ANALYSIS J)F .ABDOMINAL CASUALTIES 
THAT COMPLETED OPERATION 
IN CANADIAN ADVANCED SURGICAL CENTRES IN ITALY 
(l Dec 44 => 15 Jan 45)o 
W 
Captain J0Bo Armstrong;, R0GoA0MoCo 
lo introduction 
A previous report from this laboratory (l), on 179 abdominal cases, 
recorded a high incidence of death within 24 hours after operation, and em~ 
phasised the importance of early postoperative resuscitation,, Another re° 
port on 64.O abdominal and abdominothoracic wounds (2), records an even higher 
incidence of death within the first 24 hours post°operatively„ 
The present report is an analysis of all abdominal casualties, operated 
upon in the Advanced Surgical Centres of the First Canadian Corps„ 1 Dec 44- to 
15 Jan 45o An abdominal casualty has been taken as one in which the peritoneum 
has been pierced by a missile in the woundinge Thus explorative laparotomies 
that prove negative are not considered0 Likewise, posterior penetrating wounds, 
producing retro=peritoneal haeraatomata and possible kidney damage have not 
been included unless a nephrectomy was done. 
The analysis of these cases has been made on the basis of the 
ing factorsg 
(a) Mortalityg 
(i) simple abdominal wounds, i060 those with no other signifi= 
cant wounds other than in the abdomen, 
Cii) complicated abdominal wounds, i0ec those in which there 
are other serious wounds of the chest or extremities in 
addition to the abdominal lesions0 
(b) Wounding to Admisslong 
u) time «=> the time that elapsed from time of wounding to 
admission to the Advanced Surgical Centre, 
(ii) fluids ® the fluids administered within this period,, 
Report submitted to the Associate Committee on Array Medical 
National Research Council of Canada9 on 25 March 19459 by No„ 1 Research 
Unitp RoC'oAcMoCo 
1* Analysis of Abdominal Casualties in Canadian Advanced Surgical Units AoAoIo 
(23 Aug to 30 Sep M) = Lt. Col, A.L, CHUTE, O.B.E. 
2a Statistical Report on 640 fettle Casualties operated on in the Forward Area 
CoMoFo for Abdominal and Abdominothoracic Wounds<,”(l Jan to 30 Jun 44) - 
feigo HoC0 Edwards* Consulting Surgeon A0FoHcQ«> 2 
(c) Resuscitation (pre-operative) 
(i) time ■= the time spent in the resuscitation wards of the 
Advanced Surgical Centres0 
(ii) fluids •=• the fluids administered in these resuscitation 
wards 0 
(d) Resuscitation (2U hours postoperative) 
the fluids administered within this period. 
In addition an attempt has been made to assess the actual blood loss 
of a small group of simple and complicated abdominal wounds, by means of pre- 
operative blood volume estimations, and to gain thereby some knowledge of the 
fluid requirements of these patients0 
20 FINDINGS 
(a) Mortality 
There are 90 abdominal cases in the present series operated upon by 
5 surgical teams in the Advanced Surgical Centres of the First Canadian Corps, 
ABDOMINAL CASUALTIES TABLE I 
Postoperative Mortality Figures 
Founds 
Cases 
Total Deaths 
24 Hour Deaths 
Simple 
49 
17 (35%) 
4 
Complicated 
_n_ 
19 U6%) 
B 
Totals 
90 
WUMT 
22\ 
t 
Thirty°six of these 90 cases died in the forward areas*, a total post 
operative mortality of 0 Of the deaths*. 12 occurred within the first 24 
hours*, that is 33% of the postoperative deaths occurred within the first 24 
hourso 
The simple abdominal wounds suffered a mortality of 35%„ Four of 
the 17 deaths in this group occurred within 24 hours of operation0 
With the complicated abdominal wounds the mortality was 46%s> and 8 
of the 19 deaths occurred in the first 24 hours after operation0 3 
(b) Wounding to Admission 
(i) Time. 
