 Severe wounds exert dynamic deleterious effects on the entire body. To counteract these effects, certain resuscitative measures must be taken. Resuscitation is commonly accepted as being those first aid procedures used to revive a patient. To the surgeon, however, resuscitation is much more. It includes all the corrective procedures necessary to counteract the injurious results of the wounds. These include such procedures as arrest of hemorrhage, splitting of fractures, infusion of plasma volume expander, alleviation of pain, anxiety, and fear, maintenance of an airway, careful preoperative preparation, thoracentesis, tracheotomy, adequate replacement of blood volume, expeditious surgery, and diligent postoperative care. These procedures and principles of treatment are applicable to large numbers of casualties irrespective of causative agents. The increasing casualty rate in an ever-expanding mechanized world and the potential casualties emphasized by civil defense point up the importance of care of the severely wounded to all physicians. The utilization of these principles and methods of treatment aided considerably in the resuscitation of casualties in the Korean conflict. Devastating injuries may be caused by various destructive implements of war. The men injured are usually young and healthy. Most American soldiers wear armored vests, which reduce the incidence of chest injuries. Our men use fire from flamethrowers and missiles from machine guns, from mortars, from bazookas and from the artillery, and are injured in turn by similar destructive instruments of war used by the enemy. All these devastating forces cause a pattern of injury that is characterized by tissue destruction and blood loss. As soon as the man is injured, the corpsman initiates resuscitation by arresting hemorrhage and preparing the casualty for transportation. A rest of hemorrhage can usually be accomplished by a well-applied pressure dressing. In major arterial bleeding, a tourniquet may be necessary if a pressure dressing does not stop the hemorrhage. Immediately after injury, there is considerable anxiety but little pain. Morphine is therefore not necessary. Initial medical care is completed before the casualty is moved. Then he is transported as gently as possible to the nearest doctor. Further resuscitative efforts are carried out at the battalion aid station. Here the casualty is first treated by a doctor who makes a rapid examination and corrects obvious defects. Splinting of fractures is performed before transportation is attempted. A poorly sprinted fracture produces pain and increases muscle or vascular damage, thereby causing additional injury. If a tourniquet has already been applied, the doctor should release it and evaluate the character of the bleeding. A pressure dressing may suffice and thus eliminate the dangers of an unnecessary tourniquet. Infusion of a plasma volume expander such as dextran aids in the restoration of blood volume until whole blood is available. Alleviation of pain, anxiety and fear is essential. When valid pain exists, it may be necessary to give a small dose of morphine intravenously. Absorption from the subcutaneous tissue is unreliable. As soon as the patient is prepared to withstand the further trauma of transportation, he is moved to the helicopter port and from there evacuated to the forward hospital. Maintenance of an airway is a vital procedure in resuscitation. This casualty at another aid station has only a mild head injury, but in more severe head injuries, an adequate airway must be provided by positioning the patient on his side and pulling out his tongue. In some instances, it may be necessary to do a tracheotomy on patients who have injuries to the head or neck or on those having sucking wounds of the chest. Early in the Korean conflict, serum albumin was used as a plasma volume expander. Later, it was replaced by dextran. In addition to giving a helping hand, chaplains can contribute to resuscitation by alleviating anxiety and fear. The battalion surgeon is not merely a first aid man. He is a most important member of the resuscitation team. His aims are institution of early resuscitative measures to prevent deterioration and preparation of the patient to withstand the additional trauma of transportation. Sometimes, it is necessary to transport patients to the forward hospital by ambulance. At other times, when the terrain is rough or mountainous, the patient is carried by littered jeep to the nearest helicopter fort and then flown to the forward hospital. The battalion surgeon usually chooses to evacuate patients with massive wounds by helicopter because land transportation may aggravate the patient's weakened condition. Although helicopters are not always available, the aim should be to transport the severely wounded in the shortest time possible and with the least amount of trauma. At the 46th Mobile Army Surgical Hospital located 10 miles behind the line on the eastern front, the patient receives further resuscitative procedures and initial surgery. The rapidity and dispatch with which casualties are handled begin with the litter bearers who meet the helicopter as it lands as closely as possible to the surgical hospital. Resuscitation at the hospital may be broadly divided into three parts. Careful preoperative preparation, expeditious surgery, and diligent postoperative care. Careful preoperative preparation starts with a thorough examination. All the patient's clothing is removed immediately on admission. The patient's blood pressure must be taken immediately and at short intervals thereafter. His medical record is initiated at once. This patient is pale but alert. It is important to record all information regarding his identity together with the treatment given him at the forward level. Replacement of blood must be started immediately if there is an obvious deficiency in blood volume. It may be necessary to give two or three transfusions simultaneously. But above all, the type of administration must allow rapid infusion of blood. Small needles are not used when rapid restoration is required. A large bore 15 gauge needle is preferable. The needle is inserted well into the vein so that it will not easily be displaced. It must be anchored firmly. If it is difficult to find a suitable vein, a 13 gauge needle is inserted into the femoral vein and a long segment of plastic tubing is threaded through the needle into the inferior vena cava. As soon as a free flow of blood appears in the needle, a measured segment of plastic tubing is inserted. The tubing must not be allowed to remain in place for more than seven days or thrombosis may result. The cut down is used as a common method of infusing blood. A suitable vein is opened and a segment of tubing is inserted and tied securely into the vein. It must be sutured in such a way that the plastic tubing will not be easily displaced. Injured men thrash about because the venous lifeline is frequently pulled out. It must be well anchored. It is often necessary to give blood very rapidly. This can