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P. Lee and P. Seigne
Airway Management
An airway management plan is made for each
patient following pre-operative assessment. A key
part of that plan is the experience of the anaesthesiologists involved. It has always been our practice
that two consultant anaesthesiologists would be
present for the induction and intubation of any
patient having surgery for facial deformity subsequent to noma infection. In general, one of these
anaesthesiologists would have a lot of experience
with airway management of these patients, and
one may be gaining experience. This structure provides the safest possible conditions for the patient
and allows knowledge transfer and the accumulation of experience for the clinicians. A nurse experienced in complex airway management is a
crucial part of this team. Regardless of the airway
management plan, a wide range of airway management equipment must be checked and immediately available. Conventional laryngoscopes, video
laryngoscopes, bre-optic bronchoscopes and
screens, supraglottic airway devices such as laryngeal mask airways, front of neck access equipment, airway topicalisation devices and a full
range of sizes of endotracheal tubes, including
reinforced tubes and Rae tubes, must all be at
hand. A minority of patients with noma have
severe trismus or bony ankylosis, reducing the
inter-incisor distance and preventing subluxation
of the mandible. Oral intubation in such cases
would be extremely difcult or impossible. Hence
it is critical that anaesthesiologists working with
victims of noma must have a detailed knowledge
and experience with bre-optic intubation (FOB).
It is our experience that noma is a disease of the
anterior facial and oral structures and the lower
airway in survivors is unaffected [1]. Awake FOB
with application of topical local anaesthesia of the
airway and maintenance of spontaneous ventilation, until intubation has been achieved, is indicated in a select few cases where induction of
general anaesthesia may compromise airway
patency and the ability of the anaesthesiologist to
successfully perform bag-mask ventilation. The
use of awake FOB in this setting may be additionally complicated by the fact that patients may
never have attended a hospital before and where
language barriers may hinder communication and
reassurance of the anxious patient. We have found
asleep nasal intubation to be safe for the majority
of noma patients. Regardless of the airway management plan, following induction of general
anaesthesia bag-mask ventilation can be facilitated
by a number of techniques: two- handed application of the face mask, use of smaller-size oropharyngeal airways, use of paediatric face masks to
ventilate via the nose with occlusion of the mouth
and use of adhesive dressings to temporarily close
cheek defects. In patients with trismus and bony
ankylosis, nasal intubation is necessary using
either oral video laryngoscopy or nasal ber-optic
bronchoscopy. Nasal blood vessels should be
vasoconstricted using topical phenylephrine to
reduce the risk of bleeding and consequent
obstruction of the view. We would recommend
against elective tracheostomy for these patients
(except in emergent “can’t intubate, can’t ventilate” scenarios, because of the lack of local experience in their short- and long-term post-operative
management).
The airway management plan should also
cover extubation. In general, extubation is
straightforward in these patients although clearly
additional care has to be taken where aps have
been used to cover orofacial defects. As excess
pressure applied to the face via the face mask
may damage the surgical repairs, a nasal airway
is a useful adjunct to extubation and immediate
recovery. In rare cases where soft tissue swelling
or oedema of the airway is a possibility, an
Aintree airway exchange catheter may be briey
left in situ over which the endotracheal tube can
be removed.
Anaesthesia
Standard monitoring (electrocardiogram, pulse
oximetry, capnography, end tidal anaesthetic gas
analysis, non-invasive blood pressure monitoring) is recommended where available. In the few
cases where excessive blood loss is a possibility,
where surgery is likely to be prolonged or in
those cases where the use of a free ap is
necessary, invasive blood pressure monitoring
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473
may be required. Our experience is that this is
rarely warranted particularly where blood gas
analysis is not available. Central venous lines are
generally not indicated – they could interfere
with surgical access or damage critical vascular
structures, and rapid infusion of blood products
or vasoactive agents are rarely needed.
