World J. Surg. 16, 888-892, 1992
World Journal of Surgery © 1992 by the Soci,~t~ lnternationale de Chirurgie
The Medical Effects of Conventional Weapons Ronald F. Bellamy, M.D. Department of Surgery, Walter Reed Army Medical Center, Washington, D.C., U.S.A. The medical effects of weapons used in modern conventional warfare are, overwhelmingly, penetrating. Fragments from explosive munitions such as shells, rockets, and grenades are the predominate source of missiles, especially in high-intensity war. Bullets from assault rifles and machine guns cause fewer casualties, except in counterinsurgency operations. The threat from penetrating missiles depends upon the partof the body that is struck and, to a lesser extent, upon the physical characteristics of the missile. The missile's mass and velocity determine its potential to do physical damage, but the extent to which this potential is realized depends upon diverse factors such as shape, construction, and stability. The American experience in the wars of this century indicate that approximately 20 %-25 % of all casualties died on the battlefield and are therefore classified as killed in action. Approximately 3%-5% die while receiving care, and thus are classified as died of wounds. Wounds of the brain or heart and great vessels are the most common causes of death. Prevention of sepsis in soft-tissue and orthopedic wounds is the major medical treatment problem in survivors. S i n c e it determines the quality and quantity of combat casualty care, the single most important factor determining mortality or morbidity for combat casualties is the tactical situation.
Trauma in the combat zone is categorized into battle injuries (which result from the hostile actions of a military enemy) and nonbattle injuries (which are not caused by the enemy). Although nonbattle injuries share certain similarities with civilian trauma (motor vehicle and aircraft accidents are especially common), they usually are caused by accidents with explosive munitions. Thus, although this paper addresses battle injuries per se, much of the discussion applies equally to nonbattle injuries. M e c h a n i s m s of C o m b a t Injury
Penetrating missiles cause 90% of combat trauma (versus 25%--50% in the civilian sector) and blast, thermal, and blunt trauma account for the remaining 10%. In future high-intensity warfare, the proportion of casualties with burns will probably increase because large numbers of troops will serve in armored fighting vehicles (AFVs) and will be exposed to fires that result from battle damage. Future wars will probably also have a higher proportion of casualties with primary blast injury (PBI) Reprint requests: Ronald F. Bellamy, M.D.. Colonel, MC, U.S. Army, Walter Reed Army Medical Center, Washington, D.C. 203075001, U.S.A.
resulting from the perfection of fuel-air explosive munitions (FAEs). Blunt injury, which is the major focus of civilian trauma care, has minor significance in combat. When it occurs in combat, blunt injury is usually the result of an acceleration/deceleration mechanism and affects the crew of an A F V that has just detonated an antitank mine. W e a p o n s that Cause Penetrating Injuries
There are two sources of penetrating missiles: bullets from small arms and fragments from explosive munitions. Their relative casualty generation depends upon the type of battle. Bullets generate proportionately more casualties in low-intensity, counterinsurgency, light-infantry actions (50% of the casualties in Vietnam had bullet wounds), while fragments from explosive munitions cause most (more than 75%) of the medical workload in medium-intensity and high-intensity conventional wars [1]. Small A r m s
The two important classes of military small arms are the machine gun and the assault rifle. Both are fully automatic weapons that have a high probability of scoring multiple hits when used at close tactical range. Their bullets have characteristic muzzle velocities of 2,800-3,200 feet per second (fps). The probability that a single hit made at random by a bullet from a military small arm will be fatal is about 1 in 3. In contrast, the muzzle velocity of bullets fired from civilian handguns is characteristically 800-1200 fps. The observed mortality from a single hit made by a civilian handgun is about 1 in 10 and, until recently, fewer than 10% of the victims had multiple hits [1]. Explosive Munitions
Explosive munitions range in size from hand grenades, which weigh several ounces, to aerial bombs, which weigh several tons. The basic design of a fragmentation munition requires that a metal container break apart when an internal explosive charge detonates. Depending upon the munition's size and design, several thousand metal fragments may be produced, ranging in weight from a few milligrams to many grams and in initial
