Emergency War Surgery NATO Handbook: Part I: Types of Wounds and Injuries: Chapter VIII: Multiple Injuries

Management

United States Department of Defense

Diagnosis, Triage, and Evacuation at the Division Level

A thorough examination is carried out at the battalion or division medical facility that initially receives the casualty. Additional problems to be countered are those imposed by the tactical situation and often the generally unfavorable condition of the combatant (dehydrated, grimy clothed, burdened with equipment, and frequently confused after blood loss or sedation given in the field). Under these circumstances, an accurate medical history is difficult to obtain. Unless great care is taken, it is easy to overlook injuries.

The best way to avoid a serious oversight is to remove the patient's clothing completely and consider systematically all the injuries that may have resulted either from a particular missile type and its trajectory, or from other trauma. In addition to obvious lower extremity trauma, a thoracoabdominal blast injury should be considered following a mine explosion. Carbon monoxide poisoning and burns of the respiratory tract must be considered in casualties with burns about the face and those involved in a fire in a closed environment, such as tank or armored personnel carrier. Shock, frequently present, is often severe. It is usually proportionate to the number and magnitude of injuries sustained.

After examination and identification of injuries, the degree of urgency and priorities of treatment must be established. Immediately, life-threatening problems must be corrected; general first aid measures, establishment of the airway, control of hemorrhage, and initiation of resuscitation are carried out according to usual routines. The patient with multiple injuries presents special problems for consideration during evacuation. If these casualties are to survive, essential care must continue en route to the definitive treatment center. Skilled medical attendants are needed to maintain the airway, support the respiration, control hemorrhage, and insure the adequacy of blood or fluid volume replacement. Rapid helicopter evacuation alone is not a substitute for adherence to the above principles, nor does it permit one to ignore the need for adequate fracture immobilization. Concise, accurate records of the injury, of the types of wounds, and of the treatments administered are mandatory to facilitate subsequent medical care.

Preparation for Initial Surgery

Casualties who are seen by medical personnel for the first time at a hospital are evaluated carefully in the manner already described. The accuracy of findings and the response to previous treatment are reassessed with each admission along the evacuation chain. Priorities for care of various wounds in the same patient must be established. While many patients with multiple, extensive wounds can be treated successfully, the potential lethality of certain wounds, such as a massive central nervous system injury or a 90% third-degree burn, must be realistically assessed as the lowest priority for treatment.

Although an oral airway may be adequate in some patients, an endotracheal tube is mandatory in others to assure an adequate airway. Where indicated, chest tubes are inserted and connected to closed drainage. Major bleeding must be controlled and blood volume replenished. Intravenous routes are established with due regard for the site of major injury; for example, a major abdominal injury is best managed with large-gauge cannulae placed in the upper extremities or neck. Other measures important in a patient with multiple injuries are evacuation of the stomach by nasogastric suction and the insertion of an indwelling catheter to measure the urinary output and determine the presence or absence of hematuria. Unstable fractures must be splinted either by conventional means or with the radiolucent inflatable splint before further transport. These splints are ill-suited for fractures of the femur or humerus. While inflatable splints may reduce blood loss, they can present a threat to the circulation if inflated other than by mouth, due to the expansion of air in the splint during evacuation at flight altitude.

Appropriate roentgenograms must be obtained and should include special studies when indicated, such as intravenous pyelograms or cystograms in abdominal and pelvic wounds. Intraperitoneal injuries, produced by missiles entering through the thigh, buttock, or back, are easily overlooked. Abdominal radiographic studies in such wounds is particularly indicated.

The lack of response to vigorous resuscitation may necessitate immediate surgical intervention to control major internal blood loss. However, other causes, which produce or simulate shock must be considered (for example, drug overdose or other poisoning, cardiac tamponade, cerebral malaria, and other infectious diseases).

The complication of cardiac arrest usually is treated by closed cardiac compression; however, open cardiac compression may be required.

Operative Management

The order of priority of wound care is often difficult to establish. In general, those injuries most life threatening are treated initially; thereafter, good judgment must prevail. For example, a patient with both thoracic and abdominal injuries should have definitive operative correction of a lacerated bronchus before a repair of multiple intestinal injuries. Definitive care of intracranial, facial, ocular, and hand injuries frequently must be delayed until other more immediately threatening injuries have been dealt with. Usually, initial operative management of major chest, abdominal, and extremity wounds is performed at a forward hospital. After stabilization, the patient can be transferred to a larger supporting hospital for the appropriate care of remaining injuries. This staged approach, even though it requires a second anesthetic, is much safer than the evacuation of an unstable casualty.

Surgical staffing should provide sufficient personnel to insure appropriate care and to keep operating room and anesthesia time to a minimum. When the situation permits, this may best be accomplished by having separate teams operating on different regional injuries simultaneously. If the wounds are unrelated, it may be necessary to operate on various anatomical areas in successive procedures. Where possible, for example, a buttock wound should be debrided and bleeding controlled before exploring the abdomen. Patients in shock with continued blood loss are extremely unstable after lengthy operative procedures, and cardiac arrest is likely to occur if the procedures are performed in reverse order.

The simplest lifesaving surgical procedure consistent with established principles of combat surgery is all that should be attempted at this time. Unnecessary or meddlesome procedures, such as resection of an undiseased appendix or a Meckel's diverticulum during laparotomy and bowel repair, impose an unacceptable added risk to the patient.

Special Considerations

Despite optimal medical treatment by personnel at all echelons of care, the patients in the multiple injury category are at an extremely high risk. Respiratory support with mechanical ventilators is frequently the only way to counteract the pulmonary insufficiency and fatigue factor common to this group. This is particularly true in casualties with major blast injuries, hepatic wounds with concomitant pulmonary contusion, thoracoabdominal wounds or severe sepsis, and in patients who have required cardiorespiratory resuscitation.

A policy of restraint in intravenous crystalloid fluid administration during resuscitation and operations should be considered in cases where the development of postraumatic pulmonary insufficiency is likely. This policy does not preclude the administration of large volumes of blood or colloid where indicated.

Experience has repetitively demonstrated that constant vigilance and an inquiring attitude will help to define confusing problems and provide practical solutions to what at first may have seemed an impossible problem.

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Operational Medicine 2001

Health Care in Military Settings

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