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41 How toManage Vascular Trauma andEmergencies inLow- andMiddle-Income Countries
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Table 41.1 Hard and soft signs of vascular injury
Hard signs Soft signs
Pulsatile bleeding Non-pulsatile bleeding
Expanding
hematoma
Loss of distal
pulses
Bruit/thrill History of arterial bleeding/
Non-expanding/non-pulsatile
hematoma
Diminished pulses
hypotension
Previously applied tourniquet
Neurological decit
Wound proximity to named
vessel
operative exploration, whereas soft signs of
injury call for further evaluation or monitoring
before vascular injury may be ruled out. Patients
with neither hard nor soft signs of vascular injury
and with no other indication for admission/operation may be safely discharged. The surgeon
responsible for vascular trauma patients, especially a non-local surgeon, must be prepared for
different methods within the capabilities and limits of the hospital to successfully diagnose and
ultimately treat these patients.
A recent estimate showed that there is less
than one computer tomography (CT) scanner per
million people in LMICs, compared to almost
forty per million people in HICs [6]. Therefore,
the surgeon must be prepared to diagnose and
treat vascular injury with a total reliance on physical exam, ankle-brachial index or arterial pressure index (ABI/API), ultrasound (US), and even
surgical exploration when question remains. Due
to the lack of interventional radiology in many
LMICs, we will not discuss their use in this chapter despite its obvious value in vascular injury
when available [7].
Apart from hard signs of vascular injury
(Table1), physical examination may be a difcult
and insensitive tool in diagnosis of traumatic vascular injury. In the multi-trauma patient, there
might be a delay in diagnosis of peripheral vascular injury due to other distracting injuries, hypovolemia due to hemorrhage, and/or vasospasm,
which temporarily may decrease active bleeding.
The signicance of vascular injury might not be
completely appreciated until the patient is resus-
citated. It is not uncommon for the surgical team
to nish a damage control laparotomy only to
discover a newly bleeding wound that was previously underestimated. Strict adherence to the
principles of ATLS will help decrease these
missed/underappreciated injuries.
A blast injury (locally from bullet trajectory
or blast mechanism) may also cause occult injuries to vasculature that require intervention yet
are not initially realized; unfortunately, they are
often diagnosed only after there is critical limb
or organ damage, as is discussed later.
Concomitant orthopedic injuries such as displaced fractures or dislocations should be
reduced as soon as possible so as to permit
spontaneous return of peripheral blood ow to
the extremity and change the denitive care plan
for the patient.
Hard signs are an indication for immediate
surgical intervention without further diagnostics
or imaging necessary. A hard sign, however,
does not indicate that the basic principle of
ATLS may be shortened or compromised. After
the primary/secondary survey and adjuvants of
ATLS are completed, an unstable patient must
be taken to the operating room (OR). A stable
patient with multi-trauma or one who responds
to resuscitation and has a hard sign of vascular
trauma, with or without imaging (when available), might still be required to go to the OR to
rule out other organ system injuries before vascular operative intervention. Bleeding must be
temporarily controlled either by direct pressure
or proximal tourniquet to consider imaging, and
if unable to do so, then the patient will need an
immediate operation.
The use, and possible complications, of tourniquet are discussed below. When a patient
arrives from the eld with a tourniquet already in
place, it must be established that (1) the tourniquet is functioning as needed; (2) the time the
tourniquet was placed is known and recorded;
and (3) the tourniquet is actually indicated. In
approaching trauma patients, the ATLS protocol
starts with the evaluation of airway and respiratory status, followed by circulation. If a tourniquet is present, it will ultimately need to be
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removed to characterize the injury (if one ever
existed). However, one must do so when prepared
to handle the consequences; prior to taking down
a tourniquet, it is important to have a second tourniquet placed proximally that is not tightened but
ready to be engaged if needed. Evaluation of the
true necessity of the tourniquet is important
because of the high percentage of tourniquets
placed that are not necessary, together with the
potential iatrogenic damage caused to the limb
by the tourniquet.
