Year : 2017 | Volume
: 19 | Issue : 1 | Page : 1--3
The evolution and future of combat casualty care
Director General Medical Services, (Army), Delhi, India
Lt Gen Bipin Puri
Director General Medical Services, (Army), Delhi
|How to cite this article:|
Puri B. The evolution and future of combat casualty care.J Mar Med Soc 2017;19:1-3
|How to cite this URL:|
Puri B. The evolution and future of combat casualty care. J Mar Med Soc [serial online] 2017 [cited 2018 Nov 20 ];19:1-3
Available from: http://www.marinemedicalsociety.in/text.asp?2017/19/1/1/213103
Lessons learned from the battlefields of history have laid the foundation of modern trauma protocols. To the misfortune of humankind, the lessons of war are ongoing and relentless. Wounds of war are often gruesome and the physiological insults are horrendous. Tactical situations often mandate war wound management in suboptimal, hostile, and hazardous environments where sterility is suspect and resources are at a premium. On the other hand, combatants are generally fit before the injury event and are free of preexisting serious systemic illnesses. Their management therefore exposes the medical fraternity to the limits of the envelope of physiological stresses and their restoration.
Casualty management starts at the site of wounding with self or buddy care. Evacuation is often possible only during temporary cessation of operations. Primary onsite care, therefore, involves homeostasis with pressure bandages and local hemostatic agents such as quick clot or tourniquets. Analgesia is usually self-administered and involves the use of opioids. Evacuation proceeds through the channels of field hospitals. The time for evacuation may therefore vary from a few hours to even days in hostile terrain.
For optimal results, we need to have laid down protocols for wound assessment and management at all levels. Standardization is critical. Competence at each level needs to be credentialed and ensured. Finally, audits of war time care and the results achieved help us to prepare for tomorrow.
Hemorrhage and Hemorrhagic Shock
Hemorrhage is the primary cause of death in the war wounded. Control of hemorrhage in the war wounded involves local measures such as hemostatic gauze, regional control in war wounds of the extremities by application of tourniquets, and systemic measures including the use of Tranexamic acid. The United States Joint Trauma System recommends the use of Tranexamic acid for life-threatening hemorrhage with risk of coagulopathy and in patients receiving >10 units of blood (massive transfusion). Primary management of bleeding war wounds is by pressure dressings or the so-called shell dressing, where sterile-medicated gauze is stuffed into wounds and retained in situ by a pressure bandage.
Chitosan-based local hemostatic agents may be necessary to achieve hemostasis. Although the local exothermic reactions of “Quick Clot” or their substitutes may result in additional tissue injury, these packs are part of the kit of Special Forces the world over. These packs help hemostasis while a wounded soldier awaits evacuation and definitive treatment.
Limb injuries with exsanguinating bleeds may necessitate the application of tourniquets. In the groin area, tourniquet application is possible by specially designed devices called functional tourniquets which are like hemostatic clamps.
Concept of War Wound Care
The concept of delayed primary closure evolved the management of war wounds. Many factors are considered while deciding the timing of definitive closer. Today, negative pressure wound therapy is initiated after primary wound debridement. The timing of surgical closure is conventionally decided considering 4Cs, i.e., color, consistency, contractility when stimulated, and the capacity to bleed when incised.
Chest and Abdominal Trauma
Chest injuries may be associated with massive hemorrhage due to major vessel damage. Evaluation by whole-body computed tomography (CT) results in improved outcomes. Focused abdominal sonography in trauma (FAST) is effective in the diagnosis of intra-abdominal bleeding. FAST has replaced diagnostic peritoneal lavage which was at one time the gold standard for the diagnosis of intraperitoneal hemorrhage. A positive FAST in the absence of hemodynamic instability should be followed by a contrast CT scan. Injuries to major abdominal vessels require open surgical repair, while smaller vessel injuries can often be managed by embolization. Contained subcapsular hemorrhages of liver, kidney or spleen can be observed under close monitoring.
Damage Control Surgery
Damage control surgery involves limited surgical procedures to arrest hemorrhage and limit peritoneal contamination. Packs are often used to achieve hemostasis, and abdominal closure is usually done using mesh which can be incised for repeated easy access. Damage control orthopedic surgery involves the use of external fixators. The decision to do definitive fixation early or to manage with damage control orthopedics (external fixators) is sometimes guided by serum lactate levels. A rising serum lactate level >2.5 mmol/L indicates moderately severe tissue hypoperfusion. These patients need physiological stabilization prior to definitive skeletal fixation, and a damage control approach to resuscitation and surgery is mandated.
Orthopedic Trauma in the Military Setting
Fractures of the pelvis or femur may lead to hemorrhagic shock. Bleeding may be from the bone edges or from ruptured vascular plexuses or vessels. Fracture pelvis may be difficult to diagnose with only subtle limb shortening, deformity, or local ecchymoses as the only signs. Contrast CT for head-to-pelvis evaluation is recommended for the evaluation of hypotensive trauma patients. Pelvic fractures require binders for battlefield stabilization. Later, external fixators  are used. Failure of pelvic stabilization to provide hemostasis may necessitate angiography and embolization of bleeding vessels.
Femur fractures should be stabilized by splints or bandages in the battle field and should undergo external fixation as early as possible. Early intramedullary nailing has been recommended.
Fluids and Resuscitation
Hemorrhagic shock results in impaired tissue perfusion. Overtly, aggressive fluid resuscitation is however hazardous as fresh bleeding may get provoked. Initial resuscitation is usually with crystalloids. The “lethal triad” which is the avoidable end point of exsanguinations includes coagulopathy, hypothermia, and acidosis. The use of noradrenalin improves blood pressure resuscitation, reducing the risk of fluid overload. Persistent systolic hypotension of <90 mmHg even after administration of vasoactive drug indicates an ongoing loss and surgical intervention for bleeding control.
