
four major debridements including instruments for abdominal surgery, skull
trephination, amputations and vascular surgery; drugs and equipment for keta-
mine and regional nerve block anesthesia; battery-run electricity but no X-ray
facilities.
The central depot tent camp contained three tents for surgery, surgical
instruments for four major and four minor debridements, infusion, drugs and
bandages for 100 casualties, facilities for washing, sterilization and maintenance
of instruments and equipment, electric generator but no X-ray facilities.
The mean delay from the time of injury to the time of ambulance medical ser-
vice was one hour; the mean delay up to FC surgery was four hours. During
periods of heavy air attacks the mean delay might be 24 hours. The main meth-
od of anesthesia was ketamine in sub-anesthethic doses. The FC forwarded the
casualties to SLC as soon as life- and limb-saving surgery was done (within two
hours after surgery). When the FC or the central depot was under direct mili-
tary pressure war wounds were managed with fasciotomy and double drainage
only, leaving definitive surgery for SLCs. The results: 5500 war casualties were
managed and evacuated by this network; out of these 15% were classified as T1
injuries by triage (p. 123). The total mortality rate (those dead before reaching
the network and those dying before reaching SLC) was 20%. The central depot
tent clinic was able to manage mass casualties of 20 patients without serious
congestion and delay. Seven staff members were injured during duty, three of
these seriously. The main strengths of this model were its mobility and early
BLS. The drawbacks were relatively high costs and the risk of enemy attacks
on patients and staff.
The siege of Tripoli, Lebanon 1983
The conflict: Palestinian and patriotic Lebanese forces under siege by Syrian
and Israeli forces in the Lebanese city of Tripoli and the surrounding Palestinian
refugee camps. The attacking forces (Syrian and Israeli): close-range fighting
with ground-to-ground rockets, mortars, self-propelled cannons and naval
artillery; extensive sniping; no air attacks or cluster weapons. The defending
forces (Palestinian and Lebanese): hand weapons and some light artillery. Geo-
graphy: Tripoli city had 200 000 inhabitants, many of them Palestinian refugees
from camps outside the city; general shortage of food, fuel and medical sup-
plies; extensive popular support to the resistance. The fighting area was on the
outskirts of the city; evacuation time from injury to FC was less than 30 min-
utes, Further evacuation of casualties was impossible due to the siege.
9
Ss
1 The war medical network
5 we 5 Palestinian Forward Hospital, Tripoli: Ambulance with paramedics
\ \( giving infusion during evacuation from fighting area to the FC — the forward
ee hospital. Here definitive surgery was done on all casualties. When stable after
the surgery (1-5 days) patients were distributed among rehabilitation centers
ee (RC) inside the city to relieve the load upon the main hospital. From here they
i were readmitted to the hospital on an out-patient basis for later reconstructive
rgery.
AEE +c aa
6 The internal organization of the hospital: Emergency department (EM)
a/ \k with four beds. All casualties were taken here for triage and stabilization,
" including urgent life-saving surgery. Operating room (OR) with three opera-
ting tables, fully equipped for general anesthesia. Bed department with 50
beds. X-ray and lab: mobile X-ray apparatus with manual developer. Laborato-
ry for simple analyses, blood-typing and blood bank with 30 units of blood.
The Tripoli FC was located underground in a concrete building giving protec-
6 [ tion against artillery hits. The electric supply was sufficient and stable. The
emergency department was always manned by the senior surgeon and the most
experienced nurses. The operating theater was manned by three teams, each
with one surgeon, one assistant doctor, two scrub nurses and one anesthesia
technician. Each team could manage 10 operations/ 24 hours. The bed depart-
ment was manned by two doctors and five experienced nurses on 24 hours
duty. The surgeons made the first post-operative dressing themselves. The
rehabilitation centers were manned with two doctors, four nurses and one
physiotherapist each. The results: 1500 war casualties were admitted during 35
days. Out of these, 400 cases were hospitalized and given definitive primary
surgery, the rest were managed as out-patients. The rates of early and late
mortality were low. None of the in-patients or staff on duty was injured. The
main strengths of this model were competent primary surgery without delay,
and a high capacity for mass casualties. The drawback was the hospital being a
target to attack, should the attackers gain air control a more mobile model
with less capacity would have to be applied.
WA
SS
SOAS
|. -
INFECTED =>
Guidelines for the organizer
* Flexibility: The medical network is not a fixed system. To be efficient
and safe it must be as flexible as the military organization it serves.
* Command: Each network must have one and only one field officer in
charge. A war surgeon should not leave important organizational mat-
ters to non-professionals; a committed senior war surgeon is also the
best field officer.
° Planning: The military setting is unpredictable. The officer in charge
must continuously monitor the following key factors to which the
organization must respond.
Training of medical staff
a eo) ens Te aan
Recommendations for staff training,
also see p. 10, 581-583.
Check list
* The quality of the enemy weapons
* Means of off-road transport. The time (exactly, in hours) used for
casualty evacuation inside the area, in the dry season and during the
monsoon, during day and night, during ceasefire and under air attacks
¢ The general health condition of the population
Advanced weapons, difficult evacuation and poor general health
condition — arrange high quality FCs in very forward positions.
¢ The enemy aircraft capacity and air/ ground surveillance
¢ Enemy night vision capacity
¢ The extent of enemy infiltration inside the area
Extensive enemy surveillance and military pressure — arrange
very mobile light FCs.
¢ The extent of popular political support
© Civil medical service in the area
Good popular resources — arrange a network inside the area for
post-operative management and rehabilitation.
© The available resources of food, water and fuel inside the area
Good nutritional resources > organize high-energy food pro-
cessing inside the area.
Poor resources — concentrate on logistics.
Training of medical staft
Forward, mobile surgical units must be able to work on an independent basis.
This makes us focus on staff quality. For the senior surgeon, education of quali-
fied junior officers on all levels is as important as his own surgical performan-
ces at the operating table. Some knowledge in matters of theory and medical
routines is necessary. But first and foremost you train your staff by letting them
take part and have responsibility for the day-to-day surgery and medical proce-
dures; guided practical experience is the best teacher. As a general guideline,
we advice you to educate medical staff on three main levels: First level —
Paramedics. Second level — Surgeon 1. Third level — Surgeon 2.
Training of paramedics
They are the most numerous of the three categories of medical staff. Their
main duty is to provide early and correct medical stabilization in the combat
area and during evacuation up to the forward clinic. Experienced paramedics
should be trained in:
* Knowledge of weapons: Study Chapter 3, know the weapons actually used
in the local conflict.
———"—
1 The war medical network
p: CWP
Basic life support procedures:
The Injury Chart: p. 52.
¢ Knowledge of physiology: Study Chapters 4, 5, 6 and 17 to be able to do
proper triage.
¢ Airways and respiration: Study Chapter 7. Learn to evaluate the respira-
tory state of patients. Maintain free airway by oral airway and stable side |
position during evacuation. Provide rescue breathing, and assisted SIB venti-
lation. Do chest tubing and emergency laryngotomy.
* Circulation: Study Chapter 7. Evaluate the circulatory state of patients. Con-
trol external bleeding by compression, and proximal clamping of the main
limb arteries. Control severe abdominal bleeding by emergency laparotomy
and gauze packing, Insert bladder catheter, do venous cut-downs, give and
monitor volume therapy. Calculate and monitor the in-out balance of fluids.
¢ Analgesia: In-field reduction and splinting of fractures. Give i.v. analgesics
including low-dose intermittent ketamine.
* Documentation: Fill in the Injury Chart. To do so, a main part of the training
should be clinical examination, evaluation and diagnosis of the most common
injuries. For weeks the surgeons should let the students join in the triage and
basic life support procedures at the clinic, give them responsibility, monitor and
guide them closely.
Training of Surgeon 1
The Surgeon 1 should be able to run a forward clinic and manage basic life
support and primary surgery on 80% of all trauma cases. The category of Sur-
geon | is the key factor and the foundation for any wartime clinic. Experienced
and talented paramedics should be selected for Surgeon | training. The Sur-
geon | should know and manage the following:
* Basic knowledge of weapon physics, of the technology of common arms and
ammunition.
¢ Perform triage, including triage of mass casualties.
* Local anesthesia, regional nerve block and ketamine anesthesia.
¢ Endotracheal intubation and emergency laryngotomy. Evaluate and manage
penetrating chest injuries by chest tube and suction. Emergency thoracotomy
and minor lung resections.
* Control of grave external bleeding by exploration and ligature of the main
vessels. Perform blood-typing, cross-matching, direct transfusions and auto-
transfusions.
* Manage limb injuries by fasciotomy, exploratory incisions, debridement and
drainage. Fracture management by dynamic traction, the Trueta plaster cast
and cast-and-pins. Perform guillotine and flap amputations.
* Know the principles of emergency laparotomy: two-step surgery with gauze
packing, tying or suture of intestinal wounds, and temporary abdominal clo-
sure. Divert the fecal stream by exteriorization of intestinal wounds, or
diversion stoma.
* Manage free skin grafting and skin flap closure.
° A basic understanding of nutrition after surgery.
* Train paramedics.
ba me te oe know the details of anatomy and the essentials in physio-
‘ ial training is clinical evaluation of patients and surgical eva-
luation of injured tissue; let the trainees perform day in and day out triage and
surgery under your guidance.
Training of medical staff
a UES!
Training of Surgeon 2
That training never ends. You will find the textbooks referred to in Appendix 4
valuable, as well as continuous studies of modern weapon technology. But
again, real life experience is our main teacher. Stick closely to your patients.
Monitor and dress your own cases after surgery. If possible, collect the late
results of your surgery; register clinic complications, early and late mortality in
order to assess at regular intervals the quality of your organization and your
own skills. Never think you are too experienced to seek the advice of others;
and to look for your own mistakes.
Staff care
° You do better with five fresh and hard-working staff members than ten
exhausted ones. Train enough staff to offer them days off at regular
intervals.
¢ Monitor the mental state of your staff members. At the first signs of
depression (unrest and sleeplessness) do not hesitate to take them off
duty for at least two weeks.
¢ Some people are not at all fit to cope with the stress of working in a
forward medical position; they cannot concentrate on their duties and
you cannot rely on the decisions they take. No matter how skilled they
are, you do better to dismiss them from your forward teams.
33
34
Points to note — Chapter 2
Chapter 2 has the key tables to show you how this book can be used
as a manual.
For the surgeon
* Forward basic life support for the main types of injuries: see Table 1 on p. 37.
Find the actual procedures, and study them in detail in the black-edged
chapters
* The surgical management of different types of injuries: see Table 2 on p. 41.
Find the actual procedures, and study them in detail in the black-edged
chapters
* For medical documentation, study and copy the Injury Chart: p. 52. The Pa-
tient Chart: p. 53 and 54. The Head Injury Chart: p. 55. And the Burn Case
Chart: p. 566
* You can run quality-control programs based upon the information collected
from the Injury Chart and Patient Chart: p. 700
For the organizer
* Recommended contents of BLS kits: see Tables 5 and 6 on p. 64-65
* Equipment for the one-man mobile clinic: see p. 66
* Equipment lists for light and heavy field clinics: see Table 4 on p. 57
* Assess how much materials your clinic will consume: see Table 8 on p. 68
* Local production of foodstuffs for the clinic: p. 600, 618-624
* Handle surgical instruments with care. Let technical staff study p. 69-72
2 The forward clinic
(FC)
Organization of forward basic life support (BLS) reeset sesseeseeeeone 36
The BLS teary csccscccsteceetevcscdgh tte sleo-+nosspuancncele ana MRenRER RR Gaeurete ap ¥ esi jo
Management routines .........0.::.-:ssssssssssssssssseenersesteeeceeeecennnnathannnnnnnannnennnnnnsnessse 40
Organization of the forward elie Tel ( of ©) Me pre 09. eee 51
Standard medical and technical equipment ...........:-:: cette teen 56
Light and heavy BLS ee eo het A cn eee 64
The one-man: MO DMS BC whee bivednceysesses-s--seseeesesssvenns annnetealaemenasithtarunnanesasinnees—teest 66
Consumption of medical mratier als —scc:./...0...5)h Sree aa es vcsazevessnenee 67
Cleaning and maintenance Of instruments. .......::.ccneeeeeee ena tceanne-nkssoins 69
How to improvise — i ae ee See 70
—_—-~S-—s—i‘ t;P$.
2 The forward clinic
The actual design of the basic models
depends on the local setting. Exam-
ples of FC design: p. 19 Peue
Basic life-saving surgery: p. 130 and
153-161.
Staff-training programs: p. 10 and 31.
36
The patient starts dying at the time of injury. Our response is basic life support
(BLS) and primary surgery with minimum delay. Consequently the FC is the
most important unit in the wartime medical network. Quality and efficacy of
the medical network depends totally on high quality FCs. This chapter de-
scribes three basic models of FC organization:
¢ The light FC: A light mobile or semi-mobile surgical clinic with staff and
equipment able to do definitive primary surgery on 80% of all casualties. |
* The heavy FC: A better manned and equipped clinic able to do definitive pri-
mary surgery on any wartime casualty.
° The one-man mobile FC: A backpack clinic with a complete BLS kit and
simple surgical instruments. In skilled hands and with support from the local
population, the one-man FC may handle close to 80% of all casualties.
Organization of forward basic life support
(BLS)
BLS in the battlefield — our objective:
Casualties should be in a stable medical state before the evacuation from
the battlefield starts. Casualties should be maintained in a stable state all
the way during evacuation. The longer the evacuation, the more advanc-
ed field BLS is necessary. Consider if surgical instruments should be
included in the BLS kits (one-man clinic: p. 66).
Regard the medical support inside the battlefield and the evacuation of casual-
ties from the battlefield as parts of the FC management. The surgeon in charge
of the FC should also decide the routines for the battlefield management. Basic
life support for serious cases may also include surgery, and some emergency
surgical procedures should be done in the battlefield. The quality and extent of
battlefield medical support will vary from one area to another depending on
the intensity of the fighting, the weapons used, the mobility and military pro-
tection of forward medical staff, and the staff skill. The FC leader should
continuously try to improve the battlefield BLS support from a minimum
level, gradually include more advanced procedures and BLS kits as paramedics
gain in skill, and try to reach an optimum level. Most of the surgical proce-
dures listed in Table 1 are done within 30 minutes in the field by trained staff.
This is thus a realistic goal for high-quality FCs.
Forward basic life support
Table 1
Procedures in forward BLS support
Medical problem Procedures Procedures
Triage Clinical examination 103
Triage of mass casualties 1:27
Documentation S22
Airway obstruction Assess critical signs 136
Head tilt and jaw thrust 136
Recovery position 137
Insert oral airway 136
Cricoid pressure 140 ~~ Endotracheal intubation 137
Gastric decompression 139 Emergency laryngotomy 139
Breathing problems Assess critical signs 136
Rescue breathing 141
Mouth mask-SIB ventilation 141
Gastric decompression 139 Close open chest wounds 344
Temporary closure of abdominal
wall wounds 359
Pain Intermittent i.v. analgesia 142
Ketamine analgesia 151 = ‘Intercostal nerve block 673
Chest tube 142
Intrapleural anesthesia 674
Circulatory shock Assess critical signs 148
External bleeding Gauze pack and compression 144. Explore and ligate major vessels 189
Internal bleeding Central warming of cold patients 153 Emergency thoracotomy, aorta
clamping 154
Emergency laparotomy, 155
abdominal packing 157
Shock dress 145 Autotransfusion 270
Dbl.large cal.i.v. lines 145
Intraosseous infusion 146 Venous cut-down 146
Assess blood vol.lost 108 Peritoneal lavage 109
Volume therapy in adults 148
Volume therapy in children 262
UPH monitoring, bladder catheter 582 Suprapubic bladder catheter 436
Volume therapy complications 149
Head injury Assess critical signs 1s
Monitoring, documentation 55
Airway management
Drug therapy 136 Endotracheal intubation ioe
Hyperventilation 795
Volume therapy 144, 147
—_-————“‘ ieee
2 The forward clinic
Procedures
: blem Procedures ;
Medical proble aie level Page optimum level Page
310
Spinal injury Transport
Limb injury Fracture reduction and splinting 202. +Emergency fasciotomy LF
? iti 152
Injury during pregnancy Carbohydrate nutrition
Poe Volume theraphy 449
Support breathing 449
Blast wave injury Monitoring 82 Lung injury management 82
Abdominal injury management 83
Thermal burns Volume therapy 559
Airway management 563 Endotracheal intubation 138
Life-saving surgery 564
Hypothermia Preventive measures 277
Rewarming 153
Manage circulatory complications 277
Hyperthermia Cooling 279
Manage brain complications 295
Volume therapy 279
Hypoglycemia, malnutrition — Carbohydrate nutrition 152, 609
Drugs
— adminstration Intravenous 150
Intraosseous 146
Rectal 150
— doses and side effects Ketamine 149, 151
Diazepam 151
Morphine 151
Pentazocine 151
Metoclopramide 151
Routine antibiotics 644
Dexamethasone B2,.279
Te “oe Frusemide 82
anesthetics Fracture anesthesia 152 Nerve block anesthesia 152
Joint anesthesia 152
38
BLS team
Basic life support at the FC
Evacuation from the battlefield may be delayed; it may be a prolonged
evacuation or complications may develop due to injuries missed in the battle-
field triage.
