CHAPTER XIX
General Considerations of Shock Therapy
According to Brig. Gen. Elliott C. Cutler (1), thesingle feature of professional care that contributed most directly to theimprovement in morbidity and mortality in World War II was adequateresuscitation of the wounded man. This factor, in his opinion, transcended inimportance any single method of therapy, even the administration of blood andplasma, for it comprised the total evaluation and care of battle casualtiesbefore surgery, not attention to a single anatomic region or some particularwound. This concept led to the greatly improved management of shock, chiefly bythe liberal use of whole blood.
PRINCIPLES OF RESUSCITATION
Role of Surgery
In a report to the Surgeon, NATOUSA (North African Theater ofOperations, U.S. Army), on 2 July 1943, Col. Edward D. Churchill, MC, emphasizedwhat was, for all practical purposes, a new principle in military medicine, therole of surgery itself in resuscitation (2, 3).
The establishment of a shock or resuscitation ward, ColonelChurchill pointed out, to which casualties in actual or impending shock could besent as they were received, was an efficient arrangement and absolutelyessential when casualties were received in overwhelming numbers. When thissystem was used, however, there was one error to be guarded against:Resuscitation might come to be regarded as a subspecialty of military surgeryand, as such, as a goal in itself. Though it might seem too obvious for mention,one central fact had to be repeatedly emphasized, that a wounded man wasresuscitated not only to deliver him from his immediate peril but also toprepare him for whatever surgery he needed.
With this concept in mind, a number of principles ofresuscitation became clear:
1. Any delay in resuscitation prolongs the crucial intervalbetween the time of wounding and surgery; that is, the timelag.
2. Any delay in the reversal of shock increases thedeleterious effects of circulatory failure. Prompt restoration of blood volumestands out as the most important advance in the war to date (July 1943).
3. Resuscitation of every casualty being prepared foroperation is an integral part of the surgical management of trauma. Operatingsurgeons must not fail to follow closely the clinical course of patients in theresuscitation wards. They must not wait for the patients to be "servedup" to them. They
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must not rely on the judgment of inexperienced medicalofficers with inadequate training in surgery. To divorce the surgeon from shockis a disquieting outgrowth of war that cannot be too severely condemned.
4. Replacement fluids must be introduced rapidly. The use ofa syringe to increase the rate of flow is too infrequent.
5. Delay in the procurement of whole blood must not beinterpreted as justification for not using plasma.
6. The resuscitation ward tends to become a routine stoppingpoint to regulate the flow of casualties to the operating room. The delay causedby lack of precision in the selection of casualties for resuscitation iswasteful and intolerable.
Practical Implications
In the months that followed Colonel Churchill's report, asophisticated and highly efficacious system of resuscitation was developed inthe North African theater.1 Out of this development came the implementation ofhis concept that surgery was indeed the climax and goal of resuscitation and wasin itself the most potent of all acts of resuscitation.
The immediate outgrowth of this new concept was theestablishment of field hospitals immediately adjacent to clearing stations (4),with the result that surgeons trained and equipped to perform emergency surgerywere brought within a short litter-carry of casualties whose wounds did notpermit them to be transported to an evacuation hospital to the rear but who,after resuscitation, could be operated on close to where they were wounded.
Concepts of Shock and Its Management
It was extremely important that all medical officers and others responsible for resuscitation should understand that shock is not a fixed state but is dynamic. Once resuscitation was begun (figs. 154, 155, and 156), the casualty had to be observed frequently and carefully, so that surgery could be performed at the peak of improvement. Once that peak had passed, it was usually difficult, and sometimes impossible, to attain again the same degree of response to the measures employed. Delay during periods of pressure might mean a lost opportunity in the selection of the optimum time for operation. Stabilization of the circulatory mechanism was, however, essential before surgery was undertaken. Clinical observations were important. So were such observations as the level of the blood pressure, the pulse rate, the presence or absence of sweating, and the state of the peripheral circulation. Serial determinations (fig. 157) of the pulse and blood pressure were necessary; single observations might be highly misleading. Pulse volume was often more important than pulse rate. Collapsed veins and fluctuations of the blood pres-
1Full details of shock and resuscitation appear in another volume of this historical series, based on observations made in the Mediterranean Theater of Operations, U.S. Army, by Lt.Col. Henry K. Beecher, MC, and others (3).
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sure sounds with respiration indicated that restoration ofthe blood volume had been inadequate.
No reliable criteria were ever developed for recognition ofthe degree of hemodynamic instability in shocked patients. Blood pressurereadings provided only a rough indication. Often when the pulse rate and bloodpressure had been restored to almost normal levels, movement of the patient,however slight, might cause a rapid reversion to the original stage of shock. Ifthe significance of this reversion was not realized and if further resuscitationwas not carried out before anesthesia and operation, deep and fatal shock mightoccur. In some cases, compensation might be so complete that, while there wereno objective signs of shock, a slight additional blood loss might induce a rapidfall in the blood pressure. Continued or recurrent hemorrhage was one of themost important considerations in resuscitation. The possibility was always to besuspected in casualties who did not respond to adequate resuscitation, includingadequate blood replacement.
In general, the degree of shock was proportional to theamount of blood lost, though there was occasionally a surprising lack ofcorrelation. In wounds
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of the spleen or the mesentery, in which 1,000 to 1,500 cc.of blood could be aspirated from the peritoneal cavity, there was sometimescomplete hemodynamic compensation. It was a mistake to be content with thatstatus. The safety of these casualties required that they be transfused beforeoperation and that preparations be made to transfuse them rapidly duringoperation (fig. 158), to compensate for the blood loss during it. Many medicalofficers shared Dr. Owen H. Wangensteen's opinion that measured blood loss atoperation always proved larger than it seemed (5).