Induction is with routine agents. Maintenance
is with oxygen and nitrous (available in large cylinders, as no central gas supply is usually available) plus halothane or isourane. An oxygen
concentrator is usually available also and may
supply oxygen concentrations up to 50%. Multimodal analgesia is the norm, but morphine
remains the main agent, and supplementary
regional blocks were used in selected cases.
Careful fluid management is important,
particularly where flaps are used as part of the
surgical repair. Urinary catheterisation should
be performed for complex cases and output
monitored to ensure adequate hydration.
Blood products are rarely available in this
environment and are reserved for only the
most critical cases. Thankfully, with careful,
experienced surgical technique, transfusion is
seldom necessary.
Post-Operative Care
Recovery room and intensive care facilities are
usually very limited. It is also unlikely that local
nursing staff would have extensive experience in
caring for the complex airways and surgical
repairs seen in these patients. Post-operative care
should be performed by nursing staff experienced in this area, generally members of the
team. However, integration and education of
local staff for effective post-operative care are
important. For at least the rst post-operative
night and in some cases for longer, the patients
should be nursed in a high dependency environment with regular observations. On-call cover
must be immediately available in the early postoperative period and should consist of experienced senior surgeons, anaesthesiologists and
nursing staff.
Reference
1. Coupe MH, Johnson D, Seigne PW, Hamlin B.Airway
Management in Reconstructive Surgery for Noma
(Cancrum Oris). Anesth Analg. 2013:117210–7.
How toApproach NOMA andFacial
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Infections, Trauma andTumours
Through Charity Missions: Wound
Management andNursing
PatMcCluskey
40
Key Messages
• Healthcare professionals (HCPs) who
care for patients with wounds should
have knowledge of wound healing physiology and recognise the physiological
pathway across all wound healing
processes.
• Healthcare professionals (HCPs) who
intentionally create surgical wounds
hold a responsibility to provide
evidence- based care that minimises risk
factors to ensure optimal wound
healing.
• General wound management incorporates comprehensive assessment of both
the patient and their wound including
assessment of pain, nutrition and general health status.
• Aseptic technique is fundamental in
wound care management to reduce the
risk of infection.
• Dressings are adjunctive and provide
protection and the ideal wound healing
environment.
• Animal bites that are contaminated/dirty
require dedicated wound hygiene.
Abbreviations
FA Facing Africa
HCPs Healthcare Professionals
Introduction
Although globally the underpinning principles
remain the same, there are certain factors that
need to be considered in the context of Facing
Africa (FA) in Ethiopia. Nurses in Ethiopia have
the same standard of nursing education and
acquire a Bachelor of Science at qualication.
However, exposure to wound care is minimal,
and consequently the ‘theory-practice’ gap is
very evident. Much of wound care practice is
skill based, and the basic principles of aseptic
technique and handwashing need to be explained
rationally and repeatedly. Language used needs
to be clear and concise whilst regularly checking
that the concepts are fully understood.
Access to dressing products and cleansing
agents are diminished, and greater emphasis
needs to be concentrated on technique as opposed
to ‘dressing the wound’. Furthermore, due to
P. McCluskey (*)
Advanced Nurse Practitioner in Wound Care, Wound
Healing, and Tissue Viability, Cork University
Hospital, Cork, Ireland
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_40
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P. McCluskey
easy access of dressing products and diagnostics
in the developed world, there is less reliance on
the sensory aspects of wound care such as smell,
touch, hearing and visual. Conversely, in
Ethiopia, strengthening the sensory skills of nursing staff is paramount, thus enabling the nurses to
listen to their patients; observe for signs of infection through smell, and observe for the presence
of erythema, exudate and pain. Sensory skills
generally impact their ability to learn when the
signs and symptoms characterize how the patient
is actually presenting and progressing.
Education
Education is therefore a key aspect of the 2-week
surgical mission with FA, and the Ethiopian staff
are eager and quick to learn and practice their
skills. This aspect of the mission cannot be
understated, and it may take a little longer to
complete tasks such as dressing changes and
medication rounds; however, during subsequent
visits with FA to Ethiopia, the evidence that
learning had been achieved was notable, and
nurses had grown in condence as their skills
improved.
