Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-669899f699-8p65j Total loading time: 0 Render date: 2025-05-04T06:58:48.308Z Has data issue: false hasContentIssue false

22 - Field Anesthesia and Military Injury

Published online by Cambridge University Press:  18 January 2010

By
Peter F. Mahoney  and
Craig C. McFarland
Edited by
Charles E. Smith
Peter F. Mahoney
Affiliation:
Military Critical Care, Royal Centre for Defence Medicine, Birmingham, United Kingdom
Craig C. McFarland
Affiliation:
Department of Anesthesiology, Uniformed Services, University of the Health Sciences, Bethesda, Maryland
Charles E. Smith
Affiliation:
Case Western Reserve University, Ohio
Get access

Summary

Objectives

  1. Review the military environment and the constraints this imposes on resuscitation and anesthesia.

  2. Review the issues in resuscitation of the ballistic casualty.

  3. Discuss aspects of field anesthesia.

SUMMARY

Injuries from modern military munitions can be complex and devastating. Their management demands particular anesthetic and surgical skill sets including an understanding of time-critical injury. In addition, casualty management in the deployed military setting is subject to a number of threats and constraints that influence how care can be delivered. This chapter will consider the types of casualties that may present to the military provider; how the care is influenced by situational constraints, and suggest some anesthetic techniques that are appropriate for use in the field.

INTRODUCTION

Casualties presenting to the military anesthesiologist or anesthetist will broadly fall into a number of groups:

  1. The ill, multiply injured casualty with time-critical injuries

  2. The injured casualty needing surgery for wound care who is stable and can wait

  3. Casualties needing follow-up procedures for wound and injury care

  4. Routine problems such as appendectomies

  5. Civilian patients (adult and child) falling into the above groups

All of these would have differing requirements in the setting of a large, well-resourced civilian hospital. The constraints of the military environment can mean they are managed very differently. This chapter is structured to try and separate the three chapter objectives, but in reality they are interwoven and some repetition is necessary between the different sections. The chapter starts with an overview of these constraints.

Type
Chapter
Information
Trauma Anesthesia , pp. 343 - 359
Publisher: Cambridge University Press
Print publication year: 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Book purchase