* Senior surgeon: Take all cases for the FC to the emergency room and do fresh
triage.
* Senior surgeon: Study the Trauma Protocol and evaluate the basic life support
done in the battlefield and during evacuation.
¢ Senior surgeon: Order the basic life support to be continued for T1 and T2
cases until they reach the operating table. See Patient Chart below.
Basic life-saving surgery
It is a hazard to do surgery on a patient whose vital condition is poor or deteri-
orating. However, in some unstable cases emergency surgery must be done in
order to establish stable vital functions. These emergency surgical procedures
should be considered part of the basic life support.
Time is the critical factor
Basic life-saving surgery can be done with simple standard equipment
Basic life-saving surgery: p. 130 and under i.v. ketamine anesthesia. The procedures must not be delayed and
153-161. should be done by the surgeon at hand. Notice: even in the field basic
life-saving surgery is done on dying patients or dying limbs when the
alternative to non-intervention may be death.
There should always be one emergency kit sterilized and ready at the FC for
emergency surgery. The emergency surgical kit should contain:
* One heavy BLS kit: p. 65
* One set for general surgery
* Several gauze packs 40x40 cm
* Equipment for autotransfusion
The BLS team
The equipment should be standardized in light and heavy emergency kits
depending upon the skills of the BLS team and the available resources. The kit
Light and Heavy BLS kits: p. 64. should be packed in a solid soft bag easy to carry in the field by hand and as
backpack.
To work efficiently and smoothly, and be able to cope with mass casualties, the
staff should be organized in teams of three in the battlefield as well as at the
FC. Each team is composed of staff working well together, one of them prefer
ably senior and in charge of his staff:
° Staff no 1: The most experienced of the team members. Team leader. Takes
QO
O——
2 The forward clinic
ry support. Prescribes drugs and
o 2 and 3. Should stay with the
care of the airway management and respirato
volume therapy. Responsible for training of n
most serious case/ cases.
° Staff no 2: Takes care of the circulatory support.
° Staff no 3: Assists in establishing the i.v. lines. Takes care of drug administra-
tion according to prescriptions given. May leave the patient.
Guidelines for the battlefield BLS team
¢ The team works under pressure and needs an experienced team leader.
His orders are to be followed strictly.
* More than one casualty: Even under difficult conditions, conduct tri-
age before basic life support starts.
* Consider if emergency surgery is necessary. If so, remove that casualty
from the area of heavy fighting and fulfill the procedures (Table 1)
before he is evacuated to the FC.
¢ For all casualties: Fulfill the BLS procedures necessary before evacua-
tion starts. It is impossible even to insert an i.v. cannula inside a
moving off-road car.
¢ Fill in the Injury Chart before evacuation starts.
¢ Where long-time evacuation is expected: Give exact prescriptions for
medical support throughout the evacuation regarding analgesia and
infusion, as well as for complications that may arise.
* Continue active basic life support throughout the evacuation.
Management routines
The routines listed below are guidelines, they should be applied with care depen-
ding on the military setting, the casualty load, the staff skill, and the equipment at
hand. The references are to pages where the procedures are discussed in detail.
ay
Routines for regional injuries
Table 2
Routines for management of regional injuries at the FC
Region
Type of injury Light FC Page Heavy FC Page
| (aa er I TS Rs eS er
Head and face
Open skull fracture Debridement 297
— with brain injury Debridement of brain 297
Dura graft 298
or
Evacuation — Exploration 297
—in circulary shock Emergency laparotomy or 156
thoracotomy 154
Closed brain injury Observation 301
— with brain compression Trephination 300
Face soft tissue injury Drainage 322
Primary suture 324
Flap reconstruction 335
Face fracture Temporary reduction 322
Evacuation — Primary fixation 325
Complications to skull surgery
— brain edema Management 302
— infection Exploration 302
— skull hematoma Exploration and drainage 300
Rehabilitation after brain injury 638
Neck
Soft tissue injury Exploration and drainage 303
Larynx, trachea Primary suture 304
Cervical spine fracture
— stable Neck cast > 316
— unstable Manual traction 310
Neck cast 316
Evacuation —> X-ray 316
Skull traction 315
Lesion of the spinal chord Manual traction 310
Neck cast 316
Evacuation —> X-ray 316
Skull traction 315
Lesion of brachial plexus Exploration 304. Secondary suture? 233
Vascular injury Ligature? 304 ~—- Vascular reconstruction? 187
Complications to spinal injury
_ spinal hematoma Exploration and drainage 317
infection Exploration and drainage 317
Al
—aOOO-||U™
9 The forward clinic .
42
Definitive surgery: See below
Region ‘ Page Heavy FC Page
Type of injury Light FC g
Eye i 333
Penetrating Topical antibiotics =
Occlusion
Evacuation — Primary suture 336
Subconjunctival antibiotics 337
Extensive penetrating injuries Topical antibiotics 333
Occlusion 333
Evacuation — Enucleation 336
Complications to eye injury Management 337
Chest
Minor lung injury Analgesia 142
Intercostal nerve block 673
Exercises 630
Hemo/ pneumothorax Chest tube 142
Wound closure 344
Major hemothorax Chest tube 142
Autotransfusion 270
In circulatory shock Evacuation — Thoracotomy, aorta cross-
clamping 348
Lung resection 346
Major chest wall injury Chest tube 142 Closure with muscle flap 344
Blast wave injury Observation. Drug therapy 82
Cardiac tamponade Pericardial incision 347
Cardiac injury Suture 348
Complications to chest injury
— respiratory failure Management 588
— lung abscess Drain 350 Decortication 345
— persistent hemothorax Decortication 345
Abdomen in general
Penetrating injury
— heavy bleeding Emergency thoracotomy and
aorta clamp 154
Two-step surgery, one-hour limit 156
1 Gauze packing 365
Autotransfusion 270
Exteriorization 384
Central warming 153
Evacuation — 2 Vascular reconstruction? 367
Gastrostomy 369
Definitive surgery: See below
or
2 Ligature. Resection 367
et LLL LLL LLL LLL LLL
Penetrating injury
— stable state
ie long evacuation
“ra retroperitoneal hematoma
Blunt injury
Injury to the abdominal wall
— minor
— major
Injury to the diaphragm
Injury to the small intestine
— minor
— major
Injury to the colon
— minor
— major
Injury to the liver
— minor
major
Peritoneal lavage
Exploratory laparotomy
Definitive surgery: See below
Emergency laparotomy
Peritoneal lavage
Mobilize and explore intestines
Beware!
Peritoneal lavage
Exploratory laparotomy?
Debridement. Suture
Peritoneal lavage
Two-step surgery:
1 Temporary closure
Relief suture
Evacuation
Suture. Chest tube 346,
Suture. Drain
Primary resection. Anastomosis
or
Two-step surgery:
1 Exteriorization
Evacuation
Suture. Drain
Diversion stoma
Closure of stoma
Two-step surgery:
1 Gauze packing
Exteriorization
Diversion stoma
Evacuation
Closure of stoma
Drain
Two-step surgery:
1 Gauze packing
Drain
Evacuation
142
Routines for regional injuries
2 Definitive closure with
muscle flap
2 Definitive surgery
2 Resection. Anatomosis
2 Debridement. Suture
201
378
386
—erEe—lllt—~™
2 The forward clinic
Region
Type of injury
Injury to the stomach
— minor
— major
Injury to the duodenum
Injury to the biliary tract
Injury to the spleen
— minor and major
Injury to the pancreas
— minor
— major
Injury to the kidney
— minor
— major
Injury to the ureter
44
Light FC
Naso-gastric tube. Drain
Two-step surgery:
1 Naso-gastric tube
Gauze packing
Evacuation
or
2 Suture. Drain
Feeding gastrostomy
Feeding jejunostomy
Two-step surgery:
1 Gauze packing
Naso-gastric tube
Artificial fistula
Feeding jejunostomy
Evacuation
Drain
Splenectomy
Drain
Drain
Drain
Two-step surgery:
1 Gauze packing
Drain
Evacuation
Two-step surgery:
1 Drain
Bladder catheter
Evacuation
Page
403
403
365
a
401
369
403
393, 396
411
Heavy FC
2 Definitive surgery
2 Exploration. Suture
Reconstruction
Resection
Cholecystectomy
Resection. Drain
Exploration. Debridement
2 Resection. Suture
Nephrectomy
2 Ureter catheter
Reconstruction
Nephrostomy
Page
401
364
404
396
395
418
425
425
425
423
426
426
Routines for regional injuries
Injury to the urethra
Injury to the bladder
Injury to the female organs
— injury to the pregnant uterus
Injury to the male organs
— minor
— major
Marsupialization 437
or
Suprapubic catheter 436
Evacuation —>
Primary suture 435
or
Two-step surgery:
1 Bladder and suprapubic catheter 436
Gauze packing 365
Drain 368
Evacuation rai
Resection 453
or
Two-step surgery:
1 Gauze packing 365
Drain 368
Evacuation >
Curettage 451
Section 452
Primary suture 442
Evacuation —
Complications to abdominal injury
— wound rupture
— peritonitis
— abdominal abscess
— failure
Pelvis
Penetrating injury
— minor
— major
- retroperitoneal hematoma
Open fracture
fracture bleeding
Exploration. Secondary suture 462
Exploratory laparotomy 461
Exploratory laparotomy 461
Management 588-596
Peritoneal lavage 109
Exploratory laparotomy 356
Two-step surgery:
1 Exploratory laparotomy 356
Autotransfusion 270
Gauze packing 365
Drain 368
Evacuation —
Peritoneal lavage 109
Evacuation? —
Peritoneal lavage 109
Exploratory laparotomy? 356
Debridement iv
Traction 479
Plaster spica 475
Gauze packing 477
Reconstruction 436
2 Reconstruction 435
2 Resection 368
Reconstruction 443
2 Definitive surgery 468
Mobilize and explore colon 362, 417
External fixation apparatus 478
UU
9 The forward clinic
Region 5
Type of injury Light FC Page Hee “ae
Closed fracture Peritoneal lavage? 109
Sling compression 478
Traction 499
Plaster spica 475 External fixation apparatus 478
Complications to pelvic injury
— pelvic abscess Exploratory laparotomy. Drain 356
— buttock abscess Exploration 480
— organ failure Management 588-596
Back
Penetrating injury Peritoneal lavage 109
Exploratory laparotomy? 307, 356
Spinal fracture
— stable Debridement 312
— unstable Two-step surgery:
1 Debridement 312
Transport cast 311
Evacuation —> 2 X-ray 308, 316
Exploration 313
Immobilization 317
Spinal cord injury Transport cast 311
Evacuation — Exploration 313
Decompressive laminectomy? 309
Dura graft? 313
Complications to spinal injury
— spinal hematoma Exploration 313
. . Control bleeding 317 Decompressive laminectomy? 309
— infection Exploration. Drain 318 | Decompressive laminectomy? 309
— pressure wounds Preventive measures 318
— bladder contracture 319
Upper limb in general Evaluation of major injuries 238, 484
Exploration of the main bones, vessels and nerves
— shoulder 487
—arm 490
— elbow 495
— forearm, wrist and hand 504
Upper limb soft tissue injury
= minor Debridement. Drain 178, 180
— major Fasciotomy
—arm 491
— forearm 502
Skin flaps 255
Muscle flaps 200
46
Routines for regional injuries
Upper limb vascular injury Exploration: See above |
— minor Ligature 188
— major Fasciotomy: See above
Ligature 188
or
Evacuation — Vascular reconstruction 191
Complications to vascular surgery
— secondary bleeding Exploration 190
Ligature 188
Amputation? 239
— blood clot Embolectomy 190
Upper limb nerve injury Exploration: See above
Debridement e232 Secondary reconstruction 233
Upper limb open fracture Exploration: See above
Fasciotomy: See above
Debridement and fixation
— shoulder 489
—arm 491
— elbow 496
— forearm 505
— wrist and hand 506
Muscle flaps
— shoulder 49]
—arm 491, 498
— elbow 498
— hand 256, 509
Complications to fracture surgery
— delayed healing Soft tissue flaps 200, 255
Bone grafting 547
Orthosis 214
- osteomyelitis Sequestrectomy S51
Upper limb open joint injury Exploration: See above
Joint washing 220
Muscle/skin flaps
— shoulder 489
— elbow 491, 496
— wrist and hand 509
Complications to joint injury
~— arthritis Diagnostic puncture 223
Upper limb tendon injury Exploration. Debridement 227
Secondary repair 228
hand flexors Secondary repair 228
2 The forward clinic
Region : Page
ne asin Light FC Page Heavy FC g
limb amputations General management 238
meee : Emergency amputations
—arm 492
— elbow 499
— forearm 508
— wrist and hand 509
Early prosthesis training 242
Complications to amputations
= painful stumps Preventive measures 243
Skin graft 243
— unstable stumps Myoplasty 242
Lower limb in general Evaluation of major injuries 238, 514
Exploration of the main
bones, vessels and nerves
— pelvis 477, 480
— hip joint 474
— thigh 522
— knee 532
— lower leg 543
— foot 544
Lower limb soft tissue injury
— minor Debridement. Drain. 178, 180
~ major Fasciotomy
— thigh 522
— lower leg 540, 543
— foot 544
Skin flaps 255
Muscle flaps 200
Lower limb vascular injury Exploration: See above
= peer Ligature 188
— major Fasciotomy: See above 188, 524
Ligature?
or
Evacuation — Vascular reconstruction 191
Complications to vascular surgery
— secondary bleeding Exploration 190
Ligature 188
Amputation?
— blood clot “Aceon ms
48
Routines for regional injuries
Lower limb nerve injury Exploration: See above
Debridement 232 Secondary reconstruction 232
Lower limb open fracture Exploration: See above
Fasciotomy: See above
Debridement and fixation
— pelvis 468, 477
— hip joint 474
— femur, upper part 520, 524
— femur shaft 205525
— femur, lower part 526, 534
— tibia, upper part 539
— tibia shaft 544
— ankle 546
— calcaneus 547
Muscle flaps
— thigh 525
— lower leg 544
— foot 547
Complications to fracture surgery
— delayed healing Soft tissue flaps 547
Osteotomy 551
Bone grafting 536, 547
Orthosis 214
- osteomyelitis Sequestrectomy S51
Lower limb open joint injury Exploration: See above
Joint washing 220
Muscle/skin flaps
— hip joint 202, 508
— knee joint 534
— ankle joint 547
Complications to joint injury
— arthritis Diagnostic puncture Z23
Lower limb tendon injury Exploration. Debridement 227
Secondary repair 228
Lower limb amputations General management 238
Emergency amputations
— thigh B28,.537
— knee joint 241
— lower leg 548
— ankle 549
— foot 550
Hip joint disarticulation 475
Early prosthesis training 242
9 The forward clinic
Region Page Heavy FC Page
Type of injury Light FC 8 y
Complications to amputations
= painful stumps Preventive measures 243
Skin graft 243
— unstable stumps Myoplasty a42
Thermal burns Assessment of burn wounds 557
— 20-40% TBS Volume therapy 559
— more than 40% TBS Basic life support 563
Evacuation — Basic life support 161, 563
Early skin graft 570
High-energy nutrition 560
= partial thickness Debridement 568
Closed wound management 569
Open wound management 569
Early skin grafting 570
— full thickness, minor Stepwise debridement 571
— full thickness, major Escharectomy 570
— inhalation injury Basic life support 558
Complications to burns
— scar contracture Scar excision 251
Skin graft 252
— wound infection Management 573
Chemical burns Debridement 572
Electrical burns Prevent renal failure $72; Sez
Surgery on infected cases
_ septicemia Management 644
Be ee Management 580
— necrotizing fasciitis Management 580
50
See also Burn Case Chart: p. 566.
Organization of forward clinic
Organization of the forward clinic (FC)
In order to manage heavy casualty loads effectively there are two conditions:
* The FC must be strictly organized: The most experienced surgeon present in
the FC is in charge of the clinic. Every staff member should be assigned spe-
cific duties. The discipline has to be strict.
