Emergency War Surgery (2004)

Aeromedical Evacuation

Due to the complexity of the AE system, physicians must

identity points of contact (POCs) (local Flight Surgeons

[FSs], AELT, aeromedical staging elements, PMRC); verify

and test lines of communication; and rehearse patient

evacuation drills and procedures, before the actual need

arises.

Patient Stability. Patients validated for transport by AE must

be stabilized as well as possible (secure airway, controlled

hemorrhage, treated shock, and immobilized fractures).

ο Communicate the condition, AE category (ambulatory or

litter), and movement precedence (Table 4-1) of the patient

to the PMRC, as communications assets allow. See PMRC

contact information below.

Commercial

Military

PMRC

telephone number telephone number

Global-Scott AFB, IL

1-800-303-9301 or

DSN 779-4200 or 8184

1-800-874-8966

EUCOM Theater-

011-49-6371-47-2264

DSN 314-480-2264 or 2235

Ramstein Air Force

or 2235

Base, Germany

PACOM (Hickam AFB

808-448-8734

DSN 448-8734

Hawaii)

ο To ensure optimum care, communicate with the accepting

physician, and provide diagnosis, care rendered, and

subsequent medical care plan (next 24-48 h).

ο Ensure the patient has adequate quantities of supplies and

medications for duration of transfer (at least 72 h).

Local Flight Surgeon Responsibilities.

ο Authority for determining whether patients are physio-

logically ready for air transport.

ο Resource for AE system information, communication, and

coordination.

4.7

Emergency War Surgery

AE Process

Activity

Location at Which the Activity Occurs

Request for AE mission (see

Originating physician.

end of chapter for format).

Validation for Aeromedical

PMRC (establishes AE requirement).

Evacuation.

Clearance to move by air.

MTF (referring physician and local FS).

Request versus Requirement. AE requests and patient

movement requirements are different. Physicians at

originating MTFs submit requests for movement, timing,

destination, suggested support therapies, and so forth. Only

the validating Flight Surgeon (usually located at PMRC; not

the local FS) and the PMRC can validate those requests, which

then become AE requirements.

Validation versus Clearance for USAF AE.

ο Aeromedical evacuation clearance is a medical care event;

validation is a logistical event.

ο Clearance is a decision between the referring physician

and the local FS, addressing

♦ Description of the medical condition of the patient.

♦ Probability that patient can survive transit through an

aviation environment.

♦ What the patient needs to make the trip safely.

♦ Enroute medical capability requirements.

Key Steps for USAF AE Patient Request.

ο Contact local FS and AE liaison for clearance consultation.

ο Determine the patient’s AE category, based on diagnosis

and ability to self-help in an emergency during flight.

ο Determine need for CCATT (see below). The CCATT adds

an additional level of support to the AE system for

movement of stabilized patients who require a higher level

of medical therapy or have the potential to experience

significant deterioration during movement. The CCATT

physician is the clinical authority and, with the other team

members, is responsible for documenting and providing

4.8

Aeromedical Evacuation

care. CCATT members may be called on to consult and/

or assist in the care of other patients.

ο A four-person burn transport team can augment a CCATT

team as required for inhalation injury and/or severe burns.

ο Determine if special requirements exist for transport; eg,

CAR, and splinting.

ο Determine patient movement items (PMI) required (eg,

ventilators, pulse oximeters, among others). Flight surgeon

must verify that all items accompanying the patient are

cleared for in-flight use.

ο Determine the patient’s movement precedence.

ο Submit request.

Critical Care Air Transport Teams

Intensivist physician.

Capable of providing short term life-support, including advanced

airway management, ventilator management, and limited invasive

(nonoperative) procedures.

Trained in critical care medicine, anesthesiology, or emergency

medicine.

Critical care or emergency medicine nurse.

Experienced in managing patients requiring mechanical ventilation,

invasive monitoring, and hemodynamic support.

Cardiopulmonary technician.

Experienced in management of patients requiring mechanical

ventilation, and invasive monitoring.

Experienced in troubleshooting ventilatory support and monitoring

systems.

4.9

Chapter 5

Airway/Breathing

Introduction

Skillful, rapid, assessment and management of airway and

ventilation are critical to preventing morbidity and mortality.

Airway compromise can occur rapidly or slowly and may recur.

Frequent reassessment is necessary. Preventable causes of death

from airway problems in trauma include the following:

Failure to recognize the need for an airway.

Inability to establish an airway.

Failure to recognize the incorrect placement of an airway.

Displacement of a previously established airway.

Failure to recognize the need for ventilation.

Aspiration of the gastric contents.

Initial airway management at any level, but especially outside

of medical treatment facilities (MTFs).

Immediate goal: Move tongue, pharyngeal soft tissues, and

secretions out of airway. Until a formal airway is established,

place patients in the lateral or prone position (rescue position).

Chin-lift and head tilt: Place fingers under the tip of the

mandible to lift the chin outward from face.

Two-Handed Jaw Thrust: Place both hands behind the angles

of the mandible and displace forward. This method can be

used on the patient with cervical injury.

Oropharyngeal airway:

ο Insert oral airway upright if a tongue depressor is used

(preferred method).

ο Keep the airway inverted past the tongue then rotate 180°.

ο Too small an airway will not alleviate the obstruction.

Too long an airway may fold the epiglottis caudally,

worsening the obstruction.

ο Estimate airway size by distance from corner of mouth

to ear lobe.

ο Oral airways are not used in conscious patients.

5.1

Emergency War Surgery

Nasopharyngeal airway.

ο Pass lubricated nasal airway gently through one nostril.

ο Not used in suspected facial or basal skull injuries.

ο Is tolerated by conscious patients.

Field expedient.

ο Pull tongue forward and safety pin or suture it to corner

of mouth.

Cricothyrotomy.

Ventilation

Ventilate patient with bag valve mask (BVM).

ο Bring the face into the mask rather than pushing the

mask onto the face.

ο The chin-lift and head tilt are also employed during mask

ventilation unless they are contraindicated due to

cervical spine precautions.

Assess air movement during mask ventilation by observing

rise and fall of the chest, auscultation, absence of a mask

leak, compliant feel of self-inflating bag, and stable oxygen

saturation.

ο If air movement is not achieved, use two-person mask

ventilation (Fig. 5-1).

Fig. 5-1. Two-person mask ventilation.

5.2

Airway/Breathing

♦ One person lifts the jaw aggressively at the angles of the

mandible; the other holds the mask and ventilates.

Alternatively, one person may lift and hold the mandible

with both hands, while at the same time holding down

the mask on both sides. The other person ventilates the

patient.

♦ If air movement is still not present, obtain a definitive

airway.

ο Unsuccessful and aggressive attempts at ventilation may

result in inflation of the stomach, placing the patient at

increased risk for vomiting and aspiration.

Positive pressure ventilation can convert a simple

pneumothorax into a tension pneumothorax. Perform

frequent assessment and have equipment available for

needle chest decompression.

