Medical Science Publication No. 4, Volume 1
PREOPERATIVE AND POSTOPERATIVE CARE OF BATTLECASUALTIES*
MAJOR CURTIS P. ARTZ,MC
CAPTAIN ALVIN W. BRONWELL,MC
AND
CAPTAIN YOSHIO SAKO,MC
In recent years, more and more attention has been focused on the careof patients before and after operation. In the Korean conflict, great emphasiswas placed on preoperative and postoperative care.
General Aspects of Preoperative Care
As soon as a casualty is admitted to the hospital all his clothing shouldbe removed. In the preoperative section, it is important for the medicalofficer to examine the entire body in order that all wounds may be recognized.A brief record should be made of the findings. A review of the emergencymedical tag will point out the results of previous examinations. It maybe necessary to perform a very cursory examination and immediately beginrestorative treatment. A more complete examination can be carried out whenthe casualty's general condition improves.
A record of the blood pressure and pulse rate should be started immediatelyupon admission. This record may be maintained by the attending corpsman.It provides the medical officer with information concerning the progressof the injured soldier's condition.
Most wounded men require resuscitative fluids. Replacement therapy shouldbe instituted in accordance with the severity of the injury. Large-boreneedles should always be used for infusion. It may be necessary to exposea vein surgically and insert a cannula or to insert a long, polyethylenecatheter through a large-bore needle into the femoral vein. Since woundedmen are usually restless, the needle or cannula must be fastened securely.
*Presented 20 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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Adequate Airway
Casualties with injuries of the chest, neck or head may have obstrutionsof the respiratory passages. An adequate airway must be established assoon as possible. This may be accomplished by aspirating the posteriorpharynx and trachea and positioning the casualty on his side and pullingout his tongue. Not infrequently a tracheotomy will be necessary. Tracheotomyshould never be delayed or considered as a last-resort measure. It is asimple operative procedure that not only assists in establishing a clearairway but offers a convenient and safe method of maintaining tracheobronchialtoilet. Increased secretions or blood in the trachea may lead to anoxia.Oral or nasopharyngeal suction consume time and may be inadequate. Aftera tracheotomy is performed, it is easy for the corpsman or the nurse tokeep the trachea clear. Too frequently tracheotomy is delayed because itis believed to be a procedure that increases nursing care; actually, however,it lessens nursing care.
Control of Hemorrhage
Careful attention should be paid to control of hemorrhage. In the mostseverely wounded casualties, it may be quite difficult. In the slightlywounded casualty, hemorrhage can usually be controlled by a pressure dressing;however, all areas of injury should be observed and adequate dressingsshould be applied. Too frequently several small wounds will be neglectedand an appreciable amount of blood will ooze from them. In the preoperativesection of a forward hospital, careful attention should be paid to theproper application of tourniquets. Patients may be observed who actuallyhave an increase in the amount of blood lost from a limb because of theapplication of a tourniquet. A tourniquet will control bleeding in mostcasualties who have wounds of an extremity. Sometimes a tourniquet partiallycontrols arterial bleeding, but actually increases venous oozing. It isnecessary to apply a firm, bulky pressure dressing in order to controlvenous bleeding. In casualties with laceration of a large vessel, hemostaticclamps may be applied if the vessel can be easily located.
Narcotics
Severely wounded soldiers experience little pain but have a great dealof fear and anxiety. It is important that the medical officer, nurse andcorpsman attempt to alleviate this fear and anxiety. The patient shouldbe made as comfortable as possible. Such a simple procedure as washinga patient's face may help considerably in contributing to his feeling ofwell-being. It may be necessary to give some patients a narcotic. For animmediate effect, it should be administered intravenously.
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Prevention of Infection
American soldiers are immunized with tetanus toxoid. A booster doseof toxoid should be given as soon as a casualty is admitted to a forwardhospital. Antibiotics should be given to all wounded soldiers to preventinfection. The amount and type of antibiotic therapy may vary accordingto current practice. At the 46th Surgical Hospital, casualties were given500,000 units of penicillin and 0.5 gram of streptomycin intravenouslyas soon as they were admitted. Intravenous antibiotic therapy was continuedthroughout the early postoperative course. As soon as the injured man'scondition was stabilized, 600,000 units of crystalline penicillin and 0.5gram of streptomycin were given intramuscularly twice a day for the first5 days. Thereafter, antibiotic therapy was given only on specific indication.In abdominal injuries, some surgeons used 1 gram of terramycin intravenouslytwice a day.
Abdominal Wounds
An indwelling gastric tube should be placed in all casualties who haveabdominal injuries. An attempt should be made to empty the stomach. Thisis frequently unsuccessful because of the presence of a large amount ofundigested food in the stomach at the time of injury.