Limitations of Plasma
Since loss of blood externally or into body cavities was theprincipal cause of shock, its successful management depended upon therestorations of both red blood cells and blood volume. Plasma alone would notsuffice (p. 55). In fact, used beyond a certain point, it might do harm bydiluting the remaining blood cells at a time that rising blood pressure, causedby the plasma transfusion, could increase hemorrhage. Also, a false sense ofsecurity might be induced when elevation of the systolic pressure wasaccomplished by plasma alone. A pressure elevated by these means might fallprecipitately with induction of anesthesia, operative manipulations, or meremovement of the
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patient. Finally, the plan of giving only plasma beforeoperation, with the idea of making up the preoperative blood deficit on theoperating table, was poor practice and dangerous besides.
RESUSCITATION
Diagnostic Routine
The plan of resuscitation which evolved in the Mediterraneantheater came into general use elsewhere. It began with first aid measures, whichfrequently included the administration of plasma (figs. 159-162), on thebattlefield. They were followed, as soon as the casualty was hospitalized, byrapid, complete examination, with his clothing removed, to appraise his generalcondition; estimate his state of shock; and determine the factors
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FIGURE 157.-Type of form used for serial observations in shock ward.
which might be contributing to it and which requiredimmediate control, as part of resuscitation. These conditions includedcardiorespiratory embarrassment from such causes as painful wounds of the chestwall; sucking wounds; hemothorax, pneumothorax, and tension pneumothorax;cardiac tamponade; blood or mucus or both in the tracheobronchial tree (wetlung); paradoxical respiration; anoxia from any of these causes; inadequatelyimmobilized fractures; large soft-tissue wounds, clostridial myositis; grossperitoneal contamination; and sepsis. Blood loss was the major cause of shockand in most instances it was associated with the conditions just listed. Theywere, however, able in themselves to produce and maintain shock, and theytherefore required separate consideration. The replacement of lost blood wasessential, but it could not, in itself, eliminate other factors causing shock.
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The diagnostic routine also included roentgenologicexamination and the performance of certain laboratory tests. These tests werelimited to those absolutely necessary; a medical staff that was too energeticmight well contribute to the precipitation or aggravation of traumatic shock ina badly wounded casualty.
On the basis of these examinations, casualties were groupedinto two categories:
1. Those with minor or slight wounds, in good condition, whoneeded no special preoperative preparation. They were operated on as soon aspossible, with due regard to the more urgent needs of more seriously woundedcasualties.
2. Those with severe wounds, who were in shock, and in whomadequate resuscitation might mean the difference between survival and death. Theclassification of casualties according to their degree of shock has beendescribed elsewhere (p. 39).
Blood Replacement
Casualties admitted in severe shock, with no perceptibleblood pressure, were given low-titer group O blood immediately and rapidly,without waiting for grouping and crossmatching of the first liter. The blood wassometimes run into two, three, or even four veins, depending upon the urgency ofthe patient's state. Blood was obtained at the first venipuncture for groupingand crossmatching in subsequent transfusions.
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In cases in which there was time for laboratory examinations,a unit of plasma or albumin could be given while preparations were made fortransfusion. After 1,000 to 1,500 cc. of non-type-specific blood had been givento a bled-out casualty, a new sample of his blood was obtained for crossmatching,and the same precaution was repeated after the administration of everyadditional liter.
When the systolic blood pressure had risen to 80 mm. Hg, therate of transfusion was reduced while an additional 500 cc. of blood wasadministered over a 30- to 60-minute period. The rationale of this practice wasthat the blood pressure often reached an almost normal level before the depletedblood volume had reached a safe level. Transfusions for prophylactic purposes;that is, to guard against a possible fall of blood pressure, were also givenslowly.
Ideally, blood replacement was always an individual matter,based on the requirements of the casualty. Since the initial blood pressure wassometimes misleadingly high, the necessity for transfusion was best gaged by theextent and severity of the wound or wounds, the probable amount of blood lost,and the general state of the patient. When Maj. (later Col.) Howard E. Snyder,MC, began to visit hospitals as Consultant to the Surgeon, Fifth U.S. Army (4),he could easily tell, simply by looking at patients after operation,
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which ones had not had enough blood before operation; theylooked white and bled-out. Generally speaking, each 3- or 4-point deficit on thehematocrit scale or each 0.9-gm. percent deficit in hemoglobin required atransfusion of 500 cc. When there was doubt, it was considered better to giveblood than to withhold it.
Blood was sometimes given in larger amounts than wasnecessary (3). Aside from the waste of a scarce and precious substance,results achieved by this method were no better than those achieved with amountsmore consonant with the actual needs. The use of excessive amounts of bloodcould also be dangerous: If there was no response in the pulse or blood pressureto the transfusion of 2 to 4 pints of blood, it had to be assumed thathemorrhage was continuing or that an overwhelming infection was the cause of thefailure of resuscitation. In such cases, immediate operation offered the bestchance of life.
Blood was given during operation according to the indicationsand was also given after operation in large numbers of cases. The correction ofnutritional depletion was an essential phase of postoperative care. Many of thewounded had been living for weeks under field conditions, with suboptimumconsumption of protein, calories, and vitamins. Loss of blood and plasma atwounding increased the protein and hemoglobin deficits. Postoperative dietaryrestrictions and exudation into inflamed tissues led to further depletion. Theseconditions, which retarded wound healing and delayed convalescence,
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responded well to plasma and blood transfusions, continueduntil the red blood cell count was above 4 million per cubic millimeter andpreferably higher. The correction of these deficits was a postoperativeobjective.
