EUROPEAN THEATER OF OPERATIONS 15 MAY 1944CIRCULAR LETTER NO. 71
SUBJECT: Principles of Surgical Management in the Care of Battle Casualties
1. Surgical Echelons
2. Morphine
3. Blood Transfusions
4. "Transportable" and"Non-transportable"
5. Surgical Procedures
6. Sulfonamide Therapy
7. Penicillin Therapy
8. Secondary Closure
9. General Principles to be followed in the Use of PlasterCasts
10. Treatment of Anaerobic Infections
11. Radiology in Forward Area
12. Identification of Gases in Cylinders
1. Surgical Echelons
This first paragraph has been extracted, with only minorchanges, from a circular letter, Office of the Surgeon, North African Theater ofOperations. The policies expressed herein are sound, are based upon experiencesin combat and will in general govern the activities of Medical Departmentpersonnel in this Theater.
a. The welfare of the patient and the tactical necessity forrapid evacuation demand a clear understanding of the function or mission of eachunit of the Army Medical Corps. This is best arrived at by dividing thetreatment of a casualty into two stages, primary and definitive. Separate groupsof units provide each stage of treatment. In general, the equipment of eachgroup is designed for that purpose only.
b. Stations of the first and second echelons, Aid Stations,Collecting Stations and Clearing Stations, are equipped and staffed for theprimary phase of treatment. Arrest of hemorrhage, splinting of the injury,resuscitation measures needed to make the patient transportable, andadministration of sulfonamides are the urgent functions of these stations. Inaddition, the treatment of minor injuries that allow immediate return to duty,is carried out without evacuation. A Clearing Station or functionally similarmedical installation, is not designed to provide definitive treatment for battlecasualties.
c. It must be remembered that the lightly wounded soldier ora casualty due to accident may regain full combat status within the Theater ifproper surgical treatment is carried out, but the Theater may be deprived of hisservice by faulty surgical judgment. Because a surgical procedure appears simpleis not sufficient reason for performing it in a Clearing Station unless the mancan be returned to immediate duty without evacuation to the rear.
d. Hospitals of the third echelon, Evacuation Hospitals andField Hospitals with attached Surgical Teams, are designed to initiatedefinitive surgical treatment to battle casualties. The more delay there isbefore reaching this echelon, and the more hands the patient passes through inreaching it, the poorer will be the final results. The evacuation line is notan assembly line in which each surgeon does his bitto the patient. It is a
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conveyer line, along the course of which the progressof the patient may be halted to save life or limb, or to render himtransportable.
e. Although Field and Evacuation Hospitals with attachedSurgical Teams are adequately equipped and staffed to perform rehabilitationoperations, they are not designed for this function. Even in quiet times,patients requiring rehabilitation operations will be evacuated to a fourthechelon hospital except when the Commanding Officer decides otherwise, basedon knowledge of the tactical situation as well as the surgical aspects ofan individual case.
2. Morphine
This note appears because, although morphine is one ofhumanity's greatest aids in warfare, it is also often misused andfrequently given in unnecessarily large and dangerous quantities.
a. Dosage. Morphine sulfate gr. ? (15 mgm.) is usually adequate;? gr. (30 mgm.) may be required and is safe unlessrepeated. Always record amount and time of injection.
b. Administration. Subcutaneous or intramuscularinjection is employed when a gradual prolonged effect is desired. Massage atthe site of injection will hasten absorption. Intravenous injection (gr. 1/8,8 mgm.) is employed when a rapid effect is desired.
c. Contra-indications. The doses of morphine givenas preoperative medication for seriously wounded patients should be small (gr. 1/6, 10 mgm. or less). Morphine must beadministered with cautionto the walking wounded, to patients to be evacuated by air; or in the presenceof jaundice, cranio-cerebral injury, pneumothorax, hemothorax or pleuraleffusions. Morphine will never be used as a sedative for manic or hystericalstates.
d. Poisoning. Overdosage with morphine ischaracterized by pinpoint pupils and slow respirations. The outstanding seriouseffect is anoxia, caused by respiratory depression.
