STANDARDIZING CARE & TREATMENT OF BATTLE CASUALTIES
SPMDA
ARMY SERVICE FORCES
Office of The Surgeon General
Washington 25, D. C.
23 October 1943.
CIRCULAR LETTER NO. 178
Subject: Care of the wounded in theaters of operation.
1. The purpose of this letter is to provide broad policies and certain guiding principles on the care of the wounded in theaters of operation. Modification in accordance with existing conditions and changing circumstances may be necessary.
2. Principles of evacuation.
a. The lightly wounded whose injury is such that treatment would permit immediate return to duty will be treated in the forward echelons (battalion aid stations, collecting and clearing stations) and will not be evacuated.
b. Patients with injuries requiring immediate operation in order to save life will be treated in forward echelons if possible.
c. With exception of above, no operations will be done in forward echelons.
d. The lightly wounded who reach a forward hospital should be held in convalescent hospitals in that area and not evacuated far to the rear.
e. So far as possible, seriously wounded patients requiring surgery should be evacuated directly to evacuation hospitals or to other hospitals operating as such.
f. Patients who, in the opinion of the responsible medical officer, cannot be returned to duty status within the period determined by the evacuation policy of the theater (at present 180 days for the European and the China, Burma, India Theaters and 120 days for all other overseas theaters, defense commands, departments, and separate bases) will be returned to the United States on the available and suitable transportation, provided the travel required will not aggravate their disabilities.
3. Treatment.
a. Wounds.
(1) Soft parts.
(a) Roentgenograpbic or fluoroscopic examination should be done preceding operation.
(b) Principles. The fundamental principles in the care of wounds are reaffirmed. Special emphasis is placed on the following:
1. Adequate exposure is essential in order to permit
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access to all parts of the wound. This does not mean overexcision of the skin. Very little skin need be excised but good exposure may necessitate longitudinal incision of the skin and the fascial planes.
2. Removal of:
aa. Readily accessible foreign bodies: especially important are pieces of clothing and other nonmetallic materials.
ab. Particles of bone completely separated from the periosteum.
ac. Tissue that is soiled, devitalized, or the circulation of which is impaired (especially certain muscles such as vastus intermedius, rectus famoris, hamstrings, gluteus maximus, and the heads of the gastrocnemius).
3. Leave wound open.
4. Dressing should be placed loosely in the wound, not packed.
5. In large wounds, immobilize the part by adequate splinting even in the absence of fractures.
(2) Head wounds.
(a) These should be considered as priority for evacuation to nearest hospital where adequate surgical treatment and postoperative care are feasible. A transport time of 48 to 72 hours does not contraindicate evacuation or justify operation forward of an evacuation hospital.
Before evacuation treat as follows:
l. Gently separate edges of scalp, remove superficial dirt and blood clot, and cover with sterile gauze.
2. While gauze is held in place, shave scalp for three inches around wound and wash skin with soap and water.
3. Remove gauze, frost wound with sulfanilamide, and apply large secure dressing.
(b) Surgical treatment at hospital.
1. Carefully d?bride scalp but conserve as much skin and subcutaneous tissue as possible.
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2. Bone defect may be enlarged if necessary but avoid extensive bone flaps.
3. Loose bone fragments and accessible foreign bodies should be removed.
4. Damaged brain tissue may be removed by gentle irrigation and suction.
5. These wounds should not be packed but closed around a small drain.
(3) Face.
(a) Maintenance of a clear respiratory airway is an important consideration in these cases before evacuation. If patient cannot sit up, evacuate in the prone position. In some cases tongue traction by means of a suture or safety pin may be necessary.
(b) Surgical treatment.
1. Every effort should be made in operating on these wounds to conserve tissue in order to facilitate subsequent reconstructive procedures. Foreign bodies and completely detached fragments of bone and teeth are removed but fragments of bone which still have some attachment to soft tissue are conserved.
2. In contradistinction to the general rule of leaving war wounds open these wounds should be closed if this can be done without exerting undue tension.
