Emergency War Surgery Second United States Revision of The Emergency War Surgery NATO Handbook Thomas E. Bowen, M.D. Editor BG, MC, U.S. Army Ronald Bellamy, M.D. Co-Editor COL, MC, U.S. Army United States Department of Defense United States Government Printing Office Washington, D.C. 1988 Peer Review Status: Internally Peer Reviewed Creation Date: Unknown Last Revision Date: 1988 Contents Foreword Preface Prologue Acknowledgments Chapter I. General Considerations of Forward Surgery Part I. Types of Wounds and Injuries II. Missile-Caused Wounds III. Burn Injury IV. Cold Injury V. Blast Injuries VI. Chemical Injury VII. Mass Casualties in Thermonuclear Warfare VIII. Multiple Injuries Part II. Response of the Body to Wounding IX. Shock and Resuscitation X. Compensatory and Pathophysiological Responses to Trauma XI. Infection Part III. General Considerations of Wound Management XII. Sorting of Casualties XIII. Aeromedical Evacuation XIV. War Surgery Within the Division XV. Anesthesia and Analgesia XVI. Wounds and Injuries of the Soft Tissues XVII. Crush Injury XVIII. Vascular Injuries XIX. Wounds and Injuries of Bones and Joints XX. Wounds and Injuries of Peripheral Nerves XXI. Amputations Part IV. Regional Wounds and Injuries XXII. Craniocerebral Injury XXIII. Maxillofacial Wounds and Injuries XXIV. Wounds and Injuries of the Eye XXV. Laser Injury of the Eye XXVI. Wounds and Injuries of the Ear XXVII. Wounds and Injuries of the Neck XXVIII. Wounds and Injuries of the Chest XXIX. Wounds of the Abdomen XXX. Reoperative Abdominal Surgery XXXI. Wounds and Injuries of the Genitourinary Tract XXXII. Wounds and Injuries of the Hand XXXIII. Wounds and Injuries of the Spinal Column and Cord Appendixes A. Glossary of Drugs with National Nomenclatures B. Useful Tables Illustrations Figure 1. Generic organization of combat casualty care 2. Wound Profile - Vetterli projectile, circa 1870-1890 3. The sonic shock wave and temporary cavity 4. Wound Profile - .45 Automatic 5. Wound Profile - .22 Long Rifle 6. Wound Profile - .38 Special 7. Wound Profile - 7.62 NATO FMC 8. Wound Profile - AK 47 9. Wound Profile - AK 74 10. Wound Profile - 357 Magnum 11. Wound Profile - 7.62 Soft Point 12. Wound Profile - M-16 M-193 round 13. Wound Profile - .224 Soft Point 14. Wound Profile - 12 gauge shotgun, #4 buckshot 15. Rule of nines for use in determining percentage of burns 16. Sites for escharotomy incisions 17. Pressure-Time representation of an air explosion 18. Human tolerance to blast waves 19. Fallout decay with time after detonation 20. Postradiation syndrome dose and time relationships 21. Proposed scheme for mass casualty flow 22. Casualty care decision tree at the division level 23. A technique for cricothyroidotomy 24. Technique of debridement in soft-tissue wounds 25. External fixation of fractures 26. Immobilization of the upper extremity 27. Technique of open circular amputation 28. Self-contained plaster-incorporated traction device 29. Technique for debridement of head wounds 30. Technique of archbar application to maxillary and mandibular teeth 31. Closure by layers of lid lacerations 32. Technique of tracheostomy 33. Control of bleeding from caval and hepatic vein injuries 34. Drainage of the abdomen 35. Single layer technique for closure of small intestine 36. Exteriorization of colon wounds 37. The end colostomy and matured ileostomy 38. Technique of presacral drainage 39. Immobilization of the injured hand and forearm 40. Sensory Dermatomes 41. Cervical Immobilization using a Short Board 42. Spinal Immobilization using a Long Board 43. Two Man Arm Carry 44. Field Expedient Litter 45. Gardner-Wells Tongs Tables Number 1. Diagnosis of burn depth 2. Formula for estimating fluid requirements in burn patients 3. Chemical warfare agent classification 4. Time of onset with chemical agents 5. Early signs and symptoms of chemical exposure 6. Estimated fluid and blood requirements 7. Choice, mode of action, spectrum, and dosage of antibiotic agents 8. Anatomical distribution of battle wounds 9. Local anesthetic agents 10. Arterial wound and associated injuries, Vietnam, 1965-1970 11. Classification of craniocerebral injuries 12. Mechanism and pathophysiology of craniocerebral injuries 13. Glasgow Coma Scale 14. Typical lasers and their wavelengths 15. Support of the Spinal Column 16. Assessment of Spinal Cord Injuries 17. Extraction techniques for suspected spinal column injuries 18. Application of Gardner-Wells Cranial tongs Foreword United States Department of Defense Peer Review Status: Internally Peer Reviewed The success of any military health care system in wartime is directly related to the number of casualties adequately treated and returned to duty with their units. This must be accomplished as soon and as far forward in the theater of operations as possible. The Second Battle of Bull Run near Manassas, Virginia, was one of the major engagements of the United States Civil War. Three days after that great battle, three thousand wounded men still lay on the field. Relatives traveled to the front and took their loved ones home for treatment rather than leave