History and Evolution of Fluid Resuscitation
During the Vietnam War, a 3:1 volume resuscitation strategy was followed. Large infusions of isotonic saline were shown to increase the incidence of hyperchloremic metabolic acidosis. Ringer's lactate was therefore the crystalloid of choice for battlefield resuscitation. Ringer's lactate is, however, hypotonic. An increased incidence of acute respiratory distress syndrome or of interstitial fluid accumulation in other regions including gut, muscles, or even the pericardial cavity  was also noted with resultant lung and gut injury. Colloids were suggested as a panacea. However, colloid infusions were also found to increase mortality.
Hypertonic solutions have the theoretical advantage of drawing fluid from the interstitial compartment into the circulating blood. Hypertonic saline (7.5%) either alone or in combination with dextran (6%) was touted as an ideal fluid for prehospital resuscitation. However, studies showed no survival benefit.
The Institute of Medicine (US Army) has recommended an initial bolus of 250 ml of hypertonic saline for battle casualties in shock. The Uniformed Services University of Health Sciences, identified triggers for resuscitation which include a systolic blood pressure of <80 mmHg and altered consciousness in the absence of head injury. They recommended a hypertonic saline bolus of 500 ml in the prehospital environment. Hypotensive resuscitation targeting mean arterial pressure of 40 mmHg has been shown to result in better outcomes.
The Concept of Combat Intensive Care
An evolved combat casualty management protocol has ensured that many grievously injured combatants reach tertiary-level care. These severely injured soldiers respond to massive physiological insults with a quantum of inflammatory and immune dysregulation rarely seen in civilian practice.
The management of these cases is optimally performed in an intensive care setting with continuous physiological and biochemical evaluations.
The management of combat casualties needs standardization of management protocols, of evacuation modalities, and integrated advanced intensive case with subspecialty backup. As the weapons of war evolve, the management of war wounds too needs to advance and keep pace.
|1||Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma 2006;60 6 Suppl:S3-11.|
|2||Shahur H, Roberto I, Bautista R, Caballero J, Coats T, Dewan Y, et al. Effects of Tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH -2): A randomized placebo controlled trail. Lancet 2010;376:23-32.|
|3||Bowyer G. Débridement of extremity war wounds. J Am Acad Orthop Surg 2006;14:S52-6.|
|4||Probst C, Pape HC, Hildebrand F, Regel G, Mahlke L, Giannoudis P, et al. 30 years of polytrauma care: An analysis of the change in strategies and results of 4849 cases treated at a single institution. Injury 2009;40:77-83.|
|5||Crowl AC, Young JS, Kahler DM, Claridge JA, Chrzanowski DS, Pomphrey M. Occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. J Trauma 2000;48:260-7.|
|6||Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, et al. Effect of whole-body CT during trauma resuscitation on survival: A retrospective, multicentre study. Lancet 2009;373:1455-61.|
|7||Koller H, Balogh ZJ. Single training session for first time pelvic C-clamp users: Correct pin placement and frame assembly. Injury 2012;43:436-9.|
|8||Karadimas EJ, Nicolson T, Kakagia DD, Matthews SJ, Richards PJ, Giannoudis PV. Angiographic embolisation of pelvic ring injuries. Treatment algorithm and review of the literature. Int Orthop 2011;35:1381-90.|
|9||Nahm NJ, Vallier HA. Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries: A systematic review of randomized and nonrandomized trials. J Trauma Acute Care Surg 2012;73:1046-63.|
|10||Harvin JA, Harvin WH, Camp E, Caga-Anam Z, Burgers AR, Wade CE, et al. Early femur fracture Fixation is associated with a reduction in preliminary complications and hospital charges: A decade of experience with 1376 diaphyseal femur fractures. J Trauma Acute Case Surg 2012;73:1442-8.|
|11||Harrois A, Hamada SR, Duranteau J. Fluid resuscitation and vasopressors in severe trauma patients. Curr Opin Crit Care 2014;20:632-7.|
|12||Lee JH, Kim K, Jo YH, Kim KS, Lee CC, Kwon WY, et al. Early norepinephrine infusion delays cardiac arrest after hemorrhagic shock in rats. J Emerg Med 2009;37:376-82.|
|13||Hashim R, Frankel H, Tandon M, Rabinovici R. Fluid resuscitation-induced cardiac tamponade. J Trauma 2002;53:1183-4.|
|14||Velanovich V. Crystalloid versus colloid fluid resuscitation: A meta-analysis of mortality. Surgery 1989;105:65-71.|
|15||The NHLBI Halts Study of Concentrated Saline for Patients with Shock due to Lack of Survival Benefit. NIH News 26 March, 2009.|
|16||Puri B. Fluid resuscitation in pre hospital trauma case: A consensus view. JR Army Med Corps 2001:147;147-52.|
|17||Lu YQ, Cai XJ, Gu LH, Wang Q, Huang WD, Bao DG. Experimental study of controlled fluid resuscitation in the treatment of severe and uncontrolled hemorrhagic shock. J Trauma 2007;63:798-804.|
|18||Sheridan RL, Shumaker PR, King DR, Wright CD, Itani KM, Cancio LC, et al. Case records of the Massachusetts general hospital. Case 15-2014. A man in the military who was injured by an improvised explosive device in Afghanistan. N Engl J Med 2014;370:1931-40.|
|19||Hawksworth JS, Stojadinovic A, Gage FA, Tadaki DK, Perdue PW, Forsberg J, et al. Inflammatory biomarkers in combat wound healing. Ann Surg 2009;250:1002-7.|