Emergency War Surgery (2004)

Environmental Injuries

arising in the morning, attributed to increased

hypoxemia caused by altitude-induced sleep apnea.

♦ Anorexia.

♦ Nausea.

♦ Fatigue (weakness).

♦ General malaise.

♦ Decreased coordination.

♦ Dizziness or light-headedness.

♦ Oliguria.

♦ Emesis (vomiting).

♦ Lassitude.

♦ Insomnia: Sleep disturbances with periodic breathing

with recurrent apneic periods during sleep are usually

present, but are not necessarily a component of AMS.

Diagnosis.

♦ Occurrence of a headache and at least one other sign/

symptom in an individual who ascended from low

(1,524 m or < 5,000 ft) to high altitude, or high altitude

to higher altitude in the previous 24-48 hours.

♦ Differential diagnosis includes viral gastroenteritis,

hangover, exhaustion, dehydration, carbon monoxide

poisoning, and HACE.

♦ Presence of neurologic symptoms such as incoord-

ination, ataxia, and excessive lethargy or cognitive

dysfunction is indicative of progression to HACE, which

requires immediate therapeutic intervention.

Prophylaxis for AMS.

♦ Gradual acclimation.

◊ Staged ascent: Soldiers ascend to intermediate

altitudes and remain there for 3 or more days before

ascending further.

◊ Graded ascent: Limits daily altitude gain to allow

partial acclimation. Sleep altitude is most important.

Have soldiers spend 2 nights at 2,743 m (9,000 ft) and

limit the sleeping altitude to no more than 305 m

(1,000 ft) per day above previous night’s sleep

altitude.

◊ Combination of both staged and graded ascent is the

safest and most effective prevention method.

29.25

Emergency War Surgery

♦ Diet: High carbohydrate diet (< 70% of total energy

intake as carbohydrates) (stimulation of ventilation

through increased carbon dioxide produced from

metabolism of carbohydrates).

♦ Acetazolamide, 250 mg qid or 500 mg bid po, starting

48 hours before ascent, continuing for 48 hours after

ascent. Side effects include peripheral paresthesias,

fatigue, increased urination (polyuria), and altered taste

imparted to carbonated beverages. It prevents AMS in

50%-75% of soldiers and reduces symptoms in most

others. Short-term use when changing altitude

significantly (400 m). Contraindicated in sulfa allergy.

♦ Dexamethasone, 4 mg qid po is the prophylaxis of choice

in sulfa-allergic individuals. Dexamethasone does not

aid acclimatization and effects are gone when it is

stopped. Dexamethasone +/- acetazolamide is also

prophylaxis of choice for missions of a rapid, high (over

4,000 m [13,000 ft]), short-duration profile (raids,

rescues).

♦ Cyanosis: Oxygen 2-6 L/min. Do not delay descent.

Treatment.

♦ AMS alone does NOT mandate descent.

♦ Remain at the same elevation; do not ascend until

symptoms abate.

♦ Acetazolamide, 125 mg qid to 500 mg, tid, po—do not

use in patients with sulfa allergies. (If already receiving

a preventive dose of acetazolamide (1,000 mg/d) and

still symptomatic, 500 mg can be added with caution.

♦ Dexamethasone in doses of 2-4 mg q6h (has the same

potentially serious side effects as when used as a

prophylaxis). Symptoms may recur when medication

stopped.

♦ Oxygen by nasal cannula 2-6 L/min (severe headache).

♦ Do NOT advance sleeping altitude.

♦ Symptomatic treatment with ASA, acetaminophen,

prochlorperazine for nausea and vomiting 5-10 mg tid-

qid, po or IM, or 25 mg bid prn also stimulates

respiration; ibuprofen for headache.

♦ Minimize utilization of sleeping agents at altitude; they

29.26

Environmental Injuries

can worsen illness. Acetazolamide for sleep disorders,

250 mg qid or tid po. Temazepam for insomnia 30 mg

qhs po; triazolam for insomnia 0.125-0.25 mg qhs po.

Short-term use only. Possible short-term memory loss.

High-altitude pharyngitis and bronchitis.

ο Common condition occurring after 2-3 weeks at altitude.

ο Common at altitudes over 5,486 m (18,000 ft).

ο Sore throat, chronic cough, and severe cough spasms

(severe enough to cause rib fractures).

ο Environmental, from breathing cold dry air.

ο Altitude-induced tachypnea aggravates the problem.

ο Cold-induced vasomotor rhinitis, especially at night,

stimulates mouth breathing and also aggravates problem.

ο Usually not caused by infection, although infection can

occur.

ο Patient will not have dyspnea at rest.

ο Symptomatic treatment with lozenges, mild cough

suppressant, and decongestant nasal sprays. Personnel can

use a mask or a porous, breathable silk balaclava as a

mouth covering to reduce respiratory heat and moisture

loss.

ο Maintain hydration.

High-altitude peripheral edema.

ο Altitude-related edema of hands and face.

ο Hypoxia-induced retention of sodium and water.

ο Not considered related to AMS/HACE edema-spectrum

or HAPE.

ο Decreased urine output and weight gain of 2.7-5.4 kg

(6-12 lb) over several days; most evident upon awakening.

ο Diagnosis based on association of characteristic peripheral

edema with ascent to high altitude; recurs consistently with

repeat ascents; more common in females.

ο Differential diagnosis includes cardiogenic edema, allergic

reactions, and edema of the upper extremities caused by

pack straps or binding by tight clothes.

ο Prophylaxis includes salt restriction. The acetazolamide

regimen used to prevent AMS is often successful in

preventing peripheral edema.

29.27

Emergency War Surgery

ο Treatment with diuretics (one 20-40 mg dose of furosemide,

or 250 mg of acetazolamide every 8 h for 3 doses) and salt

restriction.

High-altitude retinal hemorrhage (HARH).

ο Bleeding from retinal vessels during altitude exposure.

One of the manifestations of hypoxia-induced retinopathy.

ο Caused by BP “surges” within the distended vessels.

ο Usually asymptomatic; normally does not adversely affect

military operations; however, can affect an individual

soldier’s vision.

ο Hemorrhages are self-limiting and resolve in 1-2 weeks

after descent.

Thromboembolic events.

Increased possibility of thromboembolic event with ascent

to high altitude: thrombophlebitis, deep venous thrombosis,

pulmonary embolus, transient ischemic attacks (TIAs), and

stroke.

Probably result from hypoxia-induced polycythemia and

clotting abnormalities but also may result from environ-

mental and mission factors such as dehydration, cold, and

venous stasis caused by prolonged periods of inactivity

during inclement weather or by constriction of tight-fitting

clothing and equipment.

Unusual below 4,267 m (14,000 ft). At very high and

extreme altitudes (> 4,200 m [13,700 ft]) these events are

not uncommon, and thrombophlebitis appears to be

relatively common.

