8 Resuscitation and Anesthesia for the Ballistic Casualty

8

Resuscitation and Anesthesia for the Ballistic Casualty

Paul R. Wood, Adam J. Brooks, and Peter F. Mahoney

151

Introduction

The first part of this chapter focuses on the assessment and resuscitation of the ballistic casualty. The second part discusses the anesthetic considera- tions required for these patients.

Resuscitation

Preparation

Medical facilities in all locations—urban, rural, or austere—need to prepare to receive casualties well before they arrive. In a civilian hospital, this is likely to involve activating the trauma team and notifying other key per- sonnel. In a military field hospital, this preparation will include putting a system in place to remove safely the casualty’s weapons and ammunition (Figure 8-1).

Casualties exposed to chemicals or other noxious agents will need decon- tamination before entering the hospital.

Trauma Teams

The trauma team needs to be briefed with any prehospital information that is available. The objectives of the trauma team are to identify, assess, and treat life-threatening injuries. The running of the team is aided by an effec- tive and organized team leader and clear allocation of tasks and roles to the team members in advance of the casualty arriving.

Driscoll

demonstrated the advantage of a trauma team approach with

horizontal organization. These works showed that there is improved effi-

ciency of the resuscitation and a reduction in the time taken for the casu-

alty to receive definitive care when tasks are carried out simultaneously by

the team members.

The ideal size of the team has not been defined, but is probably between 6 and 10 team members, including doctors, nursing staff, and a radiographer.

Team Activation

A hospital receiving trauma needs to define what criteria will initiate trauma team activation. These can be based on a combination of history, vital signs, or injuries. Many systems build a substantial overtriage into the system to prevent serious injuries being missed (Table 8-1).

Most systems include any gunshot wound as an activation criteria. In field hospitals, this may be augmented to include blast- and mine-related injuries.

Clinical

The principles that guide resuscitation of the ballistic casualty are essen- tially those described in the Advanced Trauma Life Support/Battlefield Advanced Trauma Life Support (ATLS/BATLS) Courses. The following section will highlight the differences and peculiarities associated with resus- citation of ballistic injury.

Figure 8-1. During one of many training exercises in the 1990–1991 Gulf War, troops were used as exercise casualties to test the hospital. This soldier had arrived in the resuscitation department with his hand grenades still on his person.

Airway & Cervical Spine Control

Simple First

It is easy to become fixated on advanced airway procedures and forget about simple ones. The primary issue is ensuring oxygenation of the casu- alty. The method will depend on the casualty’s injuries, the skill of the care- giver, and the resources available (Figure 8-2).

There are a number of other airway issues that are associated with ballistic trauma, especially where it involves the head and neck.

Collars

The issue of cervical spine immobilization for ballistic injury is considered in Chapters 7 and 16.

In the ballistic casualty, the pragmatic approach is that cervical spine immobilization should be undertaken in the presence of blunt injury and combined blunt and penetrating injury, but not in penetrating ballistic injury alone.

In the presence of a cervical collar, laryngoscopy becomes more difficult.

Criswell et al.

described a successful management plan:

i. An assistant provides manual in-line immobilization of the cervical spine.

ii. The equipment stabilizing the cervical spine is removed (in the case of collars, this may mean unfastened and opened rather than completely removed).

Table 8-1. Trauma activation criteria Airway compromise

Signs of pneumothorax Saturations<90%

Pulse>120 or systolic blood pressure (BP) 90-millimeters mercury (Hg)

Unconscious> five minutes

An incident with five or more casualties An incident involving fatality

High-speed motor-vehicle crash Patient ejected from the vehicle Knife wound to the groin and above Any gunshot wound or blast or mine injury Significant burns (Chapter 21)

Fall from >8 meters

Child with altered consciousness, capillary refill >3secs, pulse

>130

Child pedestrian or cyclist hit by a vehicle

Adapted from Better Care for the Severely Injured, Royal College of Surgeons of England and British Orthopedic Association, 2000.

iii. The patient is preoxygenated (ideally 2 to 3 minutes, but this depends on their condition).

iv. A separate assistant applies cricoid pressure.

v. The patient receives anesthetic drugs and rapid-acting neuromuscular- blocking drugs.

vi. The patient’s trachea is intubated, the endotracheal tube position is checked, and the tube is secured.

vii. The stabilizing devices are reapplied.

