Clinical Experiences in the Early Management of the Most Severely Injured Battle
Lieutenant Colonel Curtis P. Artz, MC, USA
Captain John M. Howard, MC, USAR
Captain Yoshio Sako, MC, USAR
Captain Alvin W. Bronwell, MC,USA
Captain Theodore Prentice, MC,USAR
War provides an exceptional experience from which the surgeon may gain information about the management of trauma. In the latter phases of the Korean conflict, the flow of casualties was moderate and the line of resistance was relatively stable. This resulted in an unusual situation whereby the forward hospital remained fixed for long periods and careful studies of the casualties could be carried out.
Selective helicopter evacuation permitted many critically wounded soldiers to reach the hospital alive who would have died during evacuation in fast-moving combat situations similar to those experienced in World War II. Since an extraordinarily large number of severely injured casualties were treated, it was believed wise to record data concerning their management.
A survey was carried out during the latter part of the Korean conflict at the 46th Surgical Hospital (Mobile Army) located approximately 10 miles behind the eastern front. All of the casualties in this survey were general surgical patients, excluding casualties having wounds of the brain and spinal cord. They were classified as the most severely wounded because they required replacement of at least one-half of their blood volume. This classification follows closely the classification used by Grant and Reeve in World War II. The casualties were divided into several categories. Criterion for the various categories was the amount of blood required for resuscitation in the first 24 hours after injury, since most casualties are successfully resuscitated or die within this period. It was the belief that this classification might furnish a rough index of the degree of injury.
It is difficult to grade the degree of injury because there are various contributing factors, such as location of the wound, organs damaged, velocity of the missile, time lag, blood loss, and duration of hypovolemia. Some casualties sustaining head or heart wounds required
*Previously published in Annals of Surgery 141: 285, 1955.
little blood; nevertheless they died. These wounded soldiers had vital organ damage and obviously were severely injured casualties. Since requirement of blood was not a primary factor in the resuscitation of soldiers sustaining head wounds, such casualties were excluded from the study. Most casualties sustaining heart wounds died before they reached the hospital.
Since most wounds are accompanied by hemorrhage of a significant degree, the severity of the injury might well be graded in part, at least, on the basis of blood loss. Blood loss begins with injury and continues throughout the preoperative, operative and, to a lesser extent, the postoperative phases of the patient`s care. One gross indication of the total amount of blood lost appears to be the amount of blood required for successful resuscitation. Experience has demonstrated that restoration of the circulation to a stable state occurs within approximately24 hours after injury. It appears that the total amount of blood required to resuscitate a casualty during the first 24 hours might be a reasonable indication of blood loss and, for clinical purposes, an indication of the severity of the injury.
This survey was prepared from available, dependable records; and it was divided into two parts. The first part was comprised of records of 138 casualties requiring from 5 to 56 pints of blood who were treated between February 1953 and August 1953. The second part consisted of records of 89 casualties treated between January 1952 and August 1953 who received 15 or more pints of blood or plasma expander. Casualties in the first group-those requiring 15 or more pints of blood or plasma expander-were also included in the second part of the survey.
One Hundred and Thirty-eight Consecutive Casualties Who Required Five or More Pints of Blood
Between February and August 1953, 995 battle casualties (684 American and 311 Korean soldiers) were admitted to the general surgical service. Only the most severely wounded Korean casualties were transferred to the United States Army Hospital and their evacuation time was prolonged. The case fatality rate for the American patients was 2.2 percent and the over-all case fatality rate for all general surgical casualties was 3.2 percent.
Of these 995 casualties, 138 (14 percent) were classified as most severely wounded.
Case Fatality Rate and Blood Requirement
The case fatality rate in relation to blood requirement in this group of 138 patients is outlined in Table1. As the blood requirement increased, mortality increased. Twenty casualties died and, of this
Table1. Case Fatality Rate Related to Blood Requirement (February to August 1953)
number 16 died within the first 48 hours. Of the 122 patients who survived 48 hours, 6 developed a marked degree of renal insufficiency; and 4 of these 6 died.
Case Fatality Rate and Type of Injury
The case fatality rate in relation to the type of injury is outlined in Table 2. Casualties whose injurieswere primarily in the abdomen had a case fatality rate of 16 percent. In the group whose injuries were primarily in the extremities the rate was 10 percent. The casualties sustaining thoraco-abdominal wounds had a higher case fatality rate (26.6 percent): For those who had chest wounds it was 9 percent.
Table2. Case Fatality Rate Related to Type of Injury
Evacuation to the Hospital
The type of evacuation to the surgical hospital from a division medical installation was carried out in accordance with the judgment of the battallion surgeon. When fllying conditions were suitable, a helicopter was used if the surgeon felt tha the patient could not with-
stand transportation to a hospital by ambulance or if he felt that it was necessary to transport a casualty quickly. Available data on 99 of the 138 casualties showed an equal division of type of evacuation between helicopter and ambulance. Of those who required over 10 pints of blood, a slightly higher percentage was moved by helicopter.
Evacuation time, time in the preoperative section, and duration of operation are outlined in Table 3. The time from injury to admission was 3.8 hours for 117 patients on whom data were available. In the 5- to 10-pint group, evacuation time was only slightly longer (4.2 hours) than in the 10- to 56-pint group (3.5 hours).
Table3. Evacuation Time and Time of Initial Care
An average of 3.5 hours was spent from the time of admission to the time of operation. This interval was almost the same for both the 5- to 10-pint and the 10- to 56-pint group. However, it was not necessarily the time required for preparation for operation. In most instances, patients were held in the preoperative section until ready for surgery. If a large number of casualties were admitted at the same time, some casualties who were fully prepared for surgery had to wait for available space in the operating room. Priority was given to severely wounded casualties who were taken to the operating room as soon as possible. Average time from injury to operation was approximately 7.25 hours.
Casualties in the 5- to 10-pint group required 2 hours for operation and the more severely wounded casualties required about 3 hours.
Resuscitative Fluids During Various Phases of Care
The amount of blood or colloid solution given prior to admission to the hospital is summarized in Table 4. Among the 138 patients, 81 received resuscitative fluids, predominantly dextran; but some received modified fluid gelatin, albumin, and blood. Patients in the 5- to 10-pint group received about 1 pint of blood or plasma expander; patients in the 10- to 56-pint group received about 3 pints of fluid prior to admission.
Table4. Preadmission Blood and Plasma Expander
The average amount of blood replacement during various phases of resuscitation is shown in Table 5. Patients in the 5- to 10-pint group were given an average of 3,440 cc. of fluid therapy during the first 24 hours after injury. Those requiring from 10 to 35 pints averaged more than twice as much as the first group (7,300 cc.). In each group, the amount of blood given preoperatively was essentially the same as the amount given during the operation. Out of the 73 patients in the 10- to 35-pint group, 38 received an average of 1,130 cc. postoperatively; and 18 of the 61 patients in the 5- to 10-pint group received 720 cc.
