Points to note – Chapter 7

This chapter on combat casualty care and Emergency Room life support is oblig-
atory reading for any wartime care provider – especially for those who happen to
believe that only surgeons can save lives.

Also see the pocket folder at the back cover; don’t leave it there. It should be in
your pocket and referred to constantly.

The chapter builds on the manual Save Lives, Save Limbs by Hans Husum, Mads Gilbert
and Torben Wisborg, see p. 846.

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7 Trauma life support
in war
Prepare! Organize! Be careful! ................................ ............. ..... 174
Read the clinical signs ............................................. ... ......... ... . 176
Not awake and not breathing: start CPR ...................................... 178
A: Control the airway ............................................. ... ......... ... . 180
Advanced life support for airways ................................ ........... 181
Airway cut-down .................... ............ ............................... 183
B: Support the breathing and give pain relief ................................. 185
Ketamine is the drug of choice ............................................. .. 186
Place a naso-gastric tube! .................... ............ ... .................. 187
Advanced life support for the breathing: Chest tube drain ............. 188
C: Support the circulation .............................. ............ .............. 195
Stop limb bleeding, no tourniquets .................... ............ ......... 196
How to control internal bleeding ................................ ........... 198
Cold blood bleeds more – keep patients warm .................... ....... 200
Intravenous cannulation ............................................. .......... 201
Venous cut-down .................... ............ ............................... 204
Volume therapy and nutrition .................... ...................... ... ... 206
Identify wounds and injuries .................... ............ ... .................. 211
Positioning of the patient ............................................. ............ 217
Transport to hospital ................................ ... ...................... ..... 219
Drugs for trauma life support .................... ............ ............. ...... 221
In-field medical documentation .................... ......... ............. ....... 228
Summary: Simple things most important ...................................... 230

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7 Trauma life support in war
Life support kits, see p. 74.
Charts for in-field medical
documentation, see p. 114.
In-field rapid sterilization, see p. 75.
Never touch (what might be) an
explosive device – move around it!
174
Prepare! Organize! Be careful!
Prepare yourself!
A first helper should be ready for action at all times. Maybe you are sleeping peace-
fully at night when some soldiers get drunk and play the fool with their guns. Or
you are called to assist the ambulance crew at the site of a bomb blast.You are going
to see mutilated bodies, bad wounds, injured people in severe pain and terrified
bystanders shouting at you. Unless you and your team are well prepared and all
the necessary equipment is ready, you cannot do the job. Always have your stan-
dard life support kit ready in your home so that you can pick it up and go instead
of going to fetch it from the health center. See to it that the kit is complete, clean
and well packed. When you need it you will need it in a hurry; there will be no
time to dig through messy bags and boxes to find the tools you need.
Ways to control your nerves
It is natural to be nervous. Even experienced soldiers and doctors are nervous and
feel the pressure when called to a hot site or a difficult surgery.That pressure makes
us do our very best – but it has to be controlled:
I have done well before, I am good! On your way to the scene of injury, recall
previous accidents where you did well. Decide to repeat now what you did well
previously.
I am well trained, I can manage this! Recall all the training you have been
through.You know how to do these things: First the airway, then the breathing and
then the blood circulation. Basic life support is not difficult – as long as you do not
forget to do the important, simple things systematically.
Visualise what the scene of accident will look like. There will be crying
and shouting. There may be several victims. The scene may be dangerous, snipers
may still be around or bodies may be booby trapped. Do NOT rush yourself and
your team into trouble.
Take on responsibility.When you get to the site, tell everybody: “I am here,
I am the doctor – now listen to me!” Then start gathering information:What kind
of weapon? How long since? How many injured? Where are they?
Is the site safe? If in doubt, do not send your team in – but take the patients out
to a safe place nearby. It is a risky job to rescue victims; somebody has to do it but
it should not be the medical team. Let a maximum of three volunteers enter the
scene and take the patients out one by one. They should strictly follow the same
path in and out; there may be unexploded munitions around or trip-wires which
can set off another blast. Organize and control everyone involved in the rescue.
Keep the others clear of the area, especially children.
When under stress
Tell yourself again and again:“I am calm, strong, and clever!”
And stick to the rules! Don’t play around!
7 Trauma life support in war

with each other: How well did we do? How do we improve? Unload painful feel-
Remember: There is no such thing as ings: What did we feel on the site – and afterwards? Can we support each other
having “correct” or “wrong” feelings. better? Do some of us soon need a week off?

To make a good performance

is not so much a question of individual skills,
as regular training of team work,
well prepared medical kits,
and a caring team leader.

Read the clinical signs

The basic response to injury: “I need more oxygen!”

Effects of oxygen starvation:

• The respiratory rate (RR) increases.The patient takes more breaths/minute.
Your own RR when reading this is probably around 15-20 breaths each minute.
If a mine victim has lost a lot of blood or he has a chest injury, the RR may increase
to 40 breaths per minute.
• Each breath is deeper. The lungs act as a suction pump. The motor for this
pump is the diaphragm. After injury the movement of the diaphragm increases.
It goes deeper into the abdomen to suck air in, and it rises further upward into
the chest cavity to push air out.

RR higher than 30/min is an important warning sign. See rules for triage, p. 278.

The signs of too little oxygen in the blood

Breathing is rapid, more than 30 breaths each minute (adults).
The victim is pale, sweating and restless.
As the supply of oxygen in the blood gets lower and lower the patient becomes con-
fused, says crazy things, pushes you away or pulls out the IV lines.

He is in danger! You have to take immediate action to get more oxygen into the
blood:

The ABC action plan of trauma life support

Step 1: Is the Airway open? If not, do something! If it is open, carry on:

Step 2: Is the Breathing good? If not, do something! If it is good, carry on:
Step 3: Circulation: First, stop the bleeding; then give IV infusions.
The lung “suction pump”.

