Extracorporeal sheath shunt technique in trauma: A different vascular shunt in civilian trauma

Background/Objective Temporary intravascular shunts are widely used in military surgery, representing a bridging until definitive vascular reconstruction. In civilian practice, shunts are mainly used as damage control and as a temporary measure until orthopaedic fixation. The objective of this report is to illustrate a new approach to the temporary restoration of perfusion during open management of extremity arterial injury. Methods The authors present a technique that uses sheaths introducers, instead of commercial or purpose-built shunts, which can be used through surgical or percutaneous approaches. Three clinical cases are presented where this technique was performed. Results/Conclusion: In the presented cases, this technique reduced time of shunt construction by avoiding artery surgical approach. This technique can facilitate the creation of an intravascular shunt among other than vascular surgeons.

Late Complications of Vascular Trauma of the Extremities in Civilian Practice: A 10 Year Experience in Cameroon

Background: To describe the different presentations, diagnostic evaluations, managements and outcome of late complications of vascular trauma of the extremities (LCVTE) in civilian practice . Methodology: All the patients with LCVTE who reported at the Yaounde General Hospital from January 2010 to December 2019 were included. Patients presenting with acute vascular injuries, neck vessels injuries and iatrogenic lesions or late complications of vascular access for hemodialysis were excluded. All cases were evaluated with either ultrasound and or Computer tomography and managed with various open vascular surgical techniques and their results were assessed. Results: Fifteen patients with 17 LCVTE underwent various vascular repairs. There were 2 females and 13 males.The age range was from 8 monyhs to 54 years with a mean age of 30.28 . The time interval between injury and presentation in the hospital was 3 weeks to 15 years with a mean of 3 months. Penetrating injuries secondary to stabs were the commonest cause in 94.11%. Lower limbs vessels were affected in 12/17 (70.58%), with Superficial femoral artery being the most frequently involved artery in 6(35.29 %) cases. Sixteen (94.11%) patients presented with pseudoaneurysm, 1 with solely traumatic arteriovenous fistulae. Some pseudoaneurysms presented with complications such as infection (2 cases), bleeding (3 cases) and rupture with hypovolemic choc (1 case). The only non vascular injuries associated were were 1 brachial plexus injury and 1 fracture of the distal femur shaft For the 15 lesions who underwent surgery, the most frequent surgical techniques used were, simple suturing ( 66.66 %); followed by resection and termino-terminal anastomoses (26.66%) Unfortunately one post operative mortality was registered. After a follow-up from 6 months to 10 years no late complications was detected (No recurrence, no wound infection). Only the patient with the brachial plexus injury ended up with a flail limb that didn’t improve and the patient with femoral fracture with a shortening of the limb.Conclusion: Penetrating wounds secondary to stabs were the main injuries and pseudoaneurysm was the most common late complication. Ameliorating the management environment could reduce the morbidity.

FAST in the deployed military setting

IntroductionFocused assessment with sonography in trauma (FAST) is historically an effective method of assessing the patient in the trauma bay in order to aid decision-making and optimise patient outcomes. However, in the UK civilian practice, the use of FAST may decline given a recent change in National Institute for Health and Care Excellence guidance as a result of improvement in CT availability and resuscitation techniques.MethodIn the Role 3 Medical Treatment Facility, Camp Bastion, 187 patients with trauma who received FAST in the trauma bay in 2014 were reviewed to determine the accuracy of FAST in the deployed environment.ResultsThe data demonstrates the sensitivity and specificity of FAST to be 75% and 99.3%, respectively.ConclusionsThis study demonstrates that FAST is accurate on operations. FAST is provided by the integrated radiologist as part of damage control radiology, which gives the team leader rapid diagnostic information to improve decision-making and ultimately patient outcomes. CT is heavily utilised in civilian practice; however, the military operates in a different environment often with multiple casualties and limited access to CT, as a result, portable ultrasound will continue to be a valuable tool on operations if used properly. The next challenge is to develop and maintain this high diagnostic accuracy in future deployments where the memories of our prior success may fade.

Military anaesthesia

War and conflict have long been associated with improvements in medical care. The recent conflicts in Afghanistan and Iraq have been no exception. The high tempo of operations has presented the United Kingdom’s Defence Medical Services (DMS) with the need to care for injured service personnel and local nationals with highly complex patterns of injury. Patients have presented to the DMS with injuries not commonly encountered in civilian practice—typically the result of blast and ballistic mechanisms. The deployed anaesthetist is involved in all stages of the patient pathway from point of wounding to the emergency department, through the resuscitative period encompassed by the damage control construct; to the critical care delivered on the ground and in the air and finally back in the United Kingdom at the interface with the civilian National Health Service. The high quality of care delivered in association with rigorous clinical audit and research including laboratory physical science, has produced developments that not only impact on military outcomes, but which are being introduced in wider civilian practice. This chapter covers all these areas from first principles to the management of pain and advances in the understanding of coagulopathy.