Clinical manifestations are similar to manifestations of

thromboembolic events at low altitude, except for their

occurrence in young and otherwise healthy personnel.

Prevention relies on reducing the risk factors by main-

taining adequate hydration and warmth and by avoiding

conditions that might cause venous stasis.

Evacuation to lower altitude is required. Treatment follows

standard treatment guidelines, including appropriate anticoa-

gulation. In the field setting, fractionated heparin (one dose

of 250 IU/d) can be used prior to and during evacuation.

Subacute mountain sickness.

29.28

Environmental Injuries

ο Prolonged deployment (weeks to months) to elevations

above 3,658 m (12,000 ft).

ο Common manifestations include sleep disturbances,

anorexia, weight loss, fatigue, daytime somnolence, and

subnormal mentation.

ο Caused by failure to acclimatize adequately.

ο Some relief of symptoms obtained from low-flow oxygen

and from acetazolamide.

ο Evacuate to lower altitude as soon as practical.

ο Some degree of immune suppression and poor wound

healing occurs in personnel at very high and extreme

altitudes. Injuries resulting from burns, ballistics, and

physical trauma should be considered more clinically

significant at high altitude.

High-altitude pulmonary edema.

Potentially fatal, noncardiogenic pulmonary edema.

Occurs in < 10% of personnel ascending above 3,700 m

(12,000 ft).

Onset 2-4 days after rapid ascent to altitudes greater than

2,438 m (8,000 ft).

Repeated ascents and descents above 3,700 m (12,000 ft)

increase susceptibility.

Risk factors.

♦ Moderate to severe exertion.

♦ Cold exposure.

♦ Anxiety.

♦ Young age.

♦ Male sex.

♦ Obesity (possibly).

Early symptoms (pulmonary edema).

♦ Nonproductive cough.

♦ Rales (few).

♦ Dyspnea on exertion.

♦ Fatigue.

♦ Weakness with decreased tolerance for physical activity

and increased time for recovery after physical exertion.

♦ Resting tachycardia and tachypnea greater than induced

by altitude alone.

29.29

Emergency War Surgery

♦ Once symptoms appear, HAPE can progress very

rapidly (< 12 hours) to coma and death.

♦ Nail beds and lips may be more cyanotic than other unit

members.

Progressing pulmonary edema.

♦ Productive cough of frothy and sometimes pink or

bloodstained sputum.

♦ Rales more numerous and widespread.

♦ Wheezing may develop.

♦ Lung sounds become audible even without stethoscope,

especially when individual is supine.

♦ Orthopnea may occur (< 20%).

♦ Progressive hypoxemia causes dyspnea and cyanosis.

♦ Arterial blood gas (if available) documents hypoxemia,

hypocapnia, and slight increase in pH.

♦ Mental status deteriorates with progressive confusion

and sometimes vivid hallucinations.

♦ Obtundation, coma, and death occur without treatment.

♦ Subfebrile temperature < 38°C (100.5°F) and a mild

increase in white blood cell count may be present.

♦ Dyspnea at rest.

♦ Marked hypoxia by oximetry.

♦ Dyspnea at rest and cough should be considered to

be the onset of HAPE.

DELAY IN TREATMENT OF PROGRESSIVE PULMONARY EDEMA AT

ALTITUDE USUALLY RESULTS IN DEATH.

ο Treatment.

♦ Depends on severity.

♦ Immediate descent is mandatory! Descent of even a few

hundred meters (300-1,000 m) can be helpful or even

lifesaving in severe cases.

♦ Mortality can approach 50% if descent cannot be

accomplished rapidly.

♦ Oxygen by cannula 2-6 L/min (mild), or by mask 4-6

L/min (moderate and severe). DO NOT DELAY

DESCENT!

29.30

Environmental Injuries

♦ Portable fabric hyperbaric chamber may be lifesaving—

Gamow bag/Certec SA.

♦ Nifedipine, 10 mg tid sublingually, or 20 mg po. A

second 10-mg, sublingual dose can be administered in

15-20 minutes if no improvement in symptoms is

apparent, followed by 30 mg qid.

Nifedipine should not be used in lieu of descent,

supplemental oxygen, or treatment in a hyperbaric bag.

It may be used in conjunction with other therapies.

♦ Immediate descent to lower elevation; if symptoms

resolve, wait at least 72 hours before attempted return

to previous elevation.

Neither furosemide nor morphine sulfate should be used

in the treatment of HAPE unless other more effective

treatment options are not available.

♦ Treatment after descent, at an MTF, is directed toward

ensuring adequate oxygenation and reducing pulmonary

artery pressure; includes bed rest, supplemental oxygen,

and nifedipine.

♦ Invasive diagnostic procedures such as bronchoscopy

or pulmonary artery catheterization are NOT indicated

unless clinical course deteriorates and the diagnosis is

in doubt. Endotracheal intubation is seldom necessary.

ο HAPE Prophylaxis.

♦ Nifedipine, 20 mg tid, po, 24 hours before ascent,

continuing 72 hours after ascent.

High-altitude cerebral edema.

ο Onset following ascent is highly variable and occurs later

than either AMS or HAPE. Mean duration of onset 5 days

with a range of 1-13 days.

ο Incidence lower than AMS or HAPE (< 1% of individuals

making rapid ascent).

ο Potentially fatal, uncommon (< 2% above 3,700 m). Can

occur as low as 2,430 m (8,000 ft) but vast majority of cases

29.31

Emergency War Surgery

above 3,600 m (12,000 ft). Untreated HACE can progress

to death over 1-3 days or become more fulminant with

death occurring in < 12 hours.

Exacerbation of unresolved, severe AMS.

Most often occurs in people who have AMS symptoms

and continue to ascend.

Signs and symptoms.

♦ Most signs and symptoms are a manifestation of

progressive cerebral edema.

♦ Early signs resemble AMS (these symptoms are not

invariably present).

♦ Severe headache

♦ Nausea

♦ Vomiting.

♦ Extreme lassitude.

Progressing signs.

♦ Mental status changes: Confusion, disorientation,

drowsiness, and impaired mentation.

♦ Truncal ataxia (swaying of upper body, especially when

walking). As the edema progresses, soldier may also

exhibit an ataxic gait in addition to the truncal ataxia.

♦ Soldier appears withdrawn, and behavior is mistakenly

attributed to fatigue or anxiety.

♦ Cyanosis and general pallor are common.

♦ Symptoms of HAPE.

Untreated HACE.

♦ Variety of focal and generalized neurologic abnormalities

may develop: visual changes, anesthesias, paresthesias,

clonus, pathological reflexes, hyperreflexia, bladder and

bowel dysfunction, hallucinations, and seizures.

♦ Papilledema may be present in up to 50% of the soldiers,

but is NOT universal.

Coma.

Ataxia at altitude is HACE.