By placing a catheter in the bladder, output of urine can be measuredand information can be obtained concerning injury to the genitourinarytract. If there has been damage to the urinary system, the urine will showgross blood. The rate of flow of urine will indicate the adequacy of resuscitation.
Whenever a wound of the rectum is suspected, a rectal examination shouldbe made. If injury cannot be determined by digital examination, a proctoscopicexamination should be performed. Most surgeons insert the proctoscope onthe operating table immediately after the induction of anesthesia.
Roentgenograms are of value in determining the presence of shell fragments,free air or retroperitoneal hemorrhage. It is difficult to localize fragmentsin the abdomen accurately, especially if they lie near the spine, in thepelvis, or near the parietal peritoneum. Free air under the diaphragm indicatesa perforated viscus, and absence of a psoas shadow usually denotes obliterationby hemorrhage.
In the preoperative preparation of casualties with abdominal injuries,it is important to determine immediately the presence of gross intra-abdominalhemorrhage. If a wounded man does not respond readily to a rapid infusionof blood and if he has a rapidly expanding abdomen, it may be assumed thata large abdominal vessel has been injured. In such instances, blood shouldbe infused rapidly and
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immediate operation should be performed without further preparation.
The surgeon who is to accept the responsibility of operation shouldgo over the casualty's entire history, record of examination and x-rays.Not infrequently certain injuries are missed by the operating surgeon unlesshe makes a thorough review of the findings. The surgeon should discussthe proposed operative procedure and resuscitative measures with the anesthesiologist.
Immediately after operation, an accurate chart should be kept of bloodpressure, pulse rate and hourly output of urine. This will indicate theprogress of the casualty and aid in determining the amount of resuscitativefluids required. A hematocrit may be of some value in determining the needfor further blood. A hypotensive casualty with a low hematocrit usuallyrequires additional blood. However, most soldiers who have abdominal injurieshave a hematocrit that may rise for the first 24 or 48 hours after operation.This is believed to be caused by loss of plasma into the lumen of the bowel,into the bowel wall and into the peritoneal cavity.
Intragastric suction should be continued. A great deal of care may berequired to keep the tube functioning. Frequent irrigation of the tubeis essential. In casualties with an intranasal gastric tube who are alsoreceiving oxygen by nasal catheter, it is important to be certain thatthe oxygen cylinder is not inadvertently connected to the gastric tube.When this occurs, tremendous gastric dilation follows and the casualty'scondition may deteriorate rapidly. Acute gastric distention may occur inthe presence of a non-functioning intragastric tube when oxygen is administeredby nasal catheter.
In the immediate postoperative period, frequent examination of the casualtyshould be made. Since atelectasis is one of the more common complicationsfollowing abdominal injuries, the patient should be urged to take deepbreaths and to cough. A good method of maintaining tracheal toilet is aspirationof the trachea through the nasopharynx at frequent intervals. When heavy,thick secretions block the bronchial tract, bronchoscopy may be necessary.
As soon as the blood volume has been restored, electrolyte solutionsand water should be given. Most casualties have been without water formany hours. Some of these soldiers may have been on patrol prior to injury.Casualties who have abdominal wounds require it least 3,000 cc. of fluidsby vein daily; 1,000 cc. or more of glucose in saline and 2,000 cc. ofglucose in water. When intragastric suction is continued for several days,the casualty may require potassium.
Most young soldiers who sustain abdominal wounds can be ambulated onthe day following the operation. On the second or third postoperative day,an abdominal wound should be examined. The
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wire stay sutures may require loosening because of edema of the woundedges. Before a casualty is evacuated, a careful examination should bemade of all his wounds.
Thoracic Wounds
Many thoracic wounds do not require operation and are therefore treatedin the preoperative section of the hospital. Hemothorax or pneumothoraxshould be diagnosed as early as possible and can usually be managed bythoracentesis. Tension pneumothorax requires immediate decompression. Ifa wounded soldier has an injury to the chest and if he has a great dealof respiratory difficulty, it is unnecessary to wait for roentgenograms.Exploratory thoracentesis may be carried out to aspirate air or blood.Sucking wounds of the chest should be closed by a large occlusion dressing.In preoperative preparation of a casualty with a thoracic injury, it isthe surgeon's aim to restore the respiratory physiology as nearly as possibleto normal. This may require a tracheotomy in order to clear the respiratorytract of excessive secretions and blood. An intercostal nerve block relievespain and permits increase in respiratory excursion.
In casualties that require multiple, frequent thoracenteses, a tubethoracotomy may be performed. When a tube is inserted and water-seal drainageis used, particular attention must be paid to the mechanics of the systemin order that water will not flow into the pleural space. The tube shouldbe removed before the casualty is evacuated. In the Korean conflict, severalwounded soldiers were evacuated with tube thoracotomies in place and subsequentlyempyema developed.