e. Delayed Morphine Poisoning in Battle Casualties. Subcutaneousinjections of morphine are poorly absorbed in patients who are cold, or whohave a low blood pressure and are in shock, under which circumstances pain maynot be relieved. As a result, repeated doses given in an attempt to relievepain may be followed by morphine poisoning when the peripheral circulation isre-established and the unabsorbed deposits of morphine are absorbed rapidly. The intravenous administration of morphine in patients who are cold, or whohave low blood pressure and are in shock, will eliminate this problem. Alwayscheck for previous administration of morphine and always record the amountand time given.
f. Treatment of Morphine Poisoning. Provide a clearairway. Administer oxygen, under intermittent pressure if necessary. A maximal dose of ephedrine, gr.? (30 mgm.) administered intravenously, using rise in blood pressure as a guide to dosage,may beemployed. Caffein sodium benzoate, gr. 7? (0.5gm.) intravenously, may be useful. Empty the stomach prior to developmentof coma. Stimulate diuresis by means of intravenous glucose. Changeposition of patient frequently.
3. Blood Transfusion
a. Blood used in the treatment of casualties in shock willordinarily be administered in the ratio of one part blood to two parts ofplasma (one pint of blood to four units of plasma).
b. Procurement of blood within unit: Units equippedwith the Field Transfusion Kit will follow the instructions contained thereinfor bleeding lightly wounded and noncombatant personnel and for care of theapparatus.
c. Procurement of blood from ETO Blood Bank: EvacuationHospitals, Field Hospitals, LST's, Holding Units and Transit Hospitals will besupplied with blood from the ETO Blood Bank. All blood from this source is TypeO and will not be cross-matched. On the bottle label is an expiration date,beyond which the blood will not be used. The following rules will be strictlyfollowed in the use of Bank blood:-
(1) Blood will be refrigerated constantly between two (2) and four (4) degrees above zero centigrade (+35 to +42 F.)and kept in thedark.
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(2) Blood will be removed from the refrigerator andadministered cold. It will under no circumstances be pre-heated.
(3) Blood which is allowed to rise above six (6) degreescentigrade will be used within four (4) hours and will not be re-cooled.
(4) All used equipment will be exchanged attime ofdelivery of blood.
d. Non-transportable Casualties
The proper sorting of casualties into transportableand non-transportable classes is of prime importance in evacuation. The following listed types of casualties are usually non-transportable and shouldbe submitted to surgery early. This classification can only serve as a guide,and each individual case deserves separate appraisal.
4. Non-transportable Casualties
a. Wounds of the abdomen
b. Wounds of the chest which are serious, either because of-
(1) a large sucking wound, or
(2) such massive intra-thoracic hemorrhage that the patient'scondition is unsuitable for transportation.c. Trans-thoracic or abdomino-thoracic wounds. These areoften difficult to diagnose and are frequently missed-note that in wounds ofthe buttock the missile may lodge in the thorax or, similarly, with woundsof the shoulder the missile may lie within the abdominal cavity. IfX-rays are available, final lodgement of the missile will make diagnosis easy,but if not, the medical officer must always examine the opposite cavity from wounding to rule this out.
d. Casualties who remain in "shock" after therapy, and whose condition cannot be made suitable for transport. In thisgroup are included multiple fractures, casualties with injury to majorvessels, and avascular extremities in which gas infection is likely to occur,and those with concealed hemorrhage.
e. Certain casualties with maxillofacial wounds, where mechanical difficulty in breathing endangers life during transport.
5. Surgical Procedures
a. Dressings. Ideally, the primary phase of treatmentwill be completed in the first unit reached that is equipped to provide it. The dressing is to then be left undisturbed until the patient reaches a thirdechelon unit for operation. There are certain safeguards and adjustments thatmust take place en route, but these do not include inspection of the wound byremoval of the dressing unless definite indications for so doing are present. Acompound fracture case may be halted at the Clearing Station for more adequateimmobilization or resuscitation, but the wound should not be re-dressed unlessnecessary to arrest continuing hemorrhage. A wound will not be re-dressedsolely for the purpose of re-applying local sulfonamide. Oral administration issufficient safeguard.