In this situation, management must include appropriate equipment and a rehearsed plan for dealing with a grade 2–3 laryngoscopy and failed intu- bation. A gum-elastic bougie and a small-diameter (uncut) endotracheal tube should be available.

Figure 8-2. Gunshot Wound (GSW) face. This casualty had multiple GSW to the face and head (fired from both a 9-millimeter pistol and 7.62-millimeter AK 47). He was very agitated, with a decreased conscious level. The paramedic used a jaw thrust to attain an airway, then a nasopharyngeal tube to help maintain it. The hospital the paramedic went to refused the patient for economic and political reasons. A heli- copter team was called, but they had to finish another job first. When they arrived, they anesthetized the casualty and performed endotracheal intubation. This was dif- ficult, as the casualty had facial swelling and other damage from the bullets. The paramedic had successfully managed the casualty’s airway for 2 hours using simple methods.

Compression

Survivors of penetrating trauma to the neck are at risk of tracheal compression from hemorrhage. If this is suspected, and particularly if the patient is to be moved for computerized tomography (CT) or other imaging, the trachea should be intubated early under controlled conditions rather than as an emergency when the airway is compromised, narrowed, or displaced.

Partial severance of the trachea (Figures 8-3 and 8-4) is a rare but poten- tially disastrous situation, and attempted endotracheal intubation may complete the disruption. Extreme care must be exercised with positioning the head and neck, and subsequent successful management will depend upon the availability of expertise in fiberoptic bronchoscopy and/or tracheostomy.

Burns

Burns of the head and neck represent a potential major airway hazard. If there is any doubt over the possibility of developing airway compromise, then early endotracheal intubation is required, especially if patient transfer is anticipated.

Figure 8-3. Cut neck. This casualty had an open trachea from a knife injury. He was managed at a resource-limited field hospital by anesthesia, gentle endotracheal intu- bation, and a tracheostomy. An alternative would have been a tracheostomy as the first procedure.

In the absence of anesthetic training, drugs, and equipment to achieve this, or in other situations where endotracheal intubation is not possible or has failed, an urgent surgical airway is required.

In most situations, this means a surgical cricothyridotomy. The aim is to secure the airway with a cuffed tracheostomy tube of 6.0-millimeter inter- nal diameter or greater. This provides a definitive airway through which the patient can breathe or receive intermittent positive-pressure ventilation.

Figure 8-4. Shot neck. This casualty arrived in extremis with a gunshot wound to the front of the neck. Air was bubbling from the wound. He presented a similar dilemma to the patient in Figure 8-3. He was intubated with a 7.0 endotracheal tube.

Attending surgeons indicated they would have done a rapid percutaneous tra- cheostomy. An X ray taken immediately after intubation demonstrated the tension pneumothorax. Everyone had been concentrating so much on “A” that “B” had dete- riorated. The triangle in the front of the neck is a bullet marker. The bullet had clipped the top of the left pleura. Following chest drainage and formal tracheostomy, the casualty made a good recovery.

On very rare occasions in the prehospital environment, it may be neces- sary to perform a cricothyroidotomy in an awake patient with progressive airway obstruction. This will require local anesthesia of the area either by careful infiltration or by bilateral superficial cervical plexus blocks. The latter approach has the advantage of not distorting the cricothyroid mem- brane, and it also avoids the risk of causing coughing by inadvertent punc- ture of the membrane.

Breathing

The exact diagnosis of chest injury in patients with major trauma can be difficult. This is especially so in the noisy field environment or during trans- port in an ambulance or helicopter. The main concerns are recognizing and appropriately treating the immediately life-threatening thoracic injuries and detecting pneumothorax and hemothorax.

Approximately 15% of low-energy transfer ballistic injuries to the chest will require emergency surgery; the remainder can be managed by the placement of a chest drain. The mortality associated with high-energy trans- fer wounds is significantly greater, and those that survive to reach a medical facility may have significant tissue destruction and loss. The elastic compo- sition of the lung makes it relatively resistant to the effect of high-energy transfer and cavitation, unlike the solid abdominal organs. Plain X ray is the mainstay of thoracic imaging in trauma, although CT of the thorax has been shown to delineate well the track of a missile through the lungs.

Penetrating chest trauma may result in an open or sucking chest wound.