¢ A written plan for the medical management must be set up for each casualty,
from the battlefield up to the post-operative rehabilitation and secondary
surgery.
Table 3
FC routines and responsibility
Level Procedures Responsible
Battlefield First triage Mobile BLS team
Basic life support
Prescriptions for evacuation
\ Fill in Injury Chart
Evacuation Basic life support BLS team member
| Note in Injury Chart
Emergency room Second triage Senior surgeon
Assess basic life support Clinic BLS team
Emergency surgery
\ Fill in Patient Chart
Operating room Surgery Surgeon
Prescribe treatment after surgery
i) Fill in Patient Chart
Bed department Monitor vital functions Nurse/ paramedic
Dress wounds
Fill in Patient Chart
wey oh | ONIN See ee ee
Injury Chart
The chart should be simple; inside the battlefield there is no time for elaborate
documentation. The chart must include facts on the weapon and range, time of
injury and the BLS given before FC admission. This is one proposal for a
standard injury chart:
2 The forward clinic
Sa an 6 ‘ Clinic
Injury chart
Pationt’S MAME? ....c.-cvnfronstennermertnrrintieere
ACCESS! aeescorsvesscsccesnesssesene
Father's NAME! (snarl 3.4 laa fal a, nd ssl hdnoncr tence
Field management
WeaPON: ........0000 Cro. Kent Barb Shire patel ED ene
< Range: ......0- [> 44. Site of INMEY: cere Chace wal BEL aR es nee
°
) Eo AG em PMB Lr GRD ENGEL Gers rnnnneseseannnnnananinnanananananniii
° 2) aa CPR... 46, Fl
Use the Injury c Respiratory rate 10-24 over 35 under 10 a
= no caroti
at es ‘ EB systolic BP over 90 50-69 under 50 pulse
_ 3 fener = Mental response ormal to sound to pain only none
quality control i —— =
: . . ow age:
ee a «owes A OO ee Y [Fieldtiage: 71 — fe} 14
pe nl ieU:.ols Ss. sm at) ony. Lule (.[O.waegs = Oe BLS starts:
a
= a pi Deel 3 ceo an eeeed Muaceatex Mrcko.. wal - Sem As a v tases
Crm lece CEL CV Ol tA En 9630...
c
2
—
©
3
5)
©
=
7)
Clinic management
z Degree of injury: | Moderate | Serious
2
2 BE Bo cpen fewur fracture, Commust ae. re irl | Time of admission:
—y - .
= 2: Ku optu. ts bia..fracturt, § egmented Vere) ee Al nyt nee
3: re... 2: CoA AA ALY La tuetratiug " sis . asiete | SL
0 3 ry
c Respiratory rate 0-24 25-35 over 35 under 10
Mental i Systolic BP (iver 90 ) 70-90 50-69 underso | no.carotd
response. <i Mental response ormal confused to sound to pain only none
* eye opening -
e speech ms SHUNHGRUEVDEOCEDS AD De RCesdibOboueueensossdvavecessncuserssecesdervosceeeensoncteeudbureenusuebiowanentasdeupensees Clinic iniage: Li 2 T3 14
a OA are bi PR. Be high. Cru Met ».s80r.i.sa.,p Leb th oe Oe
0
2 feed oe (Bt cevss:uantcked) ar 18.0-0> ial eee, BLS starts:
ey Rimegee... rr... ane: ee ALE
leon iiicioornernisigniegs Pee ae ES 09500 Aim
“e Orders: ............ Cad. lore e's) iS 2 remoral artes we sa tSall
> [Rann ii a a
o . _ 3
> de os heuceut — ao ¢ facture vex atiou ae ie Priority for surgery:
3 , 3 . <
Pe... Haesth: ame Atronin ive eoo a an feast a (K damernel xithin? hour
es eecish PeoietincnsivinBoel eee Clinic officer: eee s- eha. a ry ere
52
Organization of forward clinic
The Patient
Chart
is filled in on
admission at the
forward clinic
and the Injury
Chart stuck to
it. The Patient
Chart should
follow each
patient all the
time within the
clinic up to
rehabilitation
and secondary
surgery.
Patient Chart page 1
Patient's name: .. MONRAmAD KHAN
oe ke RE SS ee en ES a a in meen See Age: .. eee Ce
oa ee, See adh Ale Re it ah Ridlieed Sons: en were Ls Blood type: ......... 3+ ae
Serious Critical
SP Ra RT Sh eel a ee oh ae ee ee Start surgery:
SUES G OV EE ETO {ireretieai say OM. sis frtssidotecandrh echoed tae ee Ma, ?, 1010... .
Surgery
Degree of injury: | Moderate
MN Fe eo 8 ee ee ee oe ee eer critesarcimsaneresens MoM eee Msaeh [eeetnvensscurnanNtenenss Finish surgery:
0116 p.m-
Diagnosis and surgery >
—
() ~-— Bi
(3)
le! =
Dy vy v es a a a
os Swe nites |
OO -O-
< o MPV ig vv g ial et | 5
o Ties id h 7
A_ nN Ap
AS ALN A
z (Oe
> 4 500 ven (
pete (B+) svonly Bleed $90 wl
OD iv. atromine { usg (4) iv. peureUs mn 10 mega 1U
LVITS® dvaz epam Sung
Ziv. Lefouime 190mg
Rin er [000 wil Ringer {suo saan Bowes ee
eee
Infusions |
|
in A Won’ , CeCe nt Wee MEV OV? on mnnnmnnnmnnnnnnmanannannin
Complications:
Phi RE: nnd Ye mcrae (Oe 1OrUgG 2 oy
Co check Hb 0600 Pim.and May¥. Prepace bleed (roo 1)’
—Ringer(Glucose 3000 wl —2 May? 0800 0.42.0. Tear Lf |
_
Where: ones ratin JO Ww. Anesthesia/analgesia: Kete Wo" First dressing:
Monitor specially: Vi eh é ey 6 f > of 4s sue ¢ lon § thas A NM qi
Dressing
Signature surgeon: Ar orn) Anesthesiologist: De : R i \ " :
2 The forward clinic
Patient chart page 2
Day 2 tu ay
200 PRO
Temp °C3«e 41
180 BPX
160
140
120
100
80
60
Bleeding
Vomit
Urine
Daily loss
Per oral
Tube feeding
Fluid balance
Infusion
Laboratory
X-ray
Dressing
Surgery
Comments
54
Organization of forward clinic
The monitor-
ing of cases
with brain- or
spinal chord
injury must be
close and
exact both
before and
after surgery,
otherwise
complications
and indica-
tions for
surgery will
be missed.
A standard
Head Injury
Chart should
follow all
cases with
moderate and
more than
major head-
and spinal
injuries:
See also
Glascow
Coma Scale,
p: 701.
Head injury chart
Patients name:
Diagnosis: es ~ SKull oh. ro c¥UEE 2 /e Ht feu pore | Time of injury: [email protected]™«
ee ee per ballet foc tange) 9 fame lO... A288
dF iota A EMM ATR Tek AS a Aen Md ali 6, har of Time of surgery: Bam
Tee 0. A ahh ie: A ie) ae 1968
Temp °Ce 41
WMlavia (hu Me
aff VEGR
40
Sex: M &) Ase: soo8g /o..
39
38
37
36
35
34
Normal
Confusion
Response sound
Response pain
No response
Right size
Right response
Left size
Left response
Control urine
Control stools
Right arm
Left arm
Right leg
Left leg
Right arm
Left arm
Right leg
Left leg
Respiratory rate
ararae Aaa
Vomit
Others
Clinic
Mental
state
Pupils
Motor
function
N (normal)
W (weak)
F (flaccid)
Sensory
function
»| N (normal)
'| P (poor)
‘| Z (zero)
2 The forward clinic
WZ) 7s
iNrecteD
a
el
The mobile one-man clinic: p. 66.
OPR y
wa, @
¢ T4: Unit for dead and dying casualties.
¢ STORE: For infusions, drugs etc. Close to the emer-
3 gency department.
¢ INFECTED: A heavy FC should have one room
SHELTER : ;
reserved for dressing and surgery on infected cases,
Standard structure of a heavy FC: The illustration
shows one clinic building; you may apply the same plan
aie for a tent clinic.
¢ BLS: Emergency department for triage and BLS. If
X-ray service is available, it should be attached here.
i * OPR: Operating room (T1 and T2 cases), close to
the emergency department, and well protected
against shrapnel and light weapons.
¢ T3: Unit for clean dressings and minor surgery (T3
cases).
completely equipped as an OPR room.
¢ BED DEPARTMENT: A light forward clinic may
need 5 beds, a major second line clinic, 30-200.
¢ STAFF: Living/sleeping unit, should be close to the
shelter.
¢ SHELTER: For staff, T3 cases and family members.
¢ AMBULANCE: Covered from air, close to the clinic.
Notice: As a mean, one surgical team on one operating table may manage 6-10
cases/24 hours. To avoid congestion and delay before surgery, the emergency
department and the operating room in a heavy FC should each have 2-3 tables,
one for each BLS and surgical team. Also the surgical capacity is increased if
one section of the bed department (POST OP) is reserved for post-operative
monitoring and other critically ill patients. The patients, still under anesthesia,
are taken to the POST OP immediately when surgery is finished, to be moni-
tored by experienced nurses.
Standard medical and technical equipment
The lists below give guidelines only. With the equipment listed a light FC
should be able to provide definitive surgery to 85% of all admitted cases. And
the heavy FC should be able to manage all kinds of casualties. Even lighter
mobile clinics (BLS and forward surgery) may be constructed combining the
essentials from the light FC model below with a BLS kit. The number you need
eae item can be assessed from the standard consumption lists in Tables 4 to
7 below.
Medical and technical equipment
SN ee
Table 4
Standard equipment for a forward clinic
aa San oo ee
Light FC
Infusions and drugs
Ringer or NaCl 0.9%
Plasma expander?
Infusion set
I.v. cannulas diam 0.6 and 1.4
Inj. pentazocine 30 mg/ml
—morphine 10 mg/ ml or buprenorphine 0.3 mg/ml
— ketamine 50 mg/ml
— diazepam 5 mg/ ml
— atropine 1 mg/ ml
— adrenaline 0.1 mg/ ml
Inf. metronidazole 5 mg/ ml
Inj. penicillin 5 mega IU
a ampicillin 2¢
— lidocaine 10 mg/ ml
Syringes 2 ml 5 ml 10 ml
Cannulas 0.6x25 mm
0.8x40 mm
BLS equipment
Stethoscope
BP apparatus
Heavy FC
Ringer or NaCl 0.9%
Ringer lactate
Plasma expander
Glucose 120 mg/ml 240 mg/ml
Infusion sets
I.v. cannulas diam 0.6 1.0 1.4 and 1.7
Long i.v. catheter (subclavian)
3-way stopcock for infusion lines
Blood transfusion bags (autotransfusion)
Micropore filters (autotransfusion)
Inj. pentazocine
— morphine or buprenorphine
— ketamine 10 and 50 mg/ml
— diazepam
— midazolam 1mg/ml
— chlorpromazine 25 mg/ ml
— metoclopramide 5 mg/ ml
— atropine
— adrenaline
— ephedrine 50 mg/ml
— dexamethasone 4 mg/ml
— heparin 100 IU/ml 5000 IU/ml
— penicillin
— ampicillin
—frusemide 10 mg/ml
— mannitol 150 mg/ml
—KCl 1 mmol/ml
— CaCl 1 mmol/ml
— multivitamins
— lidocaine 5 mg/ml
— lidocaine 10 mg/ml with adrenaline
— bupivacaine 5 mg/ml
Syringes
Cannulas
Spinal needles
Stethoscope
BP apparatus
Ophthalmoscope
> The forward ¢ linic
Light FC
Oral airway (3 sizes)
Vacuum suction (hand/pedal)
Suction catheters 2.6-4.6 mm
Adult laryngoscope
Endotracheal tubes (set of 6)
Mouth masks (3 sizes)
Self-inflating bag
Chest tubes 8-11 mm
Naso-gastric tubes 4-7 mm
Urethral catheters (Foley) 3-6 mm
Urine bags (1.5 1) with tubing
Rubber tourniquet
Head lights, batteries 1.5V
Backpacks for BLS kits
Surgical instruments
— the set for general surgery
1
No
Knife handle no 4
Knife blades no 22
Scissors, curved 18 cm
Scissors, for bandages
Needle holder 16 cm
Dissecting forceps (surgical) 18 cm
Dissecting forceps (anatomical) 18 cm
Hemostatic forceps (curved) 12.5 cm
Hemostatic forceps (curved) 18.5 cm
Retractor (sharp)
Bowl (stainless) 17 cm
Pair of sterile gloves?
Surgeon's mask?
Surgeon's: cap?