R.F. Beilamy: Weapons Effects velocity up to 5,000-6,000 fps. Fragments radiate from the detonation site and, even though their velocity is severely degraded over a short distance, they can retain their wounding potential for up to several hundred feet. An explosion also can injure by its blast and thermal effects. However, the radii of blast and thermal effects are very much shorter than the radius of fragments, and a casualty who sustains blast and thermal injuries from an explosive munition will probably be killed by fragments. The observed lethality associated with a conventional shell is about 1 in 5. Hand grenades fatally injure about 1 in I0 [1]. Most modern explosive munitions are designed to use the improved fragmentation approach. For example, a cluster bomb contains many small submunitions that in turn are filled With small, preformed fragments, the size and shape of which have been designed to cause a large number of casualties, with multiple hits on a given casualty. Another approach favored by Weapons designers is to replace the fragments with flechettes, Small steel arrows designed for great penetration. Thus, casua/ties who have been riddled with small missiles are commonly fOUnd on modern battlefields. This type of injury has no direct civilian analogy. Modern warfare, because of its emphasis upon mechanization, generates casualties With somewhat different types of injuries than those encountered in the past. Data from studies Performed in 1945 and 1973 indicate that there are 2 to 3 casualties in each tank in which the crew compartment is Penetrated by an antiarmor round. About 40% of these casualties Will be killed. Burns (40%) and fractures (50%) are the most COmmon injuries among survivors. More than 50% of the WOUnding occurred at the moment of penetration, the casualties being injured by fragments from the penetrator, spall from the defeated armor, or burns from the jet of a shaped-charge Warhead. Secondary explosions and fires cause about 20% of the casualties. Interestingly, the data from World War II indicate that a significant number of casualties also occurred as the crew attempted to escape from a disabled tank.
Ballistics Two mechanisms by which penetrating missiles may cause tissue damage are cutting and lacerating the tissue directly in the missile's path, and radially stretching and tearing the tissue SUrrounding the missile's path. The visible hole in the tissue is known as the permanent tract. It consists of a wound of entrance and, if the projectile perforates the tissue, a wound of exit. The permanent tract is primarily caused by cutting and lacerating. The stretching and tearing mechanism, known as bemp°rary cavitation, has a variable effect that ranges from a nrely perceptible area of ecchymosis around the missile's path ~°ea grossly explosive effect such as shattering the skull or art. Which mechanism has the greater effect depends upon both the characteristics of the missile and the anatomical location of the wound tract. For a target such as the heart or the gluteus maximus, the magnitude of the tissue damage (but not necessarily the magnitude of the medical problem) is related to the amount of energy that is transferred from the missile to the target. Fast-moving, heavy missiles have more energy to transfer (1/2 MV 2) and therefore have the potential to cause more
889 tissue damage. To what extent that potential is realized depends upon several factors: 1. The projectile's shape: The more blunt the missile's penetrating aspect, the more energy transfer at the point of impact, and the more tissue damage at the wound of entrance. Large shell fragments frequently cause large wounds of entrance. 2. The projectile's stability: The more yaw (the misalignment of the missile's long axis and its trajectory) and tumbling (the missile flips over) the more energy transfer and tissue damage. Missile instability may occur at any point along the missile's trajectory within tissue. The effects of rounds fired by the AK series of assault rifles in part depend upon the propensity of the bullets to destabilize in tissue. 3. The projectile's construction: The more missiles deform or break apart within the target, the more tissue damage. Rounds fired by the M16 assault rifle tend to fragment in tissue, which increases the tissue damage. 4. The target's viscoelasticity: Temporary cavitation can be an extremely destructive process in organs that are (a) friable (the liver), (b) fluid-filled (the heart), or (c) contained within a rigid shell (the brain). Muscle is less susceptible to stretch injury and lung tolerates temporary cavitation rather well. The gross temporary cavitation that an assault-rifle bullet can cause is usually seen in dead rather than in living casualties [1]. Tissue damage caused by penetrating missiles falls into two broad categories, wounds to the viscera and wounds to soft tissue (skin, fat, and skeletal muscle) and to bone. Life-saving interventions such as those that are applied to casualties who have airway, breathing, and circulatory distress are primarily applicable to those with visceral wounds, while morbidity from wound sepsis is the primary concern in casualties with bone and soft-tissue wounds. All battlefield wounds are assumed to be contaminated and at risk of developing sepsis. The major focus of combat casualty care, in contrast to civilian trauma care, is the management of soft-tissue trauma. The military surgeon strives to prevent the development of wound sepsis by surgically removing areas of tissue damage and contamination. This is done by debriding the wound tract; the surgeon opens and mechanically cleanses the wound. Although much stress is placed upon the need to remove dead tissue around the permanent wound tract, except in unusual circumstances such as when an artery is severed, little dead tissue is actually present. Instead, there is contused tissue contaminated with foreign material from the outside that the missile carried into the wound.
