emergency war surgery course joint trauma system · 2020. 4. 17. · ews vascular injuries upper...

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Joint Trauma System

Vascular Injuries

Joint Trauma System Battlefield Trauma Educational Program

22020, v1.0

A 29 year old has been shot in the right thigh. The medics noted pulsatile bleeding and placed a tourniquet approximately three hours ago. The patient arrives at your remote Role 2 with tourniquet in place and deformed right thigh. Evacuation to Role 3 is not expected to be available for 2 hours.

What are your initial thoughts?

What interventions do you expect to perform?

EWS Vascular InjuriesScenario

32020, v1.0

Describe evaluation of the patient with a potentialvascular injury.

Explain the general principles for vascular injuries.

Describe the management techniques of specific vascularinjuries.

Define the management techniques appropriate atdifferent levels of care.

EWS Vascular Injuries Objectives

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∎ Rates of vascular injuries have increased. OEF/OIF Rate: 10-12% WWII, Korea, Vietnam Rate: 1-3%

∎ Distribution of injuries Extremity Vessels: 70-80% Cervical Region: 10-15% Torso: 5-10%

∎ Associated injuries Nerves: 40% Veins: 40% Bone: 30%

EWS Vascular InjuriesBackground

Right lower extremity traumatic amputation

52020, v1.0

∎ Penetrating: Missiles or fragments High-velocity Extensive direct vascular

and soft tissue injury

Low-velocity projectiles/fragments Direct injury

∎ Blunt: Bone fractures or dislocations Fracture Direct injury Stretch injury

Dislocation Stretch injury

EWS Vascular InjuriesMechanisms of Injury

Vascular injury

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∎ History (point of injury) Mechanism of injury Pulsatile bleeding? Amount of blood loss at

the scene

EWS Vascular InjuriesMechanisms of Injury

Distal ischemia of left arm necessitated surgical evaluation

∎ Physical examination Variable findings Hard signs, soft signs

Pulses intact in 20% of arterial injuries Injured Extremity Index

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Hard Signs: Operate/Explore

∎ Pulsatile bleeding

∎ Hemorrhage

∎ Palpable thrill/audible bruit

∎ Expanding hematoma

∎ Obvious ischemia (including 6 Ps)

EWS Vascular InjuriesPhysical Examination

1. Pain2. Pallor3. Pulselessness

4. Paresthesias5. Poikilothermia6. Paralysis

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Soft Signs: Diagnose

∎ History of significant hemorrhage

∎ Injury in proximity to major vessels (fracture pattern, dislocation, penetrating wound)

∎ Bruising

∎ Hematoma (non-expanding)

∎ Question regarding the presence or absence of a palpable pulse

∎ Associated peripheral neurologic deficit

EWS Vascular InjuriesPhysical Examination

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Injured Extremity Index (IEI)∎ Performed in the absence of hard signs.∎ Similar to ankle-brachial index.∎ Ratio of the pressure at which arterial Doppler signal returns in

the injured extremity as a cuff is deflated, over the same pressure in an uninjured extremity.

∎ A ratio greater than 0.90 is normal and has a high specificity to exclude major extremity vascular injury.

∎ Pitfalls – lower extremity IEI may be normal with an isolated femoral profunda injury.

EWS Vascular InjuriesDiagnostic Testing

Systolic Pressure in Injured Extremity

Systolic Pressure in Uninvolved Extremity

102020, v1.0

∎ Ultrasound Portable, real-time User dependent

∎ Computed Tomography-Angiography (CTA) Increasingly available in mature theaters of war, but requires time,

IV contrast and technical experience. Best used in diagnosis and triage of torso and neck wounds.

∎ Angiography Limited utility due to availability and quality of imaging technology

in austere environment. Extremity vasoconstriction associated with shock and hypothermia

may lead to false positive findings. Best use in setting of multiple penetrating wounds on same extremity.

EWS Vascular InjuriesDiagnostic Testing

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EWS Vascular InjuriesAlgorithm (1)

Hemodynamically Normal?

Resuscitation and management of life-threatening injuries, including establishing

or maintaining hemorrhage control. 1

1. Do not release tourniquets or begin vascular injury exploration if patient is in shock from associated injuries.

NO

122020, v1.0


Hemodynamically Normal?

Hard signs of vascular

injury?2

OR for exploration and management of extremity

vascular injury

Concerns for, or soft signs of

vascular injury?3

1. Hard signs: hemorrhage, expanding hematoma, absence of Doppler signal on repeatedexam, audible bruit, palpable thrill.