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Not awake and not breathing:

start CPR
Is he dead?
If a person does not respond when spoken to, he may have fainted, be very cold,
severely injured, very sick or just drunk. A person who does not respond and is
not breathing, is by definition dying or dead. To find out if he is dead, or to help
him if he is not yet dead, examine the airway, breathing and circulation as
described below. Unless you are completely sure that a victim is dead, you should
try to save him.

Examination of a lifeless person

1. Awake? Always start by speaking to a victim. If he does not respond, you should
gently shake his shoulders, and ask again: “Are you OK?”
2. Airway: Open the airway by tilting the head back and lifting the chin. Loosen
any tight clothing around the victim’s neck. Use your fingers to remove foreign
bodies from the mouth. Now you know that he has an open airway!
3. Breathing: Look for chest movements. Place your ear to his mouth, listen for
signs of breathing and feel for warm air against your ear. Check for at least 5
seconds before deciding that there is no breathing. If there is no breathing, you
must give 2 rescue breaths right away.
4. Circulation: Does the victim respond to the rescue breathing? You must
check if there is blood circulation. Feel for the pulse beat in the carotid artery.
If the victim does not start breathing on his own, and no pulse can be felt, there
is no blood circulation. This means that the heart has stopped.

This is heart arrest:

No response when shaken, no breathing, and no pulse in the carotid artery.
No blood is reaching his brain.
He is dying, and only prompt and fearless action can save his life!
CPR in adults: 2 rescue breaths

Examination of a lifeless child

The steps to examine a lifeless child are slightly different:
• Airway: Do not extend the neck too far back when doing a head tilt. Do not
press on the tongue when you lift the chin.
• Breathing: If there is no sign of breathing, give 5 rescue breaths (see oppo-
site page). Then check the pulse.
• Pulse control: In infants, check for the pulse inside the upper arm.
• Keep warm: Children lose heat even faster than adults do. Be careful to keep
the child warm.

Cardio-pulmonary resuscitation (CPR) is a way to restart a heart that has

stopped. CPR combines two techniques: Chest compression to maintain the
blood circulation while the heart is not beating. And rescue breathing to maintain
– and 30 chest compressions. the breathing while the victim is not breathing on his own.

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Airway block kills. Cambodian farmer
in the recovery position.
If the patient initially survives
aspiration to the lungs, the risk of late
complications is high, see p. 730.
Fuel-air explosives, see p. 130.
He is unconscious, the tongue is
blocking the airway. Head tilt and
chin lift opens the airway.
180
A: Control the airway
One out of four avoidable trauma deaths is due to airway obstruction. It is useless
to treat other injuries without first opening the victim’s airway.The most common
mistake is to focus on the screaming and bloody patients: those with blocked air-
ways cannot scream or even talk!
If the patient can talk, he can also control the airway.
Patients who do not respond by talking: Open the airway immediately and
find out if the patient is breathing!
The tongue may kill: The tongue is a large muscle in the mouth. If a patient is
unconscious, the tongue will be flaccid and fall back into the mouth, blocking the
airway.
Blood, vomit and mucus may kill: The strong reflexes that keep the airway
free from food and vomit (cough reflex, swallow reflex, gag reflex) do not work
in weak and unconscious patients. As a result, their airway becomes blocked, caus-
ing a quick death. This is a common and unnecessary cause of trauma death.
Airway burns may kill: In bomb blasts the temperature is extremely high
(2,500° C) close to the explosion. Initial survivors may have burn wounds from
the throat down into the lungs. The symptoms in airway burns may have slow on-
set and develop gradually when the airways constrict due to swelling and when flu-
id fills up inside the lungs.
• Look: Burn wounds in the face and mouth, burnt eyelashes or black spit indicate
damage to the airways.
• Listen: Coughing or wheezing breathing?
• Count the breathing rate: Unrest and high RR indicate a burn injury to the lungs.
Blast injury?
Most victims close to explosions of fuel-air weapons will have airway
burns.
Even if the airway is open at the initial survey: re-check every hour for
6 hours.
Action plan: Airways
Tilt the head and lift the chin: Place your hand on the patient’s forehead and
gently tilt the head backward. At the same time lift the chin with two fingertips
placed under the chin bone. Lifting the chin will move the tongue forward so that
it does not block the airway.
Finger sweep, remove foreign bodies: When you have tilted the head back
and lifted the chin, open the victim’s mouth and look into it.You may need a torch.
Remove fragments of teeth and pieces of bone with your fingers. Sweep the
mouth clean with any piece of cloth.