Table5. Blood Replacement During Phases of Resuscitation
Fifty percent of the patients in the abdominal group and 48 percent of the patients in the extremity group were given approximately 1 liter of plasma expander, in addition to blood (Table 6). Most of this plasma expander was administered before these patients arrived at the hospital.
Table6. Amount of Plasma Expander in Addition to Blood*
Control of Hemorrhage
Hemorrhage was controlled preoperatively in all 61 patients in the 5- to 10-pint group. Among the 77 patients in the 10- to 56-pint group, hemorrhage was not controlled prior to operation in 13, and control of hemorrhage preoperatively was questionable in 8. Of these 21, hemorrhage was brought under control at operation in all but four patients. Two of the four died on the operating table (one had a large laceration of the common iliac artery, the other had a high bilateral thigh amputation). One patient who sustained a massive liver wound died during the first postoperative day because of uncontrolled bleeding. The fourth patient had a massive liver and retroperitoneal muscle wound. He continued to bleed after operation, requiring 875 cc. of blood per hour to replace blood loss. He was re-explored 4 hours after the first operation. There were multiple bleeding sites in the retroperitoneal area, and this area was packed with two 5-yard-roll gauze packs. The oozing did not stop, however, until 7 pints of fresh blood had been administered. The patient subsequently recovered. This patient was given 46 pints of blood during the first 24-hour period.
In three other casualties who had uncontrolled hemorrhage preoperatively, the major points of hemorrhage were controlled at operation. Oozing continued from all surfaces, and they died after several hours. These casualties received 35, 52, and 56 pints of blood respectively.
Patients Admitted in Shock
In the group of 138 most severely wounded casualties, 33 were admitted in severe shock (Table 7); of this number, 7 died. Severe shock was a clinical diagnosis. Each of the 33 casualties had a systolic blood pressure of 80 mm. of mercury or less. The type of wound varied, but no particular type of injury predominated. The average time of evacuation was 2.3 hours. The total amount of blood
Table7. Most Severely Wounded-Admitted in Severe Shock 33 Patients-7 Deaths (Case Fatality Rate-21 Percent)
given in the first 24 hours ranged from 2,500 cc. t.o 28,000 cc. The average amount of flood administered preoperatively was 4,300 cc.; while the average for the first 24 hours was 7,600 cc.
Ten casualties in the shock group Were admitted with blood pressure too low to be obtained by the usual cuff method. Three of these died, two from uncontrolled hemorrhage; the cause of death of the other casualty was unknown. The seven casualties who lived required from 11 to 26 pints of blood in the first 24 hours.
The causes of the other four deaths in this severely shocked group were cardiac arrest, refractory postoperative shock, uncontrollable oozing, and-in one instance-the cause of death could not be determined. In the 33 most severely wounded patients who were admitted m severe shock and required an average, of 15 pints of blood, the case fatality rate was 21 percent.
Blood Volume Data
Blood volume determinations were carried out in 15 casualties (Table 8).2 The chromium 51- labeled, red-cell method was used because previous experience had suggested that it was more accurate than the T-1824 method (Evans blue dye). All determinations were performed in the early postoperative period. Because of continued hemorrhage, it is difficult to obtain accurate estimations of blood volume by any technic during the preoperative period. It was believed that postoperative volumes would give a good indication of blood loss. This seems to be a valid deduction based on the following statement. If a normal patient received 10 pints of blood during resuscitation and operation and his postoperative blood volume was approximately normal, it was assumed that. blood loss was at least 10 pints.2
Table8. Postoperative Cr 51 Blood Volumes2
Determination of postoperative blood volume in these 15 casualties, after administration of massive quantities of blood, demonstrated an average blood volume of only 80 percent of the calculated normal at the time each determination was carried out. Only one of these pa-
tients exhibited clinical evidence of shock. Patient 2 had a severe wound of the chest and of all extremities, resulting in massive bleeding into the chest and continued oozing from many areas in the subcutaneous tissues and muscles of the extremities. He received 20 pints of blood before and during operation. His condition postoperatively was unstable, and his blood volume was only 48 percent of normal; hence an additional 6 pints of blood were administered. He progressed to an uneventful recovery.
Two casualties had blood volumes somewhat higher than normal. After receiving 14 pints of blood, Patient 7 had a hematocrit of 57 per cent and a blood volume of 120 percent of the calculated normal. On the ninth postoperative day, his blood volume had decreased to 107 percent of normal. Patient 8, suffering from an abdominal wound, received 14 points of blood. At the end of operation, he had a hematocrit of 68 and a blood volume of 104 percent of normal. He died later from an overwhelming peritonitis and mediastinitis.
It is interesting that, after administration of 1 pint of blood prior to operation, Patient 10 had a hematocrit of 42.5 and a blood volume of 57 percent of normal. After resuscitation with 12 pints of blood, his hematocrit was 43.5; but his blood volume was only 94 percent of normal.
There were 20 deaths in the group of 138 most severely wounded casualties (Table 9). Most of this group were held at the hospital for a period of from 5 to 8 days and evacuated only after their condition became stable. Soon after injury, a few casualties were evac-
Table9. Cause of Death
uated to the Renal Insufficiency Center at the 11th Evacuation Hospital because of posttraumatic renal insufficiency. Deaths listed in-chide those that occurred at the 46th Surgical Hospital and at the Renal Insufficiency Center. Renal failure was not listed as a cause of death in these patients because it was considered a contributing factor rather than a primary cause of death. Causes of death were determined by clinical review of the case histories and available autopsy findings.
Eighty-nine Casualties Who Received Fifteen or More Pints of Blood or Plasma Expander
During 1952 and the first half of 1953, 89 battle casualties were studied during the first 24 hours after injury. Each of these patients required a minimum of 15 pints of blood or plasma expander--one and one-half times the normal blood volume. Because of the severity of the injury and the unusual amount of blood required for restoration, it was believed that a survey of the management and mortality of these casualties would yield valuable information. The patients who required 15 or more pints of blood or plasma expander from the previous group of 138 casualties were also included in this group of 89 casualties.
Some patients received 30, 40, and even 50 pints of resuscitative fluids within the first 24 hours. Of the patients who received more than 15 pints of blood or plasma expander, the case fatality rate was 44 percent (Table 10). There was a wide difference in mortality
Table10. Case Fatality Rate of Casualties Who Required 15 or More Pints of Blood and Plasma Expander (January 1952 to August 1953)
Table11. Casualties Admitted with an Unobtainable Blood Pressure (January 1952 to August 1953)
between the patients who had injuries limited to the abdomen (79 percent) and those who had injuries limited to the extremities (17 percent). This difference cannot be explained entirely on the basis of uncontrollable, continued hemorrhage. When the patients were excluded in whom continued hemorrhage was the obvious cause of death, there remained a difference in case fatality rate between the abdominal and the extremity groups of 61.5 percent and 14 percent respectively.