The same principles apply after operation has been completedand the patient is being evacuated to the rear. Uninformed hands do unnecessarydressings. The best safeguard for a patient is an adequate and legible recordthat accompanies him, which makes it possible for a receiving officer to referto the record rather than looking at the wound. Infection arising fromcontamination incurred at the time dressings are changed may make impossiblesecondary suture of wounds after debridement and arrival at a third echelonunit.
b. Debridement of wounds. This is the basis of theproper treatment of all battle casualties. It is definitely more important thanchemotherapy, and reliance on the latter must not diminish devotion to theproper surgical treatment of wounds. Use ample incisions, practice minimalremoval of skin and bone, and maximum removal of all dead or devitalizedmuscle. Never close primarily wounds debrided under field conditions. Packwounds open lightly, never plug tightly.
Under favorable circumstances, it is desirable that severednerves and tendons should be approximated, preferably with metallic or non-absorbable sutures (see Manual of Therapy, European Theater of Operations).
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c. Amputations. Amputations for trauma will be acircular open (guillotine) amputation at the lowest possible level, followed bythe application of skin traction. Skin traction will be applied immediately and must be maintained during all stages of evacuation, including evacuationto the Zone of Interior, and until the stump is completely healed. Skin grafting will not be used as a substitute for skin traction.
6. Sulfonamide Therapy
a. A soldier wounded in action is instructed to take bymouth, as soon as possible, 4 gms. (8 tablets) of sulfadiazine, from his ownFirst Aid packet, except when wounded in the abdomen.
b. The medical officer first dressing the wound shouldfrost it lightly with sulfanilamide powder. Not more than 5 gms.(contents of one packet) should be placed in the wounds of any individual,irrespective of the number and size of the wounds.
c. Continue sulfadiazine orally until definitive surgery isinstituted. The maintenance dosage is 1 gm. orally every 4 to 6 hours, or 2 gms.parenterally every 8 to 12 hours. Chemotherapy should be given cautiously in thepresence of dehydration (for dangers, see Manual of Therapy, European Theaterof Operations).
d. Sulfonamide and penicillin therapy will be carried outconcurrently.
e. Both penicillin and a sulfonamide should be placed inwounds after definitive surgical treatment (see par. 7h).
f. Sulfonamide therapy will be continued after surgical treatment by oral or parenteral routes, as instructed in the Manual of Therapy,European Theater of Operations.
g. Sulfonamide therapy for burns shall consist only ofparenteral therapy or local application, never both.
7. Penicillin Therapy
a. Penicillin therapy (parenteral) will begin at ClearingStations, and will be continued at Field and Evacuation Hospitals. Its localuse in wounds will begin in Field and Evacuation Hospitals where definitivesurgery is carried out.
b. The phrase "Penicillin Treated" will be enteredon the EMT or Field Medical Record after the diagnosis in every case so treated.Additional data, including dosage in units, method of administration (parenteral or local) and time and date of administration will be entered onthe back of the [EMT] or on Clinical Record form in cases where a FieldMedical Record has been initiated.
c. Penicillin is unstable and is best preserved at 4?centigrade. Where refrigerators are not available, keep in coolest spotpossible and away from sunlight. Use as soon as possible after removal from hermetically sealed vial, whether in normal saline or sulfanilamide powder. Vials which are out-dated will not be discarded.
d. Do not use in small superficial wounds of gutter type,or where missile lies close to skin and no fracture.
e. Parenteral Therapy
(1) For parenteral use penicillin is dissolved innormal saline. Add 10 cc. cold normal saline to 100,000 unit vial ofpenicillin and inject intramuscularly 2 cc. per casualty. Needles and syringesmust not be sterilized by use of antiseptic solutions and must be cold becauseboth chemicals and heat inactivate penicillin.
(2) Penetrating and perforating wounds of soft parts: give20,000 units intramuscularly every 4 hours from Clearing Station throughperiod of definitive surgery and for 48 hours thereafter.
