Medical Science Publication No. 4, Volume 1
ANESTHESIA FOR COMBAT CASUALTIES ON THE BASISOF EXPERIENCE IN KOREA*
ROBERT D. DRIPPS,M. D.
Because of the type of warfare in Korea during the 18 months precedingthe armistice, treatment of the battle casualty was almost ideal. Therewas prompt evacuation, ample supply of whole blood, rarely were peak loadsa problem and personnel, equipment and supplies were adequate generally.The mortality and morbidity figures set in Korea may never be equaled.Valuable lessons were learned, however, and possibilities for improvementin care of the combat casualty still exist. In this paper the Korean experiencewill be analyzed from the standpoint of anesthesia.
Korea did not turn up new data on the anesthetic management of the wounded.The basic problems involved were merely re-emphasized, and one had thedisturbing impression that mankind must relearn hard-won lessons from individualexperience rather than build on knowledge previously gained. A few quotationsfrom the British Medical Research Council's Special Report No. 26 entitled"Traumatic Toxemia as a Factor in Shock" (14 March 1919) makethis clear. "The surgeon experienced another disappointment. If hismeasures were sufficient to put the soldier into a state that justifiedoperation, this procedure produced a relapse. A great deal of the bad effectswere to be attributed to the anesthetic. Chloroform had long been recognizedas dangerous, but it was more evident that ether and other anestheticswere far from harmless. Gas and oxygen was the least noxious and with itswider adoption postoperative shock greatly diminished."
The severely wounded soldier is inordinately susceptible to narcosisregardless of the agent or technic selected. Prior to anesthesia he presentsa picture of apathy and depression suggestive of decreased central nervoussystem function. He appears to be partially narcotized already. In sucha patient small amounts of central nervous depressant drugs evoke a responseout of proportion to the size of the dose administered. "Normal"dosage regimens will cause death sufficiently frequently to drive thispoint home to the tyro. The pro-
*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.
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longed postoperative sleep of many of these patients tends to supportthe above. The physiological basis for this susceptibility is not completelyunderstood. It is undoubtedly bound up with the numerous factors responsiblefor shock and hence has humoral, endocrine, toxic, hemodynamic and psychicaspects, to mention a few.
Experiences in World War I also emphasized the hazard of moving thecombat casualty, the necessity for parenteral fluids, the problem of theoptimal time after resuscitation for surgical intervention and the questionof how much to do at that time. These are the crucial questions which WorldWar II revived and which were again noted in Korea. Unless atomic or hydrogenbombs bring physiologic changes peculiar to them, one can expect futureconflicts to pose essentially the same problems.
From the standpoint of "choice of anesthesia" one can setdown the following generalities.
Preoperative Medication
The use of morphine to relieve pain, to prepare an individual psychologicallyfor operation and to reduce the amount of additional drugs needed for anesthesiahas been traditional. Yet many investigators have recorded the untowardreactions of man to morphine. Its ability to impair the normal compensatoryresponse to circulatory stress is well documented. The prolonged actionof a single dose can be shown readily. Such side actions as nausea, vomiting,urinary retention and constriction of smooth muscle in the biliary andrespiratory passages are undesirable. Because of tradition, however, itis difficult to eliminate the injection of morphine. Yet morphine has littleor no place in the management of the seriously wounded. Men in shock rarelycomplain of pain. They do complain bitterly of thirst but this is not anindication for morphine. They may be anxious and fearful. These are notindications for morphine. Beecher has suggested barbiturates. I wonderif any drug is needed. The sympathetic attention of corpsmen, doctors andnurses does wonders. If, as anesthesia progresses and resuscitation becomesmore established, large amounts of anesthetic drugs appear necessary, theintravenous injection of morphine or meperidine (demerol) may be useful.
The educational campaign outlining the possibilities of harm of morphinemust be continued, for although abuse of this drug is now less frequentoverdosage is still seen. Aidmen and medical officers must be made to understandthe drug better. In the event of overdosage, n-allylnor-morphine appearsuseful in reversing both the respiratory and circulatory depressant effects.This drug, which is administered intravenously, will return respiratoryminute volume towards normal within 60 seconds. Its pressor effect is notas well
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substantiated at the moment but a blood-pressure-raising action hasbeen described.
The belladonna drugs are still used and may be given intravenously aswell as intramuscularly. Whether scopolamine is preferable to atropinecannot be stated with finality. The tendency of the former to produce mentalaberrations is undesirable.
