EUROPEAN THEATER OF OPERATIONS
UNITED STATES ARMYOffice of the Chief Surgeon17 MARCH 1945CIRCULAR LETTER NO. 23CARE OF BATTLE CASUALTIES
The following instructions are supplemental to Manual of Therapy, ETO, 5 May1944; Circular Letter No. 71, 15 May 1944; Circular Letter No. 101, 30 July1944, and Circular Letter No. 131, 8 November 1944, Office of the Chief Surgeon.
Chronic Suppurative Otitis Media
Peripheral Nerve Injury
Gunshot Wounds of the Spine with Neurological Involvement
Notes on Radiology
The Care of Immobilized Patients (avoidance of decubiti)
Closure of Wounds of the External Genitalia
1. Transfusion Instructions
a. (1) The following test will be found useful in making differentialdiagnosis between pyrogenic and hemolytic transfusion reactions. It can beemployed with accurate results as early as fifteen (15) minutes after theappearance of symptoms.
(a) Draw five (5) ccs. of blood from the patient, employing a clean, drysyringe.
(b) Remove the needle from the syringe and eject the blood gently intoa clean, dry test tube.
(c) Centrifuge immediately for five (5) minutes at three thousand (3,000)r.p.m.
(d) Read grossly for presence of free hemoglobin in the serum.
(3) The presence of hemoglobin in the serum is indicative of intravascularhemolysis. The presence of as little as ten (10) milligrams per hundred cubiccentimeters will produce a faint pink tinge and can be detected in this manner.
Alkalinization is useless in cases in which there is no intra-vascularhemolysis, and will not be carried out in those cases in which the above test isnegative.
c. Deaths from transfusion
Analysis of reports received shows that one of themajorcauses of death following transfusion is cardiac overload. The cardiac reserveof patients who have suffered wounds and prolonged shock is definitely lowered. Anuriamay also result from prolonged shock. In the attempt toproduce diuresis by the administration of intravenous fluids, the cardiac reserve is sometimes exceeded. Ordinarily, three thousand (3,000) cubiccentimeters fluid intake daily is sufficient. In the presence of hyperprexiathis may be proportionately increased. Blood and plasma received must be takeninto account in calculating the total fluid intake.
When sodium salts (citrate) are given to produce alkalineurine, the administration of sodium chloride (physiologic salt) is to beavoided. Dextrose in distilled water may be used to maintain adequate fluidintake. The administration of excess amounts of sodium may produce analkalosis of a degree resulting in itself in anuria, or the excess sodium maybe taken up by the tissues and result in edema.
e. Care of blood in hospitals
(1) Blood will be stored in refrigerators at temperaturesranging between two (2) and six (6) degrees above zero centigrade (35.6-42.8degrees F.).
(2) Blood will not be heated before transfusion.
(3) Blood left unrefrigerated for more than 30 minuteswillnot be used for transfusion.
2. Orthopedic Surgery
a. Notes fordisposition boards
Under the present evacuation policy to the Zone of Interior,very few simple or compound fractures can be rehabilitated to full duty inthis theater. Among the exceptions may be certain fractures incurred by keypersonnel occupying sedentary positions. A fracture of the clavicle, anundisplaced fracture of the head of the radius or of the lateral malleolus,some fractures of the metacarpal bones, metatarsal bones or phalanges are citedas examples of fractures that may be returned to full duty within the presentevacuation policy. There may be a few other instances of minor fractures whichwill require careful evaluation in order to determine whether there is anypossibility of salvaging the officer or soldier involved for further duty inthis theater within the time allowed.
Patients requiring elective surgical procedures for internalderangement of the knee joint or recurrent dislocation of the shoulder jointshould almost invariably be returned to the Zone of Interior for this surgery.The utmost care should be exercised in arriving at a diagnosis of either ofthese conditions. A sprain of the knee joint which may be rehabilitatedshould not be confused with an internal derangement. A recurrent dislocationof the shoulder joint should be thoroughly authenticated before this diagnosisis made.
