Medical Science Publication No. 4, Volume 1
ABDOMINAL AND THORACO-ABDOMINAL WOUNDS*
CAPTAIN ALVIN W. BRONWELL,MC
MAJOR CURTIS P. ARTZ,MC
AND
CAPTAIN YOSHIO SAKO,MC
Not until the middle of World War I were routine laparotomies performedfor exploration of abdominal wounds produced by battle injuries. Woundsof the abdomen were treated by rest and sedation prior to that time. Informationwas obtained in World War II as to the preferred method of treatment ofvarious types of abdominal injuries. During the final 6 months of the Koreanconflict, essentially the same operative procedures were used in all ofthe forward hospitals.
Incidence
Before the armored vest was used in Korea, 19 percent of the woundsof the body were in the chest, and 11 percent in the abdomen; thus 30 percentof all wounds were in the trunk. There was a decrease of 10 percent intrunk wounds after the use of the armored vest; 8.7 percent of all woundswere in the thorax and 10.8 percent in the abdomen (1).
Diagnosis
Patients with intra-abdominal injuries usually arrive at the forwardhospital with low blood pressure and a rapid pulse. The time interval frontinjury to admission, the extent of peritoneal contamination, and the amountof blood loss are factors in determining the degree of injury in casualtieswith comparable wounds. A rapid response to resuscitation is a good indicationthat the injury is not extensive. The severely wounded casualty respondsslowly to resuscitative measures. Pain is of little diagnostic value becausemany of the patients have received intravenous morphine prior to admission.Pain is not the most prominent finding even in those patients who havenot received morphine.
*Presented 22 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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In taking the history, it is of value to determine the type of missilewhich produced the injury and the position of the patient when hit. Afterpenetrating the skin, high-velocity missiles cause extensive destructionof internal organs. Low-velocity missiles of comparable size have a tearingaction on the skin, with less internal destruction of tissue; or they maynot penetrate the abdominal wall. Inspection of points of entrance andexit of the missile may suggest which organ or organs are damaged.
Abdominal distention is rarely present unless there is massive, intra-abdominalhemorrhage. Boardlike rigidity of the abdomen is seldom seen. When present,it is diagnostic of a perforated abdominal viscus. Patients with chestwounds or superficial abdominal wounds may have marked guarding or rigidityof the abdomen, even though there is no peritoneal irritation. Many patientswith perforated abdominal viscus have a soft abdomen at the time of admission.During resuscitation, such patients usually develop rigidity of the abdomen.Generalized tenderness is usually an indication of intra-abdominal injury.
A silent abdomen on auscultation is a good indication of a perforatedhollow viscus, resulting in leakage of intestinal contents. If peristalsisis present, along with other negative criteria, intra-abdominal injuryis doubtful and the patient should be carefully observed.
Roentgenograms should be taken of all casualties suspected of havingabdominal injury. They demonstrate the presence of intra-abdominal shellfragments, free air and retroperitoneal hemorrhage. One is not always ableto localize shell fragments by roentgenograms in instances where fragmentshave entered through the back or lie close to the peritoneum, and wherethere is a wound of the perineum and buttocks. When a psoas shadow cannotbe visualized on a roentgenogram, one should suspect the presence of retroperitonealhemorrhage.
Peritoneal taps are of little value in establishing the diagnosis ofintra-abdominal injury. An abdominal tap with positive findings is a definiteaid; while a negative tap does not rule out injury to intra-abdominal organs.
Technics of Abdominal Operations
All patients in this series received pentothal induction and endotrachealgas-oxygen-ether anesthesia, and curare-like drugs. The skin of the abdomenis prepared by shaving, washing with a detergent containing hexochlorophene,and irrigating with saline solution.
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Incisions
A long, muscle-splitting incision into the rectus muscle should be usedfor exploration of the abdomen. It should extend from the costal marginto the pubis. The abdominal incision should never pass through the siteof injury; but it should be placed a considerable distance from it or,if necessary, on the opposite side. A systematic examination of the abdominalcavity should be made immediately after the peritoneum has been opened.When bleeding is present, the small intestine should be eviscerated tofacilitate rapid exploration of the peritoneal cavity. The bleeding pointscan then be observed and the hemorrhage controlled immediately. When thishas been completed, the contents of the peritoneal cavity should be thoroughlyinspected from the cardia of the stomach to the peritoneal reflexion aboutthe sigmoid. When abdominal bleeding is not a problem, a complete examinationof the peritoneal cavity should be made with out eviscerating the smallintestine.
