Tactical management of urban warfare casualties in special operations

Military Medicine, Apr 2000 by Butler, Frank K Jr

16. Casualties who are unconscious from falls may have both a closed-head injury and bleeding from intrathoracic or intraabdominal injuries. The optimum fluid resuscitation strategy for these patients has not been determined. Hespan offers a theoretical advantage in these patients in that it is retained in the intravascular space and may contribute less to cerebral edema than crystalloids. The importance of maintaining cerebral perfusion pressure (avoiding hypotension] in casualties with closed-head injuries was emphasized.

17. Not all individuals injured in combat need IV fluid resuscitation. Combat medical personnel should not generally initiate fluid resuscitation in individuals who are not in shock in order to: ( 1 ) minimize interference with combatants who can continue to participate in the engagement; (2) conserve limited IV fluid supplies; and (3) attend to casualties with more severe wounds. All significantly injured patients should, however, have a saline lock started when tactically feasible in anticipation of the possible need for subsequent IV fluids, analgesia, or antibiotics.

18. Even with optimal care in civilian trauma centers, trauma patients who present with systolic blood pressures below 90 mm Hg as a result of trauma have a survival rate of only approximately 50%. The presence of hemorrhagic shock on the battlefield is a grave prognostic sign.

19. The prolonged delay to surgery in Mogadishu and the reported high incidence of subsequent infectious complications emphasizes the need for antibiotics to be administered to casualties as soon as possible. Cefoxitin was felt to be a good choice by the panel, although ceftriaxone was suggested as an alternative. Ceftriaxone was noted to be more expensive and to have a narrower range of antibiotic coverage than cefoxitin, but it does offer the advantage of once-a-day dosing in prolonged evacuation situations.

20. The antibiotic coverage and absorption after oral dosing of the fluoroquinolones is excellent. Use of a fluoroquinolone taken by mouth with a small amount of water instead of IV antibiotics in a combat setting may be helpful in reducing combat medical equipment weight and treatment complexity. Animal research is needed in this area.

21. Preliminary research data in a pig model from the U.S. Army Institute of Surgical Research has shown that needle thoracostomy with a 14-gauge needle is as successful as a chest tube in relieving a tension pneumothorax and that the therapeutic benefit persists for at least 4 hours.

22. If a casualty has a chest wound, but is having no severe or increasing difficulty with his breathing, there is no need to do either a needle thoracostomy or to insert a chest tube emergently. The theoretical advantage of expediting hemostasis in lung parenchymal wounds will not be realized unless suction is applied to the chest tube. This type of suction is not available on the battlefield. Use of a chest tube without suction has been shown in animal studies at the Army Institute of Surgical Research to be unsuccessful in re-expanding lungs with a pneumothorax following penetrating chest trauma.