Prophylaxis.

29.32

Environmental Injuries

No definitive evidence; however, due to similarity with

AMS, prophylactic measures for HACE include use of

staged or graded ascent, high carbohydrate diet, and use

of acetazolamide.

Treatment.

♦ Immediate descent is mandatory. Definitive treatment

of HACE is immediate descent. In general, the greater

the descent the better the outcome. Descent of more than

300 m (1,000 ft) may be required for clinical improvement,

and descents to altitudes of less than 2,500 m (8,000 ft)

is optimal.

♦ If descent is delayed, treatment with a portable cloth

hyperbaric chamber may be lifesaving. May require at

least 6 hours of pressurization in chamber.

♦ Oxygen by mask or cannula 2-6 L/m; should not be

used as a substitute for descent.

♦ Dexamethasone, 4-8 mg initially and then 4 mg qid,

po, IV, or IM. DO NOT DELAY DESCENT! Few side

effects if used only 3-4 days.

♦ Loop diuretics and osmotic diuretic agents, such as

mannitol, urea, and glycerol, have been suggested, but

there is little experience with them in this role. Careful

attention is required before diuretics are used.

Individual may have altitude-induced decrease in

intravascular volume concomitant with cerebral edema.

♦ Hospital management consists of supplemental oxygen

(if needed to maintain arterial oxygen levels), supportive

care, and possibly diuretics. Comatose patients may

require intubation and bladder catheterization.

HACE and HAPE often coexist. Individuals with HACE

will often have HAPE; however, most individuals with

HAPE do not have concomitant HACE.

29.33

Chapter 30

Radiological Injuries

The reader is strongly advised to supplement material

in this chapter with the following two references:

1. Medical Management of Radiological Casualties

Handbook, 2003, Armed Forces Radiobiology Research

Institute, Bethesda, MD.

2. Medical Management of the Acute Radiation Syndrome:

Recommendations of the Strategic National Stockpile.

Radiation Working Group, Strategic National

Stockpile (Annals of Internal Medicine, 15 June 2004).

Introduction

Radiological casualties on the battlefield may occur with

improvised or conventional nuclear devices or radiological

dispersal devices (“dirty bombs”) (Table 30-1).

Conventional nuclear weapons.

ο The relative casualty-causing potential depends primarily

on four factors:

♦ Yield of the weapon.

♦ Height of burst.

♦ Environmental conditions in which the detonation

occurs.

♦ Distribution and shielding of troops in the target area.

ο A nuclear detonation generally causes injuries with the

following distribution:

♦ Blast injury: 50%.

♦ Thermal injury: 35%.

♦ Ionizing radiation injury.

◊ Initial: 5%.

◊ Residual: 10%.

30.1

Emergency War Surgery

A radiological dispersal device (RDD) is any device, including

any weapon or equipment, other than a nuclear explosive

device, specifically designed to spread radiation.

ο RDDs contaminate conventional casualties with radionuc-

lides, complicating medical evacuation.

ο RDDs are ideal weapons for terrorism and are used to

intimidate and deny access to an area by spreading

radioactive material.

Table 30-1. Radiological casualties.

Weapon Effect

Weapon Yield (Kiloton)/Distance (Meters)

1 kt

10 kt

100 kt

1,000 kt

Blast (50% casualties)

140 m

360 m

860 m

3,100 m

Thermal radiation

370 m

1,100 m

3,190 m

8,020 m

(50% deep burns)

Ionizing radiation

600 m

950 m

1,400 m

2,900 m

(50% immediate transient

ineffectiveness)

Ionizing radiation

800 m

1,100 m

1,600 m

3,200 m

(50% lethality)

Triage

Different from conventionally injured patients, because

survivable radiation injury is not manifested until days to

weeks after exposure.

ο Based primarily on conventional injuries, then modified

by radiation injury level.

ο Make a preliminary diagnosis of radiation injury only for

those with exposure symptoms, such as nausea, vomiting,

diarrhea, fever, ataxia, seizures, prostration, hypotension.

ο Radiation patient triage classifications.

♦ Delayed: casualties with only radiation injury, without

gross neurological symptoms (ataxia, seizures, impaired

cognition). For trauma combined with radiation injury,

all surgical procedures must be completed within 36-

48 hours of radiation exposure, or delayed until at least

2 months after the injury.

30.2

Radiological Injuries

♦ Immediate: those requiring immediate lifesaving

intervention. Pure radiation injury is not acutely life-

threatening unless the irradiation is massive. If a

massive dose has been received, the patient is classified

as Expectant.

♦ Minimal: buddy care is particularly useful here.

Casualties with radiological injury should have all

wounds and lacerations meticulously cleaned and then

closed.

♦ Expectant: receive appropriate supportive treatment

compatible with resources; large doses of analgesics as

needed.

Table 30-2 provides medical aspects of radiation injuries.

Table 30-2. Medical aspects of radiation injuries.

Signs and Symptoms

Unlikely

Probable

+/-

Severe

+++

+/+++ +/+++

-/++

+/++

-/++

The lethal dose of radiation, which will kill 50% of a population

within 60 days of exposure, is called LD_50/60. The LD_50/60is

approximately 3-4 Gray (Gy) for a population with radiation

injury alone and with no significant medical care. The LD_50/60

for a population with radiation injury alone and the best

available medical care (including antiemetics, antivirals,

antibiotics, hematopoietic cytokines, and transfusion) may be 6

Gy or more. Combined injuries with radiation and trauma and/

or burns will markedly lower the LD₅₀.

30.3

Emergency War Surgery

Significant medical care may be required at 3-5 weeks for 10%-

50% of personnel. Anticipated problems should include

infection, bleeding, fever, vomiting, and diarrhea. Wounding

or burns will markedly increase morbidity and mortality.

Treatment.

ο Fluid and electrolytes for GI losses.

ο Cytokines for immunocompromised patients (follow

granulocyte counts).

ο Restricted duty. No further radiation exposure, elective

surgery, or wounding. May require delayed evacuation

from theater during nuclear war IAW command guidance.

ο If there are more than 1.7 • 10⁹ lymphocytes per liter, 48

hours after exposure, it is unlikely that an individual has

received a fatal dose.

Patients with low (300-500) or decreasing lymphocyte counts,

or low granulocyte counts, should be considered for cytokine

therapy and biological dosimetry using metaphase analysis

where available.

Asymptomatic patients with lethal radiation dose may

perform usual duties until symptomatic.

Potential Injuries

Thermal/flash burns or thermal pulse burns are caused

directly by infrared radiation. Close to the fireball, the thermal

output is often so great that everything is incinerated, and

even at great distances, thermal/flash burns will occur (see

Chapter 28, Burns, for management).

ο Burn mortality rates associated with radiation exposure

are significantly higher due to bone marrow suppression

and infection (a 50% TBSA burn associated with radiation

exposure has a mortality of 90%).

