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28 • Australia and New Zealand 355
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are in place. Clinical examination, the ankle-brachial
index (ABI) Doppler, and the computed tomography angiography (CTA) are commonly used as diagnostic modalities
for lower extremity vascular trauma. Chest radiography –
followed by contrast-enhanced CTA of the chest, abdomen, and pelvis – is the common approach for injuries
signicant enough to risk blunt aortic injury. As in many
parts of the world, blunt cervical vascular injury has
been underappreciated with rates of approximately 0.2%
of trauma admissions.13 With greater use of a screening
protocol and much more liberal use of CTA concurrent
with CT imaging of the head and C-spine, the diagnosed
incidence of cervical vascular injury is now closer to 1%.
Penetrating vascular trauma is often associated with hard
signs of vascular injury, such as hemorrhage or profound
ischemia. As has been well outlined in this textbook, in the
absence of hard signs, further evaluation using CTA or
duplex ultrasound is typical in most centers in Australia
and New Zealand.
Region-Specific Treatment
Strategies
With a large focus on blunt thoracic aortic injury, Australian and New Zealand surgeons have been quick to
embrace endovascular technology for the repair of these
injuries. Since approximately 2005, the vast majority of
blunt aortic injuries in both countries have been repaired
with endovascular stent grafts, nearly all of which have
been placed by certied vascular surgeons (Fig. 28.4). This
practice has been associated with excellent results, and, in
a population that is somewhat easier to follow than some
regions of the world, endovascular repair in Australia and
New Zealand has been associated with few mid- and longterm problems.
14
In the setting of penetrating trauma to the limb or a
severely mangled extremity (including traumatic amputation), Australia and New Zealand have recognized
the importance and utility of modern tourniquets. Led
by recent military experience and study, tourniquets
have been deemed important in civilian circumstances,
and all ambulances used for acute response to trauma
in New Zealand are equipped with two combat action
tourniquets (CAT). Since initiation of this policy, there
have been numerous anecdotal experiences of tourniquet application controlling extremity hemorrhage and
allowing the injured patient to be quickly stabilized. In
these cases, hemorrhage has been controlled at or close
to the scene of injury with the tourniquet, and initiation
of resuscitation, transport to the hospital, and even operative repair have been conducted in controlled circumstances (Fig. 28.5).
Penetrating neck injuries are uncommon, and traditionally those in zone II (between the cricothyroid cartilage
and the angle of the mandible), having penetrated the
platysma, underwent operative exploration. More recently,
in the era of sensitive and specic contrast CTA, a recognition has developed that in the absence of hard signs,
the likelihood of vascular or visceral injury is low. This
evolution has led to a modern practice in Australia and
New Zealand of selective exploration, in which many
penetrating neck wounds are now imaged with CTA and
observed.15 Because of the low incidence of penetrating
trauma, as well as what are generally longer transport
times in most parts of Australia and New Zealand, the need
for resuscitative thoracotomy is extremely rare. However,
this potentially lifesaving maneuver is still taught to
general surgical trainees as part of the DSTC course, and,
occasionally, there are reports of its successful application
in Australasia.
Fig. 28.4 Aortogram showing placement of a thoracic aortic stent
graft.
Fig. 28.5 A combat-action tourniquet applied to a patient with a
laceration of the brachial artery.
356 SECTION 5 • Global Perspectives on Vascular Trauma
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Strategies to Sustain and Train
the Next Generation of Trauma
Surgeons
With such a low incidence of vascular trauma in Australia and New Zealand, a greater focus needs to be placed on
training and maintenance of currency using structured
courses such as the DSTC course. General surgical training
is currently a 5-year program comprised of 6-month rotations with at least 1 year spent in a smaller regional hospital. Despite regular on-call duties, many trainees will have
minimal exposure to signicant vascular trauma during
their residency. Mandating the DSTC course and developing
others like it, some possibly dedicated exclusively to vascular injury control and repair, is an attempt to address this
deciency. However, few trainees will feel fully competent
to deal with the spectrum of vascular trauma unless they
spend time training overseas in centers with higher incidence of this injury pattern.