3. If the defect is such that primary closure is not possible and the wound enters the buccal cavity, the edges of the skin and mucous membrane should be carefully approximated. In cases in which there is an opening into the buccal or nasopharyngeal cavities complicated by a compound fracture no attempt should he made to suture the wound but the mucous membrane may be approximated if possible. Approximation of lacerated soft parts by bandage and adhesive strips is preferable in these cases
(4) Chest
(a) Sucking wounds of the chest demand immediate closure. This should never be done by suture unless adequate d?bridement of the chest wall is possible. As an emergency measure closure is best effected by the application of a pad of gauze heavily coated with vaseline and folded to fit the wound and held in position by a few sutures through the skin. Over this a supportive gauze dressing should be strapped securely. These patients should have priority in evacuation to hospitals.
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(b) Novocain block of the intercostal nerves supplying the injured area is an especially useful procedure not only in simple rib fractures and "stove-in-chest" but also in other chest injuries in which pain of the chest wall is an important factor.
(c) The occurrence of tension pneumothorax should always be considered. It may be relieved by aspiration or release of air through a needle introduced into the chest through the second or third interspace anteriorly. This may also be accomplished by inserting a small catheter into the chest and connecting it with a finger cot or condom valve.
(d) In the management of simple hemothorax conservatism is desirable. Except in progressive hemorrhage, simple aspiration is sufficient to relieve respiratory embarrassment. Air replacement will not be done. Within a few days and when the danger of secondary bleeding is past the pleural cavity should be emptied of blood by two or three aspirations on successive days.
(e) When thoracotomy is performed, an effort should be made to remove large foreign bodies. Operation in these cases should be preceded by roetgenographic examination.
(5) Abdomen
(a) Because of the importance of early operation in penetrating wounds of the abdomen and the fact that these patients do not tolerate early transportation after operation, these cases should be evacuated direct and as soon as possible to the nearest hospital where adequate surgical treatment and postoperative care are feasible.
(b) Cases requiring abdominal operations should not be moved for five to seven days after operations.
(c) In view of the frequency with which missiles producing penetrating injuries of nearby regions such as the thigh, buttocks, and chest lodge in the abdomen, all such cases should have roentgenographic examination of the abdomen.
(d) In penetrating wounds of the abdomen general anesthesia will be used wherever possible in preference to spinal anesthesia.
(e) In large bowel injuries, the damaged segment will be exteriorized by drawing it out through a separate incision, preferably in the flank. in order to facilitate subsequent closure the two limbs of the loop should be
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approximated by suture for a distance of about 2 ? inches and then returned to the abdomen leaving the apex exteriorized with a a short length of rubber tubing or Other suitable material beneath it. If the segment cannot be mobilized the injury should be repaired and a proximal colostomy done.
(f) Penetrating injuries of the rectum should have exploratory laparotomy and posterior drainage by excision of the coccyx and incision of the fascia propria.
(g) Penetrating wounds of the bladder require repair and the drainage of the urine either by suprapubic cystostomy or peringal urethrostomy. The space of Retzius should always be drained.
(h) Postoperatively, suction on an indwelling gastroduodenal tube is recommended every and every effort should be made to prevent vomiting and distention and to promote physiologic rest of the alimentary tract.
(6) Extremities
(a) Soft The principles of treatment are the same as previously stated.
(b) Nerves
1. In view of the fact that extremity wounds constitute 75 percent of all battle injuries and that 12 percent to 15 percent of all extremity wounds are complicated by injury to major nerve trunks, the possibility of nerve damage should always be considered. Effort should be directed toward early recognition of the existence of nerve injury and suitable notation must be made on the E.M.T. tag or on a cast in order to facilitate proper evacuation and the necessary early treatment.
2. Primary nerve suture should be done when the nerve ends are readily accessible and can be approximated without tension. If this is not possible and the injured nerve ends are identified, a sling suture of fine stainless steel wire should be placed between them or they should be anchored with similar suture material to the surrounding tissue in order to prevent retraction. The use of metal suture material here is desirable because it permits roentgenographic identification for subsequent repair.
3. In view of the irreparable degenerative changes that occur in the end plates of severed nerves, early repair of those nerves is absolutely essential. For this reason it is of the utmost importance to evacuate these patients as soon as possible to the zone
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of the interior where operative and necessary postoperative physiotherapy can be instituted.