In his May 1944 report to the Surgeon, NATOUSA, ColonelChurchill pointed out that not until the end of 1943 were supplies available insufficient quantities to permit the establishment of facilities for adequateresuscitation of wounded in forward areas (6). The improvement effected wasevident in comparative series: In the first, 200 casualties in Tunisia who wereoperated on in forward hospitals received 350 plasma infusions and 6 bloodtransfusions. In the second series, 297 casualties in Italy were admitted to afield hospital, a type of installation which did not exist during the Tunisiancampaign. In this series, 285 of the 297 casualties received 1,364 units ofplasma and 277 received 511 transfusions. The two series are perhaps notentirely comparable,
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since the first included many less seriously wounded than thesecond. On the other hand, more than half of the casualties in the first serieshad wounds serious enough to require immediate operation, and, had facilitiesand blood been available, there is little doubt that as many of them,proportionately, would have been treated by transfusion as in the second series.
TECHNICAL CONSIDERATIONS
A number of technical improvements and short cuts weredeveloped in all theaters as experience increased. Some of them were as follows:
If blood had to be administered rapidly, an 18-gage needleattached to a 50-cc. syringe was inserted into the tube already in situ, whichwas clamped off just below the needle. After the syringe had been filled withblood, the clamp was placed above the needle and the blood was pumped in.
When a second transfusion was to be given immediately afterthe first, the original needle was left in situ and the second transfusion setwas connected with it.
If the veins were collapsed, one of the superficial veinsabout the ankle could be exposed and a cannula inserted, which could be left inplace for 24 to 48 hours.
Blood could also be forced in rapidly by the use of a bulbfrom the blood pressure apparatus attached to the air inlet of the blood bottle.This was an effective method in extreme emergencies but not desirable, for, incareless hands, it could-and did-carry the risk of air embolism.
General Surgical Team No. 25, 2d Auxiliary Surgical Group,which once used 20,000 cc. of type O blood in 4 days, developed the practice ofcrossmatching three to four bottles
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of blood at once if the casualty seemed exsanguinated(7).This practice had two added advantages, that there was no delay in thetransfusions and that recipient sets, which were frequently in short supply atthis time, were conserved by the use of the same set for the total amount ofblood.
Intrasternal administration of parenteral fluids wasdiscussed at a number of meetings of the Subcommittee on Blood Substitutes andallied groups (8, 9) but, after a vigorous discussion, it was decided notto recommend it, for two reasons: It required a degree of skill unlikely toexist in medical officers of all degrees of training and experience. Also, somefatalities had been reported after it, from puncture of the inner table of thesternum and puncture of the mediastinum.
There was also a vigorous discussion concerningadministration of fluids by the femoral vein (8, 9). This technique hadbeen used successfully at Pearl Harbor in burned patients, but it was concludedthat it was too dangerous for general use. One reason was that a hypertonicsolution such as concentrated human albumin might cause serious damage if it wasextravasated.
As early as 1940, Dr. Elmer L. DeGowin and his associates (10)at the State University of Iowa School of Medicine had demonstrated thatpreserved blood could safely be given without reheating. This practice, whichlater became routine Army practice, had a number of advantages. It eliminatedthe frequently costly apparatus and the manpower expended by medical and nursingpersonnel in the former endeavor to keep parenteral fluids at body temperatureduring injection. It also saved the time formerly spent in heating blood, andeliminated the risk of hemolysis from the injudicious application of heat.
USE OF BLOOD IN ZONE OF INTERIOR HOSPITALS
In the spring of 1945, Col. B. Noland Carter, MC, AssistantChief, Surgical Consultants Division, Office of The Surgeon General, wasimpressed, on his visits to a number of Zone of Interior hospitals, by anapparent tendency to use too little blood in the preoperative, operative, andpostoperative management of battle casualties. Part of the explanation was thepaucity of surgical personnel trained in the use of whole blood as well as inits storage and processing. Before the war ended, the amounts being used wereincreased as medical officers who had used blood overseas returned to the UnitedStates. At a few hospitals, blood had always been used in adequate quantities.Walter Reed General Hospital, Washington, D.C., as might have been expected, wasoutstanding in this respect, for the blood for the 250-300 transfusions giventhere every month was provided by the Blood Research Section, Division ofSurgical Physiology, Army Medical School, which conducted most of the researchon whole blood carried out before and during the war.
To be certain that difficulty in obtaining blood was not theexplanation of its minimum use, Colonel Carter instituted a survey, in April andMay 1945, of the hospitals he had recently visited (11). With the end ofthe war, no action was taken in the matter, but the replies to his questionnaireare worth putting on the record:
Ashford General Hospital, White Sulphur Springs, W. Va.,which gave about 20 transfusions a week, obtained the blood from the hospitaldetachment and civilian personnel. If the necessary refrigerator could be supplied, it was thoughtthat about 50 pints of blood a week could be secured and the number of transfusions per weekincreased by 10 or 15.
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Thomas M. England General Hospital, Atlantic City, N.J., gaveabout 20 transfusions a week. It procured the necessary blood from thePhiladelphia chapter of the American Red Cross and had adequate facilities forits storage.
Mayo General Hospital, Galesburg, Ill., gave 59 transfusionsin January and 60 in March 1945, against an average of 28 in each of thepreceding 4 months. The increase was explained by the increase in the number ofoperations and in their magnitude. Blood was procured from men of thedetachment, who were paid $10 for each donation. An informal arrangement hadbeen made with the civilian hospitals in Galesburg, which paid $25 per donation,that no men of the detachment would be permitted to donate blood at any of themuntil they had first donated at Mayo General Hospital. No man was permitted todonate oftener than every 6 weeks, and 3 months was the preferable interval. Thehospital staff saw no particular advantage to establishing a blood bank withsuch a pool of donors at hand and only a limited amount of surgery being done.
Newton D. Baker General Hospital, Martinsburg, W. Va.,reported a strong tendency early in its operation to use plasma in preference toblood because of its ready availability and its ease of administration. Over thepast several months, an attempt had been made to use more blood, and an averageof three transfusions a week had been given between 1 January and 9 April 1945.Group B and group AB bloods were sometimes in short supply but there had been noshortages in donors of other types. Although the number of transfusions givenwas small, the use of blood was considered adequate. Paraplegics had sometimespresented compatibility difficulties, possibly because they had already receivedso many transfusions.