Vascular surgery also has a 5-year training program,
and again the exposure of this group to vascular trauma
is limited. In regional hospitals, the general surgical team
will be responsible for the overall care of the injured
patient, including any vascular injury. In contrast, in
larger metropolitan hospitals, vascular injury will usually be devolved to the vascular surgery service after initial resuscitation. Penetrating vascular injuries (including
iatrogenic trauma) will usually be treated by the vascular
surgeons who will also be responsible for the endovascular
treatment of blunt aortic and other patterns amenable to
this less-invasive approach.
Because of the challenges associated with low volumes
of vascular trauma, surgical graduates from either vascular surgery or general surgery with an interest in trauma
are encouraged to work for a period overseas in a region
with a high incidence of penetrating trauma and to bring
this experience back to Australia and New Zealand to their
individual and institutional practices to assist in training
the future generation of trauma specialists.
References
1. http://en.wikipedia.org/wiki/Number_of_guns_per_capita_by_
country. Accessed 9 July 2019.
2. Wilson N, Thomson G. Mass shooting in Christchurch and the epi-
demiology of sudden mass fatality events in New Zealand. N Z Med J.
2019;132(1494):68–70.
3. Spicer R, Miller T, Langley J, Stephenson S. Comparison of injury
case fatality rates in the United States and New Zealand. Inj Prev.
2005;11:71–76.
4. Cameron P, Dziukas L, Hadj A, Clark P, Hooper S. Major trauma in
Australia: a regional analysis. J Trauma. 1995;39:545–552.
5. Thompson I, Muduioa G, Gray A. Vascular trauma in New Zealand:
an 11-year review of NZVASC, the NZ Society of Vascular Surgeons’
audit database. NZ Med J. 2004;117(1201). http://www.nzma.org.
nz/journal/117-1201/1048/.
6. King MR, Paice R, Civil ID. Trauma data collection using a customised
trauma registry. NZ Med J. 1996;109:207–209.
7. Sug rue M, Caldwell EM, D’Amours SK, Cro zier JA, Deane SA. Vascular
injury in Australia. Surg Clin North Am. 2002;81:211–219.
8. Civil ID, King MR, Paice RP. Penetrating trauma in Auckland: 12 years
on. Aust NZ J Surg. 1998;68:261–263.
9. Friend J, Rao S, Sieunarine K, Woodroof P. Vascular trauma in Western
Australia: a comparison of two study periods over 15 years. Aust NZ J
Surg. 2016;86:173–178.
10. Cameron PA, Gabbe BJ, Cooper DJ, Walker T, Judson R, McNeil J. A
statewide system of trauma care in Victoria: ef fect on patient survival.
MJA. 2008;189:546–550.
11. Gabbe BJ, Simpson PM, Sutherland AM, etal. Improved functional
outcomes for major trauma patients in a regionalized inclusive
trauma system. Ann Surg. 2012;225:1009–1015.
12. https://www.surgeons.org/-/media/Project/RACS/surgeons-org/
files/reports-guidelines-publications/workforce-activities-censusreports/RPT_RACS_Workforce-Projection-to-2025_FIN.pdf ?rev=f9
982c1cce9b46b1bc59774a739ab730. Accessed 9 July 2019.
13. Beliaev AM, Barber P, Marshall RJ, Civil I. Denver screening protocol
for blunt cerebrovascular injury reduces the use of multidetector computed tomography angiography. Aust NZ J Surg. 2014;84:429–432.
14. Khashram M, He Q, Oh T, etal. Late radiological and clinical outcomes
of traumatic thoracic aortic injury managed with thoracic endovascular aortic repair. World J Surg. 2016;40:1763–1770.
15. Insull P, Adams D, Segar A, Ng A, Civil I. Is exploration mandatory in
penetrating zone 2 neck injuries? Aust NZ J Surg. 2007;77:261–264.
