96 Injury (1987) 18,9&99 Printed in Great Britain

Medical statistics of battlefield casualties

A. Trouwborst

Erasmus University and University Hospital, Rotterdam, The Netherlands

EL K. Weber

German Red Cross

D. Dufour

International Committee of the Red Cross

Summary War surgery presents conditions and problems that are radi- cally different from those of peacetime surgery. Categoriza- tion of the injured may be necessary (triage), while a short or erratic supply of drugs, materials and personnel may exist. In this study, the hospital mortality following military action was 6.4 per cent. In the group of patients with combined thoraco- abdominal injuries mortality was high. However, the inflow of this type of patient was relatively low. In 50 per cent of the cases, ketamine/benzodiazepine anaesthesia without intuba- tion and artificial ventilation was sufficient, with the result that the use of oxygen and nitrous oxide was minimized.

INTRODUCTION WAR surgery presents conditions and problems that are radically different from those of peacetime surgery. A sudden, massive influx of patients can overwhelm the limited medical facilities and staff and make it neces- sary to adopt a carefully selective approach in the surgical treatment of the injured (Nyman, 1980). The initial aim of medical and surgical intervention is to prevent preventable immediate death; treatment such as reconstructive surgery can be performed later. That war injuries should always be considered and treated as severely contaminated wounds is of the utmost import- ance. Primary operations, including adequate wound

toilet, should be performed as soon as possible after injury. Another difficulty in war is the scarcity and erratic supply of drugs, materials .and staff (Baraka, 1980). From November 1984 until March 1985, the intensity of action at the Thai/Kampuchea border was increased. All the Khmer wounded were treated in two field hospitals staffed by the International Committee of the Red Cross (ICRC). This treatment included first aid, primary surgery, occasionally reconstructive surgery, followed by initial rehabilitation. All patients received their entire treatment in these two hospitals and were not admitted to other hospitals after dis- charge.

The purpose of this study is to describe the activities in a field hospital during a war: triage, type of injury in relation to the origin or cause of injury and effective- ness of the type of anaesthesia used. In addition, the mortality rate according to the various injury sites was investigated.

MANAGEMENT Normally, the field hospital was staffed by two surgeons, two anaesthetists, three theatre nurses and four to five ward nurses. In the event of an over- whelming influx of casualties, extra staff up to a total of three surgeons, three anaesthetists, six theatre nurses and nine to ten ward nurses were available within a few hours. During a clash, a first aid post and/or triage centre was established outside the hos- pital and near to the battlefield and staffed by the medical coordinator and two or three nurses. If urgently required, the patients received intravenous infusion and the first sorting of the casualties was made to decide the order in which patients should be evacuated (by ambulance) to the field hospital. The medical coordinator informed staff inside the field hospital by radio, about the expected influx of patients. If conditions did not allow the establishment of a proper screening centre, all the wounded were evacuated directly to the field hospital where they were sorted directly after admission.

On admission, a registration team wrote the patient’s number with gentian violet on the right or left arm and on the patient’s chart (day/month/admission number for that day). Further sorting was immediately carried out by an anaesthetist and/or surgeon, who marked the patient’s forehead with the number 1,2,3 or 4. Patients were categorized as follows:

1. Patient needs immediate surgical operation. 2. Patient has small chance of survival. 3. Patient needs surgical operation, but can wait. 4. Patient does not need surgical operation. After categorization, an operation theatre list was

compiled by an anaesthetist and/or surgeon conducting the triage. Patients in category 1 had priority, followed by patients in category 3 and lastly those patients in category 2 who survived. As required, this list was adapted to cope with any new influx of war wounded.

Patients and medical treatment (in general) During the period from end November 1984 to end February 1985, 1033 male patients (mean age 22.3+0.9 years; age range 16-44) were included in this study. Directly after admission the patients were interviewed

Trouwborst et al.; Battlefield casualties 97

to identify the war weapon(s) that had caused their wounds. Blood samples were obtained and. if neces- sary, radiographs were taken. All patients received an intravenous infusion, tetanus prophylaxis and antibio- tics. followed as soon as possible by surgical treatment. Blood loss was initially replaced with Ringer’s lactate and Dextran 40. At a haematocrit below 0.20 blood transfusion was used before, during and after opera- tion. Antibiotic therapy was continued for several days. During their operations most of the patients were anaesthetized by one of the following methods:

I. General anaesthesia combined with intubation and artificial ventilation with oxygen, nitrous ox- idc and fluothane.

2. General anaesthesia without intubation or arti- ficial ventilation.

3. Local anaesthesia. The intravenous infusion was continued postoper-

atively until a normal oral intake of food and drink was possible and the haematocrit remained at an acceptable level. None of the patients received artificial ventilation postoperatively.