g P
Corrugated drain
Tube drain
ONY NY BBM NVM PHD HB DBD DB B&B HB HB HB HB RS RP eS eS
Heavy FC
Oral airway (3 sizes)
Vacuum suction
Suction catheters
Tracheostomy tubes, 6 mm 8 mm 10 mm
Adult laryngoscope (3 blade sizes)
Pediatric laryngoscope
Endotracheal tubes
Flexible introducers
Mouth masks (3 sizes)
Self-infl.bag w.oxygen reservoir
Oxygen
Chest tubes 8-11 mm
Naso-gastric tubes 4-7 mm
Bladder catheters (Foley) 4-6 mm
Suprapubic catheters 4-6 mm
Urine bags (1.5 1) with tubing
Rubber tourniquet
Headlights
Backpacks
Instrument tray 26x32 cm
Knife handle no 4
Knife blades no 15, 20 and 22
Scissors, curved 14.5 cm
Scissors, curved 18 cm
Scissors, for bandages
Needle holder 16 cm
Needle holder 18 cm
Dissecting forceps (surgical) 14 cm
Dissecting forceps (surgical) 18 cm
Dissecting forceps (anatomical) 14 cm
Dissecting forceps (anatomical) 18 cm
Hemostatic forceps (curved) 12.5 cm
Hemostatic forceps (curved) 14 cm
Hemostatic forceps (curved) 18.5 cm
Retractor (sharp)
Retractor (blunt)
Bowl (stainless) 17 cm
Towel forceps
Pair of sterile gloves
Surgeon's mask
Surgeon's cap
Surgeon's gown
Corrugated drain
Tube drain
Z it
Nee: ye Ee I EE IT AN EI
Medical and technical equipment
ee ee emuemmsmmenmnmnene
6 Surgical drape (linen) 50x70 cm
| Surgical drape with slit
4 General surgical set
Supplement for orthopedic surgery
1 Bone nibbler (straight)
1 Bone wire saw (Gigli), 3 mm
Hand drill
Steinmann pin 2 mm
Steinmann pin 4 mm
Bone wire (Kirschner) 1 mm
Bone wire (Kirschner) 1.5 mm
— O A ADO —-
Wire-cutting forceps
1 Set for orthopedic surgery
Supplement for chest and abdominal surgery
2 Abdominal retractor (50 mm broad)
1 Abdominal retractor (S-shaped)
2 Intestinal clamp (curved, elastic)
2 Surgical drape (linen) 1.5x2 m
1 Surgical drape (linen) 1.5x2 m with slit
1 Set for abdominal surgery
Supplement for vascular surgery
BhNOeR eR
aa
Surgical drape 50x70 cm
Surgical drape with slit
General surgical set
Bone nibbler (straight)
Bone nibbler (curved)
Bone wire saw (Gigli), 3 mm
Raspatorium
Chisel (straight)
Hammer
Bone hook (sharp)
Bone awl
Hand drill
Steinmann pin 2 mm
Steinmann pin 4 mm
Bone wire (Kirschner) 1 mm
Bone wire (Kirschner) 1.5 mm
Wire-cutting forceps
External fracture fixation set
Set for orthopedic surgery
Knife handle no 5
Needle holder 23 cm
Abdominal retractor (50 mm broad)
Abdominal retractor (S-shaped)
Artery forceps (curved) 24 cm
Intestinal clamp (curved, elastic)
Intestinal tissue forceps (10 teeth) 15.5 cm
Surgical drape 1.5x2 m
Surgical drape 1.5x2 m with slit
Set for abdominal surgery
Vascular scissors (curved 60 degr.) 190 mm
Artery forceps curved (Satinsky) 270 mm
Artery forceps curved (Satinsky) 200 mm
Artery forceps straight (De Bakey) 210 mm
Artery forceps curved (bulldog) 65 mm
Embolectomy catheter
Set for vascular surgery
2 The forward clinic
Light FC
Supplement for skull surgery
{Hand drill
1 Perforator (Doyen)
2 Burr (Doyen), small and large
1 Setfor trephination
Supplement for skin grafting
1 Dermatome, small (Silver)
Razor blades (for Silver)
1 Wooden plate (for grafts)
2 Dissecting forceps (anatomical) 14 cm
Adhesive skin closure, 6x10 mm
1 Set for skin grafting
Others
1 Cornea scrape
10 Set of five 10x20 cm gauze packs
10 Set of five 30x30 cm gauze packs
4 Set of six 50x70 cm surg. drape
4 One 1.5x2m surgical drape
Suture materials (size USP)
Dexon (Catgut) 1
3-0 (cutting needle)
3-0 (round needle)
Ethilon (Silk)
1
3-0 (cutting needle)
3-0 (round needle)
RARE SAR
=
Heavy FC
Hand drill
Perforator (Doyen)
Burr (Doyen), small and large
Bone nibbler (curved)
Dura elevator
Dura hook
Saw (Gigli)
Conductor for wire saw
Brain spatula
Forceps for hemostatic clips (Adson)
Hemostatic clips
Set for skull surgery
Dermatome, small (Silver)
Razor blades
Dermatome (Humby)
Blades (Humby)
Wooden plate
Dissecting forceps (anatomical) 14 cm
Adhesive skin closure
Set for skin grafting
Cornea scrape
Grates (stainless) with holes (instrument sterilz. )
Set of five 10x20 cm gauze packs
Set of five 30x30 cm gauze packs
Set of six 50x70 cm surg. drape
One 1.5x2 m surgical drape
Set of two surgeon's gowns, caps and mouth masks
Dexon/ Vicryl 1
0
3-0 (cutting needle)
3-0 (round needle)
5-0
Ethilon (Silk) 2
1
3-0 (cutting needle)
3-0 (round needle)
5-0
Vessel tie mersilene (silk) 1
3-0
Dexon 0
Dexon 3-0
Suture needles curved 3/8 cutting round
curved 1/2 cutting round
straight cutting round
Dressing materials
Gauze, rolls of 100 m
Vaseline gauze
Elastic bandage
Adhesive tape 25 mm 50 mm
Cotton, rolls
Plaster of Paris
rolls 10 cm
rolls 15 cm
Plaster shears
Plaster cast bending forceps
Flexible splinter frames
Sterilizer drums
Formalin (conc. solution)
Water tank
Buckets, 101
Kettles 7.5 |
Primus heater (kerosene)
Wash basin (stainless) 4 |
Soap
Bowls (stainless) 17 cm
Examination gloves (vinyl)
Aprons (vinyl), disposable
Drape (vinyl), rolls
Waste bags (plastic) 60x60 cm
Nail brush
Medical and technical equipment
Prolene 0
4-0
6-0
8-0 (cutting needle)
a
Vessel tie mersilene (silk)
3-0
Dexon 0
Dexon 3-0
Suture needles curved 3/8 cutting round
curved 1/2 cutting round
straight cutting round
Gauze, rolls of 100 m
Tubular gauze (no 34 and 56)
Applicator (tubular gauze) no 1
Vaseline gauze
Elastic bandage
Adhesive tape 25 mm 50 mm
Cotton, rolls
Plaster of Paris rolls 7.5 cm
rolls 10 cm
rolls 15 cm
Plaster shears
Plaster cast bending forceps
Plaster cast spreader
Plaster cast cutter (electric)
Flexible splinter frames
Sterilizer drums
Formalin (conc. solution)
Water filter and purifying equipment
Water tank
Buckets, 10 1
Kettles 7.5 |
Pressure boiler 10 1
Primus heater
Wash basin (stainless) 4 |
Soap
Hydrogen peroxide solution
Savlon (conc. solution)
Bowls (stainless) 17 cm
Examination gloves (vinyl)
Aprons (vinyl), disposable
Drape (vinyl), rolls
Waste bags (plastic) 60x60 cm
Nail brush
El
2 The forward clinic
Heavy FC
Light FC
Surgeon's mask (disposable)
Surgeon's mask (disposable)
Others — medical
Pens for marking
Injury Charts
Patient Charts
Thermometers standard
Test strip (hematuria)
Kerosene lamp
Kerosene
Flashlight
Batteries
Plain table (surgery)
Buckets
ab.
Nails
Spades
Rope 6 mm
Insecticide sprayer
Others — technical
(WHF field communication units)
Pens for marking
Injury Charts
Patient Charts
Thermometers standard low temperature
Test strip (hematuria)
Blood-typing equipment
Measure (glass), 100 ml
Measure (stainless), 1000 ml
Measure tape (100 cm)
Weighing scale
Kerosene lamp
Kerosene
Flashlight
Batteries
Operating table
Instrument table
Buckets
Ax
Nails
Spades
Rope 6 mm
Insecticide sprayer
Mosquito nets
WHE units
Antennae station
El. generator 1000 W (diesel)
Diesel
Operation lamp
Cautery unit
Refrigerator (may be kerosene run)
Electric cable
Microscope
Slides and cover glasses
Spectrophotometer (Hb test)
Cuvette micro (spectrophotom.)
Blood lancets
Mobile X-ray machine
X-ray film cassettes 24x30 cm
35x35 cm
X-ray films 24x30 cm
35x35 cm
Medical and technical equipment
Developer
Pix
Processing tanks
Lamp (safe light for darkroom)
Lead markers ("R" and "L")
Lead-rubber plate (for protection)
Lead apron
Protective equipment
It will increase the effectivity of the FC in general. Protection is not only a
matter of staff policy, it also regards the patient's rights: Reducing the strain
upon the medical staff, protective equipment will also improve the casualty
management under military pressure. Protection is essential for the forward
BLS teams; it should also be considered for the surgical teams.
* Protective vest with groin protector (total weight 1.5-2.2 kg) provides effec-
tive protection against medium- and far-range gunshots and shrapnel.
* Standard gas mask gives protection against moderately potent chemical war-
fare agents.
* Camouflage nets for tents and ambulances.
¢ A wall of sandbags 50 cm thick around tents/buildings provides protection
against everything except center hits and chemical warfare.
¢ The walls of a truck operating theater or truck clinic are made out of double
4 mm steel plates with a sheet of fine sand between them.
The technical items
Military considerations / mobility and the availability of electricity set the tech-
nical standard of the clinic.
Without electricity: You can manage well with two headlamps, in a cool
store four 1.5 V batteries provide sufficient light for four hours of surgery; a
portable pedal suction with a capacity of 1 liter; sterilization in pressure
boiler/kettle on a kerosene heater; a simple microscope with a mirror and
handlight/ sunlight as light source (blood tests); reliable refrigerators running
on kerosene are available (blood bank).
With electricity the standard of the clinic may be set at a higher level. A
diesel electric generator of size 145 cc - 400 cc will provide 1200 W - 4200 W
over 5-6 hrs from 1 liter of diesel. That is enough to carry several technical
facilities in a minor clinic. The main costs of maintenance are filters for air, oil
and fuel. A cautery unit will increase the surgical capacity and safety. The unit
consumes 250 W/hour. Rules of maintenance and use must be strictly adhered
to in order to prevent serious electric injury to patient and staff. The capacity
of a mobile X-ray apparatus depends mainly on the skill of the X-ray technici-
an. Film processing may be manual, but for good quality the water must be fil-
tered and the temperature of processing solutions is max. 18°C. Both capacity
and quality are increased by a small desk-top processor, capacity | film per
minute, electric consumption 500 W/hour. In a clinic with heavy casualty load,
an instrument washing machine and a small autoclave may have first priority.
2 The forward clinic
A 20-kg BLS backpack is developed
by the authors for casualty manage-
ment in jungle warfare. For informa-
tion, address Hans Husum.
6A
Light and heavy BLS kits
Tempo is important in basic life support. The drugs and instruments should be
properly packed in order to be ready without delay in any emergency situation:
The bags and connections must fit the different tubes and cannulas; the instru-
ments must be clean and well protected during rough field use; the materials
should be packed in standardized bags easy to carry by hand or as backpack.
The actual composition of BLS kits and the number of each item depend upon
the staff skill and the casualty rate expected. Below are listed proposals esti-
mated for management of five casualties, the evacuation time from the site of
injury to the FC being maximum four hours.
Table 5
Light BLS kit
Airway 1 Stethoscope
1 Oral airway size 1
1 Oral airway size 2
1 Oral airway size 3
Breathing 1 Mouth mask, infant
1. Mouth mask, child
1 Mouth mask, adult
1 Self-inflating bag
2 Naso-gastric tube
Circulation 1 Rubber tourniquet
5 I.v. cannulas, diam 0.6
5 _ I.v. cannulas, diam 1.0
5 I.v. cannulas, diam 1.4
5 _ I.v. cannulas, diam 1.7
5 Infusion sets
6 Lactated Ringer infusion, 1000 ml
3 Plasma expander infusion, 500 ml
2 Adhesive tape
10 Gauze packs, 10x10 cm
10 Gauze packs, 20x20 cm
2 Gauze packs, 40x40 cm
5 Elastic bandage, 10 cm
1 Scissors
Drugs 1 Inj. ketamine 50 mg/ml, 10 ml
5 _—pentazocine 30 mg/ml, 1.5 ml
5 —diazepam 5mg/ml, 2ml
2 —lidocaine 1% with adrenaline, 20 ml
5 —penicillin 5 mega I.E.
5 —ampicillin 3 g
Z
Inf. metronidazole 5 mg/ml, 100 ml
Light and heavy BLS kits
5 Syringes, 2 ml
5 Syringes, 5 ml
10 Cannulas 0.6x25 mm
10 Cannulas 0.8x40 mm
Others 1 Headlight
5 Injury Charts
2 Splinter frames (for fractures)
Table 6
Heavy BLS kit
1 Light BLS kit
AND:
Airway 1 Vacuum suction (hand/pedal)
6 Suction catheters, 3-5 mm
1 Adult laryngoscope (3 blade sizes)
1 Pediatric laryngoscope
1 Set of endotracheal tubes (set of 6)
1 Syringe (tube cuff)
2 Flexible introducers (for endotracheal tubes)
Breathing 1. Chest tube, 8 mm
1 Chest tube, 11 mm
2 Forceps (for chest tube)
Circulation 1 Venous cut-down set
1 I.v. infusion pressure bag
5 3-way stopcock for infusion lines
1 BP apparatus
1. Cannula for intraosseous infusion
Drugs 3 Inj. ketamine 50 mg/ml, 10 ml
3 Inj. morphine 10 mg/ml, 1 ml
or
3 Inj. buprenorphine 0.3 mg/ml, 1 ml
3 Inj. metoclopramide 5 mg/ml, 2 ml
2 Inj. midazolam 1mg/ml, 5 ml
2 Inj. chlorpromazine 25 mg/ml, 2 ml
2 Inj. dexamethasone 4 mg/ml, 1 ml
2 Inj. frusemide 10 mg/ml, 4 ml
Emergency surgery
See below: The one-man mobile clinic
The one-man mobile FC
When the evacuation of casualties from the battlefield to the FC lasts more
than eight hours, even the best forward basic life support cannot prevent the
loss of lives and limbs during the evacuation. The mortality rate and the risk of
complications are reduced when the field BLS teams are trained and equipped
to make the primary surgery in some village or forward camp close to the site
of injury. After primary surgery (Table 2 p. 41) the patient is transferred to
some nearby village or tent camp. His family, the local village people or the vil-
lage health worker are instructed in the details of monitoring and nursing. The
one-man FC surgeon will see to the patient 3-5 days after surgery and do the
first dressing. When stable, the patient is then transferred to the clinic for fur-
ther management.
The network clinic in Afghanistan:
p- 28.
Equipment needed
A complete one-man clinic backpack The BLS kit and surgical instruments may be carried by one man in a well-
is designed by the authors. For infor _ designed backpack, total weight 15-20 kg. To the heavy BLS kit (Table 5) is
mation, address Hans Husum. added:
¢ One debridement set: Scalpel, surgical scissors, dissecting forceps (surgi-
cal), 6 hemostatic forceps, needle holder, vessel tie and suture materials. The
size of instruments should allow emergency laparotomy and thoracotomy.
¢ Orthopedic instruments: Gigli saw (wire saw) for amputations; plaster of
Paris (rolls 15 cm) for Trueta plaster casts; Kirschner wire (2 mm) for exter-
nal fixation; Steinmann pins (4 mm) for traction management.
¢ Drugs and infusions: Either increase the amount in the backpack, or
arrange small depots in local villages or camps.
¢ Equipment for sterilization: It may be included in the backpack, or
borrowed from the local population.
The one-man clinic in function
This is minimum level surgery and you have to improvise. One assistant is
selected among the local population to manage the anesthesia. Instruct him
well in the triple maneuver to secure free airway before you start the anesthe-
sia. When the patient is under anesthesia you may introduce an oral airway.
Use intermittent i.v. ketamine anesthesia with a fixed volume of ketamine to be
given at preset time intervals. Or arrange a continuous ketamine-drip anesthe-
sia. Also select one assistant for the surgery. Instruct him on the need to keep
everything sterile, and not to touch anything without your explicit permission.
His main function is to provide manual retraction in the wound.
Sterilization is done by boiling instruments for 20 minutes, or you may dis-
infect them by formalin bath or flaming with alcohol. Surgery may be done
without gloves (wash with soap for 10 minutes; consider the risk of blood-
borne diseases). Regarding instruments, further improvisations may be
necessary (see p. 70).
pe Ya
Consumption of materials
Consumption of medical materials
The consumption depends upon several factors and cannot be exactly assessed
beforehand. Some factors will increase the consumption of the BLS teams and
at the FC:
¢ Air-to-ground attacks
¢ Urban warfare
e Extensive mining
* Good field communication and rapid evacuation from the combat area (re-
duced early mortality)
* Malnutrition and endemic diseases in the operative area
* Increased skill of the FC staff
The consumption of drugs and medical items further depends upon the quality
of the clinic management and the turnover of in-patients. Particularly chronic
cases with protracted infections create a burden on both staff and consumption.
Early primary surgery, high quality wound-care, high-energy nutrition after
surgery are all factors that may increase the patient turnover and reduce the
overall consumption of materials. The FC turnover is also increased and con-
sumption reduced when rehabilitation centers are integrated in the network
(the Tripoli model, p. 30) or the local popular support is utilized (the Afghan
model, p. 28). FCs operating in areas of famine, malnutrition and endemic
diseases should expect an increased consumption of materials.
Based upon statistics from recent regional wars we can list approximately the
frequency of the main surgical procedures:
Table 7
Mean distribution of FC surgical operations (conventional warfare)
Ohi oe ee ee eS
Type of surgery % of total surgery
Minor debridements 50
Major debridements 10
Chest drainage 10
Laparotomy 5-10
Amputations 5-10
Thoracotomy less than 5
Vascular surgery less than 5
Skull surgery less than 5
From Tables 5, 6, and 7 we can make a rough assessment of the medical
materials needed for an FC responsible for both definitive primary and
secondary surgery:
2 The forward clinic
Table 8 ‘
Mean FC consumption of m
(battlefield BLS teams included)
edical materials for 100 war casualties
Hea Unit Number of units
ee eee
Infusions
Inf. Ringer or NaCl 0.9% 1000 ml 250
— plasma expander 500 ml 25
— glucose 120 mg/ml 1000 ml 10
— glucose 240 mg/ml 500 ml 10
— metronidazole 5 mg/ml 100 ml 10
Infusion sets 150
I.v. cannulas 0.6 mm 10
I.v. cannulas 0.6 mm 30
I.v. cannulas 0.6 mm 30
Drugs
Inj. morphine 10 mg/ml 1 ml 50
— pentazocine 30 mg/ ml 1 ml 50
— ketamine 50 mg/ml 10 ml 20
— diazepam 5 mg/ml 2 ml 50
— atropine Img/ml 1 ml 20
— metoclopramide 5mg/ml 2 ml 30
— penicillin 5 mega IU 1 vial 300
— ampicillin 2 g 1 vial 150
— lidocaine 10 mg/ml 20 ml 15
— bupivacaine 5 mg/ml 20 ml 15
Syringe (disposable) 2 ml 400
Syringe 5 ml 200
BLS and dressing materials
Suction catheter 20
Urethral catheter (Foley) 20
Urine bag 20
Chest tube 10
Gauze 100 m 1 roll 5
Elastic bandage 1 roll 200
Plaster of Paris 10 cm 1 roll 30
Plaster of Paris 15 cm 1 roll 30
Drain, corrugated 1 sheet 3
Drain, tube 1m 10
Savlon (conc.) al 5
Drape (vinyl) disposable 100 m 1 roll 3
Examination glove (vinyl) disposable 1 pair 250
Apron (vinyl) disposable 100
Surgeon's mask (disposable) 100
Disinfection and sterilization: p. 656.