Osteo-arthritis of a major joint with definite disability asa result should be returned to the Zone of Interior.
Skin traction on amputation stumps must be institutedimmediately and maintained adequately and continuously except as stated inpar. 5d, of Circular Letter No. 101, this office, subject: "Care of BattleCasualties," dated 30 July 1944. In general hospitals, this traction maybe advantageously maintained by a weight suspended over a pulley. This formof traction must also be continuous. The most effective means of maintainingskin traction on the amputation stump during transportation has been describedin par. 5e, Circular Letter No. 101, Office of the Chief Surgeon, 30 July 1944.This skin traction should be inspected in each medical unit charged with the care orthe evacuation of the patient, and, if found to beinadequate, it should be reapplied immediately.
Closure of amputation stumps by suture or skin graft isnot authorized in this theater. Amputees should be evacuated to the Zone ofInterior as promptly as possible with skin traction maintained throughout allstages of their journey.
c. Wounds involving the knee joint
These wounds have been most satisfactorily treated in thefollowing manner:
(1) A thorough exploration of the joint is performed throughadequate medical and/or lateral incisions. A bloodless field should be insuredby the use of a tourniquet if there is no associated damage to the femoral orpopliteal arteries. The joint is completely irrigated with saline solution which shouldremove all blood and debris. With adequate retraction, a careful debridement of all damaged tissue, bone, cartilage and synovia is performedwith removal of all foreign bodies from the joint cavity. If a meniscus isdetached or damaged it should be excised. After further irrigation the synoviaand capsule are snugly closed with a single layer of interrupted sutures. Ifthere is loss of capsular substance, the closure may require, in someinstances, the utilization of a fascial flap.
(2) After closure of the capsule, 10,000 units of penicillinin 5 cc. of normal saline are injected into the joint cavity. The tourniquetshould be released and hemostasis insured by the ligation of all bleedingvessels. The knee joint should be immobilized by means of a plaster of paris spica bandage,knee slightly flexed, with a window over the joint.The joint is aspirated 48 hours after operation, gently washed with salinesolution, and another 10,000 units of penicillin instilled into the jointcavity. This procedure may be repeated several times at intervals of 24 to 48hours if necessary. Parenteral penicillin therapy is carried on throughout thisperiod. The skin wounds may be closed 5 days after primary surgery if thereis no evidence of infection.
d. Compound fractures
(1) Supracondylar fractures of the femur with sharpspicules of bone which may damage the popliteal vessels should be immobilizedwith the knee flexed at 20-25 degrees to minimize the dangerof this complication. At the time of primary debridement, if there is found to be direct pressure against the popliteal vessels by a sharp spicule ofbone, it should be excised. The excised piece of bone should be replaced at thefracture site and not discarded.
(2) Internal fixation of compound fractures
A recent report from the Office of the Surgeon General onthe condition of battle casualties returning from the ETO has been receivedFebruary 1945. The concensus of opinion expressed by qualified chiefs oforthopedic sections, chiefs of surgical services and consultants in nineteennamed general hospitals in the Zone of Interior was that metallicinternal fixation of compound fractures resulted in infection in 25 to 50% ofthe cases so treated. The metallic fixative agent in all of these infectedcases had to be removed. Delayed or non-union has resulted in many of thesepatients.
In view of the adverse report on the progress of thesecasualties, internal fixation of compound fractures is prohibited as a routineprocedure. It should be resorted to only after a thorough trial of skeletaltraction has failed to secure adequate reduction, and after healing of the skinhas been accomplished by suture or skin graft. The concurrence of the localorthopedic or surgical consultant will be secured in each instance whereinternal fixation of a compound fracture is deemed necessary. Combinedinjuries involving compound fractures and peripheral nerves present specialproblems. These will be treated at specialized hospitals designated forneurosurgical problems.