(c) Arteries. Peripheral vascular injuries are of special importance, particularly where major vessels are involved. In many of these cases ligation will be necessary. Ligation in continuity should not be done, but rather division between ligatures above and below the point of injury thus eliminating the danger of secondary hemorrhage, thrombosis, and vasoconstrictor influences. In the presence of thrombosis, the thrombosed segment should be excised. Localized segmental spasm of the artery should be distinguished from thrombosis. Such cases which have also been termed "concussion" or "stupeur" of the artery may follow various forms of trauma to an extremity and especially when the traumatizing agent passes near a vessel. In such cases the limb is cold, pale, and pulseless, but evidence of hemorrhage or hematoma indicating that the vessel has been lacerated is lacking. These cases respond well to d?bridement of surrounding traumatized tissue and to periarterial sympathectomy or sympathetic block. Postoperatively in all cases with peripheral vascular injuries vasodilatation should be induced by daily sympathetic block using one percent procaine hydrochloride solution. Body warmth should be carefully maintained but heat should not be applied to the involved extremity.
(d) Bones and joints
l. Open reductions in the case of simple fractures will not be done except in general hospitals.
2. Fractures of the femur are to be evacuated from field units to the forward hospitals in the Army half-ring splints using the litter bar, ankle strap, and five triangular bandages. If it is necessary to remove the shoe, traction will not be effected by the ankle strap or hitch about the ankle but skin traction will be applied.
3. Fractures of the shaft of the femur or tibia and fractures involving the hip or knee joints will be evacuated from forward hospitals to general hospitals in the Army half-ring splint with skin or skeletal traction or in a plaster spica. The use of the Tobruk splint has received favorable comment. It is applied as follows: by means of traction, preferably skin traction, the extremity is pulled down, a plaster splint is moulded to the posterior
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aspect of the thigh and leg, a half-ring splint is applied to which the traction is made fast, and the extremity and splint are wrapped by several turns of plaster. The application of multiple pins incorporated in plaster is not recommended.
4. In the general hospital fractures of the femur should be treated by traction, either skin or skeletal, until enough union has been obtained to permit safe transportation to the zone of the interior in a plaster spica.
5. Fractures of the ankle and foot are best evacuated in padded posterior and lateral wire ladder splints.
6. Fractures at the humerus should be transported to the evacuation hospitals in the Thomas arm hinged splint with skin traction and triangular bandages. An alternate method is the immobilization of the arm to the side of the chest with a sling or velpeau bandage incorporating a padded external splint if available. For evacuation to a general hospital, the best method is the use of a U-shaped molded plaster splint extending from the axilla around the elbow and up the outer surface of the arm and shoulder to the neck. This is supported by bandages and a sling.
7. Fractures of the elbow and forearm should be immobilized in posterior wire ladder or molded plaster splint extending beyond the wrist and supported by a sling.
8. Penetrating wounds of the joints, should be treated by d?bridement with removal of loose bone fragments, irrigation of the joint cavity, and closure of the synovial membrane. The soft tissue wound down to the sutured synovial membrane must be kept open by loosely placed gauze. Whereas in the upper extremity all loose bone fragments should be removed, in the lower extremity fragments necessary for stability and weight bearing should be preserved if possible. All joint injuries should be immobilized as stated above.
9. Fracture of the lumbo-dorsal spine should be transported with a blanket roll support under the site of fracture. Fractures of the cervical spine should hare an improvised collar. This may be made using the patients` two canvas leggings with hooks of each facing to leave a smooth outer surface. The ankle
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notch is fitted snugly under the chin; the leggings then are tied by means of the laces and tightly wrapped in place with a bandage. This may be used for recumbent or ambulatory cases.
10. All recent casts on the extremities should be padded and should be completely bivalved before evacuation.
(e) Amputations - All primary amputations in the combat zone should be performed at the lowest level possible which permits removal of all devitalized and contaminated tissue regardless of stump length. Revision of the stump in accordance with prosthetic consideration may subsequently be performed. The open circular method of amputation is the procedure of choice in traumatic surgery under war conditions, and is especially indicated in gunshot wounds and in controlling infection. Following circular division of the skin which is allowed to retract, the muscles are severed at the level of the retracted skin, the outer layers being divided first, and, as they contract, the deeper layers until the hone is reached. The bone is sawed without stripping the periosteum. These wounds must always be left open using a vaseline dressing. Skin traction to the stump must always immediately be applied following the amputation and continued until healing occurs. The flap type open amputation may be done only in cases in which early evacuation is not contemplated and subsequent closure at the same station is deemed possible.
b. Burns
(1) Principles
(a) Prevention and control of shock by the adequate use of plasma. In extensive burns, quantities of plasma up to 12 units may be required in the first 24 hours.