Nonpenetrating Weapons Effects Military physicians commonly encounter three nonpenetrating mechanisms of injury: blast, thermal burns, and phosphorus toxicity. Blast
An explosion produces a pressure transient that can propagate through the air at an initial velocity that exceeds the speed of sound, can have an overpressure of hundreds of pounds per
890
World J. Surg. Vol. 16, No. 5, Sept./Oct. 1992
LOCATION OF BATTLE DEATHS
Table 1. Anatomical sites of the most serious wounds. Wounds involving only skin, fat, and skeletal muscle anywhere on the body Bony skeleton and neurovascular structures, and the bony pelvis and shoulders Abdomen, including viscera, lumbar spine, and pelvic organs Multiple wounds (of equivalent severity) involving any combin~.tion of head, face, thorax, abdomen, and extremities Face, including eyes Thorax, including bony thorax, thoracic viscera, and spine Head, including skull and brain Neck, including the spine
44%
100-
28%
9oI~I
8% 5% 5% 5%
E 6o. i
giii
W W II KOREA VIETNAM
3o.
4%
1%
Reprinted with permission of publisher [2].
Battlefield Table 2. Distribution of wounds by type of surgery.
Minor soft-tissue debridement Fractures or amputations Major s0ft-tissue debridements or burns Laparotomies Chest (80% needed only a chest tube) Face, eye, and/or neck Multiple injuries (craniotomy, thoracotomy, laparotomy, debridement, amputation, and so forth) Craniotomies Or craniectomies Peripheral vascular repair
31% 27% 10% 10% 6% 6% 4% 3% 3%
Reprinted with permission of publisher [3].
square inch (psi), and lasts for several milliseconds. A blast overpressure of 5-6 psi is capable of rupturing the tympanic membranes; overpressures ten times greater will cause pulmonary contusions. Higher overpressures may cause death from massive coronary-vessel and cerebral-vessel air embolism. Vigorous positive-pressure ventilation is known to increase the probability of air embolism. These phenomena are referred to as PBI. Secondary blast injury is a penetrating wound caused by fragments, which physicians treat the same as they do any ballistic wound. Tertiary blast effects are caused by the mass of moving air (the blast wind) that follows an explosion and blows the casualty over or against solid objects. This may cause injuries that have some of the characteristics of blunt trauma.
Aid Station Surg. & Evac. & Hospital Clearing Company
General Hospital & CONUS
Fig. 1. Location of battle deaths for Unites States Army casualties in three wars of this century. The great majority of American soldiers who have been fatally wounded have died on the battlefield.