Orotracheal Intubation

Rapid Sequence Intubation (RSI)—7 steps.

1. Preoxygenate with 100% oxygen by mask.

2. Consider fentanyl—titrate to maintain adequate blood

pressure and effect (2.0-2.5 µg/kg).

3. Cricoid Pressure—Sellick maneuver until endotracheal tube

(ETT) placement is confirmed and balloon is inflated.

4. Induction Agent: etomidate 0.1-0.4 mg/kg IV push.

5. Muscle Relaxant: succinylcholine 1.0-1.5 mg/kg IV push.

6. Laryngoscopy and orotracheal intubation.

7. Verify tube placement.

Direct laryngoscopy technique.

ο Ensure optimal “sniffing” position is achieved unless

contraindicated by cervical spine injury.

ο Open the mouth by scissoring the right thumb and

middle finger.

ο Hold the laryngoscope in the left hand and insert the

blade along the right side of the mouth, slightly

displacing the tongue to the left.

♦ Macintosh (curved) blade: Advance the tip of the blade

5.3

Emergency War Surgery

into the space between the base of the tongue and the

epiglottis (valecula). Apply force at a 30°-45° angle,

lifting the entire laryngoscope/blade, without rocking

it backward (Fig. 5-2).

♦ Miller (straight) blade: Advance the tip of the blade into

the posterior oropharynx, picking up the epiglottis and

tongue base anteriorly and laterally, and apply a force

vector like that of the Macintosh blade. Avoid rocking

the laryngoscope backward (Fig. 5-3).

Fig. 5-2. Use of curved blade

Fig. 5-3. Use of straight blade

laryngoscope.

ο Visualize the vocal cords.

ο Consider the “BURP” maneuver when the laryngoscopic

view is poor (Fig. 5-4).

♦ “Backward-Upward-Rightward-Pressure” of the larynx,

also referred to as external laryngeal manipulation.

♦ Place the fingers of an assistant onto the larynx with

your right hand and manipulate the glottic opening into

the field of view.

♦ Assistant then holds the position for intubation.

Eschmann stylet or Gum Elastic Bougie (GEB) (Fig. 5-5).

♦ Blindly guide the tip of the stylet beneath the epiglottis,

then anteriorly through the vocal cords.

♦ Advance the bougie deeply. Placement into the trachea

results in the sensation of tracheal ring “clicks”, and

turning of the stylet as it passes airway bifurcations.

5.4

Airway/Breathing

Force Vector

Fig. 5-4. BURP maneuver.

Fig. 5-5. Eschmann stylet in place.

♦ The patient may cough as the stylet passes through the

airway.

♦ When passed beyond the trachea, the stylet will stop at

a terminal bronchus. If placed into the esophagus, it will

pass indefinitely into the stomach without any tactile

feedback.

♦ The ETT is guided over the stylet into the airway, and

tracheal intubation is confirmed.

o Advance the ETT between the vocal cords, withdraw

stylet, and advance the ETT to 20-21 cm at the teeth for

adult females, 22-23 cm for adult males. Deeper

placement may result in right mainstem intubation.

o Confirm placement of the ETT in the trachea.

o Auscultate over the axilla to ensure breath sounds are

equal.

Avoid making more than 3 attempts at direct laryngoscopy.

Excessive attempts may result in airway trauma and

swelling, potentially turning a “cannot intubate” urgency

into a “cannot intubate-cannot ventilate”emergency.

Difficult Airway

After three unsuccessful attempts at direct laryngoscopy,

abandon the technique and try alternatives.

Alternative intubation techniques.

ο Tactile intubation.

♦ Requires no instruments.

5.5

Emergency War Surgery

♦ No light use—good in light control situations.

♦ Slide hand closest to patient over tongue to hold it down.

♦ Lift epiglottis with first two fingers.

♦ Slide ETT along the “v” between the two fingers into

the airway.

Lighted stylet or “light wand” intubation.

♦ Flexible wand, lighted at the tip, is placed through the

ETT.

♦ Wand is advanced by tactile guidance into t h e

trachea.

♦ Position in trachea is verified by transillumination.

♦ The ETT is advanced over the wand.

Flexible fiberoptic oral or nasal intubation.

Retrograde wire intubation.

Rigid fiberoptic intubation (Bullard laryngoscope).

Alternative Airways.

♦ May NOT be definitive airways.

♦ Allow for oxygenation and ventilation when standard

airways cannot be placed.

♦ “Fastrach” model laryngeal mask airway (LMA).

♦ Esophageal-tracheal combitube (ETC).

Perform a surgical airway.

Wake the patient up and attempt an awake technique if

possible.

Surgical Cricothyrotomy

Identify cricothyroid membrane (between cricoid ring and

thyroid cartilage [Fig. 5-6a]).

Prep skin widely.

Grasp and hold trachea until airway is completely in place.

Make a vertical SKIN incision down to the cricothyroid

membrane (a No. 10 or 11 blade).

Bluntly dissect the tissues to expose the membrane.

Make a horizontal MEMBRANE incision (Fig. 5-6b).

Open the membrane with forceps or the scalpel handle.

Insert a small, cuffed ETT, 6.0-7.0 inner diameter (ID), to just

above the balloon (Fig. 5-6c).

Confirm tracheal intubation.

5.6

Airway/Breathing

Hyoid Bone

Thyroid Cartilage

Cricothyroid

Membrane

Cricoid cartilage

Thyroid gland

Trachea

Fig. 5-6 a,b,c. Steps of surgical cricothyrotomy.

Suture the ETT in place, and secure it with ties that pass

around the neck.

Laryngeal Mask Airway

Do NOT use in penetrating upper airway trauma or central

airway obstruction (foreign body).

Insert blindly without a laryngoscope. LMA rests over the

laryngeal inlet (Fig. 5-7).

Fig. 5-7 a,b,c. Fastrach laryngeal mask airway placement.

Illustration courtesy of LMA North America, Inc.

5.7

Emergency War Surgery

May be used alone or as a conduit to advance an ETT.

Compared to an ETT, the LMA supports less airway

pressures, and offers less aspiration protection.

Check LMA cuff, then deflate it until the down side (inner)

surface is smooth and flat; lubricate the pharyngeal (upper)

side of LMA.

The sniffing position works best, but LMA may be inserted

in different patient positions.

ο Insert LMA (3-4 for women, 4-5 for men) with upper

(pharyngeal) side gliding along the hard palate, down

and around into the posterior pharynx—this allows

proper direction and reduces the chance of cuff folding.

ο Do NOT push the LMA directly back into the mouth—

this folds the cuff and prohibits proper placement.

ο Inflate cuff with 20-30 cc of air via syringe—slight

upward movement of LMA tubing is seen.

ο Secure the LMA.

Blind nasal-tracheal intubation

Contraindications: Coagulopathy, midface trauma, basilar

skull fracture, and suspected elevated intracranial pressure.

Nasal-trachael intubation is better tolerated than orotracheal

techniques and requires less sedation and no paralysis.