Temporarily unavailable

References

Bellamy, RF. The nature of combat injuries and the role of ATLS in their management. In Combat Casualty Care Guidelines: Operation Desert Storm. Washington DC: Office of the Surgeon General, 1991.Google Scholar
Perrin P. Protecting the victims of armed conflicts. In Perrin, P (ed). Handbook on War and Public Health. Geneva: International Committee of the Red Cross, 1996, pp 377–403.Google Scholar
Ignatieff, M.The Warrior's Honor: Ethnic War and the Modern Conscience. London: Chatto & Windus, 1998, p 129.Google Scholar
Battlefield Advanced Trauma Life Support (BATLS) 2005. Joint Service Publication 570. Open publication as: Supplements to Journal of the Royal Army Medical Corps June 2006;152(2), September 2006;152(3) and December 2006;152(4).
Butler, FK, Hagmann, J, Butler, EG. Tactical combat care in special operations. Mil Med 1996;161(suppl 1).CrossRefGoogle ScholarPubMed
Hayward-Karlsson, J JS, Kerr, A, Schmidt, H.Hospitals for War Wounded. Geneva: International Committee of the Red Cross, 1998, p 88.Google Scholar
Botha, A, Loosemore, T, eds. Definitive Surgical Trauma Skills. London:The Royal College of Surgeons of England, 2002, pp 10–12.Google Scholar
Hodgetts, T, Mahoney, PF, Mozumder, A, McLennan, J.Care of civilians during military operations. Int J Disaster Med 2005;3:3–24.CrossRefGoogle Scholar
Hodgetts, TJ, Mahoney, PF, Russell, MQ, Byers M. ABC to <C> ABC: Redefining the military trauma paradigm. Emerg Med J 2006;23:745–6.CrossRefGoogle Scholar
Bellamy RF. Combat trauma overview. In Zajtchuk, R, Grande, CM, ed. Textbook of Military Medicine. Part 4: Surgical Combat Casualty Care: Anaesthesia and perioperative Care of the Combat Casualty. Falls Church, VA: Office of the Surgeon General, U.S. Army, 1995, pp 1–42.Google Scholar
Barkana, et al. Prehospital stabilisation of the cervical spine for penetrating injuries of the neck – Is it necessary?. Injury 2000;31(5):305–9.CrossRefGoogle Scholar
Criswell, JC, Parr, MJA, Nolan, JP.Emergency airway management in patients with cervical spine injury. Anesthesia 1994;49:900–3.CrossRefGoogle Scholar
Greaves, I, Porter, K, Revell, MP.Fluid resuscitation in pre-hospital trauma care: A consensus view. J R Coll Surg Edin 2002;47(2):451–7.Google ScholarPubMed
Pepe, PE.Shock in polytrauma. BMJ 2003;327:119–20.CrossRefGoogle ScholarPubMed
Wiggers, CJ. Physiology of Shock. New York: Common Wealth Fund, 1950, p 121–46.Google Scholar
Myers C. Fluid resuscitation. Eur J Emerg Med 1997;4:224–32.
Hess, JR, Holcomb, JB, Hoyt, DB.Damage control resuscitation: The need for specific blood products to treat the coagulopathy of trauma. Transfusion 2006;46(5):685–6.CrossRefGoogle ScholarPubMed
Surgical management of penetrating brain injury. J Trauma 2001;51:S16–25. In: Prognosis in penetrating brain injury. J Trauma 2001;(2). Supplement.
Coupland, RM PP. Craniocerebral war wounds: Non specialist management. Injury 1992;23:21–4.CrossRefGoogle ScholarPubMed
Spalding, TJW, Stewart, MPM, Tulloch, DN, Stephens, KM.Penetrating missile injuries in the Gulf war 1991. Br J Surg 1991;78:1102–4.CrossRefGoogle ScholarPubMed
Adley, R, Evans, DHC, Mahoney, PF, et al. The Gulf war: Anaesthetic experience at 32 Field Hospital Department of Anesthesia and Resuscitation. Anaesthesia 1992;42:996–9.CrossRefGoogle Scholar
Page, RJE, Wilson, IH.Draw over anesthesia. Br J Hosp Med 1989;42:320–4.Google Scholar
Craig, GR, Berry, CB, Yeats, MJ.An evaluation of the Universal PAC and the Oxford Miniature Vaporizers for paediatric field anaesthesia. Anaesthesia 1995;50:789–93.CrossRefGoogle ScholarPubMed
Houghton, IT.The Triservice anaesthetic apparatus. Anaesthesia 1981;36:1094–108.CrossRefGoogle ScholarPubMed
Brock-Utne, JG.Anaesthesia in military conflicts: Towards simpler, safer and higher standards. Mil Med 1992;157: 229–30.CrossRefGoogle ScholarPubMed
Knight, RJ, Houghton, IT.Field experience with the Triservice anaesthetic apparatus in Oman and Northern Ireland. Anaesthesia 1981;36:1122–27.CrossRefGoogle ScholarPubMed
Jowitt, MD, Knight, RJ.Anaesthesia during the Falklands campaign: The land battles. Anaesthesia 1983;38:776–83.CrossRefGoogle ScholarPubMed
Roberts, MJ, Bell, GT, Wong, LSS. The CompPAC and PortaPAC Portable ventilators. Bench tests and field experience. J R Army Med Corps 1999;145:73–7.CrossRefGoogle ScholarPubMed
Halford, FJ.A critique of intravenous anaesthesia in war surgery. Anaesthesiology 1943;4:67–9.CrossRefGoogle Scholar
Adams, RC, Gray, HK.Intravenous anaesthesia with pentothal sodium in the care of gunshot wounds associated with accompanying severe traumatic shock and loss of blood: Report of a case. Anaesthesiology 1943;4:70–3.CrossRefGoogle Scholar
Editorial: The question of intravenous anaesthesia in war surgery. Anaesthesiology 1943;4:74–7.CrossRef
Bennetts, FE.Thiopentone anaesthesia at Pearl Harbor. Br JAnaesth 1995;75:366–8.CrossRefGoogle ScholarPubMed