2. Soft signs: proximity to major vessel, fracture or dislocation patterns, diminished pulse,report of hemorrhage or shock.

YES NO

YES

132020, v1.0


Perform IEI with continuous wave

Doppler4

Concerns for, or soft signs of vascular

injury?3

3. Soft signs: proximity to major vessel, fracture or dislocation patterns, diminished pulse, report ofhemorrhage or shock.

4. IEI is occlusion pressure of arterial Doppler signal on injured extremity divided by occlusionpressure of normal limb. Normal is >0.90

Repeat Doppler exam and IEI during first hours after injury, especially if patient is cold and hypotensive.

YES NOManagement of

other injuries

142020, v1.0


Perform IEI for continuous wave Doppler4

Normal, IEI > 0.9 Abnormal, IEI < 0.9Assume vascular injury and proceed to operating room

or consider CTA or angiography to confirm

4. IEI is occlusion pressure of arterial Doppler signal on injured extremity divided by occlusion pressure ofnormal limb.

Normal is >0.90

Repeat Doppler exam and IEI during first hours after injury, especially if patient is cold and hypotensive.

Observation with repeat vascular exam and

consider duplex or CTA at higher levels of care

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∎ Expose and explore.∎ Obtain proximal and distal control.∎ Debride vessel to viable tissue.

Thrombectomy? #2-3 Fogarty for extremity #4-5 Fogarty for femoral/iliac

∎ Repair or shunt depending on conditions. Extent of extremity injury Extent of vascular injury Physiologic status of patient

∎ Create a tension-free repair.∎ Cover the repair with viable tissue.∎ Consider fasciotomy.

EWS Vascular InjuriesBasic Management Principles

Proximal and Distal Control required sternotomy and right subclavicular incision

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∎ Temporary vascular shunts

∎ Direct repair

∎ Patch angioplasty

∎ End-to-end anastomosis

∎ Interposition graft

∎ Bypass

∎ Ligation

EWS Vascular InjuriesRepair Options (1)

172020, v1.0

Temporary vascular shunts Create temporary blood flow. Allow for time to manage other

injuries (ortho). Argyle, Javid, and Sundt without

systemic anticoagulation. Secure with silk ligatures. Patent for up to 6 hours; should be

removed with formal repair in-theater prior to medevac to Role 4.

OEF/OIF shunt patency >90% up to24 hours.

EWS Vascular InjuriesVascular Shunts

Proximal and distal control required sternotomy and right subclavicular incision

Shunt placement. Dark line is vessel, with dotted and fine line shunt. Note overlap of shunt and vessel of 1 inch.

2-0 Silk

Midline Suture

Shunt

1 inch (2 cm)

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Temporary vascular shunts

Larger peripheral arteries Carotid Axillary/brachial Iliac/femoral/popliteal

Selective Radial/ulnar Tibial Venous – large peripheral

Low utility Great vessels and abdominal arteries


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∎ Direct Vessel Repair Only for very small arteriotomy/venotomy Any larger defects will risk stenosis if closed primarily.

∎ Patch Angioplasty Options include: saphenous vein patch, bovine pericardial patch,

Dacron patch, PTFE Less risk of stenosis 5-0 to 6-0 Prolene for extremity vessels 3-0 to 4-0 Prolene for aorta/iliacs


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∎ End-to-end anastomosis Minimal loss to length (<2 cm) Must debride first to healthy tissue Spatulate ends to prevent stenosis

Interposition Graft Preferred conduit is reversed great

saphenous vein Contralateral leg Flush with heparinized saline

Prosthetic grafts available (PTFE, Dacron) Not preferred due to risk of infection


Autologous vein as interposition graft

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∎ Bypass Graft Anatomic Extra-anatomic—ensure adequate soft tissue coverage

∎ Use of Prosthetic Graft Material ePTFE or Dacron for central torso vascular injuries Prosthetic conduit acceptable as last resort—notify higher levels of

care for surveillance

∎ Autologous Vein Use reversed greater saphenous vein from uninjured extremity Mark distal end as “in-flow” assuring reversal Distend with heparin saline and an olive tip


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∎ Temporary vascular shunting should be consideredbefore ligation.

∎ Continuous-wave Doppler should be checked beforeligation to judge viability of distal tissue.

∎ Ligation is an acceptable damage control maneuver,especially for small, more distal arteries and veins.