Prepare the nasopharynx and larynx (as conditions allow).

ο Spray vasoconstrictor into the nostril that appears largest

and most patent.

ο Insert a nasal trumpet soaked in lidocaine gel and leave

in place for a brief period.

ο Apply Cetacaine spray to oropharynx.

ο Administer a transtracheal injection of 4 cc lidocaine via

cricothyroid membrane.

Insert an ETT (~ 7.0 ID for adults) slowly into the nostril,

perpendicular to the face.

Advance the ETT slowly past the nasal turbinates and around

the curve of the posterior nasopharynx.

Do not use excessive force!

5.8

Airway/Breathing

The ETT is advanced as breath sounds of increasing volume

are heard at the distal end of the tube.

The ETT is advanced beyond the vocal cords into the trachea.

If the tube fails to advance into the trachea, several maneuvers

can be employed.

ο Tilt the head.

ο Apply external, downward pressure to the larynx.

ο Inflate the ETT balloon to help center the tube, then deflate

and advance it once it is engaged in the glottic opening.

5.9

Chapter 6

Hemorrhage Control

“The hemorrhage that takes place when a main artery is divided is

usually so rapid and so copious that the wounded man dies before

help can reach him.” - COL H.M. Gray, 1919

Stop the Bleeding!

Hemorrhage is the leading cause of preventable death on the

battlefield.

ο 90% of combat fatalities occur forward of medical care.

ο Half of these casualties bleed to death, ¹/5 from extremity

trauma (10%-15% of all deaths).

ο Although bleeding is a main cause of death, the vast

majority of wounds do not have life-threatening bleeding.

Under Fire

Get the patient out of the line of fire — prevent further injury.

Control obvious external bleeding once out from under fire.

If you must remain under fire, stop external bleeding with

use of a tourniquet.

Do not endanger the casualty or yourself with

unnecessary treatment.

Stay engaged in the firefight if necessary.

Keep Your Head Down

Sites of Hemorrhage

External.

ο Extremity injury (most common cause of massive external

blood loss in combat), scalp, and torso wounds.

ο Usually associated with an open fracture or amputation.

Direct Pressure Is Central to Treatment

Internal.

♦ Chest, abdomen, pelvis, and closed extremity fractures.

6.1

Emergency War Surgery

♦ High mortality if the casualty is not expeditiously

transported and salvage surgical procedures performed.

♦ Controlled (hypotensive) resuscitation may be

necessary.

Internal Torso Bleeding Requires Surgical Control

Treatment—First Responder

External hemorrhage from extremity wounds.

ο Direct pressure at site of injury is the most effective and

preferred method of hemorrhage control.

♦ If direct pressure fails to stop the hemorrhage, it signifies

deep, massive, or arterial injury, and will require surgery

or advanced hemostatic agents.

♦ Hold pressure for at least 5 minutes before looking to

see if it is effective.

♦ Impaled foreign bodies should not be removed because

profuse bleeding may occur.

Pitfall: A Bandage Does Not Equal Direct Pressure!

A bandage may wick blood from the wound without

stopping the bleeding.

A bandage hides ongoing bleeding.

Hemostatic bandages currently being developed may stop

bleeding.

♦ Elevation of the extremity will decrease most

bleeding—this is an under-appreciated technique.

♦ Point compression of the proximal artery.

Pitfalls of Blind Clamping

Blind clamping into the wound is more likely to cause

additional injury than to control bleeding.

Risk-Benefit Decision: Judgment that other measures are

not successful should be exercised before applying clamps

in a wound. Field wound exploration is not recommended.

6.2

Hemorrhage Control

◊ May help slow bleeding while attempting to gain

better control at the wound site.

◊ May require compression at the pressure point for

up to 20 minutes to provide hemostasis.

◊ Table 6-1 shows the recognized pressure points.

Table 6-1. Recognized pressure points.

Bleeding

Lower

Site

Hand

Forearm Arm Leg

Thigh

Artery Radial/Ulnar Brachial Axillary Popliteal Femoral

Pressure Wrist

Inner

Axilla Behind Below

Point

upper

knee

groin

arm

crease

Tourniquet May Be First Choice in Combat

♦ A tourniquet should be applied if previous techniques

fail.

◊ Use a tourniquet early, rather than allow ongoing

blood loss. Substitutes for issued tourniquet include

belt, torn cloth, gauze, and rope, among others.

◊ Rapid method to secure hemorrhage control.

◊ Does not require constant attention; allows first

responder to care for others — extends resources.

◊ Tourniquets should not be removed until the

hemorrhage can be reliably controlled by advanced

hemostatic agents or until arrival at surgery.

◊ Tourniquet placement on the forearm or leg may not

compress the vessels, which lie between the double

long bones. Tourniquets on the upper extremity

should be placed on the upper arm and if bleeding

from the lower extremity is not controlled by a

tourniquet on the leg, it should be moved to the thigh

where the vessel may be more easily compressed.

6.3

Emergency War Surgery

Pitfalls of Tourniquet

Application for more than 2 hours may increase limb loss.

Risk-benefit decision: Don’t avoid a tourniquet in order

to save a limb, and then lose a life! Use of tourniquet

does not always lead to limb loss.

♦ Clamping vessels: If there is continued bleeding and a

damaged vessel can be readily identified, a hemostat

may be used to clamp the vessel.

♦ Limb splints will decrease bleeding associated with

fractures and soft tissue injury by aligning, stabilizing,

and returning the limb to length.

♦ Military Anti-Shock Trousers (MAST) possible uses.

◊ Controls hemorrhage from massively injured/

mangled lower extremities.

◊ Provides temporary stabilization of pelvic fractures

to decrease hemorrhage.

◊ Splints fractures of lower extremities.

Pitfalls of MAST

Protracted MAST use leads to compartment syndrome and

ischemic limbs.

Respiratory compromise occurs due to diaphragmatic

elevation.

Increased torso bleeding.

Pressure changes within aircraft (caused by altitude

changes) affect inflation pressure.

Requires close monitoring in aircraft.

♦ Scalp bleeding: can be significant due to the rich

vasculature of the scalp.

◊ Responds to direct pressure.

◊ Compression dressings must be applied if you cannot

provide ongoing direct pressure.

◊ Difficult to apply and maintain direct pressure.

6.4

Hemorrhage Control

◊ Requires circumferential head application.

◊ Vertical mattress suture closure sometimes is

necessary to control bleeding scalp edges.

◊ A readily identified bleeding vessel can be clamped,

but the wound should generally not be explored.

◊ Avoid pushing fragments into brain when applying

pressure, but control hemorrhage even at the expense

of exposed brain.

◊ Protection of exposed brain with nonadherent gauze

or plastic can minimize injury.

♦ Internal bleeding.

◊ Blood loss into the abdomen or chest cannot be

controlled in the field and requires immediate

evacuation for salvage or definitive surgery.