(3) Wounds with compound fractures: give 20,000 unitsintramuscularly every 4 hours from Clearing Station through period ofdefinitive surgery and for 72 hours thereafter.
f. Double above doses, paras. e (2) and (3), where woundsare in region of buttock, perineum, upper thighs and popliteal space.
g. Penicillin therapy may be extended beyond the 48 and 72hour specified post-operative time, paras. e (1) and (2), if sepsis becomes a major problem.
h. Local use in wounds (both soft part wounds and compound fractures) at time of definitive surgery; Dust 20,000 units of penicillin mixed with 3 grams (1 teaspoonful)
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of sulfanilamide into the wound at the close of the debridement. This is best accomplished by mixing the contents of a 100,000 unit vial with 15 grams (5 teaspoonfuls) of sulfanilamide, and using 1teaspoonful per wound. All containers must be absolutely dry and cool before mixing. Where wounds are multiple, use up to 40,000 units of penicillin in 6 grams of sulfanilamide, distributing proportionately accordingto severity of wounds. The use of penicillin in wounds is not mandatory butis advisable in all wounds where there is severe destruction of tissue. Shouldthe supply of penicillin be limited, omit local application.
i. Penicillin therapy does not contradict or interfere withsulfonamide therapy.
8. Secondary Closure
a. Although the first principle for the military surgeon tobear in mind is not to close the wound he has freshly debrided, it isessential that he close this wound at the earliest possible moment that issafe. Early closure means limitation of infection and fibrosis, and anearlier restoration to duty. If the primary debridement has been thorough, small wounds may be closed as early as the third day, though theaverage wound not until the fifth day. Observation of the signs of inflammation,such as discharge, reddening, pain and swelling, will determine whetheror not a wound can be closed. It is wiser not to dress the originallydebrided wound until the day when secondary closure might be practical, since each dressing invites contamination of the wound. If closure isconsidered safe, it should be done loosely without undermining the edges orusing sharp instruments, and by using retention sutures of silk, or silkworm gut, spaced widely apart and looselytied. Should mild infection appear, hot, moist dressings may save breaking down of the wound and hasten the healing process. Any signs of severeinfection require immediate removal of the sutures.
b. Closure of wounds with fractures should only be undertakenwhen full penicillin therapy is being practiced and when all the signs ofinfection are absent.
c. Wounds closed early, before the establishment ofgranulation tissue or scar tissue, are easier to close than those closed afterone or two weeks. In wounds that have been open for a long time, skin graftingis often better than closure by suture. If the original debridement has beenpracticed with the minimal of skin removal, as suggested above, closure bysutures will be simple.
d. Removal of sutures from such secondary closures should nottake place before 10 days unless stitch infection develops. After removal of the sutures it may be wise to maintain approximation of the wound edges with adhesive plaster.
9. General Principles to be followed in the Use of Plaster Casts
a. No circular bandages, dressings, or strips of adhesiveshall be used under a plaster cast, as these constrict the extremity and maycause extensive damage if swelling of the part occurs.
b. Adequately padded plasters are probably safer in averagehands. Padding should be applied to all bony prominences such as malleoli andheels, knees, particularly over the head of the fibula, wrists and elbows. In addition,sufficient padding should be used over the soft parts to permit some swellingwithin the cast.
c. All layers of plaster, sheet wadding or dressings mustbe cut through down to the skin immediately after the application of acast following an operation or manipulation. Swelling of the part will occur and, unless all layers of the plaster padding anddressings are cut through,it will be impossible to spread the cast to prevent extensive damage when swelling occurs.
d. Attention should be paid to the position of the extremity encased in plaster. The foot should be at a right angle to theleg, the knee should be in 10?-15? of flexion, the hip should be inneutral position or slight flexion. The wrist should be supported in neutralposition to prevent wrist drop, and the elbow ordinarily is best supportedat a right angle. In these positions the patient will transport comfortably, will not take up undue space, and the tendency to develop troublesome fixed deformities will be minimized.