Lovell General Hospital, Ayer, Mass., which operated its ownblood bank, gave an average of 30 transfusions a week. Blood was obtainedwithout difficulty from the medical and Women's Army Corps detachments andcivilian employees and was supplemented by blood from the Worcester Blood Bankand the Boston Red Cross Chapter, which provided as many as 20 bottles a weekand could furnish more if necessary.
DeWitt General Hospital, Auburn, Calif., which gave anaverage of 12 transfusions a week, obtained blood from civilian and militarymembers of the hospital staff. Local Red Cross representatives had informed thecommanding officer of the hospital that about 100 Auburn civilians, whoperiodically gave blood for the plasma program, would be glad to contribute tothe hospital if the need should arise.
Halloran General Hospital, Staten Island, N.Y., whichoperated its own blood bank, gave about 40 transfusions per week. Group O bloodwas secured from duty personnel, and A, B, and AB blood from the Army WholeBlood Procurement Service, which procured it from the New York chapter of theAmerican Red Cross.
Billings General Hospital, Indianapolis, Ind., which operatedits own blood bank, gave 559 transfusions between 27 March and 27 April 1945.The blood was secured from individuals confined in the U.S. DisciplinaryBarracks on the post and was collected at regular intervals. The bleeding ofprisoners was always on an entirely voluntary basis.
Brooke General Hospital, San Antonio, Tex., which gave about40 transfusions per week, was not permitted to operate a blood bank because theliquid plasma center operated at the 4th Army Laboratory at Fort Sam Houstoncould supply all the blood needed. The hospital, however, had set up atransfusion section which prepared and issued all intravenous sets, typed allpatients requiring transfusion, crossmatched all bloods, drew all bloodscollected in the hospital, and investigated reactions. The transfusion sectionkept 6 pints of O blood on hand at all times for emergency use, replacing within24 hours all blood used.
The bulk of the blood collected locally came from the medicaldetachment. Donors were paid at the usual rate. Civilian donations amounted toabout 15 per week.
Walter Reed General Hospital
Late in 1943, the Division of Surgical Physiology, ArmyMedical School, undertook to supply blood for all routine transfusions at WalterReed General
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Hospital. A strict record was kept of the first 3,000transfusions given under the new system, and a continuing effort was made to seethat recipient sets were properly prepared. With this precaution, the reactionrate, as already noted, was reduced from 22 percent to approximately 0.5percent.
Only O blood was supplied. At first, the bloods were nottested for agglutinin titer, and no effort was made to avoid giving A, B, or ABrecipients transfusions of high-titer blood. During this period, there was onlyone instance in which it was suspected that an A recipient might have sufferedfrom some hemolysis of her own cells. The reaction was mild, perhaps because theblood had been collected in Alsever's solution and the amount of agglutininwas therefore diluted and was taken into the bloodstream more slowly than if theamount of solution transfused had been 500 or 600 cc.
In January 1945, a number of high-titer bloods weredeliberately given to A and B recipients. No clinical reactions were observeduntil bloods with titers of 1:1024 or higher were administered. Then, thepatients had chills, fever, vomiting, and other symptoms, and an increase in theserum bilirubin was observed.
Since these observations suggested that high-titer O bloodsmight cause reactions in non-group O recipients, all O bloods handled at thehospital in the future were separated on the basis of their agglutinin content.The titration technique which was adopted separated approximately 25 percent ofO bloods with the highest titers of anti-A or anti-B agglutinins, or both.High-titer bloods were given only to O recipients, and low-titer bloods werereserved for A, B, and AB recipients.
Maj. Leslie H. Tisdall, MC, Coordinator, Army Whole BloodProcurement Service, with his associates, made a study of the effects ofhigh-titer O blood on incompatible recipients (12) (p. 259), andfurther studies in the Zone of Interior were being planned when the war ended.
PLASMA THERAPY
Indications
While too much credit was given to plasma early in World WarII, it remained until the end of the war an extremely useful emergency agent.This has been indicated in so many discussions earlier in this volume that anyrepetition is unnecessary here.
There were certain injuries and conditions in which plasmawas of greater value than blood or was needed in addition to blood. Theseincluded:
1. Head injuries. Limitation of fluids was desirable, andplasma was given only in sufficient quantities to control shock and restoreblood volume.
2. Crushing injuries, in which hemoconcentration wasfrequent. The tremendous swelling which developed in the limbs of these victimsafter they were removed from beneath the stones and masonry which had crushedthem often was associated with very high hematocrit values. The management ofthese injuries was also complicated by the development of pigment nephropathyand anuria, which might be enhanced by blood transfusions.
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3. Fulminating clostridial myositis, particularly of the wettype. Loss of plasma through the wound or into the affected muscles was bestcombated with large plasma infusions. These same patients, however, tended topresent severe anemia, and they required whole blood as well as plasma.
4. Severe wounds associated with hypoproteinemia; abdominalwounds which required prolonged nasogastric suction; and bedsores, particularlyin paraplegics. Amino acid solutions for intravenous use were never generallyavailable in World War II and were not available at all until late in the war.Plasma proved to be an excellent substitute.
5. Burns, which furnished perhaps the most clear-cutindication of all for the use of plasma. When Elkinton (13), in 1939,reported four cases treated by this method, he pointed out:
a. That hemoconcentration or diminution of the plasma volume,as measured by serial hematocrit determinations, was evident in all fourpatients, who also all exhibited a decrease in the plasma protein concentration,a decrease which, because of the hemoconcentration also present, was even moremarked than the figures indicated.
b. That plasma infusions, to replace the lost plasma andprotein, was the most rational therapy. Whole blood would supply the necessaryelements, but to add red cells to a circulation already relatively overloadedwith them, was not logical.