Cleaning and maintenance of instruments
Nutrition
High-energy nutrients (fat) for 10 cases for 10 days
Feeding tubes 10
Others
Batteries (1.5 V) 150
Kerosene 101 3
Water 1200 |
Cleaning and maintenance of instruments
To maintain proper sterility and disinfection under field conditions is difficult.
Even more so is maintenance of instrument quality in extremely hot or cold,
extremely humid or dry climate. One staff member should be specifically
responsible for that task.
Surgical instruments
Most surgical instruments are made of stainless steel (18% chromium, 8% nic-
kel, 2-4% molybdenum, 18-8-SMO) hardened to Rockwell C 35 or 60 de-
grees. Stainless steel instruments have a special surface polish protecting them
against corrosion; if that polish is damaged, corrosion starts. Some instruments
are made of carbon steel (Rockwell C 55-65 degrees) with a nickel-chromium
surface polish protecting them against corrosion. Still, they are prone to corro-
sion after some time of use. Damaged surface polish on one instrument may
cause corrosion on other instruments during sterilization.
Cleaning: Old blood and debris will prevent effective sterilization. Clean
immediately after use: First wash them in cold water without soap to remove
blood and proteins. Then brush them thoroughly with warm water and soap,
rinse with water and dry them well. Leave scissors and forceps open during
drying. Instruments used on infected cases are kept in a disinfectant solution
for one hour before drying and resterilization.
Maintenance: Surgical instruments in use should be oiled every second day
(weapon oil or special fat-less instrument oil) and dust-free stored. In hot,
moist areas, instruments not in use should be vacuum-packed in plastic to pre-
vent corrosion. Check the instruments before each sterilization. Check the
surface polish and adjust screws. Blunt knives, chisels and scissors are sharp-
ened with a fine well-oiled grind-stone. Never use grind-steel for surgical
instruments. One main problem is surgeons using vascular clamps upon clothes
and tubes, surgical scissors upon gauze and sutures, and chisels as screw-
drivers; better tell them how to behave!
Sterilization: The instruments must be clean and dry before sterilization
starts. Remove oil and fat with alcohol. Do not close scissors, forceps etc.
during sterilization; the steam must have access to all parts of all instruments.
Wrap sharp instruments in paper, gauze or thin cloth to protect them from
damage. The drape wrapped around sets of instruments must be dry before
sterilization starts, as moisture will prevent the steam from penetrating the
2 The forwa rd clinic
rsh
cloth. Notice: Moist heat/steam makes sharp instruments and needles blunt;
either maintain them by intermittent grinding or sterilize them by dry heat or
chemical sterilization. | |
Packing of surgical sets: Preferably one stainless steel grate with holes is
used for each set of instruments. Using double sheets of drape (cloth or paper),
wrap the crate. Mark the set: Contents and date of sterilization.
Rubber and plastic equipment
Tubes, catheters, gloves etc. are washed in cold water immediately after use,
then in warm water with soap, rinsed with water and properly dried. Rubber
will adhere and become damaged if stored in a moist state. Gloves are tested by
blowing them; holes are then closed by patches from the inside. Before storage
and sterilization, gloves are powdered with talc. Rubber and plastic deteriorate
after repeated sterilizations. Do not use steam temperatures above 120 degr.C.
How to improvise
High quality standard surgical instruments are of course preferable to improvi-
sations: The maintenance is simple, the sterilization is safe and their design is
the result of years of surgical craftsmanship. However, good home-made copies
of stainless steel with nickel-chromium surface polish can be made at a local
mechanic's workshop. As the degree of metal hardening for the copies should
be at least Rockwell C 35, soft metal alloys are not fit for surgical instruments.
Handles of plastic are preferable to wood for reasons of cleaning and sterility.
Under field emergency conditions, ordinary tools from the carpenter, tailor or
mechanic may be used. Listed below are some improvisations that work. The
list does not pretend to be complete. Our intention is to encourage the
surgeon not to be dogmatic when he lacks instruments:
* Emergency laryngotomy is done (even without anesthesia) in the combat
area with any sharp knife at hand. The assistant's finger retracts the wound
edges and secures passage of air.
Chest tubes are made out of a plastic water tube of appropriate diameter.
The tube must be stiff enough not to collapse in the chest wall. The tube end
is trimmed by scissors and some side holes are made.
Instead of chest tube suction: After insertion the tube end is fixed under-
water in a bottle of soap solution, analgesia is given and the patient instructed
to blow child's balloons or surgeon's gloves. The positive respiratory pressure
inflates his lungs and promotes chest drainage.
The best large-bore venous catheters for high volume infusions are
made out of the standard sterile infusion set tube (p. 146). The tube fits most
saphenous veins (ankle cut-down), the cephalic vein in male adults (elbow
cut-down) and femoral veins in children (groin cut-down).
Carpenter's tools: Ordinary awl and drill are used to make a hole for tibia
traction. The traction pin is a thick welding rod inserted by careful blows
with a hammer. Corks are applied against the skin at the rod ends and plain
How to improvise
ropes tied to sandbags for traction. For olecranon traction (arm fractures)
and trochanter traction (pelvic acetabular fractures) carpenter's eye screws
may be used; they may create some local irritation of the tissues, but for 4-6
weeks they may be safely used. Ordinary burrs (8-12 mm) on a carpenter's
drill may be used for trephination, but take care not to penetrate dura; the
inner table of the skull bone is removed by nibbling.
Emergency guillotine amputation to free a trapped patient can be done
with an ordinary but sharp stainless steel knife. A carpenter's saw, a sharp chi-
sel or a straight gouge work well to set off the bone. As an alternative small-
caliber drill-holes are made in the bone at close intervals at the level of ampu-
tation, and the bone fractured transversely by manual force. Or a track is
made in the outer cortex around the entire circumference of the bone by
light hammer blows upon the knife, and the bone can be broken by manual
force. A cloth is used as soft tissue retractor.
* Dermatome: A scalpel blade, or better, a razor blade upon a needle holder
or a barber's knife can take skin grafts of any thickness.
¢ Retractors: Nice skin hooks can be made from bent hypodermic cannulas or
metal rods.
Home-made retractors
Stiff metal rods are formed into retractors, 3 mm rods for minor surgery, hea-
vier rods for major wounds.
Standard retractors, sharp and blunt, can be made on order by any mechanical
workshop.
¢ Wound drains: In the absence of soft plastic tubes any piece of rubber (bicy-
cle tube), cloth/canvas or synthetic rope can be used as a drain after fascio-
tomy and debridement.
¢ Instead of gauze packs: Packs with good suction capacity are made of
cloth/linen, not tightly woven, wrapped around a core of cotton.
° Suture materials: Threads of natural silk or linen/flax are excellent for
sutures and ligatures. They may be soaked in sterile water before use, or
waxed for better flexibility. Small-caliber nylon fishing cord may be used as
well. Cotton threads are not fit as suture material. Tailor's needles can be
used for sutures, round needles in soft tissues, cutting needles (triangular
sharpened leather needles) for fascia, tendons etc.
° Inside the abdomen: Incisions and resections can be done with any sharp
knife and scissors. Anastomosis is done by silk sutures on a straight fine-cali-
ber round needle. The temporary colostomy is arranged over a plastic or stiff
rubber rod. As the patient is evacuated further for definitive surgery, a sheet
of canvas or an infusion bag may be sutured over the midline incision to
relieve that incision; or it is adapted and sutured into major defects of the
abdominal wall as a temporary graft (p. 359). Copper or soft steel wires tied
around wooden rods may also be used as tension-relieving sutures (p. 370).
* Major orthopedic instruments: The models available on the market are
expensive. Local copies of skull traction devices (halo, cervical traction
tongs) may be made. Particular notice should be paid to the alloy used for
cortical screws and nails; they must be made of hardened steel (minimum
2 The forward clinic
i Be
Rockwell C 35). Apparatus for external fixation is of particular importance
in the management of major open fractures; simplified copies of the standard
models may be made, particularly the ball joint brackets and couplings may
be simplified. But again the materials used in the transfixing bone pins must
be of high quality to avoid excessive local irritation of the tissues.
Make your own instruments!
High quality surgical instruments are expensive, and the cheap copies on
the market are of poor quality, many of them not at all fit for surgery.
Better buy some essential instruments of high quality, and include an
experienced mechanic with an equipped workshop in a major field
medical network. First, his maintenance of instruments and skills in
improvisation reduce the running costs of your network. Second, his
planning and production of high quality instrument copies in peaceful
times help you avoid hurried and poor improvisations during wartime
management.
Section Z
Basies of
war surgery
Points to note — Chapter 3
The main question in all wartime injury management: How much
energy is released from the bullet inside the patient's body?
* study the projection of stones in water to find out what is energy output: p. 76
¢ different types of bullets make different wound tracks. Know the reasons why
why the bullet loses speed: p. 79
© some case studies of thigh wound tracks: p. 51 sl
Blast injury — the injury that leaves no wounds
e study how pressure waves can cause damage: p. 82
* note the early clinical signs of pressure wave injuries: p. 83
The mine injury — several injuries in one
* tissues above the amputation level are often damaged: p. 85
* there are particular problems with the anterior lower leg compartment in
mine amputations: p. 540
* do not miss pelvic and abdominal mine shrapnel injuries: p. 85 and 468
* there may be abdominal pressure wave injuries as well: p. 83
War surgeons should be interested in weapon technology
¢ local wars are used to test new weapons. Study their effect carefully to
improve the surgical treatment
* report the use and effect of new types of weapons and ammunition to the
authors
3 Physics of the
weapon
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3 Physics of the weapon
Weapon theory
The term "projectile" used in the theoretical discussions in this chapter
denotes any kind of bullet, shrapnel, stone/ debris or other projectiles
that do not carry a secondary explosive. Illustrations of wound tracks
caused by bullets correspond to wounds from any minor projectile.
How extensive is the internal injury? The question is essential in any war
casualty, and more so under field conditions without X-ray service. Your ans-
wer will determine the classification by triage, the type of anesthesia to use,
positioning of the patient on the operation table, the kind of instruments you
need, the incisions you choose etc. The extent of tissue damage depends on the
energy output from the actual projectile. So, as a wartime surgeon, in each
case you have the obligation to collect the facts necessary to estimate the ener-
gy output of the projectile that hit your patient.
1 IV What is energy output?
ea S\ /} a 1 The speed affects energy output: A stone carefully put into the water
Se = —
a ens: -~-= makes small waves. That same stone thrown forcefully into the water makes big
a waves. The bigger waves have more strength; they contain more energy.
2
i 2 The weight affects energy output: A small stone thrown into the water
ake makes small waves. A big stone thrown into the water makes big waves.
3 The retardation affects energy output: An oval-shaped stone makes
small waves. A flat-shaped stone makes big waves because the resistance bet-
ween the water and the stone is increased; its velocity is rapidly reduced; it is
retarded more.
A projectile in flight carries an amount of (kinetic) energy, Ep, deter-
mined by the law:
Ep = 0.5 x M x V7
where M is the weight (mass) of the projectile and V is the velocity of
the projectile.
Thus the energy carried by any projectile is mainly determined by its velocity:
Increasing the velocity twice causes a four-time increase in its energy; increas-
ing it three times causes a nine-time increase in its energy. The general trend in
military arms production has been a steady increase in projectile velocity.
However, the "best" projectile, the projectile with the highest capacity to kill
("stopping power", "knock-down power", "probable kill rate") should also be
able to transform most of its energy to tissue damage inside the body. The main
nar at il
Weapon theory
question is therefore not how much energy was carried by the projectile, but
how much of this energy was released within the body of your patient:
The law of energy output:
E=0.5 x Mx (V1? - V2’)
where V1 is the velocity of the projectile at the inlet wound and V2 is
the speed of the projectile through the outlet wound.
The projectile that creates most damage inside the body has a high hit
velocity (V1) and a low outlet velocity (V2). At best it does not leave
the body at all, that is, V2 is zero.
Before the physical examination of the patient, collect exact information on the
actual weapon:
Evaluate the inlet velocity!
* What kind of weapon was used? You should collect information about the
weapons commonly used in your area, and their projectile velocity. Regard-
ing rifles you should know which ammunition they may carry.
© What kind of ammunition was used? The general trends in modern assault
rifles and antipersonnel fragmentation weapons are reduction of projectile
weight and increase in projectile velocity. And to use unstable projectiles (ill.
6-10 below).
° What was the range of the hit? Due to air resistance a low-weight projectile
will lose velocity during flight more rapidly than a heavy one. Thus the range
of the hit (from the muzzle of the rifle, from the site of explosion of a
grenade) affects the inlet velocity, especially so in modern fragmentation
weapons.
* How are the flight stability and penetration of that projectile? A low-weight
projectile tends to become unstable during flight; uncontrolled tumbling will
reduce its accuracy. So there is a lower limit of assault rifle projectile weight,
even if calibers 4.85 mm and 4.6 mm are now ready for production (p. 80).
A heavy projectile has better penetration in flight. In sniper hits and during
jungle fighting you should still expect to find the traditional 7.62 mm pro-
jectile and heavy projectiles such as the .303 in (the Lee-Enfield Jungle cara-
bine) and .30 in (US Garand) with a high-inlet velocity even at wide range
hits. Even heavier bullets are known to be in use (p. 80). In pistols light
ammunition (less than 9 mm) is unstable in flight and of poor combat value
due to the low muzzle velocity of pistol bullets.
Evaluate the outlet velocity!
You have to study the outlet wound carefully, as modern and improved pro-
jectiles tend to stop inside the body (V2=zero), as projectiles may fragment
inside the body, as the wound track is seldom a straight one, and as multiple
hits in one patient are common.
3 Physics of the weapon
From a small outlet wound you can-
not draw any conclusions; the inter-
nal damage may be extensive, or it
may be small (p. 517).
SP dl
2 mee
¢ Are you sure it really is an outlet wound and not another inlet wound? Battle
rifles that fire clusters of three and three bullets are common. Rifles with
extremely rapid three-shot clusters (2000 rounds/min.) are under produc-
tion.
° How extensive is the outlet wound? If it is wide with extensive tissue damage
close to the outlet surface, the projectile has left the body with considerable
velocity; you can hope for less internal damage. Multiple small outlet wounds
indicate a projectile that fragmented inside the body; the internal damage is
probably wide.
4 The typical low-velocity wound track (9 mm pistol bullet, close range
thigh hit with inlet velocity 450 m/s) is generally narrow. The energy output
from the projectile is poor due to moderate inlet velocity. You should expect to
find necrotic tissues not more than 2-3 cm from the penetration line of the
projectile. The outlet wound, if any, will be small.
5 The typical high-velocity wound track (7.62 mm assault rifle bullet,
close range thigh hit with inlet velocity 900 m/s) is generally wide. The energy
output from the projectile is about four times that of a pistol bullet. It produces
a shock wave in the tissues making a cavity which expands and immediately col-
lapses behind the projectile. That cavitation effect is typical for high-velocity
projectiles and causes tissue necrosis 10 cm or more from the line of projectile
penetration. The vacuum created by the cavitation sucks cloth, dirt and bacte-
ria from the skin into the wound track.
The wound track
Much is written on how surgeons should manage wounds from modern "high-
velocity weapons". However, the muzzle velocity of a rifle or the inlet velocity
of any projectile is not the most important factor to consider. The inlet velocity
only determines the maximum amount of energy that may cause tissue
damage.
Table 1
Muzzle energy of common rifle bullets
Ammunition 5.45x39 5.56x45 7.62x51 7.62x54R
Bullet weight RF we 4.0 ¢ 2 38 9.65 g
Muzzle velocity 900 m/s 915 m/s 840 m/s 850 m/s
Muzzle energy 1.4kJ res 3.2 kJ ak]
From the operating table we know that the 5.45 mm (M16 rifle) and the 5.56
mm ammunition (the AK-74 rifle) cause far more damage to the tissues than
do most heavier ammunitions even if the total energy carried by the lighter
bullets are far less, as this table illustrates. The reason is that different types of
bullets behave differently after hitting the body. The main factor for surgeons
The wound track
to consider is not potential energy but how, where and how much of this
energy is actually released within the wound track. And that is a question on
how the projectile is retarded inside the human body.
Projectile retardation — energy release — cavitation — tissue
destruction
When retardation is maximal, the cavitation is also maximal. The most
effective projectile causes maximum cavitation close to or within vital
structures, that is 5-10 cm inside the inlet wound. Each kind of rifle
ammunition has its particular cavitation effect and particular wound
track, its "fingerprint". The wartime surgeon has a lesson to learn from
veteran fighters: To know the "fingerprints" of common ammunition
will make both triage and surgical performances better.