Ankle-brachial index (ABI) (or arterial pressure index, API) is an important test for the evaluation of all extremity trauma (penetrating and
blunt) with proximity to vasculature and without hard signs of vascular injury. It is a readily
available rapid test with high negative predictive
value, and it is especially useful in resourceconstrained settings where CT and angiography
are not available, since the only necessary
equipment is a blood pressure cuff. When no
hard signs of vascular injury are present, and
there is a normal ABI (>0.9), then arterial damage may be safely excluded without further
imaging or monitoring [8]. Utilization of the
ABI/API has signicantly decreased unnecessary imaging, surgical exploration, and hospital
admissions. Its efcacy has been shown for both
blunt and penetrating trauma [9]. Therefore, we
believe evaluating the ABI/API is a requirement
in any suspected vascular trauma regardless of
the setting.
Doppler ultrasound (US) has clear potential
for identifying acute vascular trauma, especially
where CT scans are not readily available.
However, ultrasound is highly operatordependent and has a high rate of false-positive
results in populations with chronic vascular disease. Thus, it is more useful in helping diagnose
vascular injury in children [10] and is also informative for post operative monitoring [1].
Despite the accuracy of the physical exam and
the value of ABI/API, surgical exploration
remains necessary to rule out vascular injury if
the patient remains unstable or appears to have
continual hemorrhage, especially when CT scans
are not available.
Treatments
Arterial Trauma
When managing vascular trauma or any operation for ischemic injury or gangrene, it is important to consider general operative principles. Like
in all vascular surgeries in any environment, the
cornerstone of exposure is securing proximal and
distal control of the vessel. Once this is obtained,
treatment options will be considered depending
on the overall condition of the trauma patient and
the contamination of the surgical eld. In nontrauma patients, planning of exposure and control
of the vessels also applies. If the patient remains
stable, then preferably, a denitive repair is to be
performed. If the patient is unstable in a trauma
patient, further debridement is necessary, or
major orthopedic surgery is needed, then a temporary shunt may be used.
The rst step in treating vascular trauma is
hemostasis. This ideally will be obtained in the
eld or the emergency room by direct pressure,
proximal arterial compression, or judicious temporary use of the tourniquet. With regard to direct
pressure, it is important that the one maintaining
pressure does not let go for any reason (to test if
it is bleeding) to avoid losing the clot that may
have formed. Pressure by the scrubbed hand
(using knuckles/st instead of extended ngers)
is only released when the surgeons are ready to
gain control of the bleeding vessel operatively.
This avoids cramps and may be sustained for longer amounts of time.
Tourniquets have a clear role in saving lives,
yet their adaptation from military to civilian use
has been met with controversy. Despite the controversy, most recent studies continue to show a
benet in overall survival, blood product use, and
limb outcome [11]. In LMICs, tourniquets may
be anything that can be tightened and tied, be it a
cloth, a belt, or a shirt. The principles of proper
tourniquet use include the following:
1. Know when to apply a tourniquet.
(a) Bright red pulsatile bleeding.
(b) Large amounts of dark red bleeding.
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(c) Bleeding that cannot be stopped by direct
pressure.
2. Place the tourniquet as close to the injury as
possible in order to avoid damage to healthy/
viable tissue.
3. If there were distal pulses before the tourniquet was placed, make sure that there are none
after.
4. Make sure the bleeding has stopped (that the
tourniquet is doing its job).
5. Lastly, record the time of placement– either
on the tourniquet, on the leg, on the forehead
of the victim– wherever it may be easily seen
by any of the teams taking care of the patient.
Junction tourniquets and prehospital endovascular exclusion have begun to gain popularity,
yet this is still far from mainstream or relevant
for LMICs.
The goal for surgery is to restore blood ow
distally to the injured area to avoid gangrene.
This should be done urgently. However, if the
patient’s hemodynamic status does not allow for
revascularization, ligation of an injured vessel
might be the most accurate option available.
Especially when it comes down to choosing to
save either life or the limb. When proximal ligation is performed, the distal extremity must be
frequently assessed closely for signs of worsening ischemia, which will mandate urgent revascularization or amputation in case revascularization
is not permitted due to the patient’s status [12].
Endovascular surgery has risen in popularity in
HIC and has allowed for minimally invasive
treatment of low-ow arteriovenous stulas,
pseudoaneurysms, and active bleeding of nondominant arteries by transcatheter embolization,
or by the placement of intravascular stents to
exclude the injured areas of the vessel or to treat
focal intimal injuries. These minimally invasive
techniques are not generally available in other
major centers in LMICs, and thus, open surgery
remains the gold standard in the treatment of
most vascular trauma, especially that of the
extremities.