Blast injuries associated with a nuclear detonation include:

ο Direct blast wave overpressure forces measured in terms

of atmosphere overpressure.

ο Indirect blast wind drag forces, measured in terms of wind

velocity, which may displace large objects such as vehicles

or cause the collapse of buildings.

30.4

Radiological Injuries

Radiation injuries are due to ionizing radiation released both

at the time of the nuclear detonation and for a considerable

time afterward. The two types of radiation released are

electromagnetic (gamma) radiation and particulate (alpha,

beta, and neutron) radiation.

ο Alpha particles can be shielded against by clothing.

ο Beta particles shielding requires solid materials, like a wall.

ο Gamma and neutron radiation are the most biologically

active, and require lead equivalent shielding for protection.

ο Fission products are the major radiation hazard in fallout,

because a large number emit penetrating gamma radiation.

This can result in injuries, even at great distances.

ο Fallout causes whole body irradiation from gamma-

emitting isotopes, because they do not actually have to be

on a person’s skin to cause damage.

Flash blindness may occur as the result of a sudden

peripheral visual observation of a brilliant flash of intense

light energy. Retinal burns may also occur and result in

scarring and permanent altered visual acuity.

Treatment of Combined Injuries

Following the detonation of a nuclear device, the majority of

resulting casualties will have sustained a combination of blast,

thermal, and radiological injuries.

The usual methods of treatment for blast injuries must be

modified in those casualties simultaneously exposed to

ionizing radiation.

Traditionally, combat wounds are left open. However, wounds

left open to heal by secondary intention in the irradiated

patient will serve as a nidus of infection. Wounds exposed to

ionizing radiation should be debrided and closed at a second-

look operation within 36-48 hours.

Hypotension should always be assumed to be hypovolemia

and not due to radiologic injury.

Hyperthermia is common.

Radiological injuries increase the morbidity and mortality of

injuries due to compromise of the normal hematopoietic and

30.5

Emergency War Surgery

immune responses to injury. Surgical procedures may need

to be delayed during bone marrow suppression if at all

possible.

Potassium iodide may be used for prevention of thyroid

uptake of radioisotopes after nuclear reactor accidents.

Chelating agents may be used to eliminate metals from the

bloodstream before they reach target organs.

Mobilizing agents are used to increase the excretion of internal

contaminants.

Prussian blue is used to remove radionuclides from the

capillary bed surrounding the intestine and prevents their

reabsorption. Delay until patient is stable. Treat ABCs first.

Decontamination

No healthcare provider has ever been injured with radiation

while performing ABCs on a radiation victim.

Removal of the casualty’s clothing can remove as much as

90% of the radiological contamination.

The first priority of surface decontamination should be to

open wounds, then other areas.

ο To prevent rapid incorporation of radioactive particles,

wounds should be copiously irrigated with normal saline

for several minutes.

ο The eyes, ears, nose, mouth, areas adjacent to uncontam-

inated wounds, hair, and remaining skin surface should

be decontaminated with soap and water.

ο Personnel providing decontamination must protect

themselves from ionizing radiation exposure with:

♦ Protective outer clothing.

♦ Aprons, gloves, and masks.

Amputation should be seriously considered when the

contamination burden is great and severe radionecrosis is likely.

Logistics of Casualty Management

If nuclear weapons are employed within the theater, the

entire medical evacuation and treatment system will be

severely overburdened and some system of classification and

sorting of casualties must be added to the normal procedures

of evacuation and hospitalization.

30.6

Radiological Injuries

Patients entering a medical treatment facility should be

routinely decontaminated if monitoring for radiation is not

available.

These two requirements, the sorting of casualties and the

holding of the excess numbers, must be planned for and

drilled as part of the normal organization and operation of

the health service support system in a theater of operations

where radiation exposure potential is high.

30.7

Chapter 31

Biological Warfare Agents

Introduction

Biological warfare (BW) agents infect the body via the same portals

of entry as infectious organisms that occur naturally. These include

inhalation into the respiratory tract, ingestion into the GI tract, and

absorption through mucous membranes, eyes, skin, or wounds. Most

BW agents will enter the body through inhalation. Usually, the

disease produced by a BW agent will mimic the naturally occurring

disease, but the clinical presentation can be different if delivery of

an agent occurs through a portal that differs from the natural portal.

Detection

Compressed epidemiology with record numbers of sick and

dying in a short time.

High attack rates (60%-90%).

High incidence of pulmonary involvement when usual form

of infection is not (eg, anthrax).

Incidence of a particular disease in an unlikely location.

Increased deaths of animals of all species.

Near simultaneous outbreaks of several different epidemics

at the same site.

Biological Identification Detection System or standoff BW

detectors alarming.

Direct evidence of an attack such as contaminated or

unexploded munitions.

Diagnosis

The first indication of an attack may be when large

numbers of patients present with the same constellation

of signs and symptoms, especially for a disease that is

not endemic to the area of operations.

31.1

Emergency War Surgery

Rapid diagnostic tests may be available in forward areas to

assist clinicians in early diagnosis:

Isolation of the etiologic agent can occur within 1-2 days for

some agents.

Enzyme-linked immunosorbent assays (ELISA).

Genome detection by polymerase chain reaction (PCR).

Antibody detection.

Prevention and Protection

Immunizations: Anthrax, and in specific scenarios, smallpox

and plague.

ο Pre- or postexposure chemoprophylaxis—anthrax, plague,

Q fever, and tularemia. Chemoprophylaxis for anthrax is

presently FDA-approved for postexposure only.

♦ Investigational new drugs exist for the treatment of

Argentine hemorrhagic fever, botulinum toxin, Q fever,

Rift Valley fever, Venezuelan Equine Encephalitis (VEE),

and tularemia.

Protective clothing and mask.

Decontamination —Personnel, Equipment, and Clothing

Mechanical decontamination removes, but not necessarily

neutralizes, the BW agent.

ο Brushing to ensure loosening of the BW agent from the

surface.

ο Filtration and chlorination of drinking water to remove

organisms.

Chemical decontamination renders BW agents harmless

through the use of disinfectants.

ο Soap and water followed with copious rinsing with water

is often sufficient.

ο For patients requiring urgent decontamination, biologic

agents are neutralized within 5 minutes when contam-

inated areas are washed with a 0.5 % hypochlorite solution

(1 part household bleach mixed with 9 parts water).

ο Do not use hypochlorite in the eyes, abdominal cavity,

or on nerve tissue.

ο A 5% hypochlorite solution (ie, household bleach) may be

used to decontaminate clothing or equipment.

31.2

Biological Warfare Agents

Physical decontamination such as heat and solar ultraviolet

(UV) radiation.

ο Dry heat for 2 hours at 160°C.

ο Autoclaving at 120°C under 1 atm of overpressure for 20

minutes.

