Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XV: Anesthesia and Analgesia

Preoperative Preparation

United States Department of Defense

In the most severe cases of massive hemorrhage, immediate surgical control of bleeding is the only means of saving life. In cases of massive ongoing hemorrhage, laparotomy or thoracotomy oftentimes may have to be performed on an inadequately resuscitated patient. With cases such as these, the patient is intubated, paralyzed, ventilated with oxygen, given life-supporting fluids and amnestics with analgesia added, while control is obtained over bleeding as blood pressure and perfusion indices allow. As blood volume is replaced, the patient will require additional anesthesia. Using these approaches, the patient who has lost more than 50% of his total blood volume can be salvaged.

During less drastic trauma care, the anesthesiologist in consultation with the triage physician can establish priorities as to when it is safe to induce anesthesia. During mass casualty periods, the anesthesiologist is usually too busy to spend a major portion of time in the triage area and must rely on the triage team. The latter requires a highly experienced surgeon with excellent executive ability. In every case, open communication and consultation between surgeon and anesthetist is essential. The evaluation of the efficacy of resuscitation and timing of operation in such casualties has been detailed previously (Chapter 9).

There is no assurance that either evacuation of gastric contents via nasogastric tube or induced emesis can lessen the hazard of aspiration in the trauma patient. Therefore, any battle casualty must be regarded as having a "full stomach" and the airway secured with a cuffed endotracheal tube by awake intubation or a rapid sequence induction.

Narcotics, sedatives, and other depressant drugs must be used cautiously in forward areas. Intramuscular or subcutaneous administration is not advised since drug absorption may be uncertain or erratic. Depressant drugs given to the head-injured casualty may confuse neurological evaluation and depress respiration, and are therefore contraindicated. Barbiturates, narcotics, and benzodiazepines are frequently useful as supplements to regional or local anesthetic techniques. They allay apprehension in most patients and may also elevate the seizure threshold in cases of local anesthetic toxicity. With the use of modern general anesthetic agents, the routine administration of anticholinergic medications preoperatively is probably not necessary.

If it is necessary at all, preoperative medication is best given intravenously in the operative room just before induction. For patients in severe pain, judicious doses of intravenous narcotics can be given. It is imperative that suction apparatus, ventilating equipment, and airway management equipment be readily available in the triage area. Judicious IV doses of narcotics in a 70 kg person would be in the range of 3-5 mg of morphine, 0.05 mg of fentanyl or 30-50 mg of meperidine.

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Operational Medicine 2001

Health Care in Military Settings

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