The multi-trauma patient requiring surgery in
more than one compartment should be prepped
and draped from the chin to the knee. In limb vascular injuries, the prep needed includes total
length and circumference. To also ensure rapid
access to vein graft harvesting, the contralateral
uninjured limb should also be circumferentially
prepped and draped. Venous harvesting may
sometimes be done from the ipsilateral limb, but
this is not advisable, especially in blast injuries.
If hemostasis has not been obtained (or adequately obtained) in the operating room, a Foley
catheter may be used for temporary tamponade
[13]. This may also be done in the emergency
room or eld. This is an important option to
understand in LMICs with limited, or overwhelmed, resources. Once a bleeding vessel is
identied intraoperatively, a proximal balloon
occlusion with a Fogarty catheter (Edwards
Lifesciences, Irvine CA), if available, may be
considered. The balloon may be inserted blindly
and should be accurately tted to the vessel’s
diameter. We strongly discourage the use of blind
clamping of vessels to avoid possible damage to
the vessel intima and wall.
A longitudinal incision should be carried out
above and below the injured area to allow for
complete control of the vessel above and below
the site of injury. In certain cases, a tourniquet
may be applied (or reapplied) proximally, to
allow for hemorrhage control until surgical
access is gained and proximal control is achieved.
Once control has been gained, the incision can be
extended over the injured area, where the damaged vessel will be exposed. For trauma to the
proximal lower extremity, a retroperitoneal incision may be required to gain proximal control of
iliac vessels. Further proximal control would be
at the bifurcation of the iliac artery and veins via
an abdominal approach. In proximal upper
extremity trauma, a supraclavicular or infraclavicular incision may be warranted to gain control
of the vessel or even a sternotomy in rare cases.
For excellent outline of various quick vascular
exposures, we strongly recommend Henry’s
book, Extensile Exposures, for every surgeon’s
library [14].
Clamping with vascular clamps the artery
proximally and distally is recommended under
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direct vision, and never blindly, prior to exposing
the injured vessel. If specic vascular claps are
unavailable, then it can be done be done with
double-looped thin rubber drains as close to the
injury as possible or with surgical Adsons dressed
in rubber booties and closed with the minimal
amount of tension needed for hemostasis.
Anticoagulation can be achieved locally by
injecting 1000U heparin into each limb prior to
clamping. If all other sources of bleeding have
been controlled, systemic heparinization can be
performed with 5000 U heparin and repeated
every 4–6h as needed. If the patient begins to
become coagulopathic, then no systemic heparin
is given. The proximal and distal areas of the vessel should be exposed, and surrounding area is
debrided, including edges of the vessel if injured
by blunt or gunshot trauma or by explosion. It is
necessary to assess inow and backow bleeding
from the proximal and distal vessels prior to nal
vascular repair. If inow or outow are not
thought to be appropriate after distal and proximal irrigation (or passage of a Fogarty balloon, if
available), one must search other areas for owlimiting injuries. If a basic c-arm x-ray is available, a single-shot intraoperative (on-table)
angiography may be performed and to determine
if there is any occlusion of ow. We use a 21 or
22G needle, with a mix of
contrast to
hep-
arinized saline (1000U heparin in 1l of saline).
If there is any question of indirect damage, we
support immediate repair in order to avoid complications, possible limb loss, and/or the need to
return to the operating room.
Wide debridement of all soft and boney
injured tissue is mandatory prior to coverage of
the vascular repair and closure, preferably with
surrounding viable muscle and skin. This is
needed to prevent vascular conduit/graft infection or disruption. Muscle and/or soft tissue aps
may become extensive originating from parts of
the lower abdomen, anks, and other parts of the
ipsilateral extremity. Muscle aps may need to be
temporary if further debridement is necessary for
large contaminated tissue defects.
Arteriotomies on damaged vessels should be
carried out longitudinally, allowing for its extension if the damage to the vessel is greater than
previously assessed. Longitudinal arteriotomy
also permits easier exploration of the posterior
vessel wall including presence of an arteriovenous stulas and of intimal tears.
