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

General Principles

United States Department of Defense

As in the civilian sector, the majority of combat-incurred vascular injuries that are amenable to surgical repair involve peripheral vessels. The majority of those with central vascular injuries or injuries of the thoracic or abdominal aorta usually do not survive to reach a surgical facility capable of dealing with these injuries. The penetrating and perforating vascular wounds of the battlefield, as opposed to those of the civil sector, are more likely to have been caused by high-velocity projectiles. High-velocity missiles more often cause secondary damage to adjacent tissues as a result of temporary cavitation. Secondary fragments resulting from either fragmentation of the projectile or from fragmentation of bone will cause additional damage. Temporary cavitation can result in thrombosis of an artery even though the missile does not actually strike the artery. This results from intimal disruption, subintimal dissection of blood, and intimal prolapse and subsequent thrombosis.

The use of various fragmentation devices in military operations creates the potential for multiple vascular injuries (as well as other major nonvascular wounds) in the same individual. The multiplicity of wounds must be taken into account in the overall management of the patient.

Although the surgical repair of vascular injuries is usually urgent, it must not be done precipitously. Every surgeon confronted with a casualty with obvious major vascular injury must also determine what other injuries are present and formulate the best overall management plan. Priority of care must be established for each injury. The ability of the patient to tolerate the additional operative time required for vascular repair must also be considered. Finally, adequate resuscitation usually must be accomplished before the reparative vascular procedure is attempted. In some cases, the control of hemorrhage will be part of the process of resuscitation. Failure to observe these basic precautions may result in loss of life as a result of overzealous attempts to salvage a limb.

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Operational Medicine 2001

Health Care in Military Settings

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