Restall, J, Tully, AM, Ward, PJ, Kidd, AG.Total intravenous anaesthesia for military surgery. A technique using ketamine, midazolam and vecuronium. Anaesthesia 1988;43:46–9.Google ScholarPubMed
Bailie, R, Craig, G, Restall, J.Total intravenous anaesthesia for laparoscopy. Anaesthesia 1989;44:60–3.CrossRefGoogle ScholarPubMed
Wilson, RJT, Ridley, SA.The use of propofol and alfentanil by infusion in military anaesthesia. Anaesthesia 1992;47:231–3.CrossRefGoogle ScholarPubMed
Restall, J, Thompson, MC, Johnston, IG, Fenton, TC.Anaesthesia in the field. Spontaneous ventilation – a new technique. Anaesthesia 1990;45:965–8.CrossRefGoogle ScholarPubMed
Smith, C, McEwan, E, Jhaveri, R, et al. The interaction of fentanyl on the CP50 of propofol for loss of consciousness and skin incision. Anesthesiology 1994;81:820–8.CrossRefGoogle ScholarPubMed
Vuyk, J, Lim, T, Engbers, FHM, et al. The pharmacodynamic interaction of propofol and alfentanil during lower abdominal surgery in female patients. Anesthesiology 1995;83:8–22.CrossRefGoogle Scholar
Vuyk, J, Mertens, MJ, Olofsen, E, et al. Propofol anesthesia and rational opioid selection: Determination of optimal EC50-EC95 propofol-opioid concentrations that assure adequate anesthesia and a rapid return of consciousness. Anesthesiology 1997;87:1549–62.CrossRefGoogle Scholar
Badrinath, S, Avramov, MN, Shadrick, M, et al. The use of ketamine-propofol combination during monitored anesthesia care. Anesth Analg 2000;90:858–62.CrossRefGoogle ScholarPubMed
Fu, ES, Miguel, R, Scharf, JE. Preemptive ketamine decreases postoperative narcotic requirements in patients undergoing abdominal surgery. Anesth Analg 1997;84:1086–90.CrossRefGoogle ScholarPubMed
Guillou, N, Tanguy, M, Seguin, P, et al. The effects of small-dose ketamine on morphine consumption in surgical intensive care unit patients after major abdominal surgery. Anesth Analg 2003;97:843–7.CrossRefGoogle ScholarPubMed
Menigaux, C, Fletcher, D, Dupont, X, et al. The benefits of intraoperative small-dose ketamine on postoperative pain after anterior cruciate ligament repair. Anesth Analg 2000;90:129–35.CrossRefGoogle ScholarPubMed
Menigaux, C, Guignard, B, Fletcher, D, et al. Intraoperative small-dose ketamine enhances analgesia after outpatient knee arthroscopy. Anesth Analg 2001;93:606–12.CrossRefGoogle ScholarPubMed
Suzuki, M, Tsueda, K, Lansing, PS, et al. Small-dose ketamine enhances morphine-induced analgesia after outpatient surgery. Anesth Analg 1999;89:98–103.Google ScholarPubMed
Weinbroum, AA.A single small dose of postoperative ketamine provides rapid and sustained improvement in morphine analgesia in the presence of morphine-resistant pain. Anesth Analg 2003;96:789–95.CrossRefGoogle ScholarPubMed
Reich, DL, Silvay, G.Ketamine: an update on the first twenty five years of clinical experience. Can J Anaesth 1989;36:186–97.CrossRefGoogle ScholarPubMed
Hirota, K, Lambert, DG. Ketamine: Its mechanism(s) of action and unusual clinical uses. Br J Anaesth 1996;77:441–4.CrossRefGoogle ScholarPubMed
Pederson, L, Benumof, J.Incidence and magnitude of hypoxemia with ketamine in a rural African hospital. Anaesthesia 1993;48:67–9.CrossRefGoogle Scholar
Drummond, GB. Comparison of sedation with midazolam and ketamine: Effects on airway muscle activity. Br J Anaesth 1996;76:663–7.CrossRefGoogle ScholarPubMed
Ketamine – a new anaesthetic (Editorial). Br Med J. 1971 June 19;2(5763):666–667.CrossRef
Kerz T, Dick WF. Analgesia and sedatives in emergencies. In Goris, RJA, Trentz, O, ed. The Integrated Approach to Trauma Care: The First 24 Hours. Berlin: Springer-Verlag, 1995.CrossRefGoogle Scholar
Mortero, RF, Clark, LD, Tolan, MM, et al. The effects of small-dose ketamine on propofol sedation: respiration, postoperative mood, perception, cognition, and pain. Anesth Analg 2001;92:1465–9.CrossRefGoogle ScholarPubMed
White, PF, Ham, J, Way, WL, Trevor, AJ.Pharmacology of ketamine isomers in surgical patients. Anesthesiology 1980;52:231–9.CrossRefGoogle ScholarPubMed
Kloss, T, Lenz, G, Schwandt-Boden, H, Bauer, J, Stehle, R.The role of regional anaesthesia under field conditions. Prehospital and disaster medicine (1990) 5(4):349–52.CrossRefGoogle Scholar
Bion, JF.Isobaric bupivacaine for spinal anaesthesia in acute war injuries. Anaesthesia 1984;39:554–9.CrossRefGoogle ScholarPubMed
Bacon, DR, Lema, MJ.Standing on the promises: The career of Samuel L. Lieberman, M.D. Sphere 1989;42:20–4.Google Scholar
Thompson, GE.Anesthesia for battle casualties in Vietnam. JAMA 1967;201:215–9.Google Scholar
Jenicek, JA, Perry, LB, Thompson, GE. Armed forces anesthesiology comes of age. Anesth Analg 1967;46:822–32.CrossRefGoogle ScholarPubMed
Lenz, G, Stehle, R.Anaesthesia under field conditions. A review of 945 cases. Acta Anaesthesiol Scand 1984;28:351–6.CrossRefGoogle ScholarPubMed
