EXPLORATION OF WAR WOUNDS IN SUSPECTED VASCULAR INJURIES IN A COMBAT SUPPORT, "B" CLASS MILITARY HOSPITAL.
Objective: To study the role of surgical exploration for vascular damage in penetrating war wounds, in the absence of diagnostic facilities.
Study Design: Descriptive/observational
Place and Duration of Study: Combined Military Hospital Kohat, Pakistan, from 4th Aug 2009 to 31st Dec 2011.
Material and Methods: All wounded military personals having penetrating wounds with expected vascular injuries with positive soft signs were included in the study. Patients having abdominal, thoracic, intracranial vascular injuries, mangled limbs, and positive hard signs were excluded from the study. The debridement incision was extended to exclude the vascular injuries in the proximity of wound. The facilities like Doppler, Duplex scanning, angiography, and CT Angiography, is not available in this "B" Class Hospital.
Results: Total 58 patients were received with expected vascular injuries. Nine were excluded and only 49 fulfilled our criteria. They were all male mainly young patients ranging age 18-45; with mean age 28.5 years (SD: 7.65). Gunshot wounds caused 42(86%), splinters 6(12%) and stab 1(2%) injuries. Region wise injured vessels were lower limb 27 (55%), upper limb 14(29%), face and neck 7 (14%), genitalia 1 (2%). Out of 49 explorations, 30(61%) vessels were found injured, so negative exploration was 19 (39%). Amongst injured vessels fourteen (47%) were repaired and sixteen (53%) were ligated for haemostasis. In 5(17%) patients reversed autogenous venous graft was applied, and in 9(30%) patients end to end anastomosis/lateral repair was done. Postoperatively there was no amputation, two (6%) vessels thrombosed needed redo, and 5(16%) got infected.
Conclusion: In combat trauma, Exploration of vessels still remains a good option in "B" Class hospital, not having diagnostic facilities, and travelling time to "A" Class hospital is expected to increase warm ischemia time.
Keywords: Blast injuries, Combat trauma, Extremity, Gunshot injuries, Military trauma, Penetrating wounds Vascular injuries, Vascular repairs.
Hemorrhage in vascular injuries remains a leading cause of potentially preventable death on the modern battlefield. So dealing with vascular trauma has a peculiar importance in the life and limb saving effort at war front. Warm ischemia time is an important deciding factor in the outcome of vascular injuries. Transportation of casualties from front line to base hospital is not a simple task especially when combat is going on. Luckily Pak Army has facility of helicopter evacuation along with efficient ambulance services. War casualties are given top priority. Although Amputations and vascular ligations were being done even before the World Wars, but trend has changed in Korean and Vietnam Wars due to early evacuation which enabled the surgeons to repair and apply autogenous graft for revascularization.
Our past goal of saving "life over limb" has been shifted to the current goal of saving both "life and limb" because of modern advances in critical care, damage control surgery, military armor technology, availability of diagnostic techniques and prosthetic grafts1. Still in "B" Class hospital diagnostic facilities do not prevail, and further transfer to "A" Class facility will waste precious time. We are left with one of the choices either wait and watch or explore.
MATERIAL AND METHODS
This study was designed as descriptive/observational. It was carried out in CMH Kohat from 4th Aug 2009 to 21st Dec 2011. All wounded military personals having penetrating wounds with expected vascular injuries with positive soft signs were included in the study. Patients having abdominal, thoracic, intracranial vascular injuries, mangled limbs, and positive hard signs were excluded from the study. Total 58 patients were received with expected vascular injuries. Nine were excluded and only 49 fulfilled our criteria. All war affected casualties were entered into a data base registry prospectively. Along with demographic data, Specific patterns of injury, mechanism of vascular injury, site and type of vessel injured, and the presence of any associated trauma were recorded. Clinical assessment noted in the form of hard and soft signs. Table-1. Vascular repairs were analyzed by the type of repair performed. The initial outcome, including the need for amputation was recorded.