3. Penicillin Therapy
The following abrogates these parts of Circular Letter No.71, 15 May 1944, with which it is in conflict.
a. Penicillin therapy will begin at clearing stations.
b. Penicillin therapy will be given to all casualties exceptthose with very minor battle wounds.
c. The use of penicillin locally in all wounds is notrequired, but its local use in joints and chests is necessary for bestresults.
d. Data concerning dosage will be recorded onEmergencyMedical Tags and Field Medical Record.
e. The distilled water in the plasma set should not be usedas the vehicle for injecting penicillin, since it contains citric acid whichinactivates penicillin. (Citric acid may inactivate other substances, and thedistilled water in plasma sets should not be used except as a vehicle fordried plasma.)
f. The rate of withdrawal of penicillin from supply depotsindicates that all wounded are not receiving penicillin as per Circular LetterNo. 71. This must be corrected, since there is no more striking advance in thetreatment of battle casualties than the relative freedom from infection. Inthis, penicillin may play a dominant role.
The dusting of a sulfonamide powder into open wounds hasproven harmful to early closure of the wound and adds little to the ability ofthe body to defend itself against bacterial invasion. Such use of sulfonamidepowder is condemned hereafter unless there be special indications.
Under the present evacuation policy, all direct and recurrenthernias should be evacuated to the Zone of Interior. Exceptions are for keypersonnel only.
6. Chronic Suppurative Otitis Media
Radical mastoidectomies will be done only on patientsin whom there is imminent danger from a spread of infection. This danger isindicated by severe pain around the ear, labyrinthine imbalance, or severemetastatic infection. Other cases of chronic suppurative otitis media andmastoiditis which cannot be treated so that they can return to full or limitedduty in this theater within the present evacuation policy will be returnedto the Zone of Interior.
7. Peripheral Nerve Injury
a. Primary suture of major nerve trunks in warwounds isundesirable and should never be attempted. The contusion of the nerve whichinvariably accompanies such wounds, precludes accurate trimming of the endswithout unnessary sacrifice of tissue. However, when nerve ends can beidentified they should be approximated as nearly as possible with a singlethrough and through suture placed not more than 1 cm. from each end. Preferablya fine metallic suture should be used in order that subsequent X-ray examination may visualize the site of the lesion. This fixation-suture isimportant in that it prevents retraction of the nerve ends.
b. The optimum time for definitive suture is three weeks.Usually at this time it is possible to trim the nerve ends accurately to normal tissue before suture, and theperineurium is sufficiently toughened to permit accurate approximation with fine interrupted sutures.
8. Gunshot Wounds of the Spine with Neurological Involvement
Patients with spinal cord injury are the most difficult ofall nursing problems. Facilities at the evacuation hospital are not ideal fortheir care. Therefore, early evacuation to fixed hospital installationsis always desirable. The following rules for the care of these patients shouldbe adhered to wherever possible:
a. No gunshot wound of the spine should be operated upon inan evacuation hospital when it is possible to transport the patient to a specialtreatment hospital for neurosurgery within 36 hours from injury. When suchevacuation facilities are not available, the neurosurgeon of the evacuationhospital may perform a laminectomy when it is indicated after consultation withthe chief of the surgical service and the orthopedic surgeon.
b. Through "holding units" these patients should besorted for early evacuation to the nearest special treatment hospital.
c. No body cast will be applied in an evacuation hospitalsolely for the spinal injury. All patients (except those with injury to thecervical cord) will be evacuated in the prone position, care being taken toprotect pressure points, especially about the iliac spines. An indwellingcatheter will be used until the patient reaches a general hospital.
d. In those cases subjected to operation inevacuationhospitals, movement to a general hospital for nursing care will proceed within 48 hours,condition of the patient and evacuation facilities permitting.
e. These rules do not apply to patients with associatedinjuries, i.e., chest, abdominal and serious extremity wounds, where theassociated lesion may take precedence in treatment over the spinal injury.
f. Cervical cord injuries will be handled according toinstuction in the ETO Manual of Therapy, and Circular Letter No. 131,Office of the Chief Surgeon. Traction by either Crutchfield Tongs or Halteris not indicated unless there is fracture-dislocation of the cervicalvertebrae. Simple gunshot wounds involving the lamina or the body of thecervical spine do not often require traction.
