Tactical management of urban warfare casualties in special operations

Military Medicine, Apr 2000 by Butler, Frank K Jr

8. Several casualties died as a result of hemorrhage from superficial but non-extremity bleeding sites where tourniquets could not be used. Attempts to maintain direct pressure on a hemorrhage site may be complicated by multiple bleeding sites and/or the need to return fire. A hemostatic dressing such as that now being developed by the Army Medical Research and Materiel Command would be an invaluable asset in such cases and is the best chance that such casualties have for survival. This project should be a top priority for research and procurement funding.

9. The prolonged ( 15-hour) delay to evacuation for most of the casualties in Mogadishu serves to emphasize that the results of civilian pre-hospital fluid resuscitation studies (in which the delay to arrival at the hospital is usually 15 minutes or less) may not be applicable to the combat environment.

10. Treatment of casualties on Special Operations missions involves a combination of good medicine and good tactics. Controlled, prospective human studies that address the entire spectrum of issues peculiar to battlefield trauma care are not likely to ever be accomplished. Optimum guidance for combat medical personnel on these issues will require a combination of combatappropriate animal studies and consensus opinion from focused expert consideration of these issues. In general, interventions of questionable value should not be undertaken when they entail significant additional risk to mission personnel or the mission itself.

11. The femoral artery bleeding described in scenario 7 was stopped with an improvised tourniquet. Many SOF operators are unhappy with the U.S. military standard issue tourniquets and stressed the need for improved tourniquets that can be put on one-handed and that can reliably stop arterial bleeding. This should be a top priority for research funding.

12. Hespan has the advantage of being retained in the intravascular space longer than lactated Ringer's solution. A majority of the panel felt that Hespan is a better choice than lactated Ringer's for the treatment of hypovolemic shock resulting from controlled hemorrhage in combat casualties who may experience delays to surgery beyond those seen in civilian trauma studies.

13. The participants in the Mogadishu action were in the field for up to 15 hours in almost 100F heat with only two canteens (2 quarts) of water, adding dehydration as a significant stressor in this operation. The impact of this level of dehydration on the management of hypovolemic shock has not been well studied. Additional research is needed in this area.

14. Although Hespan has the potential advantage of being better retained in the intravascular space, wider distribution of lactated Ringer's might make it a better choice than or a necessary addition to Hespan in patients who are both dehydrated and suffering from hemorrhagic shock. Additional animal research is needed in this area.

15. The best bet for improvement in pre-hospital fluid alternatives for combat casualties was felt to be a hypertonic saline/ colloid combination. Continued efforts to obtain FDA approval for this type of fluid should be undertaken. Additional animal research is needed to evaluate the efficacy of these solutions as compared with lactated Ringer's, normal saline, hypertonic saline, and Hespan. These studies should address the delayed surgery and dehydration that will often be present in combat and should use both controlled and uncontrolled hemorrhage models.