phorus have unique qualities that are not commonly encountered in civilian medical practice. Phosphorus can cause both thermal and chemical injury. Because it will ignite in air, phosphorus particles that are imbedded in tissue must be prevented from coming into contact with air. This can best be done by applying saline-soaked dressings to the wound. Rarely, life-threatening hypocalcemia secondary to absorbed phosphorus will develop. It is essential that all particles of phosphorus be removed from the casualty's body. Copper sulfate aids in recognizing phosphorus embedded in tissue, but with prolonged contact with tissue, it can also be toxic to the patient. Anatomical Distribution of Wounds
When the population of combat casualties in modern war is considered, penetrating missile wounds are found to be distributed as a function of body surface area, except that slightly more wounds of the head, and correspondingly fewer wounds of the trunk, occur. Analysis of anatomical distribution is complicated by several factors [2]:
Phosphorus Toxicity
1. Fatally and nonfatally wounded casualties have very different distributions by body Surface area, 2. Many casualties have multiple wounds on more than one body part; there are conceptual problems in categorizing such patients. 3. Effective body armor or unusual tactical postures can mark" edly affect the distribution of wounds. 4. Distribution by body surface area is not necessarily indicative of the severity of the wound or of the medical work load. For example, a soft-tissue wound of the abdominal wall and a perforating wound of the small intestine are both catego" rized as wounds of the abdominal body region, but the intraabdominai injury generates the much greater medical work load.
Although flame and incendiary weapons have limited application on modern battlefields, munitions that contain white phos-
The distribution of wounds seen in surviving casualties (Table I) is based upon World War II and Vietnam data, which
Thermal Burns Most burns in past wars occurred during training accidents, and patients could be cared for with standard civilian burn therapy. However, with the increased use of AFVs, initial burn care will be administered under combat conditions. As an added complication, most burn casualties will also sustain penetrating trauma, inhalation injury, or spotty deep burns associated with shaped-charge warheads (burns caused by tiny incandescent metal fragments from the vaporific effects and spalling within AFVs).
R.F. Bellamy: Weapons Effects
U.S. ARMY CASUALTIES
26%. 24%. 22%.
.-.~
-26% -24% -22%
m
J I
20%-
le%.
891
-20% 18%
,,mini
16%.
16%
I
.J
O
14%.
]4%
12%.
12% I0%
1o%. 8%6%-
1ill
2%. 0%-
E
W
'1943 1944 1945 1944 945 1944 1945 1945 SWPA POA MED EUR WW I
WW II
it O -4
-4 -,
World Journal of Surgery © 1992 by the Soci,~t~ lnternationale de Chirurgie
The Medical Effects of Conventional Weapons Ronald F. Bellamy, M.D. Department of Surgery, Walter Reed Army Medical Center, Washington, D.C., U.S.A. The medical effects of weapons used in modern conventional warfare are, overwhelmingly, penetrating. Fragments from explosive munitions such as shells, rockets, and grenades are the predominate source of missiles, especially in high-intensity war. Bullets from assault rifles and machine guns cause fewer casualties, except in counterinsurgency operations. The threat from penetrating missiles depends upon the partof the body that is struck and, to a lesser extent, upon the physical characteristics of the missile. The missile's mass and velocity determine its potential to do physical damage, but the extent to which this potential is realized depends upon diverse factors such as shape, construction, and stability. The American experience in the wars of this century indicate that approximately 20 %-25 % of all casualties died on the battlefield and are therefore classified as killed in action. Approximately 3%-5% die while receiving care, and thus are classified as died of wounds. Wounds of the brain or heart and great vessels are the most common causes of death. Prevention of sepsis in soft-tissue and orthopedic wounds is the major medical treatment problem in survivors. S i n c e it determines the quality and quantity of combat casualty care, the single most important factor determining mortality or morbidity for combat casualties is the tactical situation.
Trauma in the combat zone is categorized into battle injuries (which result from the hostile actions of a military enemy) and nonbattle injuries (which are not caused by the enemy). Although nonbattle injuries share certain similarities with civilian trauma (motor vehicle and aircraft accidents are especially common), they usually are caused by accidents with explosive munitions. Thus, although this paper addresses battle injuries per se, much of the discussion applies equally to nonbattle injuries. M e c h a n i s m s of C o m b a t Injury
Penetrating missiles cause 90% of combat trauma (versus 25%--50% in the civilian sector) and blast, thermal, and blunt trauma account for the remaining 10%. In future high-intensity warfare, the proportion of casualties with burns will probably increase because large numbers of troops will serve in armored fighting vehicles (AFVs) and will be exposed to fires that result from battle damage. Future wars will probably also have a higher proportion of casualties with primary blast injury (PBI) Reprint requests: Ronald F. Bellamy, M.D.. Colonel, MC, U.S. Army, Walter Reed Army Medical Center, Washington, D.C. 203075001, U.S.A.