29
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Sri Lanka
AMILA SANJIVA RATNAYAKE, SANJEEWA H. MUNASINGHE, and
SUJEEWA P.B. THALGASPITIYA
Introduction
In 2009 Sri Lanka emerged from a civil war which was mainly
fought in the Northern and Eastern parts of the country and
spanned 26 years. During this war, soldiers (and to a lesser
degree civilians) in the conict zones sustained injuries due
to high-velocity gunshots, artillery, mortars, rocket-propelled
grenades, and antipersonnel mines (APMs). Furthermore,
people living in villages bordering the conict zone, Colombo
(and the city’s suburbs), and other parts of the country were
subjected to suicide bomb attacks.
Surgeons and vascular services faced a multitude of
challenges managing these patients. They had to manage
combatants who had sustained penetrating vascular injuries, traumatic amputations of the limbs, and civilians with
blast injuries. This was in addition to the normal burden
of civilian injuries due to road trafc accidents, stabs, and
low-velocity gunshot injuries.
Ten years after the war, the epidemiology of vascular
injuries has changed and new challenges have arisen. With
the improvement of road infrastructure and the resultant increase of movement of people within the country,
road trafc accidents have increased.1 An inux of weapons and gunmen (who were formerly Liberation Tigers of
Tamil Eelam (LTTE) cadres) to the South has resulted in a
rise in gunshot wounds occurring amongst members of
drug cartels and the criminal underworld. The advent of
endovascular procedures (246 endovascular laser ablations; 19 angiographies, and 66 angioplasties in 2018 at
the Teaching Hospital Anuradhapura [THA]), and subsequent increase in the numbers and complexity of such procedures, has given rise to access site pseudoaneurysms.a A
unique type of injury sustained by the civilians of the dry
zones of Sri Lanka is the trap gun injury. The trap gun is a
locally made, illegal muzzle-loading rearm with a victimactivated trigger mechanism used by farmers to protect their
crops from wild animals and by poachers to obtain meat.
The most common wild animal targeted is the wild boar,
hence the trip wire is adjusted to about 70 to 90 cm above
the ground. As the gun cannot discriminate humans from
animals, an unsuspecting victim who activates the trigger
mechanism sustains injuries mainly in the vicinity of the
thigh and knee, leading to supercial femoral and popliteal
artery injuries (Fig. 29.1). In a study done at THA in 2007,
there were 58 patients with trap gun injuries. Twenty-eight
victims sustained vascular injuries and the commonest vessel injured was the supercial femoral artery (17), followed
a
Two documented access site pseudoaneurysms: personal communication
with Arudchelvam JD, MD, and Marasinghe A, MD, via email on 19th of
April 2019.
by popliteal artery (6). Four out of six limbs (66.6%) with
popliteal arterial injuries had to be amputated, in contrast
to only 2 out of 17 (11.7%) limbs in the supercial femoral
artery group.
2
Epidemiology of Wartime Injury
COMBAT-RELATED GEOGRAPHY, TERRAIN,
AND WEATHER
The conict zone comprised heterogeneous vegetation
types: semiarid at land with tropical thorn forests, dry
evergreen jungles, and bush-type vegetation.3 Occasionally, heavy ghting erupted in coastal areas where there
was minimal cover, which took a heavy toll on both sides
due to concentrated artillery re. In the urban and suburban terrains where close-range ghting occurred, injuries
sustained were predominantly due to small arms re. In the
last phase of war, a unique strategy used by the LTTE cadre
was to build 10-meter-high earth bunds-cum-ditches; the
bunds were saturated with improvised antipersonnel mines
(iAPMs) causing multiple deaths and limb losses (Fig. 29.2).
Furthermore, the areas concerned were aficted with
seasonal North-Eastern monsoon rain from December to
February.4 Therefore, the terrain became water-logged, thus
making casualty evacuation extremely challenging. This in
turn led to delay in admissions to role 3 military base hospitals (MBHs). At other times, the scorching sun caused
heatstroke to the combatants, particularly during the mass
withdrawal of the 3rd Eelam war.