Following exploration, indications for a denitive (or temporary) repair can be checked. Repair
(or bypass) is the goal for vessels that are vital for
limb function and survival while remembering
the mantra of “life over limb.” In hemodynamically unstable patients, a more aggressive
approach toward vessel ligation should be considered, especially when the vessel is not essential to distal tissue viability. Venous ligation is
usually well tolerated in the extremities without
signicant sequelae. Ligation may even be utilized for large central and major veins such as the
portal vein or the inferior vena cava (IVC) in
extreme situations with unstable patients [15]. If
necessary, arterial ligation may be done safely to
the following vessels:
– Subclavian artery.
– Radial or ulnar arteries (if intact palmar arch
is present and a normal backow is perceived
during surgery).
– Internal iliac artery.
– Supercial femoral artery (with a patent deep
femoral artery).
– Single tibial artery (when other tibial arteries
are intact).
Surgical repair may be done with primary
repair, patch repair, end-to-end anastomosis of
the damaged artery, the creation of an interposition graft, or a bypass. Primary repair may be
considered for stab wounds when there is minimal damage to the arterial wall and there are no
ow restrictions. It is done by using a nonabsorbable single or running suture. We prefer
Prolene (if unavailable, then silk) 6–0 or 7–0
depending on the size of the vessel (larger for the
aorta). A vessel defect involving more than 1cm
but less than 3 cm, or a full transection of the
artery in which both edges of the vessel are less
than 3cm apart after debridement of the edges,
can be reapproximated by an end-to-end anastomosis once both ends of the vessel are sufciently
mobilized to avoid any tension. Figure 41.1
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Fig. 41.1 Laceration to the common femoral artery that
was repaired by primary closure Source: Photos courtesy
of authors A.G. and A.S
shows a laceration to the common femoral artery
that was repaired by primary closure.
When a broader arteriotomy is required in
order to debride the damaged vessel, a patch
angioplasty is indicated, which may be obtained
from the contralateral greater saphenous vein
(GSV). If question remains regarding the viability of the vessel, then it might be safer to perform
a formal resection and repair with an interposition graft. A patch repair is shown in Fig. 41.2
together with a GSV graft repair (Fig.41.3).
When a tension-free primary anastomosis is
not possible, then an interposition graft may be
used. The conduit of choice should be an autogenous vein (especially for vessels <5 mm in
diameter), obtained from the contralateral limb
(the neck for large vessels). When a whole segment of an artery is involved and the inow and
outow vessels are not the same, a bypass with a
reversed (because of valves) GVS autogenous
vein graft should be performed. To increase the
diameter of the vein graft panel, reconstruction
Fig. 41.2 A combination of a patch repair to the common
femoral artery and an interposition reverse SVG replacing
the deep femoral artery and proximately sewn to the patch
repair (the vein graft is marked with purple and the patch
more white) Source: Photos courtesy of authors A.G. and A.S
Fig. 41.3 Supercial femoral artery repaired with reverse
SVG. Source: Photos courtesy of authors A.G. and A.S
[16] or other methods may be used (Fig.41.4).
The GSV autologous conduit, when used for
either patch angioplasty, interposition grafts, or
bypasses, has been shown to have good short-,
mid-, and long-term patency rates [17].
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abcd
Fig. 41.4 GSV graft repair of the supercial femoral
artery. Source: Photo courtesy of author M.A.H. (a) The
saphenous-vein is longitudinally opened and divided. Two
equal rectangular pieces are created. (b) First, the pieces
of saphenous vein are sewn side by side. (c) Free borders
of the saphenous veins are coiled up in a sterile cylindrical
For larger-vessel injuries, redo reconstructions, or if the GSV is not available or adequate,
then the contralateral femoral vein or jugular vein
for short segments is a good (and underutilized)
option. These much larger vessels may be harvested with limited morbidity and good long- term
results. Ideally, the femoral vein is harvested distal to the insertion of the profunda (deep) femoral
branch, allowing for adequate limb drainage.
Occasionally, a synthetic graft is needed but is
usually not readily available in LMICs. Preserved
veins from cadavers may be used and should be
obtained when possible and maintained sterilely
in an antibiotic solution in the refrigerator.