The prognosis can be determined more accurately by the amount of blood required for resuscitation than by the degree of hypotension on admission to the hospital. This analysis is shown in Table 11. There were 38 casualties who had an unobtainable blood pressure on admission to the hospital. Of this number, 12 patients required less than 15 pints of blood during the first 24 hours; 26 patients required more than 15 pints. There were no deaths among the 12 patients who had an unobtainable blood pressure on admission and required less than 15 pints of blood. In contrast, the 26 casualties who required more than 15 pints of blood had a case fatality rate of 54 percent.
Incidence of Renal Insufficiency
During 1952, 60 of the 89 casualties who required more than 15 pints of blood or plasma expander during the first 24 hours were studied consecutively in order to determine the incidence of renal insufficiency. Among these 60 patients, 43 lived for 3 days or longer. Of these 43, 21 percent developed oliguria (output of urine amounting to less than 500 cc. per day) and 14 percent developed nonoliguric azotemia (nonprotein nitrogen of 80 mg. percent or higher and output of urine amounting to more than 500 cc. per day) . These statistics are given
Table12. Incidence of Renal Insufficiency in Battle Casualties Who Required 15 or More Pints of Blood and Lived Three Days or Longer*
in Table 12. However, 35 percent of the 43 patients who lived 3 days or longer developed clinically significant post-traumatic renal insufficiency.
In order to give perspective to this experience, a survey was made of 995 consecutive casualties admitted to the general surgical service between February and August 1953. Of these 995 patients, 138 (14 percent) required replacement of 5 or more pints of blood. An analysis of the 138 patients demonstrated the major problems encountered in approximately 1,000 consecutive battle casualties treated. Among the 995 patients, 27 (3 percent) required more than 15 pints of blood and plasma expander during the first 24 hours.
Many of the casualties listed in Table 10 were so critically injured that they would not have reached the hospital alive had it not been for selective helicopter evacuation. Some of these casualties required only 15 minutes for actual transportation to the hospital. In the first 24 hours after injury, 89 patients received a total of 2,135 pints of type-O blood. This represents an average transfusion of 24 pints, or replacement of almost two and one-half times their blood volume. A case fatality rate of 44 percent in this group is not surprising. The unusual result. is that 56 percent of these men with such massive wounds were transported to the hospital and were treated successfully.
Those patients having abdominal wounds had the highest case fatality rate (see Tables 10 and 11). Most of the deaths occurred during
the first 48 hours after injury. In the patients having wounds of the abdomen and requiring 15 or more pints of blood, the case fatality rate was 79 percent; whereas, among casualties who had comparable wounds limited to the extremities, it was 17 percent.
Hemorrhage from severe wounds of the extremity can be controlled by a tourniquet while replacement therapy is being carried out. As a result, anesthesia and operation may be undertaken in the presence of a relatively normal blood volume. In contradistinction, patients who have abdominal hemorrhage may not have the benefit of hemostasis prior to operation. In spite of pressure transfusions through 3 or 4 cannulae, the patient is subjected to the further trauma of anesthesia and operation in the presence of a marked deficit of blood volume. Emergency operation is mandatory on the patient who is such a grave risk, because it is impossible to correct the deficit until hemostasis can be achieved by operative means. The high mortality associated with abdominal injury represents, in part, the difficulty in controlling intra-abdominal hemorrhage. Obviously, several other factors contribute to this higher mortality, particularly the altered physiology associated with abdominal injuries.
Discussing the experiences of the Second Auxiliary Surgical Group in World War II, Beebe and De Bakey point out that the case fatality rate was 21 percent for all patients having abdominal injuries who were operated upon within 7 hours after injury. It is composed only of the 14 percent of patients who represented the most severely wounded. The case fatality rate for those patients who had abdominal wounds was 16 percent.3
Grant and Reeve reported on 59 battle casualties of World War II who had very large wounds of the extremities. The case fatality rate was 40 percent.1 In our survey of 52 battle casualties who had extremity wounds large enough to require replacement of 5 or more pints of blood, the case fatality rate was 10 percent (see Table 2). In our group of 89 who required 15 pints or more of blood, there were 28 patients with wounds limited to the extremities (see Table 10). The case fatality rate was 17 percent in this group.
Undoubtedly this reduction in mortality has been influenced appreciably by the shorter evacuation time; but great credit must be given to the more vigorous use of whole blood.
Condition on Admission
Thirty-eight casualties were admitted to the hospital with a blood pressure so low that it was unobtainable by the usual cuff method. The results of therapy indicated a striking demonstration of the difference between severe hypotension on admission and severity of the
wound. There were no deaths among the 12 patients who received less than 15 pints of blood. Profound hypotension on admission increased mortality as evidenced by a case fatality rate of 44 per cent in the over-all group consisting of 89 patients (15 or more pints, see Table 10) and the increased case fatality rate of 54 per cent in 26 casualties (15 or more pints, see Table 11) who had an unobtainable blood pressure on admission.
A battle casualty who has a simple, rapid, but severe hemorrhage from an arterial defect can be resuscitated easily after hemorrhage is arrested. On the other hand, the casualty who has multiple, extensive wounds and hemorrhage from all areas is much more difficult to resuscitate. He will continue to lose blood from all the destroyed tissue until operative correction is carried out. He requires more blood and more extensive surgery than the patient whose hypotension on admission is caused by hemorrhage from a small arterial defect. Prognosis of a patient who is admitted with an obtainable blood pressure depends, to a large extent, upon the degree of trauma. Moreover, the influence of abdominal injury on mortality is reflected in casualties who were admitted with an unobtainable blood pressure. The case fatality rate was 65 percent among those who had only an abdominal injury, whereas the case fatality rate was much lower (12.5 percent) among those who had only extremity injuries (see Table 11).
Acute Post-traumatic Renal Insufficiency
Among 60 consecutive battle casualties requiring more than 15 pints of blood on whom a study was made, 14 casualties (35 percent) developed clinically significant post-traumatic renal insufficiency (see Table 12). Among the 122 patients receiving 5 or more pints of blood and surviving 48 hours or longer, 6 developed renal insufficiency and 4 died (see Table 1). Among the patients who received 20 or more pints of blood and survived for 48 hours, 30 percent developed renal insufficiency. Although several factors contribute to the development of renal insufficiency, it becomes apparent that this complication is encountered primarily inpatients who suffer extensive tissue damage.