These can be managed by the application of an Asherman chest seal

(Rusch, Duluth, USA) applied over the defect; this provides a seal around the injury and one-way valve for drainage of air. Following this, a chest drain should be inserted.

Circulation/Hemorrhage Control

Recognition

The detection of the clinical signs of hemorrhagic shock is essential in assessing the injured patient. These include visible bleeding, tachycardia, poor peripheral perfusion, and, in later stages, decreased conscious level.

Visible bleeding needs to be controlled quickly by direct pressure, eleva- tion, and/or tourniquets. The history and clinical signs should produce a high index of suspicion for nonvisible bleeding.

Clinical examination for intra-abdominal and thoracic bleeding at the

medical facility may be augmented with lightweight portable, hand-held

ultrasound machines during the circulation assessment of the primary

survey. These have been validated in the diagnosis of hemoperitoneum

using the Focused Assessment with Sonography for Trauma (FAST) technique.

Broadly, then, hemorrhage can be differentiated into:

i. Compressible hemorrhage that can be controlled by direct pressure or limb splinting. When this bleeding is controlled (i.e., the “tap” turned off) (Figure 8-5), the casualty can receive fluid resuscitation with near-normal blood pressure as the goal.

ii. Noncompressible hemorrhage (for example, bleeding into the abdomen or chest) that requires urgent surgical intervention. (i.e., the “tap” cannot be turned off in the resuscitation department). Current views are that management of this situation may involve hypotensive resuscitation.

Figure 8-5. 1991 Gulf War. This casualty had severe leg injuries from a mine blast.

The medics on the scene had controlled the bleeding using tourniquets.

Hypotensive Resuscitation

Hypotensive or minimal-volume resuscitation to a systolic blood pressure of around 80 to 90-millimeters Hg is increasingly being advocated in trauma resuscitation. This is not a new approach, as vascular surgeons have been advocating a minimal-fluid resuscitation approach for ruptured aneurysms for a number of years. The approach is based on the belief that giving excess fluid may raise the blood pressure, disrupt clots, cause rebleeding, and increase blood loss.

Clinical data from Houston (where 598 consecutive patients were allocated into either a standard, high-volume fluid resuscita- tion group or a minimal preoperative fluids group) has been quoted as sup- porting this approach.

The study showed a trend towards reduced blood loss and a statistically significant reduction in mortality in the minimal resuscitation group.

Dutton et al. have since challenged this work in a randomized study of patients in hemorrhagic shock.

There was no difference in mortality between patients resuscitated to a blood pressure of 70-millimeters Hg or greater than 100-millimeters Hg.

Certainly this technique is not appropriate in all trauma patients

and is not recommended in patients with prolonged entrapped or with head injury where it is vital to maintain an adequate cerebral perfusion pressure to ensure the best outcome from the cerebral injury.

Consensus guidelines for prehospital trauma care state that fluid should not be given to trauma patients before hemorrhage control if a radial pulse can be felt. In the absence of a radial pulse, 250-milliliter aliquots of normal saline may be given, but stopped temporarily once the pulse returns.

The patient should be monitored for subsequent deterioration. In penetrating torso trauma, the presence of a central pulse may be considered adequate.

This strategy requires rapid definitive surgical control of hemorrhage, and it may be the timing of surgery rather than the volume of fluid transfused that is the defining issue.

Fluids

The choice of intravenous resuscitation fluid remains contentious. In fixed civilian establishments, the choice of fluid (crystalloid, colloid, blood, or hypertonic hyperosmotic solutions) will be influenced by both its clinical effect and unwanted effects. In the military factors such as weight, ease of transport and storage characteristics must be considered.

Different scientific models of hemorrhage have been developed in an

attempt to analyze this complex issue. Various studies have been performed

comparing the effects of different fluid regimes.

Definitive evidence for

the use of hypertonic saline dextran (HSD) is limited; however, HSD may

have an advantage in traumatic head injury.

Massive Transfusion Protocols

The massively bleeding patient poses acute problems. Massive transfusion, defined as greater than twice the circulating blood volume, is associated with severe physiological and metabolic disturbances. Substantial blood loss and replacement result in severe coagulation disturbances that are compli- cated by hypothermia and acidosis. Expedient blood and blood component therapy is required.

