Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XVIII: Vascular Injuries

Conservative Management

United States Department of Defense

Some arterial injuries may be treated in the acute stage without, operation. When an artery is severed, there may be little or no external hemorrhage because of vessel retraction and arterial compression by an expanding hematoma within the associated musculofascial compartment. As the compartmental pressure approaches that in the damaged artery, hemorrhage stops and a stable pulsating hematoma develops. As encapsulation of the hematoma occurs, a false aneurysm forms. Some of these false aneurysms may be missed in the acute stages and will require repair when recognized later.

When both the artery and vein are inured, an acute arteriovenous fistula may result. Patients with wellestablished arteriovenous fistulae who present without secondary hemorrhage, and whose extremities are viable, have a low priority for operation in the combat zone This is also true for pulsating hematomas when recognition of the arterial injury has already been delayed and viability of the limb has been preserved by collaterals.

One must use caution in electing not to operate emergently on the above-mentioned vascular injuries. When surgical capabilities are adequate, there is little justification for nonoperative management of arterial injuries. Delay of operation in hopes of development of a false aneurysm or arteriovenous fistula with concomitant adequate collateral circulation can be rationalized only when the capability to perform arterial surgery is nonexistent or marginal.

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Operational Medicine 2001

Health Care in Military Settings

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