In unconscious victims contents
of the stomach may block the airway.
Recovery position prevents airway
block.
Carry victims with bleeding head
injuries face down.
Control the airway
Not talking? Not awake? Recovery position immediately:The recovery
position will prevent the tongue from falling back to block the airway. There is less
risk of vomit, blood and mucus running into the airway.
Face injuries? Place with face down: Blood from injuries to the face, mouth
or neck, may block the airway.This may even happen in the recovery position. Place
the victim with their face down, and their head tilted backwards. Make a hole in
the stretcher or the mattress. Place the victim on it with their face over the hole
to drain the blood.
Injured tongue? Pull it out of the mouth: When you pull out a bleeding
tongue, the bleeding becomes less. The tongue will also swell less – with less risk
of a blocked airway during the evacuation. Get a good grip of the tongue between
your fingers, using a piece of cloth. Pull it out of the mouth and downwards. Use
a safety pin, towel clamp or a suture through the tongue to fix it to the skin.
Airway burns:Take to hospital immediately. Pain relief is mandatory. Transport
in half-sitting position and be ready for airway cut-down, see p. 184.
Remember, the simple measures are most important
In study of 3,800 Afghan war wounded, in-field endotracheal intubation was
done in 12 patients only (0.3%); all others were safely managed by basic air-
way measures. See www.traumacare.no/publications
Advanced life support for airways
Intubation should be done:
• if the victim does not breathe or breathes poorly
• or if blood is pouring into the airway from large wounds at the face
• or if the patient is unconscious, the hospital is far away, and the transport will be
rough
• or if the patient has already aspirated vomit into the airways.
Fuel-air explosives + visible burns to face and mouth
Airway burns increase mortality in burn victims by a facor of three.
Airway cutdown (p. 184) + ketamine-diazepam sedation is the treatment
of choice.
All you need must be at hand before you start placing the tube:
• laryngoscope (check that it works!)
• endotracheal tubes in correct sizes (see table), stylet, syringe and ribbon gauze
• suction apparatus and suction catheter
• stethoscope
• self-inflating bag (but you can also give rescue breathing mouth-to-tube)
• one helper (a layperson will do).
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 Endotracheal intubation

Failed intubation
No attempt should last more than 30 seconds! Give 2 minutes of rescue breath-
ing before you try again. Before trying again: Elevate the head a little.

If victim does not breathe himself:

Attach self-inflating bag and start
assisted breathing immediately, at a
rate of approximately 20 breaths per
minute. Without bag: Start mouth- Find the cricoid ring. It’s the first
to-tube rescue breathing. cartilage below the Adam’s apple. Cricoid pressure protects the airway.

Failed intubation? Tell the helper to push the cricoid upwards and to the right.
Use a smaller tube, bend the stylet more. Not more than three attempts, edema
and bleeding in the larynx may kill the patient!

Not more than three intubations should If victim vomits: Place in recovery position immediately and clean up the airway
be attempted, edema and bleeding in with suction. Then place in supine position with cricoid pressure and try intuba-
the larynx may kill the patient. tion again.

Endotracheal intubation – in brief

Intubation gives a safe airway but it can be difficult and even impossible.
Nobody should try intubation without having trained to do it at regular
intervals.
If intubation is difficult, consider airway cutdown.

thyroid
cricoid Airway cut-down
(crico-thyrotomy or “emergency tracheostomy”)
When?
If the upper airway is blocked or partly blocked and you cannot relieve the block-
age by basic measures and you are not able to pass the endotracheal tube with the
laryngoscope, then do an airway cut-down immediately! In children under 3 years
old, airway cut-down is difficult. It is better to insert three large-bore IV catheters
through the crico-thyroid membrane.

Find the crico-thyroid membrane: Positioning is important: With the vic-

tim lying flat on his back, extend the neck by tilting the head. Or let the head hang
over the edge of a table. Or put a roll of clothes under the victim, between his shoul-
Finding the crico-thyroid membrane. ders. The cut-down is done through the membrane between the two main carti-

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Scientific study of RR as risk indicator:
see www.traumacare.no/publications
Place and carry the abdominal injured
in a half-sitting position. Note how
well the medic supports the airway.
Pain, fear and post-injury stress,
see p. 164.
Support the breathing and give pain relief
B: Support the breathing
and give pain relief
When the airway is safely open, your next task is to check the breathing:
• Don’t look for cyanosis! Cyanosis is a late sign of oxygen starvation; it is hard
to detect in colored people, and impossible to see in the dark.
• Don’t look for “respiratory distress”! In a desperate and chaotic situation every-
body is breathing hard.
Who needs life support?
Check the respiratory rate/minute (RR).
RR > 30 strongly indicates oxygen starvation – but can also be due to pain.
Give IV ketamine 15-25 mg, and check again:
Patients with RR > 30 after ketamine pain relief are risk cases – regard-
less of the location of the injuries.
Blast victims?
Blast victims – especially inside confined spaces – are exposed to extreme
pressures with high risk of tension pneumothorax.
Do needle puncture on suspicion, there is not one minute to lose!
Things can change – check again!
Slow internal bleeding may be going on.
In blast lung injuries RR may be normal for the first two hours after injury.
Place in half-sitting position
Victims lying flat on their back breathe poorly because the diaphragm is working
against abdominal contents. The diaphragm acts like the membrane of a suction
pump and is the most important muscle of breathing. For the breathing to be deep
and efficient, the diaphragm has to move 5 cm up and down. If the patient is placed
on his back, the organs inside the abdominal cavity will slip upwards, press on the
diaphragm and reduce its movements. When half-sitting, the organs inside the
abdominal cavity slip downward and the diaphragm can move freely.
Patients in pain and fear breathe poorly
Pain and/or fear make us breathe rapidly and superficially like a dog panting in the
sun.This “dog-like” breathing is very inefficient, only small amounts of air are enter-
ing the lungs.
Painkillers: Give repeated IV doses, not IM
If the patient has lost a lot of blood the IM injections have little effect.
Give the drug in repeated, small IV doses.
Wait to see the effect of one injection before giving the next.
If the intravenous route is not possible, all analgesics can be given by rec-
tum – and ketamine can also be given by the mouth as drink.
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Ketamine is the drug of choice

Ketamine is a powerful and safe analgesic. It does not affect the gag reflex, thus
ketamine patients can protect their airway. It does not reduce the breathing or cause
vomiting. Ketamine increases the BP and HR and thus helps keep up the blood cir-
culation. The drug may increase salivation, especially in children. Some patients
get hallucinations and lively dreams, but usually not enough to cause problems dur-
ing transport. Ketamine has less side-effects and works better than other analgesics.
There is one more advantage with this drug compared to other painkillers: If you
by mistake (in a chaotic setting) happen to give a too high dose of morphine, the
patient may die from it. However, if you give ketamine by ten times the recom-
mended dose, the patient drops into anesthesia – but will still breathe spontaneously
and maintain a normal HR and BP.

