Extremity Vascular Injuries on the Battlefield: Tips for Surgeons Deploying to War

Department of Surgery: General Surgery Services, Madigan Army Medical Center, Tacoma, Washington 98431-1100, USA.
The Journal of trauma (Impact Factor: 2.96). 03/2006; 60(2):432-42. DOI: 10.1097/
Source: PubMed


Recent events have refocused attention on certain principles regarding the surgical management of casualties on the battlefield. Extremity vascular injuries predominate, representing 50 to 70% of all injuries treated during Operation Iraqi Freedom, and exsanguination from extremity wounds is the leading cause of preventable death on the modern battlefield. Recent advances in military medicine have translated into a greater percentage of wounded soldiers surviving during Operations Enduring and Iraqi Freedom than in any other previous American conflict. The combat-experienced military surgeon, a fraction of those in uniform until recently, rarely has had the opportunity to convey lessons learned to the newly indoctrinated war surgeon. The purpose of this review is to do exactly that.
We collectively reviewed the experience and opinions of five U.S. Army surgeons with regard to management of extremity vascular injuries in a combat zone
The modern battlefield has a staunch reputation of being unclean, noisy, and lacking of valuable resources. High-kinetic energy injuries such as those resulting from high explosives, munitions, and high-velocity missiles often cause soft-tissue destruction that is not routinely seen in civilian settings. Military-specific considerations in the management of these injuries are reviewed.
The management of extremity vascular injuries on the modern battlefield presents many unique and demanding challenges to even the most seasoned of surgeons. Preparation goes a long way in overcoming some of the obstacles to seamless patient care.

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    • "New portable hand held ultrasound machines with excellent images and doppler color facility can be used in the battle field [22]. Duplex ultrasound has been successfully used to diagnose vascular injuries during the recent Iraq Conflict [17]. "
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    ABSTRACT: AimTo study the biomechanism, pattern of injury, management, and outcome of major vascular injuries treated at Mubarak Al-Kabeer Teaching Hospital, Kuwait during the Second Gulf War. This is a descriptive retrospective study. War-related injured patients who had major vascular injuries and were treated at Mubarak Al-Kabeer Teaching Hospital from August 1990 to September 1991 were studied. Studied variables included age, gender, anatomical site of vascular injury, mechanism of injury, associated injuries, type of vascular repair, and clinical outcome. 36 patients having a mean (SD) age of 29.8 (10.2) years were studied. 32 (89%) were males and 21 (58%) were civilians. Majority of injuries were caused by bullets (47.2%) and blast injuries (47.2%). Eight patients (22%) presented with shock.There were 31 arterial injuries, common and superficial femoral artery injuries were most common (10/31). Arterial repair included interposition saphenous vein graft in seven patients, thrombectomy with end-to-end / lateral repair in twelve patients, vein patch in two patients, and arterial ligation in four patients. Six patients had arterial ligation as part of primary amputation. 3/21 (14.3%) patients had secondary amputation after attempted arterial vascular repair of an extremity. There were a total of 17 venous injuries, 13 managed by lateral suture repair and 4 by ligation. The median (range) hospital stay was 8 (1--76) days. 5 patients died (14%). Major vascular injuries occurred in 10% of hospitalized war-related injured patients. Our secondary amputation rate of extremities was 14%. The presence of a vascular surgeon within a military surgical team is highly recommended. Basic principles and techniques of vascular repair remain an essential part of training general surgeons because it may be needed in unexpected wars.
    World Journal of Emergency Surgery 07/2013; 8(1):22. DOI:10.1186/1749-7922-8-22 · 1.47 Impact Factor
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    • "A missed vascular injury (when the damage is not severe or overt) will present itself later as an arteriovenous �stula or a pseudoaneurysm [20]. Due to body armor extremities are more vulnerable and therefore vascular injuries of the extremities comprise approximately 60–90% of all injuries [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] and 72–78% in the present study. Exsanguination from extremity wounds is still the leading cause of preventable death in combat sustained injuries. "
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    ABSTRACT: Background. Vascular injuries often result in life threatening hemorrhage or limb loss. When they present with a single entry or exit wound, surgery is immediately indicated. With multiple injuries, however, imaging such as CTA is necessary for diagnosis and choice of treatment. Methods. For all combat-related vascular cases admitted to our medical center during the Lebanon wars in 1982 and 2006, we compiled and compared presenting signs and symptoms, means of diagnosis, treatments, and results. Results. 126 patients with vascular injuries were admitted (87 in 1982, 39 in 2006). 90% were male; mean age of 29 years (range 20-53). All injuries were accompanied by insult to soft tissue, bones, and viscera. 75% presented with injury to arteries in the extremities. 75% of these patients presented with limb ischemia, and 25% sustained massive blood loss. Treatments included venous interposition graft, end-to-end anastomosis, venous patch, endovascular technique (only in 2006), and ligation/observation. Complications included thrombosis and wound infections. Mortality and amputations occurred only in 1982, and this may be attributed to the use of imaging, advanced technique, and shorter average time from injury to hospital (7 hours). Conclusions. We recommend CTA as the first line modality for diagnosis of vascular injuries, as its liberal use allowed for early and appropriate treatment. Treatment outcomes improved with fast and effective resuscitation, liberal use of tourniquets and fasciotomies, and meticulous treatment by a multidisciplinary team.
    01/2013; 2013:689473. DOI:10.1155/2013/689473
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    • "This was first observed in the 1960s when animals receiving aminoglycosides appeared to be more susceptible to noise-induced hearing loss [11] and confirmed by subsequent studies [12], [13], [14], [15]. The same ototoxic mechanism is likely responsible for the increased deafness risk in pre-term infants from neonatal intensive care units [16], [17] and in wounded soldiers [18], [19], [20], [21], [22]. Multiple cochlear events may be responsible for sound-and-drug induced synergy. "
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    ABSTRACT: Exposure to intense sound or high doses of aminoglycoside antibiotics can increase hearing thresholds, induce cochlear dysfunction, disrupt hair cell morphology and promote hair cell death, leading to permanent hearing loss. When the two insults are combined, synergistic ototoxicity occurs, exacerbating cochlear vulnerability to sound exposure. The underlying mechanism of this synergism remains unknown. In this study, we tested the hypothesis that sound exposure enhances the intra-cochlear trafficking of aminoglycosides, such as gentamicin, leading to increased hair cell uptake of aminoglycosides and subsequent ototoxicity. Juvenile C57Bl/6 mice were exposed to moderate or intense sound levels, while fluorescently-conjugated or native gentamicin was administered concurrently or following sound exposure. Drug uptake was then examined in cochlear tissues by confocal microscopy. Prolonged sound exposure that induced temporary threshold shifts increased gentamicin uptake by cochlear hair cells, and increased gentamicin permeation across the strial blood-labyrinth barrier. Enhanced intra-cochlear trafficking and hair cell uptake of gentamicin also occurred when prolonged sound, and subsequent aminoglycoside exposure were temporally separated, confirming previous observations. Acute, concurrent sound exposure did not increase cochlear uptake of aminoglycosides. Prolonged, moderate sound exposures enhanced intra-cochlear aminoglycoside trafficking into the stria vascularis and hair cells. Changes in strial and/or hair cell physiology and integrity due to acoustic overstimulation could increase hair cell uptake of gentamicin, and may represent one mechanism of synergistic ototoxicity.
    PLoS ONE 04/2011; 6(4):e19130. DOI:10.1371/journal.pone.0019130 · 3.23 Impact Factor
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