The onset of shock in severe burns is remarkably rapid andmay occur within an hour after injury. Immediately after injury, however, theneed for plasma is not yet reflected in the hematocrit, and larger amounts areneeded than its current level indicates.
The tragic experience of the fire at the Cocoanut Grove inBoston in November 1942 provided an instructive experience in the management ofshock in burns (14). The mass disaster bore a real resemblance to thesituation that might be encountered in military experience. An instructivecomparison was also furnished between the use of plasma at Massachusetts GeneralHospital, where all the patients were treated uniformly, under the direction ofDr. Churchill, and its use at the Boston City Hospital, where the patients weretreated on five separate services.
In cases of burn shock not complicated by wounds, in whichthe reduced blood volume was due almost entirely to loss of plasma, the mostcommon error of management in World War II was failure to administer plasmarapidly enough and in large enough amounts. The best results were secured whenit was given into two veins, or with positive pressure, until the hematocritbecame approximately normal. Then, administration was continued at a rate justsufficient to maintain this level. As much as 4,000 to 6,000 cc. of plasma mightbe necessary in the first 24 to 36 hours in extensive burns. After this period,secondary anemia tended to develop rapidly, and whole blood replaced plasma inthe management of the injury.
The special experience of the 77th Field Hospital in theEuropean theater, commanded by Maj. Henry Metz, MC, with the use of plasma intrue protein depletion, in which it was more valuable than whole blood, isdescribed elsewhere (p. 570).
Dosage and Administration
The dosage of plasma, as of blood, was an individual matter.The blood pressure level was the simplest method of determining the need for itand the response to it, but not necessarily the most accurate method.
The degree of hemoconcentration was another method ofdetermining the amount of plasma to be used; 50 cc. was given for every pointthat the concentration exceeded the normal 100 percent. It was also estimatedthat 100 cc. of plasma was required for every point that the hematocritdetermination exceeded the normal of 45.
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When the hematocrit was low, patients treated with plasmasometimes had a rapid pulse for days, even though the blood pressure was wellsustained.
It was realized very early in the war that 250 cc. of plasmawas never an adequate dose; if plasma was needed at all, at least 500 cc. wasnecessary, and, many times, a good deal more (15, 16). As time passed,the initial dose tended to become larger, up to 1,000 cc., and some hospitals,such as the 33d Field Hospital in November 1943, reported using as much as 5,000cc. for resuscitation (6).
The first 500 cc. of plasma was given rapidly, and rapidadministration was continued until the blood pressure became approximatelynormal. If the patient was evacuated to the rear, additional plasma was givenbefore he was put in the ambulance. This method was very useful in the Tunisiancampaign, when, field hospitals not yet being in use in their later conventionalmanner, undesirably long evacuations were often necessary. Plasma was also givenduring transportation, particularly to patients with abdominal injuries andfractures of the femur. Later, of course, patients with such injuries wereresuscitated and operated on in forward hospitals.
Isotonic plasma was recommended by the Subcommittee on BloodSubstitutes (15). Its members did not look with favor on the use ofconcentrated plasma (p. 275).
Other Proposed Uses
The suggestion that dried plasma be used as a menstruum forthe local application of penicillin to wounds did not get beyond theexperimental stage. The same was true of a study at the University of Chicago onfilling the pleural space with plasma after lung resection, to compensate forthe protein loss that occurs after such operations.
Attempts to treat decompression sickness with plasma, on theground that some patients presented decreases in specific gravity, came to nomore than the suggestion. A similar fate befell the suggestion that concentrateddried plasma be used in the treatment of acute nephritis.
The proposal that plasma be administered by hypodermoclysisin deeply shocked casualties was discouraged for the reason that if the veinswere collapsed and difficult to locate, there was all the more reason forinjecting plasma intravenously as promptly as possible to restore an effectivecirculating blood volume.
Technique of Administration
The standard Army-Navy package of dried plasma contained twosealed cans and a printed questionnaire. Filling out the questionnaire was thefinal step of administration of plasma and was particularly important in theearly days of the program, when the Blood Research Section, Army Medical School,urgently needed the data thus secured to determine further steps in procedure.
The detailed technique of plasma administration is describedin figure 163.
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SERUM ALBUMIN THERAPY
The Army, in contrast to the Navy, used very little serumalbumin because of its satisfaction with plasma and for other reasons (p. 347).Clinically, except for the need for supplying fluids when serum albumin was usedin dehydrated patients, there was little to choose between the two agents. Attimes, however, the compact size of the serum albumin package was a distinctadvantage. One medical officer, for instance, related how he and some of hiscorpsmen, after they had lost all their plasma when their landing boat was sunkoff the Normandy beaches, filled their pockets with packages of serum albuminand administered it to many seriously wounded men, most of whom lived to betaken aboard ships on which they could receive definitive care.
As albumin was put up for the Armed Forces, its highconcentration made its physiologic effect dependent upon the rapidity with whichit mobilized interstitial fluid. In a well-hydrated patient, this was noproblem; the circu-
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lating blood volume was promptly increased, and theintravascular discrepancy characteristic of shock was promptly overcome. In thedehydrated casualty, the problem was different. Since the majority of woundedsoldiers, under the rigorous conditions of combat, were dehydrated, isotonicfluids usually had to be administered along with the serum albumin. This was noproblem for the Navy but made the use of albumin by the Army far less practicaland convenient.
At the 2 June 1944 meeting of the Subcommittee on BloodSubstitutes (17), the principal discussion concerned the possibility ofresuscitation in airplanes. It was decided that if this procedure should beattempted, serum albumin would be the best agent to use. There were numerousproblems, including limitation of space, thermal stability, and the effect ofturbulence. No further action was taken, chiefly because D-day was 4 days afterthis meeting and the Army Air Forces were fully occupied with other, more urgentmatters.
