Certain small subsets of military combatants (notably Special Operations forces corpsmen and medics, referred to as "trained responders" below) receive training based on the Advanced Trauma Life Support® (ATLS®) course (American College of Surgeons, 1997). Essential elements of this approach include control of hemorrhage, airway and breathing support, and intravenous fluid resuscitation.
Because exsanguination is the single major cause of death in potentially salvageable battlefield casualties (see Chapter 1), control of external hemorrhage, preferably by pressure but even by tourniquet if necessary, is an essential and immediate priority. The effectiveness of subsequent fluid resuscitation will depend greatly on the extent to which bleeding is controlled.
According to ATLS® protocol, the trained responder should ensure that the airway is clear. If the wounded combatant is conscious and breathing, then airway intervention is not necessary. If the wounded combatant is unconscious and respiration is labored, efforts should be made to clear the airway. The first approaches involve the chin-lift or jaw-thrust maneuvers. When clearing the airway of the unconscious victim on the battlefield, the first responder should not worry about cervical spine immobilization, because cervical spine injury is uncommon in combatants (Butler et al., 1996). Attention to cervical spine immobilization is secondary to evacuation from the front line.
Tension pneumothorax may also cause inadequate breathing. As noted in Chapter 1, 10 percent of the deaths in the battlefield during the Vietnam conflict were due to tension pneumothorax. Successful treatment of battlefield injuries requires that this condition be addressed by the trained responder (Coats et al., 1995; Deakin et al., 1995; Glinz, 1986; Krome, 1983). As outlined by Butler and colleagues (1996), respiratory distress occurring in a combat casualty with a penetrating chest wound should be assumed to represent tension pneumothorax. The diagnosis of a tension pneumothorax can be strengthened by visually identifying other signs, but this is not essential and may not be possible at night or while under fire. Although the trained responder will likely be inexperienced with needle thoracostomy, any additional trauma caused by this intervention is not expected to worsen the combat casualty significantly, whether or not a tension pneumothorax is present (Cameron et al., 1993). Current protocols used by Special Operations forces medics for treatment of injury on the battlefield are summarized in Box 5-1.
Items 1 through 5 of the protocol in Box 5-1 relate to the special focus of this committee. The committee finds at least two limitations to these approaches: (1) the use of large-volume (1,000 ml) solutions limits their availability on the battlefield, and (2) fluid resuscitation protocols based on intravenous access limit the number of personnel who could provide care on the battlefield. Together, these limitations inevitably restrict fluid resuscitation to only a few of the many who might benefit from such treatment. Both limitations are addressed as part of the committee's conclusions and recommendations.