Page 166 - JSOM Spring 2020

Challenges moving ahead: WWII mortality from abdominal wounding dropped to
1. A lot of overlapping guidance with ARC and other func- 18–36%. Dr Herbert T. Wikle wrote of his experience in
tional areas of TCCC. WWII and his recommendation for prehospital care was
2. Differentiating safety and efficiency of seven different NOT to replace the intestines into the abdomen and to
whole blood options. cover them with wet bandage.
3. Outcomes data CS-LTOWB and stored walking blood The Korean conflict saw another drop in abdominal wound-
bank products. ing mortality to 12%. This trend continued in the Vietnam
Opportunities ahead of us: conflict with abdominal wound mortality dropping as low
as 4%. Some of the attributed success are due to antibiot-
1. Guidelines ultimately influence logistics ics, rapid Medevac, and wide availability of blood.
2. Delineate between TCCC fluid resuscitation and ARC
concepts A 2016 article featured in Journal of Emergency Trauma
3. Initiate resuscitation earlier/further forward Shock by Olorundare et al: Abdominal injuries in commu-
4. Improve patient outcomes nal crises: The Jos experience, outlined 897 combat-related
injuries with 109 being abdominal injuries. The one thing
There was a lot of discussion, statements and questions on that stands out is the interval between injury and arrival at
this topic. definitive care – between 2 hours and 5 days, not one met
1. Statement by Shawn Anderson, “the PJs are pulling the Golden Hour criteria. The fatality rate of these 109 was
Hextend but crystalloids still in use. What blood prod- 10.8%, which is significantly lower than 13% in Afghan-
ucts can we use in replacement of crystalloids, etc. . . .?” istan and 29.8% in Bosnia-Herzegovina; 31% of the 109
2. Dr John Holcomb: Normal saline stays but are crystal- experienced eviscerated bowels.
loids out?
3. Dr Zaf Qassim: Burn resuscitation with blood is bad.
Calcium is usually administered too late.
4. Col Stacy Shackleford: JTS CPG updated to add calcium
after first unit of whole blood.
5. Shawn: If we leave Hextend as an option, units will de-
fault to it.
6. Ed Whitt: If a medic has it, he will use it. Take it out but
then what do they have?
1033: NORTH TOWER collapse (moment of silence)

6. Abdominal Evisceration
LTC Jamie Riesberg, 10th SFG(A) physician, started his re-
marks with the standard disclaimers and disclosures with
no financial compensation or interests.
Dr Riesberg started out with the question – SO WHAT? A few “Civilian Experience” studies were looked at as well.
Why even look at this subject and what is the overall com- One by W.S. Stebbings was out of London that reviewed
bat trauma burden of abdominal eviscerations? LTC Ries- 201 patients with stab wounds. They found that eviscer-
berg proposed the following questions: ation of small bowel or omentum was always associated
1. What are the preventable causes of death in abdominal with significant intraperitoneal injury. A Cook County
injury and abdominal evisceration specifically? study by K. Nagy from 1991 to 1999, reviewed 81 patients
2. What prehospital interventions reduce the mortality of with evisceration after abdominal stab wound; 63 had in-
abdominal eviscerations? tra-abdominal injury that required repair.
3. Does wound management in the pre-hospital setting fa- Prehospital, what should you do and how? The care of
vorably impact patient mortality? eviscerated organs requires attention to detail and the or-
i. If so, what is the preferred method for managing ab- gans should be handled as little as possible. Cover the or-
dominal eviscerations? gans in sterile gauze or a sheet and wet them down with
4. Does a requirement exist for a novel wound manage- sterile saline. It is vital that they remain covered and moist
ment device to best manage abdominal evisceration? during transport. However, the Wilderness Medical Soci-
In a retrospective study by Rignault conducted of abdom- ety advises to reduce back into the abdominal cavity if the
inal trauma in war nearly 20% of all battlefield wounds bowel is not perforated.
were abdominal and the significance of this is nearly 50% What are combat medics being taught? To cover the con-
of those died of hemorrhage. Another significant study tents with sterile dressing and moisten with saline and cov-
conducted by Dr George G. Davis in 1943 showed out ered with a large dry dressing to keep the casualty warm.
of 2,525 cases under his care in WWI, only one survived.
Further looking into WWI, the mortality rates were be- Dr Riesberg looked at what are the services teaching for the
tween 55-75% for abdominal (colorectal) injuries. How- prehospital treatment “If the wound margins are too tight,
ever, anther surgeon, P. Santy, showed that if a casualty should you reduce or is there hemostatic benefit?”
with an abdominal injury arrived under an hour to sur- 1. Navy: stop hemorrhage and use water. Do NOT attempt
gery the mortality rate was under 10%. The Golden Hour to push the intestine back in or to manipulate it in any
works.
way.

160 | JSOM Volume 20, Edition 1 / Spring 2020