People react to drugs in different IV ketamine pain relief

ways. The correct dose is the dose Give 0.2-0.3 mg/kg body weight of ketamine (15-25 mg) IV for an adult.
that relieves pain. The doses listed This dose acts within 30 seconds, and the effect lasts for about 15 minutes.
here are guidelines only. Give the next dose when you notice that the victim starts to feel more pain.

Repeated doses of diazepam depress Atropine prevents salivation:

the breathing and may collapse the
circulation in patients with blood loss.
Never give diazepam to children
with blood loss, it may cause collapse
of the blood circulation.
Give one single IV dose of 1.0 mg atropine (adult) before giving the keta-
mine.
Diazepam prevents unrest and hallucinations:
Give diazepam 2.5-5 mg IV

Ketamine analgesia for children.

Ketamine is the safest and most efficient drug for pain relief in children. In
infants the IV access may be difficult. Especially in mass casualties oral or rectal
administration is useful.

Nasal: 5-10 mg/kg

Oral: 5-10 mg/kg
IV: 0.1-0.2 mg/kg
Rectal: 10 mg/kg

Morphine and buprenorphine are not recommended due to serious side-

effects. They are potent analgesics, but cause vomiting, especially during rough and
bumpy transport. The drugs depress breathing more than pentazocine.
Alcohol is another strong analgesic. It can be given as sips to the victim. But you
should first consider both its medical side-effects and any cultural reasons for not
using alcohol.
Pentazocine is an analgesic much like morphine. It may reduce breathing, HR
and BP – especially in children. Give an IV dose of 30 mg (adults). This takes effect
within 2-3 minutes, and lasts for 2-3 hours. The dose may be repeated, but watch
the breathing! Pentazocine does not cause salivation or bad dreams, so atropine and
diazepam are not needed.

186

The importance of an NG tube
treatment in primary trauma care
is not appreciated enough.
The tube is 60 cm down: Checking
the tube position.
Equipment needed: NG tube, diameter
3-5 mm. Cup of water. Tape. Torch.
Support the breathing and give pain relief
An inflated stomach blocks the diaphragm:
Place a naso-gastric (NG) tube
After injuries to the abdominal organs and severe blows to the abdominal wall the
intestines become paralyzed. Gases and fluid from the intestines leak backward and
the stomach swells up like a balloon within an hour or two after the injury. This
balloon pushes on the diaphragm so that it can hardly move.The NG tube emp-
ties the stomach, unlocks the diaphragm, and prevents vomit during the transport.
Place an NG tube in all abdominal cases more than 2 hours away from
the hospital. The technique is simple – if you have trained for it.
“Open your mouth and breath deeply!” When you see the tube in the throat
Direct the tube along the floor of the – stop! Tell him to swallow as you push
nose, towards the ear. the tube downward.
• Mark 60 cm from the tube end (marker pen or tape). In adults 60 cm is the dis-
tance from the nose down to the stomach. Place the conscious victim in a sitting
or half-sitting position.Tell him what you are going to do. Place the unconscious
victim in a side position so that vomit can easily be drained by the mouth.
• Moisten the tube with oil or water. Introduce the tube through one nostril along
the floor of the nose, directing it towards the ear. Pause for 10 seconds when you
can see the tube in the throat and tell the patient to breathe well, that helps him
to avoid vomiting.
• Now tell the patient to swallow and at the same time introduce the tube smooth-
ly down into the esophagus. Let the patient swallow repeatedly (they may take
sips of water) while you forward the tube stepwise to the stomach.
• Check that the tube is not bent inside the esophagus: Blow air through the
tube (by mouth). Press your ear over the stomach to listen – a bubbling sound
over the stomach confirms that the tube is in the correct position.
• Fix the tube to the chin with tape.
Problems?
The victim coughs when the tube passes down the pharynx: This shows that the
tube has entered the airway. Pull the tube back and try again.
Vomiting during the introduction indicates that you are too rough; calm the vic-
tim and yourself.
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7 Trauma life support in war

Basic Life Support for the breathing – in brief

All victims severely injured and awake: Place them in half-sitting position.
Count the breathing rate: RR more than 30/minute (adults) – give IV ket-
amine pain relief and check again.
RR > 30 after ketamine needs urgent follow-up.
Calm the victim: Talk to them. Touch them.
Place an NG tube in all patients with abdominal injury if they are far from
the hospital.
Signs of tension pneumothorax: Immediate needle puncture!

Advanced life support for the breathing:

Chest tube drain
Hemo-pnumothorax
Shrapnel or bullets can injure the chest wall and the lung so that blood and air col-
lect inside the chest cavity – between the lungs and the chest wall – and cause the
lung to collapse gradually (compared to the dramatic situation of sudden collapse
caused by a tension pneumothorax, see p. 189). Damage to the large central ves-
sels causes early death; in on-site survivors the main sources of bleeding are the
vessels in the chest wall – the lung wound is not bleeding that much. Note: In most
cases the other uninjured lung ensures oxygenation provided there is good pain
relief and deep and efficient breathing. But children are different.

In small children chest tubes should Hemo-pneumothorax in children: The volume of the chest cavity in chil-
be placed at a very early stage to dren and infants is small compared to adults; the chest cavity rapidly fills up
safeguard the function of the other with blood and air. The mediastinum – the mid-chest wall – is soft in small chil-
lung. dren and will shift over and gradually also compress the uninjured lung.