Massive transfusion policies have been developed for exsanguinating patients in many units (Table 8-2). These provide rapid standardized com- ponent therapy in proportion to the blood used, and they can be automati- cally repeated until discontinued. In addition, efforts must be made to minimize the physiological disturbances associated with transfusion. All infused fluids and blood should be warmed to reduce core hypothermia.

Consideration should be given to recovery of noncontaminated blood and autotransfusion.

Damage Control Ground Zero

Damage control surgery (DCS) has become the accepted approach for the trauma patient in extremis.

The prehospital/resuscitation phase is where the patient who will benefit from DCS is recognized and efforts are made to expedite their passage to the operating room.

This approach has been termed “Damage Control Ground Zero”. Damage control is an integral part of the casualty’s resuscitation in the circulation/hemorrhage stage of the primary survey. The surgical goal is rapid hemorrhage control and lim- itation of contamination. Resuscitation continues (following the surgery) in the intensive-care unit, before definitive surgery is undertaken at 24–48 hours, once acidosis, hypothermia, and coagulopathy have been corrected.

Disability

The majority of casualties who sustain a high-energy transfer wound to the head do not survive to medical care.

In head-injured survivors, the primary head injury can be compounded by secondary injury as a result of hypoxia and hypotension. The fundamental principle of resuscitation for central nervous system injury is prevention of secondary brain insult through avoidance of hypoxia, hypercapnia, and hypotension.

Table 8-2. From the trauma center at Penn, Hospital University of Pennsylvannia, USA

Massive transfusion pack

10 units group O noncross-matched–packed red blood cells 6 units of platelets

4 units of thawed fresh frozen plasma

There is an obvious conflict between the need to maintain blood pres- sure and cerebral perfusion pressure and the need to avoid uncontrolled bleeding from the abdomen and chest.

Military penetrating brain injuries frequently arise from fragments, rather than bullets. In this situation, casualties who survive to reach medical care are a preselected group who generally have received low energy trans- fer fragment injuries; the outcome for both survival and rehabilitation in this group is good.

(Exceptions can occur when very rapid evacuation systems bring live casualties with unsurvivable brain injuries to the medical facility within minutes of injury).

Environment

Ballistic casualties, especially those that received their injuries in an austere location or on a battlefield, may be markedly hypothermic on arrival at the medical facility. Climatic conditions, transport times, and the severity of injury will affect this. Hypothermia compounds coagulopathy and is asso- ciated with increased mortality. During resuscitation and in the operating room, active measures including warm air blankets and environment control, and warmed fluids should be employed routinely.

Summary—Resuscitation

Resuscitation of the ballistic casualty requires an organized approach that addresses the basics of trauma resuscitation through ATLS/ BATLS guide- lines and recognizes the unique characteristics of these devastating injuries.

The following section concentrates on practical guidance for the anes- thetic management of the casualty with ballistic injury.

Anaesthesia

Patients are likely to present for anesthesia in two broad phases;

Early:

1. as part of the patient’s resuscitation, including anesthesia for surgical control of hemorrhage and “damage control” surgery (Chapter 10), 2. anesthesia for early wound debridement and major fracture

stabilization.

These “acute” interventions usually will take place in a casualty who is

shocked, cold, and likely to be at risk of pulmonary aspiration. The anes-

thetic management here follows the general principles of emergency anes-

thesia. Successful management depends not only on technical skills, but also

on the ability to continually reassess patients whose clinical condition may

be subject to rapid and unexpected deterioration. The areas of particular

concern in the ballistic casualty will be discussed below.

Late:

This includes anesthesia for re-look and delayed procedures. Anesthesia in this situation will depend on the patient’s overall condition. A “re-look” for continued bleeding is likely to be similar to the acute interventions outlined above and not uncommonly will involve intensive-care patients where the surgery will be a necessary part of their ongoing management.

In contrast, an anesthetic for delayed primary suture in a single-limb injury in a well resuscitated and prepared patient several days post injury is more likely to be similar to a routine anesthetic.

Planning Anesthesia

Casualties injured by modern munitions containing preformed fragments are likely to have multiple penetrating injuries to different body areas

and may need frequent repositioning during surgery (Figure 8-6).

Fragments and bullets cross body cavities and regions; therefore, the theater team must be prepared for the surgeon having to convert an abdominal operation into a thoracic one and vice versa.