Synthetic grafts are undesirable for use in the
nonsterile penetrating, blast, or open blunt trauma
injuries. In civilian trauma, usually for knife and
bullet wounds to vessels that are centralized or
proximal enough that are too large for GSV
grafts, synthetic grafts are commonly used in
rod and sewn each other with a 6/0 Prolene monolament
suture. (d) The neo-vein conduit has been performed with
a caliber twice the original vein’s diameter. Source:
Ketenciler S, etal. Annals of Vascular Surgery. 2018 Nov
1;53:117–22
HICs, but the jugular vein may be employed in
LMICs.
Once the repair is completed, an assessment of
revascularization should be done before closure.
The return of distal pulses, arterial Doppler signal
distal to the repair, return of normal capillary lling time, and an increase in distal extremity temperature are all positive ndings. Primary closure
of the debrided wound may be considered for
clean and clean/contaminated wounds. However,
if a large soft-tissue defect is present, muscle coverage of the vessel is critical to prevent vascular
infection, and a vacuum dressing (available or
created) should be employed. Negative-pressure
dressings may be readily formed using suction
machines or drainage systems [18].
Temporary vascular shunting is a critical tool
for any surgeon. This procedure has acquired
widespread recognition as a temporary solution
that allows for distal perfusion of the extremity
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when additional treatment is mandated prior to
denitive vascular repair. The use of vascular
shunts has been utilized since the early 1900s.
Originally, the use of prosthetic tubbing was
meant to be permanent. Utilization of temporary
shuts are valuable when (1) the bleeding has been
controlled yet the patient is too unstable to continue with denitive vascular surgery; (2) when
signicant orthopedic surgery must also be performed to the ipsilateral limb; or (3) if damage
control surgery needs to be done before the
patient can either be transferred to a higher level
of care or when specialist surgical help can be
obtained. When used for short periods of time
(1–3h), shunt patency rate reaches 100%, even
when systemic anticoagulation is not utilized.
Temporary shunts may remain open for more
than 2 days without systemic anticoagulation
[19]. The goal is to perform denitive surgical
repair within 48 hours, with initiation of DVT
prophylaxis anticoagulation if the bleeding has
stopped. The diameter of the shunt should be
similar to that of the artery. Sterile IV set tubing,
nasogastric feeding tubes, or even chest tubes
may be used as shunts with care not to damage
the vascular intima using double-looped vessel
loops or thin Penrose drains. The shunt may be
also secured using either 2–0 or 1–0 silk ties. By
placing a longer silk tie in the middle of the shunt,
it can be easily identied and followed for any
slippage out of place in one direction or the other.
It must be inserted into the proximal vessel rst
while allowing for inow bleeding assessment
and elimination of air and then inserted distally
into the target vessel. Distal perfusion must be
assessed after placement of the shunt, ideally
with Doppler signals.
Venous Trauma
There is no unanimous decision on whether or
not to treat large venous injuries. Venous repairs
acutely thrombose much more often than arterial
repairs, although they are known to frequently
spontaneously recanalize eventually. Peripheral
edema following acute venous thrombosis or
venous ligation may be avoided in 50% of
patients with venous repair as compared with
ligation, although in both scenarios, a complete
resolution of edema usually happens with time
[20]. If repair is feasible and safe, it may be done
by simple lateral suture venorrhaphy, end-to-end
anastomosis, patch venoplasty, or interposition
graft, all depending on the anatomy and extent of
the injury. With larger veins, especially the vena
cava, it is important to perform a transverse repair
in order to avoid narrowing of the lumen. Ligation
should be done, and not postponed, if the patient
may not be able to tolerate prolonged surgery.
Whenever there is venous trauma, regardless of
the approach taken to treat it, postoperative leg
elevation and light compression of the extremity
may help reduce edema.
Fasciotomy
With all vascular trauma, especially to the lower
extremities, it is important to focus on the possible need for prophylactic distal fasciotomies.
Although they have potential morbidity and complications (especially wound infection and length
of hospital stay), a four-compartment fasciotomy
of the distal lower limb may be needed with all
combined arterial and venous injuries with blast
or blunt injuries and, even sometimes, with sharp
injuries of the vessels accompanied by soft tissue
injuries. The use of prophylactic fasciotomy
remains controversial, yet, especially in LMICs,
it might be the safest option to prevent potential
limb loss due to compartment syndrome. The risk
factors and formal clinical grading scores are not
yet accurate enough to predict with any certainty
who might benet from a prophylactic fasciotomy [21, 22].