From a review of the case histories, it is evident that most of the casualties who died had truly massive wounds. It is difficult to assess an exact cause of death in each instance. It appears that inability to maintain an effective blood volume was responsible for at least half of the deaths. Three patients died of major hemorrhage that could not be controlled; four died of hemorrhage as a result of multiple bleeding points from which diffuse, persistent oozing occurred after massive transfusion; and three died of postoperative shock in spite of large transfusions.
The forward surgeon encounters no problem that is more difficult than the management of a patient sustaining massive intra-abdominal hemorrhage. Hemorrhage can be controlled if the surgeon is able to diagnose continued, intra-abdominal hemorrhage and locate the bleeding point immediately upon opening the abdomen. Of the three patients who died of uncontrolled hemorrhage, two had a laceration of large vessels within the abdomen. In the over-all series, one patient had a large laceration of the iliac artery that was recognized early; hemorrhage was controlled immediately on opening the abdomen; the artery was repaired; and the patient recovered.
The four patients who died from uncontrolled, postoperative oozing from many areas may have had a deficiency in the clotting mechanism. This problem deserves further study. All four of these patients had intra-abdominal bleeding during the postoperative period. Two of them had a ligation of the inferior vena cava which may have contributed to the persistent oozing after operation. Uncontrolled oozing was a complication that followed the administration of 20 or more pints of blood. In occasional instances the administration of fresh, whole blood appeared to be beneficial. One patient experienced persistent oozing after the administration of 39 pints of stored blood. The oozing ceased after the infusion of 6 units of fresh, whole blood; and the patient survived.
The four patients who died of postoperative shock were all critically injured. They were hypotensive prior to operation; but all responded to rapid transfusion. Hypotension recurred during operation, or immediately thereafter, and persisted in spite of restorative efforts. In these patients, the exact mechanism of death is unknown. Although large quantities of blood were given, it might have been an inadequate amount. Many of the blood volume studies suggested that a deficit persisted in spite of massive transfusions.
One patient died of pancreatitis following injury to the pancreas. Better drainage might have prevented this death. Two patients died as a late result of cardiac arrest during operation.
Infection caused 3 of the 20 deaths. Two of the deaths were caused by peritonitis, and one by septicemia; both followed very massive injuries.
The group of casualties outlined in Table 12 required more than 15 pints of blood or plasma expander. Of these 60 patients, 43 lived 3 days or longer. Among the 17 deaths, the predominant causes were continued hemorrhage, 8; secondary hemorrhage, 1; postoperative, refractory hypotension, 4; and post-traumatic. renal insufficiency, 4. These results emphasize the need for further knowledge of the technical aspects of maintaining an adequate circulation during the first 24 hours after injury; Particular emphasis must be placed on control of intra-abdominal hemorrhage as one of the fields in which further investigation is necessary.
The wound is a dynamic. injury. It is not an injury of only the moment when the missile strikes the tissue; but it is a continuing insult involving continued loss of blood and fluids from the circulation. Resuscitation, therefore, must be a continuing process, as was pointed out by Beecher.4 A person should not speak of resuscitation and surgery, as surgery is a vital part of resuscitation.
It was not surprising to note the large amounts of blood that were necessary during various phases of resuscitation of those patients who required massive transfusions. In this group, the amount of blood given preoperatively for correction of deficit in blood volume was equal to that given during surgery. During the postoperative period, a number of patients required about one-third of the amount of blood given during operation.
Emphasis must be placed on the large amount of blood required prior to operation. In the most seriously injured group (10 to 35 pints), an average of 7 pints was given before the patient was taken to surgery. During operation, 6 pints were administered; and during the immediate postoperative period 38 of the patients required an additional 2 pints of blood. A similar ratio was found in the 5- to 10-pint group, that is 3.5 pints preoperatively and 3 pints during operation. Eighteen of the casualties required an average of 1.5 pints during the immediate postoperative period (see Table 5). The blood volume of a patient on admission to a medical installation is not an indication of the amount of blood that will be required for total resuscitation. Half of the blood volume may have been lost before a patient arrives at a hospital; but there is also a continued loss during the preoperative period and during surgery. Absolute control of hemorrhage in the severely injured battle casualty is most difficult to achieve.
The amount and rate of administration of blood during operation may be determined by the blood loss that occurs during the procedure; and underestimation of this loss is common. Restoration of blood volume does not terminate at the end of the surgical procedure. It would be ideal if a patient could be restored to a normal blood volume before surgery and if normal blood volume could be maintained by further transfusions as blood is lost during the operation. Unfortunately, this situation is most difficult to achieve in the critically injured soldier. Determination of the amount of blood required is based on: (1) response of the patient (blood pressure, pulse rate, output of urine, and response to anesthesia and to changes in posture) and (2) clinical judgment of the surgeon (observed blood loss, color of conjunctiva, and extent of tissue damage). In many instances, additional blood is necessary postoperatively either because restora-
tion has not been complete or because the patient continues to lose blood and plasma during the postoperative period. A persistently low blood pressure nearly always indicates the need for further transfusion.
The successful use of massive transfusions re-emphasizes certain lessons learned in World War II, namely, the treatment of wound shock is primarily the control of hemorrhage and the administration of adequate quantities of blood. One of the primary differences between resuscitation during the Korean conflict and during World War II was a difference in the amount of blood administered. Massive transfusions were used frequently and only rarely was there evidence of overtransfusion. From the data on blood-volume determinations after massive transfusions, it appears that large quantities of blood were lost from the effective circulation. In most instances, recovery from initial hypotension followed immediately after the administration of large quantities of blood. An occasional patient who reached the hospital alive, but who had vital organ damage, died even though there was only a minimal blood loss. This was observed most frequently in battle casualties who sustained injuries of the brain. In general, the severity of the injury was directly proportionate to the amount of blood lost. Both the injury and blood loss continued to exert a deleterious effect.
The impressions gained from the observations in this report parallel those of the Board for the Study of the Severely Wounded: "If irreversible shock was present prior to anesthesia, we missed it. If toxins caused any of the shock immediately after the injury, we failed to recognize it."4
A diagnosis of irreversible shock should not be made prior to death. Under the conditions of this study, continued hypotension prior to anesthesia and in the absence of injury to the central nervous system or heart was due to continued hemorrhage or inadequate transfusion.
Summary and Conclusions
A survey of experiences with the most severely wounded patients undergoing general surgical treatment was conducted at the 46th Surgical Hospital in Korea. The amount of blood required for resuscitation was used to categorize extent of injury. The case fatality rate for the battle casualties who required 15 or more pints of blood was44 percent. The average time of evacuation was 3.8 hours.
In all categories, mortality was higher for casualties who had wounds of the abdomen than for those who had wounds of the extremities.