Weapons of war and various sites of injury In this study, 49.2 per cent of the patients were injured by shell fragment , 2X.4 per cent by mines and 22.4 per cent by bullets. The various war weapons resulted in many different types of injury (T&e Iu) at varying sites (Tuhle lh). Most patients had soft tissues damaged in the limbs (73.0 per cent). Other injuries affected: bone (39. I per cent). thorax (7.0 per cent), abdomen (1 I .2 per cent) and brain (2.5 per cent). Surgical treatment (Tuhle If) included wound toilet (73.0 per cent), exter- nal fixation of fractures (7.9 per cent), amputation of one or more limbs (13.6 per cent), thoracotomy (2.0 per cent). drainage of thoracic cavity (4.9 per cent), laparotomy (I 1.3 per cent) and craniotomy (2.5 per cent). Many patients suffered multiple injuries. The statistics were compiled according to the different types of weapon: bullets (T&/e Ill), shells (Tuhfe IV) and mines (Tuhlr V). Fractures were predominantly caused by bullets and mines. the latter causing the most severe injuries. In 35.2 per cent of this group of patients,

Table la. Parts injured (N=1033

Table II. Type of surgical treatment (N=1033)

%

Wound toilet 73.0 External fixation 7.9 Amputation 13.6 (two: 1.7) Thoracotomy 2.0 Chest drain 4.9 Laparotomy 11.3 Craniotomy 2.5 Other 3.6 None 0

Table 111. Type of injury and type of surgical treatment (percentages) in patients with bullet wounds (N=231)

Soft-tissue damage Wound toilet

Bone injury External fixation Amputation Conservative

Thoracic injury Thoracotomy Chest drain

Abdominal injury Laparotomy

Brain injury Craniotomy

Others

67.1 67.1 100.0

51.9 13.4 25.8

1.7 3.3 36.8 70.9

7.4 3.9 52.9 3.5 47.1

10.4 IO,4 100.0

-

I and liEpercentage of total. Ill=percentage of total of patients with particular type of injury.

Tab/e IV. Type of injury and type of surgical treatment (percentages) in patients with shell fragment injuries (N=508)

I II Ill

Soft-tissue damage 74.9 Wound toilet 74.9 100.0

Bone injury 19.6 External fixation 5.5 28.0 Amputation 6.5 33.0 Conservative 7.6 39.0

Soft tissue Bone

Thorax Abdomen

Brain Other

Tab/e Ib. Sites of injury (N=1033)

%

73.0 39.1 7.0

11.3 2.5

3.6

%

Thoracic injury 8.6 Thoracotomy 2.4 27.3 Chest drain 6.3 72.7

Abdominal injury 13.8 Laparotomy 13.8 100.0

Brain injury 4.7 Craniotomy 4.7 100.0

Others 3.7

I and Il=percentage of total (N=508). Ill=percentage of total of patients with particular type of injury.

Head 4.6 Upper limbs 21.3 Lower limbs 87.1

amputation of one or more limbs was unavoidable. Most head injuries were caused by shelling.

Chest 8.9 Abdomen 13.6 Spine 0.8

Mortality (Tuhle VI)

The overall mortality rate following admission to hos- pital was 6.4 per cent. The mortality rate was high in

98 Injury: the British Journal of Accident Surgery (1987) Vol. 18/No. 2

Tab/e V, Type of injury and type of surgical treatment Tab/e VIII. DifTerent types of anaesthesia for the first (percentages) in patients with mine injuries N=294) surgical procedure (A’=10331

I II III

Soft-tissue damage 70.4 Wound toilet 70.4 100.0

Bone injury 62.8 External fixation 7.8 12.5 Amputation 35.2 56.0 Conservative 19.8 31.5

Thoracic injury 3.7 Thoracotomy -

Chest drain 3.7 - 100.0 Abdominal injury 7.5

Laparotomy 7.5 100.0 Brain injury 0.7

Craniotomy 0.7 100.0 Others 4.1

I and Il=percentage of total. Ill=percentage of total of patients with particular type of injury.

%

General anaesthesia (intubation) 20.2 Ketalar/midazolam anaesthesia 50.0 Local anaesthesia 25.3 Without anaesthesia 4.5

Total 100

(diazepam 0.2 mg/kg-’ bodyweight) or midazolam (0.1 mg/kg-’ bodyweight). These patients were not in- tubated and breathed for themselves. Intubation and artificial ventilation were indicated in only 20.2 per cent of the patients; in these cases anaesthesia was main- tained with oxygen, nitrous oxide and fluothane. Treat- ment under local anaesthesia was possible in X-3 per cent of the patients.

