Br. J..Surg. 1992, Vol. 79, December, 1307-1 308
H. M. Souka Department of Surgery, School of Medicine, Ain - Shams University, Cairo, Egypt Correspondence to: Dr H. M. Souka
Management of Gulf War casua It ies During the Gulf War 84 patients underwent surgery in the Jubail Armed Forces Hospital, Saudi Arabia. The median time to evacuate casualties to hospital was 8 h 40 min. Fragments caused 88 per cent of injuries; 11 per cent were caused by bullets. Multiple lesions were encountered in 70 per cent of patients. The extremities (76 per cent) were the most frequently injured site, the lower limbs more so than the upper. Soft tissue injuries prevailed (59 per cent).
During the Gulf War, Jubail was a key point for medical support of the allied forces. Field hospitals from Sweden, Norway, and the U K and two fleet hospitals from the USA were operating in the area. The Jubail Armed Forces Hospital has 100 beds and is situated in King Abdulaziz Naval Base, 200 km from the front. It received most of the casualties from the Arab allies’ east wing. The Gulf War had the following characteristics: 1 . Complete allied air superiority, allowing safe and effective use of helicopters for evacuation. 2. A good road network, allowing expeditious and safe ground evacuation after injury. 3. A good communications network, allowing advance knowledge of casualties. 4. Limited offensive actions, making conditions for the medical teams optimal. 5. Defensive types of weapons such as mines were responsible for the majority of casualties. 6. Unrealized expectations of high casualties, meaning that medical facilities were left with high reserves.
The management of casualties admitted to Jubail during the War is presented.
Patients and methods A total of 157 war casualties were admitted between 15 January and 8 March 1991. Five patients had bums that were managed without operation. Some had wounds managed primarily in frontline field hospitals. This surgery consisted mainly of amputation, abdominal exploration in unstable patients, and debridement for soft tissue injuries. This paper reports details of the 84 patients undergoing surgery in Jubail Hospital. The receiving doctors followed a standard protocol that included the administration of pethidine, antibiotics and tetanus toxoid, ensuring an adequate intravenous line, determination of haematological and biochemical profiles, and obtaining blood group. Triage was carried out by the most senior surgeon; radiography was requested as needed. For each patient the following details were recorded: name, hospital number, age, sex, nationality, vital data on admission, initial blood profile, time and mode of injury, scene of accident, preliminary supportive care, and anatomical site(s) and structure(s) injured. If multiple wounds were found in, for example, the upper limb, they were counted as one upper-limb injury. Multiple wounds were frequently encountered but only those needing debridement under anaesthesia were counted. The operative and postoperative course, period of hospital stay, and discharge to unit, home or to other medical facilities were recorded.
Results The 84 casualties were mainly Saudi (69 patients), with one American and 14 from other Arab allies. Their median age was 23 (range 18-43) years. There were 33 injuries (28 per cent) to the upper extremities, 55 (47 per cent) to the lower extremities, ten (9 per cent) to the head and neck, seven ( 6 per cent) to the abdomen and
0007-1323/92/ 121307-02
(
1992 Butterworth-Helnemann Ltd
back, nine (8 per cent) to the chest and two (2 per cent) to the external genitalia. Multiple injuries occurred in 59 patients (70 per cent). Penetrating wounds were encountered in the abdomen in two patients, in the chest in two and in the head in two. Fragments caused injury in 74 patients (88 per cent), bullets in nine (11 per cent) and both in one. The structures injured are shown in Table I. The type of operation performed (150 procedures in 107 sessions on 84 patients) is shown in Table 2. The time of injury was clearly established in 62 of the 84 Table 1 Structures injured in 84 casualties receiving surgical treatment No.