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e. A line diagram in indelible pencil should be inscribed on the cast, indicating the approximate location of fracture and position of fragments. The number of the unit, date of injury, date of operation and type of operation should likewise be written on the cast so that if the Field Medical Record is lost, a reasonably satisfactory substitute record will be readily available.
f. Either a platform or a loop or wicket of plaster should be applied to the foot of the cast in order to protect the toes from pressure of blankets, bed clothes, et cetera. Plaster applied to the hand should be trimmed back to the proximal palmer crease to permit full flexion of the fingers and metacarpal phalangeal joints.
10. Treatment of Anaerobic Infections
a. Gas Gangrene
(1) Types of Wound. Wounds destroying muscle, either directly or by interruption of the blood supply, are particularly susceptible to anaerobic infections. Such infections are more frequent at the following sites of wounds:-(i) buttock; (ii) upper thigh (compound fracture of femur); (iii) anterior tibial group; (iv) shoulder girdle; (v) short flexors and extensors of forearm.
(2) Types of Infection. The following types of infection must be recognized, since they require different therapy:-
a. Gas gangrene (clostridial)
(1) Diffuse myositis
(2) Localized myositis
(3) Cellulitis, "gas abscess"b. Gas gangrene (streptococcal), rare
(1) Myositis
(3) Diagnosis
a. Clinical. The differential diagnosis among the various types of clostridial gas gangrene and streptococcal myositis must be made to avoid unnecessary radical surgical treatment.
(1) Clostridial myositis, diffuse: This may develop within 6 hours from the time of wounding, usually within 3 days. The onset is acute with a severe systemic reaction. Locally there is pain,marked swelling, frequently profuse serous exudate, slight gas formation,variable odor ofdecay and pale or blue-gray appearance of involved muscle. The skin is tense and often white, but may be mottled with a livid appearance if the process is widespread.
(2) Clostridial myositis, localized: In 5-10 percent ofthe cases, localization of the process to a single muscle or group of muscles occurs. Symptoms and signs arethe same as for the diffuse type.
(3) Clostridial cellulitis: This process is limited tothe immediate area of the wound. The onset is gradual, usually after 3 days,with slight systemic reaction. Locally, there is abundant gas formationwith a foul odor, slight swelling, and little local change of the muscleand overlying skin.
(4) Streptococcal myositis: Theonset is delayed for 3-4 days, and severe systemic reactions do not appearuntil the late stages of the infection. Locally, there is marked swelling withprofuse purulent discharge, slight gas formation, and slight odor. Theinvolved muscle is slightly edematous and the overlying skin is tense, oftenwith a coppery tinge. Streptococcal myositis comprises only a few of thecases of gas gangrene.
b. Laboratory Recognition of infections with anaerobicbacteria is made on clinical findings, which should be checked, wherepossible, with a smear made from the material in the depth of the wound. Asmall piece of involved muscle, rubbed on a glass slide and stained by the Grammethod, is examined under the microscope. In the presence of clostridial gasgangrene, such smears usually show a predominance of large gram-positive rods.Pus cells are scanty and degenerate. In streptococcal myositis, gram-positivebacilli are absent and in their place large numbers of small-sizedstreptococci are
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found among masses of pus cells. Whenever facilities areavailable, anaerobic wound and blood cultures should be carried out.
The finding of anaerobic bacteria in a wound is not uncommon, and such finding should not influence the surgical treatment, unless there are local clinical signs of anaerobic infection.
(4) Prophylaxis. Early, adequate debridement of wounds is the best prophylaxis for anaerobic infections. Debridement where there has been massive destruction of tissues, moreparticularly in the region of the buttocks, perineum and upper thighs, andwhere major vessels are injured, must be radical and thorough, using long incisions. If hematoma is present, deep fascial planes must be incised, especially in the popliteal area. Bilateral incisions in thepopliteal space just inside the hamstring tendons should be made. The fasciaover both heads of the gastrocnemius should be incised-all clots should beevacuated and any continued bleeding controlled by ligature or suture. Gasgangrene antitoxin, sulfonamides and penicillin are not to be consideredsubstitutes for early, adequate debridement. However, where circumstancesdelay debridement of the wounds mentioned in para. 10. a. (1), for 24 hours orlonger, one (1) ampule of gas gangrene antitoxin may be given intramuscularly.Penicillin and sulfonamides are to be used as directed in paras. 6 and 7.