Because of continuing hemorrhage, the amount of blood required during operation was equal to the amount required preoperatively;
and the amount required postoperatively was directly proportionate to the extent of tissue damage.
It was found desirable to restore a blood volume prior to operation hut, in some instances and particularly in abdominal injuries, an emergency operation was necessary for the control of hemorrhage.
Thirty-three patients were admitted with a systolic blood pressure of 90 mm. of mercury or less and the amount of blood required averaged 15 pints. Case fatality rate for this group was 21 percent. The prognosis could be better predicated by the amount of blood required than by the degree of hypotension on admission.
Blood volume determinations by the labeled, red-cell method showed that overtransfusion rarely occurred.
Twenty-one percent of the casualties who required 15 or more pints of blood developed severe oliguria (output of urine amounting to less than 500 cc. per day).
Inability to maintain an effective blood volume (uncontrolled oozing, uncontrolled hemorrhage, postoperative shock) was the cause of half of the deaths.
Case 1. (Peritonitis, transfused 9 pints of blood)
This 23-year-old Korean soldier was injured by mortar-shell fragments on June 27 at 0950 hours. He was evacuated to a clearing station and then by helicopter to. the 46th Surgical Hospital 3.5 hours after injury. The injuries involved his back and abdomen. On admission to the hospital, his blood pressure was 120/76, pulse 84; while at the battalion aid station his blood pressure was 70/40. Preoperatively 1,500 cc. of blood were administered; then the patient was taken to surgery 1.5 hours after admission to the hospital.
Laparotomy showed laceration of the duodenum, cecum, and the left kidney. The duodenal lacerations were sutured; the posterior cecal perforation was closed; and a tube cecostomy was performed through the anterior perforation. The right perirenal area was drained posteriorly. During the 3-hour operation, 5 pints of blood were given. Blood pressure fell to 82/40 for approximately 10 minutes during surgery. Because of unstable blood pressure, it was decided not to turn the patient over in order to dèbride his back wounds. He developed oliguria postoperatively, passing 139 cc. of urine on the first postoperative day and 57 cc. on the second postoperative day.
Because of renal difficulties, the patient was transferred to the Renal Insufficiency Center on June 29. He was placed on a regimen of 25 percent glucose with insulin and vitamins. There was no laboratory evidence of hyperkalemia. He developed Cheyne-Stokes breathing during the night; his blood pressure fell, and signs of pulmonary edema developed. On June 29, 1953, he suddenly expired. The staff felt that death was caused by peritonitis and that renal insufficiency played only a minor role in the cause of death.
Case 2. (Cardiac arrest, transfused 10 pints of blood)
This 39-year-old Korean soldier was injured by mortar-shell fragments on May 21, at 1200 hours. He was evacuated to a clearing station, and then brought by ambulance to the 46th Surgical Hospital 4 hours after injury. He sus-
tained penetrating wounds of the right chest, abdomen, open, comminuted fractures of the right humerus. At the time of admission, his blood pressure was 98/70, pulse 112. He was given 1,500 cc. of blood preoperatively and then taken to surgery 1.3 hours after admission to the hospital (5.4 hours following injury). During the surgical procedure there was cardiac arrest and cardiac massage was performed to re-establish cardiac rhythm. The chest wound was débrided and a thoracotomy tube was inserted. An exploratory laparotomy revealed a laceration of the liver; this area was drained with Penrose drains. During the 4-hour operation, 2,500 cc. of blood were given.
Bleeding through endotracheal tube occurred postoperatively. An electrocardiogram taken on the first postoperative day was essentially normal. The patient expired suddenly 19 hours after completion of the operation. It was believed that death resulted from a second cardiac arrest.
Case 3. (Shock, transfused 10 pints of blood)
This 26-year-old Korean soldier was injured by mortar-shell fragments on June 20 at 1000 hours. He was evacuated by ambulance from a battalion aid station to the 46th Surgical Hospital, arriving 8.75 hours after injury. He sustained penetrating wounds of the left arm, leg and face, and partial traumatic amputation of the left hand. On admission, his blood pressure was 80/?. He was given 2,500 cc. of blood preoperatively and taken to surgery 1.25 hours after admission to the hospital.
This patient`s face, neck, leg, and foot were débrided. The left posterior tibial artery was ligated and the left hand was amputated. During the 1.5-hour operation, 1,500 cc. of blood were administered. His b1ood pressure remained around 80/60 part of the time during surgical intervention and, for approximately 36 minutes, it was unobtainable. On completion of the operative procedure, his blood pressure was 104/62, pulse 100.
The patient`s postoperative course was unsatisfactory. Twenty-four hours following surgery, his blood pressure fell to 60/40 and norephinephrine was given for the next 16 hours. Oliguria was noted for a 12-hour period during this 16-hour interval. Twenty-four hours after completion of the operation, his temperature was 1040F.; and, after 36 hours, it was 102oF. He died in shock a few hours later.
Case 4. (Cardiac arrest, transfused 12 pints of blood)
This 22-year-old American soldier was injured by mortar-shell fragments on July 20 at 2300 hours. He was brought by ambulance from a collecting station to the 46th Surgical Hospital at 0230 hours. 3.5 hours after injury. On admission, his blood pressure was 0/0. He had penetrating wounds of the neck, face and left arm, and perforating wounds of both legs. Prior to admission, he had received 500 cc. of blood, 500 cc. of dextran, and 100 cc. of albumin. He was given 2,000 cc. of blood prior to surgery.
This patient had cardiac standstill after induction of anesthesia, and cardiac massage was begun to restore cardiac rhythm. Débridement and an above-the-knee guillotine amputation of the right leg was performed. He was given 2,000 cc. of blood during the operation. Blood pressure was below 80 systolic briefly during this time and for the entire 12-hour postoperative period, at which time the patient expired. He remained comatose after surgery: and there was progressive oliguria. Temperature at the time of death was 106.80F. The patient did not appear to recover from the systemic effects of cardiac arrest.
From injury to the hour of his death, this patient was given a total of 6,000 cc. of blood.
Case 5. (Shock, transfused 12 pints of blood)
This 25-year-old Korean soldier was injured by mortar-shell fragments on June 4 at 0800 hours. He was evacuated from a battalion aid station to the 46th Surgical Hospital where he arrived at 1055 hours, 2.9 hours after injury. On admission to the hospital, his blood pressure was 90/40, pulse 120. Blood transfusion was started, but the blood pressure fell to 60. After 2,500 cc. of blood and 1,000 cc. of dextran had been given, his blood pressure rose to 120/70; and he was taken to the operating room.