Soft tissue Bones Tendons Vascular system Kidneys Urethra Penis and scrotum Lungs Chest wall Diaphragm Stomach Face (fractures) Brain Spinal cord Eyes Total
79 (59) 28 (21)
4 (3) 1(1) l(1) 1(1) 2 (1) l(1) 4 (3) 1(1) 1(1) 1(1)
2 (1) l(1) 7 ( 5) 134 (100)
Values in parentheses are percentages Table 2 Procedures performed treatment
84 patients receiving surgical
on
No. Debridement for soft tissue injury Extraction of foreign bodies External fixation for fractures Fasciotomy Vascular repair (patching) Tendon repair Abdominal exploration Thoracotomy Corneoscleral repair Enucleation of eye Delayed primary suture Minor amputation (foot, toes, etc.) Major amputation (below-knee, above-knee) Urethral repair Colostomy for diversion Total ~~
~~
~
Values in parentheses are percentages
1307
Gulf War casualties: H. M. Souka
casualties. The median delay between injury and the time the patient reached definitive surgical treatment was 8 h 40 min (range 1-25 h). Before the allied invasion of Kuwait, this time was 4 h 10 min (range 2-25 h ) and afterwards 12 h 30 min (range 1-25 h). The median hospital stay was 4 (range 1 - 16) days. Patients were evacuated further from the front for continued postoperative care (70 patients; 83 per cent), or discharged home or to unit (12 patients; 14 per cent). Two patients with penetrating head injuries needed immediate evacuation to a neurosurgical facility for specialized care. The diagnosis in these was made by computed tomography because the sites of the fragments in conventional radiographs did not coincide with the external wounds. Wound debridement was usually carried out by longitudinal extension of the wounds, exposing the underlying cavity, excising devitalized tissue, and cleaning the wound mechanically and by irrigation. Wounds were lightly packed and left open for delayed primary closure 3-5 days later'. Complete fasciotomy for one or more leg compartments was needed in two patients. Injured hand tendons were repaired primarily after adequate debridement in three patients. The wounds were not markedly devitalized. One injury to the posterior tibia1 artery caused by a fragment necessitated patch graft using saphenous vein after adequate debridement. Nephrectomy was carried out in one patient with a penetrating bullet injury that shattered the parenchyma completely. This patient also had a comminuted fracture of the first lumbar vertebra with resultant paraplegia. A urethral injury was repaired primarily in a patient with an extensive pelvic wound involving the left buttock. A transverse colostomy was required for faecal diversion from the pelvic wound. Penile and scrotal wounds were adequately debrided and closed primarily with scrotal drainage. These wounds healed primarily. Lung tears were found in one patient with chest wall trauma after a blast injury. The same patient had a facial fracture that needed interdental occlusion. One diaphragmatic injury was caused by a fragment that penetrated the stomach. The stomach wounds were debrided and closed in two layers; the diaphragm was closed in two layers with non-absorbable sutures. Seven patients had different types of injuries to the eyes; three corneoscleral repairs were carried out and one eye was enucleated. There was no immediate mortality or morbidity, but long-term results were not available because of evacuation of the casualties and difficulties in tracing them.
Discussion Field hospitals became particularly active after the start of the ground attack when the front moved forward dramatically and evacuation through the ground route became more time consuming. The nature of wounds treated in the field hospitals was similar to those in this study'.
1308
Most patients were fit young adults and the majority were haemodynamically stable. Most had soft tissue injuries with varying degrees of contamination. The anatomical distribution of injuries in this study showed higher than expected numbers in the extremities. Previous sites of war wounds have been reported as: head and neck, 12 per cent; thorax, 16 per cent; .~. abdomen, 11 per cent; and extremities, 61 per ~ e n t ~ In contrast, extremity wounds represented 76 per cent of injuries in the present study. This difference may be explained by the use of armoured vests by some allied troops or because of limited offensives by the enemy. Many injuries were caused by defensive mines, which inflicted more wounds to the extremities with lower mortality in those who survived to reach surgical facilities5. Most patients (70 per cent) had multiple lesions caused by fragments. Extraction of foreign bodies was carried out if a fragment was found during debridement. Additional wounds were not made. A limited number of foreign bodies were therefore extracted (16 procedures) in comparison with the 76 debridements for soft tissue injuries. The number of operative sessions was 107, in which 150 procedures were performed, a mean of 1.3 sessions per patient. Delayed primary wound closure was carried out between days 3 and 5, and accounted for most additional surgery. When the front was 200 km from the hospital and before the ground war started, the median lag period was 4 h 10 min (e.g. casualties from the battle for Khafji). After 24 February, when the ground attack started, the median delay was 12 h 30 min. N o difference in morbidity was noticed between these two periods, because of selection by frontline medical officers. Fixed-base hospital facilities are valuable in the management of war casualties and patients fare better than in the mobile smaller field hospitals. The only drawback is the time needed for evacuating the injured. Appropriate triage of casualties in frontline medical units and proper deployment of transportation and communication facilities allow the optimal use of the resources available.