them to the uncertain ties of military medicine. We have made phenomenal progress in the century since that battle occurred. I have had the privilege of being a physician for nearly forty years. Half of that time was spent on active duty in the military services and the other half was spent in the civilian sector. I have participated in the delivery of health care in every conceivable setting: in a battlefield tent in Korea; on a hospital ship; in an air squadron; from austere county and state hospitals to large, glossy high technology institutions. I have seen people strive for, and achieve, excellence in all those settings. I see it now in the military health care system, and no one is more proud than I of the accomplishments and the quality of that system and of the special type of men and women who make the system work. Our system is not without its problems and its frustrations. It takes a long time for equipment to be delivered; the personnel system doesn't always provide the proper mix of people in a timely manner to get the job done; but with rare exceptions, the medical mission is accomplished in exceptional fashion. This handbook should serve as a constant reminder that ours is a high calling We are here to save lives, not to destroy them. We are committed to the future, not the past, and to the primary mission of military medicine, which is to keep the soldiers, sailors, airmen and marines alive and whole: in the words of Abraham Lincoln, to minister to "him who has borne the brunt of battle." This revised edition represents the contributions of talented and gifted health professionals from the military services as well as from the civilian sector. All who contributed have the grateful appreciation of the editorial board for the enthusiasm, dedication, and perseverance which made this revision possible. William Mayer, MD Assistant Secretary of Defense (Health Affairs) Preface United States Department of Defense Peer Review Status: Internally Peer Reviewed This edition of the Emergency War Surgery Handbook is written for and dedicated to the new generation of young as yet untested surgeons, who may be given the opportunity and the honor of ministering to the needs of their fallen fellow countrymen. What is the likelihood that you will be called to serve? The ancient Plato provided the answer: "Only the dead have seen the end of war!" Will you be adequate, will you be successful in salvaging the lives and limbs of those comrades by applying the principles of the lessons hard learned by countless generations of combat surgeons that have preceded you? The answer is a resounding yes, for "I would remind you how large and various is the experience of the battlefield and how fertile the blood of warriors in the rearing of good surgeons" (T. Clifford Albutt). What sort of wounds will you be expected to manage? The Wound Data and Munitions Effectiveness Team (WDMET) data derived from the Vietnam battlefield provide some insight into the types of wounds and the casualty mix that might be expected. The WDMET data indicate that 100 combat casualties, who survive long enough to be evacuated from the field, could be statistically expected to present the following casualty mix: Thirty casualties with minor or superficial wounds, minor burns, abrasions, foreign bodies in the eye, ruptured ear drums, and deafness. Sixteen with open, comminuted fractures of a long bone, of which several will be multiple and several will be associated with injury of named nerves. Ten with major soft tissue injury or burns requiring general anesthesia for debridement. Several will have injury of named nerves. Ten will require laparotomy, of which two will be negative and several will involve extensive, complicated procedures. Six with open, comminuted fractures of the hand, fingers, feet or toes. Five will require closed thoracostomies and soft tissue wound management; at least one will have a minithoracotomy. Four will have major multiple trauma, i.e., various combinations of craniotomies, thoracotomies, laparotomies, amputations, vascular reconstructions, soft tissue debridements, or fracture management. Three will be major amputations (AK, BK, arm, forearm). In three out of four, the surgeon will simply complete the amputation. Three craniotomies. Two will be craniectomies for fragments and one will involve elevation of a depressed fracture. Three vascular reconstructions, half involving femoral arteries. One half will have associated fractures, or venous or nerve injuries. Three major eye injuries, one of which will require enucleation. Two amputations of hands, fingers, feet or toes. Two maxillofacial reconstructions. Half will have mandibular injuries and most of the remainder will have maxillary injuries. One formal thoracotomy. One neck exploration (usually negative). One casualty statistically is delivered up by the computer as "miscellaneous." If this surgical handbook is on the mark in achieving its objective, we will have provided you with specific guidelines or general principles governing the management of the foregoing 100 randomly selected battle casualties.