Choice of Anesthesia
The guiding principle for the administration of anesthesia to any patientis use of the least amount of narcotic compatible with the surgical requirements.As already stated, this is essential in the severely wounded. The susceptibilityof the serious battle casualty to anesthesia enables one to provide satisfactoryworking conditions with 50 to 60 percent nitrous oxide in oxygen in manypatients. This concentration will not produce even minimal surgical anesthesiain normal individuals, but if satisfactory results can be obtained theshocked patient has been spared the consequences of a more potent depressant.This technic deserves continued application. I used it successfully inKorea, as have others to whom it has been suggested.
It is difficult to divorce the problem of selection of anesthetic agentfrom a consideration of the background of the anesthetist. Fortunately,the training of physicians in the specialty of anesthesiology has increasedgreatly during the past decade. Specialists were available in MASH unitsin Korea and in installations behind these mobile hospitals. Some of theseindividuals were trained in one approach to the anesthetic management ofthe substandard patients. Others had had a different indoctrination. Untildefinitive data are available to prove that one agent or technic is superiorto another in the management of the severely wounded it would seem wiseto permit anesthetists to apply those methods with which they are mostfamiliar. If the patient's susceptibility is kept foremost in one's thinking,this approach appears reasonable.
Those men trained primarily in the administration of thiopental soonrealized that very small doses of this drug suffice. Profound depressionmay be produced by 25 to 50 mg. If such be the case, it is my opinion thatthiopental should be abandoned since nitrous oxide with adequate quantitiesof oxygen will undoubtedly be all that is necessary. If more thiopentalbe required but the amounts still do not compare to those used in patientsin good physical condition, this fact must constantly be remembered lestoverdosage result. Supplementation with nitrous oxide-oxygen is almostinvariable.
Beecher has stated that the induction of anesthesia with ether aloneis safe in the seriously wounded. Yet I have produced severe hypo-
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tension in battle casualties with this drug in apparently very lightplanes of anesthesia. According to recent studies the safety of ether sofar as the circulation is concerned lies in its ability to mobilize epinephrineand norepinephrine from adrenal medulla and sympathetic nerve endings.If this be prevented totally or in part, ether is a potent circulatorydepressant. Probably in certain seriously wounded patients such mobilizationis reduced.
Observations by Zweifach and Chambers of the greater tolerance of dogsto blood loss during cyclopropane as compared to ether are corroboratedby Crooke's statement during World War II that "the best anestheticused in our shocked patients was cyclopropane," and the data of Hersheyand Rovenstine on the value of cyclopropane in the management of patientswith recent severe hemorrhage. I believe that this drug has a place inthe anesthetic management of the battle casualty and that it does not deservethe neglect of military planners.
Unless it can be shown that some such technic as the use of a continuousdrip of norepinephrine will maintain adequate circulation during spinalanesthesia, this method of pain relief probably has no place in the managementof the seriously wounded. The circulatory alterations produced by spinalanesthesia would seem contraindicated for such patients.
For intra-abdominal operations in substandard patients, bilateral intercostalblock can provide excellent muscular relaxation in light planes of generalanesthesia. The block can be performed after the patient is put to sleepso that the multiple needle sticks are not objectionable. Other forms ofregional anesthesia also have a place if dilute solutions are used andoverdosage with its threat of hypotension is avoided. An 0.5 percent solutionof procaine is adequate for infiltration anesthesia. For nerve block a1 percent solution should suffice.
The "curare" group of drugs proved of great value in Korea;d-Tubocurarine and succinylcholine were most frequently used. These substancespermitted rapid intubation of the trachea, and provided muscular relaxationfor varying periods of time when this was essential. Patients in shocktended to react to succinylcholine with an exaggerated degree of muscularfasciculation. Occasionally this motor activity resembled clonic convulsions.It is possible that this represented a diminished amount of plasma cholinesterase.This deserves study as one of the derangements associated with shock.
Illustrations of some of the principles discussed above are presentedin figures 1 to 10.
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FIGURE1. A 21-year-old American soldier with both legsblown off by a mine. On the left side the loss was close to the pelvis;on the right the loss occurred at the junction of the upper and middlethird of the femur. Despite heroic transfusion therapy consisting of 14,000cc. of whole blood in 2 hours and with a preanesthetic blood pressure of110/70 and a pulse rate of 111, attempts at anesthesia with nitrous oxide-oxygen(60: 40) and attempts to prepare the wounds for débridement broughtcomplete collapse of the circulation. Operation was canceled.
Suggestions for the Future
War in the future may well involve many nations and many geographicareas. Civilian as well as military casualties can be expected. Infants,children and the aged and infirm may require anesthesia. National differencesin electric current, terminology, coloring of gas cylinders and the likeshould be anticipated and efforts at standardization made. Furthermore,the earlier habit of the Armed Forces of limiting anesthetic equipmentand supplies should be changed. Anesthesia is now an established scienceand art. As such it functions
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better if a variety of agents and technics are available. Fortunately,none of these are bulky and space for shipment or storage should not provea problem.