Wound tracks of common rifle We will study factors that determine the cavitation effect. The principles here
ammunitions: p. 517 and 518. illustrated by bullets are valid for any kind of high-velocity projectiles, frag-
mentation grenades and bombs, cluster bombs etc.
6 6 Deformation causes retardation: the thigh wound track of a .357 Mag-
num soft nose pistol bullet. The lead nose of the bullet is deformed even by
» cf |e soft structures such as skin and subcutaneous tissue. The retardation is maximal
just inside the inlet wound, and this is where you find most extensive necrosis.
Compare with the effect of a standard hard nose pistol bullet in ill 4. Another
ee ders 2h, p35 way to deform bullets is to cut their nose, forming so called "hollow-pointed"
5 10 F Sem ammunition. In high-velocity rifle bullets this is an effective method to move
the point of maximum cavitation from 25 cm down to 10-15 cm after the inlet
wound. Consequently the mortality rate is increased.
reel JACKET 7,8 Destabilization causes retardation: the 5.45 mm ammunition for AK-
EMPTY
LEAD 74, the latest and most effective assault rifle from the former Soviet countries.
What is particular about this bullet is the air-filled space in its nose. On hitting
a taibeea the target, the heavy lead-antimony core is pushed forwards; the bullet
becomes very unstable and starts rotating inside the wound track. In a thigh
EMPTY hit this causes a maximum cavitation close to the femur, the main nerves and
PROPELLENT vessels. Among the standard rifle ammunitions the destructive effect of the
AK-74 is matched only by the new model 5.56 mm ammunition for the US
rifle M16 (p. 518). In fact, when the first AK-74 rifle injuries were seen in
the Afghanistan war, one wondered whether the projectile was a chemical one;
the tissue damage was so much greater compared to the well-known 7.62 mm
git (Oy Cw AK-47 bullet injuries.
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Physics of the weapon
Most rifle ammunition are not
standardized regarding their stability.
Variations of 30% are common.
Within one and the same round one
bullet may become unstable 8 cm
inside the wound track, another
bullet 16 cm inside the wound track.
The first bullet may Cause serious
limb injury, the second one will
probably not.
RO
STEEL JACKET
LEAD CORE
9,10 Fragmentation causes retardation: the 5.56 mm bullet for the US
M16 rifle (A1, old model). The cupro-nickel jacket is open at its base and lead
core fragments are thrown out when rotation starts, thus deforming the jacket
and increasing the cavitation. Other light-jacketed bullets will also expand in-
side the wound track with a fragmentation pattern as that of the M16 bullet
ilbeleme sy
11 Bone hit causes retardation: Hitting bone, most bullets become de-
formed or broken into fragments, and you will find the main cavitation on the
outlet side of the fracture. Also bone fragments are accelerated into the tissue
as secondary projectiles, adding to the cavitation. Energy shock waves may also
travel along the bone, into structures close to the bone. Also remote organs
may be damaged.
New trends in rifle ammunition
According to the International Hague Convention, "dum-dum" bullets are pro-
hibited in warfare. The soft nose, hollow-point and expanding rifle bullets dis-
cussed above are all modern "dum-dum" bullets. As real life warfare is never
conducted under humane and fair conditions, the surgeon should prepare him-
self to handle even more sophisticated projectile injuries in the future.
Low-caliber, unstable bullets: The standard assault rifle ammunition of
the 1990s will be the 5.45 mm (Soviet) and 5.56 mm (Israel — Galil, France —
MAS, US — M16, Belgium — FN). The 7.62 mm is on its way out in infantry
fighting. The low-caliber bullets are more rapid and less stable within the tar-
get; their destructive capacity is higher. "Pencil projectiles" for rifles are under
trial (4.6 mm Heckler and Koch, 5.56 mm "Individual Weapon" of UK). The
long and thin pencil-like bullets, with muzzle velocity well above 1000 m/s,
are stable in flight but extremely unstable within the target.
Increased effective range: Optical sights (day-and-night both-eye sights)
as standard equipment on assault rifles give better accuracy and increased letha-
lity, particularly at ranges more than 300 m. Also laser sights for rifles are
under production. For these weapons heavy sniper bullets are developed with
improved stability and less loss of flight velocity. Sniper bullets of 16 g are effec-
tive at ranges well above 1000 m. Also flechette rifle bullets are very accurate
in long-range fighting. The flechettes do not rotate during flight as do standard
rifle bullets. Flechettes are stabilized by steering fins and lose less velocity in
air. They penetrate deeply into the body, but their wound track is narrow.
Cluster fire: Some rifles may fire clusters of three and three bullets. Those
rifles are very rapid, and in close-range fighting they may cause three wound
tracks close to each other with a delay of 0.03 seconds between each hit. Also
submachine shotguns of caliber 12 with 15 rounds and optical/laser sight have
Blast injuries
been developed for close-range fighting. The propellant of the shotgun ammu-
nition is improved to make it effective up to 100 m. The cavitation of tradition-
al shotgun hits is massive close to the inlet wound, but the penetration is poor.
With the improved ammunition the weapon will be extremely lethal.
How do the tissues tolerate cavitation?
Every tissue has its particular features that also affect the wound track:
¢ Skin is elastic and absorbs the cavitation well. It is stretched and returns to
normal without much necrosis.
¢ The subcutaneous fatty tissue is less elastic and has poor blood supply. Cavita-
tion causes extensive necrosis due to destruction of small vessels.
° Muscle tissue is even less elastic and will not absorb the cavitation. Muscle
cells are directly crushed by the pressure wave. Also minor vessels are torn
causing secondary hypoxia and muscle cell death.
* Bone is not elastic at all (except in small children). Compound fractures are
common even if the projectile does not hit the bone directly. And the energy
wave may travel along the bone and cause extensive necrosis in muscle bellies
and compartments close to the bone. The bone may also carry the energy
wave across joints into remote organs (p. 80).
Tangential hits
In a wound track close to the body surface the energy wave will expand more
in the direction of least tissue resistance, that is towards the surface. The ener-
gy wave is less and so is the cavitation towards the deep structures. Consider
this in debridements of tangential injuries: Most important is the debridement
of the superficial part of the wound track. You may split the entire roof of the
track, and do a limited debridement of the floor of the track only.
Blast injuries
The blast is a detonation of high-explosives (HE) in bombs, rockets, shells, gre-
nades or mines. The blast forms a high positive pressure wave moving at 3000
m/s in all directions from the point of detonation, as waves from a stone hit-
ting water. The pressure of the blast wave may reach 20 kg/square cm, that is
equivalent to 40 000 kg towards the trunk of a man (modern fuel-air explosion
bombs). Air absorbs the blast wave well, and it is rapidly reduced with increa-
sing range from the detonation point. Inside closed spaces the pressure wave is
not absorbed, and even minor blasts (blast hand grenades of 250 g HE) may
cause considerable internal damage. There are three types of blast injuries:
¢ Fragment injuries: The blast weapons are not designed to produce anti-
personnel fragments, but they spread high-velocity (primary) fragments from
their case in an irregular pattern. Also stones and debris are accelerated by
the blast into high-velocity secondary fragments. The fragment injuries may
be serious, but the hit probability is low.
¢ Crush injuries: People are thrown to the ground or against objects. In city
warfare the majority of blast cases are people trapped or buried under broken
buildings.
Q1
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om
Rd
Physics of the weapon
° Pressure wave injuries: Fragment and crush injuries have obvious clinical
signs and cannot be missed. But the specific pressure injuries are silent injuries:
Close to the blast site, people may develop signs of serious respiratory dis-
tress and/or intra-abdominal injury after an interval of 48 hours without
symptoms. Not a few of these patients die in our hands despite intensive
medical support. There are two physical effects by which the pressure wave
creates these silent injuries: a spalling effect inside organs when the pressure
wave is reflected and an implosion-explosion effect when the pressure
wave enters air-filled spaces of the body.
12 Spalling effect of pressure waves: When you hit a rust-eaten iron tube
from the outside with a hammer, rust flakes will detach from inside the tube.
This is called the spalling effect of pressure waves. When the wave enters a less
dense medium from a dense one, the pressure wave is reflected. The reflection
will compress and destroy the structures exactly at the point of reflection.
13 Spalling effect of penetrating projectiles: Not only blast weapons may
cause injury by spalling. Spalling is also utilized in some projectiles designed to
penetrate armor or reinforced concrete (antishelter projectiles). The actual
projectile does not need to completely penetrate the armor/wall. A partial
penetration may still cause detachment of internal fragments or an entire disc
due to the spalling effect. In spaced armor or concrete, the air spaces absorb
the spalling effect making the projectile less effective.
14,15 Spalling effect inside the wound track: Exactly at the point where
the pressure wave enters a less dense tissue, the tissue damage will be exten-
sive. The inner lining of the vessel, the intima, will be torn off the main vas-
cular wall and be further rolled off by the bloodstream. Thrombosis develops
at the narrow part of the vessel. Intimal injuries are common; the pressure
wave may rise from a blast weapon or, in this case, from the cavitation of a
rifle bullet hit.
Most blast pressure injuries are caused by a combined effect of spalling and
implosion. The structures at risk are air-filled spaces and organs composed of
loose connective tissues (spleen, fat, retroperitoneal tissues). The common
injuries are the following:
Blast pressure lung injury
Due to the implosion effect alveolar walls are broken, fluid collects in damaged
lung tissue and increasing lung edema may develop. The implosion effect inside
the abdominal cavity lifts the diaphragm and causes damage to the inferior
parts of the lungs. The physical signs are increasing respiratory distress with
rapid and shallow respiration and coughing of blood-stained mucus. Symptoms
develop slowly and often after a free interval of 6-48 hours. Lung X-ray may
show patchy infiltration 24-48 hours after the injury.
The management consists of:
* Bed rest, half-sitting position, and observation for 48 hours for all patients at
risk. Physical activity may provoke symptoms.
¢ Unrest and anxiety is common; intermittent diazepam Ea
Blast injuries
* Steroids i.v. may be of effect if given within three hours after the injury.
¢ Diuretics in high dose may have some effect in moderate cases.
° Generally the condition is resistant to medical therapy and serious cases are
often fatal.
Blast pressure abdominal injury
Entering the abdominal cavity the pressure wave will increase as an explosion.
So also when it further enters the lumen of stomach and intestines, particularly
in the colon. Depending on the size of the pressure wave a variety of symptoms
may develop. In moderate cases slight bleeding and edema in the stomach and
intestinal mucosa are common. Moderate cases will have few or no bowel
sounds, some tenderness on palpation and often blood with the stools. Surgery
is not indicated, but should be done if you suspect peritonitis. Serious cases
may develop circulatory shock soon after the blast due to profuse intestinal
bleeding, tears of the spleen or liver. Or they develop late signs of slowly
progressive peritonitis due to contamination through multiple minor ruptures
in the intestines.
The management consists of:
¢ 48 hours n.p.o. and close monitoring of all risk cases.
¢ Peritoneal lavage.
¢ Laparotomy is done on suspicion, several negative laparotomies are better
than missing one intestinal rupture.
Blast pressure air embolism
Through the torn alveolar septa, air bubbles enter the blood circulation from
the lungs and reach the heart coronary circulation or central nervous system.
Air embolism may give rise to a variety of symptoms: general unrest and con-
fusion; circulatory failure and falling blood pressure; total circulatory collapse;
sudden death if vital centers in the brain or medulla are put out of function.
The diagnosis is confirmed by fine-needle artery puncture: bubbles of air with
the blood. The management consists of supportive therapy depending on
which organ is affected.
Blast pressure rupture of the eardrum
The sign is acute deafness in one ear. The diagnosis is confirmed by otoscopy.
Without infection the rupture will heal spontaneously. The eardrum rupture is
important as an indicator of risk cases.
Blast pressure injuries have few early clinical signs. The diagnosis is often
missed. For all possible blast cases:
© Collect exact information on their distance from the blast site.
* General unrest and eardrum rupture indicate that serious compli-
cations may follow.
© Observe all blast cases for a minimum of 48 hours.
83
—————
3 Physics of the weapon
Management of blast wave injuries:
p 82:
QA
Mine injuries
Antipersonnel mines carry 30-300 g high-explosives. There are two main types:
¢ The fragmentation mine is located on a rod overground, or it jumps from
ground level up to 1-2 m before explosion. It is released mechanically by
wires or by computer control. Fragmentation mines are often inter-connected
in series of 3-6 mines to increase the fragment concentration. Fragment
velocity is more than 1000 m/s.
¢ The blast mine is buried in the ground or scattered on the surface by air or
artillery. It is released by direct pressure (foot, vehicle). The injury is caused
mainly by the blast pressure wave. Also irregular fragments from the mine
case and secondary fragments (stones, debris) add to the injury.
The traditional mines are defensive weapons, cheap, easy to produce and
effective. This has made AP mines popular in regional wars, and wide areas are
mined without proper mine-mapping. Injuries on civilians and soldiers are
common from both enemy and "friendly" mines. Non-detonated artillery
grenades and cluster bomblets add to the problem. Due to modern technology,
mines are no longer only a defensive weapon. In wars to come mines will have
also an offensive mission, and the rate of mine casualties will increase. AP
mines and antitank mines are now scattered by planes, rockets and artillery.
Each individual mine or the whole minefield may have remote control, either
computerized or by operator as a response to surveillance. Offensive mine-
fields may be extinguished by self-sterilization, remote sterilization or air-fuel
blast bombs. The AP fragmentation mines are also improved: Better explosives
and case design have increased the fragment velocity, and lethal range is well
above 50 m. Needle fragments further increase the AP effect.
Mine injuries are combined injuries
The typical mine amputation casualty has often associated injuries. Approxi-
mately one third of mine injuries are caused by manipulation of mines, chil-
dren’s play, clearing of minefields and spontaneous explosion of old unstable
mines; any regional injury may arise. Major AP mines may also cause blast
wave injuries to the trunk. All mine casualties should thus be closely examined
for several possible injuries:
* Limb amputation: The diagnosis cannot be missed. A 30 g mine may ampu-
tate at the ankle level. A 150 g mine may amputate through the thigh.
¢ Blast wave injury: In particular the abdominal cavity is at risk. Also monitor
respiration. Chest X-ray 24-48 hours after the injury may show patchy lung
infiltrations.
* Perineal injury: Fragments may damage the male organs. Profuse bleeding
is controlled by compression.
* Pelvic injury: Minor high-velocity fragments may penetrate deeply and
cause damage to pelvic organs (rectum, small intestine, bladder) with inter-
nal bleeding and peritonitis. This may in fact be the main injury, but easy to
miss when combined with a dramatic limb amputation.
* Head and eye injury: Penetrating fragment injuries may be seen in one of
three cases, also combined with lower limb amputations.
Mine injuries
Management of mine amputations
The mine limb amputation is an extremely high-energy injury. The mine ampu-
tation thus has particular features different from amputations caused by major
shrapnel, entrapments etc. The extent of soft tissue injury is often underesti-
mated by the surgeon; infection, delayed healing and repeated amputations
being the result.
Early basic life support: Mines continue to kill when the war is over. Civili-
an casualties damaged by accident often come late for surgery. Amputations
caused by minor mines seldom bleed much, but cases with high amputations
or double amputations are often admitted in circulatory shock. The risk of
early and late complications is reduced when village people in mined areas
are instructed in the main procedures of mine-casualty basic life support:
proper control of bleeding; volume therapy; early antibiotics in high doses;
respiratory support and analgesia during the evacuation. Depots of plasma
expander and i.v. fluids should be arranged in strategic villages.
No tourniquet, but compressive dressing: Tourniquets are seldom
effective. In most cases they cause venous stasis without obstructing the main
arteries. This adds to the problem of compartment syndrome commonly seen
in mine amputations. Compressive dressing on an elevated limb (elastic band-
age or rubber bands) controls any amputation bleeding, and reduces the com-
partment edema.
Emergency fasciotomy: As a rule the energy wave running along the limb
causes muscle necrosis and vascular damage above the amputation level. If the
evacuation to the clinic will take more than one hour, fasciotomy should be
done at the site of injury. Most important is decompression of the deep flexor
compartments of the foot (below ankle amputations), of the lateral lower leg
compartment (below knee amputations), of the flexor compartments of the
hand (finger and hand amputations) and of the forearm extensor compart-
ments (below elbow amputations).
X-ray above the amputation level — secondary fragments: Stone, dirt,
clothes and minor bone fragments may be pressed deep into the intramuscu-
lar spaces by the blast wave. They become the focus for infection unless re-
moved, but are difficult to identify by surgical exploration alone. Soft tissue
X-ray before surgery helps identify the areas to be explored.