resulting from the perfection of fuel-air explosive munitions (FAEs). Blunt injury, which is the major focus of civilian trauma care, has minor significance in combat. When it occurs in combat, blunt injury is usually the result of an acceleration/deceleration mechanism and affects the crew of an A F V that has just detonated an antitank mine. W e a p o n s that Cause Penetrating Injuries
There are two sources of penetrating missiles: bullets from small arms and fragments from explosive munitions. Their relative casualty generation depends upon the type of battle. Bullets generate proportionately more casualties in low-intensity, counterinsurgency, light-infantry actions (50% of the casualties in Vietnam had bullet wounds), while fragments from explosive munitions cause most (more than 75%) of the medical workload in medium-intensity and high-intensity conventional wars [1]. Small A r m s
The two important classes of military small arms are the machine gun and the assault rifle. Both are fully automatic weapons that have a high probability of scoring multiple hits when used at close tactical range. Their bullets have characteristic muzzle velocities of 2,800-3,200 feet per second (fps). The probability that a single hit made at random by a bullet from a military small arm will be fatal is about 1 in 3. In contrast, the muzzle velocity of bullets fired from civilian handguns is characteristically 800-1200 fps. The observed mortality from a single hit made by a civilian handgun is about 1 in 10 and, until recently, fewer than 10% of the victims had multiple hits [1]. Explosive Munitions
Explosive munitions range in size from hand grenades, which weigh several ounces, to aerial bombs, which weigh several tons. The basic design of a fragmentation munition requires that a metal container break apart when an internal explosive charge detonates. Depending upon the munition's size and design, several thousand metal fragments may be produced, ranging in weight from a few milligrams to many grams and in initial
R.F. Beilamy: Weapons Effects velocity up to 5,000-6,000 fps. Fragments radiate from the detonation site and, even though their velocity is severely degraded over a short distance, they can retain their wounding potential for up to several hundred feet. An explosion also can injure by its blast and thermal effects. However, the radii of blast and thermal effects are very much shorter than the radius of fragments, and a casualty who sustains blast and thermal injuries from an explosive munition will probably be killed by fragments. The observed lethality associated with a conventional shell is about 1 in 5. Hand grenades fatally injure about 1 in I0 [1]. Most modern explosive munitions are designed to use the improved fragmentation approach. For example, a cluster bomb contains many small submunitions that in turn are filled With small, preformed fragments, the size and shape of which have been designed to cause a large number of casualties, with multiple hits on a given casualty. Another approach favored by Weapons designers is to replace the fragments with flechettes, Small steel arrows designed for great penetration. Thus, casua/ties who have been riddled with small missiles are commonly fOUnd on modern battlefields. This type of injury has no direct civilian analogy. Modern warfare, because of its emphasis upon mechanization, generates casualties With somewhat different types of injuries than those encountered in the past. Data from studies Performed in 1945 and 1973 indicate that there are 2 to 3 casualties in each tank in which the crew compartment is Penetrated by an antiarmor round. About 40% of these casualties Will be killed. Burns (40%) and fractures (50%) are the most COmmon injuries among survivors. More than 50% of the WOUnding occurred at the moment of penetration, the casualties being injured by fragments from the penetrator, spall from the defeated armor, or burns from the jet of a shaped-charge Warhead. Secondary explosions and fires cause about 20% of the casualties. Interestingly, the data from World War II indicate that a significant number of casualties also occurred as the crew attempted to escape from a disabled tank.
