What's New in Emergencies, Trauma and Shock? Mapping and managing missile injuries.

In this issue, Wani et al, publish their extensive experience for managing cardiovascular missile injuries from Kashmir, India.[1] They have treated 26 patients with cardiac injuries and 360 patients with 360 arterial injuries of the extremities and the neck over 13 years, an average of 30 cardiovascular injuries in each year. It is interesting to notice that the annual average of proximal peripheral vascular injuries of this study is very similar to our reported series from the Gulf war.[2] The authors have to be congratulated for their results, having an amputation rate of the limbs of less than 5%. Interestingly, none of their patients had more than one peripheral arterial injury. This is different from our published experience.[2] We have seen patients with, life-threatening, devastating injuries. The mean time before arrival to our hospital was relatively shorter compared with Wani et al. study, because battle fighting occurred around our hospital.[12] Very severely injured patients arrived to the hospital, which increased our overall mortality of war-injured patients to 16.7%.[2] We had a higher amputation rate of the lower limbs (9%) despite having highly trained vascular surgeons in our hospital.[2] The amputation rate will depend on many factors besides the time between the vascular injury and repair, like the priority to save life before the limb, and the type of weapon causing the injury. Whether to amputate is sometimes one of the most difficult decisions to be taken by a treating surgeon. Being civilian surgeons who unexpectedly started treating war-injured patients during the Gulf war, we tried initially to be conservative and save limbs. Later on, we realized that we cannot save every limb. For example, the devastating tissue destruction of mine injuries is much more than what appears on the surface and a successful repair may not salvage the limb. A low threshold of amputation is usually practiced when faced with multiple casualties of severely injured patients treated with limited resources within a short time.[3]

I assume that many patients with multiple arterial injuries would have died with bleeding before arriving to the hospital in Wani et al, study explaining why none of their patients had more than one peripheral arterial injury.[1] The proper use of the tourniquet in the pre-hospital setting would have possibly reduced the pre-hospital death.[3] Furthermore, it is unusual to have popliteal artery injury as the most common vascular injury,[1] which supports the above assumption. Among 6808 published vascular injuries, in which majority was penetrating, femoral artery was the most common injured artery (35%) followed by the brachial artery (31%) and then popliteal artery (19.5%).[4] This was also supported by the results of the Balad Vascular Registry from Iraq war in which 90 femoral arteries and 44 popliteal arteries were repaired over 32 months.[5] That is different from blunt vascular injuries caused by road traffic collisions, in which brachial artery is the most common injured vessel.[6]

The authors did not use advanced radiological studies in their series and depended mainly on their clinical skills and basic Doppler studies.[1] The authors have to be congratulated for their results despite having limited resources, which indicates their rich experience. Nevertheless, the new portable hand held ultrasound machines have excellent images and Doppler color facility.[7] Duplex ultrasound has proven to be useful in diagnosing vascular injuries in the recent Iraq conflict.[3] It is a routine in our hospital to have a focused assessment sonography of trauma (FAST) for penetrating chest trauma to look for fluid in the pericardium. Combining this with looking for fluid in the pleural and peritoneal cavities, measuring the IVC diameter, and evaluating the heart chambers in shocked patients, it is much easier to differentiate between pericardial tamponade and hemorrhagic shock. Patients with shock will also have weak peripheral pulses, which can be mixed with the soft signs of vascular injuries. Furthermore, there is definitely a role for on table arterial angiography in war situations, if available and affordable, especially when there is an arterial injury and multiple penetrating sites of the limb. This would help to define the site to be explored. Conventional explosive weapons are designed to maximize the number and velocity of casing fragments so as to increase the damage radius leading to multiple penetrating wounds.[8] Furthermore, arteriography is very useful in complex knee injuries or posterior knee dislocation.[3]

The authors did not extrapolate on their working conditions, and whether they were working under mass casualty situations. They did not use temporary vascular shunts for peripheral vascular injuries neither skin staples for cardiac injuries. Simple damage control surgery methods can reduce the operating time in mass casualty situations.[910] Rasmussen et al, have used temporary vascular shunts in 30 extremities as a damage control adjunct in the Iraq war, especially for major proximal vascular injuries.[11] Local thrombectomy was performed and regional heparin was administered in these cases followed by a fasciotomy, There were no shunt related complications, 86% were patent and only 7% needed early amputation.[11] This was useful to stabilize and then transport patients.

Finally, the need to cover the vascular graft with healthy viable tissue was not addressed in the paper.[1] We found that this is a major problem especially in the popliteal region. A rotational gastrocnemius flap can be used to cover the popliteal vessels.[12]