Stomach
On many occasions, battle casualties have eaten a short time beforeinjury. At operation they may still have a full stomach, even though vigorousattempts have been made to empty it. In such instances, it is advisableto incise the stomach and empty it. If this is not done, vomiting, aspirationand acute gastric dilatation may occur postoperatively. All wounds of thestomach require a thorough exploration of the posterior surface. This isaccomplished by a transverse incision into the lesser sac through the gastrocolicomentum. The stomach can then be elevated in order that the entire posteriorsurface may be examined. Wounds of the stomach should be closed by twolayers of interrupted silk sutures.
Duodenum
A perforating wound of the anterior surface of the duodenum always requiresa thorough exploration of the posterior surface. Adequate exposure is necessaryfor an accurate repair of these wounds. The ascending colon and the hepaticflexure are mobilized. The duodenum can then be freed from its attachmentsand rotated medially, thus exposing the posterior surface of the secondand third parts. Wounds in the second portion of the duodenum require carefuldissection and repair to avoid injury to the common bile duct. It is wellrecognized that duodenal wounds heal poorly. All wounds should be suturedtransversely to prevent a constriction of the lumen. A two-layer closureshould always be made, and drains should be placed in the region of repairand brought out through a separate stab wound on the skin.
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Liver
A small, superficial laceration of the liver in which there is no bleedingat the time of the operation requires only drainage. Small wounds whichare bleeding should be sutured. Large, deep lacerations of the liver shouldbe closed with a hemostatic gauze pack placed in the wound and edges approximatedwith wide, deep, figure-of-8 absorbable sutures.
Shell fragments are removed if they can be obtained without excessivetrauma to the liver. Fragments which are embedded deep within the livershould not be removed.
All liver wounds should be drained, regardless of their size. LargePenrose tissue drains should be brought out through a stab wound in themidaxillary line and placed in each of the following areas. One shouldbe placed in the foramen of Winslow, another anterior to the common bileduct, a third between the posterior surface of the liver and the diaphragm,and a fourth between the anterior surface of the liver and the diaphragm.Patients who are not drained frequently develop bile peritonitis.
Posterior wounds of the liver can be exposed by dividing the triangularand falciform ligaments. This permits the liver to be dropped and the posteriorsurface may be visualized. Perforation of the diaphram should be closedwith interrupted sutures.
Gallbladder
Wounds of the gallbladder are treated by cholecystectomy. If the gallbladderhas been injured, the common bile duct should be carefully examined. Ifthe duct has been injured, it should be approximated over a T-tube.The T-tube should not be brought out through the anastomosis. Allinjuries of this area should be drained.
Spleen
All injuries of the spleen should be treated by splenectomy.
Small Intestine
The entire small bowel should be inspected from the ligament of Treitzto the cecum. At this time, bleeding points should be ligated. One candetermine the type of treatment that is required upon completing the examinationof the small intestine. In those instances in which there are only a fewperforations of the bowel wall, a closure of the separate wounds shouldbe made. Usually segments of the bowel with multiple perforations willrequire resection with an end-to-end anastomosis. Wounds of the small intestineshould be closed transversely with a single layer of interrupted silk.
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Cecum
One of the major problems in abdominal surgery is the treatment of woundsof the cecum. There is little or no agreement on the technic. Ileostomiesand cecostomies are contraindicated because it is difficult to maintainelectrolyte balance during evacuation. Primary closure of the cecum isfrequently unsuccessful.
In small wounds limited to the cecum, tube cecostomies or suturing ofthe wall of the cecum to the skin are acceptable procedures. If a tubececostomy is used, it is important to suture the cecum to the anteriorperitoneum about the point of exit of the catheter. This will prevent peritonealcontamination, if there is leakage. In larger wounds of the cecum and ascendingcolon, it is advisable to perform a resection of the cecum with an end-to-endileotransverse colostomy, or perform a resection of the cecum with end-to-sideileotransverse colostomy and single-barrel colostomy of the proximal colon.