Irrespective of where nurses work, there are
key elements in wound management practice
that need to be embedded to achieve good outcomes, and these include understanding what
wounds are, factors that affect wound healing,
impact of nutrition, aseptic technique, management of specic wounds (skin grafts, donor sites,
animal bites), the role of bacteria in wound healing and the ability to recognise when there is
bacterial imbalance, which needs to be promptly
treated [1].
Denition andClassication
ofWounds
A wound is dened as a cut or break in the continuity of the skin caused by injury or surgery [2].
There are two basic classications of wounds:
open, when there is a degree of tissue loss, and
closed, when there is trauma with underlying tis-
sue damage without a break in the continuity of
the skin. Surgical wound classication is further
subdivided into:
1. Clean: An incision where there is no inamma-
tion encountered during the surgical procedure
and there is integrity of the sterile technique.
2. Clean-contaminated: An incision where the
respiratory, alimentary or genitourinary tract
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is entered under controlled conditions and no
contamination is incurred.
3. Contaminated: An incision where there is a
major break in sterile technique or spillage
from the gastrointestinal tract or an incision
where acute, non-purulent inammation is
encountered. Open traumatic wounds present
for greater than 12hours are also considered
contaminated wounds.
4. Dirty or infected: An incision created surgically in which the viscera are perforated or
when acute inammation with pus is encountered. Traumatic wounds where treatment has
been delayed for a prolonged duration may
also be included in this category.
Wounds encountered in FA are a mixture of all
of the outlined. Many of the wounds reviewed
during the assessment period are well-established
wounds such as noma, wounds that have been
previously reconstructed and not fully healed,
tumours of the face and neck and some hyena or
other animal bite wounds. Additionally, some of
the more established wounds may be heavily
contaminated, and it is not unusual to have maggots feasting on the wound debris. Prior to the
arrival of the FA surgical team, the patients
requiring or hopeful for treatment will already
have been admitted to FA house for a minimum
of 2weeks.
Factors that Aect Healing
assessment will be dealt with, such as nutritional
decits, infection and personal and wound
hygiene.
Wound Healing inChildren
Many of the patients attending Facing Africa are
children who have been affected by noma. When
they present, infection is often present, children
are underweight and the impact of traveling to a
new place and meeting other people with a variety of obvious wounds can cause anxiety and distress. Children who present with tumours of the
face and neck are often outcasts in their own
communities and have lived with ridicule and
suspicion; the added stress of presenting to a new
community in fear and anticipation can be an
additional stress. However, having to live 2weeks
in a community prior to assessment and treatment, sharing meals and engaging in arts and
crafts in the care of the nurses and doctors whilst
having their needs addressed can greatly relieve
the stress.
Wound healing in children generally follows
the same process as adults; however, there is an
increased production of collagen and elastin.
Granulation tissue is created at a faster rate than
in adults, resulting in a faster healing process [4].
Considerations for the child should therefore be
included in all prevention, assessment and management strategies.
Acute wounds will generally proceed through an
orderly and timely process to produce a healed
wound that has anatomic and functional integrity.
However, there are physiological factors that may
impede wound healing such as aetiology, comorbidities, nutrition, pain, duration and size of the
wound, inammation and/or infection [3].
Additionally, patients who attend FA will have
travelled for days or maybe weeks on foot on
meagre resources. When they arrive, they are
exhausted, nutritionally deplete and dehydrated.
The factors that will have contributed to their
delayed or obstructed healing will be attended to,
and the factors that can be managed prior to
Pre- andPeri-Operative Care
Healthcare professionals (HCPs) who intentionally create surgical wounds hold a responsibility
to provide evidence-based care that minimises
risk factors to ensure optimal wound healing,
and the Facing Africa surgical team is very
attentive to this responsibility. Minimising risk
requires attention to bacterial screening, excellent hand decontamination throughout all phases
of surgical care, promotion of nutrition and
hydration (protein and calorie requirements are
increased in wound healing), pain management,
minimising length of stay pre-operatively and
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provision of prophylactic antibiotics when
required [5]. Personal hygiene is attended to,
and patients are encouraged to participate in
hand cleaning and changing soiled clothes and
cloths that are used to cover their wounds and
disgurement.
