INITIAL MANAGEMENT OF SEVERE VASCULAR TRAUMA
Vietnam Fatal Battlefield Injury Patterns
31% - CNS trauma
34% - Torso hemorrhage
10% - Extremity hemorrhage
11% - Ten PTX, airway loss
14% - Misc
SCOOP-->RUN-->CASEVAC
Prehospital Care
Tourniquets
Limited Resuscitation
Combat casualty --> control bleeding with pressure to bleeding site/consider tourniquet --> transfer to higher level of care --> vital signs and mental status
--> palpable radial pulse/good mentation --> obtain access but withhold fluids, encourage oral fluids
--> abnormal --> Obtain IV access and administer fluids (7.5% hypertonic saline up to 500cc), if more fluids needed, switch to isotonic or colloid fluids
Peripheral Vascular Trauma Dx:
Hard Signs
Active Hemorrhage
Expanding Hematoma
Pulsatile Hematoma
Pulselessness /Ischemia
Presence of Bruit
Presence of Thrill
Expanding Hematoma
Pulselessness
Soft Signs
Bleeding in Field
Small/Nonexpanding Hematoma
Diminished Distal Pulses
Injury to Related Nerve
Proximity Injury
Assessment of Soft Signs
Arterial Pressure Index (API) = (SBP of affected extremity) / (SBP of non-injured extremity)
If API < 0.9 --> 73-87% Sensitivity, 97% Specificity for vascular trauma
50% of + are Significant Injuries
Ankle Brachial Index (ABI) = (SBP of Affected Leg) / (SBP of non-injured arm)
ABI > 0.9 --> 100% Negative Pred. Value
Approach to Penetrating Extremity Trauma
Penetrating extremity wound --> Physical exam w/ hard signs?
--> yes --(+/- angio)--> immediate exploration
--> no --> shotgun wound, large soft tissue injury, thoracic outlet injury, or comminuted fracture?
-->yes --> angiogram
-->no --> API/ABI positive then angiogram, API/ABI negative then observation
If angiogram + then immediate exploration, if negative or minimal injury then observation
Atraumatic Hemorrhage Control
Remove the Contamination
Lavage Technique
Optimal technique not certain
Pulsation superior at debriding necrotic tissue & clearing superficial bacteria but may drive bacteria into tissue
Median depths of bacterial penetration increased with high pressure pulsatile lavage vs low pressure lavage
Pulsed Lavage has been associated with 2 major outbreaks of Acinetobacter -
? mechanism: aerolization of bacteria or cross-contamination from suction apparatus
Can rarely cause air embolism
Low pressure lavage and debridement may be best option
Open Fractures
Gustilo classification used for prognosis
Original description in Tibial fxs
Now utilized to describe open fx sites
Fractures should be classified in the operating room at the time of initial debridement
–Evaluate periosteal stripping
–Consider soft tissue injury
Gustilo Type I Open Fractures
Inside-out injury
Clean wound < 1 cm
Minimal soft tissue damage
No significant periosteal stripping
0-2% infection rate
Gustilo Type II Open Fractures
Moderate soft tissue damage, Wound > 1 cm
Outside-in mechanism
Higher energy injury
Some necrotic muscle, some periosteal stripping
2-7% infection rate
Type IIIA Open Fractures
High energy
Outside-in injury
Extensive muscle devitalization
Bone coverage with existing soft tissue not problematic (< 10 cm)
5% infection rate
0-2% amputation rate
Type IIIB Open Fractures
High energy
Outside in injury
Extensive muscle devitalization
Requires a local flap or free flap for bone coverage and soft tissue closure (> 10 cm)
Periosteal stripping
~50% infection rate
5-15% amputation rate
Type IIIC Open Fractures
High energy
Increased risk of amputation and infection
Major vascular injury requiring repair
20-40% infection rate
25-40% amputation rate
Assess Salvagability vs. Amputation
Decision often unclear
Very few absolute indications to amputate
Little evidenced based guidance
Medicolegal issues
Limb Salvage vs Amputation
Significant advances in:
–Vascular reconstruction
–Nerve grafting
–Tissue transfer
Is amputation therefore a treatment failure ?