Colon
A colostomy should be performed for all wounds of the colon. A singleperforation of the colon should be treated by making a stab wound throughthe abdominal wall, bringing the injured area of the bowel out, and placingit over a glass rod as a loop colostomy. The wound of the colon is leftopen and later enlarged. Multiple wounds of the colon are treated by suturingthe wound and making a defunctioning colostomy at the site of the proximalwound. In wounds of the descending colon, some surgeons prefer not to mobilizethe descending colon but to suture both wounds and perform a proximal defunctioningcolostomy in the transverse colon. Defunctioning colostomy should be broughtout through two separate stab wounds which are at least 2 inches apart.Multiple perforations with massive destruction of the colon are treatedwith a resection of the involved segment. The divided ends of the colonare brought out through separate stab wounds at a convenient point.
Pancreas
Pancreatic injuries are rare. Hemorrhage and pancreatitis are the mostfrequent complications of wounds to the pancreas. All wounds of the pancreasshould be drained with large rubber tissue drains placed about the injuredarea and brought out through a stab wound. The tail of the pancreas shouldbe resected if extensively traumatized.
Retroperitoneal Injuries
Injuries to the retroperitoneal areas frequently cause large hematomasand extensive damage to muscle. The hematomas may be caused by perforationof a large blood vessel. If this occurs, the bleeding
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should be controlled and the vessel should be repaired. Ligation ofthe vena cava, with associated retroperitoneal muscle damage, will frequentlycause a secondary hemorrhage. Retroperitoneal muscle injury presents theproblems of adequate excision of devitalized muscle and the control ofhemorrhage from multiple bleeding points. It is difficult to expose theretroperitoneal muscle in order that an adequate débridement canbe performed. When oozing occurs, it is necessary to pack the muscle bedto control the bleeding. This area should always be drained. Postoperativehypotension frequently occurs in patients who have retroperitoneal injuries,but will usually respond to adequate blood replacement. More blood is lostfrom the damaged muscle than is usually recognized.
Thoraco-abdominal Injuries
The maintenance of adequate oxygen exchange and the relieving of respiratoryembarrassment make the chest the first priority in the treatment of thoraco-abdominalwounds. Hemothorax should be treated by thoracentesis and thoracotomiesshould be performed only on proper indications.
Sucking wounds of the chest should be débrided and closed. Theabdomen should always be explored through a separate incision. All perforationsof the diaphragm should be closed with interrupted silk sutures.
Abdominal Wall Closure
The peritoneum should be closed with running sutures of chromic catgut.The muscle, fascia, and skin should be approximated with through-and-throughrubber-shod wire sutures. For better approximation, a few interrupted catgutsutures may be placed in the fascia between the wire sutures. More accurateskin approximation can be obtained with an occasional interrupted silksuture.
The technic of treatment of wounds of the rectum, kidney, ureter, bladderand arteries is a part of another discussion.
Results
During the final 3 months (1 May to 1 August 1953) of the Korean conflict,a statistical data sheet was made out on all general surgical casualtiesadmitted to the 46th Surgical Hospital. The data collected from these recordshave been used to compile statistics for a detailed study of the casualty'scare from the time of his admission to his discharge. During this period,75 patients were admitted with abdominal wounds and 29 with thoraco-abdominalinjuries (table 1). Nine
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Table 1. Mortality and Mode of Evacuation
Type of wound | Total | Deaths | Mortality (percent) | Evacuation | ||
Ambulance | Helicopter | Not stated | ||||
Abdominal | 75 | 9 | 12. 0 | 40 | 27 | 8 |
Thoraco-abdominal | 29 | 3 | 10. 3 | 19 | 8 | 2 |
Total | 104 | 12 | 11. 5 | 59 | 35 | 10 |
deaths occurred among those with abdominal injuries, a mortality rateof 12 percent. Three deaths occurred in the patients with thoraco-abdominalinjuries, a mortality rate of 10.6 percent. There is essentially no differencein the mortality rate of these two types of wounds.
Fifty-nine patients were evacuated by ambulance and 35 by helicopter.In 10 cases, the mode of evacuation was not stated. The percentage of casualtiesevacuated by helicopter in the abdominal group was slightly higher thanin the thoraco-abdominal group. In most instances the helicopter was usedto evacuate the most seriously wounded.
Time Interval
In the 75 abdominal casualties, the time from injury to admission tothe hospital was 3.1 hours (table 2). The length of time required to preparethe patients for operation was practically the same. Thus there was anaverage time interval of 6.3 hours from injury until operation.
