Taller Janos, Kamdar Jinu P, Greene Jeffrey A, Morgan Robert A, Blankenship Charles L, Dabrowski Paul, Sharpe Richard P
Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134, USA.
J Trauma. 2008 Sep;65(3):595-603. doi: 10.1097/TA.0b013e31818234aa.
Historically, penetrating injuries to the extremities account for up to 75% of wounds sustained during combat and 10% of deaths. Rapid vascular control and perfusion of injured extremities at forward deployed Echelon II surgical facilities is essential to limit loss of life and maximize limb preservation. We review our experience with the management of extremity vascular trauma and report the largest single Echelon II experience to date on temporary vascular shunting (TVS) for proximal extremity vascular injuries.
Data on combat trauma patients presenting to a US Navy Echelon II forward surgical facility in Iraq were prospectively recorded during a 7-month period. Patients with suspected vascular injuries underwent exploration in the operating room. After vessel control, thrombectomy and instillation of heparinized saline, vascular injuries in the proximal extremity were temporarily shunted in a standardized fashion. Vascular injuries in the distal extremity were routinely ligated. After shunting, patients were transported to an Echelon III facility in the Iraqi Theater and underwent vascular reconstruction. They were followed through transfer to the Continental United States or discharge into the civilian Iraqi medical system. Shunt patency, limb salvage, and survival data were obtained by retrospective review of electronic medical records.
Six hundred ten combat trauma patients were treated from August 16, 2006 to February 25, 2007. Thirty-seven patients (6.1%) sustained 73 injuries to major extremity vascular structures. Twenty-three proximal vascular shunts were placed in 16 patients with mean Injury Severity Score of 25 (range, 17-43) and mean mangled extremity severity score (MESS) of 8 (range, 5-10). Twenty-two of 23 shunts (95.6%) were patent upon arrival to the Echelon III facility and underwent successful autologous vein reconstruction. All shunt patients survived their injuries with 100% early limb preservation as followed through their first 30 days of medical care or discharge into the local medical community.
Complex combat injuries to proximal extremity vessels should be routinely shunted at forward-deployed Echelon II facilities as part of the resuscitative, damage control process.
从历史上看，四肢穿透伤占战斗中受伤创口的75%，占死亡人数的10%。在前沿部署的二级梯队外科设施中，对受伤肢体进行快速血管控制和灌注对于减少生命损失和最大限度地保留肢体至关重要。我们回顾了我们在四肢血管创伤管理方面的经验，并报告了迄今为止最大规模的关于近端肢体血管损伤临时血管分流（TVS）的二级梯队单一经验。
在7个月的时间里，前瞻性记录了前往伊拉克一家美国海军二级梯队前沿外科设施的战斗创伤患者的数据。疑似血管损伤的患者在手术室接受探查。在控制血管、进行血栓切除术并注入肝素化盐水后，以标准化方式对近端肢体的血管损伤进行临时分流。远端肢体的血管损伤常规予以结扎。分流后，患者被转运至伊拉克战区的三级梯队设施并接受血管重建。对他们进行跟踪，直至转运至美国本土或转入伊拉克民用医疗系统出院。通过回顾电子病历获得分流通畅情况、肢体保全情况和生存数据。
2006年8月16日至2007年2月25日期间，共治疗了610例战斗创伤患者。37例患者（6.1%）的主要肢体血管结构遭受73处损伤。16例患者放置了23根近端血管分流管，平均损伤严重度评分25分（范围17 - 43分），平均肢体毁损严重度评分（MESS）8分（范围5 - 10分）。23根分流管中有22根（95.6%）在抵达三级梯队设施时通畅，并成功进行了自体静脉重建。所有接受分流的患者均在受伤后存活，在最初30天的医疗护理或转入当地医疗体系后，早期肢体保全率达100%。
作为复苏性损伤控制过程的一部分，对于近端肢体血管的复杂战斗损伤，应在前沿部署的二级梯队设施中常规进行分流。