Nutrition
Identifying patients who are malnourished and
addressing their nutritional needs prior to surgery
are necessary. Deciency in protein and other
nutrients may have an adverse effect on tissue/
body structure, function and clinical outcomes
[6]. Hydration is an integral component of nutritional assessment. Dehydrated tissue becomes
inelastic, fragile and more susceptible to breakdown. Tissue perfusion at a wound site may also
be impacted due to a decreased blood volume,
limiting the supply of oxygen and nutrients [7].
Whilst 2weeks would appear to be a short time to
address many of these factors, children respond
quickly to a balanced diet and increased protein
and caloric intake and vitamins, which are provided by Facing Africa.
Post-Operative Care
Attention to hand decontamination and aseptic
technique during dressing changes minimises
cross contamination and reduces the risk of
infection. Surgical wounds heal mostly by primary intention where the wound edges have
been opposed and the method of closure will be
either through sutures, clips, surgical glue or
Steri- Strips. Appropriate surgical wound care is
essential in preventing surgical-site infections,
wound dehiscence and haematoma formation.
HCPs must be able to identify the physical
signs of infection such as redness, warmth,
pain, swelling, increased exudate, odour and
purulent discharge or systemic signs of infection such as raised C-reactive protein and white
cell count. Patient education in the recognition
of these symptoms is pivotal to assist in early
detection [8].
Dressings
Surgical wounds epithelialise in approximately
48–72h [9]. The new epithelial cells are fragile
and need protecting. The Facing Africa surgical
team provides very specic instructions on how
the wounds are to be managed and usually recommend that the surgical wound is left undisturbed for at least 48–72hours post-operatively.
The use of an aseptic, non-touch technique for
dressing changes is encouraged after all procedures, using only sterile saline to clean the
wound, and the application of an interactive, sterile, post-operative dressing. Dressings should
maintain a moist wound environment to support
epithelialisation, provide a protective barrier
against bacteria or contamination, be atraumatic
on removal and have the capacity to absorb the
minimal exudate that is produced during the normal inammatory period [10].
These procedures are initially performed by
the FA nursing team and assisted by the Ethiopian
nurses. The rationale for the techniques is
explained at each stage, and the choices made are
outlined. At each assessment of the wound, what
is visually observed is discussed, and patients are
listened to and heard. This practice works
extremely well in the sharing of knowledge and
skill and helps build condence. When the surgical team departs, nurses are able to continue
managing these wounds seamlessly.
Head andNeck Surgery
Surgical wounds in head and neck surgery can be
extensive and include skin and muscle aps and
varying suture lines due to reconstruction. These
constitute the majority of surgeries performed by
the FA surgical team. There are many variables to
consider in graft failure, and nursing staff need to
be encouraged to gain an understanding of these
variables to ensure that complications are
observed quickly and communicated to the team
to ensure that they can be treated in a timely fashion. It is important not to presume that staff will
already be aware of the possible risks and that
these risks are communicated to the nursing staff
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479
and reiterated at every opportunity so that the
standard of care becomes more of a habit than
act. To ensure this, nursing staff need to understand precisely what is being observed so the terminology does not become a barrier in itself.
Close observation and consistent monitoring of
these wounds is essential to identify early complications such as:
Poor Vascularity Vascular status is compro-
mised; colour change, diminished capillary rell
time, temperature change and oedema will be
observed.
Haematoma or Seroma Formation On observation, a swelling will be detected, and exudate/
blood can be aspirated under aseptic technique,
by the surgeon, and sent for microbiological
examination.
Infection Overt or subtle signs of infection may
be observed, and if infection is conrmed from a
culture of the aspirate with sensitivities to antibiotics attained, antibiotics will be prescribed by
the surgeon. This is especially important at FA
where infection with endemic viruses is prevalent. Many of the organisms are anaerobic, and
infection can be rapid with dire consequences.
