Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound
Management: Chapter XVIII: Vascular Injuries
Adjunctive Therapy
United States Department of Defense
Intravenous broad spectrum antibiotic therapy should be initiated as soon as possible
after injury. This should be continued throughout the operation and for roughly 24 hours
thereafter, assuming there is no continued source of contamination. In most instances, a
cephalosporin provides effective prophylaxis.
Anticoagulation of the distal arterial tree is acceptable during operation, but one
must be aware that, because of collateral flow, locally injected heparin ultimately
becomes systemic. For this reason, relatively small doses of heparin (1500-3000 units at a
concentration of 100 units per cc of physiologic saline) are used for anticoagulation of a
lower extremity. Systemic anticoagulation is usually not advisable because of the presence
of associated injuries. There is rarely, if ever, an indication for postoperative
anticoagulation. Adjunctive agents, such as low molecular weight dextran, may be used and
may be of value particularly after small artery repairs; however, dextran must be used
with caution to prevent volume overload. In most instances, vascular repairs will be
successful if the tissues are adequate, the repair is done well, and the hemodynamic and
volume status of the patient are kept within normal limits postoperatively.
Although preoperative arteriograms are rarely available in the combat setting,
single-shot handinjected intraoperative arteriograms can be easily obtained and are
helpful to rule out additional arterial injuries, distal thrombosis, and inadequacy of the
repair. Injection of full-strength contrast (Radio-Conray 60) through a 19 gauge needle
usually results in an excellent study. Fifteen to 20 cc is usually all that is needed. The
film should be exposed while the contrast material is still being injected. At times,
run-off may be so rapid that the contrast is washed out by the time the film is exposed.
Should this occur, a second injection with inflow occlusion will usually provide adequate
visualization. Sympathetic blocks and sympathectomy are of no value in the management of
acute arterial injuries. Sympathectomy, as a delayed procedure, may occasionally be
helpful to the patient who has had a suboptimal result from arterial repair.
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Operational Medicine 2001
Health Care in Military Settings
Bureau of Medicine and Surgery
Department of the Navy
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Operational Medicine
Health Care in Military Settings
CAPT Michael John Hughey, MC, USNR
NAVMED P-5139
January 1, 2001 |
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