◊ Stabilization of pelvic fracture with MAST garment,

or by wrapping the pelvis tightly with a wide strap

(such as a folded sheet), may reduce pelvic bleeding.

◊ Open torso injuries. If direct pressure does not stop

the hemorrhage, consider inserting a tamponade

with a balloon (Foley) catheter into the wound, and

then with balloon inflated pulling back to compress

the bleeding site.

Dressings, bandages, hemostatic agents, and controlled

hypotension. Dressings promote hemostasis, protect wounds

from mechanical injury and contamination, immobilize tissues,

and provide physical and psychological support to the patient.

Application of dressings and bandages.

ο Control all bleeding.

ο Assess neurologic status and circulation of extremity before

and after applying a dressing or bandage.

ο Immobilize suspected fractures.

ο Keep dressing as clean as possible.

ο Dressings should cover the entire wound.

ο Bandages should cover the entire dressing.

ο Avoid skin-to-skin contact.

ο Leave fingers and toes exposed.

6.5

Emergency War Surgery

ο Reinforcement.

♦ If at all possible, do not remove the first dressing.

♦ If the dressing becomes thoroughly saturated,

reevaluate the wound for a source of bleeding amenable

to direct pressure, and consider advanced hemostatic

agents or a proximal tourniquet. Blood loss into the

dressing can be estimated from Table 6-2.

Table 6-2. Blood loss.

Size designation

Small Medium

Large

ABD

Measurement (inch)

4 x 7

7.5 x 8

11.75 x 11.75

18 x 22

Saturation (mL)

300

750

1,000

2,500

Coagulopathy. Blood loss, massive fluid resuscitation, and

drop in body temperature may lead to inability to form clot.

♦ Keep patient warm (above 34°C).

♦ Use warm fluids.

♦ Use crystalloid fluids sparingly.

♦ Transfuse with fresh whole blood (less than 24 h old).

Hemostatic agents: new products and bandages are

available in several forms:

♦ Powders: placed in wound, then covered with a

dressing.

♦ Dressings: impregnated with hemostatic agents.

♦ Injectables.

◊ Intravenous: augment clotting cascade of body.

◊ Intracavitary: through wounds to control internal

bleeding.

♦ Two=component “glues”.

♦ If an advanced hemostatic agent is used after a

tourniquet has been placed, the tourniquet may be

carefully removed after the agent has achieved

hemostasis and the wound observed for hemorrhage.

If hemorrhage recurs, return to the tourniquet.

6.6

Hemorrhage Control

Hemostatic Agents

Product Source

Mechanism Advantages Disadvantages

Hem-

Shrimp

Sticks to

FDA approved,

Con

shell poly- blood

inexpensive

saccharide forming

& vinegar plug

Quik-

Volcanic

Acts as a

FDA approved, Thermal

Clot

rock

selective

inexpensive,

injury,

sponge for

easy to store,

requires

water/

long shelf life

removal

dehydrates

from wound

blood

Fibrin

Fibrinogen/ Activates

Natural

Not FDA

bandage thrombin clotting

clotting

approved,

mechanism mechanism

allergic

reactions

expensive

Two Field Hemostatic Agents

Two agents are recommended by the US Tactical

Combat Casualty Care Committee: 1) HemCon, 2)

QuikClot.

If standard measures such as elevation and pressure

dressings do not control bleeding, it is recommended

that tourniquet be used and that the first agent be

HemCon. If this dressing fails, it should be removed

and QuikClot used if the bleeding is life threatening.

If the bleeding is external and not at a site where a

tourniquet can be applied, HemCon and QuikClot can

be used if conventional pressure dressings fail.

Both products are to be used only on external sources

of hemorrhage.

HemCon dressing is a firm 4 x 4 inch dressing that is

sterile and individually packaged. It works by

adherence to the bleeding wound and has some

vasoconstrictive properties. The blood and clot in the

wound should be removed before application.

6.7

Emergency War Surgery

QuikClot is a granular zeolite that absorbs fluid and

causes hemostasis. It has handling properties similar

to sand. When applied it can generate significant heat

during the absorption process. Blood and clot should

be wiped out of the wound prior to application.

Remember, pressure must be applied for 3-5 minutes

at the bleeding site, after application of a hemostatic

dressing.

Field Hemostatic Dressings Considerations

Use should be delayed until after a trial of conventional

dressings.

Do not use on minor injuries.

Use on internal wounds is not yet recommended.

Must apply pressure to the bleeding site after application.

Risk of inadequate contact of HemCon to the bleeding

tissues in deep wounds.

Heat generation from QuikClot.

ο Controlled resuscitation (hypotensive resuscitation).

♦ Resuscitation as a method of hemorrhage control. The

needs of organ perfusion must be carefully balanced

against the risk of increased bleeding as blood pressure

rises. Excessive fluid resuscitation may increase

bleeding and rebleeding. Prior to definitive hemorrhage

control, a lower-than-normal blood pressure may be

accepted. Small volumes of resuscitation fluid are still

required in those casualties with decreased mentation

due to hypotension (ie, decreased or absent radial

pulse).

6.8

Chapter 7

Shock and Resuscitation

Introduction

The goal of fluid resuscitation is to maintain adequate perfusion.

Fluid resuscitation of the wounded combatant remains a

formidable challenge on the modern day battlefield. Routine

resuscitation using 2 L of crystalloid through two large bore

IVs is not appropriate in all situations and the vast majority of

the casualties do not need any IV resuscitation prior to arrival

at a forward medical treatment facility (MTF).

This chapter will briefly address shock, including recognition, class-

ification, treatment, definition, and basic pathophysiology. Initial

as well as sustained fluid resuscitation and a review of currently

available fluids and potential future products will be described.

Recognition and Classification of Shock

Shock is a clinical condition marked by inadequate organ

perfusion and tissue oxygenation, manifested by poor skin

turgor, pallor, cool extremities, capillary refill greater than 2

seconds, anxiety/confusion/obtundation, tachycardia, weak or

thready pulse, and hypotension. Lab findings include base

deficit > 2, and lactic acidosis > 2.5 mmol/L.

Hypovolemic shock: Diminished volume resulting in poor

perfusion as a result of hemorrhage, diarrhea, dehydration,

and burns (see Chapter 28, Burns). This is the most common

type of shock seen in combat soldiers (see Table 7-1).

Hypotension is a late finding in shock, after 30%-40%

lost blood volume. Earlier signs are tachycardia,

decreased pulse pressure, and mental status changes.

Tachycardia is often not reliable; however, and relative

bradycardia is common.

7.1

Emergency War Surgery

Table 7-1. Clinical Correlates in Hypovolemic Shock.

Central

Blood Vol. Heart

Respiratory Blood

Nervous

Lost*

Rate

Pressure

System

≤ 15%

Minimal

No change

tachycardia

15%-30%

Tachycardia

Tachypnea

Decreased

Anxiety or

pulse pressure

combativeness

30%-40%

Marked

Systolic

Depressed

tachycardia

tachypnea

hypotension

mental status

> 40% Marked

Marked

Severe

Comatose

tachycardia

tachypnea systolic

hypotension

*Blood volume is approximately 7%, so a 70 kg patient has a blood volume

of 4,900 mL.