188

Acidosis = too much acid in the blood.
NSAID drugs (diclofenac etc.) slow
down platelet activation. That’s
dangerous in severe bleeds.
Damage control laparotomy,
see p. 251.
Support the circulation
C: Support the circulation
The Triad of Death
If the cells do not get enough oxygen they start to call on anaerobic metab-
olism: They give off acids as waste products. Acidosis takes out the coag-
ulation system and increases bleeding.
Cold blood bleeds more: At 34º C platelets making up the blood clots get
sleepy, and bleeding increases.
The triad of uncontrolled bleeding, hypothermia and acidosis is what kills
the patients.
Three frequently asked questions
Why stop the bleeding first? Why not start with the IV infusions?
Answer: If you increase the blood flow and the blood pressure before the bleed-
ing is safely stopped, the blood clots will be washed away. The wounds will start
bleeding again. Only when all bleeding sources are controlled should you flush the
IV infusions to get BP up to 90 mm Hg.
That’s OK for limb bleeding, but how can we stop abdominal bleeds
without surgery?
Answer:We cannot. Patients bleeding inside the abdomen need life-saving laparo-
tomy immediately. If that can be done within one hour, do not give any IV volume
therapy in-field. However, if the clinic is hours away and the BP drops below 90
mm Hg you should give IV electrolytes – but don’t flush the infusion, and let it
be warm.
Some doctors say we lose time by stopping the bleeding and giving IV
infusions in the field. They say we should simply rush the patients to
the hospital. Are they right?
Answer:We cannot agree. They think in terms of Western urban rescue systems
and helicopter ambulances. We are talking war and mine fields in the Third World
where you are far away from the hospital. There are few blood banks around; and
if there should be blood packs in the fridge, bank blood does not contain platelets
necessary for hemostasis. Electrolyte infusions do not carry oxygen around, so every
drop of warm circulating blood means true life support.
Blood on the floor is lost for ever
Circulatory support = stop the bleeding as soon as possible!
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7 Trauma life support in war

Stop limb bleeding, no tourniquets

1. Compress the artery: Press your clenched hand firmly on the main artery
– pressing it against the bone beneath (humerus or femur) – at the inside of the
upper arm or in the groin.This reduces the blood flow to the limb. Do not release
the pressure before the wound is packed and a pressure dressing is in place.
2. Lift the injured limb higher than the heart: This also helps reduce the
blood flow.
3. Pack the wound firmly with gauze or cotton cloth: The wound is
already filled with dirt from the explosion so it doesn’t matter if you use
clothes that are not clean. First explore the wound track and identify all deep
pockets. Then use your finger to push the cloth carefully into all spaces inside
the wound. Beware: From outside the wound may look small – yet you often
find a large wound cavity inside. Pack the wound completely with gauze or cloth.

4. Pressure dressing:Apply a tight dressing of elastic bandage (10 or 15 cm rolls)

on the entire limb from the toes/fingers to the groin/armpit. Such a dressing
will stop the bleeding, hold the packing in place and prevent swelling of the limb.

5. Check the effect for one minute: If it doesn’t bleed through the dressing,
you can gradually reduce the pressure on the artery – but keep the limb lifted
at all times. If the wound bleeds through the dressing, press on the main artery
again and place another pressure dressing over the first one. If it still bleeds, the
packing was not properly done: remove it, pack again and apply a proper pres-
sure dressing.

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7 Trauma life support in war

Fractures – temporary stabilization reduces bleeding

First reduction: Limb fractures are roughly reduced by pulling on the limb –
no manipulation at the fracture site; just let one bystander pull steadily by the
hand/foot while you stabilize the fracture. Rough reduction reduces pain and frac-
ture bleeding.

Then stabilization: Fractures – open as well as closed – are common in wartime

mass casualty events and you cannot carry ready-made splints for all. Make it sim-
ple: Under constant manual traction, the injured leg is tied to the uninjured leg
by turns of elastic bandage. The fractured arm is tied to the body and the thigh.
The fractured finger is taped to its neighbor.

How to control internal bleeding

The main problem is to identify internal bleeding. Far too often we see patients
with seemingly dramatic injuries to the limbs being evacuated first while patients
with chest and abdominal bleeds are left at the site.

Bleeding inside?
You cannot find out if an abdominal wound is deep by probing it.
In blast injuries there are not even external wounds.
A tender abdomen is no solid indicator of internal injury.

Measure RR, HR, BP – and use your head

If RR (after ketamine) > 25-30/min,
if HR > 100/min and BP < 100 mm Hg,
Effects of a POMZ mine on an Afghan and there is no bleeding from the limbs
farmer. – internal bleeding is probably going on.

How can we slow down internal bleeding?

Try to reduce bleeding from low abdominal gunshots by manual compression of
the aorta. Then, all we can do is to get the patient to a surgeon as soon as possi-
ble while we concentrate on supporting the body’s own defenses.