ο UV radiation difficult to standardize.

Dry biological agents can be a hazard through secondary

aerosolization; but adequate liquid decontamination will

prevent this hazard. There is no vapor hazard, and special

protective masks are generally not required for surgical

personnel.

Infection Control

Infection control procedures should be reinforced for situations

involving BW agents. Standard precautions are appropriate for

BW agents once they have been identified. For an undifferen-

tiated febrile illness following a BW agent attack:

Place patients together in an isolated setting such as a

designated tent or other structure.

Surgical masks may be placed on patients when isolation is

not possible.

Employ respiratory droplet precautions along with standard

precautions until diseases transmissible by droplet (such as

plague and smallpox) have been excluded.

Medical Evacuation

If plague, smallpox, and the hemorrhagic fevers can be

excluded, patients may be evacuated using standard

precautions and the disease-specific precautions.

Plague and smallpox are internationally quarantinable

diseases (IQDs). Do not evacuate patient across

international borders unless authorized by the theater

surgeon.

Isolation precautions should be added to standard precautions.

Immediately upon diagnosing patients with smallpox, the

line and medical chain of command must be notified.

Observe strict quarantine.

31.3

Emergency War Surgery

Standard and respiratory droplet isolation precautions.

♦ Standard precautions.

◊ Hand washing after patient contact.

◊ Use of gloves when touching blood, body fluids,

secretions, excretions, and contaminated items.

◊ Use of mask, eye protection, and gown during

procedures likely to generate sprays of blood, body

fluids, secretions, or excretions.

◊ Handle contaminated patient-care equipment and

linen in a manner that precludes transfer of micro-

organisms to individuals or equipment.

◊ Practice care when handling sharps and use pocket

mask or other ventilation device when ventilating

the patient.

◊ Place patient in private room when possible. Limit

the movement or transfer of patient.

♦ Droplet precautions.

◊ Standard precautions plus:

Place patient in private room or with someone

with the same infection. If not feasible, maintain

at least 1 m distance between patients.

Use of a mask when working within 1 m of patient.

Mask the patient if he/she needs to be moved.

All contacts should be vaccinated within 7 days of

exposure and quarantined together for at least 17 days

following the most recent exposure.

Hemorrhagic fevers—Hanta, Ebola, Lassa, Rift Valley, HFRS

Except for yellow fever, quarantine is not mandatory;

however, person-to-person transmission is possible, therefore,

universal precautions are recommended.

Medical evacuation may result in increased morbidity and

mortality, thus treatment at local MTFs is preferred.

When necessary, patients may be evacuated using universal

and respiratory droplet isolation precautions.

31.4

Biological Warfare Agents

Biological Agents

There are two biological toxins that are potential BW agents:

botulinum and ricin (see Table 31-1).

Table 31-1

Biological Toxin Signs/Symptoms

Medical Management

Botulinum

Cranial nerve palsies

Antitoxin/supportive care

Paralysis

Respiratory failure

Ricin

Fever, cough, SOB

Arthralgias, pulmonary Nonspecific/Supportive care

edema

Bacterial Agents

The bacteria or rickettsia most often considered to be potential

BW threat agents include Bacillus anthracis (anthrax), Brucella

sp. (brucellosis), Vibrio cholerae (cholera) Burkholderia mallei

(glanders), Yersinia pestis (plague), Francisella tularensis

(tularemia), and Coxiella burnetii (Q Fever) (see Table 31-2).

Table 31-2

Bacterial Signs/Symptoms

Medical Management

Anthrax

Fever, malaise, cough, SOB,

Ciprofloxacin

cyanosis

Plague

High fever, chills, headache,

Streptomycin

cough, SOB, cyanosis

Brucellosis Fever, headache, myalgias,

Doxycycline

sweats, chills

Cholera

Massive watery diarrhea

Fluid therapy and antibiotics

(tetracycline, doxycycline or

ciprofloxacin)

Tularemia Local ulcer, lymphadenopathy, Streptomycin

fever, chills, headache, and

malaise

Q-fever

Fever, cough, and pleuritic chest Tetracycline

pain

31.5

Emergency War Surgery

Viral Agents

A number of viruses are BW agents, including smallpox, the

viral hemorrhagic fevers (VHF), and the alpha virus that causes

VEE (see Table 31-3).

Table 31-3

Viral

Signs/Symptoms

Medical Management

VEE

Fever and encephalitis

Nonspecific/supportive care

Smallpox

Malaise, fever, rigors, vomiting,

Antiviral under investigation

headache followed by pustular

vesicles

VHF

Flushing of the face, petechiae,

Nonspecific/supportive care

bleeding, fever, myalgias,

vomiting, and diarrhea

31.6

Chapter 32

Chemical Injuries

The reader is strongly advised to supplement material

in this chapter with the Medical Management Of

Chemical Casualties Handbook,

3rd ed.,

2000,

USAMRICD, Aberdeen Proving Ground, MD.

Personal Protection

Prevention!

ο Avoid becoming a casualty.

ο Protect yourself and instruct your personnel to do the

same.

Prevent further injury of the casualty by instructing him to

put on the protective mask and mission-oriented protective

posture (MOPP) ensemble, and administer self-aid. If

contaminated, tell the individual to remove clothing and

decontaminate potentially exposed body surfaces.

Provide buddy aid by masking the individual, administering

antidotes, and spot decontaminating exposed body areas.

Ensure completeness of decontamination process to the

greatest extent possible at the collocated patient decontam-

ination station.

ο Potential for vapor exposure from an off-gassing residual

agent or inadvertent contact with undetected liquid is a

hazard for medical personnel.

ο Avoid contamination of the medical treatment facility (MTF).

Initial Treatment Priorities

There is no single “best” way to prioritize emergency

treatment for chemical or mixed casualties, although

respiratory insufficiency and circulatory shock should be

treated first. One workable sequence is shown below.

32.1

Emergency War Surgery

1. Treat respiratory insufficiency (airway management)

and control massive hemorrhage.

2. Administer chemical agent antidotes.

3. Decontaminate the face (and protective mask if donned).

4. Remove contaminated clothing and decontaminate

potentially contaminated skin.

5. Render emergency care for shock, wounds, and open

fractures.

6. Administer supportive medical care as resources permit.

7. Transport the stabilized patient to a contamination-

free (ie, clean) area.

Specific Chemical Warfare (CW) Agents and Treatment

Considerations

Nerve Agents (GA, GB, GD, GF and VX)

General: Nerve agents are among the most toxic of the known

chemical agents. They pose a hazard in both vapor and liquid

states, and can cause death in minutes by respiratory

obstruction and cardiac failure.

Mechanism of action: Nerve agents are organophosphates

that bind with available acetylcholinesterase, permitting a

paralyzing accumulation of acetylcholine at the myoneural

junction.