(5) Therapy.
a. Surgical - This depends upon the extent of the disease and the type of anaerobic infection. Diffuse clostridial cellulitis is encountered in approximately 80 percent of cases in these categories.
(1) Clostridial myositis, diffuse: Amputation as farabove visible evidence of involvement as possible must be carried out immediately,using the guillotine method, and leaving the wound open.
(2) Clostridial myositis, localized: Extirpation of theinvolved muscle, or group of muscles, should be practiced through long incision.
(3) Clostridial cellulitis: Incise the localizedprocess and remove the devitalized tissue. Radical surgery is not indicated.
(4) Streptococcal myositis: Extensivelyincise and drain the involved muscles. Radical extirpation or immediateamputation are not indicated.
b. Serum therapy.
(1) Clostridial infections: Three(3) ampules of gas gangrene antitoxin should be given intravenously and repeatedhourly for 6 doses (see Manual of Therapy, European Theater of Operations, page 35, para. 27). This may be modified according to the condition of theindividual case. Test patient for allergy to horse serum before administrationof antitoxin. Adrenalin in a syringe should be at hand.
(2) Streptococcal infections: No serotherapy isindicated.
c. Chemotherapy.
(1) Penicillin: Give initial dose of 20,000 units, intravenously and 20,000 units intramuscularly, followed by 20,000 units intramuscularlyevery 2 hours for a period of 3 days. Period of therapy may be modified as seems necessary.Place in the wound 50,000 units mixed in 4 gms. (1 teaspoonful) of sulfanilamide, andrepeat at dressings.
(2) Sulfonamides: Give 5 gms. of sulfadiazine by mouthinitially and 1 gm. every 4 hours.
d. Supportive treatment: Since there is rapid destructionof erythrocytes, frequent whole-blood transfusions will be necessary.
e. All instruments used in anaerobic infections should besterilized by autoclaving, when available, and the instruments must not becovered with oil, since bacteria surrounded by oil cannot be wetted andtherefore are not killed at the usual temperatures.
f. If gas gangrene antitoxin isused, record number of ampules used and name of manufacturer.
b. Tetanus
(1) Types of Wound. Any wound, regardless of size orlocation, is a potential source of tetanus, particularly small puncture wounds.
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(2) Prophylaxis
a. Every wounded man will receive 1 cc. of tetanus toxoid,subcutaneously, as soon as possible. This will be recorded on the EmergencyMedical Tag, or on the Field Medical Record. If there is no record of theadministration of toxoid, or any doubt as to its previous administration, 1 cc.of tetanus toxoid will be given and so recorded.
b. Early, adequate debridement.
c. 1 cc. of tetanus toxoid will be given prior to themanipulation or exploration of an old wound.
d. After appropriate tests for sensitivity, members of AlliedForces (except Canadian), civilians and others will receive 3,000 units oftetanus antitoxin intramuscularly. The Canadian Forces will receive 1 cc. oftetanus toxoid. A syringe containing 1 cc. of 1:1,000 of epinephrine(adrenalin) should always be at hand when tetanus antitoxin is given.
(3) Signs and Symptoms. The rarity of this diseasemust not prevent its recognition. The earlier tetanus is recognized, the moreeffective treatment will be. The earliest sign is trismus. The patient maycomplain of pain and stiffness in the neck, back and abdomen. Dysphagia may bepresent. Localized tetanic contractions are not uncommon.