The disposition of the formations was such that several FoD0Ss3 
alternatively handled the priority I and II casualties for one division 
whereas a C0C0So looked after the same priority groups for the other division,, 
ABDOMINAL CASUALTIES. TABLE II 
Average Tim© Spent - Wounding to Admission 
C - t--r Mr—IXj rTjrt ,n art XZI7Z~ - I i-i-g-r fe-- r-w-~c-— r-r- - - -r-**-, -■ - — T- am —y—-l - » ■ -1 -n 
(Time in Hours; 
C o C pS o 
F0D0S 
Totals 
Surviving Gases 
s;i 
7ol 
6o3 
Fatal Cases 
—- —--— 
O 0/ 
6ol 
Totals 
5o2 
7o0 
The average time from wounding to admission was 7o0 hrs0 at the F0D0Sss 
and 5o2 hrs0 at the C0CoS0 But the average time to admission of all the cases 
that survived was 603 hrs0 and for all the fatalities, 6„1 hrsc (Graphs show- 
ing the case distribution of the time from wounding to admission are included 
in the appendix of this report)0 
(ii) Fluids 
Prior to admission to the surgical centres, 48 cases or 53% of the 
abdominal casualties, received an average of 2„0 bottles of plasma transfusion,. 
Sixty percent of this fluid was given to C0CcS0 cases$ that is, 74$ of the 
C0C0S0 casualties received an average of 1„9 bottles of plasma, whereas only 
37$ of those evacuated to the F0D0Scs received an average of 2d bottles of 
plasma, prior to admission0 
(c) Resuscitation (Pre~operative) 
ABDOMINAL CASUALTIES TABLE III 
Average Time Spent In Resuscitation 
' ~in 
G o C 0S o 
F0D,Sas 
Total© 
Surviving Cases 
5o3 
4o9 
53T 
Fatal Cases 
5ol 
Totals 
5.6 
4.8 4 
The average time spent in the resuscitation ward was 5o6 hours at 
the CoCoSo compared to 4.08 hours at the FoDoSflSo But the average time of all 
the living cases was 5o0 hrs0 and all the fatalities 5o4- hrs0 (Graphs showing 
the case distribution of the time spent in resuscitation are included in the 
appendix of this reporta 
(ii) Fluids 
In the table the fluids given in the resuscitation wards are reduced, 
for the sake of simplicity, to the number of 500 ccQ bottles of glucose, 
plasma or blood administered0 Protein fluid includes blood, plasma and serum0 
(For the relative protortions used see Appendix Table II)„ 
ABDOMINAL CiiSUALTIES,TABLEJV 
Fluids Given in Resuscitation 
Average Number of Bottles Per Patient 
Bottle s 500 ccSo of fluid 
c*c 
Total Fluid 
oS Q 
Protein Fluid 
FoDoSc So 
Total Fluid Protein Fluid 
Surviving Cases 
3o7 
3o7 
2o9 lo9 
Fatal Cases 
L?M-. 
Totals 
UoO 
Uo 0 
3o0 2ol 
The total fluid per patient given in resuscitation at the CeC0S0 
was 4-o0 bottles (500 cc0 each) of which practically all was protein fluid, in 
other words, blood and plasma0 The fatalities received an average of 0o7 
bottles more than those that lived, and most of the increase was protein fluid0 
At the FoDfls the total per patient wag 3o0 bottles of which 201 bottles were 
protein fluid0 The fatalities received on the average 0o2 more bottles of 
total fluid, but 0o5 more bottles of protein fluido 
Dividing these cases into their primary two groups, 
a0 simple => wounds primarily of the abdomen, 
b0 complicated « abdominal wounds with other gross wounds, the averages 
may be tabled as followsc 5 
ABP0MINAL_CASUALTIES TABLE,V 
Average Number of Bottles Given in Resuscitation 
CcCoSo 
FoDPSBs 
Total Fluid Protein Fluid 
Total Fluid Protein Fluid 
Simple Founds 
3,6 3,6 
2,6 1,7 
Complicated Founds 
Uo5 4-o5 
3,5 2o5 
(d) Resuscitation (2A hours Post-operatively) 
During the first 24 hours post-operatively the C0C0So and FoDoS0 
mortality was 52% and }5% respectively,. During this period each group adminis- 
tered 5=4 to 5oB bottles of fluid per patientp of which 2,3 to 2„4 bottles 
were protein fluids (bloodP serum or plasma)p and the remainder was glucose 
saline 0 
3 o BLOGp_VpLUME_ S TUPLE 
This laboratory has done pre-operative blood volume studies on 32 
abdominal cases since 4 Sep 44? of which 17 cases fall within the present 
period of studyp 1 Dec 44 to 15 Jan 45 ? and have been included in the analysis 
aboveo Pre-operative blood volume estimations were done by means of T » 1824 
(Evanb Blue) on admission to the Advanced Surgical Centres, and the normal 
blood volume was calculated from the height and weight (and surface area), 
(a) Findings of BloodJ/'olume_Studie.s 
If these 32 abdominal cases are divided according to their wounds9 the 
blood loss on admission being expressed as a percentage of the calculated 
notmal blood volume in each instance, they appear as follows. 