Table 2. Time Intervals
Type of wound | Number of cases | Hours injury to admission | Hours admission to surgery | Hours injury to surgery | Operative time (hours) |
Abdominal | 75 | 3. 1 | 3. 2 | 6. 3 | 2. 4 |
Thoraco-abdominal | 29 | 4. 7 | 2. 7 | 7. 9 | 2. 3 |
The casualties with thoraco-abdominal injuries had a greater time intervalfrom injury to admission to the hospital (4.7 hours), but a shorter periodof time was required for resuscitation for operation (2.7 hours). Differencein the time interval was probably due to the greater number of them thatwere evacuated by ambulance. Essentially there was no difference betweenthe two groups in the operative time (2.3 hours).
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Average Amount of Blood Required in Resuscitation
An analysis of the amount of blood given to the abdominal and thoraco-abdominalpatients during resuscitation was made (table 3).
Table 3. Average Blood Administered DuringResusitation
Type of wound | Total number of cases | Blood prior to admission (cc.) | Blood prior to operation (cc.) | Blood during operation (cc.) | Average amount of blood first 24 hours (cc.) |
Abdominal* | 75 | 264 | 1,464 | 1,467 | 3,428 |
Thoraco-abdominal | 29 | 103 | 1,308 | 1,187 | 2,867 |
*Patients receiving 40, 46, 52, and 56 pints excluded.
It was shown that the amount of blood (3 pints) given during the preoperativeperiod to casualties sustaining abdominal wounds was approximately equalto the amount given during the operation. The patients who had thoraco-abdominalwounds received a slightly higher amount of blood preoperatively (1,308cc.) than during the operation (1,187 cc.). About 7 pints of blood (3,428cc.) was required in the first 24 hours by patients with abdominal wounds.Those with thoraco-abdominal wounds required 2,867 cc. of blood duringthis period. Patients who received 40, 46, 52, and 56 pints of blood respectivelyduring their first 24-hour period were not included in these figures. Itwas felt that, by excluding them, a more accurate estimate of the averageamount of blood required could be obtained. Most of the casualties receivedfrom 1 to 6 units of blood in the first 24 hours.
Causes of Death
There were nine deaths in the abdominal group (table 4). Five patientsdied from uncontrolled hemorrhage, two died of peritonitis and one eachfrom aspiration pneumonia and pancreatitis. Two of the patients who diedof uncontrolled hemorrhage died during operation. In one patient the commoniliac artery was severed. He had a large retroperitoneal hematoma. Uponopening the peritoneum over the hematoma, active bleeding was controlledpromptly; however, the patient went into immediate shock and died eventhough large quantities of blood were given, 19 pints in 4 hours. One patientdied of cardiac arrest following prolonged hemorrhage; operation was delayedfor 10 hours because of the heavy casualty load. The three other patientswho died of uncontrolled hemorrhage had massive wounds of the muscle. Theyreceived 40, 52 and 56 pints of blood respectively in the first 24 hours.These patients had extensive muscle damage and illustrate the difficultyof controlling hemorrhage in such cases.
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One patient died of aspiration pneumonia. During his evacuation by helicopter,he aspirated vomitus. Bronchoscopy was done on numerous occasions, butwithout improvement. His case points out the importance of emptying thestomach of its contents as soon as possible after injury. Two patientsdied of peritonitis. Both had injuries of the cecum. One had an additionalinjury to the duodenum, while the other had an additional injury of thesmall bowel. One patient died of pancreatitis; this patient might havebeen saved by a resection of the tail of the pancreas or better drainageof the area.
Thoraco-Abdominal Group
There were three deaths in the thoraco-abdominal group, one each fromcardiac arrest, postoperative shock and hemorrhage from a lacerated liver(table 4). All died within the first 39 hours after injury. All had woundsof the right side of the diaphragm with associated liver damage. One patienthad an extensive laceration of the liver which was repaired; and hemorrhageappeared to be controlled at operation.
Table 4. Causes of Death
Abdominal: 75 cases, 9 death | Uncontrolled hemorrhage | 5 |
Thoraco-abdominal: 29 cases, 3 deaths | Uncontrolled hemorrhage | 1 |
A secondary hemorrhage from the liver occurred several hours after operationand caused his death. Another patient had extensive injuries of the liver,duodenum and ileum. It was impossible to maintain a satisfactory bloodpressure at any time during or following his operation. It was thoughtthat continued hemorrhage caused his death. The remaining patient withextensive liver and chest injuries had a cardiac arrest during operation;the heart was massaged until return of normal rhythm. Twenty-nine hoursafter his operation, the patient had another cardiac arrest and died.