EWS Vascular InjuriesLigation of Vessels

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∎ Fasciotomy is performed at the time of revascularization.

∎ When performed, complete the release of all extremitycompartments through full skin and fascial incisions.

EWS Vascular InjuriesFasciotomy

Forearm fasciotomy Lower extremity fasciotomy

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∎ Soft Tissue Coverage Cover vascular repairs with available local tissue. If no soft tissue, route grafts out of zone of injury. Poorly covered anastomosis will blowout after several days. Avoid placement of negative pressure dressings directly over

vascular structures.

∎ Anticoagulation Heparin saline is typically 1,000 IU/Liter. Can add papaverine (60 mg/Liter). Systemic anticoagulation is achieved 50 U/kg IV heparin with

1000 u repeated at 1 hr; repeat doses are not recommended.

EWS Vascular InjuriesConsiderations

252020, v1.0

∎ Pediatric Vascular Injury Intervention should be avoided in those less than ten years old given

propensity for spasm in vessels. Ligation is more well tolerated in infants and toddlers. Perform interrupted suture lines (6-0 Prolene) to allow expansion with

growth.

∎ Endovascular Capabilities and IVC Filters Increasingly applied to management of vascular injury. Availability of technology and tools vary by location/role. IVC filters for injured who have contraindications for anticoagulation.

∎ Post-Operative Care Routine pulse checks. Known baseline (should be palpable in young troops). Pulse changes may indicate graft thrombosis, even if Doppler signals remain.

EWS Vascular InjuriesConsiderations

262020, v1.0

∎ Subclavian Artery Recommendation: Shunt, ligate, definitive repair Utility of temporary shunt: High (difficult due to exposure) Method/Conduit: Interposition graft/6-8 mm ePTFE or Dacron Utility of endovascular repair: High

∎ Axillary Artery Recommendation: Shunt, ligate, definitive repair Utility of temporary shunt: High Method/Conduit: Reversed saphenous vein, interposition graft Utility of Endovascular repair: High

EWS Vascular InjuriesUpper Extremity Vessels

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∎ Brachial Artery Recommendation: Shunt, ligate,

definitive repair Utility of temporary shunt: High Method/Conduit: Reversed saphenous

vein, interposition graft

∎ Radial/Ulnar Artery Recommendation: Selective repair

(maintain at least one vessel) Utility of temporary shunt: Low Method/Conduit: Ligation or interposition

graft/reversed saphenous vein

EWS Vascular InjuriesUpper Extremity Vessels

Brachial Artery Exploration

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∎ Common Femoral Artery Recommendation: Shunt, definitive repair Utility of temporary shunt: High Method/Conduit: Interposition graft/reversed saphenous vein

or 6-8 mm prosthetic

∎ Profunda Femorus Artery Recommendation: Definitive repair if possible, ligation Utility of temporary shunt: Low Method/Conduit: Ligation or interposition graft/reversed saphenous vein

∎ Superficial Femoral Artery Recommendation: Shunt, definitive repair Utility of temporary shunt: High Method/Conduit: Interposition graft/reversed saphenous vein

EWS Vascular InjuriesLower Extremity Vessels

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∎ Popliteal Artery Recommendation: Shunt, definitive repair Utility of temporary shunt: High Method/Conduit: Reversed saphenous vein

∎ Tibial Arteries Recommendation: Ligation, definitive

repair (selective) Utility of temporary shunt: Low

(difficult exposure, low patency) Method/Conduit: Ligation or interposition

graft with reversed saphenous vein

EWS Vascular InjuriesLower Extremity Vessels

Popliteal Artery Exploration

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∎ Portal Vein and Hepatic Artery Recommendation: Pringle maneuver, then explore. Ligation of hepatic

artery if portal vein patent Utility of temporary shunt: Low Method/Conduit: Primary repair, patch angioplasty, interposition graft/ePTFE

or Dacron or saphenous vein

∎ Mesenteric Arteries/Veins Recommendation: Repair proximal injuries Utility of temporary shunt: Low Method/Conduit: Primary repair, patch angioplasty, interposition graft

∎ Renal Arteries Recommendation: Repair, nephrectomy Utility of temporary shunt: Low Method/Conduit: Primary repair, patch angioplasty/Dacron or saphenous vein

