Medical Science Publication No. 4, Volume 1
RESUSCITATION*
MAJOR CURTIS P. ARTZ,MC, CAPTAIN YOSHIO SAKO,MC, AND CAPTAIN ALVINW. BRONWELL, MC
Resuscitation, which actually means the act of reviving or restoring,is a term frequently used to describe the procedures involved in the initialmanagement of a severely wounded man. Since the wound is a continuing injuryand its effects on the entire body are dynamic ones, resuscitation maybe considered as those procedures which are carried out to counteract theeffect of the wound. Therefore, resuscitation is a process of continuingtreatment. Since the effect of the wound starts as soon as the man is injured,resuscitation should start as soon as the man is seen. One of the effectsof the wound is the loss of blood; hence resuscitation includes the administrationof blood. Since tissue is damaged, resuscitation means excision of thisdevitalized tissue. If an airway is blocked, one of the important proceduresof resuscitation is the performance of a tracheotomy in order to establishan adequate airway.
The aim of resuscitation is to restore the wounded man in order thathe may withstand evacuation to the nearest surgical installation and thento further restore him so that he may safely undergo anesthesia and surgery.Some casualties with head injuries and massive chest injuries have vitalorgan damage incompatible with life. Others may have very serious woundsbut, with judicious care, they can be evacuated to a surgical hospitalwhere a successful repair can be carried out.
Resuscitation at Division Level
The primary aims of the battalion surgeon are to arrest hemorrhage,to prevent deterioration of the casualty's condition and to prepare himfor transportation. Corpsmen are taught methods of arresting hemorrhageand of positioning for transportation; and also the value of early replacementof a deficit of blood volume with a plasma expander. Early in the Koreanconflict the company aidman learned to carry small bottles of albumin foradministration during litter-carry to an aid station. Later, early administrationof dextran became
*Presented 19 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
107
popular. Dextran in plastic bags had the advantage that the companyaidman could carry three or four of these units on patrol. Battalion surgeonsemphasized the importance of the administration of a plasma expander assoon as a casualty was seen. Although severe blood loss may not be evidentimmediately after injury, a blood-volume deficiency will always occur afterwounding; and therefore it is logical that immediate restoration be started.
As soon as a casualty arrives at a battalion aid station, it is theresponsibility of the medical officer to make a cursory examination andto correct obvious defects. This includes the control of hemorrhage, togetherwith closure of sucking wounds of the chest, and clearance of the airway.Simultaneously replacement therapy should be started.
Tourniquets should be used judiciously. Too frequently a tourniquetis used when a large, properly applied pressure dressing would better controlhemorrhage. Application of a tourniquet often increases venous bleeding.In massive arterial bleeding and in crushed or mangled extremities, a tourniquetmay be lifesaving. If necessary, tourniquets may be permitted to remainin place for 11/2 hoursor longer; but they may be loosened at shorter intervals if the casualty'scondition will not become more critical because of risk of added bloodloss. Not infrequently, a tourniquet may be used as an emergency procedure;and, after further evaluation, bleeding may be controlled by a pressuredressing. Since venous bleeding persists in spite of a tourniquet, it isalways wise to put a. firm pressure dressing over the wound at the sametime the tourniquet is applied.
A free airway must be maintained, or hypoxia will lead to rapid deterioration.Frequently, positioning of the patient on his side and pulling out histongue is sufficient to establish an adequate airway. In severe maxillofacialwounds, neck wounds, or wounds of the head and chest, it may be necessaryto do a tracheotomy in an aid station.
Fractures must be splinted properly before transportation. An unsplintedfracture increases damage to muscle and thereby promotes further bloodloss. Pain, associated with movement in all unsplinted fracture, aggravatesthe casualty's poor condition.
Since wounds break the barrier against bacteria, early antibiotic therapyis indicated. Whenever possible, large doses of penicillin should be givenintravenously. When procaine penicillin is used, 300,000 units should begiven in three or four different deposits for more rapid absorption.
The battalion surgeon is not merely a first aid man but a most importantmember of the resuscitative team. The care that he gives is of an emergencytype, but he must also take time to institute initial procedures whichwill best prepare the wounded soldier for transpor-
108
tation. A severely wounded casualty's chance of survival during transportationcan be greatly enhanced by the infusion of 2 or 3 units of a plasma expander.Hurried evacuation may lead to undue deterioration during transportation.The importance of a short time lag between injury and admission to a forwardhospital is well recognized; but the battalion surgeon must weigh the advantagesof a slightly prolonged evacuation time against the ability of the casualtyto withstand transportation.
The most common mistakes made in division units are inadequate controlof hemorrhage, inadequate splinting, overdosing with morphine, and hastyevacuation not allowing time for proper preparation of a casualty for transport.It is recognized that, in a rapidly moving type of warfare at the battalionlevel, the heavy flow of casualties may prohibit a medical officer fromadministering ideal care. At all times, however, his aim should be to puta casualty in the best possible condition for transportation in the shortestperiod of time.
Resuscitation at a Forward Surgical Hospital
Resuscitation at a forward surgical hospital may be divided into threephases: preoperative, operative and postoperative.