WAR TACTICS AND WEAPONS
During the 26 years of protracted war in Sri Lanka, there
were four main phases, with intervening periods of lesser
activity and intensity, especially during ceasere. During
the active phases, forces engaged in conventional war with
a dened front line. They used high-velocity ries (AK-47
and T-56), rocket-propelled grenades, 60-, 81-, and 120mm mortars, and heavy artillery including 122-, 130-,
and 152-mm howitzers. “No man’s land” was seeded with
iAPMs with the aim of maiming rather than killing soldiers. Unique to tiger guerrillas were improvised devises
connecting multiple blast components together to inict
severe injuries on a number of victims at a given time. In
addition, claymore mines were used; these re steel balls
in a 60-degree arc, inicting heavy damage to dismounted
5
troops.
APMs inicted heavy tolls on infantry troops, which
resulted in a large number of amputations and there
357
358 SECTION 5 • Global Perspectives on Vascular Trauma
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Fig. 29.1 (A) Trap gun, which is an improvised homemade devise. (B) Multiple pellet injuries in and around the knee of a victim. (Courtesy Dr. A.P. Nellihela)
Fig. 29.2 Earth bund-cum-ditch—a unique tactic used in the last
phase of war in Sri Lanka.
are around 6000 post-war amputees in the Sri Lankan
Army. Most of these APMs were locally manufactured and
referred as “Jony mines” and intended to be triggered by the
victim stepping on it. The shock from the explosion drives
dirt, clothing, metal, and plastic fragments into the soft tissues with the ballistic effect causing blood vessels to thrombose extensively beyond the visible injury zone. This in turn
leads to ischemic and contaminated musculofascial layers
at a high risk of infection and sepsis. Most of these victims
ended up with below-knee amputations and post-conict
rehabilitation of these amputees is a challenging task in
a resource-poor setting. Furthermore, the indiscriminate
nature of these mines caused civilian and animal injuries
during the war and post-war period.
6
In a single-surgeon experience spanning a period of 26
months commencing from June 1st, 1990, there were 191
victims of APM injuries. In this cohort, 153 (80%) were
victims of direct injuries to lower limbs (due to stepping on
an APM) and 24 (12.6%) had shrapnel injury in multiple
body regions by being close to the explosion. Ten (5.2%) had
injuries sustained while handling APMs and four victim’s
data was not adequate for analysis. Of the 191, 113 (73%)
underwent below-knee amputation.
7
In September 1997, with the clear aim of ending the suffering caused by APMs, the Antipersonnel Mine Ban Con-
vention was adopted by 133 signatories under the auspices
of the United Nations.
8
DEMOGRAPHICS
In the last phase of the civil war, an incidence of vascular
injuries of 2.2% was reported in 5821 security personnel
injured between December 2008 and June 2009. Highvelocity rie bullets (65/128) and natural and preformed
explosive fragments (52/128) were responsible for combined
arterial and venous injuries in 58 patients, arterial injuries
in 53, isolated major venous injuries in 11, and nonaxial
vessel injuries in 4. Injury types included 73 transections,
24 lacerations, 13 thromboses, 4 through-and-through
injuries, and 1 case of arterial spasm. Reconstruction with
interposition vein graft (IPVG) was the commonest mode of
repair (80/128) (Fig. 29.3).
9
System of care
Due to the intensity and nature of the protracted war,
compounded by the limitations of human and physical infrastructure, it was apparent that the Sri Lanka
Medical Corps alone could not manage the continuum of
combat casualty care from the point of injury to rehabilitation at tertiary care centers. The solution was to create
a uniquely hybrid approach by integrating military and
civilian health systems coordinated at the highest level
in order to achieve a common goal. Resuscitation, stabilization, and transport out of the battle front was carried
out by eld surgeons who were well-versed in managing
war casualties, whereas the brunt of denitive care was
borne by civilian surgeons and health-care personnel in
multiple tertiary care centers. A few Health Ministry General Hospitals, located at the border of the conict zone,
were converted to centers dedicated to the management
of battle trauma and these were provided with the necessary material and human resources. Ministry of Health
consultants, doctors, and nurses volunteered to work at
army base hospitals to cater for the number of casualties
threatening to overburden the military medical system.