Primary care was delivered at scene by paramedics and medical officers in field. The vascular surgeries were being carried out by General and Orthopedic surgeons because no vascular surgeon is available in this "B" Class Hospital. Vascular surgery care is provided at CMH Rawalpindi "A" Class Hospital. "B" Class Hospital does not have facility of Doppler, duplex scanning, angiography and CT Angiography. Our study of exploration of vascular injuries is purely based upon clinical assessment, means soft signs of vascular injuries. As all patients had penetrating injuries, so wounds were opened for debridement. The wounds were extended slightly more to have a look upon vessels in the bullet/splinter tract.
Table-1: Showing signs of vascular injuries.
Hard signs###Soft signs
1. Active hemorrhage###1.Proximity of wound to major vessels
2. Large expanding / pulsetile hematoma###2.History of Hemorrhage / Shock
3. Bruit / Thrill over wound###3.Non Expanding Hematoma
4. Absent palpable pulses distally###4.Diminished pulse compared to contra lateral
5. Distal Ischemic manifestations (pallor, pain,###5. Anatomically related nerve injuries/bone
paralysis, paresthesia, pulselessness,###fractures.
Table-2: Soft signs and complications in vascular injuries.
###Proximity of wound to major vessels###49###100%
Soft signs###History of Hemorrhage / Shock###35###71%
###Non Expanding Hematoma###10###20%
###Diminished pulse compared to contra lateral###49###100%
###Anatomically related nerve injuries/bone fractures.###28###57%
Vascular injuries associated with bone fractures, bones were stabilized first. Bleeding branches of main vessels, and vessels supplying the areas having good collateral circulations were ligated. Rents in major vessels were primarily closed and defects were repaired with autogenous reverse venous grafts. All wounds were considered contaminated, and coverage of the arterial repair with local healthy tissue flaps was used to reduce the risk of arterial rupture. Data was analyzed on SPSS.20.
During 2 years and 5 months, 612 war causalities were operated in CMH Kohat. There were 58 patients who presented with penetrating war wounds with signs of vascular injuries, 9 patients were excluded (6 had amputations, and 3 had thoracic/abdominal vascular injuries), only 49 patients were included in this study. All personals were male with age ranging 18-45; mean age was 28.5 years (SD: 7.65). Main cause of injury was gunshot wound (GSW), followed by Splinters and Stab.Fig-1.
Maximum injuries were seen in lower extremity (55%) followed by Upper extremity (29%), neck (14%), and genital (2%) regions. [Fig-2] Soft signs found in patients were shown in Table-2.
Out of 49 patients, 30 (61%), had vascular injuries. Negative exploration was only In 19 (39%). Amongst injured vessels, 14 (47%) were repaired/grafted, and 16(53%) were ligated for haemostasis. Amongst 14 repaired/grafted vessels, 5 (17%) patients grafted with reversed autogenous venous graft, and 9 (30%) vessels were repaired end to end anastomosis/lateral repair.Fig-2.
Repaired vessels included 6 upper limbs, 6 lower limb, one each for facial and genital vessel. Amongst all injured vessels, we had 17(57%) pure arterial, 3(10%) venous and 10(33%) mixed vascular injuries. Two patients needed fasciotomy following vascular repair. Bone fractures were associated with vascular injuries in 24 (80%) patient.
Postoperatively no patient ended up in amputation but we had two thrombosis. In one patient emboli lodged in distal vessel, leading to ischemia of supplying compartment but limb was saved with compromised blood supply. Second patient had thrombus at vascular anastomosis; patient was referred to "A" Class hospital for extra-anatomical bypass grafting. Infection rate was (n=5, 16 %), because of potentially infected penetrating war wounds. Most of infections settled down with antibiotics and did not affect vascular repairs.
The ongoing military conflict on our western border has lead to thousands of combat casualties. Diagnosis and management of occult vascular injuries is utmost important because it contributes a lot to the life and limb saving effort in these wounded soldiers. The study found that the rate of vascular injury in modern combat is 5 times higher than in previous wars and varies according to operational tempo, mechanism of injury, and type of war2. Management of war vascular trauma is different than peace, due to large numbers of the wounded, shortage of expert vascular surgeons, and resources3. We studied only combat penetrating trauma, even in civil 94.4% vascular injuries are because of penetrating wounds4. The injured patients in combat trauma are usually young patients; our mean age was 28 where as average age in Iraq and Afghanistan wars was 29 years5.