References I.
2.
3.
4.
5.
Oflice ol the Surgeon-General, United States Army. Surcjic.uk GuicMine.s, Opcrut ion Desert ShirkJ. Drwnthcr I Y YO. Washing on, District of Columbia: Center of Excellence in Military Medical Research and Education, Walter Reed Army Medical Center, 1990: X 16. Spalding TJW, Stewart M P M , Tulloch D N , Stephens KM. Penetrating missile injuries in the Gulf War 199 I. Br J Sury 1991; 78: 1102-4. Beehe G W , DeBakey M E . Brtttkt~Cusucik/ir~s.Springfield, Illinois: Thomas, 1952: 165 -205. Reister FA. Buttkc Cusucrkiies und Meclitcrl Siutisiicx: U S Atnty E.vpc,ricwc, rn thc Korcwi Wrrr. Washington, District of Columbia: OtIice of the Surgeon-General, Department of the Army, 1973: 35 -54. Adams DR, Schwah C W . Twenty-one-year experience with land mine injuries. J Truumcr 198X; 28: S159-62.
Paper accepted 24 May 1992
Br. J. Surg.. Vol. 79. No. 12, December 1992
H. M. Souka Department of Surgery, School of Medicine, Ain - Shams University, Cairo, Egypt Correspondence to: Dr H. M. Souka
Management of Gulf War casua It ies During the Gulf War 84 patients underwent surgery in the Jubail Armed Forces Hospital, Saudi Arabia. The median time to evacuate casualties to hospital was 8 h 40 min. Fragments caused 88 per cent of injuries; 11 per cent were caused by bullets. Multiple lesions were encountered in 70 per cent of patients. The extremities (76 per cent) were the most frequently injured site, the lower limbs more so than the upper. Soft tissue injuries prevailed (59 per cent).
During the Gulf War, Jubail was a key point for medical support of the allied forces. Field hospitals from Sweden, Norway, and the U K and two fleet hospitals from the USA were operating in the area. The Jubail Armed Forces Hospital has 100 beds and is situated in King Abdulaziz Naval Base, 200 km from the front. It received most of the casualties from the Arab allies’ east wing. The Gulf War had the following characteristics: 1 . Complete allied air superiority, allowing safe and effective use of helicopters for evacuation. 2. A good road network, allowing expeditious and safe ground evacuation after injury. 3. A good communications network, allowing advance knowledge of casualties. 4. Limited offensive actions, making conditions for the medical teams optimal. 5. Defensive types of weapons such as mines were responsible for the majority of casualties. 6. Unrealized expectations of high casualties, meaning that medical facilities were left with high reserves.
The management of casualties admitted to Jubail during the War is presented.