This integrated military–civilian hybrid system of care
was proven to be effective in Israel, where rapid dissemination of knowledge gained during war was applied to civilian trauma care.
10
29 • Sri Lanka 359
Profunda f
45
Number of vessels
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40
35
30
25
20
15
10
5
0
Illiac
Axillary vein
Axillary artery
Brachial vein
Brachial artery
Forearm vein
Forearm artery
Femoral vein
Femoral artery
Popliteal vein
Popliteal artery
MEDICAL
The rst line of care was sited in close proximity to the front
line for provision of basic casualty care immediately after
injury (Fig. 29.4A). This primary care included arrest of
bleeding, establishment of intravenous access, pain relief,
and fracture immobilization. A variety of tourniquet types
were used to manage severely mangled extremities, from
a piece of twined cloth to improvised military tourniquets
consisting of a belt and a buckle.
The second line of care consisted of advance dressing stations (ADS) (Fig. 29.4B), main dressing stations (MDS), and
eld hospitals. ADS facilities were sited equidistant from three
forward regimental aid points, around 400 to 5000 m behind
the front line. Typical ADS manning included a single medical ofcer, two nurses, and three nurse assistants who were
equipped and trained to handle emergency combat resuscitation, including intubation, chest-drain insertion, arrest of
bleeding, and infusion of intravenous uids. A single MDS
facility was sited behind three ADSs, and had capability to
were manned by one senior medical ofcer, four nurses, six
nurse assistants, and other supportive care personnel. Staff
at the MDS had the capacity to transfuse uncrossmatched
group O blood and to perform basic lifesaving surgical procedures such as tracheotomies, emergency amputations, and
wound exploration to achieve hemostasis.
The third line of care were MBHs and general hospitals capable of delivering definitive surgical care via
specialized services that included vascular, orthopedic,
oral-maxillofacial, neurosurgical, and intensive care unit
facilities. In 2008–09, the MBH in Anuradhapura, situated
180 km away from the conict zone, was converted to a center for denitive extremity vascular care. General surgeons
trained in vascular surgery were deployed to this hospital
to minimize the delay in revascularization. The MBH was
Other
Ligation
Iry repair
IPVG
emoris artery
Tibioperoneal vein
Tibioperoneal artery
Fig. 29.3 Anatomical distribution and types of
repair of 128 combatants who sustained military
vascular trauma.
Profunda femoris vein
primary.
IPVG
, Interposition vein graft;
Iry
equipped with two operating theaters (Fig. 29.4C), a threebed intensive care unit, and an 80-bed ward.
Complex vascular injuries that required combined
orthopedic and reconstructive services were transferred to
Colombo Army Hospital (CAH) and the National Hospital
of Sri Lanka (NHSL), situated 199 km from Anuradhapura
(equivalent to 5–6 hours of travelling time by road). All
injured combatants ultimately ended up in CAH and Ragama
Rehabilitation Hospital where they underwent rehabilitation.
ADMINISTRATIVE STRUCTURE
When personnel were transferred from the point of injury
to tertiary care hospitals, their specic eld medical card,
detailing injuries and management, accompanied them.
Details from these and the constant feedback received from
medical eld commanders (who visited the front line on a
weekly basis) helped to identify shortcomings and formulate
treatment guidelines. Improvement was further facilitated
by the visit of the Director of Medical Services to the battle
front who, along with the consultants, proved instrumental
in improving logistics and upgrading the system of care.
Considerations for Diagnosis
Like any other austere situations, diagnosis was primarily
based on clinical skills learned at medical schools (hard and
soft signs of vascular injury) and sharpened by teaching from
senior colleagues and consultants at formal and informal
encounters. The management of pulsatile arterial bleeding
was straightforward as the challenge was to staunch bleeding and save life. More challenging was to manage patients
presenting with ischemia but no signs of overt bleeding,
particularly when the number of casualties delivered at any
,
360 SECTION 5 • Global Perspectives on Vascular Trauma
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A
B
C
Fig. 29.4 (A) Field care under austere condition. (B) Performing a limb fasciotomy at a main dressing station (MDS) with improvised proximal tourniquet in situ. (C) Operation Theater at Military Base Hospital Anuradhapura. (B, Courtesy Col. Kalana Wijewardane, MD.)