Abdominal exploration revealed large amounts of a dark liquid, resembling bile, in the peritoneal cavity. Active bleeding was present in the retroperitoneal area. There were perforations of the liver substance, and of hepatic flexure of the colon, tangential tear of the duodenum, avulsion of two lumbar veins, a small laceration in a vein near the adrenal gland, and a perforation of terminal ileum in two places. All tears and perforations were sutured; bleeding vessels were ligated; the perforated colon was exteriorized; and chest wounds were débrided. During the 2-hour operation, 2,500 cc. of blood were given.
Postoperatively the patient was hypotensive for 20 hours; and his blood pressure varied from 70 to 86 systolic. Norephinephrine was started and continued at a slow drip to maintain the blood pressure around 100 systolic. For the first 8 hours, output of urine was 120 cc., and it was 90 cc. for the next 12 hours. A tracheotomy was performed because of respiratory distress. The patient`s progress was very unsatisfactory. Elevation of serum potassium continued and oliguria persisted. The staff decide(l to evacuate this patient to the Renal Insufficiency Center, but he died en route.
Case 6. (Aspiration pneumonia, transfused 12 pints of blood)
This 23-year-old American soldier was injured by mortar-shell fragments on June 11 at 0530 hours. He was taken to the 44th Surgical Hospital; and his initial blood pressure was76/40. Injuries consisted of traumatic amputation of the right forearm, partial penetrating wound of the abdomen, open comminuted fracture of the right humerus, fracture of the right tibia, and multiple wounds of the arms and legs. He was given 3,500 cc. of blood. It was decided to transfer this patient by helicopter to the 46th Surgical Hospital. He was given another 500 cc. of blood and taken to the operating room. At surgery, his blood pressure was 118/80.
An exploratory laparotomy revealed a large perforation of the sigmoid colon; this was exteriorized. No other organ damage was found. During the closure of the abdomen, the patient`s general condition deteriorated. On several occasions during surgery his blood pressure fell to 84/60. Débridement of wounds of the right forearm was carried out rapidly. Because of the patient`s critical Condition, it was felt that a complete débridement should not be performed. During the 2.5-hour operation, 2,000 cc. of blood were given.
While recovering from the anesthesia, the patient vomited and apparently aspirated some of the vomitus. Bilateral bronchopneumonia rapidly developed. Postoperatively the patient remained comatose; and he died on the fifth postoperative day.
Case 7. (Massive lung damage, transfused 13 pints of blood)
This 20-year-old American soldier was wounded by enemy gun fire on May 6 at 0500 hours. He was given 500 cc. of dextran and 400 cc. of blood at a battalion aid station. Upon arrival at the collecting station, his blood pressure was 106/70, and he was given another 500 cc. of dextran. He was brought by ambulance of the 46th Surgical Hospital at 0840 hours, 3.7 hours after injury.
He had sustained a penetrating wound of the left chest. On admission, his blood pressure was 174/90, pulse 140. Respiration was rapid and labored; but there was no cyanosis. The patient was taken to the operating room and, when he was turned on his side following induction of anesthesia, there was a fall in blood pressure. He was given a total of 13 pints of blood in an attempt to treat the hypotension. Pulmonary edema developed within a short time, and the patient died before the operation was actually begun. It was felt that he died because of extensive damage to a vital organ.
Case 8. (Mediastinitis, transfused 13 pints of blood)
This 22-year-old American soldier was injured by mortar-shell fragments on July 5 at 0200 hours. He was evacuated by helicopter to the 46th Surgical Hospital 4.75 hours after injury. He had a penetrating wound of the abdomen. On admission, his blood pressure was 100/80, pulse 120. Preoperatively he was given 3,250 cc. of blood; and he was taken to surgery 4.5 hours after admission to the hospital.
Laparotomy revealed a laceration of the cecum and multiple lacerations of the small bowel. Two resections of the small bowel were made and a cecostomy was performed. During the3-hour operation, lie was given 3,500 cc. of blood. His blood pressure was unobtainable on two occasions during surgery. Norepinephrine was begun as soon as he was returned from the operating room.
Postoperatively the patient did very poorly. A diagnosis was made of lower left lobar pneumonia. There was persistent hypotension and oliguria. The patient also developed signs of a pulmonary infarct. Clinical jaundice developed on the fifth day after operation. There was an episode of hematemesis on the seventh postoperative day. The patient was moved to the Renal Insufficiency Center where further resuscitative measures were carried out with blood. He continued to vomit dark-colored matter. A Levine tube was passed into the stomach and, when an x-ray was taken, the tube was shown to be coiled in the right mediastinum. Apparently there was an unrecognized perforation of the esophagus. The patient`s condition deteriorated and he died on July 13, the eighth day after injury.
Case 9. (Pancreatitis, transfused 14 pints of blood)
This 21-year-old American soldier was injured by small arms fire on May 12 at 2016 hours. He was taken to a battalion aid station and then evacuated to the 46th Surgical Hospital, arriving 2.25 hours after injury. He had a perforating gunshot wound of the upper abdomen. He was given 500 cc. of dextran at a battalion aid station. On admission to the hospital, his blood pressure was 120/60, pulse 84. Preoperatively he was given 3 bottles of blood (1,500 cc.) and taken to the operating room 2.58 hours after admission.
Laparotomy revealed perforations of the stomach, splenic flexure of the colon, ana lacerations of the spleen and left kidney. There was a slight injury to the tail of the pancreas. The stomach perforations were closed; the spleen and left kidney removed; the splenic flexure of the colon was resected; and a double-barrel colostomy performed. On several occasions during the operation the blood pressure fell; but it stabilized following administration of 9 bottles of blood and norephinephrine intravenously. The abdomen was drained with one Penrose drain in the left gutter through the wound of exit in the left lateral lumbar area.
The patient progressed satisfactorily until the evening of the 18th of May, the sixth day after injury, when he became distended and somewhat irrational. The following day lie became anuric, hypotensive, and had a convulsive seizure. It was felt that the patient had pancreatitis along with renal insufficiency. He
continued to have tetanic muscular contractions and he died at 1400 hours on May 19th.
Postmortem examination showed an inflammatory pancreatitis with necrosis. The right kidney was large, soft, and edematous.
Case 10. (Shock, transfused 16 pints of blood)
This 41-year-old Korean soldier was injured by mortar-shell fragments on April 22 at 0545 hours. He sustained penetrating wounds of the chest and abdomen, perforating wounds of the right arm. He received 1,000 cc. of dextran at a battalion aid station and 500 cc. of blood at a collecting station. He was then evacuated to the field unit of the 46th Surgical Hospital, arriving 2.4 hours after injury. A sucking wound of the chest had been closed with gauze. On admission, his blood pressure was 0/0, pulse 98. He was pale and cold; and he had labored respiration and a barely perceptible pulse. He was given 8 pints of blood intravenously and intra-arterially before being taken to surgery 5 hours after admission to the field unit. Lung tears were found at operation; and these were sutured. After the lungs were re-expanded, the chest was closed. Laparotomy revealed large amounts of free blood, a perforating wound of the hepatic flexure of the colon, a perforation of the duodenum, and retroperitoneal hemorrhage. The hepatic flexure was exteriorized and the other perforation was closed. During the operation, blood pressure varied between 116/70 and 78/58; and 8 pints of blood were transfused.