Cardiogenic shock: Pump failure from intrinsic cardiac failure

or obstructive cardiac dysfunction from a tension pneumo-

thorax, or cardiac tamponade with distended neck veins, or

unilateral absence of breath sounds.

Distributive shock: Poor perfusion due to loss of vascular

tone; neurogenic shock: bradycardia with hypotension, seen

with spinal cord injury.

ο Treat hemorrhagic shock first.

ο Volume resuscitation to maintain systolic BP > 90 mm Hg.

ο Consider the addition of a vasopressor to address the loss

in vascular tone—phenylephrine (50-300 µg/min) or

dopamine (2-10 µg/kg/min).

Septic shock: Fever, hypotension, and warm extremities from

massive vasodilation, usually seen 5-7 days after initial trauma.

Treatment of Traumatic Shock—Control Bleeding!

The goal in the treatment of shock is to restore tissue perfusion

and oxygen delivery (dependent on hemoglobin, cardiac output,

and oxygenation).

Secure the airway and administer O₂for SaO

< 92%.

Diagnose and treat tension pneumothorax.

Control obvious bleeding and assess for occult hemorrhage.

Assess circulation and establish IV access.

7.2

Shock and Resuscitation

ο Consider cardiac tamponade even if no distended neck veins.

Administer IV fluids.

ο Hemorrhagic shock: Initially, any fluid available.

♦ LR: 1,000 mL expands intravascular volume by ~ 250 mL

within 1 hour after injection.

♦ 6% hetastarch: 500 mL expands intravascular volume

by ~ 800 mL in 1 hour, is functionally equivalent to 3

bags of LR, and is sustained for at least 8 hours.

♦ 7.5% hypertonic saline (HTS) results in the same physio-

logic response with ¹/8th the volume of LR or saline. Two

infusions of 250 cc can be used. Although this recommen-

dation has been made by the Institute of Medicine

(Washington, DC) and two military consensus groups,

7.5% HTS is not commercially available. 3% and 5% HTS

can be used instead and are formulary stock items.

ο Nonhemorrhagic shock: Crystalloid is the fluid of choice.

♦ Within 1 hour, resuscitate to a mean arterial pressure of

> 60 mm Hg, a urine output of 0.5 cc/kg/h, and SaO

> 92%.

Based on response to fluids, casualties will fall into 3 groups:

ο Responders: Casualties with a sustained response to fluids

probably have had significant blood loss but have stopped

bleeding. However, they may still require definitive

surgery.

ο Transient and nonresponders are continuing to bleed.

They need immediate surgical intervention.

♦ Start blood transfusion as soon as possible.

♦ For nonresponders, fluids may be given to keep the

patient alive, but one should not attempt to restore

pressure to normal. Consideration should be taken into

account of the futility of the resuscitation depending

on the tactical scenario.

♦ Follow controlled resuscitation guidelines presented

below.

Exsanguinating hemorrhage is the cause of most

preventable deaths during war. Combat casualties in

shock should be assumed to have hemorrhagic shock

until proven otherwise.

7.3

Emergency War Surgery

Vasopressors have no role in the initial treatment of

hemorrhagic shock.

Fluid choices.

The ideal fluid for resuscitation is still debated despite decades

of research that began during WW I (see chart on next page).

Concept of Controlled (Hypotensive/Limited/Balanced)

Resuscitation

Raising the blood pressure with fluid resuscitation may

dislodge established clots leading to more blood loss. Prior

to establishing definitive hemorrhage control, use controlled

resuscitation to achieve and maintain adequate perfusion as

demonstrated by at least one of the following prioritized

goals:

ο Regains consciousness (follows commands).

ο Palpable radial pulse.

ο SBP ~90 mm Hg.

ο MAP of ~60 mm Hg.

Controlled resuscitation is NOT a substitute for definitive

surgical control. It is an attempt to keep a very sick

patient alive until he can get to definitive treatment.

Endpoints of resuscitation.

ο Following definitive hemorrhage control, more traditional

endpoints of resuscitation include

♦ Blood pressure: SBP > 120 mm Hg, MAP > 70 mm Hg.

♦ Urine output: > 0.5 mL/kg/h (approximately 30 mL/h).

♦ Correction of acidosis:

◊ base deficit < 2.

◊ serum lactate < 2.5 mmol/L.

♦ Hypothermia: It is important to maintain normal body

temperature. Fluids and patient care areas should be

warmed. This is often not possible in the deployed

environment. Patients frequently arrive at the facility

already hypothermic. Keep patients covered when on

litters, radiograph tables, and operating tables. External

warmers (such as contained forced warm air devices,

eg, Bair Hugger) should be employed in all patient care

7.4

Fluid/Initial Dose

Indication

Advantages

Cautions

*Not FDA approved

Crystalloids

Hypovolemia, dehydration,

Easy to store

Weight ratio - requires 3:1 for lost blood

Saline

hemorrhage, shock, burns

Inexpensive

Dilution, edema, coagulopathy

Ringer’s Lactate

Proven effectiveness

Isotonic

Hypertonic saline (HTS)

Hemorrhagic shock:

Lighter weight

> 500cc - Risk of hypernatremia, seizures

3%-5%

4cc/kg or 250 cc bolus,

Small volume = large effect

Do not use for dehydration from vomiting,

7.5%*

may repeat once

Increased cardiac contractility

diarrhea or sweating, or heat injuries

Hypertonic saline-

Burns—only one dose

Longer duration of effect than plain

Do not repeat without addition of other fluids

colloid combinations*

initially

HTS?

Must replace depleted extravascular fluid

HTS dextran*

HTS hetastarch*

Colloids

Hemorrhagic shock

Longer duration

Overuse may lead to “leak” into tissue

Albumin

250-500 mL bolus

1:1 replacement for blood

Binds immunoglobulins and Ca++

Artificial colloids

Burns? Third day

Raises plasma oncotic pressure

Must replace depleted extravascular fluid

Dextran

Recruits extravascular fluid

Artificial colloids:

6% hetastarch

Weight/cube better than crystalloids

Coagulopathy, allergic reaction, osmotic

(Hextend, Hespan)

diuresis, interferes with crossmatching

10% Pentastarch*

Hetastarch: ↑ fibrinolysis, ↑ Amylase

Gelatin-based colloids*

Max dose: 20 mL/kg/d (about 1.5 L)

Oral rehydration fluids

Dehydration controlled

Fluids of opportunity

Austere option in abdominal wounds and

hemorrhage

Nonsterile ingredients:

unconscious patients, but use with caution

Burns

4 tsp sugar, 1 tsp salt, 1 L water

Blood

Hemorrhage—Type O

Carries oxygen

Storage, type and cross-match

universal donor

Autotransfusion

Transfusion reactions, infection,

Walking blood bank

immunogenic

Artificial blood

Hemorrhage

Easy storage

Hemoglobin based

No type and cross matching

Experimental only, not yet available for use

Fluorocarbon based

Fluorocarbons require supplemental O₂

Future option?