Repeated roentgenograms may be necessary in order to follow the courseof the pulmonary changes. Thoracotomies should be drained postoperativelywith water-seal drainage in nearly all patients. The water trap bottleshould be clearly labeled and corpsmen should be instructed to pay particularattention to the apparatus.
Since atelectasis is a frequent complication of chest operations, everyeffort should be made to encourage the patient to breathe deeply and tocough frequently. Intercostal nerve block helps the patient to breathemore comfortably and to cough. Whenever atelectasis occurs, a bronchoscopyshould be performed.
Care should be taken not to overtransfuse casualties who have sustainedinjuries to the chest. Frequent auscultation is required to evaluate thechest findings.
A roentgenogram should be taken immediately following a chest operationand at regular intervals thereafter. Narcotics should be used sparingly.Most pain can be controlled by intercostal nerve block.
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Extremity Wounds
In wounds of the extremities, careful records should be made of nerve,vascular and bone injury. It may be necessary to refer to these findingslater.
When a fracture is present, the extremity must be immobilized. Motionin an unsplinted extremity causes considerable pain, further tissue damageand bleeding. Roentgenograms should be made in all extremity wounds inorder to determine the site and extent of bone injury and the locationand size of retained fragments. When several wounds have been débridedand left open, considerable oozing may occur. Postoperatively, frequentexaminations of wounds should be made in order to detect any further bleeding.The extremity enclosed in a cast should be examined for edema and evidenceof circulatory impairment. Although all casts have a segment resected topermit expansion when edema occurs, the surgeon must make sure that unduepressure is not being exerted on any part of the injured extremity.
In extremity wounds, it is extremely important to explain the extentof injury to the casualty. In many instances, an injured soldier is fearfulthat his injury may lead to amputation or permanent disability. In casualtieson whom amputations have been performed, great care must be taken to explainthat every effort was made to save the extremity. A soldier will usuallyaccept this new situation better if an explanation is made at the forwardhospital, rather than later. Chaplains and nurses are of assistance tothe surgeon in helping an injured soldier overcome his problems of adjustment.
Casualties who have minor wounds of the extremities may be evacuatedon the day following injury. When casualties are held longer than 24 hours,however, wounds should be examined and redressed prior to evacuation. Thisgives the surgeon an opportunity to determine the adequacy of the débridementand to make sure that the wounds are properly dressed before evacuation.It is difficult to do a complete débridement in very large woundsof the buttocks and upper thigh; hence further excision of devitalizedtissue is usually necessary. This should be carried out before the casualtyis evacuated.
Wounds of the Neck and Face
The usual preoperative procedures of blood replacement and roentgenographicexamination are carried out in casualties who have wounds of the neck.If profuse bleeding occurs inside the mouth, it may be necessary to doa tracheotomy and pack the mouth in order to control hemorrhage. In woundsof the neck, a tracheotomy may be
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required for the establishment of an airway or for tracheobronchialtoilet.
Improvement of Preoperative and Postoperative Care
In any type of medical care, it is important to maintain a record ofexperiences. Only by reviewing casualties' records can information be ascertainedabout the mortality, morbidity, complications and efficacy of treatment.Since evacuation, tactical situations and types of injury differ from warto war-even from campaign to campaign-it is imperative in forward surgicalunits to keep careful records and analyze them frequently.
Routine records are necessarily brief because of time limitations. Theserecords are usually placed in in envelope and they accompany the casualtyas he is evacuated. Unless a separate record is kept at the forward hospital,the medical officers in forward units do not have an opportunity to reviewtheir experiences. To depend upon each surgeon to maintain a record ofhis own experiences will not provide uniform data. Therefore, it is necessaryto furnish some type of standardized data sheet for use in forward areas.The data from these sheets should be thoroughly studied each month in orderthat the medical officers may obtain a summary of their experiences andbe guided accordingly if changes in technics and practices are indicated.Unless some satisfactory procedure is established for summarizing currentexperiences, it is difficult to determine the problems that require furtherstudy and to ascertain the areas in which improvements must be made.
During the final few months of the Korean conflict, a statistical datasheet was used at the 46th Surgical Hospital. This form was placed in thewounded soldier's envelope and accompanied him through the preoperativesection, operating room and recovery section. The initial information onresuscitative fluids and time intervals was completed during the operativeprocedure by the anesthesiologist. The remainder of the sheet was completedby the surgeon. These sheets were retained at the hospital and summarizedmonthly. All surgeons then had an opportunity to observe the results oftheir work.
A tremendous amount of valuable information might be gained in a theaterof combat if these data sheets were completed on every casualty seen ina forward surgical hospital. At the end of each month, summaries of theinformation on these forms could be sent to the surgical consultant inthe theater, and he, in turn, could correlate the information and obtainall overall view of the professional care being administered throughoutthe theater. Without some type of statistical summary it is impossibleto obtain the much needed information on surgical experiences and care.