(b) Relief of pain with morphine. Large doses of morphine should be avoided if anoxia is present.
(c) Prevention and control of infection by aseptic precaution and by the oral administration of sulfadiazine. The initial dose of sulfadiazine should be 4 gm. Subsequent maintenance dosage should be determined by fluid intake, urinary output, and tolerance for the drug.
(d) Prevention of contractures and excessive scarring, by proper splinting and early skin grafting.
(2) First-aid or emergency treatment of burned area. Cover with sterile petrolatum or boric acid ointment, then with strips of fine-mesh gauze (gauze bandage). Over this add thick
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layer at sterile gauze dressing, and wrap with gauze or muslin bandage to make firm pressure dressing
(3) Treatment of burned area when patient arrives at hospital
(a) Standard operating room technique with patient and attendant fully masked will used
(b) Cases in which burned surface appears clean, further preparation will not be done. The use of detergents such as lard and washing and d?bridement will be reserved for grossly soiled burns. Small blisters should not be disturbed and large areas drained by simple puncture. General anesthesia should be avoided if possible and pain controlled by morphine.
(c) Tannic acid and all other escharotics will not be used.
(d) The burned area will be covered with vaseline or, if this is not available, boric acid ointment and a firm pressure dressing as described under first-aid treatment will he applied. In burns of the extremities the pressure dressing should include all the extremity distal to the burn. Immobilization of the part by splinting should be affected when feasible. Unless complications develop, the dressing should not be disturbed from 10 days to 2 weeks.
c. Gas gangrene
(1) Prophylaxis
(a) Inadequate and delayed d?bridement and primary closure of wounds are two of the most important factors which contribute to the development of gas gangrene.
(b) Gas gangrene is particularly likely to occur in certain wounds such as compound fractures of the long bones, injuries causing extensive muscle damage, penetrating wounds of the abdomen, deep wounds of the perineum, and wounds in which the circulation of the part has been impaired. This factor of impaired circulation is especially important in certain muscles such as the gluteus maximus, the hamstrings, rectus femoris, vastus intermedius, and the gastrocnemius. Because in these muscles the blood supply is peculiar in that it is derived from only one or two sources which if cut off may result in ischemia of the entire muscle, wounds in these regions may be more frequently associated with gas bacillus infection. In performing d?bridement in these wounds special care should be exercised in removing devitalized tissue. Accordingly, cases of this nature especially those in which the injury has resulted in loss of the main blood supply of the part, will not be evacuated from hospitals until the danger from gas gangrene is past.
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(c) The primary closure of wounds greatly predisposes to th development of gas gangrene.
(2) Treatment
(a) The most important factor in treatment of established gas gangrene is early removal of all involved tissue. This frequently necessitates excision of entire muscle bellies or guillotine amputation.
(b) Chemotherapy should be maintained
(c) Polyvalent gas gangrene antitoxin should be administered preferably intravenously, after suitable precautions against anaphylactic shock have been taken. A minimum dose of three ampules repeated hourly at the discretion of the medical officer until six doses have been administered is recommended.
(d) Because in gas bacillus infection there is rapid destruction of erythrocytes, whole blood transfusions should be used.
d. Chemotherapy
(1) The value of sulfonamides in preventing sepsis and spreading infections is emphasized. Because this depends in great measure upon the systemic presence of the drug administration by oral or parenteral means is considered essential. Sulfadiazine is considered the drug of choice. An initial dose of 4 gm. administered orally as soon after injury as possible is recommended. Maintenance dosage of one gm. every four hours should be used if adequate kidney function can be assured.
(2) The untoward reactions and complications of sulfonamide therapy should be thoroughly realized. Of these the most important are the renal disturbances. Since the great majority of these can be prevented by an adequate urinary output, every effort should be made to maintain an output of at least 1,500 cc. daily. If this drops to below 1,000 cc. or if microscopic hematuria develops sulfonamide therapy should be stopped.
For The Surgeon General:
ROBERT J. CARPENTER
Lieut. Colonel, Medical Corps
Executive Officer.
DISTRIBUTION:
All officers of the Medical Corps, U. S. Army.
SOURCE: National Archives and Records Administration, Record Group 112, Records of the U.S. Army Surgeon General, World War II, SGO Circular Letters, 1942-43.