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7 Trauma life support in war
The clotting is best at 38ºC and fails
at 34ºC, see more at p. 166.
Studies of post-injury hypothermia
in warm climate, see
www.traumacare.no/publications
Don’t overload the heart at low
temperatures: Maximum 2 liters of
IV/hour.
200
Cold blood bleeds more – keep patients warm
At all times, in all places – even in hot climate – blood loss means temperature loss.
The skin and subcutaneous fat is the insulation of blood vessels and vital organs
– large wounds mean a loss of temperature.
Signs of low temperature
34ºC: The patient still talks but slowly. Gag reflexes are weak. HR is at 50/minute
or lower. It bleeds more from all wounds.
32º C: The patient is still awake but the brain works poorly. He is shivering. RR
is below 10/min and there is little oxygen in his blood. Even without blood loss
BP is at 50 mm Hg, the blood supply to the internal organs is collapsing. The patient
passes very little or no urine. It bleeds even from puncture wounds.
30ºC: The eyes are still open, but the patient cannot speak or cooperate. HR is
below 20/minute, RR around 5/minute.
Prevention of cooling is most important: Due to the laws of physics it takes
4-6 times as long to rewarm compared to the time of cooling the human body. The
lower the temperature, the slower will the rewarming be.
• Remove wet clothes immediately.
• Place blankets under and over the patient.
• Protect against wind (plastic sheets) during transport in open vehicles.
Two ways to warm patients
Warming from outside:
• Buddy warming: Let one helper sit/lie close to the patient holding around
him.
• Place plastic bottles with hot water in the armpits and groins of the patient.
Warming from inside:
• If at all possible, use warm IV infusions. Boil water and put the IV infusion bags
into the hot water; 5 minutes in water for 1 L infusion at 20ºC raises the tem-
perature to 40ºC which is perfect.
• In cold weather: keep the IV bags in your own armpit during the transport.
 Support the circulation

• Let the patient sip warm drinks if he can talk and is without injury to the abdomen.
• Central warming by enema: Explore the rectum with your finger; if there is no
blood on the glove, you can use enemas. Introduce one liter of warm water
(warmer than your skin). Empty after five minutes and repeat.
• Central warming by the bladder (in emergency room): Instill, drain, and rein-
still warm sterile saline repeatedly via the bladder catheter.

Special for burns: Burn patients lose a lot of heat through the large burn wounds:
Cover the burn wounds with several layers of clean cloth. Cover the victim with
blankets. IV infusions, drinks, and food should all be warm.

Stop bleeding – in brief

All types of bleeding: Support breathing! Stop heat loss! Rewarm the
patient!
The aim of rewarming: Body core temperature at 38º C!

External bleeds: Compress artery – lift limb –pack wound – long com-
pressive dressing.
Remove tourniquets!

Pelvic bleeds: Manual compression of the aorta!

Chest bleeds: Chest tube drain + suction/water seal!

All internal bleeds:

No IV infusions if hospital is not far!
Keep BP < 100 mm Hg during long transports!

Intravenous (IV) cannulation

An IV cannula is a thin plastic tube with a sharp, hollow metal needle (a stylet)
inside.You use the stylet to penetrate the skin and the wall of the vein. Then you
pull out the stylet and pass fluids (infusion) or blood (transfusion) through the IV
cannula.

In small children, give 5-10 mg
ketamine/kg as a rectal dose before
IV cannulation.
Simple?
Placing an IV cannula into a well-filled vein in broad daylight may be sim-
ple. Cannulation in patients with severe blood loss, after the arm veins have
collapsed, in darkness and rain, when you are in a hurry at a chaotic and dan-
gerous site of injury may be not simple at all.
It takes correct technique and regular training to be able to place IV can-
nulas when you most need them, especially in children.

201
7 Trauma life support in war
Ketamine pain relief, see p. 186.
Ketamine anesthesia, see p. 804.
In-field disinfection, see p. 77.
In adults and children older than 10
years: Make a cut-down of the saphe-
nous vein. It is always located two fin-
gers in front of the medial bone at the
ankle.
204
IV cannulation – common mistakes
You did not take your time to let the vein swell properly.
You selected a thin vein far down on the arm – look at the elbow region!
You pulled the stylet back too soon; the cannula was not yet inside the vein.
Try once more, then go for the external jugular.
Cannot access the external jugular?
Do venous cut-down
Venous cut-down is to cut through the skin to place a catheter into a vein.You need
a scalpel, two small tissue forceps without teeth, surgical scissors, skin sutures, ster-
ile gloves, IV set and IV infusion. Venous cut-down takes less than 10 minutes if
you have trained well.
Adults need one single dose of IV ketamine pain relief or local infiltration anes-
thesia. Ketamine anesthesia should be used for venous cut-down in children.
In adults: use the IV set as venous catheter
You may of course place a large-bore IV cannula into the vein when you have
found it.
But the tube of the IV set is better: it is sterile and can take high volumes
in a short time.
Place a venous stasis (BP cuff at 50 mm Find the vein. Use a small artery forceps
Hg) mid-thigh. Wash the skin well with to clear the vein of soft tissues.
soapy water, and make a 3-cm cut
through the skin – but not deep: the
vein is immediately under the skin.
7 Trauma life support in war

Make a 4-cm cut through the skin. Use
your fingertip inside the wound to find
the pulse beat of the artery. Note the
anatomy: The saphenous vein com-
ing from the ankle is located inside the
fat, but outside the muscle fascia. The
femoral vein is one level deeper, you
have to split the fascia to identify it.
Place one or two IV catheters (mini-
mum 1.6 mm) inside the vein(s). Hold
the catheters steady while you squeeze
the infusion bag. When enough IV infu-
sion is given to compensate for the
blood loss, the limb veins will fill up.
Then you can do a standard IV cannu-
lation and pull out the femoral vein
catheters.

The last option: rectal infusion

Electrolytes and drugs are absorbed by the rectal mucosa into the blood
stream.

Use double IV doses for placement of vital drugs, and leave the syringe in
the anus for a few minutes to prevent leaking.

For infusion of electrolytes: Place a bladder catheter into the rectum,

inflate the balloon and pull the catheter back until the balloon rests inside
the anal ring. Connect the IV line to the catheter and let the infusion drip
slowly, approximately one liter per hour.