ABDOMINAL CASUALTIES TABLE VI 
Admission Blood Volume Loss <=• Percentage 
Cases 
Ranee 
Average 
lo Simple abdominal wounds® 
aQ Hollow viscus only® 
10 
0 - 
10% 
b® Hollow viscus and solid viscus0 
A 
12 - ZlS 
16% 
Co Solid viscus onlyQ 
3 
21 - 25% 
23% 
20 Abdominal wounds with other serious wounds® 
a0 Hollow viscus only® 
10 
1-32% 
21% 
b0 Hollow viscus and solid viscus0 
3 
16 ° 36% 
26% 
c0 Solid viscus only® 
1 
35% 
35% 6 
The average percentage blood loss on admission for those cases with 
simple hollow viscus wounds was 10$ of the calculated normal blood volume and 
for the complicated hollow viscus wounds was 21$0 The simple abdominal wounds 
penetrating a solid as well as a hollow viscus* lost an average of l6$.„ and 
the complicated (hollow and solid viscus) an average of 26$0 
NOTE; The blood volume estimations on admission to the Surgical centres*, do not 
represent the total blood lost by these patients* as plasma was administered to 
many of the casualties prior to their admission and in some there appeared to 
be considerable haeraodilution as judged by admission haematocrits0 
(b) Discussion of Blood Volume Studies 
For the present review* a case is said to be in 55good condition” on 
admission when the clinical picture (p eripheral veins* skin temperature of 
extremities etc0) is satisfactory* the systolic blood pressure is over 100* 
and the diastolic over 50 mm0 Hg0 Cases not fulfilling these standards are 
said to be in ”poor condition” on admission0 
In reviewing the cases in table VI above in the light of their con- 
dition on admission to the Advanced Surgical Centres the following trends may 
be seenQ 
10 A simple wound penetrating a hollow viscus only was accompanied by 
less bleeding than one that also penetrated the superior or posterior abdominal 
contents* affecting the liver* spleen or kidneys0 
20 The simple abdominal wounds that were in fairly good condition* had 
a blood volume loss of 24$ or less with one exception0 The simple solid viscus 
wounds received no forward transfusion and were in each instance* admitted in 
good condition with a 21$ to 25$ blood loss0 
3o With the complicated abdominal wounds* there was not such a direct 
correlation* but of course* the extra-abdominal wounds in these cases varied 
considerablyo Generally it may be said that in the present short series if 
they arrived in poor condition* they had a greater than a 30$ blood loss* and 
if in good condition less than 20$* and that they averaged approximately 22$ 
blood loss on admission0 
4-0 In terms of blood substitutes* 1 bottle of blood plus 1 bottle of 
plasma represent 1205$ of the blood volume of an average man (5600 cc0)o Seldom 
is there greater than 30$ blood loss on admission to a resuscitation ward0 Few 
abdominal wounds therefore will require more than four bottles of protein fluid 
ioe0 blood and plasma0 
4-0 DISCUSSION 
The gross mortality of abdominal wounds in the forward areas mmains 
relatively unchanged| 10$ in the present series compared to 39$ reported by 
Lto-Colo Chuteo Bit the mortality within 24. hrs0 of operation has dropped 
from 50$ of the total deaths in the previous series* to 33$ in the presento 7 
The drop in the 24 hour mortality may be due to increased postoperative care0 
For instance, the blood pressure was recorded in many instances, every hour 
for the first 24 hours, indicating that the patients were at least seen every 
hour throughout the early postoperative period, and any vascular collapse could 
be recognized early in its onset The net result has been a prolongation of 
life by increased care, rather than a saving of life* 
There is almost a 2 hour difference in the time from wounding to ad=* 
mission to the Advanced Surgical Centre in the two divisions, but there is no 
appreciable difference in the time taken by the fatalities as compared to the 
living cases in either division, or in the corps as a whole. 
