Document Detail


Long-term follow-up and amputation-free survival in 497 casualties with combat-related vascular injuries and damage-control resuscitation.
MedLine Citation:
PMID:  23188245     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: The effectiveness of damage-control resuscitation (DCR) has been demonstrated in recent US conflicts. Wartime casualties treated for hemorrhagic shock from vascular wounds were studied to report the 24-hour transfusion requirements, graft patency, and amputation-free survival for major vascular injuries.
METHODS: Joint Theater Trauma Registry data from August 2006 to April 2011 (56 months) were retrospectively reviewed. Included were casualties with a vascular injury who presented to US combat support hospitals in Iraq or Afghanistan. Amputation-free survival and graft patency were determined from record and imaging review.
RESULTS: The study group consisted of 497 severely wounded local national and military casualties (mean [SD] Injury Severity Score [ISS], 17 [8.5]) presenting with acidosis (pH 7.29 [0.15]), tachycardia (heart rate, 110 [29.31]), and coagulopathy (international normalized ratio, 1.6 [2.33]). Given DCR and early management of vascular injury, blood pressure, heart rate, temperature, hemoglobin, and base deficit improved promptly (p < 0.05) by intensive care unit admission. Transfusion requirements included packed red blood cells (15 [13] U; range, 1-70 U), fresh frozen plasma (14 [13] U; range, 1-72 U), cryoprecipitate (13 [15] U; range, 1-49 U), and platelets (8 [6] U; range, 1-36 U). Mean operative time was 232 minutes (range, 16-763 minutes). US casualties (n = 111) had limb salvage attempted for 113 extremity vascular injuries (3 [2%] iliac, 33 [30%] femoral, 23 [20%] popliteal, 13 [12%] tibial, 33 [30%] brachial, 4 [3%] ulnar, and 4 [(3%] radial). In this subgroup, 28 (25%) were revascularized by a primary repair or end anastomosis, 80 (71%) were revascularized by saphenovenous grafts, and 15 (3%) [corrected] were revascularized by prosthetic grafts. The follow-up ranged from 29 days to 1,079 days, (mean, 347 days), during which 96 grafts (84.9%) remained patent, 16 casualties (14.2%) required a delayed amputation, and 110 (99.1%) survived. Popliteal injuries had the highest amputation rate (7 of 23, 30.4%). The amputation-free survival was 84%.
CONCLUSION: In severely wounded casualties, wartime surgical strategies to save both life and limb evidently permit definitive procedures at initial surgery with excellent limb salvage results. This outcome analysis in a large cohort can help to refine surgical judgment and support contemporary DCR practices for major vascular injury.
LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level V.
Authors:
Anahita Dua; Bhavin Patel; John F Kragh; John B Holcomb; Charles J Fox
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  The journal of trauma and acute care surgery     Volume:  73     ISSN:  2163-0763     ISO Abbreviation:  J Trauma Acute Care Surg     Publication Date:  2012 Dec 
Date Detail:
Created Date:  2012-11-28     Completed Date:  2013-08-22     Revised Date:  2013-09-25    
Medline Journal Info:
Nlm Unique ID:  101570622     Medline TA:  J Trauma Acute Care Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1517-24     Citation Subset:  AIM; IM    
Affiliation:
Division of Vascular Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA.
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MeSH Terms
Descriptor/Qualifier:
Adolescent
Adult
Afghan Campaign 2001-
Aged
Aged, 80 and over
Blood Transfusion / mortality,  statistics & numerical data
Child
Child, Preschool
Female
Follow-Up Studies
Glasgow Coma Scale
Humans
Injury Severity Score
International Normalized Ratio
Iraq War, 2003 - 2011
Male
Middle Aged
Military Medicine / methods,  statistics & numerical data
Resuscitation / mortality*,  statistics & numerical data
Retrospective Studies
Shock, Hemorrhagic / mortality,  therapy
United States
Vascular System Injuries / mortality*,  surgery,  therapy
Young Adult
Comments/Corrections
Comment In:
J Trauma Acute Care Surg. 2012 Dec;73(6):1524   [PMID:  23188246 ]
Erratum In:
J Trauma Acute Care Surg. 2013 Mar;74(3):951

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