Mechanical Shearing Graft failure may occur
as a result of excess or inappropriate movement,
which may affect new blood vessel growth or
encourage haematoma formation. Take steps to
reduce swelling by elevation, and secure dressings adequately to optimise graft adherence.
Transparent, semi-permeable, sterile dressings are usually chosen to facilitate graft inspection [11]. However, the site and depth of the graft
may require a foam dressing. It is important that
the dressing should facilitate high moisture
vapour transmissibility. Excess moisture underneath a dressing can cause maceration and interfere with graft adherence.
Head and neck wounds that are exposed after
surgery should be cleaned twice daily under
aseptic technique using sterile saline. An antibiotic ointment may be prescribed by the surgeon
for a period of 5–7 days. Ointment should be
applied in one direction (from cleanest aspect),
using sterile gloves and using one ngertip for
each new application. This reduces the possibility of cross-contamination.
Split-Skin Graft
A split-skin graft involves excision of the epidermis and part of the dermis. The most common
donor site is the thigh [12].
Donor Site Management
Donor sites are invariably more painful than the
graft site, and there is great variation in their
management. However, re-epithelialisation usually occurs within 7–10days. Appropriate analgesia for pain and elevation to reduce oedema is
provided. Dressings that ensure haemostasis,
absorb increased exudate in the acute inammatory phase and have non-slip properties are chosen. Alginates (for their haemostatic properties)
are often the dressings of choice with a secondary
absorbent layer and secured with non-slip bandages. Dressings remain in situ for 7–10days and
removed only if contamination occurs. If the
donor site has any evidence of an increased bacterial burden (increased pain, malodour), then an
antimicrobial dressing regime is implemented.
Other dressing regimes include silicones, hydrobres, foams and hydrocolloids [13]. Techniques
in bandaging are improved with practice and by
observation, and the rationale underpinning
choices is explained at each stage. This ensures
that best practice based on evidence is applied at
each stage.
Oral Care Pre- andPost Surgery
Oral cavity wounds heal in a saliva-lled environment that contains millions of microorganisms. Oral hygiene pre- and post-operatively is
essential to reduce the risks of infection [14]. A
soft toothbrush or mouth swab is provided to
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each patient when they are admitted to FA to
clean the mouth from saliva, debris and blood
post-operatively and the rationale clearly
outlined. As it is necessary to implement a food
regime as quickly as possible, this is a further
challenge. In the immediate post-operative
period, a soft suction cannula may be used to
remove the excess saliva as required. Antiseptic
mouthwash (according to local protocol) is also
encouraged twice daily and after food ingestion
to minimise bacterial growth.
Animal Bites andWound
Management
Animal bites are very common on the African
continent, and injury can be inicted from hyenas, dogs, snakes or crocodiles. Infection and
hard-to-heal wounds are often a consequence if
early intervention is not implemented. The general management of bites, irrespective of their
origin, remains the same and consists of meticulous wound hygiene. Wound hygiene describes
the cleansing, debridement, refashioning and
dressing of wounds [15]. Nursing staff at FA are
taught how to clean the wound with intent by irrigating the wound bed and surrounding tissue
regularly and repeatedly based on clinical assessment. Debridement of any devitalised tissue, biolm, debris and organic matter with gauze or
curettes is recommended based on HCP’s skill
and knowledge base. However, these skills
require training and practice, and Ethiopian
nurses approach this practice tentatively after
close observation and with experienced clinical
supervision. Refashioning of the wound edge
allows for the removal of senescent cells and
helps agitate epithelial cell growth. Dressings
should provide protection, absorption, moisture
and warmth and be non-occlusive to prevent bacterial proliferation. Anti-microbial dressings that
contain surfactants (loosen devitalised tissue)
may be benecial. However, wound irrigation
and hygiene are essential components in early
management until surgical intervention is appropriate. Nursing staff are advised on the necessity
of urgent referral for appropriate management.