Postoperatively the patient`s blood pressure ranged from 100/60 to 84/50; his respiration was 48, and output of urine on the day of surgery totaled 350 cc. On the first postoperative day he was moved from the field unit of the 46th Surgical Hospital to the rear Unit. His blood pressure at this time was ranging from 90/60 to 80/50. He died a few hours later in shock.
Case 11. (Shock, transfused 19 pints of blood)
This 21-year-old American soldier was struck by mortar-shell fragments on June 19 at 0655 hours. He sustained penetrating wounds of the face and hands, open comminuted fractures of the right and left tibia, traumatic amputation of the right hand, and multiple superficial injuries. The soft tissue of both legs was damaged extensively. This patient was evacuated by helicopter to the 46th Surgical Hospital, arriving 1.5 hours after injury. At a battalion aid station this patient had received 1,000 cc. of dextran. On arrival at the surgical hospital, his bood pressure was 80/60, pulse 90. Preoperatively he received 5,500 cc. of blood. He was then taken to surgery 6.5 hours after admission to the hospital.
A below-knee amputation was performed on the left leg; and the right hand was amputated. Extensive débridement was performed on wounds of the left leg, and a cast was applied. Remaining multiple wounds were also débrided. For 4 hours prior to surgery, the patient`s blood pressure was below 80; but It remained around 110 during the 1.5-hour operation. Pulse varied from 144 to 160.
Postoperatively the patient`s blood pressure was below 80 most of the time, even though norepinephrine was given. There was marked hemoglobinuria; and the patient died 20 hours following completion of surgery.
Case 12. (Uncontrolled hemorrhage, transfused 19 pints of blood)
This 24-year-old American soldier was injured by mortar-shell fragments on May 26 at 0845 hours. He sustained penetrating wounds of the neck, abdomen, both arms and legs. He was taken to a battalion aid station where 500 cc. of dextran were administered; and then evacuated by helicopter to the 46th
Surgical Hospital, arriving 2 hours after injury. Eleven pints of blood were given prior to the operation.
An abdominal exploration revealed a large amount of blood in the peritoneal cavity and a huge retroperitoneal hematoma. There was a laceration of the common iliac artery and a superior mesenteric artery thrombosis. When the large retroperitoneal hematoma was evacuated, the patient suddenly died. During the 50-minute surgical procedure, 8 pints of blood were given.
Case 13. (Septicemia, transfused 20 pints of blood)
This 22-year-old American soldier was injured by an M-1 rifle missile on February 24 at 0100 hours. The missile perforated the upper abdomen. He was taken to a battalion aid station; his blood pressure at that time was 115/65. At a collective station, this patient`s blood pressure was 90/60, pulse 100. After receiving 500 cc. of blood, he was evacuated by ambulance to the 46th Surgical Hospital and arrived at the hospital 4.25 hours after injury. His blood pressure upon admission was 99/80. Preoperatively he was given 2,000 cc. of blood; then he was taken to the operating room 4.5 hours after admission to the hospital.
Laparotomy revealed four perforations of the hepatic flexure of the colon, and perforations of the right lobe of the liver and inferior pole of the right kidney. The colon was exteriorized; liver injuries were packed with gel foam, and a small wedge was removed from the lower pole of the kidney. The peritoneal cavity was drained. Fifteen pints of blood were administered during surgery; but blood pressure remained around 80/50 throughout the procedure. Norepinephrine was also given.
Postoperatively the patient had a stormy course. Most of the time his blood pressure was over 100, but he became oliguric the first postoperative day. On the second postoperative day he was moved to the Renal Insufficiency Center. He was dialyzed on the artificial kidney once, but his condition continued to deteriorate. A blood culture showed that septicemia was present and the patient died on the 12th postoperative day.
Postmortem examination showed an abscess in the right kidney, peritonitis, and a large retroperitoneal hematoma.
Case 14. (Uncontrolled hemorrhage, transfused 22 pints of blood)
This 23-year-old American soldier was injured by mortar-shell fragments on May 7 at 0140 hours. Fragments penetrated the right arm, back, and right side. He was taken to a battalion aid station, and then to the clearing station where he was given 1,000cc. of dextran. He was evacuated by ambulance to the 46th Surgical Hospital and admitted 4.7 hours after injury. On admission his blood pressure was a questionable 100, pulse 128. The patient had a sucking wound of the chest and gross hematuria. He was given 3,500 cc. of blood prior to surgery.
The chest wound was débrided and closed. Laparotomy revealed lacerations of the diaphragm and liver, transection of the small bowel in three places, a perforation of the sigmoid colon, and a shattered left kidney. The tear in the diaphragm was closed, and the small bowel repaired; a left nephrectomy was performed; and a loop colostomy was made During the 3-hour operation 3,000 cc. of blood were given; and for a period of 1.75 hours there was hypotension of less than 80.
Postoperatively the patient continued to bleed. During the first 16 hours following operation he was given 4,500cc. of blood; and his output of urine was nil. Sixteen hours after completion of surgery this patient died. Apparently hemorrhage continued from the liver wound.
Case 15. (Undetermined, transfused 23 pints of blood)
This 21-year-old American soldier was injured accidentally by a grenade on July 28 at 1045 hours. Fragments struck his left hand, both eyes, buttocks, thighs, and legs. He was taken to a battalion aid station where 500 cc. if blood and 1,000 cc. of dextran were administered. Then he was evacuated by helicopter to the 46th Surgical Hospital, arriving 1.4 hours after injury. His blood pressure was 40/0 on admission. Preoperatively he was given 500 cc. of blood and taken to surgery 3.5 hours later.
At surgery an exploratory laparotomy was negative. Multiple débridements were carried out. The popliteal artery on the right side was injured and, in addition to extensive damage of the soft tissue, he had sustained fractures of the left fibula and of both the right and left tibia. The injured popliteal artery was anastomosed. During the 4-hour operation 5,000 cc. of blood were given.
Postoperatively the patient was quite ill. For 8 hours Immediately following the operation his blood pressure was around 80 to 90. His right leg was cold below the knee; and output of urine was only 200 cc. the first postoperative day. Because of the patient`s progressive deterioration, he was taken back to the operating room the second postoperative day and an above-the-knee amputation was performed on the right side. At this time. his serum potassium was 8.6 milliequivalents per liter. Because of oliguria he was placed on a fluid restriction regimen. He was then evacuated to the Renal Insufficiency Center where the left leg was amputated because of extensive damage to tissue, as it was felt that massive tissue necrosis was contributing to the oliguria and hyperpotassemia. The following day the patient died.