(4) Treatment
a. General. At the appearance of the earliest signs of tetanus, immediate therapy is indicated. All cases must be treated vigorously. The patient should be isolated in a quiet, darkened room.
b. Control of spasms. Trismus may be controlled byadministration of barbiturates, e.g. Nembutal, which are essentiallyanti-spasmodic in action. Nembutal, grs. 3 (0.2 gms.) may be given rectally ina well-lubricated capsule that has been perforated several times with a pin.More rapid absorption will be effected if the contents of a capsule aredissolved in water and the solution injected rectally through a catheter ofsmall caliber. The dose may be repeated as required, care being taken to guardagainst cumulative action and the production of anesthesia. Sodium Amytal, grs.6 (0.4 gms.) represents an equivalent dose and for treatment over a period ofdays this drug is to be preferred. Overdosage will be indicated by evidence ofhyperpyexia and incipient atelectasis or pulmonary edema. For spasm involvingmany muscular groups where anoxia is a feature, administration of Pentothalsodium in 2.5 percent solution intravenously is indicated. The objective is togive just sufficient to control the seizure and to permit effective artificialrespiration. From 2 to 4 cc. may be required. Longer acting barbiturates arepreferable for prolonged control of spasms, but supplementary administration ofPentothal may be necessary to control acute episodes producing anoxin. For thesame purpose, 0.5 gm. of Sodium Amytal, dissolved in 10 cc. of sterile distilledwater, may be injected intravenously at the rate of 1 cc. per minute. Avoid useof long acting barbiturates such as Veronal or Luminal because of itscumulative action.
Supportive treatment, administration of saline, glucoseand/or plasma, is essential. The prime requisite is to maintain oxygenation,producing muscular relaxation to permit effective respiratory action. Allefforts will be defeated if obstruction of the upper respiratory tract ispermitted.
Tracheotomy should be performed if laryngeal spasm is causingsuffocation.
c. Antitoxin.
(1) Locally: After appropriate tests for sensitization, 10,000 units of tetanus antitoxin should be used for infiltration about the wound.
(2) Intramuscularly: Therapeutic administration oftetanus antitoxin should be early and adequate. After appropriate tests ofsensitization, an initial dose of 40,000 units of antitoxin should be givenintramuscularly.
(3) Intravenously: 20,000 units may be administeredintravenously 6 hours after the intramuscular injection. This dosage may berepented on the second and third
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days if conditions require. Extremely large doses ofantitoxin are no longer considered helpful.
(4) Intraspinal: Antitoxinshould not be given intrathecally.
d. Surgical
(1) Local debridement: This is based on the fact that thebacterial anaerobes are the sole source of the toxin. The wound must be widelyopened and kept open. Amputation must be considered if other reasoning issuggestive of such a radical procedure. Such debridement should be preceded bythe local injection of antitoxin as described in para. c. (1) above.
11. Radiology in Forward Area
Attention to the following general principles will improvethe efficiency of a forward area X-ray service, especially when casualties arereceived in large numbers.
a. Housing. Evacuation hospitals should be arrangedto do radiography, fluoroscopy and processing simultaneously. One way toaccomplish this is to use a ward tent plus two darkroom tents, one forradiography and one for fluoroscopy, at least the processing tent inside the ward tent. Most hospitals place both within the ward tent. A second inside tentcan be improvised from a latrine screen if a second darkroom tent is notavailable. Improvised duckboards in the darkroom are advantageous. Waiting room for walking cases can be made with empty X-ray chests for seats betweenthe darkroom and fluoroscopic tents, and one low side of the ward tent. Fieldhospital units have only one X-ray machine, therefore will not require twodarkroom tents.
b. Power. The utmost skill should be exercised in thecare and operation of electric generators. The instructions issued with eachgenerator should be meticulously studied and followed by the radiologist andtechnicians.
c. Radiography
(1) The field unit X-ray machine on a mobile base can be usedbeside a table more efficiently if a board or other type of track is improvisedto guide the movement of the machine up and down the length of the table.
(2) Positioning should be standardized according to the guidefor forward areas furnished each X-ray department by the Office of the ChiefSurgeon.
(3) Film drying will be hastened if it can be accomplishedoutside the darkroom, unless a free current of air can be forced through thedarkroom by an improvised lightproof trap. The ventilator alone is inadequate.Item 60120, clips, photographic, will amplify hangers and permit easystringing of roentgenograms on wires or rope.
(4) Water inlets and drain outlets from the processing units,by improvised hose or pipe "plumbing," will increase the darkroomefficiency.