At the end of the war, the clinical indications andcontraindications for the use of serum albumin were quite clear:
1. It could be used in shock and in hypoproteinemic statesalmost interchangeably with plasma. It had to be borne in mind, however, thatalbumin is purified protein and contains no complement, prothrombin, or othercomponents of plasma.
2. Serum albumin was of special value in edematous patients,particularly in burned patients, because it could be administered without asignificant amount of fluid. On the other hand, if it was given to a dehydratedpatient the parenteral administration of fluid was necessary simultaneously orimmediately after the serum was injected.
3. Serum albumin was useful in patients with cranialinjuries, in which fluids were generally contraindicated.
4. The fact that albumin is hypertonic and remains in thevascular system longer than hypertonic crystalloid solutions made it necessaryto use it with great care. It was not useful in older patients if any myocardialweakness was evident; the rapid elevation of the blood pressure could causepulmonary edema. It was also contraindicated in concealed arterial bleeding andin uncontrolled or recurrent hemorrhage because of the rapid rise in bloodpressure which it produced.
Technique of Administration
The standard Army-Navy package for concentrated serum albumin(fig. 164A and B) contained three cans (fig. 164C), each of which contained:
A double-ended glass container, sealed at each end withrubber stoppers, and containing 100 cc. of 25-percent solution of serum albumin(25 gm.).
An airway.
Equipment for intravenous administration.Tape for suspension of the albumin bottle.
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Etched on the metal can were the following instructions forthe administration of the serum albumin (fig. 164):
1. Open metal can with attached key.
2. Remove air filter needle, intravenous set, and intravenousneedle.
3. Remove container of albumin.
4. Apply alcohol or iodine to both rubber stoppers.
5. Holding container in upright position, insert air filterneedle through top of rubber stopper.
6. Insert short needle of intravenous set through rubberstopper at opposite end.
7. Attach intravenous needle to observation tube.
8. Allow tubing to fill with albumin solution.
9. Insert intravenous needle into vein. If venipuncture isdifficult, cut down on vein.
10. Suspend container about 3 ft. above patient..
11. Except in severe shock, do not let rate of administrationexceed 5 cc. per minute.
MANAGEMENT OF SPECIAL TYPES OF WOUNDS
Wounds of the Extremities
Patients with multiple wounds of the extremities,particularly those produced by landmines, traumatic amputations, and fracturesof the femur, required large amounts of blood. A common mistake in themanagement of femoral fractures in the early experience of the Mediterraneantheater was failure to restore the blood volume promptly. Penicillin was broughtto the theater by Maj. Champ Lyons, MC, in the late winter of 1943, and he andMaj. (later Lt. Col.) Oscar P. Hampton, Jr., MC, introduced an extremelysuccessful three-point program of blood, penicillin, and surgery (18). Inall their instruction, they emphasized that even as potent an agent aspenicillin would be less potent without the liberal use of whole blood and thatsurgery would be much less successful-and sometimes impossible-without it.
Blood was given in preparation for operation, duringoperation, and postoperatively in the forward hospital, and was also givenlater, before reparative surgery, in the base hospital.
Secondary anemia, often of a considerable degree, was evidentin casualties admitted to base hospitals, even when they had received largeamounts of blood in forward hospitals. These anemias would undoubtedly havecorrected themselves spontaneously in time if adequate diets had been suppliedand had been supplemented by iron therapy. There was, however, an urgent need toget on rapidly with reparative surgery, not only because the military situationrequired the rapid turnover of hospital beds but, even more impellingly, in thepatient's own best interests. Wound closure with low hematocrit levels wouldhave introduced a completely preventable surgical risk (19, 20).
Three series of fractures of the long bones illustrate thesepoints (18):
1. At the 16th Evacuation Hospital, 28 of 100 casualties withfractures of the femur required between 1,500 and 2,000 cc. of blood before andduring operation, and only 9 patients in the series required no blood at all. Incontrast, only 3 of 100 patients with compound fractures of the radius, ulna, orlong bones required blood in such quantities, and
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63 required no blood at all. Casualties with compoundfractures of the humerus, tibia, fibula, or both bones of the leg constituted anintermediate group.
2. At the 23d General Hospital, 33 patients with fractures ofthe long bones had hematocrit values under 30; 80 others had values between 31and 40; and only 25 (18 percent) had values of 40 or higher, the desirable levelfor reparative operation. Only 2 of 38 patients with fractures of the femur fellinto the latter category.
3. At the 21st General Hospital, the proportions weresubstantially the same in 166 patients with fractures of the long bones; 37 hadhematocrit readings under 30, and only 31 (19 percent) were regarded as safe foroperation without further blood replacement.
While no absolute proof can be adduced to show that suchintensive blood replacement was necessary for good results, there is a greatdeal of indirect proof. The program of reparative surgery in compoundfractures, the use of penicillin, and liberal whole blood replacement therapycame into existence in the Mediterranean theater at about the same time. It isnaturally impossible to attribute the improved results that promptly followedtheir introduction to any single one of these factors. It was the generalimpression, however, that the anesthetic risk was far less in patients whosesecondary anemia had been corrected, that wound healing was prompter, and thatconvalescence was less
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complicated. It was also the impression that those who hadreceived liberal transfusions were less likely to present chronic infections.
Abdominal Injuries
Casualties with abdominal injuries required replacementtherapy by the usual routine (3). In such injuries, however, it wasimportant to observe the response carefully. If it was not what could beexpected with the amount of blood used, prompt surgery was indicated, on theground that hemorrhage might be continuing or that a fulminating chemicalperitonitis might be present.
Plasma was often used liberally in the first few days afterclosure of a colostomy, to reduce edema of the suture line, and to preventnarrowing of the anastomotic orifice.