Explore above the amputation level — two step surgery: The high-
energy blast wave is conducted along the bones above the traumatic amputa-
tion level, in particular along the long bones of the lower leg and forearm.
As aroutine the muscle bellies close to the long bones should be explored
through wide exploratory incisions. Non-bleeding muscles are excised and
arteries explored for intimal injury. If you are in doubt regarding the soft
tissue viability, leave the incisions open and re-explore after 24 hours.
The lateral lower leg compartment —a particular problem: The lower
leg amputation is the most common mine injury. In particular missed injury
of the lateral compartment is a common cause of thrombotic complications,
late infection and sepsis. In missed diagnosis and cases late for surgery you
often find the lateral compartment muscles pale with soft consistency, where-
as the posterior compartments are well circulated. Particular anatomic fea-
tures account for this problem: The lateral compartment is narrow with very
tight walls. Even moderate muscle edema causes a considerable rise in com-
Physics of the weapon
The lower leg compartment P
p: 540.
—
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FRAGMENT
VELOCIT
w
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2000
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1000
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LiMiTING VELOCITy
EXPLOSivE : CASE THICKNESS
roblem:
problem is the particular vulnerability of
the anterior tibial artery: The point where the artery enters the compart-
ment through the interosseous membrane is a common site of intimal injury.
The artery should be explored during primary surgery and ligated above the
level of injury if damaged. If the artery and compartment injury is extensive,
mid-leg amputation with long posterior flap or forward rotation of calf mus-
cles should be considered. Antithrombotic therapy should start on admission.
partment pressure. Adding to the
Modern arms and ammunition
There are two main types of ammunition. One type is discussed above (eg. rifle
ammunition). It has a propellant charge and the projectile does not carry any
secondary explosives; the destructive capacity depends on the kinetic energy of
the projectile only. The other main type has two separate charges, one propel-
lant driving the projectile and one high-explosive (HE) carried by the projectile
causing the target damage. Modern HE projectiles may cause a wide spectrum
of injuries. They also set certain limits on how, where and when we are able to
organize our war medical network.
Fragment energy and fragment distribution
The propellant charge driving the projectile burns with a speed of 500 m/s.
The HE charge detonates with a speed 2000-9000 m/s. After the Vietnam
war HE ammunition was improved; aluminium added to the explosive charge
increased the explosive energy considerably. A "post-Vietnam generation" of
antipersonnel (AP) fragmentation weapons was developed with higher
fragment velocity and a total destructive capacity far beyond that of the "old"
generation. Also propellants were improved, giving better accuracy and
fragment distribution.
Table 2
Approximate weight of fragments (in g)
From AP hand grenade 0.1-0.3
From fragmentation cluster bomblet 1-2
From flechette cluster bomblet 0.5-8
From AP mine 0.7-1
From light artillery shell 5
From heavy artillery shell 13
16 Fragment velocities: The fragment velocity increases when the relation
explosive/case thickness increases. With the HE in use at present there are
upper limits for fragment velocity. R=rifle bullet. AS=artillery shell. MB=tra-
ditional mortar bomb. APM=antipersonnel mine. GP= guided projectiles
(mortar, rocket). AB=aircraft bomb.
Modern arms and ammunition
17 Fragment distribution: During the 1980s fragment distribution from
shells, mortar bombs, grenades and rockets was greatly improved. In these
modern artillery shells, the sides are pre-notched on the inside to produce
standardized fragments with optimal distribution. Or the projectile case con-
sists of pre-formed fragments (eg. 10 mm steel balls) embedded in plastic.
A burst height of 2-4 m produces the best AP fragment effect (see below,
smart bomblet, rod-nose bombs, jumping mines).
OPTIMAL
FRAGMENTS
18 Cluster weapons: One major carrier projectile (here an airplane bomb)
contains several (from 3 to 1000) bomblets (clusters). Each bomblet has its
own initiation system. Cluster weapons are launched by cannons or mortars,
or as rockets and airplane bombs. The clusters may be AP fragmentation bomb-
lets, armor penetrating bomblets, AP mines, incendiary etc. International
conventions and law banned the use of cluster weapons against civilian targets,
but due to their effectiveness they are a common and effective offensive wea-
pon against major cities as well as village areas. Cluster weapons can provide
saturation fire on a wide ground area better than any other non-chemical wea-
pon. The light fragments (1-2 g) lose much velocity with increasing range, but
this is compensated for by a high incidence of persons with multiple injuries
within the ground cover area. Thus modern cluster weapons are said to be
Tay
Y
tactical equivalents of short-range nuclear weapons. The Chilean cluster bomb
mM
here illustrated will cover a ground area of 50 000 square meters with high-
velocity AP fragments. The 250 clusters, each of 800 g, are dispersed from the
carrier in the air; the nose cone charge of one cluster may penetrate 15 cm steel,
and the pre-fragmented cluster body produces a "cloud" of AP fragments.
Instead of the traditional, small but irregular steel fragments from anti-
personnel fragmentation weapons, flechettes will be common in the future. A
US flechette warhead under trial contains 1200 flechettes of 60 grains (1 grain
=0.0648 g); two warheads detonated simultaneously will form a flying high-
velocity cylinder 1500 square meters wide. Flechettes are relatively stable and
do not lose much velocity during flight. They are also stable after the hit, and
can penetrate deeply with a narrow wound track. Their main effect will be an
increased rate of multiple-injury casualties.
Cannons
The common HE artillery shell is illustrated above. Cannons (from 40 mm and
upwards) may also take cluster grenades; one 203 mm cluster grenade may
contain 180 AP fragmentation bomblets and cover a ground area of 60 000
square meters. With modern rocket-assisted projectiles the effective range of
heavy artillery is increased up to 90 km. Rapid fire rate ( 15-20 rounds/ min)
causes saturation fire on one target area. Steerable artillery projectiles are on
the way, laser-guided shells from 70 to 155 mm are already in production.
Combined with laser target designating systems (below) the future accuracy
of cannon fire will be far better.
Mortars
They have so far been a rather simple means of local fire support for infantry in
P|
close fighting. The destructive capacity, range and accuracy have been moderate.
87
3 Physics of the weapon
Lately mortar ammunition has been improved with thinner cases with more
and stronger HE. The result is fragment velocity above 1500 m/s, effective
fragment distribution and far better hit probability. Better propellants and
rocket-assisted mortar bombs have increased the range up to 20 km (240 mm).
In the future, cluster fragmentation ammunition will be the common mortar
ammunition. One single mortar round may cover a ground area of 4000 square
meters.” Also for mortars, laser-guided missiles are under trial; in tests they
have proved a target accuracy of 0.5 m.
19 The traditional mortar bomb (Soviet 120 mm HE fragmentation
projectile, 3.9 kg TNT).
20 The laser-guided mortar projectile (UK, Merlin). G=guidance sec-
tion. E= electronic instruments. W=warhead.
Rockets (short and medium range)
Ground-to-ground and air-to-ground rockets may carry any kind of warhead —
chemical, AP fragmentation, AP clusters, antishelter, anti-armor, incendiary
etc. The traditional GTG rockets vary from 40 to 350 mm with a range from 5
to 90 km. Improved rocket launchers may fire forty rockets within six seconds.
Despite heavy saturation fire, the hit probability has been low so far. For the
future cluster projectiles will be common. One 120 mm cluster rocket covers
1000 square meters with AP fragments. Forty rounds of a 325 mm will
saturate 60 000 square meters with AP fragments.
i
21
1536 DARTS
21 Multi-dart ATG rockets: This French concept is a modification of the
cluster rockets. One 100 mm carrier rocket contains 192 darts of 50 g each.
The plane may fire eight rockets within seconds, and the darts are released
during flight and form a flying cylinder that covers a ground area of 32 000
square meters. Unguided rocket projectiles will be rare in the future. Laser-
guided and heat-seeking projectiles with far better accuracy are already
common, even in minor local wars.
Hand grenades
With the modern improved HE and stronger (pre-notched) steel case, the hand
grenades have also increased their deadliness. There are on sale grenades that
produce a combination of steel and glassfiber fragments, making X-ray frag-
ment identification difficult. Modern offensive grenades with 250-1000 frag-
ments, fragment velocity 2000 m/s, are lethal up to 50 m radius.
Modern arms and ammunition
Aircraft bombs
They are of two main kinds: The fragmentation type of bombs has been
improved in many ways. Better HE has increased fragment velocity up to 2400
m/s. Fragments from a French 190-kg AP cluster may thus penetrate 17 mm
armored steel 50 m from detonation point. There are also double-charged
bombs particularly designed to break shelter: the first charge breaking the
concrete, the second charge being of the AP fragmentation type. And there are
fragmentation bombs (Israeli) with both heavy (armor penetrating) and light
(AP) fragments in one bomb. Also AP fragment distribution is improved by
rod-nose bombs detonating 1-2 m above ground. One should thus expect
increasing numbers of patients with more than one serious penetrating injury
among future aircraft bomb casualties. Till now, the accuracy of aircraft bombs
has been poor, with less than 25% of unguided bombs expected to find their
target. Accuracy is improved in two ways. First, retarded bombs (parachute
bombs) may be released from low-flying jet fighters (15 m above ground).
Second, "smart bombs" with a day-and-night hit rate of 90% are in produc-
tion. These are laser, heat-seeking or optical TV-guided bombs of the glide
type with a range up to 45 km. However, evidence from the US-Iraqi Gulf war
suggests an actual accuracy far less than previously claimed. Also cluster bombs
are under production with target-seeking clusters.
The other main type of conventional bombs is of the blast type, weight
from 250-2000 kg. The new generation of blast bombs are double-charged
bombs of the fuel-air type. Their first charge disperses high-explosive fuel into
the air 5-10 m above ground; the second main charge ignites the fuel-air mist
causing an extreme over-pressure blast wave. The antipersonnel effect of fuel-
air bombs is considerable; they are also used in clearing of minefields.
Future trends
Trials are done with QAZ munition (Quazi Alloy of Zirconium), AP artillery
grenades with fragments coated with zirconium, a burning agent that reacts
with water as well as CO, found in air. Penetrating QAZ fragment burns can
thus be controlled by mechanical means only, not with water or any fluid. In
most advanced armies night vision devices are standard on all weapon systems.
Combined with better ground surveillance, this makes night-fighting as effec-
tive as day-fighting. Ground surveillance radars may identify moving persons at
ranges from 50 m to 40 km. Autopilot drone surveillance planes may transmit
TV pictures day and night from the battlefield. Obviously these innovations
make forward medical service difficult. The main future improvement will
probably be in the high-tech computer field. Countries like Israel, Taiwan and
Japan have developed computerized fire control systems: The targets for fire
are identified and also designated / "marked" with laser systems. The target
information is given to the laser-guided projectile. In combination with exact
range-finders and satellite-positioning systems, the first-round hit probability
will be high. The computer systems also allow rapid adjustment of misfire.
89
3 Physics of the weapon
nyvry
Better weapons make things difficult
With increasing effectiveness of modern arms one can expect an increas-
uries (triage type T1) in the battlefield and in civi-
ing rate of serious inj
ven more than now, very forward surgical service
lian mass casualties. E
is imperative to save lives and limbs. On the other hand improved wea-
pons make forward service more difficult. In order to maintain reasona-
ble security for medical officers, forward units must be light and highly
mobile. The key factor will be training of paramedics to work indepen-
dently and perform life-saving surgery in forward field positions.
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Points to note — Chapter 4
Wound edema delays healing
¢ study the reasons why edema forms: p. 94-96
¢ know the procedures that reduce wound edema: p. 176
* study "the compartment syndrome" — why it happens: p. 521
And how to prevent it by fasciotomy: p. 177
When losing blood, the body protects its vital organs
* note the three stages of circulatory shock: p. 97
¢ learn to assess from clinical signs how much blood is lost: p. 107
¢ children are different: p. 108 and 261
In grave circulatory shock, even vital organs may fail
¢ know the signs of kidney failure: p. 584 and 591
¢ know the signs of heart failure: p. 584 and 590
Painkilling is an important part of basic life support
* note the side effects of pain: p. 98
¢ learn how to use pentazocine, morphine and ketamine for i.v. analgesia:
p- ool
Good and early basic life support reduces the risk of developing
multi-organ failure
* know how to discriminate post-operative pneumonia from ARDS: p. 584 and
588
* note the signs of multi-organ failure: p. 595
* early high-energy enteral feeding reduces the risk of multi-organ failure: p.
97 and 596
* recognize the injuries and complications that increase the risk of multi-organ
failure: p. 98
4 Physiology of the
injury
——————— i
4 Physiology of the injury
Burns cause specific tissue response,
different from other injuries:
2 Ke
K*
al — GLUCOSE
Na* K 2)
ILCOSE
SS
p. 556.
The tissue response to injury
Body tissues are composed of a variety of cells. Each cell is like a complicated
chemical factory. In order to understand how tissues respond to injury, you
have to understand how the cell reacts when it is under stress; when a crushed
cell tries to survive; or when a healthy cell is working under shortage of fuel,
that is, under hypoxemia and hypoglycemia. Let us first look at the normal
basic cell functions. We choose a limb muscle cell as an example.
1 Energy consumption: Oxygen and glucose are the fuel of cells, brought
from the lungs and liver, through the arterial capillaries, across the cell mem-
brane and into the cell. Energy for the cell is produced by chemical reactions
inside the cell. Carbon dioxide and waste products from the chemical reactions
are carried across the cell membrane, into the venous capillaries and further to
the lungs, liver and kidneys for excretion.
2 Regulation by the cell membrane pump: A chemical pump inside the
cell membrane regulates the concentration of sodium, potassium and hydrogen
inside and outside the cell. Also other chemical substrates needed for cell
function are pumped in/out by the membrane pump.
Nef
WATER Nat WATER y=
rtf
WATER
ooNe
—
3 Regulation by osmotic pressure: The cell needs water and produces
water. The water volume inside the cell is regulated by passive osmotic press-
ure: Water is sucked into the cell when the concentration of sodium increases
inside the cell. Therefore the cell will swell, and the salt inside the cell
becomes diluted to the normal level.
The response to hypoxia (shortage of oxygen): Edema
4 Tissue hypoxia causes tissue edema: When the muscle is hit by a bullet,
arteries are damaged and less blood reaches the muscle cell. Also due to pain
during the evacuation respiration is less efficient, and the blood oxygen tension
reduced. This is the response of the cell: The energy production of the cell
decreases due to lack of oxygen. The membrane pump slows down because of
this lack of energy. Less sodium is pumped out of the cell and the levels of sodi-
um and substrate increase inside the cell. Thus the cell becomes hyperosmolar
(more concentrated salt-water solution) and water is sucked into the cell from
the blood. The cell becomes swollen — cellular edema.
The tissue response to injury
|
5 Vascular obstruction causes edema: Also the neighboring cells swell and
the small veins become obstructed. The venous drainage becomes poor; fluid
collects in the tissues and accelerates the general swelling. Gradually the edema
also obstructs the arteries, and the blood oxygen supply to the cell is further
reduced — increasing cellular edema.
6 Vascular injury causes edema: Capillary vessels are also crushed by the
bullet, and they leak fluid into the tissues. Increasing volumes of fluid between
the cells further obstruct the venous drainage — increasing cellular edema.
7 Vascular cell hypoxia causes edema: The capillaries are lined with
endothelial cells. Endothelial cells regulate the vascular wall permeability but
they need oxygen for their normal function. The artery injury and the increa-
sing local edema deprive them of oxygen; they also become damaged and the
capillary wall starts leaking fluid into the tissues > increasing edema.
8 Chemically induced edema: From the crushed, hypoxic or dying cell
several chemical agents are released into the bloodstream. These agents act like
a signal to the endothelial cells to change the capillary wall permeability. White
blood cells and immuno-proteins are let through the vascular wall into the
injured tissue to prevent infection. But water also leaks through the vascular
wall — increasing edema.
The response to tissue necrosis (cell death)
The first response:
Pain — increased local blood flow
From the cells killed by the bullet and those dead from hypoxia, chemical
agents are flushed into the bloodstream. Within minutes the limb pain nerve
receptors are activated, and signal the brain to activate the sympathetic nervous
system. Increased sympathetic activity has these effects:
¢ The pulse rate increases.
¢ The blood pressure increases.
¢ Skin capillaries contract in order to shunt more blood to the muscles and vital
organs.
* Muscle capillaries become dilated: The blood supply to the injured limb
muscle increases during the first hours after trauma. This increased blood
flow to the injured limb is a response to the immediate pain, and has a positive
function. For the dead cells of the wound track nothing can be done. But the
partially damaged cells at some distance from the wound track profit from
the increased oxygen supply. It helps prevent edema, and for a while the
pain will diminish.