9. Abdominal Surgery
(1) Wounds of the large bowel should be treatedby simpleexteriorization of the involved portion, except the rectosigmoid, where thewound in the bowel will be closed and a "loop" colostomyperformed above and at the top of the 'free" loop. In this instance theremust be complete diversion of the fecal stream, and it is advisable to divide the exteriorized bowel transversely and completely at thetime of the operation. The distal end may be occluded by a clamp or asuture, as indicated.
(2) The Mikulicz type of procedure has beenunsatisfactoryin the experience of ETO surgeons and should be abandoned. It has been foundto be the cause of post-operative obstruction and much intra-abdominaldiscomfort. The spur has rarely been sutured over a long enough area, and itis unsatisfactory for complete diversion of the fecal stream. Moreover, Mikuliczdeveloped this operation as an emergency procedure in the early days ofabdominal surgery. It is not satisfactory for young people who must live withit for forty years. In the repair of colostomies in base areas, most surgeonshave come to complete exteriorization of the lesion and end to end suturein the operative wound. Infection has not resulted from this procedure, andlate results are far better than with the Mikulicz type of procedure.
b. Wounds involving the caecum alone or the caecum andileum require repair of the ileum and caecostomy, i.e., exteriorization of thedefect. Ileostomy should be avoided, and double-barrelled opening of ileum andcaecum has been proven unwise and undesirable.
c. In concurrent injuries of head and abdomen the abdominalinjury takes precedence.
10. Vascular Surgery
Every attempt must be made in forward hospitals to repairvascular defects, first by direct suture, secondly by use of improvised tubes orthe Blakemore sets. If an extremity can be given some blood for two orthree days, even if greatly diminished, collateral circulation will usually develop andsame the limb. The repair of the original lesion or animprovised method of getting some blood through the injured vessel need onlyfunction therefore for perhaps 48-72 hours.
11. Notes on Radiology
a. Unexposed X-ray film can be fogged in many ways. Twoimportant causes are:
(1) By stacking the paste board X-ray boxes flat, either indepots, medical supply departments of hospitals or in X-ray departments. Thispresses the boxes open and prevents using the bottom film boxes in turn as newones arrive.
(2) By storing films near a source of heatwhich is eithersevere for a short time or above 90 degrees F. for a longer period of time. Colddoes not injure X-ray film.
b. All X-ray film will be stored at all times on edge andaway from excessive heat.
c. Many kinds of glass can be depicted in the body byregular type of examinations. When glass from mines or other sources issuspected and needs to be located, X-ray examination should be requested. Sinceradiographs made properly dense with lower kilovoltage will depictstill more kinds of glass than high kilovoltage technique, the radiologist
should be notified when glass is suspected. Fragments fromplastic or wooden mines cannot be depicted by X-ray examination.
12. The Care of Immobilized Patients (avoidance of decubiti).
a. Patients who are unconscious or paralyzed, or who areimmobilized as the result of serious injury to the buttock, chest orextremities, need special care. Such patients cannot move themselves, and unlessmoved frequently, serious pressure sores and permanent disabilities will ensue.Pulmonary congestion resulting from immobility increases the risk of seriouspulmonary complications.
b. Lessening of the disabilities entailed by lack of movementmay be accomplished through instructions to personnel to shift the position ofthese patients frequently. Deep breathing exercises can be conveniently given atthe same time that the position is changed. The attendant nurse or enlistedpersonnel should move the patient by gently shifting the position of his pelvis.Where there is a large buttock wound or heavy cast, more than one attendant willhave to assist in such movement. The patient can be slightly rolled to one side,alternating the side on which his weight rests. Such movement not onlyrelieves the local pressure which gives rise to decubiti, but shifts the depthof respiration. It often, therefore, assists in clearing the respiratory passagethrough the coughing which may follow such a change in position.
