Vascular Damage Control

Abstract

Vascular injuries are the leading cause of potentially preventable deaths following penetrating trauma. Damage control principles in the field, the emergency department, and in the operating room play a major role in the salvage of these victims. External bleeding should be controlled by direct digital compression, judicious use of tourniquets, and rapid transportation to a trauma center, especially in an urban environment with short prehospital times. In all cases with suspected vascular injuries, the concept of permissive hypotension has become the new standard. Temporary bleeding control whenever possible, damage control resuscitation, and rapid transportation to the operating room remain the cornerstones of survival in severe vascular injuries. Damage control should be considered in all cases with exhausted physiological reserves at risk of imminent death, in complex injuries requiring special operative skills, in anatomically difficult injuries, in suboptimal environments such as in the battlefield or community hospitals, and if the surgeon is inexperienced with vascular surgery. The surgeon has many damage control technique options in his armamentarium. These techniques include temporary intraluminal shunt insertion, ligation, simple repair, balloon catheter occlusion, and extremity amputation. Running parallel to these efforts is correction of the systemic coagulation defects, by minimizing the use of crystalloid and the early aggressive use of packed red blood cells, plasma, and platelets in a balanced ratio. Complex repairs, such as end-to-end anastomosis or graft interposition should be undertaken at a later stage, after resuscitation and correction of coagulopathy, hypothermia, and acidosis.