A special understanding of blast injury with
soft tissue damage is very relevant to vascular
ends that appear normal but are microscopically damaged. Along with soft tissue damage
and contamination, this creates the perfect
storm for conduit/graft infection, potential
breakdown, and local wound infections.
Therefore, with blast injuries, it is important to
perform multiple debridements, be liberal with
the use of a temporary graft, and use synthetic
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Fig. 41.5 Different
stages of repair for a
large inguinal blast
defect. (a) Distal and
proximal control of the
vessel (femoral artery).
(b) Temporary shunt
with the silk ties– the
yellow arrow showing
the middle silk tie for
placement reference. (c)
Coverage of denitive
repair with ipsilateral
rotated sartorius muscle
ap (d) Final bandaging
with negative pressure
dressings including
prophylaxis fasciotomy
a
b
cd
grafts only as a last resort. It is important to
understand the challenges of these complex
cases to save rst the life and then the limb.
Figure 41.5a–d illustrates the steps taken following a blast injury.
Nonoperative Management
Not all vascular trauma will require surgical intervention. Patients with low-velocity injuries,
patients who have intact circulation or perfusion,
patients who are not actively hemorrhaging and
have no hard signs of bleeding, and those with
minimal vessel defects or small (<2cm) pseudoaneurysms detected on duplex ultrasound are candidates for initial observation and nonoperative
management. Patients who do not present signs of
distal ischemia and do not have a defect greater
than 2cm, nor have any extravasation on initial
evaluation, also deserve to be observed. Out of
these, only 9% required further surgical treatment
[23]. In another report by the same authors about
309 patients with injuries in proximity to major
vessels who were all observed clinically without
any imaging study, only 4 progressed to requiring
surgery. This concludes that physical examination
alone is safe to evaluate occult vascular injuries,
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which results in excellent long- term outcomes.
These results, along with many others, have
proven that there is no need for initial invasive
diagnostic evaluations that may be very difcult,
if not impossible, in LMICs. As long as there are
no hard signs of bleeding, suspected ischemia, or
danger to the limb, nonoperative management is
both indicated and feasible, especially in LMICs.
The nonoperative approach, however, mandates
close follow-up of the patient with a duplex ultrasound for at least 2weeks (stay near the center)
and a low threshold for surgical intervention in
case of any change in the limb status.
Follow-up remains a critical component of
vascular surgery. Anticoagulation use is
strongly dependent on availability and
resources. Trauma patients in LMICs (wars and
road trafc accidents (RTAs) usually have the
luxury of being young with healthy vessels or
have few risk factors for atherosclerosis. For
most vascular repairs (short conduits/grafts) in
such patients, no anticoagulation is needed with
the exception of those over 45 who might benet from aspirin therapy.
Abdominal Vascular Trauma
Abdominal vascular trauma is a major challenge
under any circumstances and worse in a station
rural hospital in LMICs with likely shortage of
necessary resources. The vast majority of such
injuries are secondary to gunshot wounds and
knife wounds along with blast wounds, usually
secondary to armed conicts. Blunt injuries can
also cause vascular injuries, especially rapid
deceleration, crushing injuries, or falls from
heights, which all can result in avulsion of vessels or intimal tears, which then leads to thrombosis or to pseudoaneurysms.
Initial Assessment
Any patient who is hypovolemic and/or in shock
should be considered as bleeding until proven
otherwise. If there are no obvious signs of bleeding, intraabdominal vascular source of exsanguination is a high suspect if the abdomen has been
injured. Abdominal distention and/or peritonitis
may be initial physical signs, but the patient may
initially present with minimal or no signs and
respond adequately to uid replacement. With
retroperitoneal tamponade of a vascular injury,
patient may become asymptomatic before crashing or may be asymptomatic initially with a
thrombosis or intimal injury. Regardless of the
patient’s condition, large-bore access, preferably
in the upper extremities, is the primary intervention along with an attempt to prepare matched
blood for transfusion if it becomes necessary.
Permissive hypotension technique, if possible, is
an alternative until intraoperative control is
obtained.