95
4 Physiology of the injury
Continuous and strong pain for hours
after the injury: Did you miss an inju-
ry? Can the circulation be improved?
Compartment syndrome on the way?
Basic life-saving surgery: p. 130 and
Po-161.
96
The second response:
Shunting of the blood volume — reduced local blood flow
The limb is bleeding and reduction of circulating blood volume threatens the
nutrition of vital organs (brain, kidney, heart, liver). To preserve the vital
organ blood supply, the sympathetic nervous system shunts blood away from
the limbs into the central organs. Also in the injured limb is a breakdown of
circulation when the central shunting occurs. The result is a dramatic and rapid
extension of the necrosis around the wound track.
The third response:
Increasing necrosis — hyperactivation of the sympathetic nervous
system
acute and ongoing necrosis causes continuous pain in the hours after the
injury. Continous pain causes hyperactivation of the sympathetic nervous sys-
tem: Further shunting of blood from the muscular tissues into the vital body
organs — accelerating local edema and accelerating necrosis.
The fourth response:
Infection starts — increasing local edema
Missile wounds are always dirty, and necrotic tissue is a nice medium for
bacteria to grow. Within 8-12 hours after the time of injury bacteria invade the
muscle cell. Bacteria release toxins into the tissues and bloodstream. The
toxins increase the regional blood flow and also the capillary permeability >
increasing local edema — extension of the necrosis around the wound track.
Prevent the chain reaction of complications en fight the local edema:
* Support airways and breathing: Oxygenation of the blood is one main
base for all life support
* Control bleeding and start aggressive volume therapy inside the battle-
field: To re-establish perfusion and prevent hypoperfusion is the other
main base of life support
* Immobilize open fractures before evacuation. Do early fasciotomy
* Give effective i.v. analgesia before and during the evacuation, mor-
phine or ketamine to serious cases
* Proper surgical debridement should be done within eight hours after
the injury
The body response to injury
The circulatory response
* Moderate blood loss: Increased blood pressure, increased pulse rate and
shunting of blood from the skin compensate for the blood loss. The skin is
pale. There are no signs of circulatory shock.
The body response to injury
SE a eee mmm
* Blood loss less than 20 % (1 liter in adult): Blood is shunted from muscles
and intestines to compensate for the blood loss. The skin is pale, the limbs
cool — the first signs of circulatory shock.
Blood loss 20-30% (1-1.5 liter): The shunting of blood cannot compensate
for the blood loss. The pulse rate increases but even the increased cardiac
output cannot compensate for the blood loss. The blood pressure falls and the
central circulation is in danger. This is a state of circulatory shock.
Blood loss more than 40% (2 liters): Despite the shunting of blood to the
vital organs and a pulse rate exceeding 120 there is a breakdown of the central
circulation. The blood pressure is too low for registration, There is a grave
circulatory shock. Vital organs may be permanently damaged if the central
cirulation is not re-established immediately.
Persistent circulatory shock (more than one hour) — liver hypoxia:
Instead of rinsing the blood of waste products, the liver itself starts to produce
waste products. Metabolism of fat and mobilization of glucose from the liver
is reduced
— blood acidosis
> hypoglycemia
—> reduced protection from infection
Persistent circulatory shock (more than one hour) — renal hypoxia:
Management of renal failure: p. 591. The active kidney pump becomes damaged —> the urine production falls
below 20 ml/hr
—> risk of permanent renal failure with general edema, acidosis and uremia
Persistent circulatory shock cardiac depression: Hypoxic tissues
release myocardial depressant chemical factors into the bloodstream
— reduced myocardial function
—> less resistance to circulatory complications
—> myocardial infarction
The metabolic response
9 The immediate response (the first 24 hours after injury) is caused by
the pain signal and chemical agents released from injured tissue:
* Mobilization of glucose from the liver glycogen depot, increased influx of
glucose into the cells to meet increased energy demands.
° Mobilization and breakdown of body fat depots, increased influx of free fatty
acids and glycerol into the cells to meet increased energy demands.
10 The delayed response (3-2 days after injury)
* Increased body metabolism.
* Increased metabolism of the injured limb.
° Increased utilization of fat from the nutrition and from body fat depots for
production of glucose.
¢ Breakdown of muscular protein to amino acids, increased influx of amino
acids into cells to forward protein resynthesis and tissue regeneration.
Notice: In hunger areas, in fighters exhausted during lengthy fighting, and in
patients admitted after long painful evacuation, the glycogen depots in the liver
are empty and their blood glucose low. The result is poor metabolic response
to injury. They cannot produce the energy (glucose, free fatty acids) needed to
97
4 Physiology of the injury
For details, see p. 601.
Monitoring after surgery: p. 582.
nO
ive inj igh- ition from the time of
cope with an extensive injury. Without high-energy mee ;
k of complications is increased compared to that of a well-
“og aan i ft ti injuries, the amino acid
es with extensive solt tissue Injuries,
nourished person. In cas 7
demand for tissue regeneration is enormous. If those cases do not get protein-
enriched nutrition, the body "steals" protein from non-injured tissues and
utilize it in the injured area, and "self-cannibalism" develops.
Side effects of pain
The pain at the time of injury is useful. It mobilizes the protective mechanisms
of the body. But continuous pain has effects that increase the risk of serious
complications:
¢ Irregular and superficial respiration
— reduced blood oxygen
—> collapse of the lower segments of the lung
—> pneumonia
¢ Hyperactivity of the sympathetic nervous system
— vomiting, aspiration
— stomach stress, gastritis and ulcers
¢ Mental depression and physical inactivity
—> venous thrombus formation
— poor general condition ,
¢ Increased cardiac load
—> cardiac infarction in the hypovolemic patient
Multi-organ failure (MOF)
In serious injuries a variety of chemical agents are released into the blood-
stream from injured tissues. In some patients these agents start an explosive
chain reaction of complications causing failure of more than one vital organ.
The details of this reaction are not yet fully understood; management is
difficult, and even in specialized trauma centers the mortality rate is high. The
best strategy is to prevent these complications arising. The main features of
MOF should be known and recognized by the war surgeon.
Table 1
The risk cases to develop MOF
Type of injury Points
Flail chest, lung contusion 10
Aspiration 10
Intestinal perforation, peritonitis 5
Lasting circulatory shock 5
Brain contusion 5
Femur or pelvic fracture 5
Arm or tibial fracture 3
Other unstable fractures (per fracture) 2
Septicemia 10
Multiple blood transfusions 5
The body response to injury
eS
Management of respiratory failure:
a 588.
Management of coagulation system
failure: p. 593.
Management of renal failure: p. 591.
Assess the risk of complications for all major injuries as a part of the clinic
triage. Note on the Patient Chart. A patient with sum of 10 risk points or more
on this scale carries high risk of MOF. He is a T1 case (p. 125).
The adult respiratory distress syndrome (ARDS )
One or two days after injury:
* Microemboli in lung capillaries
° Defects in the alveolar membrane
— moderate lung edema, hypoxemia
— risk of atelectasis and pneumonia
Four or five days after injury:
¢ Massive embolism in lung circulation
¢ Thick alveolar membrane
* Lung edema
—> manifest lung failure, ARDS
Coagulation system failure
Days or weeks after injury:
* Multiple microemboli in the vessels throughout the body tissue disseminated
intravascular coagulation — DIC
¢ Consumption of blood platelets
— total imbalance in the coagulation system
— tissue hypoxia and organ failure due to artery emboli
— general tendency for spontaneous bleeding
Renal failure
Hours after injury:
* Renal hypoxia due to persistent circulatory shock — decrease in the urine
production or anuria
Days or weeks after injury:
¢ Infarction of the kidneys due to DIC
—> decrease in the urine production or anuria
Liver failure
Hours after injury:
° Liver cell necrosis due to persistent circulatory shock
— hypoglycemia
—> reduced synthesis of protein
—> mental confusion
—> increased serum bilirubin and clinical jaundice
The liver has high capacity for regeneration when injured. The depression of
the liver function after circulatory shock is seldom permanent and will improve
spontaneously. The late liver failure may, however, be serious. Days and weeks
after injury:
* Progressive liver cell necrosis due to DIC
— increasing liver failure that may become permanent
99
4 Physiology of the injury
Prevent systemic complications by
¢ Forward and competent basic life support
¢ Forward emergency surgery and autotransfusion on unstable cases
¢ Short operation time and central warming on hypothermic cases
¢ Early high-energy nutrition to extensive injuries and undernourished
patients
100
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Points to note — Chapter 5
Assess the vital functions during a two-minute clinical examination
¢ find out if the airways are free: p. 105. Methods to establish free airways: p. 136
¢ find out if the respiration is sufficient: p. 136. Methods to support the
respiration: p. 140
¢ find out the degree of circulatory shock, and how much blood is lost: p. 107.
Volume therapy to bleeding patients: p. 145
¢ the vital signs in injured children are different: p. 108 and 262
¢ the response to injury in old people is different: p. 264
¢ study the Injury Chart on p. 52, the Patient Chart on p. 53, and the Vital
Function Index on p. 700 to assess the vital functions and the local injuries
Study the clinical signs of abdominal injuries to find out
¢ which cases need exploratory laparotomy: p. 111 and 355
¢ which cases need emergency laparotomy: p. 155 and 157
Pelvic injuries are often serious due to internal bleeding, intestinal
injuries, and urinary tract damage
¢ know the signs of bleeding inside the pelvic cavity: p. 108 and 113. How to
manage pelvic bleeding: p. 468
* know the signs of intestinal damage: p. 1 10. Diversion enterostomy as an
emergency measure: p. 378. Or tie the intestines: p 157
* study injuries to the urethra, and precautions to take when bladder catheter is
inserted: p. 434 and 436
Most artery injuries are missed at the time of the first examination
* note the signs that should make you suspect artery injury: p. 114
° when neurological signs develop, it may be too late to repair an artery injury:
p. 187
* why early fasciotomy should be done in artery injuries: p. 177
* learn the anatomy of limb nerve trunks; nerve function tests can help you
identify vascular injuries: p. 120
Learn to assess a head case during a one-minute examination to find out
° if there is brain damage: p. 115 and 301
* on which side of the brain is the injury: p. 116
° if the brain is dead: p. 116
¢ know the signs of increasing brain pressure: p. 301
* know the signs of a skull hematoma: p. 299
* study the Head Injury Chart: p. 55, and the Glascow Coma Scale p. 701
5 The clinical
examination
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102
5 The clinical examination
Quality control programs — deter-
mine the Vital Function Index: p. 700.
The Injury Part: p.52.
| First things first: Assess the vital functions and start basic life support
before you examine the regional injuries. The four targets of basic life
support are
A — airways
B — breathing
C — circulation
Pain
When his airways are free, his respiration satisfactory, bleeding control-
led, and with infusions running and i.v. analgesics given — then examine
the regional injuries:
¢ Undress the patient! Wash all blood and dirt with soap and water.
Too many injuries are missed because inlet wounds are covered by dirt
or clothes or the wound is located in the perineum, the buttocks or in
the back.
¢ Work systematically! You spare time making one thorough examina-
tion rather than several superficial ones. In this chapter we propose a
stepwise routine to follow. You may follow this routine, or make your
own. But do not ever leave your routine — a missed penetrating injury
may bea catastrophe.
* More than one injury? When one injury is identified, always look
for the second and the third. In war surgery missed multiple injuries in
one patient are the most common diagnostic failure.
¢ Exact registration in the Injury Chart there and then!
Assess vital functions — pain and anxiety
Pain causes:
* Rise of PR and BP: It may hide the clinical signs of circulatory shock.
* Respiratory distress: It may mislead you in the assessment of the respiration.
e A tense abdominal wall: It makes abdominal examination difficult.
For casualties in obvious pain and/or anxiety, give analgesia before further exa-
mination:
* I.v. morphine 0.1 mg/kg (adults: 5-10 mg), or
*I.v. ketamine 0.5 mg/kg (adults: 25-50 mg)
Airways and breathing
en .. — ——— —— ———————
The specific procedures for manage-
ment: p. 344.
Thoracic or diaphragmatic breathing?
See p. 630.
Assess vital functions
— airways and breathing
Drain a penetrating chest wound immediately!
A chest wound bubbling with the respiration in an unstable patient may
indicate a valve (tension) pneumothorax (p. 260). There is communica-
tion from the airways into the pleural space, but the injured pleura acts
like a valve: Air leaks out of the lung by inspiration but cannot leak back.
The result is increasing pressure in the pleural space and progressive col-
lapse of the lung. As first aid, enlarge the wound (scissors, two fingers)
to let the air pass easily until you can pass a chest tube and close the
wound (temporary suture or a tight dressing).
Listen!
Is the respiration wet or bubbling? Clear the mouth and throat with your
finger.
1 Wheezing during inspiration indicates some kind of obstruction (swelling
or foreign body) in the upper part of his airways. Indication for endotracheal
intubation? Emergency tracheotomy?
Rapid and shallow (dog-like) respiration indicates chest wall injury. Or
abdominal injury. Or the respiration may simply be distressed because of pain
and/or fear. Give analgesics, then re-examine.
Look!
Does he vomit? Put him in a stable side position to avoid gastric content
entering his airways. There may be a combined chest-abdominal injury.
Cyanosis of face, nail beds or palms? If so, he needs urgent respiratory sup-
port. In casualties with hemoglobin less than 5 g/100 ml it is not possible to
see the cyanosis.
Study the face: In the face of a patient with respiratory problems you can read
his anxiety.
2 Look at the chest movements
during respiration: Paradoxic move-
ment of parts of his chest, indicates "flail
chest" due to multiple rib fractures.
Retractions in the epigastric area or over
the lung tops with the inspiration indicate
considerable respiratory distress.
105
——
5 The clinical examination
Examine the chest!
3 Do not miss the chest injury: A high-velocity projectile with an abdomi-
nal inlet wound may well cause chest injury. Notice: The base of the lungs is at
level with the upper abdominal organs, and combined thoraco-abdominal inju-
ries are common. Fractures of the distal six ribs may well be associated with
abdominal injury. Notice: The top of the lung may reach above the clavicular
bone.
Palpate the chest wall: A swelling with fine crepitations (like the sound
produced by crushing fine paper) under your fingers indicates subcutaneous
emphysema. Somewhere there is a tracheal or pleural injury.
4 Press the chest between your both hands. Indirect pain indicates chest wall
fracture.
Pneumo-hemothorax
It is a common and serious wartime injury. Diagnosis should be made at
the site of injury based on clinical examination. Management must not
be delayed due to lack of X-ray facilities:
Pneumothorax: Air leaks from the lung into the chest cavity, and the
lung collapses.
Hemothorax: Bleeding into the chest cavity, the hematoma compresses
the lung.
Pneumo-hemothorax: A combination of both conditions, the most
common injury.
5,6 Percussion: Your right 3rd
finger is the "drum stick", your 3rd
left finger on the chest is the "drum
plate". Always compare one side with
the other at the same level, and seek
any difference between the two sides.
Over the uninjured part of the lung
the drum sound is resonant (plus).
Over the hemothorax the drum
sound is dull (small plus). Over the
pneumothorax the drum sound is
hyper-resonant, that is a drum sound
of greater volume than normal (big
plus).
7 Auscultation: Again compare the sounds of both lungs at equal levels.
Over the uninjured parts you can hear the normal respiration sounds (big
plus). Over the pneumothorax and over the hemothorax the sounds are weak
or absent (small plus).
Circulation
eee
Pain may mislead you; it makes the
skin cold and clammy. Warm skin is
definitely a good sign.
Brain or cervical spine injury: BP and
PR may not respond as normal.
Assessment of the circulation must be
based on
* skin color and temperature
* identification of the bleeding source
* a rough estimate of blood volume
lost.
Dull drum sound and weak stethoscopic lung sounds:
Hemothorax — insert chest tube!
Hyper-resonant drum sound and weak stethoscopic lung sounds:
Pneumothorax — insert chest tube!
Hyper-resonant drum sound at top level, dull drum sound at the lung
base and weak stethoscopic lung sounds:
Combined hemo-pneumothorax — insert chest tube!
Problem: You are in doubt if there is hemothorax or not. Eg. he has slightly
dull drum sound and slightly weak lung sound due to a lung contusion with
some blood in the lung tissue. He may well have such an injury without pneu-
mo- or hemothorax. Or he may have a blast wave injury of one or both lungs
(p. 82). Or he may have a small hemothorax. Or there is too much noise
around for you to assess his lung sounds. If you are in the least doubt, insert a
chest tube!
Problem: There are no signs of airway/ chest injury, but s
…[truncated]