Page 32 - JSOM Summer 2020

connected to a pressure monitor during evacuation to higher syndrome. 13,62 All of these are exceptionally more difficult in
levels of care or if repeated catheterization is probable but the ARSC environment, which emphasizes the importance of
comes at a risk of limb ischemia and even limb loss. Sheath readiness and training for this skill set before deployment.
complications are not uncommon and the sheath should be
removed at the earliest time after the patient has demonstrated Shunt placement is a required skill set. When placing a shunt,
stability. After sheath removal the vascular must be evaluated thrombectomy of the distal vessel should be performed be-
to ensure that there is good distal perfusion. While the sheath fore shunt placement if vigorous back-bleeding is not present.
is in place, distal pulses must be followed closely. See the “JTS Secure all shunts with suture as close to the vascular injury
Resuscitative Endovascular Balloon Occlusion of the Aorta as possible to preserve native vessel length. Leaving all vessel
(REBOA) for Hemorrhagic Shock CPG.” All ARSC pro- loops used for proximal and distal control loosened and in
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viders require REBOA training. There are multiple training place will allow the next surgeon to quickly identify relevant
courses available. anatomy and provides rapid control of a vessel if the shunt
dislodges in transport. Cover the operative field with dressings
Laparotomy and consider a temporary skin closure to protect the shunt.
Concern for NCTH with hemodynamic instability requires Primary patency rates are high for proximal shunts (86%) and
surgical intervention at the earliest opportunity that resources low for distal shunts (12%). Primary repair of partially in-
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and personnel permit; this is no different from other roles of jured vessels, such as large veins, is preferable if greater than
care. Damage-control laparotomy is the standard in the unsta- 50% stenosis can be avoided. Shunting of large veins is pref-
ble trauma patient and may be performed in forward environ- erable to ligation when primary repair is not feasible and may
ments. 13,53 In the deployed setting, damage-control surgery and increase patency rates of associated arterial shunts. Definitive
temporary abdominal closure are recommended when signifi- reconstruction such as vein graft should be delayed to a higher
cant intraabdominal injuries are found. level of care when possible. If the vascular repair is associ-
13
ated with a fracture, immobilization with an external fixator
In OIF and OEF, the rate of nontherapeutic laparotomy was is recommended; external fixation before definitive vascular
as high as 32%. A nontherapeutic laparotomy is likely safer shunting is recommended if the warm ischemia time allows.
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than a potentially prolonged transfer for a casualty who might In the case of popliteal and femoral artery injuries, the use of
have a missed injury. These decisions are very challenging, but shunts, as opposed to primary amputation, even in an unstable
succumbing to injuries in flight is never acceptable. Selective patient, does not increase risk of death and improves overall
nonoperative management should only be considered where amputation-free survival. 63,64 Balloon catheters (REBOA or
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CT scan and extended observation are possible. Fogarty) can be used to provide temporary vascular control.
Refer to the “JTS Vascular Injury.” 65
Thoracotomy
The incidence of thoracic trauma in modern conflict is ap- Subclavian Vessels
proximately 5%, with the mortality rate ranging from 12% to This injury pattern carries a high mortality rate. Most ve-
24%. 44,56 Patients with severe thoracic trauma have a signifi- nous bleeding and some arterial bleeding can be controlled
cant survival advantage if they reach surgical capability within with wound packing. A temporary skin closure over the pack-
1 hour. 57,58 Thoracotomy should be performed when indicated ing may improve tamponade. Maneuvers to obtain proxi-
with the damage-control mindset and the goals of rapid con- mal vascular control include intrathoracic exposures such as
trol of hemorrhage and contamination. The chest may be tem- sternotomy, supraclavicular, clavicular resection, trap-door
porarily packed and closed over chest tubes. approaches, and retrograde placement of a Fogarty catheter
through the brachial artery or through the zone of injury. In
Cardiac Injury addition, inflating a Foley balloon within the wound track
Imaging is usually limited to a handheld ultrasound device. may provide tamponade, particularly if able to maintain com-
Maintain a low threshold to perform a subxyphoid or trans- pression against the clavicle or chest wall. A chest tube should
diaphragmatic pericardial window if the injury pattern is con- be placed on the same side as the subclavian vascular injury if
cerning for mediastinal or cardiac injury. If there is blood in there is a concern for intrathoracic hemorrhage.
the pericardium, explore as indicated. See the “JTS Wartime
Thoracic Injury CPG.” Rarely, some patients with hemoperi- Inguinal Vessels
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cardium may present with normal hemodynamics, which may Contralateral placement of a REBOA catheter with aortic
represent a superficial injury to the myocardium, and sternot- occlusion in zone 3 is a rapid and effective way to obtain
omy may be avoided if the pericardial space is irrigated with temporary proximal control of a junctional groin injury. Ex-
warmed fluid and the bleeding is noted to have stopped. 60–62 traperitoneal control of the iliac vessels above the level of the
Place a closed suction drain and record output. A period of inguinal ligament also achieves proximal control of the injured
observation is recommended before transfer. vessel outside of the zone of injury, but a low threshold for
intraabdominal proximal control should be applied, given the
often unpredictable trajectories of combat injuries.
Vascular
Like every deployed surgeon, the ARSC surgeon should have Fasciotomy
training and experience in expeditious exposure of all named Maintain a low threshold to perform fasciotomies for the com-
vessels to identify and control hemorrhage. The initial dam- bat-injured extremity. Delay in diagnosis of compartment syn-
13
age control and stabilization of injured vessels include control drome can occur due to multiple patient handovers during the
of exsanguinating hemorrhage, recognition of extremity isch- transport process. Be proficient with techniques for the upper
13
emia, rapid restoration of flow to the ischemic limb with vas- and lower extremity, especially the common pitfalls: missing
cular shunts, and fasciotomies to treat or prevent compartment the deep posterior compartment in the lower extremity and

30 | JSOM Volume 20, Edition 2 / Summer 2020