DISCUSSION

Tab/e VI. Mortality in the different groups of injury

%

Overall mortality 6.4 Soft-tissue damage 2.3 Bone injury 6.0 Thoracic injury 32.0 Abdominal injury 25.6 Brain injury 8.3 Others 5.6

48 per cent of the patients had a combination of two or more types of injury.

Tab/e VII. Mortality during and after different types of surgical treatment

%

When the influx of wounded overwhelms the medical facilities. establishment of priorities is essential. In such circumstances, patients with severe injuries and little chance of survival will not have priority. Furthermore, time-consuming operations must be avoided. In this study, especially in the group of patients with combined thoraco-abdominal injuries. the mortality was high and a thoraco-laparotomy occupied one surgical team for many hours. However. the proportion of this type of patient was only 2.0 per cent. When several surgical teams are available, one team can be sequestered for several hours in an attempt to save these patients. The hospital mortality in the group of patients with head injury was 8.6 per cent. It is known that the prognosis of brain injury depends on the patient’s age (Braak- man. 19X2); the low average age of the wounded in this study may have had a favourable influence on the results.

Wound toilet 2.3 External fixation 6.9 Amputation 9.3 Thoracotomy* 71.4 Chest drain 16.7 Laparotomy 25.6 Craniotomy 8.3 Others 5.6 None 0

The mortality rate of all cases in this study is rather high (6.4 per cent) (Baraka, 1980) and several factors may have contributed to this figure; among them were malnutrition and delayed admission to hospital. In addition, many patients arrived with severe haemorrha- gic shock. As blood was scarce, after infusion of Ringer’s lactate and Dextran 40, blood was given when the haematocrit dropped below 0.20.

*80 per cent of the patients in this group also had abdominal injury.

patients with thoracic injury (32.0 per cent) and also in those with intra-abdominal injury (25.6 per cent). When thoracotomy was necessary the mortality rate was 71.4 per cent (Table VII). However, 80 per cent of the patients who underwent thoracotomy were also suffering from intra-abdominal damage; in 80 per cent of these patients thoraco-laparotomy was performed.

In comparison with the level of postoperative care in developed countries (with intensive care units, modern ventilators, etc.) the facilities in the field hospitals are very poor. When postoperative artificial ventilation is required for the first 4X hours (especially after thoraco- tomy) on average we needed a ventilator for every 25 admissions.

Of all our patients 38.4 per cent had fractures and in many cases amputation was unavoidable. All war wounds arc contaminated, and we used external fixa- tion of fractures in 7.9 per cent of all patients. An ample supply of external fixation devices is essential in war and military surgeons must be trained in their use.

Anaesthesia (Table Vlll) Fifty per cent of the admitted patients were treated surgically after an intravenous injection of ketamine (2 mg/kgg ’ bodyweight) together with benzodiazepine

The anaesthetist has to use the simplest method of anaesthesia possible. In general. the quality of postop- erative care is lower than in peacetime and in civilian hospitals and respiratory depression frequently occur- red without warning signals that are available from

Trouwborst et al.; Battlefield casualties 99

more elaborate equipment. For logistic reasons, the use of oxygen and nitrous oxide had to be minimized (Baraka, l%O), while the use of opiates could lead to postoperative respiratory depression. Therefore, whenever possible, ketamine was administered for its hypnotic and imalgesic effects, which are not combined with respiratory depression. Ketamine was combined with benzodiaLepinc to counteract its psychotic effect. This method was used with success in 50 per cent of the cases. Only 20-2 per cent required intubation and ven- tilation with oxygen and nitrous oxide. After the first surgical procedure most of our patients required furth- er anaesthesia for dressing, as well as for delayed primary closure of wounds. The average number of surgical procedures per patient was three. The average number of surgical procedures under anaesthesia per patient. in the groups with soft-tissue damage or

traumatic amputation, was 4.1. In all these procedures ketamine or local anaesthesia was sufficient.

REFERENCES Baraka A. (IW)) Experiences in disaster medicine during the

tragic civil war of Lebanon. In: Frey R. and Safar P. (eds)

Disaster Medicine. Berlin. Heidelberg. New York, Springer Verlag. 54.

Braakman R. (19X2) Emergency craniotomy in severe head injury and the present state ot knowledge regarding prog- nosis. Injury 14, 22.

Nyman J. (1980) The evaluation of disaster casualties. In: de Boer J. and Baille T. W. (eds) Disasters-Medical Orgn- nisation. London, Pergamon, 79.

Paper accepted IO July l9Xh

Requ~.~ts~~rrc~~~rrr~t.s.shouldheuddrc~.s.srd to: Dr A. Trouwborst. Department of Anaesthesia. University Hospital Dijkzigt, Dr. Molewaterplein 40. 3015 GD Rotterdam. The Ncthcrlands.