Preoperative Resuscitation
As soon as a wounded soldier arrives at the hospital, the surgeon mustperform the same examination as was carried out at the battalion aid station.He should determine that hemorrhage is controlled and that there is anadequate airway. He should immediately start transfusion of blood if indicated.Nasal oxygen is of value if cyanosis is present, if there is a depressedrespiration, a chest wound or massive blood loss. Blood should be startedthrough a 15- or 17-gauge needle; it may be necessary to use two or threetransfusions simultaneously. If a large amount of blood replacement isanticipated, it is wise to expose an accessible vein surgically and tiein a cannula. When it is difficult to find a suitable vein, a 13-gaugeneedle may be inserted into the femoral vein and a long segment of plastictubing threaded into the inferior vena cava. The needle can be removedimmediately allowing the plastic tubing to remain in place. This tubingshould be removed after 24 hours or clots may form, giving rise to pulmonaryembolism.
The rate of administration of blood is most important. Blood volumedeficiency should be replaced as rapidly as possible. In severely woundedpatients who are admitted with a blood pressure too low to be obtainedby the usual cuff method, it may be necessary to start blood in three orfour veins and give it at a rate of 100 cc. or
109
more per minute. As soon as the blood pressure has risen to 80 systolic,the rate of administration may be retarded.
It is difficult to determine the real value of intra-arterial transfusion.It is generally accepted that the value of this type of transfusion isthe increased rapidity with which blood can be administered. A review ofthe experiences with casualties who had marked blood volume deficiencyat the 46th Surgical Hospital showed that the average rate of administrationby the intra-arterial route was 88 cc. per minute. In a comparable groupof wounded soldiers, the rate by vein was 70 cc. per minute. No attemptwas made by the observers to achieve an absolute maximum rate of infusionby either method. No definite conclusions could be drawn from this verylimited experience. However, the impressions gained were that blood bythe intra-arterial route was of no more value in the resuscitation of patientsin deep oligemic shock than was blood by the intravenous route, providedit was given at the same rate by both methods. It was observed that theblood replacement in the small series of similarly wounded soldiers wasaccomplished as rapidly by multiple intravenous route as it was by theintra-arterial route. Further data and controlled experience must be obtainedbefore the real value of intra-arterial transfusion can be ascertained.
Regardless of route of administration, many transfusions given in aforward hospital must be infused under pressure. Pumping air into the bottleof blood is the presently accepted method. Air embolism is a grave inherentdanger in this procedure. In Korea, during 1952 and 1953, five deaths werereported from this procedure as a result of air embolism.
Transfusion must be continued until the casualty is ready for operation.It is most difficult to decide when a casualty's blood volume has beenreplaced to the extent that he can best tolerate anesthesia and surgery.Unless continued hemorrhage is present and operation is necessary to controlthis hemorrhage, a wounded soldier should be in the best condition possiblebefore being subjected to the operative procedure. The value of adequatepreparation of a patient has frequently been emphasized in elective civiliansurgery. Likewise in the surgery of trauma, the casualty withstands theoperative procedure better if he is properly restored before the operation.This means that his blood volume deficiency must be replaced to near normallevels. It is common to underestimate the amount of blood that has beenlost. Redressing is done in the chain of evacuation by nurses and corpsmen;hence the surgeon does not see the large quantities of blood that may haveexuded from the wound. His guides to adequacy of restoration consist ofblood pressure, pulse rate and output of urine. If sufficient blood hasbeen provided to permit good periph-
110
eral circulation, it will be indicated by the blood pressure. The adequacyof visceral blood flow can be estimated by the flow of urine. In severelywounded soldiers, a catheter should be inserted in the bladder in orderto observe the output of urine. If a casualty excretes urine at the rateof 30 to 40 cc. per hour, adequate replacement can be assumed. Normal bloodpressure does not always mean adequate replacement. A wounded soldier usuallyrequires one to two units of blood after his systolic blood pressure hasrisen to 100.
Surgeons with experience in forward areas are able to judge blood requirementsby the size and character of the wound and the adequacy of restorationby general appearance and color of the conjunctiva. In the absence of hemo-or pneumothorax, injury to the central nervous system, or anoxia from blockageof the respiratory passages, hypotension usually means deficiency in bloodvolume. Replacement should be completed as rapidly as possible; however,it may require a few hours. Sometimes a surgeon observes that hemorrhageis occurring as rapidly as blood is being replaced. Blood should then bestarted through two or three veins and the casualty should be placed onthe operating table immediately.
In some patients with extensive wounds, slow blood loss will continuethroughout the preoperative period and the blood pressure will rise veryslowly. There may be a tendency to hold these patients in the preoperativesection too long. It is useless to continue to replace blood endlesslywhen it is being lost almost as rapidly as it is being infused.
In the presence of slow, continuous hemorrhage, it is usually possibleto infuse 3 or 4 units of blood rapidly, and then start the operation.If the delay is too great prior to operation, the patient may require 8or 10 pints of blood before operation. He then will require about 10 pintsof blood during the operative procedure and the total amount of blood administeredwill exceed 20 pints. In casualties who have received 18 or 20 pints ofstored blood, a deficiency in the clotting mechanism may occur and fataloozing from all wound surfaces may result.