given time to role 1 and 2 MBHs stretched the capacity of
health care personnel. Medical attendants missed pulseless
limbs which were only detected at a later stage in the line
of care. Although clinical and Doppler assessment of each
injured limb was performed at the base hospital (to record the
injured extremity index and so conrm and measure severity
of ischemia), this practice was not strictly adhered to at ADS
and MDS. Duplex and CT angiogram facilities were not available at the base hospitals during the war, but they were available at CAH. X-rays were done at the MBH to detect fractures
and retained foreign bodies.
Limbs with full-blown ischemia detected too late to be salvaged had to be amputated. Other injuries which had traumatic arteriovenous stulae and pseudoaneurysms were
managed at CAH both by open and endovascular methods.
from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) demonstrating the efcacy of early use
of combat application tourniquets (CATs), training and formation of guidelines in their use, and shortened evacuation
timelines to minimize ischemia times.
12–15
In the Sri Lankan theatres of war, where terrain, tempo,
and weather meant that evacuation times were prolonged
(5.5 hours; range 2.5–16.3) the liberal application of tourniquets was discouraged, with the exception of limbs so
severely traumatized that amputation was likely. Application of direct pressure and gauze packing, sometimes with
overlay sutures, was used to control bleeding, especially in
through-and-through wounds caused by bullets or small
fragments, which helped to preserve collateral circulation,
thus preserving both life and limb (Fig.29.5A).16 Furthermore, where this did not control hemorrhage within the
Treatment strategies
HEMORRHAGE CONTROL
According to Brian Eastridge’s analysis of 4596 combat
deaths, hemorrhage is the most common cause of potentially
preventable death in the combat setting11 with experience
ADS/MDS setting, exploration and vessel ligation at ADS/
MDS were conducted. The overall efcacy of these practices is difcult to ascertain due to lack of reliable data on
killed in action (KIA) and post mortem ndings. Though
the practice of blind application of hemostats was clearly
discouraged, there was a single case recorded as presenting to MBH where multiple hemostats had been hastily and
29 • Sri Lanka 361
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indiscriminately applied in the presence of catastrophic
bleeding (Fig. 29.5B).
Three patterns of bleeding limb wound were therefore
identied: through-and-through injuries where packing
and/or overlay suture could be employed; wounds with a
large soft tissue defect not amenable to simple gauze packing where exploration and ligation of vessels at the earliest possible stage was required; and severely mangled limbs
likely to require amputation16 managed with improvised
tourniquets at the point of injury (Fig. 29.5C).
A
B
C
Fig. 29.5 (A) Gauze packing in a through-and-through wound profile to achieve successful bleeding control. (B) Blind application of hemostatic clamps.
(C) Application of improvised tourniquets to arrest bleeding.
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FASCIOTOMY AND TEMPORARY INTRALUMINAL
SHUNTING)
The second challenge of vascular trauma is limb ischemia and irrecoverable muscle necrosis resulting in limb
loss. Usually, this is diagnosed clinically, with presence
of the classic “6 P” features (pallor, paralysis, paresthesia, pain, pulselessness, poikilothermia) prompting the
attending surgeons to employ four-quadrant fasciotomy
and temporary intraluminal shunting as soon as possible. The validity of the classical 6-hour cut-off time to
reperfusion has been scrutinized
17–20
and the authors are
currently investigating the impact of time as a variable in
clinical decision-making concerning vascular reconstruction versus amputation. Ischemia was a common nding
in our series of vascular injuries (89/128) with 21 cases
undergoing four-quadrant fasciotomy at the eld (MDS
setting) and 43 at MBH. Fasciotomy was found to facilitate assessment of viability (by electrical stimulation of
muscles, color, and consistency) to aid decision-making as
to whether to proceed with revascularization or not and,
when conducted for prophylactic reasons, to be an important part of the response to war-time casualty treatment
characterized by fragmentation of care, austerity, and
unpredictable transfer times. Similarly, temporary intraluminal shunting, using intravenous infusion giving–set
tubing, was employed to “buy time” on 14 patients where
either multiple patient demand or the need to address
other injuries demanded this damage-control technique
(Fig. 29.6).