As there is a high risk of infection in these
wounds from the ora in the animal’s mouth,
antibiotics are an early and necessary intervention [16].
References
1. Health Service Executive; National Wound
Management Guidelines (2018) Ofce of the Nursing
& midwifery services director. Health Service
Executive.
2. Harman TF, Bordoni B. Wound classication
(Updated, 2021, May 4). In: StarPearls (Internet).
Treasure Island (FL): StarPearls Publishing; 2021.
3. Wounds International. International consensus, ‘the
role of proteases in wound diagnostics’ an expert
working group review. London: Wounds International;
2011.
4. Bryant R, Nix D. Acute and chronic wounds – E
Book. Elsevier Health Sciences; 2016.
5. National Institute for Health and Care Excellence
(2008) Prevention and Treatment of surgical-site
infection. https://.org.uk//337;a1924. Accessed 9 Apr
2022.
6. Elia M (2000) The malnutrition advisory group consensus Guidelines for the detection and Management
of Malnutrition in the community. Last Updated in
2020. www.researchgate.net. Accessed 15 Mar 2022.
7. Thorpe J. Nutritional assessment of people with
wounds. Wound Essentials. 2014;9(1)
8. Verdon A.Ten top tips for patient management of surgical wounds. Wounds Essentials. 2014;9(1)
9. Winter GD. Formation of the scab and the rate of
epithelisation of supercial wounds in the skin of the
young domestic pig. Nature. 1962;193:293.
10. HSE National Wound Management Guidelines.
Ofce of the Nursing & midwifery services director.
Health service. Executive. 2018;
11. Mathes SJ.Plastic surgery. In: General Principles, vol.
1. 2nd ed. Philadelphia: Elsevier; 2006.
12. Coull A.Making sense of split-skin graft donor sites.
Nurs Times. 1991;87(40):52–4.
13. Beldon P. What you need to know about skin
grafts and donor site wounds. Wound Essentials.
2007;2:149–55.
14. Shah R, Domah F, Shah N, Domah J. Surgical
wound healing in the oral cavity: a review. Oral Surg.
2020;47(2):135–40.
15. Murphy C, Atkin L, Swanson T, Tachi M, Tan YK,
Vega de Senja M, etal. International consensus document: defying hard-to-heal wounds with an early
anti-biolm intervention strategy: wound hygiene. J
Wound Care. 2020;29(Suppl. 3b):S1–28.
16. Stevens DL, Bisno AL, Chambers HF, etal. Practice
Guidelines for the diagnosis and management of
skin and soft tissue infections. Clin Infect Dis Soc.
2014;59:e10.
How toManage Vascular Trauma
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andEmergencies inLow-
41
andMiddle-Income Countries
AdamLeeGoldstein, JacobR.Krimbill,
AlbertoSaltiel, andMarkA.Hardy
Optimism is the faith that leads to achievement. Nothing can be done without hope and
condence.