13. Maxillofacial Casualties
a. Litter Evacuation
In the litter evacuation of fresh maxillofacial casualties,adequate attention occasionally has not been paid to the proper position forsuch cases. Improper position may result in fatality during evacuation.Instructions on this matter should be provided all personnel handling freshcasualties. Severe cases should be arranged in a prone position on the litterwith the head supported by blankets. Such position gives the greatest assurancethat the airway will be maintained and provides against the danger of aspirationof blood and oral secretions.
b. Jaw Fixation for Evacuation
Par. 1, Circular Letter No. 122, Office of the Chief Surgeon,"Preparation of Maxillofacial Casualties for Evacuation by Sea orAir," 7 October 1944, is amplified as follows:
(1) In preparing casualties for evacuationintermaxillaryelastic traction should be reduced to only that amount required to hold thelower teeth in gentle contact with the uppers when the jaw is at rest. (Twoelastic bands on each side are usually enough to accomplish this end.)
(2) The traction should be applied in such a manner that itwill definitely and immediately be released by pulling down on a suture passedthrough the lumen of the elastic bands.
14. Thoracic Wounds
(1) Grave thoracic wounds as seen in forward hospitals arecommonly associated with severe pain and shock. In addition there may be asucking wound, and a laceration of the lung or diaphragm. The cough mechanismmay consequently be inadequate in clearing the tracheo-bronchial tree of bloodand secretions.
(2) These patients are dyspneic and present signs of anoxia.Coarse tracheal rales may be present. Palpable rales are often felt over theaffected lung. Secretions should be aspirated immediately, preferably through abronchoscope or by means of an intratracheal catheter. Many of these patientsare apathetic or semicomatose and do not need an anesthetic. The patientsshould be moved as little as possible, and aspiration through a bronchoscope orintratracheal catheter should be done with the patient in a semisitting positionon the stretcher. Oxygen administration is desirable before and afteraspiration. When the bronchoscope is used, the flow of oxygen should be directedthrough the sidearm of this instrument after the glottis has been passed.
b. Sucking Wounds
(1) Debridement of thoracic wounds is aimed atexcision ofdevitalized tissue and removal of foreign bodies, including pieces of splinteredrib. This procedure must be done meticulously if the objective of primaryclosure is to be obtained and if infection of the pleural cavity is to beavoided. The operation should be performed under endotracheal gas-oxygen-etheranesthesia. The wound should not be prepared before the endotracheal tube is inposition. Wounds complicated by shattered ribs invariably become sucking duringthe removal of rib fragments.
(2) The fractured rib ends should be trimmed smoothly and ribfragments bare of periosteum removed. All blood should be aspirated and clotsevacuated from the pleural sac. The pleural space should be examined and allforeign bodies removed since they usually will cause empyema. Missiles seenin the X-ray film at the level of the 12th rib are frequently in thecostophrenic sinus.
(3) It is desirable to remove foreign bodies from the lungand suture lacerations of the latter when the patient's condition permits.Adequate exposure for this purpose can almost always be obtained withoutadditional rib resection by enlarging the wound and making an intercostalextension.
(4) Drainage of the pleural cavity should be establishedthrough a stab wound in an intercostal space at the level of the inferior angleof the scapula in the midaxillary line (never through the operative wound).Under field conditions it has been found that the conventional sized catheterbecomes occluded quickly. A size 26 or 28 F catheter, or tube, is consideredpreferable. The tube should be sutured to the skin and connected to a sterile water sealsystem. It should be removed in forty-eight hours.
(5) The wound should be closed in layers.