9
RESUSCITATION STRATEGY
O positive packed blood was transfused (total 78 units at
MDS and 160 units at MBH, respectively) as resuscitation uid in severely (class III or IV shock) compromised
patients. During this time, component therapy (damage
control resuscitation) was not practiced at either MDS or
9
MBH.
DEFINITIVE VASCULAR RECONSTRUCTION
Standard vascular reconstruction technique was employed
where initially proximal and distal control of injured
vessels were achieved with rubber loops. Adequate débridement of vessel ends, Fogarty embolectomy and local heparinized saline ushing were performed prior to reverse
saphenous vein graft (RSVG) (Fig. 29.7). RSVG was necessary due to the extent of damage seen with ballistic injury
and the degree of débridement required: the resulting gap
could not be approximated without replacement conduit.
RSVG was often harvested from the contralateral limb,
employing a technique to prepare the vein in situ using a
heparinized saline infusion via a 24-gauge cannula. The
proximal anastomosis was performed rst and graft perfused to gauge the correct length prior to completion of the
distal anastomosis in order to prevent kinking of the graft.
Systemic unfractionated heparin (1000 U/h) was infused
for 48 hours, unless contraindicated due to concomitant
torso or craniocerebral trauma.
Vascular repair was done as the primary step ahead of soft
tissue débridement to minimize ischemic time. Muscle viability was assessed using the time-tested criteria of contractility,
capillary bleeding, consistency, and color and erred towards
conservatism, with any doubtful cases taken back to theater
after 24 to 48 hours for reassessment. Soft tissue wounds
were managed with serial wound lavage and débridement till
the wound bed was healthy for denitive closure. The majority of vascular repairs were primarily covered with soft tissues using rotational aps and wounds were dressed in bulky
gauze, cotton, and crepe bandage. Negative pressure wound
therapy was not available for consideration at the MBH.21
Most of the fasciotomy wounds were managed with serial
wound lavage and once the edema subsided, they were covered with split-thickness skin graft.
MANAGING INFECTIONS
Thorough débridement, serial lavage, and antibiotics were
the cornerstones of successful prevention or minimization
Fig. 29.6 Sterile plastic infusion tube used as an improvised temporary
intraluminal shunt.
Fig. 29.7 Interposition vein graft (IPVG), the commonest mode of
repair in ballistic vascular trauma.
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of infections. The commonest complication at immediate
setting was soft tissue infection with Pseudomonas spp. followed by gram-positive organisms. Antibiotic cover (amoxycillin and clavulanate or cephalosporin and gentamicin)
were used in the majority of cases.
CONCOMITANT INJURIES
In the midst of time restraints and multiple casualty settings, critically injured patients with concomitant venous
injuries (58/128) were more often managed with ligation
(43/58) instead of repair (15/58). In the latter instances,
lateral suture (13/15) or complex venous repair techniques (2/15) was used successfully.22 Patients with combined arterial and venous injury needed higher volumes
of blood transfusion than those with arterial injury alone
and, when seen with concomitant skeletal trauma, resulted
in a greater chance of amputation.22 Associated popliteal vein injuries were usually ligated (3 repairs out of a
total of 28 associated venous injuries in 39 documented
popliteal artery injuries).23 Management of fractures (40
reported out of the 128, 31 had most severe comminuted
fractures) was secondary to immediate vascular priorities and skeletal stability was often addressed with plaster of Paris until external xation could be undertaken
at CAH or at other regional tertiary care centers where
orthopedic facilities were available. Concomitant fractures
(a surrogate marker of soft tissue and collateral circulation
injuries23) carried a poor prognosis for the limb, especially
in the context of popliteal vascular injury. Anastomotic
dehiscence was observed in a handful of cases where
insufcient skeletal stabilization led to vascular disruption. Nerve injuries (19/128) were tagged to be repaired
later at the tertiary care centers where reconstructive services were available.