A casualty is usually ready for operation when his systolic blood pressurereaches 110 and his pulse rate has fallen to 120. Frequently it is difficultto select the optimum time for operation. When the systolic blood pressurereaches 100 or 110, he may be moved to X-ray. If he is properly resuscitated,the movement will not cause a fall in blood pressure. On the other hand,if the casualty has an appreciable blood volume deficiency, a fall in bloodpressure will occur when he is moved. This appears to be an additionalcriterion by which a surgeon can judge the adequacy of preparation foroperation.
111
A simple tilt table was devised by the Surgical Research Team in Korea.The table was made of wood with a platform of a size convenient for holdinga litter. The platform was suspended in such a manner as to have a fulcrumin the center, thereby enabling adjustment of the degree of tilt. By tiltingthe casualty's head up 30 degrees and observing his condition and bloodpressure, the surgeon could obtain some indication as to the adequacy ofrestoration. If, by sufficient transfusion, a casualty was properly preparedfor surgery, he could withstand a tilt of his head up 30 degrees for 10minutes. If his condition deteriorated and his blood pressure fell, however,it was a good indication that additional blood was required. By generalobservation, surgeons experienced in resuscitation of the severely woundedcan usually tell when a patient is ready for surgery. In questionable cases,on the other hand, the tilt table helps to determine the adequacy of thecirculation.
Control of hemmorrage is a real problem in severely wounded casualties.In vascular injuries of appreciable extent, it may be possible to cut downon the vessel under local anesthesia above the site of injury and thenapply an artery clamp. If there is generalized oozing, an improved pressuredressing may suffice. Concealed hemorrhage in a casualty's abdomen or chestmay be the cause of failure of response. When there is a wound in thatarea, careful attention should be given to the size of the abdomen. A rapidlyexpanding abdomen may mean serious intra-abdominal hemorrhage.
A thorough search must be made for respiratory complications. Severehypotension may be due to air or blood in the chest or to cardiac tamponade.
Resuscitation During Operation
During the operative procedure the surgeon must constantly estimatethe amount of blood the patient is losing and make sure that it is replaced.Patients who have large wounds, particularly of the abdomen, chest or arteries,should have two large needles or cannulas well anchored in the veins inorder that blood can be given rapidly under pressure through multiple portals.When several areas are injured there is constant oozing until the initialsurgery is carried out. To minimize blood loss the operative procedureshould be performed as expeditiously as possible. When feasible, in casualtieswho have multiple wounds two surgical teams may work in different areasto lessen the time of anesthesia and operation.
The surgeon should always be near the patient during the induction ofanesthesia because of the possibility of cardiac arrest. During the last6 months of the Korean war 14 cases of cardiac arrest were
112
reported in forward hospitals and all but 2 of these casualties died.After the removal of the endotracheal tube at the termination of operation,it is important to clear the airway.
Resuscitation During the Postoperative Period
Continued restoration and careful observation is an important part ofresuscitation during the postoperative period. Too frequently the surgeonfeels that he has restored a casualty's blood volume, through adequateprocedure, and then he expects an uneventful recovery without further therapy.However, in patients with multiple severe wounds complications are common.It is imperative that the patient be examined frequently for continuedblood loss, atelectasis and collection of blood in the chest. Careful recordingof the blood pressure and hourly measurement of the output of urine areessential guides to therapy. A patient who is hypotensive after operationand does not excrete urine probably has a blood volume deficiency whichrequires further replacement. Among 138 severely wounded soldiers, 18 ofthe 61 requiring a total of 5 to 10 pints of blood in their first 24 hoursafter surgery were given more than a pint of blood postoperatively. Ofthose needing 10 to 35 pints of blood, in a more severely wounded group,over half were given more than 2 pints of blood in the immediate postoperativeperiod.
Most casualties who are hypotensive after surgery require additionalblood. On the other hand, there are some few whose compensatory mechanismshave been damaged by anesthesia and they will not respond to further resuscitativefluid therapy. Such wounded soldiers may be supported by norepinephrine.However, the most important and most frequent cause of postoperative hypotensionin injured soldiers is an insufficient amount of circulating blood volume.Transfusion after operation should be performed with caution. Frequentauscultation of the chest is essential for signs of pulmonary edema. Aslong as a casualty's blood pressure is below 80 systolic and he is notexcreting urine, he has need for additional blood; therefore, overtransfusionis unlikely.
Continued oozing may occur in patients who have had from 18 to 20 pintsof stored blood. No one knows what deficiency in stored blood preventsnatural clotting. Sometimes such a deficiency may be replaced by freshblood. Severe oozing occurred in one casualty who received 39 units ofstored blood. This oozing did not cease until after 6 pints of fresh typeO blood had been administered.
As soon as a casualty's blood volume is restored to near normal levels,electrolyte solutions and water should be administered.
113
Summary
Since the wound is a continuing insult to the body, resuscitation mustbe a continuing process. Restoration should begin as soon as the patientis seen and continue throughout the preoperative, operative and postoperativephases of the patient's care.