– Helen Keller
Abbreviations
ABI/API Ankle-brachial index or arterial
pressure index
ALI Acute limb ischemia
AT Aspirating thrombus
ATLS Advanced Trauma Life Support
BKA Below-knee amputation
CDL Catheter-directed lysis
CLTI Chronic limb-threatening
ischemia
A. L. Goldstein (*)
Department of Surgery, Trauma Unit, Wolfson
Medical Center, Holon, Israel
e-mail: adamleeg@wmc.gov.il
J. R. Krimbill
General Surgery, Columbia University Medical
Center and NY Presbyterian Hospital,
New York, NY, USA
e-mail: jk4226@cumc.columbia.edu
A. Saltiel
Vascular and Endovascular Surgery Department, Tel
Aviv Sourasky Medical Center, Tel Aviv, Israel
M. A. Hardy
Department of Surgery, Columbia University Vagelos
College of Physicians and Surgeons,
New York, NY, USA
e-mail: mah1@cumc.columbia.edu
CT Computed tomography
DFS Diabetic foot syndrome
DPL or DPA Diagnostic peritoneal lavage or
FAST Focused Assessment with
GSV Greater saphenous vein
HIC High-income countries
IPC Intermittent pneumatic
IV Intravenous
LMICs Low- and middle-income
NCDs Non-communicable diseases
OR Operating room
PAD Peripheral arterial disease
PE Pulmonary embolus
PTFE Polytetrauoroethylene
PVD Peripheral vascular disease
REBOA Resuscitative endovascular bal-
TIA Transient ischemic attack
TPA Tissue plasminogen activation
US Ultrasound
WHO World Health Organization
WIfI Wound, infection, and ischemia
aspiration
Sonography in Trauma
compression
countries
loon occlusion of the aorta
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
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Introduction
Vascular surgery often needs to be performed by
general surgeons in low- and middle-income
countries (LMICs). This is especially true for
emergent interventions due to traumatic injuries
or acute pathologies, limb-saving procedures,
and common necessary elective cases, since
transfer to a major hospital may be delayed or
untenable. Basic vascular surgical skills are
essential for the rural/global surgeon and are life
(and/or limb)-saving in many situations. With a
strong understanding of vascular surgery principles and techniques, the general surgeon must
be able to perform temporizing procedures that
may give the patient critical time (hours to days)
until transfer to a specialized center or arrival of
an experienced vascular surgeon or necessary
special supplies (i.e., grafts, anticoagulation
medications).
While trauma remains a signicant source of
vascular disease, the etiology of vascular disease/
injury is changing in LMICs as the prevalence of
risk factors for peripheral vascular disease
(PVD), including geriatric age, continues to rapidly grow in populations that were previously
spared from these conditions [1, 2]. This has led
to a growing need for vascular surgery competency, diagnostics and therapeutics, and infrastructural resources to support patient monitoring,
access to anticoagulation therapy, and preventative health resources [1].
In managing vascular trauma, the treating
physician must always follow the principles of
trauma care and Advanced Trauma Life Support
(ATLS), understand the source of injuries, prioritize what needs treatment rst, and understand and treat the overall condition of the
patient. To best decide what denitive or temporary vascular surgical care to provide, the
surgeon must remember rst of all to save the
life over the limb. In this chapter, we aim to
provide an outline of vascular trauma and nontraumatic emergencies, with a focus on essential diagnostics, surgical techniques, and
follow-up that might be most helpful in limitedresource environments.
Mechanism/Epidemiology
Trauma remains the major cause of death worldwide, especially on the African continent, and
often requires emergent vascular interventions. It
is not surprising that vascular injuries are more
commonly associated with hemorrhagic shock
and death than other types of injuries [3], and
reliable quantication of the burden of vascular
injuries is hindered by death in the eld prior to
transport. More broad trauma metrics including
the general ratio between blunt versus penetrating trauma, socioeconomic status of the population (i.e., rural or urban), and current armed
conicts are also often not well captured, making
development of targeted solutions to improve
care more challenging. The epidemiology of vascular trauma drastically differs in LMICs depending on the presence of armed conict, a high
percentage of remnant landmines, rural or urban
settings, and the availability and quality of prehospital care [1].
In regard to prehospital care, the Stop the
Bleed campaign was formed in the United States
in 2015in response to the persistently increasing
volume of mass shootings. This campaign was
born from evidence-based research showing the
high number of potential preventable deaths in
both combat and civilian settings by simple prehospital/bystander interventions to slow/stop
hemorrhage [4]. Severe limb hemorrhage as a
cause of preventable death has been reported as
high as 14% in recent combat literature [4], with
similar percentages in civilian trauma. Stop the
Bleed campaigns have also shown success in
LMICs [5] and remain an important public health
tool worldwide.
Diagnosis
There is a drastic difference between LMICs and
high-income countries (HICs) in available vascular interventions and diagnostic capabilities. The
approach to vascular.
trauma regardless of environment is consistent: hard signs of injury (Table 41.1) require
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