Triumph of Technology Over Reason?
Potential for costly, morbid and potentially lethal attempts at limb salvage:
“…the functional and cosmetic results of an attempt at salvage are often worse than those of early amputation, leaving the patient demoralized, divorced and destitute.” - Hansen, J Bone & Joint Surgery, 1987
Strong Indicators for Amputation
Non-reconstructable vascular injury
Transection of major nerve
Crush with warm ischemia > 6 hours
Predictive Indices
Several scoring systems proposed
–Limb Salvage Index
–Predictive Salvage Index
–Mangled Extremity Severity Score
Mangled Extremity Severity Score
Skeletal/soft tissue injury
1 - Low energy (stab, fracture, civilian gunshot wound)
2 - Medium injury (open or multiple fracture)
3 - High injury (shotgun or military gunshot wound, crush)
4 - Very high energy (above plus gros contamination)
Limb ischemia
1 - Pulse reduced or absent but perfusion normal
2 - Pulseless, diminished capillary refill
3 - Patient is cool, paralyzed, insensate, numb
Shock
0 - Systolic blood pressure always >90 mmHg
1 - Systolic blood pressure transiently <90 mmHg
2 - Systolic blood pressure persistently <90 mmHg
Age, yr
0 - <30
1 - 30-50
2 - >50
Score >6 --> high risk for amputation
Scoring System Drawbacks
Complex
Subjective
Based on retrospective data
Hard to apply prospectively to a single pt.
Not validated by functional outcome data
Factors not considered
– Multiple injuries
– Loss of knee joint
– Nerve transection
Clinical Realities
– Extent of soft tissue injury more important than skeletal trauma in ultimate function, especially nerve and muscle
Upper extremity
– Better function after salvage than lower extremity
– Poorer functional prognosis following amputation
Lower extremity
– Vascular reconstruction easier above knee
– Better function after BKA than AKA
Example case - factors considered:
– MESS Score = 5 --> salvage
– Isolated injury --> salvage
– Fracture pattern --> salvage
– Follow up care --> amputate
– Soft tissue status --> amputate
– Nerve status --> amputate
Technical Considerations
- Identify and ligate major vessels
- Cut nerves sharply and as high as possible
Restoring Perfusion
Fasciotomies
Re-establishment of Venous Outflow
Re-establishment of Arterial Inflow
Fasciotomies
Complex LE Vascular Trauma warrants
Arm & Thigh selectively on clinical grounds
Typically best to perform prior to re-perfusion
Anterior & Lateral Fasciotomies
Incision between tibia and fibula
Raise flaps toward tibia
Transverse nick
Find septum
Go posterior to get lateral compartment
Find SPN
GO anterior to get anterior compartment
Posterior Fasciotomies
Incision 2 finger bredths posterior to tibia, allow 7cm skin bridge
Careful dissection to avoid saphenous
Posterior to open superficial compartment
Take soleus off tibia to open deep compartment
1 Incision Fasciotomies
Anterior and lateral compartment release
Move posterior and release superficial posterior compartment
Retract PL anteriorally and soleus posteriorly
Detach soleus from fibula, avoid/cauterize perforators
Incise FHL fascia to open posterior deep compartment
Aggressive Resuscitation
1650 – pH 7.0 BD -15 P 140s SBP 70s --12 u pRBC, 4 amp HCO3-->
1810 – pH 7.2 BD -12 P 120s SBP 100s --reperfusion-->
1850 – pH 7.0 BD -14 P 140s SBP 60s
Restore the Blood Flow
Primary Repair - only if narrows <25%