Plunkett, AR, Brown, DS, Rogers, JM, Buckenmaier, CC III. Supraclavicular continuous peripheral nerve block in a wounded soldier: When ultrasound is the only option. Br J Anaesth 2006;97(5):715–17.CrossRefGoogle Scholar
Horlocker, TT, Wedel, DJ, Benzon, H, et al. Regional Anesthesia in the Anticoagulated Patient: Defining the Risks. (The Second ASRA Consensus Conference on Neuraxial Anesthesia and Anticoagulation April 25–28, 2002. Available at: www.asra.com/consensus-statements). Reg Anesth Pain Med 2003;28:172–97.Google ScholarPubMed
Isenbarger, DW, Atwood, JE, Scott, PT, et al. Venous thromboembolism among United States soldiers deployed to Southwest Asia. Thromb Res 2006;117(4):379–83.CrossRefGoogle ScholarPubMed
Buckenmaier, CC III, Shields, CH, Auton, AA, et al. Continuous peripheral nerve block in combat casualties receiving low-molecular weight heparin. Br J Anaesth 2006;97(6):874–7.CrossRefGoogle ScholarPubMed
Pesonen, P.Pulse oximetry during ketamine anaesthesia in war conditions. Can J Anaesth 1991;38(5):592–4.CrossRefGoogle ScholarPubMed
Bowdle, TA, et al. Psychedelic effects of ketamine in healthy volunteers: Relationship to steady-state plasma concentrations. Anesthesiology 1998;88:82–8.CrossRefGoogle ScholarPubMed
Strebel, S, et al. Effects of ketamine on cerebral blood flow velocity in humans. Anaesthesia 1995;50:223–8.CrossRefGoogle ScholarPubMed
Albanese, J, et al. Ketamine decreases intracranial pressure and elecroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology 1997;87:1328–34.CrossRefGoogle Scholar
Saegusa, K, et al. Pharmacologic analysis of ketamine-induced cardiac actions in isolated, blood-perfused canine atria. J Cardiovasc Pharmacol 1986;8:414–9.CrossRefGoogle ScholarPubMed
Gelissen, HP, et al. Inotropic effects of propofol, thiopental, midazolam, etomidate, and ketamine on isolated human atrial muscle. Anesthesiology 1996;84:397–403.CrossRefGoogle ScholarPubMed
Doenicke, A, et al. The action of S(+)-ketamine on serum catecholamine and cortisol. A comparison with ketamine racemate. Anaesthesist 1992;41:597–603.Google ScholarPubMed
Nakayama, M, Murray, P.Ketamine preserves and propofol potentiates hypoxic pulmonary vasoconstriction compared with the conscious state in chronically instrumented dogs. Anesthesiology 1999;91:760–71.CrossRefGoogle ScholarPubMed
Katz, RI, et al. Hemodynamic stability and patient satisfaction after anesthetic induction with thiopental sodium, ketamine, thiopental-fentanyl, and ketamine-fentanyl. J Clin Anesth 1993;5:134–40.CrossRefGoogle ScholarPubMed
Frizelle, HP, et al. A comparison of propofol with a propofol-ketamine combination for sedation during spinal anesthesia. Anesth Analg 1997;84:1318–22.CrossRefGoogle ScholarPubMed
Ikeda, T, et al. Induction of anesthesia with ketamine reduces the magnitude of redistribution hypothermia. Anesth Analg 2001;93:934–8.CrossRefGoogle ScholarPubMed
Engelhard, K, et al. The effect of the [alpha]2-agonist dexmedetomidine and the N-methyl-d-aspartate antagonist S(+)-ketamine on the expression of apoptosis-regulating proteins after incomplete cerebral ischemia and reperfusion in rats. Anesth Analg 2003;96:524–31.CrossRefGoogle ScholarPubMed
Kissin, I, et al. The effect of ketamine on opioid-induced acute tolerance: can it explain reduction of opioid consumption with ketamine-opioid analgesic combinations?Anesth Analg 2000;91:1483–8.CrossRefGoogle ScholarPubMed
Hill, GE, et al. ketamine inhibits the proinflammatory cytokine-induced reduction of cardiac intracellular cAMP accumulation. Anesth Analg 1998;87:1015–9.Google ScholarPubMed
Linden, , et al. Comparison of halothane, isoflurane, alfentanil, and ketamine in experimental septic shock. Anesth Analg 1990;70:608–17.Google ScholarPubMed
Mahoney, PF, Steinbruner, D, Mazur, B, Dodson, C, Mehta, SG.Management of c spine injury in combat casualties. Injury 2007;38:1220–2.CrossRefGoogle Scholar
United States Army Institute of Surgical Research. Fort Sam Houston, Texas. http://www.usaisr.amedd.army.mil/.
Malchow, RJ. Ultrasonography in Advanced Regional Anesthesia and Acute Pain Management in a Combat Environment, Randall J. Malchow, MD, COL, MC, U.S. Army, Staff Anesthesiologist, 47th Combat Support Hospital, Mosul, Iraq. (Document in preparation.)
Second Consensus Conference on Neuraxial and Anticoagulation, April 25–28, 2002.
Brooks A, Wood P, Mahoney P. Field resuscitation. Curr Anaesth Crit Care 2002;13:256–60.CrossRef
Clasper, JC, Jeffrey, PA, Mahoney, PF.The forward deployment of surgical teams. Curr Anaesth Crit Care 2003;14:122–5.CrossRefGoogle Scholar
Cantelo, R, Mahoney, PF.An introduction to field anaesthesia. Curr Anaesth Crit Care 2003;14:126–30.CrossRefGoogle Scholar
Wood PR, Brooks AJ, Mahoney PF. Resuscitation and anaesthesia for the ballistic casualty. In Mahoney, PF, Ryan, JM, Brooks, AJ, Schwab, CW, ed. Ballistic Trauma – A Practical Guide, 2nd edition. Berlin: Springer-Verlag, 2005, pp 151–67.CrossRefGoogle Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