be best accomplished by pumping air into the bottle. This is a simple technique, but it should be carried out with caution. When the blood in the bottle becomes exhausted, the pressure head may rush into the vein, causing fatal air embolism. After necessary resuscitative measures have been started, the wound should be examined again. Turnicates must be investigated. Wounds, however, may continue to bleed in spite of a turnicate. Usually when a turnicate is removed, it is held in place so that if gross bleeding occurs, the turnicate can be reapplied immediately. In this instance, this precaution was unnecessary because there was no evidence of arterial injury. Bleeding ceases as the improperly applied turnicate is released. This turnicate was not tight enough to prohibit arterial flow. It inhibited venous return, thereby increasing venous bleeding. A firm pressure dressing is applied to control local hemorrhage. The pressure dressing must be large and bulky to be absorbent and must be put on with firm, resilient compression. In some severe wounds and in burns, morphine may be necessary. As soon as resuscitative measures are carried out, the patient must be reexamined and his wounds redressed. A thorough survey of all wounds is made and the abnormal findings recorded. In patients who are severely wounded, it is important to insert an indwelling catheter into the bladder to measure the hourly output of urine. If the patient excretes urine at the rate of from 30 to 40 cc per hour, there is evidence that he is receiving adequate replacement therapy. Thorosyntesis may be required in patients having injuries of the chest with a collection of blood or air in the pleural cavity. Immediate relief of these conditions is essential to reestablish normal respiratory physiology. If air is in the pleural cavity, a needle must be inserted and connected to a water trap. If there is blood collecting in the chest, aspiration of the blood will help to reestablish near normal aeration of the lungs. These measures are life-saving, but often they are overlooked in resuscitative procedures. It may be necessary to carry out multiple aspirations of the chest as blood recollects in the pleural cavity. A tracheotomy is frequently essential in cases of severe burns to assure an airway or maintain a clean tracheobronchial treat. It may also be necessary in maxillofacial injuries, wounds of the neck, head injuries and chest injuries. The tubes must be fastened securely in place and the obturator tied to the tape to make it available immediately in the event the tracheotomy tube requires reinsertion. It is imperative that a large tracheotomy tube be inserted, a size 7 if possible. As soon as adequate resuscitation is assured, an X-ray examination should be made. This procedure may be omitted if emergency intervention is mandatory. Diagnostic films may show the position of fragments and the amount of bone damage. The surgeon who assumes the responsibility for operation must make a thorough examination of both the patient and his X-ray films before allowing the patient to be taken to the operating room. Adequacy of the circulation must be assured and a decision made as to the proper approach to the repair of the defects. Whenever possible, the anesthesiologist should be consulted before the operation. Adequate replacement of blood volume should be assured. It is very difficult to decide when a patient's blood volume has been sufficiently replaced so that he can best tolerate anesthesia and surgery. Unless continued hemorrhage necessitates immediate operation, a patient should be in the best possible condition prior to being subjected to the operative procedure. If hemorrhage is controlled, it may be assumed that restoration for operation is adequate. If the patient's systolic blood pressure is 110 or above, pulse rate 120 or below, an urinary output is at least 30 cc per hour. Expeditious surgery is facilitated by the insertion of an endotracheal tube to provide optimum control of anesthesia and the proper exchange of air. A high oxygen concentration during anesthesia is desirable. All severely wounded patients should be prepared for the operation by having two or more intravenous needles or cannulae already in place before the operative procedure is begun. If blood loss continues during the induction of anesthesia, blood should be given forcibly. Expeditious surgery requires that patients with profuse bleeding be prepared for operation at once. An incision of sufficient length must be made. During this procedure, infusion of blood should be continued energetically. As soon as the abdomen is opened, the area of hemorrhage should be located and the blood loss controlled. Extensive hemorrhage usually indicates that a major vessel has been severed. Occasionally, an additional intravenous portal is necessary. Low-titer typo blood was used in Korea with no untoward reactions. Bleeding points are ligated after adequate replacement of blood restores the patient so that he is able to withstand the remainder of the operative procedure, resection, and end-to-end anastomosis is carried out. Immediately after the operation, the trachea should be cleaned before the endotracheal tube is removed. Patients with sucking wounds of the chest require immediate surgery in order to close the wound and thus restore normal respiratory physiology. Diligent post-operative care is an important part of resuscitation. All too frequently, the surgeon believes that because he has replaced blood loss and performed a good operation, the remainder of the patient's course should be uneventful. Continued gastric suction is important following abdominal operations. The phalan suction apparatus has proved to be satisfactory for this use in forward hospitals. It is important to maintain good tracheobronchial toilet to prevent the complication of atylectasis. The catheter is inserted into the trachea, the patient is induced to cough, and secretions are removed by suction. Nasal oxygen may be necessary after some operative procedures. The catheter is measured from the ear to the tip of the nose and is inserted that distance into the nasopharynx. About six liters of oxygen per minute are administered. After operation, it is important again to measure the urinary output to determine the adequacy of restoration. A careful record is kept of the amount of urine excreted each hour. This record is then correlated with the readings of blood pressure and of pulse rate. The chest is examined frequently by auscultation to detect early development of atylectasis or pulmonary edema. The dressing should be examined to make sure that continued oozing does not occur. With proper resuscitation and with proper operative procedures, a high percentage of battle casualties can be successfully evacuated from the forward hospital by ambulance, by hospital train, or by helicopter. This is the result of the total effort of the entire medical team in carrying out the detailed resuscitative measures so important in the management of the severely wounded. Thank you.