Page 108 - JSOM Spring 2021

and effective first response. On volunteers, the compression of of skills and expertise. This course, based on presentations of
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the distal abdominal aorta with even a knee or fist has been recent experiences, lectures, and workshops, prepares military
reported to be a feasible temporizing measure; on average, a surgeons to manage complex penetrating trauma in austere
47kg weight applied in the midline close to the umbilicus was environments.
required to stop the blood flow in the common femoral ar-
tery. However, such techniques are not suitable for field and The patient, with hemodynamic shock requiring transfusion
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evacuation care. Junctional tourniquets therefore have been and resuscitative care, was clearly damage-control relevant.
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incorporated in the Tactical Combat Casualty Care guide- Hemorrhage and ischemia are the two major risks associated
lines. The Combat Ready Clamp (Combat Medical) enables with vascular wounds, and they require the use of vascular
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pressure to be applied with a ball that is screwed onto the ax- damage-control techniques. A temporary vascular shunt is
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illa or groin to apply pressure. The Junctional Emergency Tool frequently suggested for the management of combat vascular
(Chinook Medical Gear) and SAM-JT are pelvic belts that en- injury. It has demonstrated its utility and safety as a tempo-
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able iliac artery compression through a mechanical pressure rizing solution pending evacuation and definitive treatment.
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pad or inflatable bladder. These devices have been shown to be The temporary vascular shunt is also helpful in civilian ar-
effective in healthy volunteers, even though more data must be eas in cases of trauma associated with extensive orthopedic
provided of their use in trauma patients. Hemostatic gauze or soft-tissue injury. 23,24 In our case, after proximal and distal
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dressings should also be considered as a supplemental mea- vascular control, primary repair of the superficial femoral ar-
sure. Finally, invasive endovascular occlusion techniques, tery injury was quickly performed by arteriorrhaphy and did
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such as resuscitative endovascular balloon occlusion of the not compromise the damage-control procedure. On the other
aorta (REBOA), may be valuable rescue alternatives to exter- hand, the venous injury was more complex, and its repair
nal compression. REBOA has already been reported as fea- might have been time consuming. Furthermore, the combina-
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sible in the combat casualty setting for truncal hemorrhage tion of venous and arterial femoral injuries is known to be as-
control. 13 sociated with higher mortality risk. For these reasons, venous
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ligation was decided on as a damage-control procedure, even
The French trauma system includes prehospital medical teams; though proximal lower extremity venous ligation is contro-
in accordance with the European guideline on the manage- versial because of potential morbidity. For instance, after ex-
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ment of major bleeding, initial resuscitation is based on a re- ternal iliac artery shunting on an animal experimental model,
stricted volume-replacement strategy, with administration of venous ligation was reported to be responsible for an increase
crystalloid solutions and vasopressors in case of life-threaten- in ischemic histologic lesions. Venous repairs are therefore
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ing hypotension. Damage-control resuscitation with early, generally preferred in hemodynamically stable patients but are
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high ratios of blood product (i.e., plasma, platelets, red blood often delayed by trauma surgeons in case of complex injury or
cells) has been associated with improved outcomes in patients hemodynamic instability. Finally, prophylactic fasciotomies
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requiring massive transfusion. The European guideline rec- can also be justified when combined venous and arterial in-
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ommends a ratio of plasma to red blood cells of at least 1:2 juries are encountered in a patient in shock. We decided not
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and a goal-directed platelet transfusion. Pragmatic scoring to perform them because the lower limb had been quickly re-
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systems can be useful to identify these at-risk patients and for vascularized, making the risk of compartment syndrome low.
activating a massive transfusion protocol. For instance, we use
the ABC score, which is highly predictive of massive transfu- Conclusion
sion when at least two of four criteria are present in the emer-
gency room: penetrating mechanism, systolic blood pressure of Junctional hemorrhages are challenging for emergency phy-
90mmHg or less, heart rate of ≥120 bpm, and positive FAST. sicians and surgeons in both military and civilian settings.
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In our center, the first massive transfusion pack includes 2 type Effective techniques such as junctional tourniquets have been
O red blood cell units and 2 French lyophilized plasma units. developed for hemorrhage external control in the combat set-
Because the French lyophilized plasma does not need to be ting and can be equally useful in civilian settings. Out of their
thawed and is available without delay, its use in the emergency deployment periods, military medical and surgical teams’ in-
department provides faster plasma transfusion than does the tegration in civilian trauma systems is of special interest to
use of fresh-frozen plasma and reduces the time to reach a enable continuous training and skill maintenance. This case
high plasma:red blood cells ratio. French lyophilized plasma illustrates that knowledge and abilities transferred from com-
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also led to higher fibrinogen concentrations compared with bat casualty care can be highly beneficial for civilian patients.
fresh-frozen plasma, and it enables more rapid coagulopathy
improvement. 4 Authorship Contribution Statement
All authors attest that they meet the current International
The patient was treated by a general/visceral surgeon in a mili- Committee of Medical Journal Editors (ICMJE) criteria for
tary hospital without a specialized vascular surgeon. This situ- authorship.
ation is challenging but not uncommon because every surgeon
may have to deal with potential iatrogenic vascular injuries Disclaimer
or vascular wounds unrecognized during prehospital settings. The views expressed are solely those of the authors.
Despite the context of increasing surgical subspecialization
and sometimes a relative lack of major trauma exposure, mil- Financial Disclosure Statement
itary surgeons must be able to treat complex, serious combat There is no funding source.
casualties during military deployments. For these purposes,
the French Military Health Service Academy (École du Val- Declaration of Interest
de-Grâce) created in 2007 a comprehensive structured surgical On behalf of all the authors, the corresponding author states
training course for military surgeons to acquire a wide range that there is no conflict of interest.

104 | JSOM Volume 21, Edition 1 / Spring 2021