  • Field Anesthesia and Military Injury
    • By Peter F. Mahoney, Military Critical Care, Royal Centre for Defence Medicine, Birmingham, United Kingdom, Craig C. McFarland, Department of Anesthesiology, Uniformed Services, University of the Health Sciences, Bethesda, Maryland
  • Edited by Charles E. Smith, Case Western Reserve University, Ohio
  • Book: Trauma Anesthesia
  • Online publication: 18 January 2010
  • Chapter DOI: https://doi.org/10.1017/CBO9780511547447.025
Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

  • Field Anesthesia and Military Injury
    • By Peter F. Mahoney, Military Critical Care, Royal Centre for Defence Medicine, Birmingham, United Kingdom, Craig C. McFarland, Department of Anesthesiology, Uniformed Services, University of the Health Sciences, Bethesda, Maryland
  • Edited by Charles E. Smith, Case Western Reserve University, Ohio
  • Book: Trauma Anesthesia
  • Online publication: 18 January 2010
  • Chapter DOI: https://doi.org/10.1017/CBO9780511547447.025
Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

  • Field Anesthesia and Military Injury
    • By Peter F. Mahoney, Military Critical Care, Royal Centre for Defence Medicine, Birmingham, United Kingdom, Craig C. McFarland, Department of Anesthesiology, Uniformed Services, University of the Health Sciences, Bethesda, Maryland
  • Edited by Charles E. Smith, Case Western Reserve University, Ohio
  • Book: Trauma Anesthesia
  • Online publication: 18 January 2010
  • Chapter DOI: https://doi.org/10.1017/CBO9780511547447.025
Available formats
×