FIGURE2. The soldier discussedin figure 1 was re-anesthetized 48 hours after the first attempt. He hadreceived a total of 19,000 cc. of whole blood, had a blood pressure of124/70 and a pulse rate of 126. High bilateral amputation of both thighswas successfully completed under extremely light anesthesia with smallamounts of pentothal and nitrous oxide-oxygen.
1. Equipment
The Table of Supplies should he broadened to include equipment recognizedto be of value in anesthesia. Kits should be provided which would containseveral types of laryngoscope blades, oral and nasotracheal tubes of varioussizes including those for infants and children, oral and nasal airways,syringes and needles for regional anesthesia, connectors and small partsfor anesthesia machines. The
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machines should be standardized so that cylinders from various countriescan be interchanged. Portable operating tables should be standardized sothat voltage differences in different countries will not be an obstacle.Suction equipment not requiring electricity should be provided.
FIGURE3. A 23-year-old white male who was pale, "tired"and thirsty despite 2,500 cc. of whole blood. His right leg had been blownoff below the knee by a mine. Blood pressure was 144/90 and pulse rate154. The relatively high blood pressure suggested maximal efforts at compensatoryvasoconstriction, and warned of hypotension with induction of anesthesia.This occurred as pentothal (200 mg.) was administered slowly over a 10-minuteperiod. A more seriously ill casualty might have had an even greater fallin blood pressure. Note the reduction in pulse pressure following anesthesia.
A field anesthesia record should be provided which will fit into theEMT jacket and accompany the casualty. This record should have sufficientblank space to permit recording of essential data.
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FIGURE4. A 24-year-old white male with multiple penetratingwounds of the abdomen. The pre-anesthetic pulse rate of 148 and the highdiastolic pressure should have warned of circulatory instability. Inductionof anesthesia was followed by a sharp decrease in blood pressure and anarrowing of the pulse pressure. The addition of ethyl ether vapor at 4p. m. brought a further reduction in arterial pressure. Five thousand cc.of fluid was administered during the operation. A pressor drug, neosynephrine,appeared of value.
2. Supplies
Drugs should be increased in scope. Various "curare" drugs,pressor agents such as norepinephrine, adrenolytic or ganglionic blockingdrugs, and various local anesthetics should be provided. Cyclopropane shouldbe available. All gas cylinders should conform to the international colorcode to avoid the confusion and dangers noted during World War II when,for example, a green American cylinder contained oxygen and a green Britishcylinder contained carbon dioxide.
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FIGURE5. A 26-year-old white male with penetrating woundsof the right side of chest, right hand and arm and left thigh. This soldierdid not appear to be seriously wounded. The hypotension which followedthe onset of anesthesia was related to a gross overdosage of pentothal.A technician anesthetist administered 1.5 gm. of this drug in 15 minutesin an effort to facilitate tracheal intubation. One cannot blame the drugin this instance so much as the way in which it was administered. It wasfortunate that a fatality was averted.
3. Organization
Much more would have been learned in Korea had mature, experienced anesthetistsbeen assigned to FECOM and the 8th Army as consultants. The recent provisionof a senior consultant in anesthesia in the Office of The Surgeon Generalhas been a valuable step. In future wars consultants for field units shouldbe made available. These men should be urged to administer anesthesia inforward units such as the surgical hospitals so as to have first-hand knowledgeof the problems involved, and thus to be able to advise and train othersmore authoritatively.
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FIGURE6. A 24-year-old white male who was not in shockprior to anesthesia. After 2 hours of a perfectly satisfactory pentothal-nitrousoxide-oxygen anesthesia this patient began to hiccup. The anesthetist failedto realize that pentothal can accumulate in the body as anesthesia progresses.Its rate of destruction (about 15 percent per hour) is slower than manyrecognize. Injection of 125 mg. of pentothal, a dose which was well toleratedat 6 p. m., caused profound respiratory and circulatory depression at 7:50p. m.
As Tovell has pointed out in "The History of Anesthesiology inthe European Theater of Operations" and as I stated in my report toThe Surgeon General in December of 1952, the greatest need for thoroughlyqualified physician anesthetists is in forward medical installations. Decisionsrequiring judgment and experience are required in these units. If improperlymade, the casualty will suffer.
