Peripheral Vascular Injuries

Abstract

Vascular trauma in the military has special importance as combat-related injuries to major vessels offer unique surgical challenges and comprise the majority of potentially preventable deaths on the modern battlefield. The front lines of a battleground are predictably dirty, noisy, and located in predominantly harsh climates. You will routinely perform surgery in tents or abandoned buildings that lack suitable light and ventilation. These austere conditions demand early deliberate preparation to ensure successful management of vascular wounds. Lessons learned during US military operations continue to advance the practice of vascular trauma surgery and now translate into current recommended surgical practices. Despite the fact that vascular surgery has become largely separated from general surgery, all military surgeons must be well versed in basic vascular anatomy and reconstruction techniques. The majority of combat vascular injuries are not being handled by vascular surgeons, and you are unlikely to have one available to guide or assist you. Be prepared; you can be the difference between limb salvage and loss.

Civilian Translation of Military Experience and Lessons Learned

• Charles J. Fox 

Key Similarities

• Large numbers of patients with complex injuries

• Highly capable surgical teams

• Workflow efficiency

• Prehospital systems of care

Key Differences

• Resource and workspace limitations

• Resident workforce and educational mission

• Environmental conditions

• Degree of wound contamination

Discussion

There are many important advances spanning the current wartime experiences. Lessons learned during US military operations have continued to advance the field of vascular trauma surgery and now translate into many new civilian surgical practice patterns. This has been particularly evident around prehospital hemorrhage control strategies and implementation of new protocols that allow for rapid transfusion of blood products in the emergency department. No other injury pattern so suddenly causes blood loss, shock, and potential for death as vascular injury. Vascular injuries that can produce significant hemorrhage have therefore been recognized much earlier, and patients with extremity vascular injury have been saved with prehospital tourniquet application. This has shifted the focus of vascular injury diagnosis and management in modern civilian practice . The net result has been a tenfold increase in the early discovery of vascular injuries, many occult, and undoubtedly enhanced by multi-detector row computed tomography angiography in both civilian and military settings. Throughput seems remarkedly similar in the sense that both civilian and military hospitals have advanced diagnostic imaging collocated with emergency rooms, adjacent operative theaters, and adequately resourced intensive care beds that facilitate highly efficient workflow of a steady and large number of severely injured patients.

Resource availability and workspace limitations in combat continue to disrupt the expectations of specialized surgical teams trained in the modern era. While space constraints in the military are inconvenient at best and jeopardize patient safety at worst, the net result has been to produce an adaptable and flexible team focused on mission rather than quality of the infrastructure. For example, in the military, it is not infrequent that two casualties may share a single operating theater, while two or three surgical teams work simultaneously in a noisy confined space with poor lighting. This invaluable experience teaches one what is essential and what is not. While mass casualty events can occur in either setting, they occur more frequently in the military, and the result is a high state of readiness. The redundancy of military wounds may also enhance the preparedness for the next major incident. In civilian trauma centers, wounding patterns are more variable, and the same surgical team may not be present for the benefit of repetitious learning. To avoid mistakes in either setting, a consolidated and continuous training effort is mandatory. Regarding training, graduate medical education remains a mission essential component and source of manpower in civilian trauma centers. The absence of surgical trainees in deployed military settings consolidates the workforce, focuses the goal on direct patient care, and allows for direct communication between attending surgeons. This may represent a key difference between the military and civilian experiences.

Modern times have also used endovascular techniques to treat selected vascular injury. Recognized in the civilian sector as a favored option for blunt aortic and central vascular injuries, these methods have limited application in a theater of war where a robust inventory, hybrid suites, and a skilled endovascular team are lacking. What has emerged is the permeation of highly selective endovascular skills within the military such as resuscitative aortic balloon occlusion or ultrasound-guided placement of a femoral arterial sheath for hemodynamic monitoring. Once a familiarity is obtained with wires, sheaths, and catheters, the use of various adjuncts may be more achievable in austere environments. The military population tends to be younger, male, with a higher proportion of penetrating injury. The civilian population has the added challenge of comorbid conditions that produce profound physiologic deterioration in the setting of hemorrhagic shock. Therefore, endovascular solutions to these blunt civilian vascular injuries may reduce physiologic and metabolic derangements associated with the estimated blood loss of difficult surgical exposures.

Injury severity and mangled extremity scores tend to be higher in the military group. While the limb revascularization techniques and incidence of compartment syndrome are similar, the rate of amputation still appears higher in the military and is probably associated with the devastating effects of a heavily contaminated dismounted complex blast injury that requires continuous surgical debridement. These blast incidents produce horrific wounds, and the challenges of a multisystem dismounted complex blast injuries (DCBI ) that have emerged in recent conflicts are a frequent topic of interest. The response to this unique injury pattern can apply to any severely injured patient regardless of the setting. Civilians with crush injury or open pelvic fractures share similar initial hemostatic resuscitation and early management strategies, and just like DCBI during the wars in Iraq and Afghanistan, survival for these pelvic wounds has steadily improved when treated with evidence-driven protocols. A thorough understanding of this management strategy is crucial for any surgeon as a civilian setting can quickly become like a military one. Our nation, for example, frequently experiences similar sudden and unexpected enemy attacks. The truck bombing of the World Trade Center in 1993, the 1995 truck bombing in Oklahoma City, and the 1996 pipe bomb at the Summer Olympic Games produced almost 2000 casualties. Recently, the 2013 Boston Marathon bombing produced 264 DCBI-like casualties similarly described as mostly devastating lower extremity blast wounds that spared the chest and upper torso, resulting in 14 traumatic amputations from nails, ball bearings, and bits of metal. Those casualties went to 27 different local area hospitals and required the surgeon on call to deal with the unexpected blast-injured patient.

The translatable lessons learned, replete with both similarities and differences, serve as an instruction manual for managing patients with peripheral vascular injuries regardless of location. In this context partnerships between military and civilian surgeons are vitally important. Undoubtedly, the ability to respond to the vascular injuries experienced in Iraq and Afghanistan can be attributed to the excellent training received in large high-volume civilian trauma centers by world-renowned surgical educators. The reciprocal benefits of exchanging translatable experiences have proven invaluable to our nation’s preparation and maintaining surgical readiness to treat peripheral vascular injuries in both civilian and military settings.