Radiologic assessment with an abdominal
X-ray with wound markers may be helpful to
trace the track of a penetrating injury with bullet
or knife. A Focused Assessment with Sonography
in Trauma (FAST) may be helpful to identify
hemoperitoneum but is not useful for retroperitoneal bleed. CT scan with contrast is most useful
to identify specic vascular injuries but generally
is available only in major medical centers in
LMICs. To ascertain that abdominal hemorrhage
is the cause of blood loss, diagnostic peritoneal
lavage or aspiration (DPL or DPA) is indicated in
the emergency room, done with a little cutdown,
under direct vision.
As stated previously, unstable patients should
be immediately transferred to the operating room.
If they appear terminal in the emergency room,
the only way to stop the bleeding, besides thoracotomy and cross clamping of the aorta above the
diaphragm, is the use of the resuscitative endovascular balloon occlusion of the aorta (REBOA)
(Fig.41.6). Visiting faculty may bring this with
them since it may not be available in most areas
in LMICs. REBOA insertion may be taught to
non-physicians and is relatively simple and minimally invasive while offering an excellent temporizing control of intraabdominal bleeding on the
way to the OR.
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Fig. 41.6 Placement of catheter and ER-REBOA PLUS and pREBOA-PRO catheters. Source: Copyright Prytime
Medical Devices, Inc. All Rights Reserved. Reprinted with permission
A. L. Goldstein et al.
Operative Approaches
toIntraabdominal Bleeding
Initial exploration is vital to rule out any other injuries. To avoid further clotting problems, the OR
should be warm. There should be blood available
and a cell saver, if possible. One can be created to
be maintained on call [24]. Once inside the abdomen, all four quadrants are packed, and after
removal of all free blood and clots, the three zones
of the retroperitoneum are systematically explored.
Here any bleeding vessels which should be temporarily clamped off with vascular clamps, vesselloops, or Rummel tourniquets; with large vessels
the intraluminal use of Foley catheters may be very
useful. Zone 1 contains all middle vessels including the aorta and IVC with their branches. Zone 2
extends laterally from the renal vessels to the paracolic gutters, and Zone 3 does the same from the
bifurcation of the aorta to the pelvis. In Zone 1, all
hematomas should be explored, while in Zones 2
and 3, hematomas from penetrating trauma should
be explored, while those from blunt injury should
be left alone, unless they are expanding.
Initial control of any bleeding vessels is done
with manual compression prior to proximal and
distal direct control of the vessel. If control of
bleeding cannot be obtained, then temporary
compression or cross clamping of the aorta is
done above the stomach or preferably the use of
REBOA directed manually. As soon as control of
the bleeding vessel(s) is obtained, aortic occlusion is released. Surrounding the vena cava is
fraught with risk of tearing lumbar veins, and
compression with sponge sticks should precede
any manipulation of the large veins.
Management ofIndividual
Abdominal Vessels
It is beyond this chapter to describe the various
maneuvers to approach the front and back of the
various large vessels, and the reader is guided to a
standard text on vascular surgery. Sufce it to say
that due to excellent collateral circulation, the
celiac trunk and its branches may all be ligated if
needed. Ligation of the common hepatic artery, if
necessary, should be done proximal to the gastroduodenal artery takeoff to maximize collateral
ow to the liver. Injury to the mesenteric artery
may benet by a bypass from the aorta to the distal segment of the transection with ligation of the
proximal segment to avoid injury to the pancreas
and its subsequent leak. As to injuries to the portal
vein or the superior mesenteric vein, they can both
be ligated with the proviso that that the subsequent bowel swelling will require vigorous postoperative uid resuscitation to control peripheral
hypovolemia. The left renal vein over the aorta
can be divided and ligated to expose the ventral
part of the aorta. Renal artery injuries may lead to
sacrice of one kidney if it is known that the other
is well functioning, since renal artery reconstructions in emergency conditions may be very difcult and will usually require a bypass from the
aorta or the ipsilateral iliac artery. Any injuries to
the superior mesenteric artery should be repaired
to avoid bowel ischemia; if it is ligated, secondlook operation is required to evaluate small bowel
viability. Hematomas over the duodenum should
be explored even with blunt injury to conrm no
duodenal injury. Injury to the infrahepatic vena
cava repair may be difcult because of the lumbar
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