Chest Injuries
Both plasma and blood had to be given with great caution inchest injuries (21). Decompensation was always a possibility if edemawere per-
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mitted to develop. The same precautions concerning the riskof overloading the circulation held in thoracoabdominal wounds. Sometimes theneed for correction of cardiorespiratory pathophysiology, which indicatedlimitation of fluids, had to be balanced against the need for liberal amounts ofblood because of hemorrhage from associated injuries. Theoretically, if redblood cells had been available, their use might have solved the problem of theneed for blood and the risk of overloading the circulation in chest injuries.
Before blood was available in liberal quantities in theMediterranean theater, blood aspirated from the chest was sometimes used fortransfusion. Surgeons differed as to the periods within which they considered itsafe to use such blood; most were conservative, limiting the time to no morethan 6 hours. The blood was never used, of course, if there was the smallestsuspicion that a thoracoabdominal wound was present.
ADMINISTRATIVE CONSIDERATIONS
Preparation of Manual On Shock
At the first meeting of the NRC (National Research Council)Committee on Transfusions on 31 May 1940 (19), Dr. Alfred Blalock wasappointed to prepare a small pamphlet on shock and allied subjects, fordistribution to the Army and the Navy. His choice as principal author was wise,for few people had done more than he to develop the concept of hemorrhage as thebasic cause of shock.
It is of interest, therefore, and indicative of howcompletely shock therapy was revolutionized during the war, to find in thispamphlet (22):
1. A full discussion of isotonic salt and glucose solution inthe prevention of shock.
2. A statement of the limitations of blood banks in wartimebecause of the cumbersome cooling unit necessary, and the limited shelf life ofblood. It was pointed out, however, that one of the greatest advantages ofpreserved blood was that larger quantities could be given than were ordinarilyused.
3. A discussion of plasma (twice as long as the space devotedto blood), in which the concept was presented that the loss of red bloodcorpuscles would be tolerated quite well if the lost plasma were replaced. Oneof the advantages of plasma was said to be that it did not add to theconcentration of red blood corpuscles, hemoconcentration being the usual findingin shock. The intravenous injection of adequate quantities of plasma wasconsidered "probably the single most effective and valuable and practicalmethod for the prevention and treatment of shock, with the possible exception ofmethods of hemostasis."
All of these statements were correct in the light of 1940knowledge.
Shock Teams
The blood banks in the Mediterranean and European theatershad a single function, to provide blood for wounded casualties. The U.S. Armyblood service personnel, unlike the British Army Transfusion Service personnel,had nothing to do with the administration of the blood. British personnel weretrained in the processing and care of preserved blood and also in its
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administration. U.S. personnel were trained only in itsprocurement and processing.
As shock was handled in the Mediterranean theater duringWorld War II, it was the shock teams assigned from auxiliary surgical grouppersonnel and not organic personnel of field hospitals who carried the majorresponsibility for treating casualties and determined the efficiency of theircare in these hospitals (3). The supervision of shocked casualties byhospital personnel was the responsibility of the anesthesiologist, whose handswere full with his own duties, supervision of his helpers, and supervision ofreplacement therapy in the operating room.
This situation was almost inevitable. In contradistinction toother areas of medicine and surgery, there was no pool of civilian medicalpersonnel trained in the mass treatment of shock. Almost any civilian physiciancould treat single patients adequately in peacetime practice, and that was howshocked patients were usually encountered, as individuals. In warfare, therewere few occasions on which it was not necessary to treat several casualties atthe same time, and it was often necessary to treat overwhelming numbers ofseriously wounded casualties simultaneously. Few medical officers possessed thisknowledge and ability when they entered the Army and they had to be trainedafterward (p. 87).
Shock Wards
Shock wards were promptly set up in hospitals in combat areasin all theaters. The ward described by Col. Douglas B. Kendrick, MC, in October1945 (figs. 165 and 166) brings together the best features of all such wards asthey evolved with experience (23):
Facilities.-While facilities must conform to availableterrain, shock wards, whenever possible, should be located in proximity to thetriage tent and as close as possible to the surgical tent. If terrain permits,it is best to have all of these tents, plus the radiology tent, joined. Withsuch an arrangement, service is more efficient, and mud, heavy rains, andblackout regulations are less hampering.
The tentage should be sufficient to accommodate 40 patientsat the same time (fig. 165). Two squad tents, attached to each other laterally,with the adjoining sidewalls raised, will provide adequate space for 25, and athird tent, joined to one or the other, can care for an additional 15casualties. Shock wards should not be divided. When they are, additionalpersonnel and equipment are necessary, and comparative surgical priorities aremore difficult to establish.
Equipment-Good light is essential for examination,venipuncture, and laboratory work. If electrical fixtures are limited, bulbsattached to long drop cords provide adequate lighting.
Also needed are:
1. Wooden horses (80), half 25 and half 29 inches high, sothat litters can be placed in either the Fowler or the Trendelenburg position.
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2. Overhanging wires (fig. 165), strung about 7 feet high and so distributedthat a wire passes over each litter. These wires are used for intravenousfluids, individual records, and, for rapid identification, cards with eachpatient's number.
3. Tourniquets.
4. A refrigerator.
5. A large sterilizer or two small sterilizers.
6. Wash basins, kidney basins, sponge cups, and drinking cups.
7. Levin tubes, urinals, bedpans, and enema bags.
8. Oxygen tanks, reducing valves, and oxygen masks.
9. Syringes, 5-, 10-, 30-, and 50-cc., 100 of each.
10. Hypodermic needles, from 25- to 15-gage.
11. Sternal needles.
12. Intravenous cannulas.
13. Clinical thermometers.
14. Bandages, Carlisle dressings, large and small gauze squares, petrolatumgauze (for sucking wounds of chest), and adhesive tape.
15. Blankets.
16. Portable Van Slyke copper sulfate specific gravity sets and a centrifugefor determining hematocrit and plasma protein values.