(5) Roentgenograms should be identified accurately as perexisting directives.
d. All patients transferred to other hospitals will beaccompanied by their roentgenograms. A filing system should allow easyavailability of roentgenograms to those who want to see them and, at the sametime, make it possible for them to be accumulated and leave with all patients ofa convoy on short notice.
e. There should be a uniform and well-defined policy betweenthe receiving or triage officers and the radiologists as to what type of casewill require X-ray examination, and the priority and volume in which they willbe sent to the X-ray department. The use of litter bearers to and from the X-raydepartment should be mutually pre-arranged.
f. Requests for X-rays should be brief and exact throughoutthe hospital, so that the specific purpose of each request is evident, assuringthat the proper technique and positioning can be immediately selected by theradiologist. This will obviate retakes.
g. X-ray examination should only be requested when thefindings will affect treatment or, more rarely, the disposal of the patient.
h. Patients in shock, or threatened shock, should not have X-rayexaminations except in rare emergencies.
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i. Missile Wounds
(1) Upper thighs and buttocks-should have additional A.P.or P.A. radiographs of the pelvis and lower abdomen, because complicatinginvolvement is frequently found here.
(2) Thorax-should have additional A.P. and lateralradiographs of the upper abdomen, because of frequency of transdiaphragmaticinvolvement.
(3) Upper arms, shoulder and neck-should be considered foradditional A.P. (or P.A.) radiographs of the thorax toexclude upper lung involvement.
j. All soft tissue wounds ofthe extremities should have an A.P. and lateral X-ray examination of theinjured part, including the nearest joint, prior to surgical treatment.
k. Transportable cases with wounds of the face andskull should generally not have X-ray examination until special treatment isavailable.
l. Localization of foreign bodies inextremities is generally best accomplished by A.P. and lateral radiographs. Fluoroscopicorientation by the table device is generally not as practical in extremities asA.P. and lateral radiographs because bandages and wounds prevent marking theskin, and because the surgical approach to the foreign body may not bedetermined until after the X-ray study, and thus skin marking, even whenpossible, may not be placed on the proper aspect of the extremity. Lateralradiographs of extremities can, and should be made with the patient supine, when turning the patient causes pain.
m. Fluoroscopy is seldom as satisfactory asradiography. It is most useful in thoracic cases as an adjunct to radiography,and in localization of foreign bodies in the pelvis where lateral views areimpractical and stereoscopy is not available. It is used for other types ofcases mainly when facilities for radiography are not adequate to keep abreast ofthe volume of patients. Fluoroscopy, when not expertly supervised, can be amenace to patients and operators. It should never be attempted until the eyes havebeen accommodated at least 15 minutes.
12. Identification of Gases in Cylinders
a. Identification of gases in cylinders may be difficult. Inorder to avoid serious accidents, great caution must be exercised in properlyidentifying contents of any particular tank.
b. Identification of a gas in a cylinder may be made bythe following methods:
(1) By reading the chemical symbol of the gasimprinted inthe metal of the valve of British cylinders.
(2) By reading the chemical symbol or name of the gasimprinted in the metal at the shoulder of the cylinder (symbol on Britishcylinders, full name on American cylinders).
(3) By reading the paper label or tag on British orAmerican cylinders.
(4) By reading the symbol or name of the gas stencilled onor near the shoulder of a British or American cylinder. Arrangements foremploying this means of identification have recently been made with the BritishOxygen Co. and may not be found on all cylinders for some months to come.Cylinders are also being stencilled in U.S. medical depots.
(5) By interpreting the color or combinations of colorswith which British or American cylinders are painted. Color markings on acylinder must be considered only to corroborate labels and are never to be usedas a single means of identification. In no instance will the color of valvecaps be considered significant.
(6) To identify gases in cylinders, check for all thesemeans of identification. Unless all means in evidence agree, the gas should notbe used.
For the Chief Surgeon:
RETURN TO TABLE OF CONTENTSJ. H. McNinch
J. H. McNINCH
Colonel, Medical Corps,
Executive Officer.