Case 16. (Uncontrolled hemorrhage, transfused 32 pints of blood)
This Korean was struck by artillery-shell fragments on April 26 at 1040 hours and sustained traumatic amputation of both legs, penetrating wounds of both arms, and multiple superficial wounds. He was taken to a battalion aid station and then evacuated by helicopter to the 46th Surgical Hospital where he was admitted 2.08 hours after injury. On admission his blood pressure was 0/0. There was no perceptible pulse, and no reaction to painful stimuli. Blood was transfused intravenously and intra-arterially; and after 5 pints of blood had been given his blood pressure was 60/?. During a 5.3-hour resuscitative period he received 24 pints of blood; and when his blood pressure rose to 110/85 he was taken to surgery.
Six cc. of pentothal was all the anesthesia required. Four teams of surgeons reamputated both thighs and débrided both arms and hands in a total operative period of 30 minutes. After 21 pints of blood were transfused by drip, blood pressure fell to70/0. By rapidly pumping in 1,000 cc. of blood, his pressure rose to 100/0; but he died on the operating table 30 minutes after surgery was completed.
Case 17. (Uncontrollable oozing of blood, transfused 33 pints of blood)
This 24-year-old American was injured by small arms fire on April 9 at 0300 hours. The missile penetrated the abdomen and back. Blood pressure at the battalion aid station was 110/74, pulse 84; and at the collecting station blood pressure was 40/0. The patient was given 1 bottle of blood (500 cc.) and evacuated to the clearing station where 2 more bottles of blood were given prior to evacuation to the 46thSurgical Hospital. On admission 4 hours after injury, blood pressure was 120/80, pulse 118. Within the next 2 hours he was given 2 more pints of blood and then taken to the operating room.
An exploratory laparotomy revealed perforations of the inferior vena cava, hilum of the left kidney, and of the duodenum. The vena cava was ligated
above the renal veins; the left kidney was removed; and the duodenum repaired. Blood pressure varied during surgery from 110 to 60/0. He was given 28 pints of blood during the operation and when the laparotomy wound was being closed, blood was oozing from multiple areas. He died approximately 5 hours after completion of the operation. He had been given a total of 33 pints of blood.
Case 18. (Uncontrolled oozing of blood, transfused 40 pints of blood)
This 20-year-old American soldier was struck in the abdomen by shell fragments on July 7 at 0415 hours. He was given 6 pints of blood at the collecting station prior to evacuation to the 46th Surgical Hospital. Upon admission to the hospital 5.75 hours following injury, his blood pressure was 100/64, pulse 64. One hour and 10 minutes after admission he was rushed to surgery.
Laparotomy revealed perforations of the interior vena cava, the right ureter, duodenum, and colon. The vena cava was ligated; ureter repaired over a catheter; and a nephrostomy performed. The colon was exteriorized. During operation 17 pints of blood were given; but the patient`s blood pressure varied from 100 to 80/60.
Postoperatively he became oliguric. In the immediate 24 hours following surgery, the serum potassium was 9.2 milliequivalents per liter, and the electrocardiogram showed that myocardial changes had occurred. He was evacuated to the Renal Insufficiency Center where he was dialyzed on the artificial kidney on the second postoperative day. Serum potassium fell from 8 to 5.4 milli-equivalents per liter. After dialysis blood pressure was very unstable and, although large amounts of blood were given, he continued to deteriorate and died on the morning of the third postoperative day.
Postmortem examination revealed a large amount of blood in the peritoneal cavity and evidences of bleeding from the psoas muscle and surrounding areas.
Case 19. (Uncontrollable oozing of blood, transfused 52 pints of blood)
This 36-year-old Korean was injured by mortar-shell fragments on June 26 at 2210 hours. He sustained penetrating wounds of the buttocks, pelvis, and a traumatic amputation of the right foot. Prior to admission to the hospital he had received 1,500 cc. of dextran. Four hours after injury he was brought by ambulance to the 46th Surgical Hospital. On admission his blood pressure was 110/60, pulse 110. Prior to operation, however, blood pressure fell; and during a resuscitative period of 4.5 hours before he was taken to surgery, he was given a total of 11 bottles of blood.
Examination revealed multiple perforations of the rectum. A diverting colostomy was made. All wounds were débrided. There was massive destruction of the gluteal muscles, fractures of the sacrum and right femur. A right, lower leg amputation was performed. During a 2.5 hour operation he was given 20 pints of blood.
Postoperatively there was hypotension, although more blood and norepinephrine were given. He died 11 hours following operation. A total of 52 pints of blood had been given. There was continued oozing from all wounds until death.
Case 20. (Uncontrollable oozing of blood, transfused 56 pints of blood)
This 21-year-old American soldier was injured by mortar-shell fragments on July 24 at 1730 hours. He sustained extensive multiple wounds of the lips, right arm, both thighs, and right buttock. He was evacuated by helicopter from the battalion aid station to the 46th Surgical Hospital, and arrived
3 hours after injury. On admission his blood pressure was 50/30. Preoperatively he was given 22 pints of blood and then taken to the operating room.
At surgery there was a laceration of the liver and two intraperitoneal rectal perforations. The rectal perforations were repaired, a diverting colostomy was performed and the liver was sutured. Because of the poor condition of the patient, the wounds of the lips, right arm, and thighs were not débrided. Six pints of blood were given during the operation.
Postoperatively for 9 hours there was hypotension below 80, and multiple transfusions were given. The patient failed to rally and continued to ooze from various wounds. He had received a total of 56 pints of blood from time of Injury until he died 9 hours after operation.
Postmortem examination showed over 7 liters of blood in the peritoneal and pleural spaces. In addition, there had been bleeding into the retroperitoneal spaces and muscles.
1. Grant, R. T., and Reeve, E. B.: Observations on the General Effects of Injury in Man: With Special Reference to Wound Shock. Medical Research Council, Special Report No. 277, London, England.
2. Prentice, T. C.; Olney, J. M., Jr.; Artz, C. P, and Howard, J. M.: Studies of Blood Volume and Transfusion Therapy in the Korean Battle Casualty. Surg., Gynec. & Obst. 99: 542, 1954.
3. Beebe, G. W., and De Bakey, M.E.: Battle Casualties. Charles C Thomas, Springfield, Illinois, 1952.
4. Board for the Study of the Severely Wounded: The Physiologic Effects of Wounds. The Office of The Surgeon General, Department of the Army, Washington, D. C., 1952.