(6) Instillation of penicillin, 40,000 units in the pleuralsac and aspiration of air from the latter are the final steps in the operation.Air is aspirated preferably from the second interspace anteriorly with thepatient lying on his back.
c. Thoracoabdominal Wounds
(1) Late complications are common in this group when theright side is involved. These include liver abscess, subdiaphragmatic abscess,empyema, and diaphragmatic hernia. They can best be prevented by properdrainage of the spaces involved.
(2) Wounds of the liver are usually best managed by packing.The packing should be exteriorized through the most accessible point of thebody wall below the level of the costophrenic sinus. Foreign bodies in the livercommonly cause abscesses. When accessible, they should be removed.
(3) The diaphragm should be repaired with medium silk.
(4) Intercostal drainage as described in b (4) aboveshould be established.
Hemothorax is the most common complication requiringfurther treatment in rear areas. Frequent aspiration without air replacement isthe best prophylaxis against clotting and infection. Following the firstoperation, 40,000 units of penicillin should be instilled in the pleural space.Patients having a hemothorax should have a final attempt at aspiration beforethey are evacuated if there is reason to believe residual blood or fluid ispresent. Aspiration of hemothoraces is often neglected in hospitals passedthrough in the chain of evacuation. Many aspirations are attempted at too lowlevels. The most satisfactory point for aspiration is usually at the level ofthe inferior angle of the scapula at the posterior axillary line. Later, becausethe lung may become adherent posteriorly, it is commonly necessary to aspiratein the axillary area or anteriorly.
(1) Many patients are reaching general hospitals withempyemas which are already chronic. This is usually due to too prolongedtreatment with aspiration and penicillin instillation, to inadequate drainage,or because of retained foreign bodies.
(2) Empyema is best treated by rib resection drainage at themost dependent portion of the cavity. The most advantageous site for drainage isusually the ninth rib at
the posterior axillary line. Mediastinal fixation sufficientto make open drainage safe occurs within ten to fourteen days after wounding.
(3) Postoperatively the patient should sit up at once and bemade ambulatory at the earliest possible date.
f. Intercostal Nerve Block
The relief of intercostal pain associated with thoracicwounds contributes to a more satisfactory convalescence. The raising ofsecretions is facilitated, and less morphine is required. This can beaccomplished by intercostal injections of 1 percent Novocaine. During thecourse of operation, readily accessible nerves may be crushed to accomplish this purpose.
(1) Necessity for intrathoracic operative procedures usuallyoccurs in patients having sucking wounds. Such operations can almost alwaysbe performed by enlarging the original wound as described in par. b (3) above.
(2) A formal thoracotomy is rarely necessary except inthoraco-abdominal wounds where it is planned to perform both the thoracic andabdominal operation through a single incision.
15. Closure of Wounds of the External Genitalia
Experience has shown that wounds of thegenitalia,especially the scrotum, tend to break down when they are tightly closedprimarily. It is desirable either to leave the wounds open or to suture themloosely.
16. Eye Casualties
a. Atropine Sulphate
To prevent the formation of posterior synechiawheneverpossible, all casualties with evidence of intra-ocular trauma will be treatedwith one (1) percent sterile atropine sulphate solution or atropine ointmentthree times per day. Regardless of the evacuation status of the patient, thistreatment will be continued until ordered otherwise by an ophthalmologist.
b. Penicillin and Sulphadiazine in Nonbattle Injuries
Systemic administration of sulphadiazine and/or penicillinare indicated in penetrating injures to the eyeball or orbital contents exactlyas used in other wounds or injuries of the body.
Field Medical Records must contain all pertinent clinicalfactors relative to preoperative and post-operative care. Inadequate recordshinder proper care in general hospitals after evacuation of patients from Armyareas.
By order of the Chief Surgeon:
RETURN TO TABLE OF CONTENTS
H. W. Doan
H. W. DOAN
Colonel, Medical Corps,