Volume therapy and nutrition

After major blood loss and burns the blood circulation will collapse unless we
Emergency blood transfusion, replace the volume that is lost. At the hospital we use blood transfusions; in-field
see p. 417. we use IV electrolyte solutions or we give fluids by mouth.

Special rules for burns

Patients with burns need aggressive volume treatment.
If there is associated burn injury: Follow rules for burns, see p. 208.

206

Land mine victims: Entry wounds to
the abdomen and the brain.
There is no “minor head injury”
until the level of consciousness is
repeatedly examined. Life-saving
surgery in head trauma, see p. 239.
Identify wounds and injuries
Identify wounds and injuries
Do not damage!
Exclude spinal cord damage before you manipulate the patient.
So often the tiny entry wounds are missed!
Undress completely: Use large scissors to split the clothes.
Wash off blood and dirt.
Always examine the back and between the thighs.
Also examine the unconscious patient!
“Unconsciousness” is not a useful diagnosis, we should know the reason.
Additionally there may be other injuries as well.
Take an exact history of the weapon
• Low-velocity penetrating injury: Most likely the internal damage is moderate.
The risk of multi-organ injury is small.
• High-velocity penetrating injury: Most likely the internal damage is extensive.
Often there are multiple injuries. Missing associated injuries is a common mistake.
• Blast injury: The clinical signs of chest and abdominal organ injury develop
slowly. Re-examine every 6 hours until 48 hours after the injury.
• Mine injury: Was this a fragmentation mine? If so, examine between the legs so
as not to miss a penetrating pelvic or abdominal injury.
• Gunshot wound:What kind of ammunition could have been used? What was the
range of the shot?
Head and neck injury
Any head injury also has a neck injury until your examination proves otherwise.
Manipulation of a spinal injury may be dangerous and even fatal. Any patient who
presents a head injury, neck pain or back pain:
• Is he awake? Can he talk?
• Ask if he has full sensation in arms and legs.
• Ask if he felt or feels radiating sensations in his arms or legs.
• Test that he has full motor and sensory function in arms and legs.
Any neurological signs or neck pain: Stabilize the neck with a large roll of clothes.
Neck fracture or dislocation
• Press each cervical vertebra, first gently, then forcefully with your finger. Ask about
local pain or sensations into his arms at each vertebra examined.
• Ask him to rotate his head and flex his neck carefully: Ask about neck pain. Look
for restricted movements in any direction.
Examine the skull
Wash all scalp wounds and retract the wound edges for inspection: Can you see
a fracture? Explore the skull gently with your finger or forceps: Can you feel a frac-
ture line? Do not manipulate the fragments of a skull fracture or remove any pen-
etrating foreign body during the examination; that is a case for surgery.
211
 Identify wounds and injuries

19 19 The sites for pulse volume testing: These are also the pressure points
where you control distal bleeding.
• The carotid artery
• The brachial artery
• The radial artery
• The femoral artery
• The popliteal artery
• The posterior tibial artery
• The dorsal foot artery.

Test – and compare both limbs

• The capillary circulation is slow – fingerprint test: Press your finger against his
skin for a few seconds, then let go. Study the time for blood to refill the “white”
fingerprint (an early sign).
• Test the function of the fellow nerve: On most levels, the main arteries are accom-
panied by one main vein and one main nerve. Damage to the nerve indicates risk
of artery injury (an early sign). Nerve function test, the upper limb, see p. 628
and p. 643. Nerve function test, the lower limb, see p. 659.

Positioning of the patient

Most avoidable complications in primary trauma care occur either due to triage
failure or during transport to the hospital.
The most common transport failure is the incorrect positioning of the patient,
and the most common transport complication is an airway block – by the tongue
or by aspiration to the lungs.

Avoidable death: Airway block due to careless transport!

It is a sad fact that most injured are lying flat on the back during the trans-
port.
Only one type of patients should be transported flat on back: the spinal
injuries.

Studies of first helpers as life-savers, Mass education of lay persons (villagers, school children, soldiers) reduces
see www.traumacare.no/publications trauma mortality:
• Run two-days training courses in high-risk areas.
• Make short instruction videos for TV distribution, see www.traumacare.no

217
 Positioning of the patient

Who is responsible?
The team leader on-site should give clear orders for positioning before trans-
port starts.

Transport to hospital
Test yourself: How would you arrange the transport in this case?
A 10-year-old girl has been hit by a fragmentation mine. She has two injuries: a
fragment wound to the chest and a below-knee amputation. Assisted by village first
helpers you have stopped the limb bleeding by compression of the femoral artery,
gauze packing and a long compressive dressing. One infusion of warm IV fluid is
running and her BP is now up to 90 mm Hg, but the HR is still high, 130/min. She
is breathing rapidly, RR > 30/minute, and probably has a hemothorax but you have
not yet been trained to place a chest tube drain. The villagers have arranged for
a taxi car and you have got your backpack medical kit.The hospital is six hours away.

Check before you go

Airway – is everything done?
Anything to clean out of the mouth or the nose?
Awake? She is awake now and can sit but may get weak and vomit if she loses
more blood. If so, place her in recovery position.
The fragment hit her low in the chest so there may be abdominal injuries as well.
Maybe you could place a stomach tube before you start going?

Breathing – is everything done?

Find the best position: She breathes better and there is less risk of vomiting if she
half-sits. Is there a close relative around who can sit with her?
The breathing rate is too high, 30/minute, probably she is in pain: give anoth-
er IV dose of 5-10 mg ketamine. She will need frequent small ketamine doses all
the way to hospital – do you have sufficient drugs in the backpack?
Is she bleeding inside? Place your ear to the chest: the breathing sounds are def-
initely weaker at the side with the inlet wound. Probably she is still bleeding.You
are not trained to place a chest tube (it is about time to learn it) – but you can help
the body cope by keeping her warm: get some blankets and also bottles of warm
water to place under her clothes.