A suggested plan of management is:

1. Preoxygenation and rapid sequence induction with endotracheal intu- bation. The appropriate range of equipment to manage a potentially

Figure 8-6. A casualty from the first Gulf War being treated at 32 Field Hospital.

The casualty had multiple-fragment injuries involving both abdominal and thoracic cavities. The majority of these injuries were in the casualty’s back and not seen until the casualty was rolled during resuscitation. The casualty had a left pneumothorax.

This had been detected by clinical examination early in the resuscitation and treated with a chest drain.

difficult airway must be readily available. This includes a range of endotra- cheal tubes, gum-elastic bougie, and a surgical airway kit.

2. Which induction agent? This depends on what drugs you are familiar with and what you would normally use in a shocked, hypovolemic patient.

In the author’s view, Ketamine

[1 to 2 milligrams per kilogram (mg/kg), depending on the level of hemorrhagic shock in the casualty) is an excel- lent induction agent. Following initial rapid muscle relaxation with suxam- ethonium (1 to 1.5 mg/kg) and endotracheal intubation, muscle relaxation can be maintained with Vecuronium, pancuronium, or an equivalent.

3. How to maintain anesthesia? Again, this depends on what techniques you are familiar with and your normal practice for the unstable, shocked casualty. In very resource-limited environments, one of the authors (P.F.M.) tends to use Ketamine boluses or infusions until hemostasis is achieved, then gradually introduces a volatile anaesthetic agent.

4. What intravenous access? The aim is to be able to give a number of different drugs (induction agents, muscle relaxants, antibiotics, analgesics, inotropes) and fluids at the time and in the quantities that are required.

The issue is that a balance has to be achieved between time taken for anesthetic preparation (siting lines for access and monitoring) and the need to start surgery to achieve hemostasis.

It is reassuring to start a difficult anesthetic with central venous moni- toring, direct arterial monitoring, and several sites for fluid and drug admin- istration. This is rarely achievable or practical with a patient in extremis.

A practical plan is:

Ask the surgeon, “How much time do we have?”

Site lines according to your skill:

– an individual skilled at getting central access will achieve this while someone else is struggling with a peripheral line (in this case, “central access” means a large-bore rapid-infusion device, not a multilumen monitoring line).

– Cervical collars and injuries will restrict the sites available for central access

– If, however, you have sufficient peripheral access for drug administration and rapid fluid replacement once hemostasis is obtained go with this.

Hypotensive resuscitation should be maintained until surgical hemosta- sis is achieved. Although a systolic blood pressure of 90-millimeters Hg is often quoted, in practice, a pressure that produces at least 0.5 milliliters of urine per kg per hour is satisfactory (assuming there is not a head injury).

Noninvasive blood pressure (NIBP), electrocardiograph (ECG), pulse oximetry, capnography, and urine output are sufficient monitoring during resuscitation and anaesthetic induction.

If red cells are needed urgently, then O Rh negative or group-specific

blood is used until a definitive cross-match is available. Fluids must be

warmed and must be capable of being infused under pressure; all other measures should be taken to prevent hypothermia, such as covering the patients head with dressings or blankets and the use of warm air blowers.

As surgery progresses, additional monitoring is added to evaluate the effec- tiveness of surgery and fluid resuscitation.This requires central venous pres- sure (CVP) and direct arterial pressure measurement.

As the patient’s condition stabilizes, arterial blood gas analysis, coagula- tion screens, and platelet count should be used to adjust ventilation and fluid management. Near patient monitoring of coagulation using the throm- boelastogram (TEG) is established in liver transplantation and cardiac surgery and has potential in trauma patients.

Resuscitative Endpoints

A hypothetical trauma patient well resuscitated from hypovolemia involv- ing massive transfusion ideally would have minimal evidence of the phy- siological consequences of cellular hypoxia. An elevated blood lactate or failure to clear a high lactate concentration predicts a poor outcome.

The figures in Table 8-3 are acceptable endpoints, but again it is stressed that investigations are supplementary to clinical acumen and trends are often more significant than isolated numbers.

Problems in the Operating Theater

If the patient’s condition unexpectedly deteriorates, the original diagnosis must be reviewed in light of the mechanism of injury and the possible anatomical and physiological consequences. The following differential diag- noses must be considered (some, of course, are fundamental to any general anaesthetic).