The average time spent in resuscitation in the G0C0Se was 506 hrs0 
and at the FoDoS0s 4oB hrs0 These periods of time are in excess of the time 
actually required for resuscitation, as during heavy fighting, the casualties 
may have to wait 1 « 2 hrsQ in resuscitation for their turn in the operating 
theatreo 
By the blood volume studies the simple abdominal wounds seldom suffer 
a blood loss in excess of 30$ of the normal, and average at 13$c This repre- 
sents 2 bottles of protein fluid0 The simple abdominal casualties at the 
FoD0Sss were given an average of 107 bottles of protein fluid and at the CoC0So, 
3o6 bottleso (Table V)c The preponderance of protein fluids at the CoCuS0 
indicates a sparing use of glucose saline however the F0Dc,Sss gave 1.01 bottles 
on the average to each patient0 
For both divisions the fatalities received 0o5 bottles of protein 
fluid more than the living cases but the difference in time spent in resusclta- 
tion was not significant0 
5o CONCLUSIONS 
1« An analysis has been made of 90 abdominal casualties exclusive of 
negative laparotomies, operated upon by 5 Surgical Teams in the Advanced Surgical 
Centres of the First Canadian Corps0, from 1 Dec 44 to 15 Jan 45 0 
20 The gross mortality in the forward areas was 40$, l/3 of which (33$) 
died within the first 24 hours after operation, 
3o The mortality was 35$ in the simple abdominal cases (without other 
serious wounds) and 40$ in the abdominal cases complicated by other serious 
woundSo 
4<> There was no -significant difference in the average time spent from 
wounding to admission to the surgical centres, between the fatalities and the 
living cases (601 hrs0 and 6C3 hrs0 respectively)0 
5o Fiftyt3three percent of abdominal casualties received an average of 2o0 
bottles of plasma, prior to admissione 
60 The average time spent by these casualties in the resuscitation wards 8 
was perhaps excessive (4o8 hours to $®6 hours average) but there was no sign° 
ificant difference between the fatalities and the living cases® 
7® In some cases there is a tendancy to over transfuse with protein 
fluids in the resuscitation wards coupled with a sparing use of glucose saline® 
80 Pre=operative blood volume studies have been made on 32 abdominal cases 
(17 in the above series) to judge the amount of transfusion fluids required 
by these casualties® 
9o Simple penetrating abdominal wounds arriving in the resuscitation 
wards in good condition* have a probable blood loss of 2IS or less, and require 
a maximum of 2 bottles of blood and 1 of plasma® Any further administration of 
intravenous fluid should be glucose saline® The same casualty arriving in 
poor condition probably requires at least 2 bottles of each of blood and plasma® 
10® The blood loss in the complicated abdominal wounds varied according 
to the severity of the extra~abdominal w ounds as well as the intra-abdominal 
lesions* thus generalizations as to blood volume loss in these patients is 
not warranted® In general their blood volume reduction was greater than for 
the corresponding simple abdominal lesion®  
All Cases (Excluding 
Simple group (No other 
Complicated Group 
negative laparotomies) 
Significant Wounds) 
(Other Gross Wounds) 
Total 
24- Hr„ 
Total 24 Hr0 
Total 
24 Hr. 
Cases 
Deaths 
Deaths 
Cases 
Deaths Deaths 
Cases 
Deaths Deaths 
Special Group 
22 
oanacjcawi 
5 
aotacoaajao 
2 
13 
oaoaaotoo ocsc 
.JL 
3_ 
FoDoSc 
29 
12 
4 
16 
5 2 
13 
7 
2 
FoD.Sc Totals 
51 
17 
6 
29 
7 3 
22 
10 
3 
33? 