Emergency War Surgery

areas from initial emergency area through operating

room and ICU. Hypothermia is much easier to prevent

than it is to treat. See further discussion of hypothermia

in Chapter 12, Damage Control Surgery.

Transfusion Therapy

Blood transfusion.

Blood should be added to the resuscitation of patients who have

lost 30%-40% of their blood volume. Blood may also be

necessary in patients who have not reached this threshold but

have ongoing blood loss. Whole blood has a greater risk for

immunologic reactions than packed cells.

Blood products fielded with forward medical units (FST, CSH) are

predominantly group O packed red cells and FFP. Upon reaching

a stabilization phase of operations, type-specific packed cells and

platelets will be supplied through theater specific channels. Storage,

shelf-life, and availability of these products are outlined in Table 7-2.

Table 7-2. Blood Products Available to the Theater.

Blood Group

Unit of

Shelf Life for Echelon

Availability

Product Issue Storage Transfusion Availability O+/- A+/- B+/- AB+/-

Liquid

~250mL

35d

Second &

100%

—

PRBCs

third (MASH)

Third (CSH)

50%

40%

10%

—

& fourth

Frozen/

~250mL

10y

3d (postwash) Third & fourth

100%

—

deglyc-

erolized

RBCs

FFP

~250mL

24h (postthaw) Third & fourth

—

50%

25%

Platelet

~60mL

Third & fourth

50%

—*

concen-

trate

* Will be provided by blood bank platoon and medical treatment facilities by in-theater blood collections.

CHS: combat support hospital; FFP: fresh frozen plasma; MASH: mobile army surgical hospital;

PRBCs: packed red blood cells; RBCs: red blood cells

Adapted from US Department of the Army. Planning for Health Service Support. Washington,

DC: Headquarters, DA; approved final draft January 1994. Field Manual 8-55: 8-6.

7.6

Shock and Resuscitation

Familiarity with transfusion technique, patient-donor unit

infusion connections, and walking blood bank connections, is

essential and should be practiced routinely. Most serious

transfusion reactions are the result of an error at the bedside,

not an error in typing and cross-matching (ie, transfusing “the

right unit to the wrong patient”).

Transfusion reactions may be difficult to recognize in

severely or multiply injured casualties. Hemolytic (ABO

mismatch) reactions present acutely (< 24 hours) with fever,

chills, back pain, dyspnea, and renal failure. Delayed reactions

may occur. Transfusion should be halted immediately in all

cases, except minor allergic reactions (urticaria, fever, +/-

mild bronchospasm), which are treated with diphen-

hydramine (25-50 mg IV or PO), H-2 blocker, methylpred-

nisolone, +/- epinephrine.

Field Management of a Transfusion Reaction

• Stop the infusion of blood. Continue to infuse normal

saline through the intravenous line.

• Examine the urine for hemoglobinuria. Examine plasma

for hemoglobinemia.

• Maintain blood pressure and urinary output with saline.

Consider administering mannitol or furosemide after

volume repletion if the patient is oliguric.

• Reexamine the donor unit for seal integrity, evidence

of hemolysis or infection, and recheck the transfusion

log for clerical error.

• Annotate the field medical card with a description of

the suspected reaction and the therapy provided.

Transfer the unit suspected of causing the reaction to

the next echelon of care with the casualty.

Clinical relevance of the Rh bloodgroup in female

casualties.

Women, military and civilian, are becoming more frequent

victims of conflict. Approximately 85% of the American

population is Rh positive. Serious consequences to Rh

incompatible blood are rare in men. Data predict that 10% of

7.7

Emergency War Surgery

group O blood transfusions will be of Rh positive units to Rh

negative female recipients. An Rh negative woman transfused

with Rh positive blood is very likely (approximately 80%) to

produce anti-D (Rh positive) antibodies. This seroconversion

can jeopardize a subsequent pregnancy when this Rh negative

mother, now sensitized by Rh positive transfusion, conceives

an Rh positive fetus. Chronic hemolytic disease of the

newborn may result.

Under no circumstances should a life-saving transfusion be

withheld because of Rh incompatibility; saving a life takes

precedence over Rh immunization.

Prevention: When the supply of group O blood permits, group

O Rh negative blood should be reserved for women.

Massive transfusions.

Definition.

♦ >10 Units of PRBC’s in <24 hours.

♦ Whole body blood volume transfusion in a 24-hour

period.

Consequences of massive blood loss.

♦ Shock.

♦ Hypothermia.

♦ Acidosis.

♦ Decrease of coagulation factors.

♦ Decrease of platelets.

Consequences of massive blood transfusions.

♦ Dilution of coagulation factors.

♦ Dilution of platelets.

♦ Acidosis.

♦ Hypothermia.

♦ Hypocalcaemia (citrate toxicity) associated with rapid

transfusions.

For every 10 units of PRBCs give:

♦ 4 units of FFP.

♦ 1 unit of platelets (6 pack of 1 aphresis unit).

♦ Consider 1 dose of cryoprecipitate (10 single units of Cryo).

What blood to use?

7.8

Shock and Resuscitation

♦ Type specific if at all possible.

♦ O positive (preferred) in males and postreproductive

females.

♦ O negative (if available) in females of reproductive age.

♦ If still using O after 8 units, stick with O, even if blood

type is determined. Stick with O until the patient’s

forward and back typed appropriately.

ο Which FFP to use?

♦ There is no such thing as emergency release FFP.

♦ Type specific if at all possible.

♦ AB when in doubt.

♦ A as a second choice.

♦ Unless you KNOW that the patient is Type O blood,

DO NOT use Type O FFP.

Walking blood bank.

When standard blood component therapy is unavailable, the

use of fresh whole blood can be lifesaving. Because whole blood

contains clotting factors, it is effective for treating dilutional

coagulopathy associated with massive blood loss and fluid

resuscitation.

ο Equipment.

♦ Blood recipient set (bag), indirect Tx Y-type (NSN 6515

01 128 1407).

♦ Stopcock, IV therapy 3 way, with Luer lock (NSN 6515

00 864 8864).

ο Cautions.

♦ Field conditions increase the risk of bacterial contamination.

♦ Definitive testing of blood for transfusion virus diseases

is not available.

♦ “Dog tag” blood typing wrong 2%-11% of the time.

♦ Donor performance may be impaired by donation.

◊ Good for small numbers of patients—large numbers

lead to doubling of unit ineffectiveness.

◊ Should not be the “default” answer for standard

blood program planning.

◊ Donate only once a month.

◊ Avoid donation at high altitudes.

7.9

Emergency War Surgery

Even in an emergency, try to get regularly issued blood

products.

◊ Women—ideally on supplemental iron before/after

donation.