Circulation – is everything done?

The nose is still not warm and the HR high – but on its way down. She recieved
1,500 ml Ringer already; how much more would you give? BP at 90 mm Hg should
be sufficient to keep up the central circulation – and she just voided. If you push
in more infusion you dilute the blood and she may bleed even more. Let the drip
run slowly and monitor HR closely during the transport.

219
 Transport to hospital

Transport to hospital – in brief

Many avoidable complications – some of them fatal – occur during trans-
port. Common transport failures are incorrect positioning, poor pain relief
and no warming.

“Transport” is not transport but a long intensive care stage.

Drugs for trauma life support

Good life support is not a question of medicines but warm hands and a cool
Ketamine pain relief, see p. 186. head. The only medicines you must have are ketamine and electrolyte infu-
sions.

Antibiotics are not that important

You can prevent wound infection in three ways: Most important – restore the
breathing and blood circulation as soon as possible after the injury. Less important
– do not place bacteria in the wound yourself. Least important are the antibiotics.

Get white blood cells to the site of injury: Millions of bacteria are inside
the wound immediately after the injury. Six hours later, the number of bacteria has
multiplied many times. Then there is a local infection in the wound and you have
to do your best so that it does not spread.The blood contains white blood cells that
can identify and eat bacteria – on the single condition that blood circulation is
restored so that blood really gets at the site of injury.

Don’t feed the bacteria:The main food for bacteria is dead tissue and collec-
tions of blood (hematoma). More and more cells around the wound will die
unless oxygen gets to the wound area.These dying cells are extra food for the bac-
teria. This is why you have to get enough oxygen-rich blood to the wound as soon
as possible after injury.
• Stop the bleeding and get the blood pressure up to 90 mm Hg as soon as possi-
ble!
• Remove tourniquets – they are tissue killers and encourage infections.

Surgery within 8 hours: Having eaten the bacteria and dead cells, the white
blood cells carry them to the wound track.This forms a discharge (pus) and is the
body’s natural way of cleaning the wound.
• When the bleeding is stopped, leave all mine and war wounds open using a fluffy
gauze drain inside to allow the discharge to come out.
• All major war wounds need debridement, the surgeon has to cut away dead and
damaged tissue. Early surgery is far more important than early antibiotics.

221
7 Trauma life support in war

In-field medical documentation

Fill in the chart there and then!
The Field Injury Chart is filled in by
medic as he examines, treats and trans-
ports the victim to the hospital.
The weapon history: The hospital
needs to know the type of mine and
how far away the victim was from the
explosion.
Delay after the injury: The risk of
wound infection increases rapidly if the
patient is not operated on 8-10 hours
after the injury. The hospital staff should
know the how much time has passed
since the injury.
Did a village first helper help the
patient?You need this information to
determine the effect of the training giv-
en to village first helpers.
Tourniquet? If the victim had the
tourniquet for several hours, fascioto-
my should be done – either by the med-
ic or at the hospital.
List all injuries: Mark all wounds on
the drawing.
Calculate the Physiological Sever-
ity Score before treatment starts!
Measure and record three things: (1)
The breathing rate. (2) The systolic
blood pressure. (3) The mental state of
the victim: Is he confused or drowsy? Is
he unconscious, but responds when you
talk to him? Is he unconscious and
responds only when you pinch his skin?
Or is there no response at all? 4 points
is the best score, 0 points the worst
score. Calculate the Severity Score by
summing up the points for RR, BP, and
the mental state. A total of 12 points
means that the victim is in a good con-
Hospital data gathering form, dition. Scoring 10 points or less means
see p. 117. that the victim is severely injured.

228
7 Trauma life support in war
Triggers of trauma death, see p. 162.
Scientific studies of trauma first
helpers, see www.traumacare.no
230
Summary:
Simple things most important
There are two reasons why the key for war victim survival is the first helper rather
than the surgeon:
The physiological response to trauma:The patient starts dying at the time
of injury. The sooner you control the devastating triggers released by the injury,
the better effect of life support. Immediate basic life support by trained lay per-
sons has a significant impact on trauma survival.
The Gaza experience: One essential feature of 4th Generation warfare is de-
humanization. The implication of Rumsfeld’s Shock and Awe strategy is that the
target population should be scared to death by systematic inhuman conduct. The
strategy was well applied in Gaza in December 2008: local clinics, ambulances and
rescue crews were deliberately targeted by the enemy.When evacuation to the sur-
gical centers is blocked or delayed, trauma first helpers play an even more impor-
tant role for survival.
Who is doing what?
First helpers Paramedics
Airway Airway
Identify victims with airway problem. Endotracheal intubation.
Recovery position. Head tilt Airway cutdown.
– chin lift.
Tongue extraction.
Breathing Breathing
Identify victims with breathing Chest tube drainage.
problem (adults and children). Ketamine pain relief.
Half-sitting position.
Rescue breathing and CPR for
adults and children.
Circulation Circulation
Stop limb bleeding: Elevation Stop chest bleeding: Chest tube
– artery compression – subfascial drainage.
packing – compressive dressing. Stop abdominal bleeding: Damage
Manual compression of Control laparotomy.
the abdominal aorta. Stop pelvic bleeding: Extra-
Hypothermia prevention. peritoneal pelvic packing.
Oral volume therapy for burn and Core re-warming by urinary
non-burn victims. bladder or rectum.
External jugular cannulation.
Venous cutdown.
Hypotensive volume therapy: warm
IV electrolytes.
IV volume therapy in burn victims.