Negative Explorations of the Abdomen
No intra-abdominal injury was found in 36 (9.2 percent) of the 391 patientswho had abdominal operations (table 5). Prior to operation, it is sometimesdifficult to be certain that an abdominal viscus had not been perforated.This is especially true when the shell frag-
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Table 5. Negative Explorations of the Abdomen
Investigators* | Number of laparotomies | Negative laparotomies | Percent negative laparotomies |
Pearson, Tuhy, and Welch-1945, American-Northern Europe | 290 | 23 | 7. 9 |
O?Gilvie-1942-43, British-Western Desert | 247 | 42 | 17. 0 |
Edwards and Stead-1944, British-Italian Campaign | 560 | 66 | 11. 8 |
Porritt-1944-45, British | 4,319 | 740 | 17. 1 |
46th Surgical Hospital-1952-53, Korea | 391 | 36 | 9. 2 |
*See references.
ments have entered the abdominal wall anteriorly and lie close to theperitoneum. Many times, fragments that have entered the back or the perineumpresent the same problem. When it cannot be established that a viscus hasbeen perforated, an exploratory operation should be performed. Our experiencecompares favorably with that of Welch in World War II who reported negativelaparotomies in 7.9 percent of 290 operations (2). In various campaignsof World War II, the British reported negative abdominal explorations varyingfrom 11.8 to 17.1 percent (3).
Comparative Statistics for Mortality of Abdominal Wounds
A study of 384 casualties who had abdominal wounds, covering a 17-monthperiod in Korea, was compared with patients having similar injuries fromthe Second Auxilary Surgical Group in World War II (4). This numberincludes the 75 casualties discussed at the beginning of this report. Acomparison, by organs, shows that the colon, jejunum, ileum and liver werethe most commonly injured during both the Korean conflict and World WarII (table 6). The stomach, kidney and spleen were the second most commonlyinjured organs. In those instances in which injury occurred to more thanone organ, the mortality rate in Korea was approximately one-half of themortality rate in World War II. The mortality rate was approximately thesame for injuries to the duodenum and the ureter.
Mortality of Thoraco-Abdominal Wounds by Side of Body Affected
There were 72 casualties in the Korean conflict who had thoraco-abdominalwounds with perforation of the right side of the diaphragm (table 7). Twelveof these patients died, a mortality rate of 16.6 percent. The Second AuxiliarySurgical Group of World War II reported 103 deaths among 435 casualties,a mortality rate of 24 per-
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Table 6. Comparative Statistics of MortalityRates for Abdominal Wounds by Organs-Korea, 1952-53, and World
War II, 1942-45*
| Korea | World War II | ||||||
All cases, deaths | Complicated, percent dying | Uncomplicated, percent | All cases,* deaths | Complicated, percent dying | Uncomplicated, percent dying | |||
Number | Percent | Number | Percent | |||||
Colon | 140 | 15. 0 | 18. 5 | 9. 3 | 1,106 | 37 | 41 | 23 |
Jejunum and Ileum | 134 | 13. 4 | 16. 4 | 3. 0 | 1,168 | 30 | 36 | 14 |
Liver | 102 | 15. 6 | 20. 6 | 9. 0 | 829 | 27 | 39 | 10 |
Stomach | 45 | 17. 5 | 22. 8 | 0 | 416 | 41 | 42 | 29 |
Kidney | 55 | 25. 4 | 29. 1 | 0 | 427 | 35 | 38 | 16 |
Spleen | 54 | 15. 0 | 18. 6 | 0 | 341 | 25 | 30 | 12 |
Rectum | 22 | 18. 1 | 16. 0 | 11. 7 | 155 | 30 | 42 | 14 |
Bladder | 21 | 9. 4 | 13. 3 | 0 | 155 | 30 | 34 | 0 |
Duodenum | 17 | 41. 1 | 43. 7 | 0 | 118 | 56 | 56 | 50 |
Pancreas | 9 | 22. 2 | 25. 0 | 0 | 62 | 58 | 57 | 100 |
Gallbladder | 33 | 0 | 0 | 0 | 53 | 30 | 30 | 0 |
Ureter | 4 | 50. 0 | 50. 0 | 0 | 27 | 41 | 42 | 0 |
*Second Auxiliary Surgical Group from Beebe and DeBakey
cent (4). In 57 patients, the left side of the diaphragm wasperforated; a mortality rate of 8.7 percent as compared with a mortalityrate of 30 percent in World War II. The mortality rate of all wounds ofboth sides of the diaphragm was 13.1 percent for Korea as compared with27 percent in World War II. In Korea, wounds of the right side of the diaphragmcarried a higher mortality rate than those of the left side, probably becauseof injury to the liver. In World War II, there was a mortality rate of24 percent for wounds of the right side and 30 percent for wounds of theleft side (4).