Ballistics Two mechanisms by which penetrating missiles may cause tissue damage are cutting and lacerating the tissue directly in the missile's path, and radially stretching and tearing the tissue SUrrounding the missile's path. The visible hole in the tissue is known as the permanent tract. It consists of a wound of entrance and, if the projectile perforates the tissue, a wound of exit. The permanent tract is primarily caused by cutting and lacerating. The stretching and tearing mechanism, known as bemp°rary cavitation, has a variable effect that ranges from a nrely perceptible area of ecchymosis around the missile's path ~°ea grossly explosive effect such as shattering the skull or art. Which mechanism has the greater effect depends upon both the characteristics of the missile and the anatomical location of the wound tract. For a target such as the heart or the gluteus maximus, the magnitude of the tissue damage (but not necessarily the magnitude of the medical problem) is related to the amount of energy that is transferred from the missile to the target. Fast-moving, heavy missiles have more energy to transfer (1/2 MV 2) and therefore have the potential to cause more
889 tissue damage. To what extent that potential is realized depends upon several factors: 1. The projectile's shape: The more blunt the missile's penetrating aspect, the more energy transfer at the point of impact, and the more tissue damage at the wound of entrance. Large shell fragments frequently cause large wounds of entrance. 2. The projectile's stability: The more yaw (the misalignment of the missile's long axis and its trajectory) and tumbling (the missile flips over) the more energy transfer and tissue damage. Missile instability may occur at any point along the missile's trajectory within tissue. The effects of rounds fired by the AK series of assault rifles in part depend upon the propensity of the bullets to destabilize in tissue. 3. The projectile's construction: The more missiles deform or break apart within the target, the more tissue damage. Rounds fired by the M16 assault rifle tend to fragment in tissue, which increases the tissue damage. 4. The target's viscoelasticity: Temporary cavitation can be an extremely destructive process in organs that are (a) friable (the liver), (b) fluid-filled (the heart), or (c) contained within a rigid shell (the brain). Muscle is less susceptible to stretch injury and lung tolerates temporary cavitation rather well. The gross temporary cavitation that an assault-rifle bullet can cause is usually seen in dead rather than in living casualties [1]. Tissue damage caused by penetrating missiles falls into two broad categories, wounds to the viscera and wounds to soft tissue (skin, fat, and skeletal muscle) and to bone. Life-saving interventions such as those that are applied to casualties who have airway, breathing, and circulatory distress are primarily applicable to those with visceral wounds, while morbidity from wound sepsis is the primary concern in casualties with bone and soft-tissue wounds. All battlefield wounds are assumed to be contaminated and at risk of developing sepsis. The major focus of combat casualty care, in contrast to civilian trauma care, is the management of soft-tissue trauma. The military surgeon strives to prevent the development of wound sepsis by surgically removing areas of tissue damage and contamination. This is done by debriding the wound tract; the surgeon opens and mechanically cleanses the wound. Although much stress is placed upon the need to remove dead tissue around the permanent wound tract, except in unusual circumstances such as when an artery is severed, little dead tissue is actually present. Instead, there is contused tissue contaminated with foreign material from the outside that the missile carried into the wound.
Nonpenetrating Weapons Effects Military physicians commonly encounter three nonpenetrating mechanisms of injury: blast, thermal burns, and phosphorus toxicity. Blast
An explosion produces a pressure transient that can propagate through the air at an initial velocity that exceeds the speed of sound, can have an overpressure of hundreds of pounds per
890
World J. Surg. Vol. 16, No. 5, Sept./Oct. 1992
LOCATION OF BATTLE DEATHS
Table 1. Anatomical sites of the most serious wounds. Wounds involving only skin, fat, and skeletal muscle anywhere on the body Bony skeleton and neurovascular structures, and the bony pelvis and shoulders Abdomen, including viscera, lumbar spine, and pelvic organs Multiple wounds (of equivalent severity) involving any combin~.tion of head, face, thorax, abdomen, and extremities Face, including eyes Thorax, including bony thorax, thoracic viscera, and spine Head, including skull and brain Neck, including the spine
44%
100-
28%
9oI~I
8% 5% 5% 5%
E 6o. i
giii
W W II KOREA VIETNAM
3o.
4%
1%
Reprinted with permission of publisher [2].
