Chapter 29: Trauma and Warfare

INTRODUCTION

This chapter discusses trauma resuscitation, burns, organ-specific trauma, chemical warfare, and biological warfare.

RESUSCITATION

Trauma is the leading cause of death for those younger than 40 years of age, with the majority of death secondary to bleeding within the first few hours of injury.^1-3 Damage-control resuscitation has become the standard of care for battlefield resuscitation and now is becoming more common in civilian trauma.⁴ The goal is rapid hemorrhagic control with administration of balanced whole products in a plasma, platelet, and red blood cell at 1:1:1 ratio that mimic fresh whole blood, treat coagulopathy, and minimize colloid administration in patients requiring massive transfusion (≥ 10 units packed red blood cells [pRBC] in 24 hours).⁴

The European Guidelines on management of major bleeding and coagulopathy following trauma stratified their recommendation as such: Grade 1A for strong recommendation, high quality of evidence due to benefits clearly outweigh risks and quality of evidence is from randomized controlled trials (RCTs) without important limitations or from overwhelming evidence from observational studies; Grade 1B for strong recommendation moderate quality of evidence due to benefits clearly outweigh risks and quality of evidence is from randomized controlled trials with limitations; Grade 1C strong recommendation, low quality or very low quality of evidence due to benefits clearly outweigh risks and support is from observational studies; Grade 2A weak recommendation, high quality of evidence due to benefits balance risks and evidence is from randomized control trials without important limitations or from overwhelming evidence from observational studies; Grade 2B weak recommendation and moderate quality of evidence due to benefits balance risks with randomized control trials with important limitations; and Grade 2C weak recommendation and low quality of evidence due to uncertainty in estimates of benefits and risks and evidence is from observational studies or case series.⁵ Time between injury and control of bleeding needs to be minimized, since most fatalities occur within 24 hours of injury (Grade 1A).⁵ Management bundles have been created to expedite care (Table 29-1). Tourniquets need to be applied to presurgical open extremity injuries and can be left in place for up to 6 hours (Grade 1B).⁵ Major bleeding may not always be obvious and clinical presentation may correlate to the degree of blood loss (Table 29-2). Mechanisms of injury that suggest major bleeding include falling from a height of 20 feet or more, high-energy deceleration impact, and high-velocity gunshot wounds.⁵ Radiographic studies of the head, chest, abdominal cavity, and pelvis are often needed, and hemodynamic instability would warrant emergent surgery.⁵