Patients and methods A total of 157 war casualties were admitted between 15 January and 8 March 1991. Five patients had bums that were managed without operation. Some had wounds managed primarily in frontline field hospitals. This surgery consisted mainly of amputation, abdominal exploration in unstable patients, and debridement for soft tissue injuries. This paper reports details of the 84 patients undergoing surgery in Jubail Hospital. The receiving doctors followed a standard protocol that included the administration of pethidine, antibiotics and tetanus toxoid, ensuring an adequate intravenous line, determination of haematological and biochemical profiles, and obtaining blood group. Triage was carried out by the most senior surgeon; radiography was requested as needed. For each patient the following details were recorded: name, hospital number, age, sex, nationality, vital data on admission, initial blood profile, time and mode of injury, scene of accident, preliminary supportive care, and anatomical site(s) and structure(s) injured. If multiple wounds were found in, for example, the upper limb, they were counted as one upper-limb injury. Multiple wounds were frequently encountered but only those needing debridement under anaesthesia were counted. The operative and postoperative course, period of hospital stay, and discharge to unit, home or to other medical facilities were recorded.
Results The 84 casualties were mainly Saudi (69 patients), with one American and 14 from other Arab allies. Their median age was 23 (range 18-43) years. There were 33 injuries (28 per cent) to the upper extremities, 55 (47 per cent) to the lower extremities, ten (9 per cent) to the head and neck, seven ( 6 per cent) to the abdomen and
0007-1323/92/ 121307-02
(
1992 Butterworth-Helnemann Ltd
back, nine (8 per cent) to the chest and two (2 per cent) to the external genitalia. Multiple injuries occurred in 59 patients (70 per cent). Penetrating wounds were encountered in the abdomen in two patients, in the chest in two and in the head in two. Fragments caused injury in 74 patients (88 per cent), bullets in nine (11 per cent) and both in one. The structures injured are shown in Table I. The type of operation performed (150 procedures in 107 sessions on 84 patients) is shown in Table 2. The time of injury was clearly established in 62 of the 84 Table 1 Structures injured in 84 casualties receiving surgical treatment No.
Soft tissue Bones Tendons Vascular system Kidneys Urethra Penis and scrotum Lungs Chest wall Diaphragm Stomach Face (fractures) Brain Spinal cord Eyes Total
79 (59) 28 (21)
4 (3) 1(1) l(1) 1(1) 2 (1) l(1) 4 (3) 1(1) 1(1) 1(1)
2 (1) l(1) 7 ( 5) 134 (100)
Values in parentheses are percentages Table 2 Procedures performed treatment
84 patients receiving surgical
on
No. Debridement for soft tissue injury Extraction of foreign bodies External fixation for fractures Fasciotomy Vascular repair (patching) Tendon repair Abdominal exploration Thoracotomy Corneoscleral repair Enucleation of eye Delayed primary suture Minor amputation (foot, toes, etc.) Major amputation (below-knee, above-knee) Urethral repair Colostomy for diversion Total ~~
~~
~
Values in parentheses are percentages
1307
Gulf War casualties: H. M. Souka
casualties. The median delay between injury and the time the patient reached definitive surgical treatment was 8 h 40 min (range 1-25 h). Before the allied invasion of Kuwait, this time was 4 h 10 min (range 2-25 h ) and afterwards 12 h 30 min (range 1-25 h). The median hospital stay was 4 (range 1 - 16) days. Patients were evacuated further from the front for continued postoperative care (70 patients; 83 per cent), or discharged home or to unit (12 patients; 14 per cent). Two patients with penetrating head injuries needed immediate evacuation to a neurosurgical facility for specialized care. The diagnosis in these was made by computed tomography because the sites of the fragments in conventional radiographs did not coincide with the external wounds. Wound debridement was usually carried out by longitudinal extension of the wounds, exposing the underlying cavity, excising devitalized tissue, and cleaning the wound mechanically and by irrigation. Wounds were lightly packed and left open for delayed primary closure 3-5 days later'. Complete fasciotomy for one or more leg compartments was needed in two patients. Injured hand tendons were repaired primarily after adequate debridement in three patients. The wounds were not markedly devitalized. One injury to the posterior tibia1 artery caused by a fragment necessitated patch graft using saphenous vein after adequate debridement. Nephrectomy was carried out in one patient with a penetrating bullet injury that shattered the parenchyma completely. This patient also had a comminuted fracture of the first lumbar vertebra with resultant paraplegia. A urethral injury was repaired primarily in a patient with an extensive pelvic wound involving the left buttock. A transverse colostomy was required for faecal diversion from the pelvic wound. Penile and scrotal wounds were adequately debrided and closed primarily with scrotal drainage. These wounds healed primarily. Lung tears were found in one patient with chest wall trauma after a blast injury. The same patient had a facial fracture that needed interdental occlusion. One diaphragmatic injury was caused by a fragment that penetrated the stomach. The stomach wounds were debrided and closed in two layers; the diaphragm was closed in two layers with non-absorbable sutures. Seven patients had different types of injuries to the eyes; three corneoscleral repairs were carried out and one eye was enucleated. There was no immediate mortality or morbidity, but long-term results were not available because of evacuation of the casualties and difficulties in tracing them.