Signs/symptoms: Miosis, rhinorrhea, difficulty breathing,

loss of consciousness, apnea, seizures, paralysis, and copious

secretions.

Treatment: Each deployed US service member has three

MARK I kits or Antidote Treatment-Nerve Agent Autoinjectors

(ATNAAs) for IM self-injection in a pocket of the protective

mask carrier; each kit delivers 2 mg injections of atropine

sulfate and 600 mg pralidoxime chloride (2-PAMCl). Each

US service member also carries a 10 mg diazepam autoinjector

to be administered by a buddy.

ο Immediate IM or IV injection with

♦ Atropine to block muscarinic cholinergic receptors (may

require multiple doses in much greater amounts than

recommended by Advanced Cardiac Life Support

[ACLS] doses).

32.2

Chemical Injuries

♦ 2-PAM (if given soon after exposure) to reactivate

cholinesterase.

Pretreatment: Military personnel may have also received

pretreatment prior to nerve agent exposure. In the late 1990s,

the US military fielded pyridostigmine bromide (PB tablets)

as a pretreatment for nerve agent exposure (this reversibly

binds to the enzyme acetyl cholinesterase, enhancing the

efficacy of atropine against Soman).

Vesicants (HD, H, HN, L, and CX)

General: The vesicants (blister agents) are cytotoxic alkylating

compounds, exemplified by the mixture of compounds

collectively known as “mustard.” Sulphur mustard is

designated “HD” or “H”; nitrogen mustard is designated as

“HN”; Lewisite is designated as “L”; and phosgene oxime is

designated as “CX”.

Mechanism of action: Mustard is an alkylating agent that

denatures DNA, producing a radiomimetic effect, produces

liquefaction necrosis of the epidermis, severe conjunctivitis,

and if inhaled, injures the laryngeal and tracheobronchial

mucosa.

Signs/symptoms: Skin blisters, moderate-to-severe airway

injury (presentation can be delayed), conjunctivitis of varying

severity that causes the casualty to believe he has been

blinded, and mucus membrane burns. No delay with

Lewisite: immediate burning of the skin and eyes.

Treatment: Preventive and supportive. Immediate

decontamination of the casualty has top priority. Agent

droplets should be removed as expeditiously as possible

by blotting with the M-291 kit, or flushing with water or

0.5% hypochlorite. The M-291 kit is extremely effective at

inactivating mustard. Most military forces carry a

decontamination powder or liquid that should be used

immediately to remove the vesicant. Because mustard

tends to be an oily solution, water may spread the agent.

Dimercaprol is used by some nations in the treatment of

Lewisite. Dimercaprol must be used with caution because

the drug itself may be toxic.

32.3

Emergency War Surgery

Lung Damaging (Choking) Agents (Phosgene [CG],

Diphosgene [DP], Chloropicrin [PS], and Chlorine)

General: Lung damaging or choking agents produce

pronounced irritation of the upper and the lower respiratory

tracts. Phosgene smells like freshly mowed hay or grass.

Mechanism of action: Phosgene is absorbed almost exclusively

by inhalation. Most of the agent is not systemically distributed

but rather is consumed by reactions occurring at the alveolar-

capillary membrane.

Signs/symptoms: Phosgene exposure results in pulmonary

edema following a clinically latent period that varies,

depending on the intensity of exposure. Immediate eye, nose,

and throat irritations may be the first symptoms evident after

exposure (choking, coughing, tightness in the chest, and

lacrimation). Over the next 2-24 hours the patient may

develop noncardiogenic fatal pulmonary edema.

Treatment:

ο Terminate exposure, force rest, manage airway secretions,

O₂, consider steroids.

ο Triage considerations for patients seen within 12 hours after

exposure.

♦ Immediate care in ICU if available for patients in

pulmonary edema.

♦ Delayed: dyspnea without objective signs of pulmonary

edema, reassess hourly.

♦ Minimal: asymptomatic patient with known exposure.

♦ Expectant: patient presents with cyanosis, pulmonary

edema, and hypotension. Patients presenting with these

symptoms within 6 hours of exposure will not likely survive.

The Cyanogens (Blood Agents AC and CK)

General: Hydrogen cyanide (AC) and cyanogen chloride

(CK) form highly stable complexes with metalloporphyrins

such as cytochrome oxidase. The term “blood agent” is an

antiquated term used at a time when it was not understood

that the effect occurs mostly outside the bloodstream.

Mechanism of action: Cyanide acts by combining with

cytochrome oxidase, blocking the electron transport system.

As a result, aerobic cellular metabolism comes to a halt.

32.4

Chemical Injuries

Signs/symptoms: Seizures, cardiac arrest, and respiratory arrest.

Treatment:

ο Immediate removal of casualties from contaminated

atmosphere prevents further inhalation.

ο 100% oxygen.

ο If cyanide was ingested, perform GI lavage and administer

activated charcoal. Administer sodium nitrite (10 mL of

3% solution IV) over a period of 3 minutes, followed by

sodium thiosulfate (50 mL of 25% solution IV) over a 10-

minute period. The sodium nitrite produces methemo-

globin that attracts the cyanide; the sodium thiosulfate

solution combines with the cyanide to form thiocyanate,

which is excreted.

Incapacitation Agents (BZ and Indoles)

General: Heterogeneous group of chemical agents related to

atropine, scopolamine, and hyoscyamine that produces

temporary disabling conditions with potent CNS effects that

seriously impair normal function, but do not endanger life

or cause permanent tissue damage.

Signs/symptoms: Mydriasis, dry mouth, dry skin, increased

reflexes, hallucinations, and impaired memory.

Treatment:

ο Immediate removal of firearms and other weapons to

ensure safety.

ο Close observation.

ο Physostigmine, 2-3 mg IM every 15 minutes to 1 hour until

desired level is attained; maintain with 2-4 mg IV every

1-2 hours for severe cases.

Thickened Agents

Thickened agents are chemical agents that have been mixed

with another substance to increase their persistency (persistent

agents may remain in the environment over 24 h).

Casualties with thickened nerve agents in wounds are

unlikely to survive to reach surgery.

Thickened mustard has delayed systemic toxicity and can

persist in wounds, even when large fragments of cloth have

been removed.

32.5

Emergency War Surgery

Surgical Treatment of Chemical Casualties

Wound decontamination.

The initial management of a casualty contaminated by chemical

agents will require removal of MOPP gear as well as initial skin

and wound decontamination with 0.5% hypochlorite before

treatment.

ο Bandages are removed, wounds are flushed, and bandages

replaced.

ο Tourniquets are replaced with clean tourniquets after

decontamination.

ο Splints are thoroughly decontaminated.

Only the vesicants and nerve agents present a hazard from

wound contamination. Cyanogens are so volatile that it is

extremely unlikely they would remain in a wound.