ο Planning.

♦ Predeployment.

◊ Develop a current prescreened donor roster.

Blood type and Rh.

Nonreactive transfusion transmissible disease

tests (if available).

♦ Onsite.

◊ Update prescreening donor roster.

Tent/cot location.

Duty location.

Emergency (no roster in place).

ο Establish blood types with local testing or previous donor

history.

ο Choose prior blood donors in preference to nondonors

because they have been tested for the infectious diseases

in the past.

ο Rely on “dog tags” only as a last resort.

ο Draw only type “O” universal donors in mass casualty

situations to reduce the confusion of handling.

ο Draw universal or type specific donors in case of single

patient incidents. (Type O donors are 46% of the US

population.)

Procedure for walking blood bank.

ο Clean donor’s arm with povidone iodine for at least 1

minute.

ο Draw the blood from an arm vein into an unexpired, intact

commercial blood bag.

ο The bag has a 600 ml capacity and contains 63 mL of CPD

or CPDA-1 anticoagulant.

ο Draw about 450 mL, a “pint,” so that the bag is almost full.

ο Draw tubes for typing, cross-matching, and transfusion

transmissible disease testing (if available).

7.10

Shock and Resuscitation

ο Send tubes to a supporting laboratory (if available). Even

after-the-fact testing is useful to provide reassurance of

safety or explanations of untoward events.

ο Label the bag clearly with blood type and donor

identification information.

Whole blood crossmatching.

ο The white tile method uses a drop of the donor blood

mixed with the recipient serum on a white ceramic tile

and is examined in 4 minutes.

ο If no agglutination occurs, the blood is suitable for

transfusion into that recipient. A hand lens may be useful.

Storage.

Keep at room temperature no longer than 24 hours.

Blood stored warm for more than 24 hours has a significant

risk of bacterial growth and clotting factors will be lost. If

the blood has been kept at room temperature for less than

8 hours, it can be kept in a refrigerator or on wet ice for up

to 3 weeks.

Although RBCs remain viable, platelets may become

inactive in whole blood stored cold (1°C-10°C) for greater

than 24 hours, losing one of the main benefits of fresh

whole blood.

Ensure that anesthetist/anesthesiologist and surgeon are

aware that this is an emergency-drawn unit and tell them

the history of the unit.

After 24 hours, destroy warm-stored, whole-blood units.

(Stateside hospitals would do so after exceeding 10°C for

30 minutes.) They are no longer safe or fresh. You may

save cold-stored units until a regular supply of tested blood

is reestablished.

Keep a record of donors and patients transfused so they

can be tested on return to stateside.

Keep a record of number of units transfused, donor names,

and outcome.

Autotransfusion.

ο Blood collected into sterile containers (eg, suction, chest

tube, among others) may be returned to the patient through

a blood filter.

7.11

Emergency War Surgery

ο Blood from sterile cavities, such as the chest or abdomen

without visceral injuries is preferred.

ο Blood from contaminated abdominal wounds can be used

at an increased risk of systemic infection.

ο Blood may be filtered through sterile gauze as a field

expedient method.

The Future

Because the definition of shock is inadequate oxygenation at

the cellular level, the most ideal fluid would provide volume

expansion and oxygen-carrying capacity. For this fluid to be

useful in deployed settings it needs to be stable at a variety of

temperatures and have a low-risk profile. Hemoglobin based

oxygen carrying compounds (HBOCs) currently under

investigation may be such fluids. There are HBOCs derived from

either bovine or human sources that require no refrigeration,

have a shelf life of up to 3 years, are disease free, and require no

crossmatching.

7.12

Chapter 8

Vascular Access

Introduction

Vascular access is a critical early step in the management of

trauma. Peripheral access should be attempted first; if

unsuccessful, additional percutaneous central access locations

include the subclavian vein, the internal and external jugular

veins, and the common femoral veins. Cutdowns for the

saphenous vein at ankle or femoral sites are alternative options.

Basic Equipment.

ο Tourniquet.

ο 1%-2% Lidocaine.

ο Sterile prep solution, drape, gloves, and 4 x 4 gauze pads.

ο 3mL syringe with 25-gauge needle.

ο Scalpel, hemostat, 11 blade scalpel and fine scissors.

ο Vein introducer or “vein pick”.

ο IV catheter; IV tubing (modified with distal connector cut

off), and 8 F NG tube are field expedients.

ο 3-0 or 4-0 silk ties to secure catheter in vein.

ο 2-0 or 3-0 suture to secure catheter to skin.

ο Central catheter kit (for central lines) or intraosseous device

for intraosseous insertion.

Subclavian Vein Access or Internal Jugular Venipuncture

Place the patient supine in Trendelenburg (15° head down).

Prep and drape subclavian/jugular area. Sterile gloves should

be worn.

ο Subclavian line.

♦ With an index finger placed at the sternal notch, the

thumb is placed at the junction of the medial and middle

third of the clavicle.

♦ 1% lidocaine is infiltrated into the skin, subcutaneous

tissue and periosteum of the clavicle.

8.1

Emergency War Surgery

♦ Introduce a large caliber needle with attached 5 mL

syringe. Insert with the bevel of the needle up, directing

the needle towards the contralateral clavicular head.

Keep the needle horizontal to avoid a pneumothorax.

♦ While aspirating, slowly advance the needle underneath

the clavicle.

Jugular vein line.

♦ Turn the patient’s head 45° toward the contralateral side

to expose the neck.

♦ Identify the apex of the anterior cervical triangle formed

by the heads of the sternocleidomastoid muscle to locate

the carotid artery.

♦ Palpate the carotid artery and stay lateral with your

venipuncture.

♦ Introduce a large-bore needle on 10mL syringe at a 45°

angle into the apex of the triangle, lateral to the carotid

pulse.

♦ Carotid Puncture: Immediately withdraw the needle

and place pressure on site for a minimum of 5 minutes.

♦ Advance the needle caudally, parallel to the sagittal

plane and at a 30° posterior angle (eg, toward the

ipsilateral nipple).

♦ When free flow of venous blood appears, advance the

needle an additional 4 mm (the length of the needle

bevel), then remove the syringe and quickly cover the

hub of the needle to prevent air embolism.

◊ If air or arterial blood appears, stop immediately.

Withdraw needle immediately and place pressure at

the site for at least 5 minutes.

♦ If no venous blood return after advancing 5 cm, slowly

withdraw the needle while aspirating. If this fails,

redirect the needle.

Subclavian vein or internal jugular vein catheter insertion.

♦ Once the needle is in the vein, introduce the “J” wire

through the needle (Seldinger technique). The wire

should pass with minimal resistance. If wire does not

pass easily, withdraw the entire apparatus and

reattempt line placement.

♦ Remove the needle.

8.2

Vascular Access

♦ Enlarge the puncture site with a scalpel and dilator.

♦ Pass the catheter over the wire while holding the wire in

place, to a depth of 18 cm on the left and 15 cm on the right

for subclavian, and to a depth of 9 cm on the right and 12

cm on the left for jugular vein, then remove the wire.