EWS Vascular InjuriesTorso Vascular Injury

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∎ Thoracic Aorta Recommendations: Selective repair Utility of temporary shunt: None, except in extremis Method/Conduit: Observation and medical optimization or Dacron graft

replacement Utility of Endovascular Repair: preferred where available

∎ Abdominal Aorta Recommendation: Repair Utility of temporary shunt: Low Method/Conduit: Interposition graft/Dacron Utility of Endovascular Repair: preferred where available


322020, v1.0

∎ Vena Cava Recommendation: Repair, ligation as

damage control (w/BLE fasciotomies) Utility of temporary shunt: Low Method/Conduit: Lateral repair, patch

angioplasty or interposition graft/ePTFE∎ Iliac Arteries

Recommendation: Definitive repair,ligation, shunt

Utility of temporary shunt: High Method/Conduit: Interposition

graft/ePTFE or Dacron or saphenous vein Utility of endovascular repair: High


Vena cava injury

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∎ Carotid Artery Recommendation: Definitive repair, shunt, ligate Utility of temporary shunt: High Method/Conduit: Vein patch or vein interposition graft Utility of endovascular repair: High

∎ Vertebral Artery Recommendation: Ligate Utility of temporary shunt: None Method/Conduit: N/A

∎ Jugular Vein Recommendation: Selective Repair Utility of temporary shunt: None Method/Conduit: Lateral venorrhaphy, vein patch or saphenous vein

EWS Vascular InjuriesCervical Vascular Injury

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∎ Veins Internal/external jugular Brachiocephalic Infrarenal inferior vena cava Left renal Internal iliac Subclavian Mesenteric Tibials Common Femoral Superficial Femoral Popliteal Brachial

EWS Vascular InjuriesLigation

Vessels Amenable to Ligation∎ Arteries

Digital Radial or ulnar, but not both;

preserve ulnar when possible External carotid Brachial distal to profundi and

adequate wrist; Doppler signal Subclavian branches Internal iliac Profunda femoris Hepatic

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∎ Role 1 – Point of injury care/front line Hemorrhage control or other life-saving interventions and evacuation

∎ Role 2 – Highly mobile forward surgical teams Intervention on extremity vascular injury is important and may increase

the rate of meaningful limb salvage. Damage control procedures for limb salvage when appropriate Remove tourniquets, explore and control vascular injury. Removal of thrombus, flush with heparinized saline. Restoration of flow (shunt or repair) and fasciotomy.

Ligation or amputation of limb is acceptable if patient in extremis. NEVER close a stump primarily.

EWS Vascular InjuriesRoles of Care Treatment

Expected Level of Treatment—Role 1, Role 2

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∎ Role 3 – Combat support hospitals This is where definitive vascular injury diagnosis and repair occurs. Remove tourniquets, shunts. Determine route. Saphenous vein is preferred conduit, but synthetic conduit can be

used. Soft-tissue coverage Assessment of adequate of limb perfusion, fasciotomy, and wound

debridement prior to evacuation. Damage control procedures are acceptable if required.


Expected Level of Treatment—Role 3

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∎ Role 4 – Hospital outside of the combat zone (Safe Haven) Surveillance of vascular repair and close assessment of soft tissue

wounds and tissue coverage

∎ CONUS Surveillance of vascular repair Ultrasound or CTA Revision of repairs and injuries Assessment of subtle vascular injuries


Expected level of Treatment—Role 4/CONUS

382020, v1.0

A 29 year old has been shot in the right thigh. The medics noted pulsatile bleeding and placed a tourniquet approximately three hours ago. The patient arrives at your remote Role 2 with tourniquet in place and deformed right thigh. Evacuation to Role 3 is not expected to be available for 2 hours.

1. What are your initial thoughts?

2. What interventions do you expect to perform?

EWS Vascular InjuriesExercise

392020, v1.0

∎ JTS, Vascular Injury Clinical Practice Guideline, 12 Aug 2016.https://jts.amedd.army.mil/assets/docs/cpgs/JTS_Clinical_Practice_Guidelines_(CPGs)/Vascular_Injury_12_Aug_2016_ID46.pdf

∎ The Office of The Surgeon General, Borden Institute. Emergency WarSurgery, 5th U.S. Edition, 2018. Chap 25.https://www.cs.amedd.army.mil/Portlet.aspx?ID=cb88853d-5b33-4b3f-968c-2cd95f7b7809

EWS Vascular InjuriesReferences

Photos are part of the JTS image library unless otherwise noted.

emergency war surgery course joint trauma system · 2020. 4. 17. · ews vascular injuries upper...

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