Discussion Field hospitals became particularly active after the start of the ground attack when the front moved forward dramatically and evacuation through the ground route became more time consuming. The nature of wounds treated in the field hospitals was similar to those in this study'.
1308
Most patients were fit young adults and the majority were haemodynamically stable. Most had soft tissue injuries with varying degrees of contamination. The anatomical distribution of injuries in this study showed higher than expected numbers in the extremities. Previous sites of war wounds have been reported as: head and neck, 12 per cent; thorax, 16 per cent; .~. abdomen, 11 per cent; and extremities, 61 per ~ e n t ~ In contrast, extremity wounds represented 76 per cent of injuries in the present study. This difference may be explained by the use of armoured vests by some allied troops or because of limited offensives by the enemy. Many injuries were caused by defensive mines, which inflicted more wounds to the extremities with lower mortality in those who survived to reach surgical facilities5. Most patients (70 per cent) had multiple lesions caused by fragments. Extraction of foreign bodies was carried out if a fragment was found during debridement. Additional wounds were not made. A limited number of foreign bodies were therefore extracted (16 procedures) in comparison with the 76 debridements for soft tissue injuries. The number of operative sessions was 107, in which 150 procedures were performed, a mean of 1.3 sessions per patient. Delayed primary wound closure was carried out between days 3 and 5, and accounted for most additional surgery. When the front was 200 km from the hospital and before the ground war started, the median lag period was 4 h 10 min (e.g. casualties from the battle for Khafji). After 24 February, when the ground attack started, the median delay was 12 h 30 min. N o difference in morbidity was noticed between these two periods, because of selection by frontline medical officers. Fixed-base hospital facilities are valuable in the management of war casualties and patients fare better than in the mobile smaller field hospitals. The only drawback is the time needed for evacuating the injured. Appropriate triage of casualties in frontline medical units and proper deployment of transportation and communication facilities allow the optimal use of the resources available.
References I.
2.
3.
4.
5.
Oflice ol the Surgeon-General, United States Army. Surcjic.uk GuicMine.s, Opcrut ion Desert ShirkJ. Drwnthcr I Y YO. Washing on, District of Columbia: Center of Excellence in Military Medical Research and Education, Walter Reed Army Medical Center, 1990: X 16. Spalding TJW, Stewart M P M , Tulloch D N , Stephens KM. Penetrating missile injuries in the Gulf War 199 I. Br J Sury 1991; 78: 1102-4. Beehe G W , DeBakey M E . Brtttkt~Cusucik/ir~s.Springfield, Illinois: Thomas, 1952: 165 -205. Reister FA. Buttkc Cusucrkiies und Meclitcrl Siutisiicx: U S Atnty E.vpc,ricwc, rn thc Korcwi Wrrr. Washington, District of Columbia: OtIice of the Surgeon-General, Department of the Army, 1973: 35 -54. Adams DR, Schwah C W . Twenty-one-year experience with land mine injuries. J Truumcr 198X; 28: S159-62.
Paper accepted 24 May 1992
Br. J. Surg.. Vol. 79. No. 12, December 1992