_35?_ 
57?_ 
24? 
43? 
_45? 
n n 
39 
19 
6 
20 
10 1 
19 
9 
5 
v/ o v ou e 
49? 
32% 
51? 
50% 
49? 
47? 
Grand Totals 
90 
36 
12 
49 
17 4 
41 
19 
8 
4.0$ 
33% 
54? 
35? 
46% 
46$ 
ABDOMINAL CASUALTIES THAT COMPLETED OPERATION IN CANADIAN ADVANCED SURGICAL CENTRES 
M.JmX - LMecJA - to 15 Jan .45« 
APPENDIX ° TABLE I 
MORTALITY FIGURES AND PERCENTAGES  
Glucose 
• 
Plasma 
Blood 
Total Avers 
No0 No0 of 500 
cc T$o0 
‘ TSTW 
cc No0 No0 of 500 
cc 
Total 
Protein 
Patients Bottles 
Patients 
s Bottles 
Patients Bottles 
Fluid 
Fluid 
Living 22 34 
24 
31 
24 34 
COCO CD 60 CO C3 CO CO CO COSO CO CO CO CO COCO COCO CO CO CO COCO « 
52 
34 
s 2o9 6j g lo9 
34 
Deaths 
9 12 11 
19 
13 22 
U 
d„12. 
s 3d 
41 s 
. 17 . 
2 <>4 
Totals 
31 A6 35 
50 
37 56 
152 
S 3o0 106 S 
2.1 
awocao oocoo aooac ctoco co coco coco coco csasjsaa aao csotaa ooaoooo oao 
Qorooaoocoaoawa 
Jl. 
51 
loaaoooooaooc 
Average 
lo5 
i«4 
lo5 
Living 
0 0 
17 
33 
17 41 
74 
20. 
■ 3c7 74 « 
, . ... .20 
3o? 
Deaths 
1 2 
16 
34 
17 47 82 
19 
0 4o4 Hi ® 4®3 
19 
iooOcoqoB* otoaoKjO 
§ 4c0 155 s 4o0 
39 
=> oacooaoooooooooaooocoaoo «GOco aoooo oaoo coco coco o«3# coco coro oooooooooow co oooo«c 
Totals 1 2 33 67 
34 88 
152 
39 
Average 
2o0 
2o0 
206 
3 60 «»0 CC 
ABDOMINAL CASUALTIES THAT COMPLETED OPERATION IN CANADIAN ADVANCED SURGICAL CENTRES 
ea»xn_.^-KT-jrs.«-ii»c.wn™ oiw»: e-f-» «u. a.ajran t \’jz^rxrcrts*rx-tts*czszxzzzr^-xzxss.-==srrxam.*.., ,Jng|S:«i t-=— .at* ;n—a im, ' -7. „ rr-r: rx~ri i ,71.- ,.i -««w.v-rr_-:\y.-. z? 
IN ITALY - 1 Dec LL to 15 Jan L5o 
APPENDIX ° TABLE II 
Fluids Given in Resuscitation ABDOMINAL CASUALTIES THAT COMPLETED OPERATION IN 
CANADIAN ADVANCED SURGICAL CENTRES IN ITALY ooec^ejahgs) 
TIME IN RESUSCITATION 
I I i l il i I i T 1 
C.CS. CASES 
FATAL CASES 
SURVIVING CASES 
HOURS 
HOURS 
TIME-WOUNDING TO ADMISSION 
i i i i i i i i i i i i i i i i 
« 10 II 12 
HOURS 
HOURS 
APPENDIX - GRAPH Z 
NO. OF CASES 
NO. OF CASES ABDOMINAL CASUALTIES THAT COMPLETED OPERATION IN 
CANADIAN ADVANCED SURGICAL CENTRES IN ITALY (l DEO44-15JAN45) 
time in resuscitation 
SURVIVING CASES 
P.0.8. CASES 
HOURS 
H6JR§ 
FATAL CASES 
HOURS 
HOURS 
APPENDIX - GRAPH II 
TIME-WOUNDING TO ADMISSION 
NO. OF CASES 
NO. OF CASES