9
COMPLICATIONS
Postoperative thrombosis (10), anastomotic dehiscence (5),
secondary amputation (5), and death (4) were observed in
this cohort of 128 patients.
9
Sustaining and Training the Next
Generation
CHALLENGES
Sustaining surgical readiness for the management of war
casualties proved challenging in the post-war period due
to the reduced number of trauma-related admissions to
army hospitals, reduced opportunities for recruitment of
surgeons (in peacetime where patriotic recruitment drivers are less evident), and because the harsh, hierarchical
nature of remote deployments, often separated from family, are unattractive to newly graduated state sector medical professionals. Furthermore, the peacetime requirement
to divert funds away from the military sector toward other
development projects has had an impact, as has the limited
number of vascular and trauma surgeons working within
Sri Lanka to sustain this capability. There remains a need to
train more surgeons and establish dedicated vascular and
trauma centers in strategic locations to sustain the ability
to manage patients with vascular injury.
MILITARY-RELATED STRATEGIES
After the war, the military medical community established
the Sri Lanka College of Military Medicine (SLCOMM)
which started collaborative endeavors with international
institutes such as the Uniformed Services University of the
Health Sciences in Bethesda, USA. The College’s planned
development of an MSc in military medicine and launch
of programs such as the Advanced Surgical Skill for Exposure in Trauma [ASSET] and Tactical Combat Casualty
Course [C4] will invigorate interest among junior doctors in
military medicine as a viable career with opportunities to
maintain high professional standards.
b
With the advent of lightened responsibilities at home,
Sri Lankan army has participated in multiple UN missions
which have provided valuable experience in eld medical
care to members of the Medical Corps. For instance, the
SRIMED level 2 hospital was established to provide medical care for UN forces, workers, and civilians in South
Sudan.c Recent deployment of military medical core in
support of the Nepal earthquake, and in national ood
disaster management, justies the necessity of maintaining a well-equipped and prepared military medical
core during peacetime; close-knit teams which are easily
deployable are especially suited to support domestic emergency situations such as Easter Sunday massacre in 2019.
The Kotelawala Defense University (named after the 3rd
Prime Minister of Sri Lanka) recruits cadets drawn from
the three Armed Forces and trains them with the aim of
producing professionals competent in both military and
medical duties. Over the last 5 years, the medical school
has produced 159 military medical ofcers with 211 cadet
ofcers ready to join them during the next 5 years.
d
GENERAL STRATEGIES
Several strategies to improve the standards of trauma
care have been implemented. Medical schools have introduced trauma and vascular modules to the undergraduate curriculum. The Post Graduate Institute of Medicine
has a dedicated program to train surgeons in vascular and
transplant surgery and introduced programs to train surgeons in general surgery with a special interest in trauma or
vascular surgery.24 The College of Surgeons of Sri Lanka
commenced a National Trauma Management Course
(NTMC) in 2009 and an Advanced Trauma Life Support
(ATLS) course in 2017 for medical graduates, as well as a
dedicated course for nurses, aiming to enhance the quality
of trauma care in the country.
b
Personal communication with Brig. DTN Munasinghe, MD, verbal com-
munication on 23 March 2019 and CDR Tamara J Worlton, MD, email
communication on 12 October 2018.
c
Personal communication with Col. Saveen Semage, MD, email communi-
cation on 4 March 2019.
d
Personal communication with Dr RN Ellawala, MS, FRCS. email commu-
nication on 25 April 2019.
25
364 SECTION 5 • Global Perspectives on Vascular Trauma
https://t.me/medicina_free
Conclusion
The civil war in Sri Lanka produced a large case-load
of war-injured that required the development of a system that combined both military and civilian elements,
where austere conditions necessitated improvised techniques to sustain life and limb in the forward areas, followed by damage control surgery in more sophisticated
settings. A decade of peace and changes in injury epidemiology has meant that new strategies have had to be
exploited in order to maintain the military and civilian
surgical skill base.
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