Regarding pattern of injuries we had maximum patients of GSW 86% followed by splinters 12%, stab2% where as in Iraq-Afghan War Fox CJ et all had 64% explosive device and 25% with GSW and in world war II, Korean and Vietnam war >64% of vascular injuries were of IED. The distribution of injuries in our study was lower extremity n-27(55%) followed by Upper extremity n-14(29%), neck n-7(14%), and genital n-1(2%) regions. Distribution in Iraq-Afghan war was 51% lower extremity, 39% upper extremity, 7% neck and 3% pelvis5. We had 80% of vascular injuries associated with bone fractures where as in Iraq war 1/3 rd(33%) of vascular injuries were associated with fractures3. We had 17(57%) pure arterial, 3(10%) venous and 10(33%) mixed vascular injuries, where as other centers showed 76.3% arterial and 23.7% venous injuries6. We explored all the cases who had soft signs of vascular injury, our positive exploration rate was 61%.
Other surgeons in Pakistan had probably the same setup so they also advocated exploration7,8. Angiography was found positive in 68% of patients with diminished pulse (soft sign)9. Military explosives with splinters produce deep cavitational effect leading to lot of dead tissues with segmental arterial loss. This will need thorough debridement before vascular repair. In missile fragment like gunshot and stab wounds arterial laceration is common. Mobilization of the arterial end in a young patient with non disease arteries often allows the construction of a tensionless primary arterial repair10. In most cases in which the injured segment is 1 cm or less, dissecting and freeing edges and performing a primary anastomosis is frequently possible2. Development of compartment syndrome in vascular repair is a devastating complication, immediate fasciotomies are recommended if there is a significant arterial injury or a mixed arterial/venous injury11,12.
We had 2 fasciotomies following vascular repairs. Limb loss in World Wars due to vascular injuries were 40% which reduced to 15% in late Korean and Vietnam wars, because of introduction of autogenous grafting2. Generally, the science and understanding of injury and its therapy are continually improving. The decrease rate of amputations is because of damage control surgery. The forward area surgeons have switched over to temporary vascular shunts and fasciotomy instead of ligation and application of tourniquet13. Narrow pre hospital tourniquet are replaced with pneumatic tourniquet, and extra luminal balloon tamponade are used for temporary haemostasis11. The use of tourniquets, especially those left for prolonged periods, markedly increases the incidence of amputation of an injured extremity2. During World War II: Popliteal artery injuries were routinely ligated with an amputation rate of 73%, which reduced to 32% in Vietnam War because of arterial repair procedures14.
Warm Ischemia of striated muscles >4-6 hours leads to myonecrosis and major amputations14,15. In a combat setting the decision between limb salvage and amputation requires mature surgical judgment which depends upon the location, available resources, severity of injury, and, overall condition of the patient. Distal pulses may be intact in 20% of cases of arterial injuries14. Duplex is highly operator dependent and may fail to detect all arterial injuries. The liberal application of arteriography provides high-yield data in the vascular evaluation of extremities injuries16. CT Angiography is reported to have a sensitivity of 95.1% and specificity of 98.7%17. On the basis of war experience using prosthetic grafts for combat injuries is uniformly associated with poor outcome, and their use is to be discouraged5,18. Vacuum dressings have expedited the wound closure, which reduces the requirement of rotational flaps or split thickness graft11.
Exploration of vessels still remains a good option in "B" Class hospital, not having investigating facility, and travelling to "A" Class hospital is such that it increases warm ischemia time. Wait and watch policy can be adopted if hospital setting is supported with diagnostic tools like Doppler, duplex, angiography and CT Angiography.
CONFLICT OF INTEREST
This study has no conflict of interest to declare by any author.
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|Publication:||Pakistan Armed Forces Medical Journal|
|Date:||Apr 30, 2016|
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