Off-Gassing

The risk of vapor off-gassing from chemically contaminated

fragments and cloth in wounds is very low and insignificant.

Off-gassing from a wound during surgical exploration will

be negligible or zero.

Use of Hypochlorite Solution

Household bleach is 5% sodium hypochlorite, hence, mix 1

part bleach with 9 parts water to create ~ 0.5% solution.

Dilute hypochlorite (0.5%) is an effective skin decontaminant,

but the solution is contraindicated for use in or on a number

of anatomical areas:

ο Eye: may cause corneal injuries.

ο Brain and spinal cord injuries.

ο Peritoneal cavity: may lead to adhesions.

ο Thoracic cavity: hazard is still unknown although it may

be less of a problem.

Full strength 5% hypochlorite is used to decontaminate

instruments, clothing, sheets, and other inanimate objects.

Wound Exploration and Debridement

Surgeons and assistants should wear well-fitting, thin, butyl

rubber gloves or double latex surgical gloves. Gloves should

32.6

Chemical Injuries

be changed often while ascertaining that there are no foreign

bodies or thickened agents remaining in the wound.

Wound excision and debridement should be conducted using a

no-touch technique. Removed fragments of tissue should be

dumped into a container of 5% hypochlorite solution. Superficial

wounds should be wiped thoroughly with a 0.5% hypochlorite

and then irrigated with copious amounts of normal saline.

Following the Surgical Procedure

Surgical and other instruments that come into contact with

possible contamination should be placed in 5% hypochlorite

for 10 minutes prior to normal cleansing and sterilization.

Reusable linen should be checked with the chemical agent

monitor (CAM), M8 paper, or M9 tape for contamination.

Soak contaminated linen in 5% hypochlorite.

32.7

Chapter 33

Pediatric Care

Introduction

The military surgeon needs to be familiar with the unique

challenges the pediatric population presents, not only in war,

but also in military-operations-other-than-war scenarios. This

includes proper diagnostic evaluation and resuscitation, and the

necessary equipment to ensure success. For US Army medical

units, the humanitarian augmentation medical equipment set

(MES), requested by the hospital commander through command

channels, provides medical supplies and equipment for a

population of 10,000 people. Additionally, the special care

augmentation team can be requested for this mission.

Anatomic and Physiologic Considerations

Fluid, electrolyte, and nutrition.

ο Normal fluid requirements in children are estimated via a

weight-based method (Table 33-1).

Table 33-1

Weight (kg)

Volume

0-10

120 mL/kg/d (after the first week of life)

11-20

1,000 mL + 50 mL/kg over 10 kg

over 20

1,500 mL + 20 mL/kg over 20 kg

o Maintenance IV fluid replacement is D₅1/2NS + 20 mEq/

dL KCl for children over 3 months or D₁₀1/2NS + 20 mEq/

dl KCl for children under 3 months.

ο Fluid resuscitation is best performed with isotonic fluids

at 20 cc/kg boluses. (See Evaluation and Diagnosis below.)

ο Total fluid requirement should be adjusted for a goal urine

output of 1-2 cc/kg/h.

33.1

Emergency War Surgery

ο Daily sodium requirements are 2-3 mEq/kg/d and daily

potassium requirements are 1-2 mEq/kg/d.

ο Daily caloric and protein requirements are estimated by

weight and age as follows (Table 33-2):

Table 33-2

Age (y)

kcal/kg

Protein (g/kg

body weight

body weight)

0-1

90-120

2.0-3.5

1-7

75-90

2.0-2.5

7-12

60-75

2.0

12-18

30-60

1.5

> 18

25-30

1.0

ο Breast milk is always the first choice when initiating oral

intake in infants. Alternatively, infant formulas contain 20

kcal/oz. An estimate of the amount of formula needed to

provide 120 kcal/kg/d is

Infant’s wt (kg) • 22 = Amt (in cc) of formula needed q 4 h.

Pulmonary.

ο Newborns tend to be obligate nasal breathers, thus nasal

airways should be avoided if possible.

ο The child’s larynx is positioned more anterior in the neck,

thus making it more difficult to visualize during

intubation, and necessitating a more forward position of

the head.

ο The acceptable range of PaO₂ (60-90 mm Hg) correlates to

oxygen saturations of 92%-97%. A premature infant’s

oxygenation saturation should never exceed 94% to avoid

retinopathy of the premature.

ο Infants breathe mostly with their diaphragm, thus

increases in intraabdominal pressure or other problems

that limit diaphragmatic movement can significantly

inhibit respiration.

Cardiovascular.

ο Vital signs by age group (Table 33-3).

33.2

Pediatric Care

Table 33-3

Age

Weight Resp.

Pulse

(kg)

Rate

(systolic)

Premie

< 3

40-60

130-150

42±10

Term

120-140

60±10

1-5 yr

~10-20

20-30

100-130

95±30

6 -10 yr

20-32

12-25

75-100

100±15

Adolescent

12-18

120±20

ο Cardiac stroke volume in children is relatively fixed. Therefore,

bradycardia or relative bradycardia can significantly decrease

cardiac output. Stimulation and oxygen therapy are

corrective for over 90% of significant bradycardias in infants.

Limit peripheral IV access attempts to 2 within 60 seconds

for the child in shock, then immediately proceed to

saphenous vein cutdown or intraosseous (IO) infusion (see

Chapter 8, Vascular Access).

Burns.

ο An infant or child’s head tends to encompass more of the

BSA, with the lower extremities being a smaller percentage.

The palm of the child’s hand can be used to estimate 1%

of total BSA for burn calculations (Fig. 33-1).

Gastrointestinal.

ο Reflux is a common finding,

18%

especially in the newborn period.

This predisposes some children to

Back 13%

difficulty with digestion and

frequent emesis.

Unilateral

18%

ο Children are predisposed to

buttock 2.5%

hypoglycemia due to low

glycogen storage capacity of their

Legs 7.5% on

15% 15%

each side

liver. Full-term infants will tolerate

NPO status for approximately 5

days (with an appropriate D₁₀

solution). Premature infants will

tolerate only 3 days of NPO status Fig. 33-1. BSA percentages

prior to the initiation of TPN.

for infants and children.

33.3

Emergency War Surgery

ο A child’s GI tract is very sensitive to most insults, including

electrolyte abnormalities and systemic illnesses. This can

result in an ileus and manifest as feeding intolerance, and

may precipitate necrotizing enterocolitis (NEC).

ο Gastroenteritis with diarrhea, often associated with fevers,

is also a very common cause of severe dehydration.

Hematology and blood volume.

ο Infants have a physiologic anemia during the first 3-5

months with a hematocrit of 30%-33%.

ο Estimates of blood volume are as follows:

Age

Volume (cc/kg)

Premature

85-100

Term

~80

1-3 mo

75-80

> 3 mo

~70

Renal.