Table 7. Comparative Statistics of MortalityRates for Thoraco-abdominal Wounds by Side of Body Affected
Theater | Right diaphragm | Left diaphragm | Total | ||||||
Number wounded | Deaths | Number wounded | Deaths | Number wounded | Deaths | ||||
Number | Percent | Number | Percent | Number | Percent? | ||||
Korea, 1952-53 | 72 | 12 | 16. 6 | 57 | 5 | 8. 7 | 129 | 17 | 13. 1 |
World War II,* |
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*Second Auxiliary Surgical Group from Beebe and DeBakey.
?Chi Square Test=10.8; P=0.001.
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Comparative Statistics for Abdominal Wounds by Number of Organs Damaged
A direct comparison of the number of organs damaged was made betweenthose casualties with abdominal wounds in Korea and those from World WarII (table 8) (4). It was felt that this would be an accurate comparison,since it was based on the number of organs injured. There was little differencein the time interval from injury to operation: in World War II, from zeroto 7 hours; in Korea, an average of 7 hours.
Table 8. Comparative Statistics of MortalityRate for Abdominal Wounds By Number of Organs Damaged
| Korea-Injury to operation, average 7 hours | World War II-Injury to operation,* 7 hours orless |
| ||
Number wounded | Percentage dying | Number wounded | Percentage dying | ||
0 | 36 | 2. 8 | 98 | 5 |
X2 (5) = 11.95 |
1 | 181 | 6. 62 | 496 | 10 | |
2 | 102 | 6. 82 | 402 | 24 | |
3 | 45 | 26. 6 | 132 | 42 | |
4 | 12 | 8. 3 | 41 | 54 | |
5 | 6 | 16. 0 | 13 | 92 | |
6 | 2 | 50. 0 | 3 | 100 | |
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| Overall statistics: X |
*Second Auxiliary Surgical Group from Beebe and DeBakey.
The casualties without organ damage had essentially the same mortalityrate. Little difference was seen in the mortality rates of casualties whohad four, five, or six organs damaged. There was a significant differencebetween the overall mortality of 10.68 percent in Korea and 20.51 percentin World War II. Although there was little difference in the slightly wounded(no organ damage) and the most severely wounded (four, five, or six organdamage), the significant differences in the moderately wounded (one, two,or three organ damage) and the overall mortality rate points out the improvedresults achieved in Korea.
Summary
A study of the casualties who had abdominal and thoraco-abdominal woundswas made at the 46th Surgical Hospital in Korea.
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The surgical technics proven to be acceptable in the management of thesecasualties have been outlined.
The average time from injury to admission for casualties with abdominalwounds was 3.1 hours; for thoraco-abdominal wounds, 4.7 hours. The abdominalcasualties received an average of 3,400 cc. of blood and the thoraco-abdominalcasualties received an average of 2,800 cc. of blood in the first 24 hoursafter injury. More than half of the deaths were caused by uncontrolledhemorrhage.
The mortality rate for 129 thoraco-abdominal casualties in the lastyear and a half of the Korean war was 13.1 percent. In World War II themortality rate for 883 casualties with thoraco-abdominal wounds was 27percent.
The mortality rate for 384 casualties who had abdominal injuries inKorea was 10.68 percent. In a series of 1,185 casualties who had comparableorgan damage and comparable evacuation times treated by the Second AuxiliarySurgical Group, the mortality rate was 20.51 percent.
Acknowledgment
Some of the data pertaining to the Korean conflict intables 6, 7, and 8 were compiled from the records of Captain John Howardand Captain Frank Inui.
References
1. Holmes, R. H.: Regional Distribution of Wounds. Personalcommunication.
2. Welch, C. S., Tuhy, J. E., and Pearson, R. W.: AbdominalSurgery in the Evacuation Hospital. Surgery 21: 1, 1947.
3. Chest and Abdomen, War Supplement No. 3. British Journalof Surgery.
4. Beebe, G. W., and DeBakey, M. E.: Battle Casualties.Charles C. Thomas, Springfield, Illinois, 1952.
