The Effectiveness of a Damage Control Resuscitation Strategy for Vascular Injury in a Combat Support Hospital: Results of a Case Control Study (original) (raw)
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Contemporary management of wartime vascular trauma
Journal of Vascular Surgery, 2005
Objective: The treatment of wartime injuries has led to advances in the diagnosis and treatment of vascular trauma. Recent experience has stimulated a reappraisal of the management of such injuries, specifically assessing the effect of explosive devices on injury patterns and treatment strategies. The objective of this report is to provide a single-institution analysis of injury patterns and management strategies in the care of modern wartime vascular injuries. Methods: From December 2001 through March 2004, all wartime evacuees evaluated at a single institution were prospectively entered into a database and retrospectively reviewed. Data collected included site, type, and mechanism of vascular injury; associated trauma; type of vascular repair; initial outcome; occult injury; amputation rate; and complication. Liberal application of arteriography was used to assess these injuries. The results of that diagnostic and therapeutic approach, particularly as it related to the care of the blast-injured patient, are reviewed. Results: Of 3057 soldiers evacuated for medical evaluation, 1524 (50%) sustained battle injuries. Known or suspected vascular injuries occurred in 107 (7%) patients, and these patients comprised the study group. Sixty-eight (64%) patients were wounded by explosive devices, 27 (25%) were wounded by gunshots, and 12 (11%) experienced blunt traumatic injury. The majority of injuries (59/66 [88%]) occurred in the extremities. Nearly half (48/107) of the patients underwent vascular repair in a forward hospital in Iraq or Afghanistan. Twenty-eight (26%) required additional operative intervention on arrival in the United States. Vascular injuries were associated with bony fracture in 37% of soldiers. Twenty-one of the 107 had a primary amputation performed before evacuation. Amputation after vascular repair occurred in 8 patients. Of those, 5 had mangled extremities associated with contaminated wounds and infected grafts.
Outcome after vascular trauma in a deployed military trauma system
British Journal of Surgery, 2011
Background: Military injuries to named blood vessels are complex limb-and life-threatening wounds that pose significant difficulties in prehospital and surgical management. The aim of this study was to provide a comprehensive description of the epidemiology, treatment and outcome of vascular injury among service personnel deployed on operations in Afghanistan and Iraq.
In-Theater Management of Vascular Injury: 2 Years of the Balad Vascular Registry
Journal of the American College of Surgeons, 2007
BACKGROUND: Wartime vascular injury management has traditionally advanced vascular surgery. Despite past military experience, and recent civilian publications, there are no reports detailing current in-theater treatment. The objective of this analysis is to describe the management of vascular injury at the central echelon III surgical facility in Iraq, and to place this experience in perspective with past conflicts. STUDY DESIGN: Vascular injuries evaluated at our facility between September 1, 2004 and August 31, 2006 were prospectively entered into a registry and reviewed.
2019
TCCC has previously recommended interventions that can effectively prevent 4 of the top 5 causes of prehospital preventable death in combat casualties-extremity hemorrhage, junctional hemorrhage, airway obstruction, and tension pneumothorax- and deaths from these causes have been markedly reduced in US combat casualties. Noncompressible torso hemorrhage (NCTH) is the last remaining major cause of preventable death on the battlefield and often causes death within 30 minutes of wounding. Increased use of whole blood, including the capability for massive transfusion, if indicated, has the potential to increase survival in casualties with either thoracic and/or abdominopelvic hemorrhage. Additionally, Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide temporary control of bleeding in the abdomen and pelvis and improve hemodynamics in casualties who may be approaching traumatic cardiac arrest as a result of hemorrhagic shock. Together, these two interven...
2008
Medical care in modern warfare is challenged by the use of high-explosive weapons that can induce mass casualties. In the current conflicts, improvements in body armour, the use of tourniquets and hemostatic dressings and in most cases, rapid evacuation times has resulted in higher survival rates than seen in prior wars. A major medical advance in the current conflicts is the initiation of damage control resuscitation for the treatment of severely injured Soldiers, particularly those who require massive transfusion and have dysfunction of their blood clotting system and the highest risk of dying. Recent retrospective analysis of traumatic injuries has revealed that patients who received plasma or a plasma to RBC ratio close to 1:1, had improved survival compared to patients who received standard transfusion therapy of plasma to RBC ratios of 1:4 or greater. As further analysis of the benefits of plasma are realized, research efforts in the laboratory are investigating and characterizing a freeze-dried plasma compared to standard fresh frozen plasma, so the benefits of this blood product can be delivered to far forward locations for the early treatment of severely injured Soldiers. 14. ABSTRACT 15. SUBJECT TERMS 16. SECURITY CLASSIFICATION OF: 17. LIMITATION OF ABSTRACT UU 18. NUMBER OF PAGES 7 19a. NAME OF RESPONSIBLE PERSON a. REPORT unclassified b. ABSTRACT unclassified c. THIS PAGE unclassified Standard Form 298 (Rev. 8-98) Prescribed by ANSI Std Z39-18
Characteristics and Distribution of Extremity Vascular Injuries in a Wartime Military Cohort
Journal of Vascular Surgery, 2020
was similar compared to the larger population of patients with arterial injury but without patency data (n ¼ 352) except veterans with patency data had higher Injury Severity Scores (P < .03), Abbreviated Injury Scale-Extremities (P < .001) and a higher percentage of gunshot wounds (P < .03). Of the 141 arterial repairs, 82% were vein grafts, 33% were in the upper extremity and 8 repairs occluded or otherwise failed (Table I). Three transtibial amputations were performed for chronic pain and poor function after an average of 27 6 4 months (range, 24-32 months). Average patency follow-up since injury was 35 6 40 (range, 1-175 months). Kaplan-Meier analysis of all repairs estimated patency rates of 98%, 96%, 92% and 90% at 6, 12, 24, and 36 months, respectively (Fig 1), with similar results for upper and lower extremity repairs (Table II and Fig 2). Conclusions: Amputations occurring after the 3-month, acute phase of injury were rare and performed for associated fractures and nerve injuries. Arterial repairs for combat EVI have excellent long-term patency with similar patency rates in upper and lower extremity repairs. These results justify continued assertive attempts at vascular repair and limb salvage.