Bypass
Temporary Vascular Shunting (TVS)
Damage Control Ortho – Pros & Cons
Early definitive fixation (EDF)
- Early mobilization
- Decreased LOS
- Better Function
Damage control ortho (DCO)
- Decreased SIRS
- Decreased PRBCs
- Decreased ARDS
Initial OR time (min): ETC 125, DCO 22, p <0.005
Initial estimated blood loss (mL): ETC 330, DCO 37, p <0.005
Total OR time (min): ETC 125, DCO 152, p=0.754
Total estimated blood loss (mL): ETC 330, DCO 348, p=0.811
ICU LOS (d): ETC 13.2, DCO 12.1, p=0.580
Hospital LOS (d): ETC 20.9, DCO 17.2, p=0.745
Transfusion requirements (pRBC units): ETC 3.2, DCO 3.7, p=0.582
Ventilator days: ETC 11.4, DCO 10.8, p=0.671
MOF score: ETC 2.78, DCO 3.08, p=0.371
ARDS score: ETC 1.81, DCO 1.79, p=-.232
The literature suggests that early definitive treatment may be used safely for most patients with multiple injuries, however a subgroup of patients with multiple injuries may benefit DCO
Prospective trial with DCO in femur fractures ongoing
DC Management of Extremity Vascular Trauma
1. Stop the Bleeding
2. Remove the Contamination
3. Restore the Blood Flow
4. Stabilize the Fractures
5. Don’t burn bridges for the next guy
The Balance of Damage Control Vascular Surgery
Temporary vascular shunting (TVS)
- Rapid hemorrhage control
- Rapid restoration of perfusion
- Flexibility with concurrent ortho procedures
- Necessitates return to OR
- Loss of length
Up front repair
- Increased physiologic insult
- Compromised repair
- Avoid further OR
- Avoid length loss
Temporary Vascular Shunting (TVS)
Initial report in WW11
Modern description c 36 Israeli Combat Traumas2
Civilian Experience c Complex Ortho Cases & Damage Control
Benefits: Straightforward, Restores Perfusion, Allows deferment of definitive repair
Technical Points
Straight Lie of Shunts
1) minimize stasis/turbulence
2) increase stability of placement
3) Ensure not against wall
Native vessels left intact
1) avoids retraction
2) ligate intermediate branches and tributaries
3) secure close to middle
Concurrent venous shunting use largest shunt which will fit
Native Vessels left intact
Temporary Vascular Shunting
Chamber's Iraq Experience:
RSVG to vein & artery c good results at 31st CSH
37 Ligation (47%)
13 Primary Repair (16%)
29 Temporary Vascular
Shunting (37%)
29 TVS in 22 Casualties
2 TVS concurrent c Resuscitative Thoracotomy
27 Evaluable TVS in 20 Patients
- ISS 15
- MESS 9 (6-11)
- 11 Hypotensive and acidotic
- 13 Hypothermic
- 14 w/ tourniquets
- TTP 61 min (16-150)
- Vessels shunted: 7 femoral artery, 6 femoral vein, 3 popliteal artery, 3 popliteal vein, 3 PTA, 2, Brachial artery, 1 iliac artery, 1 brachial vein, 1 PTV
27 Evaluable TVS in 20 Casualties
100% Survival
0 Bleeding Complications
78% Shunt Patency
85% Limb Salvage
- 2 amputations due to soft tissue loss from blast effect despite good distal pulses
- 1 amputation due to unrecognized tibial nerve injury
No “Burned Bridges”
TVS – Civilian Indications
Damage Control
- Truncal
- Extremity
Intraop Use
- Ortho injuries
- Prep for complex vascular repairs
- Reimplantation cases
Grady TVS Experience
Data supported selective use in the ~ 10% of Vascular Injuries meeting indications
Anticoagulation doesn’t appear to be necessary
Longest patencies observed:
- Arterial - 71 hr
- Venous - 35 hr
(longest reported dwell time in lit. = 10 days in axillary artery)