Wound Shock: A History of Its Study and Treatment by Military Surgeons

Military Medicine, Apr 2004 by Hardaway, Robert M

Korean War

The Korean War (1950-1954) saw many advances in care of the wounded: whole blood was available in adequate amounts, plastic bags were used, helicopter evacuation became routine, and Ringer's lactate was used frequently to maintain vascular volume. The Mobile Army Surgical Hospital (MASH) concept was instituted for the first time. These advances were instrumental in reducing mortality from abdominal wounds from 21% in World War II to 12% in Korea and to 3.9% in Vietnam.15 Many of these advances were important in the station hospitals back in the United States, to which casualties were often evacuated within 48 hours. As Chief of Surgery at the Surgical and Orthopedic Center in Fort Belvoir, Virginia, I made great use of the new plastic blood bags and Ringer's lactate in treating hundreds of Korean war wounded. It was also during this war that disseminated intravascular coagulation (DIC) and multiple organ failure (MOF) were first described.11

Vietnam

In the War in Vietnam from 1964 to 1972, 153,303 American wounded were admitted to military hospitals.17 As mentioned above, the hospital mortality was less than 2%. Blood and Ringer's lactate were often available and were administered at the battalion aid stations.15 Patients were frequently treated at a hospital in less than 1 hour, having bypassed the aid stations. The Vietnam War saw the beginnings of serious shock research in the Army, with the first description of shock lung,18 later called adult respiratory distress syndrome (ARDS). Intravascular clotting was proposed as the possible cause, and treatment with fibrinolytic enzymes was postulated. In support of this research, blood gases and pH, as well as central venous pressure, were measured for the first time in combat. Ringer's lactate also came into its own as the primary IV fluid in the treatment of shock. These findings were the result of research performed at the first shock-trauma unit, which was established at Walter Reed Army Medical Center in Washington, DC, in 1963, and in a duplicate unit in Vietnam in 1965.15,18,19 The unit in Vietnam was under the direct command of the following physicians in turn over a 6-year period: Dr. John A. Collins, Dr. Paul M. James, Dr. Terruo Matsumoto, Dr. Carl Bredenberg, and finally by Dr. R.L. Simmons. This unit, at the 3rd Surgical Hospital, treated and studied many of the most severely wounded,15,18,19 These studies indicated that "shock lung" and MOF could be caused by intravascular coagulation. The studies were continued over the next 30 years in animals, and culminated in a successful clinical trial of thrombolytics in 2001, based on data from these studies.20-24

Recent Developments

The past 30 years have seen a tremendous surge in the study of hemorrhagic and septic shock in the Army and elsewhere. A computer search for references on hemorrhagic and septic shock in 1999 revealed more than 40,000 entries. Many of these articles treat hemorrhagic shock and traumatic shock as a single entity, and their recommended treatments reflect this concept. A variety of IV fluids, including hypertonic saline and starch compounds, have been introduced. A delay in administering massive IV fluids until bleeding can be controlled may minimize blood loss, according to some. Emphasis has also been placed on warming IV fluids, especially blood, although the cooling of fluids may be effective in cases of high fever. The wide availability of artificial blood is on the horizon and will no doubt prove very significant in times of inadequate or tainted blood supply. The treatment of hypovolemic (hemorrhagic) shock without extensive tissue damage has proved very successful, approaching 100%, providing hemorrhage can be controlled. Pure hemorrhagic shock is always reversible with adequate and timely IV fluids. In fact, the problem of treating true hypovolemic shock has been essentially resolved.