Battlefield Table 2. Distribution of wounds by type of surgery.
Minor soft-tissue debridement Fractures or amputations Major s0ft-tissue debridements or burns Laparotomies Chest (80% needed only a chest tube) Face, eye, and/or neck Multiple injuries (craniotomy, thoracotomy, laparotomy, debridement, amputation, and so forth) Craniotomies Or craniectomies Peripheral vascular repair
31% 27% 10% 10% 6% 6% 4% 3% 3%
Reprinted with permission of publisher [3].
square inch (psi), and lasts for several milliseconds. A blast overpressure of 5-6 psi is capable of rupturing the tympanic membranes; overpressures ten times greater will cause pulmonary contusions. Higher overpressures may cause death from massive coronary-vessel and cerebral-vessel air embolism. Vigorous positive-pressure ventilation is known to increase the probability of air embolism. These phenomena are referred to as PBI. Secondary blast injury is a penetrating wound caused by fragments, which physicians treat the same as they do any ballistic wound. Tertiary blast effects are caused by the mass of moving air (the blast wind) that follows an explosion and blows the casualty over or against solid objects. This may cause injuries that have some of the characteristics of blunt trauma.
Aid Station Surg. & Evac. & Hospital Clearing Company
General Hospital & CONUS
Fig. 1. Location of battle deaths for Unites States Army casualties in three wars of this century. The great majority of American soldiers who have been fatally wounded have died on the battlefield.
phorus have unique qualities that are not commonly encountered in civilian medical practice. Phosphorus can cause both thermal and chemical injury. Because it will ignite in air, phosphorus particles that are imbedded in tissue must be prevented from coming into contact with air. This can best be done by applying saline-soaked dressings to the wound. Rarely, life-threatening hypocalcemia secondary to absorbed phosphorus will develop. It is essential that all particles of phosphorus be removed from the casualty's body. Copper sulfate aids in recognizing phosphorus embedded in tissue, but with prolonged contact with tissue, it can also be toxic to the patient. Anatomical Distribution of Wounds
When the population of combat casualties in modern war is considered, penetrating missile wounds are found to be distributed as a function of body surface area, except that slightly more wounds of the head, and correspondingly fewer wounds of the trunk, occur. Analysis of anatomical distribution is complicated by several factors [2]:
Phosphorus Toxicity
1. Fatally and nonfatally wounded casualties have very different distributions by body Surface area, 2. Many casualties have multiple wounds on more than one body part; there are conceptual problems in categorizing such patients. 3. Effective body armor or unusual tactical postures can mark" edly affect the distribution of wounds. 4. Distribution by body surface area is not necessarily indicative of the severity of the wound or of the medical work load. For example, a soft-tissue wound of the abdominal wall and a perforating wound of the small intestine are both catego" rized as wounds of the abdominal body region, but the intraabdominai injury generates the much greater medical work load.
Although flame and incendiary weapons have limited application on modern battlefields, munitions that contain white phos-
The distribution of wounds seen in surviving casualties (Table I) is based upon World War II and Vietnam data, which
Thermal Burns Most burns in past wars occurred during training accidents, and patients could be cared for with standard civilian burn therapy. However, with the increased use of AFVs, initial burn care will be administered under combat conditions. As an added complication, most burn casualties will also sustain penetrating trauma, inhalation injury, or spotty deep burns associated with shaped-charge warheads (burns caused by tiny incandescent metal fragments from the vaporific effects and spalling within AFVs).
R.F. Bellamy: Weapons Effects
U.S. ARMY CASUALTIES
26%. 24%. 22%.
.-.~
-26% -24% -22%
m
J I
20%-
le%.
891
-20% 18%
,,mini
16%.
16%
I
.J
O
14%.
]4%
12%.
12% I0%
1o%. 8%6%-
1ill
2%. 0%-
E
W
'1943 1944 1945 1944 945 1944 1945 1945 SWPA POA MED EUR WW I
WW II
it O -4
-4 -,
![[Medical aspects of common non-lethal weapons].](/assets/img/hold.png)