Initial Assessment and Resuscitation of the Battlefield Casualty—an Overview
Current Trauma Reports, 2020
Purpose of Review This review focuses on the recent evolution of the initial resuscitation of combat-injured personnel. It summarizes the recommendations of TCCC and makes recommendations based on literature review and author experience. Recent Findings Over nearly 20 years, the experience in caring for combat casualties in the global war on terror has led to significant changes within military trauma care. Evolution of pre-hospital care, utilization of tourniquets and TXA for hemorrhage control, and use of whole blood as the preferred resuscitative fluid have significantly reduced mortality. Additionally, the collective wisdom of experienced trauma surgeons serves as an invaluable guide for managing setup and flow within the various levels of the military trauma system. Summary This review article highlights recommended practices for the initial resuscitation of personnel injured in combat along with providing proven methods for trauma team preparation and management that can and should be used by any surgeon preparing to deploy.
Journal of Vascular Surgery, 2007
Background: Although the management of vascular injury in coalition forces during Operation Iraqi Freedom has been described, there are no reports on the in-theater treatment of wartime vascular injury in the local population. This study reports the complete management of extremity vascular injury in a local wartime population and illustrates the unique aspects of this cohort and management strategy. Methods: From September 1, 2004, to August 31, 2006, all vascular injuries treated at the Air Force Theater Hospital (AFTH) in Balad, Iraq, were registered. Those in noncoalition troops were identified and retrospectively reviewed. Results: During the study period, 192 major vascular injuries were treated in the local population in the following distribution: extremity 70% (n ؍ 134), neck and great vessel 17% (n ؍ 33), and thoracoabdominal 13% (n ؍ 25). For the extremity cohort, the age range was 4 to 68 years and included 12 pediatric injuries. Autologous vein was the conduit of choice for these vascular reconstructions. A strict wound management strategy providing repeat operative washout and application of the closed negative pressure adjunct was used. Delayed primary closure or secondary coverage with a split-thickness skin graft was required in 57% of extremity wounds. All patients in this cohort remained at the theater hospital through definitive wound healing, with an average length of stay of 15 days (median 11 days). Patients required an average of 3.3 operations (median 3) from the initial injury to definitive wound closure. Major complications in extremity vascular patients, including mortality, were present in 15.7% (n ؍ 21). Surgical wound infection occurred in 3.7% (n ؍ 5), and acute anastomotic disruption in 3% (n ؍ 4). Graft thrombosis occurred in 4.5% (n ؍ 6), and early amputation and mortality rates during the study period were 3.0% (n ؍ 4) and 1.5% (n ؍ 2), respectively. Conclusions: To our knowledge, this study represents the first large report of wartime extremity vascular injury management in a local population. These injuries present unique challenges related to complex wounds that require their complete management to occur in-theater. Vascular reconstruction using vein, combined with a strict wound management strategy, results in successful limb salvage with remarkably low infection, amputation and mortality rates. ( J Vasc Surg 2007;45:1197-1205.)
Journal of Surgical Orthopaedic Advances, 2015
Battlefield injuries and high-energy civilian trauma present orthopaedic surgeons with treatment challenges. Despite efforts at limb salvage, some patients elect late amputation. This article reviews risk factors that predispose to late amputation. Using a MEDLINE search, English language peer-reviewed articles from 1993 to 2013 having data on late amputation following limb salvage were included. Late lower extremity amputation after limb salvage varied from 3.9% to 40% in civilian patients and from 5.2% to 15.2% in military patients. Factors influencing a patient's decision to undergo late amputation included a combination of complex pain symptoms with neurologic dysfunction, infection, a desire for improved limb functionality, and unwillingness to endure an often complicated and lengthy course of treatment. In military patients, rank was a significant risk factor since officers were 2.5 times more likely to elect late amputation (p < .05) than enlisted personnel. Despite often extraordinary efforts toward limb salvage, results may be disappointing. (Journal of Surgical Orthopaedic Advances 24(3): 170-173, 2015) Treatment of combat casualties with severely injured limbs is challenging, and the outcomes can be unpredictable (1). Traditional war wound epidemiology has changed as a result of modem body armor, which has decreased lethality from thoracoabdominal wounds, with resultant improved survival with mutilating extremity injuries (2). Limb salvage in this patient group is often difficult, outcomes can be unpredictable, and sometimes amputation is the end result. A recent study found that for the Iraq and Afghanistan Wars, 5.2% of seriously injured U.S. casualties underwent major limb amputation and that the vast majority (95%) ofthe·se amputations were performed early in the medical evacuation chain before reaching definitive care and not the result of later limb reconstruction (3). There is a small subset of patients who sustain severe battlefield injuries that result in salvage of a major limb, who later elect to undergo amputation after surgical treatment and rehabilitation. Historically, little has been known about the incidence of, risk factors for,