ο Infants and young children have a limited ability to

concentrate urine (max 400-600 mOsm/L) and a fixed

ability to excrete sodium, causing an inability to handle

excess sodium, resulting in hypernatremia if they receive

too much sodium. Premature infants are salt wasters and

full-term infants are salt retainers. It takes 6 years to achieve

normal tubular concentrating ability.

ο Infants can excrete water just like an adult. At 2 weeks of age

the glomerular filtration rate (GFR) is 75% of the eventual

adult rate and reaches maximum capacity at 2 years.

ο Total body water is 80% at 32 weeks, 75% at term, 60%

beyond 1 year.

Thermoregulation.

ο Infants and young children are predisposed to heat loss

and they poorly compensate for wide fluctuations in

ambient temperatures. Children have a higher ratio of

body surface area to mass, and therefore are likely to

become dehydrated earlier than adults when febrile.

ο Reduce exposure and keep infants and children in a

regulated warm environment.

Immune system.

33.4

Pediatric Care

ο Premature infants have incomplete development of their

immune system, causing a 60-fold increased risk of sepsis.

All elective surgery in infants under 30 days of age requires

48 hours of prophylactic antibiotics (with anaerobic coverage

added when appropriate) after the first week of life.

ο Early signs of sepsis can include lethargy, intolerance to

feedings, fever, hypothermia, tachycardia, and irritability

before a rise in the white blood cell count.

Evaluation and Diagnosis

History.

ο Duration/location of pain is important in injury diagnosis.

Over one third of pediatric patients evaluated for

abdominal pain lasting more than a few hours will have

an underlying pathologic condition.

ο Any bilious emesis, especially in the newborn period, may

be a sign of intestinal obstruction, and mandates further

workup.

ο GI bleeding requires immediate attention. The character

(bright red vs melena), quantity, and associated stool

history (ie, diarrhea with infectious source or currant-jelly-

like with intussusception) may provide clues as to the

underlying disorder.

Physical examination.

ο Basic ATLS guidelines should direct the initial assessment

and evaluation for all children involved in traumas. It is

essential to keep the patient warm because children are

much more prone to heat loss than adults.

♦ Modified GCS for children < 4 years old:

Verbal Response

V-Score

Appropriate words/social

smile/fixes/follows

Cries, but consolable

Persistently irritable

Restless, agitated

None

Radiological studies.

33.5

Emergency War Surgery

ο All bilious vomiting in infants and children should be

evaluated with contrast radiographic imaging. As a general

rule contrast enemas are safer as an initial approach.

♦ Ultrasound is an excellent screening test for the

identification of free abdominal fluid and is also used

in cases of abdominal pain to evaluate appendicitis

(noncompressible appendix with fecolith) and

intussusception (target sign), and others.

♦ Constipation is a common complaint in children that

can be readily diagnosed with plain radiographs and

by history.

Treatment

The treatment algorithm shown below provides the proper

sequence for the rapid sequence intubation (RSI) of the

pediatric patient (Fig. 33-2).

Preoxygenate

Atropine sulfate, 0.1-0.5 mg

Sedation

Midazolam HCl,

Thiopental sodium

0.1 mg/kg (5 mg max)

4-5 mg/kg

Cricoid Pressure

Paralysis

Succinylcholine chloride

Weight < 10 kg: 2mg/kg

Weight > 10 kg: 1 mg/kg

Intubate, Check Tube Position, Release Cricoid Pressure

Fig. 33-2. Rapid sequence intubation for the pediatric patient.

33.6

Pediatric Care

Equipment and Supplies

Accessory pediatric medical/surgical equipment arranged

according to age and weight (Table 33-4).

Surgical instruments.

ο If a pediatric surgical set

is not immediately

available, a peripheral

vascular set will usually

contain instruments

delicate enough to

accomplish most tasks in

newborns.

Commonly Used Drugs and

Dosages

Phenobarbital 2-3 mg/kg

IV.

Diazepam 0.25 mg/kg IV

Midazolam HCl 0.1 mg/

kg IV (max 5 mg).

Atropine 0.1-0.5 mg IV.

Phenytoin 15-20 mg/kg,

administered at 0.5 to 1.5

ml/kg/min as a loading

dose, then 4-7 mg/kg/d

for maintenance.

Mannitol 0.5-1.0 g/kg IV.

Succinylcholine chloride 2

mg/kg IV for < 10 kg, and

1 mg/kg IV for > 10 kg.

Ampicillin 25-50 mg/kg IV

q8h (q12-18h in newborns).

Gentamicin 2.5 mg/kg IV

q8h (q12-18h in newborns).

Metronidazole 10 mg/kg

IV.

Acetaminophen 15 mg/kg

po.

33.7

Emergency War Surgery

Surgical Management

Basics.

ο As a general guideline, transverse incisions should be used

in infants. This minimizes the risk of postoperative

dehiscence, while still allowing adequate exposure.

ο Absorbable suture such as Vicryl or PDS (2-0) should be

used to close the rectus fascia, regardless of the incision.

The skin can then be closed using staples or absorbable

monofilament suture (eg, Monocryl 4-0).

ο When placing retention sutures for severe malnutrition,

permanent sutures such as Prolene or nylon can be used

as a full thickness through the rectus muscle and skin. Care

should be taken to avoid the epigastric vessels. The sutures

can be passed through small pieces of a 14F red rubber

catheter prior to tying to avoid excess pressure on the skin.

ο Personnel: Remember that if obstetrics is part of the

mission, pediatric support will be required!

33.8

Chapter 34

Care of Enemy

Prisoners of War/Internees

Introduction

Healthcare personnel of the Armed Forces of the United States

have a responsibility to protect and treat, in the context of a

professional treatment relationship and universal principles of

medical ethics, all detainees in the custody of the Armed Forces.

This includes enemy prisoners of war, retained personnel,

civilian internees, and other detainees. For the purposes of this

chapter, all such personnel are referred to as internees.

It is the policy of the Department of Defense that healthcare

personnel of the Armed Forces and the Department of Defense

should make every effort to comply with “Principles of Medical

Ethics Relevant to the Role of Health Personnel, Particularly

Physicians, in the Protection of Prisoners and Detainees Against

Torture and Other Cruel, Inhuman or Degrading Treatment or

Punishment,” adopted by United Nations General Assembly

Resolution 37/194 of 18 December 1982 (and provided as

Appendix 1 to this book). This is in addition to compliance with

all applicable DoD issuances.

The Geneva Conventions

Define medical personnel as those individuals “exclusively

engaged in the search for, or the collection, transport, or

treatment of the wounded or sick, or in the prevention of

disease; and staff exclusively engaged in the administration

of medical units and establishments” (Geneva Convention

for the Amelioration of the Wounded and Sick in Armed

Forces in the Field [GWS]).

34.1

Emergency War Surgery (2004) - page 11