17. Phlebotomy sets and chest aspirating sets.
18. Morphine solution in 100-cc. bottles, procaine hydrochloride solution,sodium amytal, and aspirin.
19. Penicillin.
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20. Whole blood, plasma, isotonic sodium chloride solution, and 5-percentdextrose solution in distilled water.
21. Forms for recording transfusions and other intravenous medication.
22. A bulletin board for posting lists of casualties under treatment forshock, with recommended surgical priorities.
A center table, with multiple shelves, placed in the center of the ward makesall equipment and supplies readily accessible. Glassware is washed and preparedon a small table near the sterilizer.
Staffing.-Shock wards must operate fully staffed 24 hours a day. Theminimum personnel to handle 30 patients in shock is two officers and fourenlisted men, so assigned as to provide efficient coverage in the circumstances.
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Enlisted men should be well trained in aseptic techniques andin the preparation and administration of blood and other intravenous fluids.
Because of the volume of work on a shock ward, it isdesirable to utilize personnel from other services. After adequate instruction,dental officers prove very useful, and personnel from the medical services canalso help, especially early in a combat operation, when, as a rule, there arefew medical admissions.
Assignment of duties-The duties of medical officerson a shock ward are to make an initial examination; control hemorrhage; closesucking wounds of the chest; aspirate hemothoraces; relieve tension pneumothorax; perform intercostal nerve block; take blood for hematocrit and plasmaprotein determinations; maintain a check on the blood pressure; orderreplacement therapy and assist in giving it; outline the therapeutic measures tobe employed; supervise the setting up and maintenance of records; record alltherapy; follow the results of treatment; correlate them with the shock process;determine transportability; and, in conference with the chief of surgery,establish operative priorities, with due regard to relative possibilities ofsurvival.
The medical officer in charge of the ward also organizes theduty roster of officers and enlisted men on shock teams and assigns them tospecific tasks.
The duties of enlisted men are to administer morphine,penicillin, blood, plasma, and other therapy as directed by the medicalofficers; maintain adequate supplies; attend to the care and operation of thesterilizer; clean glassware; record all procedures carried out on patients;provide ordinary nursing care, such as taking temperatures; removing bloodyblankets and clothing; cleanse patients, at least superficially; and supplycoffee, water, and other fluids if the patients are able to take them.
Experience proved that the methods just outlined provided asimple and efficient routine for the management of shocked casualties.
References
1. Administrative and Logistical History of the MedicalService, Communications Zone, European Theater of Operations, vol. 13, chapter14, Professional Aspects of the Medical Service. [Official record.]
2. Report of Consultant Surgeon to the Surgeon, NATOUSA, 2July 1943.
3. Medical Department, United States Army. Surgery in WorldWar II. General Surgery. Volume II. Washington: U.S. Government Printing Office,1955.
4. Snyder, Howard E.: Fifth U.S. Army. In MedicalDepartment, United States Army. Surgery in World War II. Activities of SurgicalConsultants. Volume I. Washington: U.S. Government Printing Office, 1962.
5. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 24 Sept. 1943.
6. Report of Consultant Surgeon to the Surgeon, NATOUSA, 31May 1944.
7. Hurt, Maj. Lawrence E.: General Surgical Team No. 25, 8Aug. 1944.
8. Minutes, Conference on Albumin, Division of MedicalSciences, NRC, 5 Jan. 1942.
9. Minutes, meeting of Subcommittee on Blood Substitutes,Division of Medical Sciences, NRC, 23 June 1942.
10. DeGowin, E. L., Hardin, R. C., and Swanson, L. W.:Studies on Preserved Human Blood. IV. Transfusions of Cold Blood Into Man.J.A.M.A. 114: 859-861. 9 Mar. 1940.
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11. Use of Whole Blood in Zone of Interior Hospitals. Survey, Col. B. N.Carter, MC, April-May 1945
12. Tisdall, L. H., Garland, D. M., Szanto, P. B., Hand, A. M., and Barnett,J. C.: The Effects of the Transfusion of Group O Blood of High Iso-Titer IntoRecipients of Other Blood Groups. Am. J. Clin. Path. 16: 193-206, March 1946.
13. Elkinton, J. R.: The Systemic Disturbances in Severe Burns and TheirTreatment. Bull. Ayer Clin. Lab., Pennsylvania Hosp. 3: 279-291, December1939.
14. Memorandum, Lt. Col. D. B. Kendrick, MC, to Director, Army MedicalSchool, 15 Dec. 1942, subject: A Preliminary Report on the Cocoanut Grove DisasterFrom the Massachusetts General Hospital, 6 December 1942.
15. Minutes, meeting of Subcommittee on Blood Substitutes, Division ofMedical Sciences, NRC, 23 May 1941.
16. Robinson, G. C.: American Red Cross Blood Donor Service During World WarII. Its Organization and Operation. Washington: The American Red Cross, 1 July1946.
17. Minutes, meeting of Subcommittee on Blood Substitutes, Division ofMedical Sciences, NRC, 2 June 1944.
18. Medical Department, United States Army. Surgery in World War II.Orthopedic Surgery in the European Theater of Operations. Washington: U.S.Government Printing Office, 1956.
19. Minutes, meeting of Committee on Transfusions, Division of MedicalSciences, NRC, 31 May 1940.
20. Churchill, E. D.: The Surgical Management of the Wounded in theMediterranean Theater at the Time of the Fall of Rome. Ann. Surg. 120: 269-283,September 1944.
21. Medical Department, United States Army. Surgery in World War II. ThoracicSurgery, Volume I. Washington: U.S. Government Printing Office, 1963.
22. Shock, Prevention and Treatment. A manual prepared for the Medical Corpsof the Army and Navy, under the direction of the Medical Division of theNational Research Council, by Alfred Blalock, Nashville, Tenn.
23. Kendrick, Lt. Col. Douglas B.: Organization of a Shock Service in aCombat Area Hospital. J. Mil. Med. Pacific 1: 14-21, October 1945.