♦ Aspirate from all ports, flush all ports, suture in place,

apply antibiotic ointment, dress area, secure tubing, and

label date of insertion.

♦ Chest radiograph to ensure line position and rule out

pneumothorax.

Greater Saphenous Vein Cutdowns

Contraindications.

ο Deep vein thrombosis (DVT) or severe ipsilateral lower

extremity trauma.

Procedure.

Expose, prep, and drape ankle or femoral site.

For ankle, administer local anesthetic proximal to the

medial malleolus.

Make a superficial transverse incision through the skin

over the entire width of the flat tibial edge (~3cm) in the

area of the saphenous vein.

Using a curved hemostat, isolate the greater saphenous

vein from the nerve and underlying bone.

Using the open hemostat as a platform, cut a 1-2 mm

venotomy in the anterior surface of the vein with a number

11 blade (Fig. 8-1a).

Place the intravenous tubing (previously beveled) or

angiocatheter at least 4 cm into the vein (may require use

of a vein introducer) (Fig. 8-1b).

Secure the catheter with a proximal silk ligature, and tie

off the distal vein.

Secure the catheter with a suture.

Apply a clean dressing.

Femoral procedure is essentially the same, with site being

a handbreadth below the inguinal ligament, medial to the

midline of the thigh. After skin incision, finger bluntly

dissects through the fat to the fascia. Hook the finger and

lift, and the vein comes up with it.

8.3

Emergency War Surgery

Fig. 8-1a,b. Saphenous vein cutdown.

Cutdown can also be performed on the common femoral

veins, the jugular veins, and on veins of the forearm.

IO Infusion

Contraindications.

ο Trauma or infection at insertion site.

ο Recent IO device at the same site.

ο Fracture of insertion bone.

ο Recent sternotomy.

Devices/ Procedure.

ο F.A.S.T. 1, BIG, SurFast, Jamshidi Needle, VidaPort.

ο Procedures vary based on model; all IV fluids acceptable

except possibly hypertonic solutions.

ο BIG, SurFast, and Jamshidi may be placed in proximal

medial tibia, distal medial tibia, or the radius.

ο F.A.S.T. 1 is designed for sternal placement, 1.5 cm below

the sternal notch.

ο Pediatric: Insert a bone-marrow aspiration needle or 14-

19-gauge spinal needle, directing it caudally through the

outer cortex. Common sites: tibia, distal femur.

ο Aspirate to confirm placement.

8.4

Chapter 9

Anesthesia

Introduction

Battlefield anesthesia primarily describes a state of balanced

anesthesia using adequate amounts of anesthetic agents to

minimize cardiovascular instability, amnesia, analgesia, and a

quiescent surgical field in a technologically austere environment.

Adapting anesthetic techniques to battlefield conditions requires

flexibility and a reliance on fundamental clinical skills. While

modern monitors provide a wealth of data, the stethoscope may

be the only tool available in an austere environment. Thus, the

value of crisp heart sounds and clear breath sounds when caring

for an injured service member should not be underestimated.

In addition, close collaboration and communication with the

surgeon is essential.

Airway

Many methods for securing a compromised airway exist,

depending on the condition of the airway, the comorbid state of

the patient, and the environment in which care is being rendered.

When a definitive airway is required, it is generally best secured

with direct laryngoscopy and an endotracheal tube (ETT), firmly

secured in the trachea.

Indications for a Definitive Airway

Apnea/airway obstruction/hypercarbia.

Impending airway obstruction: facial fractures, retrophar-

yngeal hematoma, and inhalation injury.

Excessive work of breathing.

Shock (bp < 80 mm Hg systolic).

Glasgow Coma Scale (GCS) < 8. (See Appendix 2.)

Persistent hypoxia (SaO

< 90%).

9.1

Emergency War Surgery

Secondary Airway Compromise Can Result From

Failure to recognize the need for an airway.

Inability to establish an airway.

Failure to recognize an incorrectly placed airway.

Displacement of a previously established airway.

Failure to recognize the need for ventilation.

Induction of General Anesthesia

The Anesthesia Provider Must Evaluate the Patient for

Concurrent illness and current state of resuscitation.

Airway — facial trauma, dentition, hyoid-to-mandibular

symphysis length, extent of mouth opening.

Cervical spine mobility (preexistent and trauma related).

Additional difficult airway indicators.

ο Immobilization.

ο Children.

ο Short neck/receding mandible.

ο Prominent upper incisors.

Rapid Sequence Intubation Checklist

Equipment.

ο Laryngoscope, blades, and batteries (tested daily).

ο Suction, O₂ setup.

ο Endotracheal tubes and stylet.

ο Alternative tubes (oro, nasopharyngeal, LMA [laryngeal

mask airway]).

ο IV access items.

ο Monitors — pulse ox, ECG, BP, end-tidal CO₂.

ο Positive pressure ventilation (Ambu bag or anesthesia

machine).

Drugs.

ο Narcotics.

ο Muscle relaxants.

ο Anxiolytics and amnestics.

ο Induction agents and sedatives.

ο Inhalation agents.

Narcotics.

ο Fentanyl, 2.0-2.5 µg/kg IV bolus, then titrate to effect.

9.2

Anesthesia

ο Morphine, 5-10 mg IV bolus to load, then 2 mg q5min to

effect.

o Dilaudid (Hydromorhone), 1-2 mg IV to load, then 0.5

mg q5min to effect.

Muscle relaxants.

ο Depolarizing.

♦ Succinylcholine.

◊

1.0-1.5 mg/kg.

◊ Onset 30-60 sec.

◊ Duration 5-10 min.

◊ Can cause bradycardia, fasciculations, elevated

intragastric pressure, elevated ICP, elevated intra-

cranial pressure, potassium release (especially in

“chronic” burn or immobile patients).

◊ Potent trigger of malignant hyperthermia (MH).

Succinylcholine should be NOT be used in patients

with burns or crush injuries > 24 hours old or chronic

neuromuscular disorders due to risk for hyperkalemia

— rocuronium is the next best choice.

ο Nondepolarizing.

♦ Vecuronium: induction dose of 0.1 mg/kg with an onset

of 2-3 minutes and duration of action of 30-40 minutes.

♦ Rocuronium: induction dose of 0.6 mg/kg with an onset

of 1.5-2.5 minutes and duration of action of 35-50

minutes. At 1.2 mg/kg onset similar to succinyl-choline,

but, unfortunately, a duration of action that can exceed

60-90 minutes.

♦ Pancuronium: induction dose of 0.15 mg/kg with an

onset of 3.5-6 minutes and duration of action of 70-120

minutes.

Anxiolytics and amnestics.

ο Versed (midazolam), 1-2 mg IV slowly (over 2 min).

ο Scopolamine, 0.4 mg IV.

Induction agents and sedatives (Table 9-1).

9.3

Emergency War Surgery (2004) - page 3