Airway and Ventilation

One of the concerns for the anesthetist is that intermittent positive- pressure ventilation (IPPV) following endotracheal intubation can cause

Table 8-3. Endpoints of resuscitation 1. pH 7.35–7.45

2. Base deficit -3.0 or higher with a lactate concentration of 1.0 mmol per liter or less 3. Core temperature >35.5 degrees centigrade

4. International normalized ratio (INR) <1.5 PT* <16 seconds PTT** <42 seconds 5. Hemoglobin (Hb) 80 grams per liter or greater

6. Platelets >50 ¥ 10⁹per liter 7. Fibrinogen >1 gram per liter

* PT = prothrombin time.

** PTT = partial thromboplastin time.

tension in an existing pneumothorax and, in addition, may reduce cardiac output in the hypovolemic patient.

If the patient cannot be adequately ventilated, or oxygenation is inadequate, the following issues should be considered.

a. Has the endotracheal tube slipped into a main stem bronchus?

b. Is there an undiagnosed chest injury?

c. If present, is the chest drain performing as intended?

d. If a blast injury has occurred, is the patient already developing ventilation perfusion mismatch due to a developing lung injury?

When there is progressive difficulty in ventilating the patient associated with an increase in the airway pressures, always assume an obstructed airway until proved otherwise. This is particularly so if the airway was estab- lished with difficulty and has now become obstructed due to bleeding, soiling, endotracheal tube kinking, etc.

Difficulty ventilating due to intrinsically stiff lungs may be associated with unacceptably high airway pressures. In this situation, the recognized intensive-care ventilation strategy of permissive hypercapnia, using small tidal volumes and rapid respiratory rates, may be necessary to avoid further barotraumas. If the theater ventilator is capable, then pressure-controlled modes of ventilation may be appropriate.

Circulation

The differential diagnosis of unexplained hypotension includes: bleeding from a missed injury, a missed high spinal cord lesion, undiagnosed tension pneumothorax, cardiac contusion, infarction, or tamponade.

Less commonly, anaphylaxis from colloids, drugs, or a transfusion reac- tion may be responsible. Cardiac ischemia on the ECG of a previously fit young adult may be associated with profoundly low hemoglobin, particu- larly in the presence of ischemic limb injuries.

Poor urine output following restoration of a normal CVP in crush injuries is an ominous marker of impaired renal function due to myoglobinuria and the development of renal tubular necrosis. A forced mannitol diuresis is necessary to save renal tubular function; a renal output of at least 100 milliliters per hour is required.

Deterioration of the patient at a later stage associated with persistent

bleeding or massive transfusion may reflect a dilutional coagulopathy or the

onset of disseminated intravascular coagulation (DIC). Treatment of this

complication will require expert hematological advice and treatment with

fresh frozen plasma, platelets, and cryoprecipitate, depending on the results

of hematological and clotting studies. These investigations will need to be

repeated on a regular basis. The use of antifibrinolytic drugs as an attempt

to reduce transfusion volumes continues to attract interest. A variety of

different drugs have been used, but there are few studies to support their

routine use. Aprotinin is used in liver resection surgery and may be of benefit in liver trauma.

The use of Factor VIIa is considered in the chapter on abdominal and pelvic trauma.

Critical Care

Intensive care of the ballistic trauma patient is discussed in Chapter 22.

Conclusion

Anesthesia for ballistic trauma can be challenging and will frequently test both the technical and diagnostic abilities of the anesthetist.

Practical management needs to follow a logical sequence of assessment and treatment and should be kept as simple as possible.

Frequent discussion between the anesthetist and surgeon and reassess- ment of treatment priorities is vital to maximize the chance of a successful outcome.

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Further Reading

Resuscitation

Fluid resuscitation of combat casualties. J Trauma. 2003;54(suppl 5s).

Rhee P, Alam HB, Ling GSF. Hemorrhagic shock and resuscitation. In: Tsokos GC, Atkins JL, eds. Combat Medicine: Basic and Clinical Research in Military, Trauma and Emergency Medicine. Totowa, NJ: Humana Press Inc.; 2003:177–218.

ISBN 1 58829 070 0 Anesthesia

Gwinnutt C, Bethelmy L, Nolan J. Anaesthesia in trauma. Trauma. 2003;5:51–60.

Cantelo R, Mahoney PF. An introduction to field anaesthesia. Curr Anaesth Critical Care. 2003;14:126–130.