A monthly report of the anesthetics administered, the physical conditionof the anesthetized subjects, and the results obtained should be requiredfrom each medical installation. It is a platitude to state that war iswasteful. Yet in reviewing the medical opportunities
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FIGURE7. A 24-year-old white male with gas gangrenein a right thigh amputation stump. Inadequate fluid therapy was partiallyresponsible for the severe hypotension noted. Ether anesthesia, however,although only mid-first plane according to clinical signs, appeared tocontribute to the profound circulatory collapse.
presented by combat-whatever the field of interest-one is impressedwith how much is lost, unrecorded and unappraised. How important, for example,it would be to have data on deaths related to anesthesia; to have recordsof different methods of management of various types of casualties; to knowthe course of the soldier who ultimately develped post-traumatic renalfailure, i. e., how long did hypotension exist, what kind of blood wasadministered; what were the incidence and sequelae of vomiting during anesthesiaof the soldier with a full stomach. These and dozens of other problemsdemand solutions. All personnel should be indoctrinated in the necessityof collecting data. Anesthetists should be stimulated to observe, recordand make sugges-
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FIGURE8. A 23-year-old white malewho did well during secondary closure of 35 penetrating wounds of the headand extremities. Operation, which required almost 3 hours, was performedunder dilute procaine 0.5 percent. The total volume of solution was high,but it must be remembered that this amount was given over a long periodof time.
tions based on their experience. Such an approach should increase interestamong anesthetists but must be initiated at top levels.
Under "Organization" should also be listed the provision offacilities for photography, wherever possible in color. This can preserveexperiences which otherwise are lost.
Finally, on the basis of World War II and Korean experience, facilitiesfor research should be planned in advance. The Surgical Research Team inKorea justified itself beyond expectation.
4. Education and Training
Manuals and training films for military anesthetists should be preparednow rather than waiting for an outbreak of hostilities. The
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FIGURE9. A 23-year-old white malewith a large gaping wound of the face and multiple penetrating wounds ofthe thighs. On admission this individual was pale, thirsty and had a bloodpressure of 90/70. After what appeared to be successful resuscitation withparenteral fluids, the patient was moved about 60 feet for X-ray examinations.Blood pressure promptly fell from 130/86 to 80/60 (The adverse effect ofmotion on the blood pressure was commonly seen.) After additonal effortsat resuscitation, induction of anesthesia was also followed by a declineof blood pressure from 112/72 to 60/45.
Subcommittee on Anesthesia of the National Research Council might begiven this responsibility in consultation with experts who have servedin World War II and in Korea. A sufficient amount of knowledge has nowaccumulated to make such manuals and films of value. Basic aspects of resuscitation,pharmacology and physiology should be included.
5. Projects for Research in Civilian and Military Centers
A number of problems bearing on the anesthetic management of battlecasualties require investigation. These include the effects of anes-
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FIGURE 10. A criticallyinjured 29-year-old Negro with penetrating wounds of the abdomen, skulland lower extremities. Onset of anesthesia was followed by profound hypotension.Neosynephrine was of no value, but norepinephrine by constant intravenousinfusion restored blood pressure to normal limits. Each time that the dripof this drug was slowed hypotension occurred.
thetic agents and technics on the adrenal cortex and medulla; the effectsof anesthetic agents on blood flow to various tissues and organs; the valueof adrenolytic or ganglionic blocking drugs in the management of hemorrhagicor wound shock; the role of vasoconstrictor drugs such as norepinephrinein the management of patients in shock of varying types; the utility ofhypothermia as an adjunct to anesthesia; the value of intra-arterial transfusion;the etiology and therapy of uncontrolled oozing during operation; the physiologicalterations in the circulation related to motion and change of position.
In addition, one must anticipate whether such future possibilities asatomic or hydrogen bomb warfare, combat in the Arctic, or use of
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chemical warfare agents will pose specific problems for the anesthetist.
Finally, clinical evaluation of such new technics as transtracheal injectionof topical anesthetics, continuous drip of pentothal, continuous drip ofsuccinylcholine and the use of trichlorethylene is needed. This shouldbe done by a number of competent individuals with subsequent discussionand analysis of results by a group. Again the Subcommittee on Anesthesiaof the National Research Council is suggested as an advisory body.
One is uncertain as to whether to recommend pharyngeal irritation toproduce vomiting in casualties who face anesthesia and who have full stomachs.This deserves exploration.
The severe, shaking chills seen during the immediate postoperative periodappear undesirable. Their cause and prevention should be considered. Thesemay be related to the effects of narcotics on temperature regulation, tothe administration of a large volume of cold blood or to exposure duringoperation.
The establishing of tests to assist in the selection of the ideal timefor initial surgical intervention merits thought. As a rule this decisioninvolves the art of anesthesia and surgery at the moment rather than thescience of these branches of medicine.
It is no exaggeration to say that World War II provided great impetusfor the growth of the specialty of anesthesiology. There are now many trainedindividuals available and more are being trained each year. Research workin anesthesia is progressing in a number of laboratories. The Armed Forcesshould benefit from this growth and development in any future conflict.But maximal benefit will come only if plans are made in advance.
